Facilitators and barriers to the introduction of atrial fibrillation screening in primary care: a qualitative descriptive study of general practitioners in primary care.

INTRODUCTION: Atrial fibrillation (AF), the most common cardiac arrhythmia, is a major risk factor for stroke. AF is often asymptomatic and, if identified, treatment can be offered that can reduce stroke risk by up to two thirds. AF screening meets many of the Wilson Jungner criteria for screening. While AF screening is recommended in clinical practice and internationally, the optimal mode and location for AF screening remains under investigation. Primary care has been identified as a potential setting. This study aimed to identify facilitators and barriers to AF screening from the perspective of GPs. METHODS: The study adopted a qualitative descriptive design conducted in the south of Ireland. 58 GPs were invited from the north Cork region to participate in individual interviews at their practices, rural and urban, with a view to recruiting a purposive sample of up to 12 GPs. The interviews were audio-recorded, transcribed verbatim and analysed using a framework analysis. RESULTS: Eight GPs (four male, four female) from five practices participated. Five GPs were from urban practices and three were from rural practices. Facilitators and barriers were sub-categorised into patient facilitators, practice facilitators, GP facilitators, patient barriers, practice barriers, GP barriers, attitudes to AF screening, willingness to facilitate and priority ranking. All eight participants expressed a willingness to engage in AF screening. Time was the barrier discussed most frequently by all participants along with the need for additional staff. Programme structure was the most discussed facilitator by all participants and patient awareness campaigns. DISCUSSION: Despite barriers to AF screening identified by GPs, there was a significant willingness to engage and identify potential facilitators to support such screening.

Impact of changes in controlled drugs legislation on benzodiazepine receptor agonist prescribing in Ireland: a repeated cross-sectional study.

PURPOSE: To examine the impact of new controlled drugs legislation introduced in May 2017 on benzodiazepine receptor agonist (BZRA) prescribing in Ireland. METHODS: A repeated cross-sectional analysis was conducted using publically available monthly pharmacy claims data from the General Medical Services (GMS) database. The study population comprised all GMS-eligible individuals aged ≥ 16 years from January 2016 to September 2019. Monthly prevalence rates of individuals receiving BZRA prescriptions per 10,000 eligible population were calculated and trends examined over time. Segmented linear regression of prevalence rates was used to examine changes before and after introduction of the legislation stratified by gender and age groups. Regression coefficients (ß) and 95% confidence intervals (CIs) for monthly change were calculated. RESULTS: Pre-legislation (January 2016 to April 2017), there was a significant monthly decline in benzodiazepine prevalence rate (ß = - 1.18; 95% CI - 1.84, - 0.51; p < 0.001) but no significant change in Z-drug prescribing. Post-legislation (May 2017 to September 2019), increases in prevalence rates were observed for benzodiazepines (ß = 1.04; 95% CI 0.17, 1.92; p = 0.021) and Z-drugs (ß = 1.04; 95% CI 0.26, 1.83; p = 0.010). Post-legislation trends showed increases in BZRA prevalence rates among the youngest subgroup (16-44 years), with variable changes in the middle-aged subgroup (45-64 years) and no changes in the oldest subgroup (≥ 65 years). CONCLUSIONS: This study indicates that introduction of new legislation had limited impact on BZRA prescribing on the main public health scheme in Ireland. Interventions targeting specific population subgroups may be required to achieve sustained reductions in prescribing.

Medication reconciliation: time to save? A cross-sectional study from one acute hospital.

