Assessing cost-effectiveness in mental health : vocational rehabilitation for schizophrenia and related conditions

Objective: Existing evidence suggests that vocational rehabilitation services, in particular individual placement and support (IPS), are effective in assisting people with schizophrenia and related conditions gain open employment. Despite this, such services are not available to all unemployed people with schizophrenia who wish to work. Existing evidence suggests that while IPS confers no clinical advantages over routine care, it does improve the proportion of people returning to employment. The objective of the current study is to investigate the net benefit of introducing IPS services into current mental health services in Australia.

Method: The net benefit of IPS is assessed from a health sector perspective using cost–benefit analysis. A two-stage approach is taken to the assessment of benefit. The first stage involves a quantitative analysis of the net benefit, defined as the benefits of IPS (comprising transfer payments averted, income tax accrued and individual income earned) minus the costs. The second stage involves application of 'second-filter' criteria (including equity, strength of evidence, feasibility and acceptability to stakeholders) to results. The robustness of results is tested using the multivariate probabilistic sensitivity analysis.

Results: The costs of IPS are $A10.3M (95% uncertainty interval $A7.4M–$A13.6M), the benefits are $A4.7M ($A3.1M–$A6.5M), resulting in a negative net benefit of $A5.6M ($A8.4M–$A3.4M).

Conclusions: The current analysis suggests that IPS costs are greater than the monetary benefits. However, the evidence-base of the current analysis is weak. Structural conditions surrounding welfare payments in Australia create disincentives to full-time employment for people with disabilities.

Assessing cost-effectiveness of drug interventions for schizophrenia

Objective: To assess from a health sector perspective the incremental cost-effectiveness of eight drug treatment scenarios for established schizophrenia.

Method: Using a standardized methodology, costs and outcomes are modelled over the lifetime of prevalent cases of schizophrenia in Australia in 2000. A two-stage approach to assessment of health benefit is used. The first stage involves a quantitative analysis based on disability-adjusted life years (DALYs) averted, using best available evidence. The robustness of results is tested using probabilistic uncertainty analysis. The second stage involves application of 'second filter' criteria (equity, strength of evidence, feasibility and acceptability) to allow broader concepts of benefit to be considered.

Results: Replacing oral typicals with risperidone or olanzapine has an incremental costeffectiveness ratio (ICER) of A$48 000 and A$92 000/DALY respectively. Switching from low-dose typicals to risperidone has an ICER of A$80 000. Giving risperidone to people experiencing side-effects on typicals is more cost-effective at A$20 000. Giving clozapine to people taking typicals, with the worst course of the disorder and either little or clear deterioration, is cost-effective at A$42 000 or A$23 000/DALY respectively. The least costeffective intervention is to replace risperidone with olanzapine at A$160 000/DALY.

Conclusions: Based on an A$50 000/DALY threshold, low-dose typical neuroleptics are indicated as the treatment of choice for established schizophrenia, with risperidone being reserved for those experiencing moderate to severe side-effects on typicals. The more expensive olanzapine should only be prescribed when risperidone is not clinically indicated. The high cost of risperidone and olanzapine relative to modest health gains underlie this conclusion. Earlier introduction of clozapine however, would be cost-effective. This work is limited by weaknesses in trials (lack of long-term efficacy data, quality of life and consumer satisfaction evidence) and the translation of effect size into a DALY change. Some stakeholders, including SANE Australia, argue the modest health gains reported in the literature do not adequately reflect perceptions by patients, clinicians and carers, of improved quality of life with these atypicals.

Reviewing the learning organisation model in a child and adolescent mental health service

From 1995 onwards, a child and adolescent mental health service (CAMHS) applied Senge's learning organisation model. This review compared service performance with that of peer services 5 years later and explored whether any differences were associated with the application of this model. The comparison methodology used quantitative analysis of external data from the Department of Human Services, together with qualitative analysis of material including interviews with CAMHS directors and service managers. Results showed high evaluation activity and high quality, efficiency and efficacy of care compared with other services. Several restraints to the optimal application of the model were identified, including inadequate training of new managers, service overload, major external organisational change and limited investment in information systems. Other outcomes are discussed.

