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Background: Structured management of uncomplicated diabetes in primary care constitutes good quality diabetes care. The cycle of care is a national initiative that financially remunerates general practitioners to provide structured diabetes care for people with type 2 diabetes. However, eligibility for the cycle of care is limited to those with means-tested public health insurance. We investigate the national coverage of the cycle of care and describe the socio-demographic and clinical profile of those eligible and non-eligible for the initiative. Methods: A cross-sectional analysis of The Irish LongituDinal study on Ageing (TILDA) Wave 1 was conducted. Type 2 diabetes was defined using self-reported doctor-diagnosis of diabetes, age at diagnosis and use of insulin/oral hypoglycaemic agents. Findings were applied to the 2016 Irish census figures to estimate the absolute population eligible and non-eligible for the cycle of care. Pearson’s chi-square test was used to compare the profiles of those eligible and non-eligible for the initiative. Results: Of the 8,107 TILDA participants, 609 had type 2 diabetes (7.9% [95%CI: 7.3%, 8.5%]) and 31.6% (95%CI: 27.8, 35.6) of these were not eligible for the cycle of care. Applying these estimates to census data, an estimated 36,567 (95%CI: 32,170, 41,196) individuals aged ≥50 years with type 2 diabetes in Ireland are not eligible for the initiative. Those not eligible were less likely to be on insulin and more likely to be managing their diabetes without medication. Conclusions: Nearly one-third of people with type 2 diabetes aged ≥50 years are not eligible for the cycle of care and appear to fit the outlined criteria for uncomplicated diabetes which can be appropriately managed in primary care. Financial barriers to managing uncomplicated diabetes in primary care exist. It is essential that the cycle of care is extended to all those likely to benefit from regular structured diabetes management.

Aims To describe trends in the incidence of visual impairment and blindness due to diabetic retinopathy among adults aged 18–69 years in Ireland between 2004 and 2013. Methods Data on visual impairment due to diabetic retinopathy in adults aged 18–69 years or over who are registered with the National Council for the Blind of Ireland, (2004–2013) were analysed. Annual incidence rates were calculated for the adult population and the population with diagnosed diabetes. Poisson regression was used to test for changes in rates over time. The relative, attributable and population risk of blindness and visual impairment due to diabetic retinopathy were calculated for 2013. Results Over the decade, the prevalence of diagnosed diabetes increased from 2.1% to 3.6%. Among people with diagnosed diabetes, the incidence of visual impairment due to diabetic retinopathy increased from 6.4 (95% CI 2.4–13.9) per 100,000 in 2004 to 11.7 (95% CI 5.9–21.0) per 100,000 in 2013. The incidence of blindness due to diabetic retinopathy varied from 31.9 per 100,000 (95% CI 21.6–45.7) in 2004 to 14.9 per 100,000 (95% CI 8.2–25.1) in 2013. Conclusions Our findings indicate the need for increased attention to preventive measures for microvascular complications among adults with diabetes in Ireland. Retinopathy screening has been standardised in Ireland, these findings provide useful baseline statistics to monitor the impact of this population-based screening programme.

Background Over the last three decades in response to the growing burden of diabetes, countries worldwide have developed national and regional multifaceted programmes to improve the monitoring and management of diabetes and to enhance the coordination of care within and across settings. In Ireland in 2010, against a backdrop of limited dedicated strategic planning and engrained variation in the type and level of diabetes care, a national programme was established to standardise and improve care for people with diabetes in Ireland, known as the National Diabetes Programme (NDP). The NDP comprises a range of organisational and service delivery changes to support evidence-based practices and policies. This realist evaluation protocol sets out the approach that will be used to identify and explain which aspects of the programme are working, for whom and in what circumstances to produce the outcomes intended. Methods/design This mixed method realist evaluation will develop theories about the relationship between the context, mechanisms and outcomes of the diabetes programme. In stage 1, to identify the official programme theories, documentary analysis and qualitative interviews were conducted with national stakeholders involved in the design, development and management of the programme. In stage 2, as part of a multiple case study design with one case per administrative region in the health system, qualitative interviews are being conducted with frontline staff and service users to explore their responses to, and reasoning about, the programme’s resources (mechanisms). Finally, administrative data will be used to examine intermediate implementation outcomes such as service uptake, acceptability, and fidelity to models of care. Discussion This evaluation is using the principles of realist evaluation to examine the implementation of a national programme to standardise and improve services for people with diabetes in Ireland. The concurrence of implementation and evaluation has enabled us to produce formative feedback for the NDP while also supporting the refinement and revision of initial theories about how the programme is being implemented in the dynamic and unstable context of the Irish healthcare system. Electronic supplementary material The online version of this article (doi:10.1186/s13012-016-0464-9) contains supplementary material, which is available to authorized users.

Objective To estimate the prevalence and incidence of type 2 diabetes using a national pharmacy claims database. Research design and methods We used data from the Health Service Executive-Primary Care Reimbursement Service database in Ireland for this cross-sectional study. Prevalent cases of type 2 diabetes were individuals using an oral hypoglycemic agent, irrespective of insulin use, in 2012. Incident cases were individuals using an oral hypoglycemic agent in 2012 who had not used one in the past. Population level estimates were calculated and stratified by age and sex. Results In 2012, there were 114 957 prevalent cases of type 2 diabetes giving a population prevalence of 2.51% (95% CI 2.49% to 2.52%). Among adults (≥15yrs), this was 3.16% (95% CI 3.15% to 3.18%). The highest prevalence was in those aged 70+ years (12.1%). 21 574 people developed type 2 diabetes in 2012 giving an overall incidence of 0.48% (95% CI 0.48% to 0.49%). In adults, this was 0.60% (95% CI 0.60% to 0.61%). Incidence rose with age to a maximum of 2.08% (95% CI 2.02% to 2.15%) in people aged 65–69 years. Men had a higher prevalence (2.96% vs 2.04%) and incidence (0.54% vs 0.41%) of type 2 diabetes than women. Conclusions Pharmacy claims data allow estimates of objectively defined type 2 diabetes at the population level using up-to-date data. These estimates can be generated quickly to inform health service planning or to evaluate the impact of population level interventions.

Background Ambiguity exists regarding the effectiveness of workplace dietary interventions. Rigorous process evaluation is vital to understand this uncertainty. This study was conducted as part of the Food Choice at Work trial which assessed the comparative effectiveness of a workplace environmental dietary modification intervention and an educational intervention both alone and in combination versus a control workplace. Effectiveness was assessed in terms of employees’ dietary intakes, nutrition knowledge and health status in four large manufacturing workplaces. The study aimed to examine barriers to and facilitators of implementing complex workplace interventions, from the perspectives of key workplace stakeholders and researchers involved in implementation. Methods A detailed process evaluation monitored and evaluated intervention implementation. Interviews were conducted at baseline (27 interviews) and at 7–9 month follow-up (27 interviews) with a purposive sample of workplace stakeholders (managers and participating employees). Topic guides explored factors which facilitated or impeded implementation. Researchers involved in recruitment and data collection participated in focus groups at baseline and at 7–9 month follow-up to explore their perceptions of intervention implementation. Data were imported into NVivo software and analysed using a thematic framework approach. Results Four major themes emerged; perceived benefits of participation, negotiation and flexibility of the implementation team, viability and intensity of interventions and workplace structures and cultures. The latter three themes either positively or negatively affected implementation, depending on context. The implementation team included managers involved in coordinating and delivering the interventions and the researchers who collected data and delivered intervention elements. Stakeholders’ perceptions of the benefits of participating, which facilitated implementation, included managers’ desire to improve company image and employees seeking health improvements. Other facilitators included stakeholder buy-in, organisational support and stakeholder cohesiveness with regards to the level of support provided to the intervention. Anticipation of employee resistance towards menu changes, workplace restructuring and target-driven workplace cultures impeded intervention implementation. Conclusions Contextual factors such as workplace structures and cultures need to be considered in the implementation of future workplace dietary interventions. Negotiation and flexibility of key workplace stakeholders plays an integral role in overcoming the barriers of workplace cultures, structures and resistance to change. Trial registration Current Controlled Trials: ISRCTN35108237. Date of registration: 02/07/2013 Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1413-7) contains supplementary material, which is available to authorized users.

