Opportunistic atrial fibrillation screening in primary care in Ireland: results of a pilot screening programme.

BACKGROUND: Atrial fibrillation (AF), a common, frequently asymptomatic cardiac arrhythmia, is a major risk factor for stroke. Identification of AF enables effective preventive treatment to be offered, potentially reducing stroke risk by up to two-thirds. There is international consensus that opportunistic AF screening is valuable though uncertainty remains about the optimum screening location and method. Primary care has been identified as a potential location for AF screening using one-lead ECG devices. METHODS: A pilot AF screening programme is in primary care in the south of Ireland. General practitioners (GPs) were recruited from Cork and Kerry. GPs invited patients ≥65 years to undergo AF screening. The screening comprised a one-lead ECG device, Kardia Mobile, blood pressure check and ascertainment of smoking status. Possible AF on one-lead ECG was confirmed with a 12-lead ECG. GPs also recorded information including medical history, current medication and onward referral. The Keele Decision Support tool was used to assess patients for oral anticoagulation (OAC). RESULTS: 3555 eligible patients, attending 52 GPs across 34 GP practices, agreed to undergo screening. 1720 (48%) were female, 1780 (50%) were hypertensive and 285 (8%) were current smokers. On the one-lead ECG, 3282 (92%) were in normal sinus rhythm, 101 (3%) had possible AF and among 124 (4%) the one-lead ECG was unreadable or unclassified. Of the 101 patients with possible AF, 45 (45%) had AF confirmed with 12-lead ECG, an incidence rate of AF of 1.3%. Among the 45 confirmed AF cases, 27 (60%) were commenced on OAC therapy by their GP. CONCLUSION: These findings suggest that AF screening in primary care may prove useful for early detection of AF cases that can be assessed for treatment. One-lead ECG devices may be useful in the detection of paroxysmal AF in this population and setting. Current OAC of AF may be suboptimal.

Use of telemedicine in general practice in Europe since the COVID-19 pandemic: A scoping review of patient and practitioner perspectives.

General practice is generally the first point of contact for patients presenting with COVID-19. Since the start of the COVID-19 pandemic general practitioners (GPs) across Europe have had to adopt to using telemedicine consultations in order to minimise the number of social contacts made. GPs had to balance two needs: preventing the spread of COVID-19, while providing their patients with regular care for other health issues. The aim of this study was to conduct a scoping review of the literature examining the use of telemedicine for delivering routine general practice care since the start of the pandemic from the perspectives of patients and practitioners. The six-stage framework developed by Arksey and O'Malley, with recommendations by Levac et al was used to review the existing literature. The study selection process was conducted according to the PRISMA Extension for Scoping Reviews guidelines. Braun and Clarke's' Thematic Analysis' approach was used to interpret data. A total of eighteen studies across nine countries were included in the review. Thirteen studies explored the practitioner perspective of the use of telemedicine in general practice since the COVID-19 pandemic, while five studies looked at the patient perspective. The types of studies included were: qualitative studies, literature reviews, a systematic review, observational studies, quantitative studies, Critical incident technique study, and surveys employing both closed and open styled questions. Key themes identified related to the patient/ practitioner experience and knowledge of using telemedicine, patient/ practitioner levels of satisfaction, GP collaboration, nature of workload, and suitability of consultations for telemedicine. The nature of general practice was radically changed during the COVID-19 pandemic. Certain patient groups and areas of clinical and administrative work were identified as having performed well, if not better, by using telemedicine. Our findings suggest a level of acceptability and satisfaction of telemedicine by GPs and patients during the pandemic; however, further research is warranted in this area.

Irish general practitioner (GP) perspectives on impact of direct access radiology on patient care in the community: results from a mixed-methods study.

BACKGROUND: Since winter 2020/21, general practitioners (GPs) in the Republic of Ireland (RoI) have been granted access to diagnostic imaging studies on a new publicly funded pathway, expediting access to services previously obtained via hospital-based doctors. AIMS: Outline GP perspectives on imaging studies obtained via the new "GP Access to Community Diagnostics" initiative. METHODS: A mixed-methods design was employed. Referrals over the first six months of 2019 and 2021 were collated by a private imaging provider, and a randomly selected subset of 2021 studies (maximum 30 referrals per GP) was returned to participating GPs to provide detail on the impact on each patient's care. In-depth qualitative interviews were also conducted with participating GPs. RESULTS: Eleven GPs supplied detailed information on 81 studies organized through the new initiative. GPs reported that the initiative had led to a large proportion of cases being managed solely in general practice, with an 81% reduction in referrals to acute hospital settings and a 58% reduction in referrals to secondary care clinics. GPs felt imaging studies improved patient care in 86% of cases and increased GP workload in 58% of cases. GP qualitative interviews revealed four key themes: improved patient care, increased GP workload, reduction in hospital referrals, and opinions on ongoing management of such initiatives, including guidelines. CONCLUSIONS: GPs felt enhancing access to diagnostics improved patient care by expediting diagnosis, decision-making, and treatment and by reducing hospital referrals. GPs were generally positive about the initiative and made some suggestions on future management of the initiative.

