Cost-effectiveness of a central venous catheter care bundle

Background: A bundled approach to central venous catheter care is currently being promoted as an effective way of preventing catheter-related bloodstream infection (CR-BSI). Consumables used in the bundled approach are relatively inexpensive which may lead to the conclusion that the bundle is cost-effective. However, this fails to consider the nontrivial costs of the monitoring and education activities required to implement the bundle, or that alternative strategies are available to prevent CR-BSI. We evaluated the cost-effectiveness of a bundle to prevent CR-BSI in Australian intensive care patients. ---------- Methods and Findings: A Markov decision model was used to evaluate the cost-effectiveness of the bundle relative to remaining with current practice (a non-bundled approach to catheter care and uncoated catheters), or use of antimicrobial catheters. We assumed the bundle reduced relative risk of CR-BSI to 0.34. Given uncertainty about the cost of the bundle, threshold analyses were used to determine the maximum cost at which the bundle remained cost-effective relative to the other approaches to infection control. Sensitivity analyses explored how this threshold alters under different assumptions about the economic value placed on bed-days and health benefits gained by preventing infection. If clinicians are prepared to use antimicrobial catheters, the bundle is cost-effective if national 18-month implementation costs are below $1.1 million. If antimicrobial catheters are not an option the bundle must cost less than $4.3 million. If decision makers are only interested in obtaining cash-savings for the unit, and place no economic value on either the bed-days or the health benefits gained through preventing infection, these cost thresholds are reduced by two-thirds.---------- Conclusions: A catheter care bundle has the potential to be cost-effective in the Australian intensive care setting. Rather than anticipating cash-savings from this intervention, decision makers must be prepared to invest resources in infection control to see efficiency improvements.

Using economic data to reduce healthcare-acquired infection

In this issue Burns et al. report an estimate of the economic loss to Auckland City Hospital from cases of healthcare-associated bloodstream infection. They show that patients with infection stay longer in hospital and this must impose an opportunity cost because beds are blocked. Harder to measure costs fall on patients, their families and non-acute health services. Patients face some risk of dying from the infection.

Estimating the cost of health care–associated infections : mind your p’s and q’s

Monetary valuations of the economic cost of health care–associated infections (HAIs) are important for decision making and should be estimated accurately. Erroneously high estimates of costs, designed to jolt decision makers into action, may do more harm than good in the struggle to attract funding for infection control. Expectations among policy makers might be raised, and then they are disappointed when the reduction in the number of HAIs does not yield the anticipated cost saving. For this article, we critically review the field and discuss 3 questions. Why measure the cost of an HAI? What outcome should be used to measure the cost of an HAI? What is the best method for making this measurement? The aim is to encourage researchers to collect and then disseminate information that accurately guides decisions about the economic value of expanding or changing current infection control activities.

Who makes the news : Australia : global media monitoring project 2010 national report

The Australian report for the Global Media Monitoring Project 2010 (GMMP 2010) involved a study of 374 stories that were sampled from 26 Australian newspapers, radio and television stations, and internet news services on 10 November 2009. This snapshot of reporting on that day suggests that women are under-represented in the Australian news media as both the sources and creators of news. Females made up only 24% of the 1012 news sources who were heard, read about or seen in the stories that were studied. Neglect of female sources was particularly noticeable in sports news. Women made up only 1% of the 142 sources who were talked about or quoted in sports stories. Female sources of news were disproportionately portrayed as celebrities and victims. Although women made up only 24% of sources overall, they comprised 44% of victims of crimes, accidents, war, health problems, or discrimination. Unsurprisingly, women made up 32% of sources in stories about violent crimes and 29% in stories about disasters, accidents or emergencies – usually in the role of victim. Females were commonly defined in terms of their status as a mother, daughter, wife, sister or other family relationship. Family status was mentioned for 33% of women quoted or discussed in the news stories compared to only 13% of male sources. Women also made up 75% of sources described as homemakers or parents. The Australian GMMP 2010 study also indicates a gender division among the journalists who wrote or presented the news. Only 32% of the stories were written or presented by female reporters and newsreaders. The gender inequality was again most evident in sports journalism. Findings from the Australian report also contributed to the GMMP 2010 Global Report and the Pacific GMMP 2010 Regional Report, which are available at http://whomakesthenews.org/gmmp/gmmp-reports/gmmp-2010-reports

