Research Posters 2028 – 2034
2028 Variation in prescribing for type 2 diabetes mellitus in Ireland in 2013 and 2014
Background: Type 2 Diabetes Mellitus (T2DM) is rising in prevalence, causing a substantial burden to both patients and society. Variation in the management of T2DM has been postulated as one cause of poor diabetes control. Our aim was to assess variation in the prescribing of anti-diabetic medications by geographical region in the Republic of Ireland (RoI).
Methods: Cross sectional analyses were undertaken on the two main national community drug schemes in the RoI between 2013 and 2014. Direct standardised rates of individual anti-diabetic medication prescribing per 100,000 population were calculated by local and regional geographical areas. Prescribing was compared across geographical areas using the systematic component of variation (SCV). Estimated total costs of prescribing were calculated per geographical area using the 2013 and 2014 medication wholesale costs.
Results: The SCV was over 10 for GLP-1 agonists indicating very high levels of geographical variation and over 5 for DPP4-inhibitors indicating high geographical variation. Prescribing rates of all anti-diabetic medications increased in 2014 compared to 2013. There were no apparent explanatory factors that affected variation in prescribing. Geographical variation in the RoI leads to an estimated total cost differential of €600,000 for DPP4-inhibitors and €500,000 for GLP-1 agonists, per 100,000 population, between the highest and lowest prescribing areas.
Conclusion: Substantial geographical variation in the standardised prescribing rate of GLP-1 agonists and DPP4-inhibitors was present in Ireland. This could represent a variation in the application of guidelines in T2DM management in Ireland and has implications on the quality of care delivery and cost.
2029 Use of Unscheduled Care by Patients with Terminal Cancer
AIM: To understand the patterns, causes and effects of patient attendance in unscheduled care by patients with cancer in their last 12 months of life.
METHOD: This research is a retrospective cohort study of NHS Tayside residents who have died from cancer between 01/01/2012 and 30/06/2015, using GPOOH and A&E attendance records linked using Community Hospital Index (CHI) numbers to demographic, General Registry Office, Cancer Registry, clinical, and prescribing datasets.
RESULTS: There were 5,788 patients in the cohort, accounting for 8,897 presentations to unscheduled care. Of these 8,897 presentations, 5,922 were to GPOOH and 2,975 to A&E. Data were analysed with descriptive statistics.
RELEVANCE/IMPACT: This research can potentially identify factors associated with unscheduled care use and suggest clinical and service provision changes that could be made to improve the patient journey in patients with terminal cancer.
DISCUSSION: The majority of patients with terminal cancer use unscheduled care in their last year of life. A quarter of patients with terminal cancer used GPOOH, and a third used A&E. Patients tend to use either A&E or GPOOH; very few use both services. Half the contacts with unscheduled care are due to uncontrolled palliative symptoms. Patients who attend GPOOH tend to do so multiple times; whereas patients attending A&E attend less frequently. Use of unscheduled increases significantly in the month before death and increases dramatically again in the week before death.
OUTCOMES:Patients with cancer commonly present to A&E in their last year of life. Such presentations become more common in the weeks before death. Presentations are commonly due to uncontrolled pain. Adequate pain relief is an important factor in improving patient journey and minimizing unscheduled care use.
2030 Is the NHS breast cancer screening programme cost-effective? A systematic review and economic analysis
Meelad Sayma, Robert Morton
Aims and Objectives: To evaluate if the current breast cancer screening programme is cost-effective for the NHS and therefore congruent with NICE guidance.
Content of Presentation The financial burden of cancer is continually rising, currently costing the NHS over £700million-a-year. One of the key tools thought to combat the large costs of late stage cancer diagnosis is the use of cancer screening. One programme currently in use is the NHS breast cancer screening programme.
Relevance The availability of more effective treatments and risk-implications of using mammography as part of the screening programme has led to the cost-effectiveness of breast cancer screening to come under scrutiny. This papers evaluates the current cost-effectiveness of the programme, through a systematic literature review and economic analysis.
Outcomes A cost-utility analysis was conducted with multiple sensitivities. The mean incremental cost-effectiveness ratio (ICER) was £11,546/QALY. The first sensitivity analysis used maximum costs at each node, the ICER was £17,254/QALY. A second sensitivity analysis assumed that the majority of costs for screening would be fixed costs i.e. the screening centres, and staff would be paid regardless of use. In this model the ICER was £14,172/QALY. In the final sensitivity analysis, the last two models were combined to produce a ‘worst case’ scenario, resulting in an ICER of £20,823/QALY.
Discussion The results indicate some element of doubt as to the cost-effectiveness of the programme when compared to NICE guideline thresholds. Five systematic reviews of economic evaluations from OECD countries were analysed for their congruence to results, demonstrating similarities.
2031 Children with Anxiety Disorders in Primary Care: the views of General Practitioners
Aim/objectives: Anxiety disorders affect 6.5% of children and often run a chronic course. Effective treatments for these disorders are available, yet only a minority of affected children access them. This is of serious concern, particularly considering the far-reaching and long-term negative consequences at an individual and societal level. Primary care is usually the first port of call for parents concerned about their child’s mental health and, as such, General Practitioners are in an optimum position to manage childhood anxiety disorders. Therefore, it is important to understand how GPs manage these disorders, including potential barriers they face. The aim of this study is to ascertain GP’s perceptions of barriers to effective management of childhood anxiety disorders.
