Economic evaluations of clinical pharmacy services in Ireland, 2007-2015

Introduction The concept of this thesis was driven by stagnation within the Irish healthcare system. Multiple reports from pharmacy organisations had outlined possible future directions for the profession but progress was minimal, especially in comparison with other countries. The author’s directive was to evaluate the economic impact of a series of clinical pharmacy services (CPS) in hospital and community settings. Methods A systematic review of economic evaluations of clinical pharmacy services in hospital patients was undertaken to gain insight into recent research in the field. Eligible studies were evaluated using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS), to establish the quality, consistency and transparency of relevant research. A retrospective analysis of an internal hospital pharmacy interventions database was conducted. A method first described by Nesbit et al. was implemented to estimate the level of cost avoidance achieved. A cost-effectiveness analysis based on data from a randomised controlled trial of a pharmacist-supervised patient self-testing (PST) of warfarin therapy is presented. Outcome measure was the incremental cost associated with six months of intervention management. A similar cost-effectiveness analysis based on previously published RCT data was used to evaluate a novel structured pharmacist review of medication in older hospitalised patients. Cost-effectiveness analysis was presented in the form of an incremental cost-effectiveness ratio (ICER). An ICER is an additional cost per unit effect, in the case of this study, the cost of preventing an additional non-trivial ADR in hospital. A method described by Preaud et al. was adapted to estimate the clinical and economic benefit gained from vaccination of patients by a community pharmacist in Ireland in 2013/14. Sample demographic data was obtained from a national chain of community pharmacies and applied to overall national vaccination data. Results Systematic review identified twenty studies which were eligible for inclusion. Overall, pharmacist interventions had a positive impact on hospital budgets. Only three studies (15%) were deemed to be “good-quality” studies. No ‘novel’ clinical pharmacist intervention was identified during the course of this review. Analysis of internal hospital database identified 4,257 interventions documented on 2,147 individual patients over a 12 month period. Substantial cost avoidance of €710,000 was generated over a 1 year period from the perspective of the health care provider. Mean cost avoidance of €166 per intervention was generated. The cost of providing these interventions was €82,000. Substantial net cost-benefits of €626,279 and a cost-benefit ratio of 8.64 : 1 were generated based on this evaluation of pharmacist interventions. Results from an evaluation of a novel pharmacist-led form of warfarin management indicated indicated that on a per patient basis, PST was slightly more expensive than established anticoagulant management. On a per patient basis over a six month period, PST resulted in an incremental cost of €59.08 in comparison with routine care. Overall cost of managing a patient through pharmacist-supervised PST for a six month period is €226.45. However, for this increase in cost a clinically significant improvement in care was provided. Patients achieved a significantly higher time in therapeutic range during the PST arm in comparison with routine care, (72 ± 19.7% vs 59 ± 13.5%). Difference in overall cost was minimal and PST was the dominant strategy in some scenarios examined during sensitivity analysis. Structured pharmacist review of medication was determined to be dominant in comparison to usual pharmaceutical care. Even if the healthcare payer was unwilling to pay any money for the prevention of an ADR, the intervention strategy is still likely to be cost-effective (probability of being determined cost-effective = 0.707). Implementation of pharmacist-led influenza vaccination has resulted in substantial clinical and economic benefits to the healthcare system. The majority of patients (64.9%) who availed of this service had identifiable influenza-related risk factors. Of patients with influenza-related risk factors, age ≥65 year was the most commonly cited risk factor. Pharmacist vaccination services averted a total of 848 influenza cases across all age groups during the 2013/2014 influenza season. Due to receipt of vaccination in a pharmacy setting, 444 influenza-related GP visits were prevented. In terms of more serious influenza-associated events, 11 hospitalisations and five influenza-related deaths were averted. Costs averted were approximately €305,000. These were principally wider societal-related costs associated with lost productivity. Conclusion Overall, clinical pharmacy services are adding value to the Irish healthcare system in both hospital and community settings, but provision of additional funding for new services would enable them to offer a great deal more.

