Child Health Care in Ireland.

The Irish health care system is based on a complex and costly mix of private, statutory, and voluntary provisions. The majority of health care expenditure comes from the state, with a significant proportion of acute hospital care funded from private insurance, but there are relatively high out-of-pocket costs for most service users. There is free access to acute hospital care, but not for primary care, for all children. About 40% of the population have free access to primary care. Universal preventive public health services, including vaccination and immunization, newborn blood spot screening, and universal neonatal hearing screening are free. Major health challenges include poverty, obesity, drug and alcohol use, and mental health. The health care system has been dominated for the last 5 years by the impact of the current recession, which has led to very sharp cuts in health care expenditure. It is unclear if the necessary substantial reform of the system will happen. Government policy calls for a move toward a patient-centered, primary care-led system, but without very substantial transfers of resources and investment in Information and Communication Technology, this is unlikely to occur.

National and subnational hypertension prevalence estimates for the Republic of Ireland: better outcome and risk factor data are needed to produce better prevalence estimates.

BACKGROUND: Hypertension is a global public health challenge. National prevalence estimates can conceal important differences in prevalence in subnational areas. This paper aims to develop a consistent set of national and subnational estimates of the prevalence of hypertension in a country with limited data for subnational areas. METHODS: A nationally representative cross-sectional Survey of Lifestyle, Attitudes and Nutrition (SLÁN) 2007 was used to identify risk factors and develop a national and a subnational model of the risk of self-reported, doctor-diagnosed hypertension among adults aged 18+ years in the Republic of Ireland. The subnational model's group-specific risk estimates were applied to group-specific population count estimates for subnational areas to estimate the number of adults with doctor-diagnosed hypertension in subnational areas in 2007. A sub-sample of older adults aged 45+ years who also had their blood pressure objectively measured using a sphygmomanometer was used to estimate the national prevalence of diagnosed and undiagnosed hypertension among adults aged 45+ years. RESULTS: The prevalence of self-reported, doctor-diagnosed hypertension among adults aged 18+ years was 12.6% (95% CI = 11.7%-13.4%). After adjustment for other explanatory variables the risk of self-reported, doctor-diagnosed hypertension was significantly related to age (p < 0.001), body mass index (p < 0.001), smoking (p = 0.001) and fruit and vegetable consumption (p = 0.003). Among adults aged 45+ years the prevalence of undiagnosed hypertension (38.7% (95% CI 34.6%-42.8%)) was higher than self-reported, doctor-diagnosed hypertension (23.4% (95% CI = 22.0%-24.7%)). Among adults aged 45+ years, the prevalence of undiagnosed hypertension was higher among men (46.8%, 95% CI 41.2%-52.4%) than women (31.2%, 95% CI 25.7%-36.6%). There was no significant variation in the prevalence of self-reported, doctor-diagnosed hypertension across subnational areas. CONCLUSIONS: Services need to manage diagnosed hypertension cases and to detect and manage undiagnosed cases. Further population level improvements in lifestyle risk factors for hypertension are key in developing a more integrated approach to prevent cardiovascular disease. Better subnational data on hypertension outcomes and risk factors are needed to better describe the distribution of hypertension risk and hypertension prevalence in subnational areas.

Impact of the introduction of a new policy of direct faecal immunochemical home screening test provision in a national bowel screening programme, both during and outside of advertising campaigns.

