Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 20
Filtrar
1.
Clin Nutr ESPEN ; 36: 116-127, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32220354

RESUMO

BACKGROUND & AIMS: Malnutrition or undernutrition, arising from a deficiency of energy and protein intake, occurs commonly among community-dwelling individuals in developed countries. Once identified, malnutrition can be effectively treated in the majority of cases with dietary advice and the prescription of oral nutritional supplements (ONS) for patients who can eat and drink orally. However, previous research has reported inadequate screening and treatment of malnutrition in the community. The aim of this qualitative study was to explore general practitioners' (GPs) experiences and opinions on the management of malnutrition and the prescription of ONS in the primary care/community setting in Ireland. METHODS: Sixteen semi-structured interviews including chart stimulated recalls (CSR) were conducted with GPs. The interviews and CSRs explored, among others, the following domains; barriers and facilitators in the management of malnutrition, ONS prescribing in the primary care/community setting, and future directions in the management of malnutrition and ONS prescribing. Recorded interviews were transcribed and analysed following a generic qualitative approach with inductive thematic analysis using NVIVO 12 to facilitate data management. RESULTS: Three main themes were identified. Theme 1: 'Malnutrition is a secondary concern', encapsulating the idea that the identification of malnutrition is usually secondary to other clinical issues or disease rather than an independent clinical outcome. This theme also includes the idea that obesity is viewed as a dominant nutritional issue for GPs. Theme 2: 'Responsibility for malnutrition and ONS management in the community', highlighting that GPs feel they do not know who is responsible for the management of malnutrition in the community setting and expressed their need for more support from other healthcare professionals (HCPs) to effectively monitor and treat malnutrition. Theme 3: 'Reluctance to prescribe ONS', emerging from the GPs reported lack of knowledge to prescribe the appropriate ONS, their concern that ONS will replace the patient's meals and the costs associated with the prescription of ONS. CONCLUSIONS: GPs in Ireland do not routinely screen for malnutrition in their clinics as they feel unsupported in treating and managing malnutrition in the community due to limited or no dietetic service availability and time constraints. GPs also view malnutrition as a secondary concern to disease management and prioritise referral to dietetic services for patients with overweight and obesity. GPs reported that they have insufficient knowledge to change or discontinue ONS prescriptions. This study demonstrates that there is a clear need for primary care training in malnutrition identification, treatment and management and more community dietetic services are needed in order to support GPs and deliver high quality care to patients.

2.
Artigo em Inglês | MEDLINE | ID: mdl-32147895

RESUMO

Evidence indicates that homelessness is increasing within Europe and the United States (US), particularly for women. Pregnancy rates among homeless women are exceptionally high compared to their housed counterparts and homeless women engage poorly with antenatal care. The aim of this review is to explore the barriers and facilitators perceived by homeless women, while pregnant, or within six weeks postpartum in accessing antenatal and/or postnatal healthcare. A qualitative systematic review and synthesis was conducted. Key words and search terms were derived using the SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, Research type) framework. Titles and abstracts were screened in accordance with inclusion and exclusion criteria. The methodological quality of included papers was assessed using criteria described by the Critical Appraisal Skills Programme (CASP) with data analysis using thematic synthesis. Two primary linked themes were generated: (a) lack of person-centred care; (b) complexity of survival. At an organisational level, a fragmented health service and accessibility to the health system were barriers, and resulted in poor person-centred care. At a clinical level, attitude & treatment from healthcare providers together with health knowledge all combined to illustrate poor person-centred care as barriers to homeless women accessing antenatal/postnatal healthcare. Sub-themes associated with complexity of survival included: disillusion with life, distrust of services, competing lifestyle demands and support and relationships. The findings of this review highlight that poor engagement may be partly explained by the complex interplay between both the healthcare system (person-centred care) and the individual (complexity of survival). Future services should be delivered in a way that recognises homeless people's complex and diverse needs, and should be reconfigured in order to try to meet them, through decreasing fragmentation of health services and staff training.

3.
Eur J Ophthalmol ; : 1120672120901693, 2020 Jan 20.
Artigo em Inglês | MEDLINE | ID: mdl-31957482

RESUMO

OBJECTIVE: To establish if there is a difference in health-related quality of life and vision-related quality of life in patients with a confirmed diagnosis of giant cell arteritis compared with those with clinical features suspicious for the disease at initial presentation but in whom giant cell arteritis is ultimately excluded. METHODS: A cross-sectional study of 116 patients who presented to two tertiary referral hospitals in Ireland with symptoms suspicious for giant cell arteritis was performed between August 2011 and June 2017. The Vision Core Measurement 1 and Short Form-36 questionnaires were used as assessment tools. RESULTS: The mean (standard deviation) age of all 116 participants was 69.4 (9.3) years of whom 74 (63.8%) were female. In the giant cell arteritis group, 19.7% had permanent loss of vision and 54.7% had non-permanent visual disturbance. Vision Core Measurement 1 score in the giant cell arteritis group correlated with worse eye visual acuity (r = 0.4233, p = 0.0002). The Short Form-36 subscales of role physical (p = 0.0002), role emotional (p = 0.024), and the mental composite score (p = 0.012) were significantly worse in patients with giant cell arteritis. A significant correlation was found between vision-related quality of life scores and all Short Form-36 subscale scores except bodily pain (r = -0.215 to -0.399, p < 0.05 for all), and between social functioning and visual acuity in the better eye (r = -0.242, p = 0.038). CONCLUSION: Vision-related quality of life is an important subjective concern for both patients presenting with a suspicion of giant cell arteritis and those with a definite diagnosis of giant cell arteritis. Features of giant cell arteritis impact on patients' physical and emotional states and vision influences global quality of life in giant cell arteritis. A long-term multidisciplinary approach is warranted for clinical, physical, and psychological treatment and support.

