Assessing care quality in general practice: a qualitative study of GPs in Ireland.

BACKGROUND: It is estimated that each year in Ireland, approximately 29 million consultations occur in general practice with a patient satisfaction level of 90%. To date, research has been lacking on how GPs assess the quality of care. AIM: To examine how GPs assess care quality during routine practice with respect to the following pillars of quality improvement: effectiveness, safety, timeliness, equity, efficiency, sustainability, and person-centredness. DESIGN & SETTING: Qualitative study of GPs in Ireland. METHOD: In this qualitative study, semi-structured interviews were conducted with 10 GPs who were recruited via a snowball sampling strategy. Interviews were recorded, transcribed, and analysed. Quality 'assessment points' were identified and themes were synthesised to produce a theoretical framework. RESULTS: Five female and five male GPs practising in a variety of settings were interviewed. The age range was 33-68 years. In total, 122 assessment points emerged from the data and were collated into the following eight themes: the GP as a professional person factors; the patient and coproduction factors; care team factors; direct care factors; outcome factors; practice environment and organisation factors; external environment factors; and improvement approach factors. CONCLUSION: This is the first study to examine how GPs in Ireland assess care quality as a holistic construct during daily care. The qualitative approach applied yielded rich and diverse insights into the many assessment points that GPs use to inform their approach and actions as clinicians, managers, collaborators, and leaders to maximise patient care. The theory produced is likely useful and applicable for practising GPs, healthcare administration, policymakers, and funders in planning and executing changes for quality improvement.

The prevalence and treatment of mental health conditions documented in general practice in Ireland.

OBJECTIVES: As prevalence of mental health disorders increases worldwide, recognition and treatment of these disorders falls increasingly into the remit of primary care. This study investigated the prevalence and management of adults presenting to their general practitioner (GP) in Ireland with a psychological condition. METHODS: A random number function was used to select 100 patients with a consultation in the previous 2 years from 40 general practices around Ireland. The clinical records of these patients were examined using a standardised reporting tool to extract information on demographics, eligibility for free care, prevalence and treatment of psychological conditions. RESULTS: From a sample of 3845 'active' patients, 620 (16%, 95% confidence interval 15-17%) had a documented psychological condition in the previous 2 years. The most common diagnoses were depression (54%) followed by stress and anxiety (47%). The following patient characteristics were associated with having a documented mental health condition: female gender; higher GP consultation rate; a referral or attendance at secondary care and eligibility for free GP care. Of those with a psychological condition, 34% received a psychological intervention and 81% received a pharmacological intervention. CONCLUSIONS: The overall prevalence estimate of mental health disorders for this sample was lower than previously documented in primary care. Patients diagnosed with mental health disorders had higher utilisation of health services and pharmacological treatment was common.

Prescription of psychotropic medication in patients with type two diabetes mellitus: A multi-practice study from Ireland.

Background: Comorbid anxiety and depression and type two diabetes mellitus (T2DM) are commonly managed by General Practitioners (GPs). Objectives: To investigate the proportion of people with T2DM who are prescribed either antidepressant or benzodiazepine medications in general practice; to compare people with T2DM that have a prescription with those that do not in terms of patient characteristics, glycaemic control and healthcare utilization. Methods: Anonymized data was collected by GPs and senior medical students from electronic medical records of patients with T2DM in 34 Irish general practices affiliated with the University of Limerick Graduate Entry Medical School during the 2013/14 academic year. Data included demographics, healthcare utilization, prescriptions and most recent glycosylated haemoglobin (HbA1c) measurement. Results: The sample included 2696 patients with T2DM, of which 733 (36.7%) were female, and with a median age of 66 years. The percentage with a current prescription for an antidepressant or benzodiazepine was 22% (95%CI: 18.9-24.9). Those with a current prescription for either drug were more likely to have attended the emergency department (28.3% vs 15.7%, P <0.001), to have been admitted to hospital (35.4% vs 21.3%, P <0.001) in the past year and attend their GP more frequently (median of 9 vs 7, P <0.001) than those without a prescription. Rates of poor glycaemic control were similar in those with and without a current prescription. Conclusion: Over one-fifth of people with T2DM in Irish general practice are prescribed an antidepressant or benzodiazepine medication. Prescription of these is associated with increased healthcare utilization but not poorer glycaemic control.