Background Childhood obesity is an urgent global concern with a complex multifactorial aetiology. Infant feeding behaviours are a potential target for childhood obesity prevention. However, evidence for the effectiveness of interventions to improve infant feeding behaviours is inconsistent, and knowledge of how interventions have been implemented, what aspects work, and why, is lacking. This review aimed to synthesise qualitative evidence about parents' and health-care professionals' views and experiences of infant feeding interventions, and identify factors influencing intervention implementation. Methods A systematic review and synthesis of qualitative evidence was conducted. CINAHL, Medline, PsycINFO, Embase, and SCOPUS were searched from database inception to Sept 25, 2017, for English-language qualitative studies reporting the implementation of infant feeding interventions from the perspectives of health-care workers, parents, or both. 4794 studies were screened using a-priori inclusion and exclusion criteria. Two reviewers independently extracted data and judged quality. A framework synthesis was conducted and GRADE-CERQual was used to assess confidence in findings. This review is registered with PROSPERO, number CRD42016039652. Findings Of 4794 screened studies, 13 UK, US, and Australian-based studies were included. Supportive relationships and environments were integral to the successful implementation of infant feeding interventions for both health-care professionals and parents. Issues with capacity (ie, time and resources) negatively influenced implementation by health-care professionals; for parents, a focus on practical elements and sustainability beyond the intervention was crucial to ensure success. Interpretation This review provides valuable information to enable informed and robust decisions about future infant feeding interventions and policy development, ensuring that these decisions are guided by stakeholder experiences and are cognisant of previous implementation challenges or successes. Methodologically, this study provides an innovative example of using qualitative evidence synthesis to explore factors influencing intervention implementation and engagement from both provider and participant perspectives. This review provides deeper insight into potential interactions between provider and participant experiences, and a comprehensive holistic overview of factors that are important to consider for future infant feeding interventions. Funding Health Research Board Interdisciplinary Capacity Enhancement Award 2015-1026.

Background Diabetic retinopathy is a leading cause of visual impairment (VI). The last study to report the trends of blindness due to diabetic retinopathy was carried out in 2003 and since then a national diabetic retinopathy screening programme has been introduced (2013). Contemporary data are needed to evaluate the future impact of screening. The aim was to describe trends in the incidence and prevalence of blindness due to diabetic …

Background: Diabetes is an increasingly prevalent chronic illness that places a huge burden on the individual, the health system and society. Patients with active foot disease and lower limb amputations due to diabetes have a significant amount of interaction with the health care services. The purpose of this study was to explore the attitudes and experiences of foot care services in Ireland among people with diabetes and active foot disease or lower limb amputations. Methods: A purposive sample of individuals who had either active foot disease or a lower limb amputation as a result of diabetes were recruited from the Prosthetic, Orthotic and Limb Absence Rehabilitation (POLAR) Unit of an Irish hospital. One-to-one interviews were conducted in the POLAR unit using a semi-structured topic guide. Thematic analysis was used to identify, analyse and describe patterns within the data. Results: Ten males participated in the study. Most participants expressed a need for emotional support alongside the medical management of their condition. There were substantial differences between participants with regard to the level of education and information they appeared to have received regarding their illness. There were also variations in levels of service received. Transport and medication costs were considered barriers. Having a medical card, which entitles the holder to free medical care, eased the burden of the patient’s illness. A number of participants attributed some of the problems they faced with services to the health care system as a whole rather than health care professionals. Conclusion: Results suggest that rehabilitation services should place a strong focus on psychological as well as physical adjustment to active foot disease or lower limb amputations. The delivery of services needs to be standardised to ensure equal access to medical care and supplies among people with or at risk of lower extremity amputations. The wider social circumstances of patients should be taken into consideration by health care professionals to provide effective support while patients adjust to this potentially life changing complication. The patient’s perspective should also be used to inform health service managers and health professionals on ways to improve services.

This article aims to estimate the workforce and resource implications of the proposed age extension of the national breast screening programme, under the economic constraints of reduced health budgets and staffing levels in the Irish health system. Using a mixed method design, a purposive sample of 20 participants were interviewed and data were analysed thematically (June-September 2012). Quantitative data (programme-level activity data, screening activity, staffing levels and screening plans) were used to model potential workload and resource requirements. The analysis indicates that over 90% operational efficiency was achieved throughout the first six months of 2012. Accounting for maternity leave (10%) and sick leave (3.5%), 16.1 additional radiographers (whole time equivalent) would be required for the workload created by the age extension of the screening programme, at 90% operational efficiency. The results suggest that service expansion is possible with relatively minimal additional radiography resources if the efficiency of the skill mix and the use of equipment are improved. Investing in the appropriate skill mix should not be limited to clinical groups but should also include administrative staff to manage and support the service. Workload modelling may contribute to improved health workforce planning and service efficiency.

Introduction: In 2013, the national diabetic retinopathy screening programme (NDRSP) was introduced in Ireland to offer free, regular retinopathy screening to people with diabetes. Ensuring a high uptake of a national retinopathy screening programme is challenging [1]. Non-attendance for screening has been identified as a risk factor for poor visual outcomes among those with diabetes [2]. Suboptimal uptake has been previously highlighted by regional screening programmes in Ireland, with attendance rates ranging from 49-80% [3-5]. Therefore, it is essential and timely to understand factors that facilitate or deter screening attendance as the NDRSP is implemented. The aim of this study was to identify and explain why the NDRSP was working (or not working), for whom and in what circumstances to produce outcomes. Methods: This study was guided by a realist evaluation framework and adopts a multi-stage mixed methods design. Qualitative data from documents and semi-structured interviews with a purposive sample of national stakeholders (n=19) were used to develop the initial programme theories. These theories were tested in two large primary health centre in Ireland. Quantitative data extracted the medical records of all adults aged ≥18 years with diabetes registered with the practices were collected to establish uptake rates. A qualitative component was conducted using semi-structured interviews. Sampling was based on four outcome groups identified during the quantitative component of the study: consenting, attending, non-attending, not consenting. Framework analysis was used to identify factors that influenced the decision to participate in the NDRSP. Results: Against the back drop of a variation in existing retinopathy screening services, it was expected that members of the target population would decide to attend the NDRSP and a national uptake of 80% would be achieved. A total of 581 people with diabetes were included in the quantitative analysis. Over a 14 month period, the uptake of the screening programme was 63%. Qualitative analysis suggested that a fear of blindness and a belief that retinopathy screening could reduce the risk of diabetes-related blindness enabled screening attendance. Having had a recent eye examination at another screening provider was a common reason for not attending the NDRSP. No relative advantage of attending the NDRSP over exiting screening providers was a barrier to consenting to the newly established service. Discussion/conclusion: Little is known about the characteristics which determine the uptake of retinal screening among those with diabetes in Ireland. Findings from this research will inform the ongoing implementation of the national diabetic retinopathy screening programme and its advertising and recruitment activities. Lessons learned: It is important that efforts to increase the uptake of the NDRSP include increasing the awareness around this change in service provision among members of the target population. Limitations: In the absence of national level data, quantitative analysis relied on data from two primary health care centres. Future research: This study is part of an ongoing evaluation of the National Clinical Programme for Diabetes. Findings from this research will be verified and refined during a multiple case study in four geographical regions in Ireland.

