Biomedical subjects

J Feely

Publications and source records attributed to J Feely.

At least 19 recordsLinked to original sources

PubMed2006

Impact of Helicobacter pylori on the management of dyspepsia in primary care.

BACKGROUND: It is unclear what impact Helicobacter pylori infection has had on the management of dyspepsia in primary care and to what extent published guidelines on H. pylori are implemented in routine clinical practice. AIM: To assess the impact of H. pylori infection on the management of dyspepsia in primary care. METHODS: Patients referred by primary care doctors to an open-access 13-carbon urea breath test service over a 2-year period for their first urea breath test were included in the study. Individual breath results were linked with data on prescribing obtained from the General Medical Services prescription database. RESULTS: Of 805 patients, 374 (47%) had a positive urea breath test and 431 (54%) a negative urea breath test. Of positive urea breath test patients, only 245 (64%) were prescribed eradication therapy in the 3 months after the breath test and only 43% were referred back for re-testing. In the year after the urea breath test, there was a significant fall in prescribing of antisecretory therapy which was greatest in the patients who received H. pylori therapy (P < 0.001). CONCLUSIONS: There appears to be under and inappropriate treatment of H. pylori infection in primary care, and a low rate of re-testing after eradication, indicating that current guidelines are not well implemented in practice.

Adult↗

PubMed2006

The population mortality benefits of maximizing the number of eligible patients receiving appropriate cardiology treatments in Ireland.

BACKGROUND: Coronary heart disease (CHD) mortality rates have been decreasing in many industrialized countries since the 1980s. Up to half this decrease can be attributed to evidence-based medical and surgical cardiology interventions. However, recent studies suggest that modern cardiology treatment uptake levels remain disappointingly low in many patient categories. AIM: To determine the potential for further reductions in CHD mortality in Ireland from increasing the number of eligible patients receiving cardiology treatments. METHODS: A previously validated, cell-based IMPACT CHD mortality model was used to integrate large amounts of data describing CHD patient numbers, and the effectiveness and uptake levels of specific medical and surgical treatments. The CHD mortality reductions potentially achievable through the increased use of specific treatments were then calculated, stratified by age and gender and tested using sensitivity analyses. RESULTS: In 2000, medical and surgical coronary disease treatments together prevented or postponed approximately 1950 CHD deaths in the adult population aged 25-84. However, increasing treatment levels to reach 80% of eligible patients might have prevented or postponed a further 2280 CHD deaths in 2000 (minimum estimate 860, maximum estimate 4000). The biggest gain was from maximizing the treatment uptake of eligible heart failure patients, followed by those receiving statins and secondary prevention therapies. DISCUSSION: Many eligible patients are currently not receiving appropriate evidence-based treatments that would reduce CHD mortality and morbidity. Our results suggest that increasing cardiology treatment uptake in Ireland could at least double the current therapeutic reduction in CHD mortality.

Adult↗

PubMed2006

Collagen type-I degradation is related to arterial stiffness in hypertensive and normotensive subjects.

Although arterial stiffness is an independent cardiovascular risk factor associated with both aging and hypertension, relatively little is known regarding the structural changes in the vessel wall that occur with vessel stiffening. We determined if collagen type-I metabolism is related to arterial stiffening in both hypertensive and normotensive subjects. Arterial stiffness was assessed by aortic pulse wave velocity (PWV) and augmentation index (AIx) in 46 subjects (48.7 +/- 2 years, 32 hypertensives) and related to circulating markers of collagen type-I turnover. Collagen synthesis was assessed by the measurement of carboxy-terminal peptide of procollagen type-I (PIP) and collagen degradation by the measurement of carboxy-terminal telopeptide of collagen type-I (ICTP), by quantitative immunoassay. Matrix metalloproteinase-1 (MMP-1) and the tissue inhibitor of metalloproteinase-1 (TIMP-1) were also quantified by immunoassay. The ratio of collagen type-I synthesis to degradation was negatively correlated with both PWV (P<0.05) and AIx (P<0.05), whereas plasma MMP-1 levels displayed a positive correlation with both PWV (P<0.01) and AIx (P<0.01), after adjustment for age and mean arterial pressure. The relationship between collagen type-I turnover and arterial stiffness was similar in both the normotensive and hypertensive subjects. Although circulating markers of collagen synthesis were increased in the hypertensive subjects, this was not related to arterial stiffness. Collagen type-I degradation is increased in relation to collagen type-I synthesis in subjects with stiffer arteries. Matrix metalloproteinase-1, the enzyme responsible for collagen type-I degradation, is positively related to both large elastic and muscular artery stiffness in normotensive and hypertensive subjects.

