Search

BackgroundTo date, research on adverse drug reactions (ADRs) has focused on secondary care, and there is a paucity of studies that have prospectively examined ADRs affecting older adults in general practice.AimTo examine the cumulative incidence and severity of ADRs and associated patient characteristics in a sample of community-dwelling older adults.Design and settingProspective cohort study of older adults (aged ≥70 years,N= 592) recruited from 15 general practices in the Republic of Ireland.MethodManual review of the participant’s general practice electronic medical record, linked to the national dispensed prescription medicine database, and a detailed, self-reported patient postal questionnaire. The primary outcomes were ADR occurrence and severity over a 6-year period (2010–2016). Unadjusted and adjusted logistic regression models examined potential associations between patient characteristics and ADR occurrence.ResultsA total of 211 ADRs were recorded for 159 participants, resulting in a cumulative incidence of 26.9% over 6 years. The majority of ADRs detected were mild (89.1%), with the remainder classified as moderate (10.9%). Eight moderate ADRs, representing 34.8% of moderate ADRs and 3.8% of all ADRs, required an emergency hospital admission. ADRs were independently associated with female sex (adjusted odds ratio [OR] 1.83, 95% confidence interval [CI] = 1.17 to 2.85;P= 0.008), polypharmacy (5–9 drug classes) (adjusted OR 1.81, 95% CI = 1.17 to 2.82;P= 0.008), and major polypharmacy (≥10 drug classes) (adjusted OR = 3.33, 95% CI = 1.62 to 6.85;P= 0.001).ConclusionThis prospective cohort study of ADRs in general practice shows that over one-quarter of older adults experienced an ADR over a 6-year period. Polypharmacy is independently associated with ADR risk in general practice and older adults on ≥10 drug classes should be prioritised for regular medication review.

Medications provide many therapeutic benefits; however, these must be balanced against the potential for patient harm. Two high-risk medications are benzodiazepine receptor agonists or BZRAs (including benzodiazepines and Z-drugs hypnotics) and opioid analgesics, which carry a risk of dependence, misuse, and abuse. Use of these medications has been growing internationally, along with associated morbidity and mortality. These medications are often classified as 'controlled drugs' and subject to legal restrictions in order to balance therapeutic benefits and risks of misuse. The aim of this project is to evaluate prescribing of analgesic and sedative drugs, in particular opioid and BZRA medications, to characterise time trends, the impact of policy changes, and regional and GP practice variation. This will be addressed across three workpackages, primarily using data on prescriptions dispensed to individuals eligible for the General Medical Services scheme in Ireland, held by the HSE Primary Care Reimbursement Service, along with other national and international data collections. Workpackage 1 will derive volume and patterns of utilisation indicators of controlled drugs and related medications and describe time trends in primary care in Ireland between 2014 and 2021 in two repeated cross-sectional studies. Workpackage 2 will consist of two interrupted time series studies on the impact of recent policy changes on prescribing. Workpackage 3 is a cohort study of GP practices, which will aim to quantify and explain regional and GP practice-level variation in analgesic and sedative prescribing, and, in relation to policy changes. This research will provide data-driven insights to inform policy-makers' decisions and clinical practice to optimise regulation and use of these medications for the benefit of patients and society.

IntroductionIn 2017, two distinct interventions were implemented in Ireland and England to reduce prescribing of lidocaine medicated plasters. In Ireland, restrictions on reimbursement were introduced. In England, updated guidance on items not to routinely prescribe in primary care, including lidocaine plasters, was published. This study aims to compare how the interventions impacted prescribing of lidocaine plasters in these countries.MethodsWe conducted an interrupted time series study using general practice data. For Ireland, monthly dispensing data (2015-2019) from the means-tested General Medical Services scheme was used. For England, data covered all patients. Outcomes were the rate of dispensings, quantity and costs of lidocaine plasters, and we modelled level and trend changes from the first full month of the policy/guidance change.FindingsIreland had higher rates of lidocaine dispensings compared to England throughout the study period; this was 15.22/1,000 population immediately pre-intervention, and there was equivalent to a 97.2% immediate reduction following the intervention. In England, the immediate pre-intervention dispensing rate was 0.36/1,000, with an immediate reduction of 0.0251/1,000 (a 5.8% decrease), followed by a small but significant decrease in the monthly trend relative to the pre-intervention trend of 0.0057 per month.InterpretationAmong two different interventions aiming to decrease low-value lidocaine plaster prescribing, there was a substantially larger impact in Ireland of reimbursement restriction compared to issuing guidance in England. However, this is in the context of much higher baseline rates of use in Ireland compared to England.FundingThis study was funded by the Health Research Board (SDAP-2019-023).

BackgroundMedical device industry payments to healthcare organisations (HCOs) can create conflicts of interest which can undermine patient care. One way of addressing this concern is by enhancing transparency of industry financial support to HCOs. MedTech Europe, a medical device trade body, operate a system of disclosure of education payments to European HCOs. This study aimed to characterise payments reported in this database and to evaluate the disclosure system.MethodsAn observational study of education-related payments to HCOs reported by the medical device industry in Europe was conducted. Data was manually extracted from transparentmedtech.eu. The primary outcome variable is the value of the payments, overall, and for each year, payment type, and country. The accessibility, availability and quality of the database was also analysed, using a proforma with 15 measures.FindingsOverall, 116 medical device companies reported education-related payments in 53 countries, valuing over €420 million between 2017-2019, increasing in value between 2017-2019, from €91,289,672 to €175,414,302. Ten countries accounted for 94% of all payments and ten companies accounted for 80% of all payments. The accessibility, availability and quality of the database, rated low for six measures, medium for six measures and high for three measures.InterpretationThere is a large amount of education-related payments from medical device companies to European HCOs, creating substantial potential for conflicts of interest. MedTech Europe’s disclosure system has many shortcomings. A European-wide publicly mandated disclosure system for both the medical device and pharmaceutical industries should be introduced.FundingSwedish Research Council (SM, PO)

IntroductionAs health reforms move Ireland from a mixed public-private system toward universal healthcare, it is important to understand variations in prescribing practice for patients with differing health cover and socioeconomic status. This study aims to determine how prescribing patterns for patients aged ≥65 years in primary care in Ireland differ between patients with public and private health cover.MethodsThis was an observational study using anonymised data collected as part of a larger study from 44 general practices in Ireland (2011-2018). Data were extracted from electronic records relating to demographics and prescribing for patients aged ≥65 years. The cohort was divided between those with public health cover (via the General Medical Services (GMS) scheme) and those without. Standardised rates of prescribing were calculated for pre-specified drug classes. We also analysed the number of medications, polypharmacy, and trends over time between groups, using multilevel linear regression adjusting for age and sex.ResultsOverall, 42,456 individuals were included (56% female). Most were covered by the GMS scheme (62%, n=26,490). The rate of prescribing in all medication classes was higher for GMS patients compared to non-GMS patients, with the greatest difference in benzodiazepine anxiolytics. The mean number of unique medications prescribed to GMS patients was 10.9 (SD 5.9), and 8.1 (SD 5.8) for non-GMS patients. The number of unique medications prescribed to both GMS and non-GMS cohorts increased over time. The increase was steeper in the GMS group where the mean number of medications prescribed increased by 0.67 medications/year. The rate of increase was 0.13 (95%CI 0.13, 0.14) medications/year lower for non-GMS patients, a statistically significant difference.ConclusionOur study found a significantly larger number of medicines were prescribed to patients with public health cover, compared to those without. Increasing medication burden and polypharmacy among older adults may be accelerated for those of lower socioeconomic status. These findings may inform planning for moves towards universal health care, and this would provide an opportunity to evaluate the effect of expanding entitlement on prescribing and medicines use.

ObjectiveTo examine factors associated with continuation of hospital-initiated benzodiazepine receptor agonists (BZRAs) among adults aged ≥65 years, specifically instructions on hospital discharge summaries.MethodsThis retrospective cohort study involved anonymised electronic record data on prescribing and hospitalisations for 38,229 patients aged ≥65 from forty-four GP practices in Ireland 2011-2016. BZRA initiations were identified among patients with no BZRA prescription in the previous 12 months. Multivariate regression examined whether instructions on discharge messages for hospital-initiated BZRA prescriptions was associated with continuation after discharge in primary care and time to discontinuation.ResultsMost BZRA initiations occurred in primary care, however the rate of hospital-initiated BZRAs was higher. Almost 60% of 418 hospital initiations had some BZRA instructions (e.g. duration) on the discharge summary. Approximately 40% (n=166) were continued in primary care. Lower age, being prescribed a Z-drug or great number of medicines were associated with higher risk of continuation. Of those continued in primary care, in 98 cases (59.6%) the BZRA was discontinued during follow-up (after a mean 184 days). Presence of instructions was associated with higher likelihood of discontinuation (hazard ratio 1.67, 95%CI 1.09-2.55).ConclusionsImproved communication to GPs after hospital discharge may be important in avoiding long-term BZRA use.

