Opportunistic atrial fibrillation screening in primary care in Ireland: results of a pilot screening programme.

BACKGROUND: Atrial fibrillation (AF), a common, frequently asymptomatic cardiac arrhythmia, is a major risk factor for stroke. Identification of AF enables effective preventive treatment to be offered, potentially reducing stroke risk by up to two-thirds. There is international consensus that opportunistic AF screening is valuable though uncertainty remains about the optimum screening location and method. Primary care has been identified as a potential location for AF screening using one-lead ECG devices. METHODS: A pilot AF screening programme is in primary care in the south of Ireland. General practitioners (GPs) were recruited from Cork and Kerry. GPs invited patients ≥65 years to undergo AF screening. The screening comprised a one-lead ECG device, Kardia Mobile, blood pressure check and ascertainment of smoking status. Possible AF on one-lead ECG was confirmed with a 12-lead ECG. GPs also recorded information including medical history, current medication and onward referral. The Keele Decision Support tool was used to assess patients for oral anticoagulation (OAC). RESULTS: 3555 eligible patients, attending 52 GPs across 34 GP practices, agreed to undergo screening. 1720 (48%) were female, 1780 (50%) were hypertensive and 285 (8%) were current smokers. On the one-lead ECG, 3282 (92%) were in normal sinus rhythm, 101 (3%) had possible AF and among 124 (4%) the one-lead ECG was unreadable or unclassified. Of the 101 patients with possible AF, 45 (45%) had AF confirmed with 12-lead ECG, an incidence rate of AF of 1.3%. Among the 45 confirmed AF cases, 27 (60%) were commenced on OAC therapy by their GP. CONCLUSION: These findings suggest that AF screening in primary care may prove useful for early detection of AF cases that can be assessed for treatment. One-lead ECG devices may be useful in the detection of paroxysmal AF in this population and setting. Current OAC of AF may be suboptimal.

Atrial fibrillation (AF) pilot screening programme in primary care in Ireland: an implementation study protocol.

INTRODUCTION: Atrial fibrillation (AF) is a major risk factor for stroke. There is a fivefold increase in stroke risk in the presence of AF. The irregular beating of the heart enables blood stasis which allows clots to form. These can migrate to the brain causing a stroke. AF is common and its incidence increases with age. AF is often asymptomatic and early detection enables effective preventive treatment reducing stroke risk by up to two-thirds.Stroke contributes significantly to morbidity and mortality globally. In Ireland, it is the leading cause of acquired disability and second leading cause of death. The cost associated with stroke is significant. Stroke risk increases with age and is a public health priority.Internationally, there is consensus among experts that AF screening is valuable. In Ireland, the National Cardiovascular Policy recommended establishing a screening programme. However, there are many ways to screen for AF including pulse palpation, mobile ECG devices, 12-lead ECG and personal health monitoring devices.This study aims to investigate the acceptability, feasibility and impact of AF screening in primary care using a handheld mobile ECG device. METHODS AND ANALYSIS: General practitioners (GPs) and practice nurses in the South of Ireland will opportunistically screen patients aged ≥65 years for AF at routine consultation using a handheld one-lead ECG device, KardiaMobile. This study will screen up to 4000 patients. Blood pressure and smoking status will be checked concurrently. A mixed-method evaluation will be undertaken including a partial economic evaluation. Anonymised data will be collected from participating practices and qualitative interviews will be conducted with GP, nurse and patient participants. ETHICS AND DISSEMINATION: Ethical approval has been granted by the Clinical Research Ethics Committee in University College Cork. Dissemination will involve publication in peer-reviewed journals and presentation at national and international conferences.

Development of an intervention to facilitate implementation and uptake of diabetic retinopathy screening.

