General Practice In Ireland Research Articles

Drug-Drug Interactions and Their Association with Adverse Health Outcomes in the Older Community-Dwelling Population: A Prospective Cohort Study.

Evidence on associations between drug-drug interactions (DDIs) and health outcomes in the older community-dwelling population is limited. We estimate potentially clinically important DDI prevalence and examine the association between DDIs and (1) adverse drug events (ADEs), (2) emergency hospital attendance and (3) health-related quality of life (HRQoL) in an older community-dwelling population in Ireland. This is a prospective cohort study of community-dwelling older adults (N = 904) aged ≥ 70 years from 15 general practices in Ireland recruited in 2010 (wave-1) and followed-up over 2 years (wave-2; 2012-2013), with linked national pharmacy claims data. Individuals dispensed two or more drugs (wave-1: N = 842; wave-2: N = 763) were included. DDI prevalence at baseline, follow-up and 6 months prior to each health outcome was estimated. Multi-level regression was used to model the association between DDI-exposure and health outcomes at follow-up. DDI prevalence, adjusted incidence-rate ratios (aIRR), adjusted odds ratios (aOR), β coefficients and robust standard error (RSE) from multi-level regression analyses, and 95% confidence intervals (CIs) are reported. At wave-1, n = 196 (23.3% [95% CI 20.5-26.3]), individuals were potentially exposed to ≥ 1 DDI, increasing to n = 345 (45.2% [41.7-48.9]) at wave-2. At 2-year follow-up, the median number of ADEs was 3 (interquartile range [IQR 2-5]); 229 (30.1%) had ≥ 1 emergency hospital attendance, and the mean EQ-5D was 0.74 (± 0.23). Evidence for the association between DDI-exposure and emergency hospital attendance at follow-up was lacking (aOR = 1.38 [0.42-4.53]). DDI-exposure was associated with an increasing number of ADEs (aIRR = 1.26 [1.03-1.55]), and decreasing EQ-5D utility (β = - 0.07, [-0.11 to -0.04], RSE = 0.02). Aspirin-warfarin, clarithromycin-prednisolone, amiodarone-furosemide, clarithromycin-salbutamol, rosuvastatin-warfarin, amiodarone-bisoprolol, and aspirin-nicorandil were common DDIs 6 months preceding these health outcomes. We found a two-fold increase in DDI prevalence between wave 1 and 2. DDI exposure was associated with increasing ADEs and declining HRQoL at 2-year follow-up. Common DDIs involved anticoagulants, cardiovascular and antimicrobial drugs, which should be targeted for medicine optimisation.

Patient safety incidents in Irish general practice during the COVID-19 pandemic: an exploratory practice level analysis

BackgroundPatient safety is defined as the prevention of harm to patients and aims to prevent errors. This analysis explores factors associated with the reported occurrence of patient safety incidents (PSIs) in general practices in Ireland at the start of the COVID-19 pandemic.MethodsThe PRICOV-19 was a cross-sectional study to record the (re)organisation of care provided in general practice and changes implemented during the COVID-19 pandemic in 38 countries. Primary outcomes include three potential scenarios of PSIs: delayed care due to practice factors, delayed care due to patient factors, and delayed care due to triage. Exploratory variables included demographic and organisational characteristics, triage, collaboration, and strategies to safeguard staff members’ well-being.ResultsOf the 172 participating Irish general practices, 71% (n = 122) recorded at least one potential PSI. The most frequent incident was delayed care due to patient factors (65%), followed by practice (33%) and triage (30%). Multivariate analysis showed that delayed care due to patient factors was associated with changes in the process of repeat prescriptions (OR 6.7 [CI 95% 2.5 to 19.6]). Delayed care due to practice factors was associated with suburbs/small towns (OR 4.2 [1.1 to 19.8]) and structural changes to the reception (OR 3.5 [1.2 to 11.4]). While delayed care due to patient factors was associated with having a practice population of 6000–7999 patients (OR 4.7 [1.1 to 27.6]) and delayed care due to practice factors was associated with having a practice population of 2000–3999 patients (OR 4.2 [1.2 to 17.1]). No linear associations were observed with higher or lower patient numbers for any factor. Delayed care due to triage was not associated with any exploratory variables.ConclusionThe COVID-19 pandemic resulted in dramatic changes in the delivery of care through general practices in Ireland. Few factors were associated with the reported occurrence of PSIs, and these did not show consistent patterns. Sustained improvements were made in relation to repeat prescriptions. The lack of consistent patterns, potentially confirms that the autonomous decisions made in general practice in response to the challenges of the COVID-19 pandemic could have benefitted patient safety (See Graphical abstract).Graphical