Background: The pharmaceutical industry makes large numbers of payments to healthcare organisations (HCOs) and healthcare professionals (HCPs). Ireland has a large pharmaceutical industry presence and national debate on legislating for greater industry payment transparency. This study characterises payments in Ireland to HCPs and HCOs during 2015-2019, and the content, consistency and methodology of the data source.Methods: An observational study of TransfersOfValue.ie, the disclosure website for the Irish Pharmaceutical Health Association pharmaceutical companies. We conducted a quantitative analysis, summarising payments to HCOs, HCPs and for research and development (R&D). We quantified disclosure rates of names for HCP and HCO payment recipients. We also conducted a content analysis of the methodology notes and website content.Results: Payments totalling €163 million were reported by 47 companies during 2015-2019, €84.6 million for R&D, with non-R&D payments of €45.1 million to HCOs and €33.6 million to HCPs. HCOs were named for 91.2% of payments, and HCPs for 55.1-62.8% across study years. For 2019, ten companies disclosed >€1 million in payments, and three disclosed >€1 million in HCO and HCP payments. Content analysis of 132 data reports and 46 methodology notes indicated substantial variation in methodologies for reporting between companies.Conclusions: There are substantial payments in Ireland, often the recipient is undisclosed, and companies differ in their reporting. A mandatory disclosure system could enhance transparency.

ObjectiveThe DASSL Model, conceived by the Health Research Board, aims to overcome challenges to linking data in Ireland including lack of unique patient identifiers, inconsistent application of legislation and siloed data. The objective of the Proof-of-Concept is to develop and test a demonstrator technical infrastructure to support this model. ApproachA stakeholder committee of representatives from government, health services, data controllers, patients/public and researchers was established. National and international data sharing and linkage landscapes were reviewed via interviews, scientific papers and grey literature. Five case studies were developed to demonstrate different linkages, data and research purposes, with synthetic data mimicking real health/social datasets generated using data dictionaries, data controller input, national statistics and Synthpop, Synthetic Data Vault and General Adversarial Networks. The technical infrastructure remains under development with linkage software being evaluated. Stakeholders will test this infrastructure and a final report will outline considerations for a national solution. ResultsSynthetic versions of administrative data, patient registries, electronic patient records, longitudinal cohorts, imaging and genomics are being generated. Matching variables and content data will be split and securely shared respectively with the Trusted Third Party (TTP) and Health Data Hub (HDH) on a project-by-project basis and at regular intervals. The selected linkage software will be used to match both unique identifiers and personally-identifiable data using probabilistic and deterministic techniques between datasets and with a population spine. The encrypted linkage key will be shared with the HDH, where the data view for each case study will be created by the Research Support Unit using the content data. A locked down virtual Safe Haven will support researcher access with disclosure control check on any outputs. ConclusionA DASSL infrastructure could support sharing, linking and analysis of health and social data in Ireland. However, high quality data including matching variables need to be collected to produce beneficial findings. A national rollout requires a governance and legislative model, improvements in data collection, further public engagement and significant resourcing.

The misattribution of an adverse drug reaction (ADR) as a symptom or illness can lead to the prescribing of additional medication, referred to as a prescribing cascade. The aim of this systematic review is to identify published prescribing cascades in community-dwelling adults. A systematic review was reported in line with the PRISMA guidelines and pre-registered with PROSPERO. Electronic databases (Medline [Ovid], EMBASE, PsycINFO, CINAHL, Cochrane Library) and grey literature sources were searched. Inclusion criteria: community-dwelling adults; risk-prescription medication; outcomes-initiation of new medicine to "treat" or reduce ADR risk; study type-cohort, cross-sectional, case-control, and case-series studies. Title/abstract screening, full-text screening, data extraction, and methodological quality assessment were conducted independently in duplicate. A narrative synthesis was conducted. A total of 101 studies (reported in 103 publications) were included. Study sample sizes ranged from 126 to 11 593 989 participants and 15 studies examined older adults specifically (≥60 years). Seventy-eight of 101 studies reported a potential prescribing cascade including calcium channel blockers to loop diuretic (n = 5), amiodarone to levothyroxine (n = 5), inhaled corticosteroid to topical antifungal (n = 4), antipsychotic to anti-Parkinson drug (n = 4), and acetylcholinesterase inhibitor to urinary incontinence drugs (n = 4). Identified prescribing cascades occurred within three months to one year following initial medication. Methodological quality varied across included studies. Prescribing cascades occur for a broad range of medications. ADRs should be included in the differential diagnosis for patients presenting with new symptoms, particularly older adults and those who started a new medication in the preceding 12 months.

Background: The misattribution of an adverse drug reaction (ADR) as a symptom or illness can lead to the prescribing of additional medication, referred to as a prescribing cascade. The aim of this systematic review is to identify published prescribing cascades in community-dwelling adults. Methods: Systematic review reported in line with the PRISMA guidelines and pre-registered with PROSPERO. Electronic databases (Medline (Ovid), EMBASE, PsycINFO, CINAHL, Cochrane Library) and grey literature sources were searched. Inclusion criteria: Community-dwelling adults; Risk-prescription medication; Outcomes-initiation of new medicine to ‘treat’ or reduce ADR risk; Study type-cohort, cross-sectional, case-control and case-series studies. Title/abstract screening, full-text screening, data extraction and methodological quality assessment was conducted independently in duplicate. A narrative synthesis was conducted. Results: A total of 101 studies (reported in 103 publications) were included. Study sample sizes ranged from 126 to 11,593,989 participants and 15 studies examined older adults specifically (≥60 years). Seventy-eight of 101 studies reported a potential prescribing cascade including calcium channel blockers to loop diuretic (n=5), amiodarone to levothyroxine (n=5), inhaled corticosteroid to topical antifungal (n=4), antipsychotic to anti-Parkinson drug (n=4), and acetylcholinesterase inhibitor to urinary incontinence drugs (n=4). Identified prescribing cascades occurred within three months to one year following initial medication. Methodological quality varied across included studies. Conclusion and implications: Prescribing cascades occur for a broad range of medications. ADRs should be included in the differential diagnosis for patients presenting with new symptoms, particularly older adults and those who started a new medication in the preceding 12 months. Word count: 245

BackgroundAdults at high risk of fragility fracture should be offered pharmacological treatment when not contraindicated, however under-treatment is common.ObjectiveThis study aimed to investigate factors associated with bone-health medication initiation in older patients attending primary care.DesignRetrospective cohort study.Setting44 general practices in Ireland from 2011-2017.SubjectsAdults aged ≥65 years who were naïve to bone-health medication for 12 months.MethodsOverall fracture-risk (based on QFracture) and individual fracture-risk factors were described for patients initiated and not initiated onto medication and compared using generalised linear model regression with Poisson distribution.ResultsOf 36,799 patients (51 % female, mean age 75.4 (SD=8.4)) included, 8% (n=2,992) were observed to initiate on bone-health medication during the study. One fifth of all patients (n=8,193) had osteoporosis or had high fracture-risk but only 21% of them (n=1,687) initiated on medication. Female sex, older age, state-funded health cover and osteoporosis were associated with initiation. Independently of osteoporosis and co-variates, high 5-year QFracture risk for hip (IRR=1.33 (95% CI=1.17-1.50), pConclusionsBone-health medication initiation is targeted at patients at higher fracture-risk but much potential under-treatment remains, particularly in those >80 years and with co-morbidities. This may reflect clinical uncertainty in older multimorbid patients, and further research should explore decision-making in preventive bone medication prescribing.Key pointsDuring this study, 23% of women and 11% of men defined as high-risk of fracture were newly initiated on bone-health medication.Rates of potential under-treatment were highest in patients over 80 years old.Fracture history, corticosteroid use, and rheumatoid arthritis were independently associated with medication initiation.Patients with diabetes, and liver, kidney, or cardiovascular disease were less likely to be initiated on medication.Clinical guidelines should provide advice on risk-benefit decisions in osteoporosis treatment where co-morbidities are present.

