Effect of rurality on patients’ satisfaction with out of hours care provided by a family doctor cooperative’

Introduction: Reacting to demand and supply pressures, European healthcare systems are undergoing significant structural changes to the organisation and delivery of out of hours care. Such pressures are of particular concern to rural practice. Although patient satisfaction with out of hours care has been extensively studied, the effect of rurality on satisfaction levels has not, to our knowledge, been previously examined. Objective: To investigate whether rurality has an influence on patient satisfaction with out of hours care provided by a family doctor co-operative. Methods: All patients contacting the service over a designated 24-day period were forwarded a postal questionnaire. Patients' satisfaction was measured using a version of the McKinley questionnaire, and rurality, by subjective patient assessment, distance from treatment centre or previous rota cover. Results: The response rate was 55% (531/966). Overall satisfaction levels were high with 88% of patients rating the service as either good or excellent. 47.8% of respondents perceived themselves as living in a town, 14.6% as living in a village, and 37.6% as living in the countryside. Perceived rurality, distance from treatment centre or previous rota cover did not significantly affect satisfaction levels. Conclusion: Family doctor co-operatives have significantly altered the way out of hours care is delivered. Patients from rural areas are equally satisfied with the provision of out of hours care by co-operatives, as urban patients. Extension of co-operatives to rural areas need not be constrained by concerns regarding decreased patient satisfaction

Additional file 2: of Development of a complex intervention to promote appropriate prescribing and medication intensification in poorly controlled type 2 diabetes mellitus in Irish general practice

Linking intervention functions to individual behaviour change techniques to help intervention content development. (DOCX 69 kb

Improving risk factor management for patients with poorly controlled type 2 diabetes: a systematic review of healthcare interventions in primary care and community settings

Objectives Poorly controlled type 2 diabetes mellitus (T2DM) is a major international health problem. Our aim was to assess the effectiveness of healthcare interventions, specifically targeting patients with poorly controlled T2DM, which seek to improve glycaemic control and cardiovascular risk in primary care settings. Design Systematic review. Setting Primary care and community settings. Included studies Randomised controlled trials (RCTs) targeting patients with poor glycaemic control were identified from Pubmed, Embase, Web of Science, Cochrane Library and SCOPUS. Poor glycaemic control was defined as HbA1c over 59 mmol/mol (7.5%). Interventions Interventions were classified as organisational, patient-oriented, professional, financial or regulatory. Outcomes Primary outcomes were HbA1c, blood pressure and lipid control. Two reviewers independently assessed studies for eligibility, extracted data and assessed study quality. Meta-analyses were undertaken where appropriate using random-effects models. Subgroup analysis explored the effects of intervention type, baseline HbA1c, study quality and study duration. Meta-regression analyses were undertaken to investigate identified heterogeneity. Results Forty-two RCTs were identified, including 11 250 patients, with most undertaken in USA. In general, studies had low risk of bias. The main intervention types were patient-directed (48%) and organisational (48%). Overall, interventions reduced HbA1c by −0.34% (95% CI −0.46% to −0.22%), but meta-analyses had high statistical heterogeneity. Subgroup analyses suggested that organisational interventions and interventions on those with baseline HbA1c over 9.5% had better improvements in HbA1c. Meta-regression analyses suggested that only interventions on those with population HbA1c over 9.5% were more effective. Interventions had a modest improvement of blood pressure and lipids, although baseline levels of control were generally good. Conclusions This review suggests that interventions for T2DM, in primary care, are better targeted at individuals with very poor glycaemic control and that organisational interventions may be more effective

Additional file 1: of Development of a complex intervention to promote appropriate prescribing and medication intensification in poorly controlled type 2 diabetes mellitus in Irish general practice

Linking intervention functions to the relevant COM-B components from the behavioural diagnosis, in step 5 of the BCW.(DOCX 72 kb

Using postal questionnaires to evaluate physical activity and diet behaviour change: case study exploring implications of valid responder characteristics in interpreting intervention outcomes.

BACKGROUND: Patient reported outcome measures (PROMs) are used to evaluate lifestyle interventions but little is known about differences between patients returning valid and invalid responses, or of potential for bias in evaluations. We aimed to examine the characteristics of patients who returned valid responses to lifestyle questionnaires compared to those whose responses were invalid for evaluating lifestyle change. METHODS: We conducted a secondary data analysis from the SPHERE Study, a trial of an intervention to improve outcomes for patients with coronary heart disease in primary care. Postal questionnaires were used to assess physical activity (Godin) and diet (DINE) among study participants at baseline and 18 month follow-up. Three binary response variables were generated for analysis: (1) valid Godin score; (2) valid DINE Fibre score; and (3) valid DINE Total Fat score. Multivariate analysis comprised generalised estimating equation regression to examine the association of patients' characteristics with their return of valid responses at both timepoints. RESULTS: Overall, 92.1% of participants (832/903) returned questionnaires at both baseline and 18 months. Relatively fewer valid Godin scores were returned by those who left school aged(36.5%) than aged 18 and over (50.5%), manual workers (39.5%) than non-manual (49.5%) and those with an elevated cholesterol (>5 mmol) (34.7%) than those with a lower cholesterol (44.4%) but multivariate analysis identified that only school leaving age (p = 0.047) was of statistical significance.Relatively fewer valid DINE scores were returned by manual than non-manual workers (fibre: 80.8% v 86.8%; fat: 71.2% v 80.0%), smokers (fibre: 72.6% v 84.7%; fat: 67.5% v 76.9%), patients with diabetes (fibre: 75.9% v 82.9%; fat: 66.9% v 75.8%) and those with cholesterol >5 mmol (fat: 68.2% v 76.2%) but multivariate analysis showed statistical significance only for smoking (fibre: p = 0.013; fat: p = 0.045), diabetes (fibre: p = 0.039; fat: p = 0.047), and cholesterol (fat: p = 0.039). CONCLUSIONS: Our findings illustrate the importance of detailed reporting of research methods, with clear information about response rates, respondents and valid outcome data. Outcome measures which are relevant to a study population should be chosen carefully. The impact of methods of outcome measurement and valid response rates in evaluating healthcare requires further study.</p

Health professional-delivered obesity prevention interventions during the first 1,000 days: a systematic review of external validity reporting.

