The effects of copayment policies on adherence to prescription medicines in publicly insured populations

Introduction: Copayments for prescriptions are associated with decreased adherence to medicines resulting in increased health service utilisation, morbidity and mortality. In October 2010 a 50c copayment per prescription item was introduced on the General Medical Services (GMS) scheme in Ireland, the national public health insurance programme for low-income and older people. The copayment was increased to €1.50 per prescription item in January 2013. To date, the impact of these copayments on adherence to prescription medicines on the GMS scheme has not been assessed. Given that the GMS population comprises more than 40% of the Irish population, this presents an important public health problem. The aim of this thesis was to assess the impact of two prescription copayments, 50c and €1.50, on adherence to medicines.Methods: In Chapter 2 the published literature was systematically reviewed with meta-analysis to a) develop evidence on cost-sharing for prescriptions and adherence to medicines and b) develop evidence for an alternative policy option; removal of copayments. The core research question of this thesis was addressed by a large before and after longitudinal study, with comparator group, using the national pharmacy claims database. New users of essential and less-essential medicines were included in the study with sample sizes ranging from 7,007 to 136,111 individuals in different medication groups. Segmented regression was used with generalised estimating equations to allow for correlations between repeated monthly measurements of adherence. A qualitative study involving 24 individuals was conducted to assess patient attitudes towards the 50c copayment policy. The qualitative and quantitative findings were integrated in the discussion chapter of the thesis. The vast majority of the literature on this topic area is generated in North America, therefore a test of generalisability was carried out in Chapter 5 by comparing the impact of two similar copayment interventions on adherence, one in the U.S. and one in Ireland. The method used to measure adherence in Chapters 3 and 5 was validated in Chapter 6. Results: The systematic review with meta-analysis demonstrated an 11% (95% CI 1.09 to 1.14) increased odds of non-adherence when publicly insured populations were exposed to copayments. The second systematic review found moderate but variable improvements in adherence after removal/reduction of copayments in a general population. The core paper of this thesis found that both the 50c and €1.50 copayments on the GMS scheme were associated with larger reductions in adherence to less-essential medicines than essential medicines directly after the implementation of policies. An important exception to this pattern was observed; adherence to anti-depressant medications declined by a larger extent than adherence to other essential medicines after both copayments. The cross country comparison indicated that North American evidence on cost-sharing for prescriptions is not automatically generalisable to the Irish setting. Irish patients had greater immediate decreases of -5.3% (95% CI -6.9 to -3.7) and -2.8% (95% CI -4.9 to -0.7) in adherence to anti-hypertensives and anti-hyperlipidaemic medicines, respectively, directly after the policy changes, relative to their U.S. counterparts. In the long term, however, the U.S. and Irish populations had similar behaviours. The concordance study highlighted the possibility of a measurement bias occurring for the measurement of adherence to non-steroidal anti-inflammatory drugs in Chapter 3. Conclusions: This thesis has presented two reviews of international cost-sharing policies, an assessment of the generalisability of international evidence and both qualitative and quantitative examinations of cost-sharing policies for prescription medicines on the GMS scheme in Ireland. It was found that the introduction of a 50c copayment and its subsequent increase to €1.50 on the GMS scheme had a larger impact on adherence to less-essential medicines relative to essential medicines, with the exception of anti-depressant medications. This is in line with policy objectives to reduce moral hazard and is therefore demonstrative of the value of such policies. There are however some caveats. The copayment now stands at €2.50 per prescription item. The impact of this increase in copayment has yet to be assessed which is an obvious point for future research. Careful monitoring for adverse effects in socio-economically disadvantaged groups within the GMS population is also warranted. International evidence can be applied to the Irish setting to aid in future decision making in this area, but not without placing it in the local context first. Patients accepted the introduction of the 50c charge, however did voice concerns over a rising price. The challenge for policymakers is to find the ‘optimal copayment’ – whereby moral hazard is decreased, but access to essential chronic disease medicines that provide advantages at the population level is not deterred. This evidence presented in this thesis will be utilisable for future policy-making in Ireland.