ObjectivesTo describe the characteristics of clinical study report (CSR) documents published by the European Medicines Agency (EMA), and for included pivotal trials, to quantify the timeliness of access to trial results from CSRs compared with conventional published sources.DesignCross-sectional analysis of CSR documents published by the EMA from 2016 to 2018.MethodsCSR files and medication summary information were downloaded from the EMA. Individual trials in each submission were identified using document filenames. Number and length of documents and trials were determined. For pivotal trials, trial phase, dates of EMA document publication and matched journal and registry publications were obtained.ResultsThe EMA published documents on 142 medications that were submitted for regulatory drug approval. Submissions were for initial marketing authorisations in 64.1%. There was a median of 15 (IQR 5–46) documents, 5 (IQR 2–14) trials and 9629 (IQR 2711–26,673) pages per submission, and a median of 1 (IQR 1–4) document and 336 (IQR 21–1192) pages per trial. Of all identified pivotal trials, 60.9% were phase 3 and 18.5% were phase 1. Of 119 unique submissions to the EMA, 46.2% were supported by a single pivotal trial, with 13.4% based on a single pivotal phase 1 trial. No trial registry results were identified for 26.1% trials, no journal publications for 16.7% and 13.5% of trials had neither. EMA publication was the earliest information source for 5.8% of pivotal trials, available a median 523 days (IQR 363–882 days) before the earliest publication.ConclusionsThe EMA Clinical Data website contains lengthy clinical trial documents. Almost half of submissions to the EMA were based on single pivotal trials, many of which were phase 1 trials. CSRs were the only source and a timelier source of information for many trials. Access to unpublished trial information should be open and timely to support decision-making for patients.

China is facing ever-increasing constraints in airspace capacity due to a 9.7% average annual increase rate in air traffic over the past decade. This situation underscores the need for the capabili...

Background There is some evidence to suggest that pharmacists integrated into primary care improves patient outcomes and prescribing quality. Despite this growing evidence, there is a lack of detail about the context of the role. Objective To explore the implementation of The General Practice Pharmacist (GPP) intervention (pharmacists integrating into general practice within a non-randomized pilot study in Ireland), the experiences of study participants and lessons for future implementation. Design and setting Process evaluation with a descriptive qualitative approach conducted in four purposively selected GP practices. Methods A process evaluation with a descriptive qualitative approach was conducted in four purposively selected GP practices. Semi-structured interviews were conducted, transcribed verbatim and analysed using a thematic analysis. Results Twenty-three participants (three pharmacists, four GPs, four patients, four practice nurses, four practice managers and four practice administrators) were interviewed. Themes reported include day-to-day practicalities (incorporating location and space, systems and procedures and pharmacists’ tasks), relationships and communication (incorporating GP/pharmacist mode of communication, mutual trust and respect, relationship with other practice staff and with patients) and role perception (incorporating shared goals, professional rewards, scope of practice and logistics). Conclusions Pharmacists working within the general practice team have potential to improve prescribing quality. This process evaluation found that a pharmacist joining the general practice team was well accepted by the GP and practice staff and effective interprofessional relationships were described. Patients were less clear of the overall benefits. Important barriers (such as funding, infrastructure and workload) and facilitators (such as teamwork and integration) to the intervention were identified which will be incorporated into a pilot cluster randomized controlled trial.

ObjectivesInfectious mononucleosis (IM) is a clinical syndrome that is characterised by lymphadenopathy, fever and sore throat. Although generally not considered a serious illness, IM can lead to significant loss of time from school or work due to profound fatigue, or the development of chronic illness. This study aimed to derive and externally validate clinical prediction rules (CPRs) for IM caused by Epstein-Barr virus (EBV).DesignProspective cohort study.Setting and participants328 participants were recruited prospectively for the derivation cohort, from seven university-affiliated student health centres in Ireland. Participants were young adults (17–39 years old, mean age 20.6 years) with sore throat and one other additional symptom suggestive of IM. The validation cohort was a retrospective cohort of 1498 participants from a student health centre at the University of Georgia, USA.Main outcome measuresRegression analyses were used to develop four CPR models, internally validated in the derivation cohort. External validation was carried out in the geographically separate validation cohort.ResultsIn the derivation cohort, there were 328 participants, of whom 42 (12.8%) had a positive EBV serology test result. Of 1498 participants in the validation cohort, 243 (16.2%) had positive heterophile antibody tests for IM. Four alternative CPR models were developed and compared. There was moderate discrimination and good calibration for all models. The sparsest CPR included presence of enlarged/tender posterior cervical lymph nodes and presence of exudate on the pharynx. This model had moderate discrimination (area under the receiver operating characteristic curve (AUC): 0.70; 95% CI: 0.62–0.79) and good calibration. On external validation, this model demonstrated reasonable discrimination (AUC: 0.69; 95% CI: 0.67–0.72) and good calibration.ConclusionsThe alternative CPRs proposed can provide quantitative probability estimates of IM. Used in conjunction with serological testing for atypical lymphocytosis and immunoglobulin testing for viral capsid antigen, CPRs can enhance diagnostic decision-making for IM in community settings.

In recent decades, opioid use has increased internationally and is a major public health concern. This study aims to characterize changes in opioid and other analgesic prescribing in Ireland over a 15‐year period (2000–2015). This is a repeated cross‐sectional study of administrative pharmacy claims data in 2000 and 2015. Individuals of all ages in Ireland's Eastern Health Board region who were eligible for the General Medical Services (GMS) scheme were included. This scheme covers 40% of the population, mostly those on lower incomes and older people. The primary outcome was dispensing of opioids, both prevalence of any use and rate per 1000 GMS eligible population (standardized to the 2015 population). Logistic regression was used to assess odds of opioid dispensing in 2015 versus 2000, controlling for demographic differences. The eligible study population was 364 436 in 2000 and 523 653 in 2015. In 2000, 19.4% of the eligible population had at least one opioid dispensing compared to 20.8% in 2015. The rate increased from 671 to 1098 dispensings per 1000 population. The increase was highest in the dispensing rates of codeine, tramadol, oxycodone, buprenorphine, and fentanyl. Compared to 2000, there was higher odds in 2015 of being dispensed a strong opioid (adjusted odds ratio 2.0, 95%CI 1.97–2.04) or long‐acting formulation (3.75, 95%CI 3.58–3.92). Increased prescribing of opioids, particularly strong opioids, between 2000 and 2015 is evident in Ireland. This is concerning due to the potential for misuse, and opioid‐related morbidity/mortality., This repeated cross‐sectional study examined opioid and analgesic utilisation in Ireland in 2000 and 2015. Over this 15‐year period, the rate of opioid dispensing increased by 64%.

Background: Potentially inappropriate care can result from overuse or underuse of treatments, tests, or procedures. Overuse is defined as the use of health services with no clear benefit to the recipient or where harms outweigh benefits and/or costs of care. Underuse is defined as failure to deliver an effective and cost-effective healthcare intervention. Cardiovascular procedures such as coronary artery bypass grafting, carotid endarterectomy, coronary angiography, and coronary angioplasty (with/without stenting) are potentially both underused and overused. This systematic review aims to identify rates of potential overuse and underuse of these cardiovascular procedures and explore any associated patient or healthcare system factors. Methods: A systematic review and meta-analysis will be conducted in accordance with the PRISMA guidelines. A systematic search of MEDLINE (via Ovid), Embase, Cumulative Index to Nursing and Allied Health Literature and the Cochrane library will be conducted using a predefined search strategy. Eligible studies for inclusion will examine rates of overuse and underuse of cardiovascular procedures, measured against national/international guidelines, for adults aged ≥18 years. Primary observational studies including cross-sectional and cohort studies will be included. Titles, abstracts, and full texts will be screened for inclusion by two reviewers. Data will be extracted using a standardised form. Risk of bias for all included studies will be assessed using a modified version of the Hoy risk of bias tool. Where adequate data exists, and if statistically appropriate, meta-analyses will be conducted. If statistical pooling of the data is not possible, the findings will be narratively summarised focusing on the review’s objectives. Conclusion: This systematic review will examine overuse and underuse of cardiovascular procedures for adults. The results will help inform policy makers, researchers, patients, and clinicians in the appropriate use of these procedures, in line with international guidelines. Registration: This protocol has been submitted for registration on PROSPERO (CRD42021239041).

Objectives To determine the feasibility, implementation and outcomes of an Anticipatory Care Planning (ACP) intervention in primary care to assist older adults at risk of functional decline by developing a personalized support plan. Design Feasibility cluster randomized control trial. Setting and participants Eight primary care practices (four in Northern Ireland, United Kingdom and four in the Republic of Ireland) were randomly assigned to either intervention or control arm. Eligible patients were those identified in each practice as 70 years of age or older and assessed as at risk of functional decline. Study participants (intervention n = 34, control n = 31) and research staff were not blinded to group assignment. Anticipatory care intervention The intervention delivered by a registered nurse including: a) a home-based patient assessment; b) care planning on the basis of a holistic patient assessment, and c) documentation of a support plan. Outcome measures A conceptual framework (RE-AIM) guided the assessment on the potential impact of the ACP intervention on patient quality of life, mental health, healthcare utilisation, costs, perception of person-centred care, and reduction of potentially inappropriate prescribing. Data were collected at baseline and at 10 weeks and six months following delivery of the intervention. Results All pre-specified feasibility indicators were met. Patients were unanimous in the acceptance of the ACP intervention. Health care providers viewed the ACP intervention as feasible to implement in routine clinical practice with attending community supports. While there were no significant differences on the primary outcomes (EQ-5D-5L: -0.07 (-0.17, 0.04) p = .180; CES-D: 1.2 (-2.5, 4.8) p = .468) and most secondary measures, ancillary analysis on social support showed responsiveness to the intervention. Incremental cost analysis revealed a mean reduction in costs of €320 per patient (95% CI -31 to 25; p = 0.82) for intervention relative to the control. Conclusions We successfully tested the ACP intervention in primary care settings and have shown that it is feasible to implement. The ACP intervention deserves further testing in a definitive trial to determine whether its implementation would lead to better outcomes or reduced costs. Trial registration Clinicaltrials.gov, ID: NCT03902743. Registered on 4 April 2019.

