One of the key objectives of MPHC is to carry out continuous audit and research on the processes and protocols utilised in the general practices and the centre as a whole. This is done with the aim of improving patient care and patient outcomes. We decided that the study of compliance with both medicines and medical processes was the most important element in improving patient care and have dedicated our longitudinal research to this. Our aim is to build up our knowledge of the reasons for poor compliance so that we can make improvements to the care of the patient. We feel that Primary Care is the correct environment to do this research based on our close relationship with the patients over their lifetime and this is proving to be the case. That is why we have provided the READ (research, education, audit and development) centre.
Over the last 12 months there has been significant research conducted at MPHC, which has examined compliance and non-compliance among patients. The overall findings will lead to exciting and innovative research over the coming years at MPHC, which will bring improvements in patient care, and greater compliance. Our long term goal is to be a leader in compliance education and interventions, and this will require ongoing investment to reach our goal. We wish to acknowledge the support we have received from Lundbeck Ireland Ltd in our research endeavours.
Listed below are short descriptions of completed projects which focused on compliance and are the baseline from which MPHC will become a leader in compliance education and interventions for patients.
Reasons For Encounter
Published 23rd November 2015 – Irish Journal of Medical Science
70,489 primary care encounters: retrospective analysis of morbidity at a primary care centre in Ireland.
Molony D1,2,3, Beame C4, Behan W5,6, Crowley J7, Dennehy T7, Quinlan M7, Cullen W5
- 1Mallow Primary HealthCare Centre, Mallow, Co. Cork, Ireland. firstname.lastname@example.org.
- 2Graduate-Entry Medical School, University of Limerick, Limerick, Ireland. email@example.com.
- 3HSE Southwest Specialist Training Programme in General Practice, Tralee, Co Kerry, Ireland. firstname.lastname@example.org.
- 4‘CompleteGP’, Mallow, Co. Cork, Ireland.
- 5UCD School of Medicine, Health Sciences Building, Belfield, Dublin 4, Ireland.
- 6Walkinstown Primary Care Centre, Dublin 12, Ireland.
- 7HSE Southwest Specialist Training Programme in General Practice, Tralee, Co Kerry, Ireland.
While considerable changes are happening in primary care in Ireland and considerable potential exists in intelligence derived from practice-based data to inform these changes, relatively few large-scale general morbidity surveys have been published.
To examine the most common reasons why people attend primary care, specifically ‘reasons for encounter’ (RFEs) among the general practice population and among specific demographic groups (i.e., young children and older adults).
We retrospectively examined clinical encounters (which had a diagnostic code) over a 4-year time period. Descriptive analyses were conducted on anonymised data.
70,489 RFEs consultations were recorded (mean 13.53 recorded RFEs per person per annum) and consultations involving multiple RFEs were common. RFE categories for which codes were most commonly recorded were: ‘general/unspecified’ (31.6 %), ‘respiratory’ (15.4 %) and ‘musculoskeletal’ (12.6 %). Most commonly recorded codes were: ‘medication renewal’ (6.8 %), ‘cough’ (6.6 %), and ‘health maintenance/prevention’ (5.8 %). There was considerable variation in the number of RFEs recorded per age group. 6239 RFEs (8.9 %) were recorded by children under 6 years and 15,295 RFEs (21.7 %) were recorded by adults aged over 70. RFEs recorded per calendar month increased consistently through the study period and there was a marked seasonal and temporal variation in the number of RFEs recorded.
Practice databases can generate intelligence on morbidity and health service utilisation in the community. Future research to optimise diagnostic coding at a practice level and to promote this activity in a more representative sample of practices is a priority.
WONCA the international GP conference was held in Prague this year from June 25th to 29th bringing together GPs from all over the world. The topics covered were numerous and included Primary Care Policy, Financing, Practice Organisation, Consultation Skills, Research in General Practice, Quality of Care, Integrated Care to name but a few. There were also sessions on clinical management including Prevention and Screening, Respiratory Problems, Mental Health, Vaccination and many more. Prior to the conference there was a call for posters and MPHC submitted 6 of the posters we had exhibited at the National Primary Care Conference in MPHC in November 2012.
1. Management of Iron Deficency Anaemia in Primary Care – Dr. Lisa Horgan
2. Audit of a dedicated Warfarin Clinic in Primary Care – Dr. David Molony
3. Reasons for Encounter in Primary Care – Dr. David Molony and Carl Beame
4. Group based psychoeducational training for family caregivers of people with dementia -Sheena Cadoo, Dr Rosarie Crowley and Amy Murphy of The Alheimers Society
5. Communication between Primary and Secondary Care – Dr. Audrey Russell
6. The last poster on the EARLI Study was accepted as an oral presentation which was ably delivered by Dr Michael O’Grady.
The 6 posters were presented at the conference and we are delighted that 2 were awarded best posters ‘ Reasons for Encounter in Primary Care – Dr. David Molony’ and ‘Group based psychoeducational training for family caregivers of people with dementia – Sheena Cadoo and Rosarie Crowley of the HSE. This is even more significant in that only 6 posters are selected for awards every 3 years. Well done to Dr David Molony, Dr Audrey Russell, Carl Beame, Sheena Cadoo and Rosarie Crowley. Last year there was only 1 poster from Ireland and we are delighted that MPHC had 6 this year and even more delighted to have won two prizes recognising the quality and quantity of research we do in MPHC.
