Educational interventions for preventing vascular catheter bloodstream infections in critical care: Evidence map, systematic review and economic evaluation

Background Bloodstream infections resulting from intravascular catheters (catheter-BSI) in critical care increase patients' length of stay, morbidity and mortality, and the management of these infections and their complications has been estimated to cost the NHS annually £19.1–36.2M. Catheter-BSI are thought to be largely preventable using educational interventions, but guidance as to which types of intervention might be most clinically effective is lacking. Objective To assess the effectiveness and cost-effectiveness of educational interventions for preventing catheter-BSI in critical care units in England. Data sources Sixteen electronic bibliographic databases – including MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, Cumulative Index to Nursing and Allied Health Literature (CINAHL), NHS Economic Evaluation Database (NHS EED), EMBASE and The Cochrane Library databases – were searched from database inception to February 2011, with searches updated in March 2012. Bibliographies of systematic reviews and related papers were screened and experts contacted to identify any additional references. Review methods References were screened independently by two reviewers using a priori selection criteria. A descriptive map was created to summarise the characteristics of relevant studies. Further selection criteria developed in consultation with the project Advisory Group were used to prioritise a subset of studies relevant to NHS practice and policy for systematic review. A decision-analytic economic model was developed to investigate the cost-effectiveness of educational interventions for preventing catheter-BSI. Results Seventy-four studies were included in the descriptive map, of which 24 were prioritised for systematic review. Studies have predominantly been conducted in the USA, using single-cohort before-and-after study designs. Diverse types of educational intervention appear effective at reducing the incidence density of catheter-BSI (risk ratios statistically significantly < 1.0), but single lectures were not effective. The economic model showed that implementing an educational intervention in critical care units in England would be cost-effective and potentially cost-saving, with incremental cost-effectiveness ratios under worst-case sensitivity analyses of < £5000/quality-adjusted life-year. Limitations Low-quality primary studies cannot definitively prove that the planned interventions were responsible for observed changes in catheter-BSI incidence. Poor reporting gave unclear estimates of risk of bias. Some model parameters were sourced from other locations owing to a lack of UK data. Conclusions Our results suggest that it would be cost-effective and may be cost-saving for the NHS to implement educational interventions in critical care units. However, more robust primary studies are needed to exclude the possible influence of secular trends on observed reductions in catheter-BSI.

The relationship between parents' and their adolescent children's mental health and mental illness

Depression and anxiety disorders are high-prevalence disorders with a significant impact globally and high social and economic costs. Promotion of mental health and the prevention of depression and anxiety disorders are key health priorities internationally. It is now understood that mental health and mental illness are not two ends of one spectrum but two separate, related spectrums. The relationship between mental illness in parents and the development of mental illness in their children has been well documented however this relationship has not yet been examined from a mental health perspective. A number of mental health protective factors (also known as flourishing factors) have been shown to have a preventative effect on the development of depression and anxiety disorders, however whether parents’ mental health protective factors may have any effect on children’s depression and anxiety disorder outcomes remains unknown.

Planning, development and management of sustainable cities: A commentary from the guest editors

Cities are the most dramatic manifestations of human activities on the surface of the earth. These human-dominated organisms—i.e., cities—degrade natural habitats, simplify species composition, disrupt hydrological systems, and modify energy flow and nutrient cycling. Today, these consequential impacts of human activities, originated from population increase, rapid urbanization, high private motor vehicle dependency, deregulated industrialization and mass livestock production, are increasing exponentially and causing great deal of environmental, social, and economic challenges both at global and local scales. In such a situation, establishment of sustainable cities, through sustainable urban development practices, is seen as a potential panacea to combat these challenges responsibly, effectively, and efficiently. This paper offers a critical review of the key literature on the issues relating to planning, development and management of sustainable cities, introduces the contributions from the Special Issue, and speculates on the prospective research directions to place necessary mechanisms to secure a sustainable urban future for all.