Objective To investigate the association between potentially serious alcohol–medication interactions (POSAMINO criteria), hypothesised to increase the risk of falls in older adults, and falls in community-dwelling older adults at two and 4 years follow-up. Design A prospective cohort study. Setting The Irish Longitudinal Study on Ageing. Subjects A total of 1,457 community-dwelling older adults aged ≥65 years, with a complete alcohol and regular medication data to allow for the application of the POSAMINO criteria. Outcomes Self-reported falls at 2 and 4 years follow-up, any falls (yes/no), injurious falls (yes/no) and number of falls (count variable). Results The number of participants who reported falling since their baseline interview at 2 and 4 years were 357 (24%) and 608 (41.8%), respectively; 145 (10%) reported an injurious fall at 2 years and 268 (18%) at 4 years. Median (IQR) number of falls was 1 (1–2) at 2 years and 2 (1–3) at 4 years. Exposure to CNS POSAMINO criteria, hypothesised to increase the risk of falls due primarily to increased sedation, was associated with a significantly increased risk for falling (adjusted relative risk (RR) 1.50, 95% confidence interval (CI) 1.21–1.88) and for injurious falls (adjusted RR 1.62, 95% CI: 1.03–2.55) at 4 years. These equate to an absolute risk of 19% for falling (95% CI: 5–33%) and 8% for injurious falls (95% CI, 4–20%) at 4 years. Conclusions Assessment and management strategies to prevent falls in community-dwelling older adults should consider patients’ alcohol consumption alongside their assessment of patient medications, particularly among those receiving CNS agents.

Background Hospitalisation for specific conditions considered to be `ambulatory-care sensitive' (ACS) could signify problems with primary or outpatient care access. The aims of this study are to quantify and explore potential causes for geographical variation across emergency hospital admissions for relevant ACS conditions in older adults in Ireland. Methods The number of emergency hospital admissions among adults aged 65+ with a diagnosis of an ACS condition between 2012-2016 were extracted from Ireland’s Hospital Inpatient Enquiry system according to condition, sex, age-group, residence area and year. Conditions included chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), diabetes complications, angina (excluding therapeutic procedures), pyelonephritis and urinary tract infections (UTI), dehydration and pneumonia. Age-sex standardised discharge rates (SDRs) were calculated for 21 areas. Systematic components of variance (SCV) quantified variation. Regression analyses were conducted between SDRs and year, unemployment rate, % urban population, General Practitioner (GP) supply, and % short emergency hospital stays. Results In total, 147,722 emergency hospital admissions (50 per 1,000 eligible population; 49% male) were included. COPD was the most common condition (31%), followed by pneumonia (22%), pyelonephritis/UTI (21%) and CHF (16%). CHF showed low geographic variation (SCV=2-3). COPD, diabetes, pyelonephritis/UTI and pneumonia showed high variation (SCV=4-12). Angina and dehydration showed very high variation (SCV=12-50). In multivariable analysis, higher unemployment was associated with higher SDRs for COPD. Lower GP supply was associated with higher SDRs for CHF, diabetes and pneumonia. Rurality was associated with SDRs for angina. Conclusion The rate of emergency admissions for ACS conditions studied is in line with research in the United States, although COPD and angina account for a higher proportion of admissions in our study. There is significant geographical variation in ACS admission rates among older adults in Ireland. Further research should explore local factors influencing emergency admission, particularly in socio-economically disadvantaged areas and those with lower GP supply.

BACKGROUND: The CRB-65 score is recommended as a decision support tool to help identify patients with community-acquired pneumonia (CAP) who can safely be treated as outpatients. OBJECTIVE: To perform an updated meta-analysis of the accuracy, discrimination, and calibration of the CRB-65 score using a novel approach to calculation of stratum-specific likelihood ratios. DESIGN: Meta-analysis of accuracy, discrimination, and calibration. METHODS: We searched PubMed, Google, previous systematic reviews, and reference lists of included studies. Data was abstracted and quality assessed in parallel by two investigators. The quality assessment used an adaptation of the TRIPOD and PROBAST criteria. Measures of discrimination, calibration, and stratum-specific likelihood ratios are reported. KEY RESULTS: Twenty-nine studies met our inclusion criteria and provided usable data. Most studies were set in Europe, none in North America, and 12 were judged to be at low risk of bias. The pooled estimate of area under the receiver operating characteristic curve was 0.74 (95% CI 0.71–0.77) for all studies. Calibration was good although there was significant heterogeneity; the pooled estimate of the ratio of observed to expected mortality for all studies was 1.04 (95% CI 0.91–1.19). The corresponding values for studies at low risk of bias where patients could be treated as outpatients or inpatients were 0.76 (0.70–0.81) and 0.88 (0.69–1.13). Summary estimates of stratum-specific likelihood ratios for all studies were 0.19 for the low-risk group, 1.1 for the moderate-risk group, and 4.5 for the high-risk group, and 0.13, 1.3, and 5.6 for studies at low risk of bias where patients could be treated as outpatients or inpatients. CONCLUSIONS: The CRB-65 is useful for identifying low-risk patients for outpatient therapy. Given a 4% overall mortality risk, patients classified as low risk by the CRB-65 had an outpatient mortality risk of no more than 0.5%. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-019-04869-z) contains supplementary material, which is available to authorized users.

There is strong evidence that potentially inappropriate prescribing is associated with falls in older adults. Fall-related hospitalizations should trigger medication review. The aim of this before-and-after cohort study was to explore patterns of relevant potentially inappropriate prescribing in older people with fall-related hospitalizations. Data on older adults with hospitalizations for falls, fractures and syncope between 2012 and 2016 were collected from 44 general practices in Ireland. Fall-related prescribing was defined from the Screening Tool for Older Persons’ Prescriptions (sedatives and vasodilators) and the Screening Tool to Alert doctors to Right Treatment (vitamin D). Prevalence of prescriptions were estimated from general practice and hospital discharge records. Mixed-effects logistic regression was conducted to compare the 12-month pre- and post-hospitalization periods. Overall, 927 individuals (68% female, average age 81.2 years; standard deviation 8.6) were included, 45% of whom had a diagnosis of fracture, 28% had syncope, and 27% had a fall without fracture/syncope. After adjustment for covariates and practice clustering effects, both vitamin D and sedatives had higher odds of prescription post-hospitalization (adjusted odds ratio [aOR] 4.47, 95% confidence interval [CI] 2.09–9.54, and aOR 1.75, 95% CI 1.29–2.39, respectively). With adjustments for age and sex, having a fracture was associated with new initiation of vitamin D (aOR 2.81, 95% CI 1.76–4.46) and having syncope was associated with continuing on vasodilators (aOR 1.99, 95% CI 1.06–3.74). No factors were associated with new sedative initiation. Fall-related potentially inappropriate prescribing is prevalent in older adults who have a history of falls, and continues after discharge from hospital. Future studies should investigate why such prescribing is initiated after a fall-related hospitalization, and explore interventions that could reduce such hazardous prescribing.

This study aims to estimate (i) the prevalence of potentially serious alcohol-medication interactions in a nationally representative sample of older adults using the Potentially Serious Alcohol-Medication Interactions in Older adults (POSAMINO) criteria, and (ii) whether POSAMINO prevalence changes over time. A prospective cohort study of adults aged ≥ 65 years, using data from the first three waves of The Irish Longitudinal Study on Ageing (TILDA). All 38 POSAMINO criteria were applied at each wave using respondents’ information on regular medications and alcohol consumption. Multilevel logistic regression and negative binomial models were used to investigate whether the prevalence of POSAMINO varied over time. The overall prevalence of POSAMINO was 18% at baseline, with 8% at risk of one potentially serious alcohol-medication interaction, and 10% at risk of two or more. The most common POSAMINO involved cardiovascular (CVS) agents (15% baseline; 11% wave 2; 14% wave 3), followed by central nervous system (CNS) agents (4% baseline; 4% wave 2; 5% wave 3). Prevalence of any POSAMINO (AOR 0.94, 95% CI 0.81, 1.08) or number of POSAMINO criteria (AIRR 0.97, 95% CI 0.91, 1.04) did not change over time. Any POSAMINO and number of POSAMINO were associated with younger age, male sex and number of medications and chronic conditions. Potentially serious alcohol-medication interactions occurred in 18% of older adults in this study. Alcohol screening and brief interventions should be considered for high-risk groups at the point of prescribing, particularly among younger older adults, men and as patients receive more medications or develop additional illnesses.