Adult↗

PubMed2006

Effect of clinical trial publicity on HRT prescribing in Ireland.

OBJECTIVE: To evaluate the effect of publicity surrounding the Women's Health Initiative (WHI) and Million Women (MW) studies on prescribing of all hormone replacement therapy (HRT) preparations and bisphosphonates in Ireland. METHODS: The General Medical Services (GMS) prescription database was used to identify the study population. Prescriptions were identified for HRT and bisphosphonate preparations [using WHO Anatomical Therapeutic Chemical (ATC) classification codes] in female patients aged 45-69 years in Ireland during a 4-year study period (January 2001-December 2004). Prescription rates were calculated monthly. Prevalence and incidence of HRT use was examined. RESULTS: There was a significant reduction in prevalence for all HRT preparations following the WHI trial (test for change in trend p<0.0001), which persisted after the MW study. The incidence of combined oestrogen/progestogen HRT declined after the WHI trial (test for change in trend p=0.004). Bisphosphonate prescribing showed a significant increase throughout the study period (p<0.0001). CONCLUSION: The findings suggest that coverage surrounding the publication of clinical trials appears to have had a negative impact on the rate of HRT prescribing. The findings regarding the coincident increase in use of bisphosphonates may suggest that prescribers and users were less likely to regard HRT as an appropriate therapy in the management of osteoporosis for some time before guidance was issued by the regulatory authorities.

Advertising↗

PubMed2006

Socioeconomic influences on benzodiazepine consumption in an Irish Region.

Misuse of prescription sedatives is a significant problem for addiction treatment services. The aim of this study was to examine the prescribing of diazepam in disadvantaged Irish communities, and to identify factors which may predict diazepam consumption in that population. We examined prescribing trends for those aged 16-69 years in 2002 in a region of the state-funded General Medical Services Scheme. Material deprivation was based on the 2002 Small Area Health Research Unit (SAHRU) deprivation index. The average defined daily dose (DDD) was calculated and logistic regression analysis was used to predict diazepam use by age, gender and deprivation index. Results showed that patients living in the most-deprived areas were more likely to receive diazepam than patients living in the least-deprived areas (OR = 1.21, 95% CI 1.15-1.27). Female patients living in the most-deprived areas were also more likely to receive diazepam than those living in the least-deprived areas (OR = 1.36, 95% CI 1.18-1.57). It is concluded that there is a pattern of higher diazepam prescribing in areas of greatest deprivation, where prescription sedatives play a complex role within troubled families.

Adolescent↗

PubMed2006

Prescribing for patients with diabetes in the community drug schemes.

The aim of the study was to examine the management of diabetes patients particularly in relation to secondary preventative therapies within the community drug schemes across the health board regions in Ireland. The study population was identified using two national primary care prescribing databases from the Long Term Illness (LTI) and General Medical Services (GMS) scheme for 2003. 65,593 patients were identified as having 'treated' diabetes. Logistic regression was used to predict the likelihood of receiving secondary preventative therapies by region and drug scheme using adjusted odds ratios (ORs) and 95% confidence intervals (CI). The proportion of diabetes patients in each drug scheme with Ischaemic Heart Disease (IHD) was also calculated. Prevalence of 'treated' diabetes was calculated for each health board also. Regional and scheme-based variations within each region exist in the prescribing of secondary preventative therapies after adjustment for IHD rates. Prevalence of treated diabetes varied between regions from 1.5% in the Eastern region to 2.2% in the Southern region. While the location of specialised diabetes clinics may be a contributing factor, inequalities in prescribing across regions within the drug schemes are apparent.

Aged↗

PubMed2005

The application of prescribing indicators to a primary care prescription database in Ireland.

