Stakeholder perceptions of and attitudes towards problematic polypharmacy and prescribing cascades: a qualitative study.

INTRODUCTION: Problematic polypharmacy is the prescribing of five or more medications potentially inappropriately. Unintentional prescribing cascades represent an under-researched aspect of problematic polypharmacy and occur when an adverse drug reaction (ADR) is misinterpreted as a new symptom resulting in the initiation of a new medication. The aim of this study was to elicit key stakeholders' perceptions of and attitudes towards problematic polypharmacy, with a focus on prescribing cascades. METHODS: qualitative one-to-one semi-structured interviews were conducted with predefined key stakeholder groups. Inductive thematic analysis was employed. RESULTS: Thirty-one stakeholders were interviewed: six patients, two carers, seven general practitioners, eight pharmacists, four hospital doctors, two professional organisation representatives and two policymakers. Three main themes were identified: (i) ADRs and prescribing cascades-a necessary evil. Healthcare professionals (HCPs) expressed concern that experiencing an ADR would negatively impact patients' confidence in their doctor. However, patients viewed ADRs pragmatically as an unpredictable risk. (ii) Balancing the risk/benefit tipping point. The complexity of prescribing decisions in the context of polypharmacy made balancing this tipping point challenging. Consequently, HCPs avoided medication changes. (iii) The minefield of medication reconciliation. Stakeholders, including patients and carers, viewed medication reconciliation as a perilous activity due to systemic communication deficits. CONCLUSION: Stakeholders believed that at a certain depth of polypharmacy, the risk that a new symptom is being caused by an existing medication becomes incalculable. Therefore, in the absence of harm, medication changes were avoided. However, medication reconciliation post hospital discharge compelled prescribing decisions and was seen as a high-risk activity by stakeholders.

General practitioners' attitudes towards and experiences of using the DermaBuddy health app for the management of patients with dermatological conditions - a descriptive cross-sectional study.

BACKGROUND: Dermatological presentations are common in primary care. The digital health space is growing in investment, revenue and in usership numbers. Doctors utilise mobile Health apps for referencing, communicating and for clinical decision-makin. Dermabuddy is a secure mobile health app by which information and expertise around skin problems can be shared among a group of medical professionals with the aim of finding the best treatment and management plan. AIM: The primary aim of this study is to assess the utility of the DermaBuddy health app for General Practitioners and associated trainees in Ireland. DESIGN & SETTING: This is a descriptive cross-sectional study, which involved a survey link distributed by email. METHOD: General Practitioners were surveyed, on their experiences of using the dermatology mobile application Dermabuddy RESULTS: 203 members took this questionnaire (13.5% response rate). 96% responding to "This app was easy to use" agreed it was easy or very easy. 87% of those who responded to "I would use this app again" agreed they would. 58% of those who responded to "This app is useful for my healthcare practice" gave it a five star rating. The content of 36 comments included advice for improvement and positive feedback. CONCLUSION: The Dermabuddy app is well received by participants in this study. Across all sections of the questionnaire looking at the aspects of the app including ease of use, interface and satisfaction and usefulness there was a positive response. Mobile health apps such as Dermabuddy may provide alternative solutions to meet the rising challenge of managing patients with Dermatological conditions in primary care.

A qualitative study of the dementia-care experiences and educational needs of physiotherapists in the Republic of Ireland.