Changes in analgesic prescribing among older adults hospitalised for osteoarthritis or joint replacements

Abstract Introduction Osteoarthritis is a chronic, progressive joint disease, associated with frequent pain, and functional decline. The primary risk factor for developing osteoarthritis is advanced age. Older patients are more susceptible to the adverse effects of commonly prescribed analgesics such as opioids and non-steroidal anti-inflammatory drugs (NSAIDs), owing to a greater prevalence of comorbidities and age-related changes in this cohort. The analgesic burden and prescribing trends in this cohort are largely unknown in the Irish context despite their increased susceptibility to adverse effects. Aim This study aims to evaluate analgesic prescribing patterns before and after an osteoarthritis or joint arthroplasty related hospital admission in patients aged ≥65 years and to identify factors associated with long-term prescribing of opioids and oral NSAIDs post-discharge. Methods This was an observational study of older adults with an osteoarthritis or joint arthroplasty hospitalisation. Data were collected for a larger study from 44 general practices in Ireland from 2012-2018 and included general practice records (12 months pre/post-index hospitalisation) and hospital discharge summaries, which was extracted as anonymous data from the practice software system. The analysis described prevalence of use of analgesics in the 12 months pre and post their hospitalisation. To assess long-term prescribing, multivariable analysis assessed discharge prescription and patient characteristics associated with opioid and oral NSAID use 3-12 months post-discharge. Results Overall, 738 individuals were included (52.9% female, mean age 78.1 years). Compared to 12 months pre-hospitalisation, patients were less likely to be prescribed a weak opioid or oral NSAID from discharge to 3 months post-discharge, or in the 3-12 months post-discharge. For strong opioids, prescribing was significantly less likely in the 3-12 months post-discharge compared to pre-discharge (odds ratio (OR) 0.54, 95%CI 0.40-0.74). Female sex (OR 1.61, 95%CI 1.10-2.36), strong opioid prescribing at discharge (OR 2.47, 95%CI 1.56-3.90) and pregabalin discharge prescribing (OR 2.21, 95%CI 1.12-4.33) were significantly associated with long-term strong opioid prescribing 3-12 months post-discharge. For oral NSAID prescribing, lower age (OR 0.97, 95%CI 0.95-1.00), female sex (OR 1.56, 95%CI 1.08-2.25), and discharge prescribing of strong opioids (OR 1.94, 95%CI 1.23-3.04) were significantly associated. Conclusion The use of opioids and oral NSAIDs is typically reduced for patients post-discharge from an osteoarthritis or joint arthroplasty hospitalisation. Female sex and strong opioids at discharge are associated with the prescribing of strong opioids and oral NSAIDs. Although our study was limited by use of prescription records which may not accurately represent what was dispensed or utilised by patients, it is the first to examine changing patterns of analgesic prescribing among osteoarthritis/joint arthroplasty patients. This contributes knowledge on modifiable characteristics which could reduce long-term use of these medications where appropriate.

Prescribing differences among older adults with differing health cover and socioeconomic status: a cohort study

