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1.  Influence of patient payment on antibiotic prescribing in Irish general practice: a cohort study 
The British Journal of General Practice  2011;61(590):e549-e555.
Background
Antibiotics are widely believed to be overused and misused. Approximately 80% of all prescriptions for antibiotics are written by GPs. There are many external factors that influence a GP's decision to prescribe, including patient pressure. Access to primary care services operates on a two-tier system in the Republic of Ireland: General Medical Service (GMS) card holders have free access to GPs and medications; and non-card holders (private patients) must pay a non-subsidised fee to visit their GP
Aim
To ascertain whether there was a difference in antibiotic prescribing practice between those who pay a fee for their GP consultation and those who attend free of charge
Design and setting
Cohort study in Irish general practice
Method
All GPs attending continuing medical education (CME) groups nationwide were invited to participate from October 2008 until April 2010. GPs gathered data on 100 consecutive consultations including diagnosis and patient characteristics.
Results
Data were collected from 171 GPs (distributed throughout Ireland), which resulted in 16 899 consultations. Antibiotics were prescribed at 3407 (20.16%) consultations. Nearly half of the prescriptions were for GMS card holders (n = 1669; 48.99%) and 1526 (44.79%) were for private patients; for 212 (6.22%) the payment status of the patient was unknown. Private patients were more likely to receive a prescription forantibiotics (odds ratio 1.23, 95% confidence interval = 1.14 to 1.33).
Conclusion
These results demonstrate that a GP's decision to provide a prescription for antibiotics may be influenced by whether or not the patient pays for their consultation at the GP interface. Private patients are more likely than GMS card holders to receive a prescription forantibiotics.
doi:10.3399/bjgp11X593820
PMCID: PMC3162177  PMID: 22152734
antibacterial agents; fees, medical; general practice; patient expectation
2.  Quality-assured screening for diabetic retinopathy delivered in primary care in Ireland: an observational study 
The British Journal of General Practice  2013;63(607):e134-e140.
Background
At present, there is no national population-based retinopathy screening programme for people in Ireland who have diabetes, such as those operating in the UK for over a decade.
Aim
To evaluate a community-based initiative that utilised existing resources in general practice and community optometry/ophthalmology services to provide screening for diabetic retinopathy.
Design and setting
Cross-sectional study using electronic ophthalmic patient screening records in community optometry clinics in Cork, Ireland.
Method
A purposive sample of 32 practices was recruited from Diabetes in General Practice, a general practice-led initiative in the South of Ireland. Practices invited all adult patients registered with diabetes to participate in free retinopathy screening (n = 3598), provided by 15 community optometry practices and two community ophthalmologists. Data were recorded on an electronic database used by optometrists and the performance was benchmarked against proposed national standards for retinopathy screening.
Result
In total, 30 practices participated (94%). After 6 months, 49% of patients (n = 1763) had been screened, following one invitation letter and no reminder. Forty-three per cent of those invited consented to their data being used in the study and subsequent analyses are based on that sample (n = 1542). The mean age of the patients screened was 65 years (standard deviation = 13.0 years), 57% were male (n = 884), and 86% had type 2 diabetes (n = 1320). In total, 26% had some level of retinopathy detected (n = 395); 21% had background retinopathy (n = 331), 3% had pre-proliferative retinopathy (n = 53), and 0.7% had proliferative retinopathy (n = 11).
Conclusion
The detection of retinopathy among 26% of those screened highlights the need for a national retinopathy screening programme in Ireland. Significant learning, derived from the implementation of this initiative, will inform the national programme.
doi:10.3399/bjgp13X663091
PMCID: PMC3553639  PMID: 23561692
diabetic retinopathy; general practice; optometry; quality assurance; primary care; screening
3.  Timing of access to secondary healthcare services for diabetes management and lower extremity amputation in people with diabetes: a protocol of a case–control study 
BMJ Open  2013;3(10):e003871.
Background
Lower extremity amputation (LEA) is a complication of diabetes and a marker of the quality of diabetes care. Clinical and sociodemographic determinants of LEA in people with diabetes are well known. However, the role of service-related factors has been less well explored. Early referral to secondary healthcare is assumed to prevent the occurrence of LEA. The objective of this study is to investigate a possible association between the timing of patient access to secondary healthcare services for diabetes management, as a key marker of service-related factors, and LEA in patients with diabetes.
Methods/design
This is a case–control study. The source population is people with diabetes. Cases will be people with diabetes who have undergone a first major LEA, identified from the hospital discharge data at each of three regional centres for diabetes care. Controls will be patients with diabetes without LEA admitted to the same centre either electively or as an emergency. Frequency-matching will be applied for gender, type of diabetes, year and centre of LEA. Three controls per case will be selected from the same population as the cases. With a power of 90% to detect OR of 0.4 for an association between ‘good quality care’ and LEA in people with diabetes, 107 cases and 321 controls are required. Services involved in diabetes management are endocrinology, ophthalmology, renal, cardiology, vascular surgery and podiatry; timing of first contact with any of these services is the main exploratory variable. Using unconditional logistic regression, an association between this exposure and the outcome of major LEA in people with diabetes will be explored, while adjusting for confounders.
