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1.
BMJ Open ; 10(2): e032594, 2020 Feb 12.
Artigo em Inglês | MEDLINE | ID: mdl-32051304

RESUMO

OBJECTIVES: We developed a complex intervention called DECIDE (ComputeriseD dECisIonal support for suboptimally controlleD typE 2 Diabetes mellitus in Irish General Practice) which used a clinical decision support system to address clinical inertia and support general practitioner (GP) intensification of treatment for adults with suboptimally controlled type2 diabetes mellitus (T2DM). The current study explored the feasibility and potential impact of DECIDE. DESIGN: A pilot cluster randomised controlled trial. SETTING: Conducted in 14 practices in Irish General Practice. PARTICIPANTS: The DECIDE intervention was targeted at GPs. They applied DECIDE to patients with suboptimally controlled T2DM, defined as a glycated haemoglobin (HbA1c) ≥70 mmol/mol and/or blood pressure ≥150/95 mmHg. INTERVENTION: The intervention incorporated training and a web-based clinical decision support system which supported; (i) medication intensification actions; and (ii) non-pharmacological actions to support care. Control practices delivered usual care. PRIMARY AND SECONDARY OUTCOME MEASURES: Feasibility and acceptability was determined using thematic analysis of semi-structured interviews with GPs, combined with data from the DECIDE website. Clinical outcomes included HbA1c, medication intensification, blood pressure and lipids. RESULTS: We recruited 14 practices and 134 patients. At 4-month follow-up, all practices and 114 patients were followed up. GPs reported finding decision support helpful navigating increasingly complex medication algorithms. However, the majority of GPs believed that the target patient group had poor engagement with GP and hospital services for a range of reasons. At follow-up, there was no difference in glycaemic control (-3.6 mmol/mol (95% CI -11.2 to 4.0)) between intervention and control groups or in secondary outcomes including, blood pressure, total cholesterol, medication intensification or utilisation of services. Continuation criteria supported proceeding to a definitive randomised trial with some modifications. CONCLUSION: The DECIDE study was feasible and acceptable to GPs but wider impacts on glycaemic and blood pressure control need to be considered for this patient population going forward. TRIAL REGISTRATION NUMBER: ISRCTN69498919.

2.
Aging Ment Health ; : 1-9, 2019 Dec 17.
Artigo em Inglês | MEDLINE | ID: mdl-31847539

RESUMO

Objective: To explore the factors associated with the cost of care and admission to long-term care (LTC) for people with dementia living at home in Ireland.Methods: Data on formal and informal resource use for people with dementia, and their LTC admission, were obtained from a national study of spousal dementia caregivers. Functional status was measured using the Bristol Activities of Daily Living Scale, while behavioural and psychiatric symptoms were evaluated using the Neuropsychiatric Inventory. Multivariable regression analysis was used to model costs and the predictors of LTC admission.Results: Physical and cognitive symptoms were significantly associated with costs. Severely impaired functional ability was associated with a €2,308 increase in mean total 30-day monthly costs. Psychosis was associated with a €335 increase in primary and community 30-day monthly care costs. These factors also make it more likely that a person with dementia is admitted to LTC. Having an older caregiver also increases the risk of admission to LTC, while living in a rural area and having a female caregiver reduce the likelihood of admission.Conclusions: Dependency matters for the cost of care. Physical and cognitive symptoms, caregiver age and gender, and geographic location are significant predictors of admission to LTC.

3.
Artigo em Inglês | MEDLINE | ID: mdl-31333875

RESUMO

Background: There is overwhelming evidence to support the promotion of physical activity in adults in terms of benefits to well-being, physical and mental health. Physical activity guidelines suggest that adults should accumulate at least 150 min of moderate to vigorous physical activity per week. In Ireland, the majority of adults do not achieve these guidelines, with costs to health and economy. 'Move for Life' (MFL) employs behavioural change techniques delivered by an instructor and peer mentor, using a train-the-trainer (cascade) model. This study will conduct a feasibility cluster randomised controlled trial of the MFL intervention for modifying physical activity behaviours in inactive adults aged 45 years and older. Methods: The trial is set in eight Local Sports Partnership (LSP) hubs that have structured physical activity programmes. The hubs are the units of randomisation (clusters), and individuals are the units of analysis (participants). Eligible participants will contact one of the hubs, with each hub running four physical activity programmes. Each programme requires between 12-15 inactive adults, resulting in 48-60 participants per hub. Allowing for 20% dropout rate, an additional 96 people will be recruited giving a maximum sample of 576. The hub will be randomised: true control, usual programme or MFL intervention. The true control group will be given information about physical activity but will not be included in a programme for the duration of the trial; the intervention will involve the instructor training one (or more) of the participants to be a peer mentor using an educational toolkit; and usual care groups will have physical activity classes delivered as normal. Baseline data will collect physical activity measures and follow-up measurements will be obtained at 3 and 6 months. All participants will be asked to wear a device for measuring activity on the thigh (activPAL) for 7 days before commencing the programme and at 3 and 6 months. The primary objective of the study is to investigate if it is feasible to deliver the intervention and collect data on moderate to vigorous physical activity (MVPA) on all participants, thereby providing valuable information to guide sample size calculation for a future, more definitive trial. Trial registration number: ISRCTN11235176.