IntroductionAs health reforms move Ireland from a mixed public-private system toward universal healthcare, it is important to understand variations in prescribing practice for patients with differing health cover and socioeconomic status. This study aims to determine how prescribing patterns for patients aged ≥ 65 years in primary care in Ireland differ between patients with public and private health cover.MethodsThis was an observational study using anonymised data collected as part of a larger study from 44 general practices in Ireland (2011–2018). Data were extracted from electronic records relating to demographics and prescribing for patients aged ≥ 65 years. The cohort was divided between those with public health cover (via the General Medical Services (GMS) scheme) and those without. Standardised rates of prescribing were calculated for pre-specified drug classes. We also analysed the number of medications, polypharmacy, and trends over time between groups, using multilevel linear regression adjusting for age and sex, and hospitalisations.ResultsOverall, 42,456 individuals were included (56% female). Most were covered by the GMS scheme (62%, n = 26,490). The rate of prescribing in all drug classes was higher for GMS patients compared to non-GMS patients, with the greatest difference in benzodiazepine anxiolytics. The mean number of unique medications prescribed to GMS patients was 10.9 (SD 5.9), and 8.1 (SD 5.8) for non-GMS patients. The number of unique medications prescribed to both GMS and non-GMS cohorts increased over time. The increase was steeper in the GMS group where the mean number of medications prescribed increased by 0.67 medications/year. The rate of increase was 0.13 (95%CI 0.13, 0.14) medications/year lower for non-GMS patients, a statistically significant difference.ConclusionOur study found a significantly larger number of medications were prescribed to patients with public health cover, compared to those without. Increasing medication burden and polypharmacy among older adults may be accelerated for those of lower socioeconomic status. These findings may inform planning for moves towards universal health care, and this would provide an opportunity to evaluate the effect of expanding entitlement on prescribing and medications use.

445 GPs’ perceptions of pharmacists working in general practices in Ireland: a cross-sectional survey

Abstract Introduction Pharmacists are increasingly incorporated into general practice teams globally, and in such positions have been shown to enhance patient outcomes. However, there is limited research to date on determining general practitioners’ (GPs’) perceptions of practice pharmacists in countries where this role has yet to be established, such as Ireland, and it is also unclear how GP and practice characteristics may affect future integration. Aim To explore GPs’ perceptions towards integrating pharmacists into practices in Ireland and determine if any significant associations were present between GPs’ perceptions and their demographic characteristics. Methods The survey was constructed based on the findings from a qualitative evidence synthesis (1) and an interview study that utilised the Theoretical Domains Framework (2). In June 2022, the survey was disseminated to a random sample of 500/842 GPs in Munster, Ireland via post and also through Twitter, WhatsApp, and an online GP support and education network. Quantitative data were captured through multiple option, ranking, binary, and Likert scale questions, and analysed using descriptive and inferential statistics. Post-hoc analysis was performed using the z-test to compare column proportions; adjustment for multiple testing using the Bonferroni method was also conducted. Differences were considered statistically significant where p<0.05. Qualitative data were captured by use of free-text boxes and analysed using reflexive thematic analysis. Results In total, 152 valid responses were received (24.6% response to postal survey). GPs were broadly welcoming and optimistic about the future role of a general practice-based pharmacist. Nearly all respondents agreed with practice pharmacists providing medicines information (98%) versus 47%, 42%, and 23% agreeing with practice pharmacists vaccinating, managing minor ailments, and independent prescribing respectively. The three most frequently agreed-with outcomes of having a practice pharmacist were improved access to medicines information (92%), increased patient safety (90%), and increased adherence to clinical guidelines (85%). GPs in large practices were more likely to select the optimal frequency of pharmacist presence in practices as 1-2 days per week compared to those in small/medium-size practices (70% versus 40/45%; p<0.05). Most (78.6%) agreed they would partake in a practice pharmacist pilot; GPs who approved of pharmacists performing independent prescribing were significantly more likely to agree with this (p<0.05). When GPs were asked if the potential outcomes of practice pharmacists justified the theoretical cost of employing them, 48.6% agreed and 24.7% disagreed. Most thought practice pharmacists being fully funded by the government was most feasible (84.6%). The GPs’ free-text comments were synthesised into five overarching themes, which describe the current pressures in general practice, the utility of pharmacists and possibility of expanding their roles, funding and governance, practice pharmacist roles, and anticipated outcomes. Conclusion Although limited by a somewhat low response rate, this theory-informed survey study provides a deeper understanding of GPs’ perceptions of integrating pharmacists into practices. With these findings showing that most GPs perceive positive outcomes with practice pharmacists, policymakers should allocate funding to these roles in Ireland, coupled with robust cost-effectiveness analyses, to better demonstrate the impact that these novel pharmacist roles can have on primary care health service provision.

GPs at the Edge: a quantitative description of Irish Rural General Practice.