BACKGROUND: 'Implementation interventions' refer to methods used to enhance the adoption and implementation of clinical interventions such as diabetic retinopathy screening (DRS). DRS is effective, yet uptake is often suboptimal. Despite most routine management taking place in primary care and the central role of health care professionals (HCP) in referring to DRS, few interventions have been developed for primary care. We aimed to develop a multifaceted intervention targeting both professionals and patients to improve DRS uptake as an example of a systematic development process combining theory, stakeholder involvement, and evidence. METHODS: First, we identified target behaviours through an audit in primary care of screening attendance. Second, we interviewed patients (n = 47) and HCP (n = 30), to identify determinants of uptake using the Theoretical Domains Framework, mapping these to behaviour change techniques (BCTs) to develop intervention content. Thirdly, we conducted semi-structured consensus groups with stakeholders, specifically users of the intervention, i.e. patients (n = 15) and HCPs (n = 16), regarding the feasibility, acceptability, and local relevance of selected BCTs and potential delivery modes. We consulted representatives from the national DRS programme to check intervention 'fit' with existing processes. We applied the APEASE criteria (affordability, practicability, effectiveness, acceptability, side effects, and equity) to select the final intervention components, drawing on findings from the previous steps, and a rapid evidence review of operationalised BCT effectiveness. RESULTS: We identified potentially modifiable target behaviours at the patient (consent, attendance) and professional (registration) level. Patient barriers to consent/attendance included confusion between screening and routine eye checks, and fear of a negative result. Enablers included a recommendation from friends/family or professionals and recognising screening importance. Professional barriers to registration included the time to register patients and a lack of readily available information on uptake in their local area/practice. Most operationalised BCTs were acceptable to patients and HCPs while the response to feasibility varied. After considering APEASE, the core intervention, incorporating a range of BCTs, involved audit/feedback, electronic prompts targeting professionals, HCP-endorsed reminders (face-to-face, by phone and letter), and an information leaflet for patients. CONCLUSIONS: Using the example of an intervention to improve DRS uptake, this study illustrates an approach to integrate theory with user involvement. This process highlighted tensions between theory-informed and stakeholder suggestions, and the need to apply the Theoretical Domains Framework (TDF)/BCT structure flexibly. The final intervention draws on the trusted professional-patient relationship, leveraging existing services to enhance implementation of the DRS programme. Intervention feasibility in primary care will be evaluated in a randomised cluster pilot trial.

Hollow-Core Photonic Crystal Fiber Mach-Zehnder Interferometer for Gas Sensing.

A novel and compact interferometric refractive index (RI) point sensor is developed using hollow-core photonic crystal fiber (HC-PCF) and experimentally demonstrated for high sensitivity detection and measurement of pure gases. To construct the device, the sensing element fiber (HC-PCF) was placed between two single-mode fibers with airgaps at each side. Great measurement repeatability was shown in the cyclic test for the detection of various gases. The RI sensitivity of 4629 nm/RIU was demonstrated in the RI range of 1.0000347-1.000436 for the sensor with an HC-PCF length of 3.3 mm. The sensitivity of the proposed Mach-Zehnder interferometer (MZI) sensor increases when the length of the sensing element decreases. It is shown that response and recovery times of the proposed sensor inversely change with the length of HC-PCF. Besides, spatial frequency analysis for a wide range of air-gaps revealed information on the number and power distribution of modes. It is shown that the power is mainly carried by two dominant modes in the proposed structure. The proposed sensors have the potential to improve current technology's ability to detect and quantify pure gases.

Improving medication management for patients with multimorbidity in primary care: a qualitative feasibility study of the MY COMRADE implementation intervention.

BACKGROUND: For the majority of patients with multimorbidity, the prescription of multiple long-term medications (polypharmacy) is indicated. However, polypharmacy poses a risk of adverse drug events, drug interactions and excessive treatment burdens. To help general practitioners (GPs) conduct more comprehensive medication reviews for patients with multimorbidity, we developed the theoretically-informed MultimorbiditY COllaborative Medication Review And DEcision Making (MY COMRADE) implementation intervention. In this study, we assessed the feasibility and acceptability of MY COMRADE by GPs. METHODS: A non-randomised feasibility study using a qualitative framework approach was conducted. General practices were recruited by purposively sampling from interested GPs attending continuing professional development meetings (CPD) in southwest Ireland. Participating practices were instructed on the MY COMRADE implementation intervention which has five components: (i) action planning; (ii) allocation of protected time; (iii) peer-supported medication review; (iv) use of a prescribing checklist and (v) self-incentives (allocation of CPD points). GPs in participating practices agreed to conduct medication reviews on multimorbid patients from their own caseload using the MY COMRADE approach. After completing these reviews, qualitative interviews were conducted to evaluate GPs' experiences of the intervention and were analysed using the framework method. RESULTS: GPs from ten practices participated in the study. The GPs reported that MY COMRADE was an acceptable approach to implementing medication review in general practice, especially for complex patients with multimorbidity. Action plans for the medication reviews varied between practices, but all reviews led to recommendations for optimising medications and patient safety. Many GPs felt that using the MY COMRADE approach would ultimately lead to more efficient use of their time, but a minority felt that the time and cost implications of using two GPs to review medications would not be sustainable unless greater incentives were used. CONCLUSIONS: This study demonstrates that MY COMRADE is an acceptable and feasible approach to supporting comprehensive medication reviews for patients with multimorbidity. These findings indicate that a large scale trial of the effectiveness of MY COMRADE is now required to fully evaluate its potential to change prescribing behaviour and improve downstream outcomes such as prescribing appropriateness and treatment burden. TRIAL REGISTRATION: ISRCTN registry: ISRCTN34837446.

