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.

Asymmetrical DC link voltage configuration for a diode-clamped inverter

There is a trade off between a number of output voltage levels and the reliability and efficiency of a multilevel converter. A new configuration of diode-clamped multilevel inverters with a different combination of DC link capacitors voltage has been proposed in this paper. Two different symmetrical and asymmetrical unequal arrangements for a four-level diode-clamped inverter have been compared, in order to find an optimum arrangement with lower switching losses and optimised output voltage quality. The simulation and hardware results for a four-level inverter show that the asymmetrical configuration can obtain more output voltage levels with the same number of components compared with a conventional four-level inverter and this will lead to the reduction of the harmonic content of the output voltage. A new family of multi-output DC-DC converters with a simple control strategy has been utilised as a front-end converter to supply the DC link capacitor voltages for the optimised configuration.

A high voltage power converter with a frequency and voltage controller

A high voltage power converter is presented in this paper and is based on a Capacitor-Diode Voltage Multiplier (CDVM) supplied through an inverter. This power converter has the capabilities of generating variable high DC voltage with improved transient response. The simulation results which are presented in this paper verify that due to its fast transient response, this converter can be used as a high DC voltage source in many applications.

A bidirectional two-leg resonant converter for high voltage pulsed power application

A high voltage pulsed power supply is proposed in this paper based on oscillation between an inductor and a capacitor in an LC circuit. A two-leg resonant circuit, supplied through an inverter with an alternative voltage waveform, can generate output voltage up to four times an input voltage magnitude. Bipolar and unipolar modulations are used in a single phase inverter to analyse their effects on the proposed resonant converter. Simulations have been carried out to evaluate the proposed topology and control.

Operation and control of a hybrid microgrid containing unbalanced and nonlinear loads

This paper shows how the power quality can be improved in a microgrid that is supplying a nonlinear and unbalanced load. The microgrid contains a hybrid combination of inertial and converter interfaced distributed generation units where a decentralized power sharing algorithm is used to control its power management. One of the distributed generators in the microgrid is used as a power quality compensator for the unbalanced and harmonic load. The current reference generation for power quality improvement takes into account the active and reactive power to be supplied by the micro source which is connected to the compensator. Depending on the power requirement of the nonlinear load, the proposed control scheme can change modes of operation without any external communication interfaces. The compensator can operate in two modes depending on the entire power demand of the unbalanced nonlinear load. The proposed control scheme can even compensate system unbalance caused by the single-phase micro sources and load changes. The efficacy of the proposed power quality improvement control and method in such a microgrid is validated through extensive simulation studies using PSCAD/EMTDC software with detailed dynamic models of the micro sources and power electronic converters

Improvement of stability and load sharing in an autonomous microgrid using supplementary droop control loop

This paper investigates the problem of appropriate load sharing in an autonomous microgrid. High gain angle droop control ensures proper load sharing, especially under weak system conditions. However it has a negative impact on overall stability. Frequency domain modeling, eigenvalue analysis and time domain simulations are used to demonstrate this conflict. A supplementary loop is proposed around a conventional droop control of each DG converter to stabilize the system while using high angle droop gains. Control loops are based on local power measurement and modulation of the d-axis voltage reference of each converter. Coordinated design of supplementary control loops for each DG is formulated as a parameter optimization problem and solved using an evolutionary technique. The sup-plementary droop control loop is shown to stabilize the system for a range of operating conditions while ensuring satisfactory load sharing.

Protective behavior in adolescent friendships : the influence of attitudes toward the consequences, friendship norms and perceived control

The current study sought to understand adolescent protective behavior in friendship using a Theory of Planned Behavior framework. In particular, the study sought to consider a young persons’ direct and active intervention to inhibit their friends’ risky behavior or to assist them when the behavior leads to injury. The role of attitudes regarding the consequences, norms and control about protective behavior were examined both qualitatively through focus groups (n= 50) and quantitatively through surveys from a sample of 540 Year 9 students (13-14 years old). There was some support for the theory with attitudes regarding the consequences of the behavior and norms predicting intended protective behavior. A path analysis was conducted with a sub-sample of 140 students which showed that intentions to be protective and perceived control to undertake protective behavior directly predicted such behavior after a 3 month interval. Attitudes towards the consequences and norms only indirectly predicted protective behavior via intention. The findings provide important applied information for interventions designed to increase adolescent protective behavior in their friendships.