Introduction: While proponents of integrated EUCSs claim that such models deliver higher quality, safety and efficiency standards without introducing spatial inequalities [1], a conflicting view is that reconfiguration is usually performed for political reasons and represents a conflict of values between different stakeholder groups [2]. A series of EUCS reconfiguration programmes have recently been implemented, albeit to varying degrees, in the Republic of Ireland. This study investigated stakeholder perspectives on the rationale of this initiative. It considered the hypothesis that individuals from different stakeholder groups will endorse different positions in relation to reconfiguration. Methods: Documentary analysis was used to identify the official justifications for change in region-specific reconfiguration planning documents. Semi-structured interviews with 175 purposively sampled stakeholders explored their perspectives on the rationale for this remodelling of care across the country. They comprised ‘internal’ (hospital staff) and ‘external’ stakeholders (general practitioners, ambulance personnel and members of the public including local politicians and hospital campaign groups). Framework analysis was used. Results: While a majority of stakeholders agreed with the need for an accessible and well-functioning health system, their understanding of what it meant and how it should be achieved in the delivery of urgent and emergency care varied considerably between the two stakeholder groups. There was some cynicism predominantly among external stakeholders as to the true motivations behind reconfiguration. They broadly perceived decision-making around service change to be influenced by political and cost-saving concerns. Discussions: Findings mirror experiences in other countries [2]. Considerable public angst has been documented over the safety issue of centralising services and associated risks potentially involved in having to travel longer distances for emergency care [3]. People have perceived service change as cuts to services [4]. Proponents of change have tended to emphasise the perceived quality and safety benefits of reconfiguration rather than focusing on cost-savings [5]. Conclusions: When it comes to reconfiguration, there are clear differences depending on stakeholder position on what a health service should look like in the delivery of EUCS care. A ‘win for all’ scenario is perceived as unattainable for there is always a trade-off of interest. Understanding what concerns the public and the trade-offs that patients and their families are prepared to make when deliberating over major service change would help those tasked with planning EUCS provision to make decisions that address the range of issues at hand. Lessons learned: Where regions have not been fully reconfigured, findings will inform those in the driving seat of change of the diversity of viewpoints on EUCSs. It will enable them to understand the concerns, misconceptions and conflicting perspectives that hinder a united effort to improving care. Limitations: This was a retrospective study. There was also discrepancy in the sum of stakeholders interviewed in each region, particularly in one region, although extensive and well documented reconfiguration had taken place there which provided a larger sample frame to recruit from. Suggestions for future research: The extent to which lessons learned from this study inform EUCS policy implementation in regions not fully reconfigured is a possible avenue for research. References: 1- Ham C, Smith J, Temple J. Hubs, spokes and policy cycles: a paper for the King’s Fund London Commission. London: King’s Fund; 1998. 2-Spurgeon P, Cooke M, Fulop N, Walters R, West P, Perri S, Barwell F, Mazelan P. Evaluating models of service delivery: reconfiguration principles. National Institute for Health Research Service Delivery and Organisation programme. London: HMSO; 2010. 3- Farrington-Douglas J, Brooks R. The future hospital: the politics of change. London: Institute for Public Policy Research; 2007. 4- Farrington-Douglas J, Brooks R. The future hospital: the progressive case for change. London: Institute for Public Policy Research; 2007. 5- Fulop N, Walters R, Spurgeon P. Implementing changes to hospital services: Factors influencing the process and ‘results’ of reconfiguration. Health Policy; 2012; 104:128-135.

Introduction: Numerous interventions have been shown to effectively reduce the rate and risk of falling among older people. In Ireland, our national falls strategy recommends the use of evidence-based interventions that are equitable and sustainable. However, there are practical, cultural, and professional challenges to implementing service changes that require input from multiple professionals across settings. Our aim is to investigate the acceptability, feasibility and sustainability of community-based falls risk assessment clinics (FRAC), designed to deliver timely access to standardised assessment conducted by existing staff in the appropriate setting with onward referral for treatment as necessary. The clinics are part of a wider integrated falls pathway, accessible via a single point of referral, which links emergency, specialist, primary care and community services, coordinated by a dedicated pathway coordinator. Methods: Using a mixed methods design, semi-structured interviews are being conducted pre-implementation and at 6 months with a purposive sample of primary care staff delivering the clinics (occupational therapists, physiotherapists, nurses) (n=18). Thematic analysis using implementation theory will identify the barriers and facilitators, and elicit perceptions of the appropriateness, acceptability, feasibility, and sustainability. Referral rates, attendance, and onward referrals for treatment are being extracted from administrative databases and analysed descriptively as indicators of adoption, uptake and sustainability. Data are reported for two of the six clinics established between June and August 2016. Results: Pre-implementation interviews suggest staff were comfortable conducting risk assessments given the expertise available within the multidisciplinary team and the tailored training and support provided by a dedicated coordinator and administrator. However, physical resources and space required to operate a multidisciplinary service are constrained. Of the 165 referrals to the falls pathway, 42 were triaged for assessment at a FRAC (25%). The uptake rate was 74% (n=31). Non-attendance was highlighted as a particular challenge at one site while all staff expressed concern about the impact of assessments on waiting lists for intervention at community services. Over half of those assessed at a FRAC were referred on to the GP, physiotherapist and/or public health nurse. Discussion: The implementation of the clinics is dependent on changes in ways of working among existing primary care staff, together with new resources to provide training, coordination and administrative support. The introduction of the clinics appears to be acceptable to those delivering the service and feasible in the primary care setting. However, its initial implementation success and sustainability are dependent on investment at multiple levels. Lessons learned: Formative evaluations conducted in collaboration with health service managers, healthcare professionals and service users ensures that results are useful and used to inform ongoing service development. Limitations: This study does not assess the effectiveness of the individual components of the pathway or the various strategies used to integrate care. Future research: postal survey and interviews are being conducted among service users, and interviews are being conducted among healthcare professionals with referral access to the falls pathway. Understanding the challenges for those adopting, implementing and attended services on the pathway will increase the likelihood of its success, spread and sustainability.

Introduction: To address major deficits in the delivery of acute services in Ireland, the National Acute Medicine Programme (NAMP) was established to optimize the management of acutely ill patients in the hospital setting, and ensure their supported discharge to primary and community-based care. NAMP aims to reduce inappropriate hospital admissions, reduce length of hospital stay and ensure timely treatment in the most appropriate setting. To meet these aims, the NAMP has established four patient pathways: 1- Ambulatory care pathway - provides access to care and avoids admission by utilizing Acute Medical Assessment Units (AMAUs) 2- Medical short stay pathway - Short Stay Units (SSUs) for assessment and treatment up to 48 hours 3- Routine specialist in-patient pathways - efficient processing of patients with stays between 3 and 14 nights 4- Pathway for frailer and older patients with complex needs after discharge - appropriate care and discharge of complex patients Methods: Study design: This mixed method study will follow a realist evaluation approach to understand how implementation of NAMP has improved patient flow across care settings. To assess its impact, data on structures (e.g., patient flow through ED and the AMAUs, access to senior medical staff), processes (e.g., patient experience time ,length of stay, readmission rates), clinical outcomes and programme sustainability will be examined. This approach involves successive phases of data collection to first establish the underlying rationale for the NAMP and to specify intervention strategies to improve patient flow, secondly generate hypotheses about how the programme is working, and thirdly test these hypotheses using data from hospital administrative systems and interviews with frontline staff. Data sources: The evaluation will draw on multiple data sources: i- Documentary analysis Documents outlining new models of care and patient pathways, and programme reports will be analyzed to develop initial programme theories, identify interventions, and refine evaluation questions. ii- Qualitative data Focus groups and interviews with NAMP programme staff will be conducted to generate hypotheses about how the programme works in different contexts. ii- Hospital administrative datasets Hospital level datasets will be analyzed to examine structural and process outcomes. ii- Comparative case studies - mix of quantitative and qualitative data Six hospital sites will be purposively sampled based on their performance on process indicators. A value stream map will be created for each site and hospital specific documents (e.g., protocols, SOPs, hospital audits and surveys, staffing levels) will be reviewed to create a profile of each hospital. Interviews with front-line staff will be conducted to identify what aspects are working, for whom, how, and in what circumstances. Data analysis: Data will be analyzed using an explanatory sequential design. Quantitative data will firstly be analyzed to assess variation across hospitals, and qualitative research conducted to explain these results. Findings will be synthesised using analytic induction to develop middle range theory on how the programme leads to specific outcomes. Discussion: Evaluation of this large national programme will enable us to generate practical theory about how specific adaptations in hospital acute care pathways can promote effective patient flow through the continuum of care from presentation at the emergency department through safe discharge home.