PURPOSE: Medication errors during transitional care are an important patient safety issue. Medication reconciliation is an established intervention to reduce such errors. Current evidence has not demonstrated an associated reduction in healthcare costs, however, with complexity and resource intensity being identified as issues. The aims of this study were to examine an existing process of medication reconciliation in terms of time taken, to identify factors associated with additional time, and to determine if additional time is associated with detecting errors of clinical significance. METHODS: A cross-sectional study was conducted. Issues arising during medication reconciliation incurring a time burden additional to the usual process were logged and quantified by pharmacists. Regression analyses investigated associations between patient characteristics and clinically significant errors and additional time. Cost for additional time in terms of hospital pharmacist salary was calculated. RESULTS: Eighty-nine patients were included. Having a personal record of medication at admission (OR 3.30, 95% CI: (1.05 to 10.42), p = 0.004) was a significant predictor of additional time. No significant associations were found between the occurrence of clinically significant error and additional time (p > 0.05). The most common reason for additional time was clarifying issues pertaining to primary care medication information. Projected annual 5-year costs for the mean additional time of 3.75 min were €1.8-1.9 million. CONCLUSIONS: Spending additional time on medication reconciliation is associated with economic burden and may not yield benefit in terms of capturing clinically significant errors. There is a need to improve communication of medication information between primary and secondary care.

Benzodiazepine and Z-drug prescribing in Ireland: analysis of national prescribing trends from 2005 to 2015.

AIMS: The aim of this study was to examine prescribing trends for benzodiazepines and Z-drugs to General Medical Services (GMS) patients in Ireland. METHODS: A repeated cross-sectional analysis of the national pharmacy claims database was conducted for GMS patients aged ≥16 years from 2005 to 2015. Prescribing rates per 1000 eligible GMS population were calculated with 95% confidence intervals (CIs). Negative binomial regression was used to determine longitudinal trends and compare prescribing rates across years, gender and age groups. Duration of supply and rates of concomitant benzodiazepine and Z-drug prescribing were determined. Age (16-44, 45-64, ≥65 years) and gender trends were investigated. RESULTS: Benzodiazepine prescribing rates decreased significantly from 225.92/1000 population (95% CI 224.94-226.89) in 2005 to 166.07/1000 population (95% CI 165.38-166.75) in 2015 (P < 0.0001). Z-drug prescribing rates increased significantly from 95.36/1000 population (95% CI 94.73-96.00) in 2005 to 109.11/1000 population (95% CI 108.56-109.67) in 2015 (P = 0.048). Approximately one-third of individuals dispensed either benzodiazepines or Z-drugs were receiving long-term prescriptions (>90 days). The proportion of those receiving >1 benzodiazepine and/or Z-drug concomitantly increased from 11.9% in 2005 to 15.3% in 2015. Benzodiazepine and Z-drug prescribing rates were highest for older women (≥65 years) throughout the study period. CONCLUSIONS: Benzodiazepine prescribing to the GMS population in Ireland decreased significantly from 2005 to 2015, and was coupled with significant increases in Z-drug prescribing. The study shows that benzodiazepine and Z-drug prescribing is common in this population, with high proportions of individuals receiving long-term prescriptions. Targeted interventions are needed to reduce potentially inappropriate long-term prescribing and use of these medications in Ireland.

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

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

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

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

Physician and practice characteristics associated with immunoglobulin test ordering.

Background: Primary care test requests for serum immunoglobulins are rising rapidly, with concerns that many requests may be unnecessary. Evidence suggests some characteristics of general practitioners (GPs) and practices are associated with higher test ordering. Objective: To identify the physician and practice characteristics associated with immunoglobulin test ordering. Methods: Retrospective, cross-sectional study using routine laboratory data on primary care serum immunoglobulin requests. Data were linked with GP patient list size data. The primary outcome measure was the count of test requests per GP. Predictor variables were physician gender, years experience, practice region and type (number of GPs), GP patient list size and composition. Mixed-effects multilevel regression models were used to calculate incidence rate ratios (IRRs) with 95% confidence intervals (CIs) for the associations between physician and practice characteristics and GP requesting. Sensitivity analysis was performed by limiting the model to the more than 70 years age category. Results: In total, 5990 immunoglobulin tests were ordered by 481 GPs in the South of Ireland during 2013. The number of tests ordered by individual GPs varied from one to 377. In the final fully adjusted Poisson regression analysis, female gender (IRR: 1.81; 95% CI: 1.45-2.26) and less experience (IRR: 2.27; 95% CI: 1.47-3.51) were associated with higher requesting (P < 0.001). None of the practice factors were associated with test ordering. Sensitivity analysis on the 70 years or more age category found similar results. Conclusion: Further research is required to explore the potential reasons for higher requesting among GPs with fewer years of experience and also among female GPs.

