Setting hospital infection control policy : a decision-making framework incorporating health economics and healthcare epidemiology

Background: Reducing rates of healthcare acquired infection has been identified by the Australian Commission on Safety and Quality in Health Care as a national priority. One of the goals is the prevention of central venous catheter-related bloodstream infection (CR-BSI). At least 3,500 cases of CR-BSI occur annually in Australian hospitals, resulting in unnecessary deaths and costs to the healthcare system between $25.7 and $95.3 million. Two approaches to preventing these infections have been proposed: use of antimicrobial catheters (A-CVCs); or a catheter care and management ‘bundle’. Given finite healthcare budgets, decisions about the optimal infection control policy require consideration of the effectiveness and value for money of each approach. Objectives: The aim of this research is to use a rational economic framework to inform efficient infection control policy relating to the prevention of CR-BSI in the intensive care unit. It addresses three questions relating to decision-making in this area: 1. Is additional investment in activities aimed at preventing CR-BSI an efficient use of healthcare resources? 2. What is the optimal infection control strategy from amongst the two major approaches that have been proposed to prevent CR-BSI? 3. What uncertainty is there in this decision and can a research agenda to improve decision-making in this area be identified? Methods: A decision analytic model-based economic evaluation was undertaken to identify an efficient approach to preventing CR-BSI in Queensland Health intensive care units. A Markov model was developed in conjunction with a panel of clinical experts which described the epidemiology and prognosis of CR-BSI. The model was parameterised using data systematically identified from the published literature and extracted from routine databases. The quality of data used in the model and its validity to clinical experts and sensitivity to modelling assumptions was assessed. Two separate economic evaluations were conducted. The first evaluation compared all commercially available A-CVCs alongside uncoated catheters to identify which was cost-effective for routine use. The uncertainty in this decision was estimated along with the value of collecting further information to inform the decision. The second evaluation compared the use of A-CVCs to a catheter care bundle. We were unable to estimate the cost of the bundle because it is unclear what the full resource requirements are for its implementation, and what the value of these would be in an Australian context. As such we undertook a threshold analysis to identify the cost and effectiveness thresholds at which a hypothetical bundle would dominate the use of A-CVCs under various clinical scenarios. Results: In the first evaluation of A-CVCs, the findings from the baseline analysis, in which uncertainty is not considered, show that the use of any of the four A-CVCs will result in health gains accompanied by cost-savings. The MR catheters dominate the baseline analysis generating 1.64 QALYs and cost-savings of $130,289 per 1.000 catheters. With uncertainty, and based on current information, the MR catheters remain the optimal decision and return the highest average net monetary benefits ($948 per catheter) relative to all other catheter types. This conclusion was robust to all scenarios tested, however, the probability of error in this conclusion is high, 62% in the baseline scenario. Using a value of $40,000 per QALY, the expected value of perfect information associated with this decision is $7.3 million. An analysis of the expected value of perfect information for individual parameters suggests that it may be worthwhile for future research to focus on providing better estimates of the mortality attributable to CR-BSI and the effectiveness of both SPC and CH/SSD (int/ext) catheters. In the second evaluation of the catheter care bundle relative to A-CVCs, the results which do not consider uncertainty indicate that a bundle must achieve a relative risk of CR-BSI of at least 0.45 to be cost-effective relative to MR catheters. If the bundle can reduce rates of infection from 2.5% to effectively zero, it is cost-effective relative to MR catheters if national implementation costs are less than $2.6 million ($56,610 per ICU). If the bundle can achieve a relative risk of 0.34 (comparable to that reported in the literature) it is cost-effective, relative to MR catheters, if costs over an 18 month period are below $613,795 nationally ($13,343 per ICU). Once uncertainty in the decision is considered, the cost threshold for the bundle increases to $2.2 million. Therefore, if each of the 46 Level III ICUs could implement an 18 month catheter care bundle for less than $47,826 each, this approach would be cost effective relative to A-CVCs. However, the uncertainty is substantial and the probability of error in concluding that the bundle is the cost-effective approach at a cost of $2.2 million is 89%. Conclusions: This work highlights that infection control to prevent CR-BSI is an efficient use of healthcare resources in the Australian context. If there is no further investment in infection control, an opportunity cost is incurred, which is the potential for a more efficient healthcare system. Minocycline/rifampicin catheters are the optimal choice of antimicrobial catheter for routine use in Australian Level III ICUs, however, if a catheter care bundle implemented in Australia was as effective as those used in the large studies in the United States it would be preferred over the catheters if it was able to be implemented for less than $47,826 per Level III ICU. Uncertainty is very high in this decision and arises from multiple sources. There are likely greater costs to this uncertainty for A-CVCs, which may carry hidden costs, than there are for a catheter care bundle, which is more likely to provide indirect benefits to clinical practice and patient safety. Research into the mortality attributable to CR-BSI, the effectiveness of SPC and CH/SSD (int/ext) catheters and the cost and effectiveness of a catheter care bundle in Australia should be prioritised to reduce uncertainty in this decision. This thesis provides the economic evidence to inform one area of infection control, but there are many other infection control decisions for which information about the cost-effectiveness of competing interventions does not exist. This work highlights some of the challenges and benefits to generating and using economic evidence for infection control decision-making and provides support for commissioning more research into the cost-effectiveness of infection control.