ObjectiveTo explore the barriers and facilitators experienced by those implementing a government-funded, community-based childhood weight management programme.DesignQualitative using semistructured interviews.SettingTwo geographical regions in the south and west of Ireland.Participants29 national-level and local-level stakeholders responsible for implementing the programme, including professionals from dietetics, psychology, public health nursing, physiotherapy, health promotion and administration.MethodsFramework analysis was used to identify barriers and facilitators, which were mapped onto six levels of factors influencing implementation outlined by Grol and Wensing: the innovation, the individual professional, the patient, the social context, the organisational context and the external environment.ResultsMost barriers occurred at the level of the organisational context. For all stakeholders, barriers arose due to the multidisciplinary nature of the programme, including the lack of role clarity and added complexity of working in different locations. Health professionals’ low-perceived self-efficacy in approaching the subject of weight with parents and parental resistance to hearing about their child’s weight status were barriers to programme implementation at the individual professional and patient levels, respectively. The main facilitators of implementation, occurring at the level of the health professional, included stakeholders’ recognition of the need for a weight management programme and personal interest in the area of childhood obesity. Having a local lead and supportive colleagues were further implementation drivers.ConclusionsThis study highlights the complexities associated with implementing a multidisciplinary childhood weight management programme, particularly translating such a programme to a community setting. Our results suggest the assignment of clear roles and responsibilities, the provision of sufficient practical training and resources, and organisational support play pivotal roles in overcoming barriers to change. This evidence can be used to develop an implementation plan to support the translation of interventions into real-world settings.

Background There is increasing interest in how to successfully integrate care for people with Type 2 diabetes mellitus (T2DM), coordinating management between primary and secondary care. In Ireland, diabetes nurse specialists (DNSs) have been introduced into the community to facilitate a new model of integrated care where uncomplicated T2DM is managed in primary care, and complicated T2DM is managed between primary and secondary care. Our aim is to describe DNS service delivery in Ireland and examine regional variation in service implementation. Methods Online questionnaires were administered by email to 150 DNSs, identified through various sources, including the Irish Diabetes Nurse Specialist Association, who asked members to register their contact details with the research team. The questionnaire, based on a UK survey adapted for the Irish health system, addressed the nurse’s clinical role, links with primary and secondary care, and referral access to support services. In open-ended questions, respondents outlined barriers and facilitators to diabetes management in their area. Fisher’s exact test was used to test differences across 4 regional networks of the Health Service Executive. A p-value of Results In total, 97 (64.6%) DNSs returned questionnaires. Almost all hospital (n = 62, 87.3%) and community nurses (n = 23, 95.8%) reported that patients with complicated T2DM attended their service. Although most (n = 86, 88.7%) had a liaison role with other professionals (GPs, Practice Nurses, DNSs, endocrinologists), less than half (n = 37, 39.2%) reported a formal agreement between primary and secondary care on how their service operates. While 92.8% (n = 90) could refer to other specialists, there were regional differences in access to psychologists and ophthalmologists (non-significant after adjustment). Barriers to service delivery included inadequate resourcing, limited guidance on the DNS role, and issues with integration, including GPs’ lack of engagement with community DNSs. Conclusion Encouragingly, most community DNSs were seeing patients with complicated T2DM, as recommended under the national model of integrated care, with liaison part of the role for most respondents. However, the lack of formal agreements on DNS services across settings, regional issues with integration and referral access, indicate areas for attention as service changes continue. This includes the cycle of care which will remunerate GPs for primary care management of stable T2DM, and likely increase demand for DNS support in the community.

Background Research suggests multi-component family-based lifestyle programmes are efficacious in treating paediatric obesity. However, success relies heavily on family attendance and retention. While attendance offers the support to make long-lasting, positive, lifestyle changes, in addition to the opportunity to identify underlying health issues, the majority of families referred to treatment decline. Moreover, for those who do attend, benefits are often compromised by high programme attrition. While non-attendance directly impacts on the children and their families, it also negatively impacts the health service due to missed appointments and loss of productivity. This systematic review aimed to investigate the factors influencing attendance at community-based lifestyle programmes among families of overweight or obese children. Within this overall review question we specifically sought to explore the barriers and facilitators related to both initial and continued attendance. Methods A narrative synthesis approach was used to allow for the inclusion of a range of research designs. Quantitative, qualitative and mixed-methods studies were included. Articles published in English were included if they (1) were original research studies, (2) included children aged 4–12 years, (3) had a primary focus on paediatric weight management that (4) incorporated lifestyle (i.e. diet, physical activity and behavioural) components, and (5) reported on the factors influencing attendance at family-based programmes that were delivered in the community setting. The electronic databases, PubMed, CINAHL, EMBASE and PsychINFO were searched from inception to March 2015 and the reference lists of all relevant studies were hand searched for additional articles. Results Thirteen studies were included. Children enrolled primarily to have fun and make friends. However, the stigma associated with attending these programmes discouraged others. For parents, the main factors influencing enrolment included the concern for their child’s psychological health, the desire to reduce any adverse social experiences their child may be experiencing and to increase their child’s self-esteem. Denial of the issue amongst parents presented a barrier to enrolment and many parents refused to accept their child was carrying excess weight. Logistical factors such as time, transport, conflicting schedules and changing family circumstances influenced families’ decisions to drop out of treatment while group support and good trainer–participant relationships were viewed as crucial to continued attendance. Conclusion Efforts are urgently required to optimise the effectiveness of childhood obesity treatment in the community setting. This study provides practical recommendations to guide future policy makers, programme delivery teams and researchers in developing strategies to boost recruitment and minimise attrition.

Background Research suggests that community-based family-focused weight management programmes that incorporate physical activity, diet and behavioural components can be effective in treating paediatric obesity. However, the majority of these programmes are small, feasibility trials whose findings have yet to be replicated in the real-world context. This study explores the barriers and facilitators experienced by those implementing a government-funded, multi-component childhood weight management programme in the community setting. Methods Semi-structured interviews were conducted with a purposive sample of 28 stakeholders responsible for referring to or implementing the programme including professionals from dietetics, clinical psychology, public health nursing, physiotherapy, and health promotion. Interviews were audiotaped, with participants’ informed consent and transcribed verbatim. Framework analysis was used to identify barriers and facilitators which were then mapped onto six levels of influential factors outlined by Grol and Wensing: the innovation, the individual professional, the patient, the social context, the organisational context, and the external environment. This framework describes how barriers and facilitators can be identified, categorised, and used for the development of tailored-based implementation strategies to facilitate desired change. Results Most perceived barriers occurred at the level of the social and organisational context while the majority of facilitators were at the level of the individual professional. For all participants, barriers arose due to the multi-disciplinary nature of the programme, including the lack of role clarity, lack of understanding of other disciplines as well as the added complexities of working in different locations. Participants’ recognition of the need for a programme and their own personal interest in the area were the main drivers behind implementation while the provision of incentives and the presence of supportive colleagues were further enabling factors. Conclusion This study highlights the complexities associated with implementing multi-disciplinary childhood weight management programmes in the community setting from a wide range of stakeholder perspectives. Our results suggest the assignment of clear roles and responsibilities, the provision of sufficient training and resources as well as organisational support play pivotal roles in overcoming barriers to change. This evidence should be used to develop an implementation plan to support the translation of efficacious interventions into real world settings.