Improving medication management in multimorbidity: development of the MultimorbiditY COllaborative Medication Review And DEcision Making (MY COMRADE) intervention using the Behaviour Change Wheel.

BACKGROUND: Multimorbidity, the presence of two or more chronic conditions, affects over 60 % of patients in primary care. Due to its association with polypharmacy, the development of interventions to optimise medication management in patients with multimorbidity is a priority. The Behaviour Change Wheel is a new approach for applying behavioural theory to intervention development. Here, we describe how we have used results from a review of previous research, original research of our own and the Behaviour Change Wheel to develop an intervention to improve medication management in multimorbidity by general practitioners (GPs), within the overarching UK Medical Research Council guidance on complex interventions. METHODS: Following the steps of the Behaviour Change Wheel, we sought behaviours associated with medication management in multimorbidity by conducting a systematic review and qualitative study with GPs. From the modifiable GP behaviours identified, we selected one and conducted a focused behavioural analysis to explain why GPs were or were not engaging in this behaviour. We used the behavioural analysis to determine the intervention functions, behavioural change techniques and implementation plan most likely to effect behavioural change. RESULTS: We identified numerous modifiable GP behaviours in the systematic review and qualitative study, from which active medication review (rather than passive maintaining the status quo) was chosen as the target behaviour. Behavioural analysis revealed GPs' capabilities, opportunities and motivations relating to active medication review. We combined the three intervention functions deemed most likely to effect behavioural change (enablement, environmental restructuring and incentivisation) to form the MultimorbiditY COllaborative Medication Review And DEcision Making (MY COMRADE) intervention. MY COMRADE primarily involves the technique of social support: two GPs review the medications prescribed to a complex multimorbid patient together. Four other behavioural change techniques are incorporated: restructuring the social environment, prompts/cues, action planning and self-incentives. CONCLUSIONS: This study is the first to use the Behaviour Change Wheel to develop an intervention targeting multimorbidity and confirms the usability and usefulness of the approach in a complex area of clinical care. The systematic development of the MY COMRADE intervention will facilitate a thorough evaluation of its effectiveness in the next phase of this work.

Psychosocial complexity in multimorbidity: the legacy of adverse childhood experiences.

BACKGROUND: To effectively meet the health care needs of multimorbid patients, the most important psychosocial factors associated with multimorbidity must be discerned. Our aim was to examine the association between self-reported adverse childhood experiences (ACEs) and multimorbidity and the contribution of other social, behavioural and psychological factors to this relationship. METHODS: We analysed cross-sectional data from the Mitchelstown study, a population-based cohort recruited from a large primary care centre. ACE was measured by self-report using the Centre for Disease Control ACE questionnaire. Multimorbidity status was categorized as 0, 1 or ≥2 chronic diseases, which were ascertained by self-report of doctor diagnosis. Ordinal logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (95% CIs) for multimorbidity, using ACE as the independent variable with adjustment for social (education, public health cover), behavioural (smoking, exercise, diet, body mass index) and psychological factors (anxiety/depression scores). RESULTS: Of 2047 participants, 45.3% (n = 927, 95% CI: 43.1-47.4) reported multimorbidity. ACE was reported by 28.4% (n = 248, 95% CI: 25.3-31.3%) of multimorbid participants, 21% (n = 113, 95% CI: 18.0-25.1%) of single chronic disease participants and 16% (n = 83, 95% CI: 13.2-19.7%) of those without chronic disease. The OR for multimorbidity with any history of ACE was 1.6 (95% CI: 1.4-2.0, P < 0.001). Adjusting for social, behavioural and psychological factors only marginally ameliorated this association, OR 1.4 (95% CI: 1.1-1.7, P = 0.002). CONCLUSIONS: Multimorbidity is independently associated with a history of ACEs. These findings demonstrate the psychosocial complexity associated with multimorbidity and should be used to inform health care provision in this patient cohort.

