Dr Aline Brennan, UCC 2011
Dr Aline Brennan
Model of care for HIV infection in Ireland
Institution: UCC, 2011 cohort
Supervisors: Prof. Mary Horgan (UCC), Prof. Colm Bergin (TCD), Prof. John Browne (UCC)
Highly active anti‐retroviral therapy (HAART) has completely transformed the clinical course of HIV. HIV is now considered a chronic disease, with patients living for decades on treatment. It is anticipated that health services will be placed under increasing pressure as the prevalence and age profile of the HIV population increases. A deeper understanding of the specific factors driving the use and cost of HIV care in Ireland is needed to allow quantification of future resource needs as well as the identification of potentially cost‐effective service delivery modifications. This thesis investigates the current use and direct cost of hospital care by HIV patients, and explores some of the patients and clinic level factors influencing the cost of HIV care in Ireland.
The total number of patients in care annually as well as the changing age profile of patients over time was estimated using routine data on the number of notified cases and general mortality in combination with published estimates of HIV related deaths. Current resource use and costs of care in 2012 were estimated from two studies carried out in the HIV centre located in Cork University Hospital. The first study estimated the total cost of outpatient HIV care using micro‐costing, including data on HAART use and cost. The second study used data extracted from the finance department of Cork University Hospital to identify and describe the pattern of use and non‐drug cost of all hospital services (including inpatient episodes, non‐ID outpatient appointments and emergency department attendances) by HIV patients in 2012. A national estimate of the cost of ambulatory HIV care in 2012 was then generated adjusting the estimated unit costs of outpatient visits, for variation in service delivery across the six centres providing adult HIV care in Ireland in 2012 and using national anti‐retroviral sales data.
The number of HIV patients accessing HIV care was estimated to be 3,820 in 2012, with 18% of patients aged ≥50 years. Assuming the rate of new diagnosis remains stable we estimated that the number of patients in care will have increased by 40% to 4,607 by 2020 and that the proportion of patients aged ≥50 years will have increased to 30%. HAART is the overwhelming driver of the cost of outpatient HIV care. Treatment costs accounted for 90% of the total cost of outpatient HIV care estimated in the micro‐costing study. Patient factors associated with increased total outpatient HIV costs on multivariate analysis were younger age (< 50 years), female gender and being on HAART but not suppressed. When categories of costs were examined separately older patients were found to have both significantly lower HAART costs as well as HIV outpatient visit costs while female patients only had significantly higher HAART costs. On analysis of non‐drug hospital costs (i.e. including inpatient admissions, non‐ID outpatient appointments and emergency department attendances) low CD4 count and treatment status were significant, but no demographic factors were identified. A small number of patients (2%) with very low CD4 counts incurred a disproportionate amount of inpatient (61%) and total hospital non drug costs (31%). Extrapolating from the micro‐costing estimates and taking into account variation in service delivery across centres, we estimate that the annual non‐drug cost of providing ambulatory HIV care in Ireland in 2012 was €1,127 per patient or €4.31 million, and that including HAART, the cost to the health service provider in 2012 was approximately €50 million.
The age profile of HIV patients in care is increasing in Ireland at a similar rate as in other developing countries. However, in contrast to what has previously reported in the literature, older patients in our study did not appear to incur increased total costs compared to their younger counterparts. The main reason for this was that the older patients were on less expensive treatment regimens, and HAART cost is the main driver of total cost of outpatient HIV care. Exactly why this was is unclear, but regimen choice is influenced by many health‐system (e.g. drugs available, clinician preference etc) as well as patient factors (treatment history, resistance, patient preference etc). There was also no difference identified in the non‐drug cost of care for older patients. This may have been due to the patients themselves being possibly younger and/or healthier than in other published studies, but may also be due to a lack of co‐ordinated routine screening for age‐related comorbidities in HIV patients in Ireland, as well as the cost estimates being based on data collected in a single centre which did not include costs incurred in other hospital, community and primary care settings. As the increasing age and total number of patient increases demands on HIV services it is imperative that measures to improve service efficiency are evaluated in terms of both clinical outcomes and costs. Interventions such as increased screening to reduce the number of patients diagnosed with advanced disease and increased use of generics have the potential to generate cost‐savings, however a nationally co‐ordinated approach is needed to drive such changes while ensuring the current standard of care is maintained.