Background The increasing prevalence and cost of Type 2 diabetes mellitus (T2DM) has driven the reorientation of diabetes care in recent years. Health systems have moved from reactive, episodic management in the acute setting to greater primary-care-led structured disease management. Structured diabetes management, whereby patients are managed in primary care in a systematic, organised way, with structured specialist support, has been associated with improved patient outcomes. However, there is limited research on the long-term performance. The aim of this study was to examine the quality of care delivered by a primary care-based structured diabetes management programme for T2DM over 10 years. Methods Data were collected from patients with T2DM (≥18 years) registered with practices participating in the Midlands Diabetes Structured Care Programme. In this programme patients are managed in primary care with support from clinical nurse specialists (CNS), dietetics, ophthalmology, and chiropody. Data were collected by CNS at three time points, 1998/1999, 2003 and 2008, on demographic, clinical, and lifestyle variables, including processes and clinical outcomes. Chi-square tests for trend were used to test differences in the processes and outcomes over time, benchmarked against national guidelines and the English National Diabetes Audit 2012–2013. A p-value of Results Data on 333 patients with T2DM from 10 practices in 1998/1999; 841 from 20 practices in 2003; and 989 from 31 practices in 2008, were available for analysis. BMI, HbA1c, total cholesterol, triglycerides, blood pressure, and creatinine documentation improved significantly over time (p Conclusion Over a 10-year period of structured diabetes care, improvements were observed both in process of care documentation and patient outcomes, suggesting that primary-care-led management of diabetes can perform favourably in the long-term. These results are encouraging in light of the new diabetes cycle of care, which will, for the first time in Ireland, remunerate GPs for routine primary care management of T2DM.

Background Health service redesign involves several interventions across multiple organisations and stakeholders. It is important to understand the conditions for successful implementation including how outcomes are attained. Realist evaluation explores ‘what works for whom in what circumstances and why’. Our aim is to use this approach to evaluate the implementation of the National Clinical Programme for Diabetes (NCPD), a multifaceted change programme led by healthcare professionals (HCP). Methods The evaluation is being conducted in three phases. During phase 1, semi-structured interviews were conducted with a purposive sample of members of the national working group (n = 20). Framework analysis was used to identify the initial programme theory (underlying rationale) and develop hypotheses regarding the conditions (context, mechanisms) that facilitated or impeded implementation (outcome). These hypotheses will be examined in phase 2 using a mixed methods multiple case study design. Interviews will be conducted with local stakeholders in four geographical regions (HCP, management, patients), supplemented with analysis of routine activity data. Data will be integrated during interpretation and synthesised on a thematic basis. During phase 3, the programme theory will be refined and cross-case comparison will examine whether the components for successful implementation differed across regions. Results Preliminary analysis suggests that in the context of service ‘black spots’ and ‘pockets’ of good practice, the purpose of the programme was to develop ‘a cohesive strategy’ for resource allocation to ensure a standardised service across the country. Part of the programme theory was that establishing national clinical leadership would foster buy-in and empower frontline staff. However, implementation has been impeded by ‘missed opportunities’ to utilise local clinical experience. One participant suggested that the poor uptake of the national retinopathy screening programme was due in part to the lack of a clear ‘connexion with the clinicians on the ground’. Two priority areas, the retinopathy screening programme and national foot care model, were ‘at least moving in the right direction’. However, there has been little change in the shared management of patients between primary and secondary care. Discussion There is consensus among national stakeholders on the need for and purpose of the programme. However, the lack of progress on integrated care challenges the intended outcome of a standardised diabetes service for all patients. Findings on the more successful contexts and mechanisms for change will inform the future implementation plans for the NCPD as well as other programmes seeking to work with and across disciplines to introduce change.

Background The Health Service Executive (HSE) has embarked on a series of regional system re-designs to radically change the organisation of urgent and emergency care services in Ireland, at a time when budgets and staff levels have been substantially reduced and there is growing awareness of problems with quality and safety. The first priority of this initiative is to “develop integrated services across all stages of the care journey” with the goal of increasing efficiency and improving performance. Major changes initiated so far include the reconfiguration of acute hospital services and the introduction of ambulance bypass protocols. Our aim was to examine the consultation process in re-designing urgent and emergency care services, with a specific focus on trade-offs and the role of evidence. Methods Two qualitative methods were employed. A documentary analysis was conducted of current national and regional policy documents. In addition, approximately 200 semi-structured interviews were conducted with key providers of urgent and emergency care at a national and local level, along with health service campaigners, local politicians and media, across eight geographical regions covering the whole of the country. Information from the documentary analysis and the interviews was synthesised using NVivo software. Yin’s multiple case study methodology was used to collate information at a regional level. Findings from all eight regions were compared and contrasted. Results Preliminary findings suggest that policy documents considered contextual evidence and local consultation. However, data from the interviews identified mixed levels of stakeholder involvement in the consultation process across the eight regions. Moreover, there was a perceived hierarchy of policy drivers behind the system re-design at a regional level and a concern over the resource implications behind the trade-offs that arose from the changes to acute hospital services. Conclusion Planning change for urgent and emergency services is a complex process, guided by local as well as national stakeholder considerations, resources and motivations. The results of this study shed a more transparent light on national and regional healthcare system planning for urgent and emergency care to date. Policy makers need to consider stakeholder perceptions of proposed changes. It is important that there is local engagement from the outset and that this is followed through to secure support for implementation across different regional contexts.

Background Research has shown that those who have experienced adverse childhood events (ACE) are at increased risk of developing chronic diseases later in life. The relationship between ACE and health service use (HSU) is subject to potential confounding factors including those chronic diseases. Existing evidence is largely based on hospital administrative data, limiting the investigation of other influential predisposing, enabling and need factors. Our aim was to examine the association between ACE and HSU using data from a primary care-based survey. Methods We analysed cross-sectional data from the Mitchelstown study, a population based cohort of people aged 50 to 69 recruited from a large primary care centre (2010/2011). ACE was measured by self-report using the Centre for Disease Control ACE questionnaire. Health service use in the previous 12 months (number of GP consultations and hospital discharges) was extracted from electronic medical records. Negative binomial regression was conducted, adjusting for predisposing (age, sex), enabling (education, social class, having a medical card entitling holder to free GP care) and need factors (multimorbidity: 0, 1 or ≥2 chronic diseases), using Stata 12. Results HSU data were available on 2026 participants (99% of total sample = 2047), 1885 of whom completed the ACE questionnaire. Overall, 23.4% ( n = 4 41, 95% CI: 21–25%) reported a history of ACE. Adjusting for age, sex, education, social class and medical card status, a history of ACE was significantly associated with a higher number of GP consultations (incidence rate ratio, IRR = 1.2, p 0.001; 95% CI 1.0–1.3). However, the association was not significant when multimorbidity was included in the model (IRR = 1.1, p > 0 .05, 95% CI: 1.0–1.2). Significant factors included having a medical card (IRR = 1.92, 95% CI: 1.7–2.1), multimorbidity (IRR = 1.9, 95% CI: 1.7–2.2) and third level education (IRR = 0.8. 96% CI = 0.7–0.9). ACE was not significantly associated with number of hospital discharges (IRR = 1.5, p = 0 .124, 95% CI: 0.9–2.5). Discussion Adverse childhood experience has been conceptualised as a need factor which may influence health service utilisation. Our results suggest that the impact of ACE on the frequency of GP consultations may be mediated through enabling factors such as free access to services and other need factors such as multimorbidity.

