Drug prescribing patterns in the General Medical Services Scheme in Ireland and projected costs to 2026

The primary objective is to investigate the main factors contributing to GMS expenditure on pharmaceutical prescribing and projecting this expenditure to 2026. This study is located in the area of pharmacoeconomic cost containment and projections literature. The thesis has five main aims: 1. To determine the main factors contributing to GMS expenditure on pharmaceutical prescribing. 2. To develop a model to project GMS prescribing expenditure in five year intervals to 2026, using 2006 Central Statistics Office (CSO) Census data and 2007 Health Service Executive{Primary Care Reimbursement Service (HSE{PCRS) sample data. 3. To develop a model to project GMS prescribing expenditure in five year intervals to 2026, using 2012 HSE{PCRS population data, incorporating cost containment measures, and 2011 CSO Census data. 4. To investigate the impact of demographic factors and the pharmacology of drugs (Anatomical Therapeutic Chemical (ATC)) on GMS expenditure. 5. To explore the consequences of GMS policy changes on prescribing expenditure and behaviour between 2008 and 2014. The thesis is centered around three published articles and is located between the end of a booming Irish economy in 2007, a recession from 2008{2013, to the beginning of a recovery in 2014. The literature identified a number of factors influencing pharmaceutical expenditure, including population growth, population aging, changes in drug utilisation and drug therapies, age, gender and location. The literature identified the methods previously used in predictive modelling and consequently, the Monte Carlo Simulation (MCS) model was used to simulate projected expenditures to 2026. Also, the literature guided the use of Ordinary Least Squares (OLS) regression in determining demographic and pharmacology factors influencing prescribing expenditure. The study commences against a backdrop of growing GMS prescribing costs, which has risen from e250 million in 1998 to over e1 billion by 2007. Using a sample 2007 HSE{PCRS prescribing data (n=192,000) and CSO population data from 2008, (Conway et al., 2014) estimated GMS prescribing expenditure could rise to e2 billion by2026. The cogency of these findings was impacted by the global economic crisis of 2008, which resulted in a sharp contraction in the Irish economy, mounting fiscal deficits resulting in Ireland's entry to a bailout programme. The sustainability of funding community drug schemes, such as the GMS, came under the spotlight of the EU, IMF, ECB (Trioka), who set stringent targets for reducing drug costs, as conditions of the bailout programme. Cost containment measures included: the introduction of income eligibility limits for GP visit cards and medical cards for those aged 70 and over, introduction of co{payments for prescription items, reductions in wholesale mark{up and pharmacy dispensing fees. Projections for GMS expenditure were reevaluated using 2012 HSE{PCRS prescribing population data and CSO population data based on Census 2011. Taking into account both cost containment measures and revised population predictions, GMS expenditure is estimated to increase by 64%, from e1.1 billion in 2016 to e1.8 billion by 2026, (ConwayLenihan and Woods, 2015). In the final paper, a cross{sectional study was carried out on HSE{PCRS population prescribing database (n=1.63 million claimants) to investigate the impact of demographic factors, and the pharmacology of the drugs, on GMS prescribing expenditure. Those aged over 75 (ẞ = 1:195) and cardiovascular prescribing (ẞ = 1:193) were the greatest contributors to annual GMS prescribing costs. Respiratory drugs (Montelukast) recorded the highest proportion and expenditure for GMS claimants under the age of 15. Drugs prescribed for the nervous system (Escitalopram, Olanzapine and Pregabalin) were highest for those between 16 and 64 years with cardiovascular drugs (Statins) were highest for those aged over 65. Females are more expensive than males and are prescribed more items across the four ATC groups, except among children under 11, (ConwayLenihan et al., 2016). This research indicates that growth in the proportion of the elderly claimants and associated levels of cardiovascular prescribing, particularly for statins, will present difficulties for Ireland in terms of cost containment. Whilst policies aimed at cost containment (co{payment charges, generic substitution, reference pricing, adjustments to GMS eligibility) can be used to curtail expenditure, health promotional programs and educational interventions should be given equal emphasis. Also policies intended to affect physicians prescribing behaviour include guidelines, information (about price and less expensive alternatives) and feedback, and the use of budgetary restrictions could yield savings.

A Jaworskian analysis of four senior class primary teachers endeavouring to teach mathematics from a constructivist-compatible perspective

A constructivist philosophy underlies the Irish primary mathematics curriculum. As constructivism is a theory of learning its implications for teaching need to be addressed. This study explores the experiences of four senior class primary teachers as they endeavour to teach mathematics from a constructivist-compatible perspective with primary school children in Ireland over a school-year period. Such a perspective implies that children should take ownership of their learning while working in groups on tasks which challenge them at their zone of proximal development. The key question on which the research is based is: to what extent will an exposure to constructivism and its implications for the classroom impact on teaching practices within the senior primary mathematics classroom in both the short and longer term? Although several perspectives on constructivism have evolved (von Glaserfeld (1995), Cobb and Yackel (1996), Ernest (1991,1998)), it is the synthesis of the emergent perspective which becomes pivotal to the Irish primary mathematics curriculum. Tracking the development of four primary teachers in a professional learning initiative involving constructivist-compatible approaches necessitated the use of Borko’s (2004) Phase 1 research methodology to account for the evolution in teachers’ understanding of constructivism. Teachers’ and pupils’ viewpoints were recorded using both audio and video technology. Teachers were interviewed at the beginning and end of the project and also one year on to ascertain how their views had evolved. Pupils were interviewed at the end of the project only. The data were analysed from a Jaworskian perspective i.e. using the categories of her Teaching Triad of management of learning, mathematical challenge and sensitivity to students. Management of learning concerns how the teacher organises her classroom to maximise learning opportunities for pupils. Mathematical challenge is reminiscent of the Vygotskian (1978) construct of the zone of proximal development. Sensitivity to students involves a consciousness on the part of the teacher as to how pupils are progressing with a mathematical task and whether or not to intervene to scaffold their learning. Through this analysis a synthesis of the teachers’ interpretations of constructivist philosophy with concomitant implications for theory, policy and practice emerges. The study identifies strategies for teachers wishing to adopt a constructivist-compatible approach to their work. Like O’Shea (2009) it also highlights the likely difficulties to be experienced by such teachers as they move from utilising teacher-dominated methods of teaching mathematics to ones in which pupils have more ownership over their learning.