The comparative diagnostic accuracy of the Mini Mental State Examination (MMSE) and the General Practitioner assessment of Cognition (GPCOG) for identifying dementia in primary care: a systematic review protocol

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Development of a complex intervention to promote appropriate prescribing and medication intensification in poorly controlled type 2 diabetes mellitus in Irish general practice

BACKGROUND: Poorly controlled type 2 diabetes mellitus (T2DM) can be seen as failure to meet recommended targets for management of key risk factors including glycaemic control, blood pressure and lipids. Poor control of risk factors is associated with significant morbidity, mortality and healthcare costs. Failure to intensify medications for patients with poor control of T2DM when indicated is called clinical inertia and is one contributory factor to poor control of T2DM. We aimed to develop a theory and evidence-based complex intervention to improve appropriate prescribing and medication intensification in poorly controlled T2DM in Irish general practice. METHODS: The first stage of the Medical Research Council Framework for developing and evaluating complex interventions was utilised. To identify current evidence, we performed a systematic review to examine the effectiveness of interventions targeting patients with poorly controlled T2DM in community settings. The Behaviour Change Wheel theoretical approach was used to identify suitable intervention functions. Workshops, simulation, collaborations with academic partners and observation of physicians were utilised to operationalise the intervention functions and design the elements of the complex intervention. RESULTS: Our systematic review highlighted that professional-based interventions, potentially through clinical decision support systems, could address poorly controlled T2DM. Appropriate intensification of anti-glycaemic and cardiovascular medications, by general practitioners (GPs), for adults with poorly controlled T2DM was identified as the key behaviour to address clinical inertia. Psychological capability was the key driver of the behaviour, which needed to change, suggesting five key intervention functions (education, training, enablement, environmental restructuring and incentivisation) and nine key behaviour change techniques, which were operationalised into a complex intervention. The intervention has three components: (a) a training program/academic detailing of target GPs, (b) a remote finder tool to help GPs identify patients with poor control of T2DM in their practice and (c) A web-based clinical decision support system. CONCLUSIONS: This paper describes a multifaceted process including an exploration of current evidence and a thorough theoretical understanding of the predictors of the behaviour resulting in the design of a complex intervention to promote the implementation of evidence-based guidelines, through appropriate prescribing and medication intensification in poorly controlled T2DM

Temporal trends in between and within‐country inequalities in caesarean delivery in low‐ and middle‐income countries: a Bayesian analysis

Objective: To provide updated information about between-country variations, temporal trends and changes in inequalities within countries in caesarean delivery (CD) rates. Design: Cross-sectional study of Demographic and Health Survey (DHS) during 1990–2018. Setting: 74 low- and middle-income countries (LMICs). Population: Women 15–49 years of age who had live births in the last 3 years. Methods: Bayesian linear regression analysis was performed and absolute differences were calculated. Main outcome measure: Population-level CD by countries and sociodemographic characteristics of mothers over time. Results: CD rates, based on the latest DHS rounds, varied substantially between the study countries, from 1.5% (95% CI 1.1–1.9%) in Madagascar to 58.9% (95% CI 56.0–61.6%) in the Dominican Republic. Of 62 LMICs with at least two surveys, 57 countries showed a rise in CD during 1990–2018, with the greatest increase in Sierra Leone (19.3%). Large variations in CD rates were observed across mother's wealth, residence, education and age, with a higher rate of CD by the richest and urban mothers. These inequalities have widened in many countries. Stratified analyses suggest greater provisioning of CD by the richest mothers in private facilities and poorest mothers in public facilities