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.

Techno-economic analysis of three HVAC retrofitting options

Accounting for around 40% of the total final energy consumption, the building stock is an important area of focus on the way to reaching the energy goals set for the European Union. The relatively small share of new buildings makes renovation of existing buildings possibly the most feasible way of improving the overall energy performance of the building stock. This of course involves improvements on the climate shell, for example by additional insulation or change of window glazing, but also installation of new heating systems, to increase the energy efficiency and to fit the new heat load after renovation. In the choice of systems for heating, ventilation and air conditioning (HVAC), it is important to consider their performance for space heating as well as for domestic hot water (DHW), especially for a renovated house where the DHW share of the total heating consumption is larger. The present study treats the retrofitting of a generic single family house, which was defined as a reference building in a European energy renovation project. Three HVAC retrofitting options were compared from a techno-economic point of view: A) Air-to-water heat pump (AWHP) and mechanical ventilation with heat recovery (MVHR), B) Exhaust air heat pump (EAHP) with low-temperature ventilation radiators, and C) Gas boiler and ventilation with MVHR. The systems were simulated for houses with two levels of heating demand and four different locations: Stockholm, Gdansk, Stuttgart and London. They were then evaluated by means of life cycle cost (LCC) and primary energy consumption. Dynamic simulations were done in TRNSYS 17. In most cases, system C with gas boiler and MVHR was found to be the cheapest retrofitting option from a life cycle perspective. The advantage over the heat pump systems was particularly clear for a house in Germany, due to the large discrepancy between national prices of natural gas and electricity. In Sweden, where the price difference is much smaller, the heat pump systems had almost as low or even lower life cycle costs than the gas boiler system. Considering the limited availability of natural gas in Sweden, systems A and B would be the better options. From a primary energy point of view system A was the best option throughout, while system B often had the highest primary energy consumption. The limited capacity of the EAHP forced it to use more auxiliary heating than the other systems did, which lowered its COP. The AWHP managed the DHW load better due to a higher capacity, but had a lower COP than the EAHP in space heating mode. Systems A and C were notably favoured by the air heat recovery, which significantly reduced the heating demand. It was also seen that the DHW share of the total heating consumption was, as expected, larger for the house with the lower space heating demand. This confirms the supposition that it is important to include DHW in the study of HVAC systems for retrofitting.

Development of a responsive fisheries management system for the Portuguese crustacean bottom trawl fishery: Lessons learnt

A prototype for a Responsive Fisheries Management System (RFMS) was developed in the context of the European FP7 project EcoFishMan and tested on the Portuguese crustacean trawl fishery. Building on Results Based Management principles, RFMS involves the definition of specific and measurable objectives for a fishery by the relevant authorities but allows resource users the freedom to find ways to achieve the objectives and to provide adequate documentation. Taking into account the main goals of the new Common Fisheries Policy, such as sustainable utilization of the resources, end of discards and unwanted catches, a management plan for the Portuguese crustacean trawl fishery was developed in cooperation with the fishing industry, following the process and design laid out in the RFMS concept. The plan considers biological, social and economic goals and assigns a responsibility for increased data collection to the resource users. The performance of the plan with regard to selected indicators was evaluated through simulations. In this paper the process towards a RFMS is described and the lessons learnt from the interaction with stakeholders in the development of an alternative management plan are discussed. (C) 2014 Elsevier Ltd. All rights reserved.

Conservation Agriculture and its contribution to the achievement of agri-environmental and economic challenges in Europe

Conservation Agriculture is an ecosystem approach to farming capable of providing solutions for numerous of the agri-environmental concerns in Europe. Certainly, most of the challenges addressed in the Common Agriculture Policy (CAP) could be tackled through Conservation Agriculture (CA). Not only the agri-environmental ones, but also those concerning farmer and rural communities’ prosperity. The optimisation of inputs and similar yields than conventional tillage, make Conservation Agriculture a profitable system compared to the tillage based agriculture. Whereas this sustainable agricultural system was conceived for protecting agrarian soils from its degradation, the numerous collateral benefits that emanate from soil conservation, i.e., climate change mitigation and adaptation, have raised Conservation Agriculture as one of the global emerging agrosciences, being adopted by an increasing number of farmers worldwide, including Europe.