4.
J Wound Care ; 28(6): 324-330, 2019 Jun 02.
Artigo em Inglês | MEDLINE | ID: mdl-31166856

RESUMO

OBJECTIVE: To estimate the cost of wound care to the Irish health-care system. METHODS: A bottom-up, prevalence-based analysis was undertaken using a decision analytic model to estimate costs. Health-care resource activity was identified from a recently published study from the UK and was valued using unit cost data for Ireland. RESULTS: The base case analysis estimated the total annual healthcare cost of wound care to be €629,064,198 (95% Confidence interval (CI): €452,673,358 to €844,087,124), accounting for 5% (95% CI: 3% to 6%) of total public health expenditure in Ireland in 2013. The average cost per patient was €3,941 (95% CI: €2,836 to €5,287). However, this study is subject to many limitations and plausible changes in the model's inputs showed that the total annual health-care cost of wound care could range from €281,438,970 to €844,316,912. CONCLUSION: Caring for wounds places a substantial burden on the Irish health-care system. In light of growing pressures to finance an already resource-constrained health-care system, these results provide useful information for those charged with future wound care service design and provision in Ireland and elsewhere.


Assuntos
Custos de Cuidados de Saúde , Gastos em Saúde , Ferimentos e Lesões/economia , Assistência Ambulatorial/economia , Enfermagem em Saúde Comunitária/economia , Custos e Análise de Custo , Técnicas de Apoio para a Decisão , Equipamentos e Provisões/economia , Hospitalização/economia , Visita Domiciliar/economia , Humanos , Irlanda/epidemiologia , Prevalência , Ferimentos e Lesões/epidemiologia , Ferimentos e Lesões/terapia
5.
Br J Gen Pract ; 69(683): e373-e380, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31015226

RESUMO

BACKGROUND: Changes in clinical guidelines for primary prevention of cardiovascular disease (CVD) have widened eligibility for statin therapy. AIM: To illustrate the potential impacts of changes in clinical guidelines. DESIGN AND SETTING: Modelling the impacts of seven consecutive European guidelines based on a cohort of people aged ≥50 years from the Irish Longitudinal Study on Ageing. METHOD: The eligibility for statin therapy of a sample of people without a history of CVD was established, according to changing guideline recommendations and modelled associated potential costs. The authors calculated the numbers needed to treat (NNT) to prevent one major vascular event in patients at the lowest baseline risk for which each of the seven guidelines recommended treatment, and for those at low, medium, high, and very-high risk according to 2016 guidelines. These were compared with the NNT that patients reported as required to justify taking a daily medicine. RESULTS: The proportion of patients eligible for statins increased from approximately 8% in 1987 to 61% in 2016; associated costs rose from €13.9 million to €107.1 million per annum. The NNT for those at the lowest risk for which each guideline recommended treatment rose from 40 to 400. By 2016, the NNT for low-risk patients was 400 compared to ≤25 very-high risk patients. The proportion of patients eligible for statins achieving NNT levels that patients regarded as justified to taking a daily medicine fell as guidelines changed over time. CONCLUSION: Increased eligibility for statin therapy impacts large proportions of the present population and healthcare budgets. Decisions to take and reimburse statins should be considered on the basis of expected cost-effectiveness and acceptability to patients.


