Background As prevalence of multimorbidity and polypharmacy rise, health care systems must respond to these challenges. Data is needed from general practice regarding the impact of age, number of chronic illnesses and medications on specific metrics of healthcare utilisation. Methods This was a retrospective study of general practices in a university-affiliated education and research network, consisting of 72 practices. Records from a random sample of 100 patients aged 50 years and over who attended each participating practice in the previous two years were analysed. Through manual record searching, data were collected on patient demographics, number of chronic illnesses and medications, numbers of attendances to the general practitioner (GP), practice nurse, home visits and referrals to a hospital doctor. Attendance and referral rates were expressed per person-years for each demographic variable and the ratio of attendance to referral rate was also calculated. Results Of the 72 practices invited to participate, 68 (94%) accepted, providing complete data on a total of 6603 patients’ records and 89,667 consultations with the GP or practice nurse; 50.1% of patients had been referred to hospital in the previous two years. The attendance rate to general practice was 4.94 per person per year and the referral rate to the hospital was 0.6 per person per year, giving a ratio of over eight attendances for every referral. Increasing age, number of chronic illnesses and number of medications were associated with increased attendance rates to the GP and practice nurse and home visits but did not significantly increase the ratio of attendance to referral rate. Discussion As age, morbidity and number of medications rise, so too do all types of consultations in general practice. However, the rate of referral remains relatively stable. General practice must be supported to provide person centred care to an ageing population with rising rates of multi-morbidity and polypharmacy.

BACKGROUND:Longitudinal integrated clerkships (LICs) are an innovation in medical education that are often successfully implemented in general practice contexts. The aim of this study was to explore the experiences and perspectives of general practitioner (GP)-tutors on the impact of LICs on their practices, patients and the wider community.METHODS:GPs affiliated with the University of Limerick School of Medicine- LIC were invited to participate in in-depth interviews. Semi-structured interviews were conducted in person and over the phone and were based on a topic guide. The guide and approach to analysis were informed by symbiosis in medical education as a conceptual lens. Data were recorded, transcribed and analysed using an inductive thematic approach.RESULTS:Twenty-two GPs participated. Two main themes were identified from interviews: 'roles and relationships' and 'patient-centred physicians'. Five subthemes were identified which were: 'GP-role model', 'community of learning', and 'mentorship', 'student doctors' and 'serving the community'.CONCLUSION:LICs have the potential to develop more patient-centred future doctors, who have a greater understanding of how medicine is practised in the community. The LIC model appears to have a positive impact on all stakeholders but their success hinges on having adequate support for GPs and resourcing for the practices.

BACKGROUND:Longitudinal integrated clerkships (LICs) are a relatively new model of clinical medical education, whereby students participate in patient care over time and develop relationships with those patients', their clinicians, and other health care staff involved in the care of those patients. It has been called 'relationship-based education' but, to date, no review has investigated the development and impact of these central relationships within this curricula model.AIMS:The aim of this study is to review the literature pertaining to relationships in LICs, specifically to understand how they come about and how they affect learning.METHODS:The search strategy systematically explored PubMed, ERIC (EBSCO) and Academic Search Complete, using key words and MESH terms. Original research published in peer-reviewed journals between January 2007 and August 2020 that were written in the English language were included in the review.RESULTS:After applying set inclusion and exclusion criteria, 43 studies were included in this review. A qualitative thematic analysis was undertaken, and results were synthesised narratively. Four distinct categories were identified: defining relationships in LICs, developing relationships in LICs, relationship maintenance and multi-stakeholder impact.CONCLUSIONS:The longitudinal integrated clerkship model of clinical education facilitates the development of meaningful triangular relationships between student, clinical teacher and patient, which are the central drivers of successful learning within the context of an LIC. These relationships are nested in a set of important supporting relationships involving other supervisors, the medical school and university, the practice clinical and administrative team and peers.

