Multimorbidity and Polypharmacy

Multimorbidity, the co-occurrence of two or more chronic conditions in the one individual patient, is increasingly the norm in Irish General Practice. Patients with multimorbidity are often prescribed multiple medications. The resulting polypharmacy can lead to dilemmas for prescribers who on the one hand want to avoid the problems associated with increasing numbers while on the other want to ensure their patients benefit from evidence-based care. Here in the Department of General Practice in University College Cork, we are trying to understand the prescribing dilemmas faced by GPs in the management of their patients with multimorbidity. Additionally, we are developing a tool to assist prescribing for these complex patients. If you are interested in hearing more about this project, please contact Dr Carol Sinnott, Research Fellow at csinnott@ucc.ie 

Dementia - PREPARED

Primary Care Education, Pathways and Research in Dementia (PREPARED)

Funded by the Health Service Executive and The Atlantic Philanthropies as part of Ireland's National Dementia Strategy Implementation Programme (2014-2018) 

The PREPARED project is a primary care focused national research and service development initiative coordinated by the Department of General Practice at UCC which ran between 2015 and 2019.  

PREPARED contributed to the delivery of the priority actions and objectives for primary care health services set out in the Department of Health's publication 'The Irish National Dementia Strategy (December 2014). The strategy aims to improve the lives of people with dementia by increasing awareness, ensuring early diagnosis and developing enhanced community based interventions.

The overall aims of the PREPARED project were to develop, deliver and evaluate training and education interventions for primary care clinicians which led to:

• Patients receiving optimal, evidence based dementia care in General Practice by GPs who are upskilled to assess, diagnose and care for patients with dementia, and who are empowered by clear, accessible dementia care pathways;
• Patients recieve an integrated, collaborative dementia care response from a prepared, proactive Primary Care Team.

The PREPARED project consisted of 4 inter-related workstreams which will address the following:

• The preparation and dissemination of primary care dementia training and education packages for GPs and members of Primary Care Teams
• The delivery of education and training with support to clinical dementia experts to lead education and mapping of local dementia care pathways, and the engagement of and support for GPs and PCTs to deliver best practice dementia care
• To facilitate behaviour change with the application of decision support software and integrated dementia care pathways, guidelines and clinical toolkits
• To research and evaluate the project on an ongoing basis by conducting dementia learning needs assessments, and assessing the impact on the education, engagement and IT innovation in the delivery of dementia care by GPs and PCTs

The PREPARED project was coordinated by the Department of General Practice at UCC and was led by Dr Tony Foley, Lecturer at UCC and GP in Kinsale, collaborating with the ICGP and with the Dementia Elevator Programme, School of Nursing and Human Sciences at DCU. The PREPARED project team consisted of Katherine Thackeray (Project Manager), Dr Aisling Jennings (GP and PhD candidate), Siobhan Boyle (Research Support Officer) and Kathleen McCloughlin (Research Fellow). The PREPARED project was launched at UCC on 2nd March 2015 by Minister Kathleen Lynch T.D., Minister of State for Primary Care, Social Care and Mental Health.  A video film from the PREPARED launch which provides an overview of the project is on youtube.  

Since its launch, the PREPARED has developed and published a clinical web resource called dementiapathways.ie which is specifically designed for GPs and primary care health professionals, and which includes clinical care pathways, a comprehensive compendium of information leaflets and guidelines, information about education and training opportunities for GPs and primary care clinicians, and a database of community based clinical services and supports available for patients with dementia across Ireland.  

The PREPARED project developed and delivered a range of educational interventions including workshops and seminars for GPs on the diagnosis and management of dementia in primary care. These consisted of short practice-based locally provided accredited workshops faciliated by a group of GP facilitators in a number of locations around the country.  Between May 2016 and December 2018, over 90 workshops have been run, with a combined total of over 550 GPs and practice staff participating.  The PREPARED project has shared the GP dementia workshop content with the ICGP CME tutor network, and the workshops have also been used in local small group CME sessions in Cork, Dungarvan, Waterford, Galway and Dublin South West reaching a further 230 GPs.  A full workshop facilitators guide and clinical content is published and available for use on the dementiapathways.ie website

The PREPARED project, in collaboration with the ICGP, launched a comprehensive dementia e-learning module for GPs which is available on the ICGP e-learning website (login required).  