Photo Dr David Molony with the award for Best Poster at WONCA 2013
EARLI (Emergency Admission Risk Likelihood Index) Research
The EARLI research project is a postal survey of all over 70 patients in MPHC. There were over 1300 letters sent out to patients, and we had over 80% response rate. Of those returned, 76 were deemed to be at risk and very high risk of emergency hospitalization. Overall the results show, there was a 30% (22 total less admissions) reduction in the emergency hospital admissions for the 76 patients identified, with 50% reduction in the Very High Risk Category (8 less admissions) , and 10% reduction in High Risk category (13 less admissions).
In Ireland there are 400,000 persons over the age of 70. An estimated 40,000 (10%) are in the Very High and High Risk of emergency hospitalisation, if the EARLI study was implemented throughout Ireland, it is possible to achieve significant savings annually.
Stockpiling and Compliance Research
Findings showed that patients with large volumes of prescriptions were compliant with their medication, with the exception of anti-depressants. However, patients were not fully aware of what medications were for, did not dispose of the medicines properly, took medicines while out of date, and some shared their prescribed medication with others.
Compliance and Adherence Literature Review Completed
A full and comprehensive literature review was carried out . The review examined research published in the last 10 years and with a minimum 6 months follow-up, it included randomized control trials (RCTs), systematic reviews and/or meta-analyses of RCTs interventions of any sort intended to affect patient adherence, studies that include objective measurements.
Compliance and Adherence Intervention Review Completed
A full and systematic review of possible interventions to increase compliance was completed.
One Small Change: Family Intervention Programme and Diabetes Type 2 and Impaired Glucose Tolerance
One Small Change, proved to be big success for 10 families, who are patients and have evidence of generational diabetes and/or high BMI’s and/or pre-diabetes. Over six months, educational and family friendly evenings were held at MPHC. Those in attendance have reported weight loss and major changes in diet and lifestyle.
Patient Expectations of GP consultations
A survey of patients was conducted prior to consultation with their GP at MPHC. The most significant findings showed that with over 80% of patients surveyed (regardless of medical issue) expected a prescription.
Therapeutic Recall of Patients in General Practice
Aim of this study was to examine the understanding that patients in general practice have about their repeat and non repeat prescriptions and to identify areas of poor doctor patient information transfer. This information is crucial to improving compliance as poor understanding of taking medication is a major factor in patients not their medications. It reinforced the educational role of the General Practitioner when prescribing.
An Audit of Compliance in Patients on Methotrexate/Lithium
This is an audit of compliance with practice guidelines on blood test monitoring in patients on long-term Lithium & Methotrexate. This study raised the issue of shared care between primary care and secondary care and who was responsible for the patients.
Ongoing protocol guideline adherence by medical staff is the issue here and relates to many medicines and health processes.
An Audit of Daily Workload and Clinical Tasks performed in General Practice
This study assessed the workload of the practice nurses in the 3 practices in MPHC using a questionnaire. The study showed that nurses demonstrated a wide variety and array of clinical skills and play a significant role in patient care. Their role was also very important in the education of patients and their involvement improved patient understanding and compliance.
Audit of Vitamin D Prescription for 6 Week Old Infants
The aim of this study was to discover if infants consume Vitamin D supplements in accordance with the HSE guidelines of 2010 and also to determine if GPs and nurses are aware of the guidelines. The results showed that the awareness was low and advice given was not recorded.
An Audit of Structured Diabetic Care in a General Practice Setting
This study looked at the provision of care for diabetic patients in line the ICGP and The Cork Diabetes Interest Group, DIG, guidelines and found that the practice was complying with same. This then is the baseline criteria for future research.
A Review of Anti Platelet Therapy in MPHC
The aim of this study was to investigate the use of anti platelet therapy and showed the need to manage and review and audit all clinical guidelines and their relevance and adherence.
Compliance Study: Improving compliance through the use of text message reminders, education and GP consultation
Through systematic reviews of compliance literature and compliance intervention literature it was decided to review the compliance study using text messages. We now have a detailed understanding of why patients are both compliant and non-compliant, and more importantly we have a greater understanding of the types of interventions needed to improve compliance. The use of text alert services, especially as reminders for appointments has proved to be a successful in a number of projects. In the case of the taking of medications and improvement of compliance, there are encouraging signs of progress.
Parental Attitudes to children with Asthma
This is 12 month interview based research into the attitudes of parent to their children who have been diagnosed with asthma. In part this research will examine the attitudes to their children’s health in light of this diagnosis, and question if parents feel that their children are more at risk to infection, and ‘weaker’ than non-asthmatic children. A central theme in this research will be compliance with prescribed medication for asthma.
An open label true to life randomized controlled trial for Cough as a trick measure to reduce pain for skin puncture during intra-articular knee joint injection – Dr J Rathi
Intra-articular knee injections are carried out routinely in primary care for alleviation of symptoms associated with flares of OA. We hypothesized that use of the cough trick at the moment of injection would result in reduction in patient perceived pain, compared with injections received without use of the cough trick.
In conclusion, our study demonstrated that the Cough Trick implemented during Intra-articular knee steroid injections has proven to be statistically significant in reducing pain associated with the procedure. Further studies are needed to replicate this study with a bigger sample size in a randomized controlled trial setting.