General Practice - Doctoral Theses

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    Development of an intervention to improve the management of behavioural and psychological symptoms of dementia in general practice in Ireland
    (University College Cork, 2018-12-01) Jennings, Aisling A.; Bradley, Colin P.; Coffey, Alice; Browne, John P.; Health Service Executive, Ireland; Atlantic Philanthropies; Irish College of General Practitioners
    Background General practitioners (GPs) play a pivotal and increasing role in the care of people with dementia. However, GPs are challenged by the complexities of dementia care. A triangulated educational needs analysis conducted by the PREPARED project identified that GPs find the management of behavioural and psychological symptoms of dementia (BPSD) a particularly challenging aspect of dementia care. BPSD encompasses a wide range of non-cognitive symptoms such as anxiety and hallucinations that affect people with dementia. Although BPSD has been identified as a challenging area for GPs, an area in which they lack confidence, we do not have a good understanding of why this is a challenging area for GPs or the root causes of their lack of confidence. Furthermore, evidence suggests that current management of BPSD is sub-optimal. In BPSD non-pharmacological strategies are recommended first-line but uptake of these strategies is low. Despite their adverse effects, potentially harmful pharmacological treatments, such as antipsychotics, are frequently employed. Interventions are needed to improve the management of BPSD. It is apposite that these interventions should target GPs. However, interventions to date to improve the management of BPSD have either not targeted GPs or not effectively involved GPs in intervention development, a notable gap in the literature. Aim To enhance our understanding of the management of BPSD in general practice with a view to informing a theoretically-based, behaviour change intervention to improve the management of BPSD. Methods This was a mixed methods study underpinned by the UK Medical Research Council (MRC) guidance on the development of complex interventions in health care. Existing evidence on GPs’ knowledge of, attitudes towards and experiences with BPSD was systematically reviewed using a mixed methods approach and synthesised using meta-ethnography. Findings of this review were supplemented with new evidence from three studies. A descriptive interpretive qualitative study which explored GPs experiences of managing BPSD. The data collected from 16 semi-structured interviews with a purposively selected sample of GPs were then thematically analysed. The second study was a cross-sectional descriptive study which assessed GPs’ knowledge of and attitudes towards pain in dementia, a key trigger for BPSD. In this study, a postal questionnaire was sent to a census sample of all GPs in Cork. The results were statistically analysed to explore associations between demographic data and responses. To further investigate the findings of the qualitative study a descriptive cross-sectional study was conducted that aimed to explore the knowledge and attitudes of GPs to the prescribing of antipsychotics in people with dementia. The study used an anonymous postal questionnaires that was sent to a census sample of all GPs based in Cork and Kerry. To develop the intervention, results from the systematic review, the qualitative and the two cross-sectional studies were integrated, using the behavioural change theoretical approach outlined in the Behaviour Change Wheel (BCW). In addition, a modified eDelphi study was conducted with multidisciplinary experts on antipsychotic prescribing in dementia. The eDelphi study helped to achieve consensus on the clinical components of the intervention. Findings The over-arching finding from the systematic review was that a lack of practical, implementable non-pharmacological treatment strategies created a therapeutic void for GPs, which led to over-reliance on family caregivers and on psychotropic medications. In the qualitative study some GPs described the challenges of managing BPSD as insurmountable and many struggled at an ethical level with the decision to prescribe potentially harmful psychotropic medication but felt they had little else to offer. Key challenges identified by GPs were; stretched resources, unrealistic expectations and a lack of implementable clinical guidelines. The cross-sectional descriptive study of GPs’ knowledge of and attitudes towards the management of pain identified aspects of GPs’ management of pain in dementia that could be improved upon and highlighted the importance of good relationships between GP and nursing home staff when managing dementia. The descriptive cross-sectional study of GPs’ attitudes towards antipsychotic prescribing in dementia found that the majority of GPs recommended non-pharmacological strategies first line when managing BPSD. The GPs reported that the main influencers of prescribing antipsychotics in BPSD were nursing staff and family. Of note the majority of respondents did not routinely monitor antipsychotic prescribing in people with dementia Using the approach outlined in the Behaviour Change Wheel the findings of these four studies were used to select an aspect of GPs’ behaviour in the management of BPSD to target with an intervention: ‘GPs to systematically monitor their prescribing of antipsychotic medication to people with dementia in nursing home settings’. To address this behaviour, a three-component intervention was developed, consisting of: an interprofessional educational session with GPs and nursing home staff; a repeat prescribing monitoring tool and the facilitation of a self-audit. Conclusion The research presented in this thesis adds depth to existing literature and advances our knowledge of the management of BPSD in general practice. Prior to this research it was known that GPs found BPSD challenging but the reasons for why GPs found BPSD to be challenging had not been explored. This research offers new insights into GPs’ perspectives on the management of BPSD. This new insight helps to explain apparent discrepancies between best practice recommendations in BPSD and real-life clinical practice. This deeper understanding of GPs’ management of BPSD informed the development of an intervention to improve an aspect of BPSD management that was identified as being sub-optimal. The intervention developed focuses on GP self-monitoring of their prescribing of antipsychotic medication to people with BPSD in nursing home settings. This intervention has the potential to improve GPs’ management of BPSD.