Governance and regional planning outcomes: Using governance indicators to support a policy implementation approach

Regional planning faces numerous decision making uncertainties related to the complex interdependencies between urban and regional centres. Questions about how to achieve sustainable planning solutions across regions are a key uncertainty and relate to a lack of information about the actual achievement of outcomes as proposed by the objectives of a plan. Regional plan implementation and its impact on environmental, social and economic outcomes have been little explored within Australian urban and regional planning research. Despite a desire to improve the conditions across Australian regions, ambiguity persists regarding the results of regional planning efforts. Of the variables affecting regional planning, scholars argue that governance has a significant impact on achieving outcomes (see Pahl-Wostl 2009). In order to better analyse the impact of governance, we propose a set of governance indicators to examine decisions across regional planning institutions and apply this to governance models across Queensland’s regions. We contend that these governance indicators can support a more rigorous assessment of the impacts of governance models on plan implementation and outcomes. We propose that this is a way to better understand the relationship between planning and outcomes across urban and regional areas.

Foucault, Weber, neoliberalism and the politics of governmentality

This paper argues that Michel Foucault’s lectures that form The Birth of Biopolitics owe a considerable debt to the thought of Max Weber, particularly in their analysis of how different socio-legal regimes shape distinctive national forms of capitalist economies, and the role that is played by social and economic institutions in the shaping of individual identities. This is in contrast to a common interpretation of Foucault’s account of neoliberalism, which synthesizes his work into neo-Marxist notions of hegemony and capitalist domination. It also identifies Foucault’s approach to neoliberalism as an exploratory one, which considers insights into how a particular relationship between ideas and institutional practices may help in imagining socialist forms of government practice.

Recognising change and seeking affirmation: Themes for embeddding Indigenous knowledges on teaching practicum

The imperative for Indigenous education in Australia is influenced by national political, social and economic discourses as Australian education systems continue to grapple with an agreed aspiration of full participation for Aboriginal and Torres Strait Islander students. Innovations within and policies guiding our education systems are often driven by agendas of reconciliation, equity, equality in participation and social justice. In this paper, we discuss key themes that emerged from a recent Australian Office for Learning and Teaching (OLT) research project which investigated ways in which preservice teachers from one Australian university embedded Indigenous knowledges (IK) on teaching practicum . Using a phenomenological approach, the case involved 25 preservice teacher and 23 practicum supervisor participants, over a 30 month investigation. Attention was directed to the nature of subjective (lived) experiences of participants in these pedagogical negotiations and thus preservice and supervising teacher voice was actively sought in naming and analysing these experiences. Findings revealed that change, knowledge, help and affirmation were key themes for shaping discourses around Indigenous knowledges and perspectives in the Australian curriculum and defined the nature of the pedagogical relationships between novice and experienced teachers. We focus particularly on the need for change and affirmation by preservice teachers and their teaching practicum supervisors as they developed their pedagogical relationships whilst embedding Indigenous knowledges in learning and teaching.

Do stakeholders or social obligations drive corporate social and environmental responsibility reporting? Managerial views from a developing country

Purpose – The purpose of this study is to explore senior managers’ perception and motivations of corporate social and environmental responsibility (CSER) reporting in the context of a developing country, Bangladesh. Design/methodology/approach – In-depth semi-structured interviews were conducted with 25 senior managers of companies listed on the Dhaka Stock Exchange. Publicly available annual reports of these companies were also analysed. Findings – The results indicate that senior managers perceive CSER reporting as a social obligation. The study finds that the managers focus mostly on child labour, human resources/rights, responsible products/services, health education, sports and community engagement activities as part of the social obligations. Interviewees identify a lack of a regulatory framework along with socio-cultural and religious factors as contributing to the low level of disclosures. These findings suggest that CSER reporting is not merely stakeholder-driven, but rather country-specific social and environmental issues play an important role in relation to CSER reporting practices. Research limitations/implications – This paper contributes to engagement-based studies by focussing on CSER reporting practices in developing countries and are useful for academics, practitioners and policymakers in understanding the reasons behind CSER reporting in developing countries. Originality/value – This paper addresses a literature “gap” in the empirical study of CSER reporting in a developing country, such as Bangladesh. This study fills a gap in the existing literature to understand managers’ motivations for CSER reporting in a developing country context. Managerial perceptions on CSER issues are largely unexplored in developing countries.