Time-dependent analysis of length of stay and mortality due urinary tract infections in ten developing countries : INICC findings

Catheter associated urinary tract infections (CAUTI) are a worldwide problem that may lead to increased patient morbidity, cost and mortality.1e3 The literature is divided on whether there are real effects from CAUTI on length of stay or mortality. Platt4 found the costs and mortality risks to be largeyetGraves et al found the opposite.5 A reviewof the published estimates of the extra length of stay showed results between zero and 30 days.6 The differences in estimates may have been caused by the different epidemiological methods applied. Accurately estimating the effects of CAUTI is difficult because it is a time-dependent exposure. This means that standard statistical techniques, such asmatched case-control studies, tend to overestimate the increased hospital stay and mortality risk due to infection. The aim of the study was to estimate excess length of stay andmortality in an intensive care unit (ICU) due to a CAUTI, using a statistical model that accounts for the timing of infection. Data collected from ICU units in lower and middle income countries were used for this analysis.7,8 There has been little research for these settings, hence the need for this paper.

Order supported by law : the enforcement of norms in virtual communities

As online social spaces continue to grow in importance, the complex relationship between users and the private providers of the platforms continues to raise increasingly difficult questions about legitimacy in online governance. This article examines two issues that go to the core of egitimate governance in online communities: how are rules enforced and punishments imposed, and how should the law support legitimate governance and protect participants from the illegitimate exercise of power? Because the rules of online communities are generally ultimately backed by contractual terms of service, the imposition of punishment for the breach of internal rules exists in a difficult conceptual gap between criminal law and the predominantly compensatory remedies of contractual doctrine. When theorists have addressed the need for the rules of virtual communities to be enforced, a dichotomy has generally emerged between the appropriate role of criminal law for 'real' crimes, and the private, internal resolution of 'virtual' or 'fantasy' crimes. In this structure, the punitive effect of internal measures is downplayed and the harm that can be caused to participants by internal sanctions is systemically undervalued.

Perioperative mortality after hemiarthroplasty related to fixation method : a study based on the Australian Orthopaedic Association National Joint Replacement Registry

Background and purpose: The appropriate fixation method for hemiarthroplasty of the hip as it relates to implant survivorship and patient mortality is a matter of ongoing debate. We examined the influence of fixation method on revision rate and mortality.----- ----- Methods: We analyzed approximately 25,000 hemiarthroplasty cases from the AOA National Joint Replacement Registry. Deaths at 1 day, 1 week, 1 month, and 1 year were compared for all patients and among subgroups based on implant type.----- ----- Results: Patients treated with cemented monoblock hemiarthroplasty had a 1.7-times higher day-1 mortality compared to uncemented monoblock components (p < 0.001). This finding was reversed by 1 week, 1 month, and 1 year after surgery (p < 0.001). Modular hemiarthroplasties did not reveal a difference in mortality between fixation methods at any time point.----- ----- Interpretation: This study shows lower (or similar) overall mortality with cemented hemiarthroplasty of the hip.

Sex, crime and morality

Over the last few decades, there has been a marked increase in media and debate surrounding a specific group of offences in modern Democratic nations which bear the brunt of the label ‘crimes against morality’. Included within this group are offences related to prostitution and pornography, homosexuality and incest and child sexual abuse. This book examines the nexus between sex, crime and morality from a theoretical perspective. This is the first academic text to offer an examination and analysis of the philosophical underpinnings of sex-related crimes and social attitudes towards them and the historical, anthropological and moral reasons for differentiating these crimes in contemporary western culture. The book is divided into three sections corresponding to three theoretical frameworks: Part 1 examines the moral temporality of sex and taboo as a foundation for legislation governing sex crimes Part 2 focuses on the geography of sex and deviance, specifically notions of public morality and the public private divide Part 3 examines the moral economy of sex and harm, including the social construction of harm. Sex, Crime and Morality will be key reading for students of criminology, criminal justice, gender studies and ethics, and will also be of interest to justice professionals.