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    Medication error at the primary secondary care interface: costs, causes, consequences
    (University College Cork, 2019) Walsh, Elaine K.; Kearney, Patricia M.; Bradley, Colin P.; Sahm, Laura; Irish College of General Practitioners; MediSec Ireland; University College Cork
    Background: Medication error is an important patient safety issue worldwide and results in morbidity, mortality and economic burden. The true cost of medication error is unclear from current evidence. Medication error is particularly common at the primary secondary care interface as patients move between hospital and the community. Developing interventions to reduce medication error (and in particular error at this interface in care) is currently an international priority. Existing interventions, such as medication reconciliation, are often resource intensive. Within healthcare systems, where resources are limited, measures to reduce costs and improve process efficiency are required in addition to optimising patient care. Aim: The overarching aim of this thesis is to examine medication error at the primary secondary care interface in terms of cost, causes and consequences in order to develop a pragmatic intervention to facilitate its reduction. Structure and methods: The Medical Research Council, UK (MRC) guidance on the development and evaluation of complex interventions in healthcare was employed. Existing evidence on the cost of medication error was systematically reviewed and synthesised in a narrative synthesis. A cost per error was extracted and expressed in Euro. A cross-sectional study was conducted. The study examined an existing process of medication reconciliation in terms of factors predicting time burden and associated financial cost. Logistic regression was used to investigate associations between patient characteristics and clinically significant errors and additional time. Cost for additional time was calculated in terms of hospital pharmacist salary. The new evidence generated was used, along with the existing evidence base, to develop a novel intervention aiming to reduce the occurrence of medication error at the primary secondary care interface. The intervention, the PHARMS (Patient Held Active Record of Medication Status) device, is a patient held electronic record used to transmit medication information between primary and secondary care. The intervention was evaluated by a mixed methods feasibility study (non-randomised controlled intervention and a process evaluation of qualitative interviews and non-participant observation). The study was informed by the Consolidated Framework for Implementation Research (CFIR). The occurrence of medication error was compared between groups and factors associated with medication error investigated using negative binomial regression. Thematic analysis of data from semi-structured interviews with key stakeholders was conducted. Results: Systematic review: 16 studies were included in the systematic review. The review identified that medication error is associated with significant economic impact with an associated cost of up to €111,727.08 per error. In view of the limited parameters used to establish economic impact, it was concluded that the true economic burden of medication error may have been underestimated to date. Cross-sectional study: 89 patients were included. Having a personal record of medication at admission (OR 3.30, 95% CI: (1.05 to 10.42), p=0.004) was a significant predictor of additional time. No significant associations were found between the occurrence of clinically significant error and additional time (p>0.05). The most common reason for additional time was clarifying issues pertaining to communication of medication information from primary care. Projected annual five year costs for the mean additional time of 3.75 minutes of the study were €1.8-1.9 million. Feasibility study: 102 patients were included (Intervention n=41, Control n=63). Total error number was lower in the intervention group Median=1 (0,3 IQR) than the control group Median=8 (4,13.5 IQR) p< 0.001, with the clinical significance score in the intervention group Median= 2 (IQR 0,4) also being lower than the control group Median=11 (IQR 5,20) p< 0.001. The device was found to be technically implementable using existing IT infrastructure and acceptable to all key stakeholders. Conclusion: Medication error is a costly problem, the true extent of which may have been underestimated. Issues pertaining to communication of medication information at the primary secondary care interface were identified as contributing to the economic burden associated with medication reconciliation. In addition, it was identified that increasing time for medication reconciliation may not necessarily result cost savings in terms of reducing medication error. The intervention developed as a result of this thesis may have the potential to facilitate more efficient medication reconciliation and reduce medication error at the interface of primary and secondary care. This may result in both clinical and economic benefit. Limitations: The overall numbers of patients included in the cross-sectional and feasibility studies in this thesis are small. In addition, these studies included only older adult patients in a single geographical location and involved a single hospital.