What to give the patient who has everything? A qualitative study of prescribing for multimorbidity in primary care.

BACKGROUND: Using clinical guidelines in the management of patients with multimorbidity can lead to the prescription of multiple and sometimes conflicting medications. AIM: To explore how GPs make decisions when prescribing for multimorbid patients, with a view to informing intervention design. DESIGN AND SETTING: In-depth qualitative interviews incorporating chart-stimulated recall with purposively sampled GPs in the Republic of Ireland. METHOD: Grounded theory analysis with iterative theory development. RESULTS: Twenty GPs were interviewed about 51 multimorbid cases. In these cases, GPs integrated information from multiple sources including the patient, specialists, and evidence-based medicine. Difficulties arose when recommendations or preferences conflicted, to which GPs responded by 'satisficing': accepting care that they deemed satisfactory and sufficient for a particular patient. Satisficing was manifest as relaxing targets for disease control, negotiating compromise with the patient, or making 'best guesses' about the most appropriate course of action to take. In multimorbid patients perceived as stable, GPs preferred to 'maintain the status quo' rather than rationalise medications, even in cases with significant polypharmacy. Proactive changes in medications were facilitated by continuity of care, sufficient consultation time, and open lines of communication with the patient, other healthcare professionals, and other GPs. CONCLUSION: GPs respond to conflicts in the management of multimorbid patients by making compromises between patient-centred and evidence-based care. These findings will be used to inform interventions that aim to care in multimorbidity.

Smokers still underestimate the risks posed by secondhand smoke: a repeated cross-sectional study.

BACKGROUND: Little is known about risk perception of secondhand smoke (SHS) and its changes over time. The aim of the study was to examine the role of smoking status and demographics on perceiving a range of health risks of SHS exposure and their trends over time among a representative sample of the Irish general population. METHODS: This study included 2 repeated cross-sectional samples of Irish adults in 1999 (n = 1,240) and 2006 (n = 1,000), in addition to a representative sample of General Practitioners (2006: n = 248), sampled as a health care professional's view on SHS risk. Participants were asked to consider whether a nonsmoker, exposed to SHS, is at an increased risk of asthma, lung cancer, heart disease, bronchitis, diabetes, and ear infections in children. RESULTS: There was a significant increase in the general population's risk perception of SHS for asthma, lung cancer, heart disease, and bronchitis from 1999 to 2006. Not even half of the general population in 1999 and in 2006 perceived a risk for the development of ear infections in children with SHS exposure (45% in 1999, 46% in 2006). With the exception of ear infections in children in 2006, the risk perception of all diseases differed significantly by smoking status; smokers' risk perception of SHS was significantly lower. Encouraging results suggest that the differences in risk perception between smokers and nonsmokers have decreased. CONCLUSION: Risk perception of SHS exposure has improved as has the gap in perception between smokers and nonsmokers. This research points to a lack of awareness among the general population of the risk perception of SHS exposure to children.

Timing of access to secondary healthcare services for diabetes management and lower extremity amputation in people with diabetes: a protocol of a case-control study.

