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.

Can Compensation Committees Effectively Mitigate the CEO Horizon Problem? The Role of Co-opted Directors

Extant research finds inconclusive evidence about the CEO horizon problem. One possibility is that compensation committees design CEO compensation in a way that discourages retiring CEOs from opportunistic earnings management and R&D reduction. However, compensation committees dominated by co-opted directors may not be as effective as those with fewer co-opted directors in mitigating the CEO horizon problem, because directors co-opted by the CEO tend to bias their decisions in favor of the CEO. I find that compensation committees dominated by co-opted directors are associated with higher CEO compensation packages. I document R&D reduction and accruals management in firms with retiring CEOs and compensation committees dominated by co-opted directors, and find that R&D reduction and income-increasing accruals are less discouraged by compensation committees dominated by co-opted directors when deciding CEO compensation. I also examine the effect of boards of directors and compensation committee characteristics on CEO compensation and on mitigating the CEO horizon problem. I find that CEO compensation positively associates with CEO power, director independence, and the percentage of busy directors, and negatively associates with board of directors and committee size and director ownership. Moreover, I find that retiring CEOs are more likely to reduce R&D expenditures when CEOs have more power, and director tenure is longer; retiring CEOs in firms with large boards of directors and compensation committees are less likely to manage accruals.

Presupuestos y gastos del estado en la provincia de Buenos Aires para afrontar las inundaciones de los campos, 1870-1930

Nos proponemos estudiar la participación de la agencia estatal encargada de la gestión de las obras hídricas en el presupuesto de la provincia de Buenos Aires, puesto que indica la importancia que los gobiernos le dieron al problema de las inundaciones en los campos, y ponderar el aporte privado toda vez que se compelía a los propietarios a pagar un impuesto especial. Nuestro período se extiende desde los primeros esfuerzos realizados por los gobiernos provinciales en la década de 1870, hasta 1930 en que empezó un ciclo más seco y los problemas en los métodos de desagüe se postergaron. Enfocaremos el análisis a través de los registros oficiales, los debates en las cámaras de la Legislatura provincial y los mensajes de los gobernadores. Vamos a ponderar la importancia del Ministerio de Obras Públicas entre los diferentes rubros aprobados por la legislatura, seguidamente analizaremos con mayor detalle las transformaciones en la agencia dedicada a las cuestiones hídricas y la, todavía escasa, información sobre los gastos especiales en obras de desagüe

Presupuestos y gastos del estado en la provincia de Buenos Aires para afrontar las inundaciones de los campos, 1870-1930

Nos proponemos estudiar la participación de la agencia estatal encargada de la gestión de las obras hídricas en el presupuesto de la provincia de Buenos Aires, puesto que indica la importancia que los gobiernos le dieron al problema de las inundaciones en los campos, y ponderar el aporte privado toda vez que se compelía a los propietarios a pagar un impuesto especial. Nuestro período se extiende desde los primeros esfuerzos realizados por los gobiernos provinciales en la década de 1870, hasta 1930 en que empezó un ciclo más seco y los problemas en los métodos de desagüe se postergaron. Enfocaremos el análisis a través de los registros oficiales, los debates en las cámaras de la Legislatura provincial y los mensajes de los gobernadores. Vamos a ponderar la importancia del Ministerio de Obras Públicas entre los diferentes rubros aprobados por la legislatura, seguidamente analizaremos con mayor detalle las transformaciones en la agencia dedicada a las cuestiones hídricas y la, todavía escasa, información sobre los gastos especiales en obras de desagüe

Presupuestos y gastos del estado en la provincia de Buenos Aires para afrontar las inundaciones de los campos, 1870-1930

Nos proponemos estudiar la participación de la agencia estatal encargada de la gestión de las obras hídricas en el presupuesto de la provincia de Buenos Aires, puesto que indica la importancia que los gobiernos le dieron al problema de las inundaciones en los campos, y ponderar el aporte privado toda vez que se compelía a los propietarios a pagar un impuesto especial. Nuestro período se extiende desde los primeros esfuerzos realizados por los gobiernos provinciales en la década de 1870, hasta 1930 en que empezó un ciclo más seco y los problemas en los métodos de desagüe se postergaron. Enfocaremos el análisis a través de los registros oficiales, los debates en las cámaras de la Legislatura provincial y los mensajes de los gobernadores. Vamos a ponderar la importancia del Ministerio de Obras Públicas entre los diferentes rubros aprobados por la legislatura, seguidamente analizaremos con mayor detalle las transformaciones en la agencia dedicada a las cuestiones hídricas y la, todavía escasa, información sobre los gastos especiales en obras de desagüe