OBJECTIVES: Gait disturbance and impaired balance lead to a greater risk of falls and hip fractures for people with dementia. Physiotherapists play an important role in multidisciplinary dementia care. This study aimed to explore physiotherapists' experiences of dementia care and sought to identify their dementia-specific educational needs. DESIGN: Qualitative design, using focus group interviews. SETTING: Primary care and secondary care physiotherapy services in the Republic of Ireland. PARTICIPANTS: Six focus groups with thirty-two physiotherapists, working in community care and hospital settings. RESULTS: Physiotherapists described a significant dementia-related workload. Challenges to care included absence of a formal diagnosis, clinical uncertainty, scarcity of resources, physical working environment and the assessment of rehabilitation potential. Dementia care was enhanced by the involvement of family members and by collaboration with other allied healthcare professionals. Participants expressed a wish to receive further dementia training and clear evidence-based physiotherapy guidelines. Identified areas of educational need included enhanced communication techniques, use and interpretation of cognitive screening tools, sub-typing of dementia, and ethical issues in dementia care. CONCLUSIONS: Our findings indicate that physiotherapists remain challenged by complex aspects of dementia care. Tailored dementia training for physiotherapists should be developed, focusing on their educational needs. Delivery of training should incorporate interactive case-based activities and interprofessional education with other allied healthcare professionals.

The candidate perspective of the clinical competency test (CCT) of the MICGP examination: a mixed-methods study.

BACKGROUND: The clinical competency test (CCT) was introduced by the Irish College of General Practitioners (ICGP) in 2015. Similar to the clinical skills assessment (CSA) of the Membership of the Royal College of General Practitioners exam (MRCGP), the CCT is a modified objective structured clinical examination (OSCE). AIM: The aim of this study was to evaluate the MICGP CCT from the candidates' perspective, to gain an insight into their views of its fairness, relevance, and acceptability. DESIGN & SETTING: This mixed-methods study was conducted with GP registrars in Ireland. METHOD: The study was conducted in two phases. Firstly, focus groups were conducted with participants who had previously undertaken the CCT to explore their experience of the CCT. Secondly, findings from the focus groups informed the development of an online questionnaire, which was sent to all GP registrars who completed the CCT in the 2017 summer sitting. RESULTS: Two focus groups were held with a total of nine participants. Following this, the online questionnaire was emailed to 134 registrars. Of these, 83 registrars completed the questionnaire in full. Registrars reported that the CCT is a fair exam and is relevant to daily general practice. They considered the exam to be a comprehensive assessment that has a positive educational impact. However, they were challenged by time restrictions, and found it financially and emotionally stressful. CONCLUSION: This is the first study to evaluate the candidate's perspective of an exiting GP membership exam in the UK or Ireland. The CCT is well-regarded by registrars. The study results will help to inform the future development of the CCT exam.

Development of a tool for monitoring the prescribing of antipsychotic medications to people with dementia in general practice: a modified eDelphi consensus study.

BACKGROUND: Despite their adverse effects, antipsychotics are frequently used to manage behavioral and psychological symptoms of dementia. Regular monitoring of antipsychotic prescribing has been shown to improve the appropriateness of prescribing. However, there is currently no consensus on what the components of such a monitoring tool would be. AIM: The aim of this study was to use an expert consensus process to identify the key components of an antipsychotic repeat prescribing tool for use with people with dementia in a general practice setting. METHODS: A modified eDelphi technique was employed. We invited multidisciplinary experts in antipsychotic prescribing to people with dementia to participate. These experts included general practitioners (GPs), geriatricians and old age psychiatrists. The list of statements for round 1 was developed through a review of existing monitoring tools and international best practice guidelines. In the second round of the Delphi, any statement that had not reached consensus in the first round was presented for re-rating, with personalized feedback on the group and the individual's response to the specific statement. The final round consisted of a face-to-face expert meeting to resolve any uncertainties from round 2. RESULTS: A total of 23 items were rated over two eDelphi rounds and one face-to-face consensus meeting to yield a total of 18 endorsed items and five rejected items. The endorsed statements informed the development of a structured, repeat prescribing tool for monitoring antipsychotics in people with dementia in primary care. CONCLUSION: The development of repeat prescribing tool provides GPs with practical advice that is lacking in current guidelines and will help to support GPs by providing a structured format to use when reviewing antipsychotic prescriptions for people with dementia, ultimately improving patient care. The feasibility and acceptability of the tool now need to be evaluated in clinical practice.

The knowledge and attitudes of general practitioners to the assessment and management of pain in people with dementia.

