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.

The economics of the FIFA Football World Cup

The expansion of economics to ‘non-market topics’ has received increased attention in recent years. The economics of sports (football) is such a sub-field. This paper reports empirical evidence of team and referee performances in the FIFA World Cup 2002. The results reveal that being a hosting nation has a significant impact on the probability of winning a game. Furthermore, the strength of a team measured with the FIFA World Ranking does not play the important role presumed, which indicates that the element of uncertainty is working. The findings also indicate that the influence of a referee on the game result should not be neglected. Finally, the previous World Cup experiences seem to have the strongest impact on referees' performances during the game.

Economics of non-market innovation and digital literacy

This article is an abbreviated version of a debate between two economists holding somewhat different perspectives on the nature of non-market production in the space of new digital media. While the ostensible focus here is on the role of markets in the innovation of new technologies to create new economic value, this context also serves to highlight the private and public value of digital literacy.

Modelling the process of learning in economics

Student learning research literature has shown that students' learning approaches are influenced by the learning context (Evans, Kirby, & Fabrigar, 2003). Of the many contextual factors, assessment has been found to have the most important influence on the way students go about learning. For example, assessment that is perceived to required a low level of cognitive abilities will more likely elicit a learning approach that concentrate on reproductive learning activities. Moreover, assessment demand will also interact with learning approach to determine academic performance. In this paper an assessment specific model of learning comprising presage, process and product variables (Biggs, 2001) was proposed and tested against data obtained from a sample of introductory economics students (n=434). The model developed was used to empirically investigate the influence of learning inputs and learning approaches on academic performances across assessment types (essay assignment, multiple choice question exam and exam essay). By including learning approaches in the learning model, the mechanism through which learning inputs determine academic performance was examined. Methodological limitations of the study will also be discussed.

An instrument to measure the approach to learning for assessment in economics

Economics education research studies conducted in the UK, USA and Australia to investigate the effects of learning inputs on academic performance have been dominated by the input-output model (Shanahan and Meyer, 2001). In the Student Experience of Learning framework, however, the link between learning inputs and outputs is mediated by students' learning approaches which in turn are influenced by their perceptions of the learning contexts (Evans, Kirby, & Fabrigar, 2003). Many learning inventories such as Biggs' Study Process Questionnaires and Entwistle and Ramsden' Approaches to Study Inventory have been designed to measure approaches to academic learning. However, there is a limitation to using generalised learning inventories in that they tend to aggregate different learning approaches utilised in different assessments. As a result, important relationships between learning approaches and learning outcomes that exist in specific assessment context(s) will be missed (Lizzio, Wilson, & Simons, 2002). This paper documents the construction of an assessment specific instrument to measure learning approaches in economics. The post-dictive validity of the instrument was evaluated by examining the association of learning approaches to students' perceived assessment demand in different assessment contexts.

Teaching the economic way of thinking : a new approach to teaching introductory economics in a business degree

In teaching introductory economics there has been a tendency to put a lot of emphasis on imparting abstract models and technical skills to students (Stilwell, 2005; Voss, Blais, Greens, & Ahwesh, 1986). This model building approach has the merit of preparing the grounding for students 10 pursue further studies in economics. However, in a business degree with only a small proportion of students majoring in economics, such an approach tend to alienate the majority of students transiting from high school in to university. Surveys in Europe and Australia found that students complained about the lack of relevance of economics courses to the real world and the over-reliance of abstract mathematical modelling (Kirman, 2001; Lewis and Norris, 1997; Siegfried & Round, 2000). BSB112 Economics 1 is one of the eight faculty core units in the Faculty of Business at QUT, with over 1000 students in each semester. In semester I 2008, a new approach to teaching this unit was designed aiming to achieve three inter-related objectives: (1) to provide business students with a first insight into economic thinking and language, (2) to integrate economic analysis with current Australian social, environmental and political issues, and (3) to cater for students with a wide range of academic needs. Strategies used to achieve these objectives included writing up a new text which departs from traditional economics textbooks in important ways, integrating students' cultures in teaching and learning activities, and devising a new assessment format to encourage development of research skills and applications rather than reproduction of factual knowledge. This paper will document the strategies used in this teaching innovation, present quantitative and qualitative evidence to evaluate this new approach and suggest ways of further improvement.

