This document summarizes a presentation given at the Primary Care Conference on livinghealth on November 17th, 2011 by Dr. David Molony. The presentation discussed innovation, research, and standards in primary care as well as barriers to development. Specific examples were given of an innovative warfarin clinic, a research study on ear health in the elderly, and developing standards for primary healthcare centers. Barriers to primary care development mentioned included a lack of flexibility and proper commitment of resources from hospitals. The presentation argued that primary care can provide many services more efficiently than hospitals and help address issues of cost and wait times if given more support and flexibility.

1. PRIMARY CARE CONFERENCE
Livinghealth
17/11/2011
Dr David Molony

2. Mallow Primary Healthcare Centre (MPHC)
Co. Cork

3. DISCUSS
• Innovation
• Research
• Standards in Primary Care
• Barriers to development

4. INNOVATION
WARFARIN CLINIC
• 200 PATIENTS—13 STEPS
• Computerised Solution(CompleteGP)-4 STEPS
• Highly satisfied patient group
• Fast efficient model, 3 min ap., TTR >65%
• Printed dosage instructions-safer.
• HSE lab saved 3,700 tests pa.
POSTER PRESENTATION

5. RESEARCH—EARLI
STUDY
In conjunction with Local HSE services
• QUESTIONAIRE to all > 70 yrs old (1,056)
• 86% Response Rate
• 69 Patients Identified as at “HIGH RISK”
• Intervene and cut overall admissions 30-50%
• Primary Care Teams show value.
• Real Value to Hospitals.
POSTER PRESENTATION

6. STANDARDS IN PRIMARY CARE
• Building—UK Technical Memorandum standards
• MPHC Developed Standard for Primary
Healthcare Centres includes the fundamental
principals of international standards:
– ISO 9001:2008 Quality Standard
– ISO 14001:2004 Environmental Standard
– ISO 18001:2007 Health & Safety Standard
– JCI Primary Care Standard
MPHC is EQA (INAP) Accredited 2010,2011 to
ISO 18001:2007

7. Resource of
Primary Care
• GP four year training – specialty skills not
being used—2,700 GPs (& 1,700 PNs)
• Many services can be provided in PC at 30% of
hospital cost
• IT available in PC with complete patient record
• Every community serviced / same day
• Underestimated utilisation & overestimation
of cost in PC by the state bodies –article Dr W
Behan IMT today.

8. BARRIERS to DEVELOPMENT of
PRIMARY CARE MODEL
• Money NOT following the patient
• No competition allowed for services
• No flexibility in Hospitals systems
• HSE poorly committed to PC service
development—control issues?
• “PPARS Syndrome”– afraid of technology
development

9. The Future
Uncertain
but
Primary Care
can save the day.

10. The Future
Uncertain
but
Primary Care
can save the day.

11. Procedures that could be done in 4TH Practice
• Excision - Pigmented Naevi, Sebaceous cysts, Simple cysts, Lipomata, Skin lesions BCC, SCC
• Biopsy - skin lesions
• Skin abscess - evacuation and packing under LA
• Cryotherapy/Electrocautery - Keratoses solar actinic, Warts single multiple, Verucca single
multiple, Skin lesions single multiple
• Toe/Hand - Nails-- Wedge resection, Removal of
• Suturing lacerations - < and > 4cms, single multiple, Face, Scalp, Body
• Haemorrhage - Nasal haemorrhage plugging/cauterisation
• Cardiac - ECG, SINGLE, 24 HRLY, Holter, WEEKLY. Stress testing, 24 Hr Blood Pressure Monitoring
• Phlebotomy - Hospital and private sector
• Warfarin - near patient testing
• Haemochromatosis - venesection
• Eyes - Adherent FB eyes-removal, Ophthalmic Assessment, Chalazion removal
• Hydrocoele - Drainage
• Joint Injections - Major , Medium, Minor joints Injection and/or Aspiration of joints.
• Gynaecology - Mirena / Implanon / Hysteroscopy
• Vasectomy
• STD Clinic
• GIT - Gastroscopy / Colonoscopy / Sigmoidoscopy / Proctoscopy
• Nose - Nasenoscopy, Cauterisations
• Infusion Therapy - Cancer, Osteoporosis, Bowel and Joint disease, infection
• Health Screening – Well Man/Woman
• Diagnostics – Xray, Ultascound, Dexa Scan

12. Same Service
Hospital Primary Care
Doctor higher fee >> Doctor lesser fee
Equipment cost == Equipment cost
Capital/facility cost pd. >> NO capital/facility
All capable procedures >> Limited procedures
Poor flexibility >> Very flexible
High rigid costings >> ? 60% less costly
Simple mole excision can cost company 3 to 5 times more in hospital than in PC.