Dr Aoife Fleming, UCC 2011
Dr Aoife Fleming
Antimicrobial Stewardship in Ireland, with a focus on Long Term Care Facilities
Institution: UCC, 2011 cohort
Supervisors: Prof. Stephen Byrne (UCC), Prof. John Browne (UCC), Prof. Martin Henman (TCD), Prof. Colin Bradley (UCC)
Antimicrobial resistance is a major public health concern, and its increasing incidence in the Long Term Care Facility (LTCF) setting warrants attention (1). The prescribing of antimicrobials in this setting is often inappropriate and higher in Ireland than the European average (2). The aim of the study was to generate an evidence base for the factors influencing antimicrobial prescribing in LTCFs and to investigate Antimicrobial Stewardship (AMS) strategies for LTCFs.
An initial qualitative study was conducted to determine the factors influencing antimicrobial prescribing in Irish LTCFs. This allowed for the informed implementation of an AMS feasibility study in LTCFs in the greater Cork region. Hospital AMS was also investigated by means of a national survey. A study of LTCF urine sample antimicrobial resistance rates was conducted in order to collate information for incorporation into future LTCF AMS initiatives.
The qualitative interviews determined that there are a multitude of factors, unique to the LTCF setting, which influence antimicrobial prescribing. There was a positive response from the doctors and nurses involved in the feasibility study as they welcomed the opportunity to engage with AMS and audit and feedback activities. While the results did not indicate a significant change in antimicrobial prescribing over the study period, important trends and patterns of use were detected. The antimicrobial susceptibility of LTCF urine samples compared to GPs samples found that there was a higher level of antimicrobial resistance in LTCFs.
This study has made an important contribution to the development of AMS in LTCFs. The complexity of care and healthcare organisation, and the factors unique to LTCFs must be borne in mind when developing quality improvement strategies.
Dr Patrick Moran, TCD 2011
Dr Patrick Moran
Economic analysis of the detection and management of atrial fibrillation
Institution: TCD, 2011 cohort
Supervisors: Dr. Mairin Ryan (HIQA), Prof. Charles Normand (TCD), Prof. Susan Smith (RCSI)
Dr Mary Ann O’Donovan, RCSI 2011
Dr Mary Ann O’Donovan
Exploring choice, home and health service utilisation for people ageing with an intellectual disability during a time of housing relocation and transition
Institution: RCSI, 2011 cohort
Supervisors: Dr Elaine Byrne (RCSI), Prof. Mary McCarron (TCD), Prof. Philip McCallion (TCD)
The study aims to understand if and how older people with an intellectual disability are involved in the decision to change place of residence, the relationship between this choice opportunity and choice in other areas of life and how both choice and moving impact on health service utilisation.
National policy promotes the closure of congregated living for people with ID. For people who live with family, longer life expectancy presents different challenges in preparing for later life living arrangements. This context provides strong rationale for current study.
The research design consists of three main elements; (i) a content analysis of relevant health and housing policies; (ii) a systematic review of healthcare utilisation models; and (iii) quantitative analysis of the Intellectual Disability Supplement to the Irish Longitudinal Study on Ageing (IDS-TILDA).
The data analysis showed three types of moves made by IDS-TILDA participants – more restrictive, more community based and lateral moves (which represented the majority). The main drivers for change differed by type of move but the predominant stakeholder in these decisions was the ID service provider.
In conclusion, the duality of home and health for people with ID was evidenced across the various elements of the analysis with the quantitative analysis demonstrating that people with ID continue to be excluded from decisions on major life events and transition points such as moving home, and that regardless of type of living arrangement and type of moves made by movers, that many older people with ID continue to have choice for everyday and key life decisions made by someone else. This has implications for future health and housing policy and the need for complementarity in policy development and implementation.
