Is pay for performance promoting inverse inequality in Irish general practice?

BACKGROUND: In 2020, the Chronic Disease Management (CDM) programme was introduced in Ireland. This programme resources GPs to review public (GMS) patients, diagnosed with eight named chronic diseases, twice yearly according to a structured protocol. This pay for performance initiative has been widely adopted by GPs. However, it is hypothesised that private patients (PPs) receive a poorer standard of care, as they may be reluctant to attend due to the cost involved. AIM: To assess whether the management of eight chronic diseases named in the CDM programme is to the same standard among both PPs and GMS patients. METHOD: A retrospective audit of GP practices in the Midwest of Ireland. Data relating to 25 GMS patients and 25 PPs, matched by age, gender, and clinical condition, is collected from each practice. Patients have at least 1 of the eight named chronic diseases. Parameters include vaccination status (influenza, pneumococcal, COVID); body mass index; blood pressure; smoking status; renal function; HbA1c; lipid profile; brain natriuretic peptide (BNP) in patients with heart failure; and lung function tests in patients with COPD or asthma. COVID vaccination status acts as a control because it is freely available for both PPs and GMS patients. RESULTS: Preliminary results from 2 GP practices show large consistent disparities in management between PPs and GMS patients in most parameters. CONCLUSION: Limiting Pay for Performance to the care of GMS patients only, based on age or income, promotes inverse inequality. We argue that CDM care should be offered to all patients.

Integration of migrant and refugee data in health information systems in Europe: advancing evidence, policy and practice.

Coverage of migrant and refugee data is incomplete and of insufficient quality in European health information systems. This is not because we lack the knowledge or technology. Rather, it is due to various political factors at local, national and European levels, which hinder the implementation of existing knowledge and guidelines. This reflects the low political priority given to the topic, and also complex governance challenges associated with migration and displacement. We review recent evidence, guidelines, and policies to propose four approaches that will advance science, policy, and practice. First, we call for strategies that ensure that data is collected, analyzed and disseminated systematically. Second, we propose methods to safeguard privacy while combining data from multiple sources. Third, we set out how to enable survey methods that take account of the groups' diversity. Fourth, we emphasize the need to engage migrants and refugees in decisions about their own health data. Based on these approaches, we propose a change management approach that narrows the gap between knowledge and action to create healthcare policies and practices that are truly inclusive of migrants and refugees. We thereby offer an agenda that will better serve public health needs, including those of migrants and refugees and advance equity in European health systems. Funding: No specific funding received.

Framework for refugee and migrant health research in the WHO European Region.

Migration is a longstanding, growing global phenomenon. As a social determinant of health, migration can lead to health inequities between people on the move and host populations. Thus, it is imperative that there is a coordinated effort to advance migration- and health-related goals. WHO has a specific remit to support evidence-based decision-making in its Member States. As part of that remit, WHO Europe presents this Framework for Refugee and Migrant Health Research in the WHO European Region. It is designed as a starting point for debating and analysing a broad range of options and approaches to help inform a WHO global research agenda on health and migration. This is important because refugee and migrant health research is a complex interdisciplinary field that is expanding in a fast-changing socio-political environment. The Framework is intended for all stakeholders involved: academic, civil society organisations, refugees, migrants, policy-makers, healthcare providers, educators and funders. It is developed by academics in consultation with these stakeholder groups. It reflects on three specific interrelated dynamics in research practice. These are (i) research prioritisation; (ii) study samples and (iii) research design. The Framework offers recommendations to consider for each one of these. It elucidates the value of involving refugees and migrants in research and research agendas and the need to develop an ecosystem that will support and sustain participatory, interdisciplinary, transdisciplinary and inter-sectoral projects.

How do multi-morbidity and polypharmacy affect general practice attendance and referral rates? A retrospective analysis of consultations.

