Conceptual framework for understanding the demand for emergency health services

Background & Objectives Emergency health services (EHS) throughout the world are increasingly congested. As more people use EHS, factors such as population growth and aging cannot fully explain this increase. Also, focus on patients’ clinical characteristics ignores the role that attitudinal and perceptual factors and motivations play in directing their decisions and actions. The aim of this study is to review and synthesize an integrated conceptual framework for understanding social psychological factors underpinning demand for EHS. Methodology A comprehensive search and review of empirical and theoretical studies about the utilization of EHS was conducted using major medical, health, social and behavioral sciences databases. Results A small number of studies used a relevant conceptual framework (e.g. Health Services Utilization Model or Health Belief Model) or their components to analyze patients’ decision to use EHS. The studies evidenced that demand was affected by perceived severity of the condition; perceived costs and benefits (e.g. availability, accessibility and affordability of alternative services); experience, preference and knowledge; perceived and actual social support; and demographic characteristics (e.g. age, sex, socioeconomic status, ethnicity, marital and living circumstances, place of residence). Conclusions Conceptual models that are commonly used in areas like social and behavioral sciences have rarely been applied in the EHS utilization field. Understanding patients’ decision-making and associated factors will lay the groundwork for identification of the evidence to inform improved policy responses and the development of demand management strategies. An integrated conceptual framework will be introduced as part of this study.

In Response: "Oral versus IV treatment for catheter-related bloodstream infections - by Burke A. Cunha"

In his letter Cunha suggests that oral antibiotic therapy is safer and less expensive than intravenous therapy via central venous catheters (CVCs) (1). The implication is that costs will fall and increased health benefits will be enjoyed resulting in a gain in efficiency within the healthcare system. CVCs are often used in critically ill patients to deliver antimicrobial therapy, but expose patients to a risk of catheter-related bloodstream infection (CRBSI). Our current knowledge about the efficiency (i.e. costeffectiveness) of allocating resources toward interventions that prevent CRBSI in patients requiring a CVC has already been reviewed (2). If for some patient groups antimicrobial therapy can be delivered orally, instead of through a CVC, then the costs and benefits of this alternate strategy should be evaluated...

Sustainability in infrastructure investment : building the business case

Many infrastructure agencies adopt sustainability objectives at a corporate level and incorporate sustainability targets and indicators as part of corporate reporting processes. These objectives are expected to translate to all stages of the project delivery process, including project selection. For infrastructure capital works projects and programs, a robust project management approach involves the development of a business case to guide investment decision making. A key tool in the assessment of project options and selection of a delivery strategy is Cost Benefit Analysis (CBA). Infrastructure providers are required to undertake cost benefit analysis to support project selection through regulatory approval and budgetary processes. This tool has emerged through the prism of economic analysis rather than sustainability. A literature review reveals the limitations of CBA alone to effectively evaluate economic, environmental and social externalities or impacts that apply over a long time frame, and that are ultimately irreversible. Multi-Criteria Analysis (MCA) has been introduced as a means to incorporate a wider array of factors into decision making such as sustainability. This, however, presents new challenges with issues around how to transparently represent wider community values in the selection of a preferred solution. Are these tools effective in assessing the wider sustainability costs and benefits taking into account that these are public works with long life spans and significant impacts across institutional boundaries? The research indicates a need to develop clear guidelines for investment decision making in order to better align with corporate sustainability objectives. Findings from the literature review indicate that a more sustainable approach to investment decision-making framework should include: the incorporation of sustainability goals from corporate planning documents; problem definition and option generation using best practice investment management guidelines; improved guidelines for Business Case development using a combination of both Cost Benefit Analysis and Multi-Criteria Analysis; and an integrated public participation process.