Economic impact of medication error: a systematic review.

PURPOSE: Medication error is a significant source of morbidity and mortality among patients. Clinical and cost-effectiveness evidence are required for the implementation of quality of care interventions. Reduction of error-related cost is a key potential benefit of interventions addressing medication error. The aim of this review was to describe and quantify the economic burden associated with medication error. METHODS: PubMed, Cochrane, Embase, CINAHL, EconLit, ABI/INFORM, Business Source Complete were searched. Studies published 2004-2016 assessing the economic impact of medication error were included. Cost values were expressed in Euro 2015. A narrative synthesis was performed. RESULTS: A total of 4572 articles were identified from database searching, and 16 were included in the review. One study met all applicable quality criteria. Fifteen studies expressed economic impact in monetary terms. Mean cost per error per study ranged from €2.58 to €111 727.08. Healthcare costs were used to measure economic impact in 15 of the included studies with one study measuring litigation costs. Four studies included costs incurred in primary care with the remaining 12 measuring hospital costs. Five studies looked at general medication error in a general population with 11 studies reporting the economic impact of an individual type of medication error or error within a specific patient population. CONCLUSIONS: Considerable variability existed between studies in terms of financial cost, patients, settings and errors included. Many were of poor quality. Assessment of economic impact was conducted predominantly in the hospital setting with little assessment of primary care impact. Limited parameters were used to establish economic impact. Copyright © 2017 John Wiley & Sons, Ltd.

A scoping review of the potential for chart stimulated recall as a clinical research method.

BACKGROUND: Chart-stimulated recall (CSR) is a case-based interviewing technique, which is used in the assessment of clinical decision-making in medical education and professional certification. Increasingly, clinical decision-making is a concern for clinical research in primary care. In this study, we review the prior application and utility of CSR as a technique for research interviews in primary care. METHODS: Following Arksey & O'Malley's method for scoping reviews, we searched seven databases, grey literature, reference lists, and contacted experts in the field. We excluded studies on medical education or competence assessment. Retrieved citations were screened by one reviewer and full texts were ordered for all potentially relevant abstracts. Two researchers independently reviewed full texts and performed data extraction and quality appraisal if inclusion criteria were met. Data were collated and summarised using a published framework on the reporting of qualitative interview techniques, which was chosen a priori. The preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines informed the review report. RESULTS: From an initial list of 789 citations, eight studies using CSR in research interviews were included in the review: six from North America, one from the Netherlands, and one from Ireland. The most common purpose of included studies was to examine the influence of guidelines on physicians' decisions. The number of interviewees ranged from seven to twenty nine, while the number of charts discussed per interview ranged from one to twelve. CSR gave insights into physicians' reasoning for actions taken or not taken; the unrecorded social and clinical influences on decisions; and discrepancies between physicians' real and perceived practice. Ethical concerns and the training and influence of the researcher were poorly discussed in most of the studies. Potential pitfalls included the risk of recall, selection and observation biases. CONCLUSIONS: Despite the proven validity, reliability and acceptability of CSR in assessment interviews in medical education, its use in clinical research is limited. Application of CSR in qualitative research brings interview data closer to the reality of practice. Although further development of the approach is required, we recommend a role for CSR in research interviews on decision-making in clinical practice.

Psychosocial complexity in multimorbidity: the legacy of adverse childhood experiences.

