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Public discourse on medicine provision predominantly focuses on overall expenditure. However, current literature suggests measurement of alternative indicators can provide a method to benchmark or ameliorate medicine provision. Previous research has investigated the viability of using health-related outcome metrics, such as the number of patients treated, quality-adjusted life-year gain and life-year gain, to provide macro-level estimates on medicines’ societal contributions. This editorial provides an overview of the evolving healthcare landscape surrounding medicine usage estimation and valuation in Ireland and offers recommendations on how improved methods of measuring health-related outcomes may help ameliorate efficiencies and the sustainability of a healthcare system.

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.

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 €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.

Background: The Irish healthcare system is currently recognised as being understaffed and under-resourced due to historic underfunding and the aftermath of the 2008 global financial crisis. This descriptive study investigated healthcare providers’ perceptions of the safety culture in a large Irish teaching hospital. Aim: The aim of this study was to investigate healthcare workers’ perceptions of the safety culture in a large Irish teaching hospital in a climate of national under-resourcing of healthcare. Methods: Seventeen semi-structured interviews were carried out with patient-attending staff between February and June 2019. Interviews were transcribed verbatim and analysed using thematic analysis. Results: Two predominant themes emerged from the interviews: (1) challenging environment and (2) thirst for change. Study participants described the poor working conditions in the hospital, but also recognised the importance of teamwork and communication in maintaining patient safety and had a strong appetite for change regarding the safety culture in the hospital. Conclusion: This study highlights the complex relationship between working conditions and safety culture. Hospital staff were committed to providing the best possible care for their patients but struggled to provide safe care in a challenging work environment. A clear appetite for change was identified amongst HCPs regarding patient safety culture in Irish healthcare.

Purpose: Ireland's Sláintecare health plan is placing an increased focus on primary care. A community oncology nursing programme was developed to train community nurses to deliver care in the community. While the initial pilot was proven to be clinically safe, no cost evaluation was carried out. This study aims to compare the costs of providing cancer support services in a day-ward versus in the community. Methods: 183 interventions (40 in day-ward and 143 in community) were timed and costed using healthcare professional salaries and the Human Capital method. Results: From the healthcare provider perspective, the day-ward was a significantly cheaper option by an average of €17.13 (95% CI €13.72 - €20.54, p

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.

Introduction Communication is widely recognised to play a key role in patient care. The US Institute of Medicine’s 2002 report, ‘Crossing the Quality Chasm’, stated that ‘effective methods of communication, both among caregivers and between caregivers and patients, are critical to providing high-quality care’.(1) Interdisciplinary communication (IDC) can be challenging due to differences in training, education and roles between healthcare professions. Due to the nature of IDC, the majority of research on this subject has been qualitative, exploring the views of healthcare professionals on IPC. To date, however, the qualitative evidence on IDC has not been synthesised in a systematic manner. Therefore, a systematic review of the qualitative literature on healthcare providers’ experiences of interprofessional communication was conducted and registered with PROSPERO (registration number CRD42020177967). Aim The primary aim of this systematic review was to synthesise the qualitative evidence regarding healthcare providers’ perceptions of IDC in the hospital setting. A secondary aim was to identify the barriers and facilitators to IDC in the hospital setting. Methods Studies were eligible for inclusion in the review if they met the following criteria: 1) studies examining healthcare professionals’ experiences of IDC, 2) studies conducted in the hospital setting, and 3) studies conducted using qualitative research methods. Four databases (PubMed, CINAHL, Web of Science and Embase) were searched from inception until May 2020. Quality appraisal of the identified studies was conducted using the Critical Appraisal Skills Programme (CASP) tool for qualitative research. Data from the results sections of eligible studies were synthesised using thematic synthesis as described by Thomas and Harden.(2) Thematic synthesis consists of three stages: 1) line-by-line coding of all text relevant labelled ‘results’ or ‘findings’ in the included studies, 2) organisation of codes into descriptive themes that reflect the results of the included studies, and 3) development of descriptive themes into analytical themes that address the review question. Results Eighteen studies were identified as being eligible for inclusion in this review (Figure 1). Five descriptive themes emerged during thematic synthesis: 1) ‘Hierarchy’, 2) ‘Interprofessional Ethos’, 3) ‘Healthcare Environment’, 4) ‘Personal Factors’ and 5) ‘Methods of Communication’, which were developed into two analytical themes: ‘Barriers to IDC’ and ‘Facilitators to IDC’. Personal factors, such as strong interprofessional relationships, were found to facilitate IDC, while organisational factors, such as challenging and hierarchical working environments, were found to pose barriers to IPC. Conclusion We believe that this review makes a significant contribution to the literature. To our knowledge, it is the first study to synthesis the qualitative evidence on healthcare providers’ perceptions of IDC in hospitals. Maintaining an interprofessional ethos and building positive working relationships were identified as facilitators to IDC, while hierarchy and challenging working conditions were identified as barriers. A key finding is the significance that healthcare providers associate with personal aspects of IDC, such as mutual respect and understanding among healthcare professionals. Future research should involve the theory- and evidence-driven design of interventions to improve personal aspects of IDC, such as interprofessional education and engagement. References 1. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century - Institute of Medicine. Institute of Medicine. 2001. 2. Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol. 2008;8(45).

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.

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.

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.

Ss verbalized or wrote predetermined stimulus names during visual discrimination learning. Those verbalizing or writing only the names of correct stimuli made significantly fewer errors in learning the discriminations than did those required to verbalize or write a mixed pattern of correct and incorrect names. Although Ss writing a mixed pattern tended to make slightly fewer errors than those verbalizing the same pattern, a difference which appears to be statistically significant given large samples, the overall conclusion was that as auxiliary responses, verbalizing and writing have essentially equivalent effects.