Currently, more than 1.6 million Irish people live rurally. Rural populations in Ireland are older and have more health needs compared with younger urban areas. Meanwhile, since 1982, the proportion of general practices in rural areas has decreased by 10%. In this study, we look at new survey data to investigate the needs and challenges of rural general practice in Ireland. This study will make use of survey responses from the 2021 membership survey by the Irish College of General Practitioners (ICGP). The anonymous, online, survey was sent by email to the ICGP membership in late 2021, with a series of questions pertaining to practice location, and prior experience of living and working in a rural area designed specifically for this project. A series of statistical tests will be undertaken as appropriate for the data. This study is ongoing; we aim to present data on the demographics of those working in rural general practice and related factors. Previous research has shown that people who grew up or trained in rural areas are more likely to work there after qualifying. As the analysis of this survey continues, it will be important to see if this pattern is evident here as well.

Introducing advanced paramedics into the rural general practice team in Ireland - general practitioners' attitudes.

As Ireland's population increases and chronic disease becomes more prevalent, demand on limited general practice services will increase. Nursing roles within general practice are now considered to be standard, yet alternative non-medical professional roles are underexplored within an Irish context. Non-medical personnel such as Advanced Paramedics (APs) may have the capability to provide support to general practice. To explore GPs' attitudes and opinions about integrating Advanced Paramedics into rural general practice in Ireland. A sequential explanatory mixed methodology was adopted. A questionnaire was designed and distributed to a purposeful sample of GPs attending a rural conference followed by semi-structured interviews. Data were recorded and transcribed verbatim and thematically analysed. In total, n=27 GPs responded to the survey and n=13 GPs were interviewed. Most GPs were familiar with APs and were receptive to the concept of closely collaborating with APs within a variety of settings, including out-of-hours services, home visits, nursing homes and even roles within the general practice surgery. GP and AP clinical practice dovetail within many facets of primary care and emergency care. GPs recognise that current rural models are unsustainable, and they realise the potential of integrating APs into the general practice team to help support and sustain the future of rural general practice services in Ireland. These interviews provided an exclusive, detailed insight into the world of general practice in Ireland that has not been previously documented in this way.

Decision making capacity assessment in general practice in Ireland.

It has been reported internationally that doctors have a limited understanding of the legal standard that applies to decision making capacity (DMC). No research on this has been conducted in Ireland to date. We sought to assess the understanding of legal principles relating to capacity and consent among Irish general practitioners (GPs), alongside how DMC assessments are conducted. This study utilised a cross-sectional cohort model circulating online questionnaires to Irish GPs associated with a university research network. Data were analysed using SPSS to conduct a variety of statistical tests. There were 64 participants, with 50% aged 35-44 years and 60.9% being female. Of these, 62.5% found DMC assessments time-consuming. Only 10.9% of participants felt extremely confident in their abilities; most participants (59.4%) felt 'somewhat confident' in their ability to assess DMC. Also, 90.6% of GPs routinely engaged with families when assessing capacity. GPs felt their medical training did not prepare them for DMC assessment (undergraduate 90.6%, non-consultant hospital doctor 78.1%, GP training 65.6%). 70.3% felt guidelines relating to DMC would be helpful and 65.6% felt they needed additional training. Most GPs recognise the importance of DMC assessment, and it is not considered a complex or burdensome task. There was limited knowledge of the legal instruments relevant to DMC. GPs felt there should be extra support available to assist them with DMC assessment; specific guidelines for different categories of patients was found to be the most popular resource requested.

The availability of general practice in Ireland's Mid-West Region: does the 'Inverse Care Law' still apply?

The 'Inverse Care Law' suggests the availability of good medical care tends to vary inversely with the needs of the local population. Dr Julian Tudor Hart's observations related to lack of access to care for those in both socially deprived and geographically remote areas. In this study, we aim to examine if the 'Inverse Care Law' is still relevant to GP service provision in the Mid-West of Ireland. GP clinic locations in Limerick and Clare were identified using the Health Service Executive (HSE) Service Finder and geocoded. GeoHive.ie was used to determine Electoral District (ED) centroids across the Mid-West. The shortest linear distance to a GP clinic was calculated for each ED. PobalMaps.ie was used to determine population and social deprivation scores of each ED. In total, 122 GP practices were identified across 324 EDs. The average travel distance to a GP clinic in the Mid-West is 4.7 km. Limerick City EDs had the smallest patient population per GP clinic and were all found to be within 1.5 km of a GP clinic. Proximity to GP clinics did not correlate with deprivation. However, by removing GP clinics from the analyses, it was possible to determine how vulnerable different areas (rural vs urban, deprived vs affluent) are to potential changes in GP clinic availability in the future. People living in urban areas such a Limerick City have improved geographic accessibility to GP clinics compared with their rural counterparts. However, within urban areas assessed, GP clinics were rarely found in deprived areas. Therefore, remote and urban-deprived areas are far more vulnerable to negative proximity effects secondary to practice closures, suggesting the principles of the 'Inverse Care Law' may still be active in the Mid-West of Ireland.