4.
Artigo em Inglês | MEDLINE | ID: mdl-31771958

RESUMO

BACKGROUND: Understanding patient perceptions of their spiritual needs when approaching the end of life is essential to support the delivery of patient-centred care. AIM: To conduct a qualitative evidence synthesis on spirituality and spiritual care needs at the end of life in all healthcare settings from the patients' perspective. DESIGN: Studies were included where they were primary qualitative studies exploring spirituality in patients with a life expectancy of 12 months or less in any setting. Two reviewers independently screened titles, extracted data and conducted methodological quality appraisal. A thematic synthesis was conducted. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) - Confidence in the Evidence from Reviews of Qualitative research (CERQual) was used to summarise the certainty of the evidence. DATA SOURCES: Six databases (Medline, Embase, Cochrane, CINAHL, PsycINFO, Applied Social Science Index and Abstracts) were searched from inception up to January 2019. RESULTS: Fifty papers (42 unique datasets), incorporating data from 710 patients were included. Studies recruited from a mix of inpatient, outpatient, hospice and community settings across 12 different countries. Three overarching themes were generated: the concept of spirituality, spiritual needs and distress, and spiritual care resources. Relationships were an intrinsic component of spirituality. CONCLUSION: Meeting patients' spiritual needs is an integral part of end-of-life care. This work emphasises that supporting relationships should be a central focus of spiritual care for patients at the end of life. PROSPERO REGISTRATION NUMBER: CRD42019122062.

5.
J Am Geriatr Soc ; 66(6): 1206-1212, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29461621

RESUMO

OBJECTIVES: To develop a core outcome set (COS) for use in effectiveness trials of interventions aiming to improve the appropriateness of polypharmacy in older people in primary care. DESIGN: Standard COS development methodology was followed, comprising identification of outcomes of studies from an update of a Cochrane systematic review and previously collected qualitative data and an online Delphi consensus exercise involving three rounds. PARTICIPANTS: An international panel of 160 stakeholders comprising 120 healthcare experts and a public participant panel of 40 older people. MEASUREMENTS: Outcomes identified from studies included in the Cochrane review and secondary analysis of previously collected qualitative data were scored on a 9-point Likert scale using the GRADE scoring system anchored at 1 (not important) and 9 (critical). Consensus criteria for the COS were defined as 70% or more of participants scoring the outcome as critical and 15% or fewer scoring the outcome as not important. RESULTS: Twenty-nine outcomes identified from the Cochrane review and existing qualitative data were included in the Delphi exercise. The final COS comprised 16 outcomes. The 7 highest-ranked outcomes were serious adverse drug reactions, medication appropriateness, falls, medication regimen complexity, quality of life, mortality, and medication side effects. CONCLUSION: A COS for interventions aiming to improve the appropriateness of polypharmacy for older people in primary care has been developed. Future work will focus on identifying appropriate tools to measure.


Assuntos
Prescrição Inadequada/prevenção & controle , Conduta do Tratamento Medicamentoso , Polimedicação , Atenção Primária à Saúde , Qualidade de Vida , Idoso , Consenso , Técnica Delfos , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/etiologia , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/prevenção & controle , Humanos , Prescrição Inadequada/psicologia , Prescrição Inadequada/estatística & dados numéricos , Conduta do Tratamento Medicamentoso/organização & administração , Conduta do Tratamento Medicamentoso/normas , Atenção Primária à Saúde/métodos , Atenção Primária à Saúde/normas , Melhoria de Qualidade
6.
Int J Technol Assess Health Care ; 33(4): 494-503, 2017 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29019297

RESUMO

OBJECTIVES: This study examines the cost-effectiveness of the OPTI-SCRIPT intervention on potentially inappropriate prescribing in primary care. METHODS: Economic evaluation, using incremental cost-effectiveness and cost utility analyses, conducted alongside a cluster randomized controlled trial of twenty-one general practices and 196 patients, to compare a multifaceted intervention with usual practice in primary care in Ireland. Potentially inappropriate prescriptions (PIPs) were determined by a pharmacist. Incremental costs, PIPs, and quality-adjusted life-years (QALYs) at 12-month follow-up were estimated using multilevel regression. Uncertainty was explored using cost-effectiveness acceptability curves. RESULTS: The intervention was associated with a nonsignificant mean cost increase of €407 (95 percent CIs, -357-1170), a significant mean reduction in PIPs of 0.379 (95 percent CI, 0.092-0.666), and a nonsignificant mean increase in QALYs of 0.013 (95 percent CIs, -0.016-0.042). The incremental cost per PIP avoided was €1,269 (95 percent CI, -1400-6302) and the incremental cost per QALY gained was €30,535 (95 percent CI, -334,846-289,498). The probability of the intervention being cost-effective was 0.602 at a threshold value of €45,000 per QALY gained and was at least 0.845 at threshold values of €2,500 per PIP avoided and higher. CONCLUSIONS: While the OPTI-SCRIPT intervention was effective in reducing potentially inappropriate prescribing in primary care in Ireland, our findings highlight the uncertainty with respect to its cost-effectiveness. Further studies are required to explore the health and economic implications of interventions targeting potentially inappropriate prescribing.