EBanking adaptation and dot.com viability : a comparison of Australian and Indian experiences in the banking sector

With the advent of widely-accepted eBusiness activities, many banks have floated dot.com entities to create a presence on the Internet and take advantage of its power and reach. Like many other businesses, banks expected an increase in market capitalisation as a result of their dot.com floats, perceived broadly as a measure of growing profitability. Despite the negative publicity that the recent spate of dot.com crashes has generated, banks seem to continue floating online spin-offs. Our exploratory study investigates this phenomenon, studying the drivers for change in the evolution of the banking sector, and the move towards electronic banking. We focussed on two economies – Australia and India – to aggregate the major factors in this evolution from the perspective of two disparate economies.

The paper describes our qualitative, document-based investigation of the Australian and Indian banking sectors, and subsequent quantitative analysis of the impact of dot.com floats on market capitalisation within this market sector. We then describe the effect of applying both Transaction Cost Economics to our findings, which indicates that the cost of transacting business has been reduced overall by the creation of dot.com entities; and “catch-up, fall-behind, forge ahead” theory to gain an economic perspective. The paper provides both practical assistance for banks in making decisions regarding e-portfolios, as well as for policy makers in the economies reviewed; and has the potential to contribute to academic research into eBanking more generally.

Predicting spatio-temporal distribution for eastern Australian birds using birds Australia's atlas data : survey method, habitat and seasonal effects

Faunal atlases are landscape-level survey collections that can be used for describing spatial and temporal patterns of distribution and densities. They can also serve as a basis for quantitative analysis of factors that may influence the distributions of species. We used a subset of Birds Australia’s Atlas of Australian Birds data (January 1998 to December 2002) to examine the spatio-temporal distribution patterns of 280 selected species in eastern Australia (17–37°S and 136–152°E). Using geographical information systems, this dataset was converted into point coverage and overlaid with a vegetation polygon layer and a half-degree grid. The exploratory data analysis involved calculating species-specific reporting rates spatially, per grid and per vegetation unit, and also temporally, by month and year. We found high spatio-temporal variability in the sampling effort. Using generalised linear models on unaggregated point data, the influences of four factors – survey method and month, geographical location and habitat type – were analysed for each species. When counts of point data were attributed to grid-cells, the total number of species correlated with the total number of surveys, while the number of records per species was highly variable. Surveys had high interannual location fidelity. The predictive values of each of the four factors were species-dependent. Location and habitat were correlated and highly predictive for species with restricted distribution and strong habitat preference. Month was only of importance for migratory species. The proportion of incidental sightings was important for extremely common or extremely rare species. In conclusion, behaviour of species differed sufficiently to require building a customized model for each species to predict distribution. Simple models were effective for habitat specialists with restricted ranges, but for generalists with wide distributions even complex models gave poor predictions.

Reservation of important wetlands - recent experiences in conservation planning and practical implementation in Victoria

The establishment of a comprehensive, adequate and representative (CAR) reserve system is not only an objective of all States and Territories but it is an international commitment, since Australia signed the Convention on Biological Diversity. Various reviews note that Australia lacks a representative freshwater reserve system. However, there has been surprisingly little quantitative analysis on the reservation of freshwater ecosystems from which to identify the gaps or deficiencies in the reserve system.

We compared aspects of reservation in wetlands in northern Victoria before and after a major public land use investigation by the government-appointed Victorian Environmental Assessment Council, which sought specifically to recommend a CAR reserve system. Significant improvements in the reservation status for depleted and under-reserved wetland ecosystems, and improved reserve design have been recommended by the investigation. Increases in the reservation of nationally and internationally significant wetlands were also recommended. These recommendations are now under consideration by the Victorian Government.

Some of the challenges in decision-making during this investigation and their implications on wetland conservation are highlighted. The paper concludes by outlining broader policy dilemmas, decisions and debates that that require addressing in relation to developing a system of Freshwater Protected Areas in Australia.

Conducting event studies with Asia-Pacific security market data

We investigate the effectiveness of several well-known parametric and non-parametric event study test statistics with security price data from the major Asia-Pacific security markets. Extensive Monte Carlo simulation experiments with actual daily security returns data reveal that the parametric test statistics are prone to misspecification with Asia-Pacific returns data. Two non-parametric tests, a rank test [Corrado and Zivney (Corrado, C.J., Zivney, T.L., 1992, The specification and power of the sign test in event study hypothesis tests using daily stock returns, Journal of Financial and Quantitative Analysis 27(3), 465-478)] and a sign test [Cowan (Cowan, A.R., 1992, Non-parametric event study tests, Review of Quantitative Finance and Accounting 1(4), 343–358)] were the best performers overall with market model excess returns computed using an equal weight index.

