Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn

Four fully-funded PhDs: HRB CDA ‘Right Care’ PhD programme

The ‘Right Care’ PhD programme is a Collaborative Doctoral Award funded by the Health Research Board. This programme is offering four doctoral awards that will enable structured methodological training to a cohort of multi-disciplinary PhD candidates from both clinical and non-clinical backgrounds.

The doctoral trainees will undertake thematically-linked research on the topic of ‘Right Care’ for older people, examining how right care can be given at the right time and in the right setting, so that older people get the greatest benefit and the least harm from health interventions.

The research topic of appropriate and safe care means that the research outputs will have significant impact on the safe, efficient and cost-effective care provided to older people in Ireland.

The programme is a collaboration between researchers from the Royal College of Surgeons in Ireland, the University of Limerick, and Trinity College Dublin, with involvement from national and international stakeholders.

It is a four-year programme and the structured training will provide high-level quantitative skills in epidemiology, biostatistics, health services research and health economics using a variety of methodological approaches - prognostic modelling, multi-level modelling, intervention development and piloting, and meta-analysis. The doctoral candidates will be able to select from a suite of training modules across educational institutions to ensure bespoke training to meet their specific learning and development needs. They will also have the opportunity to undertake a national and an international placement at leading partner institutions and organisations.

Details of the four doctoral projects included in the programme are listed below.

'Right Care': a programme of research to enhance safe and appropriate care for older patients in Ireland

Project 1 - Characterising appropriate care for older community-dwelling people. 

Appropriate care should balance patient benefits with potential harms. However, quantifying benefits and potential harms is challenging. While some treatments are clearly beneficial, others clearly are not, and though under-researched, many tests and treatments fall into a more ambiguous zone. Overuse and underuse of healthcare are now being seen as essential markers of an ineffective and iniquitous healthcare system. A systematic review focusing on acute medical care for older people estimated that up to 20% of care was inappropriate. Furthermore, using data from The Irish Longitudinal Study on Ageing (TILDA) >50% of participants had a potentially inappropriate prescription and >35% a potential prescribing omission. This doctoral project aims to quantify overuse and underuse of drug treatments, diagnostic tests and hospital procedures for older community-dwelling people, and examine variation in care and the gatekeeping role of GPs for people as they age.

Initially, a systematic review will be conducted to examine the totality of evidence relating to appropriate care. Following this, a prospective cohort study of participants aged ≥65 years (TILDA) will be linked with the electronic medical record (EMR) held by their General Practitioner (GP). The research will quantify overuse and underuse of medical services using international benchmarked standards of care, and additionally, patient characteristics (e.g. demographics, medications, activities of daily living), GP practice characteristics (e.g. deprivation, size of practice,) and health system factors (e.g. access to services) will be examined for associations with appropriate care. Finally, using complex hierarchical models, the research will examine the interaction of demographic, medical and social issues for older people changes as they age, in terms of appropriate care across the domains of drug treatments, diagnostic tests and surgical procedures, and how these changes are managed by their GP as gatekeepers to health services.

The doctoral trainee will gain experience in systematic reviewing, data linkage and data management (using The Irish Longitudinal Study on Ageing or TILDA), and observational analysis methods, including multilevel models for longitudinal studies/complex hierarchical modelling.

  • Registered at Trinity College Dublin (TILDA), in collaboration with the HRB Centre for Primary Care Research, RCSI.
  • Supervisors: Dr Fiona Boland (RCSI), Prof. Rose Anne Kenny (TCD), Dr Emma Wallace (RCSI) 
  • Proposed PhD candidate: Biostatistician, or similar strong quantitative qualifications.

 

Project 2 - Predicting avoidable emergency attendances and ambulatory care sensitive admissions in older people. 

