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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.
Magn Reson Imaging ; 67: 85-89, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31931112

RESUMO

PURPOSE: To investigate the correlations between cortical bone microstructural properties and total water proton density (TWPD) obtained from three-dimensional ultrashort echo time Cones (3D-UTE-Cones) magnetic resonance imaging techniques. MATERIALS AND METHODS: 135 cortical bone samples were harvested from human tibial and femoral midshafts of 37 donors (61 ± 24 years old). Samples were scanned using 3D-UTE-Cones sequences on a clinical 3T MRI and on a high-resolution micro-computed tomography (µCT) scanner. TWPD was measured using 3D-UTE-Cones MR images. Average bone porosity, pore size, and bone mineral density (BMD) were measured from µCT images at 9 µm voxel size. Pearson's correlation coefficients between TWPD and µCT-based measures were calculated. RESULTS: TWPD showed significant moderate correlation with both average bone porosity (R = 0.66, p < 0.01) and pore size (R = 0.57, p < 0.01). TWPD also showed significant strong correction with BMD (R = 0.71, p < 0.01). CONCLUSIONS: The presented 3D-UTE-Cones imaging technique allows assessment of TWPD in human cortical bone. This quick UTE-MRI-based technique was capable of predicting bone microstructure differences with significant correlations. Such correlations highlight the potential of UTE-MRI-based measurement of bone water proton density to assess bone microstructure.

3.
Quant Imaging Med Surg ; 9(10): 1664-1673, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31728310

RESUMO

Background: Degradation of cartilage and meniscus may be mediated by changes in extracellular pH. The purpose of this study was to optimize saturation powers used with the acidoCEST magnetic resonance imaging (MRI) technique with a 3D ultrashort echo time readout (acidoCEST-UTE) and to demonstrate feasibility of the method for measuring pH in cartilage and meniscus in vivo. Methods: Magnetization transfer ratio asymmetry and ratio of radiofrequency (RF) power mismatch at different powers were evaluated in cartilage and meniscus tissue phantoms for iopamidol and iohexol. Using optimized RF powers, the acidoCEST-UTE MRI sequence was used to assess pH of joint fluid and tissues in four patients after direct intra-articular administration of iodinated contrast. Results: In the phantoms, the ratio of powers 0.54/1.10 µT showed the strongest correlation with pH. In vivo acidoCEST-UTE pH measurements of intra-articular fluid were similar to electrode measurements of the contrast agent (7.22 vs. 7.1 for iopamidol, respectively; 7.65 vs. 7.5 for iohexol, respectively). As measured with the acidoCEST-UTE technique, overall mean cartilage pH was significantly lower than overall mean meniscus pH (6.60 vs. 6.72, respectively; P=0.043). Conclusions: AcidoCEST-UTE MRI after direct intra-articular administration of either iopamidol or iohexol can be used to measure cartilage and meniscus pH in vivo.

4.
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.

5.
Health Info Libr J ; 35(2): 87-90, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29873897

RESUMO

This editorial is based on the keynote by Dr Mark Murphy, Department of General Practice, Royal College of Surgeons, Ireland, at the Health Libraries Group conference, Keele University on 13-15 June 2018. https://bit.ly/2rubsIR#HLG2018.


Assuntos
Medicina Baseada em Evidências/tendências , Conhecimento , Humanos
6.
Implement Sci ; 12(1): 115, 2017 09 16.
Artigo em Inglês | MEDLINE | ID: mdl-28915897