An analysis of childhood consultations in general practice: a multi-practice study.

BACKGROUND: The majority of illnesses in children are managed by general practitioners (GPs) and there is a need for up to date data on consultations with children in order to improve healthcare service planning and allocation of resources. AIMS: To investigate the presenting symptoms, diagnoses and actions taken by the GP at consultations with children in general practice. METHODS: Senior medical students on general practice placement and their GP supervisors used practice management software to collect data on 100 randomly selected patients aged between 12 months and 14 years of age in each practice. Presenting symptoms, diagnoses and actions taken by the GP for the most recent attendance in the previous 12 months were summarised by age group (1-4 years; 5-10 years; 11-14 years). RESULTS: Data were collected from 5959 patients at 64 practices. During the 12-month study, 3241 (54%) of children had a consultation with their GP. The most common presenting symptoms were respiratory (1-4 yrs, 28%; 5-10 yrs, 39%; 11-14 yrs, 32%) and skin complaint (1-4 yrs, 13%; 5-10 yrs, 16%; 11-14 yrs, 21%). The most common actions for all age groups were prescribing (1-4 yrs, 55%; 5-10 yrs, 58%; 11-14 yrs, 56%) and providing reassurance (1-4 yrs, 53%; 5-10 yrs, 51%; 11-14 yrs, 48%). Rates of referral and requiring further investigation increased with age. CONCLUSION: This study provides a comprehensive snapshot of what children commonly present with in general practice, common diagnoses and the actions taken by GPs. The findings will help GPs to organise their practice systems and will inform healthcare service planners.

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.

Is problem alcohol use being detected and treated in Irish general practice?

BACKGROUND: The pattern of alcohol consumption in Ireland has serious societal and health consequences. General practice is well placed to screen for problem alcohol use and to carry out brief interventions. The aims of this study were to investigate the prevalence of documentation of problem alcohol use in patient records in Irish general practice, and to describe the documentation of its diagnosis and treatment. METHODS: General practitioners (GPs) affiliated with an Irish medical school were invited to participate in the study. One hundred patients were randomly selected from each participating practice using the practice software and the clinical records were reviewed for evidence of problem alcohol use. The following was recorded: patient demographics, whether problem alcohol use was documented, whether they had an intervention, a psychotropic medication or if a referral was made. Descriptive statistics and an estimate of the prevalence were calculated using SPSS and SAS software. RESULTS: Seventy one percent of the practices participated (n = 40), generating a sample of 3, 845 active patients. Only 57 patients (1.5%, 95% confidence interval 1 to 2%) were identified as having problem alcohol use in the previous two years. 29 (51%) of those with documented problem alcohol use were referred to other specialist services. 28 (49%) received a psychological intervention. 40 (70%) were prescribed psychotropic medications. CONCLUSION: This is the first large scale study of patient records in general practice in Ireland looking at documentation of screening and treatment of problem alcohol use. It highlights the current lack of documentation of alcohol problems and the need to re-inforce positive attitudes among GPs in relation to preventive work.

A snapshot of type two diabetes mellitus management in general practice prior to the introduction of diabetes Cycle of Care.