Using parent report to assess early lexical production in children exposed to more than one language

Limited expressive vocabulary skills in young children are considered to be the first warning signs of a potential Specific Language Impairment (SLI) (Ellis & Thal, 2008). In bilingual language learning environments, the expressive vocabulary size in each of the child’s developing languages is usually smaller compared to the number of words produced by monolingual peers (e.g. De Houwer, 2009). Nonetheless, evidence shows children’s total productive lexicon size across both languages to be comparable to monolingual peers’ vocabularies (e.g. Pearson et al., 1993; Pearson & Fernandez, 1994). Since there is limited knowledge as to which level of bilingual vocabulary size should be considered as a risk factor for SLI, the effects of bilingualism and language-learning difficulties on early lexical production are often confounded. The compilation of profiles for early vocabulary production in children exposed to more than one language, and their comparison across language pairs, should enable more accurate identification of vocabulary delays that signal a risk for SLI in bilingual populations. These considerations prompted the design of a methodology for assessing early expressive vocabulary in children exposed to more than one language, which is described in the present chapter. The implementation of this methodological framework is then outlined by presenting the design of a study that measured the productive lexicons of children aged 24-36 months who were exposed to different language pairs, namely Maltese and English, Irish and English, Polish and English, French and Portuguese, Turkish and German as well as English and Hebrew. These studies were designed and coordinated in COST Action IS0804 Working Group 3 (WG3) and will be described in detail in a series of subsequent publications. Expressive vocabulary size was measured through parental report, by employing the vocabulary checklist of the MacArthur-Bates Communicative Development Inventory: Words and Sentences (CDI: WS) (Fenson et al., 1993, 2007) and its adaptations to the participants’ languages. Here we describe the novelty of the study’s methodological design, which lies in its attempt to harmonize the use of vocabulary checklist adaptations, together with parental questionnaires addressing language exposure and developmental history, across participant groups characterized by different language exposure variables. This chapter outlines the various methodological considerations that paved the way for meaningful cross-linguistic comparison of the participants’ expressive lexicon sizes. In so doing, it hopes to provide a template for and encourage further research directed at establishing a threshold for SLI risk in children exposed to more than one language.

Linearity analysis and comparison study on the epoc® point-of-care blood analysis system in cardiopulmonary bypass patients

The epoc® blood analysis system (Epocal Inc., Ottawa, Ontario, Canada) is a newly developed in vitro diagnostic hand-held analyzer for testing whole blood samples at point-of-care, which provides blood gas, electrolytes, ionized calcium, glucose, lactate, and hematocrit/calculated hemoglobin rapidly. The analytical performance of the epoc® system was evaluated in a tertiary hospital, see related research article “Analytical evaluation of the epoc® point-of-care blood analysis system in cardiopulmonary bypass patients” [1]. Data presented are the linearity analysis for 9 parameters and the comparison study in 40 cardiopulmonary bypass patients on 3 epoc® meters, Instrumentation Laboratory GEM4000, Abbott iSTAT, Nova CCX, and Roche Accu-Chek Inform II and Performa glucose meters.

Learning to Teach and its Implications for the Continuum of Teacher Education: A Nine Country Cross-national Study.

The purpose of this Report is to inform discussions, policy formulation, and strategic planning on teacher education in Ireland. The research gives priority to initial teacher education (ITE) and induction, their interface, and implications for the continuum of teacher education, including continuing professional development (CPD). The study involved a two-pronged approach: a narrative review of recent and relevant literature and a cross-national review of teacher education policies in nine countries, namely, Ireland, Northern Ireland, Scotland, England, Finland, USA, Poland, Singapore and New Zealand. Adopting a broad, balanced and comprehensive understanding of the role of the contemporary teacher, it provides a framework for developing quality teacher education in Ireland. The Report incorporates exemplars of good practice and notes their implementation challenges for the Irish context.  Chapter One provides a framework for conceptualising quality teacher education and the continuum. Key features that emerge from the literature are discussed: teachers¿ practice, quality teaching, the professional life-cycle, teacher learning and relationships. With more specific reference to the continuum, Chapter Two overviews initial teacher education, induction, learning outcomes and accreditation in the selected countries, including Ireland. Key features of policy in the various countries are summarised. Individual country profiles, incorporating descriptions of socio-political, teaching and teacher education contexts, are further detailed in Appendix A. Chapter Three analyses relevant literature on initial teacher education, induction, learning outcomes/professional standards and accreditation. Along with previous chapters it provides the basis for recommendations for teacher education that are presented in Chapter Four. Chapter Four draws together the findings emerging from the cross-national review in terms of the contemporary context of teacher education in Ireland and identifies key challenges and possible lines of policy development as well as recommendations for the Teaching Council and other teacher education stakeholders. Each generation has an opportunity to provide the vision and resources for renewing teacher education in light of ambitious social, economic and educational aspirations to meet perceived societal and education challenges (as occurred in the 1970s). Despite the publication of two key reviews of initial teacher education a number of years ago, there is considerable scope for further reform of teacher education. However, significant changes have occurred to teacher education course provision and content over the last 100 years. In this report, we have stressed the need for, and called for investment in, greater system and programme coherence, mentoring to support assisted practice, knowledge integration, critical reflective practice, inquiry and the development of vibrant partnerships between higher education institutions and schools as the basis for teacher education reform across the continuum. This Executive Summary presents the Report¿s context, key findings and recommendations emerging from the analysis.  