PREPARED also developed and delivered a UCC CPD postgraduate module on dementia care in primary care that is a fully accredited 10 ECTS CPD blended learning module. 19 GP students successfully completed the course in 2017/2018, and 17 more completed the course in 2018/2019. More information on the postgraduate module can be found on the UCC CPD website.

The PREPARED team worked closedly with the National Dementia Office of the HSE, and with a number of primary care healthcare professionals on the development of training and educational packages and tools geared towards the needs of the wider Primary Care Team (PCT).  This included resources on the dementiapathways.ie website.  A three hour workshop on collaborative teamworking and dementia care in primary care has been developed by Anne Quinn, Advanced Nurse Practitioner in the HSE working with the PREPARED team, and tested with three groups of primary care based staff and PCTs in Cashel, Tipperary, Kinsale, County Cork and Blackrock, Cork City in 2016/7.  A number of PCT workshops were run around the country in various locations and are now offered to staff in the HSE and primary care through a number of Centres of Nursing and MIdwifery Education (CNMEs), and a facilitators workshop guide is available at dementiapathways.ie  Further resources for individual professional groups are being developed with funding from PREPARED in conjunction with the National Dementia Office in the HSE and the Dementia Services and Information Development Centre (DSIDC) at St James, Dublin.

The PREPARED project also developed a research evidence base for dementia training for GPs through research, learning needs assessment and interviews with clinicians, patients and carers, and has worked in conjunction with the School of Nursing at DCU and with Dr Maria Pierce on evaluation of the project.  A full list of publications associated with the PREPARED project are available on dementiapathways.ie  PREPARED has also worked with the Irish Primary Care Research Networks (iPCRN) on the development of dementia research and audit tools on GP software systems which are available to many GPs through their practice software to help generate practice based dementia registers and auditable information on dementia diagnoses, medication and care.  The PREPARED team has also produced a clinical audit guide on dementia for GPs, which is available on the dementiapathways.ie website.

NEIL Memory Research Unit, Mallow

Failing cognitive function prevents millions of older adults from living independently. The goal of the Neuro Enhancement for Independent Lives (NEIL) Programme at Trinity College Dublin is to enable independent living and improve quality of life by conducting research and developing interventions aimed at dementia prevention.  Mallow Primary Healthcare Centre (MPHC) in Cork is the first satellite NEIL Memory Research Unit joining forces with Trinity College Dublin to engage older adults in brain health research.  The purpose of this unit, and of the Dublin-based NEIL Memory Research Unit, is to collect rich and comprehensive data from up to 1000 healthy adults aged 50+, with the aim of furthering understanding of memory and related processes, and the aspects of our lives that influence these processes as we age.

Dr. Cormac Sheehan of the HSE and The Department of General Practice UCC, who is overseeing for the running of the Memory Research Unit Mallow said:  “We are delighted to be opening the first satellite study site for the NEIL Memory Research Unit in MPHC. The main study at TCD is already very successful with over 800 participants. We want to develop ways to help people to protect their memory and other aspects of brain function as they age. This study will provide an accurate baseline of the cognitive functions of healthy adults over the age of 50. We also hope that this will open exciting opportunities for more research at MPHC and lead to experience and employment opportunities of young graduates of  UCC and our other national universities”. 

If you are aged 50+ we want you to take part in a comprehensive memory and attention study at our Memory Research Unit Mallow. You will be provided with a personalised feedback report, containing information that can help you to 'stay sharp' as you get older.

You will help further our understanding of memory and attention, and how these are influenced by people’s day to day lives as we get older.

If you are interested in hearing more about taking part in the NEIL study please contact us and leave your name, phone number and address by calling 0864128797 or  by email mrumallow@gmail.com, or the Memory Research Unit Mallow, MPHC, Mallow, Co. Cork.