The development of corporate real estate practices in India : a survey of CRE professionals

Business process outsourcing (BPO) is transforming Western companies? corporate real estate (CRE) requirements. When business processes move to a developing country there are consequences for that country?s CRE practice. This paper considers the effects of western BPO on Indian CRE. Qualitative and quantitative analysis was used to analyze data from a survey of professionals operating in Indian CRE. Location issues, quality of workspace, and the availability of human resources were identified as important in establishing BPO activities in India. Suburban, and campus or built-to-suit facilities, were increasingly preferred locations and styles of workplace that were transforming Indian CRE practice. Also, the effect of western BPO was impacting on the types of CRE services being offered. With the continuing growth in BPO to ?secondary cities? the transformational effects on local CRE practice are likely to spread and further transform CRE practice in India.

New educational service products : tertiary EC/EB education - the Asia-Pacific region

Electronic Commerce (EC) / Electronic Business (EB) has been (and is expected to continue to be) a dynamic, rapidly evolving area of technology, requiring skilled people with up-to-date knowledge and skills. The global community has required (and still requires) tertiary academic programs to prepare and train these people quickly. In the late nineties, following a tidal wave of tertiary EC program development in the United States, new tertiary programs began to appear in the Asia-Pacific (AP) region to satisfy this need, over a very short period of time. This research project aims to examine whether the development and effectiveness of tertiary EC/EB educational programs can be enhanced through employing a particular marketing paradigm. Four regions - Australia, New Zealand, Hong Kong SAR and the Republic of Singapore — were selected from the AP region, for this study. Based on a review of marketing literature, an inductive approach is adopted to build a model for new educational service product offerings. I also provide a description and comprehensive analysis of EC/EB education, and explore the model empirically, examining how it applies to the way EC education programs have been developed, to date. Essentially, this project consists of two major activities: theory building and theory testing – and is divided into three parts. Part 1: Preliminary study – literature review for theory building. This section of the thesis provides a literature review of the domains of curriculum development, EC/EB program development and management, EC/EB component models and new service product development. Part 2 : Understanding the marketplace – quantitative analysis. This section comprises five major surveys which provide an understanding of EC/EB education. Part 3 : In-depth analysis – qualitative research for theory testing. This section discusses the results of the multiple case studies of EC/EB degree programs undertaken over a five year period. The results of this project highlight both theoretical and practical aspects of the topic. In terms of the theoretical aspect, I provide a contribution to existing theory concerning the planning and development of new tertiary education programs. Research into academic course development in the past has tended to assume that all program development is pedagogically based and influenced. There is an assumption that people only develop academic programs and academic courses for pedagogic reasons. What this research project has done is to suggest that there are, in fact, many possible reasons for developing new programs and that, although these reasons might be pedagogic in nature, they can also be industry-focased, and market-oriented in the following ways: -the university is shaping the way it is perceived by the public – that is, the market; -the university is highlighting where its expertise lies. This led me to a form of new service product development consistent with the new image of the university. There is a clear need for diverse models for program development which accommodate the dynamic roles of modern universities. My research project develops such a model based on conditions in the Asia-Pacific region, and discusses findings arising from the overall project, which can be used to improve new educational program offerings in future, in both the Asia-Pacific and, I suggest, in other regions. This potential use of my findings highlights the practical contribution made by the research Project.