Impact of enhancing GP access to diagnostic imaging: A scoping review.

BACKGROUND: Direct access to diagnostic imaging in General Practice provides an avenue to reduce referrals to hospital-based specialities and emergency departments, and to ensure timely diagnosis. Enhanced GP access to radiology imaging could potentially reduce hospital referrals, hospital admissions, enhance patient care, and improve disease outcomes. This scoping review aims to demonstrate the value of direct access to diagnostic imaging in General Practice and how it has impacted on healthcare delivery and patient care. METHODS: A search was conducted of 'PubMed', 'Cochrane Library', 'Embase' and 'Google Scholar' for papers published between 2012-2022 using Arksey and O'Malley's scoping review framework. The search process was guided by the PRISMA extension for Scoping Reviews checklist (PRISMA-ScR). RESULTS: Twenty-three papers were included. The studies spanned numerous geographical locations (most commonly UK, Denmark, and Netherlands), encompassing several study designs (most commonly cohort studies, randomised controlled trials and observational studies), and a range of populations and sample sizes. Key outcomes reported included the level of access to imaging serves, the feasibility and cost effectiveness of direct access interventions, GP and patient satisfaction with direct access initiatives, and intervention related scan waiting times and referral process. CONCLUSION: Direct access to imaging for GPs can have many benefits for healthcare service delivery, patient care, and the wider healthcare ecosystem. GP focused direct access initiatives should therefore be considered as a desirable and viable health policy directive. Further research is needed to more closely examine the impacts that access to imaging studies have on health system operations, especially those in General Practice. Research examining the impacts of access to multiple imaging modalities is also warranted.

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.

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.

The Limerick Declaration on Rural Health Care 2022.

The 19th World Rural Health Conference, hosted in rural Ireland and the University of Limerick, with over 650 participants coming from 40 countries and an additional 1600 engaging online, has carefully considered how best rural communities can be empowered to improve their own health and the health of those around them. The conference also considered the role of national health systems and all stakeholders, in keeping with the commitments made through the Sustainable Development Goals and the enjoyment of the highest attainable standard of health as one of the fundamental rights of every human being. This conference declaration, the Limerick Declaration on Rural Healthcare, is designed to inform rural communities, academics and policymakers about how to achieve the goal of delivering high quality health care in rural and remote areas most effectively, with a particular focus on the Irish healthcare system. Congruent with current evidence and best international practice, the participants of the conference endorsed a series of recommendations for the creation of high quality, sustainable and cost-effective healthcare delivery for rural communities in Ireland and globally. The recommendations focused on four major themes: rural healthcare needs and delivery, rural workforce, advocacy and policy, and research for rural health care. Equal access to health care is a crucial marker of democracy. Hence, we call on all governments, policymakers, academic institutions and communities globally to commit to providing their rural dwellers with equitable access to health care that is properly resourced and fundamentally patient-centred in its design.

COVID-19 community assessment hubs in Ireland: A study of staff and patient perceptions of their value.

BACKGROUND: Critical care bed capacity per capita in Ireland is among the lowest in Europe. The COVID-19 pandemic has put additional strain on an over-stretched healthcare system. COVID-19 community assessment hubs (CAHs) were established to prevent unnecessary admission to acute hospitals and to reduce infection spread. OBJECTIVE: The aim of this study was to assess the effectiveness and acceptability of CAHs and identify how the service might be improved or adapted for possible future use. DESIGN: This was a mixed methods study, incorporating co-design with clinical stakeholders. Data collection was via an online survey and semistructured telephone interviews with staff and patients conducted between January and May 2021. SETTING AND PARTICIPANTS: Thirty-one patients completed the survey and nine were interviewed. Twenty interviews were conducted with staff. RESULTS: The findings suggest that the CAH model was successful in providing a dedicated pathway for assessing patients with COVID-19 symptoms, whilst mitigating the risk of infection. Patients were particularly positive about the timely, comprehensive and holistic care they received, as well as the accessibility of the clinics and the friendly attitudes of the staff. Staff welcomed the training and clinical protocols which contributed to their feelings of safety and competency in delivering care to this cohort of patients. They also highlighted the benefits of working in a multidisciplinary environment. Both staff and patients felt that the hubs could be repurposed for alternative use, including the treatment of chronic diseases. DISCUSSION: This study describes staff and patients' experiences of these hubs. An unexpected outcome of this study is its demonstration of the true value of effective multidisciplinary working, not only for the staff who were deployed to this service but also for the patients in receipt of care in these hubs. CONCLUSION: This multidisciplinary patient-centred service may provide a useful model for the delivery of other services currently delivered in hospital settings. PATIENT OR PUBLIC CONTRIBUTION: An earlier phase of this study involved interviews with COVID-19-positive patients on a remote monitoring programme. The data informed this phase. Several of the authors had worked in the CAHs and provided valuable input into the design of the staff and patient interviews.