BACKGROUND: Pain in people with dementia is underdiagnosed and undertreated. General practitioners (GPs) play a pivotal role in dementia care but their perspectives on pain in people with dementia remains under-researched. The aim of this study was to explore GPs' knowledge and attitudes towards pain assessment and management in people with dementia. METHODS: This was a descriptive cross-sectional study. A questionnaire was adapted from a previous study and piloted with 5 GPs. The questionnaire was posted to a census sample of all GPs in Cork city and county in the southern region of Ireland. The questionnaire collected demographic information, responses to a series of Likert-type statements assessing GPs' knowledge and attitudes, and provided an opportunity for the GP to give qualitative feedback on their experiences of managing pain in dementia. SPSS v25 was used for statistical analysis. Qualitative responses were thematically analysed. RESULTS: Of the 320 questionnaires posted, 157 completed questionnaires were returned (response rate of 49%). The sample was representative of GPs nationally in terms of years in GP practice and practice location. Over two-thirds (108/157) of respondents had a nursing home commitment. Only 10% of respondents (16/157) were aware of any dementia-specific pain assessment tools. The larger the nursing home commitment of the GP the more likely they were to be familiar with these tools (p = 0.048). The majority of respondents (113/157) believed people with dementia could not self-report pain. Respondents were uncertain about the safety of using opioid medications to treat pain in people with dementia with only 51.6% agreeing that they were safe. The qualitative comments highlighted the importance the GPs placed on surrogate reports of pain, GPs' uncertainty regarding the value of formal pain assessment tools and the challenges caused by under-resourcing in general practice. CONCLUSION: This study has highlighted aspects of pain assessment and management in dementia that GPs find challenging. Guidance on pain assessment and management in people with dementia do not appear to be translating into clinical practice. The findings will inform educational interventions being developed by our research team as part of the implementation of the Irish national dementia strategy. The knowledge and attitudes of general practitioners to the assessment and management of pain in people with dementia.

The development and evaluation of an online dementia resource for primary care based health professionals.

BACKGROUND: Primary care based health professionals struggle with many aspects of dementia care. General practitioners (GPs) find providing post-diagnosis information on services and supports particularly challenging. Likewise, people with dementia and their family caregivers feel they need more support from their GPs in this post-diagnosis period. OBJECTIVE: This study aimed to develop and evaluate an online educational resource for primary care health professionals that included a dementia specific services and supports directory. METHOD: A previously conducted educational needs analysis informed the content of the resource. This content was further developed by a review of the literature and through consultation with an expert reference group and a stakeholder group. A mixed method approach was taken to the evaluation of the online resource which included analysis of the website traffic, qualitative feedback from stakeholders and evaluation by general practitioners. RESULTS: The online resource www.dementiapathways.ie was developed. Initial qualitative feedback obtained from potential end-users was positive. Data analysis was performed on over 4000 people who accessed the site. Finally, the online resource was demonstrated to 190 general practitioners in 36 workshops. All of the general practitioners surveyed felt that dementipathways.ie would be a useful resource for them. Several potential barriers to the successful development and implementation of a services and supports directory were identified. CONCLUSION: This study provides a prototype for the development of an online dementia educational resource and demonstrates the value of a dementia-specific services and supports directory for primary care based health professionals.

General practitioners' knowledge, attitudes, and experiences of managing behavioural and psychological symptoms of dementia: A mixed-methods systematic review.

OBJECTIVES: To synthesise the existing published literature on general practitioners (GP)'s knowledge, attitudes, and experiences of managing behavioural and psychological symptoms of dementia (BPSD) with a view to informing future interventions. METHODS: We conducted a systematic review and synthesis of quantitative and qualitative studies that explored GPs' experiences of managing BPSD (PROSPERO protocol registration CRD42017054916). Seven electronic databases were searched from inception to October 2017. Each stage of the review process involved at least 2 authors working independently. The meta-ethnographic approach was used to synthesise the findings of the included studies while preserving the context of the primary data. The Confidence in the Evidence from Reviews of Qualitative research (CERQual) was used to assess the confidence in our individual review findings. RESULTS: Of the 1638 articles identified, 76 full texts were reviewed and 11 were included. Three main concepts specific to GPs' experiences of managing BPSD emerged: unmet primary care resource needs, justification of antipsychotic prescribing, and the pivotal role of families. A "line of argument" was drawn, which described how in the context of resource limitations a therapeutic void was created. This resulted in GPs being over reliant on antipsychotics and family caregivers. These factors appeared to culminate in a reactive response to BPSD whereby behaviours and symptoms could escalate until a crisis point was reached. CONCLUSION: This systematic review offers new insights into GPs' perspectives on the management of BPSD and will help to inform the design and development of interventions to support GPs managing BPSD.