On measuring the value of information, with implications for communications systems.

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Value of information in product recovery decisions: A Bayesian approach

There is a widespread recognition of the need for better information sharing and provision to improve the viability of end-of-life (EOL) product recovery operations. The emergence of automated data capture and sharing technologies such as RFID, sensors and networked databases has enhanced the ability to make product information; available to recoverers, which will help them make better decisions regarding the choice of recovery option for EOL products. However, these technologies come with a cost attached to it, and hence the question 'what is its value?' is critical. This paper presents a probabilistic approach to model product recovery decisions and extends the concept of Bayes' factor for quantifying the impact of product information on the effectiveness of these decisions. Further, we provide a quantitative examination of the factors that influence the value of product information, this value depends on three factors: (i) penalties for Type I and Type II errors of judgement regarding product quality; (ii) prevalent uncertainty regarding product quality and (iii) the strength of the information to support/contradict the belief. Furthermore, we show that information is not valuable under all circumstances and derive conditions for achieving a positive value of information. © 2010 Taylor & Francis.

The value of information in an agency model with moral hazard

I show that the principal and the agent may each prefer that the principal or the agent has imperfect information about the principal's technology in a principal-agent environment with moral hazard. Principals expend considerable resources on data cumulation and analysis. However, such investments in information acquisition are benecial only if the agent will know that the principal is not ignorant or it allows the principal to implement a dierent action. When the principal is perfectly informed about her technology, the agent prefers to be ignorant. In addition, the value of perfect information for the agency is negative if the principal would implement the same action with either possible technology. I also investigate the dierences between ex ante and ex post contracting, and the ramications of the principal being ignorant or potentially ignorant about the technology. Finally, I determine if the principal's utility varies continuously with the degree of informativeness of the agent about the principal's technology. In this vein, I determine whether the agent's uncertainty may make the principal better o if she has the less informative technology.

A note on the property rights theory and the ex ante value of information

This paper examines the ex ante value of information in the property rights model where the possibility exists that an investing agent can be provided with relevant information before investments are undertaken. When contracts are incomplete, from an ex ante perspective, informing the investing agent does not necessarily increase the expected surplus resulting from a relationship between two economic agents. The paper highlights the fact that the second-best nature of the problem that arises from contractual incompleteness can ensure this.

Identity, incentives and the value of information

We examine the impact of identity preferences on the interrelation between incentives and performance measurement. In our model, a manager identifies with an organization and loses utility to the extent that his actions conflict with effort-standards issued by the principal. Contrary to prior arguments in the literature, we find conditions under which a manager who identifies strongly with the organization receives stronger incentives and faces more performance evaluation reports than a manager who does not identify with the organization. Our theory predicts that managers who experience events that boost their identification with the firm can decrease their effort in short-term value creation. We also find that firms are more likely to employ less precise but more congruent performance measures, such as stock prices, when contracting with managers who identify little with the organization. In contrast, they use more precise but less congruent measures, such as accounting earnings, when contracting with managers who identify strongly with the firm.

An interpretive approach to analysing the role and value of information systems in Jordanian financial organisations