Understanding educational process in leadership development

This thesis is a case study of educational process in the leadership development program of the Australian Defence Force Academy. The intention is to determine the relative emphasis in educational process on the conventional command and managerial compliance (Type A) style and the emergent contingent and creative (Type B) style of leadership. The Type A style is theorised as emphasizing hierarchy and control, whereas the emphasis in a Type B style is on adaptive and entrepreneurial behaviour. This study looks at the learning process in a cultural and structural context rather than focus on curriculum and instructional design. Research in this wider context is intended to enable development processes to successfully bridge a gap between theory and practice, implicit in studies that identify theories 'in-operation' as different from the theories 'espoused' (Argyris 1992, Savage 1996). In terms of espoused and in-use theory, the study seeks to produce a valid and reliable result to the question: what is the relative emphasis on the two leadership styles in the operation of the three educational mechanisms of curriculum, pedagogy (teaching practice) and assessment? The quantitative analysis of results (n = 114) draws attention to both leadership styles in terms of two and three-way relationships of style, cadet or work group and service type. The data shows that both Type A and Type B leadership styles are evident in the general conversation of the organisation. This trend is present as espoused theory in the curriculum of the Defence Academy. However, the data also confirm a clear and strong emphasis towards command and managerial compliance as theory-in-use, particularly by cadets. This emphasis is noticeably evident in the teaching and assessment practice of the Defence Academy. Other research outcomes include the observation that: Contextually, while studies show it is difficult to isolate skills from their cultural and biographical context (Watkins, 1991:15), this study suggests that it is equally difficult to isolate skills development from this context. There is a strong task or instrumental link identified by cadet responses in terms of content and development process at the Defence Academy, in contrast to the wider developmental emphasis in general literature and senior officer interviews. There is a lack of awareness of teaching strategies and development activity consistent with espoused Type B leadership theory and curriculum content. This gap is compounded by the use in the Defence Academy of personnel without teaching expertise or suitable developmental experience. The socialisation of cadets into the military workplace is the primary purpose of training. This purpose appears taken for granted by all concerned - staff, cadets and senior officers. Defence Academy development processes appear to be faced with a dilemma. Arguably, training and learning from experience are limited approaches to development. Training, which involves learning by replication, and learning from experience, which is largely imitative, are both of little use when people are faced with novel and ambiguous situations. This study suggests that in order to support the development of capabilities that go beyond training based competence a learning and development approach is needed. This more expansive approach requires educational planners to consider the cultural and social context that can inadvertently promote the status quo in practice over espoused outcomes.

When the whole 'bloke' thing starts to crumble : men's access to chronic illness (arthritis) self management programs

This thesis explores the issue of men's access to chronic illness self management programs from a social constructionist perspective. A combination of research methodologies was used; a quantitative analysis to confirm gender differences in levels and patterns of service use; a qualitative analysis to gain an increased understanding of the factors affecting men's access; and a trial to test the application of the research findings. The clients and services of Arthritis Victoria were chosen as the setting for this research. The quantitative analyses were conducted on contingency tables and odds ratios and confirmed that men were under-represented as service users. The analyses also identified gender differences in patterns of service use. The qualitative analysis was based on a series of in-depth, semi-structured interviews. It was undertaken from a grounded theory approach to allow for the development of theoretical explanations grounded in the data. It was found that men's decisions to access chronic illness self management programs were strongly influenced by dominant social constructions of masculinity which constrained help-seeking and health management behaviour. However, the restrictive influence of hegemonic masculinity was progressively undermined by the increasing severity of the chronic condition until a crisis point was reached in terms of the severity of the condition or its impact on lifestyle. This resulted in a reformulation or rejection of hegemonic masculinity. The described conceptual framework was consistent for men from diverse social groupings, although it appeared less prominent in both younger and older men, suggesting that dominant social constructions of masculinity have the greatest influence on health decisions during the middle stage of adulthood when work and family obligations are greatest. The thesis findings informed the development of some guiding principles for reviewing the structure and delivery of chronic illness self management services for men. The guiding principles will have direct application in the planning of Arthritis Victoria programs, and implications for other chronic illness self management programs in Australia, and also in Western countries with a similar health and sociocultural setting to Australia.