Adaptive dual control of topic-based information retrieval

Information Retrieval is an important albeit imperfect component of information technologies. A problem of insufficient diversity of retrieved documents is one of the primary issues studied in this research. This study shows that this problem leads to a decrease of precision and recall, traditional measures of information retrieval effectiveness. This thesis presents an adaptive IR system based on the theory of adaptive dual control. The aim of the approach is the optimization of retrieval precision after all feedback has been issued. This is done by increasing the diversity of retrieved documents. This study shows that the value of recall reflects this diversity. The Probability Ranking Principle is viewed in the literature as the “bedrock” of current probabilistic Information Retrieval theory. Neither the proposed approach nor other methods of diversification of retrieved documents from the literature conform to this principle. This study shows by counterexample that the Probability Ranking Principle does not in general lead to optimal precision in a search session with feedback (for which it may not have been designed but is actively used). Retrieval precision of the search session should be optimized with a multistage stochastic programming model to accomplish the aim. However, such models are computationally intractable. Therefore, approximate linear multistage stochastic programming models are derived in this study, where the multistage improvement of the probability distribution is modelled using the proposed feedback correctness method. The proposed optimization models are based on several assumptions, starting with the assumption that Information Retrieval is conducted in units of topics. The use of clusters is the primary reasons why a new method of probability estimation is proposed. The adaptive dual control of topic-based IR system was evaluated in a series of experiments conducted on the Reuters, Wikipedia and TREC collections of documents. The Wikipedia experiment revealed that the dual control feedback mechanism improves precision and S-recall when all the underlying assumptions are satisfied. In the TREC experiment, this feedback mechanism was compared to a state-of-the-art adaptive IR system based on BM-25 term weighting and the Rocchio relevance feedback algorithm. The baseline system exhibited better effectiveness than the cluster-based optimization model of ADTIR. The main reason for this was insufficient quality of the generated clusters in the TREC collection that violated the underlying assumption.

On the use of different spatial reference frames for movement control

Previous work has shown that amplitude and direction are two independently controlled parameters of aimed arm movements, and performance, therefore, suffers when they must be decomposed into Cartesian coordinates. We now compare decomposition into different coordinate systems. Subjects pointed at visual targets in 2-D with a cursor, using a two-axis joystick or two single-axis joysticks. In the latter case, joystick axes were aligned with the subjects’ body axes, were rotated by –45°, or were oblique (i.e., one axis was in an egocentric frame and the other was rotated by –45°). Cursor direction always corresponded to joystick direction. We found that compared with the two-axis joystick, responses with single-axis joysticks were slower and less accurate when the axes were oriented egocentrically; the deficit was even more pronounced when the axes were rotated and was most pronounced when they were oblique. This confirms that decomposition of motor commands is computationally demanding and documents that this demand is lowest for egocentric, higher for rotated, and highest for oblique coordinates. We conclude that most current vehicles use computationally demanding man–machine interfaces.

An evaluation of current and future botnet defenses

Botnets are large networks of compromised machines under the control of a bot master. These botnets constantly evolve their defences to allow the continuation of their malicious activities. The constant development of new botnet mitigation strategies and their subsequent defensive countermeasures has lead to a technological arms race, one which the bot masters have significant incentives to win. This dissertation analyzes the current and future states of the botnet arms race by introducing a taxonomy of botnet defences and a simulation framework for evaluating botnet techniques. The taxonomy covers current botnet techniques and highlights possible future techniques for further analysis under the simulation framework. This framework allows the evaluation of the effect techniques such as reputation systems and proof of work schemes have on the resources required to disable a peer-to-peer botnet. Given the increase in the resources required, our results suggest that the prospects of eliminating the botnet threat are limited.

Autonomous control of underground mining vehicles using reactive navigation

Describes how many of the navigation techniques developed by the robotics research community over the last decade may be applied to a class of underground mining vehicles (LHDs and haul trucks). We review the current state-of-the-art in this area and conclude that there are essentially two basic methods of navigation applicable. We describe an implementation of a reactive navigation system on a 30 tonne LHD which has achieved full-speed operation at a production mine.

