Fiona Riordan

A systematic review of methods to assess intake of fruits and vegetables among healthy European adults and children: a DEDIPAC (DEterminants of DIet and Physical Activity) study

OBJECTIVE Evidence suggests that health benefits are associated with consuming recommended amounts of fruits and vegetables (F&V), yet standardised assessment methods to measure F&V intake are lacking. The current review aims to identify methods to assess F&V intake among children and adults in pan-European studies and inform the development of the DEDIPAC (DEterminants of DIet and Physical Activity) toolbox of methods suitable for use in future European studies. DESIGN A literature search was conducted using three electronic databases and by hand-searching reference lists. English-language studies of any design which assessed F&V intake were included in the review. SETTING Studies involving two or more European countries were included in the review. SUBJECTS Healthy, free-living children or adults. RESULTS The review identified fifty-one pan-European studies which assessed F&V intake. The FFQ was the most commonly used (n 42), followed by 24 h recall (n 11) and diet records/diet history (n 7). Differences existed between the identified methods; for example, the number of F&V items on the FFQ and whether potatoes/legumes were classified as vegetables. In total, eight validated instruments were identified which assessed F&V intake among adults, adolescents or children. CONCLUSIONS The current review indicates that an agreed classification of F&V is needed in order to standardise intake data more effectively between European countries. Validated methods used in pan-European populations encompassing a range of European regions were identified. These methods should be considered for use by future studies focused on evaluating intake of F&V.

Evaluating the implementation of a national clinical programme for diabetes to standardise and improve services: a realist evaluation protocol.

BackgroundOver the last three decades in response to the growing burden of diabetes, countries worldwide have developed national and regional multifaceted programmes to improve the monitoring and management of diabetes and to enhance the coordination of care within and across settings. In Ireland in 2010, against a backdrop of limited dedicated strategic planning and engrained variation in the type and level of diabetes care, a national programme was established to standardise and improve care for people with diabetes in Ireland, known as the National Diabetes Programme (NDP). The NDP comprises a range of organisational and service delivery changes to support evidence-based practices and policies. This realist evaluation protocol sets out the approach that will be used to identify and explain which aspects of the programme are working, for whom and in what circumstances to produce the outcomes intended.Methods/designThis mixed method realist evaluation will develop theories about the relationship between the context, mechanisms and outcomes of the diabetes programme. In stage 1, to identify the official programme theories, documentary analysis and qualitative interviews were conducted with national stakeholders involved in the design, development and management of the programme. In stage 2, as part of a multiple case study design with one case per administrative region in the health system, qualitative interviews are being conducted with frontline staff and service users to explore their responses to, and reasoning about, the programme’s resources (mechanisms). Finally, administrative data will be used to examine intermediate implementation outcomes such as service uptake, acceptability, and fidelity to models of care.DiscussionThis evaluation is using the principles of realist evaluation to examine the implementation of a national programme to standardise and improve services for people with diabetes in Ireland. The concurrence of implementation and evaluation has enabled us to produce formative feedback for the NDP while also supporting the refinement and revision of initial theories about how the programme is being implemented in the dynamic and unstable context of the Irish healthcare system.

Physical and psychosomatic health outcomes in people bereaved by suicide compared to people bereaved by other modes of death: a systematic review