BACKGROUND: Diabetes is associated with complications, including coronary heart disease, stroke, kidney failure, blindness and amputation, and ultimately is a major cause of disability and death worldwide. Adherence to best practice guidelines is limited in unstructured diabetes management in primary care settings. AIMS: This study aims to establish what data was being collected in general practice prior to the introduction of the Cycle of Care, which is a proactive model of diabetes management introduced in Ireland. METHODS: Medical students in general practices with the University of Limerick Graduate Entry Medical School and their supervisors used practice software to collect quantitative data from the clinical records of patients with T2DM. RESULTS: The sample included 2696 patients with T2DM who had visited their GP in the previous year. During the 12 months studied, 18.5% of patients with T2DM attended an emergency department and 24% were admitted to hospital. The results of the documentation of three modifiable risk factors associated with T2DM were as follows: 49.5% had BMI documented, 51.7% had smoking status documented and 33.9% had alcohol consumption documented. Two hundred and fifty people were diagnosed with T2DM in the previous 12 months. Of these, 19% had been referred to a chiropodist and 23% to a dietician. CONCLUSIONS: This study provides a comprehensive snapshot of care in Irish general practice for patients with T2DM prior to the introduction of the Cycle of Care. Future research must investigate the impact of Cycle of Care on patient care in general practice.

Psychological morbidity among young adults attending primary care: a retrospective study.

AIM: Currently, Ireland has the fourth highest rate of youth suicide in the European Union with psychological morbidity ranging from 21% to 27% in young adults. Primary care is ideally situated to address mental health problems and provide direction and support to young adults. This study investigates the prevalence and management of young adults aged 18-25 presenting to their general practitioner with a psychological problem as part of a larger study on all adults. METHODS: A random sample of 100 patients aged 18 and over with a consultation in the previous 2 years was selected from the practice management systems of 40 general practices in Ireland. Clinical records of active patients (excluding temporary visitors to the practice) were examined using a standardized reporting tool to extract information on demographics, prevalence, diagnoses and treatments for psychological problems. RESULTS: Of the 3845 active patients sampled aged 18 and over, 479 were in the target age group of 18-25. Of the 479 young adults identified (51% female, 60% fee paying), 57 (12%, 95% CI: 9-15%) had a documented psychological problem within the previous 2 years. Those with psychological problems were more likely to be frequent attenders and eligible for free medical care. Depression (23%) and stress and anxiety (23%) were most commonly identified. CONCLUSIONS: The estimated prevalence rate is considerably lower than previous studies which may indicate reluctance among young adults in presenting to primary care or reflect under-identification of psychological problems. Given the high rate of prescribing, enhancing access to non-pharmacological treatments in primary care is a priority.

Mindfulness based stress reduction for medical students: optimising student satisfaction and engagement.

BACKGROUND: Medical practitioners and students are at increased risk of a number of personal and psychological problems. Stress and anxiety due to work-load and study requirements are common and self-care methods are important in maintaining well-being. The current study examines perceptions of and satisfaction ratings with a mindfulness based stress reduction (MBSR) programme for 1(st) year (compulsory) and 2(nd) year (optional) Graduate Entry Medical School students. METHODS: A mixed method pre and post study of Year 1 (n = 140) and Year 2 (n = 88) medical students completing a 7 week MBSR course compared student satisfaction ratings. Thematic analysis of feedback from the students on their perception of the course was also carried out. RESULTS: Year 1 students (compulsory course) were less satisfied with content and learning outcomes than Year 2 students (optional course) (p < .0005). Thematic analysis of year 1 student feedback identified themes including great concept, poorly executed; and less discussion, more practice. Year 2 themes included session environment and satisfaction with tutors. CONCLUSIONS: The MBSR course was associated with high levels of satisfaction and positive feedback when delivered on an optional basis. Catering for the individual needs of the participant and promoting a safe environment are core elements of a successful self-care programme.

Retrograde optogenetic characterization of the pontospinal module of the locus coeruleus with a canine adenoviral vector.