Flying-capacitor-based chopper circuit for DC capacitor voltage balancing in diode-clamped multilevel inverter

This paper proposes a flying-capacitor-based chopper circuit for dc capacitor voltage equalization in diode-clamped multilevel inverters. Its important features are reduced voltage stress across the chopper switches, possible reduction in the chopper switching frequency, improved reliability, and ride-through capability enhancement. This topology is analyzed using three- and four-level flying-capacitor-based chopper circuit configurations. These configurations are different in capacitor and semiconductor device count and correspondingly reduce the device voltage stresses by half and one-third, respectively. The detailed working principles and control schemes for these circuits are presented. It is shown that, by preferentially selecting the available chopper switch states, the dc-link capacitor voltages can be efficiently equalized in addition to having tightly regulated flying-capacitor voltages around their references. The various operating modes of the chopper are described along with their preferential selection logic to achieve the desired performances. The performance of the proposed chopper and corresponding control schemes are confirmed through both simulation and experimental investigations.

Physical activity and regulation of food intake: current evidence

Objective: The evidence was reviewed on how physical activity could influence the regulation of food intake by either adjusting the sensitivity of appetite control mechanisms or by generating an energy deficit that could adjust the drive to eat. Design: Interventionist and correlational studies that had a significant influence on the relationship between physical activity and food intake were reviewed. Interventionist studies involve a deliberate imposition of physical activity with subsequent monitoring of the eating response. Correlational studies make use of naturally occurring differences in the levels of physical activity (between and within subjects) with simultaneous assessment of energy expenditure and intake. Subjects: Studies using lean, overweight, and obese men and women were included. Results: Only 19% of interventionist studies report an increase in energy intake after exercise; 65% show no change and 16% show a decrease in appetite. Of the correlational studies, approximately half show no relationship between energy expenditure and intake. These data indicate a rather loose coupling between energy expenditure and intake. A common sense view is that exercise is futile as a form of weight control because the energy deficit drives a compensatory increase in food intake. However, evidence shows that this is not generally true. One positive aspect of this is that raising energy expenditure through physical activity (or maintaining an active life style) can cause weight loss or prevent weight gain. A negative feature is that when people become sedentary after a period of high activity, food intake is not “down-regulated” to balance a reduced energy expenditure. Conclusion: Evidence suggests that a high level of physical activity can aid weight control either by improving the matching of food intake to energy expenditure (regulation) or by raising expenditure so that it is difficult for people to eat themselves into a positive energy balance.

Acute and long-term effects of exercise on appetite control: Is there any benefit for weight control?

Purpose of review: To examine the relationship between energy intake, appetite control and exercise, with particular reference to longer term exercise studies. This approach is necessary when exploring the benefits of exercise for weight control, as changes in body weight and energy intake are variable and reflect diversity in weight loss. Recent findings: Recent evidence indicates that longer term exercise is characterized by a highly variable response in eating behaviour. Individuals display susceptibility or resistance to exercise-induced weight loss, with changes in energy intake playing a key role in determining the degree of weight loss achieved. Marked differences in hunger and energy intake exist between those who are capable of tolerating periods of exercise-induced energy deficit, and those who are not. Exercise-induced weight loss can increase the orexigenic drive in the fasted state, but for some this is offset by improved postprandial satiety signalling. Summary: The biological and behavioural responses to acute and long-term exercise are highly variable, and these responses interact to determine the propensity for weight change. For some people, long-term exercise stimulates compensatory increases in energy intake that attenuate weight loss. However, favourable changes in body composition and health markers still exist in the absence of weight loss. The physiological mechanisms that confer susceptibility to compensatory overconsumption still need to be determined.