Abstract Background A lack of standardisation of documentation accompanying older people when transferring from residential to acute care is common and this may result in gaps in information and in care for older people. In Ireland, this lack of standardisation prompted the development of an evidence based national transfer document. Objectives To pilot a new national transfer document for use when transferring older people from residential to acute care and obtain the perceptions of its use from staff in residential and acute care settings. Methods This was a pre‐ and post‐study design using purposive sampling following the STROBE guidelines. The pilot was conducted in 26 sites providing residential care and three university hospitals providing acute care. Pre‐pilot questionnaires focused on current documentation and were distributed to staff in residential care (n = 875). A pilot of the new paper‐based transfer document was then conducted over three months and post‐pilot questionnaires distributed to staff from both residential and acute care settings (n = 1085). The findings of the pilot study were discussed with multidisciplinary expert advisory and stakeholder groups who recommended some revisions. This consensus informed the development of the final design of the new revised transfer document. Results Pre‐pilot: 23% response rate; 83% (n = 168) participants agreed/strongly agreed that existing documentation was straightforward to complete but could be more person‐centred. Post‐pilot: 11% response rate; 75% (n = 93) of participants agreed/strongly agreed that the new transfer document promoted person‐centred care but recommended revisions to the new document regarding layout and time to complete. Conclusions This study highlighted some of the challenges of providing safe, effective and relevant transfer information that is feasible and usable in everyday practice. Implications for practice Standardisation and being person‐centred are important determining factors in the provision of relevant up to date information on the resident being transferred.

Objective The objective of this study is to explore the experiences and perspectives of general practitioners’ and medical students’ use of, and behaviour on, social media and to understand how they negotiate threats to professional and personal life on social media. Design A two-phase qualitative design was used, consisting of semistructured interviews and follow-up vignettes, where participants were asked to respond to vignettes that involved varying degrees of unprofessional behaviour. Data were analysed using template analysis. Setting and participants Participants were general practitioner tutors and third year medical students who had just completed placement on the University of Limerick longitudinal integrated clerkship. Five students and three general practitioners affiliated with the medical school were invited to participate in one-to-one interviews. Results Three overarching themes, each containing subthemes were reported. ‘Staying in contact and up to date’ outlines how social media platforms provide useful resources and illustrates the potential risks of social media. ‘Online persona’ considers how social media has contributed to changing the nature of interpersonal relationships. ‘Towards standards and safety’ raises the matter of how to protect patients, doctors and the medical profession. Conclusion Guidance is required for students and medical practitioners on how to establish reasonable boundaries between their personal and professional presence on social media and in their private life so that poorly judged use of social media does not negatively affect career prospects and professional efficacy.

Background: To explore graduates' perceptions of significant factors affecting professional identity formation (PIF) throughout their graduate medical school education journey and early practice years.Methods: A qualitative study with medical graduates using non-probability sampling. Data collected with graduates via face to face and telephone interviews. Interviews (n = 9) completed with medical graduates of the School of Medicine, University of Limerick.Results: Graduates described their experiences in general practice, during the early patient contact programme and the longitudinal integrated clerkship (LIC) as highly influential. The lasting impact of positive role models was highlighted. The importance of socialisation and entering a community of practice were identified as drivers of professional development. Role modelling and mentorship between students and GP tutors were pivotal as part of early clinical years and clinical LIC. This seemed to have a positive influence on graduate's consideration of general practice as a future career pathway.Conclusion: Professional identity formation occurs for medical students who participate in early patient contact programmes and longitudinal integrated clerkships in GP. Factors such as positive role modelling, good mentorship, communities of practice and a positive learning environment appear to be the main contributors to this process. Experiences as part of longitudinal integrated clerkships are meaningful for graduates, regardless of postgraduate specialisation choices. Educators should acknowledge this when designing medical curricula to ensure that students' professional identity formation is optimally facilitated. Training should be available to support the educators involved in longitudinal integrated clerkships, as they become role models and mentors to students.

