Irish General Practices Research Articles

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

Interactive dashboard development for Irish general practices to visualise and compare patient data

Abstract Background Health information technology has increased worldwide, transforming health and healthcare programs in which information visualisation and visual analytics processes are central. However, aggregating and comparing patient data remains challenging. Therefore, a dashboard was developed with and for Irish general practitioners (GPs) to improve their understanding of their patient population, disease management and prescribing. This paper describes the design and development process of the CARA dashboard. Methods The design and development of the CARA dashboard used an Action Design Research approach, which consists of (1) problem formulation, (2) building, intervention and evaluation, (3) reflection and learning and (4) formalisation of learning. The process included interviews, to explore what type of information GPs need, as well as iterative testing of the CARA dashboard prototype. Results Key challenges identified from the interviews (Context, Sense-making, Audits, Relevancy, Action, Engagement and Ease of Use) formed the basis for the development of the CARA dashboard prototype. The first exemplar dashboard focused on antibiotic prescribing to develop and showcase the proposed platform, including automated audit reports, filters (within practice) and between-practice comparisons as well as a visual overview of practice demographics. Conclusions User involvement in the design and development of the CARA dashboard is crucial to ensure GPs are enabled and supported to visually access and monitor their patients’ data. Next steps will include an exploratory study on dashboard engagement and the development of additional dashboards for topics such as chronic disease and mental health. Key messages • Good knowledge of operating systems, effective use of data, user interaction and context factors are required to design and implement an interactive dashboard. • Crucial components to make sense of the information provided in dashboards include the context, transparency about the data transformation processes and adherence to design principles.

Access to general practice during the COVID-19 pandemic - a cross-sectional view of the opinions of adults who use social media.

The COVID-19 pandemic has had a significant impact on the health and wellbeing of people worldwide. General practices were forced to adapt to constantly changing circumstances, leading to predominance of virtual consultations. The aim of this study was to examine the impact the pandemic had on the ability of patients to access general practice. Other focuses included determining the nature of changes to appointment cancellations or delays and the level of disruption to long-term medication regimes during this period. A 25-question online survey was administered using Qualtrics®. Adult patients of Irish general practices were recruited via social media between October 2020 and February 2021. The data were examined for associations between participant groupings and key findings using chi-squared tests. 670 persons participated. Half of all doctor-patient consultations during that time were completed virtually, predominantly via telephone. Overall, 497 (78%) participants accessed their healthcare teams as scheduled, and without disruption. 18% of participants (n=104) reported difficulty in accessing their long-term medications; those who were younger, and those who typically attend general practice on a quarterly or more basis, were associated most with this disruption (p<0.05; p<0.05). Despite the COVID-19 pandemic, Irish general practice has maintained its schedule for appointments in greater than three quarters of cases. There was a clear shift away from face-to-face consultations to telephone appointments. Maintaining the prescription of long-term medications for patients remains a challenge. Further work needs to be done to ensure the continuation of care and undisrupted medication schedules during any future pandemics.

Establishing the worth of deprescribing inappropriate medications: are we there yet?

Establishing the worth of deprescribing inappropriate medications: are we there yet?

Access to general practice during COVID-19: a cross-sectional view of the opinions of adults who use social media.

Background/Aim: Since the onset of the COVID-19 pandemic, virtual consultations have become commonplace, and access to healthcare more complex. The study was designed to examine the impact COVID-19 has had on access to general practice care in Ireland. Methods: A 25-question online survey was designed in Qualtrics®. Adult patients of Irish general practices were recruited via social media between October 2020 and February 2021 and volunteered their opinions. Results: 670 persons participated. Half of all doctor-patient consultations were now completed virtually-predominantly via telephone. Overall, 497 (78%) participants accessed their healthcare teams as scheduled, and without disruption. 18% of participants (n=104) reported difficulty in accessing their long-term medications; those who are younger, and those who typically attend general practice quarterly or more, were associated most with this disruption (p<0.05). Fifty-nine instances where a new health concern was subject to an appointment cancellation or rescheduling were reported. Conclusions: Despite the COVID-19 pandemic, Irish general practice has maintained its schedule for appointments in 78% of cases despite the challenges of the pandemic. Half of consultations were provided virtually; teleconsultation use was very infrequent. Maintaining the supply chain for long-term medications for patients remains a challenge during a pandemic. Authors accept that study participants were confined to those who use social media. A protocol may need to be designed by each practice to optimize the continuation of care and of medication schedules during any future pandemics.