Assuntos
Doenças Cardiovasculares/prevenção & controle , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Idoso , Doenças Cardiovasculares/etiologia , Estudos de Coortes , Definição da Elegibilidade , Feminino , Humanos , Irlanda , Masculino , Pessoa de Meia-Idade , Preferência do Paciente , Seleção de Pacientes , Guias de Prática Clínica como Assunto , Prevenção Primária , Fatores de Risco
6.
Pilot Feasibility Stud ; 4: 159, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30345068

RESUMO

Background: Poorly controlled type 2 diabetes mellitus (T2DM) is associated with significant morbidity, mortality and healthcare costs. Control of T2DM can be challenging for healthcare professionals for a number of reasons, including poor concordance with medications, difficulties modifying lifestyle behaviour and also clinical inertia, which is defined as a reluctance among health professionals to intensify medications. A complex intervention, called ComputeriseD dECisIonal support for poorly controlleD typE 2 Diabetes mellitus in Irish General Practice (DECIDE), was developed, identifying T2DM patients with poor glycaemic and blood pressure control and aiming to target clinical inertia, by supporting therapeutic action, including GP-led medication intensification where appropriate. A small-scale, uncontrolled, non-randomised feasibility study highlighted the acceptability of the DECIDE intervention within Irish General Practice. This paper presents a protocol for a pilot cluster randomised controlled trial (RCT) of the DECIDE intervention. Methods/Design: The pilot cluster RCT will involve 14 practices and 140 patients in Irish General Practice. Intervention GPs will participate in the DECIDE intervention, comprising (a) a training programme for the practices and (b) a web-based clinical decision support system supporting treatment escalation, tailored to specific patient information. Only patients who have poorly controlled T2DM (defined as HbA1c > 70 mmol/mol and/or BP > 150/95) will be included. The primary outcomes will include measures of feasibility such as recruitment and retention of practices and acceptability of the intervention and also HbA1c. Secondary outcomes will include medication intensification, blood pressure and lipids. Control GPs will continue to provide usual care. A process evaluation will be performed to determine whether the intervention is delivered as intended and treatment fidelity assessed to monitor and enhance the reliability and validity of interventions. An exploratory health economic analysis will examine the potential costs and cost effectiveness of the intervention relative to the control. Discussion: A pilot cluster RCT will establish the feasibility of a complex intervention which aims to support primary care for patients with poorly controlled T2DM in Irish General Practice. Trial registration: The protocol for the pilot cluster RCT is registered on the ISRCTN Registry at: ISRCTN69498919.

7.
Trials ; 19(1): 461, 2018 Aug 29.
Artigo em Inglês | MEDLINE | ID: mdl-30157920

RESUMO

BACKGROUND: Older adults living in nursing homes spend the majority of their time inactive. The associated levels of chronic disease place an increasing burden on healthcare systems. Physical activity (PA) interventions delivered through exercise classes may be resource-intensive and require specialist staff. The aim of this study is to explore the feasibility and acceptability of a PA programme embedded into the daily lives of older adults living in nursing homes and to examine the preliminary effects of this on physical mobility and quality of life. METHODS: A randomised controlled pilot feasibility study, including embedded qualitative and economic components will be carried out. Two randomly selected nursing homes will take part in the study; participants (n = 20) in one nursing home will receive a three-month PA intervention and participants (n = 20) in the other will be a usual care control. Nursing home staff will be provided with training and support to monitor participants PA programmes. Feasibility data will be collected on recruitment, randomisation, assessment and intervention procedures. Criteria for progression of the pilot feasibility study to a definitive trial will be specified. The Timed Up and Go test, Nottingham Health Profile, 10-Metre Walk test, the Investigating Choice Experiments for the Preferences of Older People Capability index and the Bangor Goal Setting Interview will be assessed at baseline, three-month and 12-month follow-up. Between-group and within-individual effects will be estimated using appropriate linear mixed models. Semi-structured interviews will be conducted with staff and participants of the intervention group within one month after the intervention to explore the feasibility and acceptability of the programme. A subset of control participants will be interviewed to describe usual care. Economic data will be collected to examine costs of the intervention in comparison with costs in the control group. DISCUSSION: The findings will facilitate refinement of the PA programme and development of a clear protocol for subsequent evaluation of the PA intervention in a definitive randomised controlled trial. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03484715 . Registered on 30 March 2018.


