Evaluation of the cost-effectiveness of strategies claiming to reduce the risk of surgical site infections following primary total hip arthroplasty

Background Total hip arthroplasty (THA) is a commonly performed procedure and numbers are increasing with ageing populations. One of the most serious complications in THA are surgical site infections (SSIs), caused by pathogens entering the wound during the procedure. SSIs are associated with a substantial burden for health services, increased mortality and reduced functional outcomes in patients. Numerous approaches to preventing these infections exist but there is no gold standard in practice and the cost-effectiveness of alternate strategies is largely unknown. Objectives The aim of this project was to evaluate the cost-effectiveness of strategies claiming to reduce deep surgical site infections following total hip arthroplasty in Australia. The objectives were: 1. Identification of competing strategies or combinations of strategies that are clinically relevant to the control of SSI related to hip arthroplasty 2. Evidence synthesis and pooling of results to assess the volume and quality of evidence claiming to reduce the risk of SSI following total hip arthroplasty 3. Construction of an economic decision model incorporating cost and health outcomes for each of the identified strategies 4. Quantification of the effect of uncertainty in the model 5. Assessment of the value of perfect information among model parameters to inform future data collection Methods The literature relating to SSI in THA was reviewed, in particular to establish definitions of these concepts, understand mechanisms of aetiology and microbiology, risk factors, diagnosis and consequences as well as to give an overview of existing infection prevention measures. Published economic evaluations on this topic were also reviewed and limitations for Australian decision-makers identified. A Markov state-transition model was developed for the Australian context and subsequently validated by clinicians. The model was designed to capture key events related to deep SSI occurring within the first 12 months following primary THA. Relevant infection prevention measures were selected by reviewing clinical guideline recommendations combined with expert elicitation. Strategies selected for evaluation were the routine use of pre-operative antibiotic prophylaxis (AP) versus no use of antibiotic prophylaxis (No AP) or in combination with antibiotic-impregnated cement (AP & ABC) or laminar air operating rooms (AP & LOR). The best available evidence for clinical effect size and utility parameters was harvested from the medical literature using reproducible methods. Queensland hospital data were extracted to inform patients’ transitions between model health states and related costs captured in assigned treatment codes. Costs related to infection prevention were derived from reliable hospital records and expert opinion. Uncertainty of model input parameters was explored in probabilistic sensitivity analyses and scenario analyses and the value of perfect information was estimated. Results The cost-effectiveness analysis was performed from a health services perspective using a hypothetical cohort of 30,000 THA patients aged 65 years. The baseline rate of deep SSI was 0.96% within one year of a primary THA. The routine use of antibiotic prophylaxis (AP) was highly cost-effective and resulted in cost savings of over $1.6m whilst generating an extra 163 QALYs (without consideration of uncertainty). Deterministic and probabilistic analysis (considering uncertainty) identified antibiotic prophylaxis combined with antibiotic-impregnated cement (AP & ABC) to be the most cost-effective strategy. Using AP & ABC generated the highest net monetary benefit (NMB) and an incremental $3.1m NMB compared to only using antibiotic prophylaxis. There was a very low error probability that this strategy might not have the largest NMB (<5%). Not using antibiotic prophylaxis (No AP) or using both antibiotic prophylaxis combined with laminar air operating rooms (AP & LOR) resulted in worse health outcomes and higher costs. Sensitivity analyses showed that the model was sensitive to the initial cohort starting age and the additional costs of ABC but the best strategy did not change, even for extreme values. The cost-effectiveness improved for a higher proportion of cemented primary THAs and higher baseline rates of deep SSI. The value of perfect information indicated that no additional research is required to support the model conclusions. Conclusions Preventing deep SSI with antibiotic prophylaxis and antibiotic-impregnated cement has shown to improve health outcomes among hospitalised patients, save lives and enhance resource allocation. By implementing a more beneficial infection control strategy, scarce health care resources can be used more efficiently to the benefit of all members of society. The results of this project provide Australian policy makers with key information about how to efficiently manage risks of infection in THA.