OBJECTIVE: To develop appropriate prescribing indicators and apply these to Irish prescription data. METHODS: A postal survey of 145 randomly selected general practitioners working within the Eastern Health Board region of the State-supported General Medical Services scheme in Ireland regarding the applicability of selected prescribing indicators was carried out. Such indicators were then applied to aggregate prescription data. RESULTS: Prescribing indicators based on agents of questionable efficacy/poor quality prescribing and those based on good prescribing practice were thought to make suitable indicators. Low rates of prescribing were noted for indicators based on drugs of limited efficacy, e.g. cerebral and peripheral vasodilators (rate 3.1 per 1,000 prescriptions), whilst indicators based on drugs associated with good prescribing practice were associated with higher prescribing rates, e.g. the prescription of aspirin in patients receiving nitrate therapy(rate 7.13 per 1,000 patients). However, a low rate of generic prescribing (4.6%) was found amongst general practitioners in the study. The largest variability in prescribing was seen with the prescribing of peripheral and cerebral vasodilators (75th/25th centile=5.6) and the prescription of long-acting sulphonylureas (75th/25th centile=66.6). CONCLUSIONS: Quality indicators based on aggregate prescribing provide valuable information on prescribing standards and should be developed with the close involvement of prescribers.

Databases, Factual↗

PubMed2005

The influence of guidelines on the use of statins: analysis of prescribing trends 1998-2002.

AIMS: To monitor statin prescribing trends over time in order to determine whether prescribers were influenced by study results and/or clinical guidelines in terms of type and dosage of statin prescribed. METHODS: The GMS (General Medical Services) prescription database in Ireland was used to identify a cohort of patients, prescribed statins, in order to investigate prescribing trends from January 1998-December 2002. Statin prescribing rates for patients with ischaemic heart disease and diabetes were compared with rates in the general GMS population. Logistic regression analysis was used in patients with ischaemic heart disease and diabetes and adjusted odds ratios and 95% confidence intervals presented. RESULTS: Increased statin prescribing over time was noted (test for linear trend P < 0.0001). Pravastatin was the most frequently prescribed, followed by atorvastatin; simvastatin and fluvastatin showed lower rates of prescribing. Atorvastatin showed the greatest increased rate over time. An increase in the overall dose prescribed (test for trend P < 0.01) was chiefly due to increases in pravastatin dose, but doses were still below those recommended from clinical trials. Statins were prescribed more frequently in patients with ischaemic heart disease and diabetes, 44% (95% CI 43-45%) compared with the total GMS population, 7.7% (95% CI 7.6-7.8%), by December 2002. However, statins were only prescribed to 52% (95% CI 51-53%) of ischaemic heart disease patients and 40% (95% CI 39-41%) of patients with diabetes by December 2002. Patients aged 45-64 years were more likely to receive statins, compared with those aged 65 years and older. CONCLUSION: These findings suggest that the beneficial effects of statins shown in clinical studies may not be achieved in practice.

Adolescent↗

PubMed2004

Initial uptake and evidence of safe prescribing practice with Buproprion (Zyban).

PURPOSE: To study the effect of safety concerns and the introduction of freely available nicotine replacement therapy (NRT) on the prescribing of Buproprion within the General Medical Services (GMS) scheme in Ireland. METHODS: Using the state-supported GMS prescription database in Ireland, we identified 8166 patients who were prescribed Buproprion and 18,450 patients who were prescribed NRT over a 12-month-period. RESULTS: A decline in the prescribing of Buproprion was noted which coincided with concerns regarding the safety of the drug but which preceded the introduction of NRT to the GMS. Furthermore, patients who were prescribed Buproprion were less likely to be co-prescribed potentially interacting drugs (odds ratio (OR): 0.48, 95% confidence intervals (CI): 0.42, 0.54) or drugs known to reduce seizure threshold (OR: 0.63, 95% CI: 0.6, 0.67) indicating good prescribing practice. Patients aged 65 years or more were less likely to be prescribed any form of smoking cessation therapy compared with those aged <65 years (OR: 0.23, 95% CI: 0.22-0.24) indicating that such therapy was targeted at those most likely to benefit. CONCLUSIONS: We provide evidence that prescribers exercised caution in the prescription of Buproprion and were likely to have been influenced both by the safety concerns and the introduction of freely available NRT to the GMS population.

