Using the health policy triangle framework to describe local, regional and national healthcare policy changes within Ireland's diverse healthcare settings

Introduction: Developed in the late 20th century, the conceptual descriptive framework for this thesis was inspired by Walt and Gilson’s health policy triangle (HPT). The HPT model is a policy analysis framework universally used and applied in the literature to analyse various health-related issues, mainly at national or international level. Robust research is required to seek a greater understanding of the application and utilisation of the HPT framework to describe smaller-scale health policy decisions under investigation at local and regional level. Such local and regional decisions may then inform both national and international decisions. The author’s directive was to retrospectively analyse local, regional and national health policy change within different Irish healthcare settings over the last decade with regard to (i) development processes, (ii) evidence generation, (iii) implementation, and (iv) outcomes using the HPT framework within the context of the current Irish Sláintecare reforms. Methods: Using diverse local, regional and national Irish healthcare settings, this thesis examined the generalisable nature of the HPT framework when applied to variety of health-related policy decisions at different stages in their life cycle. Methodologies such as literature reviews, economic evaluations (cost-effectiveness analysis and cost minimisation analysis), and qualitative analysis (using the Framework Approach) helped provide evidence on the health-related policy decisions. Results: The narrative literature review in Chapter 2 identified that the types of health policies analysed by the HPT framework were mainly positioned at national or international level in lower to upper-middle-income countries and were primarily focused upon public health topics. This research concluded that given its generalisable nature, future research that utilises the HPT framework in smaller scale health policy decisions investigated at local and regional levels, could also be beneficial. A subsequent literature review in Chapter 3 applied Walt and Gilson’s health policy triangle model, as a scaffolding framework, to help describe how emerging evidence was used by a large acute Irish teaching hospital to permit the introduction of biosimilar infliximab CT-P13, for the treatment of IBD, into routine care in a safe and timely manner. The review of this local policy decision found that there was a significant time lag of over three years between regulatory approval and clinical acceptance for biosimilar infliximab CT-P13 in this large local hospital’s switching process. The actors concluded that with the existential concern and uncertainty still surrounding biosimilar medicines, a distinct and individualised approach for biosimilar medicine implementation is required. The cost-effectiveness analysis in Chapter 4 demonstrated that on average, the intervention arm of a physician-led medication review programme was more costly but was also more effective. Compared with usual care, the intervention was associated with a non-statistically significant increase of €877 (95% CI −€1,807, €3,561) in mean healthcare cost, and a statistically significant decrease of −0.164 (95% CI −0.257, −0.070) in the mean number of adverse drug reaction events per inpatient. The HPT framework was used to describe how this local level policy decision concerning the physician-led STOPP/START intervention was not implemented but that the generated economic evidence contributed to the evolving STOPP/START criteria policy formation, growth and future evaluation. The cost minimisation analysis in Chapter 5 assessed which formulation of trastuzumab (injected via different administration routes) was more cost-effective and time saving in relation to active healthcare professional (HCP) time. Over a full treatment course of 17 cycles, average HCP time saved accumulated to 16.78 hours with an estimated direct cost saving of €1,609.99 in favour of the trastuzumab subcutaneous formulation. The HPT framework elaborated on various contributing components concerning this contemporary regional policy which ultimately led to the replacement of the trastuzumab intravenous formulation by the trastuzumab subcutaneous formulation in clinical practice. The qualitative interview study in Chapter 6 revealed that both community pharmacists and general practitioners (GPs) accepted the theoretical concept of a co-payment attached to the Irish public health insurance scheme as it prevents moral hazard. GPs independently suggested that a co-payment system introduced in their field of practice may inhibit moral hazard by publicly insured patients in the utilisation of GP services. The HPT framework was used to depict the interrelated factors which underpin this national pharmaceutical policy where going forward, both GP and pharmacy unions have expressed interest to be more involved in the policy formation stages, not the post-implementation stages. Conclusion: This research has illustrated how generalisable and adaptable the HPT framework is when applied to health-related policy decisions in various Irish healthcare settings. Given this advantage, it is proposed that the HPT framework should be used in Sláintecare reform policy. Using a common descriptive framework and standardising the approach to health policy analysis during this ten-year reform has the potential to increase the successful fruition of Sláintecare policy goals