Assuntos
Atividades Cotidianas , Terapia por Exercício/métodos , Exercício Físico , Instituição de Longa Permanência para Idosos , Casas de Saúde , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores Etários , Idoso , Estudos de Viabilidade , Feminino , Avaliação Geriátrica , Humanos , Irlanda , Masculino , Limitação da Mobilidade , Satisfação do Paciente , Projetos Piloto , Qualidade de Vida , Fatores de Tempo , Resultado do Tratamento
8.
Artigo em Inglês | MEDLINE | ID: mdl-29988602

RESUMO

Background: Many people living with cardiovascular disease (CVD) are affected by sexual problems associated with the condition. International guidelines recommend all patients with CVD should receive sexual counselling, yet this is rarely provided by health professionals. The current study piloted the Cardiac Health and Relationship Management and Sexuality (CHARMS) intervention, a complex multi-level intervention designed to increase the implementation of sexual counselling guidelines in hospital-based cardiac rehabilitation (CR) in Ireland. Methods: The CHARMS intervention, consisting of awareness training and skills development for staff, and education and support for patients, was implemented in two CR centres. Following a repeated measures design, quantitative and qualitative feasibility, fidelity, cost, and outcome data were collected from staff and patients at baseline (T1, pre-intervention), at 3 months post-baseline (T2, post-intervention), and at 6 months post-baseline (T3, post-intervention). Data were organised according to a 14-point reporting framework of methodological issues that should be examined in pilot and feasibility studies. To inform a future definitive trial, potential solutions to identified feasibility issues were generated using the ADePT process for decision-making after pilot and feasibility trials. Results: Most elements of the study protocol were executed smoothly, and intervention implementation was successful. Patients' (N = 42) responses to the intervention were positive. The reporting framework and the ADePT process facilitated the identification of two overarching feasibility problems, as well as solutions to be implemented in a definitive trial: (1) a high level of patient attrition in the pilot study, to be addressed through the use of financial incentives, reducing the length of the patient questionnaire, and providing a telephone survey option; and (2) negative staff perceptions, to be addressed through an augmented staff intervention, reframing 'sexual counselling' as 'sexual education and support' to fit with professional role perceptions, and reviewing all intervention terminology with a CR staff member to ensure acceptability. Conclusions: This article reports the successful piloting of a novel sexual counselling implementation intervention in cardiac rehabilitation. The utilisation of an extended reporting framework and the ADePT process facilitated the identification of adaptations necessary to ensure the feasibility of a definitive trial, thereby maximising methodological transparency.

9.
Drugs Aging ; 35(8): 751-762, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-30003429

RESUMO

BACKGROUND: A recent randomised controlled trial conducted in an Irish University teaching hospital that evaluated a physician-implemented medication screening tool, demonstrated positive outcomes in terms of a reduction in incident adverse drug reactions. OBJECTIVE: The present study objective was to evaluate the cost effectiveness of physicians applying this screening tool to older hospitalised patients compared with usual hospital care in the context of the earlier randomised controlled trial. METHOD: We used a cost-effectiveness analysis alongside a conventional outcome analysis in a cluster randomised controlled trial. Patients in the intervention arm (n = 360) received a multifactorial intervention consisting of medicines reconciliation, communication with patients' senior medical team, and generation of a pharmaceutical care plan in addition to usual medical and pharmaceutical care. Control arm patients (n = 372) received usual medical and pharmaceutical care only. Incremental cost effectiveness was examined in terms of costs to the healthcare system and an outcome measure of adverse drug reactions during inpatient hospital stay. Uncertainty in the analysis was explored using a cost-effectiveness acceptability curve. RESULTS: On average, the intervention arm was more costly but was also more effective. Compared with usual care (control), the intervention was associated with a non-statistically significant increase of €877 (95% confidence interval - €1807, €3561) in the mean healthcare cost, and a statistically significant decrease of - 0.164 (95% confidence interval - 0.257, - 0.070) in the mean number of adverse drug reaction events per patient. The associated incremental cost-effectiveness ratio per adverse drug reaction averted was €5358. The probability of the intervention being cost effective at threshold values of €0, €5000 and €10,000 was 0.236, 0.455 and 0.680, respectively. CONCLUSION: Based on the evidence presented, this physician-led intervention is not likely to be cost effective compared with usual hospital care. To inform future healthcare policy decisions in this field, more economic analyses of structured medication reviews by other healthcare professionals and by computerised clinical decision support software need to be conducted.


Assuntos
Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/prevenção & controle , Médicos/organização & administração , Idoso , Idoso de 80 Anos ou mais , Análise Custo-Benefício , Sistemas de Apoio a Decisões Clínicas , Feminino , Humanos , Irlanda , Tempo de Internação , Masculino , Médicos/economia , Ensaios Clínicos Controlados Aleatórios como Assunto
10.
Fam Pract ; 35(2): 172-178, 2018 03 27.
Artigo em Inglês | MEDLINE | ID: mdl-29092028