BACKGROUND: To effectively meet the health care needs of multimorbid patients, the most important psychosocial factors associated with multimorbidity must be discerned. Our aim was to examine the association between self-reported adverse childhood experiences (ACEs) and multimorbidity and the contribution of other social, behavioural and psychological factors to this relationship. METHODS: We analysed cross-sectional data from the Mitchelstown study, a population-based cohort recruited from a large primary care centre. ACE was measured by self-report using the Centre for Disease Control ACE questionnaire. Multimorbidity status was categorized as 0, 1 or ≥2 chronic diseases, which were ascertained by self-report of doctor diagnosis. Ordinal logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (95% CIs) for multimorbidity, using ACE as the independent variable with adjustment for social (education, public health cover), behavioural (smoking, exercise, diet, body mass index) and psychological factors (anxiety/depression scores). RESULTS: Of 2047 participants, 45.3% (n = 927, 95% CI: 43.1-47.4) reported multimorbidity. ACE was reported by 28.4% (n = 248, 95% CI: 25.3-31.3%) of multimorbid participants, 21% (n = 113, 95% CI: 18.0-25.1%) of single chronic disease participants and 16% (n = 83, 95% CI: 13.2-19.7%) of those without chronic disease. The OR for multimorbidity with any history of ACE was 1.6 (95% CI: 1.4-2.0, P < 0.001). Adjusting for social, behavioural and psychological factors only marginally ameliorated this association, OR 1.4 (95% CI: 1.1-1.7, P = 0.002). CONCLUSIONS: Multimorbidity is independently associated with a history of ACEs. These findings demonstrate the psychosocial complexity associated with multimorbidity and should be used to inform health care provision in this patient cohort.

Service users' and caregivers' perspectives on continuity of care in out-of-hours primary care.

Modernization policies in primary care, such as the introduction of out-of-hours general practice cooperatives, signify a marked departure from many service users' traditional experiences of continuity of care. We report on a case study of accounts of service users with chronic conditions and their caregivers of continuity of care in an out-of-hours general practice cooperative in Ireland. Using Strauss and colleagues' Chronic Illness Trajectory Framework, we explored users' and caregivers' experiences of continuity in this context. Whereas those dealing with "routine trajectories" were largely satisfied with their experiences, those dealing with "problematic trajectories" (characterized by the presence of, for example, multimorbidity and complex care regimes) had considerable concerns about continuity of experiences in this service. Results highlight that modernization policies that have given rise to out-of-hours cooperatives have had a differential impact on service users with chronic conditions and their caregivers, with serious consequences for those who have "problematic" trajectories.

Facilitators and barriers to atrial fibrillation screening in primary care: a qualitative descriptive study of GPs in primary care in the Republic of Ireland.

BACKGROUND: Atrial fibrillation (AF), the most common cardiac arrhythmia, is a major risk factor for stroke. AF is often asymptomatic, making it difficult to diagnose. Globally, stroke is a leading cause of morbidity and mortality. Opportunistic AF screening has been recommended in clinical practice within the Republic of Ireland (RoI) and internationally, though the optimal mode and location remains under investigation. Currently, there is no formal AF screening programme. Primary care has been proposed as a suitable setting. AIM: To identify the facilitators and barriers to AF screening in primary care from the perspective of GPs. DESIGN & SETTING: A qualitative descriptive study design was adopted. Fifty-four GPs were invited from 25 practices in the RoI to participate in individual interviews at their practices. Participants were from both rural and urban locations. METHOD: A topic guide was developed to guide the interview content towards identification of facilitators and barriers to AF screening. The interviews were conducted in person, audio-recorded, transcribed verbatim, and analysed using framework analysis. RESULTS: Eight GPs from five practices participated in an interview. Three GPs, two male and one female, were recruited from two rural practices and five GPs, two male and three female, were recruited from three urban practices. All eight GPs expressed a willingness to engage in AF screening. Time pressures and the need for additional staff to support were identified as barriers. Programme structure and patient awareness campaigns and education were identified as facilitators. CONCLUSION: The findings will help to anticipate barriers to AF screening and aid the development of clinical pathways for people with or at risk of AF. The results have been integrated into a pilot primary care-based screening programme for AF.

Antibiotic prescribing in primary care, adherence to guidelines and unnecessary prescribing--an Irish perspective.