BACKGROUND: As prevalence of multimorbidity and polypharmacy rise, health care systems must respond to these challenges. Data is needed from general practice regarding the impact of age, number of chronic illnesses and medications on specific metrics of healthcare utilisation. METHODS: This was a retrospective study of general practices in a university-affiliated education and research network, consisting of 72 practices. Records from a random sample of 100 patients aged 50 years and over who attended each participating practice in the previous two years were analysed. Through manual record searching, data were collected on patient demographics, number of chronic illnesses and medications, numbers of attendances to the general practitioner (GP), practice nurse, home visits and referrals to a hospital doctor. Attendance and referral rates were expressed per person-years for each demographic variable and the ratio of attendance to referral rate was also calculated. RESULTS: Of the 72 practices invited to participate, 68 (94%) accepted, providing complete data on a total of 6603 patients' records and 89,667 consultations with the GP or practice nurse; 50.1% of patients had been referred to hospital in the previous two years. The attendance rate to general practice was 4.94 per person per year and the referral rate to the hospital was 0.6 per person per year, giving a ratio of over eight attendances for every referral. Increasing age, number of chronic illnesses and number of medications were associated with increased attendance rates to the GP and practice nurse and home visits but did not significantly increase the ratio of attendance to referral rate. DISCUSSION: As age, morbidity and number of medications rise, so too do all types of consultations in general practice. However, the rate of referral remains relatively stable. General practice must be supported to provide person centred care to an ageing population with rising rates of multi-morbidity and polypharmacy.

The impact of economic recession on the health of migrant fathers over time: results from the Growing up in Ireland longitudinal study.

BACKGROUND: The relationship between economic conditions and health can depend on both the health outcome measured and the composition of the population. Analysis of outcomes by both ethnicity and country of birth has been recommended. The aim of our study is to explore the impact of recession on self-rated health and depression of migrant fathers in Ireland over time, considering both ethnicity and country of birth. METHODS: Longitudinal data from waves of a population-representative cohort study (Growing up in Ireland, 2008-2013) was used with Wave 1 collected before the recession and Wave 2 collecting information on how the recession affected families. Socio-demographic variables, self-rated health and depression were compared across three groups of fathers classified by self-identified ethnicity and country of birth: White Irish (n = 5628), Other White European (EU-10) (n = 431), and Black African (n = 192) using chi-square tests and logistic regression models. Rates of follow-up were compared across groups at Wave 3. RESULTS: Prior to the recession, the rate of employment was lowest for African fathers (51% vs 81% for EU-10 fathers and 92% for Irish fathers, p < 0.001). At Wave 2, African families were more likely to have experienced a very significant effect of the recession (40.1% compared to 22.4% for families from EU-10 and 21.3% for Irish families, p < 0.001). However, the impact of the recession on depression and self-rated health was only found in Irish fathers. By Wave 3, rates of follow-up were lower for migrant fathers, particularly for EU-10 fathers. CONCLUSIONS: Understanding the relationship between economic conditions and health is complex and may be related to multiple dimensions of socio-economic advantage and disadvantage. African families were already more likely to be disadvantaged prior to the recession and that pattern persisted during the recession. Further research on attrition rates of migrants in population cohort studies is needed and the development of effective strategies for recruitment, follow-up and analysis.

'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.

CONTEXT: 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. OBJECTIVE: This study examines whether and how ethnicity data can be collected in Irish general practices in a meaningful and acceptable way. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Interdisciplinary team working in the Irish primary healthcare system: Analysis of 'invisible' bottom up innovations using Normalisation Process Theory.