Emergency Health Services (EHS) : demand and service delivery models. [Monograph 2 : Queensland EHS users’ profile]

Emergency health is a critical component of Australia’s health system and one which is increasingly congested from growing demand and blocked access to inpatient beds. The Emergency Health Services Queensland (EHSQ) study aims to identify the factors driving increased demand for emergency health and to evaluate strategies which may safely reduce the future demand growth. This monograph addresses the characteristics of users of emergency health services with an aim to identify those that appear to contribute to demand growth. This study utilises data on patients treated by Emergency Departments (ED) and Queensland Ambulance Service (QAS) across Queensland. ED data was derived from the Emergency Department Information System (EDIS) for the period 2001-02 through to 2010-11. Ambulance data was extracted from the QAS’ Ambulance Information Management System (AIMS) and electronic Ambulance Report Form (eARF) for the period 2001-02 through to 2009-10. Due to discrepancies and comparability issues for ED data, this monograph compares data from the 2003-04 time period with 2010-11 data for 21 of the reporting EDs. Also a snapshot of users for the 2010-11 financial year for 31 reporting EDs is used to describe the characteristics of users and to compare those characteristics with population demographics. For QAS data, the 2002-03 and 2009-10 time periods were selected for detailed analyses to identify trends. • Demand for emergency health care services is increasing, representing both increased population and increased relative utilisation. Per capita demand for ED attention has increased by 2% per annum over the last decade and for ambulance attention by 3.7% per annum. • The growth in ED demand is prominent in more urgent triage categories with actual decline in less urgent patients. An estimated 55% of patients attend hospital EDs outside of normal working hours. There is no evidence that patients presenting out of hours are significantly different to those presenting within working hours; they have similar triage assessments and outcomes. • Patients suffering from injuries and poisoning comprise 28% of the ED workload (an increase of 65% in the study period), whilst declines of 32% in cardiovascular and circulatory conditions, and musculoskeletal problems have been observed. • 25.6% of patients attending EDs are admitted to hospital. 19% of admitted patients and 7% of patients who die in the ED are triage category 4 or 5 on arrival. • The average age of ED patients is 35.6 years. Demand has grown in all age groups and amongst both men and women. Men have higher utilisation rates for ED in all age groups. The only group where the growth rate in women has exceeded men is in the 20-29 age group; this growth is particularly in the injury and poisoning categories. • Considerable attention has been paid publicly to ED performance criteria. It is worth noting that 50% of all patients were treated within 33 minutes of arrival. • Patients from lower socioeconomic areas appear to have higher utilisation rates and the utilisation rate for indigenous people appears to exceed those of European and other backgrounds. The utilisation rates for immigrant people is generally less than that of Australian born however it has not been possible to eliminate the confounding impact of different age and socioeconomic profiles. • Demand for ambulance service is also increasing at a rate that exceeds population growth. Utilisation rates have increased by an average of 5% per annum in Queensland compared to 3.6% nationally, and the utilisation rate in Queensland is 27% higher than the national average. • The growth in ambulance utilisation has also been amongst the more urgent categories of dispatch and utilisation rates are higher in rural and regional areas than in the metropolitan area. The demand for ambulance increases with age but the growth in demand for ambulance service has been more prominent in younger age groups. These findings contribute significantly to an understanding of the growth in demand for emergency health. It shows that the growth is amongst patients in genuine need of emergency healthcare and public rhetoric that the congestion of emergency health services is due to inappropriate attendees is unable to be substantiated. The consistency of the growth in demand over the last decade reflects not only the changing demographics of the Australian population but also the changes in health status, standards of acute health care and other social factors. The growth is also amongst patients with acute injury and poisoning which is inconsistent with rates of chronic disease as a fundamental driver. We have also interviewed patients in regard to their decision making choices for acute health care and the factors that influence these decisions and this will be the subject of a third Monograph and publications.

Managing the production of a Cochrane systematic review

Undertaking a Cochrane systematic review can be an incredibly rewarding experience. It is however a challenging and time-consuming task. The Cochrane Handbook for Systematic Reviews of Interventions1 provides an essential resource to help reviewers navigate the often complex methodological issues of systematic review research. Additional guidelines have been developed for those undertaking reviews of public health topics,2 and Cochrane Centres throughout the world offer invaluable training opportunities. This emphasis on training and methodological rigour has helped Cochrane reviews become one of the most respected sources of synthesized research available. Even with the assistance available, however, many authors with good intentions register titles and prepare protocols but fail to publish the completed review. Data extracted from Cochrane’s Information Management System (Archie) in June 2010 showed that there were 1,301 titles registered more than two years ago that have not been published as a full review.3 Of these registered titles, 697 have had protocols published (25 are no longer active) while 604 have not even progressed to this stage (154 are no longer active). There are also 146 protocols that have been published for more than two years without being converted into completed reviews. These registered titles and protocols that have not yet progressed to a completed review represent a significant amount of time and energy invested by review authors, Cochrane editorial staff and, in some cases, external referees...

