Spatial Variation in General Medical Services Income in Dublin General Practitioners

The general medical services (GMS) scheme provides care free at the point of use for the 30% most economically deprived section of the population and the elderly. Almost all people of over-70-year olds are eligible for the GMS scheme potentially directing resources away from those most in need. The aim of this study is to analyse the relationship between practice GMS income and deprivation amongst Dublin-based general practitioners (GPs). The practice GMS income in Dublin was analysed in relation to practice characteristics including the number of GPs, catchment area population, proportion of over-70-year olds in the catchment area, catchment deprivation, number of GMS GPs within 2 km, and average GMS practice income within 2 km. Practice GMS income was highest in deprived areas but is also a valuable source of income in the least deprived areas. The capitation rate for over-70-year olds provides an incentive for GPs to locate in affluent areas and potentially directs resources away from those in greater need

Suppression of residual single-photon absorption relative to two-photon absorption in high finesse planar microcavities

Suppression of residual single-photon absorption (SPA) relative to two-photon absorption (TPA) in a high finesse GaAs planar microcavity is explored. The TPA photocurrent becomes larger than the SPA photocurrent as long as the incident continuous-wave optical power exceeds 0.09 mW. An optical power of 5 mW would be required if the relative SPA suppression did not exist

Changing illness perceptions in patients with poorly controlled type 2 diabetes, a randomised controlled trial of a family-based intervention: protocol and pilot study

<p>Abstract</p> <p>Background</p> <p>This paper presents the pilot study and protocol for a randomised controlled trial to test the effectiveness of a psychological, family-based intervention to improve outcomes in those with poorly controlled type 2 diabetes. The intervention has been designed to change the illness perceptions of patients with poorly controlled type 2 diabetes, and their family members. It is a complex psychological intervention, developed from the Self-Regulatory Model of Illness Behaviour. The important influence the family context can have in psychological interventions and diabetes management is also recognised, by the inclusion of patients' family members.</p> <p>Methods/design</p> <p>We aim to recruit 122 patients with persistently poorly controlled diabetes. Patients are deemed to have persistent poor control when at least two out of their last three HbA1c readings are 8.0% or over. Patients nominate a family member to participate with them, and this patient/family member dyad is randomly allocated to either the intervention or control group. Participants in the control group receive their usual care. Participants in the intervention group participate, with their family members, in three intervention sessions. Sessions one and two are delivered in the participant's home by a health psychologist. Session one takes place approximately one week after session two, with the third session, a follow-up telephone call, one week later. The intervention is based upon clarifying the illness perceptions of both the patient and the family member, examining how they influence self-management behaviours, improving the degree of similarity of patient and family member perceptions in a positive direction and developing personalized action plans to improve diabetes management.</p> <p>Discussion</p> <p>This study is the first of its kind to incorporate the evidence from illness perceptions research into developing and applying an intervention for people with poorly controlled diabetes and their families. This study also acknowledges the important role of family members in effective diabetes care.</p> <p>Trial registration</p> <p>ISRCTN62219234</p

Psychological Family Intervention for Poorly Controlled Type 2 Diabetes

OBJECTIVE: To evaluate the effectiveness of a psychological, family-based intervention to improve diabetes-related outcomes in patients with poorly controlled type 2 diabetes. METHODS: This study was a randomized controlled trial of a psychological family-based intervention targeted at individuals with poorly controlled type 2 diabetes. Recruitment and follow-up occurred at specialist diabetes clinics. Patients were randomly allocated to an intervention group (n=60) or a control group (n=61). Poor control was defined as at least 2 of the patient's last 3 glycated hemoglobin (A1C) readings at >8.0%. The intervention consisted of 2 sessions delivered by a health psychologist to the patient and a family member in the patient's home, with a third session involving a 15-minute follow-up telephone call. RESULTS: At 6-month follow-up, the intervention group reported significantly lower mean A1C levels than the control group (8.4% [SD=0.99%] vs 8.8% [SD=1.36%]; P=.04). The intervention was most effective in those with the poorest control at baseline (A1C>9.5%) (intervention 8.7% [SD=1.16%, n=15] vs control 9.9% [SD=1.31%, n=15]; P=.01). The intervention group also reported statistically significant improvements in beliefs about diabetes, psychological well-being, diet, exercise, and family support. CONCLUSIONS: After participating in a family-based intervention targeting negative and/or inaccurate illness perceptions, patients with poorly controlled type 2 diabetes showed improvements in A1C levels and other outcomes. Our results suggest that adding a psychological, family-based component to usual diabetes care may help improve diabetes management

Psychological Family Intervention for Poorly Controlled Type 2 Diabetes

OBJECTIVE: To evaluate the effectiveness of a psychological, family-based intervention to improve diabetes-related outcomes in patients with poorly controlled type 2 diabetes. METHODS: This study was a randomized controlled trial of a psychological family-based intervention targeted at individuals with poorly controlled type 2 diabetes. Recruitment and follow-up occurred at specialist diabetes clinics. Patients were randomly allocated to an intervention group (n=60) or a control group (n=61). Poor control was defined as at least 2 of the patient's last 3 glycated hemoglobin (A1C) readings at >8.0%. The intervention consisted of 2 sessions delivered by a health psychologist to the patient and a family member in the patient's home, with a third session involving a 15-minute follow-up telephone call. RESULTS: At 6-month follow-up, the intervention group reported significantly lower mean A1C levels than the control group (8.4% [SD=0.99%] vs 8.8% [SD=1.36%]; P=.04). The intervention was most effective in those with the poorest control at baseline (A1C>9.5%) (intervention 8.7% [SD=1.16%, n=15] vs control 9.9% [SD=1.31%, n=15]; P=.01). The intervention group also reported statistically significant improvements in beliefs about diabetes, psychological well-being, diet, exercise, and family support. CONCLUSIONS: After participating in a family-based intervention targeting negative and/or inaccurate illness perceptions, patients with poorly controlled type 2 diabetes showed improvements in A1C levels and other outcomes. Our results suggest that adding a psychological, family-based component to usual diabetes care may help improve diabetes management