Noradrenergic neurons of the brainstem extend projections throughout the neuraxis to modulate a wide range of processes including attention, arousal, autonomic control and sensory processing. A spinal projection from the locus coeruleus (LC) is thought to regulate nociceptive processing. To characterize and selectively manipulate the pontospinal noradrenergic neurons in rats, we implemented a retrograde targeting strategy using a canine adenoviral vector to express channelrhodopsin2 (CAV2-PRS-ChR2-mCherry). LC microinjection of CAV2-PRS-ChR2-mCherry produced selective, stable, transduction of noradrenergic neurons allowing reliable opto-activation in vitro. The ChR2-transduced LC neurons were opto-identifiable in vivo and functional control was demonstrated for >6 months by evoked sleep-wake transitions. Spinal injection of CAV2-PRS-ChR2-mCherry retrogradely transduced pontine noradrenergic neurons, predominantly in the LC but also in A5 and A7. A pontospinal LC (ps:LC) module was identifiable, with somata located more ventrally within the nucleus and with a discrete subset of projection targets. These ps:LC neurons had distinct electrophysiological properties with shorter action potentials and smaller afterhyperpolarizations compared to neurons located in the core of the LC. In vivo recordings of ps:LC neurons showed a lower spontaneous firing frequency than those in the core and they were all excited by noxious stimuli. Using this CAV2-based approach we have demonstrated the ability to retrogradely target, characterise and optogenetically manipulate a central noradrenergic circuit and show that the ps:LC module forms a discrete unit. This article is part of a Special Issue entitled SI: Noradrenergic System.

Intrathecal reboxetine suppresses evoked and ongoing neuropathic pain behaviours by restoring spinal noradrenergic inhibitory tone.

The descending noradrenergic (NAergic) projection to the spinal cord forms part of an endogenous analgesic system. After nerve injury, a localised failure in this compensatory system has been implicated as a permissive factor in the development of neuropathic sensitisation. We investigated whether restoring descending NAergic tone with intrathecal reboxetine can oppose the development of the neuropathic pain phenotype after tibial nerve transection (TNT). Rats had a lumbar intrathecal catheter implanted at the time of nerve injury for administration of reboxetine (10 µg) in both acute and chronic dosing experiments. In acute dosing experiments, both intrathecal and systemic (30 mg/kg) reboxetine partially reversed mechanical allodynia. This antiallodynic effect of intrathecal reboxetine was blocked by prior administration of yohimbine (α2-adrenoceptor antagonist, 30 µg) but not by prazosin (α1-adrenoceptor antagonist, 30 µg) or propranolol (ß-adrenoceptor antagonist, 100 µg). Chronic intrathecal reboxetine (10 µg, intrathecally, twice daily for 2 weeks) suppressed the development of cold and mechanical allodynia. Nerve-injured animals demonstrated a place preference for intrathecal reboxetine, suggesting that it also reduced spontaneous pain. In contrast, an equivalent antiallodynic dose of systemic reboxetine (30 mg/kg) was aversive in both naive and TNT rats. On cessation of chronic intrathecal reboxetine, there was a gradual development of allodynic sensitisation that was indistinguishable from control TNT animals by 7 days after the end of dosing. Our results suggest that pharmacological restoration of spinal NAergic tone with intrathecal reboxetine can suppress both allodynia and spontaneous pain in the TNT model.

Optoactivation of locus ceruleus neurons evokes bidirectional changes in thermal nociception in rats.

Pontospinal noradrenergic neurons are thought to form part of a descending endogenous analgesic system that exerts inhibitory influences on spinal nociception. Using optogenetic targeting, we tested the hypothesis that excitation of the locus ceruleus (LC) is antinociceptive. We transduced rat LC neurons by direct injection of a lentiviral vector expressing channelrhodopsin2 under the control of the PRS promoter. Subsequent optoactivation of the LC evoked repeatable, robust, antinociceptive (+4.7°C ± 1.0, p < 0.0001) or pronociceptive (-4.4°C ± 0.7, p < 0.0001) changes in hindpaw thermal withdrawal thresholds. Post hoc anatomical characterization of the distribution of transduced somata referenced against the position of the optical fiber and subsequent further functional analysis showed that antinociceptive actions were evoked from a distinct, ventral subpopulation of LC neurons. Therefore, the LC is capable of exerting potent, discrete, bidirectional influences on thermal nociception that are produced by specific subpopulations of noradrenergic neurons. This reflects an underlying functional heterogeneity of the influence of the LC on the processing of nociceptive information.