Adolescent↗

PubMed2004

Community-based study of atrial fibrillation and stroke prevention.

The benefits of anticoagulation and antiplatelet agents for stroke prevention in atrial fibrillation (AF) have been established. There is little data on the use of this form of stroke prevention in patients with AF in Ireland. To determine whether adequate stroke prevention measures are taken regarding anticoagulation and aspirin use for patients in the community with chronic AF. Audit of general medical services (GMS) patients with atrial fibrillation in two Dublin general practices. A total of 70 patients with AF were identified from 2684 GMS patients in the two practices: contraindications to anticoagulation were established in 26 of these. In those for whom warfarin was indicated, 21 of 44 (47%) were not anticoagulated. In those not anticoagulated and where aspirin was not contra-indicated, 20 of 42 were not on aspirin. Our study found that almost one third of patients with AF could be anticoagulated but were not, and the alternative of aspirin was only used in just over one half of patients. This represents a lost opportunity for stroke prevention. Various approaches should be explored to remedy this.

Aged↗

PubMed2004

Prescription patterns in the elderly population--"new" versus "old" medical card holders.

INTRODUCTION: In July 2001, the GMS Scheme was extended to the whole elderly population aged 70 and over, permitting access to medical care services free of charge. We undertook a study to compare prescribing patterns between those relatively affluent people referred to as "new" over 70s with those relatively deprived people referred to as "old" over 70's, over the 18 months since the introduction of the scheme. Patients who had received a prescription for antibacterials, diuretics, psycholeptics, psychoanaleptics, statins, b-blockers, antithrombolytics, antianaemic drugs and drugs for obstructive airway diseases, were identified over the 18 month period using the GMS database. We also compared the average defined daily dose (DDD) received per month for each of the therapies above. RESULTS: All therapies directed at treatment were significantly more likely to be prescribed to the old over 70's, such as the vasodilators (OR=1.59, 1.51-1.67), peptic ulcer drugs (OR=1.37, 1.33-1.43) and the antibacterials (OR=1.37, 1.33-1.41) with the exception of those associated with cardiovascular prevention; statins (OR=0.88, 0.85-0.92), beta-blockers (OR=0.95, 0.92-0.98) and antithrombolytics (OR=0.96, 0.93-0.99). The old over 70's received more prescriptions with a higher than the average DDD per month for vasodilators, diuretics, and drugs for obstructive airway disease. This study highlights a potential inequality in prescribing in primary care, evident following a change in the health policy in Ireland. These results suggest that differences in socio-economic status (such as income) and morbidity may be associated with differences in prescribing by GPs.

Aged↗

PubMed2003

Influence of material deprivation on prescribing patterns within a deprived population.

OBJECTIVE: To study the effect of material deprivation on prescribing trends in primary care, using a locally derived deprivation score. METHODS: A retrospective analysis of prescribing trends linked to material deprivation by district electoral division (DED) in the Eastern Region of the General Medical Services in Ireland (population of 334,031) was performed. Standardised prescribing ratios were determined for a number of drug classes, including those that could be used to identify particular diseases for 181,647 patients who were assigned a locally derived material deprivation score. RESULTS: Prescribing rates for a number of medications including anti-asthma, nitrate and benzodiazepine medications increased, whilst the prescribing of other medications such as anti-parkinsonian and antidepressive agents decreased with increasing deprivation. CONCLUSIONS: Our results suggest that, even within a population considered to be economically deprived, different levels of deprivation may significantly influence general practitioner prescribing patterns. Within the group of centrally active medications, the prescription of symptomatic medications increased with increasing material deprivation, whilst the prescription of disease-specific medications decreased with increasing material deprivation.

Cultural Deprivation↗

PubMed2003

Under-prescribing of cardiovascular therapies for diabetes in primary care.