Objective To systematically review clinical prediction rules (CPRs) that have undergone validation testing for predicting response to physiotherapy-related interventions for musculoskeletal conditions. Study design and setting PubMed, EMBASE, CINAHL and Cochrane Library were systematically searched to September 2020. Search terms included musculoskeletal (MSK) conditions, physiotherapy interventions and clinical prediction rules. Controlled studies that validated a prescriptive CPR for physiotherapy treatment response in musculoskeletal conditions were included. Two independent reviewers assessed eligibility. Original derivation studies of each CPR were identified. Risk of bias was assessed with the PROBAST tool (derivation studies) and the Cochrane Effective Practice and Organisation of Care group criteria (validation studies). Results Nine studies aimed to validate seven prescriptive CPRs for treatment response for MSK conditions including back pain, neck pain, shoulder pain and carpal tunnel syndrome. Treatments included manipulation, traction and exercise. Seven studies failed to demonstrate an association between CPR prediction and outcome. Methodological quality of derivation studies was poor and for validation studies was good overall. Conclusion Results do not support the use of any CPRs identified to aid physiotherapy treatment selection for common musculoskeletal conditions, due to methodological shortcomings in the derivation studies and lack of association between CPR and outcome in validation studies.

Retention in methadone maintenance treatment (MMT) is associated with reduced illicit drug use, criminal activity, and mortality; however, many clients move in and out of MMT. This study aims to identify determinants of time to dropout of MMT across multiple treatment episodes in specialist addiction services in Ireland.Cohort study of persons attending specialist addiction clinics between 2010 and 2015. MMT episodes were periods of continuous treatment if there were no interruptions to treatment lasting7days. Proportional hazards frailty models were used to assess factors associated with time to dropout from recurrent MMT episodes at 3 (90 days) and 12 months (91-365 days). MMT episodes were right- censored at time of death, transfer to prison or primary care, and study end.A total of 2,035 individuals experienced 4,969 MMT episodes, with 2,724 dropout events during the six-year follow-up. Factors associated with dropout at 3 months included low dose methadone (60 mg/day) (HR = 1.49, 95% CI 1.29-1.73) and previous dropout (HR = 1.65, 95% CI 1.41-1.92). Adherence was protective (HR = 0.91, 95% CI 0.90-0.92). Dropout at 12 months was associated with low dose methadone (HR = 1.44, 95% CI 1.23-1.68), previous dropout (HR = 1.37, 95% CI 1.16-1.61), males (HR 1.26, 95% CI 1.06-1.50), benzodiazepines (HR = 1.22, 95% CI 1.03-1.45) and number of comorbidities (HR = 1.12, 95% CI 1.05-1.20); adherence was protective (HR = 0.86, 95% CI 0.84-0.87).Clients with a previous history of treatment dropout and those on low dose methadone should be identified as high risk for both early and later dropout. Inversely, adherence to treatment, not missing methadone doses, is protective.

Background The use of multiple medications (polypharmacy) is a concern in older people (≥65 years) and is associated with negative health outcomes. For older populations with multimorbidity, polypharmacy is the reality and the key challenge is ensuring appropriate polypharmacy (as opposed to inappropriate polypharmacy). This external pilot cluster randomised controlled trial (cRCT) aims to further test a theory-based intervention to improve appropriate polypharmacy in older people in primary care in two jurisdictions, Northern Ireland (NI) and the Republic of Ireland (ROI). Methods Twelve GP practices across NI (n=6) and the six counties in the ROI that border NI will be randomised to either the intervention or usual care group. Members of the research team have developed an intervention to improve appropriate polypharmacy in older people in primary care using the Theoretical Domains Framework of behaviour change. The intervention consists of two components: (1) an online video which demonstrates how a GP may prescribe appropriate polypharmacy during a consultation with an older patient and (2) a patient recall process, whereby patients are invited to scheduled medication review consultations with GPs. Ten older patients receiving polypharmacy (≥4 medications) will be recruited per GP practice (n=120). GP practices allocated to the intervention arm will be asked to watch the online video and schedule medication reviews with patients on two occasions; an initial and a 6-month follow-up appointment. GP practices allocated to the control arm will continue to provide usual care to patients. The study will assess the feasibility of recruitment, retention and study procedures including collecting data on medication appropriateness (from GP records), quality of life and health service use (i.e. hospitalisations). An embedded process evaluation will assess intervention fidelity (i.e. was the intervention delivered as intended), acceptability of the intervention and potential mechanisms of action. Discussion This pilot cRCT will provide evidence of the feasibility of a range of study parameters such as recruitment and retention, data collection procedures and the acceptability of the intervention. Pre-specified progression criteria will also be used to determine whether or not to proceed to a definitive cRCT. Trial registration ISRCTN, ISRCTN41009897. Registered 19 November 2019. ClinicalTrials.gov, NCT04181879. Registered 02 December 2019.

ObjectiveTo determine the prevalence and predictors of oral to intravenous antibiotic switch among adult emergency department (ED) patients with acute bacterial skin and skin structure infections (ABSSSIs).DesignMulticentre, pilot cohort study.SettingThree urban EDs in Dublin, Ireland.ParticipantsConsecutive ED patients aged >16 years old with ABSSSIs between March 2015 and September 2016.InterventionOral flucloxacillin 500 mg–1 g four times a day (alternative in penicillin allergy).Primary and secondary outcome measuresThe primary outcome was to determine the prevalence and predictors of oral to intravenous antibiotic switch. Secondary outcomes were to determine the prevalence and predictors of receiving an extended course of oral antibiotic treatment and measurement of interobserver reliability for clinical predictors at enrolment.ResultsOverall, 159 patients were enrolled of which eight were lost to follow-up and five were excluded. The majority of patients were male (65.1%) and ConclusionThe prevalence of oral to intravenous antibiotic switch in this pilot study is 8.9% (95% CI 4.8% to 14.7%). We identify the predictors of oral to intravenous switch worthy of future investigation.Trial registration numberNCT02230813.

BackgroundAspirin use for cardiovascular indications is widespread despite evidence not supporting use in patients without cardiovascular disease (CVD). This study characterises aspirin prescribing among people aged ≥50 years in Ireland for primary and secondary prevention, and factors associated with prescription.MethodsThis cross-sectional study includes participants from wave 3 (2014-2015) of The Irish Longitudinal Study on Ageing. We identified participants reporting use of prescribed aspirin, other antiplatelets/anticoagulants, and doctor-diagnosed CVD (MI, angina, stroke, TIA) and other cardiovascular conditions. We examined factors associated with aspirin use for primary and secondary prevention in multivariate regression. For a subset, we also examined 10-year cardiovascular risk (using the Framingham general risk score) as a predictor of aspirin use.ResultsAmong 6,618 participants, the mean age was 66.9 years (SD 9.4) and 55.6% (3,679) were female. Prescribed aspirin was reported by 1,432 participants (21.6%), and 77.6% of aspirin users had no previous CVD. Among participants with previous CVD, 17% were not prescribed aspirin/another antithrombotic. This equates to 201,000 older adults nationally using aspirin for primary prevention, and 16,000 with previous CVD not prescribed an antithrombotic. Among those without CVD, older age, male sex, free health care, and more GP visits were associated with aspirin prescribing. Cardiovascular risk was significantly associated with aspirin use (adjusted relative risk 1.15, 95%CI 1.08-1.23, per 1% increase in cardiovascular risk).ConclusionAlmost four-fifths of people aged ≥50 years on aspirin have no previous CVD, equivalent to 201,000 adults nationally, however prescribing appears rational in targeting higher cardiovascular risk patients.