Heartwatch: an Irish cardiovascular secondary prevention programme in primary care, a secondary analysis of patient outcomes

ObjectivesTo investigate patient follow-up data from Heartwatch: Ireland’s secondary prevention programme for cardiovascular disease delivered in general practice.DesignRetrospective descriptive study based on secondary analysis of routinely collected data from Heartwatch.SettingHeartwatch...

A mixed methods study of the awareness and management of familial hypercholesterolaemia in Irish general practice.

IntroductionFamilial Hypercholesterolemia (FH) is one of the most common genetic disorders, with an estimated global prevalence of 1:200-500, which leads to premature cardiovascular disease. Nevertheless, public and professional awareness of FH is often lacking, with an estimated 20,000 largely undiagnosed cases in Ireland.PurposeThe overall aim of the project was to test the feasibility of a model of care that would include electronic record screening, clinical assessment, and coding of possible FH patients across a network of general practices in Ireland. In addition, a secondary aim was to gauge the awareness and knowledge of FH across the network.MethodsThis study took part in multiple phases, employing a mixed methods design. The study included a validated questionnaire, tailored online educational resources, a retrospective chart review of patients with a history of elevated LDL cholesterol (LDLc) and an active review with a selection of those patients. Results were analyzed using SPSS V27, where descriptive statistics and relevant correlation tests were employed.ResultsEighteen general practices agreed to take part in the study. In the initial survey, respondents rated their personal and practice familiarity with FH as slightly below average. Around one-third of respondents were not aware of FH guidelines. Of over 55,000 adult patient records searched, only 0.2% had a recorded FH diagnosis and 3.9% had ever had an LDLc above 4.9 mmol/l. Eight practices completed 198 chart reviews. Among these, 29.8% of patients had a family history recorded, and 22.2% had a family history of CVD recorded. Female patients had higher averages for highest and recent LDLc. Seventy patients underwent a clinical review—with 27% of these patients identified as “probable” or “definite FH.” There was a statistically significant (p = 0.002) relationship between FH status and whether the patient had other CVD risk factors.ConclusionGeneral practitioners in Ireland had similar levels of awareness of FH compared to findings from elsewhere. The activities discussed encouraged clinicians to consider FH when talking to their patients, especially those with elevated LDLc at an early age. Broader awareness of the condition could increase conversations about FH and benefit patient outcomes.

Introducing Advanced Paramedics into the rural general practice team in Ireland – general practitioners attitudes

IntroductionAs Ireland's population increases and chronic disease becomes more prevalent, demand on limited general practice services will increase. Nursing roles within general practice are now considered to be standard, yet alternative allied health professional roles are under explored within an Irish context. Allied health personnel such as Advanced Paramedics (APs) may have the capability to provide support to general practice.AimTo explore General Practitioners’ (GPs) attitudes and opinions of integrating Advanced Paramedics (APs) into rural general practice in Ireland.MethodsA sequential explanatory mixed methodology was adopted. A questionnaire was designed and distributed to a purposeful sample of GPs attending a rural conference followed by semi-structured interviews. Data was recorded and transcribed verbatim and thematically analysed.ResultsIn total n = 27 GPs responded to the survey and n = 13 GPs were interviewed. The majority of GPs were familiar with APs and were receptive to the concept of closely collaborating with APs within a variety of settings including out-of-hours services, home visits, nursing homes and even roles within the general practice surgery.ConclusionGeneral Practitioner and Advanced Paramedic clinical practice dovetail within many facets of primary care and emergency care. GPs recognise that current rural models are unsustainable and realise the potential of integrating APs into the general practice team to help support and sustain the future of rural general practice services in Ireland. These interviews provided an exclusive, detailed insight into the world of general practice in Ireland that has not been previously documented in this way.