Background: In 2018, the Office of the Nursing and Midwifery Services Director (ONMSD) completed phase one of work which culminated in the development and launch of seven research reports with defined suites of quality care process metrics (QCP-Ms) and respective indicators for the practice areas – acute care, midwifery, children’s, public health nursing, older persons, mental health and intellectual disability nursing in Ireland. This paper presents a rapid realist review protocol that will systematically review the literature that examines QCP-Ms in practice; what worked, or did not work for whom, in what contexts, to what extent, how and why? Methods: The review will explore if there are benefits of using the QCP-Ms and what are the contexts in which these mechanisms are triggered. The essence of this rapid realist review is to ascertain how a change in context generates a particular mechanism that produces specific outcomes. A number of steps will occur including locating existing theories on implementation of quality care metrics, searching the evidence, selecting relevant documents, data extraction, validation of findings, synthesising and refining programme theory. This strategy may help to describe potential consequences resulting from changes in context and their interactions with mechanisms. Initial theories will be refined throughout the process by the local reference panel, comprised of eight key intervention stakeholders, knowledge users such as healthcare professionals and an expert panel. Ethical approval is not required for this rapid realist review. Conclusion: It is anticipated that the final programme theory will help to explain how QCP-Ms work in practice; for whom, why and in what circumstances. Findings of this review could help to give insights into the use of a rapid realist review as a framework and how nursing and midwifery QCP-Ms have been implemented previously.

Background: The ‘cycle of care’ (COC) pay for performance (PFP) programme, introduced in 2015, has resourced Irish GPs to provide structured care to PCRS eligible patients with type 2 diabetes mellitus (T2DM). Aim: To investigate the effect of COC on management processes. Design &setting: Cross-sectional observational study undertaken with two points of comparison (2014 and 2017) in participating practices (Republic of Ireland general practices), with comparator data from the United Kingdom National Diabetes Audit (UKNDA) 2015–2016. Method: Invitations to participate were sent to practices using a discussion forum for Health One clinical software. Participating practices provided data on the processes of care in the management of patients with T2DM. Data on PCRS eligible patients was extracted from the electronic medical record system of participating practices using secure customised software. Descriptive analysis, using IBM SPSS Statistics for Windows (version 25), was performed. Results: Of 250 practices invited, 41 practices participated (16.4%), yielding data from 3146 patients. There were substantial improvements in the rates of recording of glycosylated haemoglobin ([HbA1c] 53.1%–98.3%), total cholesterol ([TC] 59.2%–98.8%), urinary albumin:creatinine ratio ([ACR] 9.9%–42.3%), blood pressure ([BP] 61.4%–98.2%), and body-mass index ([BMI] 39.8%–97.4%) from 2014 to 2017. For the first time, rates of retinopathy screening (76.3%), foot review (64.9%), and influenza immunisation (69.9%) were recorded. Comparison of 2017 data with UKNDA 2015–2016 was broadly similar. Conclusion: The COC demonstrated much improved rates of recording of clinical and biochemical parameters, and improved achievement of targets in TC and BP, but not HbA1c. Results demonstrate substantial improvements in the processes and quality of care in the management of patients with T2DM.

Background Chronic obstructive pulmonary disease (COPD) is a leading cause of death and disability. Its diagnosis, classification and management are complex. There is a paucity of data on the standard of COPD management in Irish general practice. Aims We studied whether COPD diagnosis and management was in accordance with the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. We investigated if patients who were smokers had received smoking cessation advice. We examined whether influenza and pneumococcal vaccination had been given. Methods Ten general practices affiliated with the Irish Mid-West Specialist Training Programme in General Practice (GP) were searched, to determine which patients had a diagnosis of COPD. A data-collection audit tool was developed using GOLD 2019 guidelines. Results were tabulated in SPSS. Descriptive statistics were used. Results Of 482 patients studied, 91.7% were eligible for free GP care. In 49.4%, the diagnosis of COPD had been made appropriately. In 56.2%, there was no evidence that the stage of COPD had been formally assessed. Of the patients studied, 33.2% were deemed to be receiving appropriate therapy. Smoking status was documented in 99.6% of cases studied and 59.9% were ex-smokers, while 25.9% were current smokers. Appropriate smoking cessation advice had been offered to 71% of eligible patients. Influenza vaccine had been given to 66.2% in the previous 12 months. A total of 53.9% had ever received pneumococcal vaccination. Conclusions This study provides a comprehensive snapshot of care in Irish general practice for patients with COPD prior to introduction of the Chronic Disease Management programme (CDM).

