Contexts and mechanisms relevant to General Practitioner (GP) based interventions to reduce adverse drug events (ADE) in community dwelling older adults: a rapid realist review.

Background: Older adults in Ireland are at increased risk of adverse drug events (ADE) due, in part, to increasing rates of polypharmacy. Interventions to reduce ADE in community dwelling older adults (CDOA) have had limited success, therefore, new approaches are required.A realist review uses a different lens to examine why and how interventions were supposed to work rather than if, they worked. A rapid realist review (RRR) is a more focused and accelerated version.The aim of this RRR is to identify and examine the contexts and mechanisms that play a role in the outcomes relevant to reducing ADE in CDOA in the GP setting that could inform the development of interventions in Ireland. Methods: Six candidate theories (CT) were developed, based on knowledge of the field and recent literature, in relation to how interventions are expected to work. These formed the search strategy. Eighty full texts from 633 abstracts were reviewed, of which 27 were included. Snowballing added a further five articles, relevant policy documents increased the total number to 45. Data were extracted relevant to the theories under iteratively developed sub-themes using NVivo software. Results: Of the six theories, three theories, relating to GP engagement in interventions, relevance of health policy documents for older adults, and shared decision-making, provided data to guide future interventions to reduce ADEs for CDOA in an Irish setting. There was insufficient data for two theories, a third was rejected as existing barriers in the Irish setting made it impractical to use. Conclusions: To improve the success of Irish GP based interventions to reduce ADEs for CDOA, interventions must be relevant and easily applied in practice, supported by national policy and be adequately resourced. Future research is required to test our theories within a newly developed intervention.

Increasing evidence-based treatments to reduce coronary heart disease mortality in Sweden: quantifying the potential gains.

OBJECTIVES: Between 1986 and 2002, coronary heart disease (CHD) mortality in Sweden fell by more than 50%. Approximately one-third (4800 fewer deaths) of this decline in age-adjusted CHD mortality could be attributed to treatments in patients with CHD and primary prevention medications. High treatment levels were achieved in some cases, but in others, only 50-80% of eligible patients received appropriate therapy. We therefore examined to what extent increasing the use of specific treatments in eligible patients might have reduced CHD mortality rates in Sweden. DESIGN AND METHODS: We used the previously validated IMPACT CHD model to combine data on CHD patient numbers, medical and surgical uptake levels and treatment effectiveness. We estimated the number of deaths prevented or postponed for 2002 (baseline scenario) and for an alternative scenario (if at least 60% of eligible patients were treated). RESULTS: If treatments were increased to consistently cover at least 60% of eligible patients, approximately 8900 deaths could have been postponed or prevented, representing a potential gain of approximately 4100 fewer deaths than actually occurred in 2002. Approximately 45% of the 4100 gain would have come from primary prevention with statins, 23% from acute coronary syndrome treatments, 15% from secondary prevention therapies and 15% from treatments for heart failure. CONCLUSION: Increasing the proportion of eligible patients with CHD who receive evidence-based treatment could have resulted in approximately 4100 fewer deaths in 2002, almost doubling the actual mortality reduction. These findings further emphasize the importance of aggressively identifying and treating patients with CHD and high-risk individuals.

Evidence for a Diagenetic Origin of Vera Rubin Ridge, Gale Crater, Mars: Summary and Synthesis of Curiosity's Exploration Campaign.

This paper provides an overview of the Curiosity rover's exploration at Vera Rubin ridge (VRR) and summarizes the science results. VRR is a distinct geomorphic feature on lower Aeolis Mons (informally known as Mount Sharp) that was identified in orbital data based on its distinct texture, topographic expression, and association with a hematite spectral signature. Curiosity conducted extensive remote sensing observations, acquired data on dozens of contact science targets, and drilled three outcrop samples from the ridge, as well as one outcrop sample immediately below the ridge. Our observations indicate that strata composing VRR were deposited in a predominantly lacustrine setting and are part of the Murray formation. The rocks within the ridge are chemically in family with underlying Murray formation strata. Red hematite is dispersed throughout much of the VRR bedrock, and this is the source of the orbital spectral detection. Gray hematite is also present in isolated, gray-colored patches concentrated toward the upper elevations of VRR, and these gray patches also contain small, dark Fe-rich nodules. We propose that VRR formed when diagenetic event(s) preferentially hardened rocks, which were subsequently eroded into a ridge by wind. Diagenesis also led to enhanced crystallization and/or cementation that deepened the ferric-related spectral absorptions on the ridge, which helped make them readily distinguishable from orbit. Results add to existing evidence of protracted aqueous environments at Gale crater and give new insight into how diagenesis shaped Mars' rock record.