13. Public Patients
•GMS –small number of procedures covered
Pressure on GP not to provide service as no
return
For Example:
Suturing laceration PC cost
€23.50 – pay €28.60

14. Public Patients
•GMS –small number of procedures covered
Pressure on GP not to provide service as no
return
For Example:
Suturing laceration PC cost
€23.50 – pay €28.60

15. Mirena Costing
Out Patient Waiting time Cost
Department
Hospital costs visits (OPD)
required
Consultant OPD --Mirena assessment. 1 3-12 Weeks €260
Total saving for Carrying out
Procedure Cost --hosp bed+OT+Nurse+Anaes+Gynae
(Conservative estimate)
1 3-12 weeks €500
Facilities payment made to Public Hostipals-HSE paid
Mirena insertion in Primary care:
(Conservative estimate--lump sums to cover all hospital costs)
Consultant OPD--review visit 1 3-12 weeks
€700
€260
2 OPD Visits
Totals Waiting time and cost for Merina in Hospital 2 OPD+1 Hosp
9-24 weeks Waiting time €1,720
(Conservative estimate) night
6-24 weeks Waiting time Out Patient
Department
visits (OPD)
Waiting time Cost
Mirena in Primary Care Centre required
€1641
GMS Mirena No OPD No waiting time €79
Facilities payment Fee (currently not paid for by GMS) €0
Total
NO OPD's No waiting time €79
(Not sustainable---no incentive to do in PC.)

16. Retinopathy Screening Costings
Total saving by carrying out
Current Hospital based : Consultant check for Retinopathy
Out Patient
Department
Waiting time Cost Total Cost
visits (OPD)
Retinopathy testing in Mallow
Consultant outpatient visit required for a Retinopathy test
that can be sent to NCSS for Screening.
required
500 OPDs 3-12 Weeks €260 €130,000
Primary Healthcare centre (MPHC):
Out Patient
500 OPD Visits
Primary Care based Retinopathy screening
Department
visits (OPD)
required
Waiting time Cost Total cost
9 – 36 Weeks Waiting
500 Retinopathy test with Retinal Camera were Carried out
500 In House
in house in Mallow Primary Healthcare Centre MPHC no waiting time €44 €22,000
(NO OPDs)
and sent to NCSS for Screening.
€108,000

17. Diagnostics Costings
Out Patient
Total saving per Ultrasound
Current Hospital based ultrasound
Department
visits (OPD)
required
Waiting time Cost
examination carried out in Primary
Patient requires an ultra sound as determined by a GP and sends
Patient to Hospital consultant.
Ultrasound Done and report sent to the Consultant
1 3-12 Weeks
3-12 weeks
€260
€100
Care Centre:
2nd OPD required: the consultant sees the Ultrasound and sends
report to the GP
Totals Waiting time and cost for Ultra sound in Hospital
1
2 OPDs
3-12 Weeks
9-36 weeks Waiting time
€260
€620
2 OPD Visits
Out Patient
8-35 Weeks Waiting Time
Ultrasound done in Primary Care Centre
Department
visits (OPD)
required
Waiting time Cost
required.
€520
Patient visits GP and GP determined that an Ultrasound is
The Ultrasound is Done in the primary Care centre within 7 days
Ultrasound Done within 7 days
24 Hours €110
and report sent to the GP within 24 hours
(100 US saves €52,000; 200 OPD Visits)
Total NO OPD's Ultra sound report in 2-8 Days €110

18. IT and Clinical Delivery
• Warfarin Clinic –costly (274pa 2009)
• 60+ patients averaging 12pa.
• Communication problems.
• Too many steps.
• Too many hands involved.
• Solution –near pt testing, same day, cost
containment, one patient contact, clear
written instructions, IT decision support using
Rosendaal Method (British Committee for Standards in Haematology)