Assuntos
Prescrição Inadequada/economia , Prescrição Inadequada/prevenção & controle , Padrões de Prática Médica/organização & administração , Atenção Primária à Saúde/organização & administração , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Análise Custo-Benefício , Feminino , Humanos , Irlanda , Masculino , Conduta do Tratamento Medicamentoso/organização & administração , Padrões de Prática Médica/economia , Atenção Primária à Saúde/economia , Anos de Vida Ajustados por Qualidade de Vida
7.
Implement Sci ; 12(1): 99, 2017 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-28764753

RESUMO

BACKGROUND: Multimorbidity, defined as the presence of at least two chronic conditions, becomes increasingly common in older people and is associated with poorer health outcomes and significant polypharmacy. The National Institute for Clinical Excellence (NICE) recently published a multimorbidity guideline that advises providing an individualised medication review for all people prescribed 15 or more repeat medicines. This study incorporates this guideline and aims to assess the effectiveness of a complex intervention designed to support general practitioners (GPs) to reduce potentially inappropriate prescribing and consider deprescribing in older people with multimorbidity and significant polypharmacy in Irish primary care. METHODS: This study is a cluster randomised controlled trial, involving 30 general practices and 450 patients throughout Ireland. Practices will be eligible to participate if they have at least 300 patients aged 65 years and over on their patient panel and if they use either one of the two predominant practice management software systems in use in Ireland. Using a software patient finder tool, practices will identify and recruit patients aged 65 years and over, who are prescribed at least 15 repeat medicines. Once baseline data collection is complete, practices will be randomised using minimisation by an independent third party to either intervention or control. Given the nature of the intervention, it is not possible to blind participants or study personnel. GPs in intervention practices will receive login details to a website where they will access training videos and a template for conducting an individualised structured medication review, which they will undertake with each of their included patients. Control practices will deliver usual care over the 6-month study period. Primary outcome measures pertain to the individual patient level and are the proportion of patients with any PIP and the number of repeat medicines. DISCUSSION: Disease-specific approaches in multimorbidity may be inappropriate and result in fragmented and poorly co-ordinated care. This pragmatic study is evaluating a complex intervention that is relevant across multiple conditions and addresses potential concerns around medicines safety in this vulnerable group of patients. The potential for system-wide implementation will be explored with a parallel mixed methods process evaluation. TRIAL REGISTRATION: ISRCTN: 12752680 , Registered 20 October 2016.


Assuntos
Doença Crônica/tratamento farmacológico , Prescrições de Medicamentos/normas , Guias como Assunto , Multimorbidade , Polimedicação , Atenção Primária à Saúde/métodos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Irlanda , Masculino , Projetos Piloto
8.
Br J Gen Pract ; 67(660): e507-e518, 2017 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-28533200

RESUMO

BACKGROUND: Polypharmacy (≥5 medications) is common in older patients and is associated with adverse outcomes. Patients' beliefs about medication can influence their expectations for medication, adherence, and willingness to deprescribe. Few studies have examined beliefs about prescribed medication among older patients with polypharmacy in primary care. AIM: To explore medication-related beliefs in older patients with polypharmacy and factors that might influence beliefs. DESIGN AND SETTING: A mixed methods study utilising data from a randomised controlled trial aiming to decrease potentially inappropriate prescribing in older patients (≥70 years) in Ireland. METHOD: Beliefs were assessed quantitatively and qualitatively. Participants completed the Beliefs about Medicines Questionnaire by indicating their degree of agreement with individual statements about medicines on a 5-point Likert scale. Semi-structured qualitative interviews were conducted with a purposive sample of participants. Interviews were transcribed verbatim and a thematic analysis conducted. Quantitative and qualitative data were analysed separately and triangulated during the interpretation stage. RESULTS: In total, 196 patients were included (mean age 76.7 years, SD 4.9, 54% male), with a mean of 9.5 (SD 4.1) medications per patient. The majority (96.3%) believed strongly in the necessity of their medication, while 33.9% reported strong concerns. Qualitative data confirmed these coexisting positive and negative attitudes to medications and suggested the importance of patients' trust in GPs in establishing positive beliefs and potential willingness to deprescribe. CONCLUSION: Participants reported strong beliefs in medications with coexisting positive and negative attitudes. The doctor-patient relationship may have influenced beliefs and attitudes towards medicines, highlighting the importance of strong doctor-patient relationships, which need to be considered in the context of deprescribing.


Assuntos
Desprescrições , Serviços de Saúde para Idosos , Preferência do Paciente/estatística & dados numéricos , Polimedicação , Atenção Primária à Saúde , Idoso , Idoso de 80 Anos ou mais , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Entrevistas como Assunto , Irlanda , Masculino , Educação de Pacientes como Assunto , Preferência do Paciente/psicologia , Relações Médico-Paciente , Pesquisa Qualitativa , Ensaios Clínicos Controlados Aleatórios como Assunto
9.
BMJ Open ; 7(3): e014096, 2017 03 06.
Artigo em Inglês | MEDLINE | ID: mdl-28264830