'The ones with the beastly lives': Gender and textuality in Jean Rhys's Voyage in the Dark

Anna Morgan, the central character of Jean Rhys's Voyage in the Dark, has previously been read as a victim of her own inability to fashion some form of life for herself.1 It is possible, however, to suggest an alternative to such character-based readings and instead examine the systems of oppression which work to ensure that Anna remains an excluded, marginalized subject. Rather than personal failings, it is Anna's gender and colonial status which prevent her from participating fully in the dominant social and economic order of Voyage in the Dark. Anna is textually constrained on three levels, which may be defined as economic, colonialist, and narrative. Imbricated within these is the question of gender, which functions to place Anna in a position of double-exclusion within the text. These forms of exclusion function at the levels of discourse and narrative; I would argue that Anna's position is not, therefore, a product of realist character 'flaws' but rather that her discursive placement within the novel offers insight into the ways in which colonialism and sexism function in terms of textuality.

Comparison of decision tree, support vector machines, and Bayesian network approaches for classification of falls in Parkinson’s disease

Being able to accurately predict the risk of falling is crucial in patients with Parkinson’s dis- ease (PD). This is due to the unfavorable effect of falls, which can lower the quality of life as well as directly impact on survival. Three methods considered for predicting falls are decision trees (DT), Bayesian networks (BN), and support vector machines (SVM). Data on a 1-year prospective study conducted at IHBI, Australia, for 51 people with PD are used. Data processing are conducted using rpart and e1071 packages in R for DT and SVM, con- secutively; and Bayes Server 5.5 for the BN. The results show that BN and SVM produce consistently higher accuracy over the 12 months evaluation time points (average sensitivity and specificity > 92%) than DT (average sensitivity 88%, average specificity 72%). DT is prone to imbalanced data so needs to adjust for the misclassification cost. However, DT provides a straightforward, interpretable result and thus is appealing for helping to identify important items related to falls and to generate fallers’ profiles.

Social and physical environments in senior communities: The Finnish experience

Purpose – The purpose of this paper is to discuss residents’ views of social and physical environments in a co-housing and in a senior housing setting in Finland. Also, the study aims to point out important connections between well-being and built environment. Design/methodology/approach – The data include interviews and survey responses gathered in the cases. The results and analysis are presented at different case study levels, with the discussion and conclusions following this. Findings – The findings show that the physical environment and common areas have an important role to activate residents. When well-designed common areas exist, a higher level of engagement can be achieved by getting residents involved in the planning and running of activities. Research limitations/implications – This paper discusses residents’ experiences in two Finnish housing settings and it focuses on the housing market in Finland. Practical implications – The findings encourage investors and housing operators to design and invest common areas which could activate residents and create social contacts. Also, investors have to pay attention to the way these developments are managed. Originality/value – This study is the first to investigate the Finnish co-housing setting and compare social and physical environments in a co-housing and a senior house.

Social enterprises: Examining accountability for social and financial performance

This research examined the influence commercial customers have on the social and financial accountability of social enterprises, specifically considering whether a dominant or diversified customer base impacts on social enterprise accountability. Findings revealed that social enterprise accountability was influenced by social enterprises' main stakeholder(s), not necessarily the dominant customer. Accountability practices focused on fulfilling social enterprises' main stakeholders' accountability demands, and reporting to them rather than reporting on performance to a broader range of stakeholders. This research enhances the understanding of stakeholder impact on social enterprises' accountability, and develops an understanding of accountability theory in a social enterprise context.

Understanding the roles of social and tangible technologies in maintaining social interaction, habits and independence into old age

The research offers a deeper understanding of how objects currently facilitate social interaction and physical activity for older adults living independently. It uses this awareness to develop, from a human perspective, considerations for the design of internet connected objects that provide novel ways of maintaining contact with loved ones. The research found that people invest emotional attachment to objects and objects foster emotional responses in people. Objects can facilitate feeling connected to another however the relationship is a result of time and repeated interaction. Recreating this connection/relationship digitally is not as simple as attaching a hyperlink.