RESUMO

BACKGROUND: Poorly controlled type 2 diabetes mellitus (T2DM) can be seen as failure to meet recommended targets for management of key risk factors including glycaemic control, blood pressure and lipids. Poor control of risk factors is associated with significant morbidity, mortality and healthcare costs. Failure to intensify medications for patients with poor control of T2DM when indicated is called clinical inertia and is one contributory factor to poor control of T2DM. We aimed to develop a theory and evidence-based complex intervention to improve appropriate prescribing and medication intensification in poorly controlled T2DM in Irish general practice. METHODS: The first stage of the Medical Research Council Framework for developing and evaluating complex interventions was utilised. To identify current evidence, we performed a systematic review to examine the effectiveness of interventions targeting patients with poorly controlled T2DM in community settings. The Behaviour Change Wheel theoretical approach was used to identify suitable intervention functions. Workshops, simulation, collaborations with academic partners and observation of physicians were utilised to operationalise the intervention functions and design the elements of the complex intervention. RESULTS: Our systematic review highlighted that professional-based interventions, potentially through clinical decision support systems, could address poorly controlled T2DM. Appropriate intensification of anti-glycaemic and cardiovascular medications, by general practitioners (GPs), for adults with poorly controlled T2DM was identified as the key behaviour to address clinical inertia. Psychological capability was the key driver of the behaviour, which needed to change, suggesting five key intervention functions (education, training, enablement, environmental restructuring and incentivisation) and nine key behaviour change techniques, which were operationalised into a complex intervention. The intervention has three components: (a) a training program/academic detailing of target GPs, (b) a remote finder tool to help GPs identify patients with poor control of T2DM in their practice and (c) A web-based clinical decision support system. CONCLUSIONS: This paper describes a multifaceted process including an exploration of current evidence and a thorough theoretical understanding of the predictors of the behaviour resulting in the design of a complex intervention to promote the implementation of evidence-based guidelines, through appropriate prescribing and medication intensification in poorly controlled T2DM.


Assuntos
Diabetes Mellitus Tipo 2/tratamento farmacológico , Medicina Geral/métodos , Hipoglicemiantes/uso terapêutico , Padrões de Prática Médica , Humanos , Irlanda , Atenção Primária à Saúde/métodos
7.
BMJ Open ; 7(8): e015135, 2017 Aug 04.
Artigo em Inglês | MEDLINE | ID: mdl-28780542

RESUMO

OBJECTIVES: Poorly controlled type 2 diabetes mellitus (T2DM) is a major international health problem. Our aim was to assess the effectiveness of healthcare interventions, specifically targeting patients with poorly controlled T2DM, which seek to improve glycaemic control and cardiovascular risk in primary care settings. DESIGN: Systematic review. SETTING: Primary care and community settings. INCLUDED STUDIES: Randomised controlled trials (RCTs) targeting patients with poor glycaemic control were identified from Pubmed, Embase, Web of Science, Cochrane Library and SCOPUS. Poor glycaemic control was defined as HbA1c over 59 mmol/mol (7.5%). INTERVENTIONS: Interventions were classified as organisational, patient-oriented, professional, financial or regulatory. OUTCOMES: Primary outcomes were HbA1c, blood pressure and lipid control. Two reviewers independently assessed studies for eligibility, extracted data and assessed study quality. Meta-analyses were undertaken where appropriate using random-effects models. Subgroup analysis explored the effects of intervention type, baseline HbA1c, study quality and study duration. Meta-regression analyses were undertaken to investigate identified heterogeneity. RESULTS: Forty-two RCTs were identified, including 11 250 patients, with most undertaken in USA. In general, studies had low risk of bias. The main intervention types were patient-directed (48%) and organisational (48%). Overall, interventions reduced HbA1c by -0.34% (95% CI -0.46% to -0.22%), but meta-analyses had high statistical heterogeneity. Subgroup analyses suggested that organisational interventions and interventions on those with baseline HbA1c over 9.5% had better improvements in HbA1c. Meta-regression analyses suggested that only interventions on those with population HbA1c over 9.5% were more effective. Interventions had a modest improvement of blood pressure and lipids, although baseline levels of control were generally good. CONCLUSIONS: This review suggests that interventions for T2DM, in primary care, are better targeted at individuals with very poor glycaemic control and that organisational interventions may be more effective.