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    Development of an intervention to support medication management in patients with multimorbidity in primary care
    (University College Cork, 2016) Sinnott, Carol; Bradley, Colin P.; Health Research Board
    The overarching aim of this thesis was to develop an intervention to support patient-centred prescribing in the context of multimorbidity in primary care. Methods A range of research methods were used to address different components of the Medical Research Council, UK (MRC) guidance on the development and evaluation of complex interventions in health care. The existing evidence on GPs’ perceptions of the management of multimorbidity was systematically reviewed. In qualitative interviews, chart-stimulated recall was used to explore the challenges experienced by GPs when prescribing for multimorbid patients. In a cross-sectional study, the psychosocial issues that complicate the management of multimorbidity were examined. To develop the complex intervention, the Behaviour Change Wheel (BCW) was used to integrate behavioural theory with the findings of these three studies. A feasibility study of the new intervention was then conducted with GPs. Results The systematic review revealed four domains of clinical practice where GPs experienced difficulties in multimorbidity. The qualitative interview study showed that GPs responded to these difficulties by ‘satisficing’. In multimorbid patients perceived as stable, GPs preferred to ‘maintain the status quo’ rather than actively change medications. In the cross-sectional study, the significant association between multimorbidity and negative psychosocial factors was shown. These findings informed the development of the ‘Multimorbidity Collaborative Medication Review and Decision-making’ (MY COMRADE) intervention. The intervention involves peer support: two GPs review the medications prescribed to a complex multimorbid patient together. In the feasibility study, GPs reported that the intervention was appropriate for the context of general practice; was widely applicable to their patients with multimorbidity; and recommendations for optimising medications arose from all collaborative reviews. Conclusion Applying theory to empirical data has led to an intervention that is implementable in clinical practice, and has the potential to positively change GPs’ behaviour in the management of medications for patients with multimorbidity.
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    Lower extremity amputation in people with diabetes: Trends and determinants
    (University College Cork, 2014) Buckley, Claire M.; Perry, Ivan J.; Kearney, Patricia M.; Bradley, Colin P.; Health Research Board; Irish College of General Practitioners
    Introduction: The prevalence of diabetes is rising rapidly. Assessing quality of diabetes care is difficult. Lower Extremity Amputation (LEA) is recognised as a marker of the quality of diabetes care. The focus of this thesis was first to describe the trends in LEA rates in people with and without diabetes in the Republic of Ireland (RoI) in recent years and then, to explore the determinants of LEA in people with diabetes. While clinical and socio-demographic determinants have been well-established, the role of service-related factors has been less well-explored. Methods: Using hospital discharge data, trends in LEA rates in people with and without diabetes were described and compared to other countries. Background work included concordance studies exploring the reliability of hospital discharge data for recording LEA and diabetes and estimation of diabetes prevalence rates in the RoI from a nationally representative study (SLAN 2007). To explore determinants, a systematic review and meta-analysis assessed the effect of contact with a podiatrist on the outcome of LEA in people with diabetes. Finally, a case-control study using hospital discharge data explored determinants of LEA in people with diabetes with a particular focus on the timing of access to secondary healthcare services as a risk factor. Results: There are high levels of agreement between hospital discharge data and medical records for LEA and diabetes. Thus, hospital discharge data was deemed sufficiently reliable for use in this PhD thesis. A decrease in major diabetes-related LEA rates in people with diabetes was observed in the RoI from 2005-2012. In 2012, the relative risk of a person with diabetes undergoing a major LEA was 6.2 times (95% CI 4.8-8.1) that of a person without diabetes. Based on the systematic review and meta-analysis, contact with a podiatrist did not significantly affect the relative risk (RR) of LEA in people with diabetes. Results from the case-control study identified being single, documented CKD and documented hypertension as significant risk factors for LEA in people with diabetes whilst documented retinopathy was protective. Within the seven year time window included in the study, no association was detected between LEA in patients with diabetes and timing of patient access to secondary healthcare for diabetes management. Discussion: Many countries have reported reduced major LEA rates in people with diabetes coinciding with improved organisation of healthcare systems. Reassuringly, these first national estimates in people with diabetes in the RoI from 2005 to 2012 demonstrated reducing trends in major LEA rates. This may be attributable to changes in diabetes care and also, secular trends in smoking, dyslipidaemia and hypertension. Consistent with international practice, LEA trends data in Ireland can be used to monitor quality of care. Quantifying this improvement precisely, though, is problematic without robust denominator data on the prevalence of diabetes. However, a reduction in major diabetes-related LEA rates suggests improved quality of diabetes care. Much controversy exists around the reliability of hospital discharge data in the RoI. This thesis includes the first multi-site study to explore this issue and found hospital discharge data reliable for the reporting of the procedure of LEA and diagnosis of diabetes. This project did not detect protective effects of access to services including podiatry and secondary healthcare for LEA in people with diabetes. A major limitation of the systematic review and meta-analysis was the design and quality of the included studies. The data available in the area of effect of contact with a podiatrist on LEA risk are too sparse to say anything definitive about the efficacy of podiatry on LEA. Limitations of the case-control study include lack of a diabetes register in Ireland, restricted information from secondary healthcare and lack of data available from primary healthcare. Due to these issues, duration of disease could not be accounted for in the study which limits the conclusions that can be drawn from the results. The model of diabetes care in the RoI is currently undergoing a re-configuration with plans to introduce integrated care. In the future, trends in LEA rates should be continuously monitored to evaluate the effectiveness of changes to the healthcare system. Efforts are already underway to improve the availability of routine data from primary healthcare with the recent development of the iPCRN (Irish Primary Care Research Network). Linkage of primary and secondary healthcare records with a unique patient identifier should be the goal for the future.