Interdisciplinary team working in primary care is a key policy goal across healthcare jurisdictions. The National Primary Care Strategy (2001) in Ireland is a top down policy for primary healthcare reform, which prioritised the development and implementation of interdisciplinary Primary Care Teams. The number of Primary Care Teams and features of their clinical meetings have been the key metric in Ireland for appraising progress with the implementation of the strategy. However, these have been challenging to organise in practice. The aim of this paper is to analyse empirical evidence of other forms of interdisciplinary working in Irish primary care, using Normalisation Process Theory. Drawing on data from an on-line survey (71 GPs and 498 other healthcare professionals), and an interview study (37 participants; 8 GPs, 7 practice managers/admin support and 22 health care professionals) in three of the four Health Service Executive (HSE) regions in Ireland, we analyse the nature of these other forms of interdisciplinary working and describe innovations for service delivery that have been developed 'from the ground up' as a result. We examine levers and barriers to the implementation of these bottom up innovations. The levers are that these innovations make sense to professionals, are based on local needs and focus on preventive patient-centred care. They are driven forward by small groups of professionals from different backgrounds with complementary skills. The evaluations show positive impacts of the innovative services for patients, however, many have ceased to operate due to negative effects of the recent economic recession on the Irish healthcare system. These flexible and localised innovations were shaped in part by the reforms set out in the 2001 Primary Care Strategy but also represent unintended effects of that policy because they are the result of bottom up interdisciplinary working that occurs alongside, or instead of, Primary Care Team clinical meetings. Furthermore, as they not captured by existing metrics, the interdisciplinary work and resultant services have been 'invisible' to senior management and policy makers. If appropriately acknowledged and supported, they can shape primary care in the future.

A Single-arm, Practical Application Assessment of User Experience and Peristomal Skin Condition Among Persons With an Ileostomy Using a New Barrier Seal With Assisted Flow.

Peristomal skin complications are a common problem for persons with an ileostomy. PURPOSE: The purpose of this pilot study was to solicit user feedback and perform an initial assessment of the performance of a new barrier seal designed to decrease the risk of chemical-induced dermatitis. METHODS: Seven (7) potential participants who were at least 18 years of age, >6 months post surgery, with an end or loop ileostomy and unbroken peristomal skin, and who were capable of changing their appliance themselves or had the availability of care assistance were identified and recruited by the stoma care nurse at the University Hospital, Limerick, Ireland. At the initial visit and after 1 and 2 weeks, participants were asked to rate device comfort, security, and handling; skin condition was assessed by the research nurse using the Ostomy Skin Tool. Descriptive statistics were used to tabulate the results. RESULTS: Five (5) participants completed the study. Discoloration, erosion, and tissue overgrowth scores improved in 3 of 5 patients, and the mean Ostomy Skin Tool score decreased from 5.4 ± 2.19 at the initial assessment to 4 ± 1.87 at the week 2 visit. Comfort, handling, and security ratings increased from a median of 8 at the beginning of the study to 10 at week 2. CONCLUSION: Initial patient feedback regarding the new product was positive, and skin assessment results suggest the new seal may help improve peristomal skin condition. Larger studies with longer patient follow-up are needed to confirm the results of this pilot evaluation.

Utilization of conventional radiography in a regional neonatal intensive care unit in Ireland.

OBJECTIVE: To audit the demand and radiation exposure of conventional radiography in a regional neonatal intensive care unit (NICU) in Ireland. METHODS: A retrospective study of radiographs performed on all admissions to the NICU in University Maternity Hospital Limerick (UMHL) over 2 years. RESULTS: A total of 1405 radiographs were performed on 506 infants. 153.5 radiographs per 1000 live births was the observed demand and 44% of radiographs were done out of hours. 47% of all radiographs were performed on infants <1500 g. Median number of radiographs per infant was one (IQR 1-2; range 1-39). Significant negative correlation was observed between number of radiographs and gestational age. Mean lung radiation doses estimated using published values for normal weight (>2500 g), very low birth weight (VLBW), and extremely low birth weight (ELBW) infants based on the median number of chest X-rays were 31.7 µGym, 84.66 and 232.75 µGy, respectively. CONCLUSIONS: Conventional radiography remains a key diagnostic tool in neonatology particularly in VLBW and ELBW infants and is invaluable in supporting timely clinical decision making. Clinicians should be aware of the cost and potential hazards of neonatal radiography and is recommend that the cumulative radiation exposure among the ELBW and VLBW infants is monitored. Increasing awareness and standardisation of point-of-care ultrasonography could decrease the reliance on conventional radiography in neonatal units.