Dr Sinéad O’Neill, UCC 2011
Dr Sinéad O’Neill
Caesarean section and subsequent pregnancy outcome: a Danish register-based cohort study
Institution: UCC, 2011 cohort
Supervisors: Dr. Ali Khashan (UCC), Prof. Patricia Kearney (UCC), Prof. Louise Kenny (UCC), Prof. Richard Greene (UCC), Prof. Esben Agerbo (Aarhus University, Denmark)
Caesarean section rates have increased in recent decades and the effects on subsequent pregnancy outcome are largely unknown. Prior research has hypothesised that Caesarean section delivery may lead to an increased risk of subsequent stillbirth, miscarriage, ectopic pregnancy and sub-fertility.
A 23% increased odds of subsequent stillbirth; no increase in odds of subsequent ectopic pregnancy and a 10% reduction in the odds of subsequent live birth among women with a previous Caesarean section were found in the various meta-analyses. Results from the Danish Civil Registration System (CRS) cohort revealed a small increased rate of subsequent stillbirth and ectopic pregnancy among women with a primary Caesarean section, which remained in the analyses by type of Caesarean. No increased rate of miscarriage was found among women with a primary Caesarean section. In the CRS data, women with a primary Caesarean section had a significantly reduced rate of subsequent live birth particularly among women with primary elective and maternal-requested Caesarean sections. In the Aarhus Birth Cohort, overall the effect of mode of delivery on the rate and time to next live birth was minimal. Primary Caesarean section was associated with a small increased rate of stillbirth and ectopic pregnancy, which may be in part due to underlying medical conditions. No increased rate of miscarriage was found. A reduced rate of subsequent live birth was found among Caesarean section in the CRS data. In the smaller ABC cohort, a small reduction in rate of subsequent live birth was found among women with a primary Caesarean section and is most likely due to maternal choice rather than any ill effects of the Caesarean. The findings of this study, the largest and most comprehensive to date will be of significant interest to health care providers and women globally.
Dr Patrick Redmond, RCSI 2011
Dr Patrick Redmond
Medication management, specifically inappropriate prescribing and medicines reconciliation, at the primary-secondary care interface
Institution: RCSI, 2011 cohort
Supervisors: Prof. Tom Fahey (RCSI), Dr.Ronan McDonnell (RCSI), Dr. Tamasine Grimes (TCD)
The aim of this thesis was to examine medication reconciliation at the primary secondary care interface and to identify the impact of hospitalisation on the continuity of medication post discharge as well methods to both implement and improve reconciliation.
A mixed methods research approach was used. A questionnaire was used to gather the opinion of primary care based healthcare professionals (HCPs) on the perceived quality of medication reconciliation both within and between primary and secondary care. A retrospective cohort of general practice patients was recruited to assess the impact of hospitalisation on the continuity of chronic medications post hospitalisation. A systematic review of the literature was performed to report the most effective method of reconciliation (e.g. HCP mediated, Information Communication Technology (ICT), multifaceted). Qualitative techniques were used to gather the opinions of secondary and primary care based HCPs on the barriers and facilitators to implementing effective reconciliation. The findings from all studies were triangulated to provide recommendations on methods to improve medication safety at this transition point.
A total of 897 general practitioners (GPs) and community pharmacists (CPs) responded to the questionnaire – reporting satisfaction with GP/CP communication, mixed quality of communication with secondary care and an extremely common experience of prescribing errors following transitions of care (>80%). Analysis of a cohort of patients (n=19,777) from 44 practices, prescribed chronic medications long-term, reported a proportion of medication discontinuity ranging from 6-12% in the six months post-hospitalisation. There was reduced odds of discontinuity of respiratory inhalers (adjusted odds ratio AOR 0.53 95%CI [0.39, 0.71]) and thyroid medications (AOR 0.54 95%CI [0.33, 0.89]) in those hospitalised versus those not hospitalised, with no impact of hospitalisation on the continuity of antithrombotics and lipid lowering medication. A systematic review and meta-analysis of reconciliation interventions showed a positive impact on medication discrepancies with a reduction in the relative risk (RR 0.58, 95%CI [0.46 to 0.73], 18 studies) by interventions that were primarily delivered by pharmacists. There is no certainty of this effect due to the low quality of included studies. Thematic analysis, of interviews with thirty-five HCPs, revealed that existing organisational practices, infrastructural deficits and the opinion of HCPs were the main barriers to effective reconciliation with improved communication, multidisciplinary teams and use of information technology listed as facilitators.