Traffic Medicine, Fitness to Drive and Mild Cognitive Impairment

Left to right: Dr Siobhán Cusack; Prof Colin Bradley; Prof Mary Horgan, UCC; Declan Naughton, Road Safety Authority; Dr Carol Sinnott, UCC; and Prof Des O’Neill, National Programme Office for Traffic Medicine

The Road Safety Authority (RSA), in association with the National Programme Office for Traffic Medicine (NPOTM), awarded the €40,000 grant following a competitive process.  Co-leads Research Fellow Dr Carol Sinnott and Professor of General Practice and Head of Department Prof Colin Bradley, both in the Department of General Practice at UCC, will head a team of researchers, representing UCC (Dr Tony Foley and Dr Kathleen McCloughlin, and Linda Horgan, Departments of General Practice and Occupational Therapy, respectively), the ICGP (Dr Claire Collins, Research Director) and the Alzheimer Society of Ireland (Dr Emer Begley).

The research project, ‘Talking to patients with cognitive impairment about fitness to drive: Current approaches and possible improvement strategies for a general practice setting’, will investigate driving with cognitive impairment. Its main purpose is to look at how patients with cognitive impairment and GPs manage the discussion around safe driving.

Prof Desmond O’Neill, National Director of the NPOTM, emphasised the importance of research in the area of cognitive impairment and driving. “A part of the success of the [Traffic Medicine] Programme on Medical Fitness to Drive in Ireland stems from its roots in evidence-based practice. It is very important that we develop research in traffic medicine in Ireland that is reflected in clinical practice, and we are delighted that this comprehensive project on cognitive impairment and driving is the focus of the first RSA Research Award in Traffic Medicine, as this is an emerging and very relevant topic to road safety and patient care.”

Declan Naughton, Director of Driver Testing and Licensing, RSA, added: “Research that provides an evidence base for future policy is critical. This research will give us an insight into the engagement between drivers and GPs at a time when drivers may be feeling vulnerable. Understanding and responding to any barriers to this conversation, happening in a positive environment, will benefit both drivers and their doctors.”

Both the approaches currently used by GPs and the experiences that patients with cognitive impairment have had when discussing fitness to drive with their GPs will be explored by carrying out separate sets of interviews with patients or their carers.

The data from both sets of interviews will then be merged and used to develop new training materials for GPs.

For more information about this project, please contact Dr Carol Sinnott at csinnott@ucc.ie or Dr Kathleen McLoughlin at kathleenmcloughlin@ucc.ie

 

Diabetes

The Department of General Practice has had a long history in research, audit and education initiatives linked to the management of diabetes in primary care.

‌Diabetes in General Practice (DiGP) is a general practice focused initiative whose aim is to provide a forum for GP’s and practice nurses to ensure best practice in their management of diabetes in general practice, through peer support, education and audit.

DiGP have also hosted a national collaborative diabetes conference in Cork since 2008.  

More information and booking forms for the conference can be found on the Diabetes in General Practice (DiGP) website

Epilepsy

The epilepsy research theme in the Department of General Practice is led by Henry Smithson who is involved with 3 projects:

Epilepsy and Pregnancy

1.  The UK and Ireland Epilepsy Pregnancy Register collects data from pregnancy outcomes from pregnant women with epilepsy and has been active since 1996 and holds data on 9,000 women. The register focuses on the association between anti-epileptic drugs (AED) taken by expectant mothers and Major Congenital Malformations (MCM) of their babies and also provides evidence about the association of MCM and maternal folic acid use and the effect of socio-economic status on pregnancy outcomes. The register is led by investigators at the RVI Belfast and RCSI Dublin.

