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.

Screening, isolation, and decolonisation strategies in the control of meticillin resistant Staphylococcus aureus in intensive care units : cost effectiveness evaluation

Objective: To assess the cost-effectiveness of screening, isolation and decolonisation strategies in the control of methicillin-resistant Staphylococcus aureus (MRSA) in intensive care units (ICUs). Design: Economic evaluation. Setting: England and Wales. Population: ICU patients. Main outcome measures: Infections, deaths, costs, quality adjusted life years (QALYs), incremental cost-effectiveness ratios for alternative strategies, net monetary benefits (NMBs). Results: All strategies using isolation but not decolonisation improved health outcomes but increased costs. When MRSA prevalence on admission to the ICU was 5% and the willingness to pay per QALY gained was between £20,000 and £30,000, the best such strategy was to isolate only those patients at high risk of carrying MRSA (either pre-emptively or following identification by admission and weekly MRSA screening using chromogenic agar). Universal admission and weekly screening using polymerase chain reaction (PCR)-based MRSA detection coupled with isolation was unlikely to be cost-effective unless prevalence was high (10% colonised with MRSA on admission to the ICU). All decolonisation strategies improved health outcomes and reduced costs. While universal decolonisation (regardless of MRSA status) was the most cost-effective in the short-term, strategies using screening to target MRSA carriers may be preferred due to reduced risk of selecting for resistance. Amongst such targeted strategies, universal admission and weekly PCR screening coupled with decolonisation with nasal mupirocin was the most cost-effective. This finding was robust to ICU size, MRSA admission prevalence, the proportion of patients classified as high-risk, and the precise value of willingness to pay for health benefits. Conclusions: MRSA control strategies that use decolonisation are likely to be cost-saving in an ICU setting provided resistance is lacking, and combining universal PCR-based screening with decolonisation is likely to represent good value for money if untargeted decolonisation is considered unacceptable. In ICUs where decolonisation is not implemented there is insufficient evidence to support universal MRSA screening outside high prevalence settings.

Funding grant proposals for scientific research : retrospective analysis of scores by members of grant review panel

Objectives: To quantify randomness and cost when choosing health and medical research projects for funding. Design: Analysis of retrospective data from grant review panels. Setting: The National Health & Medical Research Council of Australia. Participants/Data: All panel members’ scores for grant proposals submitted in 2009. Main outcome measure: The proportion of grant proposals that were always, sometimes and never funded after accounting for random variability arising from variation in panel members’ scores; the cost-effectiveness of different size assessment panels. Results: 59% of 620 funded grants were sometimes not funded when random variability was accounted for. Only 9% of grant proposals were always funded, 61% were never funded and 29% were sometimes funded. The extra cost per grant effectively funded from the most effective system was $18,541. Conclusions: Allocating funding for scientific research in health and medicine is costly and somewhat random. There are many useful research questions to be addressed that could improve current processes.

Comparing the cost-effectiveness of MRSA control strategies between ICU and non-ICU settings

Introduction / objectives Many strategies are used to control MRSA in hospitals. Only a few have been assessed in clinical trials and it is not obvious how findings should be generalised between settings. Uncertainty remains about which strategies represent the most appropriate use of scarce resources. We assess the cost-effectiveness of alternative MRSA screening and infection control strategies in England and Wales and discuss international relevance. Methods Models of MRSA transmission in ICUs and general medical (GM) wards were developed and used to evaluate different screening methods combined with decolonisation or isolation. Strategies were compared in terms of costs and health benefits (quality adjusted life years, QALYs). Different prevalences, proportions of high risk patients and ward sizes were investigated, and probabilistic sensitivity analyses (PSA) conducted. Results Decolonisation strategies were cost-saving in ICUs at a 5% admission prevalence, with admission and weekly PCR screening the most cost-effective (£3,929/QALY). In ICUs, screening and isolation reduced infection rates by ~10%. With admission prevalence ≤5%, targeting screening and isolation to high risk patients was optimal. In GM wards decolonisation and isolation strategies, though able to reduce MRSA infection rates up to ~50%, were not cost-effective. Conclusion The largest reductions in MRSA infection were achieved by screening and decolonisation strategies, and were cost-effective in ICU settings. In comparison, there is limited potential for screening and control strategies to be cost-effective in GM wards due to lower infection and mortality rates.