OBJECTIVE: To determine the extent to which cardiovascular therapies are prescribed in primary care for those with diabetes, compared with those without diabetes. METHODS: Population study of patients with and without diabetes identified using a national primary care prescribing database. All patients receiving a prescription for any diabetes therapy, including insulin and oral hypoglycaemic drugs, or diagnostic test kit for glucose ( n=8523) and those receiving no such therapies ( n=145,756) during a 1-year period (September 1999-August 2000) in the Eastern Regional Health Authority of Ireland were identified. In addition, a sub-set of patients receiving a nitrate prescription, a marker for ischaemic heart disease (IHD), were also identified ( n=14,826). Odds ratios and 95% confidence intervals for prescribing of cardiovascular therapies between those with diabetes and those without, adjusted for age and gender, were calculated using logistic regression. RESULTS: The proportion of those (and 95% CES) with diabetes and IHD prescribed secondary preventative therapies was 37.3% (35.0, 39.6) for statins, 55.3% (53.0, 57.6) for angiotension converting enzyme inhibitors, 34.7% (32.5, 36.9) for beta blockers, 73.3% (71.2, 75.4) for aspirin, 4.4% (3.4, 5.4) for angiotensin-II antagonists and 2.5% (1.8, 3.2) for fibrates. The adjusted odds ratios for prescribing in those with diabetes compared with those without are 1.44 (1.30, 1.61) for statins, 3.09 (2.79, 3.42) for angiotension converting enzyme inhibitors, 0.82 (0.74, 0.91) for beta blockers, 1.23 (1.09, 1.38) for aspirin, 1.47 (1.13, 1.87) for angiotensin-II receptor blockers and 4.23 (2.88, 6.14) for lipid-lowering fibrates. CONCLUSION: The greater rate of prescribing of cardiovascular therapies in those with diabetes relative to those without is not unexpected given the higher risk of coronary heart disease in those with diabetes. However, the proportion of patients with diabetes, particularly those with established IHD, prescribed cardiovascular therapies is considerably below that recommended in local and international guidelines.

Adrenergic beta-Antagonists↗

PubMed2003

Prescription monitoring in an Irish hospital.

The prescribing of medicines is an integral part of the provision of healthcare and represents a relatively safe, effective and inexpensive mode of treatment. Hospital prescribing is of importance not alone for patients but also for the impact that it has on the prescribing of drugs in the community. We conducted a 'snap-shot' study of 1,488 hospital prescriptions and assessed such areas as legibility, generic prescribing and drug dosage. The average number of active prescriptions per patient was 5.47 for medical in-patients and 5.05 for surgical in-patients. 5% of prescriptions were deemed illegible and the rate of generic prescribing was relatively low. However the rate of compliance with the hospital formulary was good. The spectrum of drugs prescribed changed significantly from a previous study performed in 1987. Continuous review of doctors' prescribing habits will ensure the safe and economic use of medications.

Drug Prescriptions↗

PubMed2002

St Johns wort increases expression of P-glycoprotein: implications for drug interactions.