Antidepressant medication prescribing patterns in Irish general practice from 2016 to 2020 to assess for long-term use.

Background/aimsThe aim of this study was to identify the trends in antidepressant (AD) medication use in two Irish general practices over a 5-year period, 2016 to 2020. The rationale for this study is attributed to the growing prevalence of depression amongst the Irish general public as well as concerns surrounding long-term AD medication use.MethodsThe research was undertaken in 2021 examining AD prescription rates from 2016 to 2020. The medications of interest were selective serotonin and norepinephrine reuptake inhibitors (SSRI and SNRIs): sertraline, escitalopram, fluoxetine and venlafaxine. The number of medical card holders (MCH) and prescription dispensing rates were analysed for observable trends.ResultsAD medication use is rising amongst the Irish MCH population. The number of MCH prescribed AD grew from 9.42 to 12.3 per 100 MCH between the years 2016 and 2020, respectively. The year 2020 represented the largest proportion of MCH prescriptions, 6.32 AD prescriptions per 1000 MCH prescriptions. The years 2019 to 2020 represented the largest annual increase in prescription dispensing with a growth of 0.45 per 1000 MCH prescriptions. Annual figures show a continual increase in AD dispensing refill rates from 4.14 to 5.67 per 1000 MCH prescriptions in 2016 and 2020, respectively.ConclusionThis study illustrates a steady rise in AD medication within the general practice setting, with an observed rise in prescription dispensing rates. The high proportion of refill prescriptions demonstrates the long-term use of AD medications. This may be indicative of chronic depression or may highlight a lack of appropriate medication cessation strategies.

'If relevant, yes; if not, no': General practitioner (GP) users and GP perceptions about asking ethnicity questions in Irish general practice: A qualitative analysis using Normalization Process Theory.

The use of ethnic identifiers in health systems is recommended in several European countries as a means to identify and address heath inequities. There are barriers to implementation that have not been researched. This study examines whether and how ethnicity data can be collected in Irish general practices in a meaningful and acceptable way. Qualitative case study data generation was informed by Normalization Process Theory (NPT) constructs about 'sense' making and 'engagement'. It consisted of individual interviews and focus group discussions based on visual participatory techniques. There were 70 informants, including 62 general practitioner (GP) users of diverse ethnic backgrounds recruited through community organisations and eight GPs identified through an inter-agency steering group. Data were analysed according to principles of thematic analysis using NPT. The link between ethnicity and health was often considered relevant because GP users grasped connections with genetic (skin colour, lactose intolerance), geographic (prevalence of disease, early years exposure), behavioural (culture/food) and social determinant (housing) factors. The link was less clear with religion. There was some scepticism and questions about how the collection of data would benefit GP consultations and concerns regarding confidentiality and the actual uses of these data (e.g. risk of discrimination, social control). For GPs, the main theme discussed was relevance: what added value would it bring to their consultations and was it was their role to collect these data? Their biggest concern was about data protection issues in light of the European Union (EU) General Data Protection Regulation (GDPR). The difficulty in explaining a complex concept such as 'ethnicity' in the limited time available in consultations was also worrying. Implementation of an ethnicity identifier in Irish general practices will require a strong rationale that makes sense to GP users, and specific measures to ensure that its benefits outweigh any potential harm. This is in line with both our participants' views and the EU GDPR.

Measuring adherence to therapy in apparent treatment-resistant hypertension: a feasibility study in Irish primary care.

Apparent treatment-resistant hypertension (aTRH) is defined as uncontrolled blood pressure (BP) in patients taking three or more antihypertensive medications. Some patients will have true treatment-resistant hypertension, some undiagnosed secondary hypertension, while others have pseudo-resistance. Pseudo-resistance occurs when non-adherence to medication, white-coat hypertension (WCH), lifestyle, and inadequate drug dosing are responsible for the poorly controlled BP. To examine the feasibility of establishing non-adherence to medication, for the first time in primary care, using mass spectrometry urine analysis. Operationalisation would be established by at least 50% of patients participating and 95% of samples being suitable for analysis. Clinical importance would be confirmed by >10% of patients being non-adherent. Eligible patients with aTRH (n = 453) in 15 university research-affiliated Irish general practices were invited to participate. Participants underwent mass spectrometry urine analysis to test adherence and ambulatory BP monitoring (ABPM) to examine WCH. Of the eligible patients invited, 52% (n = 235) participated. All 235 urine samples (100%) were suitable for analysis: 174 (74%) patients were fully adherent, 56 (24%) partially adherent, and five (2%) fully non-adherent to therapy. A total of 206 patients also had ABPM, and in total 92 (45%) were categorised as pseudo-resistant. No significant associations were found between adherence status and patient characteristics or drug class. In patients with aTRH, the authors have established that it is feasible to examine non-adherence to medications using mass spectrometry urine analysis. One in four patients were found to be partially or fully non-adherent. Further research on how to incorporate this approach into individual patient consultations and its associated cost-effectiveness is now appropriate.

