Did the Celtic Tiger Decrease Socio-Economic Differentials in Perinatal Mortality in Ireland?

Irish perinatal mortality rates have been falling steadily for a number of decades but evidence from the 1980s showed pronounced differentials in mortality rates across socio-economic groups. Between 1995 and 2006 Irish gross national product increased from 60 per cent of the EU average to 110 per cent. Real incomes increased across the income distribution during this period but income inequality between the top and bottom income deciles increased marginally. This paper examines whether socio-economic differentials in Irish perinatal mortality rates changed between the 1980s and 2000s. This task is complicated by demographic change in Ireland since the 1980s and its interaction with the birth registration process. Overall perinatal mortality rates have fallen from 14 per 1,000 in 1984 to 7 per 1,000 in 2006. Without adjusting for demographic change, differentials between professional and unskilled/unemployed groups have decreased from 1.99 to 1.79. Adjusted estimates suggest the real differential has decreased to 1.88.

Did the Celtic Tiger Decrease Socio-Economic Differentials in Perinatal Mortality in Ireland? ESRI WP312. September 2009

Irish perinatal mortality rates have been falling steadily for a number of decades but evidence from the 1980s showed pronounced differentials in mortality rates across socio-economic groups. Between 1995 and 2007 Irish gross national product increased from 60 per cent of the EU average to 110 per cent. Real incomes increased across the income distribution during this period but income inequality between the top and bottom income deciles increased. This paper examines whether this increase in affluence led to an overall improvement in Irish perinatal mortality rates and the extent to which any improvement was shared across socio-economic groups. This task is complicated by demographic change in Ireland since the 1980s and its interaction with the birth registration process. Overall perinatal mortality rates have fallen from 14 per 1,000 in 1984 to 7 per 1,000 in 2006. Without adjusting for demographic change differentials between professional and unskilled/unemployed groups have decreased from 1.99 to 1.79. Adjusted estimates suggest the real differential has decreased to 1.88

Effectiveness of medicines review with web-based pharmaceutical treatment algorithms in reducing potentially inappropriate prescribing in older people in primary care: a cluster randomised trial (OPTI-SCRIPT study)

Background: Potentially inappropriate prescribing (PIP) is common and can result in increased morbidity, adverse drug events and hospitalisations. In 2007, 36% of Irish people aged 70 years or over received at least one potentially inappropriate prescription, with an associated expenditure of €45 million. This thesis documents the design, conduct, and evaluation of a cluster randomised controlled trial (RCT) in Irish primary care focused on reducing PIP in older patients (\u3e 70 years). Methods: The intervention development was guided by the Medical Research Council (MRC) framework for the development and evaluation of complex interventions. Literature and information from experts were combined to define the main components of the intervention which was then tested with five GPs during the pilot and evaluated using qualitative interviews During the OPTI-SCRIPT trial 21 practices and 196 patients were allocated to intervention (11 practices, 99 patients) or control (10 practices, 97 patients) using minimisation. Intervention participants received a multifaceted intervention incorporating academic detailing with a pharmacist, medicines review with web-based pharmaceutical treatment algorithms that provided recommended alternative treatment options, and tailored patient information leaflets. Control practices delivered usual care and received simple patient-level PIP feedback. Primary outcomes were the proportion of participants with PIP and the mean number of potentially inappropriate prescriptions per group. Secondary outcomes included drug-specific outcomes, well-being and beliefs about medication. Routinely collected national prescribing data were analysed as a contemporary national comparison. During the mixed methods process evaluation, semi-structured interviews with participating GPs and a purposive sample of patients in the intervention group were conducted. Interviews were transcribed verbatim and the data analysed using a thematic analysis. Data were also collected from practice questionnaires, website activity and researcher logs. Results: All 21 practices and 190 patients were followed up. At follow-up there was a statistically significant difference between groups. For patients in the intervention group, the odds of not having PIP were 3 times higher than the odds in the control group (OR 3.1 95% Cl 1.4, 6.5). The average PIP in the intervention group was also significantly lower than control (0.70 v 1.19, p=0.004). In the control group, the incidence rate for PIP was 1.42 times the incidence rate for the intervention group. The intervention had a statistically significant effect in reducing proton pump inhibitor prescribing but not on the other secondary outcomes. Exploratory analysis of national prescribing data highlighted that PIP was increasing during the study period and that the control group did not act differently to national trends. The process evaluation highlighted that requiring GPs to be involved in patient recruitment was time consuming. GPs received a standardised academic detailing session but delivered the intervention differently. Patient information leaflets were not used at all. Participants identified important barriers and facilitators to the future effectiveness of such an intervention, with time being a barrier reported by both GPs and patients. Overall, the intervention was positively received with participants referring to the value of medication reviews to improve prescribing practices and reduce unnecessary medications in older patients. Conclusions: The study found that a multifaceted intervention incorporating academic detailing with a pharmacist, medicines review with web-based pharmaceutical treatment algorithms that provide recommended alternative treatment options, but not tailored patient information leaflets, was effective in reducing PIP, particularly for proton pump inhibitors, but had no effect on other secondary outcomes. The process evaluation highlighted that the intervention was acceptable to the majority of participants