Transport energy demand: techno-economic modelling and scenarios for Irish climate policy

The case for energy policy modelling is strong in Ireland, where stringent EU climate targets are projected to be overshot by 2015. Policy targets aiming to deliver greenhouse gas and renewable energy targets have been made, but it is unclear what savings are to be achieved and from which sectors. Concurrently, the growth of personal mobility has caused an astonishing increase in CO2 emissions from private cars in Ireland, a 37% rise between 2000 and 2008, and while there have been improvements in the efficiency of car technology, there was no decrease in the energy intensity of the car fleet in the same period. This thesis increases the capacity for evidenced-based policymaking in Ireland by developing techno-economic transport energy models and using them to analyse historical trends and to project possible future scenarios. A central focus of this thesis is to understand the effect of the car fleet‘s evolving technical characteristics on energy demand. A car stock model is developed to analyse this question from three angles: Firstly, analysis of car registration and activity data between 2000 and 2008 examines the trends which brought about the surge in energy demand. Secondly, the car stock is modelled into the future and is used to populate a baseline “no new policy” scenario, looking at the impact of recent (2008-2011) policy and purchasing developments on projected energy demand and emissions. Thirdly, a range of technology efficiency, fuel switching and behavioural scenarios are developed up to 2025 in order to indicate the emissions abatement and renewable energy penetration potential from alternative policy packages. In particular, an ambitious car fleet electrification target for Ireland is examined. The car stock model‘s functionality is extended by linking it with other models: LEAP-Ireland, a bottom-up energy demand model for all energy sectors in the country; Irish TIMES, a linear optimisation energy system model; and COPERT, a pollution model. The methodology is also adapted to analyse trends in freight energy demand in a similar way. Finally, this thesis addresses the gap in the representation of travel behaviour in linear energy systems models. A novel methodology is developed and case studies for Ireland and California are presented using the TIMES model. Transport Energy

The political and economic context of Keynes’s 1933 Finlay lecture: transforming a business practitioner’s ways of knowing

This thesis is structured in the format of a three part Portfolio of Exploration to facilitate transformation in my ways of knowing to enhance an experienced business practitioner’s capabilities and effectiveness. A key factor in my ways of knowing, as opposed to what I know, is my exploration of context and assumptions. By interacting with my cultural, intellectual, economic, and social history, I seek to become critically aware of the biographical, historical, and cultural context of my beliefs and feelings about myself. This Portfolio is not exclusively for historians of economics or historians of ideas but also for those interested in becoming more aware of how these culturally assimilated frames of reference and bundles of assumptions that influence the way they perceive, think, decide, feel and interpret their experiences in order to operate more effectively in their professional and organisational lives. In the first part of my Portfolio, I outline and reflect upon my Portfolio’s overarching theory of adult development; the writings of Harvard’s Robert Kegan and Columbia University’s Jack Mezirow. The second part delves further into how meaning-making, the activity of how one organises and makes sense of the world and how meaning-making evolves to different levels of complexity. I explore how past experience and our interpretations of history influences our understandings since all perception is inevitably tinged with bias and entrenched ‘theory-laden’ assumptions. In my third part, I explore the 1933 inaugural University College Dublin Finlay Lecture delivered by economist John Maynard Keynes. My findings provide a new perspective and understanding of Keynes’s 1933 lecture by not solely reading or relying upon the text of the three contextualised essay versions of his lecture. The purpose and context of Keynes’s original longer lecture version was quite different to the three shorter essay versions published for the American, British and German audiences.

Experiences of the foster care process in the Republic of Ireland: retrospective accounts from biological children of foster carers

This thesis examines the experiences of the biological children of foster carers. In particular it explores their experiences in relation to inclusion, consultation and decision-making. The study also examines the support and training needs of birth children in foster families. Using a qualitative methodology in-depth, semi-structured interviews were conducted with fifteen birth children of foster carers aged between 18 and 30 years. The research findings show that for the majority of birth children, fostering was overall a positive experience which helped them develop into individuals who were caring and nonjudgemental. However, from the data collected in this study, it is clear that fostering also brings a range of challenges for birth children in foster families, such as managing feelings of loss, grief, jealousy and guilt when foster children leave. Birth children are reluctant to discuss these issues with their parents and often did not approach fostering social workers as they did not have a meaningful relationship in order to discuss their concerns. The findings also demonstrate that birth children undertake a lot of emotional work in supporting their parents, birth siblings and foster siblings. Despite the important role played by birth children in the fostering process, this contribution often goes unrecognised and unacknowledged by fostering professionals and agencies with birth children not included or consulted about foster care decisions that affect them. It is argued here that birth children are viewed by foster care professionals and agencies from a deficit based perspective. However, this study contends that it is not just foster parents who are involved in the foster care process, but the entire foster family. The findings of this study show that birth children are competent social actors capable of making valuable contributions to foster care decisions that affect their lives and that of their family.