Prescribing for patients with diabetes in the community drug schemes.

The aim of the study was to examine the management of diabetes patients particularly in relation to secondary preventative therapies within the community drug schemes across the health board regions in Ireland. The study population was identified using two national primary care prescribing databases from the Long Term Illness (LTI) and General Medical Services (GMS) scheme for 2003. 65,593 patients were identified as having 'treated' diabetes. Logistic regression was used to predict the likelihood of receiving secondary preventative therapies by region and drug scheme using adjusted odds ratios (ORs) and 95% confidence intervals (CI). The proportion of diabetes patients in each drug scheme with Ischaemic Heart Disease (IHD) was also calculated. Prevalence of 'treated' diabetes was calculated for each health board also. Regional and scheme-based variations within each region exist in the prescribing of secondary preventative therapies after adjustment for IHD rates. Prevalence of treated diabetes varied between regions from 1.5% in the Eastern region to 2.2% in the Southern region. While the location of specialised diabetes clinics may be a contributing factor, inequalities in prescribing across regions within the drug schemes are apparent.

"Best practice' for Helicobacter pylori eradication in the primary care setting.

This study determined the relative cost effectiveness of proton pump inhibitor (PPI) based triple therapy regimens for Helicobacter pylori eradication in the primary care setting. Using decision tree analysis the expected cost for each H. pylori eradication strategy was determined from the cost of each treatment option multiplied by the probability of that option occurring. Probabilities were obtained using the GMS prescribing database where all patients who received amoxycillin, clarithromycin and a PPI in the ERHA region in 2002 were followed for one year. Depending on the regimen adopted, 40.8% to 46.1% of patients did not require any further medication in the year following H. pylori eradication treatment. The strategy of rabeprazole, amoxycillin and clarithromycin was the most cost effective option with a cost of Euro466 per asymptomatic patient. Two-way sensitivity analysis indicated that the cost of rabeprazole triple therapy and the duration of rabeprazole maintenance therapy would each have to increase by 30% before this strategy ceased to be the most cost effective and hence best practice option for eradicating Helicobacter pylori in the primary care setting in Ireland.

On the same page: a novel interprofessional model of patient-centered perinatal consultation visits.

OBJECTIVE: To plan and implement an interprofessional collaborative care clinic for women in midwifery care needing a consultation with a maternal-fetal medicine specialist. STUDY DESIGN: A community-engaged design was used to develop a new model of collaborative perinatal consultation, which was tested with 50 women. Participant perinatal outcomes and semistructured interviews with 15 women (analyzed using qualitative descriptive analysis) and clinic providers were used to evaluate the model. RESULTS: Participant perinatal outcomes following a simultaneous consultation visit involving a nurse-midwife and maternal-fetal medicine specialist were similar to practice and hospital averages. Women's comments on their experience were positive and had the theme 'on the same page' with six subcategories: clarity, communication, collaboration, planning, validation and 'above and beyond'. Providers also were pleased with the model. CONCLUSION: A simultaneous consultation involving the woman, a nurse-midwife and a maternal-fetal medicine specialist improved communication and satisfaction among women and providers.

Benzodiazepine prescribing in children under 15 years of age receiving free medical care on the General Medical Services scheme in Ireland.