Gone for good? An online survey of emigrant health professionals using Facebook as a recruitment tool

Background Health professionals, particularly doctors, nurses and midwives, are in high demand worldwide. Therefore, it is important to assess the future plans and likelihood of return of emigrating health professionals. Nevertheless, health professionals are, by definition, a difficult population to track/survey. This exploratory study reports on the migration intentions of a sample of doctors, nurses and midwives who had emigrated from Ireland, a high-income country which has experienced particularly high outward and inward migration of health professionals since the year 2000. Methods Health professionals who had emigrated from Ireland were identified via snowball sampling through Facebook and invited to complete a short online survey composed of closed and open response questions. Results A total of 388 health professionals (307 doctors, 73 nurses and 8 midwives) who had previously worked in Ireland completed the survey. While over half had originally intended to spend less than 5 years in their destination country at the time of emigration, these intentions changed over time, with the desire to remain abroad on a permanent basis increasing from 10 to 34 % of doctor respondents. Only a quarter of doctors and a half of nurses and midwives intended to return to practice in Ireland in the future. Conclusions The longer health professionals remain abroad, the less likely they are to return to their home countries. Countries should focus on the implementation of retention strategies if the ‘carousel’ of brain drain is to be interrupted. This would allow source countries to benefit from their investments in training health professionals, rather than relying on international recruitment to meet health system staffing needs. Improved data collection systems are also needed to track the migratory patterns and changing intentions of health professionals. Meanwhile, social networking platforms offer alternative methods of filling this information gap

‘Potentially inappropriate or specifically appropriate?’ Qualitative evaluation of general practitioners views on prescribing, polypharmacy and potentially inappropriate prescribing in older people

BACKGROUND: Potentially inappropriate prescribing (PIP) is common in older people in primary care, as evidenced by a significant body of quantitative research. However, relatively few qualitative studies have investigated the phenomenon of PIP and its underlying processes from the perspective of general practitioners (GPs). The aim of this paper is to explore qualitatively, GP perspectives regarding prescribing and PIP in older primary care patients. METHOD: Semi-structured qualitative interviews were conducted with GPs participating in a randomised controlled trial (RCT) of an intervention to decrease PIP in older patients (≥70 years) in Ireland. Interviews were conducted with GP participants (both intervention and control) from the OPTI-SCRIPT cluster RCT as part of the trial process evaluation between January and July 2013. Interviews were conducted by one interviewer and audio recorded. Interviews were transcribed verbatim and a thematic analysis was conducted. RESULTS: Seventeen semi-structured interviews were conducted (13 male; 4 female). Three main, inter-related themes emerged (complex prescribing environment, paternalistic doctor-patient relationship, and relevance of PIP concept). Patient complexity (e.g. polypharmacy, multimorbidity), as well as prescriber complexity (e.g. multiple prescribers, poor communication, restricted autonomy) were all identified as factors contributing to a complex prescribing environment where PIP could occur, as was a paternalistic-doctor patient relationship. The concept of PIP was perceived to be of variable usefulness to GPs and the criteria to measure it may be at odds with the complex processes of prescribing for this patient population. CONCLUSIONS: Several inter-related factors contributing to the occurrence of PIP were identified, some of which may be amenable to intervention. Improvement strategies focused on improved management of polypharmacy and multimorbidity, and communication across primary and secondary care could result in substantial improvements in PIP. TRIAL REGISTRATION: Current controlled trials ISRCTN4169400

Diagnosing malignant melanoma in ambulatory care: a systematic review of clinical prediction rules.

