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.

Improving the use of asset-building financial services by Latino immigrants in Langley Park, Maryland

Gemstone Team ANSWER Poverty (Assessing the Need for Services Which Effectively Reduce Poverty)

Teaching neuraxial anesthesia techniques for obstetric care in a Ghanaian referral hospital: achievements and obstacles.

Anesthesia providers in low-income countries may infrequently provide regional anesthesia techniques for obstetrics due to insufficient training and supplies, limited manpower, and a lack of perceived need. In 2007, Kybele, Inc. began a 5-year collaboration in Ghana to improve obstetric anesthesia services. A program was designed to teach spinal anesthesia for cesarean delivery and spinal labor analgesia at Ridge Regional Hospital, Accra, the second largest obstetric unit in Ghana. The use of spinal anesthesia for cesarean delivery increased significantly from 6% in 2006 to 89% in 2009. By 2012, >90% of cesarean deliveries were conducted with spinal anesthesia, despite a doubling of the number performed. A trial of spinal labor analgesia was assessed in a small cohort of parturients with minimal complications; however, protocol deviations were observed. Although subsequent efforts to provide spinal analgesia in the labor ward were hampered by anesthesia provider shortages, spinal anesthesia for cesarean delivery proved to be practical and sustainable.

Federal Nutrition Assistance at Farmers’ Markets: Evaluating Self-Efficacy and the Home Nutrition Environment

SNAP and WIC help alleviate food insecurity among low-income families; however, some still struggle with fruit and vegetable accessibility. Farmers' markets present the opportunity to purchase fresher foods than other food retailers; therefore, we chose this environment to conduct our research. A survey of 70 WIC/SNAP shoppers at three D.C. metropolitan area farmers' markets assessed the correlation between parental self-efficacy and the home nutrition environment (composed of family health behavior, perceived barriers, and fruit and vegetable offerings in the home) and found a significant relationship. Interviews were used to evaluate market accessibility, SNAP/WIC benefit redemption, and the feasibility of accepting these benefits. Both market participants and coordinators mentioned the greater variety and superior quality of farmers' market produce but also suggested several improvements. Findings suggest that SNAP incentive programs may increase fruit and vegetable purchases. Programs targeting consumer self efficacy may also produce positive outcomes.

Be rich or don’t be sick: Estimating Vietnamese patients’ risk of falling into destitution

This paper represents the first research attempt to estimate the probabilities for Vietnamese patients to fall into destitution facing financial burdens occurring during their curative stay in hospital. The study models the risk against such factors as level of insurance coverage, location of patient, costliness of treatment, among others. The results show that very high probabilities of destitution, approximately 70%, apply to a large group of patients, who are nonresident, poor and ineligible for significant insurance coverage. There is also a probability of 58% that low-income patients who are seriously ill and face higher health care costs would quit their treatment. These facts will put Vietnamese government’s ambitious plan of increasing both universal coverage (UC) to 100% of expenditure and rate of UC beneficiaries to 100% at a serious test. The study also raises issues of asymmetric information and alternative financing options for the poor, who are most exposed to risk of destitution, following market-based health care reforms.

Water

The Water chapter of the Poor Choices report.