Comparing China's city transportation and economic networks

The city system has been a prevailing research issue in the fields of urban geography and regional economics. Not only do the relationships between cities in the city system exist in the form of rankings, but also in a more general network form. Previous work has examined the spatial structure of the city system in terms of its separate industrial networks, such as in transportation and economic activity, but little has been done to compare different networks. To rectify this situation, this study analyzes and reveals the spatial structural features of China’s city system by comparing its transportation and economic urban networks, thus providing new avenues for research on China’s city network. The results indicate that these two networks relate with each other by sharing structural equivalence with a basic diamond structure and a layered intercity structure decreasing outwards from the national centers. A decoupling effect also exists between them as the transportation network contributes to a balanced regional development, while the economic network promotes agglomeration economies. The law of economic development and the government both play important roles in the articulation between these two networks, and the gap between them can be shortened by related policy reforms and the improvement of the transportation network.

The clinical effectiveness and cost-effectiveness of exercise referral schemes: A systematic review and economic evaluation

- Background Exercise referral schemes (ERS) aim to identify inactive adults in the primary-care setting. The GP or health-care professional then refers the patient to a third-party service, with this service taking responsibility for prescribing and monitoring an exercise programme tailored to the needs of the individual. - Objective To assess the clinical effectiveness and cost-effectiveness of ERS for people with a diagnosed medical condition known to benefit from physical activity (PA). The scope of this report was broadened to consider individuals without a diagnosed condition who are sedentary. - Data sources MEDLINE; EMBASE; PsycINFO; The Cochrane Library, ISI Web of Science; SPORTDiscus and ongoing trial registries were searched (from 1990 to October 2009) and included study references were checked. - Methods Systematic reviews: the effectiveness of ERS, predictors of ERS uptake and adherence, and the cost-effectiveness of ERS; and the development of a decision-analytic economic model to assess cost-effectiveness of ERS. - Results Seven randomised controlled trials (UK, n = 5; non-UK, n = 2) met the effectiveness inclusion criteria, five comparing ERS with usual care, two compared ERS with an alternative PA intervention, and one to an ERS plus a self-determination theory (SDT) intervention. In intention-to-treat analysis, compared with usual care, there was weak evidence of an increase in the number of ERS participants who achieved a self-reported 90-150 minutes of at least moderate-intensity PA per week at 6-12 months' follow-up [pooled relative risk (RR) 1.11, 95% confidence interval 0.99 to 1.25]. There was no consistent evidence of a difference between ERS and usual care in the duration of moderate/vigorous intensity and total PA or other outcomes, for example physical fitness, serum lipids, health-related quality of life (HRQoL). There was no between-group difference in outcomes between ERS and alternative PA interventions or ERS plus a SDT intervention. None of the included trials separately reported outcomes in individuals with medical diagnoses. Fourteen observational studies and five randomised controlled trials provided a numerical assessment of ERS uptake and adherence (UK, n = 16; non-UK, n = 3). Women and older people were more likely to take up ERS but women, when compared with men, were less likely to adhere. The four previous economic evaluations identified suggest ERS to be a cost-effective intervention. Indicative incremental cost per quality-adjusted life-year (QALY) estimates for ERS for various scenarios were based on a de novo model-based economic evaluation. Compared with usual care, the mean incremental cost for ERS was £169 and the mean incremental QALY was 0.008, with the base-case incremental cost-effectiveness ratio at £20,876 per QALY in sedentary people without a medical condition and a cost per QALY of £14,618 in sedentary obese individuals, £12,834 in sedentary hypertensive patients, and £8414 for sedentary individuals with depression. Estimates of cost-effectiveness were highly sensitive to plausible variations in the RR for change in PA and cost of ERS. - Limitations We found very limited evidence of the effectiveness of ERS. The estimates of the cost-effectiveness of ERS are based on a simple analytical framework. The economic evaluation reports small differences in costs and effects, and findings highlight the wide range of uncertainty associated with the estimates of effectiveness and the impact of effectiveness on HRQoL. No data were identified as part of the effectiveness review to allow for adjustment of the effect of ERS in different populations. - Conclusions There remains considerable uncertainty as to the effectiveness of ERS for increasing activity, fitness or health indicators or whether they are an efficient use of resources in sedentary people without a medical diagnosis. We failed to identify any trial-based evidence of the effectiveness of ERS in those with a medical diagnosis. Future work should include randomised controlled trials assessing the cinical effectiveness and cost-effectivenesss of ERS in disease groups that may benefit from PA. - Funding The National Institute for Health Research Health Technology Assessment programme.

