Centre for Policy Studies - Doctoral Theses

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    An evaluation of Ireland’s water fluoridation policy
    (University College Cork, 2024) Cronin, Jodi; Woods, Noel; Harding, Mairead; Moore, Stephen; Whelton, Helen
    Introduction Community water fluoridation (CWF), the controlled addition of fluoride to the water supply, is an approved preventive oral health intervention to reduce the prevalence and severity of dental caries (dental decay). Celebrated for its role in reducing dental caries, it is recognised as one of the ten great public health promotion measures of the 20th century. Today, 60 years since fluoride was first added to the public water supply in Dublin, 71% of the Irish population have access to fluoridated water, emphasising the lasting influence of CWF as a fundamental aspect of public health in Ireland. This thesis aims to comprehensively assess the economic and oral health implications of Ireland’s CWF policy within the context of the nation’s hybrid oral healthcare system. This system, operating in parallel to the main healthcare system, combines public and private service provision, with most individuals paying out-of-pocket fees to independent dental practitioners. Methods The thesis explores historical, contextual, and methodological landscapes to provide a comprehensive understanding of the Ireland’s CWF policy and its implications for public health policy. To address the gaps in the evidence relating to CWF in the Irish setting, three studies were undertaken. The first study described in Chapter 6, critically appraises the methodological conduct and reporting quality of economic evaluations (EEs) of CWF. Guided by established principles for reviewing economic evidence, the study assesses the economic evidence using reliable quality appraisal instruments, specifically the Consensus on Health Economic Criteria list (CHEC) and the Consolidated Health Economic Evaluation Reporting Standards statement (CHEERS). Chapter 7, presents an economic evaluation of CWF for schoolchildren, the first formal assessment of its cost-effectiveness in the Irish setting since the adoption of the policy in 1964. Following traditional economic evaluation methods and using epidemiological data from a representative sample of schoolchildren with and without lifetime exposure to CWF, a cost-effectiveness analysis (CEA) is performed from the health-payer perspective. The third study, presented in Chapter 8, examines the long-term effects of exposure to the Ireland’s CWF policy on dental caries among adults. The study uses epidemiological, demographic, and sociological data from adult residents of the Republic of Ireland (Ireland) with lifelong exposure to a CWF policy and adults in Northern Ireland without exposure to CWF. Negative binomial regressions are employed to estimate the relative risks of various explanatory variables, including CWF exposure, on dental caries experience among adults. Results Collectively, the results of these three studies provide a more comprehensive understanding of the effects of Ireland’s CWF policy on oral health outcomes. Chapter 6, highlights persistent misunderstandings in valuing consequences within cost-benefit analyses of CWF. The study also identifies shortcomings in the measurement and valuation of costs and outcomes across all evaluation types. Moreover, it reveals methodological subtleties that may not be discerned by the quality assessment instruments, such as accurately estimating the impact of fluoridation and the inclusion of treatment savings within cost estimates. This chapter provides valuable insights into the existing economic evidence of CWF, helping policymakers effectively leverage it to inform resource allocation decisions. Additionally, it may serve as a resource for researchers, facilitating improvements in the methodological rigor and reporting standards of future EEs of CWF. In Chapter 7, compelling economic evidence highlights the imperative of maintaining public provision of CWF for schoolchildren despite the current environment of multiple fluoride sources. CWF as a health intervention provides a reduction in the national disease burden and offers cost-savings to the health-payer, which in Ireland, is often the private individual. The findings presented by the analysis in Chapter 8, reveals that adults, exposed to a CWF policy for most of their lives, show a significantly reduced dental caries experience compared to individuals of similar age with no exposure. Furthermore, exposure to the CWF policy emerges as the most influential variable affecting caries outcomes when compared to the other variables examined in the study. Conclusions The mandatory legislation surrounding CWF in the Irish context has been instrumental in ensuring widespread access to the benefits of this preventive measure. The findings of this thesis affirm that Ireland’s CWF policy has not only been the cornerstone of its preventive oral healthcare strategy but also a steadfast pillar of the publicly funded oral healthcare service. Despite the challenges posed by a fragmented and underfunded oral healthcare system that has yet to be fully integrated into the broader healthcare agenda, the CWF policy has reliably maintained the population’s oral health since its introduction in 1964. This highlights the policy’s critical role in mitigating the negative impacts of systemic shortcomings while also demonstrating its capacity to drive enhancements in oral health outcomes for all members of the community. By providing a consistent and accessible source of fluoride through the public water supply (PWS), CWF offers a cost-effective and broad-reaching intervention to improve oral health outcomes. The findings of this thesis emphasise the significance of CWF as a public health measure in reducing the prevalence of dental caries and health inequalities, supporting its continued implementation as a public health strategy.
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    Drug prescribing patterns in the General Medical Services Scheme in Ireland and projected costs to 2026
    (University College Cork, 2015) Conway Lenihan, Aisling; Woods, Noel; Health Research Board; Cork Institute of Technology
    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.
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    Compilation and analysis of integrated regional input-output tables for NUTS 2 regions in Ireland
    (University College Cork, 2011-09) MacFeely, Stephen; Moloney, Richard
    In 1966, Roy Geary, Director of the ESRI, noted “the absence of any kind of import and export statistics for regions is a grave lacuna” and further noted that if regional analyses were to be developed then regional Input-Output Tables must be put on the “regular statistical assembly line”. Forty-five years later, the lacuna lamented by Geary still exists and remains the most significant challenge to the construction of regional Input-Output Tables in Ireland. The continued paucity of sufficient regional data to compile effective regional Supply and Use and Input-Output Tables has retarded the capacity to construct sound regional economic models and provide a robust evidence base with which to formulate and assess regional policy. This study makes a first step towards addressing this gap by presenting the first set of fully integrated, symmetric, Supply and Use and domestic Input-Output Tables compiled for the NUTS 2 regions in Ireland: The Border, Midland and Western region and the Southern & Eastern region. These tables are general purpose in nature and are consistent fully with the official national Supply & Use and Input-Output Tables, and the regional accounts. The tables are constructed using a survey-based or bottom-up approach rather than employing modelling techniques, yielding more robust and credible tables. These tables are used to present a descriptive statistical analysis of the two administrative NUTS 2 regions in Ireland, drawing particular attention to the underlying structural differences of regional trade balances and composition of Gross Value Added in those regions. By deriving regional employment multipliers, Domestic Demand Employment matrices are constructed to quantify and illustrate the supply chain impact on employment. In the final part of the study, the predictive capability of the Input-Output framework is tested over two time periods. For both periods, the static Leontief production function assumptions are relaxed to allow for labour productivity. Comparative results from this experiment are presented.