Ethnicity recording in health and social care data collections in Ireland: where and how is it measured and what is it used for?

BACKGROUND: In the European Union (EU), discrimination based on racial and ethnic origin is prohibited under the Racial Equality Directive. Ireland is one of only three EU countries where a legal duty of equality data collection is placed on public bodies. It provides an important context in which to study ethnic equality monitoring; however no systematic mapping of where it occurs in health information systems has been carried out. The aim of this study is to identify all existing national health and social care data collections with information on ethnicity and to explore how this data has been collected and used. METHODS: An electronic search of a national catalogue of health and social care data collections (N = 97) was carried out to identify any collections which contained information on ethnicity. Data dictionaries were searched and key informants contacted. For each of the data collections that collected information on ethnicity, data was extracted on the ethnic categories used and how this data is collected; the completeness of ethnicity recording; and other measures related to ethnicity in the data collection. Relevant outputs for these data collections, related to ethnicity, were identified through key informants and electronic searches. RESULTS: Of the 97 data collections, 14 (14%) collected information on ethnic or cultural background. Country of birth was collected by 10 of these 14 data collections. Most used the ethnic categories in the Census and recommended that ethnicity should be self-identified and not assigned. Reported rates of identification were generally high (≥90%). Data collections which recorded ethnicity tended to be focused on potentially high-risk populations with no routine recording in primary care. There were some examples of where ethnic equality monitoring had informed targeted interventions e.g. vaccination awareness initiatives or cultural training for healthcare staff. CONCLUSIONS: Despite strong policy and legal imperatives, there is limited data collection of ethnicity in health and social care data collections in Ireland. While there are some examples of where differences by ethnicity have been identified and acted upon, a more coordinated and comprehensive approach to the collection, quality and utilization of ethnicity data is needed to promote health equity.

What effect do point of care fees have on childhood consultations in general practice?

BACKGROUND: General practice (GP) has historically been central to the prevention and treatment of childhood illnesses. In Ireland, this role has recently expanded with the introduction of free GP care for children aged under six years in 2015. The Republic of Ireland has the only health system in the European Union which does not offer universal coverage for primary care. This study aims to analyse general practice records to investigate the effect of point of care consultation fees on childhood attendances. METHODS: GPs affiliated to the medical school (n = 72) were invited to participate. 100 children aged 1 to 14 years were randomly sampled from each. Data was collected on service utilisation in the previous 12 months, specifically: age, gender, eligibility for free care and whether they had consulted their GP in the 12 month period. RESULTS: Sixty-four practices participated, producing data on 6007 eligible children. The median age of children was seven years; 3688(62%) were 'fee-paying'. GMS patients aged under six years had a median of three consultations/year, with a quarter attending six times a year or more, while fee paying patients had a median of two consultations/year with a quarter attending four times a year or more. CONCLUSIONS: Children eligible for free care attend more often with a subgroup attending very frequently. This study provides important information on the possible impact of fees on healthcare utilisation for countries considering co-payment.

Ethnic Minority Health in Ireland-Co-creating knowledge (EMH-IC): a participatory health research protocol.