BACKGROUND: Information about antibiotic prescribing practice in primary care is not available for Ireland, unlike other European countries. The study aimed to ascertain the types of antibiotics and the corresponding conditions seen in primary care and whether general practitioners (GPs) felt that an antibiotic was necessary at the time of consultation. This information will be vital to inform future initiatives in prudent antibiotic prescribing in primary care. METHODS: Participating GPs gathered data on all antibiotics prescribed by them in 100 consecutive patients' consultations as well as data on the conditions being treated and whether they felt the antibiotic was necessary. RESULTS: 171 GPs collected data on 16,899 consultations. An antibiotic was prescribed at 20.16% of these consultations. The majority were prescribed for symptoms or diagnoses associated with the respiratory system; the highest rate of prescribing in these consultations were for patients aged 15-64 years (62.23%). There is a high rate of 2nd and 3rd line agents being used for common ailments such as otitis media and tonsillitis. Amoxicillin, which is recommended as 1st line in most common infections, was twice as likely to be prescribed if the prescription was for deferred used or deemed unnecessary by the GP. CONCLUSION: The study demonstrates that potentially inappropriate prescribing is occurring in the adult population and the high rate of broad-spectrum antimicrobial agents is a major concern. This study also indicates that amoxicillin may be being used for its placebo effect rather than specifically for treatment of a definite bacterial infection.

Atrial fibrillation (AF) pilot screening programme in primary care in Ireland: an implementation study protocol.

INTRODUCTION: Atrial fibrillation (AF) is a major risk factor for stroke. There is a fivefold increase in stroke risk in the presence of AF. The irregular beating of the heart enables blood stasis which allows clots to form. These can migrate to the brain causing a stroke. AF is common and its incidence increases with age. AF is often asymptomatic and early detection enables effective preventive treatment reducing stroke risk by up to two-thirds.Stroke contributes significantly to morbidity and mortality globally. In Ireland, it is the leading cause of acquired disability and second leading cause of death. The cost associated with stroke is significant. Stroke risk increases with age and is a public health priority.Internationally, there is consensus among experts that AF screening is valuable. In Ireland, the National Cardiovascular Policy recommended establishing a screening programme. However, there are many ways to screen for AF including pulse palpation, mobile ECG devices, 12-lead ECG and personal health monitoring devices.This study aims to investigate the acceptability, feasibility and impact of AF screening in primary care using a handheld mobile ECG device. METHODS AND ANALYSIS: General practitioners (GPs) and practice nurses in the South of Ireland will opportunistically screen patients aged ≥65 years for AF at routine consultation using a handheld one-lead ECG device, KardiaMobile. This study will screen up to 4000 patients. Blood pressure and smoking status will be checked concurrently. A mixed-method evaluation will be undertaken including a partial economic evaluation. Anonymised data will be collected from participating practices and qualitative interviews will be conducted with GP, nurse and patient participants. ETHICS AND DISSEMINATION: Ethical approval has been granted by the Clinical Research Ethics Committee in University College Cork. Dissemination will involve publication in peer-reviewed journals and presentation at national and international conferences.

Paediatric attendances of the emergency department in a major Irish tertiary referral centre before and after expansion of free GP care to children under 6: a retrospective observational study.

Objectives: To examine the characteristics of paediatric attendances to the emergency department (ED) in Cork University Hospital (CUH) before and after the expansion of free general practitioner (GP) care to children under the age of 6 years. Design: This is a retrospective observational study that used a large administrative dataset. Setting: The study was conducted in major Irish tertiary referral centre that serves a total population of over 1.1 million. It is a public hospital, owned and managed by the health service executive. Participants: Children aged 0-15 years who attended CUH ED during the study period of 6 years (2012-2018) were included in this study (n=76 831). Interventions: Free GP care was expanded to all children aged 0-5 years in July 2015. Main outcome measures: Paediatric attendances to CUH ED were examined before (Time Period 1: July 2012-June 2015) and after (Time Period 2: July 2015-June 2018) the expansion of free GP care to children under 6. Changes in GP referral rates and inpatient hospital admissions were investigated. Results: Paediatric presentations to CUH ED increased from 35 819 during the Time Period 1 to 41 012 during the Time Period 2 (14.5%). The proportion of the CUH ED attendances through GP referrals by children under 6 increased by over 8% in the Time Period 2 (from 10 148 to 14 028). Although the number of all children who attended CUH ED and were admitted to hospital increased in Time Period 2 (from 8704 to 9320); the proportion of children in the 0-5 years group who attended the CUH ED through GP referral and were subsequently admitted to hospital, decreased by over 3%. Conclusion: The expansion of free GP care has upstream health service utilisation implications, such as increased attendances at ED, and should be considered and costed by policy-makers.