OBJECTIVES: Malignant melanoma has high morbidity and mortality rates. Early diagnosis improves prognosis. Clinical prediction rules (CPRs) can be used to stratify patients with symptoms of suspected malignant melanoma to improve early diagnosis. We conducted a systematic review of CPRs for melanoma diagnosis in ambulatory care. DESIGN: Systematic review. DATA SOURCES: A comprehensive search of PubMed, EMBASE, PROSPERO, CINAHL, the Cochrane Library and SCOPUS was conducted in May 2015, using combinations of keywords and medical subject headings (MeSH) terms. STUDY SELECTION AND DATA EXTRACTION: Studies deriving and validating, validating or assessing the impact of a CPR for predicting melanoma diagnosis in ambulatory care were included. Data extraction and methodological quality assessment were guided by the CHARMS checklist. RESULTS: From 16 334 studies reviewed, 51 were included, validating the performance of 24 unique CPRs. Three impact analysis studies were identified. Five studies were set in primary care. The most commonly evaluated CPRs were the ABCD, more than one or uneven distribution of Colour, or a large (greater than 6 mm) Diameter (ABCD) dermoscopy rule (at a cut-point of \u3e4.75; 8 studies; pooled sensitivity 0.85, 95% CI 0.73 to 0.93, specificity 0.72, 95% CI 0.65 to 0.78) and the 7-point dermoscopy checklist (at a cut-point of ≥1 recommending ruling in melanoma; 11 studies; pooled sensitivity 0.77, 95% CI 0.61 to 0.88, specificity 0.80, 95% CI 0.59 to 0.92). The methodological quality of studies varied. CONCLUSIONS: At their recommended cut-points, the ABCD dermoscopy rule is more useful for ruling out melanoma than the 7-point dermoscopy checklist. A focus on impact analysis will help translate melanoma risk prediction rules into useful tools for clinical practice

A process evaluation of a cluster randomised trial to reduce potentially inappropriate prescribing in older people in primary care (OPTI-SCRIPT study)

BACKGROUND: The OPTI-SCRIPT cluster randomised controlled trial (RCT) found that a three-phase multifaceted intervention including academic detailing with a pharmacist, GP-led medicines reviews, supported by web-based pharmaceutical treatment algorithms, and tailored patient information leaflets, was effective in reducing potentially inappropriate prescribing (PIP) in Irish primary care. We report a process evaluation exploring the implementation of the intervention, the experiences of those participating in the study and lessons for future implementation. METHODS: The OPTI-SCRIPT trial included 21 GP practices and 196 patients. The process evaluation used mixed methods. Quantitative data were collected from all GP practices and semi-structured interviews were conducted with GPs from intervention and control groups, and a purposive sample of patients from the intervention group. All interviews were transcribed verbatim and analysed using a thematic analysis. RESULTS: Despite receiving a standardised academic detailing session, intervention delivery varied among GP practices. Just over 70 % of practices completed medicines review as recommended with the patient present. Only single-handed practices conducted reviews without patients present, highlighting the influence of practice characteristics and resources on variation. Medications were more likely to be completely stopped or switched to another more appropriate medication when reviews were conducted with patients present. The patient information leaflets were not used by any of the intervention practices. Both GP (32 %) and patient (40 %) recruitment rates were modest. For those who did participate, overall, the experience was positively viewed, with GPs and patients referring to the value of medication reviews to improve prescribing and reduce unnecessary medications. Lack of time in busy GP practices and remuneration were identified as organisational barriers to future implementation. CONCLUSIONS: The OPTI-SCRIPT intervention was positively viewed by both GPs and patients, both of whom valued the study’s objectives. Patient information leaflets were not a successful component of the intervention. Academic detailing and medication reviews are important components in changing PIP, and having patients present during the review process seems to be a more effective approach for decreasing PIP. TRIAL REGISTRATION: Current controlled trials ISRCTN41694007. Registered on 21 March 2012

Beliefs about prescribed medication among older patients with polypharmacy: a mixed methods study in primary care