RESUMO

Purpose: Patients with coronary heart disease (CHD) experience reduced quality of life which may be associated with mortality in the longer term. This study explores whether patient-rated physical and mental health status was associated with mortality at 6-year follow-up among patients with CHD attending primary care in Ireland and Northern Ireland. Methods: This study is a secondary data analysis of patients with CHD recruited to a cluster randomized controlled trial from 2004 to 2010. Data collected included patient-rated physical component summary (PCS) and mental component summary (MCS) scores of health status (from the 12-Item Short-Form Health Survey (SF-12)), demographics and clinical parameters at baseline, and all-cause mortality at 6-year follow-up. Multivariate regression was conducted using generalized estimating equations (GEE) with a log-link function. Results are presented as odds ratios (ORs) and 95% confidence intervals (CIs). Results: The study consisted of 762 individuals with mean age 67.6 years [standard deviation (SD): 9.8], and was 29% female. Mean baseline SF-12 mental (MCS) and physical (PCS) component scores were 50.0 (SD: 10.8) and 39.6 (SD: 11.2), respectively. At 6-year follow-up, the adjusted OR for the baseline MCS for mortality was 0.97 (95% CI: 0.95-0.99) and for the PCS 0.97 (95% CI: 0.95-0.99). For every five-point increase in MCS and PCS scores, there was a 14% reduction in the likelihood of all-cause mortality. Conclusions: Overall, the magnitude of effect for both mental health status and physical health status was similar; higher scores were significantly associated with a lower risk of mortality at 6-year follow-up.


Assuntos
Doença das Coronárias/mortalidade , Nível de Saúde , Qualidade de Vida , Idoso , Causas de Morte , Doença das Coronárias/fisiopatologia , Doença das Coronárias/psicologia , Feminino , Seguimentos , Humanos , Irlanda/epidemiologia , Masculino , Saúde Mental , Pessoa de Meia-Idade , Análise Multivariada , Irlanda do Norte/epidemiologia , Análise de Regressão , Autorrelato , Fatores de Tempo
11.
Respirology ; 23(3): 272-283, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29194864

RESUMO

Chronic obstructive pulmonary disease is a common, preventable and treatable disease. Exercise training programmes (ETPs) improve symptoms, health-related quality of life (HRQoL) and exercise capacity, but the optimal setting is unknown. In this review, we compared the effects of ETPs in different settings on HRQoL and exercise capacity. We searched (5 July 2016) the Cochrane Airways Group Specialised Register, ClinicalTrials.gov and World Health Organization trials portal. We selected studies, extracted data and assessed risk of bias with two independent reviewers. We calculated mean differences (MD) with 95% CI. We assessed the quality of evidence using Grades of Recommendation, Assessment, Development and Evaluation. Ten trials (934 participants) were included. Hospital (outpatient) and home-based ETPs (seven trials) were equally effective at improving HRQoL on the Chronic Respiratory Questionnaire (CRQ) (dyspnoea: MD -0.09, 95% CI: -0.28 to 0.10; fatigue: MD -0.00, 95% CI: -0.18 to 0.17; emotional: MD 0.10, 95% CI: -0.24 to 0.45; and mastery: MD -0.02, 95% CI: -0.28 to 0.25; moderate quality) and on the St George's Respiratory Questionnaire (SGRQ) (MD -0.82, 95% CI: -7.47 to 5.83, low quality). Hospital (outpatient) and community-based ETPs (three trials) were equally effective at improving HRQoL (CRQ dyspnoea: MD 0.29, 95% CI: -0.05 to 0.62, moderate quality; fatigue: MD -0.02, 95% CI: -1.09 to 1.05, low quality; emotional: MD 0.10, 95% CI: -0.40 to 0.59, moderate quality; and mastery: MD -0.08, 95% CI: -0.45 to 0.28, moderate quality). There was no difference in exercise capacity. There was low to moderate evidence that outpatient and home-based ETPs are equally effective. See related Editorial.


Assuntos
Assistência Ambulatorial/métodos , Terapia por Exercício/métodos , Serviços de Assistência Domiciliar , Pacientes Ambulatoriais , Avaliação de Programas e Projetos de Saúde , Doença Pulmonar Obstrutiva Crônica/reabilitação , Humanos , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Qualidade de Vida
12.
BMC Emerg Med ; 17(1): 38, 2017 12 06.
Artigo em Inglês | MEDLINE | ID: mdl-29212452