Multimorbidity in younger deprived patients: An exploratory study of research and service implications in general practice

<p>Abstract</p> <p>Background</p> <p>Multimorbidity has been defined as the co-existence of two or more chronic conditions. It has a profound impact on both the individuals affected and on their use of healthcare services. The limited research to date has focused on its epidemiology rather than the development of interventions to improve outcomes in multimorbidity patients, particularly for patients aged less than 65 years. Potential barriers to such research relate to methods of disease recording and coding and examination of the process of care. We aimed to assess the feasibility of identifying younger individuals with multimorbidity at general practice level and to explore the effect of multimorbidity on the type and volume of health care delivered. We also describe the barriers encountered in attempting to carry out this exploratory research.</p> <p>Methods</p> <p>Cross sectional survey of GP records in two large urban general practices in Dublin focusing on poorer individuals with at least three chronic conditions and aged between 45 and 64 years.</p> <p>Results</p> <p>92 patients with multimorbidity were identified. The median number of conditions was 4 per patient. Individuals received a mean number of 7.5 medications and attended a mean number of GP visits of 11.3 in the 12 months preceding the survey. Barriers to research into multimorbidity at practice level were identified including difficulties relating to GP clinical software; variation in disease coding; assessment of specialist sector activity through the GP-specialist communications and assessment of the full scale of primary care activity in relation to other disciplines and other types of GP contacts such as home visits and telephone contacts.</p> <p>Conclusion</p> <p>This study highlights the importance of multimorbidity in general practice and indicates that it is feasible to identify younger patients with multimorbidity through their GP records. This is a first step towards planning a clinical intervention to improve outcomes for such patients in primary care.</p

Fibrotic interstitial lung disease - palliative care needs:a World-Café qualitative study

Objectives: The importance of palliative care in those with advanced fibrotic interstitial lung diseases (F-ILD) is recognised, but the palliative care requirements of patients and caregivers affected by F-ILD regardless of disease course are not established. We set out to explore this and identify optimal solutions in meeting the needs of a F-ILD population in Ireland. Methods: Implementing a World-Café qualitative research approach, we captured insights evolving, iteratively in interactive small group discussions in response to six predefined topics on palliative care and planning for the future. Thirty-nine stakeholders participated in the World-Café including 12 patients, 13 caregivers, 9 healthcare professionals, 4 industry representatives and 1 representative of the clergy. Results: Palliative care emerged as fundamental to the care and treatment of F-ILDs, regardless of disease progression. Unmet palliative care needs were identified as psychological and social support, disease education, inclusion of caregivers and practical/legal advice for disease progression and end-of-life planning. Participants identified diagnosis as a particularly distressing time for patients and families. They called for the introduction of palliative care discussions at this early-stage alongside improvements in integrated care, specifically increasing the involvement of primary care practitioners in referrals to palliative services. Conclusion: Patients and caregivers need discussions on palliative care associated with F-ILD to be included at the point of diagnosis. This approach may address persisting inadequacies in service provision previously identified over the course of the last decade in the UK, Ireland and European F-ILD patient charters.</p

General practitioner workforce planning: assessment of four policy directions

<p>Abstract</p> <p>Background</p> <p>Estimating the supply of GPs into the future is important in forecasting shortages. The lengthy training process for medicine means that adjusting supply to meet demand in a timely fashion is problematic. This study uses Ireland as a case study to determine the future demand and supply of GPs and to assess the potential impact of several possible interventions to address future shortages.</p> <p>Methods</p> <p>Demand was estimated by applying GP visit rates by age and sex to national population projections. Supply was modelled using a range of parameters derived from two national surveys of GPs. A stochastic modelling approach was adopted to determine the probable future supply of GPs. Four policy interventions were tested: increasing vocational training places; recruiting GPs from abroad; incentivising later retirement; increasing nurse substitution to enable practice nurses to deliver more services.</p> <p>Results</p> <p>Relative to most other European countries, Ireland has few GPs per capita. Ireland has an ageing population and demand is estimated to increase by 19% by 2021. Without intervention, the supply of GPs will be 5.7% less than required in 2021. Increasing training places will enable supply to meet demand but only after 2019. Recruiting GPs from overseas will enable supply to meet demand continuously if the number recruited is approximately 0.8 per cent of the current workforce per annum. Later retirement has only a short-term impact. Nurse substitution can enable supply to meet demand but only if large numbers of practice nurses are recruited and allowed to deliver a wide range of GP services.</p> <p>Conclusions</p> <p>A significant shortfall in GP supply is predicted for Ireland unless recruitment is increased. The shortfall will have numerous knock-on effects including price increases, longer waiting lists and an increased burden on hospitals. Increasing training places will not provide an adequate response to future shortages. Foreign recruitment has ethical considerations but may provide a rapid and effective response. Increased nurse substitution appears to offer the best long-term prospects of addressing GP shortages and presents the opportunity to reshape general practice to meet the demands of the future.</p