RESUMO

OBJECTIVES: Malignant melanoma has high morbidity and mortality rates. Early diagnosis improves prognosis. Clinical prediction rules (CPRs) can be used to stratify patients with symptoms of suspected malignant melanoma to improve early diagnosis. We conducted a systematic review of CPRs for melanoma diagnosis in ambulatory care. DESIGN: Systematic review. DATA SOURCES: A comprehensive search of PubMed, EMBASE, PROSPERO, CINAHL, the Cochrane Library and SCOPUS was conducted in May 2015, using combinations of keywords and medical subject headings (MeSH) terms. STUDY SELECTION AND DATA EXTRACTION: Studies deriving and validating, validating or assessing the impact of a CPR for predicting melanoma diagnosis in ambulatory care were included. Data extraction and methodological quality assessment were guided by the CHARMS checklist. RESULTS: From 16 334 studies reviewed, 51 were included, validating the performance of 24 unique CPRs. Three impact analysis studies were identified. Five studies were set in primary care. The most commonly evaluated CPRs were the ABCD, more than one or uneven distribution of Colour, or a large (greater than 6 mm) Diameter (ABCD) dermoscopy rule (at a cut-point of >4.75; 8 studies; pooled sensitivity 0.85, 95% CI 0.73 to 0.93, specificity 0.72, 95% CI 0.65 to 0.78) and the 7-point dermoscopy checklist (at a cut-point of ≥1 recommending ruling in melanoma; 11 studies; pooled sensitivity 0.77, 95% CI 0.61 to 0.88, specificity 0.80, 95% CI 0.59 to 0.92). The methodological quality of studies varied. CONCLUSIONS: At their recommended cut-points, the ABCD dermoscopy rule is more useful for ruling out melanoma than the 7-point dermoscopy checklist. A focus on impact analysis will help translate melanoma risk prediction rules into useful tools for clinical practice.


Assuntos
Assistência Ambulatorial/métodos , Técnicas de Apoio para a Decisão , Melanoma/diagnóstico , Humanos , Sensibilidade e Especificidade
10.
Cochrane Database Syst Rev ; 2: CD004910, 2017 02 23.
Artigo em Inglês | MEDLINE | ID: mdl-28230899

RESUMO

BACKGROUND: Shared care has been used in the management of many chronic conditions with the assumption that it delivers better care than primary or specialty care alone; however, little is known about the effectiveness of shared care. OBJECTIVES: To determine the effectiveness of shared care health service interventions designed to improve the management of chronic disease across the primary/specialty care interface. This is an update of a previously published review.Secondary questions include the following:1. Which shared care interventions or portions of shared care interventions are most effective?2. What do the most effective systems have in common? SEARCH METHODS: We searched MEDLINE, Embase and the Cochrane Library to 12 October 2015. SELECTION CRITERIA: One review author performed the initial abstract screen; then two review authors independently screened and selected studies for inclusion. We considered randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after studies (CBAs) and interrupted time series analyses (ITS) evaluating the effectiveness of shared care interventions for people with chronic conditions in primary care and community settings. The intervention was compared with usual care in that setting. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data from the included studies, evaluated study quality and judged the certainty of the evidence using the GRADE approach. We conducted a meta-analysis of results when possible and carried out a narrative synthesis of the remainder of the results. We presented the results in a 'Summary of findings' table, using a tabular format to show effect sizes for all outcome types. MAIN RESULTS: We identified 42 studies of shared care interventions for chronic disease management (N = 18,859), 39 of which were RCTs, two CBAs and one an NRCT. Of these 42 studies, 41 examined complex multi-faceted interventions and lasted from six to 24 months. Overall, our confidence in results regarding the effectiveness of interventions ranged from moderate to high certainty. Results showed probably few or no differences in clinical outcomes overall with a tendency towards improved blood pressure management in the small number of studies on shared care for hypertension, chronic kidney disease and stroke (mean difference (MD) 3.47, 95% confidence interval (CI) 1.68 to 5.25)(based on moderate-certainty evidence). Mental health outcomes improved, particularly in response to depression treatment (risk ratio (RR) 1.40, 95% confidence interval (CI) 1.22 to 1.62; six studies, N = 1708) and recovery from depression (RR 2.59, 95% CI 1.57 to 4.26; 10 studies, N = 4482) in studies examining the 'stepped care' design of shared care interventions (based on high-certainty evidence). Investigators noted modest effects on mean depression scores (standardised mean difference (SMD) -0.29, 95% CI -0.37 to -0.20; six studies, N = 3250). Differences in patient-reported outcome measures (PROMs), processes of care and participation and default rates in shared care services were probably limited (based on moderate-certainty evidence). Studies probably showed little or no difference in hospital admissions, service utilisation and patient health behaviours (with evidence of moderate certainty). AUTHORS' CONCLUSIONS: This review suggests that shared care improves depression outcomes and probably has mixed or limited effects on other outcomes. Methodological shortcomings, particularly inadequate length of follow-up, may account in part for these limited effects. Review findings support the growing evidence base for shared care in the management of depression, particularly stepped care models of shared care. Shared care interventions for other conditions should be developed within research settings, with account taken of the complexity of such interventions and awareness of the need to carry out longer studies to test effectiveness and sustainability over time.