Background A well-functioning general practice sector that has a strong research component is recognised as a key foundation of any modern health system. General practitioners (GPs) are more likely to collaborate in research if they are part of an established research network. The primary aims of this study are to describe Ireland’s newest general practice-based research network and to analyse the perspectives of the network’s members on research engagement. Method A survey was sent to all GPs participating in the network in order to document practice characteristics so that this research network’s profile could be compared to other national profiles of Irish general practice. In depth interviews were then conducted and analysed thematically to explore the experiences and views of a selection of these GPs on research engagement. Results All 134 GPs responded to the survey. Practices have similar characteristics to the national profile in terms of location, size, computerisation, type of premises and out of hours arrangements. Twenty-two GPs were interviewed and the resulting data was categorised into subthemes and four related overarching themes: GPs described catalysts for research in their practices, the need for coherence in how research is understood in this context, systems failures, whereby the current health system design is prohibitive of GP participation and aspirations for a better future. Conclusion This study has demonstrated that the research network under examination is representative of current trends in Irish general practice. It has elucidated a better understanding of factors that need to be addressed in order to encourage more GPs to engage in the research process.

BACKGROUNDTimely and accurate communication between primary and secondary care is essential for delivering high-quality patient care.OBJECTIVEThe aim of this study is to evaluate the content contained in both referral and response letters between primary and secondary care and measure this against the recommended national guidelines.METHODSUsing an observational design, senior medical students and their general practice supervisors applied practice management software to identify 100 randomly selected adults, aged greater than 50 years, from a generated list of consults over a 2-year period (2013-2015). All data included in referral and response letters for these adults were examined and compared with the gold standard templates that were informed by international guidelines.RESULTSData from 3293 referral letters and 2468 response letters from 68 general practices and 17 hospitals were analysed. The median time that had elapsed between a patient being referred and receiving a response letter was 4 weeks, ranging from 1 week for Emergency Department referral letters to 7 weeks for orthopaedic surgery referral letters. Referral letters included the reason for referral (98%), history of complaint (90%) and current medications (82%). Less commonly included were management prior to referral (65%) and medication allergies (57%). The majority of response letters included information on investigations (73%), results (70%) and follow-up plan (85%). Less commonly, response letters included medication changes (30%), medication lists (33%) and secondary diagnoses (13%).CONCLUSIONSFuture research should be aimed at developing robust strategies to addressing communication gaps reported in this study.

Abstract Background The transition of older persons between care settings is recognised as a particularly critical and vulnerable period (Renom-Guiteras et al. 2014). Appropriate documentation and processes are key in assisting the provision of quality, safe, person-centred care when transferring older persons from residential to acute care settings. This paper reports on the design phase of a national transfer document for older persons. The objective was to inform the development of a draft national transfer document. Methods Development consisted of two phases 1) an integrative review and 2) focus group interviews with stakeholders. The review was guided by Whittemore and Knafl‘s (2005) integrative review framework. Data from studies using both quantitative and qualitative methodologies were extracted and thematically analysed. Using a qualitative descriptive approach, focus group interviews (n=8) were conducted with a convenience sample of key stakeholders (n=68) to establish their perspectives regarding transfer documents. Data were analysed using content analysis. Results from both phases were integrated to guide the development of the draft document. A multidisciplinary panel of experts in older persons care, reviewed and provided feedback on the draft transfer document. Results Within the review, thirty identified papers focused on transfer documentation between residential and acute care. Results indicated that using a standardised document can potentiate the delivery and acceptance of relevant person-centred information between all parties when transferring an older person between residential and acute care settings. Qualitative interview findings highlighted important aspects for consideration regarding the layout, content and format of future transfer documentation. Following collaboration with the expert panel the transfer document was developed for piloting. Conclusion Consistency and clarity of information is key for a successful transfer of older persons from residential to acute settings. Information needs to be evidence-based, current, and subject to response and change in accordance with best available international practice.