Background Falls are a common and serious concern facing older adults and the prevalence is increasing internationally. Falls lead to injury, hospitalisation, and substantial healthcare costs. Older people with diabetes may be at increased risk of falls, given the potential for polypharmacy and the development of microvascular complications. We aimed estimate prevalence of falls and examine the association between diabetes and a risk of falls in the older population using The Irish Longitudinal Study of Ageing (TILDA). Methods Cross-sectional analysis was conducted on the first wave of TILDA data (2009–2011): a nationally representative sample of community-dwelling adults aged ≥50 years. Data were collected using a computer-assisted personal interview, self-completion survey and health assessment. Diabetes was based on self-report of doctor-diagnosis, the prevalence of falls in the previous year was also ascertained by self-report. The relationship between diabetes and falls risk was assessed using Pearson’s Chi-squared test. Multivariate poisson regression was used to examine the association between diabetes and falls, adjusted for age, sex, polypharmacy (≥5 different medications) and multimorbidity (≥3 chronic illnesses). Results In the sample (n = 8175), the prevalence of falls in those with diabetes was 24% (n = 152 95% CI: 21–28%; P When adjusted for age and gender, diabetes was significantly associated with an increased risk of falling (IRR: 1.23 95% CI: 1.04–1.45%; P Polypharmacy (IRR: 1.24 95% CI: 1.09–1.42%; P Conclusion One-quarter of adults with diabetes experienced a fall in the preceding year. Our analysis showed an association between those who had fallen at least once in the previous year and diabetes, adjusted for age and gender. The relationship was not significant after adjustment for polypharmacy and multimorbidity. Given the potential for multimorbidity and polypharmacy in this group, people with diabetes may benefit from early recognition of their fall-risk and interventions to reduce risk.

Background Research suggests that variation in laboratory requesting patterns may indicate unnecessary test use. Requesting patterns for serum immunoglobulins vary significantly between General Practitioners (GPs). This study aims to explore GP views on testing to identify the determinants of behaviour and recommend feasible intervention strategies for improving immunoglobulin test use in General Practice. Methods Qualitative semi-structured interviews were conducted with GPs requesting laboratory tests at Cork University Hospital or Kerry General Hospital in the South of Ireland. GPs were identified using a Health Service Executive laboratory list of GPs in the Cork-Kerry region. A random sample (stratified by GP requesting patterns) of GPs was generated from this list. GPs were purposively sampled based on the sampling criteria of: location (urban/rural); length of time qualified; and practice size (single-handed/group). Interviews were carried out between December 2014 and February 2015. Interviews were transcribed verbatim using NVivo 10 software, and analysed iteratively using thematic analysis. Emerging themes were then mapped to the theoretical domains framework (TDF), which identifies 12 domains that can enable or inhibit behaviour change. The behaviour change wheel and behaviour change technique (BCT) taxonomy were then used to recommend potential intervention strategies. Results Sixteen GPs were interviewed, including ten males and six females. Preliminary analysis, using the TDF and BCT taxonomy, found that serum immunoglobulin test use in General Practice is influenced by many social and contextual factors. The main domains from the TDF which emerged were: ‘knowledge’, ‘environmental context and resources’, ‘social influences’, ‘beliefs about capabilities’, ‘beliefs about consequences’, with the findings identifying a need for ‘shaping knowledge’. In particular, GPs identified education and feedback strategies as feasible interventions to change their behaviour. Conclusion This study identified GP challenges with serum Immunoglobulin testing, which included difficulty interpreting test results, patient expectations, personal experiences, and the lack of implementation of guidelines and knowledge about when to test for serum immunoglobulins. Study findings and the application of the TDF and BCT taxonomy, will inform the development of a feasible intervention for improving immunoglobulin test use in General Practice.

Background An increasing and often inappropriately large proportion of the resources and attention of the healthcare system is being diverted into the Emergency and Urgent Care System (EUCS). This aim of this study was to describe the evolution of health policy relevant to EUCS in Ireland, using the Health Policy Triangle, to examine coherence between different policy documents and to assess implementation of these policies. Methods A retrospective documentary analysis of published national and regional policy documents related to the EUCS was conducted. Current policy documents governing EUCS were included, encompassing National Health Policy (e.g. Strategy), National Reconfiguration Reports (e.g. Report on the Establishment of Hospital Groups as a Transition to Independent Hospital Trusts), Regional Reconfiguration Reports (e.g. Reconfiguration Roadmap), Regulatory Reports (HIQA), and National Clinical Programme Reports (e.g. Emergency Medicine Programme). A framework approach was used to analyse the documents, identifying context, actors, content and processes. Results The EUCS policy context in Ireland is influenced by the socio-political, economic and cultural environment. Historically, the Churches and medical profession were dominant actors but recently national and international regulators, the media and the general public are visible. Drivers have remained consistent over time and include quality, access and equity, specialisation, patient safety, clinical governance and cost. The analysis revealed three types of evidence which informed policy formation; expert opinion, peer review research, and assessment of the status quo (a de facto limited evaluation of current policy). The use of each type of evidence in policy formation has evolved over time with increasing use of peer review research as it has become available. Public consultation and involvement has also improved over time, though this is a poorly developed area. EUCS policy demonstrates both coherence and inconsistency. The main recommendations of all current EUCS policy relate to a new model of care, which sees centralisation of acute complex care, and the development of critical enablers needed to achieve implementation. However, incoherence emerges in implementation attributable to repeatedly changing governance and management structures. Conclusion Emergency and urgent care is a developing area. There are sustained efforts to develop a systems approach. Public opinion when expressed is often negative as service user involvement particularly in policy and health service development is piecemeal.

Background Diabetes is considered an exemplar of the challenges facing health systems including the need to reorganise chronic disease management from acute episodic treatment to planned integrated care. In Ireland, a central pillar of the plan for a national model of integrated diabetes care is the introduction of a number of integrated Diabetes Nurse Specialist (DNS) positions. Our aim was to conduct a systematic review to identify the role of the DNS as part of an improvement strategy and elucidate their involvement in facilitating integrated care. Methods A systematic search of primary intervention studies involving the DNS to improve diabetes care was conducted using PubMed, Medline, EMBASE, CINAHL and PsycINFO (2000–2014). English language studies, both quantitative and qualitative, were included where the improvement strategy was either DNS led, co-ordinated or delivered. Studies of routine or existing services were excluded. Two authors extracted data on study design, nature of the DNS role and involvement within the diabetes care teams. Studies were synthesised through a qualitative content analysis method using NVivo V.10 software. Results Eleven studies were eligible for inclusion, most of which were conducted in the Netherlands (n = 5) or the UK (n = 4). Seven domains of responsibility were identified: clinical practice (n = 6), disease control (n = 3), prescribing (n = 4), and guidance on self-care (n = 2), education (n = 5), prevention of complications (n = 3) and a liaison role (n = 4). In two studies, the DNS acted as a link between the hospital team and primary care providers. Referrals, part of the liaison role, involved not only GPs referring patients to the DNS but also the DNS referring patients to other health care professionals. The DNS consulted with the GP only if complications or problems arose with patient care. Few studies reported how the DNS role was integrated within the existing team of care providers. Discussion The clinical role of the DNS is well-defined through the use of care protocols. However, the liaison role between settings and providers is not as clear. This role needs to be delineated to avoid ambiguity and blurring of professional boundaries and to facilitate other health care professionals drawing on the expertise of the DNS.

Background Pre-Eclampsia is a multisystem disorder, which can affect both mother and child. It can lead to the development of long term morbidities such as chronic hypertension, increase the risk of hospitalisation and also accounts for a substantial proportion of maternal mortality. The only treatment for pre-eclampsia is delivery which involves increased monitoring during pregnancy. This has substantial health service use implications. However, to date, there has been minimal research examining health service use associated with pre-eclampsia. The aim is to compare health service use among women with and without pre-eclampsia using data from the Screening for Pregnancy Endpoints Study (SCOPE), an international multi-centre prospective study. Methods Cross-sectional analysis of data from the SCOPE study was conducted. SCOPE participants were healthy, nulliparous women with singleton pregnancies recruited between November 2004 and February 2011 in Cork, Ireland (n = 1774). Data were extracted on women with pre-eclampsia (n = 68), and a 10% random sample of women without pre-eclampsia (n = 171). Health service use indicators were divided into antenatal, perinatal and post-natal. Antenatal health service use included number of hospital visits, any hospital admissions, and number of scans. Perinatal indicators included maternal and infant length of hospital stay post-delivery, type of delivery, whether the mother was induced, if an episiotomy or an epidural was performed. Postpartum included admissions of the infant the Neonatal Intensive Care Unit (NICU). Results Preliminary results suggest that 44% (n = 30, 95% CI 32–56%]) of women with pre-eclampsia had a caesarean section compared to 25% (n = 43, 95% CI 19–32%]) of women without pre-eclampsia. Furthermore women with pre-eclampsia had longer average length of hospital stay with 24% (n = 16, 95% CI 13–34%]) staying an average of more than five days post-partum compared to 5% (n = 9, 95% CI 2–9%]) of women without pre-eclampsia. 28% (n = 19, 95% CI 17–39%]) of infants born to mothers with pre-eclampsia were admitted to the NICU compared to 9% (n = 16, 95% CI 5–14%]) of infants born to mothers without pre-eclampsia. Conclusion Preliminary results suggest increased obstetric intervention and health service use among women with pre-eclampsia which had resource implications for the health service. The results of this study will be used to estimate the direct health service costs of pre-eclampsia in the absence of current international data.

