BackgroundPeople with enduring mental illness (EMI) have higher morbidity and mortality from chronic diseases than the general population, and this results in a significantly reduced relative life expectancy—accounted for primarily by physical illness. This gap may be partly influenced by the reduced likelihood of access to and uptake of regular physical health screening.AimTo establish Irish service providers’ perspectives regarding the care of the physical health of people with EMI in an effort to inform future service developments aimed at improving the physical health of people with EMI.Design and settingQualitative study of healthcare providers—general practitioners (GPs) and members of the community mental health teams—in Ireland.ParticipantsGPs and mental health service providers.MethodsQualitative semi-structured interviews were conducted with 34 service providers. Thematic analysis was undertaken.ResultsParticipants considered that the physical health of people with EMI is not currently regularly addressed by the patient’s GP or the mental health team. Factors associated with this include patient compliance with attendance, time constraints in consultations to adequately support patient self-management, communication difficulties with the patient and between primary and secondary care, and lack of clarity as to whose responsibility it is to ensure physical health is monitored. In participants’ view, a barrier to improvement is the present funding approach.ConclusionThe evidence from this study has the potential to form the basis for innovation and change in service delivery for people with an EMI in Ireland and internationally, specifically in countries where it is not clear who has the overall responsibility to monitor the physical health of patients with EMI. This role requires time and regular contact, and both the organisation and the funding of the health system need to support it.
Introduction The SPPiRE cluster randomized controlled trial found that a general practitioner (GP)‐delivered medication review that incorporated screening for potentially inappropriate prescriptions (PIP), a brown bag review and a patient priority assessment, resulted in a significant but small reduction in the number of medicines and no significant reduction in PIP. This process evaluation aims to explore the experiences of GPs and patients and the potential for system‐wide implementation. Methods The trial included 51 general practices and 404 participants with multimorbidity aged ≥65 years, prescribed ≥15 medicines. The process evaluation used mixed methods and ran parallel to the trial. Quantitative data was collected from the SPPiRE intervention website and analysed descriptively. Qualitative data on medication changes were collected from intervention GPs (18/26) and a purposive sample of intervention patients (27/208) via semi‐structured telephone interviews. All interviews were transcribed verbatim and analysed using a thematic analysis. Qualitative and quantitative data were integrated using a triangulation protocol. Results The analysis generated two themes, intervention implementation and mechanisms of action, and both were underpinned by the theme of context. Intervention delivery varied among practices and 45 patients (28%) had no review, primarily due to insufficient GP time. 80% of reviewed patients had ≥1 PIP identified, 59% had ≥1 problem identified during the brown bag review and 79% had ≥1 priority recorded. The brown bag review resulted in the most deprescription of medications. GPs and patients responded positively to the intervention but most GPs did not engage with the patient priority‐setting process. GPs identified a lack of integration into practice software and resources as barriers to future implementation. Conclusion The SPPiRE intervention had a small effect in reducing the number of medicines and this was primarily mediated through the brown bag review. The context of resource shortages and deep‐seated views around medical decision‐making influenced intervention implementation. Patient or Public Contribution Qualitative data on the implementation of the medication review and their wider views on their medicines was collected from older people with multimorbidity through semi‐structured telephone interviews. Clinical Trial Registration The SPPiRE trial was registered prospectively on the ISRCTN registry (ISRCTN12752680).
BackgroundThe pharmaceutical industry invests heavily in promoting medications to physicians. This promotion may influence physicians’ prescribing behaviour and lead to inappropriately increased prescribing rates.AimTo understand GPs’ experience of interacting with the pharmaceutical industry, and explore their views and perceptions of the impact of this interaction in general practice in Ireland.Design & settingA qualitative design was used, and GPs practicing in Ireland were eligible.MethodA combination of purposive and snowball sampling techniques was applied and semi-structured interviews were conducted. Thematic analysis was used to develop themes from the data.ResultsTwenty-one GPs and one GP trainee participated. Five themes were developed: GP and pharmaceutical industry interface, the industry’s methods of influence, the uncomfortable relationship between GPs and industry, GPs’ perceptions of being unconsciously influenced, and GPs’ lack of knowledge of relevant regulations. Participants interacted with pharmaceutical representatives in their surgery and through continuing professional development (CPD). Reported methods of influence included biassed information and the offer of gifts. Most participants felt their prescribing was unconsciously influenced. A minority felt that they were only influenced in a way that improved their prescribing.ConclusionThe study shows that there can be a lack of clarity among GPs about relevant regulations and about the potential impact of interactions with the pharmaceutical industry on prescribing. Education of trainees and GPs has the potential to address this. Restrictions on interactions with the pharmaceutical industry may also play a role, although alternative CPD funding sources would need to be established.
Background Older patients with multimorbidity are under-represented in experimental research. Objective To explore the barriers and facilitators to general practitioner (GP) and older patient recruitment and retention in a cluster randomized controlled trial (RCT). Method This descriptive study uses qualitative and quantitative data from a cluster RCT, designed to evaluate the effectiveness of a medicines optimization intervention. The SPPiRE cluster RCT enrolled 51 general practices and 404 patients aged ≥65 years and prescribed ≥15 medicines. Quantitative data were collected from all recruited practices and 32 additional practices who were enrolled, but unable to recruit sufficient participants. Qualitative data were collected from purposive samples of intervention GPs (18/26), patients (27/208), and researcher logs and analysed thematically using inductive coding. Results Enrolment rates for practices and patients were 37% and 25%, respectively. Barriers to GP recruitment were lack of resources and to patient recruitment were difficulty understanding trial material and concern about medicines being taken away. GPs’ primary motivation was perceived importance of the research question, whereas patients’ primary motivation was trust in their GP. All general practices were retained. Thirty-five patients (8.6%) were lost to follow-up for primary outcomes, mainly because they had died and 45% did not return patient-reported outcome measures (PROMs). Conclusion Patient retention for the primary outcome was high, as it was collected directly from patient records. Patient completion of PROM data was poor, reflecting difficulty in understanding trial material. Recruiting older patients with multimorbidity to clinical trials is possible but requires significant resource and planning. Trial registration ISRCTN Registry ISRCTN12752680.
BackgroundA lack of manpower and negative health statistics have increased the workload for Irish GPs. Consequently, recent GP graduates are considering emigration or part-time employment.AimTo report on trends of the current status and future work intentions of recent GP graduates in Ireland.Design & settingQuantitative study based on online surveys in the Irish setting.MethodA ‘career intentions’ survey was emailed to all recent GP graduates in Ireland, in 2014, 2015, and 2017. The data presented includes GPs who graduated in the previous 4 years at each survey time point. The average response rate across the three surveys was 38.2%.ResultsThe number of graduates who had already emigrated increased over the survey years, accounted for 16.9% in 2014, 17.4% in 2015, and 19.2% in 2017 survey. The majority of doctors who emigrated did so in the first 2 years after graduation (74.7%). ‘Quality of life’ became the most frequent reason for emigration over the survey years, accounting for 32.0% in the 2017 survey. In the 2014 survey, 47.3% of graduates stated that they intend to work part-time in 5 years; this rose to 51.2% in 2015, reaching 60.0% in 2017. Female participants were more than twice as likely to plan to work part time in 5 years compared to their male colleagues, across all three surveys.ConclusionThe first and second years after graduation were the most critical for emigration. Interventions in this period may reduce the 'brain drain' of Irish GPs. Part-time working is becoming more attractive and should be considered in future workforce planning.
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