BackgroundIn May 2018, abortion laws in Ireland were liberalised allowing medical abortion for the first time. It was envisaged that Irish GPs would provide this service.AimTo elicit the views and level of preparedness of Irish GPs to provide medical termination of pregnancy.MethodIn total 222 practising GPs were surveyed. Participants are affiliated with the Graduate Entry Medical School (GEMS) in the University of Limerick, as well as graduates of the University Specialist Training Programme in General Practice.ResultsThe response rate was 57% (127/222): 93.7% of GPs were willing to share abortion information with their patients; 48.0% would be willing to prescribe abortion pills before 12 weeks’ gestation, with 37.0% unwilling to do so. A further 40.9% of responders believed that such a service should not be part of general practice, with a further 17.3% indicating uncertainty. 72.4% believed that those who do not wish to be part of the process should be entitled to a conscientious objection (CO) but should also be obliged to refer a woman to a participating doctor. Over four-fifths (82.7%) of GPs had no training in this area of practice, with 3.2% indicating that they had sufficient training. The majority of responders feel that necessary support services such as counselling are not currently available.ConclusionExploring the views and experiences of GPs in Ireland on this topic reveals many issues which need to be resolved before the service can be rolled out in a safe manner. It will be vital for state and professional bodies to provide appropriate education and guidance.

Objectives The purpose of this study was to examine the expectations of patients attending an urban primary care out-of-hours (OOH) facility with acute upper respiratory tract infection (acute URTI) regarding clinical examination, symptom management, information on their condition, reassurance, antibiotic treatment and other possible options including referral. Design Cross-sectional design. Setting One urban primary care OOH facility located in the midwest of Ireland. Participants 457 patients filled out a questionnaire while waiting in the OOH facility; 22 surveys were excluded as the patients did not present with symptoms of acute URTI resulting in 435 patients' data being included in this study. There were 59.5% female participants and 40.5% male participants. Results 435 patients with acute URTI symptoms participated in the survey, representing 25.4% of those attending the single branch where the survey was conducted (n=1715). Of the study participants, 43% were aged under 6 years and 60% were women. The most common presenting symptoms were cough (72%), throat ache (46%) and common cold (26%). The most common expectations were for further examination (53%), reassurance (51%), information (49%) and medication for cough (47%), with 34% expecting an antibiotic. Conclusions Only one in three patients attending this primary care OOH facility with acute URTI symptoms had an expectation of antibiotics, with most seeking further assessment, information and reassurance. Recognition of such expectations may be important considerations for clinicians when deciding on management options for patients with acute URTI.

Background In May 2018, the Irish Constitution was changed following a referendum allowing termination of pregnancy by abortion. It is envisaged that the majority of terminations will be by medical abortion and will take place in general practice before 12 weeks gestation. Aim To elicit attitudes and level of preparedness of Irish GPs to provide medical abortion services. Design & setting Cross-sectional study of 222 GPs who were associated with the University of Limerick Graduate Entry Medical School (GEMS) and GP training programme. Method An anonymous online questionnaire was distributed via email. Reminders were sent 2 and 4 weeks later. Results The response rate was 57.2% ( n = 127/222). Of the responders, 105 (82.7%) had no training in this area, with only 4 (3.1%) indicating that they had sufficient training. Nearly all responders ( n = 119, 93.7%) were willing to share abortion information with patients. Just under half of responders ( n = 61, 48.0%) would be willing to prescribe abortion pills, with 47 (37.0%) unwilling to do so. Only 53 (41.7%) responders believed that provision of abortion services should be part of general practice, with 52 (40.9%) saying that it should not. As to whether doctors should be entitled to a conscientious objection but should also be obliged to refer the patient, 92 (72.4%) responders agreed. Over two-thirds of responders ( n = 89, 70.1%) felt that necessary patient support services are not currently available. Conclusion There is a lack of training and a considerable level of unwillingness to participate in this process among Irish GPs. There is also a perceived lack of patient support services for women experiencing unwanted pregnancy. It is incumbent upon state and professional bodies to address these issues.

Anti-microbial resistance (AMR) is a global threat to public health and antibiotics are often unnecessarily prescribed for acute respiratory tract infections (ARTIs) in general practice. We aimed to investigate why general practitioners (GPs) continue to prescribe antibiotics for ARTIs despite increasing knowledge of their poor efficacy and worsening antimicrobial resistance.