Background The Health Service Executive (HSE) has embarked on a series of regional system re-designs to radically change the organisation of urgent and emergency care delivery in Ireland, at a time when budgets and staff levels have been substantially reduced and there is growing awareness of problems with quality and safety. The general purpose of this initiative is to “develop integrated services across all stages of the care journey” with the goal of increasing efficiency and improving performance. Major changes initiated so far include the reconfiguration of acute hospital services and the introduction of ambulance bypass protocols. Our aim was to identify and describe the typology of models employed in re-designing urgent and emergency care services, with a specific focus on the use of evidence and resources. Methods Two qualitative methods were employed. A documentary analysis was conducted of current national and regional policy documents. Also, approximately 200 semi-structured interviews were conducted with key stakeholders providing urgent and emergency care, along with health service campaigners and local politicians and media, across eight different regions covering the whole of the country. Information from the documentary analysis and interviews was synthesised using NVivo software. Results Preliminary findings suggest that there are numerous policy initiatives developing in parallel. These are generally well aligned in principle but there is a substantial implementation gap across regions. As a consequence, system re-design to date has taken place in a non-uniform manner across the country with varying levels of implementation and provision of services. Four models have been identified that reflect the re-design of urgent and emergency care services in Ireland, namely: (1) system re-design within existing hospital networks; (2) system re-design to formalise and amalgamate individual hospital networks with current group structures; (3) system re-design to maintain academic relations; and (4) system re-design at planning stage. There are a number of overlaps between these models since this typology represents the continuum of system re-design programmes being implemented across the country, rather than discrete categories. Conclusion Implementing change in urgent and emergency care services is a complex process, guided by local as well as national considerations, resources and motivations. The results of this study will inform national and regional healthcare system planning on urgent and emergency care with the goal of increasing efficiency and improving performance.

Background Pharmacy claims data have been demonstrated to be specific and sensitive in identifying patients with diabetes. This study generates new up to date estimates of the prevalence and incidence of type 1 (T1DM) and type 2 diabetes mellitus (T2DM) in Ireland using the national pharmacy claims database. In the absence of a national diabetes register, this augments existing estimates based on survey data or modelling. Methods The Primary Care Reimbursement Services database houses data on all prescriptions filled in the Republic of Ireland on the main national health insurance programme, referred to as the General Medical Services (GMS) scheme. This scheme covers approximately 40% of the population on a means tested basis, with almost 100% of the over 70s represented due to different income thresholds. We used data from July 2011–December 2012. T1DM was classified as any individual under 45 years who used an insulin product (ATC A10A) and who had never used an oral/injectable hypo-glycaemic agent. T2DM was classified as any user of an oral/injectable anti-diabetic agent (ATC A10B), irrespective of insulin use and with no age restriction. Incidence of T1DM and T2DM was calculated by estimating the number of new users of A10A or A10B respectively, precluding prior use in a 6 month look back period. Prevalence was calculated using number of prevalent users divided by the age specific GMS eligible population. Results We used data from 1,799,285 individuals to calculate an incidence rate of 0.14% (95% CI 0.13–0.14) and a prevalence rate of 0.42% (95% CI 0.41–0.43) for T1DM. In the general GMS population, the incidence rate of T2DM was 0.90% (95% CI 0.88–0.91), while prevalence was estimated at 4.38% (95% CI 4.35–4.41). When stratified across 8 age groups ranging from Conclusion Our estimates are similar to prior estimates but provide a more up to date reference and are derived from a larger sample population, including almost all the over 70s population in Ireland. A limitation is that undiagnosed diabetes cannot be estimated. Further analyses will include sensitivity analyses for the length of look back period in estimating new users and age used to define TIDM. Indirect age standardisation will be used to calculate prevalence and incidence in the entire Irish population.

Background Overweight and obesity during pregnancy is associated with an increased risk of gestational diabetes mellitus (GDM), preeclampsia and macrosomia among other complications. Antenatal lifestyle interventions have been shown to be effective in this population however studies often fail to identify the mechanisms by which the intervention is expected to be effective. Our aim is to identify the barriers and enablers to behaviour change from the perspective of obese pregnant women and their healthcare providers (HCP), with a view to informing a lifestyle intervention to reduce the risk of GDM. Methods Semi-structured interviews are being conducted with a purposive sample of doctors and midwives recruited from a large academic maternity hospital in the Republic of Ireland (n = 1–15). A purposive sample of obese women at different stages of pregnancy will also be recruited from public and private antenatal clinics (nn = 1–15). The Framework approach is being used during analysis, drawing on the Theoretical Domains Framework (TDF). The TDF identifies 12 domains which can act as barriers or facilitators to behaviour change. Results Preliminary analysis of HCP interviews suggests that pregnancy is ‘a wake-up call’ for some women as the risks of obesity are made explicit. Social influences were identified as a potential facilitator; HCP suggested behaviour change was easier for pregnant women when supported by their partners or when partners also engaged in healthy lifestyle behaviours. Healthcare professionals identified the environmental context and resources as barriers, particularly the lack of dedicated obesity clinics and the limited access to dietetic services. Discussion Healthcare professionals believe pregnancy offers a window of opportunity to engage women in behaviour change as beliefs about consequences of overweight and obesity for the baby may trigger behaviour change in the pregnant woman. However, there are limited resources available to them to support women to make health behaviour changes.

Background and objective Ireland does not have a national strategy for diabetes management akin to policy frameworks developed in other European countries. In 2006, the Irish Health Service Executive (HSE) established an Expert Advisory Group for diabetes, to act ‘as the HSE’s primary source of operational policy and strategic advice9. The aim of this study is to examine the Diabetes Expert Advisory Group (EAG) process as an instrumental case study of policy formulation in the health service. Methods A case description was built through interviews and documentary analysis. Fifteen in-depth interviews were conducted with a purposive sample of EAG members. The topic guide was informed by three theories of policy formulation; Rational Model of Decision Making (1), Advocacy Coalition Framework (ACF) (2) and Multiple Streams Theory (3). Thematic analysis was conducted using the theoretical assumptions as analytical tools. NVIVO software was used for data management. Results Preliminary analysis suggests the EAG followed a sequential process; identifying priorities, developing recommendations and proposing a strategy for approval by the HSE. However the rational model of decision-making became less relevant as the process moved from approval to implementation. There was lack of clarity around what constituted a decision and who made decisions in the health system. ACF theory assumes ‘advocacy coalitions’ share ‘policy core beliefs’ although members may disagree about secondary beliefs. This fits with accounts of the EAG process; “I think we were all there with the same purpose but how we went about it, how the problem is going to be solved might be slightly different…” The economic recession could be considered an ‘external shock’ which constrained the resources available to the group and pushed implementation down the agenda. The Multiple Streams Theory identifies three streams in the policy arena (problem, policy, politics). By 2006 the problem of diabetes had been well established with an international evidence base informing the management of the illness (policy). However the political commitment (politics) to the EAG recommendations faded as the implications emerged; “in order to do it the way other countries do it, it is going to require investment. Our first report sketched out the sort of investment it might need and I think that just frightened them off.” Conclusions Different aspects of the policy formulation process were highlighted and hidden by applying an ‘alternative lens’ perspective (4). The story of the Diabetes EAG illuminates broader policy issues including the role of evidence in health policy, the impact of external events on decision making and the gap between decision-making and implementation.