BackgroundLittle research has been conducted into the physical health implications of suicide bereavement compared to other causes of death. There is some evidence that suicide bereaved parents have higher morbidity, particularly in terms of chronic illness. This systematic review aims to examine the physical and psychosomatic morbidities of people bereaved by a family member’s suicide and compare them with family members bereaved by other modes of death.MethodsMEDLINE, EMBASE, CINAHL, and PsycINFO were searched from 1985 to February 2016. The search was re-run in March 2017. Peer-reviewed English language articles comparing suicide-bereaved family members to non-suicide bereaved family members on measures of physical or psychosomatic health were eligible for inclusion. Cohort, cross-sectional, case-control and cohort-based register studies were eligible for inclusion. A modified version of the Newcastle Ottawa Scale was used for quality assessment. Results were synthesised using narrative synthesis.ResultsThe literature search located 24 studies which met the inclusion criteria. Seven studies found statistically significant associations between physical health and suicide bereavement. Five of the studies found that suicide-bereaved family members were more likely to experience pain, more physical illnesses and poorer general health. They were also at increased risk of cardiovascular disease, hypertension, diabetes and chronic obstructive pulmonary disease. In contrast, another study in Denmark found that those bereaved by suicide had a lower risk of a number of physical health disorders, including cancers, diabetes, cardiovascular and chronic lower respiratory tract disorders compared to those bereaved by other causes of death. Additionally, a further study conducted in the United States found that suicide-bereaved children visited a GP less frequently than non-suicide bereaved children.ConclusionsReview findings are relevant for clinicians working with people bereaved by suicide as they highlight that such clients are at increased risk of several adverse physical health outcomes. Future research should examine health risk behaviours of suicide-bereaved and non-suicide bereaved family members as they may confound the association between exposure and outcome.Trial RegistrationsThe review protocol has been registered on PROSPERO, registration number CRD42016030007.

Clinical handover practices in maternity services in Ireland: A qualitative descriptive study

OBJECTIVE the objective was to examine and describe clinical handover practices in Irish maternity services. DESIGN the study design incorporated interviews and focus group discussions with a purposive sample of healthcare practitioners working in Irish maternity services. SETTING five maternity hospitals and fourteen co-located maternity units. PARTICIPANTS midwives, obstetricians and other healthcare professionals, specifically physiotherapists and radiologists, midwifery students and health care assistants working in maternity services. FINDINGS the study participants provided nuanced and differentiated accounts of clinical handover practices, which indicated a general absence of formal policy and training on clinical handover and the practice of midwifery and medical teams holding separate clinical handovers based on their separate, respective needs for transferring information and clinical responsibility. Participants spoke of barriers to effective clinical handover, including unsuitable environments, lack of dedicated time and fatigue during duty shift clinical handover, lack of supportive information technology (IT) infrastructure, and resistance of some staff to the adoption of new technologies to support clinical handover. KEY CONCLUSIONS whether internal and external to clinical handover events, the barriers to effective clinical handover represent threats to patient safety and quality of care, since effective clinical handover is essential to the provision of safe quality care. IMPLICATIONS FOR PRACTICE clear and effective communication between collaborating professionals within maternity teams is essential.

Sustaining quality in the community: trends in the performance of a structured diabetes care programme in primary care over 16 years

To examine the quality of care delivered by a structured primary care‐led programme for people with Type 2 diabetes mellitus in 1999–2016.

A systematic review of methods to assess intake of saturated fat (SF) among healthy European adults and children: a DEDIPAC (Determinants of Diet and Physical Activity) study

BackgroundDietary fat is an essential macronutrient. However, saturated fact has been associated with negative health outcomes including cardiovascular disease. Shifting consumption from saturated fat to unsaturated fats and limiting the level of saturated fat in the diet has been recommended. Currently, there is no standard method to measure saturated fat intake in etiologic studies. Therefore, it is difficult to obtain a reliable picture of saturated fat intake in Europe. To inform the development of the DEDIPAC (DEterminants of DIet and Physical Activity) toolbox of methods, we aimed to identify the assessment methods and specific instruments which have been used to assess saturated fat intake among children or adults in pan-European studies.MethodsThree electronic databases were searched for English language studies of any design which assessed intake of saturated fat. Reference lists were hand-searched. Studies were included if they were conducted in two or more European countries, and involved healthy, free-living children and adults.ResultsThe review identified 20 pan-European studies which assessed saturated fat intake. Food Frequency Questionnaires (n = 8) and diet records (n = 7) were most common, followed by 24-h recalls (n = 5). Methods differed in portion size estimation and the composition data which was used to calculate nutrient intake. Of the instruments used in more than two European countries, five Food Frequency Questionnaires had been specifically tested for validity to assess saturated fat intake; four among adults (Food4me, PURE, IMMIDIET, Health, Alcohol and Psychosocial factors in Eastern Europe (HAPIEE)) and one among children (used by Piqueras et al.).ConclusionsA standardised approach to portion size estimation and a common source of food composition data are required to measure saturated fat intake across Europe effectively. Only five instruments had been used in more than two European countries and specifically tested for validity to assess saturated fat intake. These instruments may be most appropriate to evaluate intake of saturated fat in future pan-European studies. However, only two instruments had been tested for validity in more than one European country. Future work is needed to assess the validity of the identified instruments across European countries.