Ethics and dissemination
Ethical approval was granted by the Clinical Research Ethics Committee of the Cork Teaching Hospitals, Ireland. Results will be presented at conferences and published in peer-reviewed journals.
doi:10.1136/bmjopen-2013-003871
PMCID: PMC3816241  PMID: 24171939
5.  Concordance studies between hospital discharge data and medical records for the recording of lower extremity amputation and diabetes in the Republic of Ireland 
BMC Research Notes  2013;6:148.
Background
Hospital discharge data have been used to study trends in Lower Extremity Amputation (LEA) rates in people with and without diabetes. The aim of this study was to assess the reliability of routine hospital discharge data in the Republic of Ireland (RoI) for this purpose by determining the level of agreement between hospital discharge data and medical records for both the occurrence of LEA and diagnosis of diabetes.
Methods
Two concordance studies between hospital discharge data (HIPE) and medical records were performed. To determine the level of agreement for LEA occurrence, HIPE records were compared to theatre logbooks in 9 hospitals utilising HIPE over a two-year period in a defined study area. To determine the level of agreement for diabetes diagnosis, HIPE records were compared to laboratory records in each of the 4 largest hospitals utilising HIPE over a one week period in the same study area. The proportions of positive and negative agreement and Cohen’s kappa statistic of agreement were calculated.
Results
During a two-year study period in 9 hospitals, 216 LEAs were recorded in both data sources. Sixteen LEAs were recorded in medical records alone and 25 LEAs were recorded in hospital discharge records alone. The proportion of positive agreement was 0.91 (95% CI 0.88-0.94), the proportion of negative agreement was 0.99 (95% CI 0.98-0.99) and the kappa statistic was 0.91 (95% CI 0.88-0.94).
During a one-week study period in 4 hospitals, 49 patients with diabetes and 716 patients without diabetes were recorded in both data sources. Eighteen patients had diabetes in medical records alone and 2 patients had diabetes in hospital discharge records alone. The proportion of positive agreement was 0.83 (95% CI 0.76-0.9), the proportion of negative agreement was 0.99 (95% CI 0.98-0.99) and the kappa statistic was 0.82 (95% CI 0.75-0.89).
Conclusions
This study detected high levels of agreement between hospital discharge data and medical records for LEA and diabetes in a defined study area. Based on these findings, we suggest that HIPE is sufficiently reliable to monitor trends in LEAs in people with and without diabetes in the RoI.
doi:10.1186/1756-0500-6-148
PMCID: PMC3640954  PMID: 23587134
Concordance study; Lower extremity amputation; Diabetes; Hospital discharge data; Medical records; Agreement statistics
9.  Trends in the Incidence of Lower Extremity Amputations in People with and without Diabetes over a Five-Year Period in the Republic of Ireland 
PLoS ONE  2012;7(7):e41492.
Aims
To describe trends in the incidence of non-traumatic amputations among people with and without diabetes and estimate the relative risk of an individual with diabetes undergoing a lower extremity amputation compared to an individual without diabetes in the Republic of Ireland.
Methods
All adults who underwent a nontraumatic amputation during 2005 to 2009 were identified using HIPE (Hospital In-patient Enquiry) data. Participants were classified as having diabetes or not having diabetes. Incidence rates were calculated using the number of discharges for diabetes and non-diabetes related lower extremity amputations as the numerator and estimates of the resident population with and without diabetes as the denominator. Age-adjusted incidence rates were used for trend analysis.
Results
Total diabetes-related amputation rates increased non-significantly during the study period; 144.2 in 2005 to 175.7 in 2009 per 100,000 people with diabetes (p = 0.11). Total non-diabetes related amputation rates dropped non-significantly from 12.0 in 2005 to 9.2 in 2009 per 100,000 people without diabetes (p = 0.16). An individual with diabetes was 22.3 (95% CI 19.1–26.1) times more likely to undergo a nontraumatic amputation than an individual without diabetes in 2005 and this did not change significantly by 2009.
Discussion
This study provides the first national estimate of lower extremity amputation rates in the Republic of Ireland. Diabetes-related amputation rates have remained steady despite an increase in people with diabetes. These estimates provide a base-line and will allow follow-up over time.
doi:10.1371/journal.pone.0041492
PMCID: PMC3409236  PMID: 22859991
10.  Antibiotic prescribing in primary care, adherence to guidelines and unnecessary prescribing - an Irish perspective 
BMC Family Practice  2012;13:43.