Assuntos
Doença Crônica/terapia , Medicina de Família e Comunidade , Medicina , Equipe de Assistência ao Paciente , Especialização , Continuidade da Assistência ao Paciente , Estudos Controlados Antes e Depois , Depressão/terapia , Diabetes Mellitus/terapia , Gerenciamento Clínico , Humanos , Hipertensão/terapia , Ensaios Clínicos Controlados não Aleatórios como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto
11.
Trials ; 17(1): 386, 2016 08 03.
Artigo em Inglês | MEDLINE | ID: mdl-27488272

RESUMO

BACKGROUND: The OPTI-SCRIPT cluster randomised controlled trial (RCT) found that a three-phase multifaceted intervention including academic detailing with a pharmacist, GP-led medicines reviews, supported by web-based pharmaceutical treatment algorithms, and tailored patient information leaflets, was effective in reducing potentially inappropriate prescribing (PIP) in Irish primary care. We report a process evaluation exploring the implementation of the intervention, the experiences of those participating in the study and lessons for future implementation. METHODS: The OPTI-SCRIPT trial included 21 GP practices and 196 patients. The process evaluation used mixed methods. Quantitative data were collected from all GP practices and semi-structured interviews were conducted with GPs from intervention and control groups, and a purposive sample of patients from the intervention group. All interviews were transcribed verbatim and analysed using a thematic analysis. RESULTS: Despite receiving a standardised academic detailing session, intervention delivery varied among GP practices. Just over 70 % of practices completed medicines review as recommended with the patient present. Only single-handed practices conducted reviews without patients present, highlighting the influence of practice characteristics and resources on variation. Medications were more likely to be completely stopped or switched to another more appropriate medication when reviews were conducted with patients present. The patient information leaflets were not used by any of the intervention practices. Both GP (32 %) and patient (40 %) recruitment rates were modest. For those who did participate, overall, the experience was positively viewed, with GPs and patients referring to the value of medication reviews to improve prescribing and reduce unnecessary medications. Lack of time in busy GP practices and remuneration were identified as organisational barriers to future implementation. CONCLUSIONS: The OPTI-SCRIPT intervention was positively viewed by both GPs and patients, both of whom valued the study's objectives. Patient information leaflets were not a successful component of the intervention. Academic detailing and medication reviews are important components in changing PIP, and having patients present during the review process seems to be a more effective approach for decreasing PIP. TRIAL REGISTRATION: Current controlled trials ISRCTN41694007 . Registered on 21 March 2012.


Assuntos
Prescrição Inadequada/prevenção & controle , Conduta do Tratamento Medicamentoso , Atenção Primária à Saúde , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Atitude do Pessoal de Saúde , Análise por Conglomerados , Substituição de Medicamentos , Feminino , Clínicos Gerais/psicologia , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Entrevistas como Assunto , Irlanda , Masculino , Folhetos , Educação de Pacientes como Assunto , Polimedicação , Padrões de Prática Médica , Projetos de Pesquisa
12.
BMC Fam Pract ; 17(1): 109, 2016 08 11.
Artigo em Inglês | MEDLINE | ID: mdl-27515854

RESUMO

BACKGROUND: Potentially inappropriate prescribing (PIP) is common in older people in primary care, as evidenced by a significant body of quantitative research. However, relatively few qualitative studies have investigated the phenomenon of PIP and its underlying processes from the perspective of general practitioners (GPs). The aim of this paper is to explore qualitatively, GP perspectives regarding prescribing and PIP in older primary care patients. METHOD: Semi-structured qualitative interviews were conducted with GPs participating in a randomised controlled trial (RCT) of an intervention to decrease PIP in older patients (≥70 years) in Ireland. Interviews were conducted with GP participants (both intervention and control) from the OPTI-SCRIPT cluster RCT as part of the trial process evaluation between January and July 2013. Interviews were conducted by one interviewer and audio recorded. Interviews were transcribed verbatim and a thematic analysis was conducted. RESULTS: Seventeen semi-structured interviews were conducted (13 male; 4 female). Three main, inter-related themes emerged (complex prescribing environment, paternalistic doctor-patient relationship, and relevance of PIP concept). Patient complexity (e.g. polypharmacy, multimorbidity), as well as prescriber complexity (e.g. multiple prescribers, poor communication, restricted autonomy) were all identified as factors contributing to a complex prescribing environment where PIP could occur, as was a paternalistic-doctor patient relationship. The concept of PIP was perceived to be of variable usefulness to GPs and the criteria to measure it may be at odds with the complex processes of prescribing for this patient population. CONCLUSIONS: Several inter-related factors contributing to the occurrence of PIP were identified, some of which may be amenable to intervention. Improvement strategies focused on improved management of polypharmacy and multimorbidity, and communication across primary and secondary care could result in substantial improvements in PIP. TRIAL REGISTRATION: Current controlled trials ISRCTN41694007.


Assuntos
Atitude do Pessoal de Saúde , Clínicos Gerais/psicologia , Prescrição Inadequada , Polimedicação , Atenção Primária à Saúde , Idoso , Comunicação , Comorbidade , Feminino , Humanos , Entrevistas como Assunto , Irlanda , Masculino , Paternalismo , Equipe de Assistência ao Paciente , Relações Médico-Paciente , Padrões de Prática Médica , Autonomia Profissional , Pesquisa Qualitativa , Ensaios Clínicos Controlados Aleatórios como Assunto
13.
Hum Resour Health ; 14(Suppl 1): 34, 2016 06 30.
Artigo em Inglês | MEDLINE | ID: mdl-27381189

