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.

From cultural to creative industries : theory, industry, and policy implications

Across post-industrial societies worldwide, the creative industries are increasingly seen as a key economic driver. These industries - including fields as diverse as advertising, art, computer games, crafts, design, fashion, film, museums, music, performing arts, publishing, radio, theatre and TV - are built upon individual creativity and innovation and have the potential to create wealth and employment through the mechanism of intellectual property. Creative Industries: Critical Readings brings together the key writings - drawing on both journals and books - to present an authoritative and wide-ranging survey of this emerging field of study. The set is presented with an introduction and the writings are divided into four volumes, organized thematically: Volume 1: Concepts - focuses on the concept of creativity and the development of government and industry interest in creative industries; Volume 2: Economy - maps the role and function of creative industries in the economy at large; Volume 3: Organization - examines the ways in which creative institutions organize themselves; and Volume 4: Work - addresses issues of creative work, labour and careers This major reference work will be invaluable to scholars in economics, cultural studies, sociology, media studies and organization studies.

The Creative Industries, Culture and Policy

The rise of creative industries requires new thinking in communication, media and cultural studies, media and cultural policy, and the arts and information sectors. The Creative Industries, Culture and Policy sets the agenda for these debates, providing a richer understanding of the dynamics of cultural markets, creative labor, finance and risk, and how culture is distributed, marketed and creatively reused through new media technologies. This book: develops a global perspective on the creative industries and creative economy draws insights from media and cultural studies, innovation economics, cultural policy studies, and economic and cultural geography explores what it means for policy-makers when culture and creativity move from the margins to the center of economic dynamics makes extensive use of case studies in ways that are relevant not only to researchers and policy-makers, but also to the generation of students who will increasingly be establishing a ‘portfolio career’ in the creative industries. International in coverage, The Creative Industries traces the historical and contemporary ideas that make the cultural economy more relevant that it has ever been. It is essential reading for students and academics in media, communication and cultural studies. Table of Contents - Introduction - Origins of Creative Industries Policy - International Models of Creative Industries Policy - From Culture Industries to Cultural Economy - Products, Services, Production and Creative Work - Consumption, Markets, Technology and Cultural Trade - Globalization, Cities and Creative Spaces - Creative Industries and Public Policy - Conclusion

Separating resource rents from intra-marginal rents in fisheries economics survey data

Economic surveys of fisheries are undertaken in several countries as a means of assessing the economic performance of their fisheries. The level of economic profits accruing in the fishery can be estimated from the average economic profits of the boats surveyed. Economic profits consist of two components—resource rent and intra-marginal rent. From a fisheries management perspective, the key indicator of performance is the level of resource rent being generated in the fishery. Consequently, these different components need to be separated out. In this paper, a means of separating out the rent components is identified for a heterogeneous fishery. This is applied to the multi-purpose fleet operating in the English Channel. The paper demonstrates that failing to separate out these two components may result in a misrepresentation of the economic performance of the fishery.

Economic Analysis and Policy moves forward

As Editor of Economic Analysis and Policy (EAP) I am delighted to announce that EAP is now published by Elsevier. EAP is the journal of the Economic Society of Australia (Queensland branch). As a result of this move, four issues of EAP will be published per year instead of the current three. This will include special issues. EAP will now receive wider coverage in the relevant abstracting and indexing services...

Can biophilic urbanism deliver strong economic and social benefits in cities? An economic and policy invetigations into the increased use of natural elements in urban design

Biophilic urbanism, or urban design that reflects humanity’s innate need for nature, stands to make significant contributions to a range of national, state and local government policies related to climate change mitigation and adaptation, by investigating ways in which nature can be integrated into, around and on top of buildings. Potential benefits of such design include reducing the heat island effect, reducing energy consumption for thermal control, enhancing urban biodiversity, improving well being and productivity, improving water cycle management, and assisting in the response to growing needs for densification and revitalisation of cities. This report will give an overview of the concept of biophilia and consider enablers and disablers to its application to urban planning and design. The paper will present findings from stakeholder engagement and a series of detailed case studies, related to a consideration of the economics of the use of biophilic elements (direct and indirect).