Apparent Size as the Determinant of Prey Selection by Bluegill Sunfish (Lepomis Macrochirus)

Copyright by the Ecological Society of America. This is the publisher's version, also available electronically from http://www.jstor.org/stable/1935055.Although it is known that visual predation by planktivorous fish tends to be size selective, the mechanism by which fish select their prey has not previously been described. Experiments in which bluegill sunfish (Lepomis macrochirus) were given a binary choice between prey of different sizes presented at different distances showed the fish selected the prey that appeared largest, either because of its actual size or its proximity to the fish. This paper incorporates this mechanism of prey selection by apparent size into a model of bluegill predation. According to the model, bluegill, in choosing the apparently largest prey under all conditions, alter their diet composition depending upon the abundance of prey. When prey are abundant, bluegill predominantly select prey of the largest size class available because these have the greatest probability of appearing largest; as large prey become scarce and smaller prey have a greater chance of appearing large, the fish tend to eat more prey from smaller size classes. When the model is tested against data from published fish-feeding experiments, the predicted size ratios of prey eaten correlate accurately with the observed ratios and numbers of prey eaten

Biosimilar infliximab introduction into the gastro-enterology care pathway in a large acute Irish teaching hospital: a story behind the evidence

Background and aim: Biosimilar medicines are not considered exact replicas of originator biological medicines. As a result, prescribers can be hesitant to introduce such medicines into the clinical setting until evidence surfaces confirming their safety and effectiveness. In Ireland, a national biosimilar medicines policy is currently in development but the decision to prescribe biosimilar medicines remains at the discretion of the physician. The aim of this descriptive review is to tell the story of the evidence used by a large acute Irish teaching hospital to introduce biosimilar infliximab CT-P13 for the treatment of inflammatory bowel disease (IBD) in a safe and timely manner into routine care. Methods: To explore the evidence supporting the effective introduction of biosimilar infliximab in a large acute Irish teaching hospital, a literature review was conducted. Evidence consisted of published studies, reviews, reports, position statements, articles, clinical guidelines, and recommendations from national bodies, regulatory authorities and professional organizations. All evidence was published in English. Results and discussion: In September 2014, the accumulated evidence base provided physicians with reassurance to prescribe biosimilar infliximab CT-P13 for new patients suffering from IBD in this large acute Irish teaching hospital. In September 2016, as the evidence base grew, physicians began to safely and confidently switch patients from the originator infliximab product to the biosimilar product. Conclusion: There was a significant time lag between regulatory approval and clinical acceptance given that the European Medicines Agency had granted market authorization for biosimilar infliximab CT-P13 three years prior to the initiation of this hospital's switching process. Although conservative in their execution, the authors conclude that with the existential concern and uncertainty still surrounding biosimilar medicines, a distinct and individualized approach for biosimilar medicine implementation is required. It is with hope that the Irish biosimilar medicines policy will improve upon biosimilar medicine clinical acceptance once published

Computerised interventions designed to reduce potentially inappropriate prescribing in hospitalised older adults: a systematic review and meta-analysis

Background: computerised interventions have been suggested as an effective strategy to reduce potentially inappropriate prescribing (PIP) for hospitalised older adults. This systematic review and meta-analysis examined the evidence for efficacy of computerised interventions designed to reduce PIP in this patient group. Methods: an electronic literature search was conducted using eight databases up to October 2017. Included studies were controlled trials of computerised interventions aiming to reduce PIP in hospitalised older adults (≥65 years). Risk of bias was assessed using Cochrane’s Effective Practice and Organisation of Care criteria. Results: of 653 records identified, eight studies were included—two randomised controlled trials, two interrupted time series analysis studies and four controlled before–after studies. Included studies were mostly at a low risk of bias. Overall, seven studies showed either a statistically significant reduction in the proportion of patients prescribed a potentially inappropriate medicine (PIM) (absolute risk reduction {ARR} 1.3–30.1%), or in PIMs ordered (ARR 2–5.9%). However, there is insufficient evidence thus far to suggest that these interventions can routinely improve patient-related outcomes. It was only possible to include three studies in the meta-analysis—which demonstrated that intervention patients were less likely to be prescribed a PIM (odds ratio 0.6; 95% CI 0.38, 0.93). No computerised intervention targeting potential prescribing omissions (PPOs) was identified. Conclusions: this systematic review concludes that computerised interventions are capable of statistically significantly reducing PIMs in hospitalised older adults. Future interventions should strive to target both PIMs and PPOs, ideally demonstrating both cost-effectiveness data and clinically significant improvements in patient-related outcomes