INTRODUCTION: International policy recommends continuous, cost-effective monitoring of health data to enable health services to identify and respond to health inequities as experienced by different ethnic groups. However, there is a lack of routinely collected ethnicity data, particularly in primary care, and very little implementation research internationally to understand how ethnic identifiers are introduced, embedded and used in healthcare settings. This paper describes a protocol for a novel participatory health research project with the objective of building the evidence base on ethnic minority health in Ireland. Findings on the participatory appraisal of ethnic identifiers as an intervention to generate useful data about minority and majority ethnic groups will have relevance in other settings and countries. METHODS AND ANALYSIS: This multidisciplinary project is designed as a participatory health research study where all stakeholders, including ethnic minority communities, participate in co-design of the research protocol, project governance, collaborative data interpretation and disseminating findings. A national catalogue of all routinely collected health data repositories will be electronically searched for any repositories that contain information on ethnicity. A secondary quantitative analysis of a population-representative cohort study, Growing Up in Ireland, will be carried out to compare the health of ethnic minority and majority groups. A qualitative case study informed by normalisation process theory will be carried out at three primary care sites to monitor the implementation of an ethnic identifier and identify barriers and levers to implementation. ETHICS AND DISSEMINATION: Ethical approval for the qualitative case study has been granted by the Irish Council for General Practitioners (06/09/17). Permission to access data from Growing Up in Ireland has been granted by the Director General of the Central Statistics Office. Dissemination will be carried out at community events and academic conferences, in peer-reviewed journal publications, and through academic and healthcare provider networks.

Implementing community participation via interdisciplinary teams in primary care: An Irish case study in practice.

BACKGROUND: Community participation in primary care is enshrined in international and Irish health policy. However, there is a lack of evidence about how stakeholders work collectively to implement community participation within interdisciplinary teams; community perspectives are rarely captured, and a theoretical underpinning for implementation of community participation in primary care is absent. OBJECTIVE: To conduct a theoretically informed, multiperspectival empirical analysis of the implementation of community participation via primary care teams (PCTs) in Ireland. METHODS/DESIGN/PARTICIPANTS: Participatory learning and action (PLA) focus groups and interviews were held with 39 participants across four case study sites within a nationally funded programme designed to enable disadvantaged communities to participate in primary care. Normalization process theory (NPT) informed data generation and analysis of how diverse stakeholder groups worked together to implement community participation via PCTs. RESULTS: The various stakeholders had a shared understanding of the value of community participation on PCTs. Motivations to get involved in this work varied, but were strong overall. Challenges to enacting community participation on PCTs included problems with the functioning of PCTs and a lack of clarity and confidence in the role of community representatives at PCT meetings. Informal appraisals were positive, but formal appraisal was limited. DISCUSSION AND CONCLUSION: The implementation and sustainability of community participation on PCTs in Ireland will be limited unless (i) the functioning of PCTs is strong, (ii) there is increased confidence and clarity on community representatives' roles among all health-care professionals, and (iii) more sophisticated methods for formal appraisal are used.

Indicators for early assessment of palliative care in lung cancer patients: a population study using linked health data.

BACKGROUND: Analysing linked, routinely collected data may be useful to identify characteristics of patients with suspected lung cancer who could benefit from early assessment for palliative care. The aim of this study was to compare characteristics of newly diagnosed lung cancer patients dying within 30 days of diagnosis (short term survivors) with those surviving more than 30 days. To identify indicators for early palliative care assessment we distinguished between characteristics available at diagnosis (age, gender, smoking status, marital status, comorbid disease, admission type, tumour stage and histology) from those available post diagnosis. A second aim was to examine the association between receiving any tumour-directed treatment, place of death and survival time. METHODS: A retrospective observational population based study comparing lung cancer patients who died within 30 days of diagnosis (short term survivors) with those who survived longer using Chi-squared tests and logistic regression. Incident lung cancer (ICD-03:C34) patients diagnosed 2005-2012 inclusive who died before 01-01-2014 (n = 14,228) were identified from the National Cancer Registry of Ireland linked to death certificate data and acute hospital episode data. RESULTS: One in five newly diagnosed lung cancer patients died within 30 days of diagnosis. After adjusting for stage and histology, death within 30 days was higher in patients who were aged 80 years or older (adjusted OR 2.46; 95%CI 2.05-3.96; p < 0.001), patients with emergency admissions at diagnosis (adjusted OR 2.96; 95%CI 2.61-3.37; p < 0.001) and patients with any comorbidities at diagnosis (adjusted OR 1.32 95%CI 1.15-1.52; p < 0.001). Overall, 75% of those who died within 30 days died in hospital compared to 43% of longer term survivors. CONCLUSIONS: We have shown a high proportion of lung cancer patients who die within 30 days of diagnosis are older, have comorbidities and are admitted through the emergency department. These characteristics, available at diagnosis, may be useful prognostic factors to guide decisions on early assessment for palliative care for lung cancer patients. Patients who die shortly after diagnosis are more likely to die in hospital so reporting place of death by survival time may be useful to evaluate interventions to reduce deaths in acute hospitals.