Analysing investments in ISs in order to maximise benefits has become a prime concern, especially for private corporations. No formula of equilibrium exists that could link the injected amounts and accrued returns. The relationship is simply not straightforward. This thesis is based upon empirical work which involved sketching organisational ethnographies (four organographies and a sectography) into the role and value of information systems in Jordanian financial organisations. Besides deciphering the map of impacts, it explains the attributions of the variations in the impacts of ISs which were found to be related to the internal organisational processes: culturally and politically specific considerations, economically or technically rooted factors and environmental factors. The research serves as an empirical attempt to test out the applicability of adopting the interpretive paradigm to researching organisations in a developing country. The fieldwork comprised an exploratory stage, a detailed investigation of four case studies and a survey stage encompassing 16 organisations. Primary and secondary data were collected from multiple sources using a range of instruments. The evidence highlights the fact that little long term strategic planning was pursued; the emphasis was more focused on short term planning. There was no noticeable adoption of any strategic fit principle linking IS strategy to the corporate strategy. In addition, the benefits obtained were mostly intangible. Although ISs were central to the work of the organisations surveyed as the core technology, they were considered as tools or work enablers rather than weapons for competitive rivalry. The cultural specificity of IS impacts was evident and the cultural and political considerations were key factors in explaining the attributions of the variations in the impacts of ISs in JFOs. The thesis confirms that measuring the benefits of ISs is the problematic. However, in order to gain more insight, the phenomenon of "the use of ISs" has to be studied within its context.

Determinants and Consequences of Information Sharing with Key Suppliers

As companies become more efficient with respect to their internal processes, they begin to shift the focus beyond their corporate boundaries. Thus, the recent years have witnessed an increased interest by practitioners and researchers in interorganizational collaboration, which promises better firm performance through more effective supply chain management. It is no coincidence that this interest comes in parallel with the recent advancements in Information and Communication Technologies, which offer many new collaboration possibilities for companies. However, collaboration, or any other type of supply chain integration effort, relies heavily on information sharing. Hence, this study focuses on information sharing, in particular on the factors that determine it and on its value. The empirical evidence from Finnish and Swedish companies suggests that uncertainty (both demand and environmental) and dependency in terms of switching costs and asset specific investments are significant determinants of information sharing. Results also indicate that information sharing improves company performance regarding resource usage, output, and flexibility. However, companies share information more intensely at the operational rather than the strategic level. The use of supply chain practices and technologies is substantial but varies across the two countries. This study sheds light on a common trend in supply chains today. Whereas the results confirm the value of information sharing, the contingent factors help to explain why the intensity of information shared across companies differ. In the future, competitive pressures and uncertainty are likely to intensify. Therefore, companies may want to continue with their integration efforts by focusing on the determinants discussed in this study. However, at the same time, the possibility of opportunistic behavior by the exchange partner cannot be disregarded.

Towards measuring the impact of information availability on maintenance decisions

Decisions concerning maintenance have become increasingly important and requires a diverse set of information as systems become more complex. The availability of information has an impact on the effectiveness of these decisions, and thus on the performance of the asset. This paper highlights the importance of quantifying the value of information on maintenance decisions and asset performance. In particular, we emphasise the need to focus on measuring value as opposed to cost of maintenance, which is the current practice. In this direction, we propose a measure - Value of Ownership (VOO) - to assess the value of information and performance of maintenance decisions throughout an assets lifecycle. © 2009 IFAC.

Modeling the Aesthetic Axis of Information Organization Frameworks, Part 1: Theoretical Basis

Purpose – The purpose of this paper is to propose a theoretical framework, based on contemporary philosophical aesthetics, from which principled assessments of the aesthetic value of information organization frameworks may be conducted.Design/methodology/approach – This paper identifies appropriate discourses within the field of philosophical aesthetics, constructs from them a framework for assessing aesthetic properties of information organization frameworks. This framework is then applied in two case studies examining the Library of Congress Subject Headings (LCSH), and Sexual Nomenclature: A Thesaurus. Findings – In both information organization frameworks studied, the aesthetic analysis was useful in identifying judgments of the frameworks as aesthetic judgments, in promoting discovery of further areas of aesthetic judgments, and in prompting reflection on the nature of these aesthetic judgments. Research limitations/implications – This study provides proof-of-concept for the aesthetic evaluation of information organization frameworks. Areas of future research are identified as the role of cultural relativism in such aesthetic evaluation and identification of appropriate aesthetic properties of information organization frameworks.Practical implications – By identifying a subset of judgments of information organization frameworks as aesthetic judgments, aesthetic evaluation of such frameworks can be made explicit and principled. Aesthetic judgments can be separated from questions of economic feasibility, functional requirements, and user-orientation. Design and maintenance of information organization frameworks can be based on these principles.Originality/value – This study introduces a new evaluative axis for information organization frameworks based on philosophical aesthetics. By improving the evaluation of such novel frameworks, design and maintenance can be guided by these principles.Keywords Evaluation, Research methods, Analysis, Bibliographic systems, Indexes, Retrieval languages