There is a frustration with the current standard of medication reconciliation between primary and secondary care with the experience of errors following transitions being commonly reported. This thesis provides evidence on the impact of transitions post hospital discharge on medication continuity, reviews successful reconciliation interventions, and examines the key suggestions of stakeholders in implementing reconciliation.
Dr Lorna Roe, TCD 2011
Dr Lorna Roe
An exploration of frailty and resource use in the Irish older population and the implications for the policy and practice of integrated care: A mixed methods study
Institution: TCD, 2011 cohort
Supervisors: Prof. Charles Normand (TCD), Prof. John Browne (UCC), Dr. Maev-Ann Wren (ESRI)
Abstract: Not available
Dr Emma Wallace, RCSI 2011
Dr Emma Wallace
Predicting adverse health outcomes in older community dwelling adults
Institution: RCSI, 2011 cohort
Supervisors: Prof. Susan Smith (RCSI), Prof. Tom Fahey (RCSI), Prof. Kathleen Bennett (RCSI)
This thesis aimed to investigate if adverse health outcomes in older community-dwelling people can be predicted, through the application of measures of prescribing, multimorbidity and emergency admission risk models. There were five objectives: 1) to determine if there is a longitudinal association between potentially inappropriate prescribing (PIP) and future adverse drug events (ADEs), reduced health related quality of life (HRQOL) and increased use of Accident & Emergency (A&E) and emergency admissions; 2) to assess the performance of different measures of multimorbidity and vulnerability in predicting emergency hospital attendance and functional decline; 3) to conduct a systematic review of emergency admission risk prediction models developed for use in community-dwelling adults; 4) to systematically review and meta-analyse the validation studies of the Probability of repeated admissions (Pra) risk model; and, 5) to externally validate the Pra risk model in predicting emergency hospital admission over the following year.
A prospective cohort study with two year follow-up was conducted linked to the national Health Services Executive Primary Care Reimbursement Services (HSE-PCRS) pharmacy claims database (2010-2012). At baseline a total of 904 older (≥70 years) community-dwelling people were recruited from 15 general practices. The Screening Tool of Older Persons Prescriptions (STOPP) and Beers 2012 prescribing indicator sets were applied to the pharmacy data to elicit PIP. ADEs were recorded through patient interview with corresponding review of the GP medical record. HRQOL was determined through the Euro-Qul-5Dimensions (EQ-5D) administered through a patient questionnaire. Emergency attendance was ascertained through a detailed review of the GP medical record. Multilevel regression modelling was used to investigate if PIP was longitudinally associated with ADEs, HRQOL and emergency hospital attendance (Poisson (incidence rate ratio (IRR) (95% CI) and linear regression models (regression co-efficient (95% CI)). Different medication and diagnosis based measures of multimorbidity, the Vulnerable Elders Survey (VES-13) and the Pra model were investigated by examining their discrimination (the ability of the model to distinguish correctly the patients with different outcomes, c-statistic (95% CI)) and calibration (reflects how closely predicted outcomes agree with the actual outcomes, Hosmer-lemeshow statistic).
Of 791 participants eligible for follow-up, 673 (85%) returned a questionnaire and 605 (77%) also completed an ADE interview. Baseline STOPP PIP prevalence was 42% and 445 (74%) patients reported ≥1 ADE at follow-up. In multivariable analysis, ≥2 STOPP PIP was associated with ADEs (adjusted IRR: 1.29 (95% CI 1.03, 1.85, p=0.03); poorer HRQoL (adjusted regression co-efficient: -0.11 (-0.16, -0.06; p
Older community-dwelling people, prescribed ≥2 PIP, as defined by the STOPP prescribing criteria, are more likely to report ADEs, poorer HRQOL and attend A&E over two-year follow-up. Both medication and diagnosis-based measures of multimorbidity demonstrated similar performance in predicting emergency admission. The VES-13 may be useful in identifying older people at risk of functional decline in the community. In certain circumstances, while acknowledging the limitations of risk stratification, the Pra tool may have a role in targeting older people at higher risk of emergency admission.