Raising awareness of traffic pollution: the potential benefits and problems of using a warning smell

Exposure to traffic pollution is increasing worldwide as people move to cities, and as more vehicles join the roads, creating longer journeys and more traffic jams. Most traffic pollutants are odourless and invisible, which hides exposure from the public. If traffic pollution had a distinctive smell it would enable people to avoid exposure, and increase the political will for difficult policy changes. A smell may also instigate longer-term changes, such as switching to active transport for school pick-ups. A smell could be added using a fuel additive or a temporary device attached to vehicle exhausts.

Evaluating the economics of the Australian National Hand Hygiene Initiative

The National Hand Hygiene Initiative, implemented in Australia in 2009, is currently being evaluated for effectiveness and cost-effectiveness by a multidisciplinary team of researchers. Data from a wide range of sources are being harvested to address the research questions. The data are observational and appropriate statistical and economic modelling methods are being used. Decision makers will be provided with new knowledge about how hand hygiene interventions should be organised and what investment decisions are justified. This is novel research and the authors are unaware of any other evaluation of hand hygiene improvement initiatives. This paper describes the evaluation currently underway.

Occupational therapy students’ contribution to occasions of service during practice placements in health settings

Currently in the Australian higher education sector, the productivity benefits of occupational therapy clinical education placements are a contested issue. This article will report results of a study that developed a methodology for documenting time use during placements and investigated the productivity changes associated with occupational therapy clinical education placements in Queensland, Australia. Supervisors’ and students’ time use during placements and how this changed for supervisors compared to pre- and post-placement is also presented. Methods: Using a cohort survey design, participants were students from two Queensland universities, and their supervisors employed by Queensland Health. Time use was recorded in 30 minute blocks according to particular categories. Results: There was a significant increase in supervisors’ time spent in patient care activities (F = 94.0112,12.37 df, P < 0.001) between pre- and during placement (P < 0.001) and decrease between during and post-placement (P < 0.001). Supervisors’ time spent in all non-patient care activities was also significant (F = 4.5802,16 df, P = 0.027) increasing between pre- and during placement (P = 0.028). There was a significant decrease in supervisors’ time spent in placement activities (F = 5.1332,19.18 df, P = 0.016) from during to post-placement. Students spent more time than supervisors in patient care activities while on placement. Discussion: A novel method for reporting productivity and time-use changes during clinical education programs for occupational therapy has been applied. Supervisors spent considerable time in assessing and managing students and their clinical education role should be seen as core business in standard occupational therapy practice. This paper will contribute to future assessments of the economic.

The Working After Cancer Study (WACS): a population-based study of middle-aged workers diagnosed with colorectal cancer and their return to work experiences

Background The number of middle-aged working individuals being diagnosed with cancer is increasing and so too will disruptions to their employment. The aim of the Working After Cancer Study is to examine the changes to work participation in the 12 months following a diagnosis of primary colorectal cancer. The study will identify barriers to work resumption, describe limitations on workforce participation, and evaluate the influence of these factors on health-related quality of life. Methods/Design An observational population-based study has been designed involving 260 adults newly-diagnosed with colorectal cancer between January 2010 and September 2011 and who were in paid employment at the time they were diagnosed. These cancer cases will be compared to a nationally representative comparison group of 520 adults with no history of cancer from the general population. Eligible cases will have a histologically confirmed diagnosis of colorectal cancer and will be identified through the Queensland Cancer Registry. Data on the comparison group will be drawn from the Household, Income and Labour Dynamics in Australia (HILDA) Survey. Data collection for the cancer group will occur at 6 and 12 months after diagnosis, with work questions also asked about the time of diagnosis, while retrospective data on the comparison group will be come from HILDA Waves 2009 and 2010. Using validated instruments administered via telephone and postal surveys, data will be collected on socio-demographic factors, work status and circumstances, and health-related quality of life (HRQoL) for both groups while the cases will have additional data collected on cancer treatment and symptoms, work productivity and cancer-related HRQoL. Primary outcomes include change in work participation at 12 months, time to work re-entry, work limitations and change in HRQoL status. Discussion This study will address the reasons for work cessation after cancer, the mechanisms people use to remain working and existing workplace support structures and the implications for individuals, families and workplaces. It may also provide key information for governments on productivity losses.