General practitioners' knowledge, attitudes and experiences of managing behavioural and psychological symptoms of dementia: protocol of a mixed methods systematic review and meta-ethnography.

BACKGROUND: In the context of rising dementia prevalence, the workload of general practitioners (GPs) in dementia care is set to increase. However, there are many aspects of dementia care that GPs find challenging. Behavioural and psychological symptoms of dementia (BPSD) affect the majority of people with dementia and is an aspect of dementia care that GPs find particularly difficult to manage. The aim of this mixed methods systematic review is to undertake a synthesis of qualitative and quantitative studies on GPs' knowledge, attitudes and experiences of managing BPSD. METHODS: Seven electronic bibliographic databases will be searched from inception to present. All qualitative or quantitative studies that explore the knowledge, attitude or experiences of GPs towards the management of BPSD in community and/or residential settings will be eligible for inclusion. A meta-ethnography will be conducted to synthesise included studies. Primary outcome measures will include GPs' experiences of managing BPSD, GPs' knowledge of BPSD and their attitude to different approaches to the management of BPSD, in particular their attitude to non-pharmacological approaches. All included papers will be independently assessed for methodological validity by two reviewers using the following tools: the Joanna Briggs Institute checklist for qualitative research, the Effective Public Health Practice Project (EPHPP) tool for intervention studies and the National Institute of Health (NIH) quality assessment tool for observational and analytical cross-sectional studies. As there is no agreed quality assessment tool for descriptive cross-sectional studies, an original tool will be developed. Two independent reviewers will apply the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) tool to the review findings. The results will be reported in line with the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement. DISCUSSION: This study will be the first systematic review that synthesises the existing literature of GPs' knowledge, attitudes and experiences of managing BPSD in community and residential care. This review will improve our understanding of GPs' perspectives on the management of BPSD, and the results will be used to inform the development of an intervention to improve the management of BPSD in general practice. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42017054916 .

'Working away in that Grey Area ' A qualitative exploration of the challenges general practitioners experience when managing behavioural and psychological symptoms of dementia.

Background: general practitioners (GPs) have identified the management of behavioural and psychological symptoms of dementia (BPSD) as a particularly challenging aspect of dementia care. However, there is a paucity of research on why GPs find BPSD challenging and how this influences the care they offer to their patients with dementia. Objectives: to establish the challenges GPs experience when managing BPSD; to explore how these challenges influence GPs' management decisions; and to identify strategies for overcoming these challenges. Design: qualitative study of GPs experiences of managing BPSD. Methods: semi-structured interviews were conducted with 16 GPs in the Republic of Ireland. GPs were purposively recruited to include participants with differing levels of experience caring for people with BPSD in nursing homes and in community settings to provide maximum diversity of views. Interviews were analysed thematically. Results: three main challenges of managing BPSD were identified; lack of clinical guidance, stretched resources and difficulties managing expectations. The lack of relevant clinical guidance available affected GPs' confidence when managing BPSD. In the absence of appropriate resources GPs felt reliant upon sedative medications. GPs believed their advocacy role was further compromised by the difficulties they experienced managing expectations of family caregivers and nursing home staff. Conclusions: this study helps to explain the apparent discrepancy between best practice recommendations in BPSD and real-life practice. It will be used to inform the design of an intervention to support the management of BPSD in general practice.