19. Clinical audit of the management of patients in an
anticoagulant primary care clinic in Ireland
Sarah Molony1, Dr. David Molony2 , Dr. Aisling O’Leary1.
1. School of Pharmacy, Royal College of Surgeons Ireland. 2. The Red House Family Practice, Mallow Primary Healthcare Centre.
Introduction
• 778,973 prescriptions for warfarin in Ireland (2008) Aim of study
Audit to assess standard of care provided to patients as determined by TTR
 Atrial fibrillation
 Pulmonary embolism / Deep vein thrombosis
 Post-valve replacement  Rosendaal and point prevalence method
 Secondary objective to undertake an economic assessment of the
• AF associated stroke increases progressively with age model of care
 RR reduction of stroke with warfarin over aspirin
39% Audit standards
 BCSH recommendation - 60% TTR (+/- 0.5 units target)
• North Dublin Population Stroke Study 2010:
 4 weekly testing for those stabilised (Ansell et al)
 <25% of those with known AF anticoagulated with
warfarin prior to stroke onset  Rosendaal 69%, Point Prevalence 86%,
– Oppenkowski et al, 2007.
Models of care Methods
• Protocol development and ICGP Ethical Approval (Nov ’09)
• Primary care, secondary care, patient self-testing
• Strict control to target INR essential • Patient identification - 1mg warfarin Rx
• Time in therapeutic range (TTR) assessment • Inclusion of Rosendaal’s method of linear interpolation Complete GP®
Rosendaal linear interpolation method or % time spent in • Data collection and analysis
range
• Re-audit 2010
Study Setting
• General Practice urban/rural mix • Microcosting analysis
• Complete GP ® software
• Primary care anti-coagulant model adopted in 2002
• Patient care pathways and proactive audit assessments

20. Clinical audit of the management of patients in
an anticoagulant primary care clinic in Ireland
Sarah Molony1, Dr. David Molony2 , Dr. Aisling O’Leary1.
1. School of Pharmacy, Royal College of Surgeons Ireland. 2. The Red House Family Practice, Mallow Primary Healthcare Centre.
100
Clinical outcomes
80
Rosendaal for last 12 months of tx
Results 60
 166 patients treated with warfarin 2002-2009 Haemorrhagic events 40
 n=143 in practice  2009 n=8 (1 major) 20
 2009 n=57 (audit population)  2010 n=6 0
No event recorded Haemorrhagic Event on at least one occassion
Haemorrhagic Events
Thromboembolic events
 2010 n=64 (audit population)  2009 n=4
 2010 n=0
Patient demographics
 Median age 77 years Conclusion
 Gender 57% male:43% female  Simple adjustment to software allowed incorporation of TTR
(Rosendaal method)
 AF 61%, DVT/PE 13%, Post-valve replacement 14.5%
 TTR in re-audit increased to 61% from 54% (12 months)
 Cost to practice of managing one GMS AF patient on
 Adverse events decreased
warfarin per year, €276.35
Time in Therapeutic Range
Study outcomes
2009 2010  On-going audit to maintain standard of care
n=57 n=64
 Flagging system for warfarin patients and at risk patients
TTR (12 months) 54% 61%
Point prevalence 60.5% 75%  Point of care testing imminent
INR tests 12 15  Dosage adjustment software now incorporated into software Dec 2010
Kelly et al. Stroke Associated with Atrial Fibrillation- Incidence and Early Outcomes in the North Dublin Population Stroke Study. Cerebrovasc Dis 2010;29;43-49
Hart et al. Adjusted-dose warfarin verus aspirin for preventing stroke in patients with atrial fibrillation. Ann Intern med. 2007;147;590-2
Baglin TP, Keeling DM, Watson HG; British Committee for Standards in Haematology. Guidelines on oral anticoagulation (warfari n): third edition--2005 update. Br J Haematol. 2006 Feb;132(3):277-85.
Baglin TP, Cousins D, Keeling DM, Perry DJ, Watson HG. British Committee for Standards in Haematology and National Patient Safety Agency. Br J Haematol. 2007 Feb;136(4):681.
Ansell J et al (2004). The pharmacology and management of the vitamin K antagonists: the Seventh ACCP Conference Antithrombotic and Thrombolytic Therapy. Chest 126(suppl),204S-233S.
Oppenkowski TP, Murray ET, Sandhar H, Fitzmaurice DA. External quality assessment for warfarin dosing using computerised decision support software. J Clin Pathol. 2003;56:605-607.

22. Ardfert Medical Centre Co. Kerry

23. Living Health Mitchelstown, Co. Cork

24. Vista Primary Care Centre, Naas

25. Waterford Health Park

26. Wherlands Lane Medical Centre, Cork City

27. Killarney Primary Care Centre

28. Mallow Primary Healthcare Centre (MPHC)
Co. Cork

29. Primary Care can make the
difference.
Who else can see that ????