BACKGROUND: Lower extremity amputation (LEA) is a complication of diabetes and a marker of the quality of diabetes care. Clinical and sociodemographic determinants of LEA in people with diabetes are well known. However, the role of service-related factors has been less well explored. Early referral to secondary healthcare is assumed to prevent the occurrence of LEA. The objective of this study is to investigate a possible association between the timing of patient access to secondary healthcare services for diabetes management, as a key marker of service-related factors, and LEA in patients with diabetes. METHODS/DESIGN: This is a case-control study. The source population is people with diabetes. Cases will be people with diabetes who have undergone a first major LEA, identified from the hospital discharge data at each of three regional centres for diabetes care. Controls will be patients with diabetes without LEA admitted to the same centre either electively or as an emergency. Frequency-matching will be applied for gender, type of diabetes, year and centre of LEA. Three controls per case will be selected from the same population as the cases. With a power of 90% to detect OR of 0.4 for an association between 'good quality care' and LEA in people with diabetes, 107 cases and 321 controls are required. Services involved in diabetes management are endocrinology, ophthalmology, renal, cardiology, vascular surgery and podiatry; timing of first contact with any of these services is the main exploratory variable. Using unconditional logistic regression, an association between this exposure and the outcome of major LEA in people with diabetes will be explored, while adjusting for confounders. ETHICS AND DISSEMINATION: Ethical approval was granted by the Clinical Research Ethics Committee of the Cork Teaching Hospitals, Ireland. Results will be presented at conferences and published in peer-reviewed journals.

Quality-assured screening for diabetic retinopathy delivered in primary care in Ireland: an observational study.

BACKGROUND: At present, there is no national population-based retinopathy screening programme for people in Ireland who have diabetes, such as those operating in the UK for over a decade. AIM: To evaluate a community-based initiative that utilised existing resources in general practice and community optometry/ophthalmology services to provide screening for diabetic retinopathy. DESIGN AND SETTING: Cross-sectional study using electronic ophthalmic patient screening records in community optometry clinics in Cork, Ireland. METHOD: A purposive sample of 32 practices was recruited from Diabetes in General Practice, a general practice-led initiative in the South of Ireland. Practices invited all adult patients registered with diabetes to participate in free retinopathy screening (n = 3598), provided by 15 community optometry practices and two community ophthalmologists. Data were recorded on an electronic database used by optometrists and the performance was benchmarked against proposed national standards for retinopathy screening. RESULT: In total, 30 practices participated (94%). After 6 months, 49% of patients (n = 1763) had been screened, following one invitation letter and no reminder. Forty-three per cent of those invited consented to their data being used in the study and subsequent analyses are based on that sample (n = 1542). The mean age of the patients screened was 65 years (standard deviation = 13.0 years), 57% were male (n = 884), and 86% had type 2 diabetes (n = 1320). In total, 26% had some level of retinopathy detected (n = 395); 21% had background retinopathy (n = 331), 3% had pre-proliferative retinopathy (n = 53), and 0.7% had proliferative retinopathy (n = 11). CONCLUSION: The detection of retinopathy among 26% of those screened highlights the need for a national retinopathy screening programme in Ireland. Significant learning, derived from the implementation of this initiative, will inform the national programme.

A study of innovative patient safety education.

BACKGROUND: Medical error continues to significantly harm patients, notwithstanding the continued efforts to improve the situation over the past decade. We report a pilot project using high-fidelity simulation to integrate the World Health Organisation (WHO) patient safety curriculum into undergraduate medical education. METHODS: From the literature on avoidable medical error we developed a series of authentic clinical scenarios using a Clinical Skills Lab (CSL) and simulated patients to produce a high-fidelity simulated ward environment. The clinical challenges embody common day-to-day encounters experienced by newly graduated doctors. After participating, final-year medical students were given time to reflect on the experience, given feedback and completed a quantitative evaluation. RESULTS: Twenty final-year medical students completed the scenarios, and gave written feedback using a Likert scale (ranging from 1, strongly disagree, to 7, strongly agree). The responses showed 18 students agreed or strongly agreed that the session was valuable, all 20 would recommend the session to peers and 18 would be interested in attending further sessions. The students gave more mixed views of faculty feedback: 13 agreed or strongly agreed that this was useful, five were undecided and two were undecided or disagreed. CONCLUSION: With the caveats of a small sample size, first experience of high-fidelity simulation, the 'halo' effect in the evaluation, and with possible omissions from our evaluation, the students reported predominantly positively on the experience. We believe that the use of high-fidelity simulation in patient safety is a promising, safe and low-cost curricular development in undergraduate medical education. It is transferable worldwide and has the potential to improve patient safety outcomes by reducing medical error.