Dr Mary-Claire Kennedy, TCD 2010
Dr Mary-Claire Kennedy
Factors affecting the pharmacotherapeutic management of chronic non-malignant pain in ageing and elderly populations in Ireland
Institution: TCD, 2010 cohort
Supervisors: Prof. Martin Henman (TCD), Prof. Charles Normand (TCD), Dr. Gráinne Cousins (RCSI)
Chronic non-malignant pain (CNMP) has emerged as a global health priority due to the prevalence, complexity and presentation of the condition across all age-groups, social classes and ethnicities. Pharmacotherapeutic, non-pharmacotherapeutic and surgical interventions may be used separately or in combination to provide pain relief for patients. A mixed methods approach was used to examine the pharmacotherapeutic management of ageing and elderly patients with CNMP in the Republic of Ireland and to describe the GP and patient factors that influence use of analgesics, particularly opioids. A systematic review of guidelines directing the prescribing of opioids for CNMP in primary care was initially undertaken. The purpose of this review was to evaluate the quality of development and clinical content of these guidelines. Analysis of the Health Service Executive-Primary Care Reimbursement Service (HSE-PCRS) and The Irish Longitudinal Study of Ageing (TILDA) datasets provided further information on the prevalence of CNMP among ageing and elderly populations and insight into the nature of analgesic use in Ireland. Semi-structured interviews were then completed with GPs and patients with CNMP to further explore the nature of analgesic prescribing and use.
Research findings from this PhD have been published in the following papers:
Kennedy M-C; Cousins G; Henman MC (2017) Analgesic use by ageing and elderly patients with chronic non-malignant pain: a qualitative study. International Journal of Clinical Pharmacy, 39 (4), pp. 798-807.
Kennedy M-C; Henman MC; Cousins G (2016) General Practitioners and Chronic Non-Malignant Pain Management in Older Patients: A Qualitative Study. Pharmacy (Basel, Switzerland), 4 (1).
Dr Aoife McNamara, UCC 2010
Dr Aoife McNamara
Parents’ personal and economic experiences of caring for children with life-limiting neurodevelopmental disabilities at home in Ireland – A Mixed Methods Study
Institution: TCD, 2010 cohort
Supervisors: Prof Charles Normand (TCD), Prof Honor Nicholl (TCD)
A mixed methodological approach facilitated an in-depth examination of the service experiences, service preferences and financial costs associated with caring for children with life-limiting neurodevelopmental conditions at home in Ireland. A qualitative study using Interpretative Phenomenological Analysis (IPA) examined parents’ lived experiences of caring for and using services in relation to their child. The IPA findings revealed the overwhelming nature of parents’ experiences and needs around 8 major themes: (I) transitioning from hospital to home, (2) the perpetual wait for services, (3) the crucial role of liaison nurse (4) parents as advocates, (5) physiotherapy – a highly valued service (6) the financial costs of caring, (7) emotional effects of caring and (8) future concerns. A quantitative study using a Discrete Choice Experiment (DCE) elicited parents’ preferences for hypothetically designed monthly care packages and revealed parents’ valuation of services in the form of willingness to pay and willingness to trade for various services. Analysis revealed that parents have a preference for more of the following services for their child: physiotherapy, speech & language therapy, day nursing care and a cash maintenance payment.
Finally, a descriptive study outlined the financial out of pocket costs associated with caring for a child with a life-limiting disability. Findings revealed that parents face significant out of pocket payments in relation to providing care to their child and lose on average up to fifty-percent of their household income. Having developed an evidence base and characterization of the range and scope of the issues facing families caring for children with life-limiting conditions, we provide recommendations to the Irish health care system.
Dr Susan Spillane, TCD 2010
Dr Susan Spillane
Metaformin, asprin, and colorectal cancer outcomes.
Institution: TCD, 2010 cohort
Supervisors: Prof. Kathleen Bennett (RCSI), Prof. Linda Sharp (Newcastle University), Prof. Ian Barron (TCD)
Metaformin, asprin, and colorectal cancer outcomes.