For the majority of older people, primary care is the most appropriate and cost-effective setting for healthcare. Reducing emergency admissions, both as a measure of care quality and to contain escalating expenditure, is gaining interest internationally. Approximately 2 in every 10 older Irish people will be admitted to hospital as an emergency every year. A proportion of these admissions, caused by ambulatory care sensitive (ACS) conditions, are amenable to prevention through intensifying primary care management. A recent systematic review reported that existing emergency admission prediction models developed to identify all-cause emergency admissions perform relatively poorly. This could be addressed by focusing prediction efforts on ACS emergency admissions, which we will examine by applying risk prediction models designed for this purpose.

This doctoral project aims to examine patient and healthcare system characteristics associated with ACS emergency care attendances and admissions so we can better predict, avoid and manage these attendances/admissions. 

 

  • Work package 1: Study design: Two existing primary care cohort datasets established by the HRB CPCR will be utilised. Cohort A (2011-2015), n=44 general practices, 38,000 older people with prospective follow up ongoing. Cohort B (2010-2017) n=15 general practices, 904 older people. Exposure(s): Patient characteristics; external validation of risk prediction models. Primary outcome: ACS emergency admissions.
  • Work package 2: Study design: Cross-sectional study in one tertiary ED. Exposure(s): Patient (e.g. age, gender, morbidity) and system characteristics (e.g. access to GP care). Primary outcome: Avoidable ED attendances.
  • Work package 3: Study design: Prospective cohort study in one tertiary ED over three months. Exposure: External validation of the ISAR. Primary outcomes: i) ED return, ii) Emergency hospital admission, iii) Mortality, iv) Functional decline and v) Nursing home admission at 30, 90 and 180 days following ED discharge. 
  • Work package 4: Study design: Prospective cohort study in an out of hours GP service over three months. Exposure: Characteristics including patient (e.g. age, gender, morbidity) and system factors (e.g. GP access and location). Primary outcome: Avoidable out-of-hours GP attendances. 

The doctoral trainee will gain experience of literature review, external validation of risk prediction models, secondary analysis of existing datasets focusing on ACS admissions, primary data collection for a prospective cohort study across different clinical sites, data management and statistical analysis.

  • Registered at the Royal College of Surgeons in Ireland
  • Supervisors: Dr Emma Wallace (RCSI), Dr Abel Wakai (RCSI/Beaumont Hospital), Dr Fiona Boland (RCSI).
  • Proposed PhD candidate: General practitioner, or another clinical discipline.

 

Project 3 - Preventing adverse outcomes in older adults discharged from the Emergency Department (ED): A pilot randomised controlled trial of a community-based physiotherapy-led intervention. 

Older adults represent an increasing proportion of emergency department (ED) users and evidence from international studies estimate that their rate of functional decline within 30 days is almost 40%. The six-item Identification of Seniors At Risk (ISAR) tool identifies older adults at ‘high risk’ of early adverse outcomes following ED visit including ED return, functional decline, unplanned hospitalisation, or death. Following screening with the ISAR, it is recommended that older adults who score ≥2 points are referred for targeted assessment and intervention either in the hospital or community setting. However, there is a lack of research exploring community-based interventions targeting this ‘high risk’ cohort. This doctoral project aims to explore the impact of a community-based, physiotherapy-led multi-factorial intervention on rates of adverse outcomes among ‘high risk’ older adults following discharge from the emergency department (ED). 

The doctoral student (a clinical physiotherapist) will use a range of research methods to develop the proposed pilot intervention. This mixed-methods approach includes the completion of a systematic review to examine the totality of evidence relating to the impact of physiotherapy interventions on outcomes including falls, function and healthcare utilisation among older adults following hospital discharge. In addition, the views of older adults on the proposed intervention will be explored using a participatory research approach. Secondary analysis of routinely collected data at the ED in one clinical site during the period 2015-2016 will also be conducted to determine the incidence of ED return within 30 days, 90 days and six months among older adults discharged from the ED. Finally, the doctoral candidate will conduct a pilot evidence-based and user-informed physiotherapy intervention aimed at preventing adverse outcomes among ‘high risk’ older adults discharged from the ED.

