Maximum recovery after knee replacement - the MARKER study rationale and protocol

Background There is little scientific evidence to support the usual practice of providing outpatient rehabilitation to patients undergoing total knee replacement surgery (TKR) immediately after discharge from the orthopaedic ward. It is hypothesised that the lack of clinical benefit is due to the low exercise intensity tolerated at this time, with patients still recovering from the effects of major orthopaedic surgery. The aim of the proposed clinical trial is to investigate the clinical and cost effectiveness of a novel rehabilitation strategy, consisting of an initial home exercise programme followed, approximately six weeks later, by higher intensity outpatient exercise classes. Methods/Design In this multicentre randomised controlled trial, 600 patients undergoing primary TKR will be recruited at the orthopaedic pre-admission clinic of 10 large public and private hospitals in Australia. There will be no change to the medical or rehabilitative care usually provided while the participant is admitted to the orthopaedic ward. After TKR, but prior to discharge from the orthopaedic ward, participants will be randomised to either the novel rehabilitation strategy or usual rehabilitative care as provided by the hospital or recommended by the orthopaedic surgeon. Outcomes assessments will be conducted at baseline (pre-admission clinic) and at 6 weeks, 6 months and 12 months following randomisation. The primary outcomes will be self-reported knee pain and physical function. Secondary outcomes include quality of life and objective measures of physical performance. Health economic data (health sector and community service utilisation, loss of productivity) will be recorded prospectively by participants in a patient diary. This patient cohort will also be followed-up annually for five years for knee pain, physical function and the need or actual incidence of further joint replacement surgery. Discussion The results of this pragmatic clinical trial can be directly implemented into clinical practice. If beneficial, the novel rehabilitation strategy of utilising outpatient exercise classes during a later rehabilitation phase would provide a feasible and potentially cost-effective intervention to optimise the physical well-being of the large number of people undergoing TKR.

The level and quality of Value-at-Risk disclosure by commercial banks

In this paper we study both the level of Value-at-Risk (VaR) disclosure and the accuracy of the disclosed VaR figures for a sample of US and international commercial banks. To measure the level of VaR disclosures, we develop a VaR Disclosure Index that captures many different facets of market risk disclosure. Using panel data over the period 1996–2005, we find an overall upward trend in the quantity of information released to the public. We also find that Historical Simulation is by far the most popular VaR method. We assess the accuracy of VaR figures by studying the number of VaR exceedances and whether actual daily VaRs contain information about the volatility of subsequent trading revenues. Unlike the level of VaR disclosure, the quality of VaR disclosure shows no sign of improvement over time. We find that VaR computed using Historical Simulation contains very little information about future volatility.

Air quality and its impact on health: focus on particulate matter

Inadequate air quality and the inhalation of airborne pollutants pose many risks to human health and wellbeing, and are listed among the top environmental risks worldwide. The importance of outdoor air quality was recognised in the 1950s and indoor air quality emerged as an issue some time later and was soon recognised as having an equal, if not greater importance than outdoor air quality. Identification of ambient air pollution as a health hazard was followed by steps, undertaken by a broad range of national and international professional and government organisations, aimed at reduction or elimination of the hazard. However, the process of achieving better air quality is still in progress. The last 10 years or so have seen an unprecedented increase in the interest in, and attention to, airborne particles, with a special focus on their finer size fractions, including ultrafine (< 0.1 m) and their subset, nano particles (< 0.05 m). This paper discusses the current status of scientific knowledge on the links between air quality and health, with a particular focus on airborne particulate matter, and the directions taken by national and international bodies to improve air quality.

Access and Quality of Heart Failure Management Programs in Australia

Background/aim In response to the high burden of disease associated with chronic heart failure (CHF), in particular the high rates of hospital admissions, dedicated CHF management programs (CHF-MP) have been developed. Over the past five years there has been a rapid growth of CHF-MPs in Australia. Given the apparent mismatch between the demand for, and availability of CHF-MPs, this paper has been designed to discuss the accessibility to and quality of current CHF-MPs in Australia. Methods The data presented in this report has been combined from the research of the co-authors, in particular a review of the inequities in access to chronic heart failure which utilised geographical information systems (GIS) and the survey of heterogeneity in quality and service provision in Australian. Results Of the 62 CHF-MPs surveyed in this study 93% (58) centres had been located areas that are rated as Highly Accessible. This result indicated that most of the CHF-MPs have been located in capital cities or large regional cities. Six percent (4 CHF-MPs) had been located in Accessible areas which were country towns or cities. No CHF-MPs had been established outside of cities to service the estimated 72,000 individuals with CHF living in rural and remote areas. 16% of programs recruited NYHA Class I patients and of these 20% lacked confirmation (echocardiogram) of their diagnosis. Conclusion Overall, these data highlight the urgent need to provide equitable access to CHF-MP's. When establishing CHF-MPs consideration of current evidence based models to ensure quality in practice.

Examination of process to develop a framework for better implementation of quality practices in building projects

Quality, as well as project success, in construction projects should be capable of being regarded as the fulfillment of expectation of those contributors and stakeholders involved in such projects. Although a significant amount of quality practices have been introduced within the industry, establishment and attainment of reasonable levels of quality internationally in construction projects continues to be an ongoing problem. To date, some investigation into the introduction and improvement of quality practices and stakeholder management in the construction industry has been accomplished independently, but so far no major studies have been completed that examine comprehensively how quality management practices that particularly concentrate on the stakeholders’ perspective of quality can be used to contribute to final project quality outcomes. This paper aims to examine the process for development of a framework for better involvement of stakeholders in quality planning and practices and subsequently to contribute to higher quality outcomes within construction projects. Through extensive literature review it highlights various perceptions of quality, categorizes quality issues with particular focus on benefits and shortcomings and also examines stakeholders’ viewpoint of project quality in order to promote the improvement of outcomes throughout a project’s lifecycle. It proposes a set of arranged information as a basis for development of prospective framework which ultimately aims to improve project quality outcomes. The subsequent framework that will be developed from this research will provide project managers and owners with the required information and strategic direction to achieve their own and their stakeholders’ targets for implementation of quality practices and achievement of high quality outcomes on their future projects.