Absence of malice: Constructing the female sex offender

It could be argued that all crimes have a general moral basis, condemned as ‘wrong’ or ‘bad’ in the society in which they are proscribed, however, there are a specific group of offences in modern democratic nations which bear the brunt of the label, crimes against morality. Included within this group are offences related to prostitution and pornography, homosexuality and incest, as well as child sexual abuse. While the places where sex and morality meet have shifted over time, these two concepts continue to form the basis of much criminal legislation and associated criminal justice responses. Offenders of sexual mores are positioned as the reviled corruptors of innocent children, the purveyors of disease, an indictment on the breakdown of the family and/or the secularisation of society, and a corruptive force (Davidson 2008, Kincaid 1998). Other types of offending may divide public and political opinion, but the consensus on sex crimes appears constant.

Living well with diabetes: a randomized controlled trial of a telephone-delivered intervention for maintenance of weight loss, physical activity and glycaemic control in adults with type 2 diabetes

Background By 2025, it is estimated that approximately 1.8 million Australian adults (approximately 8.4% of the adult population) will have diabetes, with the majority having type 2 diabetes. Weight management via improved physical activity and diet is the cornerstone of type 2 diabetes management. However, the majority of weight loss trials in diabetes have evaluated short-term, intensive clinic-based interventions that, while producing short-term outcomes, have failed to address issues of maintenance and broad population reach. Telephone-delivered interventions have the potential to address these gaps. Methods/Design Using a two-arm randomised controlled design, this study will evaluate an 18-month, telephone-delivered, behavioural weight loss intervention focussing on physical activity, diet and behavioural therapy, versus usual care, with follow-up at 24 months. Three-hundred adult participants, aged 20-75 years, with type 2 diabetes, will be recruited from 10 general practices via electronic medical records search. The Social-Cognitive Theory driven intervention involves a six-month intensive phase (4 weekly calls and 11 fortnightly calls) and a 12-month maintenance phase (one call per month). Primary outcomes, assessed at 6, 18 and 24 months, are: weight loss, physical activity, and glycaemic control (HbA1c), with weight loss and physical activity also measured at 12 months. Incremental cost-effectiveness will also be examined. Study recruitment began in February 2009, with final data collection expected by February 2013. Discussion This is the first study to evaluate the telephone as the primary method of delivering a behavioural weight loss intervention in type 2 diabetes. The evaluation of maintenance outcomes (6 months following the end of intervention), the use of accelerometers to objectively measure physical activity, and the inclusion of a cost-effectiveness analysis will advance the science of broad reach approaches to weight control and health behaviour change, and will build the evidence base needed to advocate for the translation of this work into population health practice.

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.

Optimising collection of footprint evidence from crime scenes and suspects

Analysis of either footprints or footwear impressions which have been recovered from a crime scene is a well known and well accepted part of forensic investigation. When this evidence is obtained by investigating officers, comparative analysis to a suspect’s evidence may be undertaken. This can be done either by the detectives or in some cases, podiatrists with experience in forensic analysis. Frequently asked questions of a podiatrist include; “What additional information should be collected from a suspect (for the purposes of comparison), and how should it be collected?” This paper explores the answers to these and related questions based on 20 years of practical experience in the field of crime scene analysis as it relates to podiatry and forensics. Elements of normal and abnormal foot function are explored and used to explain the high degree of variability in wear patterns produced by the interaction of the foot and footwear. Based on this understanding the potential for identifying unique features of the user and correlating this to footwear evidence becomes apparent. Standard protocols adopted by podiatrists allow for more precise, reliable, and valid results to be obtained from their analysis. Complex data sets are now being obtained by investigating officers and, in collaboration with the podiatrist; higher quality conclusions are being achieved. This presentation details the results of investigations which have used standard protocols to collect and analyse footwear and suspects of recent major crimes.