Comparison of deterministic, stochastic and fuzzy logic uncertainty modelling for capacity extension projects of DI/WFI pharmaceutical plant utilities with variable/dynamic demand

The last 30 years have seen Fuzzy Logic (FL) emerging as a method either complementing or challenging stochastic methods as the traditional method of modelling uncertainty. But the circumstances under which FL or stochastic methods should be used are shrouded in disagreement, because the areas of application of statistical and FL methods are overlapping with differences in opinion as to when which method should be used. Lacking are practically relevant case studies comparing these two methods. This work compares stochastic and FL methods for the assessment of spare capacity on the example of pharmaceutical high purity water (HPW) utility systems. The goal of this study was to find the most appropriate method modelling uncertainty in industrial scale HPW systems. The results provide evidence which suggests that stochastic methods are superior to the methods of FL in simulating uncertainty in chemical plant utilities including HPW systems in typical cases whereby extreme events, for example peaks in demand, or day-to-day variation rather than average values are of interest. The average production output or other statistical measures may, for instance, be of interest in the assessment of workshops. Furthermore the results indicate that the stochastic model should be used only if found necessary by a deterministic simulation. Consequently, this thesis concludes that either deterministic or stochastic methods should be used to simulate uncertainty in chemical plant utility systems and by extension some process system because extreme events or the modelling of day-to-day variation are important in capacity extension projects. Other reasons supporting the suggestion that stochastic HPW models are preferred to FL HPW models include: 1. The computer code for stochastic models is typically less complex than a FL models, thus reducing code maintenance and validation issues. 2. In many respects FL models are similar to deterministic models. Thus the need for a FL model over a deterministic model is questionable in the case of industrial scale HPW systems as presented here (as well as other similar systems) since the latter requires simpler models. 3. A FL model may be difficult to "sell" to an end-user as its results represent "approximate reasoning" a definition of which is, however, lacking. 4. Stochastic models may be applied with some relatively minor modifications on other systems, whereas FL models may not. For instance, the stochastic HPW system could be used to model municipal drinking water systems, whereas the FL HPW model should or could not be used on such systems. This is because the FL and stochastic model philosophies of a HPW system are fundamentally different. The stochastic model sees schedule and volume uncertainties as random phenomena described by statistical distributions based on either estimated or historical data. The FL model, on the other hand, simulates schedule uncertainties based on estimated operator behaviour e.g. tiredness of the operators and their working schedule. But in a municipal drinking water distribution system the notion of "operator" breaks down. 5. Stochastic methods can account for uncertainties that are difficult to model with FL. The FL HPW system model does not account for dispensed volume uncertainty, as there appears to be no reasonable method to account for it with FL whereas the stochastic model includes volume uncertainty.

A benchmark comparison between reconfigurable, intelligent and autonomous wireless inertial measurement and photonic technologies in rehabilitation

Advanced sensory systems address a number of major obstacles towards the provision for cost effective and proactive rehabilitation. Many of these systems employ technologies such as high-speed video or motion capture to generate quantitative measurements. However these solutions are accompanied by some major limitations including extensive set-up and calibration, restriction to indoor use, high cost and time consuming data analysis. Additionally many do not quantify improvement in a rigorous manner for example gait analysis for 5 minutes as opposed to 24 hour ambulatory monitoring. This work addresses these limitations using low cost, wearable wireless inertial measurement as a mobile and minimal infrastructure alternative. In cooperation with healthcare professionals the goal is to design and implement a reconfigurable and intelligent movement capture system. A key component of this work is an extensive benchmark comparison with the 'gold standard' VICON motion capture system.

A simulation-based design method to transfer surface mount RF system to flip-chip die implementation

The flip-chip technology is a high chip density solution to meet the demand for very large scale integration design. For wireless sensor node or some similar RF applications, due to the growing requirements for the wearable and implantable implementations, flip-chip appears to be a leading technology to realize the integration and miniaturization. In this paper, flip-chip is considered as part of the whole system to affect the RF performance. A simulation based design is presented to transfer the surface mount PCB board to the flip-chip die package for the RF applications. Models are built by Q3D Extractor to extract the equivalent circuit based on the parasitic parameters of the interconnections, for both bare die and wire-bonding technologies. All the parameters and the PCB layout and stack-up are then modeled in the essential parts' design of the flip-chip RF circuit. By implementing simulation and optimization, a flip-chip package is re-designed by the parameters given by simulation sweep. Experimental results fit the simulation well for the comparison between pre-optimization and post-optimization of the bare die package's return loss performance. This design method could generally be used to transfer any surface mount PCB to flip-chip package for the RF systems or to predict the RF specifications of a RF system using the flip-chip technology.