OP15 Long term outcomes and mortality among patients enrolled in a structured primary care-led diabetes programme

Background Limited data exists, internationally and in Ireland, on long-term outcomes among people with diabetes who are managed in primary care. The Midlands Diabetes Structured Care Programme encompasses evidence-based strategies to structure diabetes management within general practice: patient registration and recall, regular diabetes review visits, active role of the practice nurse in ongoing management, multidisciplinary specialist access, professional education, and remuneration. Our aim was to examine clinical outcome targets, complications and mortality among patients with diabetes enrolled in the programme since its establishment in 1998. Methods Data were collected in 1999, 2003, 2008 and 2015, on outcomes (clinical parameters, complications and mortality) among patients with diabetes (≥18 years) registered with participating practices. Data were extracted from patient notes by clinical nurse specialists using a paper-based data collection form. Cause and date of death were obtained from national death records. Using Stata, chi-square tests were used to test differences in clinical outcomes over time. Cox proportional hazards regression was used to examine the association of baseline factors and mortality. Results Patients from 1999 (n=376), were followed up in 2003 (n=229), 2008 (n=96) and 2016 (n=376).The proportion of patients with a recommended blood pressure target (<130/80 mmHg) increased from 9% in 1999 to 26% in 2016 (p<0.001), as did the proportion with a total cholesterol of <4.5 mmol/L (22% vs. 71%, p<0.001), and triglycerides<2.0 mmol/L (47% vs. 81%, p<0.001). The percentage achieving optimal glycaemic control (HbA1c≤7.0%) declined (52% vs. 34%). Between 1999–2016, 22% (n=81) of patients had ever experienced a macrovascular complication; primarily CVA (n=21, 6%), MI (n=16, 4%). In 1999, 18% (n=33) had retinopathy, increasing to 57% (n=59) by 2016. In total, 184 (49%) had died. Between 1999–2013 mortality was higher than background rates in the general population (SMR=2.2, 95% CI 1.9, 2.6). Only 25% (n=46) had cause of death recorded in their GP record. Where cause of death was obtained from national records (n=163), primary causes were MI (n=29, 17.8%) and pneumonia (n=23, 14%). Mean age at death was 77.7±9.3 years. Mortality was significantly higher among patients who were older at baseline. Gender, diabetes type, smoking status and clinical parameters at baseline were not significant predictors of mortality. Discussion Improvements in the clinical profile of patients enrolled in the programme since its introduction suggests primary-care-led integrated diabetes management can perform favourably in the long-term. However, the high incidence of macrovascular complications, prevalence of retinopathy and mortality rate indicates the importance of effective management.

OP16 Challenges experienced by community-based clinical nurse specialists in supporting the delivery of integrated diabetes care: a qualitative study