A Missense Mutation in Canine CLN6 in an Australian Shepherd with Neuronal Ceroid Lipofuscinosis

The childhood neuronal ceroid lipofuscinoses (NCLs) are inherited neurodegenerative diseases that are progressive and ultimately fatal. An Australian Shepherd that exhibited a progressive neurological disorder with signs similar to human NCL was evaluated. The cerebral cortex, cerebellum, and retina were found to contain massive accumulations of autofluorescent inclusions characteristic of the NCLs. Nucleotide sequence analysis of DNA from the affected dog identified a T to C variant (c.829T>C) in exon 7 of CLN6. Mutations in the human ortholog underlie a late-infantile form of NCL in humans. The T-to-C transition results in a tryptophan to arginine amino acid change in the predicted protein sequence. Tryptophans occur at homologous positions in the CLN6 proteins from all 13 other vertebrates evaluated. The c.829T>C transition is a strong candidate for the causative mutation in this NCL-affected dog. Dogs with this mutation could serve as a model for the analogous human disorder

Out of pocket or out of control: A qualitative analysis of healthcare professional stakeholder involvement in pharmaceutical policy change in Ireland

Background: Mandatory co-payments attached to prescription medicines on the Irish public health insurance [General Medical Services (GMS)] scheme have undergone multiple iterations since their introduction in October 2010. To date, whilst patients’ opinions on said co-payments have been evaluated, the perspectives of community pharmacists and general practitioners (GPs) have not. Objective: To explore the involvement and perceptions of community pharmacists and GPs on this pharmaceutical policy change. Methods: A qualitative study using purposive sampling alongside snowballing recruitment was used. Nineteen interviews were conducted in a Southern region of Ireland. Data were analysed using the Framework Approach. Results: Three major themes emerged: 1) the withered tax-collecting pharmacist; 2) concerns and prescribing patterns of physicians; and 3) the co-payment system – impact and sustainability. Both community pharmacists and GPs accepted the theoretical concept of a co-payment on the GMS scheme as it prevents moral hazard. However, there were multiple references to the burden that the current method of co-payment collection places on community pharmacists in terms of direct financial loss and reductions in workplace productivity. GPs independently suggested that a co-payment system may inhibit moral hazard by GMS patients in the utilisation of GP services. It was unclear to participants what evidence is guiding the GMS co-payment fee changes. Conclusion: Interviewees accepted the rationale for the co-payment system, but reform is warranted

The strengthening mechanism of a magnesia core ceramic

A high-expansion core material containin magnesia and forsterite may be used to make all-ceramic dental crowns with porcelain-fused-to-metal body porcelains. The purpose of this study was to investigate the strengthening mechanism for the magnesia core material. Six batches of the magnesia core material were made by reacting magnesia with a silica glass with holding times ranging from 17 to 120 min. The flexural strength was measured using three-point loading according to the ISO specification for dental ceramics. The forsterite content was measured using quantitative x-ray diffraction. A statistically significant correlation was found between the forsterite content and flexural strength. The proposed mechanism for strengthening is the precipitation of fine forsterite crystals in the glass matrix surrounding unreacted magnesia. Longer reaction times produced more dissolution of magnesia and subsequent precipitation of forsterite. This method results in a new strengthening mechanism for dental ceramics which have previously relied on the incorporation of alumina, leucite or ceramic whiskers.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/30708/1/0000354.pd

Safety culture in a major accredited Irish university teaching hospital: a mixed methods study using the safety attitudes questionnaire.