The economics of credence goods: An experimental investigation of the role of verifiability, liability, competition and reputation in credence goods markets

Credence goods markets are characterized by asymmetric information between sellers and consumers that may give rise to inefficiencies, such as under- and overtreatment or market break-down. We study in a large experiment with 936 participants the determinants for efficiency in credence goods markets. While theory predicts that either liability or verifiability yields efficiency, we find that liability has a crucial, but verifiability only a minor effect. Allowing sellers to build up reputation has little influence, as predicted. Seller competition drives down prices and yields maximal trade, but does not lead to higher efficiency as long as liability is violated.

Learning approach and perception of learning context in economics education : a causality test

In the study of student learning literature, the traditional view holds that when students are faced with heavy workload, poor teaching, and content that they cannot relate to – important aspects of the learning context, they will more likely utilise the surface approach to learning due to stresses, lack of understanding and lack of perceived relevance of the content (Kreber, 2003; Lizzio, Wilson, & Simons, 2002; Ramdsen, 1989; Ramsden, 1992; Trigwell & Prosser, 1991; Vermunt, 2005). For example, in studies involving health and medical sciences students, courses that utilised student-centred, problem-based approaches to teaching and learning were found to elicit a deeper approach to learning than the teacher-centred, transmissive approach (Patel, Groen, & Norman, 1991; Sadlo & Richardson, 2003). It is generally accepted that the line of causation runs from the learning context (or rather students’ self reported data on the learning context) to students’ learning approaches. That is, it is the learning context as revealed by students’ self-reported data that elicit the associated learning behaviour. However, other research studies also found that the same teaching and learning environment can be perceived differently by different students. In a study of students’ perceptions of assessment requirements, Sambell and McDowell (1998) found that students “are active in the reconstruction of the messages and meanings of assessment” (p. 391), and their interpretations are greatly influenced by their past experiences and motivations. In a qualitative study of Hong Kong tertiary students, Kember (2004) found that students using the surface learning approach reported heavier workload than students using the deep learning approach. According to Kember if students learn by extracting meanings from the content and making connections, they will more likely see the higher order intentions embodied in the content and the high cognitive abilities being assessed. On the other hand, if they rote-learn for the graded task, they fail to see the hierarchical relationship in the content and to connect the information. These rote-learners will tend to see the assessment as requiring memorising and regurgitation of a large amount of unconnected knowledge, which explains why they experience a high workload. Kember (2004) thus postulate that it is the learning approach that influences how students perceive workload. Campbell and her colleagues made a similar observation in their interview study of secondary students’ perceptions of teaching in the same classroom (Campbell et al., 2001). The above discussions suggest that students’ learning approaches can influence their perceptions of assessment demands and other aspects of the learning context such as relevance of content and teaching effectiveness. In other words, perceptions of elements in the teaching and learning context are endogenously determined. This study attempted to investigate the causal relationships at the individual level between learning approaches and perceptions of the learning context in economics education. In this study, students’ learning approaches and their perceptions of the learning context were measured. The elements of the learning context investigated include: teaching effectiveness, workload and content. The authors are aware of existence of other elements of the learning context, such as generic skills, goal clarity and career preparation. These aspects, however, were not within the scope of this present study and were therefore not investigated.

Economics of maritime disasters : essays on the Titanic and Lusitania

This work seeks to fill some of the gap existing in the economics and behavioural economics literature pertaining to the decision making process of individuals under extreme environmental situations (life and death events). These essays specifically examine the sinking’s of the R.M.S. Titanic, on 14th April of 1912, and the R.M.S. Lusitania, on 7th May 1915, using econometric (multivariate) analysis techniques. The results show that even under extreme life and death conditions, social norms matter and are reflected in the survival probabilities of individuals onboard the Titanic. However, results from the comparative analysis of the Titanic and Lusitania show that social norms take time to organise and be effective. In the presence of such time constraints, the traditional “homo economicus” model of individual behaviour becomes evident as a survival of the fittest competition.