Assuntos
Doenças Cardiovasculares/prevenção & controle , Serviços de Saúde Comunitária , Diabetes Mellitus Tipo 2/tratamento farmacológico , Atenção Primária à Saúde , Melhoria de Qualidade/normas , Gestão de Riscos/normas , Glicemia , Serviços de Saúde Comunitária/organização & administração , Serviços de Saúde Comunitária/normas , Diabetes Mellitus Tipo 2/sangue , Hemoglobina A Glicada , Promoção da Saúde , Humanos , Atenção Primária à Saúde/organização & administração , Atenção Primária à Saúde/normas , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Risco
8.
Fam Pract ; 34(5): 587-592, 2017 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-28472488

RESUMO

Background: Several new medications for type 2 diabetes (T2DM) have been introduced, including dipeptidyl peptidase-4 (DPP-4) inhibitors and glucagon-like peptide-1 receptor (GLP-1) agonists. Variation in the prescribing of these agents has implications for quality, safety and costs. We aimed to investigate geographical variation in the prescribing of anti-diabetic medications in Ireland. Methods: Cross-sectional analyses were undertaken on the two main national pharmacy claims databases in Ireland in 2013 and 2014. Direct standardized rates of individual anti-diabetic medication prescribing per 100 000 population were calculated by geographical area. Variation in prescribing was assessed using the systematic component of variation (SCV) and classified as very high (>10), high (5.4-10), moderate (3-5.4) or low (<3). Estimated total costs of prescribing were calculated per geographical area using medication wholesale costs. Results: Very high levels of geographical variation of GLP-1 agonists (SCV 11.4 and 10.3 in 2013 and 2014) and moderate variation of DPP-4 inhibitors (SCV 3.8 and 4.1) were found. There was low/moderate variation in the prescribing of sulphonylureas (SVC 2.8 and 3.6) and low variation in prescribing of metformin (SVC 1.7 and 2.0). Geographical variation in Ireland leads to an estimated total wholesale cost differential of €500 000 for GLP-1 agonists, per 100 000 population, between the highest and lowest prescribing areas. Conclusions: There is substantial geographical variation in the prescribing of new T2DM medicines, particularly GLP-1 agonists. The prescribing variation which was identified may not only represent differences in the application of clinical guidelines, but also variation in professional opinion or patient preference.


Assuntos
Diabetes Mellitus Tipo 2/tratamento farmacológico , Geografia Médica , Hipoglicemiantes/uso terapêutico , Metformina/uso terapêutico , Estudos Transversais , Diabetes Mellitus Tipo 2/economia , Diabetes Mellitus Tipo 2/epidemiologia , Inibidores da Dipeptidil Peptidase IV/administração & dosagem , Receptor do Peptídeo Semelhante ao Glucagon 1/agonistas , Humanos , Irlanda , Padrões de Prática Médica/estatística & dados numéricos
9.
J Med Ethics ; 43(11): 778-783, 2017 11.
Artigo em Inglês | MEDLINE | ID: mdl-28356488

RESUMO

INTRODUCTION: The provision of abortion services in the Republic of Ireland is legally restricted. Recent legislation that has been implemented allows for abortion if there is a real and substantial risk to the woman's life, but in general Irish women must travel abroad for abortion services. The aims of this study were to investigate the clinical experiences of Irish obstetric non-consultant hospital doctors (NCHDs) that work in this environment and to assess their attitudes towards termination of pregnancy (ToP). METHODS: We conducted an online cross-sectional descriptive survey of 184 Irish obstetric NCHDs. Quantitate and qualitative analysis was performed. RESULTS: There was a 28% response rate. 88% of respondents thought that ToP should be permitted for fatal fetal abnormality if the parents choose, 96% if the woman's health is severely affected and 86% in cases of rape and incest. Over 90% of respondents believed a woman's health suffers because of the need to travel abroad to undergo a ToP. Physical, psychological and social reasons were explored. The research also highlights that obstetric trainees are actively involved in the provision of preabortion and postabortion care. CONCLUSIONS: The clinical experiences and opinions of the respondents suggest that the current legal availability of abortion in Ireland is insufficient to guide best clinical practice and does not represent the views of those that provide obstetric care.


Assuntos
Aborto Induzido , Atitude do Pessoal de Saúde , Educação de Pós-Graduação em Medicina , Ginecologia , Obstetrícia , Médicos , Especialização , Aborto Legal , Adulto , Estudos Transversais , Feminino , Humanos , Irlanda , Masculino , Gravidez , Serviços de Saúde Reprodutiva , Adulto Jovem
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