Can a practice pharmacist improve prescribing safety and reduce costs in polypharmacy patients? A pilot study of an intervention in an Irish general practice setting

ObjectivesThis study aimed to develop and assess the feasibility and cost impact of an intervention involving a practice pharmacist embedded in general practice to improve prescribing safety, deprescribe where appropriate...

Prescribing differences among older adults with differing health cover and socioeconomic status: a cohort study

Abstract Introduction Ireland currently has a mixed public-private health system, where about 40% of individuals are entitled to free or low-cost public care based on their income and age (1). As health reforms move Ireland toward universal healthcare, it is important to understand divergent prescribing practice to patients with differing health cover and socioeconomic status. Aim To determine how prescribing patterns for patients aged ≥65 years in primary care in Ireland differ between public and private patients. Methods Data were collected during a larger study from 44 general practices in Ireland (2). Data were extracted from the patient management system relating to demographics and prescribing. Patients were included in the present analysis if they had prescriptions issued on at least two dates during the study period (2011-2018), and had demographics (age and sex) and prescription dates recorded. The cohort was divided between those with public health cover (via the GMS scheme, which over-represents socioeconomically deprived people) and those without. We calculated the standardised rate of prescribing for drug classes separately for GMS and non-GMS (private) patients. We pre-specified 12 drug classes of specific interest, due to their prevalence, inclusion in Ireland’s Preferred Drugs Initiative, or potential for sub-optimal prescribing. We also analysed the number of medications, polypharmacy, and trends over time between groups, using multilevel linear regression adjusting for age and sex. Results The study included 42,456 individuals, 62% with GMS cover. The rate of prescribing for all pre-specified drug classes was higher for GMS patients compared to non-GMS patients. In all cases, the rate of prescribing was at least 1.6 times higher in the public group, with this being the minimum difference between groups in the rate of antibacterials for systemic use. We saw the greatest disparity in inhaled adrenergics combined with corticosteroids and/or anticholinergics where the rate of public prescribing was 2.25 times higher. The mean number of unique medications prescribed to GMS patients was 10.9 (SD 5.9), and 8.1 (SD 5.8) for non-GMS patients. Among GMS patients, 85% had polypharmacy (being on ≥5 medications) compared to 77% among the non-GMS patients, while 51% and 43% respectively had major polypharmacy (≥10 medications). The mean number of medications prescribed per person increased in both groups over time. The increase was steeper and more sustained in the public health cover group where the mean number of medications prescribed increased by 0.67 medications/year for GMS patients. The rate of increase was 0.13 (95%CI 0.13, 0.14) medications/year lower for non-GMS patients, a statistically significant difference. Conclusion Our study found a significantly larger number of unique medicines were prescribed to patients with public health cover, compared to those without. This disparity increased over time and was consistent within all drug classes analysed. This may be driven by socioeconomic deprivation rather than health cover, although a limitation is that we were unable to examine or adjust for these potential contributors separately. Our study provides new evidence that the growth in medication burden and polypharmacy among older adults is accelerated for those of lower socioeconomic status. References (1) Thomson S, Jowett M, Mladovsky P. The editors Observatory Studies Series No. 33 33 Observatory Studies Series Health system responses to financial pressures in Ireland. (2) Pérez T, Moriarty F, Wallace E, McDowell R, Redmond P, Fahey T. Prevalence of potentially inappropriate prescribing in older people in primary care and its association with hospital admission: Longitudinal study. BMJ. 2018;363.

Role dimensions of practice nurses and interest in introducing advanced nurse practitioners in general practice in Ireland.