Re-thinking home economics : from modern to postmodern accounts of pedagogical bodies

Two perceptions of the marginality of home economics are widespread across educational and other contexts. One is that home economics and those who engage in its pedagogy are inevitably marginalised within patriarchal relations in education and culture. This is because home economics is characterised as women's knowledge, for the private domain of the home. The other perception is that only orthodox epistemological frameworks of inquiry should be used to interrogate this state of affairs. These perceptions have prompted leading theorists in the field to call for non-essentialist approaches to research in order to re-think the thinking that has produced this cul-de-sac positioning of home economics as a body of knowledge and a site of teacher practice. This thesis takes up the challenge of working to locate a space outside the frame of modernist research theory and methods, recognising that this shift in epistemology is necessary to unsettle the idea that home economics is inevitably marginalised. The purpose of the study is to reconfigure how we have come to think about home economics teachers and the profession of home economics as a site of cultural practice, in order to think it otherwise (Lather, 1991). This is done by exploring how the culture of home economics is being contested from within. To do so, the thesis uses a 'posthumanist' approach, which rejects the conception of the individual as a unitary and fixed entity, but instead as a subject in process, shaped by desires and language which are not necessarily consciously determined. This posthumanist project focuses attention on pedagogical body subjects as the 'unsaid' of home economics research. It works to transcend the modernist dualism of mind/body, and other binaries central to modernist work, including private/public, male/female,paid/unpaid, and valued/unvalued. In so doing, it refuses the simple margin/centre geometry so characteristic of current perceptions of home economics itself. Three studies make up this work. Studies one and two serve to document the disciplined body of home economics knowledge, the governance of which works towards normalisation of the 'proper' home economics teacher. The analysis of these accounts of home economics teachers by home economics teachers, reveals that home economics teachers are 'skilled' yet they 'suffer' for their profession. Further,home economics knowledge is seen to be complicit in reinforcing the traditional roles of masculinity and femininity, thereby reinforcing heterosexual normativity which is central to patriarchal society. The third study looks to four 'atypical'subjects who defy the category of 'proper' and 'normal' home economics teacher. These 'atypical' bodies are 'skilled' but fiercely reject the label of 'suffering'. The discussion of the studies is a feminist poststructural account, using Russo's (1994) notion of the grotesque body, which is emergent from Bakhtin's (1968) theory of the carnivalesque. It draws on the 'shreds' of home economics pedagogy,scrutinising them for their subversive, transformative potential. In this analysis, the giving and taking of pleasure and fun in the home economics classroom presents moments of surprise and of carnival. Foucault's notion of the construction of the ethical individual shows these 'atypical' bodies to be 'immoderate' yet striving hard to be 'continent' body subjects. This research captures moments of transgression which suggest that transformative moments are already embodied in the pedagogical practices of home economics teachers, and these can be 'seen' when re-looking through postmodemist lenses. Hence, the cultural practices ofhome economics as inevitably marginalised are being contested from within. Until now, home economics as a lived culture has failed to recognise possibilities for reconstructing its own field beyond the confines of modernity. This research is an example of how to think about home economics teachers and the profession as a reconfigured cultural practice. Future research about home economics as a body of knowledge and a site of teacher practice need not retell a simple story of oppression. Using postmodemist epistemologies is one way to provide opportunities for new ways of looking.

Media Economics

A concise introduction to the key ideas and issues in the study of media economics, drawing on a broad range of case studies - from Amazon and Twitter, to Apple and Netflix - to illustrate how economic paradigms are not just theories, but provide important practical insights into how the media operates today. Understanding the economic paradigms at work in media industries and markets is vitally important for the analysis of the media system as a whole. The changing dynamics of media production, distribution and consumption are stretching the capacity of established economic paradigms. In addition to succinct accounts of neo-classical and critical political economics, the text offers fresh perspectives for understanding media drawn from two 'heterodox' approaches: institutional economics and evolutionary economics. Applying these paradigms to vital topics and case studies, Media Economics stresses the value – and limits – of contending economic approaches in understanding how the media operates today. It is essential reading for all students of Media and Communication Studies, and also those from Economics, Policy Studies, Business Studies and Marketing backgrounds who are studying the media. Table of Contents: 1. Media Economics: The Mainstream Approach 2. Critical Political Economy of the Media 3. Institutional Economics 4. Evolutionary Economics 5. Case Studies and Conclusions

Integrating the resource-based view and transaction cost economics in immigrant business performance

This paper presents a new integrated framework that integrates the resource-based view and transaction cost economics to explain the phenomenon of immigrant entrepreneurship. We extend the existing literature on immigrant entrepreneurship by identifying different types of ethnic network resources and demonstrating how these resources interact with transaction costs in the context of Chinese immigrants. Thus, our study contributes to the literature by providing a theoretical framework which identifies mechanisms immigrant entrepreneurs use to strategically deploy resources to minimize costs and maximize performance outcomes.