Background: The measurement of safety culture, the way in which members of an organisation think about and prioritise safety, in a hospital can provide valuable insight and inform quality improvement strategies. Aims: The aim of this study is to describe the safety culture of a university teaching hospital in the Republic of Ireland. Methods: This is a mixed methods survey study using the Safety Attitudes Questionnaire (SAQ). The SAQ was distributed to all staff in the study hospital. Staff attitudes towards six domains of patient safety culture were assessed over 32 Likert-scaled items. Thematic analysis was performed on qualitative data. Results: A total of 768 staff members completed and returned a copy of the SAQ. The hospital scored above the international benchmark in five out of six domains, indicating a positive safety culture, but scored below the international benchmark in the domain 'Working Conditions'. This positive safety culture was not mirrored in the qualitative data, from which five themes emerged; three major-Staffing Issues, Patient-Focused Care and Hospital Environment-and two minor-Safe Reporting Culture and Training and Education. Conclusions: In this study, a mixed methods approach was successfully used to investigate the safety culture in a large Irish hospital. Although the SAQ results indicated a positive safety culture, the qualitative data revealed a number of issues that the hospital staff felt impacted negatively on patient safety. The results of this study will inform future work on the design of an intervention to improve patient safety in the hospital

Cost minimization analysis of intravenous or subcutaneous trastuzumab treatment in patients with HER2-positive breast cancer in Ireland

Background: Two large acute Irish University teaching hospitals changed the manner in which they treated human epidermal growth factor receptor (HER)2-positive breast cancer patients by implementing the administration of trastuzumab via the subcutaneous (SC) route into their clinical practice. The study objective is to compare the trastuzumab SC and trastuzuamb intravenous (IV) treatment pathways in both hospitals and assess which route is more cost-effective and time saving in relation to active health care professional (HCP) time. Materials and Methods: A prospective observational study in the form of cost minimization analysis constituted the study design. Active HCP time for trastuzumab SC- and IV-related tasks were recorded. Staff costs were calculated using fully loaded salary costs. Loss of productivity costs for patients were calculated using the human capital method. Results: On average, the total HCP time saved per trastuzumab SC treatment cycle relative to trastuzumab IV treatment cycle was 59.21 minutes. Time savings in favor of trastuzumab SC resulted from quicker drug reconstitution, no IV catheter installation/removal, and less HCP monitoring. Over a full treatment course of 17 cycles, average HCP time saved accumulates to 16.78 hours, with an estimated direct cost saving of â ¬1609.99. Loss of productivity for patients receiving trastuzumab IV (2.15 days) was greater than that of trastuzumab SC (0.60 days) for a full treatment course. Conclusion: Trastuzumab SC treatment has proven to be a more cost-effective option than trastuzumab IV treatment that generated greater HCP time savings in both study sites. Healthcare policymakers should consider replacing trastuzumab IV with trastuzumab SC treatment in all eligible patients

Cost-effectiveness analysis of a physician-implemented medication screening tool in older hospitalised patients in Ireland

Background: A recent randomised controlled trial conducted in an Irish University teaching hospital that evaluated a physician-implemented medication screening tool, demonstrated positive outcomes in terms of a reduction in incident adverse drug reactions. Objective: The present study objective was to evaluate the cost effectiveness of physicians applying this screening tool to older hospitalised patients compared with usual hospital care in the context of the earlier randomised controlled trial. Method: We used a cost-effectiveness analysis alongside a conventional outcome analysis in a cluster randomised controlled trial. Patients in the intervention arm (n = 360) received a multifactorial intervention consisting of medicines reconciliation, communication with patients’ senior medical team, and generation of a pharmaceutical care plan in addition to usual medical and pharmaceutical care. Control arm patients (n = 372) received usual medical and pharmaceutical care only. Incremental cost effectiveness was examined in terms of costs to the healthcare system and an outcome measure of adverse drug reactions during inpatient hospital stay. Uncertainty in the analysis was explored using a cost-effectiveness acceptability curve. Results: On average, the intervention arm was more costly but was also more effective. Compared with usual care (control), the intervention was associated with a non-statistically significant increase of €877 (95% confidence interval − €1807, €3561) in the mean healthcare cost, and a statistically significant decrease of − 0.164 (95% confidence interval − 0.257, − 0.070) in the mean number of adverse drug reaction events per patient. The associated incremental cost-effectiveness ratio per adverse drug reaction averted was €5358. The probability of the intervention being cost effective at threshold values of €0, €5000 and €10,000 was 0.236, 0.455 and 0.680, respectively. Conclusion: Based on the evidence presented, this physician-led intervention is not likely to be cost effective compared with usual hospital care. To inform future healthcare policy decisions in this field, more economic analyses of structured medication reviews by other healthcare professionals and by computerised clinical decision support software need to be conducted