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.

Modular average case analysis: Language implementation and extension

Motivated by accurate average-case analysis, MOdular Quantitative Analysis (MOQA) is developed at the Centre for Efficiency Oriented Languages (CEOL). In essence, MOQA allows the programmer to determine the average running time of a broad class of programmes directly from the code in a (semi-)automated way. The MOQA approach has the property of randomness preservation which means that applying any operation to a random structure, results in an output isomorphic to one or more random structures, which is key to systematic timing. Based on original MOQA research, we discuss the design and implementation of a new domain specific scripting language based on randomness preserving operations and random structures. It is designed to facilitate compositional timing by systematically tracking the distributions of inputs and outputs. The notion of a labelled partial order (LPO) is the basic data type in the language. The programmer uses built-in MOQA operations together with restricted control flow statements to design MOQA programs. This MOQA language is formally specified both syntactically and semantically in this thesis. A practical language interpreter implementation is provided and discussed. By analysing new algorithms and data restructuring operations, we demonstrate the wide applicability of the MOQA approach. Also we extend MOQA theory to a number of other domains besides average-case analysis. We show the strong connection between MOQA and parallel computing, reversible computing and data entropy analysis.

Practical programming for static average-case analysis: the MOQA investigation

This work considers the static calculation of a program’s average-case time. The number of systems that currently tackle this research problem is quite small due to the difficulties inherent in average-case analysis. While each of these systems make a pertinent contribution, and are individually discussed in this work, only one of them forms the basis of this research. That particular system is known as MOQA. The MOQA system consists of the MOQA language and the MOQA static analysis tool. Its technique for statically determining average-case behaviour centres on maintaining strict control over both the data structure type and the labeling distribution. This research develops and evaluates the MOQA language implementation, and adds to the functions already available in this language. Furthermore, the theory that backs MOQA is generalised and the range of data structures for which the MOQA static analysis tool can determine average-case behaviour is increased. Also, some of the MOQA applications and extensions suggested in other works are logically examined here. For example, the accuracy of classifying the MOQA language as reversible is investigated, along with the feasibility of incorporating duplicate labels into the MOQA theory. Finally, the analyses that take place during the course of this research reveal some of the MOQA strengths and weaknesses. This thesis aims to be pragmatic when evaluating the current MOQA theory, the advancements set forth in the following work and the benefits of MOQA when compared to similar systems. Succinctly, this work’s significant expansion of the MOQA theory is accompanied by a realistic assessment of MOQA’s accomplishments and a serious deliberation of the opportunities available to MOQA in the future.

Optically injected multi-mode semiconductor lasers

As a device, the laser is an elegant conglomerate of elementary physical theories and state-of-the-art techniques ranging from quantum mechanics, thermal and statistical physics, material growth and non-linear mathematics. The laser has been a commercial success in medicine and telecommunication while driving the development of highly optimised devices specifically designed for a plethora of uses. Due to their low-cost and large-scale predictability many aspects of modern life would not function without the lasers. However, the laser is also a window into a system that is strongly emulated by non-linear mathematical systems and are an exceptional apparatus in the development of non-linear dynamics and is often used in the teaching of non-trivial mathematics. While single-mode semiconductor lasers have been well studied, a unified comparison of single and two-mode lasers is still needed to extend the knowledge of semiconductor lasers, as well as testing the limits of current model. Secondly, this work aims to utilise the optically injected semiconductor laser as a tool so study non-linear phenomena in other fields of study, namely ’Rogue waves’ that have been previously witnessed in oceanography and are suspected as having non-linear origins. The first half of this thesis includes a reliable and fast technique to categorise the dynamical state of optically injected two mode and single mode lasers. Analysis of the experimentally obtained time-traces revealed regions of various dynamics and allowed the automatic identification of their respective stability. The impact of this method is also extended to the detection regions containing bi-stabilities. The second half of the thesis presents an investigation into the origins of Rogue Waves in single mode lasers. After confirming their existence in single mode lasers, their distribution in time and sudden appearance in the time-series is studied to justify their name. An examination is also performed into the existence of paths that make Rogue Waves possible and the impact of noise on their distribution is also studied.

Fingerprints of a size-dependent crossover in the dimensionality of electronic conduction in Au-seeded Ge nanowires

We studied the electrical transport properties of Au-seeded germanium nanowires with radii ranging from 11 to 80 nm at ambient conditions. We found a non-trivial dependence of the electrical conductivity, mobility and carrier density on the radius size. In particular, two regimes were identified for large (lightly doped) and small (stronger doped) nanowires in which the charge-carrier drift is dominated by electron-phonon and ionized-impurity scattering, respectively. This goes in hand with the finding that the electrostatic properties for radii below ca. 37 nm have quasi one-dimensional character as reflected by the extracted screening lengths.