Modeling the Aesthetic Axis of Information Organization Frameworks, Part 2: Case Studies

Purpose – The purpose of this paper is to propose a theoretical framework, based on contemporary philosophical aesthetics, from which principled assessments of the aesthetic value of information organization frameworks may be conducted.Design/methodology/approach – This paper identifies appropriate discourses within the field of philosophical aesthetics, constructs from them a framework for assessing aesthetic properties of information organization frameworks. This framework is then applied in two case studies examining the Library of Congress Subject Headings (LCSH), and Sexual Nomenclature: A Thesaurus. Findings – In both information organization frameworks studied, the aesthetic analysis was useful in identifying judgments of the frameworks as aesthetic judgments, in promoting discovery of further areas of aesthetic judgments, and in prompting reflection on the nature of these aesthetic judgments. Research limitations/implications – This study provides proof-of-concept for the aesthetic evaluation of information organization frameworks. Areas of future research are identified as the role of cultural relativism in such aesthetic evaluation and identification of appropriate aesthetic properties of information organization frameworks.Practical implications – By identifying a subset of judgments of information organization frameworks as aesthetic judgments, aesthetic evaluation of such frameworks can be made explicit and principled. Aesthetic judgments can be separated from questions of economic feasibility, functional requirements, and user-orientation. Design and maintenance of information organization frameworks can be based on these principles.Originality/value – This study introduces a new evaluative axis for information organization frameworks based on philosophical aesthetics. By improving the evaluation of such novel frameworks, design and maintenance can be guided by these principles.Keywords Evaluation, Analysis, Bibliographic systems, Indexes, Retrieval languages, Philosophy

Information gathering and decision making about resource value in animal contests

Contestants are predicted to adjust the cost of a fight in line with the perceived value of the resource and this provides a way of determining whether the resource has been assessed. An assessment of resource value is predicted to alter an animal's motivational state and we note different methods of measuring that state. We provide a categorical framework in which the degree of resource assessment may be evaluated and also note limitations of various approaches. We place studies in six categories: (1) cases of no assessment, (2) cases of internal state such as hunger influencing apparent value, (3) cases of the contestants differing in assessment ability, (4) cases of mutual and equal assessment of value, (5) cases where opponents differ in resource value and (6) cases of particularly complex assessment abilities that involve a comparison of the value of two resources. We examine the extent to which these studies support game theory predictions and suggest future areas of research. (C) 2008 The Association for the Study of Animal Behaviour. Published by Elsevier Ltd. All rights reserved.

Decision making in patients with acute abdominal pain at a university and at a rural hospital: Does the value of abdominal sonography differ?

Introduction and objectives Abdominal sonography is regarded as a quick and effective diagnostic tool for acute abdominal pain in emergency medicine. However, final diagnosis is usually based on a combination of various clinical examinations and radiography. The role of sonography in the decision making process at a hospital with advanced imaging capabilities versus a hospital with limited imaging capabilities but more experienced clinicians is unclear. The aim of this pilot study was to assess the relative importance of sonography and its influence on the clinical management of acute abdominal pain, at two Swiss hospitals, a university hospital (UH) and a rural hospital (RH). Methods 161 patients were prospectively examined clinically. Blood tests and sonography were performed in all patients. Patients younger than 18 years and patients with trauma were excluded. In both hospitals, the diagnosis before and after ultrasonography was registered in a protocol. Certainty of the diagnosis was expressed on a scale from 0% to 100%. The decision processes used to manage patients before and after they underwent sonography were compared. The diagnosis at discharge was compared to the diagnosis 2 – 6 weeks thereafter. Results Sensitivity, specificity and accuracy of sonography were high: 94%, 88% and 91%, respectively. At the UH, management after sonography changed in only 14% of cases, compared to 27% at the RH. Additional tests were more frequently added at the UH (30%) than at the RH (18%), but had no influence on the decision making process-whether to operate or not. At the UH, the diagnosis was missed in one (1%) patient, but in three (5%) patients at the RH. No significant difference was found between the two hospitals in frequency of management changes due to sonography or in the correctness of the diagnosis. Conclusion Knowing that sonography has high sensitivity, specificity and accuracy in the diagnosis of acute abdominal pain, one would assume it would be an important diagnostic tool, particularly at the RH, where tests/imaging studies are rare. However, our pilot study indicates that sonography provides important diagnostic information in only a minority of patients with acute abdominal pain. Sonography was more important at the rural hospital than at the university hospital. Further costly examinations are generally ordered for verification, but these additional tests change the final treatment plan in very few patients.