Informing the development of a national diabetes register in Ireland: a literature review of the impact of patient registration on diabetes care.

BACKGROUND: Research suggests that a structured approach to diabetes care can lead to improved patient outcomes. In order to enable greater organisation of care, an electronic patient registration system is required. As part of the development of a national disease register in Ireland, we conducted a review of literature relating to the impact of registration systems on processes and outcomes of care. OBJECTIVE: The aim of the review is to establish the impact of a registration system on patient care and clinical outcomes. The review explores the role played by a patient registration system, particularly in the primary care setting. METHODS: The literature review applied a search strategy to six identified databases. Included studies were those based on original research, including a patient registration system and published between 1999 and 2009 in the English language. Studies including only patients with type 2 diabetes or those with both type 1 and type 2 diabetes were included. Some papers did not specify which type of diabetes was included. FINDINGS: In interventions of structured care which used a patient registration system, modest results for clinical outcomes were demonstrated as well as significant improvements in the processes of care. A patient register was a necessary step along the path towards improved patient clinical outcomes, notably glycated haemoglobin (HbA1c), blood pressure and cholesterol measurements. CONCLUSIONS: This review suggested that registers are generally assumed to be an essential element of quality improvement interventions rather than an optional addition. A diabetes register is central to the development of a comprehensive diabetes management system in primary care, which can lead to improvements in the processes and outcomes of diabetes care.

Brief interventions targeting long-term benzodiazepine and Z-drug use in primary care: a systematic review and meta-analysis.

AIMS: To assess the effectiveness of brief interventions in primary care aimed at reducing or discontinuing long-term benzodiazepine/Z-drug (BZRA) use. METHOD: Systematic review of randomized controlled trials of brief interventions in primary care settings aimed at reducing or discontinuing long-term BZRA use in adults taking BZRAs for ≥ 3 months. Four electronic databases were searched: PubMed, EMBASE, PsycINFO and CENTRAL. The primary outcome was BZRA use, classified as discontinuation or reduction by ≥ 25%. The Theoretical Domains Framework (TDF) was used to retrospectively code behavioural determinants targeted by the interventions. The Behaviour Change Technique (BCT) Taxonomy was used to identify the interventions' active components. Study-specific estimates were pooled, where appropriate, to yield summary risk ratios (RRs) and 95% confidence intervals (CIs). Pearson's correlations were used to determine the relationship between intervention effect size and the results of both the TDF and BCT coding. RESULTS: Eight studies were included (n = 2071 patients). Compared with usual care, intervention patients were more likely to have discontinued BZRA use at 6 months (eight studies, RR = 2.73, 95% CI = 1.84-4.06) and 12 months post-intervention (two studies, RR = 3.41, 95% CI = 2.22-5.25). TDF domains 'knowledge', 'memory, attention and decision processes', 'environmental context and resources' and 'social influences' were identified as having been included in every intervention. Commonly identified BCTs included 'information about health consequences', 'credible source' and 'adding objects to the environment'. There was no detectable relationship between effect size and the results of either the TDF or BCT coding. CONCLUSION: Brief interventions delivered in primary care are more effective than usual care in reducing and discontinuing long-term benzodiazepine/Z-drug use.

Educational intervention to optimise serum immunoglobulin test use in Irish primary care: an interrupted time series with segmented regression analysis.