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.
doi:10.1186/1471-2296-13-43
PMCID: PMC3430589  PMID: 22640399
11.  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.
doi:10.1186/1472-6823-9-6
PMCID: PMC2664817  PMID: 19232113
12.  Can we avoid bias? 
BMJ : British Medical Journal  2005;330(7494):784.
PMCID: PMC555890  PMID: 15802724
14.  Prescribing new drugs: qualitative study of influences on consultants and general practitioners 
BMJ : British Medical Journal  2001;323(7309):378.
Objective
To explore consultants' and general practitioners' perceptions of the factors that influence their decisions to introduce new drugs into their clinical practice.
Design
Qualitative study using semistructured interviews. Monitoring of hospital and general practice prescribing data for eight new drugs.
Setting
Teaching hospital and nearby general hospital plus general practices in Birmingham.
Participants
38 consultants and 56 general practitioners who regularly referred to the teaching hospital.
Main outcome measures
Reasons for prescribing a new drug; sources of information used for new drugs; extent of contact between consultants and general practitioners; and amount of study drugs used in hospitals and by general practitioners.
Results
Consultants usually prescribed new drugs only in their specialty, used few new drugs, and used scientific evidence to inform their decisions. General practitioners generally prescribed more new drugs and for a wider range of conditions, but their approach varied considerably both between general practitioners and between drugs for the same general practitioner. Drug company representatives were an important source of information for general practitioners. Prescribing data were consistent with statements made by respondents.
Conclusions
The factors influencing the introduction of new drugs, particularly in primary care, are more multiple and complex than suggested by early theories of drug innovation. Early experience of using a new drug seems to strongly influence future use.
What is already known on this topicUK studies show that use of new drugs by general practitioners is influenced by consultants, the nature of the drug, and perceived riskWhat this study addsConsultants generally introduced fewer drugs than general practitioners, usually within their specialtyDecisions were said to be based mainly on the evidence from the scientific literature and meetingsGeneral practitioners prescribed more new drugs and the basis of decisions was more variedDoctors' interpretations of using a new drug were not consistent
PMCID: PMC37400  PMID: 11509431
15.  Patients' unvoiced agendas in general practice consultations: qualitative study 
BMJ : British Medical Journal  2000;320(7244):1246-1250.
Objective
To investigate patients' agendas before consultation and to assess which aspects of agendas are voiced in the consultation and the effects of unvoiced agendas on outcomes.
Design
Qualitative study.
Setting
20 general practices in south east England and the West Midlands.
Participants
35 patients consulting 20 general practitioners in appointment and emergency surgeries.
Results
Patients' agendas are complex and multifarious. Only four of 35 patients voiced all their agendas in consultation. Agenda items most commonly voiced were symptoms and requests for diagnoses and prescriptions. The most common unvoiced agenda items were: worries about possible diagnosis and what the future holds; patients' ideas about what is wrong; side effects; not wanting a prescription; and information relating to social context. Agenda items that were not raised in the consultation often led to specific problem outcomes (for example, major misunderstandings), unwanted prescriptions, non-use of prescriptions, and non-adherence to treatment. In all of the 14 consultations with problem outcomes at least one of the problems was related to an unvoiced agenda item.
Conclusion
Patients have many needs and when these are not voiced they can not be addressed. Some of the poor outcomes in the case studies were related to unvoiced agenda items. This suggests that when patients and their needs are more fully articulated in the consultation better health care may be effected. Steps should be taken in both daily clinical practice and research to encourage the voicing of patients' agendas.
PMCID: PMC27368  PMID: 10797036
16.  Misunderstandings in prescribing decisions in general practice: qualitative study 
BMJ : British Medical Journal  2000;320(7233):484-488.
Objectives
To identify and describe misunderstandings between patients and doctors associated with prescribing decisions in general practice.
Design
Qualitative study.
Setting
20 general practices in the West Midlands and south east England.
Participants
20 general practitioners and 35 consulting patients.
Main outcome measures
Misunderstandings between patients and doctors that have potential or actual adverse consequences for taking medicine.
Results
14 categories of misunderstanding were identified relating to patient information unknown to the doctor, doctor information unknown to the patient, conflicting information, disagreement about attribution of side effects, failure of communication about doctor's decision, and relationship factors. All the misunderstandings were associated with lack of patients' participation in the consultation in terms of the voicing of expectations and preferences or the voicing of responses to doctors' decisions and actions. They were all associated with potential or actual adverse outcomes such as non-adherence to treatment. Many were based on inaccurate guesses and assumptions. In particular doctors seemed unaware of the relevance of patients' ideas about medicines for successful prescribing.
Conclusions
Patients' participation in the consultation and the adverse consequences of lack of participation are important. The authors are developing an educational intervention that builds on these findings.
PMCID: PMC27293  PMID: 10678863
17.  Electronic DTB, eBNF/eMeReC 
BMJ : British Medical Journal  1999;318(7183):610.
PMCID: PMC1115054  PMID: 10037665

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