Analysis of distrubances in large interconnected power systems

World economies increasingly demand reliable and economical power supply and distribution. To achieve this aim the majority of power systems are becoming interconnected, with several power utilities supplying the one large network. One problem that occurs in a large interconnected power system is the regular occurrence of system disturbances which can result in the creation of intra-area oscillating modes. These modes can be regarded as the transient responses of the power system to excitation, which are generally characterised as decaying sinusoids. For a power system operating ideally these transient responses would ideally would have a “ring-down” time of 10-15 seconds. Sometimes equipment failures disturb the ideal operation of power systems and oscillating modes with ring-down times greater than 15 seconds arise. The larger settling times associated with such “poorly damped” modes cause substantial power flows between generation nodes, resulting in significant physical stresses on the power distribution system. If these modes are not just poorly damped but “negatively damped”, catastrophic failures of the system can occur. To ensure system stability and security of large power systems, the potentially dangerous oscillating modes generated from disturbances (such as equipment failure) must be quickly identified. The power utility must then apply appropriate damping control strategies. In power system monitoring there exist two facets of critical interest. The first is the estimation of modal parameters for a power system in normal, stable, operation. The second is the rapid detection of any substantial changes to this normal, stable operation (because of equipment breakdown for example). Most work to date has concentrated on the first of these two facets, i.e. on modal parameter estimation. Numerous modal parameter estimation techniques have been proposed and implemented, but all have limitations [1-13]. One of the key limitations of all existing parameter estimation methods is the fact that they require very long data records to provide accurate parameter estimates. This is a particularly significant problem after a sudden detrimental change in damping. One simply cannot afford to wait long enough to collect the large amounts of data required for existing parameter estimators. Motivated by this gap in the current body of knowledge and practice, the research reported in this thesis focuses heavily on rapid detection of changes (i.e. on the second facet mentioned above). This thesis reports on a number of new algorithms which can rapidly flag whether or not there has been a detrimental change to a stable operating system. It will be seen that the new algorithms enable sudden modal changes to be detected within quite short time frames (typically about 1 minute), using data from power systems in normal operation. The new methods reported in this thesis are summarised below. The Energy Based Detector (EBD): The rationale for this method is that the modal disturbance energy is greater for lightly damped modes than it is for heavily damped modes (because the latter decay more rapidly). Sudden changes in modal energy, then, imply sudden changes in modal damping. Because the method relies on data from power systems in normal operation, the modal disturbances are random. Accordingly, the disturbance energy is modelled as a random process (with the parameters of the model being determined from the power system under consideration). A threshold is then set based on the statistical model. The energy method is very simple to implement and is computationally efficient. It is, however, only able to determine whether or not a sudden modal deterioration has occurred; it cannot identify which mode has deteriorated. For this reason the method is particularly well suited to smaller interconnected power systems that involve only a single mode. Optimal Individual Mode Detector (OIMD): As discussed in the previous paragraph, the energy detector can only determine whether or not a change has occurred; it cannot flag which mode is responsible for the deterioration. The OIMD seeks to address this shortcoming. It uses optimal detection theory to test for sudden changes in individual modes. In practice, one can have an OIMD operating for all modes within a system, so that changes in any of the modes can be detected. Like the energy detector, the OIMD is based on a statistical model and a subsequently derived threshold test. The Kalman Innovation Detector (KID): This detector is an alternative to the OIMD. Unlike the OIMD, however, it does not explicitly monitor individual modes. Rather it relies on a key property of a Kalman filter, namely that the Kalman innovation (the difference between the estimated and observed outputs) is white as long as the Kalman filter model is valid. A Kalman filter model is set to represent a particular power system. If some event in the power system (such as equipment failure) causes a sudden change to the power system, the Kalman model will no longer be valid and the innovation will no longer be white. Furthermore, if there is a detrimental system change, the innovation spectrum will display strong peaks in the spectrum at frequency locations associated with changes. Hence the innovation spectrum can be monitored to both set-off an “alarm” when a change occurs and to identify which modal frequency has given rise to the change. The threshold for alarming is based on the simple Chi-Squared PDF for a normalised white noise spectrum [14, 15]. While the method can identify the mode which has deteriorated, it does not necessarily indicate whether there has been a frequency or damping change. The PPM discussed next can monitor frequency changes and so can provide some discrimination in this regard. The Polynomial Phase Method (PPM): In [16] the cubic phase (CP) function was introduced as a tool for revealing frequency related spectral changes. This thesis extends the cubic phase function to a generalised class of polynomial phase functions which can reveal frequency related spectral changes in power systems. A statistical analysis of the technique is performed. When applied to power system analysis, the PPM can provide knowledge of sudden shifts in frequency through both the new frequency estimate and the polynomial phase coefficient information. This knowledge can be then cross-referenced with other detection methods to provide improved detection benchmarks.