BackgroundInternationally many countries have implemented strategies to enhance primary care, to strengthen their health systems to cope with an aging population, the rise of chronic conditions, and increased costs. Primary care has the potential to address these challenges, however, general practitioners are increasingly struggling to meet patient demand resulting from a growing and aging population. Expanding the role of general practice nurses to advanced nurse practitioner (ANP) level has worked internationally and could equally be a solution to the Irish context. However, their current role must first be established as well as their level of interest in becoming an ANP.AimTo explore the role of general practice nurses and their interest in becoming an ANP.DesignA survey design.MethodA purposeful sample of general practice nurses (n = 40) was undertaken between April and June 2019. Data were analyzed using the Statistical Package for Social Science (SPSS V 25.0; IBM).ResultsGeneral practice nurses appear to have an agenda in relation to activities associated with wound care, immunizations, respiratory and cardiovascular issues. Just over half of the respondents were not interested in becoming an ANP. Their perceived challenges associated with the implementation of the role include a lack of support from general practitioners, a lack of resources, insurance issues, and a lack of understanding of the role. Challenges were associated with undertaking further training and their experience of having more work transferred to general practice without concomitant reallocation of resources.ConclusionGeneral practice nurses have extensive clinical experience to deliver major improvements in primary care. Educational opportunities need to be provided for upskilling existing general practice nurses to advanced practice level. Greater understanding of the role and the potential contribution of the role in general practice is required among medical colleagues and the public.

Health professionals’ views of the first national GP payment scheme for structured type 2 diabetes care in Ireland: a qualitative study

Background: Payment schemes are widely used to improve chronic disease management in general practice. Although stakeholder views of such schemes could provide valuable learning regarding aspects that work and those which are more difficult to implement, there is a paucity of such data. We explored health professionals’ views of the implementation of the first national general practice payment scheme for type 2 diabetes (T2DM) care in Ireland, the ‘cycle of care’. Methods: Qualitative data were drawn from a multiple case study evaluating the implementation of a National Clinical Programme for Diabetes, collected from April 2016 to June 2017. Interview and focus group transcripts from participants involved in providing diabetes management in general practice and who referenced the cycle of care were eligible for inclusion in the current analysis. Data were analysed using reflective thematic analysis. Results: We analysed data from 28 participants comprising general practitioners (GPs) (n=8), practice nurses (n=9) and diabetes nurse specialists (DNS) (n=11). Participants perceived the cycle of care as “not adequate, but…a good start” to improve T2DM care in general practice in Ireland. Perceived benefits were greater financial viability for T2DM management in general practice, fostering a more proactive approach to T2DM care, delivery of T2DM care closer to patients’ homes, and increased use of other community diabetes services e.g., DNS and podiatry. Participants identified the limited resource for practice nurse time, inflexibility to provide care based on patient need and issues with data submission as drawbacks of the cycle of care. Conclusions: The cycle of care was viewed as a positive first step to increase and improve T2DM care delivered in general practice in Ireland. The implementation issues identified in this study should be considered in the design of future payment schemes targeting chronic disease management in general practice.

Development of a primary care research network focused on chronic disease: a feasibility study for both practices and research networks

Background: High quality data should be a key resource for research and planning of healthcare, but low quality general practice data has been documented internationally. This study assessed the feasibility of collecting reliable chronic disease data in Irish general practice, using a program of training and feedback to improve the quality of coding for chronic conditions in practice information systems. Methods: Training in chronic disease coding and reporting was provided to a purposive sample of general practices in Ireland. From July to December 2020, practices reported the number of patients receiving free medical care, and the number of patients coded with each of eight chronic conditions: type 2 diabetes mellitus (T2DM), asthma, chronic obstructive pulmonary disease (COPD), ischaemic heart disease (IHD), heart failure (HF), atrial fibrillation (ATF), transient ischaemic attack (TIA) and cerebrovascular accident/stroke (CVA). Calculated prevalences were compared with national and international estimates. Results: We recruited and trained 16 practices with 65.5 full-time equivalent GPs and a study-eligible patient population of 36,327. There was a large degree of variation across practices for all conditions. For example, in July, reported prevalence of IHD ranged from 0.3% to 10.2% (a 34-fold difference), and reported prevalence of HF ranged from 0.2% to 4.0% (a 20-fold difference). No single practice had high or low prevalences across all conditions. Changes over time across all practices were minimal, averaging between 0.1% and 0.3% for all conditions. By December, a large degree of variation across practices remained. Across all conditions, average prevalences were higher than previously published estimates. Conclusions: Although hampered by the COVID-19 pandemic, it was feasible to implement this programme of training and feedback to report on chronic disease data recorded in general practice. Coding quality in Irish general practice is highly varied, and improvement would require a greater degree of intervention, including audit.

SARS-CoV-2 infection in general practice in Ireland: a seroprevalence study.

BackgroundSevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibody testing in community settings may help us better understand the immune response to this virus and, therefore, help guide public health efforts.AimTo conduct a seroprevalence study of immunoglobulin G (IgG) antibodies in Irish GP clinics.Design & settingParticipants were 172 staff and 799 patients from 15 general practices in the Midwest region of Ireland.MethodThis seroprevalence study utilised two manufacturers’ point-of-care (POC) SARS-CoV-2 immunoglobulin M (IgM)—IgG combined antibody tests, which were offered to patients and staff in general practice from 15 June to 10 July 2020.ResultsIgG seroprevalence was 12.6% in patients attending general practice and 11.1% in staff working in general practice, with administrative staff having the lowest seroprevalence at 2.5% and nursing staff having the highest at 17.6%. Previous symptoms suggestive of COVID-19 and history of a polymerase chain reaction (PCR) test were associated with higher seroprevalence. IgG antibodies were detected in approximately 80% of participants who had a previous PCR-confirmed infection. Average length of time between participants’ positive PCR test and positive IgG antibody test was 83 days.ConclusionPatients and healthcare staff in general practice in Ireland had relatively high rates of IgG to SARS-CoV-2 compared with the national average between 15 June and 10 July 2020 (1.7%). Four-fifths of participants with a history of confirmed COVID-19 disease still had detectable antibodies an average of 12 weeks post-infection. While not proof of immunity, SARS-CoV-2 POC testing can be used to estimate IgG seroprevalence in general practice settings.

Factors associated with initiation of bone-health medication among older adults in primary care in Ireland

BackgroundAdults at high risk of fragility fracture should be offered pharmacological treatment when not contraindicated, however, under-treatment is common.ObjectiveThis study aimed to investigate factors associated with bone-health medication initiation in older patients attending primary care.DesignThis was a retrospective cohort study.SettingThe study used data from forty-four general practices in Ireland from 2011–2017.SubjectsThe study included adults aged ≥ 65 years who were naïve to bone-health medication for 12 months.MethodsOverall fracture-risk (based on QFracture) and individual fracture-risk factors were described for patients initiated and not initiated onto medication and compared using generalised linear model regression with the Poisson distribution.ResultsOf 36,799 patients (51% female, mean age 75.4 (SD = 8.4)) included, 8% (n = 2,992) were observed to initiate bone-health medication during the study. One-fifth of all patients (n = 8,193) had osteoporosis or had high fracture-risk but only 21% of them (n = 1,687) initiated on medication. Female sex, older age, state-funded health cover and osteoporosis were associated with initiation. Independently of osteoporosis and co-variates, high 5-year QFracture risk for hip (IRR = 1.33 (95% CI = 1.17–1.50), P < 0.01) and all fractures (IRR = 1.30 (95% CI = 1.17–1.44), P < 0.01) were associated with medication initiation. Previous fracture, rheumatoid arthritis and corticosteroid use were associated with initiation, while liver, kidney, cardiovascular disease, diabetes and oestrogen-only hormone replacement therapy showed an inverse association.ConclusionsBone-health medication initiation is targeted at patients at higher fracture-risk but much potential under-treatment remains, particularly in those >80 years and with co-morbidities. This may reflect clinical uncertainty in older multimorbid patients, and further research should explore decision-making in preventive bone medication prescribing.

How many general practice consultations occur in Ireland annually? Cross-sectional data from a survey of general practices

BackgroundGeneral practice plays a central role in the Irish health system. This study aimed to determine a baseline estimate of the number of consultations completed in general practice in Ireland annually to facilitate evidence-based healthcare planning.MethodsA survey was emailed to all 3378 individual members of the Irish College of General Practitioners in February 2020 asking each practice to report on consultations by general practitioners and practice nurses occurring on the previous day of practice.ResultsA total of 507 practices responded to the survey, reporting 34,594 general practitioner consultations and 13,161 nurse consultations on one day. Extrapolating this figure nationally, we estimate 21,353,731 GP consultations and 7,749,615 practice nurse consultations occur in Ireland annually. An Irish person visits their GP an estimated 4.34 times a year and the average consultation time is 13.7 min.ConclusionsThis study shows that over 29.1 million consultations take place in Irish general practice every year. Innovative interventions to increase the capacity of general practice are needed to ensure high-quality care continues to be accessible in Ireland.