Cost effectiveness of nutrition support in the prevention of pressure ulcer in hospitals

Background/objectives This study estimates the economic outcomes of a nutrition intervention to at-risk patients compared with standard care in the prevention of pressure ulcer. Subjects/methods Statistical models were developed to predict ‘cases of pressure ulcer avoided’, ‘number of bed days gained’ and ‘change to economic costs’ in public hospitals in 2002–2003 in Queensland, Australia. Input parameters were specified and appropriate probability distributions fitted for: number of discharges per annum; incidence rate for pressure ulcer; independent effect of pressure ulcer on length of stay; cost of a bed day; change in risk in developing a pressure ulcer associated with nutrition support; annual cost of the provision of a nutrition support intervention for at-risk patients. A total of 1000 random re-samples were made and the results expressed as output probability distributions. Results The model predicts a mean 2896 (s.d. 632) cases of pressure ulcer avoided; 12 397 (s.d. 4491) bed days released and corresponding mean economic cost saving of euros 2 869 526 (s.d. 2 078 715) with a nutrition support intervention, compared with standard care. Conclusion Nutrition intervention is predicted to be a cost-effective approach in the prevention of pressure ulcer in at-risk patients.

Productivity and time use during occupational therapy and nutrition/dietetics clinical education : a cohort study

Background: Currently in the Australian higher education sector higher productivity from allied health clinical education placements are a contested issue. This paper will report results of a study that investigated output changes associated with occupational therapy and nutrition/dietetics clinical education placements in Queensland, Australia. Supervisors’ and students’ time use during placements and how this changes for supervisors compared to when students are not present in the workplace is also presented. Methodology/Principal Findings: A cohort design was used with students from four Queensland universities, and their supervisors employed by Queensland Health. There was an increasing trend in the number of occasions of service delivered when the students were present, and a statistically significant increase in the daily mean length of occasions of service delivered during the placement compared to pre-placement levels. For project-based placements that were not directly involved in patient care, supervisors’ project activity time decreased during placements, with students undertaking considerably more time in project activities. Conclusions/Significance: A novel method for estimating productivity and time use changes during clinical education programs for allied health disciplines has been applied. During clinical education placements there was a net increase in outputs, suggesting supervisors engage in longer consultations with patients for the purpose of training students, while maintaining patient numbers. Other activities are reduced. This paper is the first time these data have been shown and form a good basis for future assessments of the economic impact of student placements for allied health disciplines.

Key priorities for Australian infection control : summary of findings from the launch of the Centre for Research Excellence in Reducing Healthcare Associated Infections

The launch of the Centre of Research Excellence in Reducing Healthcare Associated Infection (CRE-RHAI) took place in Sydney on Friday 12 October 2012. The mission of the CRE-RHAI is to generate new knowledge about strategies to reduce healthcare associated infections and to provide data on the cost-effectiveness of infection control programs. As well as launching the CRE-RHAI, an important part of this event was a stakeholder Consultation Workshop, which brought together several experts in the Australian infection control community. The aims of this workshop were to establish the research and clinical priorities in Australian infection control, assess the importance of various multi-resistant organisms, and to gather information about decision making in infection control. We present here a summary and discussion of the responses we received.