BACKGROUND: Implementation science experts recommend that theory-based strategies, developed in collaboration with healthcare professionals, have greater chance of success. AIM: This study evaluated the impact of a theory-based strategy for optimising the use of serum immunoglobulin testing in primary care. DESIGN AND SETTING: An interrupted time series with segmented regression analysis in the Cork-Kerry region, Ireland. An intervention was devised comprising a guideline and educational messages-based strategy targeting previously identified GP concerns relevant to testing for serum immunoglobulins. METHOD: Interrupted time series with segmented regression analysis was conducted to evaluate the intervention, using routine laboratory data from January 2012 to October 2016. Data were organised into fortnightly segments (96 time points pre-intervention and 26 post-intervention) and analysed using incidence rate ratios with their corresponding 95% confidence intervals. RESULTS: In the most parsimonious model, the change in trend before and after the introduction of the intervention was statistically significant. In the 1-year period following the implementation of the strategy, test orders were falling at a rate of 0.42% per fortnight (P<0.001), with an absolute reduction of 0.59% per fortnight, corresponding to a reduction of 14.5% over the 12-month study period. CONCLUSION: The authors' tailored guideline combined with educational messages reduced serum immunoglobulin test ordering in primary care over a 1-year period. Given the rarity of the conditions for which the test is utilised and the fact that the researchers had only population-level data, further investigation is required to examine the clinical implications of this change in test-ordering patterns.

Self-care coping strategies in people with diabetes: a qualitative exploratory study.

BACKGROUND: The management of diabetes self-care is largely the responsibility of the patient. With more emphasis on the prevention of complications, adherence to diabetes self-care regimens can be difficult. Diabetes self-care requires the patient to make many dietary and lifestyle changes. This study will explore patient perceptions of diabetes self-care, with particular reference to the burden of self-care and coping strategies among patients. METHODS: A maximum variation sample of 17 patients was selected from GP practices and diabetes clinics in Ireland to include patients with types 1 and 2 diabetes, various self-care regimens, and a range of diabetes complications. Data were collected by in-depth interviews; which were tape-recorded and transcribed. The transcripts were analysed using open and axial coding procedures to identify main categories, and were reviewed by an independent corroborator. Discussion of the results is made in the theoretical context of the health belief, health value, self-efficacy, and locus of control frameworks. RESULTS: Patients' perceptions of their self-care varied on a spectrum, displaying differences in self-care responsibilities such as competence with dietary planning, testing blood sugar and regular exercise. Three patient types could be distinguished, which were labeled: "proactive manager," a patient who independently monitors blood glucose and adjusts his/her self-care regime to maintain metabolic control; "passive follower," a patient who follows his/her prescribed self-care regime, but does not react autonomously to changes in metabolic control; and "nonconformist," a patient who does not follow most of his/her prescribed self-care regimen. CONCLUSION: Patients have different diabetes self-care coping strategies which are influenced by their self-care health value and consequently may affect their diet and exercise choices, frequency of blood glucose monitoring, and compliance with prescribed medication regimens. Particular attention should be paid to the patient's self-care coping strategy, and self-care protocols should be tailored to complement the different patient types.

The Patient-Held Active Record of Medication Status (PHARMS) study: a mixed-methods feasibility analysis.

BACKGROUND: Medication errors frequently occur as patients transition between hospital and the community, and may result in patient harm. Novel methods are required to address this issue. AIM: To assess the feasibility of introducing an electronic patient-held active record of medication status device (PHARMS) at the primary-secondary care interface at the time of hospital discharge. DESIGN AND SETTING: A mixed-methods study (non-randomised controlled intervention, and a process evaluation of qualitative interviews and non-participant observation) among patients >60 years in an urban hospital and general practices in Cork, Ireland. METHOD: The number and clinical significance of errors were compared between discharge prescriptions of the intervention (issued with a PHARMS device) and control (usual care, handwritten discharge prescription) groups. Semi-structured interviews were conducted with patients, junior doctors, GPs, and IT professionals, in addition to direct observation of the implementation process. RESULTS: In all, 102 patients were included in the final analysis (intervention n = 41, control n = 61). Total error number was lower in the intervention group (median 1, interquartile range [IQR] 0-3) than in the control group (median 8, IQR (4-13.5, P<0.001), with the clinical significance score in the intervention group also being lower than the control group (median 2, IQR 0-4 versus median 11, IQR 5-20, P<0.001). The PHARMS device was found to be technically implementable using existing information technology infrastructure, and acceptable to all key stakeholders. CONCLUSION: The results suggest that using PHARMS devices within existing systems in general practice and hospitals is feasible and acceptable to both patients and doctors, and may reduce medication error.