Steroidogenesis in cultured mammalian glial cells

A protocol for culturing mammalian type 1 astrocytic cells, using female post-natal rat cerebral cortical tissue, was established and refined for use in steroidogenic metabolic studies incorporating progestin radioisotopes. Cultures were characterised for homogeneity using standard morphological and immunostaining techniques. Qualitative and quantitative studies were conducted to characterise the progesterone (P) metabolic pathways present in astrocytes in vitro. Of particular interest was the formation of the P metabolite, 5á-pregnan-3á-ol-20-one (THP). THP is a GABA(A) receptor agonist, believed to play a vital role in neural functioning and CNS homeostasis. One aim of this study was to observe any modulatory effects selected neuroactive ligands have on the conversion of P into THP, in an attempt to link astrocytic steroidogenesis with neuronal control. In qualitative studies, chromatographic procedures were used to establish the progestin profile of cerebral cortical astrocytes. Tritiated P, DHP (5á-pregnan-3,20-dione) and THP incurbates were preliminary fractionated by either normal phase (NP) or reverse phase (RP) high performance liquid chromatography (HPLC). The radiometabolites associated with each fraction were further chromatographed, before and/or after chemical derivatistation, by the aforemention HPLC procedures and thin layer chromatography (TLC). Steroid radiometabolites were tentatively identified by comparing their chromatographic mobility with authentic steroids. The identity of the main putative 5á-reduced P metabolities, DHP, THP and 5á-pregnan-3á,20á-diol (20áOH-THP) were further confirmed by isotopic dilution analysis. Their conclusive identification, along with the tentative identification of 20á-hydroxypreg-4-en-3-one (20áOH-P) and 20á-hydroxy-5á-pregnan-3-one (20áOH-DHP), verify the localisation of 5á-reductase, 3á-hydroxy steroif oxidoreductase (HSOR), and 20á-HSOR activity in the cultured astrocytes utilised in this study programme. Other minor metabolites detected were tentatively identified, including 5á-pregnan-3á,21-diol-20-one (THDoc), indicating the presence of 21-hydroxylase enzymatic activity. THDoc, like THP, is a GABA(A) receptor agonist. The chemical and physical characterisation of several yet unidentified progestin metabolites, associated with a highly polar RP HPLC fraction (designated RP peak 1*), indicate the presence of one or more extra hydroxylase enzymes. Quantitative analysis included a preliminary study. In this study, the percentage yields of radiometabolites formed in cultures incubated with increasing substrate concentrations of (3)H-P for 24 hours were determined. At the lower concentrations examined (ie 0.5 to 50nM), the metabolites associated with the polar RP HPLC fraction (RP peak 1*) collectively have the highest percentage yield. They are subsequently considered metabolic end products of degradative catabolic P pathways. The percentage yield of THP peaks in the medium concentration ranges (ie 5 to 500nM), whereas DHP remains fairly static at a low level with increasing concentration. Both DHP and THP are considered metabolic pathway intermediates. The percentage yield of 20áOH-THP continues to increase with increasing concentration over 5nM, superseding THP approaching the highest concentration examined (5000nM). This indicated the formation of 20áOH-THP does not occur entirely via THP. 20áOH-THP also possibly serves as the direct intermediate in the formation of the main radiometabolites associated with RP peak 1*. A time/yield study incorporating incubation times from one to 24 hours was also conducted. The full array of radiometabolites (individually or in groups) formed in astrocyte cultures incubated with 50nM tritiated P, DHP of THP, were assayed. Cultures were observed to rapidly convert any DHP into THP, showing astrocytic 3á-HSOR activity is very high. The study also showed 5á-reduction (ie the conversation of P into DHP) is the rate limiting reaction in the two step conversion of P into THP. 5á-Reduction also appears to be a rate limiting step in the formation of 20á-hydroxylated metabolites in astrocytes. Cultures incubated with the tritiated 5á-reduced pregnanes from one to four hours form greater quantities to 20á-hydroxylated radiometabolites compared to cultures incubated with (3)H-P. The time yield/studies also provided further evidence the unidentified polar radiometabolites associated with RP peak 1* are metabolic end products. For the P and DHP incubates, the collective formation of the aforementioned polar radiometabolites initially lags behind the formation of THP. As the formation of the latter begins to plateau with increasing time between four to 24 hours, the net yield of radiometabolites associated with RP peak 1* continues to rise. The time/yield studies also indicate 5á-reduction and perhaps 3á-hydroxylation are pre-requisite steps in the formation of the polar metabolites. Cultures incubated with the 5á-reduced progestins from one to four hours form higher yields of the radiometabolites associated with RP peak 1* compared to cultures incubated with P as substrate. The net yields of the radiometabolites associated with RP peak 1* for cultures incubated with THP were substantially higher compared to cultures incubated with DHP after equivalent times. The effect selected neuroligands have on the yield of radiometabolites formed by cultured astrocytes incubated with 50nM (3)H-P was also examined. Dibutyryl cyclic adenosine monophosphate (DBcAMP), not actually a neuroligand per se, but an analog of the intracellular secondary messenger cAMP, was also utilised in these studies. The inhibitory neurotransmitter ă-amino-nbutyric acid (GABA), DBcAMP and isoproterenol (a â-adrenergic receptor agonist) all quickly induce a transient but substantial increase in 20á-HSOR activity in cultured astrocytes. Cultures pretreated with these three compounds (10, 20 and 1µM respectively) form substantially higher yields of 20á-hydroxylated metabolites, including 20áOH-THP (between 200 to 580% greater), when incubated with 50nM (3)H-P for one to four hours. These increases also coincide with increases in the net yield of metabolites formed (by 16 to 48%). The same pre-treated cultures form significantly lower yields of THP, by 25 to 41%, after one hour. This is most likely due to the increased metabolism of any formed THP into 20áOH-THP. Octopamine (an á-adrenergic agonist) only induces a slight increase in 20á-HSOR activity, having relatively little effect on the yield of 20áOH-THP formed. Pretreatment with octopamine induces a significant increase in the yield of THP for cultures incubated with (3)H-P for four hours (by 24%). The increase in THP formation appears to be due to an increase in 3á-HSOR activity, as judged by the concomitant drop in the yield of the 5á-reduced, 3-keto substrates. An increase in 5á-reductase activity cannot be excluded however. Isoproterenol appears to induce an increase in 5á-reductase activity as isoproterenol appears to induce an increase in 5á-reductase activity as isoproterenol one and four hour incubates have higher yields of DHP. This is in contrast to the other three incubates. After 12 hours, all incubates have higher yields of THP (15-30%).