Does Age Impact on Expectations and Concerns of Patients Attending a Chronic Pain Clinic?

BACKGROUND: Recognizing expectations and concerns of patients leads to more specialized management plans and greater adherence to treatment and improves outcomes. Little is known about how age impacts on expectations or concerns regarding pain in patients attending a chronic pain clinic. METHODS: We prospectively assessed the expectations and concerns of 100 adult patients at their first visit to a pain clinic. Patients reported their expectations and concerns for the clinic visit using a self-completed questionnaire. Categories of concerns and expectations were compared across age groups (≤ 65 years, > 65 years) using the chi-square test and Fisher's exact test. RESULTS: Thirty-nine patients (39%) were over 65 years of age (older patients). The most frequently stated site of pain was the lumbar spine for all patients regardless of age. Common concerns of all patients related to sleep and mobility, and the most common expectation related to analgesia. Younger patients were more concerned about employment (23% vs. 3% of older patients, P = 0.005) and social participation (21% vs. 5%, P = 0.03), whereas older patients were more likely to be concerned about mobility (46% vs. 15% of younger patients, P = 0.001). More younger patients expected education on the source of pain than did older patients (23% vs. 3%, P = 0.005), whereas older patients were more likely to be unsure or have no expectations (26% vs. 3%, P = 0.005). CONCLUSION: We found differences in patient expectations and concerns by age of those attending a chronic pain clinic. These differences can inform the communication process between physician and patient on treatment plans and outcomes.

Understanding pain among older persons: Part 2-the association between pain profiles and healthcare utilisation.

Background: While polypharmacy and multimorbidity predict healthcare utilisation among older people, the influence of differing pain profiles on healthcare utilisation is unclear. Objective: To compare healthcare utilisation between people with different pain profiles. Methods: Baseline data from The Irish LongituDinal study on Ageing (TILDA), a population-representative cohort study involving over 8,171 community living people resident in Ireland aged 50 or over, was used. Following the creation of four novel pain profiles, variables relating to healthcare utilisation were compared across the different profiles using chi-square tests and logistic regression. Results: Healthcare utilisation differed across the four pain profiles, with pain being an independent predictor of resource use. Pain profiles 3 and 4 had higher use of general practitioner (GP) care and outpatient visits than people with no pain and pain that had less impact. The odds of being a frequent GP attender increased across pain profiles, with those in profile 4 being almost three times as likely to be frequent attenders compared to those with no pain (adjusted odds ratio (OR) = 2.79; 95% CI 2.74, 2.83). People in profile 4 were almost twice as likely to have a hospital outpatient visit compared to people with no pain (adjusted OR = 1.75; 95% 1.73, 1.78). Conclusions: Healthcare utilisation differed between the four pain profiles, with people in profiles 3 and 4 having greater usage of primary and secondary healthcare resources. Pain profile membership was a significant independent predictor of the utilisation of GP care and hospital outpatient visits.

In vitro comparative assessment of the mechanical properties of PMMA cement and a GPC cement for vertebroplasty.