The doctoral trainee will gain experience in both quantitative and qualitative methodological skills including systematic literature review, secondary analysis of routine data and primary qualitative and quantitative data collection.

  • Registered at the University of Limerick
  • Supervisors: Dr Rose Galvin (UL), Professor Cathal Walsh (UL), Dr Dominic Trépel (TCD).
  • Proposed PhD candidate: Physiotherapist

 

Project 4 - Evaluating the evidence base for prescribing decisions in older adults and its impact on outcomes. 

Right care for older people should be underpinned by high-quality guidelines to inform clinical decision-making, generally based on systematic reviews of published randomised controlled trials (RCTs). However, published RCTs can differ from unpublished trials, in both the likelihood of demonstrating benefit and the quality of reporting of efficacy and safety outcomes. Relying only on published evidence may distort the benefit/risk ratio and result in policy-makers, patients, and clinicians making sub-optimal decisions. Documents used to obtain drug approval from regulators, such as clinical study reports (CSRs), are a source of unpublished and more comprehensive data on RCTs. This doctoral project aims to explore the role of CSRs as unpublished sources of RCT reporting in evidence synthesis and its impact on estimates of effectiveness, safety, and cost-effectiveness. 

The research will focus on the evidence for two novel drug treatments used for chronic conditions. In work package 1, systematic reviews of RCTs of these two agents will be undertaken, and CSRs will be obtained for identified trials. Meta-analysis of all available evidence will be conducted to estimate benefits and harms, and will be repeated using only published sources of evidence to determine the impact of including CSRs. The second work package will evaluate differences in the quality of reporting and risk of bias between CSRs and published reports of trials, incorporating trials from work package 1 for which both a CSR and published source is available. Lastly, work package 3 will comprise a decision analytical modelling study. The beneficial and adverse outcomes and cost-effectiveness of the novel drug treatments will be modelled using health economic approaches. These will use estimates from work package 1 to determine the impact of using CSR-informed evidence compared to published evidence alone.

The doctoral trainee will develop both subject (clinical domain; medicines approval, regulation, and reimbursement; health economics; and research transparency and integrity) and methods (systematic reviewing, critical appraisal, data management and analysis, meta-analysis, meta-regression, epidemiological and economic modelling) expertise.

  • Registered at the Royal College of Surgeons in Ireland
  • Supervisors: Dr Frank Moriarty (RCSI), Prof. Tom Fahey (RCSI), Dr Dominic Trépel (TCD).
  • Proposed PhD candidate: Pharmacist, or other clinical discipline/health economics.

 

Eligibility criteria

Essential

  • Undergraduate degree in a relevant scientific/health discipline.
  • An interest in the topic area of ‘Right care’ for older people.
  • An ability to understand and address complex problems.
  • The capability to undertake doctoral-level research and complete the four year programme.
  • English language proficiency (native speaker or an IELTS score of 6.5 or above).

Desirable

  • Masters degree in a relevant discipline.
  • Undergraduate degree with a mark of 2.1 or higher.
  • Previous research experience.
  • Evidence of peer-reviewed publications.
  • Excellent interpersonal, communication and presentation skills.
  • A capacity to work collaboratively as part of a team and independently.

Application process

The closing date for application is Wednesday, 13 June at 5pm GMT. Interviews are expected to be held on Thursday, 21 and Friday, 22 June in Dublin. The application should include:

  • a cover letter outlining your interest in and suitability for the programme, and which project(s) you are applying for.
  • an up-to-date CV including contact details for two referees.

Informal queries to: Dr Fiona Boland (fionaboland@rcsi.ie) or Dr Frank Moriarty (frankmoriarty@rcsi.ie)

Please submit applications for all projects here

Note: this Job Description may be subject to change to reflect the evolving requirements of the Department and RCSI in developing healthcare leaders who make a difference worldwide.

RCSI is an equal opportunities employer.

Mentors Prof. Tom Fahey