RESUMO

BACKGROUND: Health professionals, particularly doctors, nurses and midwives, are in high demand worldwide. Therefore, it is important to assess the future plans and likelihood of return of emigrating health professionals. Nevertheless, health professionals are, by definition, a difficult population to track/survey. This exploratory study reports on the migration intentions of a sample of doctors, nurses and midwives who had emigrated from Ireland, a high-income country which has experienced particularly high outward and inward migration of health professionals since the year 2000. METHODS: Health professionals who had emigrated from Ireland were identified via snowball sampling through Facebook and invited to complete a short online survey composed of closed and open response questions. RESULTS: A total of 388 health professionals (307 doctors, 73 nurses and 8 midwives) who had previously worked in Ireland completed the survey. While over half had originally intended to spend less than 5 years in their destination country at the time of emigration, these intentions changed over time, with the desire to remain abroad on a permanent basis increasing from 10 to 34 % of doctor respondents. Only a quarter of doctors and a half of nurses and midwives intended to return to practice in Ireland in the future. CONCLUSIONS: The longer health professionals remain abroad, the less likely they are to return to their home countries. Countries should focus on the implementation of retention strategies if the 'carousel' of brain drain is to be interrupted. This would allow source countries to benefit from their investments in training health professionals, rather than relying on international recruitment to meet health system staffing needs. Improved data collection systems are also needed to track the migratory patterns and changing intentions of health professionals. Meanwhile, social networking platforms offer alternative methods of filling this information gap.


Assuntos
Emigração e Imigração , Intenção , Enfermeiras e Enfermeiros , Seleção de Pessoal , Médicos , Área de Atuação Profissional , Mídias Sociais , Adulto , Atitude do Pessoal de Saúde , Assistência à Saúde , Emigrantes e Imigrantes , Pessoal Profissional Estrangeiro , Humanos , Irlanda , Enfermeiras Obstétricas , Inquéritos e Questionários , Migrantes , Recursos Humanos
14.
Implement Sci ; 11(1): 79, 2016 06 02.
Artigo em Inglês | MEDLINE | ID: mdl-27255504

RESUMO

BACKGROUND: Potentially inappropriate prescribing (PIP) is common in older people in primary care and can result in increased morbidity, adverse drug events and hospitalisations. We previously demonstrated the success of a multifaceted intervention in decreasing PIP in primary care in a cluster randomised controlled trial (RCT). OBJECTIVE: We sought to determine whether the improvement in PIP in the short term was sustained at 1-year follow-up. METHODS: A cluster RCT was conducted with 21 GP practices and 196 patients (aged ≥70) with PIP in Irish primary care. Intervention participants received a complex multifaceted intervention incorporating academic detailing, medicine review with web-based pharmaceutical treatment algorithms that provide recommended alternative treatment options, and tailored patient information leaflets. Control practices delivered usual care and received simple, patient-level PIP feedback. Primary outcomes were the proportion of patients with PIP and the mean number of potentially inappropriate prescriptions at 1-year follow-up. Intention-to-treat analysis using random effects regression was used. RESULTS: All 21 GP practices and 186 (95 %) patients were followed up. We found that at 1-year follow-up, the significant reduction in the odds of PIP exposure achieved during the intervention was sustained after its discontinuation (adjusted OR 0.28, 95 % CI 0.11 to 0.76, P = 0.01). Intervention participants had significantly lower odds of having a potentially inappropriate proton pump inhibitor compared to controls (adjusted OR 0.40, 95 % CI 0.17 to 0.94, P = 0.04). CONCLUSION: The significant reduction in the odds of PIP achieved during the intervention was sustained after its discontinuation. These results indicate that improvements in prescribing quality can be maintained over time. TRIAL REGISTRATION: Current controlled trials ISRCTN41694007 .


Assuntos
Prescrição Inadequada/prevenção & controle , Padrões de Prática Médica/estatística & dados numéricos , Atenção Primária à Saúde/métodos , Avaliação de Programas e Projetos de Saúde , Idoso , Análise por Conglomerados , Feminino , Seguimentos , Humanos , Prescrição Inadequada/estatística & dados numéricos , Irlanda , Masculino
15.
J Am Geriatr Soc ; 64(6): 1210-22, 2016 06.
Artigo em Inglês | MEDLINE | ID: mdl-27321600

RESUMO

OBJECTIVES: To perform a systematic review to determine the effectiveness of interventions designed to reduce potentially inappropriate prescribing (PIP) in community-dwelling older adults. DESIGN: Systematic review and narrative synthesis. SETTING: Primary and community care. PARTICIPANTS: Community-dwelling older adults. MEASUREMENTS: The primary outcome was change in PIP measured using implicit or explicit tools. Studies were grouped into organizational, professional, financial, regulatory, and multifaceted interventions. RESULTS: Twelve randomized controlled trials were identified with baseline PIP prevalence of 18% to 100%. Four of six organizational interventions reported a reduction in PIP, particularly through pharmacists conducting medication reviews. Evidence of the effectiveness of multidisciplinary teams was weak. Both of the two professional (targeting prescriber's directly) interventions were computerized clinical decision support interventions and were effective in decreasing new PIP but not existing PIP. Three of four multifaceted approaches were effective in reducing PIP. The risk of bias was often high, particularly in reporting selection bias. CONCLUSION: Interventions including organizational (pharmacist interventions), professional (computerized clinical decision support systems), and multifaceted approaches appear beneficial in terms of reducing PIP, but the range of effect sizes reported was modest, and it is unclear whether such interventions can result in clinically significant improvements in patient outcomes. Ongoing assessment of interventions to reduce PIP is needed in community-dwelling older adults, particularly in relation to preventing initiation of PIP.