AIMS: St John's Wort (SJW) is widely used in the treatment of depression but concerns have been raised about its potential to interact with other drugs. Co-administration with SJW has resulted in significant reductions in trough plasma concentrations of indinavir and cyclosporin [1, 2]. Induction of cytochrome P450 3A4 (CYP3A4) has been implicated as the most likely interaction mechanism. However, the magnitude of the interaction seen in clinical practice is greater than that predicted by in vitro studies suggesting additional interaction mechanisms may exist. As indinavir and cyclosporin are substrates for both CYP3A4 and the multi drug transporter P-glycoprotein we hypothesized that modulation of P-glycoprotein expression and function by SJW may contribute to the development of potentially harmful drug-drug interactions. METHODS: Healthy volunteers were randomized to either SJW (0.15%) 600 mg three times daily for 16 days (n = 15) or placebo (n = 7). Blood samples were obtained for P-glycoprotein expression and function at baseline, 16 and 32 days post treatment. Peripheral blood lymphocytes (PBMCs) were isolated by Ficoll density gradient centrifugation, fixed and permeabilized. Cells were stained with a P-glycoprotein specific antibody, quantified by flow cytometry and median fluorescence intensity (MFI) values obtained. Vimentin and IE (nonsense antibody) were used as controls. The presence of the MDR 1 gene product was confirmed by RT-PCR. P-glycoprotein mediated drug efflux was determined as a function of rhodamine efflux in the absence and presence of ritonavir. Data are expressed as mean +/- s.d. and were subjected to nonparametric analysis. RESULTS: P-glycoprotein expression increased 4.2 fold from baseline in subjects treated with SJW (7.0 +/- 1.9 vs 29.5 +/- 14.3 (MFI); P < 0.05). There was no effect with placebo (5.1 +/- 1.3 vs 6.0 +/- 1.9 MFI). SJW increased P-glycoprotein mediated rhodamine efflux (reduced ratio) compared with baseline (0.12 +/- 0.04 vs 0.24 +/- 0.18 P < 0.05). There was no change with placebo. Ritonavir (5 microm) inhibited P-glycoprotein mediated efflux in both groups producing greater intracellular accumulation of rhodamine. However, this effect was attenuated following treatment with SJW (23.9 +/- 15.3% vs 75.4 +/- 16.4% P < 0.05). CONCLUSIONS: SJW increased expression and enhanced the drug efflux function of the multi drug transporter P-glycoprotein in PBMCs of healthy volunteers. This may represent a second mechanism for the drug-herb interactions seen in clinical practice and account for the discrepancies between in vitro and in vivo data. Since P-glycoprotein and CYP3A4 have distinct though overlapping substrates, patients receiving drugs, which are P-glycoprotein substrates should be warned against self-medication with SJW as clinically significant drug interactions may occur.

ATP Binding Cassette Transporter, Subfamily B, Mem↗

PubMed2002

Inequalities in prescribing of secondary preventative therapies for ischaemic heart disease in Ireland.

The study aim is to quantify the variation in prescribing rates of secondary preventative therapies for Ischaemic Heart Disease (IHD) across regions, age and gender. Patients receiving any prescriptions for a nitrate during a one year period (September 1999-August 2000) were considered using a national primary care prescribing database. Age-sex standardised prescribing rates of four secondary preventative therapies for IHD (Ace inhibitors, beta-blockers, aspirin, statins) were calculated for each region. Wide variations between regions were observed with significantly higher variability for Ace inhibitors compared with aspirin (F-ratio=22.8, p<0.001). Men were more likely to prescribed these therapies and the elderly were less likely (except Ace inhibitors). The study suggests that access to secondary preventative therapy is not equitable across regions, gender and age in Ireland. The wide variability may be due to uncertainty in prescribing secondary preventative therapies and/or variability in clinical need between regions.

Adrenergic beta-Antagonists↗

PubMed2002

Comparison of secondary prevention of heart disease in Europe: lifestyle getting worse, therapy getting better in Ireland.

We compared the implementation of secondary prevention some 18 months following acute myocardial infarction or coronary artery bypass surgery in Ireland in 1994 to that in 15 European countries, including Ireland, in 2000. While there were substantial improvements in the use of statins, b-blockers and the availability of rehabilitation programmes since the early 1990s, more patients now smoke, take no exercise and are overweight. The prevalence of non-insulin dependent diabetes has increased by 70%. In comparison with other European countries, we have the highest use of aspirin and the highest prevalence of smoking in women. Despite a considerable improvement in the use of drug therapy we will not achieve the full potential of secondary prevention unless lifestyle factors, including smoking, overweight and exercise receive greater attention by patients with coronary heart disease.

Adrenergic beta-Antagonists↗

PubMed2001

Pharmacoepidemiology--an Irish perspective.

The Irish healthcare system is a mixture of free, state-supported and private medicine. The state-supported General Medical Services (GMS) scheme maintains a large prescription database, which has been used to conduct pharmacoepidemiological studies in Ireland. The dataset is anonymized thus maintaining patient and prescriber confidentiality. Three recent studies using this data are described, two of which outline the effect of regulatory advice and the media on prescribing patterns and one which describes the development of an index of prescribing quality which may be applied to prescription data. The GMS prescription database is presently being complemented by a database for some 0.7 million people who seek reimbursement for prescriptions from individuals or families in excess of 42 Pounds per month which together will have an important role for the continued development of pharmacoepidemiology in Ireland.

Clinical Trials as Topic↗