Abstract: Not available
Dr Irene O’Farrell, UCC 2010
Dr Irene O’Farrell
Hospital treated deliberate self-harm : mortality risk and area level associations – a national registry cohort study
Institution: UCC, 2010 cohort
Supervisors: Prof. Ivan Perry (UCC), Dr. Paul Corcoran (UCC)
Suicide is a major public health problem. Suicide is hard to predict, however research has identified that deliberate self-harm is the strongest predictor for future suicide. The magnitude of the risk of suicide and non-suicide external causes of death (mainly poisonings, falls and road traffic accidents) in the period following a hospital presentation with self-harm, has not been well estimated in representative samples of well-defined patients. Furthermore, to better understand the causes of suicidal behaviour the characteristics of the areas in which people reside need to be examined also. An ecological perspective on suicidal behaviours examines how area level characteristics such as socioeconomic deprivation and social fragmentation influence small area rates of deliberate self-harm and suicide.
The main aims of this thesis are to examine the risk of suicide and non-suicide external cause mortality in a cohort of individuals who have presented to hospital due to self-harm in the Republic of Ireland. Additionally, the ecological relationship between suicidal behaviour (both self-harm and suicide) and area level determinants in the Republic of Ireland will be examined.
To identify mortality due to external causes among the self-harm patient cohort, the National Registry of Deliberate Self Harm Ireland data (for the years 2009-2011) was linked using probabilistic data linkage techniques to official external cause mortality data (for the years 2009-2011). Separate negative binomial regression models were used to examine the relationship between deliberate self-harm and area level determinants and suicide and area level determinants.
Findings from the linkage study showed that 437 of 26,168 self-harm patients died from external causes during the study follow-up. The 1-year cumulative incidence for suicide, non-suicide external cause mortality and all external causes combined were 0.8% (95%CI 0.7-0.1), 0.5% (95%CI 0.4-0.6) and 1.3% (95%CI 1.2-1.5), respectively. The risk of suicide was 46 times (95% CI 39-54) greater in self-harm population compared to the general population. The risk of non-suicide external cause mortality was 22 times greater (95% CI 18-27) in the self-harm population compared to the general population.
Findings from the self-harm area-level study showed that socioeconomic deprivation, social fragmentation and population density had a positive linear association with self-harm, with socioeconomic deprivation having the strongest independent effect. Findings from the suicide area-level study showed that socioeconomic deprivation had the strongest independent effect on small-area rates of suicide.
The findings of this thesis show the extremely high risk of death from suicide and non-suicide external causes following hospital presentation with self-harm. Furthermore, this thesis demonstrates the marked geographical inequalities in the distribution of both suicide and self-harm in Ireland and highlights the importance of targeting suicide prevention resources in the most deprived areas.
Dr Eithne Sexton, RCSI 2010
Dr Eithne Sexton
Pathways and Protective Factors: Modelling the Effect of Chronic Conditions on Quality of Life in Midlife and Older Irish Adults
Institution: RCSI, 2010 cohort
Supervisors: Prof. Anne Hickey (RCSI), Prof. Richard Layte (TCD), Dr. George Savva (Quadram Institute)
Quality of life (QoL) outcomes are increasingly important as a target for healthcare intervention and for measuring healthcare effectiveness. However, the effect of physical health on QoL at older ages is poorly understood. The aim of this thesis was to empirically test an explanatory model of the relationship between chronic conditions and QoL in older people in Ireland.
This is a cross-sectional and longitudinal cohort study, using data from the Irish Longitudinal Study of Ageing (TILDA), a general-population sample of community-dwelling adults aged 50+ in the Republic of Ireland (n=8,175). Exploratory and confirmatory factor analysis was used to evaluate and revise the CASP-19 measure of QoL. Structural equation modelling was used to test a model of the pathway between chronic conditions and QoL, via disability and affective wellbeing. Conditional change linear regression was used to evaluate longitudinal effects along this pathway, and to examine how these longitudinal effects were modified by personal characteristics (e.g., personality) and environmental factors (e.g., social support).