Methods/Content of Presentation: Twenty GPs were purposively sampled throughout England to obtain a diverse range of characteristics. Interviews explored GPs’ experiences of managing anxiety disorders in children (< 12 years) in relation to recognition, management practices, referral, delivery of local services and suggestions for improvements. Data were analysed using Thematic Analysis, which occurs on a latent level, involving substantial interpretive analysis.
Outcomes & Discussion: The data highlighted numerous barriers that GPs in England experience in the management of childhood anxiety disorders. Three main themes emerged: GP’s emotional response, decision-making and responsibility. Results will also be discussed regarding the different barriers experienced by GPs with particular characteristics.
Relevance/Implications: This study has clear implications for the management and treatment of childhood anxiety disorders, particularly regarding the need to strengthen the ability of GPs to identify and manage these disorders and to be able to gain efficient access to specialist services for affected children and thier families.
2032 Doctors with dyslexia: Strategies and support
Background Looking beyond dyslexia as an individual doctor’s issue requires adjusting a working environment to better serve the needs of doctors with dyslexia. With an increasing number of doctors disclosing dyslexia at medical school, how is it best for educators to provide this support? Our research looks at the impact of dyslexia on clinical practice and the coping strategies used by doctors to minimise the effect.
Summary of Work Qualitative data was collected from 14 doctors with dyslexia using semi-structured interviews and by survey. ‘In situ’ demonstration interviews were conducted in order to understand how dyslexia is managed in the workplace from first-hand experience. Employers and educators who have responsibility for meeting the needs of this group were also consulted.
Summary of Results Even in cases of doctors who had a diagnosis, they often did not disclose their dyslexia to the employer. Study participants reported having developed individual ways of coping and devised useful ‘workarounds’. Support from employers comes in the form of ‘reasonable adjustments’ although from our data we cannot be sure that such adjustments contribute to an ‘enabling’ work environment. Supportive characteristics included the opportunity to shadow others and the time and space to complete paperwork on a busy ward.
Conclusions /Take home messages Doctors with dyslexia need to be helped to feel comfortable enough to disclose. Educators need to challenge any negative assumptions that exist as well as promote understanding about the elements that contribute to a positive working environment. There is practice guidance available for educators to identify strategies and resources that are evidence based.
2033 Stroke survivors’ experiences of and need for primary care and community health services—a systematic review of the qualitative literature
Background: Long-term community healthcare services for stroke survivors remain underdeveloped while patients report many unmet needs. We systematically reviewed qualitative literature on stroke survivors’ long-term needs and experiences of primary care and community healthcare services. Method: Four databases were systematically searched: MEDLINE, EMBASE, PsycINFO and CINAHL. We included peer reviewed qualitative studies in English which focused on community dwelling adults diagnosed with stroke. The quality was assessed using the Critical Appraisal Skills Programme (CASP) and Dixon-Woods criteria. Meta-ethnography was used to synthesise the findings by two independent reviewers.Findings: 37 papers with 722 participants (565 survivors and 182 carers) were included. Studies originated from the UK (46%), North America (24%), Australia (16%), Scandinavia (13%) and Iran (2%). Stroke severity was reported in 27% of studies. Participants in the chronic post-stroke phase (at least 12 months) were represented in 62% of the studies.
The review identified service-specific (structural and communication related) factors contributing to survivors’ feelings of abandonment following hospital discharge. The tension between service passivity and survivors’ need for proactive contact from services (e.g. GP-initiated follow-up, coordinated and personalised information about stroke and recovery) was identified as an overarching concept. The fragmented nature of community healthcare services made it difficult for survivors to access the help they needed.
Conclusions: The passivity of services limits survivor engagement with community healthcare services. Interventions focused on proactive contact of community health services with stroke survivors and improving communication between community health services have potential to address survivors’ feelings of abandonment after hospital discharge.
2034 The experiences of and need for primary care and community health services in informal carers of stroke survivors – a systematic qualitative review
Background: This is the first systematic review of qualitative literature on the long-term needs and experiences of primary care and community healthcare services in carers of stroke survivors.
Method: Four databases were systematically searched: MEDLINE, EMBASE, PsycINFO and CINAHL. We included peer reviewed qualitative studies in English which focused on community dwelling adults informal carers of adult stroke survivors. The quality was assessed using the Critical Appraisal Skills Programme (CASP)and Dixon-Woods criteria. Meta-ethnography was used to synthesise the findings by two independent reviewers.
Results: 34 papers with 874 participants (362 survivors and 537 carers) were included. Studies originated from the UK (53%), North America (32%), Australia (12%) and Scandinavia (3%). Carers of stroke survivors who were at least 12 months after stroke were represented in 62% of the studies. A striking finding of the review was that carers talked primarily about survivors’ service needs. The key carer specific needs were: carer-focused training (e.g. what to expect and how to establish a routine, help with practical caregiving skills, information on recovery) and back-up services. Lack of service support and service providers’ assumptions that carers would just ‘get on with things’ contributed to feelings of isolation and concerns about continuing in the caregiving role.
Conclusion: There is scope to develop interventions that focus on basic caregiving knowledge and skills and ensure availability of support for the patient when the carer is under stress. Needs of carers are not addressed by community services with the result that some carers discontinue their caregiving role.