OBJECTIVE: To examine the prevalence and secular trends in benzodiazepine (BZD) prescribing in the Irish paediatric population. In addition, we examine coprescribing of antiepileptic, antipsychotic, antidepressant and psychostimulants in children receiving BZD drugs and compare BZD prescribing in Ireland to that in other European countries. SETTING: Data were obtained from the Irish General Medical Services (GMS) scheme pharmacy claims database from the Health Service Executive (HSE)--Primary Care Reimbursement Services (PCRS). PARTICIPANTS: Children aged 0-15 years, on the HSE-PCRS database between January 2002 and December 2011, were included. PRIMARY AND SECONDARY OUTCOME MEASURES: Prescribing rates were reported over time (2002-2011) and duration (≤ or >90 days). Age (0-4, 5-11, 12-15) and gender trends were established. Rates of concomitant prescriptions for antiepileptic, antipsychotics, antidepressants and psychostimulants were reported. European prescribing data were retrieved from the literature. RESULTS: Rates decreased from 2002 (8.56/1000 GMS population: 95% CI 8.20 to 8.92) to 2011 (5.33/1000 GMS population: 95% CI 5.10 to 5.55). Of those children currently receiving a BZD prescription, 6% were prescribed BZD for >90 days. Rates were higher for boys in the 0-4 and 5-11 age ranges, whereas for girls they were higher in the 12-15 age groups. A substantial proportion of children receiving BZD drugs are also prescribed antiepileptic (27%), antidepressant (11%), antipsychotic (5%) and psychostimulant (2%) medicines. Prescribing rates follow a similar pattern to that in other European countries. CONCLUSIONS: While BZD prescribing trends have decreased in recent years, this study shows that a significant proportion of the GMS children population are being prescribed BZD in the long term. This study highlights the need for guidelines for BZD prescribing in children in terms of clinical indication and responsibility, coprescribing, dosage and duration of treatment.

Randomized comparison of oral misoprostol and oxytocin for labor induction in term prelabor membrane rupture.

OBJECTIVES: To compare labor induction intervals between oral misoprostol and intravenous oxytocin in women who present at term with premature rupture of membranes. METHODS: One hundred eight women were randomly assigned to misoprostol 50 microg orally every 4 hours as needed or intravenous oxytocin. The primary outcome measure was time from induction to vaginal delivery. Sample size was calculated using a two-tailed alpha of 0.05 and power of 80%. RESULTS: Baseline demographic data, including maternal age, gestation, parity, Bishop score, birth weight, and group B streptococcal status, were similar. The mean time +/-standard deviation to vaginal birth with oral misoprostol was 720+/-382 minutes compared with 501+/-389 minutes with oxytocin (P = .007). The durations of the first, second, and third stages of labor were similar. There were no differences in maternal secondary outcomes, including cesarean birth (eight and seven, respectively), infection, maternal satisfaction with labor, epidural use, perineal trauma, manual placental removal, or gastrointestinal side effects. Neonatal outcomes including cord pH, Apgar scores, infection, and admission to neonatal intensive care unit were not different. CONCLUSION: Although labor induction with oral misoprostol was effective, oxytocin resulted in a shorter induction-to-delivery interval. Active labor intervals and other maternal and neonatal outcomes were similar.

Do GPs have the techniques for 'watchful waiting' in glue ear?

'Watchful waiting' for glue ear in children within primary care as a precursor or alternative to surgery is one of the increasing pressures on general practitioners (GPs) to limit outpatient referrals. An equipment survey questions whether primary care is properly equipped to 'watch', given the limited access to audiological equipment that might objectively underpin a decision on when 'waiting' should end.

Inequalities in prescribing of secondary preventative therapies for ischaemic heart disease in Ireland.

The study aim is to quantify the variation in prescribing rates of secondary preventative therapies for Ischaemic Heart Disease (IHD) across regions, age and gender. Patients receiving any prescriptions for a nitrate during a one year period (September 1999-August 2000) were considered using a national primary care prescribing database. Age-sex standardised prescribing rates of four secondary preventative therapies for IHD (Ace inhibitors, beta-blockers, aspirin, statins) were calculated for each region. Wide variations between regions were observed with significantly higher variability for Ace inhibitors compared with aspirin (F-ratio=22.8, p<0.001). Men were more likely to prescribed these therapies and the elderly were less likely (except Ace inhibitors). The study suggests that access to secondary preventative therapy is not equitable across regions, gender and age in Ireland. The wide variability may be due to uncertainty in prescribing secondary preventative therapies and/or variability in clinical need between regions.