Background In Ireland, more Diabetes Nurse Specialists (DNSs) have been introduced into the community as part of a national programme to standardise and improve diabetes care. DNSs support the delivery of a new model of care whereby uncomplicated type 2 diabetes (T2DM) is managed in primary care, and complicated T2DM is managed between primary and secondary care. Historically diabetes care in Ireland has often been delivered in an unstructured way, lacking integration between primary and secondary care. Given this context we wanted to understand the challenges faced by community-based DNSs in delivering a standardised service. Methods We purposively sampled DNSs from community-based respondents to a national survey (n=25) according to four administrative regions of the national health service. We conducted focus groups and interviews using a semi-structured topic guide. Interviews were digitally recorded and transcribed into NVivo V.11 software for coding and analysis. Data analysis is on-going using thematic analysis. Results Sixteen DNSs participated in 2 focus groups, and 8 interviews. Preliminary analysis suggested elements of the role presented a challenge. As DNSs require their Collaborative Practice Agreement to be signed off by each GP using their service, they were currently unable to prescribe in the community. Despite describing this as ‘frustrating’, DNSs suggested that prescribing could remove opportunities for relationship-building with GPs through discussion of medications. In the community, DNSs lacked the safety net of the hospital team to check things with, and had to work more autonomously, described as ‘daunting’. Role understanding by other staff was another challenge; DNSs felt managers did not understand how the community role should work, which created difficulty when negotiating aspects of the role, including flexible working hours. The lack of a shared record between settings meant patient information from hospital appointments was not readily accessible by DNSs at GP practices and vice versa. This made patient follow-up and case discussion difficult when DNSs were off-site. The absence of administrative support in the role, considered ‘crucial’, was also highlighted. Further interviews with community DNSs are ongoing. Conclusion Community-based DNSs faced challenges presented by aspects of their role, their relationship with other staff, their work environment, and the available organisational infrastructure and resources. Although recent policy reforms in Ireland have focused on improving the integrated management of diabetes in the community, findings from this study suggest DNSs may need to be better supported to ensure delivery of a standardised model of diabetes care.

P104 Trends in the Quality of Structure Diabetes Care in Primary Care in Ireland

Background The increasing prevalence and cost of Type 2 diabetes mellitus (T2DM) has driven the reorientation of diabetes care in recent years. Health systems have moved from reactive, episodic management in the acute setting to greater primary-care-led structured disease management. Structured diabetes management, whereby patients are managed in primary care in a systematic, organised way, with structured specialist support, has been associated with improved patient outcomes. However, there is limited research on the long-term performance. The aim of this study was to examine the quality of care delivered by a primary care-based structured diabetes management programme for T2DM over 10 years. Methods Data were collected from patients with T2DM (≥18 years) registered with practices participating in the Midlands Diabetes Structured Care Programme. In this programme patients are managed in primary care with support from clinical nurse specialists (CNS), dietetics, ophthalmology, and chiropody. Data were collected by CNS at three time points, 1998/1999, 2003 and 2008, on demographic, clinical, and lifestyle variables, including processes and clinical outcomes. Chi-square tests for trend were used to test differences in the processes and outcomes over time, benchmarked against national guidelines and the English National Diabetes Audit 2012–2013. A p-value of <0.001 was considered statistically significant. Results Data on 333 patients with T2DM from 10 practices in 1998/1999; 841 from 20 practices in 2003; and 989 from 31 practices in 2008, were available for analysis. BMI, HbA1c, total cholesterol, triglycerides, blood pressure, and creatinine documentation improved significantly over time (p < 0.001), however smoking status remained similar (p = 0.003). In 2008, BMI (73.5%) and smoking status (76.9%) documentation were lower than recorded in the English audit (91.1% and 86.5% respectively), although other processes were comparable. The percentage of patients with T2DM achieving the target blood pressure of ≤140/80 mmHg increased significantly, from 35.7% in 1998/1999 to 57.1% in 2008 (P < 0.001), as did the percentage who achieved the recommended total cholesterol level of <4.5 mmol/L (23.1% vs. 66.6%, p < 0.001), triglycerides ≤ 1.7 mmol/L (37.5% vs. 60.1%, p < 0.001), and HbA1c ≤ 7.0% (55.9% in 1998/1999 vs. 60.8% in 2008, p < 0.001). Conclusion Over a 10-year period of structured diabetes care, improvements were observed both in process of care documentation and patient outcomes, suggesting that primary-care-led management of diabetes can perform favourably in the long-term. These results are encouraging in light of the new diabetes cycle of care, which will, for the first time in Ireland, remunerate GPs for routine primary care management of T2DM.