Exploring an agent as an economic insider threat solution

The insider threat is a security problem that is well-known and has a long history, yet it still remains an invisible enemy. Insiders know the security processes and have accesses that allow them to easily cover their tracks. In recent years the idea of monitoring separately for these threats has come into its own. However, the tools currently in use have disadvantages and one of the most effective techniques of human review is costly. This paper explores the development of an intelligent agent that uses already in-place computing material for inference as an inexpensive monitoring tool for insider threats. Design Science Research (DSR) is a methodology used to explore and develop an IT artifact, such as for this intelligent agent research. This methodology allows for a structure that can guide a deep search method for problems that may not be possible to solve or could add to a phenomenological instantiation.

Biased group decision-making and the effect of computer-mediated communication: separating the effects of anonymity, voting and blind picking

The influence of communication technology on group decision-making has been examined in many studies. But the findings are inconsistent. Some studies showed a positive effect on decision quality, other studies have shown that communication technology makes the decision even worse. One possible explanation for these different findings could be the use of different Group Decision Support Systems (GDSS) in these studies, with some GDSS better fitting to the given task than others and with different sets of functions. This paper outlines an approach with an information system solely designed to examine the effect of (1) anonymity, (2) voting and (3) blind picking on decision quality, discussion quality and perceived quality of information.

Depression and 'crises of meaninglessness' in the political-economic theology of the money-God

The thesis starts with a historical analysis of the development of depression as a concept. Through this inquiry, the controversies behind the apparent consensus about depression’s etiology and treatment are illuminated, suggesting that the understanding of the climbing rates of depression in contemporary Western civilization is still up for grabs. That’s what the thesis sets out to investigate. In order to accomplish this aim, the study builds upon the classical accounts of Georg Simmel, Émile Durkheim and the more contemporary ideas of Dany-Robert Dufour, in dialogue with an array of supplementary theoretical sources. Navigating through this ‘sea’ of extraordinary and different theories, a new avenue of reflections arises, contributing for the sophistication of the questions made about the phenomenon of depression’s rates. The fundamental argument emerging from this theoretical undertaking is that ‘crises of meaninglessness’ that pervade the collective body of Western contemporary societies have, as one of its consequences, the expansion of depression rates. Meaninglessness in contemporary times is the primary object of investigation of the thesis. The concept, in the context of this study, is not understood as merely an effect of the historical decline of shared social norms due to processes of individualization. Rather, it is claimed, it originates from and is reinforced by the ‘political-economic theology of neo-liberalism’ which becomes virtually generalized in the West, erecting money as a God. The study concludes that by undermining culturally established values, ideals, institutions and principles that may block the dissemination of commodities this new transcendence has been challenging the task of signifying life, potentializing – among other subjective difficulties – the diffusion of depression.

From the demise of theory to its resurgence. A retrospective on the postmodern turn to rethink the 'desire for narrative' and the sublime untimeliness of emancipation

Cultural Marxist Theory, commonly known as theory, enjoyed a moment of extraordinary success in the 1970s, when the works of leading post-war French philosophers were published in English. After relocating to Anglophone academia, however, theory disavowed its original concerns and lost its ambition to understand the world as a whole, becoming the play of heterogeneities associated with postcolonialism, multiculturalism and identity politics, commonly referred to as postmodern theory. This turn, which took place during a period that seemed to have spelt the death of Marxism, the 1990s, induced many of its supporters to engage in an ongoing funeral wake designating the merits of theory and dreaming its resurgence. According to them, had theory been resurrected in historical circumstances completely different from those which had led to its rise, it would have never reacquired the significance that had originally connoted it. This thesis demonstrates how theory has survived its demise and entirely regained its prominence in our socio-political context marked by the effects of the latest crisis of capitalism and by the global threat of terrorisms rooted in messianic eschatologies. In its current form theory does no longer need to show allegiance to certain intellectual stances or political groupings in order to produce important reformulations of the projects it once gave life to. Though less overtly radical and epistemologically bounded, theory remains a necessary form of enquiry justified by the political commitment which originated it in the first place. Its voice continues to speak to us about justice ‘where it is not yet, not yet there, where it is no longer’ (Derrida, 1993, XVIII).