Assuntos
Prescrição Inadequada/prevenção & controle , Vida Independente , Idoso , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto
16.
BMJ Open ; 6(3): e009957, 2016 Mar 15.
Artigo em Inglês | MEDLINE | ID: mdl-27008685

RESUMO

OBJECTIVES: Following appropriate validation, clinical prediction rules (CPRs) should undergo impact analysis to evaluate their effect on patient care. The aim of this systematic review is to narratively review and critically appraise CPR impact analysis studies relevant to primary care. SETTING: Primary care. PARTICIPANTS: Adults and children. INTERVENTION: Studies that implemented the CPR compared to usual care were included. STUDY DESIGN: Randomised controlled trial (RCT), controlled before-after, and interrupted time series. PRIMARY OUTCOME: Physician behaviour and/or patient outcomes. RESULTS: A total of 18 studies, incorporating 14 unique CPRs, were included. The main study design was RCT (n=13). Overall, 10 studies reported an improvement in primary outcome with CPR implementation. Of 6 musculoskeletal studies, 5 were effective in altering targeted physician behaviour in ordering imaging for patients presenting with ankle, knee and neck musculoskeletal injuries. Of 6 cardiovascular studies, 4 implemented cardiovascular risk scores, and 3 reported no impact on physician behaviour outcomes, such as prescribing and referral, or patient outcomes, such as reduction in serum lipid levels. 2 studies examined CPRs in decision-making for patients presenting with chest pain and reduced inappropriate admissions. Of 5 respiratory studies, 2 were effective in reducing antibiotic prescribing for sore throat following CPR implementation. Overall, study methodological quality was often unclear due to incomplete reporting. CONCLUSIONS: Despite increasing interest in developing and validating CPRs relevant to primary care, relatively few have gone through impact analysis. To date, research has focused on a small number of CPRs across few clinical domains only.


Assuntos
Tomada de Decisões , Técnicas de Apoio para a Decisão , Atenção Primária à Saúde/normas , Humanos , Análise de Séries Temporais Interrompida , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Risco
17.
Ann Fam Med ; 13(6): 545-53, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-26553894

RESUMO

PURPOSE: Potentially inappropriate prescribing (PIP) is common in older people and can result in increased morbidity, adverse drug events, and hospitalizations. The OPTI-SCRIPT study (Optimizing Prescribing for Older People in Primary Care, a cluster-randomized controlled trial) tested the effectiveness of a multifaceted intervention for reducing PIP in primary care. METHODS: We conducted a cluster-randomized controlled trial among 21 general practitioner practices and 196 patients with PIP. Intervention participants received a complex, multifaceted intervention incorporating academic detailing; review of medicines with web-based pharmaceutical treatment algorithms that provide recommended alternative-treatment options; and tailored patient information leaflets. Control practices delivered usual care and received simple, patient-level PIP feedback. Primary outcomes were the proportion of patients with PIP and the mean number of potentially inappropriate prescriptions. We performed intention-to-treat analysis using random-effects regression. RESULTS: All 21 practices and 190 patients were followed. At intervention completion, patients in the intervention group had significantly lower odds of having PIP than patients in the control group (adjusted odds ratio = 0.32; 95% CI, 0.15-0.70; P = .02). The mean number of PIP drugs in the intervention group was 0.70, compared with 1.18 in the control group (P = .02). The intervention group was almost one-third less likely than the control group to have PIP drugs at intervention completion, but this difference was not significant (incidence rate ratio = 0.71; 95% CI, 0.50-1.02; P = .49). The intervention was effective in reducing proton pump inhibitor prescribing (adjusted odds ratio = 0.30; 95% CI, 0.14-0.68; P = .04). CONCLUSIONS: The OPTI-SCRIPT intervention incorporating academic detailing with a pharmacist, and a review of medicines with web-based pharmaceutical treatment algorithms, was effective in reducing PIP, particularly in modifying prescribing of proton pump inhibitors, the most commonly occurring PIP drugs nationally.


Assuntos
Assistência à Saúde/métodos , Quimioterapia Assistida por Computador/métodos , Prescrição Inadequada/prevenção & controle , Padrões de Prática Médica , Atenção Primária à Saúde/métodos , Idoso , Algoritmos , Análise por Conglomerados , Feminino , Humanos , Prescrição Inadequada/estatística & dados numéricos , Irlanda , Masculino , Avaliação de Programas e Projetos de Saúde , Inibidores da Bomba de Prótons/administração & dosagem , Análise de Regressão
18.
BMC Health Serv Res ; 13: 307, 2013 Aug 14.
Artigo em Inglês | MEDLINE | ID: mdl-23941110

