The quality of diabetes care in the community: practice, policy and culture

Aim: Diabetes is an important barometer of health system performance. This chronic condition is a source of significant morbidity, premature mortality and a major contributor to health care costs. There is an increasing focus internationally, and more recently nationally, on system, practice and professional-level initiatives to promote the quality of care. The aim of this thesis was to investigate the ‘quality chasm’ around the organisation and delivery of diabetes care in general practice, to explore GPs’ attitudes to engaging in quality improvement activities and to examine efforts to improve the quality of diabetes care in Ireland from practice to policy. Methods: Quantitative and qualitative methods were used. As part of a mixed methods sequential design, a postal survey of 600 GPs was conducted to assess the organization of care. This was followed by an in-depth qualitative study using semi-structured interviews with a purposive sample of 31 GPs from urban and rural areas. The qualitative methodology was also used to examine GPs’ attitudes to engaging in quality improvement. Data were analysed using a Framework approach. A 2nd observation study was used to assess the quality of care in 63 practices with a special interest in diabetes. Data on 3010 adults with Type 2 diabetes from 3 primary care initiatives were analysed and the results were benchmarked against national guidelines and standards of care in the UK. The final study was an instrumental case study of policy formulation. Semi-structured interviews were conducted with 15 members of the Expert Advisory Group (EAG) for Diabetes. Thematic analysis was applied to the data using 3 theories of the policy process as analytical tools. Results: The survey response rate was 44% (n=262). Results suggested care delivery was largely unstructured; 45% of GPs had a diabetes register (n=157), 53% reported using guidelines (n=140), 30% had formal call recall system (n=78) and 24% had none of these organizational features (n=62). Only 10% of GPs had a formal shared protocol with the local hospital specialist diabetes team (n=26). The lack of coordination between settings was identified as a major barrier to providing optimal care leading to waiting times, overburdened hospitals and avoidable duplication. The lack of remuneration for chronic disease management had a ripple effect also creating costs for patients and apathy among GPs. There was also a sense of inertia around quality improvement activities particularly at a national level. This attitude was strongly influenced by previous experiences of change in the health system. In contrast GP’s spoke positively about change at a local level which was facilitated by a practice ethos, leadership and special interest in diabetes. The 2nd quantitative study found that practices with a special interest in diabetes achieved a standard of care comparable to the UK in terms of the recording of clinical processes of care and the achievement of clinical targets; 35% of patients reached the HbA1c target of <6.5% compared to 26% in England and Wales. With regard to diabetes policy formulation, the evolving process of action and inaction was best described by the Multiple Streams Theory. Within the EAG, the formulation of recommendations was facilitated by overarching agreement on the “obvious” priorities while the details of proposals were influenced by personal preferences and local capacity. In contrast the national decision-making process was protracted and ambiguous. The lack of impetus from senior management coupled with the lack of power conferred on the EAG impeded progress. Conclusions: The findings highlight the inconsistency of diabetes care in Ireland. The main barriers to optimal diabetes management center on the organization and coordination of care at the systems level with consequences for practice, providers and patients. Quality improvement initiatives need to stimulate a sense of ownership and interest among frontline service providers to address the local sense of inertia to national change. To date quality improvement in diabetes care has been largely dependent the “special interest” of professionals. The challenge for the Irish health system is to embed this activity as part of routine practice, professional responsibility and the underlying health care culture.

Reactivity of sub 1 nm supported clusters: (TiO2)(n) clusters supported on rutile TiO2 (110)

Metal oxide clusters of sub-nm dimensions dispersed on a metal oxide support are an important class of catalytic materials for a number of key chemical reactions, showing enhanced reactivity over the corresponding bulk oxide. In this paper we present the results of a density functional theory study of small sub-nm TiO2 clusters, Ti2O4, Ti3O6 and Ti4O8 supported on the rutile (110) surface. We find that all three clusters adsorb strongly with adsorption energies ranging from -3 eV to -4.5 eV. The more stable adsorption structures show a larger number of new Ti-O bonds formed between the cluster and the surface. These new bonds increase the coordination of cluster Ti and O as well as surface oxygen, so that each has more neighbours. The electronic structure shows that the top of the valence band is made up of cluster derived states, while the conduction band is made up of Ti 3d states from the surface, resulting in a reduction of the effective band gap and spatial separation of electrons and holes after photon absorption, which shows their potential utility in photocatalysis. To examine reactivity, we study the formation of oxygen vacancies in the cluster-support system. The most stable oxygen vacancy sites on the cluster show formation energies that are significantly lower than in bulk TiO2, demonstrating the usefulness of this composite system for redox catalysis.

Revisiting Irish poetic modernisms

This thesis discusses Irish Modernist poetry written between 1905 and 1970, specifically the poetry of Joseph Campbell (1879-1944), Thomas MacGreevy (1893-1967), Denis Devlin (1908-1959) and Brian Coffey (1905-1995). All four poets have been largely neglected in criticism until a growth of interest encouraged by Michael Smith and Trevor Joyce’s New Writers’ Press during the 1970s. J.C.C. Mays, Stan Smith, Susan Schreibman, Terence Brown, Patricia Coughlan and Alex Davis published subsequent critical support during the ‘80s and ‘90s. My research aims to highlight poetry previously omitted from the canon of Irish literature, those with connections to British or continental European literary movements as well as poetry by women writers and writers from the North. Part of this exploration of Irish Poetic Modernisms involves an investigation of intersections between poetic modernisms and Irish war poetry and of depictions of Irish masculinity in the poetry of Devlin and Coffey. My discussion of Campbell’s poetry focuses on links between the early regional modernism of his poetry and later Irish modernist poetry, including his participation in the Ulster Literary Theatre, with the Literary Revival community in Dublin and his association with the proto-Imagist movement in London. My examination of connections between Irish war poetry and Irish modernism allows me to discuss the writing of several underrecognized Irish poets who are contemporaries and near contemporaries of the main subjects of my thesis. Thomas MacGreevy’s poetry is the most clear case study of the links between Irish modernist poetry and poetry about Ireland’s participation in the Great War. MacGreevy’s writing reveals his multiple allegiances: he both elegizes and challenges the increasing cultural inhibitions of Free State Ireland. Denis Devlin’s poetic portrayals of Ireland reveal his rejection both of the Literary Revival’s fascination with Celticism and of Dublin’s literary community while upholding tradition poetic gender roles. My research explores representations of masculinity and Irish politics, including heroic masculine imagery, in the long poems of Devlin and Coffey. My discussion of Brian Coffey considers the importance of the figure of the “poet as maker” to his writing and his relationship with Ireland during his long writing career. I also consider his role as the editor and executor of Devlin’s literary estate and the impact that had on both the latter’s posthumous reputation and Coffey’s later writing.