Background The General Medical Services (GMS) scheme is a means tested public health insurance, covering approximately 40% of the Irish population. Eligibility for this scheme depends largely on income; however it is unknown how other demographic and socio-economic factors influence eligibility. We aimed to evaluate how demographic and socio-economic factors predicted GMS coverage from years 2006 (economic boom) to 2008 (start of recession) and 2010 (impact of austerity). Methods Cross-sectional data from the nationally representative EU Survey of Income and Living Conditions (EU-SILC) were used, n = 12,140 for 2006, n = 10,315 for 2008 and n = 8968 for 2010. Response rates were >77% for each year; missing data were generated by children. Variables are available on income, education, employment status, health status, private health insurance status, and multiple demographic factors (age, sex, marital status and nationality). The outcome variable was having GMS coverage or not. Logistic regression models were used to examine how the strength of predictors varied from year to year using R version 2.15.2. Results In univariate models, younger age (15–24 years and 25–49 years) and educational attainment predicted GMS status to a greater extent in 2010 than in 2006. The strength of unemployment as a predictor decreased over the study period, but this reduction was not significant (change in OR 1.210, 95% CI -3.411–2.940). Retired people were less likely to qualify for a medical card in 2010 than in 2006 (change in OR 12.260, 95% CI, 9.440–12.790). In multivariate models, only age and income remained predictive across the study period. For 15–24 years age category the OR increased each year, 2006 OR=0.021 (95% CI, 0.016–0.028), 2008 OR = 0.036 (95% CI, 0.019–0.070) and 2010 OR = 0.062 (95% CI, 0.032–0.120). For the 24–49 years age category in 2006 OR = 0.036 (95% CI, 0.028–0.045), in 2008 OR = 0.040 (95% CI, 0.023–0.070) and in 2010 OR = 0.078(95% CI, 0.045–0.135). While income was strongly predictive in each year, no yearly change in OR was observed. Conclusion Younger age categories increasingly predicted GMS status from 2006 through to 2010. This may be indicative of unemployment and falling income resulting from economic recession, however, unemployment did not appear as a significant predictor. Income was a consistent predictor each year. This is the first study to characterise population characteristics associated with GMS coverage. The results are timely given on-going and planned revisions to eligibility criteria as part of the phased introduction of universal health insurance.

Background To date estimates of the prevalence of diabetes in Ireland have been based on models of UK data. Since 2009 the International Expert Committee has recommended that the diagnosis of diabetes and pre-diabetes can be made on the basis of HbA1c levels. The objectives of this study are to estimate the prevalence of diabetes and pre-diabetes in a nationally representative sample of adults living in private households in Ireland and to assess whether the discrepancy between self-report and objective diabetes status is influenced by socio-demographic characteristics. Methods Estimates were based on a nationally representative sample of participants in the Survey of Lifestyles, Attitude and Nutrition (SLAN) whom provided a blood sample at the physical examination. Diabetes was diagnosed based on an HbA1C level ≥6.5% or self-report of occurrence of diabetes or reporting of diabetes medications. Pre-diabetes was diagnosed based on HbA1c level ≥5.7% and 2 test. A p-value of less than 0.05 was considered statistically significant. Results The overall response rate among eligible adults (18+ years) was 62% for the main survey (n=10,364) and 66% for the physical examination substudy (aged 45+, n=1202). Among the 1202 participants who underwent a physical examination, 8 were excluded because they did not complete the questions on diabetes history and 65 were excluded from the analysis because they did not have HbA1c measurements. Among the remaining 1132 participants, 54 had diagnosed diabetes and 34 had undiagnosed diabetes based on HbA1c levels. Based on the HbA1c threshold, prediabetes was found in 214 individuals. The overall prevalence of diabetes was 7.7% (95% CI 6.2–9.4) and of pre-diabetes was 18.7% (95% CI 16.5–21). Prevalence of both diabetes and pre-diabetes were higher among men than women. A logistic regression model was used to investigate risk factors for undiagnosed diabetes. Conclusion The prevalence of diabetes and pre-diabetes in this study is high. Pre-diabetes is a well-established risk factor for progression to diabetes and of cardiovascular disease. Despite efforts to increase awareness and screening for diabetes, some individuals with diabetes remain undiagnosed. Undiagnosed diabetes is highest in younger men (46–64 years). Increased efforts are required to improve detection of diabetes and pre-diabetes and thus, identify and manage this high-risk population.

Objective Health professionals are key players in the success or failure of quality management depending on their willingness to accept and adapt to changes in practice. The aim of this study was to explore GPs9 experiences of providing diabetes care and their thoughts on the factors affecting its development. Design Semi-structured qualitative interviews were conducted with GPs to explore their experience of care provision in Ireland, opinions on the factors influencing the development of care and their attitude to registration and audit. The topic guide was informed by the findings of a preceding national survey on the organisation of diabetes care. Analysis was conducted using a pragmatic approach drawing on the Framework method. Participants A purposive sample of 30 GPs was selected based on 3 sets of inclusion criteria; (a) location (rural/urban), (b) computerised/non-computerised practice, (c) single-handed/group practice. Results Preliminary analysis has identified both convergent and divergent themes. There were varying attitudes as to how diabetes care should be integrated between primary and secondary care settings. The locus of care varied across participant experiences from primary care-based management to supplementing hospital-led care. Lack of access to auxiliary services and resources were among the common barriers to an effective community-based diabetes service. Those GPs who have developed a structured approach to diabetes care tended to do so as a “labour of love”; most doing so without direct recompense. There were mixed attitudes towards the development of a national register with some questioning its use and benefit at a practice level. A number of GPs felt a national register should to be tailored to meet the needs of health professionals and patients, and not solely used as a research tool. There was ambivalence towards efforts to improve care based on previous experience in the Irish health setting. When asked about the future of diabetes care, GPs proposed regional diabetes management clinics and hoped for greater recognition of the contribution of general practice to diabetes care. Conclusion Preliminary findings suggest there is a typology of care models in existence in Ireland with varying levels of involvement by GPs and diverse access to services. There were tentative attitudes towards quality improvement initiatives including the establishment of a register suggesting a sense of inertia towards organisational change. Extending high quality care to all patients with diabetes can no longer rely solely on the interest of care providers and may require commitment systems-level change.

Background Accurate estimates of the burden of diabetes are essential for future planning and evaluation of services. In Ireland, there is no diabetes register and prevalence estimates vary. The aim of this review was to systematically identify and review studies reporting the prevalence of diabetes and complications among adults in Ireland between 1998 and 2015 and to examine trends in prevalence over time. Methods A systematic literature search was carried out using PubMed and Embase. Diabetes prevalence estimates were pooled by random-effects meta-analysis. Poisson regression was carried out using data from four nationally representative studies to calculate prevalence rates of doctor diagnosed diabetes between 1998 and 2015 and was also used to assess whether the rate of doctor diagnosed diabetes changed over time. Results Fifteen studies (eight diabetes prevalence and seven complication prevalence) were eligible for inclusion. In adults aged 18 years and over, the national prevalence of doctor diagnosed diabetes significantly increased from 2.2 % in 1998 to 5.2 % in 2015 (p trend ≤ 0.001). The prevalence of diabetes complications ranged widely depending on study population and methodology used (6.5–25.2 % retinopathy; 3.2–32.0 % neuropathy; 2.5-5.2 % nephropathy). Conclusions Between 1998 and 2015, there was a significant increase in the prevalence of doctor diagnosed diabetes among adults in Ireland. Trends in microvascular and macrovascular complications prevalence could not be examined due to heterogeneity between studies and the limited availability of data. Reliable baseline data are needed to monitor improvements in care over time at a national level. A comprehensive national diabetes register is urgently needed in Ireland. Electronic supplementary material The online version of this article (doi:10.1186/s12889-016-2818-2) contains supplementary material, which is available to authorized users.