BACKGROUND Creating an ontology for COVID-19 surveillance should help ensure transparency and consistency. Ontologies formalize conceptualizations at either the domain or application level. Application ontologies cross domains and are specified through testable use cases. Our use case was an extension of the role of the Oxford Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) to monitor the current pandemic and become an in-pandemic research platform. OBJECTIVE This study aimed to develop an application ontology for COVID-19 that can be deployed across the various use-case domains of the RCGP RSC research and surveillance activities. METHODS We described our domain-specific use case. The actor was the RCGP RSC sentinel network, the system was the course of the COVID-19 pandemic, and the outcomes were the spread and effect of mitigation measures. We used our established 3-step method to develop the ontology, separating ontological concept development from code mapping and data extract validation. We developed a coding system–independent COVID-19 case identification algorithm. As there were no gold-standard pandemic surveillance ontologies, we conducted a rapid Delphi consensus exercise through the International Medical Informatics Association Primary Health Care Informatics working group and extended networks. RESULTS Our use-case domains included primary care, public health, virology, clinical research, and clinical informatics. Our ontology supported (1) case identification, microbiological sampling, and health outcomes at an individual practice and at the national level; (2) feedback through a dashboard; (3) a national observatory; (4) regular updates for Public Health England; and (5) transformation of a sentinel network into a trial platform. We have identified a total of 19,115 people with a definite COVID-19 status, 5226 probable cases, and 74,293 people with possible COVID-19, within the RCGP RSC network (N=5,370,225). CONCLUSIONS The underpinning structure of our ontological approach has coped with multiple clinical coding challenges. At a time when there is uncertainty about international comparisons, clarity about the basis on which case definitions and outcomes are made from routine data is essential.

BackgroundMedication error at transitions of care is common. The implementation of medicines reconciliation processes to improve this issue has been recommended by many regulatory and safety organisations. The aim of this study was to gain insight from healthcare professionals on the barriers and facilitators to the medicines reconciliation implementation process.MethodsSemi-structured interviews were conducted in Ireland with a wide range of healthcare professionals (HCPs) involved with medicines reconciliation at transitions of care. Thematic analysis was undertaken using an adaptation of a combined theoretical framework of Grol, Cabana and Sluisveld to classify the barriers and facilitators to implementation of medicines reconciliation.ResultsThirty-five participants were interviewed, including eleven community pharmacists (CPs), eight hospital pharmacists (HPs), nine hospital consultants (HCs), five general practitioners (GPs), and two non-consultant hospital doctors (NCHDs). Themes were categorized into barriers and facilitators. Barriers included resistance from existing professional cultures, staff interest and training, poor communication and minimal information and communications technology (ICT) support. Solutions (facilitators) suggested included supporting effective multidisciplinary teams, greater involvement of pharmacists in medicines reconciliation, ICT solutions (linked prescribing databases, decision support systems) and increased funding to provide additional (e.g. admission and discharge reconciliation) and more advanced services (e.g. community pharmacist delivered medicines use review).ConclusionsMedicines reconciliation is advocated as a solution to the known problem of medication error at transitions of care. This study identifies the key challenges and potential solutions that policy makers, managers and HCPs should consider when reviewing the practices and processes of medicines reconciliation in their own organisations.

Background Despite efforts to improve the accuracy and transparency of the design, conduct, and reporting of randomised controlled trials (RCTs), deficiencies remain. Such deficiencies contribute to significant, avoidable waste of health research investment and impede reproducibility. This study aimed to synthesise and critically analyse changes over time in the conduct and reporting of internationally published evidence on patient and/or population health-oriented RCTs conducted in one country. Methods This observational study drew on systematic review methods. We searched six databases for published RCTs (database inception to December 2018) where ≥ 80% of participants were recruited in the Republic of Ireland. RCTs of interventions targeted at patients, providers and/or policy makers intended to improve health, healthcare or health research were included. For each study, screening, data extraction and methodological quality appraisal were conducted by one member of the author team. Results From 17,560 titles and abstracts, 752 unique RCTs were published in 745 papers between 1968 and 2018, with a steady year-on-year increase since 1968. The number of participants was in the range of 2–8628. The majority were parallel design (86%) and classified as treatment evaluation. Of the 418 RCTs published since the introduction of mandatory clinical trial registration by the International Committee of Medical Journal Editors in 2005, 32% (n = 134) provided a trial registration number. This increased to 47% when taking studies published between 2013 and 2018 (n = 232). Since the 1996 publication of the CONSORT statement, 16% of included RCTs made specific reference to a standardised reporting guideline and this increased to 31% for more recent studies published between 2013 and 2018. Overall, 7% (n = 53) of studies referred to a published study protocol, increasing to 20% for studies published between 2013 and 2018. Conclusion Evidence from this single-country study of RCTs published in the international literature suggests that both the number overall, the number registered and the number referencing reporting guidelines have increased steadily over time. Despite widespread endorsement of reporting standards, reporting of RCTs remains suboptimal in domains such as compliance with the CONSORT statement and prospective trial registration. Researchers, funders and journal editors, nationally and internationally, should continue to focus on improving reporting and examining avoidable waste of health research investment.

Objective: The objective of this study was to determine whether trajectories of older adults’ alcohol consumption are influenced by the following life course transitions, relationship status, employment status, and self-rated health. Method: Volume and frequency of drinking were harmonized across first three waves of The Irish Longitudinal Study on Ageing (TILDA; N = 4,295). Multilevel regression models were used to model frequency, average weekly consumption, and heavy episodic drinking. Results: Men and women drank more frequently over time, with frequency decreasing with age for women. Average weekly consumption decreased over time and with increasing age. Transitions in self-rated health, particularly those reflecting poorer health, were associated with lower frequency and weekly consumption. Heavy episodic drinking decreased with age. Men who were retired across all waves were more likely to engage in heavy episodic drinking at baseline. Discussion: Despite the decline in average weekly consumption and heavy episodic drinking, the observed quantities consumed and the increase in frequency of consumption suggest that older Irish adults remain vulnerable to alcohol-related harms.

Older people with several chronic conditions require multiple drugs from different classes to be adequately treated. This study aims to: (i) measure medication adherence across multiple conditions and therapeutic drug groups in older community-dwelling patients, and (ii) examine the effect of multimorbidity on adherence. This is a retrospective cohort study of medication adherence in 855 community-dwelling patients aged ≥ 70 years from 15 practices in Ireland using the Health Service Executive Primary Care Reimbursement Service (HSE-PCRS) pharmacy claims database. Multimorbidity was measured using the RxRisk-V and by the number of different drug classes. The RxRisk-V algorithm classifies prescription drug fills into 45 chronic disease classes for older populations based on the WHO Anatomical Therapeutic Chemical classification system. Adherence to medications was assessed by: (i) calculating the average medication possession ratio (MPR) per patient and (ii) an MPR

Introduction: Internationally, health systems face the challenge of managing a growing ageing population living with multimorbidity and polypharmacy. Potentially inappropriate prescribing is common among patients with polypharmacy, increasing the risk for adverse drug reactions (ADRs). Several prescribing indicator sets exist to improve prescribing and reduce potentially inappropriate prescribing, but do not address prescribing cascades. Prescribing cascades occur when a medication is prescribed to treat an ADR to another prescribed medication, whether intentionally or unintentionally, and constitute an important area to consider when characterising problematic polypharmacy. This is a protocol for a systematic review examining prescribing cascades in community-dwelling adults. Methods: The review will be reported adhering to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A systematic search of Medline (Ovid), EMBASE, PsycINFO, CINAHL and the Cochrane Library will be conducted from inception to March 2021, using a predetermined strategy. Grey literature will be searched using Open Grey, MedNar, Dart Europe, and the Turning Research Into Practice (TRIP) databases. No restrictions will be placed on language or publication year. Inclusion criteria are: population - community-dwelling adults (≥18 years), including those in residential or nursing homes; risk - prescription medication with the potential to cause side effects; outcomes - initiation of a new medicine to ‘treat’ or reduce the risk of experiencing an ADR. Prospective and retrospective cohort studies, case control and case series studies will be included. Two reviewers will independently screen titles and abstracts; studies meeting inclusion criteria will undergo independent full-text screening by two reviewers. A narrative synthesis will be conducted. Study quality will be independently assessed using the relevant Joanna Briggs Institute Critical Appraisal Checklist. Discussion: This systematic review will identify examples of prescribing cascades for community-dwelling adults and contribute to developing an evidence base regarding such cascades. Registration: PROSPERO [CRD42021243163, 31/03/2021].

Aspirin use for cardiovascular indications is widespread despite evidence not supporting use in patients without cardiovascular disease (CVD). This study characterises aspirin prescribing among people aged ≥50 years in Ireland for primary and secondary prevention, and factors associated with prescription. This cross-sectional study includes participants from wave 3 (2014-2015) of The Irish Longitudinal Study on Ageing. We identified participants reporting use of prescribed aspirin, other antiplatelets/anticoagulants, and doctor-diagnosed CVD (MI, angina, stroke, TIA) and other cardiovascular conditions. We examined factors associated with aspirin use for primary and secondary prevention in multivariate regression. For a subset, we also examined 10-year cardiovascular risk (using the Framingham general risk score) as a predictor of aspirin use. Among 6618 participants, the mean age was 66.9 years (SD 9.4) and 55.6% (3679) were female. Prescribed aspirin was reported by 1432 participants (21.6%), and 77.6% of aspirin users had no previous CVD. Among participants with previous CVD, 16.5% were not prescribed aspirin/another antithrombotic. This equates to 201,000 older adults nationally using aspirin for primary prevention, and 16,000 with previous CVD not prescribed an antithrombotic. Among those without CVD, older age, male sex, free health care, and more GP visits were associated with aspirin prescribing. Cardiovascular risk was significantly associated with aspirin use (adjusted relative risk 1.15, 95%CI 1.08-1.23, per 1% increase in cardiovascular risk). Almost four-fifths of people aged ≥50 years on aspirin have no previous CVD, equivalent to 201,000 adults nationally, however prescribing appears to target higher cardiovascular risk patients.