Controls on body size during the Late Permian mass extinction event

This study examines the morphological responses of Late Permian brachiopods to environmental changes. Quantitative analysis of body size data from Permian–Triassic brachiopods has demonstrated significant, directional changes in body size before, during and after the Late Permian mass extinction event. Brachiopod size significantly reduced before and during the extinction interval, increased for a short time in more extinction-resistant taxa in the latter stages of extinction and then dramatically reduced again across the Permian ⁄ Triassic boundary. Relative abundances of trace elements and acritarchs demonstrate that the body size reductions which happened before, during and after extinction were driven by primary productivity collapse, whereas declining oxygen levels had less effect. An episode of size increase in two of the more extinction-resistant brachiopod species is unrelated to environmental change and possibly was the result of reduced interspecific competition for resources following the extinction of competitors. Based on the results of this study, predictions can be made for the possible responses of modern benthos to present-day environmental changes.

Media discourse and Iraq's democratisation : reporting the 2005 constitution in the Australian and Middle Eastern print media

This paper analyses in detail the coverage of two milestones in Iraq's shift towards democracy: the drafting and approval of the constitution by Iraq s interim government (August 2005) and the ratification of this constitution via the Iraqi polls (October 2005). Aside from some rudimentary quantitative analysis, a critical discourse analysis method is utilised to compare and contrast the discursive practices used in three of Australia s leading daily newspapers (The Australian, The Sydney Morning Herald and The Age) with three Middle Eastern English-language papers (The Daily Star, Anadolu Agency and the Jordan Times). The paper finds that the Australian print media continues the neo-Orientalist tradition of media coverage of Middle Eastern democracy, while the Middle Eastern press eschews these discourses in favour of a more open, varied debate on Iraq s constitution and the future of democracy across the region.

Modelling relational aspects of critical infrastructure systems

The relational aspects for critical infrastructure systems are not readily quantifiable as there are numerous variability’s and system dynamics that lack uniformity and are difficult to quantify. Notwithstanding this, there is a large body of existing research that is founded in the area of quantitative analysis of critical infrastructure networks, their system relationships and the resilience of these networks. However, the focus of this research is to investigate the aspect of taking a different, more generalised and holistic system perspective approach. This is to suggest that that through applying network theory and taking a ‘soft’ system-like modelling approach that this offers an alternative approach to viewing and modelling critical infrastructure system relational aspects that warrants further enquiry.