Health status of an elderly population in Sharpeville, South Africa

The objective of this cross-sectional study was a comprehensive nutrition and health assessment to provide a basis for future intervention strategies for an elderly population attending a day-care centre. Socio-demographic, health and 24-hour recall dietary intake questionnaires were administered and anthropometric and biochemical measurements taken. The results indicate that the majority of respondents had an income of between R501 and R1 000 (South African rand) per month and most of them reported an occasional lack of funds to meet basic household needs, confirming the presence of food insecurity. Daily dietary intakes (mean [+ or -] Standard Deviation [SD]) of the women were 5 395 [+ or -] 2 946 kJ energy, 47 [+ or -] 27 g protein, 28 [+ or -] 21 g fat and 196 [+ or -] 123 g carbohydrates compared to 8 641 [+ or -] 3 799 kJ, 86 [+ or -] 48 g, 49 [+ or -] 32 g and 301 [+ or -] 139 g of the men, respectively. The majority (83.6%) of the women were overweight (body mass index [BMI] [greater than or equal to] 25) or obese (BMI [greater than or equal to] 30) whilst 78% had a mid-upper arm circumference (MUAC) of [greater than or equal to] 21.7 cm. Mean intakes of micronutrients were low in comparison to reference standards and serum zinc levels were suboptimal. Obesity, hypertension and raised total serum cholesterol levels indicated an increased risk for coronary heart disease. It can be concluded that a low income, household food insecurity and risk factors associated with malnutrition and non-communicable diseases were prevalent in this elderly population. OPSOMMING Die doelwit van hierdie dwarssnitstudie was ‘n omvattende bepaling van voeding- en gesondheidstatus om as basis te dien vir toekomstige intervensiestrategieë vir ’n groep bejaardes wat ’n dagsentrum besoek. Sosiodemografiese, gesondheid- en 24-uur herroep-dieetinname vraelyste is voltooi en antropometriese en biochemiese metings is geneem. Die resultate het bevestig dat die meerderheid respondente ‘n maandelikse inkomste van tussen R501 en R1 000 (Suid-Afrikaanse rand) gehad het. Die meeste het ‘n geldtekort vir basiese huishoudelike behoeftes gerapporteer wat dui op huishoudelike voedselinsekuriteit. Daaglikse dieetinnames (gemiddeld±standaardafwyking [SA]) van die vroue was onderskeidelik 5 395±2 946 kJ energie, 47±27 g proteïen, 28±21 g vet en 196±123 g koolhidrate in vergelyking met 8 641±3 799 kJ, 86±48 g, 49±32 g en 301±139 g vir die mans. Die meerderheid (83.6%) van die vroue was oorgewig (liggaamsmassa-indeks [LMI] >25) of vetsugtig (LMI > 30) en 78% het ’n middel-bo-armomtrek (MUAC) van > 21.7 cm gehad. Gemiddelde mikronutriëntinnames was laag in vergelyking met die verwysingstandaarde en serumsink was suboptimaal. Vetsug, hipertensie en verhoogde totale serumcholesterolvlakke het op ‘n verhoogde risiko van kardiovaskulêre siekte gedui. Die resultate het dus bewys dat lae inkomste, huishoudelike voedselinsekuriteit en die risikofaktore wat met wanvoeding en leefstylsiektes geassosieer word, teenwoordig was.

Profitability and the poor: corporate strategies, innovation and sustainability

Based on empirical evidence, the article looks at the implications of private sector participation (PSP) for the delivery of water supply and sanitation to the urban and peri-urban poor in developing countries, with particular reference to Africa and Latin America. More precisely, the article addresses the impact produced by multinational companies’ (MNCs) strategies, in light of the pursuit of profitability, on the extension of connections to the pipeline network. It does so by questioning the assumptions that greater private sector efficiency and innovation, together with contract design, will enable the sustainable extension of service coverage to low income dwellers. The strategies of the major water MNCs are considered both in relation to the global expansion of their operations and the adjustment of local strategies to commercial considerations. The latter might result in identifying proWtable markets, modifying contractual provisions, attempting to reduce costs and increase income, reducing risks and exiting from non-performing contracts. The evidence reviewed allows for re-assessing the relative roles of the public and private sectors in extending and delivering water services to the poor. First, the most far reaching innovative approaches to extending connections are more likely to come from communities, public authorities and political activity than from MNCs. Secondly, whenever MNCs are liable to exit from non-profitable contracts, the public sector has no other option than to deal with external risks aVecting continuity of provision. Finally, market limitations affecting MNCs’ ability to serve marginal populations and access cheap capital do not apply to well-organised, politically led public sector undertakings

Public transport

Public transport plays an essential role in enabling people from low income and other disadvantaged groups to access employment and services. It also contributes to the development of social networks and social capital, by helping people to visit friends and relatives and take part in community and other social activities. Public policy makers have begun to recognise that adequate public transport provision can play an important role in reducing social exclusion. [Taken from introductory paragraph.]