Background: Polypharmacy (≥5 medications) is common in older patients and is associated with adverse outcomes. Patients’ beliefs about medication can influence their expectations for medication, adherence, and willingness to deprescribe. Few studies have examined beliefs about prescribed medication among older patients with polypharmacy in primary care.Aim: To explore medication-related beliefs in older patients with polypharmacy and factors that might influence beliefs.Design and setting: A mixed methods study utilising data from a randomised controlled trial aiming to decrease potentially inappropriate prescribing in older patients (≥70 years) in Ireland.Method: Beliefs were assessed quantitatively and qualitatively. Participants completed the Beliefs about Medicines Questionnaire by indicating their degree of agreement with individual statements about medicines on a 5-point Likert scale. Semi-structured qualitative interviews were conducted with a purposive sample of participants. Interviews were transcribed verbatim and a thematic analysis conducted. Quantitative and qualitative data were analysed separately and triangulated during the interpretation stage.Results: In total, 196 patients were included (mean age 76.7 years, SD 4.9, 54% male), with a mean of 9.5 (SD 4.1) medications per patient. The majority (96.3%) believed strongly in the necessity of their medication, while 33.9% reported strong concerns. Qualitative data confirmed these coexisting positive and negative attitudes to medications and suggested the importance of patients’ trust in GPs in establishing positive beliefs and potential willingness to deprescribe.Conclusion: Participants reported strong beliefs in medications with coexisting positive and negative attitudes. The doctor–patient relationship may have influenced beliefs and attitudes towards medicines, highlighting the importance of strong doctor–patient relationships, which need to be considered in the context of deprescribin

Sustained effectiveness of a multifaceted intervention to reduce potentially inappropriate prescribing in older patients in primary care (OPTI-SCRIPT study)

BACKGROUND: Potentially inappropriate prescribing (PIP) is common in older people in primary care and can result in increased morbidity, adverse drug events and hospitalisations. We previously demonstrated the success of a multifaceted intervention in decreasing PIP in primary care in a cluster randomised controlled trial (RCT). OBJECTIVE: We sought to determine whether the improvement in PIP in the short term was sustained at 1-year follow-up. METHODS: A cluster RCT was conducted with 21 GP practices and 196 patients (aged ≥70) with PIP in Irish primary care. Intervention participants received a complex multifaceted intervention incorporating academic detailing, medicine review with web-based pharmaceutical treatment algorithms that provide recommended alternative treatment options, and tailored patient information leaflets. Control practices delivered usual care and received simple, patient-level PIP feedback. Primary outcomes were the proportion of patients with PIP and the mean number of potentially inappropriate prescriptions at 1-year follow-up. Intention-to-treat analysis using random effects regression was used. RESULTS: All 21 GP practices and 186 (95 %) patients were followed up. We found that at 1-year follow-up, the significant reduction in the odds of PIP exposure achieved during the intervention was sustained after its discontinuation (adjusted OR 0.28, 95 % CI 0.11 to 0.76, P = 0.01). Intervention participants had significantly lower odds of having a potentially inappropriate proton pump inhibitor compared to controls (adjusted OR 0.40, 95 % CI 0.17 to 0.94, P = 0.04). CONCLUSION: The significant reduction in the odds of PIP achieved during the intervention was sustained after its discontinuation. These results indicate that improvements in prescribing quality can be maintained over time. TRIAL REGISTRATION: Current controlled trials ISRCTN41694007

‘Potentially inappropriate or specifically appropriate?’ Qualitative evaluation of general practitioners views on prescribing, polypharmacy and potentially inappropriate prescribing in older people

Background: Potentially inappropriate prescribing (PIP) is common in older people in primary care, as evidenced by a significant body of quantitative research. However, relatively few qualitative studies have investigated the phenomenon of PIP and its underlying processes from the perspective of general practitioners (GPs). The aim of this paper is to explore qualitatively, GP perspectives regarding prescribing and PIP in older primary care patients. Method: Semi-structured qualitative interviews were conducted with GPs participating in a randomised controlled trial (RCT) of an intervention to decrease PIP in older patients (≥70 years) in Ireland. Interviews were conducted with GP participants (both intervention and control) from the OPTI-SCRIPT cluster RCT as part of the trial process evaluation between January and July 2013. Interviews were conducted by one interviewer and audio recorded. Interviews were transcribed verbatim and a thematic analysis was conducted. Results: Seventeen semi-structured interviews were conducted (13 male; 4 female). Three main, inter-related themes emerged (complex prescribing environment, paternalistic doctor-patient relationship, and relevance of PIP concept). Patient complexity (e.g. polypharmacy, multimorbidity), as well as prescriber complexity (e.g. multiple prescribers, poor communication, restricted autonomy) were all identified as factors contributing to a complex prescribing environment where PIP could occur, as was a paternalistic-doctor patient relationship. The concept of PIP was perceived to be of variable usefulness to GPs and the criteria to measure it may be at odds with the complex processes of prescribing for this patient population. Conclusions: Several inter-related factors contributing to the occurrence of PIP were identified, some of which may be amenable to intervention. Improvement strategies focused on improved management of polypharmacy and multimorbidity, and communication across primary and secondary care could result in substantial improvements in PIP. Trial registration: Current controlled trials ISRCTN4169400