Supervised consumption ensures patients take methadone as prescribed and prevents diversion, however, the influence of supervised consumption on retention is unclear. We examined association between supervised consumption and retention across multiple treatment episodes.Cohort study of persons experiencing ≥1 MMT episodes in primary care (2004-2010), excluding ongoing episodes at the start of follow-up. Length of treatment episodes based on methadone prescriptions, retention classified as no interruption in prescribed methadone lasting7 days. When a patient did not receive a new prescription within seven days after the end of coverage of a prescription, they were considered to have ceased treatment. We evaluated the relationship between supervised consumption and time to discontinuation of treatment using proportional hazards gamma frailty models to account for recurrent MMT episodes. Age, gender, median daily methadone dose, and comorbidities included as potential confounders.6393 patients experienced 19,715 treatment episodes over the six-year follow-up period. A J-shaped relationship was observed; having between 20 and 60% of methadone scripts supervised (compared to20%) associated with reduced time to discontinuation (20-39% HR=0.88, 95% CI 0.81-0.95; 40-59%: HR=0.87, 95% CI 0.81-0.94). Beyond a threshold of 60%, retention reduced (60-79% of scripts: HR=1.28, 95% CI 1.20-1.36;80% of scripts: HR=3.59, 95% CI 3.38-3.81). Median daily dose between 60 and 120mg/per day, and multiple treatment episodes also associated with longer time to discontinuation of treatment.A J-shaped relationship was observed between supervised consumption and retention in treatment. Additionally, patients experiencing multiple treatment episodes tend to stay in treatment for progressively longer periods of time.

Background. Hypercholesterolaemia is an important modifiable risk factor for cardiovascular disease (CVD) which requires monitoring and management at a population level. Aims. This study aims to describe the distribution of serum cholesterol in a community living population of older adults in Ireland and to examine the awareness, treatment and control of hypercholesterolaemia according to CVD risk status. Method. This is a cross-sectional study in a nationally representative sample of adults aged 50–79 years (n = 5287). Hypercholesterolaemia was defined as lowdensity lipoprotein cholesterol (LDL-C) in excess of the recommended CVD risk category target and/or on lipidlowering medication. Results. This study reports a mean total cholesterol (TC) of 5.1 mmol/L (95% CI 5.0–5.1 mmol/L) and a mean LDL-C of 2.9 mmol/L (95% CI 2.8–2.9 mmol/L) in those aged 50–79 years. In a subgroup aged 50–64 years, 73% (95% CI 71.5–74.5%) were hypercholesterolaemic. LDL-C was controlled to the guideline target in 57% of those with CVD and 49% of those with diabetes. Lack of awareness of hypercholesterolaemia was high across the remainder of the population. Conclusion. Despite a substantial reduction in population mean TC from a high of 6.0 mmol/L in the 1980s to 5.1 mmol/L, this study reports a failure to control hypercholesterolaemia to recommended risk-stratified targets in the Irish adult population. Recommendations for policy include continued monitoring of those at highest risk and CVD risk assessment in those perceived to be at low risk in order to inform shared decision making in relation to lifestyle modification and medication management.

Objectives: This study examines the cost-effectiveness of the OPTI-SCRIPT intervention on potentially inappropriate prescribing in primary care.Methods: Economic evaluation, using incremental cost-effectiveness and cost utility analyses, conducted alongside a cluster randomized controlled trial of twenty-one general practices and 196 patients, to compare a multifaceted intervention with usual practice in primary care in Ireland. Potentially inappropriate prescriptions (PIPs) were determined by a pharmacist. Incremental costs, PIPs, and quality-adjusted life-years (QALYs) at 12-month follow-up were estimated using multilevel regression. Uncertainty was explored using cost-effectiveness acceptability curves.Results: The intervention was associated with a nonsignificant mean cost increase of €407 (95 percent CIs, −357–1170), a significant mean reduction in PIPs of 0.379 (95 percent CI, 0.092–0.666), and a nonsignificant mean increase in QALYs of 0.013 (95 percent CIs, −0.016–0.042). The incremental cost per PIP avoided was €1,269 (95 percent CI, −1400–6302) and the incremental cost per QALY gained was €30,535 (95 percent CI, −334,846–289,498). The probability of the intervention being cost-effective was 0.602 at a threshold value of €45,000 per QALY gained and was at least 0.845 at threshold values of €2,500 per PIP avoided and higher.Conclusions: While the OPTI-SCRIPT intervention was effective in reducing potentially inappropriate prescribing in primary care in Ireland, our findings highlight the uncertainty with respect to its cost-effectiveness. Further studies are required to explore the health and economic implications of interventions targeting potentially inappropriate prescribing.

Background The treatment and management of long-term health conditions is the greatest challenge facing health systems around the world today. Innovative approaches to patient care in the community such as Anticipatory Care Planning (ACP), which seek to help with the provision of high-quality comprehensive care to older adults at risk of functional decline, require evaluation. This study will evaluate one approach that will include primary care as the setting for ACP. Methods/design This study will help to determine the feasibility for a definitive randomised trial to evaluate the implementation and outcomes of an ACP intervention. The intervention will be delivered by specially trained registered nurses in a primary care setting with older adults identified as at risk of functional decline. The intervention will comprise: (a) information collection via patient assessment; (b) facilitated informed dialogue between the patient, family carer, general practitioner and other healthcare practitioners; and, (c) documentation of the agreed support plan and follow-up review dates. Through a structured consultation with patients and their family carers, the nurses will complete a mutually agreed personalised support plan. Discussion This study will determine the feasibility for a full trial protocol to evaluate the implementation and outcomes of an (ACP) intervention in primary care to assist older adults aged 70 years of age or older and assessed as being at risk of functional decline. The study will be implemented in two jurisdictions on the island of Ireland which employ different health systems but which face similar health challenges. This study will allow us to examine important issues, such as the impact of two different healthcare systems on the health of older people and the influence of different legislative interpretations on undertaking cross jurisdictional research in Ireland. Protocol version Version 1, 17 September 2019. Trial registration Clinicaltrials.gov, ID: NCT03902743. Registered on 4 April 2019.

Objectives The aim of the study was to develop an improved search strategy for clinical prediction rules. Study Design and Setting We first refined a list of 30 primary care–relevant journals and improved the efficiency of the Haynes Narrow Filter/Teljour/Murphy Inclusion Filter with 26 items by removing one term (Modified Haynes 26 filter). We then developed the “Royal College of Surgeons in Ireland (RCSI) filter” and compared it with the modified HNF/TMIF26 for its ability to detect prediction rules in the primary care literature. All abstracts and, if necessary, full text were reviewed independently in parallel by primary care physicians. The key outcomes were the percentage of prediction rules identified out of the total identified by both search strategies (sensitivity) and the number of articles that had to be reviewed to identify them (efficiency). Results The Modified Haynes 26 filter returned 1,701 abstracts vs. 1,062 for the RCSI filter. The RCSI filter identified 105 of 111 of all prediction rules identified by either filter, compared with 107 of 111 by the Modified Haynes 26 filter (94.6% vs. 96.4%; P = 0.52). In addition, 9.9% of abstracts found using the RCSI filter were prediction rules, compared with only 6.3% using the Modified Haynes 25 filter (P = 0.001). Conclusion We have developed a novel “RCSI filter” that more efficiently identifies prediction rules in the medical literature.