Dasatinib, nilotinib and standard-dose imatinib for the first line treatment of chronic myeloid leukaemia: Systematic reviews and economic analyses

- Background Nilotinib and dasatinib are now being considered as alternative treatments to imatinib as a first-line treatment of chronic myeloid leukaemia (CML). - Objective This technology assessment reviews the available evidence for the clinical effectiveness and cost-effectiveness of dasatinib, nilotinib and standard-dose imatinib for the first-line treatment of Philadelphia chromosome-positive CML. - Data sources Databases [including MEDLINE (Ovid), EMBASE, Current Controlled Trials, ClinicalTrials.gov, the US Food and Drug Administration website and the European Medicines Agency website] were searched from search end date of the last technology appraisal report on this topic in October 2002 to September 2011. - Review methods A systematic review of clinical effectiveness and cost-effectiveness studies; a review of surrogate relationships with survival; a review and critique of manufacturer submissions; and a model-based economic analysis. - Results Two clinical trials (dasatinib vs imatinib and nilotinib vs imatinib) were included in the effectiveness review. Survival was not significantly different for dasatinib or nilotinib compared with imatinib with the 24-month follow-up data available. The rates of complete cytogenetic response (CCyR) and major molecular response (MMR) were higher for patients receiving dasatinib than for those with imatinib for 12 months' follow-up (CCyR 83% vs 72%, p < 0.001; MMR 46% vs 28%, p < 0.0001). The rates of CCyR and MMR were higher for patients receiving nilotinib than for those receiving imatinib for 12 months' follow-up (CCyR 80% vs 65%, p < 0.001; MMR 44% vs 22%, p < 0.0001). An indirect comparison analysis showed no difference between dasatinib and nilotinib for CCyR or MMR rates for 12 months' follow-up (CCyR, odds ratio 1.09, 95% CI 0.61 to 1.92; MMR, odds ratio 1.28, 95% CI 0.77 to 2.16). There is observational association evidence from imatinib studies supporting the use of CCyR and MMR at 12 months as surrogates for overall all-cause survival and progression-free survival in patients with CML in chronic phase. In the cost-effectiveness modelling scenario, analyses were provided to reflect the extensive structural uncertainty and different approaches to estimating OS. First-line dasatinib is predicted to provide very poor value for money compared with first-line imatinib, with deterministic incremental cost-effectiveness ratios (ICERs) of between £256,000 and £450,000 per quality-adjusted life-year (QALY). Conversely, first-line nilotinib provided favourable ICERs at the willingness-to-pay threshold of £20,000-30,000 per QALY. - Limitations Immaturity of empirical trial data relative to life expectancy, forcing either reliance on surrogate relationships or cumulative survival/treatment duration assumptions. - Conclusions From the two trials available, dasatinib and nilotinib have a statistically significant advantage compared with imatinib as measured by MMR or CCyR. Taking into account the treatment pathways for patients with CML, i.e. assuming the use of second-line nilotinib, first-line nilotinib appears to be more cost-effective than first-line imatinib. Dasatinib was not cost-effective if decision thresholds of £20,000 per QALY or £30,000 per QALY were used, compared with imatinib and nilotinib. Uncertainty in the cost-effectiveness analysis would be substantially reduced with better and more UK-specific data on the incidence and cost of stem cell transplantation in patients with chronic CML. - Funding The Health Technology Assessment Programme of the National Institute for Health Research.