Offending Youth : Crime, Sex and Justice

Rates of female delinquency, especially for violent crimes, are increasing in most common law countries. At the same time the growth in cyber-bullying, especially among girls, appears to be a related global phenomenon. While the gender gap in delinquency is narrowing in Australia, United States, Canada and the United Kingdom, boys continue to dominate the youth who commit crime and have a virtual monopoly over sexually violent crimes. Indigenous youth continue to be vastly over-represented in the juvenile justice system in every Australian jurisdiction. The Indigenisation of delinquency is a persistent problem in other countries such as Canada and New Zealand. Young people who gather in public places are susceptible to being perceived as somehow threatening or riotous, attracting more than their share of public order policing. Professional football has been marred by repeated scandals involving sexual assault, violence and drunkenness. Given the cultural significance of footballers as role models to thousands, if not millions, of young men around the world, it is vitally important to address this problem. Offending Youth explores these key contemporary patterns of delinquency, the response to these by the juvenile justice agencies and moreover what can be done to address these problems. The book also analyses the major policy and legislative changes from the nineteenth to twenty first centuries, chiefly the shift the penal welfarism to diversion and restorative justice. Using original cases studied by Carrington twenty years ago, Offending Youth illustrates how penal welfarism criminalised young people from socially marginal backgrounds, especially Aboriginal children, children from single parent families, family-less children, state wards and young people living in poverty or in housing commission estates. A number of inquiries in Australia and the United Kingdom have since established that children committed to these institutions, supposedly for their own good, experienced systemic physical, sexual and psychological abuse during their institutionalisation. The book is dedicated to the survivors of these institutions who only now are receiving official recognition of the injustices they suffered. The underlying philosophy of juvenile justice has fundamentally shifted away from penal welfarism to embrace positive policy responses to juvenile crime, such as youth conferencing, cautions, warnings, restorative justice, circle sentencing and diversion examined in the concluding chapter. Offending Youth is aimed at a broad readership including policy makers, juvenile justice professionals, youth workers, families, teachers, politicians as well as students and academics in criminology, policing, gender studies, masculinity studies, Indigenous studies, justice studies, youth studies and the sociology of youth and deviance more generally.-- [from publisher website]

Libya and the international community’s 'responsibility to protect'

The Libyan regime’s attacks on its own civilian population are a test case for the international community’s commitment to the notion of a “responsibility to protect” (R2P). The UN Security Council’s statement on 22 February 2011 explicitly invoked this concept by calling on “the Government of Libya to meet its responsibility to protect its population”. Yet, with Muammar Gaddafi encouraging further violence against protesters and threatening to fight “until the last drop of blood” it seems unlikely that the Security Council’s warning will be heeded. Greater pressure from the international community will be needed to bring an end to the atrocities in Libya. The international response to the Libyan crisis represents an opportunity to translate the theory of R2P into practice.

Responsibility to Protect and Sovereignty

The responsibility to protect ('R2P') principle articulates the obligations of the international community to prevent conflict occurring, to intervene in conflicts, and to assist in rebuilding after conflicts. The doctrine is about protecting civilians in armed conflicts from four mass atrocity crimes: genocide, war crimes, crimes against humanity and ethnic cleansing. This book examines interventions in East Timor, Sri Lanka, Sudan and Kosovo. The chapters explore and question UN debates with respect to the doctrine both before and after its adoption in 2005; contrasting state attitudes to international military intervention; and what takes place after intervention. It also discusses the ability of the Security Council to access reliable information and credible and transparent processes to enable it to make a determination on the occurrence of atrocities in a Member State. Questioning whether there is a need to find a closer operational link between the responsibilities to prevent and react and a normative link between R2P and principles of international law, the contributions examine the effectiveness of the framework of R2P for international decision-making in response to mass atrocity crimes and ask how an international system to deal with threats and mass atrocities can be developed in the absence of a central authority. This book will be valuable to those interested in international law, human rights, and security, peace and conflict studies