Links: www.epilepsypregnancyregister.ie  www.epilepsyandpregnancy.co.uk/ 

Publications from the register can be found at http://www.epilepsyandpregnancy.co.uk/pages/publications.htm

VNS Health Utilisation Study

Vagal Nerve Stimulator (VNS) devices are used as adjunct treatment for refractory epileptic seizures and are recommended by both the American Association of Neurologists and the National Institute for Health and Social Care Excellence (NICE) UK. However, referral of patients with drug resistant epilepsy to surgical centres for assessment for the suitability of surgical treatment (including VNS) is variable across regions and is lower in the UK and Ireland than in the USA. Prof Smithson is leading a before and after study using UK Hospital Episode Statistics data to determine whether there is a benefit for patients with VNS in a reduction of healthcare use and whether this would offset the costs of implanting and maintaining the device

Epilepsy Deaths Register for Ireland

Epilepsy is the commonest serious neurological condition with a prevalence rate of about 9 per 1000. In Ireland there are therefore 37,000 people treated for the condition. The majority of people with epilepsy (PWE) respond to treatment and are seizure free but about 30% have seizures that do not respond to medicines. This leads to an increased risk of injury, depression and suicide. A few people may be at risk of sudden unexpected death in epilepsy (SUDEP) and it is estimated that 100 PWE die each year in Ireland, giving a mortality rate that is 20 times higher than the mortality rate for asthma. It is important to identify factors that can be modified to reduce the number of deaths. Prof Smithson leads the Expert Advisory Committee and is responsible for the analysis of data collected from the register.

Link: www.epilepsy.ie

Preparation for Professional Practice (e-PrePP)

The ePrePP project is funded by the National Forum for the Enhancement of Teaching and Learning and is a collaborative venture between UCC, TCD, IT Tralee, UL, UCD and NUIG .  The project is led by a group consisting of medicine, nursing, pharmacy and pedagogy and has appliatications not only for other health disciplines but also the wider student body.

The ePrePP initiative came about as a collaborative project to build a suite of digital resources to assist students and tutors in enhancing the educational experience in clinical placements. The placement resources use eportfolios to enable competency based learning supported by digital packages.

The project focuses on the transition to clinical placement, how digital media is helping to ease the transition and develop the skills that apply across the professions. Key areas covered by the project are:

• Enhancing placement learning in healthcare
• Easing transition to professional practice
• Embedding interprofessional education

For more information please visit the ePrePP website at http://www.eprepp.ie 

Medication Errors

The PHARMS (Patient Held Active Record of Medication Status) Study  

Funded by the Strategic research Fund, UCC and MediSec Ltd

Medication errors are common and result in suboptimal clinical outcomes. Many errors occur during transitional care; the time where patients move between different stages and settings of care. The interface of primary and secondary care at time of discharge from hospital is particularly error prone. Key areas within this error process are poor documentation of medication and poor communication between health care professionals in primary and secondary care. Through collaboration between the Department of General Practice and GP software provider Si-Key Ltd, the INSIGHT centre for Data Analytics, the Technology Transfer Office and the Health Information Systems Research Centre, an electronic patient held medication record has been developed as a potential solution to this issue. Led by Dr Elaine Walsh; the PHARMS Study is a feasibility study of the introduction of a patient held electronic record in both primary and secondary care. For more details on the PHARMS study please contact Dr Elaine Walsh at elaine.walsh@ucc.ie

INSPIRE - End of Life Supports

The INSPIRE study investigates social and practical supports for people and their family caregivers, who are living at home during their last year of life with a particular focus on Milford Care Centre’s Compassionate Communities Good Neighbour Partnership.  

The study commenced in October 2014 and will run to September 2017.

The INSPIRE study is funded through the 2014 All Ireland Institute of Hospice and Palliative/Irish Cancer Society Research Fellowship Award.

It is anticipated that the findings from the various elements of the INSPIRE study will represent an invaluable addition to international literature, illuminating the efficacy, utility and acceptability of a unique model of social and practical care for people with life-limiting illness. This may help to inform the development of similar models. 

Dr Kathleen McLoughlin, Principal Investigator, Department of General Practice, University College Cork is leading the study in collaboration with Prof. Sinéad McGilloway at Maynooth University (Mental Health and Social Research Unit) and Milford Care Centre in Limerick.