Enhancing the management of long COVID in general practice: a scoping review.

BACKGROUND: Long COVID is a multifaceted condition, and it has impacted a considerable proportion of those with acute COVID-19. Affected patients often have complex care needs requiring holistic and multidisciplinary care, the kind routinely provided in general practice. However, there is limited evidence regarding GP interventions. AIM: This study aimed to identify key concepts and knowledge gaps around long COVID by conducting a scoping review of literature on the condition's management by GPs. DESIGN & SETTING: Arksey and O'Malley's six-stage scoping review framework, with recommendations by Levac et al, was used. METHOD: PubMed, Google Scholar, the Cochrane Library, Scopus, and Google searches were conducted to identify relevant peer reviewed and grey literature, and study selection process was conducted according to the PRISMA Extension for Scoping Reviews guidelines. Braun and Clarke's 'Thematic Analysis' approach was used to interpret data. RESULTS: Nineteen of 972 identified articles were selected for review. These included peer reviewed articles and grey literature spanning a wide range of countries. Six themes were identified regarding GP management of long COVID, these being: (1) GP uncertainty, (2) listening and empathy, (3) assessment and monitoring of symptoms, (4) coordinating access to appropriate services, (5) facilitating provision of continual and integrated multidisciplinary care and (6) need to provide or facilitate psychological support. CONCLUSION: The findings show that GPs can play and have played a key role in the management of long COVID, and that patient care can be improved through better understanding of patient experiences, standardised approaches for symptom identification and treatment, and facilitation of access to multidisciplinary specialist services when needed. Future research evaluating focused GP interventions is needed.

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.

GPs' practice and attitudes to initiating isotretinoin for acne vulgaris in Ireland: a cross-sectional questionnaire survey in primary care.

BACKGROUND: Isotretinoin is prescribed in secondary care for severe acne vulgaris. Anecdotal reports suggest that GPs in Ireland currently initiate isotretinoin. AIM: To ascertain the prevalence and management of isotretinoin in Irish general practice and to describe GPs' attitudes about the use of isotretinoin in Ireland. DESIGN AND SETTING: A cross-sectional questionnaire survey of GPs in Ireland between October 2018 and February 2019. METHOD: Two short questionnaires were developed: one for GPs who prescribe isotretinoin and one for GPs who do not prescribe isotretinoin. Questionnaires were distributed via email and online via GP Forum to GPs in Ireland. RESULTS: Of a total 298 GPs who completed the questionnaire, 52 (17%) initiated isotretinoin. Older GPs (aged 35 years) and male GPs were more likely to prescribe isotretinoin. GPs cited prolonged dermatology waiting lists (n = 34, 65%) and a special interest in dermatology (n = 31, 60%) as two key drivers to initiating isotretinoin. However, this study found evidence of suboptimal blood monitoring, pregnancy testing, and contraceptive advice. Most GPs (n = 246, 83%) did not initiate isotretinoin and identified multiple barriers: medicolegal concerns (n = 150, 61%), being unaware that GPs may initiate isotretinoin (n = 135, 55%), and being unfamiliar with managing isotretinoin (n = 102, 41%). Important enablers to initiating isotretinoin cited by GPs include Irish College of General Practitioners guidelines (n = 118, 48%) and dermatologist support (n = 119, 48%). Two-thirds of the GPs questioned (n = 164, 67%) expressed an interest in initiating isotretinoin and most (n = 223, 91%) agreed that GPs can safely manage isotretinoin. CONCLUSION: Few GPs in Ireland currently initiate treatment of acne with isotretinoin, and there is suboptimal adherence to recommended monitoring. Barriers to and enablers for GPs initiating isotretinoin were identified. Most GPs expressed an interest in initiating isotretinoin.

A pilot study of the duration of GP consultations in Ireland.