AIMS: To develop a Glass Polyalkenoate Cement that is suitable for vertebroplasty. METHODS: Testing was carried out to assess the effect of gamma irradiation used for sterilisation, on the glass transition temperature as well as its mechanical properties, including compressive strength and biflexural strength in vivo as well as testing GPC and PMMA cements post injection in cadaveric human vertebral bone. RESULTS: There was a trend to a higher failure load required for the GPC cement group compared to the current standard PMMA injected group but this was not statistically significant with this small sample size. CONCLUSION: The results are encouraging for future research to continue on GPC cements for use in vertebroplasty.

How do variations in definitions of “migrant” and their application influence the access of migrants to health care services?

Variations in definitions used for “migrant” and for different groups of migrants in different areas can affect health systems’ policies and migrants’ access to health care. This systematic review explored this issue using evidence from academic peer-reviewed and grey literature in 169 publications in English or Russian from 2010 to 2015 that focused on primary care or both primary and secondary care, including screening services and emergency departments. There is no universally accepted definition for migrant at an international level and the heterogeneity of the definitions used limits the comparability of routinely collected data. Legal status was one of the most significant factors determining access to affordable and adequate health services for migrants in a country. This publication recommends as policy options: identifying preferred terms for migrants; seeking consensus on important migration-related variables for collection across health information systems; and progressing towards universal access to health care across the WHO European Region.

Therapeutic use of compression stockings for orthostatic hypotension: an assessment of patient and physician perspectives and practices.

BACKGROUND: Elastic compression stockings (ECS) can be used as a non-pharmacological therapeutic option for older patients with orthostatic hypotension (OH). We aimed to investigate the practices and views of patients and physicians regarding the use of ECS for OH. METHODS: Two surveys were designed. The first was sent to 90 patients known to have been prescribed ECS for OH. This questionnaire included items related to the frequency of use and issues related to non-compliance. The second was sent to 69 consultant physicians in geriatric medicine. This included items related to prescribing practices and perceived patient compliance. RESULTS: Sixty-seven patients responded (response rate, 74%) and of those 64% were female. Mean age (SD) was 75.1 years (10.5), range 45-91 years. Thirty-three per cent wore ECS daily, whereas 43% never used them. Over half (51%) of the patients reported difficulty in application and 31% reported discomfort. Those aged 75 or older were more likely to report difficulty in application (P=0.003). Forty-eight physicians responded (response rate, 70%). Eighty-nine per cent prescribe ECS for OH. There were significant differences between the frequency of use reported by patients and predicted by physicians (P<0.001), with physicians less likely to predict daily or non-use. Eighty-nine per cent of physicians predicted that difficulty in application was the main reason for non-compliance. CONCLUSION: Although prescribed frequently, the use of ECS in patients with OH is often limited by issues related to practicality. Physicians correctly predicted the main reasons for non-compliance although underestimated the scale of patient compliance with ECS.

Physician and pharmacist perceptions of generic medicines: what they think and how they differ.

INTRODUCTION: This study is the first comparative assessment, internationally, of perceptions of generic medicines between general practitioners (GPs) and pharmacists in at least the last decade. METHODOLOGY: One-to-one semi-structured interviews were performed with 34 GPs and 44 community pharmacists in Ireland. Interviews were transcribed and qualitative analyses were performed using NVivo (version 9). RESULTS: GPs expressed more negative opinions than pharmacists. 94.1% of GPs and 88.6% of pharmacists reported receiving complaints from patients related to generics. 11.8% of GPs versus 2.3% of pharmacists believed generics do not work as well as originators. More than twice as many GPs (14.7%) as pharmacists (6.8%) expressed a preference for the originator medication. Participants believed that most negative experiences reported by patients (with generic medicines) were not actual but imagined/nocebo. DISCUSSION: Education of stakeholders is a requirement for increased usage of generics. Resources to facilitate healthcare professionals in educating patients are needed. GPs' opinions could negatively influence patient opinions; countering these opinions may prove important for successful influencing of patient perceptions.