Energy

The Energy chapter of the Poor Choices report

Introduction

The seven sectors examined in this report represent the goods and services essential for, at the least, social inclusion and, in most instances, survival in a modern society. For the lowest three income deciles, they represent about 60 per cent of total household expenditure. [From final paragraph of Introduction]

Conclusion

We conclude that there are significant problems with the operation of the markets in all those sectors we look at that are, to a greater or less extent, operated as commercial markets. That said, the way in which the water sector operates (the only remaining regulated monopoly) seems to serve low-income consumers little better. [From 'Summary of conclusions']

Projecting marine fish production and catch potential in Bangladesh in the 21st century under long-term environmental change and management scenarios

The fisheries sector is crucial to the Bangladeshi economy and wellbeing, accounting for 4.4% of national Gross Domestic Product (GDP) and 22.8% of agriculture sector production, and supplying ca.60% of the national animal protein intake. Fish is vital to the 16 million Bangladeshis living near the coast, a number that has doubled since the 1980s. Here we develop and apply tools to project the long term productive capacity of Bangladesh marine fisheries under climate and fisheries management scenarios, based on downscaling a global climate model, using associated river flow and nutrient loading estimates, projecting high resolution changes in physical and biochemical ocean properties, and eventually projecting fish production and catch potential under different fishing mortality targets. We place particular interest on Hilsa shad (Tenualosa ilisha), which accounts for ca.11% of total catches, and Bombay duck (Harpadon nehereus), a low price fish that is the second highest catch in Bangladesh and is highly consumed by low income communities. It is concluded that the impacts of climate change, under greenhouse emissions scenario A1B, are likely to reduce the potential fish production in the Bangladesh Exclusive Economic Zone (EEZ) by less than 10%. However, these impacts are larger for the two target species. Under sustainable management practices we expect Hilsa shad catches to show a minor decline in potential catch by 2030 but a significant (25%) decline by 2060. However, if overexploitation is allowed catches are projected to fall much further, by almost 95% by 2060, compared to the Business as Usual scenario for the start of the 21st century. For Bombay duck, potential catches by 2060 under sustainable scenarios will produce a decline of less than 20% compared to current catches. The results demonstrate that management can mitigate or exacerbate the effects of climate change on ecosystem productivity.

Social identification and prevalence of PTSD in Northern Ireland

Background Understanding of the psychological impact of politically motivated violence is poor. Aims To examine the prevalence of post-traumatic symptoms subsequentto the ‘troubles’ in Northern Ireland. Method A telephone survey of 3000 adults, representative of the population in Northern Ireland and the border counties of the Irish Republic, examined exposure to political violence, post-traumatic stress disorder (PTSD) and national identity. Results Ten per cent of respondents had symptoms suggestive of clinical PTSD. These people were most likely to come from low-income groups, rate national identity as relatively unimportant and have higher overall experience of the ‘troubles’than other respondents. Conclusions Direct experience of violence and poverty increase the risk of PTSD, whereas strong national identification appears to reduce this risk.

Cooperativism, entrepreneurship and economic development: a linking theoretical model

Cooperatives, as a kind of firms, are considered by many scholars as an remarkable alternative for overcoming the economic crisis started in 2008. Besides, there are other scholars which pointed out the important role that these firms play in the regional economic development. Nevertheless, when one examines the economic literature on cooperatives, it is detected that this kind of firms is mainly studied starting from the point of view of their own characteristics and particularities of participation and solidarity. In this sense, following a different analysis framework, this article proposes a theoretical model in order to explain the behavior of cooperatives based on the entrepreneurship theory with the aim of increasing the knowledge about this kind of firms and, more specifically, their contribution to regional economic development.