Background: Childhood obesity prevention interventions delivered by health professionals during the first 1,000 days show some evidence of effectiveness, particularly in relation to behavioural outcomes. External validity refers to how generalisable interventions are to populations or settings beyond those in the original study. The degree to which external validity elements are reported in such studies is unclear however. This systematic review aimed to determine the extent to which childhood obesity interventions delivered by health professionals during the first 1,000 days report on elements that can be used to inform generalizability across settings and populations. Methods: Eligible studies meeting study inclusion and exclusion criteria were identified through a systematic review of 11 databases and three trial registers. An assessment tool based on the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework was used to assess the external validity of included studies. It comprised five dimensions: reach and representativeness of individuals, reach and representativeness of settings, implementation and adaptation, outcomes for decision making maintenance and/or institutionalisation. Two authors independently assessed the external validity of 20% of included studies; discrepancies were resolved, and then one author completed assessments of the remaining studies. Results: In total, 39 trials involving 46 interventions published between 1999 and 2019 were identified. The majority of studies were randomized controlled trials (n=24). Reporting varied within and between dimensions. External validity elements that were poorly described included: representativeness of individuals and settings, treatment receipt, intervention mechanisms and moderators, cost effectiveness, and intervention sustainability and acceptability. Conclusions: Our review suggests that more emphasis is needed on research designs that consider generalisability, and the reporting of external validity elements in early life childhood obesity prevention interventions. Important gaps in external validity reporting were identified that could facilitate decisions around the translation and scale-up of interventions from research to practice. Registration: PROSPERO CRD42016050793 03/11/16

Supporting self-management and clinic attendance in young adults with type 1 diabetes: development of the D1 now intervention

Background: Self-management of type 1 diabetes (T1D) is complex and can be particularly challenging for young adults. This is reflected in the high blood glucose values and rates of clinic non-attendance in this group. There is a gap for a theory-based intervention informed by key stakeholder opinions to support and improve self management in young adults with T1D. Purpose: The aim of the work was to systematically co-develop an evidence-based and stakeholder-led intervention to support self-management and clinic engagement in young adults living with T1D in Ireland. Co-development was led by the Young Adult Panel. Methods: The Behaviour Change Wheel was used to guide the development. Five evidence sources were used to inform the process. An iterative co-design process was used with the Young Adult Panel. Initial intervention components were refined and feasibility tested using qualitative methods. Results: Environmental restructuring, education and training were selected as appropriate intervention functions. The co-design process, along with qualitative refinement and feasibility work, led to the final intervention content which consisted of 17 behaviour change techniques. The final D1 Now intervention consists of three components: a support worker, an agenda setting tool and an interactive messaging service. Conclusions: The D1 Now intervention is now at pilot evaluation stage. Its transparent and systematic development will facilitate evaluation and future replications

Supporting care for suboptimally controlled type 2 diabetes mellitus in general practice with a clinical decision support system: a mixed methods pilot cluster randomised trial.

Objectives: We developed a complex intervention called DECIDE (ComputeriseD dECisIonal support for suboptimally controlleD typE 2 Diabetes mellitus in Irish General Practice) which used a clinical decision support system to address clinical inertia and support general practitioner (GP) intensification of treatment for adults with suboptimally controlled type2 diabetes mellitus (T2DM). The current study explored the feasibility and potential impact of DECIDE.Design: A pilot cluster randomised controlled trial. Setting Conducted in 14 practices in Irish General Practice. Participants The DECIDE intervention was targeted at GPs. They applied DECIDE to patients with suboptimally controlled T2DM, defined as a glycated haemoglobin (HbA1c) ≥70 mmol/mol and/or blood pressure ≥150/95 mmHg.Intervention: The intervention incorporated training and a web-based clinical decision support system which supported; (i) medication intensification actions; and (ii) non-pharmacological actions to support care. Control practices delivered usual care. Primary and secondary outcome measures Feasibility and acceptability was determined using thematic analysis of semi-structured interviews with GPs, combined with data from the DECIDE website. Clinical outcomes included HbA1c, medication intensification, blood pressure and lipids.Results: We recruited 14 practices and 134 patients. At 4-month follow-up, all practices and 114 patients were followed up. GPs reported finding decision support helpful navigating increasingly complex medication algorithms. However, the majority of GPs believed that the target patient group had poor engagement with GP and hospital services for a range of reasons. At follow-up, there was no difference in glycaemic control (-3.6 mmol/mol (95% CI -11.2 to 4.0)) between intervention and control groups or in secondary outcomes including, blood pressure, total cholesterol, medication intensification or utilisation of services. Continuation criteria supported proceeding to a definitive randomised trial with some modifications.Conclusion: The DECIDE study was feasible and acceptable to GPs but wider impacts on glycaemic and blood pressure control need to be considered for this patient population going forward. Trial registration number: ISRCTN69498919</div

Contraceptive users in the study (n = 18).

<p>Contraceptive users in the study (n = 18).</p

Interview topic guide.

<p>Interview topic guide.</p