The BPMVE Wunderkammer

In this Column, I have decided to give you an insight into a both outward and forward looking area of BPM research; in fact, we want to discuss one of the streams of research and development that are yet to find a way of translation into practice. To that end, I have teamed up with colleagues and students here at Queensland University of Technology with whom I have shared some thinking and research around BPM in Virtual Environments (hence, BPMVE).

Procuring OSM : base-line models of off-site manufacture business processes in Australia

A pressing cost issue facing construction is the procurement of off-site pre-manufactured assemblies. In order to encourage Australian adoption of off-site manufacture (OSM), a new approach to underlying processes is required. The advent of object oriented digital models for construction design assumes intelligent use of data. However, the construction production system relies on traditional methods and data sources and is expected to benefit from the application of well-established business process management techniques. The integration of the old and new data sources allows for the development of business process models which, by capturing typical construction processes involving OSM, provides insights into such processes. This integrative approach is the foundation of research into the use of OSM to increase construction productivity in Australia. The purpose of this study is to develop business process models capturing the procurement, resources and information flow of construction projects. For each stage of the construction value chain, a number of sub-processes are identified. Business Process Modelling Notation (BPMN), a mainstream business process modelling standard, is used to create base-line generic construction process models. These models identify OSM decision-making points that could provide cost reductions in procurement workflow and management systems. This paper reports on phase one of an on-going research aiming to develop a proto-type workflow application that can provide semi-automated support to construction processes involving OSM and assist in decision-making in the adoption of OSM thus contributing to a sustainable built environment.

Sustainable, safe, smart—three key elements of Singapore’s evolving transport policies

Sustainability, safety and smartness are three key elements of a modern transportation system. This study illustrates various policy directions and initiatives of Singapore to address how its transportation system is progressing in light of these three components. Sustainability targets economical efficiency, environmental justice and social equity by including policies for integrating land use and transport planning, ensuring adequate transport supply measures, managing travel demand efficiently, and incorporating environment-friendly strategies. Safety initiatives of its transportation system aim to minimize injuries and incidents of all users including motorists, public transport commuters, pedestrians, and bicyclists. Smartness incorporates qualities like real time sensing, fast processing and decision making, and automated action-taking into its control, monitoring, information management and revenue collection systems. Various policy implications and technology applications along these three directions reveal that smart technologies facilitate implementation of policies promoting sustainability and safety. The Singapore experience could serve as a good reference for other cities in promoting a transportation system that is sustainable, safe and smart.

A lightweight biometric signature scheme for user authentication over networks

We introduce a lightweight biometric solution for user authentication over networks using online handwritten signatures. The algorithm proposed is based on a modified Hausdorff distance and has favorable characteristics such as low computational cost and minimal training requirements. Furthermore, we investigate an information theoretic model for capacity and performance analysis for biometric authentication which brings additional theoretical insights to the problem. A fully functional proof-of-concept prototype that relies on commonly available off-the-shelf hardware is developed as a client-server system that supports Web services. Initial experimental results show that the algorithm performs well despite its low computational requirements and is resilient against over-the-shoulder attacks.

Empirical study to identify the key business activities contributing to manufacturing business performance

Purpose: Within the context of high global competitiveness, knowledge management (KM) has proven to be one of the major factors contributing to enhanced business outcomes. Furthermore, knowledge sharing (KS) is one of the most critical of all KM activities. From a manufacturing industry perspective, supply chain management (SCM) and product development process (PDP) activities, require a high proportion of company resources such as budget and manpower. Therefore, manufacturing companies are striving to strengthen SCM, PDP and KS activities in order to accelerate rates of manufacturing process improvement, ultimately resulting in higher levels of business performance (BP). A theoretical framework along with a number of hypotheses are proposed and empirically tested through correlation, factor and path analyses. Design/methodology/approach: A questionnaire survey was administered to a sample of electronic manufacturing companies operating in Taiwan to facilitate testing the proposed relationships. More than 170 respondents from 83 organisations responded to the survey. The study identified top management commitment and employee empowerment, supplier evaluation and selection, and design simplification and modular design as the key business activities that are strongly associated with the business performance. Findings: The empirical study supports that key manufacturing business activities (i.e., SCM, PDP, and KS) are positively associated with BP. The findings also evealed that some specific business activities such as SCMF1,PDPF2, and KSF1 have the strongest influencing power on particular business outcomes (i.e., BPF1 and BPF2) within the context of electronic manufacturing companies operating in Taiwan. Practical implications: The finding regarding the relationship between SCM and BP identified the essential role of supplier evaluation and selection in improving business competitiveness and long term performance. The process of forming knowledge in companies, such as creation, storage/retrieval, and transfer do not necessarily lead to enhanced business performance; only through effectively applying knowledge to the right person at the right time does. Originality/value: Based on this finding it is recommended that companies should involve suppliers in partnerships to continuously improve operations and enhance product design efforts, which would ultimately enhance business performance. Business performance depends more on an employee’s ability to turn knowledge into effective action.