Munchausen syndrome by proxy abuse.

The difficulties in diagnosing Munchausen Syndrome by Proxy Abuse (MSbPA) are examined. The perpetrators of MSbPA are usually the victim's primary care giver. The warning signs of MSbPA include unexplained, prolonged and extraordinary illness with the signs and symptoms only being evident when the suspected perpetrator is present. Confrontation, exclusion and covert video surveillance are all possible routes to gaining further evidence. The problems associated with covert video surveillance are explored.

Predictors and moderators of response to internet-delivered Interpersonal Psychotherapy and Cognitive Behavior Therapy for depression.

BACKGROUND: By identifying which predictors and moderators lead to beneficial outcomes, accurate selection of the best initial treatment will have significant benefits for depressed individuals. METHOD: An automated, fully self-guided randomized controlled internet-delivered noninferiority trial was conducted comparing two new interventions (Interpersonal Psychotherapy [IPT; n=620] and Cognitive Behavioral Therapy [CBT; n=610]) to an active control intervention (MoodGYM; n=613) over a period of 4 weeks to spontaneous visitors of an internet-delivered therapy website (e-couch). A range of putative predictors and moderators (socio-demographic characteristics [age, gender, marital status, education level], clinical characteristics [depression/anxiety symptoms, disability, quality of life, medication use], skills [mastery and dysfunctional attitudes] and treatment preference) were assessed using internet-delivered self-report measures at baseline and immediately following treatment and at six months follow-up. Analyses were conducted using Mixed Model Repeated Measures (MMRM). RESULTS: Female gender, lower mastery and lower dysfunctional attitudes predicted better outcome at post-test and/or follow-up regardless of intervention. No overall differential effects for condition on depression as a function of outcome were found. However, based on time-specific estimates, a significant interaction effect of age was found. For younger people, internet-delivered IPT may be the preferred treatment choice, whereas older participants derive more benefits from internet-delivered CBT programs. LIMITATIONS: Although the sample of participants was large, power to detect moderator effects was still lacking. CONCLUSIONS: Different e-mental health programs may be more beneficial for specific age groups. The findings raise important possibilities for increasing depression treatment effectiveness and improving clinical practice guidelines for depression treatment of different age groups.

Hypertension in Ireland: public awareness and doctors choice of therapy.

BACKGROUND: Hypertension is the commonest medical condition in Ireland. AIMS: (1) To examine the level of awareness of blood pressure (BP) in the population and (2) to ascertain the opinion of general practitioners (GPs) in diagnosis and management of hypertension. METHODS: BP measurements and assessment of BP awareness were performed in a sub-sample of the general population (n = 1,071). The opinion of GPs (n = 1,037) on hypertension was determined in a postal survey. RESULTS: Amongst the population sampled (45 ± 13 years, mean age ± SD), almost half had elevated BP (>140/90 mmHg) but only half of those were already on antihypertensives. 40% had no knowledge of their BP and 54% were not aware of what constituted normal BP. While some 80% of GPs said they followed British guidelines, their practice was more in keeping with the European guidelines. Approximately, 90% of GPs required ambulatory BP recording to confirm diagnosis of hypertension. First choice antihypertensive agents were ACE inhibitors and angiotensin receptor antagonists in younger patients and diuretics and ACE inhibitors in older patients. CONCLUSION: These results suggest that there is a need for further public education on BP and nationally agreed hypertension guidelines.

The application of prescribing indicators to a primary care prescription database in Ireland.