Prescription of psychotropic medication in patients with type two diabetes mellitus: A multi-practice study from Ireland

Background: Comorbid anxiety and depression and type two diabetes mellitus (T2DM) are commonly managed by General Practitioners (GPs).Objectives: To investigate the proportion of people with T2DM who are prescribed either antidepressant or benzodiazepine medications in general practice; to compare people with T2DM that have a prescription with those that do not in terms of patient characteristics, glycaemic control and healthcare utilization.Methods: Anonymized data was collected by GPs and senior medical students from electronic medical records of patients with T2DM in 34 Irish general practices affiliated with the University of Limerick Graduate Entry Medical School during the 2013/14 academic year. Data included demographics, healthcare utilization, prescriptions and most recent glycosylated haemoglobin (HbA1c) measurement.Results: The sample included 2696 patients with T2DM, of which 733 (36.7%) were female, and with a median age of 66 years. The percentage with a current prescription for an antidepressant or benzodiazepine was 22% (95%CI: 18.9–24.9). Those with a current prescription for either drug were more likely to have attended the emergency department (28.3% vs 15.7%, P <0.001), to have been admitted to hospital (35.4% vs 21.3%, P <0.001) in the past year and attend their GP more frequently (median of 9 vs 7, P <0.001) than those without a prescription. Rates of poor glycaemic control were similar in those with and without a current prescription.Conclusion: Over one-fifth of people with T2DM in Irish general practice are prescribed an antidepressant or benzodiazepine medication. Prescription of these is associated with increased healthcare utilization but not poorer glycaemic control.

Ten years of cardiac arrest resuscitation in Irish general practice

AimThe aim of this study is to establish the role and outcome of general practitioner (GP) involvement in out of hospital cardiac arrest (OHCA) resuscitation in the Republic of Ireland. MethodsA ten year prospective observational study involving a cohort of Irish general practices. Setting521 general practice settings distributed throughout the Republic of Ireland, representing approximately one quarter of all practices and a third of Irish GPs. Participants534 patients suffering cardiac arrest in the community for whom resuscitation was attempted. InterventionsCardiac arrest with resuscitation attempted (CARA) in which a GP played a role. ResultsOver a ten year period almost half of participating practices reported one or more CARAs. A total of 534 CARAs were reported at a variety of locations; 161 (30%) had ROSC (return of spontaneous circulation) at some point, with outcome data available for 147/161; 90 patients survived to hospital discharge. Most survivors for whom follow up data are available were discharged home and were completely independent. The highest rate of survival was achieved when CARAs occurred at a GP practice premises (47.4%). ConclusionsResuscitation following OHCA is a key task in general practice. Over time a significant number of GPs encounter OHCA, attempt resuscitation and achieve higher survival to hospital discharge rates than occur nationally among OHCAs in Ireland. We conclude that a defibrillator should be routinely available at all general practices and staff should have appropriate resuscitation skills.

Perceived safety climate in Irish primary care settings—a comparison with Scotland and England

Background: Safety climate (SC) measurement is a key component of quality and safety initiatives in primary healthcare.Objectives: To (1) measure perceived SC in Irish primary care; (2) examine whether perceptions of safety varied according to respondent characteristics; and (3) compare responses from our Irish sample to data from England and Scotland.Methods: PC-SafeQuest Survey was administered to all practice staff in Irish general practices between March and May 2016. This survey consists of 30 items across five safety domains (workload, communication, leadership, teamwork, and safety systems). Multiple regression analysis was used to identify predictor variables of perceived safety. The effect size of the difference between the Irish sample’s scores and published English and Scottish data were calculated.Results: A total of 231 questionnaires (38.5%) were returned. Generally, positive perceptions of perceived safety were identified among Irish respondents, but workload had the lowest overall mean score (M = 4.3, SD = 1.2) of the five domains. Comparisons across the Irish, English and Scottish samples identified a medium size effect difference in workload; Scottish respondents perceived workload to have less of a negative impact on safety than Irish or English counterparts (Cohen’s d = 0.602, 0.67 respectively). Analyses indicated that Irish GP principals perceived a more negative impact of workload on safety than administrative staff (β = 0.28, P = 0.03).Conclusion: Irish SC data are largely similar to those of England and Scotland. The perceived potential for workload to negatively impact upon safety emerged within each country. In Ireland, GP principals perceive this as a greater threat than practice administrators do.