RESUMO

BACKGROUND: Changes to physiological parameters precede deterioration of ill patients. Early warning and track and trigger systems (TTS) use routine physiological measurements with pre-specified thresholds to identify deteriorating patients and trigger appropriate and timely escalation of care. Patients presenting to the emergency department (ED) are undiagnosed, undifferentiated and of varying acuity, yet the effectiveness and cost-effectiveness of using early warning systems and TTS in this setting is unclear. We aimed to systematically review the evidence on the use, development/validation, clinical effectiveness and cost-effectiveness of physiologically based early warning systems and TTS for the detection of deterioration in adult patients presenting to EDs. METHODS: We searched for any study design in scientific databases and grey literature resources up to March 2016. Two reviewers independently screened results and conducted quality assessment. One reviewer extracted data with independent verification of 50% by a second reviewer. Only information available in English was included. Due to the heterogeneity of reporting across studies, results were synthesised narratively and in evidence tables. RESULTS: We identified 6397 citations of which 47 studies and 1 clinical trial registration were included. Although early warning systems are increasingly used in EDs, compliance varies. One non-randomised controlled trial found that using an early warning system in the ED may lead to a change in patient management but may not reduce adverse events; however, this is uncertain, considering the very low quality of evidence. Twenty-eight different early warning systems were developed/validated in 36 studies. There is relatively good evidence on the predictive ability of certain early warning systems on mortality and ICU/hospital admission. No health economic data were identified. CONCLUSIONS: Early warning systems seem to predict adverse outcomes in adult patients of varying acuity presenting to the ED but there is a lack of high quality comparative studies to examine the effect of using early warning systems on patient outcomes. Such studies should include health economics assessments.


Assuntos
Deterioração Clínica , Serviço Hospitalar de Emergência , Monitorização Fisiológica/métodos , Humanos , Índice de Gravidade de Doença , Triagem
13.
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
14.
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
15.
Econ Hum Biol ; 27(Pt A): 84-92, 2017 11.
Artigo em Inglês | MEDLINE | ID: mdl-28550809

RESUMO

Rising levels of childhood overweight and obesity represent a major global public health challenge. A number of studies have explored the association between childhood overweight and obesity and healthcare utilisation and costs. This paper adds to the literature by estimating the causal effect of child overweight and obesity status on use of general practitioner (GP) and hospital inpatient stays at two time points using instrumental variable (IV) methods The paper uses data from two waves of the Growing Up in Ireland survey of children when they are 9 and 13 years respectively and uses the biological mother's body mass index (BMI) as an instrument for the child's BMI. Our results demonstrate that child overweight and obesity status do not have a significant effect on healthcare utilisation for children when they are 9 years, but do have a large and significant effect at 13 years. Across all our models, the effects on both GP and hospital inpatient stays are found to be larger when endogeneity in childhood BMI status is addressed. Previous studies that did not address endogeneity concerns are likely to have significantly underestimated the impact of child overweight and obesity status on healthcare utilisation.


Assuntos
Serviços de Saúde/estatística & dados numéricos , Sobrepeso/epidemiologia , Obesidade Pediátrica/epidemiologia , Adolescente , Adulto , Fatores Etários , Índice de Massa Corporal , Criança , Feminino , Medicina Geral/estatística & dados numéricos , Nível de Saúde , Hospitalização/estatística & dados numéricos , Humanos , Irlanda , Masculino , Mães/estatística & dados numéricos
16.
J Public Health (Oxf) ; 39(4): e282-e289, 2017 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-27679664

RESUMO

Background: Antimicrobial resistance is a major public health issue. This study examines the cost effectiveness of the SIMPle (Supporting the Improvement and Management of Prescribing for Urinary Tract Infections (UTI)) intervention to improve antimicrobial prescribing in primary care in Ireland. Methods: An economic evaluation was conducted alongside a cluster randomized controlled trial of 30 general practices and 2560 patients with a diagnosis of UTI. Practices were randomized to the usual practice control or the SIMPle intervention (arm A or B). Data at 6 months follow-up were used to estimate incremental costs, incremental effectiveness in terms of first-line antimicrobial prescribing for UTI and cost effectiveness acceptability curves. Results: The SIMPle intervention was, on average, more costly and more effective than the control. The probability of intervention arm A being cost effective was 0.280, 0.995 and 1.000 at threshold values of €50, €150 and €250 per percentage point increase in first-line antimicrobial prescribing respectively. The equivalent probabilities for intervention arm B were 0.121, 0.863 and 0.985, respectively. Conclusions: The cost effectiveness of the SIMPle intervention depends on the value placed on improving antimicrobial prescribing. Future studies should examine the wider and longer term costs and outcomes of improving antimicrobial prescribing.