BackgroundDiabetes is a major cause of death and disability worldwide and is associated with vascular complications, which are reduced by control of risk factors. The introduction of the diabetes ‘cycle of care’ pay-for-performance programme in Ireland in January 2016 means that GPs have been resourced to provide structured care to patients with type 2 disease.AimTo examine the effectiveness of the ‘cycle of care’ programme.MethodA computerised search was developed for diabetes data. Forty-one practices returned data for a 12-month period before (2014) and after (2017) the introduction of the ‘cycle of care’. International guidelines informed the analysis.ResultsIn total, 3189 patients were examined from 41 practices for the years 2014 and 2017. Nine practices were located in an urban setting (22%), 16 rural (39%), and 16 in a mixed location (39%); 1781 males (55.8%) and 1408 females (44.2%). In 2017, the mean age of participants was 68.5 years (standard deviation [SD] = 12.3) and 2277 (71.4%) patients had clinical data provided for both 2017 and 2014, 875 (27.4%) for 2017 only, 5 (0.2%) for 2014 only, and 32 (1.0%) for neither year. Substantial improvements in rates of recording and in levels of missing data were shown for HbA1c, lipids, renal function, blood pressure, and body mass index. Rates of foot review, retinopathy screening, treatment review, influenza immunisation, and patient education were recorded for the first time in 2017.ConclusionThe ‘cycle of care’ programme has resulted in substantial improvements in type 2 diabetes care in Ireland, supporting pay for performance.

Increasing pressure on limited healthcare resources has necessitated the development of measures promoting early discharge and avoiding inappropriate hospital (re)admission. This systematic review examines the evidence for interventions in acute hospitals including (i) hospital-patient discharge to home, community services or other settings, (ii) hospital discharge to another care setting, and (iii) reduction or prevention of inappropriate hospital (re)admissions. Academic electronic databases were searched from 2005 to 2018. In total, ninety-four eligible papers were included. Interventions were categorized into: (1) pre-discharge exclusively delivered in the acute care hospital, (2) pre- and post-discharge delivered by acute care hospital, (3) post-discharge delivered at home and (4) delivered only in a post-acute facility. Mixed results were found regarding the effectiveness of many types of interventions. Interventions exclusively delivered in the acute hospital pre-discharge and those involving education were most common but their effectiveness was limited in avoiding (re)admission. Successful pre- and post-discharge interventions focused on multidisciplinary approaches. Post-discharge interventions exclusively delivered at home reduced hospital stay and contributed to patient satisfaction. Existing systematic reviews on tele-health and long-term care interventions suggest insufficient evidence for admission avoidance. The most effective interventions to avoid inappropriate re-admission to hospital and promote early discharge included integrated systems between hospital and the community care, multidisciplinary service provision, individualization of services, discharge planning initiated in hospital and specialist follow-up.

The effective management of care for older people across all sectors of healthcare is a key issue for health care policy and practice. Transitions of older adults with multiple chronic conditions are particularly vulnerable and frequently characterised by breakdowns in communication both within and between services that can lead to poorer outcomes for the older person. The provision of quality care to older adults is dependent upon clear concise and contemporary communication. However, international research suggests that documentation and handover deficiencies between age care facilities and acute services are common and in some cases absent. A variety of nursing transfer documents exist and there is a lack of consensus regarding the information considered essential for inclusion in transfer documentation. Standardised tools have demonstrated improvements in the quality of communication from aged care facilities and the acute hospital. The National Clinical Programme for Older People in Ireland, supported by Office of Nursing and Midwifery Services Director in recognition of the importance of improving communication between residential and acute care facilities, commissioned this research. To develop an evidence based and person centred national transfer document for use when an older person is being transferred from residential to acute care settings. Stages of development included: an integrated review of international literature, a stakeholder focus group study, a consultative process with an expert advisory group and an expert in person centred care. A pilot of the transfer document was then conducted, in twenty-eight residential and three acute care sites, across three geographical locations over a three-month period. Staff surveys were conducted, to ascertain their perceptions on the usability, layout and design of the document. Results: There was general agreement in the literature, the focus group study and pilot study that a standardised transfer document was required for safe and effective transfer of older people from residential to acute care and a need for a holistic, person-centred approach to this documentation. Results of the pilot were used to inform revisions to the design and layout of the national transfer document i.e. to divide the piloted document into two parts (Transfer Document and Health Profile/Passport) retaining the evidence based content and the person centred perspective. A consultation/focus group discussion with participants in the pilot study was then convened to reach consensus on the final design and layout.