Knowledge sharing leveraging new product development activities to derive enhanced business performance : mixed method study

Knowledge has been widely recognised as a determinant of business performance. Business capabilities require an effective share of resource and knowledge. Specifically, knowledge sharing (KS) between different companies and departments can improve manufacturing processes since intangible knowledge plays an enssential role in achieving competitive advantage. This paper presents a mixed method research study into the impact of KS on the effectiveness of new product development (NPD) in achieving desired business performance (BP). Firstly, an empirical study utilising moderated regression analysis was conducted to test whether and to what extent KS has leveraging power on the relationship between NPD and BP constructs and variables. Secondly, this empirically verified hypothesis was validated through explanatory case studies involving two Taiwanese manufacturing companies using a qualitative interaction term pattern matching technique. The study provides evidence that knowledge sharing and management activities are essential for deriving competitive advantage in the manufacturing industry.

Knowledge sharing for strengthening manufacturing operation and business performance

Manufacturing companies have strived to enhance managerial and technical capabilities to improve business performance. Building these capabilities requires effective share of knowledge - the strategic resource. Specifically, knowledge sharing (KS) between different manufacturing departments can improve manufacturing processes since leveraging organisational knowledge plays an enssential role in achieving competitive advantage. This paper presents an empirical investigation into the impact of KS on the effectiveness of supply chain management (SCM) and the product development process (PDP) in achieving desired business performance (BP). A questionnaire survey was administered from electronic manufacturing companies operating in Taiwan. 168 valid responses were received and used to statistically examine the relationships between the concepts (SCM, PDP, KS, BP). The study findings reveal that within the Taiwanese electronic manufacturing companies KS is an essential enabler for facilitating the effectiveness of SCM and PDP in achieving desired BP.

Towards tacit knowledge sharing over social web tools

Purpose - Researchers debate whether tacit knowledge sharing through Information Technology (IT) is actually possible. However, with the advent of social web tools, it has been argued that most shortcomings of tacit knowledge sharing are likely to disappear. This paper has two purposes: firstly, to demonstrate the existing debates in the literature regarding tacit knowledge sharing using IT, and secondly, to identify key research gaps that lay the foundations for future research into tacit knowledge sharing using social web. Design/methodology/approach - This paper reviews current literature on IT-mediated tacit knowledge sharing and opens a discussion on tacit knowledge sharing through the use of social web. Findings - First, the existing schools of thoughts in regards to IT ability for tacit knowledge sharing are introduced. Next, difficulties of sharing tacit knowledge through the use of IT are discussed. Then, potentials and pitfalls of social web tools are presented. Finally, the paper concludes that whilst there are significant theoretical arguments supporting that the social web facilitates tacit knowledge sharing there is a lack of empirical evidence to support these arguments and further work is required. Research limitations/implications - The limitations of the review includes: covering only papers that were published in English, issues of access to full texts of some resources, possibility of missing some resources due to search strings used or limited coverage of databases searched. Originality/value - The paper contributes to the fast growing literature on the intersection of KM and IT particularly by focusing on tacit knowledge sharing in social media space. The paper highlights the need for further studies in this area by discussing the current situation in the literature and disclosing the emerging questions and gaps for future studies.

Leveraging power of learning capability upon manufacturing operations

Learning capability (LC) is a special dynamic capability that a firm purposefully builds to develop a cognitive focus, so as to enable the configuration and improvement of other capabilities (both dynamic and operational) to create and respond to market changes. Empirical evidence regarding the essential role of LC in leveraging operational manufacturing capabilities is, however, limited in the literature. This study takes a routine-based approach to understand capability, and focuses on demonstrating leveraging power of LC upon two essential operational capabilities within the manufacturing context, i.e., operational new product development capability (ONPDC), and operational supplier integration capability (OSIC). A mixed-methods research framework was used, which combines sources of evidence derived from a survey study and a multiple case study. This study identified high-level routines of LC that can be designed and controlled by managers and practitioners, to reconfigure underlying routines of ONPDC and OSIC to achieve superior performance in a turbulent environment. Hence, the study advances the notion of knowledge-based dynamic capabilities, such as LC, as routine bundles. It also provides an impetus for managing manufacturing operations from a capability-based perspective in the fast changing knowledge era.