Assuntos
Antibacterianos/economia , Antibacterianos/uso terapêutico , Prescrição Inadequada/prevenção & controle , Infecções Urinárias/tratamento farmacológico , Infecções Urinárias/economia , Análise Custo-Benefício , Uso de Medicamentos , Humanos , Irlanda , Uso Excessivo de Medicamentos Prescritos/prevenção & controle , Atenção Primária à Saúde
17.
Eur J Health Econ ; 18(3): 321-335, 2017 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-26961365

RESUMO

While cardiac secondary prevention in primary care is established practice, little is known about its long-term cost effectiveness. This study examines the cost effectiveness of a secondary prevention intervention in primary care in the Republic of Ireland and Northern Ireland over 6 years. An economic evaluation, based on a cluster randomised controlled trial of 903 patients with heart disease, was conducted 4.5 years after the intervention ceased to be delivered. Patients originally randomised to the control received usual practice while those randomised to the intervention received a tailored care package over the 1.5-year delivery period. Data on healthcare costs and quality adjusted life expectancy were used to undertake incremental cost utility analysis. Multilevel regression was used to estimate mean cost effectiveness and uncertainty was examined using cost effectiveness acceptability curves. At 6 years, there was a divergence in the results across jurisdictions. While the probability of the intervention being cost effective in the Republic of Ireland was 0.434, 0.232, 0.180, 0.150, 0.115 and 0.098 at selected threshold values of €5000, €15,000, €20,000, €25,000, €35,000 and €45,000, respectively, all equivalent probabilities for Northern Ireland equalled 1.000. Our findings suggest that the intervention in its current format is likely to be more cost effective than usual general practice care in Northern Ireland, but this is not the case in the Republic of Ireland.


Assuntos
Doença da Artéria Coronariana/prevenção & controle , Atenção Primária à Saúde/organização & administração , Prevenção Secundária/organização & administração , Idoso , Idoso de 80 Anos ou mais , Análise Custo-Benefício , Feminino , Comportamentos Relacionados com a Saúde , Gastos em Saúde , Serviços de Saúde/economia , Serviços de Saúde/estatística & dados numéricos , Humanos , Irlanda , Estilo de Vida , Masculino , Pessoa de Meia-Idade , Modelos Econométricos , Irlanda do Norte , Atenção Primária à Saúde/economia , Qualidade de Vida , Anos de Vida Ajustados por Qualidade de Vida , Prevenção Secundária/economia
18.
Fam Pract ; 33(6): 733-739, 2016 12.
Artigo em Inglês | MEDLINE | ID: mdl-27587565

RESUMO

BACKGROUND: Data on health care utilization may be collected using a variety of mechanisms within research studies, each of which may have implications for cost and cost effectiveness. OBJECTIVE: The aim of this observational study is to compare data collected from medical records searches and self-report questionnaires for the cost analysis of a cardiac secondary prevention intervention. METHODS: Secondary data analysis of the Secondary Prevention of Heart Disease in General Practice (SPHERE) randomized controlled trial (RCT). Resource use data for a range of health care services were collected by research nurse searches of medical records and self-report questionnaires and costs of care estimated for each data collection mechanism. A series of statistical analyses were conducted to compare the mean costs for medical records data versus questionnaire data and to conduct incremental analyses for the intervention and control arms in the trial. RESULTS: Data were available to estimate costs for 95% of patients in the intervention and 96% of patients in the control using the medical records data compared to 65% and 66%, respectively, using the questionnaire data. The incremental analysis revealed a statistically significant difference in mean cost of -€796 (95% CI: -1447, -144; P-value: 0.017) for the intervention relative to the control. This compared to no significant difference in mean cost (95% CI: -1446, 860; P-value: 0.619) for the questionnaire analysis. CONCLUSIONS: Our findings illustrate the importance of the choice of health care utilization data collection mechanism for the conduct of economic evaluation alongside randomized trials in primary care. This choice will have implications for the costing methodology employed and potentially, for the cost and cost effectiveness outcomes generated.