OBJECTIVE: To develop appropriate prescribing indicators and apply these to Irish prescription data. METHODS: A postal survey of 145 randomly selected general practitioners working within the Eastern Health Board region of the State-supported General Medical Services scheme in Ireland regarding the applicability of selected prescribing indicators was carried out. Such indicators were then applied to aggregate prescription data. RESULTS: Prescribing indicators based on agents of questionable efficacy/poor quality prescribing and those based on good prescribing practice were thought to make suitable indicators. Low rates of prescribing were noted for indicators based on drugs of limited efficacy, e.g. cerebral and peripheral vasodilators (rate 3.1 per 1,000 prescriptions), whilst indicators based on drugs associated with good prescribing practice were associated with higher prescribing rates, e.g. the prescription of aspirin in patients receiving nitrate therapy(rate 7.13 per 1,000 patients). However, a low rate of generic prescribing (4.6%) was found amongst general practitioners in the study. The largest variability in prescribing was seen with the prescribing of peripheral and cerebral vasodilators (75th/25th centile=5.6) and the prescription of long-acting sulphonylureas (75th/25th centile=66.6). CONCLUSIONS: Quality indicators based on aggregate prescribing provide valuable information on prescribing standards and should be developed with the close involvement of prescribers.

The utilization review program. Essential for hospital survival.

The survival of a health care institution in today's economic climate is dependent on, among other things, the efficiency of its utilization review program. The purpose of this article is to serve as a basic guideline for an institution to develop an adequate utilization review program. It emphasizes that a utilization review program is essential for the economic survival of any health care industry. The utilization review program should be an integrated organization with the support of administration, and the participation of staff physicians, physician advisors, review nurses, and important hospital departments, such as social service, laboratory, medical records, preplanning, and so forth. Following the format presented in this paper, an institution may easily develop a utilization review program. The ideas presented in this paper have been time-proven at our institution. There must be educational programs for physicians on the basics of managing patients according to the prospective payment system and the economic impact physicians can make on the hospital's economic status. These educational presentations must take place as often as necessary to reinforce policy and procedure, and to carry out effective patient management. The utilization review department, as well as the medical staff, must work in close harmony with administration to assist the facility in surviving trying economical times.

Under-prescribing of cardiovascular therapies for diabetes in primary care.

OBJECTIVE: To determine the extent to which cardiovascular therapies are prescribed in primary care for those with diabetes, compared with those without diabetes. METHODS: Population study of patients with and without diabetes identified using a national primary care prescribing database. All patients receiving a prescription for any diabetes therapy, including insulin and oral hypoglycaemic drugs, or diagnostic test kit for glucose ( n=8523) and those receiving no such therapies ( n=145,756) during a 1-year period (September 1999-August 2000) in the Eastern Regional Health Authority of Ireland were identified. In addition, a sub-set of patients receiving a nitrate prescription, a marker for ischaemic heart disease (IHD), were also identified ( n=14,826). Odds ratios and 95% confidence intervals for prescribing of cardiovascular therapies between those with diabetes and those without, adjusted for age and gender, were calculated using logistic regression. RESULTS: The proportion of those (and 95% CES) with diabetes and IHD prescribed secondary preventative therapies was 37.3% (35.0, 39.6) for statins, 55.3% (53.0, 57.6) for angiotension converting enzyme inhibitors, 34.7% (32.5, 36.9) for beta blockers, 73.3% (71.2, 75.4) for aspirin, 4.4% (3.4, 5.4) for angiotensin-II antagonists and 2.5% (1.8, 3.2) for fibrates. The adjusted odds ratios for prescribing in those with diabetes compared with those without are 1.44 (1.30, 1.61) for statins, 3.09 (2.79, 3.42) for angiotension converting enzyme inhibitors, 0.82 (0.74, 0.91) for beta blockers, 1.23 (1.09, 1.38) for aspirin, 1.47 (1.13, 1.87) for angiotensin-II receptor blockers and 4.23 (2.88, 6.14) for lipid-lowering fibrates. CONCLUSION: The greater rate of prescribing of cardiovascular therapies in those with diabetes relative to those without is not unexpected given the higher risk of coronary heart disease in those with diabetes. However, the proportion of patients with diabetes, particularly those with established IHD, prescribed cardiovascular therapies is considerably below that recommended in local and international guidelines.

The measurement iterative loop: a framework for the critical appraisal of need, benefits and costs of health interventions.

A framework for organizing health services data is presented that subdivides the spectrum of health information into subgroups that constitute a logical progression from quantifying the burden of illness, through identifying its likely causes, to validating interventions that prevent or ameliorate it and evaluating their efficiency, to monitoring the application of these interventions and coming full-circle to determine whether the burden of illness has been reduced.