A 12-item version of CASP-19 was developed, comprising two dimensions: control/autonomy and self-realisation/pleasure. The cross-sectional effect of chronic conditions on both QoL dimensions was mediated by physical impairment and affective wellbeing. Partner support reduced the effect of physical impairment on control/autonomy and religiosity reduced the effect of physical impairment on self-realisation/pleasure. Self-realisation/pleasure was less responsive to variation and change in physical health relative to control/autonomy.
The effect of chronic conditions on QoL in later life depends on the level of disability, the availability of environmental supports, and personal characteristics. Models of healthcare which focus on patient-specific goals, circumstances and health needs, rather than specific conditions and disease processes, may be more effective for improving QoL outcomes in chronic disease. Control/autonomy emerged as a useful indicator of QoL which is responsive to variation in physical health.
Dr Linda O’Keefe, UCC 2010
Dr Linda O’Keefe
Monitoring behaviours and experiences before, during and after pregnancy in Ireland
Institution: UCC, 2010 cohort
Supervisors: Prof. Patricia Kearney (UCC), Prof. Richard Greene (UCC)
On-going surveillance of behaviours during pregnancy is an important but overlooked population health activity that is particularly lacking in Ireland. Few, if any, nationally representative estimates of most maternal behaviours and experiences are available. While on-going surveillance of maternal behaviours has not been a priority thus far in European countries including Ireland, on-going surveillance was identified as a key priority in the United States (US) during the 1980’s when the Pregnancy Risk Assessment Monitoring System (PRAMS), was established. Today, PRAMS is the only surveillance programme of maternal behaviours and experiences world-wide. Although on-going prevalence estimates are required in Ireland, studies which examine the offspring health effects of maternal behaviours are also required, since various questions regarding maternal exposures and their offspring health effects remain unanswered. Gestational alcohol consumption is one such important maternal exposure which is common in pregnancy, though its offspring health effects are unclear, particularly at lower or moderate levels. Thus, guidelines internationally have not reached consensus on safe alcohol recommendations for pregnant women.
The aims of this thesis are to implement the PRAMS in Ireland (PRAMS Ireland), to describe the prevalence of health behaviours around the time of pregnancy in Ireland and to examine the effect of health behaviours on pregnancy and child outcomes (specifically the relationship between alcohol use during pregnancy and infant and child growth).
Implementation of PRAMS: PRAMS may be an effective system for the surveillance of health behaviours around the time of pregnancy in the Irish context. PRAMS Ireland had high response rates (67% and 61% response rates in the pilot and main study respectively), high item completion rates and valid prevalence estimates for many health behaviours. Examining prevalence of health behaviours: We found high levels of alcohol consumption before and during pregnancy, poor adherence to healthy diets and high levels of smoking before and during pregnancy among women in Ireland. Socially disadvantaged women had higher rates of deleterious health behaviours before pregnancy, although women with the most deleterious behaviour profiles before pregnancy appeared to experience the greatest gain in protective health behaviours during pregnancy. The impact of alcohol use on infant and offspring growth: We found that low and moderate levels of alcohol use did not impact on birth outcomes or offspring growth whereas heavy alcohol consumption resulted in reduced birth length and birth weight; however, this finding was not consistently observed across all studies. Selection, reporting and confounding biases which are common in observational research could be masking harmful effects.
PRAMS is a valid and feasible method of surveillance of health behaviours around the time of pregnancy in Ireland. A surveillance program of maternal behaviours and experiences is immediately warranted due to high levels of deleterious health behaviours around the time of pregnancy in Ireland. Although our results do not indicate any evidence of harm, given the quality of evidence available, abstinence and advice of abstinence from alcohol may be the most prudent choice for patients and healthcare professionals respectively. Further studies of the effects of gestational alcohol use are required; particularly those which can reduce selection bias, reporting bias and confounding.