Projecting the fate of fish populations using ecological-economic modeling

Four marine fish species are among the most important on the world market: cod, salmon, tuna, and sea bass. While the supply of North American and European markets for two of these species - Atlantic salmon and European sea bass - mainly comes from fish farming, Atlantic cod and tunas are mainly caught from wild stocks. We address the question what will be the status of these wild stocks in the midterm future, in the year 2048, to be specific. Whereas the effects of climate change and ecological driving forces on fish stocks have already gained much attention, our prime interest is in studying the effects of changing economic drivers, as well as the impact of variable management effectiveness. Using a process-based ecological-economic multispecies optimization model, we assess the future stock status under different scenarios of change. We simulate (i) technological progress in fishing, (ii) increasing demand for fish, and (iii) increasing supply of farmed fish, as well as the interplay of these driving forces under different sce- narios of (limited) fishery management effectiveness. We find that economic change has a substantial effect on fish populations. Increasing aquaculture production can dampen the fishing pressure on wild stocks, but this effect is likely to be overwhelmed by increasing demand and technological progress, both increasing fishing pressure. The only solution to avoid collapse of the majority of stocks is institutional change to improve management effectiveness significantly above the current state. We conclude that full recognition of economic drivers of change will be needed to successfully develop an integrated ecosystem management and to sustain the wild fish stocks until 2048 and beyond.

The Economic Case for Electric Mining Equipment and Technical Considerations Relating to their Implementation

Underground hardrock mining can be very energy intensive and in large part this can be attributed to the power consumption of underground ventilation systems. In general, the power consumed by a mine’s ventilation system and its overall scale are closely related to the amount of diesel power in operation. This is because diesel exhaust is a major source of underground air pollution, including diesel particulate matter (DPM), NO2 and heat, and because regulations tie air volumes to diesel engines. Furthermore, assuming the size of airways remains constant, the power consumption of the main system increases exponentially with the volume of air supplied to the mine. Therefore large diesel fleets lead to increased energy consumption and can also necessitate large capital expenditures on ventilation infrastructure in order to manage power requirements. Meeting ventilation requirements for equipment in a heading can result in a similar scenario with the biggest pieces leading to higher energy consumption and potentially necessitating larger ventilation tubing and taller drifts. Depending on the climate where the mine is located, large volumes of air can have a third impact on ventilation costs if heating or cooling the air is necessary. Annual heating and cooling costs, as well as the cost of the associated infrastructure, are directly related to the volume of air sent underground. This thesis considers electric mining equipment as a means for reducing the intensity and cost of energy consumption at underground, hardrock mines. Potentially, electric equipment could greatly reduce the volume of air needed to ventilate an entire mine as well as individual headings because they do not emit many of the contaminants found in diesel exhaust and because regulations do not connect air volumes to electric motors. Because of the exponential relationship between power consumption and air volumes, this could greatly reduce the amount of power required for mine ventilation as well as the capital cost of ventilation infrastructure. As heating and cooling costs are also directly linked to air volumes, the cost and energy intensity of heating and cooling the air would also be significantly reduced. A further incentive is that powering equipment from the grid is substantially cheaper than fuelling them with diesel and can also produce far fewer GHGs. Therefore, by eliminating diesel from the underground workers will enjoy safer working conditions and operators and society at large will gain from a smaller impact on the environment. Despite their significant potential, in order to produce a credible economic assessment of electric mining equipment their impact on underground systems must be understood and considered in their evaluation. Accordingly, a good deal of this thesis reviews technical considerations related to the use of electric mining equipment, especially ones that impact the economics of their implementation. The goal of this thesis will then be to present the economic potential of implementing the equipment, as well as to outline the key inputs which are necessary to support an evaluation and to provide a model and an approach which can be used by others if the relevant information is available and acceptable assumptions can be made.

La Unión Europea y la OTAN en el marco de la nueva Estrategia Global de Seguridad de la Unión Europea

El artículo analiza la relación entre la Unión Europea y la OTAN en cuestiones de defensa, según se ha reflejado en las estrategias de seguridad de la Unión Europea, con particular atención a la Estrategia Global de la Unión Europea presentada en 2016. Se estudia la Estrategia de Seguridad Europea de 2003, el Informe de Implementación de 2008, y las nuevas aproximaciones al contexto internacional y a la seguridad europea que se reflejan en la Estrategia Global. Se analiza también el papel de la OTAN, así como la evolución de la política de seguridad de los Estados Unidos hacia Europa durante la Administración Obama. Finalmente se discute el posible futuro de la Política Común de Seguridad y Defensa de la UE (PCSD) después del Bréxit, así como las consecuencias para su relación con la OTAN.