Prescribing and practice development decision-making in Irish general practices

In Ireland, primary care is considered the appropriate setting to meet the majority of health and personal social service needs, with GPs central to its provision. Irish general practices are characterised by considerable autonomy in terms of commercial practice and the range of medical services they provide; however, little is known about what influences their decision-making with respect to the adoption of new health-care technologies. The aim of this paper is to provide a holistic overview on prescribing and practice development decision-making in Irish general practices. A summary of recent publications examining the factors influencing the adoption of new drugs, medical equipment and information and communications technology (ICT) by Irish GPs is undertaken. These studies identify experiential learning, connectedness with others, and GP and practice characteristics as significant influences in the adoption of new drugs, medical equipment and ICT in Irish general practices. This summary identifies possible levers for encouraging the adoption of health-care technologies by Irish GPs.

The influence of experiential learning on medical equipment adoption in general practices

The benefits of the availability and use of medical equipment for medical outcomes are understood by physicians and policymakers alike. However, there is limited understanding of the decision-making processes involved in adopting and using new technologies in health care organisations. Our study focuses on the adoption of medical equipment in Irish general practices which are marked by considerable autonomy in terms of commercial practice and the range of medical services they provide. We examine the adoption of six items of medical equipment taking into account commercial, informational and experiential stimuli. Our analysis is based on primary survey data collected from a sample of 601 general practices in Ireland on practice characteristics and medical equipment use. We use a multivariate Probit to identify commonalities in the determinants of the adoption. Many factors, such as GP and practice characteristics, influence medical equipment adoption. In addition, we find significant and consistent evidence of the influence of learning-by-using effects on the adoption of medical equipment in a general practice setting. Knowledge generated by experiential or applied learning can have commercial, organisational and health care provision benefits in small health care organisations.

ICT use in Irish general practices: an intra-practice adoption study

Given the potential of ICT to improve efficiency and quality of care, it is necessary to understand healthcare organisations’ decision-making concerning ICT adoption and use. In this paper, we explore the factors that influence the intensity of ICT use by general practices in Ireland. Drawing on an encompassing theoretical model, we explore how commercial considerations and informational stimuli influence ICT use in Irish general practices. The data source is the medical equipment and IT in general practice survey, which provides information relating to practice characteristics and ICT use for 601 general practices in Ireland. We use ordered probit analysis to examine intensity of ICT use. We find some evidence that GP and practice characteristics influence the extent to which a practice uses ICT. Also, educational and interaction activities positively influence ICT use. Furthermore, we find strong support of the influence of learning-by-using effects on intensity of ICT use.

The standardized prescribing ratio--a new method for comparing prescribing between GPs, controlling for patient age and sex.

To develop a method for comparing the proportion of patients on any drug or group of drugs for individual GP patient panels in Ireland, taking account of the age and sex structure of the panel. Calculations based on prescribing data for the fourth-quarter of 1995 supplied by the Irish General Medical Services Payments Board for the Eastern Health Board area.Setting-Five hundred and fifty Irish general practices serving 355,000 persons entitled to free medical care under the General Medical Services Scheme in the Eastern Health Board area (28% of the population). Weightings for number of persons prescribed each of four drug groups, and all drugs combined, for 22 age/sex groupings, leading to a single age/sex adjusted prescribing index-the standardized prescribing ratio (SPR) for each GPs practice population. The SPRs showed a large amount of variation from the average figure of 100 for practices of 1000 or more patients for all drugs and for each of the four drug groups studied: all drugs 54-125, antibiotics 52-165, H(2) antagonists/proton pump inhibitors 38-197, antidepressants 13-213 and thyroxine 33-175. Practices with above average SPRs for all drugs, antibiotics and H(2) antagonists/proton pump inhibitors were significantly larger than those with below-average SPRs. Practices with below average SPRs for thyroxine were significantly larger than those with above-average SPRs. The SPR provides a useful age/sex adjusted method of comparing prescribing between GPs and it can be applied to any drug or group of drugs.