Building organizational capability through a quality assurance program within a business school and encouraging organizational culture change

This study explores organizational capability and culture change through a project developing an assurance of learning program in a business school. In order to compete internationally for high quality faculty, students, strategic partnerships and research collaborations it is essential for Universities to develop and maintain an international focus and a quality produce that predicts excellence in the student experience and graduate outcomes that meet industry needs. Developing, marketing and delivering that quality product requires an organizational strategy to which all members of the organization contribute and adhere. Now, the ability to acquire, share and utilize knowledge has become a critical organizational capability in academia as well as other industries. Traditionally the functional approach to business school structures and disparate nature of the social networks and work contact limit the sharing of knowledge between academics working in different disciplines. In this project a community of practice program was established to include academics in the development of an embedded assurance of learning program affecting more than 5000 undergraduate students and 250 academics from nine different disciplines across four schools. The primary outcome from the fully developed and implemented assurance of learning program was the five year accreditation of the business schools programs by two international accrediting bodies, EQUIS and AACSB. However this study explores a different outcome, namely the change in organizational culture and individual capabilities as academics worked together in teaching and learning teams. This study uses a survey and interviews with academics involved, through a retrospective panel design which contained an experimental group and a control group. Results offer insights into communities of practice as a means of addressing organizational capability and changes in organizational culture. Knowledge management and shared learning can achieve strategic and operational benefits equally within academia as within other industrial enterprises but it comes at a cost. Traditional structures, academics that act like individual contractors and deep divides across research, teaching and service interest served a different master and required fewer resources. Collaborative structures; fewer master categories of discrete knowledge areas; specific strategic goals; greater links between academics and industry; and the means to share learned insights will require a different approach to resourcing both the individual and the team.

Improved image quality for x-ray CT imaging of gel dosimeters

Purpose: This study provides a simple method for improving precision of x-ray computed tomography (CT) scans of irradiated polymer gel dosimetry. The noise affecting CT scans of irradiated gels has been an impediment to the use of clinical CT scanners for gel dosimetry studies. Method: In this study, it is shown that multiple scans of a single PAGAT gel dosimeter can be used to extrapolate a ‘zero-scan’ image which displays a similar level of precision to an image obtained by averaging multiple CT images, without the compromised dose measurement resulting from the exposure of the gel to radiation from the CT scanner. Results: When extrapolating the zero-scan image, it is shown that exponential and simple linear fits to the relationship between Hounsfield unit and scan number, for each pixel in the image, provides an accurate indication of gel density. Conclusions: It is expected that this work will be utilised in the analysis of three-dimensional gel volumes irradiated using complex radiotherapy treatments.

Ensuring student success : the role of support services in improving the quality of the student learning experience

This paper is based on the premise that universities have an obligation to provide adequate student support services, such as learning assistance (that is, assistance with academic writing and other study skills) and that in order to be effective such services must be responsive to the wider policy and social implications of student attrition and retention. The paper outlines briefly some of the factors that have influenced the development of learning assistance practices in Australia and America. This is followed by an account of experiences at one Australian metropolitan university where learning assistance service provision shifted from a decentralised, faculty-based model to a centralised model of service delivery. This shift was in response to concerns about lack of quality and consistency in a support model dependent upon faculty resources yet a follow up study identified other problems in the centralised delivery of learning assistance services. These problems, clustered under the heading contextualised versus decontextualised learning assistance, include the relevance of generic learning assistance services to students struggling with specific course related demands; the apparent tensions between challenging students and assisting students at risk of failure; and variations in the level of collaboration between learning advisers and academic staff in supporting students in the learning environment. These problems are analysed using the theoretical modelling derived from the tools made available through cultural historical activity theory and expansive visibilisation (Engeström & Miettinen, 1999).

Utility of routine data sources for feedback on the quality of cancer care: an assessment based on clinical practice guidelines

Background Not all cancer patients receive state-of-the-art care and providing regular feedback to clinicians might reduce this problem. The purpose of this study was to assess the utility of various data sources in providing feedback on the quality of cancer care. Methods Published clinical practice guidelines were used to obtain a list of processes-of-care of interest to clinicians. These were assigned to one of four data categories according to their availability and the marginal cost of using them for feedback. Results Only 8 (3%) of 243 processes-of-care could be measured using population-based registry or administrative inpatient data (lowest cost). A further 119 (49%) could be measured using a core clinical registry, which contains information on important prognostic factors (e.g., clinical stage, physiological reserve, hormone-receptor status). Another 88 (36%) required an expanded clinical registry or medical record review; mainly because they concerned long-term management of disease progression (recurrences and metastases) and 28 (11.5%) required patient interview or audio-taping of consultations because they involved information sharing between clinician and patient. Conclusion The advantages of population-based cancer registries and administrative inpatient data are wide coverage and low cost. The disadvantage is that they currently contain information on only a few processes-of-care. In most jurisdictions, clinical cancer registries, which can be used to report on many more processes-of-care, do not cover smaller hospitals. If we are to provide feedback about all patients, not just those in larger academic hospitals with the most developed data systems, then we need to develop sustainable population-based data systems that capture information on prognostic factors at the time of initial diagnosis and information on management of disease progression.