Predictors of caregiver burden across the home-based palliative care trajectory in Ontario, Canada

Family caregivers of patients enrolled in home-based palliative care programmes provide unpaid care and assistance with daily activities to terminally ill family members. Caregivers often experience caregiver burden, which is an important predictor of anxiety and depression that can extend into bereavement. We conducted a longitudinal, prospective cohort study to comprehensively assess modifiable and non-modifiable patient and caregiver factors that account for caregiver burden over the palliative care trajectory. Caregivers (n = 327) of patients with malignant neoplasm were recruited from two dedicated home-based palliative care programmes in Southern Ontario, Canada from 1 July 2010 to 31 August 2012. Data were obtained from bi-weekly telephone interviews with caregivers from study admission until death, and from palliative care programme and home-care agency databases. Information collected comprised patient and caregiver demographics, utilisation of privately and publicly financed resources, patient clinical status and caregiver burden. The average age of the caregivers was 59.0 years (SD: 13.2), and almost 70% were female. Caregiver burden increased over time in a non-linear fashion from study admission to patient death. Increased monthly unpaid care-giving time costs, monthly public personal support worker costs, emergency department visits and low patient functional status were associated with higher caregiver burden. Greater use of hospice care was associated with lower burden. Female caregivers tended to report more burden compared to men as death approached, and burden was higher when patients were male. Low patient functional status was the strongest predictor of burden. Understanding the influence of modifiable and non-modifiable factors on the experience of burden over the palliative trajectory is essential for the development and targeting of programmes and policies to support family caregivers and reduce burden. Supporting caregivers can have benefits such as improved caregiver health outcomes, and enhancing their ability to meet care-giving demands, thereby potentially allowing for longer patient care in the home setting.

Cost-effectiveness of zoledronic acid and strontium-89 as bone protecting treatments in addition to chemotherapy in patients with metastatic castrate-refractory prostate cancer: results from the TRAPEZE trial (ISRCTN 12808747)

OBJECTIVE: To evaluate the cost-effectiveness of adding zoledronic acid or strontium-89 to standard docetaxel chemotherapy for patients with castrate-refractory prostate cancer (CRPC).

PATIENTS AND METHODS: Data on resource use and quality of life for 707 patients collected prospectively in the TRAPEZE 2 × 2 factorial randomised trial (ISRCTN 12808747) were used to assess the cost-effectiveness of i) zoledronic acid versus no zoledronic acid (ZA vs. no ZA), and ii) strontium-89 versus no strontium-89 (Sr89 vs. no Sr89). Costs were estimated from the perspective of the National Health Service in the UK and included expenditures for trial treatments, concomitant medications, and use of related hospital and primary care services. Quality-adjusted life-years (QALYs) were calculated according to patients' responses to the generic EuroQol EQ-5D-3L instrument, which evaluates health status. Results are expressed as incremental cost-effectiveness ratios (ICERs) and cost-effectiveness acceptability curves.

RESULTS: The per-patient cost for ZA was £12 667, £251 higher than the equivalent cost in the no ZA group. Patients in the ZA group had on average 0.03 QALYs more than their counterparts in no ZA group. The ICER for this comparison was £8 005. Sr89 was associated with a cost of £13 230, £1365 higher than no Sr89, and a gain of 0.08 QALYs compared to no Sr89. The ICER for Sr89 was £16 884. The probabilities of ZA and Sr89 being cost-effective were 0.64 and 0.60, respectively.

CONCLUSIONS: The addition of bone-targeting treatments to standard chemotherapy led to a small improvement in QALYs for a modest increase in cost (or cost-savings). ZA and Sr89 resulted in ICERs below conventional willingness-to-pay per QALY thresholds, suggesting that their addition to chemotherapy may represent a cost-effective use of resources.

On the Economics and Politics of Mobility

Exit, Voice and Political Change: Evidence from Swedish Mass Migration to the United States. During the Age of Mass Migration, 30 million Europeans immigrated to the United States. We study the long-term political effects of this large-scale migration episode on origin communities using detailed historical data from Sweden. To instrument for emigration, we exploit severe local frost shocks that sparked an initial wave of emigration, interacted with within-country travel costs. Because Swedish emigration was highly path dependent, the initial shocks strongly predict total emigration over 50 years. Our estimates show that emigration substantially increased membership in local labor organizations, the strongest political opposition groups at the time. Furthermore, emigration caused greater strike participation, and mobilized voter turnout and support for left-wing parties in national elections. Emigration also had formal political effects, as measured by welfare expenditures and adoption of inclusive political institutions. Together, our findings indicate that large-scale emigration can achieve long-lasting effects on the political equilibrium in origin communities. Mass Migration and Technological Innovation at the Origin. This essay studies the effects of migration on technological innovations in origin communities. Using historical data from Sweden, we find that large-scale emigration caused a long-run increase in patent innovations in origin municipalities. Our IV estimate shows that a ten percent increase in emigration entails a 7 percent increase in a muncipality’s number of patents. Weighting patents by a measure of their economic value, the positive effects are further increased. Discussing possible mechanisms, we suggest that low skilled labor scarcity may be an explanation for these results.  Richer (and Holier) Than Thou? The Impact of Relative Income Improvements on Demand for Redistribution. We use a tailor-made survey on a Swedish sample to investigate how individuals' relative income affects their demand for redistribution. We first document that a majority misperceive their position in the income distribution and believe that they are poorer, relative to others, than they actually are. We then inform a subsample about their true relative income, and find that individuals who are richer than they initially thought demand less redistribution. This result is driven by individuals with prior right-of-center political preferences who view taxes as distortive and believe that effort, rather than luck, drives individual economic success. Wealth, home ownership and mobility. Rent controls on housing have long been thought to reduce labor mobility and allocative efficiency. We study a policy that allowed renters to purchase their rent-controlled apartments at below market prices, and examine the effects of home ownership and wealth on mobility. Treated individuals have a substantially higher likelihood of moving to a new home in a given year. The effect corresponds to a 30 percent increase from the control group mean. The size of the wealth shock predicts lower mobility, while the positive average effect can be explained by tenants switching from the previous rent-controlled system to market-priced condominiums. By contrast, we do not find that the increase in residential mobility leads to a greater probability of moving to a new place of work.

B-1 Monthly Report of Medical Services Provided under Title XIX of the Social Security Act, April 2016

B-1 Medicaid Reports -- The monthly Medicaid series of eight reports provide summaries of Medicaid eligibles, recipients served, and total payments by county, category of service, and aid category. These reports may also be known as the B-1 Reports. These reports are each available as a PDF for printing or as a CSV file for data analysis. Report Report name IAMM1800-R001--Medically Needy by County - No Spenddown and With Spenddown; IAMM1800-R002--Total Medically Needy, All Other Medicaid, and Grand Total by County; IAMM2200-R002--Monthly Expenditures by Category of Service; IAMM2200-R003--Fiscal YTD Expenditures by Category of Service; IAMM3800-R001--ICF & ICF-MR Vendor Payments by County; IAMM4400-R001--Monthly Expenditures by Eligibility Program; IAMM4400-R002--Monthly Expenditures by Category of Service by Program; IAMM4600-R002--Elderly Waiver Summary by County.

B-1 Monthly Report of Medical Services Provided under Title XIX of the Social Security Act, May 2016

B-1 Medicaid Reports -- The monthly Medicaid series of eight reports provide summaries of Medicaid eligibles, recipients served, and total payments by county, category of service, and aid category. These reports may also be known as the B-1 Reports. These reports are each available as a PDF for printing or as a CSV file for data analysis. Report Report name IAMM1800-R001--Medically Needy by County - No Spenddown and With Spenddown; IAMM1800-R002--Total Medically Needy, All Other Medicaid, and Grand Total by County; IAMM2200-R002--Monthly Expenditures by Category of Service; IAMM2200-R003--Fiscal YTD Expenditures by Category of Service; IAMM3800-R001--ICF & ICF-MR Vendor Payments by County; IAMM4400-R001--Monthly Expenditures by Eligibility Program; IAMM4400-R002--Monthly Expenditures by Category of Service by Program; IAMM4600-R002--Elderly Waiver Summary by County.

B-1 Monthly Report of Medical Services Provided under Title XIX of the Social Security Act, February 2016

B-1 Medicaid Reports -- The monthly Medicaid series of eight reports provide summaries of Medicaid eligibles, recipients served, and total payments by county, category of service, and aid category. These reports may also be known as the B-1 Reports. These reports are each available as a PDF for printing or as a CSV file for data analysis. Report Report name IAMM1800-R001--Medically Needy by County - No Spenddown and With Spenddown; IAMM1800-R002--Total Medically Needy, All Other Medicaid, and Grand Total by County; IAMM2200-R002--Monthly Expenditures by Category of Service; IAMM2200-R003--Fiscal YTD Expenditures by Category of Service; IAMM3800-R001--ICF & ICF-MR Vendor Payments by County; IAMM4400-R001--Monthly Expenditures by Eligibility Program; IAMM4400-R002--Monthly Expenditures by Category of Service by Program; IAMM4600-R002--Elderly Waiver Summary by County.

Training Technology Carry-Forward Report, January 6, 2016

A report from the Iowa Department of Human Services. The report details expenditures for fiscal year ’15 funds encumbered by the Department.