Aims To examine the risk of mortality associated with interruptions to the continuity of methadone maintenance treatment (MMT), including transfers between services, in opioid‐dependent individuals attending specialist addiction services. Design Retrospective cohort study using addiction services and primary care dispensing records, the National Methadone Register and National Drug‐Related Death Index (NDRDI). Setting Geographically defined population in Dublin, Ireland. Participants A total of 2899 people prescribed and dispensed methadone in specialist addiction services between January 2010 and December 2015. There were five exposure groups: weeks 1–4 following transfer between treatment providers; weeks 1–4 out of treatment; weeks 5–52 out of treatment; weeks 1–4 of treatment initiation; and weeks 5+ of continuous treatment (reference category). Measurements Primary outcome: drug‐related poisoning (DRP) deaths. Secondary outcome: all‐cause mortality (ACM). Mortality rates calculated by dividing number of deaths (DRP; ACM) in exposure groups by person‐years exposure. Unadjusted and adjusted Poisson regression (covariates age, sex, incarceration, methadone dose and comorbidities) estimated differences in mortality rates. Findings There were 154 ACM deaths, 55 (35.7%) identified as DRP deaths. No deaths were observed in the first month following transfer between treatment providers. The risk of DRP mortality was highest in weeks 1–4 out of treatment [adjusted relative risk (aRR = 4.04, 95% confidence interval (CI) = 1.43–11.43, P = 0.009] and weeks 1–4 of treatment initiation (ARR = 3.4, 95% CI = 1.2–9.64, P = 0.02). Similarly, risk of ACM was highest in weeks 1–4 out of treatment (ARR = 11.78, 95% CI = 7.73–17.94, P

Objective To assess the agreement of several different measures of potentially inappropriate prescribing (PIP) in older people and compare their relationship with patient-reported outcomes. Design Prospective cohort study including participants in The Irish Longitudinal Study on Ageing (TILDA). Setting Waves 1 and 2 of TILDA, a nationally representative aging cohort study. Participants A total of 1753 community-dwelling TILDA participants with linked administrative pharmacy claims data on medications. Measurements Potentially inappropriate medications were assessed using the Screening Tool of Older Persons' Potentially Inappropriate Prescriptions (STOPP) v1, American Geriatrics Society (AGS) Beers Criteria® 2012, and relevant Assessing Care of Vulnerable Elders (ACOVE) v3 indicators. Potential prescribing omissions were assessed using the Screening Tool to Alert Doctors to the Right Treatment (START) v1 and ACOVE v3 indicators. Their agreement was assessed via κ statistics, and multivariate regression was used to assess relationships with emergency department visits, general practitioner (GP) visits, quality of life, and functional decline (increased assistance needed for activities of daily living). Results There was slight agreement between STOPP and AGS Beers Criteria® (κ = 0.20) and ACOVE indicators (κ = 0.15), while agreement between AGS Beers Criteria® and ACOVE indicators was fair (κ = 0.31). Agreement was fair between START and ACOVE indicators (κ = 0.34). All measures of inappropriate medications were significantly associated with increased GP visits. Only exposure to two or more START indicators was associated with reduced quality of life (adjusted mean difference = -1.12; 95% confidence interval [CI] = -1.92 to -0.33), and only two or more AGS Beers Criteria® were associated with functional decline (adjusted odds ratio = 2.11; 95% CI = 1.37-3.28). For omissions, both measures were associated with functional decline, but only ACOVE indicators were associated with increased GP visits. Conclusion Prevalence of PIP and relationships with outcomes can differ substantially between tools with little agreement. Choice of PIP measure for research or practice should be considered in light of the circumstances and requirements in each case. J Am Geriatr Soc 68:526-534, 2020.

ObjectiveTo examine the extent of geographical variation across musculoskeletal surgical procedures and associated factors in Ireland.DesignRepeated cross-sectional study.Setting36 public hospitals in Ireland.ParticipantsAdult admissions for hip fracture, hip and knee replacement, knee arthroscopy and lumbar spine interventions over 5 years (2012–2016).Primary outcome measureStandardised discharge rate (SDR).AnalysisAge and sex SDRs were calculated for 21 geographical areas. Extremal quotients, coefficients of variation and systematic components of variance were calculated. Linear regression analyses were conducted exploring the relationship between SDRs and year, unemployment, % urban population, number of referral hospitals, % on waiting lists>6 months and % with private health insurance for each procedure.ResultsAcross 36 public hospitals, n=102 756 admissions were included. Hip fracture repair showed very low variation. Elective hip and knee procedures showed high variation in particular years, while variation for lumbar interventions was very high. Knee arthroscopy rates decreased over time. Higher unemployment was associated with knee and hip replacement rates and urban areas had lower hip replacement rates. Spinal procedure rates were associated with a lower number of referral hospitals in a region and spinal injection rates were associated with shorter waiting lists. A higher proportion of patients having private health insurance was associated with higher rates of hip and knee replacement and lumbar spinal procedures.ConclusionsVariation and factors associated with SDRs for publicly funded hip and knee procedures are consistent with similar international research in this field. Further research should explore reasons for high rates of spinal injections and the impact of private practice on musculoskeletal procedure variation.

AimTo apply the drug utilisation 90% (DU90%) indicator (the number of unique drugs which makes up 90% of a doctor’s prescribing) to general practitioner (GP) practices prescribing in England to examine time trends, practice-level variation, and relationships with practice characteristics, prescribing costs and low-value prescribing.Study designRetrospective cohort study.SettingPrimary care in England, using publicly available prescribing data available from the National Health Service (NHS) digital platform for 2013–2017.ParticipantsAll general practices in England (n=7620).Primary and secondary outcome measuresThe DU90% was calculated on an annual basis for each practice based on medication British National Formulary codes. Low-value prescribing was defined using NHS 2017 guidance (including lidocaine plasters, liothyronine, omega-3 supplements). Descriptive statistics were generated per year on time trends and practice-level variation in the DU90%. Multilevel linear regression was used to examine the practice characteristics (relating to staff, patients and deprivation of the practice area).ResultsAmong 7620 practices, mean DU90% ranged from 130.0 to 131.0 across study years, and regarding variation between practices, there was a 1.4-fold difference between the lowest and highest 5% of practices. A range of medications were included in the DU90% of virtually all practices, including atorvastatin, levothyroxine, omeprazole, ramipril, amlodipine, simvastatin and aspirin. A higher volume of prescribing was associated with a lower DU90%, while having more patients, higher proportions of patients who are women or aged ≥45 years, higher number of GPs working in the practice and being in a more deprived area were associated with a higher DU90%. Practices in higher quintiles of DU90% had higher levels of low-priority prescribing and prescribing costs.ConclusionGP practices typically use 130 different medications in the bulk of their prescribing. Higher DU90% was associated with higher levels of low-priority prescribing and prescribing costs. Increasing use of personal formularies may enhance prescribing quality and reduce costs.

Surgical site infection (SSI) is one of the main causes of morbidity and death after surgical intervention. The use of physical barriers, including gloves, drapes, and gowns to reduce SSI after abdominal surgery is long-standing practice. The aim of this systematic review and meta-analysis was to determine the efficacy of ring incision retractors in reducing the risk of SSI in abdominal surgery.PubMed, CINAHL, the Cochrane randomized controlled trials (RCTs) Central Register, and the ISRCTN registry were searched for RCTs in which ring retractors were utilized to reduce SSI in abdominal surgery. The PRISMA guidelines and RevMan 5.3 were used for study selection and analysis. Additional subgroup analyses were performed, including trials using incision class (clean, clean-contaminated contaminated, and dirty) and trials that used the U.S. Centers for Disease Control and Prevention's SSI definition in their protocol.A total of 19 RCTs inclusive of 4,229 patients were included. The utility of ring retractors in reducing SSI was suggested by an overall risk ratio of 0.62 (95% confidence interval 0.48-0.81). However, study heterogeneity caused by differences in effect size between individual RCTs, the non-standardized utilization of concomitant measures to reduce SSI, and an overall lack of high-quality trials was found.A reduction in SSI incidence with the use of ring retractors is suggested by the findings. However, this result must be treated with caution because in addition to some old trials poor quality and the large number of factors affecting SSI, there were substantial differences between trials in effect sizes in statistical heterogeneity. Further RCTs are needed to confirm this provisional finding.

Objective. The aim of this study was to survey GPs and community pharmacists (CPs) in Ireland regarding current practices of medication management, specifically medication reconciliation, communication between health care providers and medication errors as patients transition in care.Methods. A national cross-sectional survey was distributed electronically to 2364 GPs, 311 GP Registrars and 2382 CPs. Multivariable associations comparing GPs to CPs were generated and content analysis of free text responses was undertaken.Results. There was an overall response rate of 17.7% (897 respondents—554 GPs/Registrars and 343 CPs). More than 90% of GPs and CPs were positive about the effects of medication reconciliation on medication safety and adherence. Sixty per cent of GPs reported having no formal system of medication reconciliation. Communication between GPs and CPs was identified as good/very good by >90% of GPs and CPs. The majority (>80%) of both groups could clearly recall prescribing errors, following a transition of care, they had witnessed in the previous 6 months. Free text content analysis corroborated the positive relationship between GPs and CPs, a frustration with secondary care communication, with many examples given of prescribing errors.Conclusions. While there is enthusiasm for the benefits of medication reconciliation there are limited formal structures in primary care to support it. Challenges in relation to systems that support inter-professional communication and reduce medication errors are features of the primary/secondary care transition. There is a need for an improved medication management system. Future research should focus on the identified barriers in implementing medication reconciliation and systems that can improve it.