Dr Padhraig Ryan, TCD 2010
Dr Padhraig Ryan
Changing the Mix of Healthcare Providers: Impact on Price, Efficiency and Quality
Institution: TCD, 2010 cohort
Supervisors: Prof. Charles Normand (TCD), Prof. Martin Henman (TCD)
Service providers, the personnel and organisations that deliver care, are the foundation of any health care system. The personnel include not only doctors, but pharmacists, nurses, and an array of allied health professions, while the organisations include hospitals, pharmacies, and ambulatory surgery centres. The configuration of providers influences dimensions of performance such as access, clinical quality, and value. In health systems around the world there are challenges in assuring high quality and compassionate care, equitable access to services, and prudent use of resources. A key policy instrument is reconfiguration of skill mix and provider organisations. Yet there is limited evidence on the effects of such changes.
This thesis generates evidence to improve our understanding. The first of three papers examines skill mix arrangements in the context of chronic warfarin therapy in the United States (USA). In one warfarin management centre, pharmacists are the primary caregivers and patients do not attend the clinic in person. The second site is nurse-led and also operates remotely. In the remaining two sites, nurses care for patients through face-to-face consultations. The surrogate clinical outcome is the “time in the therapeutic range” (TTR), and I measured elements of patient experience, such as satisfaction and comprehension of clinical instructions, using surveys such as the Duke Anticoagulation Satisfaction Scale. The EQ-5D instrument measured health-related quality of life.
For the TTR calculations I collected 7,678 patient years of observation, and a total of 854 patients responded to the survey. According to multivariate linear regression analysis, TTR was positively associated with older age, male gender, an indication of atrial fibrillation, and a proxy marker of lower poverty levels. Quality of care in each site was comparable to recent clinical trials. There were no significant differences in TTR between sites after adjusting for potential confounding variables. Survey responses were comparable between sites for most items, but significant differences emerged with regard to communication standards and convenience of care. The results suggest that provider organisations can utilise a variety of skill mix arrangements to achieve high quality warfarin care, if underpinned by rigorous training, performance measurement, and a culture of continuous improvement. Since 2010, pharmacists in Ireland have administered vaccinations to prevent influenza.
The second paper models the effectiveness and cost-effectiveness of this change in skill mix. This paper did not uncover evidence of a significant increase in vaccination rates due to provision by pharmacists. Dynamic models of infectious disease transmission resulted in estimates of costeffectiveness falling within generally acceptable ranges. A range of sensitivity analyses tested the robustness of the results under different assumptions, such as varying vaccine effectiveness.
Results suggest that pharmacist provision of vaccination is cost-effective under many assumptions, but oversight is needed to assure effective training and to avoid care fragmentation. The traditional setting for surgery is the hospital, but in recent decades much surgery in the USA has shifted to ambulatory surgery centres (ASCs). These providers specialise in day surgery and may compete against hospitals. Proponents argue that ASCs enable clinicians to meet the needs of patients more effectively, and may leverage the benefits of multidisciplinary, team-based health care.
The third paper deploys fixed effects models, a tool of econometrics designed to minimise bias in longitudinal observational studies, to analyse the effects of ASCs on price and volume. For the base case model, market entry of ASCs was associated with a significant reduction in price for five of twelve surgical procedures, while none had a significant increase in price. The reduction in price ranged from $27.99 to $82.25 for a net increase of one ASC per 100,000 population. ASC market structure was not associated with a significant change in volume. Results suggest that ASCs may lower the price of surgery without resulting in supplier-induced demand, but further evidence is needed to validate this. Collectively, these studies suggest that reconfiguration of service providers may facilitate the attainment of high quality, equitable and affordable health care in some circumstances, but this is dependent on effective planning and change management.
Dr Sarah Jo Sinnott, UCC 2010
Dr Sarah Jo Sinnott
The effects of copayment policies on adherence to prescription medicines in publicly insured populations
Institution: UCC, 2010 cohort
Supervisors: Prof. Helen Whelton (UCC), Prof. Charles Normand (UCC), Prof. Stephen Byrne (UCC), Dr. Noel Woods (UCC)
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.
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.
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.
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.