The growing demand for emergency healthcare

Emergency health is a critical component of health systems; one increasingly congested from growing demand and blocked access to care. The Emergency Health Services Queensland (EHSQ) study aimed to identify the factors driving increased demand for emergency healthcare. This study examined data on patients treated by the ambulance service and Emergency Departments across Queensland. Data was derived from the Queensland Ambulance Service’s (QAS) Ambulance Information Management System and electronic Ambulance Report Form and from the Emergency Department Information System (EDIS). Data was obtained for the period 2001-02 through to 2009-10. A snapshot of users for the 2009-10 year was used to describe the characteristics of users and comparisons made with the year 2003-04 to identify trends. Per capita demand for EDs has increased by 2% per annum over the decade and for ambulance by 3.7% per annum. The growth in ED demand is most significant in more urgent triage categories with decline in less urgent patients. The growth is most prominent amongst patients suffering injuries and poisoning, amongst both men and women and across all age groups. Patients from lower socioeconomic areas appear to have higher utilisation rates and the utilisation rate for indigenous people exceeds those of other backgrounds. The utilisation rates for immigrant people is less than Australian born however it has not been possible to eliminate the confounding impact of age and socioeconomic profiles. These findings contribute to an understanding of the growth in demand for emergency health. It is evident that the growth is amongst patients in genuine need of emergency healthcare and public rhetoric that congested emergency health services is due to inappropriate attendees is unsustainable. The growth in demand over the last decade reflects not only on changing demographics of the Australian population but also changes in health status, standards of acute health care and other social factors.

Going offline : An exploratory cultural artifact analysis of an internet dating site's development trajectories

In this study we develop a theorization of an Internet dating site as a cultural artifact. The site, Gaydar, is targeted at gay men. We argue that contemporary received representations of their sexuality figure heavily in the site’s focus by providing a cultural logic for the apparent ad hoc development trajectories of its varied commercial and non-­‐commercial services. More specifically, we suggest that the growing sets of services related to the website are heavily enmeshed within current social practices and meanings. These practices and meanings are, in turn, shaped by the interactions and preferences of a variety of diverse groups involved in what is routinely seen within the mainstream literature as a singularly specific sexuality and cultural project. Thus, we attend to two areas – the influence of the various social engagements associated with Gaydar together with the further extension of its trajectory ‘beyond the web’. Through the case of Gaydar, we contribute a study that recognizes the need for attention to sexuality in information systems research and one which illustrates sexuality as a pivotal aspect of culture. We also draw from anthropology to theorize ICTs as cultural artifacts and provide insights into the contemporary phenomena of ICT enabled social networking.

The government as proprietor, preserver and user of copyright material under the Copyright Act 1968 (CTH)

This thesis examines the role of government as proprietor, preserver and user of copyright material under the Copyright Act 1968 (Cth) and the policy considerations which Australian law should take into account in that role. There are two recurring themes arising in this examination which are significant to the recommendations and conclusions. The first is whether the needs and status of government should be different from private sector institutions, which also obtain copyright protection under the law. This theme stems from the 2005 Report on Crown Copyright by the Copyright Law Review Committee and the earlier Ergas Committee Report which are discussed in Chapters 2 and 8 of this thesis. The second is to identify the relationship between government copyright law and policy, national cultural policy and fundamental governance values. This theme goes to the essence of the thesis. For example, does the law and practice of government copyright properly reflect technological change in the way we now access and use information and does it facilitate the modern information management principles of government? Is the law and practice of government copyright consistent with the greater openness and accountability of government? The thesis concludes that government copyright law and practice in each of the three governmental roles recognised under the Copyright Act 1968 has not responded adequately to the information age and to the desire and the ability of individuals to access information quickly and effectively. The solution offered in this thesis is reform of the law and of public policy that is in step with access to information policy, the promotion of better communication and interaction with the community, and the enhanced preservation of government and private copyright materials for reasons of government accountability, effective administration and national culture and heritage.