RESUMO

BACKGROUND: Potentially inappropriate prescribing (PIP) in older people is common in primary care and can result in increased morbidity, adverse drug events, hospitalizations and mortality. The prevalence of PIP in Ireland is estimated at 36% with an associated expenditure of over €45 million in 2007. The aim of this paper is to describe the application of the Medical Research Council (MRC) framework to the development of an intervention to decrease PIP in Irish primary care. METHODS: The MRC framework for the design and evaluation of complex interventions guided the development of the study intervention. In the development stage, literature was reviewed and combined with information obtained from experts in the field using a consensus based methodology and patient cases to define the main components of the intervention. In the pilot stage, five GPs tested the proposed intervention. Qualitative interviews were conducted with the GPs to inform the development and implementation of the intervention for the main randomised controlled trial. RESULTS: The literature review identified PIP criteria for inclusion in the study and two initial intervention components - academic detailing and medicines review supported by therapeutic treatment algorithms. Through patient case studies and a focus group with a group of 8 GPs, these components were refined and a third component of the intervention identified - patient information leaflets. The intervention was tested in a pilot study. In total, eight medicine reviews were conducted across five GP practices. These reviews addressed ten instances of PIP, nine of which were addressed in the form of either a dose reduction or a discontinuation of a targeted medication. Qualitative interviews highlighted that GPs were receptive to the intervention but patient preference and time needed both to prepare for and conduct the medicines review, emerged as potential barriers. Findings from the pilot study allowed further refinement to produce the finalised intervention of academic detailing with a pharmacist, medicines review with web-based therapeutic treatment algorithms and tailored patient information leaflets. CONCLUSIONS: The MRC framework was used in the development of the OPTI-SCRIPT intervention to decrease the level of PIP in primary care in Ireland. Its application ensured that the intervention was developed using the best available evidence, was acceptable to GPs and feasible to deliver in the clinical setting. The effectiveness of this intervention is currently being tested in a pragmatic cluster randomised controlled trial. TRIAL REGISTRATION: Current controlled trials ISRCTN41694007.


Assuntos
Prescrição Inadequada/prevenção & controle , Atenção Primária à Saúde , Idoso , Algoritmos , Consenso , Grupos Focais , Medicina Geral , Humanos , Irlanda , Projetos Piloto , Pesquisa Qualitativa
19.
Trials ; 14: 72, 2013 Mar 13.
Artigo em Inglês | MEDLINE | ID: mdl-23497575

RESUMO

BACKGROUND: Potentially inappropriate prescribing in older people is common in primary care and can result in increased morbidity, adverse drug events, hospitalizations and mortality. In Ireland, 36% of those aged 70 years or over received at least one potentially inappropriate medication, with an associated expenditure of over €45 million.The main objective of this study is to determine the effectiveness and acceptability of a complex, multifaceted intervention in reducing the level of potentially inappropriate prescribing in primary care. METHODS/DESIGN: This study is a pragmatic cluster randomized controlled trial, conducted in primary care (OPTI-SCRIPT trial), involving 22 practices (clusters) and 220 patients. Practices will be allocated to intervention or control arms using minimization, with intervention participants receiving a complex multifaceted intervention incorporating academic detailing, medicines review with web-based pharmaceutical treatment algorithms that provide recommended alternative treatment options, and tailored patient information leaflets. Control practices will deliver usual care and receive simple patient-level feedback on potentially inappropriate prescribing. Routinely collected national prescribing data will also be analyzed for nonparticipating practices, acting as a contemporary national control. The primary outcomes are the proportion of participant patients with potentially inappropriate prescribing and the mean number of potentially inappropriate prescriptions per patient. In addition, economic and qualitative evaluations will be conducted. DISCUSSION: This study will establish the effectiveness of a multifaceted intervention in reducing potentially inappropriate prescribing in older people in Irish primary care that is generalizable to countries with similar prescribing challenges. TRIAL REGISTRATION: Current controlled trials ISRCTN41694007.


Assuntos
Algoritmos , Quimioterapia Assistida por Computador , Serviços de Saúde para Idosos , Prescrição Inadequada/prevenção & controle , Internet , Reconciliação de Medicamentos/métodos , Atenção Primária à Saúde , Projetos de Pesquisa , Fatores Etários , Idoso , Custos e Análise de Custo , Quimioterapia Assistida por Computador/economia , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos , Custos de Cuidados de Saúde , Conhecimentos, Atitudes e Prática em Saúde , Serviços de Saúde para Idosos/economia , Humanos , Internet/economia , Irlanda , Reconciliação de Medicamentos/economia , Folhetos , Educação de Pacientes como Assunto , Polimedicação , Padrões de Prática Médica , Atenção Primária à Saúde/economia
20.
Clin Geriatr Med ; 28(2): 301-22, 2012 May.
Artigo em Inglês | MEDLINE | ID: mdl-22500545

RESUMO

This review provided an overview of the current evidence in relation to the use of e-prescribing and other forms of technology, such as CDSS, to reduce inappropriate prescribing in older people. The evidence indicates that various types of e-prescribing and CDSS interventions have the potential to reduce inappropriate prescribing and polypharmacy in older people, but the magnitude of their effect varies according to study design and setting. There was significant heterogeneity in the studies reported in terms of study designs, intervention design, patient settings, and outcome measures with patient outcomes seldom reported. Widespread diffusion of these interventions has not occurred in any of the health care settings examined. Overall, health care providers report being satisfied with e-prescribing systems and see the systems as having a positive impact on the safety of their prescribing practices, yet the problem of overriding or ignoring alerts persists. The problem of large numbers of inaccurate and insignificant alerts and this issue, along with the other barriers that have been identified, warrant further investigation.


Assuntos
Sistemas de Informação em Farmácia Clínica , Sistemas de Apoio a Decisões Clínicas , Prescrição Eletrônica , Prescrição Inadequada , Polimedicação , Padrões de Prática Médica/normas , Idoso , Idoso de 80 Anos ou mais , Prescrições de Medicamentos/normas , Revisão de Uso de Medicamentos/organização & administração , Medicina Baseada em Evidências , Feminino , Humanos , Masculino , Erros de Medicação/prevenção & controle , Padrões de Prática Médica/tendências , Ensaios Clínicos Controlados Aleatórios como Assunto
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA