What We Have Here is a Failure to Communicate! Improving Communication between Tertiary to Primary Care for Chronic Heart Failure Patients

Background:  The aims of this study were to determine the documentation of pharmacotherapy optimization goals in the discharge letters of patients with the principal diagnosis of chronic heart failure. Methods:  A retrospective practice audit of 212 patients discharged to the care of their local general practitioner from general medical units of a large tertiary hospital. Details of recommendations regarding ongoing pharmacological and non-pharmacological management were reviewed. The doses of medications on discharge were noted and whether they met current guidelines recommending titration of angiotensin-converting enzyme inhibitors and beta-blockers. Ongoing arrangements for specialist follow up were also reviewed. Results:  The mean age of patients whose letters were reviewed was 78.4 years (standard deviation ± 8.6); 50% were men. Patients had an overall median of six comorbidities and eight regular medications on discharge. Mean length of stay for each admission was 6 days. Discharge letters were posted a median of 4 days after discharge, with 25% not posted at 10 days. No discharge letter was sent in 9.4% (20) of the cases. Only six (2.8%) letters had any recommendations regarding future titration of angiotensin-converting enzyme inhibitors and 6.6% (14) for beta-blockers. Recommendations for future non-pharmacological management, for example, diuretic action plans, regular weight monitoring and exercise plans were not found in the letters in this audit. Conclusion:  Hospital discharge is an opportunity to communicate management plans for treatment optimization effectively, and while this opportunity is spurned, implementation gaps in the management of cardiac failure will probably remain.

Rural and Urban Differentials in Primary Care Management of Chronic Heart Failure: New Data from the CASE Study

Objective: To determine whether primary care management of chronic heart failure (CHF) differed between rural and urban areas in Australia. Design: A cross-sectional survey stratified by Rural, Remote and Metropolitan Areas (RRMA) classification. The primary source of data was the Cardiac Awareness Survey and Evaluation (CASE) study. Setting: Secondary analysis of data obtained from 341 Australian general practitioners and 23 845 adults aged 60 years or more in 1998. Main outcome measures: CHF determined by criteria recommended by the World Health Organization, diagnostic practices, use of pharmacotherapy, and CHF-related hospital admissions in the 12 months before the study. Results: There was a significantly higher prevalence of CHF among general practice patients in large and small rural towns (16.1%) compared with capital city and metropolitan areas (12.4%) (P < 0.001). Echocardiography was used less often for diagnosis in rural towns compared with metropolitan areas (52.0% v 67.3%, P < 0.001). Rates of specialist referral were also significantly lower in rural towns than in metropolitan areas (59.1% v 69.6%, P < 0.001), as were prescribing rates of angiotensin-converting enzyme inhibitors (51.4% v 60.1%, P < 0.001). There was no geographical variation in prescribing rates of β-blockers (12.6% [rural] v 11.8% [metropolitan], P = 0.32). Overall, few survey participants received recommended “evidence-based practice” diagnosis and management for CHF (metropolitan, 4.6%; rural, 3.9%; and remote areas, 3.7%). Conclusions: This study found a higher prevalence of CHF, and significantly lower use of recommended diagnostic methods and pharmacological treatment among patients in rural areas.

Crisis communication under transformative change : the emergent context and roles of primary and secondary organisations

In an era of complex challenges that draw sustained media attention and entangle multiple organisational actors, this thesis addresses the gap between current trends in society and business, and existing scholarship in public relations and crisis communication. By responding to calls from crisis communication researchers to develop theory (Coombs, 2006a), to examine the interdependencies of crises (Seeger, Sellnow, & Ulmer, 1998), and to consider variation in crisis response (Seeger, 2002), this thesis contributes to theory development in crisis communication and public relations. Through transformative change, this thesis extends existing scholarship built on a preservation or conservation logic where public relations is used to maintain stability by incrementally responding to changes in an organisation‘s environment (Cutlip, Center, & Broom, 2006; Everett, 2001; Grunig, 2000; Spicer, 1997). Based on the opportunity to contribute to ongoing theoretical development in the literature, the overall research problem guiding this thesis asks: How does transformative change during crisis influence corporate actors’ communication? This thesis adopts punctuated equilibrium theory, which describes change as alternating between long periods of stability and short periods of revolutionary or transformative change (Gersick, 1991; Romanelli & Tushman, 1994; Siggelkow, 2002; Tushman, Newman, & Romanelli, 1986; Tushman & Romanelli, 1985). As a theory for change, punctuated equilibrium provides an opportunity to examine public relations and transformative change, building on scholarship that is based primarily on incremental change. Further, existing scholarship in public relations and crisis communication focuses on the actions of single organisations in situational or short-term crisis events. Punctuated equilibrium theory enables the study of multiple crises and multiple organisational responses during transformative change. In doing so, punctuated equilibrium theory provides a framework to explain both the context for transformative change and actions or strategies enacted by organisations during transformative change (Tushman, Newman, & Romanelli, 1986; Tushman & Romanelli, 1985; Tushman, Virany, & Romanelli, 1986). The connections between context and action inform the research questions that guide this thesis: RQ1: What symbolic and substantive strategies persist and change as crises develop from situational events to transformative and multiple linked events? RQ2: What features of the crisis context influence changes in symbolic and substantive strategies? To shed light on these research questions, the thesis adopts a qualitative approach guided by process theory and methods to explicate the events, sequences and activities that were essential to change (Pettigrew, 1992; Van de Ven, 1992). Specifically, the thesis draws on an alternative template strategy (Langley, 1999) that provides several alternative interpretations of the same events (Allison, 1971; Allison & Zelikow, 1999). Following Allison (1971) and Allison and Zelikow (1999), this thesis uses three alternative templates of crisis or strategic response typologies to construct three narratives using media articles and organisational documents. The narratives are compared to identify and draw out different patterns of crisis communication strategies that operate within different crisis contexts. The thesis is based on the crisis events that affected three organisations within the pharmaceutical industry for four years. The primary organisation is Merck, as its product recall crisis triggered transformative change affecting, in different ways, the secondary organisations of Pfizer and Novartis. Three narratives are presented based on the crisis or strategic response typologies of Coombs (2006b), Allen and Caillouet (1994), and Oliver (1991). The findings of this thesis reveal different stories about crisis communication under transformative change. By zooming in to a micro perspective (Nicolini, 2009) to focus on the crisis communication and actions of a single organisation and zooming out to a macro perspective (Nicolini, 2009) to consider multiple organisations, new insights about crisis communication, change and the relationships among multiple organisations are revealed at context and action levels. At the context level, each subsequent narrative demonstrates greater connections among multiple corporate actors. By zooming out from Coombs‘ (2006b) focus on single organisations to consider Allen and Caillouet‘s (1994) integration of the web of corporate actors, the thesis demonstrates how corporate actors add accountability pressures to the primary organisation. Next, by zooming further out to the macro perspective by considering Oliver‘s (1991) strategic responses to institutional processes, the thesis reveals a greater range of corporate actors that are caught up in the process of transformative change and accounts for their varying levels of agency over their environment. By zooming in to a micro perspective and out to a macro perspective (Nicolini, 2009) across alternative templates, the thesis sheds light on sequences, events, and actions of primary and secondary organisations. Although the primary organisation remains the focus of sustained media attention across the four-year time frame, the secondary organisations, even when one faced a similar starting situation to the primary organisation, were buffered by the process of transformative change. This understanding of crisis contexts in transforming environments builds on existing knowledge in crisis communication. At the action level, the thesis also reveals different interpretations from each alternative template. Coombs‘ (2006b) narrative shows persistence in the primary organisation‘s crisis or strategic responses over the four-year time frame of the thesis. That is, the primary organisation consistently applies a diminish crisis response. At times, the primary organisation drew on denial responses when corporate actors questioned its legitimacy or actions. To close the crisis, the primary organisation uses a rebuild crisis posture (Coombs, 2006). These finding are replicated in Allen and Caillouet‘s (1994) narrative, noting this template‘s limitation to communication messages only. Oliver‘s (1991) narrative is consistent with Coombs‘ (2006b) but also demonstrated a shift from a strategic response that signals conformity to the environment to one that signals more active resistance to the environment over time. Specifically, the primary organisation‘s initial response demonstrates conformity but these same messages were used some three years later to set new expectations in the environment in order to shape criteria and build acceptance for future organisational decisions. In summary, the findings demonstrate the power of crisis or strategic responses when considered over time and in the context of transformative change. The conclusions of this research contribute to scholarship in the public relations and management literatures. Based on the significance of organisational theory, the primary contribution of the theory relates to the role of interorganisational linkages or legitimacy buffers that form during the punctuation of equilibrium. The network of linkages among the corporate actors are significant also to the crisis communication literature as they form part of the process model of crisis communication under punctuated equilibrium. This model extends existing research that focuses on crisis communication of single organisations to consider the emergent context that incorporates secondary organisations as well as the localised contests of legitimacy and buffers from regulatory authorities. The thesis also provides an empirical base for punctuated equilibrium in public relations and crisis communication, extending Murphy‘s (2000) introduction of the theory to the public relations literature. In doing this, punctuated equilibrium theory reinvigorates theoretical development in crisis communication by extending existing scholarship around incrementalist approaches and demonstrating how public relations works in the context of transformative change. Further research in this area could consider using alternative templates to study transformative change caused by a range of crisis types from natural disasters to product tampering, and to add further insight into the dynamics between primary and secondary organisations. This thesis contributes to practice by providing guidelines for crisis response strategy selection and indicators related to the emergent context for crises under transformative change that will help primary and secondary organisations‘ responses to crises.

Early years teachers’ attitudes towards mathematics

Worldwide, there is considerable attention to providing a supportive mathematics learning environment for young children because attitude formation and achievement in these early years of schooling have a lifelong impact. Key influences on young children during these early years are their teachers. Practising early years teachers‟ attitudes towards mathematics influence the teaching methods they employ, which in turn, affects young students‟ attitudes towards mathematics, and ultimately, their achievement. However, little is known about practising early years teachers‟ attitudes to mathematics or how these attitudes form, which is the focus of this study. The research questions were: 1. What attitudes do practising early years teachers hold towards mathematics? 2. How did the teachers‟ mathematics attitudes form? This study adopted an explanatory case study design (Yin, 2003) to investigate practising early years teachers‟ attitudes towards mathematics and the formation of these attitudes. The research took place in a Brisbane southside school situated in a middle socio-economic area. The site was chosen due to its accessibility to the researcher. The participant group consisted of 20 early years teachers. They each completed the Attitude Towards Mathematics Inventory (ATMI) (Schackow, 2005), which is a 40 item instrument that measures attitudes across the four dimensions of attitude, namely value, enjoyment, self-confidence and motivation. The teachers‟ total ATMI scores were classified according to five quintiles: strongly negative, negative, neutral, positive and strongly positive. The results of the survey revealed that these teachers‟ attitudes ranged across only three categories with one teacher classified as strongly positive, twelve teachers classified as positive and seven teachers classified as neutral. No teachers were identified as having negative or strongly negative attitudes. Subsequent to the surveys, six teachers with a breadth of attitudes were selected from the original cohort to participate in open-ended interviews to investigate the formation of their attitudes. The interview data were analysed according to the four dimensions of attitudes (value, enjoyment, self-confidence, motivation) and three stages of education (primary, secondary, tertiary). Highlighted in the findings is the critical impact of schooling experiences on the formation of student attitudes towards mathematics. Findings suggest that primary school experiences are a critical influence on the attitudes of adults who become early years teachers. These findings also indicate the vital role tertiary institutions play in altering the attitudes of preservice teachers who have had negative schooling experiences. Experiences that teachers indicated contributed to the formation of positive attitudes in their own education were games, group work, hands-on activities, positive feedback and perceived relevance. In contrast, negative experiences that teachers stated influenced their attitudes were insufficient help, rushed teaching, negative feedback and a lack of relevance of the content. These findings together with the literature on teachers‟ attitudes and mathematics education were synthesized in a model titled a Cycle of Early Years Teachers’ Attitudes Towards Mathematics. This model explains positive and negative influences on attitudes towards mathematics and how the attitudes of adults are passed on to children, who then as adults themselves, repeat the cycle by passing on attitudes to a new generation. The model can provide guidance for practising teachers and for preservice and inservice education about ways to foster positive influences to attitude formation in mathematics and inhibit negative influences. Two avenues for future research arise from the findings of this study both relating to attitudes and secondary school experiences. The first question relates to the resilience of attitudes, in particular, how an individual can maintain positive attitudes towards mathematics developed in primary school, despite secondary school experiences that typically have a negative influence on attitude. The second question relates to the relationship between attitudes and achievement, specifically, why secondary students achieve good grades in mathematics despite a lack of enjoyment, which is one of the dimensions of attitude.

Data modelling in the beginning school years

This paper argues for a renewed focus on statistical reasoning in the beginning school years, with opportunities for children to engage in data modelling. Some of the core components of data modelling are addressed. A selection of results from the first data modelling activity implemented during the second year (2010; second grade) of a current longitudinal study are reported. Data modelling involves investigations of meaningful phenomena, deciding what is worthy of attention (identifying complex attributes), and then progressing to organising, structuring, visualising, and representing data. Reported here are children's abilities to identify diverse and complex attributes, sort and classify data in different ways, and create and interpret models to represent their data.

Design on the future: developing and enacting sustainable living programs in primary schools

Sustainable living is high on the international agenda (Ginsberg & Frame, 2004; Sutton, 2004). If education is fundamental to global transformation towards sustainability, then schools are in strategic positions to facilitate this change. Over recent years, schools in Australia have become more active in encouraging sustainability with the implementation of programs such as Science Education for Sustainable Living (SESL) that focus on topics such as energy efficiency, recycling, enhancing biodiversity, protecting species, and managing resources. This paper reports on a government funded Australian School Innovation in Science, Technology and Mathematics (ASISTM) project titled “Integrating science, technology and mathematics for understanding sustainable living” in which teachers, preservice teachers and other science professionals worked collaboratively to plan and enact a range of SESL programs for primary school students. Participants in this study included: 6 teachers, 5 preservice teachers, 2 university partners, 2 scientists, 4 consultants, and over 250 primary students. The findings from this qualitative study revealed a need for: (1) professional development for understanding SESL, (2) procedures for establishing and implementing SESL, and (3) strategies to devise, implement and evaluate SESL units of work.

Sunscreen application thickness amongst primary school children : the children and sunscreen study

Childhood sun exposure has been associated with increased risk of developing melanoma later in life. Sunscreen, children.s preferred method of sun protection, has been shown to reduce skin cancer risk. However, the effectiveness of sunscreen is largely dependent on user compliance, such as the thickness of application. To reach the sun protection factor (SPF) sunscreen must be applied at a thickness of 2mg/cm2. It has been demonstrated that adults tend to apply less than half of the recommended 2mg/cm2. This was the first study to measure the thickness at which children apply sunscreen. We recruited 87 primary school aged children (n=87, median age 8.7, 5-12 years) from seven state schools within one Brisbane education district (32% consent rate). The children were supplied with sunscreen in three dispenser types (pump, squeeze and roll-on) and were asked to use these for one week each. We measured the weight of the sunscreen before and after use, and calculated the children.s body surface area (based on height and weight) and area to which sunscreen was applied (based on children.s self-reported body coverage of application). Combined these measurements resulted in an average thickness of sunscreen application, which was our main outcome measure. We asked parents to complete a self-administered questionnaire which captured information about potential explanatory variables. Children applied sunscreen at a median thickness of 0.48mg/cm2, significantly less than the recommended 2mg/cm2 (p<0.001). When using the roll-on dispenser (median 0.22mg/cm2), children applied significantly less sunscreen thickness, compared to the pump (median 0.75mg.cm2, p<0.001), and squeeze (median 0.57mg/cm2, p<0.001) dispensers. School grade (1-7) was significantly associated with thickness of application (p=0.032), with children in the youngest grades applying the most. Other variables that were significantly associated with the outcome variable included: number of siblings (p=0.001), household annual income (p<0.001), and the number of lifetime sunburns the child had experienced (p=0.007). This work is the first to measure children.s sunscreen application thickness and demonstrates that regardless of their age or the type of dispenser that they use, children do not apply enough sunscreen to reach the advertised SPF. It is envisaged that this study will assist in the formulation of recommendations for future research, practice and policy aimed at improving childhood sun protection to reduce skin cancer incidence in the future.

Alternative primary sources for studying Australian television history : an annotated list of online private collections

It is possible to write many different histories of Australian television, and these different histories draw on different primary sources. The ABC of Drama, for example, draws on the ABC Document Archives (Jacka 1991). Most of the information for Images and Industry: television drama production in Australia is taken from original interviews with television production staff (Moran 1985). Ending the Affair, as well as archival work, draws on ‘over ten years of watching … Australian television current affairs’ (Turner 2005, xiii). Moran’s Guide to Australian TV Series draws exhaustively on extant archives: the ABC Document Archives, material sourced through the ABC Drama department, the Australian Film Commission, the library of the Australian Film, Television and Radio School, and the Australian Film Institute (Moran 1993, xi)...

Quality of work life and turnover intention in primary healthcare organisations : a cross-sectional study of registered nurses in Saudi Arabia

Purpose: The purpose of this study was to improve the retention of primary healthcare (PHC) nurses through exploring and assessing their quality of work life (QWL) and turnover intention. Design and methods: A cross-sectional survey design was used in this study. Data were collected using a questionnaire comprising four sections (Brooks’ survey of Quality of Nursing Work Life [QNWL], Anticipated Turnover Intention, open-ended questions and demographic characteristics). A convenience sample was recruited from 143 PHC centres in Jazan, Saudi Arabia. A response rate of 87% (n = 508/585) was achieved. The SPSS v17 for Windows and NVivo 8 were used for analysis purposes. Procedures and tests used in this study to analyse the quantitative data were descriptive statistics, t-test, ANOVA, General Linear Model (GLM) univariate analysis, standard multiple regression, and hierarchical multiple regression. Qualitative data obtained from responses to the open-ended questions were analysed using the NVivo 8. Findings: Quantitative findings suggested that PHC nurses were dissatisfied with their work life. Respondents’ scores ranged between 45 and 218 (mean = 139.45), which is lower than the average total score on Brooks’ Survey (147). Major influencing factors were classified under four dimensions. First, work life/home life factors: unsuitable working hours, lack of facilities for nurses, inability to balance work with family needs and inadequacy of vacations’ policy. Second, work design factors: high workload, insufficient workforce numbers, lack of autonomy and undertaking many non-nursing tasks. Third, work context factors: management practices, lack of development opportunities, and inappropriate working environment in terms of the level of security, patient care supplies and unavailability of recreation room. Finally, work world factors: negative public image of nursing, and inadequate payment. More positively, nurses were notably satisfied with their co-workers. Conversely, 40.4% (n = 205) of the respondents indicated that they intended to leave their current employment. The relationships between QWL and demographic variables of gender, age, marital status, dependent children, dependent adults, nationality, ethnicity, nursing tenure, organisational tenure, positional tenure, and payment per month were significant (p < .05). The eta squared test for these demographics indicates a small to medium effect size of the variation in QWL scores. Using the GLM univariate analysis, education level was also significantly related to the QWL (p < .05). The relationships between turnover intention and demographic variables including gender, age, marital status, dependent children, education level, nursing tenure, organisational tenure, positional tenure, and payment per month were significant (p < .05). The eta squared test for these demographics indicates a small to moderate effect size of the variation in the turnover intention scores. Using the GLM univariate analysis, the dependent adults’ variable was also significantly related to turnover intention (p < .05). Turnover intention was significantly related to QWL. Using standard multiple regression, 26% of the variance in turnover intention was explained by the QWL F (4,491), 43.71, p < .001, with R² = .263. Further analysis using hierarchical multiple regression found that the total variance explained by the model as a whole (demographics and QWL) was 32.1%, F (17.433) = 12.04, p < .001. QWL explained an additional 19% of the variance in turnover intention, after controlling for demographic variables, R squared change =.19, F change (4, 433) = 30.190, p < .001. The work context variable makes the strongest unique contribution (-.387) to explain the turnover intention, followed by the work design dimension (-.112). The qualitative findings reaffirmed the quantitative findings in terms of QWL and turnover intention. However, the home life/work life and work world dimensions were of great important to both QWL and turnover intention. The qualitative findings revealed a number of new factors that were not included in the survey questionnaire. These included being away from family, lack of family support, social and cultural aspects, accommodation facilities, transportation, building and infrastructure of PHC, nature of work, job instability, privacy at work, patients and community, and distance between home and workplace. Conclusion: Creating and maintaining a healthy work life for PHC nurses is very important to improve their work satisfaction, reduce turnover, enhance productivity and improve nursing care outcomes. Improving these factors could lead to a higher QWL and increase retention rates and therefore reinforcing the stabilisation of the nursing workforce. Significance of the research: Many countries are examining strategies to attract and retain the health care workforce, particularly nurses. This study identified factors that influence the QWL of PHC nurses as well as their turnover intention. It also determined the significant relationship between QWL and turnover intention. In addition, the present study tested Brooks’ survey of QNWL on PHC nurses for the first time. The qualitative findings of this study revealed a number of new variables regarding QWL and turnover intention of PHC nurses. These variables could be used to improve current survey instruments or to develop new research surveys. The study findings could be also used to develop and appropriately implement plans to improve QWL. This may help to enhance the home and work environments of PHC nurses, improve individual and organisational performance, and increase nurses’ commitment. This study contributes to the existing body of research knowledge by presenting new data and findings from a different country and healthcare system. It is the first of its kind in Saudi Arabia, especially in the field of PHC. It has examined the relationship between QWL and turnover intention of PHC nurses for the first time using nursing instruments. The study also offers a fresh explanation (new framework) of the relationship between QWL and turnover intention among PHC nurses, which could be used or tested by researchers in other settings. Implications for further research: Review of the extant literature reveals little in-depth research on the PHC workforce, especially in terms of QWL and organisational turnover in developing countries. Further research is required to develop a QWL tool for PHC nurses, taking into consideration the findings of the current study along with the local culture. Moreover, the revised theoretical framework of the current study could be tested in further research in other regions, countries or healthcare systems in order to identify its ability to predict the level of PHC nurses’ QWL and their intention to leave. There is a need to conduct longitudinal research on PHC organisations to gain an in-depth understanding of the determents of and changes in QWL and turnover intention of PHC nurses at various points of time. An intervention study is required to improve QWL and retention among PHC nurses using the findings of the current study. This would help to assess the impact of such strategies on reducing turnover of PHC nurses. Focusing on the location of the current study, it would be valuable to conduct another study in five years’ time to examine the percentage of actual turnover among PHC nurses compared with the reported turnover intention in the current study. Further in-depth research would also be useful to assess the impact of the local culture on the perception of expatriate nurses towards their QWL and their turnover intention. A comparative study is required between PHC centres and hospitals as well as the public and private health sector agencies in terms of QWL and turnover intention of nursing personnel. Findings may differ from sector to sector according to variations in health systems, working environments and the case mix of patients.

The relative risk of second primary cancers in Queensland, Australia: A retrospective cohort study

Background Cancer survivors face an increased likelihood of being subsequently diagnosed with another cancer. The aim of this study was to quantify the relative risk of survivors developing a second primary cancer in Queensland, Australia. Methods Standardised incidence rates stratified by type of first primary cancer, type of second primary cancer, sex, age at first diagnosis, period of first diagnosis and follow-up interval were calculated for residents of Queensland, Australia, who were diagnosed with a first primary invasive cancer between 1982 and 2001 and survived for a minimum of 2 months. Results A total of 23,580 second invasive primary cancers were observed over 1,370,247 years of follow-up among 204,962 cancer patients. Both males (SIR = 1.22; 95% CI = 1.20-1.24) and females (SIR = 1.36; 95% CI = 1.33-1.39) within the study cohort were found to have a significant excess risk of developing a second cancer relative to the incidence of cancer in the general population. The observed number of second primary cancers was also higher than expected within each age group, across all time periods and during each follow-up interval. Conclusions The excess risk of developing a second malignancy among cancer survivors can likely be attributed to factors including similar aetiologies, genetics and the effects of treatment, underlining the need for ongoing monitoring of cancer patients to detect subsequent tumours at an early stage. Education campaigns developed specifically for survivors may be required to lessen the prevalence of known cancer risk factors.

Indoor and outdoor particle concentrations and elemental and organic carbon at 17 primary schools

The focus of this paper is on the measured particle number concentrations (PNC) as well as elemental and organic carbon in 17 primary schools. This study is part of the “Ultrafine Particles from Traffic Emissions and Children’s Health (UPTECH)”, which aims to determine the relationship between exposure to traffic related ultrafine (UF) particles and children’s health (http://www.ilaqh.qut.edu.au/Misc/UPTECH%20Home.htm). To achieve this, air quality and health data are being collected at 25 schools within Brisbane Metropolitan Area in Australia over two years. This paper presents the general aspects of UF particles data and preliminary results from the first 17 schools (S01 to S17), tested from Oct 2010 to Dec 2011.

Evaluation of the cost-effectiveness of strategies claiming to reduce the risk of surgical site infections following primary total hip arthroplasty

Background Total hip arthroplasty (THA) is a commonly performed procedure and numbers are increasing with ageing populations. One of the most serious complications in THA are surgical site infections (SSIs), caused by pathogens entering the wound during the procedure. SSIs are associated with a substantial burden for health services, increased mortality and reduced functional outcomes in patients. Numerous approaches to preventing these infections exist but there is no gold standard in practice and the cost-effectiveness of alternate strategies is largely unknown. Objectives The aim of this project was to evaluate the cost-effectiveness of strategies claiming to reduce deep surgical site infections following total hip arthroplasty in Australia. The objectives were: 1. Identification of competing strategies or combinations of strategies that are clinically relevant to the control of SSI related to hip arthroplasty 2. Evidence synthesis and pooling of results to assess the volume and quality of evidence claiming to reduce the risk of SSI following total hip arthroplasty 3. Construction of an economic decision model incorporating cost and health outcomes for each of the identified strategies 4. Quantification of the effect of uncertainty in the model 5. Assessment of the value of perfect information among model parameters to inform future data collection Methods The literature relating to SSI in THA was reviewed, in particular to establish definitions of these concepts, understand mechanisms of aetiology and microbiology, risk factors, diagnosis and consequences as well as to give an overview of existing infection prevention measures. Published economic evaluations on this topic were also reviewed and limitations for Australian decision-makers identified. A Markov state-transition model was developed for the Australian context and subsequently validated by clinicians. The model was designed to capture key events related to deep SSI occurring within the first 12 months following primary THA. Relevant infection prevention measures were selected by reviewing clinical guideline recommendations combined with expert elicitation. Strategies selected for evaluation were the routine use of pre-operative antibiotic prophylaxis (AP) versus no use of antibiotic prophylaxis (No AP) or in combination with antibiotic-impregnated cement (AP & ABC) or laminar air operating rooms (AP & LOR). The best available evidence for clinical effect size and utility parameters was harvested from the medical literature using reproducible methods. Queensland hospital data were extracted to inform patients’ transitions between model health states and related costs captured in assigned treatment codes. Costs related to infection prevention were derived from reliable hospital records and expert opinion. Uncertainty of model input parameters was explored in probabilistic sensitivity analyses and scenario analyses and the value of perfect information was estimated. Results The cost-effectiveness analysis was performed from a health services perspective using a hypothetical cohort of 30,000 THA patients aged 65 years. The baseline rate of deep SSI was 0.96% within one year of a primary THA. The routine use of antibiotic prophylaxis (AP) was highly cost-effective and resulted in cost savings of over $1.6m whilst generating an extra 163 QALYs (without consideration of uncertainty). Deterministic and probabilistic analysis (considering uncertainty) identified antibiotic prophylaxis combined with antibiotic-impregnated cement (AP & ABC) to be the most cost-effective strategy. Using AP & ABC generated the highest net monetary benefit (NMB) and an incremental $3.1m NMB compared to only using antibiotic prophylaxis. There was a very low error probability that this strategy might not have the largest NMB (<5%). Not using antibiotic prophylaxis (No AP) or using both antibiotic prophylaxis combined with laminar air operating rooms (AP & LOR) resulted in worse health outcomes and higher costs. Sensitivity analyses showed that the model was sensitive to the initial cohort starting age and the additional costs of ABC but the best strategy did not change, even for extreme values. The cost-effectiveness improved for a higher proportion of cemented primary THAs and higher baseline rates of deep SSI. The value of perfect information indicated that no additional research is required to support the model conclusions. Conclusions Preventing deep SSI with antibiotic prophylaxis and antibiotic-impregnated cement has shown to improve health outcomes among hospitalised patients, save lives and enhance resource allocation. By implementing a more beneficial infection control strategy, scarce health care resources can be used more efficiently to the benefit of all members of society. The results of this project provide Australian policy makers with key information about how to efficiently manage risks of infection in THA.

Low SES primary school students engaging in an after-school robotics program

Recent attention in education within many western contexts has focused on improved outcomes for students, with a particular focus on closing the gap between those who come from disadvantaged backgrounds and the rest of the student population. Much of this attention has supported a set of simplistic solutions to improving scores on high stakes standardized tests. The collateral damage (Nichols & Berliner, 2007) of such responses includes a narrowing of the curriculum, plateaus in gain scores on the tests, and unproductive blame games aimed by the media and politicians at teachers and communities (Nichols & Berliner, 2007; Synder, 2008). Alternative approaches to improving the quality and equity of schooling remain as viable alternatives to these measures. As an example in a recent study of school literacy reform in low SES schools, Luke, Woods and Dooley (2011) argued for the increase of substantive content and intellectual quality of the curriculum as a necessary means to re-engaging middle school students, improving outcomes of schooling and achieving a high quality, high equity system. The MediaClub is an afterschool program for students in years 4 to 7 (9-12 year old) at a primary school in a low SES area of a large Australian city. It is run as part of an Australian Research Council funded research project. The aim of the program has been to provide an opportunity for students to gain expertise in digital technologies and media literacies in an afterschool setting. It was hypothesized that this expertise might then be used to shift the ways of being literate that these students had to call on within classroom teaching and learning events. Each term, there is a different focus on digital media, and information and communication technology (ICT) activities in the MediaClub. The work detailed in this chapter relates to a robotics program presented as one of the modules within this afterschool setting. As part of the program, the participants were challenged to find creative solutions to problems in a constructivist-learning environment.

Differentiating first episode substance induced and primary psychotic disorders with concurrent substance use in young people

Objective: Substance use is common in first-episode psychosis, and complicates the accurate diagnosis and treatment of the disorder. The differentiation of substance-induced psychotic disorders (SIPD) from primary psychotic disorders (PPD) is particularly challenging. This cross-sectional study compares the clinical, substance use and functional characteristics of substance using first episode psychosis patients diagnosed with a SIPD and PPD. Method: Participants were 61 young people (15-24 years) admitted to a psychiatric inpatient service with first episode psychosis, reporting substance use in the past month. Diagnosis was determined using the Psychiatric Research Interview for DSM-IV Substance and Mental disorders (PRISM-IV). Measures of clinical (severity of psychotic symptoms, level of insight, history of trauma), substance use (frequency/quantity, severity) and social and occupational functioning were also administered. Results: The PRISM-IV differentially diagnosed 56% of first episode patients with a SIPD and 44% with a PPD. Those with a SIPD had higher rates of substance use and disorders, higher levels of insight, were more likely to have a forensic and trauma history and had more severe hostility and anxious symptoms than those with a PPD. Logistic regression analysis indicated a family history of psychosis, trauma history and current cannabis dependence were the strongest predictors of a SIPD. Almost 80% of diagnostic predictions of a SIPD were accurate using this model. Conclusions: This clinical profile of SIPD could help to facilitate the accurate diagnosis and treatment of SIPD versus PPD in young people with first episode psychosis admitted to an inpatient psychiatric service.