Vanadium Redox Flow Battery Storage System Linked to the Electric Grid

This paper focuses on technology state of the art for the charge/discharge of electric energy storage supported by vanadium redox flow battery linked to the electric grid. Properties of vanadium, the main configuration and the reaction of charge/discharge of a vanadium redox flow battery are addressed. The vanadium redox flow battery has the highest cell voltage among the other redox flow battery, implying higher power and energy density which favours application at power plants. This electric energy storage is viewed as a promising contribution to be integrated in power system due to a reasonably bulky size and to successful applications currently allowing storage of energy at power plants or at electrical grids. For instances, allowing storage of energy as an economic improvement providing spin reserve to avoid penalty for imbalances between the energy delivered and energy contracted at closing of electricity market or as an economic improvement to diminish the cost of electricity usage of a consumer. The vanadium redox flow battery has the advantages of scalability customized to meet requirements for power and energy capacity and of excellent combination of energy efficiency, capital cost and life cycle costs compared with other technology.

Emergy analysis of a silvo-pastoral system, a case study in southern Portugal

The Mediterranean silvo-pastoral system known as Montado, in Portugal, is a complex land use system composed of an open tree stratum in various densities and an herbaceous layer, used for livestock grazing. Livestock also profit from the acorns, and the grazing contributes to avoid shrub encroachment. In the last 20 years, subsidies from the European Union have greatly promoted cattle rearing in this system and the introduction of heavy breeds, at the expense of sheep, goats or the native cattle breeds. The balance of the traditional system is thus threatened, and a precise assessment of the balance between the different components of the system, therefore is highly needed. The goal of this study was to gain a better under- standing of a Montado farm system with cattle rearing as the major economic activity by applying the emergy evaluation method to calculate indices of yield, investment, environmental loading and sustainability. By integrating different ecosystem components, the emergy evaluation method allows a comprehensive evaluation of this complex and multifunctional system at the scale of an individual farm. This method provides a set of indices that can help us understand the system and design management strategies that maximize emergy flow in the farm. In this paper, we apply the emergy evaluation method to a Montado farm with cattle rearing, as a way to gain a better understanding of this system at the farm scale. The value for the transformity of veal (2.66E?06 sej J-1) is slightly higher, when compared to other systems producing protein. That means that the investment of nature and man in this product was higher and it requires a premium price on the market. The renewa- bility for Holm Oaks Farm (49 %), lower than for other similar systems, supports the assumption that this is a farm in which, comparing with others, the number of purchased inputs in relation to renewable inputs provided by nature, is higher. The Emergy Investment Ratio is 0.91 for cattle rearing compared to a value of 0.49 for cork and 0.43 for firewood harvesting, making it clear that cattle rearing is a more labor demanding activity comparing with extractive activities as cork and firewood harvesting.

Model of Small Holders Dairy Cattle Waste Pollution at Several Natural Physical and Economic Social Conditions: A Case Study in the Province of Central Java

Most of dairy farmings in Indonesia are managed in the forms of smallholder farmings that give more attention to productivity rather than ecological concerns. The purpose of this study was to make models of dairy cattle animal waste pollution on clean water quality and degree of smell at several regions with different natural physical and economic social conditions. This study also investigated the waste management that match with the characteristics, behavior, and the attitude of the farmers in each region.  System approach was used as the method of this study through model simulation with program of Powersim 2.5c. Model compiled based on to component situation of livestock, condition of environment and situation of farmer. Determination of regional sample of sub-province or town until chosen countryside conducted with multistage sampling without randomization (purposive sampling).  Based on the result of research can be concluded that (1) low natural physical region and low economic social condition to have endangering pollution level of environment, (2) the waste management for the region with high natural physical and high economic social of bio gas and composting accompanied by removing to excess of animal waste for regional with low natural physical and low economic social. (Animal Production 6(2): 68-75 (2004) Key Words: model, dairy  cattle, waste pollution