Assuntos
Pesquisa Biomédica/métodos , Análise Custo-Benefício/métodos , Medicina Geral/economia , Custos de Cuidados de Saúde , Registros Médicos , Inquéritos e Questionários , Idoso , Feminino , Recursos em Saúde/economia , Recursos em Saúde/estatística & dados numéricos , Cardiopatias/economia , Cardiopatias/prevenção & controle , Humanos , Masculino , Pessoa de Meia-Idade , Anos de Vida Ajustados por Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Prevenção Secundária/economia
19.
Eur J Endocrinol ; 175(4): 287-97, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-27422889

RESUMO

OBJECTIVE: An increase in gestational diabetes mellitus (GDM) prevalence has been demonstrated across many countries with adoption of the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) diagnostic criteria. Here, we determine the cumulative incidence of abnormal glucose tolerance among women with previous GDM, and identify clinical risk factors predicting this. DESIGN: Two hundred and seventy women with previous IADPSG-defined GDM were prospectively followed up for 5years (mean 2.6) post-index pregnancy, and compared with 388 women with normal glucose tolerance (NGT) in pregnancy. METHODS: Cumulative incidence of abnormal glucose tolerance (using American Diabetes Association criteria for impaired fasting glucose, impaired glucose tolerance and diabetes) was determined using the Kaplan-Meier method of survival analysis. Cox regression models were constructed to test for factors predicting abnormal glucose tolerance. RESULTS: Twenty-six percent of women with previous GDM had abnormal glucose tolerance vs 4% with NGT, with the log-rank test demonstrating significantly different survival curves (P<0.001). Women meeting IADPSG, but not the World Health Organization (WHO) 1999 criteria, had a lower cumulative incidence than women meeting both sets of criteria, both in the early post-partum period (4.2% vs 21.7%, P<0.001) and at longer-term follow-up (13.7% vs 32.6%, P<0.001). Predictive factors were glucose levels on the pregnancy oral glucose tolerance test, family history of diabetes, gestational week at testing, and BMI at follow-up. CONCLUSIONS: The proportion of women developing abnormal glucose tolerance remains high among those with IADPSG-defined GDM. This demonstrates the need for continued close follow-up, although the optimal frequency and method needs further study.


Assuntos
Glicemia/metabolismo , Diabetes Gestacional/sangue , Intolerância à Glucose/epidemiologia , Adulto , Feminino , Intolerância à Glucose/sangue , Teste de Tolerância a Glucose , Humanos , Incidência , Período Pós-Parto , Gravidez , Prevalência , Fatores de Risco
20.
BMJ Open ; 6(6): e011219, 2016 06 24.
Artigo em Inglês | MEDLINE | ID: mdl-27342240

RESUMO

INTRODUCTION: Sexual problems are common with cardiovascular disease, and can negatively impact quality of life. To address sexual problems, guidelines have identified the importance of sexual counselling during cardiac rehabilitation, yet this is rarely provided. The Cardiac Health and Relationship Management and Sexuality (CHARMS) intervention aims to improve the provision of sexual counselling in cardiac rehabilitation in Ireland. METHODS AND ANALYSIS: This is a multicentre pilot study for the CHARMS intervention, a complex, multilevel intervention delivered within hospital-based cardiac rehabilitation programmes. The intervention includes (1) training in sexual counselling for staff, (2) a staff-led patient education and support intervention embedded within the cardiac rehabilitation programme, (3) a patient information booklet and (4) an awareness raising poster. The intervention will be delivered in two randomly selected cardiac rehabilitation centres. In each centre 30 patients will be recruited, and partners will also be invited to participate. Data will be collected from staff and patients/partners at T1 (study entry), T2 (3-month follow-up) and T3 (6-month follow-up). The primary outcome for patients/partners will be scores on the Sexual Self-Perception and Adjustment Questionnaire. Secondary outcomes for patients/partners will include relationship satisfaction; satisfaction with and barriers to sexual counselling in services; sexual activity, functioning and knowledge; physical and psychological well-being. Secondary outcomes for staff will include sexuality-related practice; barriers to sexual counselling; self-ratings of capability, opportunity and motivation; sexual attitudes and beliefs; knowledge of cardiovascular disease and sex. Fidelity of intervention delivery will be assessed using trainer self-reports, researcher-coded audio recordings and exit interviews. Longitudinal feasibility data will be gathered from patients/partners and staff via questionnaires and interviews. ETHICS AND DISSEMINATION: This study is approved by the Research Ethics Committee (REC) of the National University of Ireland, Galway. Findings will be disseminated to cardiac rehabilitation staff, patients/partners and relevant policymakers via appropriate publications and presentations.


Assuntos
Reabilitação Cardíaca/métodos , Doenças Cardiovasculares/complicações , Aconselhamento Sexual , Disfunções Sexuais Fisiológicas/terapia , Atitude Frente a Saúde , Estudos de Viabilidade , Feminino , Humanos , Irlanda , Masculino , Motivação , Educação de Pacientes como Assunto , Recursos Humanos em Hospital/educação , Projetos Piloto , Autoimagem , Disfunções Sexuais Fisiológicas/etiologia , Inquéritos e Questionários
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