BACKGROUND: BowelScreen, The National Bowel Screening Programme in Ireland, offers free colorectal screening to persons aged 60-69 through a home Faecal Immunochemical Test (FIT) kit. 40.2% uptake in the first screening round was below the programme standard (≥50.0%). To improve uptake, an intervention saw FIT kits sent directly to previously screened clients rather than by the usual invitation process comprising a letter of invitation followed by a FIT kit if requested. The intervention proved successful and was fully implemented into the programme for subsequent clients. Despite the improved uptake it was noted over time that the unsatisfactory FIT rate was approaching the programme standard (≤3%). The aim of this study is to compare uptake by two invite methods occurring contemporaneously alongside advertising and to compare unsatisfactory rates before and after full FIT-Direct implementation. METHODS: Percentage uptake and 95% confidence intervals (CI) were calculated for each invite method before and after advertising and compared using two-proportion z-tests. Rate ratios and 95% CI compared the unsatisfactory FIT rate before and after full-FIT Direct implementation. RESULTS: Uptake was significantly higher amongst FIT-Direct compared with Usual-Invite clients during (91.0% vs 84.9%, p < 0.0001) and outside advertising (93.8% vs 85.3%, p < 0.0001). The unsatisfactory FIT rate was 2.3 times higher (95% CI: 1.84-2.92, p < 0.0001) after full FIT-Direct implementation compared with before. CONCLUSIONS: The FIT-Direct intervention had an overall positive effect on uptake. After adjusting for advertising, uptake of FIT was higher outside advertising periods. Monitoring of the unsatisfactory rate is ongoing; a communication enhancement strategy may be required should this persist.

A National Bowel Cancer Screening Programme using FIT: Achievements and Challenges.

Colorectal cancer accounts for 11% of all cancer-related deaths in Ireland. With the aim of diagnosing these cancers at an earlier stage, and detecting premalignant lesions, the National Screening Service (NSS) offered a fecal immunochemical test (FIT) to all individuals aged 60 to 69. All individuals in the age range were contacted by post and invited to participate in the programme. Those with a positive FIT result were offered a colonoscopy in an internationally accredited unit. From an eligible population of 488,628, 196,238 individuals participated giving an uptake of 40.2%. Commencing at a FIT threshold of 20 µg Hg/g feces, the positivity rate was 8.6%, which overwhelmed colonoscopy capacity and, thus, the threshold was increased to 45 µg, resulting in an overall 5% positivity rate. A total of 520 individuals had cancer detected (68.3% stage I or II), of which 104 were removed endoscopically (pT1s). Adenomas were present in 54.2% of all colonoscopies, 17.4% deemed high risk. Despite a lower uptake, males were twice as likely to have colorectal cancers as females and had a 59% increased rate of high-risk adenomas diagnosed. Challenges facing the programme include increasing participation, especially among males, and increasing colonoscopy capacity. The ability to alter the sensitivity of FIT to match colonoscopy capacity is a valuable option for such a programme as it ensures that the maximum public health benefit can be achieved within available resources.

Prevalence of diabetes in the Republic of Ireland: results from the National Health Survey (SLAN) 2007.

BACKGROUND: Current estimates of diabetes prevalence in the Republic of Ireland (RoI) are based on UK epidemiological studies. This study uses Irish data to describe the prevalence of doctor-diagnosed diabetes amongst all adults aged 18+ years and undiagnosed diabetes amongst those aged 45+ years. METHODS: The survey of lifestyle attitudes and nutrition (SLAN) 2007 is based on a nationally representative sample of Irish adults aged 18+ years (n = 10,364). Self-reported doctor-diagnosed diabetes was recorded for respondents in the full sample. Diabetes medication use, measured height and weight, and non-fasting blood samples were variously recorded in sub-samples of younger (n = 967) and older (n = 1,207) respondents. RESULTS: The prevalence of doctor-diagnosed diabetes amongst adults aged 18+ years was 3.5% (95% CI 3.1%-3.9%). After adjustment for other explanatory variables; the risk of self-reported doctor-diagnosed diabetes was significantly related to age (p < 0.0001), employment status (p = 0.0003) and obesity (p = 0.0003).Amongst adults aged 45+ years, the prevalence of doctor-diagnosed diabetes was 6.1% (95% CI 5.3% - 6.9% ) [corrected] and undiagnosed diabetes was 2.8% (95% CI 1.4% - 4.1%). This represented 31.2% of diabetes cases in this age group. CONCLUSION: Notwithstanding methodological differences, these prevalence estimates are consistent with those in the UK and France. However, the percentage of undiagnosed cases amongst adults aged 45+ years appears to be higher in the RoI. Increased efforts to improve early detection and population level interventions to address adverse diet and lifestyle factors are urgently needed.