Economic analyses and policy implications for microalgae biofuels in Australia

The benefits of microalgae biofuels over first and second generation counterparts suggest it has potential as a major biofuel feedstock in Australia. However, the high costs of cultivation and processing has been a major drawback for investors and policymakers. This presentation outlines the economic potential for microalgae biofuels: firstly, through production of microalgae co-products (e.g feed and fertiliser); and secondly, deriving what consumers are willing to pay for microalgae biofuels based on external benefits. These findings will assist decision-makers in both private and public sectors and inform policy development with respect to microalgae as a feedstock for biofuels and other products. This study adds an economics perspective to the current technical literature which has been dominated by biochemical, engineering and financial valuation studies.

Decomposition of energy-related CO2 emissions in Australia: Challenges and policy implications

Changes in energy-related CO2 emissions aggregate intensity, total CO2 emissions and per-capita CO2 emissions in Australia are decomposed by using a Logarithmic Mean Divisia Index (LMDI) method for the period 1978-2010. Results indicate improvements in energy efficiency played a dominant role in the measured 17% reduction in CO2 emissions aggregate intensity in Australia over the period. Structural changes in the economy, such as changes in the relative importance of the services sector vis-à-vis manufacturing, have also played a major role in achieving this outcome. Results also suggest that, without these mitigating factors, income per capita and population effects could well have produced an increase in total emissions of more than 50% higher than actually occurred over the period. Perhaps most starkly, the results indicate that, without these mitigating factors, the growth in CO2 emissions per capita could have been over 150% higher than actually observed. Notwithstanding this, the study suggests that, for Australia to meet its Copenhagen commitment, the relative average per annum effectiveness of these mitigating factors during 2010-2020 probably needs to be almost three times what it was in the 2005-2010 period-a very daunting challenge indeed for Australia's policymakers.

Exchange relationships in building services maintenance activity : a test of transaction cost economics and the resource dependency view

The firm is faced with a decision concerning the nature of intra-organizational exchange relationships with internal human resources and the nature or inter-organizational exchange relationships with market firms. In both situations, the firm can develop an exchange that ranges from a discrete exchange to a relational exchange. Transaction Cost Economics (TCE) and the Resource Dependency View (RDV) represent alternative efficiency-based explanations fo the nature of the exchange relationship. The aim of the paper is to test these two theories in respect of air conditioning maintenance in retail centres. Multiple sources of information are genereated from case studies of Australian retail centres to test these theories in respoect of internalized operations management (concerning strategic aspects of air conditioning maintenance) and externalized planned routine air conditioning maintenance. The analysis of the data centres on pattern matching. It is concluded that the data supports TCE - on the basis of a development in TCE's contractual schema. Further research is suggested towards taking a pluralistic stance and developing a combined efficiency and power hypothesis - upon which Williamson has speculated. For practice, the conclusions also offer a timely cautionary note concerning the adoption of one approach in all exchange relationships.

Framing Culture : Criticism and Policy in Australia

How is contemporary culture 'framed' - understood, promoted, dissected and defended - in the new approaches being employed in university education today? How do these approaches compare with those seen in the public policy process? What are the implications of these differences for future directions in theory, education, activism and policy? Framing Culture looks at cultural and media studies, which are rapidly growing fields through which students are introduced to contemporary cultural industries such as television, film and video. It compares these approaches with those used to frame public policy and finds a striking lack of correspondence between them. Issues such as Australian content on commercial television and in advertising, new technologies and new media, and violence in the media all highlight the gap between contemporary cultural theories and the way culture and communications are debated in public policy. The reasons for this gap must be investigated before closer relations can be established. Framing Culture brings together cultural studies and policy studies in a lively and innovative way. It suggests avenues for cultural activism that have been neglected in cultural theory and practice, and it will provoke debates which are long overdue.