BACKGROUND: General practitioner (GP)-led primary care is the linchpin of health care in Ireland. Reflecting international trends, there are increasing concerns about the sustainability of the current Irish GP service due to an increasing workload. Objective data on the duration of GP consultations are currently not available in Ireland. The objective of this pilot study is to demonstrate how the duration of consultations can be collected, using readily available administrative data. METHODS: Software was developed to extract the duration of GP consultations using the opening and closing of electronic patient records associated with a GP consultation. GP practices (N = 3) comprising 15 GPs were recruited from a university-affiliated research network. A retrospective analysis of GP consultations with patients with diabetes for the 9 years between 2010 and 2018 was used to assess the feasibility of using this system to measure the duration of consultations. RESULTS: The average duration of a consultation was 14.1 min for the 9 years spanning 2010 to 2018. Patients had an average time between consultations of 99 days. CONCLUSIONS: This pilot study confirms that an administrative data set can be utilised at negligible cost to monitor GP practice consultation workload over time. Our preliminary pilot data show that GP consultation durations among participating practices were longer than the 5-11.7 min reported in the UK and show an increase over the period. Clearly, a larger number of practices and patients are required to substantiate this finding.

Use of text messaging in general practice: a mixed methods investigation on GPs' and patients' views.

BACKGROUND: Text messaging has become more prevalent in general practice as a tool with which to communicate with patients. AIM: The main objectives were to assess the extent, growth, and perceived risks and benefits of text messaging by GPs to communicate with patients, and assess patients' attitudes towards receiving text messages from their GP. DESIGN AND SETTING: A mixed methods study, using surveys, a review, and a focus group, was conducted in both urban and rural practices in the south-west of Ireland. METHOD: A telephone survey of 389 GPs was conducted to ascertain the prevalence of text messaging. Subsequently, the following were also carried out: additional telephone surveys with 25 GPs who use text messaging and 26 GPs who do not, a written satisfaction survey given to 78 patients, a review of the electronic information systems of five practices, and a focus group with six GPs to ascertain attitudes towards text messaging. RESULTS: In total, 38% (n = 148) of the surveyed GPs used text messaging to communicate with patients and 62% (n = 241) did not. Time management was identified as the key advantage of text messaging among GPs who used it (80%; n = 20) and those who did not (50%; n = 13). Confidentiality was reported as the principal concern among both groups, at 32% (n = 8) and 69% (n = 18) respectively. Most patients (99%; n = 77) were happy to receive text messages from their GP. The GP focus group identified similar issues and benefits in terms of confidentiality and time management. Data were extracted from the IT systems of five consenting practices and the number of text messages sent during the period from January 2013 to March 2016 was generated. This increased by 40% per annum. CONCLUSION: Collaborative efforts are required from relevant policymakers to address data protection and text messaging issues so that GPs can be provided with clear guidelines to protect patient confidentiality.

Can HbA1c detect undiagnosed diabetes in acute medical hospital admissions?

OBJECTIVE: To study hyperglycaemia in acute medical admissions to Irish regional hospital. RESEARCH DESIGN AND METHODS: From 2005 to 2007, 2061 white Caucasians, aged >18 years, were admitted by 1/7 physicians. Those with diabetes symptoms/complications but no previous record of hyperglycaemia (n=390), underwent OGTT with concurrent HbA1c in representative subgroup (n=148). Comparable data were obtained for 108 primary care patients at risk of diabetes. RESULTS: Diabetes was diagnosed immediately by routine practice in 1% (22/2061) [aged 36 (26-61) years (median IQ range)/55% (12/22) male] with pre-existing diabetes/dysglycaemia present in 19% (390/2061) [69 (58-80) years/60% (235/390) male]. Possible diabetes symptoms/complications were identified in 19% [70 (59-79) years/57% (223/390) male] with their HbA1c similar to primary care patients [54 (46-61) years], 5.7 (5.3-6.0)%/39 (34-42)mmol/mol (n=148) vs 5.7 (5.4-6.1)%/39 (36-43)mmol/mol, p=0.35, but lower than those diagnosed on admission, 10.2 (7.4-13.3)%/88 (57-122)mmol/mol, p<0.001. Their fasting plasma glucose (FPG) was similar to primary care patients, 5.2 (4.8-5.7) vs 5.2 (4.8-5.9) mmol/L, p=0.65, but 2hPG higher, 9.0 (7.3-11.4) vs 5.5 (4.4-7.5), p<0.001. HbA1c identified diabetes in 10% (15/148) with 14 confirmed on OGTT but overall 32% (48/148) were in diabetic range on OGTT. The specificity of HbA1c in 2061 admissions was similar to primary care, 99% vs 96%, p=0.20, but sensitivity lower, 38% vs 93%, p<0.001 (63% on FPG/23% on 2hPG, p=0.037, in those with possible symptoms/complications). CONCLUSION: HbA1c can play a diagnostic role in acute medicine as it diagnosed another 2% of admissions with diabetes but the discrepancy in sensitivity shows that it does not reflect transient/acute hyperglycaemia resulting from the acute medical event.

Quality-assured screening for diabetic retinopathy delivered in primary care in Ireland: an observational study.

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.