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.  

PREPARED has been designed to inform and contribute to the delivery of the priority actions and objectives 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 are to develop, deliver and evaluate training and education interventions for primary care clinicians which will contribute 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 consists 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 is coordinated by the Department of General Practice at UCC, collaborating with the ICGP and with the Dementia Elevator Programme, School of Nursing and Human Sciences at DCU. 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 has designed and is delivering educational workshops and seminars for GPs on the diagnosis and management of dementia.  These consist of 2 1-hour or 1 2-hour practice-based locally provided accredited workshops provided by one of our GP facilitators in a number of locations around the country.  Between May 2016 and July 2017, over 60 workshops have been run, with 260 GPs and practice staff participating.  For information on these workshops or to register an interest in participating in a workshop, please email the team at dementiapathways@ucc.ie.  

The PREPARED project has developed the GP dementia workshop content to be run in CME small group meetings.  This session has already been run successfully in Cork City CME sessions (October 2016) and in Dungarvan and Waterford CME sessions (April 2017), with over 100 GPs attending the sessions.  Any local CME tutors who are interested in using the PREPARED resources to run a dementia session should contact the team at dementiapathways.ie.  

The PREPARED team is also working in collaboration with the ICGP in the development and launch of online GP dementia modules which will be available on the ICGP e-learning website.  2 of these modules are currently available for GPs and other primary care healthcare professionals on the ICGP e-learning portal, or on the IPNA website e-learning section (access to the course materials is open to all on the IPNA website, but registration is required on both sites in order to access assessment, completion record and or certificate for CPD).  

In September 2017, a UCC fully accredited 10 ECTS CPD blended learning postgraduate module on dementia care in primary care was launched with 20 GP students undertaking the course.  It is hoped that future courses will be run in 2018.   More information on the postgraduate module can be found on the UCC CPD website.

The PREPARED team has worked with a number of primary care healthcare professionals over 2016 and 2017 on the development of training and educational packages and tools geared towards the needs of the wider Primary Care Team (PCT). A three hour workshop on collaborative teamworking and dementia care in primary care has been tested with three groups of primary care based staff and PCTs in Cashel, Tipperary, Kinsale, County Cork and Blackrock, Cork City, and a finalised workshop has now been launched and a facilitators workshop guide is available at dementiapathways.ie  The workshop is also now being run in locations across the country by Anne Quinn, who developed the content of the workshop and is an advanced nurse practitioner in dementia alongside other HSE colleagues with an interest in dementia.  The locations of the workshops for 2017 are as follows:

• Tuesday 19th September 2017 - Kilbarrack Primary Care Team, Kilbarrack, Dublin 5

• Wednesday 4th October 2017 - Killarney Community Hospital

• Monday 13th November 2017 pm - Maynooth Health Centre

• Tuesday 14th November 2017 pm - Wicklow Town Health Centre

• Monday 27th November 2017 am - Castlebar Primary Care Centre, Mayo

• Tuesday 28th November 2017 am - Ballyshannon Health Campus, Donegal

• Monday 11th December pm - Ely Hospital, Wexford

• Tuesday 12th December pm - Tyone Health Centre, Nenagh, Tipperary

• Wednesday 13th December 2017 pm - Cluain Lir Care Centre, Mullingar, Westmeath

If you are interested in booking a place, then you should contact the HSE National Dementia Office on dementia.office@hse.ie providing your name, role and location of the training.  Places are allocated on a strictly first-come, first-served basis.

The PREPARED project is developing an evidence base for dementia training for GPs through research, learning needs assessment and interviews with clinicians, patients and carers.  Ongoing review of the effectiveness and impact of educational interventions and online resources will be undertaken to inform the roll out of the PREPARED project nationally.  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 all 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.

The PREPARED project will also be developing further resources for GPs and HSE staff working in primary care teams, and is delighted to be working with colleagues in the HSE National Dementia Office, the ICGP, DCU Dementia Elevator Programme and other partners in collectively contributing to improving awareness and skills in dementia care.

The PREPARED project team are keen to hear from anyone who would like more information about the PREPARED project, or would like to be involved in our education and training initiatives.  The team contact details are:

PROJECT EMAIL ADDRESS:  dementiapathways@ucc.ie

Dr Tony Foley, Lecturer in the Department of General Practice and GP in Kinsale:   tonyfoley@ucc.ie

Ms Katherine Thackeray, Dementia Project Manager  (021 4205557):  katherine.thackeray@ucc.ie

Ms Siobhan Boyle, Research Support Officer  (021 4205596):  siobhan.boyle@ucc.ie

Dr Aisling Jennings, GP Researcher/PhD candidate  (021 4205597):   aisling.jennings@ucc.ie

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.