Managing moose harvests by the seat of your pants

Moose populations are managed for sustainable yield balanced against costs caused by damage to forestry or agriculture and collisions with vehicles. Optimal harvests can be calculated based on a structured population model driven by data on abundance and the composition of bulls, cows, and calves obtained by aerial-survey monitoring during winter. Quotas are established by the respective government agency and licenses are issued to hunters to harvest an animal of specified age or sex during the following autumn. Because the cost of aerial monitoring is high, we use a Management Strategy Evaluation to evaluate the costs and benefits of periodic aerial surveys in the context of moose management. Our on-the-fly "seat of your pants" alternative to independent monitoring is management based solely on the kill of moose by hunters, which is usually sufficient to alert the manager to declines in moose abundance that warrant adjustments to harvest strategies. Harvests are relatively cheap to monitor; therefore, data can be obtained each year facilitating annual adjustments to quotas. Other sources of "cheap" monitoring data such as records of the number of moose seen by hunters while hunting also might be obtained, and may provide further useful insight into population abundance, structure and health. Because conservation dollars are usually limited, the high cost of aerial surveys is difficult to justify when alternative methods exist. © 2012 Elsevier Inc.

Using conservation evidence to guide management

Almost 10 years ago, Pullin and Knight (2001) called for an “effectiveness revolution in conservation” to be enabled by the systematic evaluation of evidence for conservation decision making. Drawing from the model used in clinicalmedicine, they outlined the concept of “evidencebased conservation” in which existing information, or evidence, from relevant and rigorous research is compiled and analyzed in a systematic manner to inform conservation actions (Cochrane 1972). The promise of evidencebased conservation has generated significant interest; 25 systematic reviews have been completed since 2004 and dozens are underway (Collaboration for Environmental Evidence 2010). However we argue that an “effectiveness revolution” (Pullin & Knight 2001) in conservation will not be possible unless mechanisms are devised for incorporating the growing evidence base into decision frameworks. For conservation professionals to accomplish the missions of their organizations they must demonstrate that their actions actually achieve objectives (Pullin & Knight 2009). Systematic evaluation provides a framework for objectively evaluating the effectiveness of actions. To leverage the benefit of these evaluations, we need resource-allocation systems that are responsive to their outcomes. The allocation of conservation resources is often the product of institutional priorities or reliance on intuition (Sutherland et al. 2004; Pullin & Knight 2005; Cook et al. 2010). We highlight the NICE technologyappraisal process because it provides an example of formal integration of systematic-evidence evaluation with provision of guidance for action. The transparent process, which clearly delineates costs and benefits of each alternative action, could also provide the public with new insight into the environmental effects of different decisions. This insight could stimulate a wider discussion about investment in conservation by demonstrating how changes in funding might affect the probability of achieving conservation objectives. ©2010 Society for Conservation Biology

Who pays for standardised testing? A cost-benefit study of mandated testing in three Queensland secondary schools

This paper reports on an Australian study that explored the costs and benefits of the National Assessment Programme, Literacy and Numeracy (NAPLAN) testing, both tangible and intangible, of Year 9 students in three Queensland schools. The study commenced with a review of pertinent studies and other related material about standardised testing in Australia, the USA and UK. Information about NAPLAN testing and reporting, and the pedagogical impacts of standardised testing were identified, however little about administrative costs to schools was found. A social constructivist perspective and a multiple case study approach were used to explore the actions of school managers and teachers in three Brisbane secondary schools. The study found that the costs of NAPLAN testing to schools fell into two categories: preparation of students for the testing; and administration of the tests. Whilst many of the costs could not be quantified, they were substantial and varied according to the education sector in which the school operated. The benefits to schools of NAPLAN testing were found to be limited. The findings have implications for governments, curriculum authorities and schools, leading to the conclusion that, from a school perspective, the benefits of NAPLAN testing do not justify the costs.

Interim financial reporting in the Asia-Pacific region

This study examines Interim Financial Reporting disclosure compliance and associated factors for listed firms in Asia-Pacific countries: Australia, Hong Kong, Malaysia, Singapore, the Philippines, Thailand, and Vietnam. Employing disclosure theory (in the context of information economics), with the central premise being that manager' trade-off costs and benefits relating to disclosure, the factors influencing the variation in interim reporting disclosure compliance are examined. Using researcher-constructed disclosure indices and regression modelling, the results reveal significant cross-country variation in interim reporting disclosure compliance, with higher compliance associated with IFRS adoption, audit review, quarterly reporting (rather than six-monthly) and shorter reporting lags.

The cost-effectiveness of exercise referral schemes

Background Exercise referral schemes (ERS) aim to identify inactive adults in the primary care setting. The primary care professional refers the patient to a third party service, with this service taking responsibility for prescribing and monitoring an exercise programme tailored to the needs of the patient. This paper examines the cost-effectiveness of ERS in promoting physical activity compared with usual care in primary care setting. Methods A decision analytic model was developed to estimate the cost-effectiveness of ERS from a UK NHS perspective. The costs and outcomes of ERS were modelled over the patient's lifetime. Data were derived from a systematic review of the literature on the clinical and cost-effectiveness of ERS, and on parameter inputs in the modelling framework. Outcomes were expressed as incremental cost per quality-adjusted life-year (QALY). Deterministic and probabilistic sensitivity analyses investigated the impact of varying ERS cost and effectiveness assumptions. Sub-group analyses explored the cost-effectiveness of ERS in sedentary people with an underlying condition. Results Compared with usual care, the mean incremental lifetime cost per patient for ERS was £169 and the mean incremental QALY was 0.008, generating a base-case incremental cost-effectiveness ratio (ICER) for ERS at £20,876 per QALY in sedentary individuals without a diagnosed medical condition. There was a 51% probability that ERS was cost-effective at £20,000 per QALY and 88% probability that ERS was cost-effective at £30,000 per QALY. In sub-group analyses, cost per QALY for ERS in sedentary obese individuals was £14,618, and in sedentary hypertensives and sedentary individuals with depression the estimated cost per QALY was £12,834 and £8,414 respectively. Incremental lifetime costs and benefits associated with ERS were small, reflecting the preventative public health context of the intervention, with this resulting in estimates of cost-effectiveness that are sensitive to variations in the relative risk of becoming physically active and cost of ERS. Conclusions ERS is associated with modest increase in lifetime costs and benefits. The cost-effectiveness of ERS is highly sensitive to small changes in the effectiveness and cost of ERS and is subject to some significant uncertainty mainly due to limitations in the clinical effectiveness evidence base.

Public Demand for Safer Speeds: Identification of Interventions for Trial

Speeding is a major contributor to road injuries and fatalities and remains prevalent. Changing community perceptions about speeding is an important priority. Austroads commissioned research to identify a range of potential interventions for future trial and evaluation aimed at creating, increasing, and/or sustaining public demand for safer speeds. This project had three phases: a literature review; consultations with key stakeholders regarding intervention options (including feasibility, and likely benefits and costs of identified interventions); and providing research results, including recommendations for future phases of the program of work. The literature review led to the development of a draft Campaign Strategy targeting nine aims across three themes underpinning this research: 1) creating, 2) increasing, and 3) sustaining public demand for safer speeds on the road. Twenty-one stakeholders commented on the suitability and feasibility of, and likely barriers to, countermeasures within the draft Campaign Strategy and its applicability to the Australian and New Zealand context. There was overwhelming positive support for the proposed Campaign Strategy by the majority of respondents; many, noting that it addressed key misperceptions and complemented many existing approaches. A small number of respondents expressed some concerns with various aspects. Stakeholder feedback was incorporated into the final proposed Campaign Strategy to enhance its potential effectiveness. Wide diversity across jurisdictions makes the recommendation of individual interventions for specific areas problematic. Individual jurisdictions should consider a range of costs and benefits of the proposed Campaign Strategy to determine the likely feasibility from their unique perspective. Issues to be addressed when considering implementation of the proposed Campaign Strategy include speed limit setting policies, resourcing, messaging and advertising strategies, and political will associated with promoting safer speeds.

Process makes perfect: High-performance design creates healthy environments for high-performance learning

Considering the staggering benefits of high-performance schools, it seems an obvious choice to “go green.” High-performance schools offer an exceptionally cost-effective means to enhance student learning, using on average 33 percent less energy than conventionally designed schools, and provide substantial health gains, including reduced respiratory problems and absenteeism. According to the 2006 study, Greening America's Schools, Costs and Benefits, co-sponsored by the American Institute of Architects (AIA) and Capital E, a green building consulting firm, high-performance lighting is a key element of healthy learning environments, contributing to improved test scores, reduced off-task behavior, and higher achievement among students. Few argue this point more convincingly than architect Heinz Rudolf, of Portland-Oregon-based Boora Architects, who has designed sustainable schools for more than 80 school districts in Oregon, Washington, Colorado, and Wyoming, and has pioneered the high-performance school movement. Boora's recently completed project, the Baker Prairie Middle School in Canby, Oregon is one of the most sustainable K-12 facilities in the state, and illustrates Rudolf's progressive and research-intensive approach to school design.

Public private partnership infrastructure delivery: Benefits and costs for society

This research provides additional knowledge on the benefits and costs to society, in particular of road transport procured through Public-Private Partnership (PPP) arrangements. Currently, the public sector comparator (PSC) and cost-benefit analysis (CBA) used to evaluate and measure the benefits and costs of PPP are limited in their capacity to predict and forecast long-term events. PPP is attractive to governments due to the non-upfront payment, perceived value for money, and risk allocation and transfer to the private investor. However, public sector remains the guarantor, and under-writer of the private investor's loan from financial institutions and other voluntary risks which are unlimited to future compensatory claims. The new knowledge from this research is the introduction of a framework capable of evaluating, and measuring the associated PPP benefits, as well as the costs, effects, and impacts to society which are protracted and sporadic by nature.

Report : review of the literature : maintenance and rehabilitation costs for roads (Risk-based Analysis)

Realistic estimates of short- and long-term (strategic) budgets for maintenance and rehabilitation of road assessment management should consider the stochastic characteristics of asset conditions of the road networks so that the overall variability of road asset data conditions is taken into account. The probability theory has been used for assessing life-cycle costs for bridge infrastructures by Kong and Frangopol (2003), Zayed et.al. (2002), Kong and Frangopol (2003), Liu and Frangopol (2004), Noortwijk and Frangopol (2004), Novick (1993). Salem 2003 cited the importance of the collection and analysis of existing data on total costs for all life-cycle phases of existing infrastructure, including bridges, road etc., and the use of realistic methods for calculating the probable useful life of these infrastructures (Salem et. al. 2003). Zayed et. al. (2002) reported conflicting results in life-cycle cost analysis using deterministic and stochastic methods. Frangopol et. al. 2001 suggested that additional research was required to develop better life-cycle models and tools to quantify risks, and benefits associated with infrastructures. It is evident from the review of the literature that there is very limited information on the methodology that uses the stochastic characteristics of asset condition data for assessing budgets/costs for road maintenance and rehabilitation (Abaza 2002, Salem et. al. 2003, Zhao, et. al. 2004). Due to this limited information in the research literature, this report will describe and summarise the methodologies presented by each publication and also suggest a methodology for the current research project funded under the Cooperative Research Centre for Construction Innovation CRC CI project no 2003-029-C.

The importance of environmental issues and costs in Life Cycle Cost Analysis (LCCA) for highway projects

Sustainability has been increasingly recognised as an integral part of highway infrastructure development. In practice however, the fact that financial return is still a project’s top priority for many, environmental aspects tend to be overlooked or considered as a burden, as they add to project costs. Sustainability and its implications have a far-reaching effect on each project over time. Therefore, with highway infrastructure’s long-term life span and huge capital demand, the consideration of environmental cost/ benefit issues is more crucial in life-cycle cost analysis (LCCA). To date, there is little in existing literature studies on viable estimation methods for environmental costs. This situation presents the potential for focused studies on environmental costs and issues in the context of life-cycle cost analysis. This paper discusses a research project which aims to integrate the environmental cost elements and issues into a conceptual framework for life cycle costing analysis for highway projects. Cost elements and issues concerning the environment were first identified through literature. Through questionnaires, these environmental cost elements will be validated by practitioners before their consolidation into the extension of existing and worked models of life-cycle costing analysis (LCCA). A holistic decision support framework is being developed to assist highway infrastructure stakeholders to evaluate their investment decision. This will generate financial returns while maximising environmental benefits and sustainability outcome.

Essays on irrigation development, farm production and unaccounted costs : theory and empirical evidence

A review of the literature related to issues involved in irrigation induced agricultural development (IIAD) reveals that: (1) the magnitude, sensitivity and distribution of social welfare of IIAD is not fully analysed; (2) the impacts of excessive pesticide use on farmers’ health are not adequately explained; (3) no analysis estimates the relationship between farm level efficiency and overuse of agro-chemical inputs under imperfect markets; and (4) the method of incorporating groundwater extraction costs is misleading. This PhD thesis investigates these issues by using primary data, along with secondary data from Sri Lanka. The overall findings of the thesis can be summarised as follows. First, the thesis demonstrates that Sri Lanka has gained a positive welfare change as a result of introducing new irrigation technology. The change in the consumer surplus is Rs.48,236 million, while the change in the producer surplus is Rs. 14,274 millions between 1970 and 2006. The results also show that the long run benefits and costs of IIAD depend critically on the magnitude of the expansion of the irrigated area, as well as the competition faced by traditional farmers (agricultural crowding out effects). The traditional sector’s ability to compete with the modern sector depends on productivity improvements, reducing production costs and future structural changes (spillover effects). Second, the thesis findings on pesticides used for agriculture show that, on average, a farmer incurs a cost of approximately Rs. 590 to 800 per month during a typical cultivation period due to exposure to pesticides. It is shown that the value of average loss in earnings per farmer for the ‘hospitalised’ sample is Rs. 475 per month, while it is approximately Rs. 345 per month for the ‘general’ farmers group during a typical cultivation season. However, the average willingness to pay (WTP) to avoid exposure to pesticides is approximately Rs. 950 and Rs. 620 for ‘hospitalised’ and ‘general’ farmers’ samples respectively. The estimated percentage contribution for WTP due to health costs, lost earnings, mitigating expenditure, and disutility are 29, 50, 5 and 16 per cent respectively for hospitalised farmers, while they are 32, 55, 8 and 5 per cent respectively for ‘general’ farmers. It is also shown that given market imperfections for most agricultural inputs, farmers are overusing pesticides with the expectation of higher future returns. This has led to an increase in inefficiency in farming practices which is not understood by the farmers. Third, it is found that various groundwater depletion studies in the economics literature have provided misleading optimal water extraction quantity levels. This is due to a failure to incorporate all production costs in the relevant models. It is only by incorporating quality changes to quantity deterioration, that it is possible to derive socially optimal levels. Empirical results clearly show that the benefits per hectare per month considering both the avoidance costs of deepening agro-wells by five feet from the existing average, as well as the avoidance costs of maintaining the water salinity level at 1.8 (mmhos/Cm), is approximately Rs. 4,350 for farmers in the Anuradhapura district and Rs. 5,600 for farmers in the Matale district.

ICT shared services in the higher education sector : foundations, benefits, success factors and issues

Universities are more and more challenged by the emerging global higher education market, facilitated by advances in Information and Communication Technologies (ICT). This requires them to reconsider their mission and direction in order to function effectively and efficiently, and to be responsive to changes in their environment. In the face of increasing demands and competitive pressures, Universities like other companies, seek to continuously innovate and improve their performance. Universities are considering co-operating or sharing, both internally and externally, in a wide range of areas to achieve cost effectiveness and improvements in performance. Shared services are an effective model for re-organizing to reduce costs, increase quality and create new capabilities. Shared services are not limited to the Higher Education (HE) sector. Organizations across different sectors are adopting shared services, in particular for support functions such as Finance, Accounting, Human Resources and Information Technology. While shared services has been around for more than three decades, commencing in the 1970’s in the banking sector and then been adopted by other sectors, it is an under researched domain, with little consensus on the most fundamental issues even as basic as defining what shared services is. Moreover, the interest in shared services within Higher Education is a global phenomenon. This study on shared services is situated within the Higher Education Sector of Malaysia, and originated as an outcome resulting from a national project (2005 – 2007) conducted by the Ministry of Higher Education (MOHE) entitled "Knowledge, Information Communication Technology Strategic Plan (KICTSP) for Malaysian Public Higher Education"- where progress towards more collaborations via shared services was a key recommendation. The study’s primary objective was to understand the nature and potential for ICT shared services, in particular in the Malaysian HE sector; by laying a foundation in terms of definition, typologies and research agenda and deriving theoretically based conceptualisations of the potential benefits of shared services, success factors and issues of pursuing shared services. The study embarked on this objective with a literature review and pilot case study as a means to further define the context of the study, given the current under-researched status of ICT shared services and of shared services in Higher Education. This context definition phase illustrated a range of unaddressed issues; including a lack of common understanding of what shared services are, how they are formed, what objectives they full fill, who is involved etc. The study thus embarked on a further investigation of a more foundational nature with an exploratory phase that aimed to address these gaps, where a detailed archival analysis of shared services literature within the IS context was conducted to better understand shared services from an IS perspective. The IS literature on shared services was analysed in depth to report on the current status of shared services research in the IS domain; in particular definitions, objectives, stakeholders, the notion of sharing, theories used, and research methods applied were analysed, which provided a firmer base to this study’s design. The study also conducted a detailed content analysis of 36 cases (globally) of shared services implementations in the HE sector to better understand how shared services are structured within the HE sector and what is been shared. The results of the context definition phase and exploratory phase formed a firm basis in the multiple case studies phase which was designed to address the primary goals of this study (as presented above). Three case sites within the Malaysian HE sector was included in this analysis, resulting in empirically supported theoretical conceptualizations of shared services success factors, issues and benefits. A range of contributions are made through this study. First, the detailed archival analysis of shared services in Information Systems (IS) demonstrated the dearth of research on shared services within Information Systems. While the existing literature was synthesised to contribute towards an improved understanding of shared services in the IS domain, the areas that are yet under-developed and requires further exploration is identified and presented as a proposed research agenda for the field. This study also provides theoretical considerations and methodological guidelines to support the research agenda; to conduct better empirical research in this domain. A number of literatures based a priori frameworks (i.e. on the forms of sharing and shared services stakeholders etc) are derived in this phase, contributing to practice and research with early conceptualisations of critical aspects of shared services. Furthermore, the comprehensive archival analysis design presented and executed here is an exemplary approach of a systematic, pre-defined and tool-supported method to extract, analyse and report literature, and is documented as guidelines that can be applied for other similar literature analysis, with particular attention to supporting novice researchers. Second, the content analysis of 36 shared services initiatives in the Higher Education sector presented eight different types of structural arrangements for shared services, as observed in practice, and the salient dimensions along which those types can be usefully differentiated. Each of the eight structural arrangement types are defined and demonstrated through case examples, with further descriptive details and insights to what is shared and how the sharing occurs. This typology, grounded on secondary empirical evidence, can serve as a useful analytical tool for researchers investigating the shared services phenomenon further, and for practitioners considering the introduction or further development of shared services. Finally, the multiple case studies conducted in the Malaysian Higher Education sector, provided further empirical basis to instantiate the conceptual frameworks and typology derived from the prior phases and develops an empirically supported: (i) framework of issues and challenges, (ii) a preliminary theory of shared services success, and (iii) a benefits framework, for shared services in the Higher Education sector.