Bayesian hierarchical models in statistical quality control methods to improve healthcare in hospitals

Quality oriented management systems and methods have become the dominant business and governance paradigm. From this perspective, satisfying customers’ expectations by supplying reliable, good quality products and services is the key factor for an organization and even government. During recent decades, Statistical Quality Control (SQC) methods have been developed as the technical core of quality management and continuous improvement philosophy and now are being applied widely to improve the quality of products and services in industrial and business sectors. Recently SQC tools, in particular quality control charts, have been used in healthcare surveillance. In some cases, these tools have been modified and developed to better suit the health sector characteristics and needs. It seems that some of the work in the healthcare area has evolved independently of the development of industrial statistical process control methods. Therefore analysing and comparing paradigms and the characteristics of quality control charts and techniques across the different sectors presents some opportunities for transferring knowledge and future development in each sectors. Meanwhile considering capabilities of Bayesian approach particularly Bayesian hierarchical models and computational techniques in which all uncertainty are expressed as a structure of probability, facilitates decision making and cost-effectiveness analyses. Therefore, this research investigates the use of quality improvement cycle in a health vii setting using clinical data from a hospital. The need of clinical data for monitoring purposes is investigated in two aspects. A framework and appropriate tools from the industrial context are proposed and applied to evaluate and improve data quality in available datasets and data flow; then a data capturing algorithm using Bayesian decision making methods is developed to determine economical sample size for statistical analyses within the quality improvement cycle. Following ensuring clinical data quality, some characteristics of control charts in the health context including the necessity of monitoring attribute data and correlated quality characteristics are considered. To this end, multivariate control charts from an industrial context are adapted to monitor radiation delivered to patients undergoing diagnostic coronary angiogram and various risk-adjusted control charts are constructed and investigated in monitoring binary outcomes of clinical interventions as well as postintervention survival time. Meanwhile, adoption of a Bayesian approach is proposed as a new framework in estimation of change point following control chart’s signal. This estimate aims to facilitate root causes efforts in quality improvement cycle since it cuts the search for the potential causes of detected changes to a tighter time-frame prior to the signal. This approach enables us to obtain highly informative estimates for change point parameters since probability distribution based results are obtained. Using Bayesian hierarchical models and Markov chain Monte Carlo computational methods, Bayesian estimators of the time and the magnitude of various change scenarios including step change, linear trend and multiple change in a Poisson process are developed and investigated. The benefits of change point investigation is revisited and promoted in monitoring hospital outcomes where the developed Bayesian estimator reports the true time of the shifts, compared to priori known causes, detected by control charts in monitoring rate of excess usage of blood products and major adverse events during and after cardiac surgery in a local hospital. The development of the Bayesian change point estimators are then followed in a healthcare surveillances for processes in which pre-intervention characteristics of patients are viii affecting the outcomes. In this setting, at first, the Bayesian estimator is extended to capture the patient mix, covariates, through risk models underlying risk-adjusted control charts. Variations of the estimator are developed to estimate the true time of step changes and linear trends in odds ratio of intensive care unit outcomes in a local hospital. Secondly, the Bayesian estimator is extended to identify the time of a shift in mean survival time after a clinical intervention which is being monitored by riskadjusted survival time control charts. In this context, the survival time after a clinical intervention is also affected by patient mix and the survival function is constructed using survival prediction model. The simulation study undertaken in each research component and obtained results highly recommend the developed Bayesian estimators as a strong alternative in change point estimation within quality improvement cycle in healthcare surveillances as well as industrial and business contexts. The superiority of the proposed Bayesian framework and estimators are enhanced when probability quantification, flexibility and generalizability of the developed model are also considered. The empirical results and simulations indicate that the Bayesian estimators are a strong alternative in change point estimation within quality improvement cycle in healthcare surveillances. The superiority of the proposed Bayesian framework and estimators are enhanced when probability quantification, flexibility and generalizability of the developed model are also considered. The advantages of the Bayesian approach seen in general context of quality control may also be extended in the industrial and business domains where quality monitoring was initially developed.

The role of alternative message strategies in advertising performance : challenges to the B2B marketing paradigm

In this study the impact of message strategy on advertising performance will be in examined in a business-to-business (B2B) context. From a theoretical standpoint, the study will explore differences in message type between symbolic and literal approaches in B2B advertisements. While there has been much discussion on the effect of symbolism, (eg. metaphors, abstract images and figurative language), an empirically-tested scale that measures the degree of symbolism has not been developed. This research project focuses on development of a methodological scale to accurately test the difference in the direction of message appeals. Thus, insights in the role of message strategy in the B2B adoption process are anticipated with contributions in future consumer and business advertising research.

Axial length changes with shifts of gaze direction in myopes and emmetropes

Purpose. The purpose of the study was to investigate the changes in axial length occurring with shifts in gaze direction. Methods. Axial length measurements were obtained from the left eye of 30 young adults (10 emmetropes, 10 low myopes, and 10 moderate myopes) through a rotating prism with 15° deviation, along the foveal axis, using a noncontact optical biometer in each of the nine different cardinal directions of gaze over 5 minutes. The subject's fellow eye fixated on an external distance (6 m) target to control accommodation, also with 15° deviation. Axial length measurements were also performed in 15° and 25° downward gaze with the biometer inclined on a tilting table, allowing gaze shifts to be achieved with either full head turn but no eye turn, or full eye turn with no head turn. Results. There was a significant influence of gaze angle and time on axial length (both P < 0.001), with the greatest axial elongation (+18 ± 8 μm) occurring with inferonasal gaze (P < 0.001) and a slight decrease in axial length in superior gaze (−12 ± 17 μm) compared with primary gaze (P < 0.001). In downward gaze, a significant axial elongation occurred when eye turn was used (P < 0.001), but not when head turn was used to shift gaze (P > 0.05). Conclusions. The angle of gaze has a small but significant short-term effect on axial length, with greatest elongation occurring in inferonasal gaze. The elongation of the eye appears to be due to the influence of the extraocular muscles, in particular the oblique muscles.

Contextual models and the non-Newtonian paradigm

Biological systems exhibit a wide range of contextual effects, and this often makes it difficult to construct valid mathematical models of their behaviour. In particular, mathematical paradigms built upon the successes of Newtonian physics make assumptions about the nature of biological systems that are unlikely to hold true. After discussing two of the key assumptions underlying the Newtonian paradigm, we discuss two key aspects of the formalism that extended it, Quantum Theory (QT). We draw attention to the similarities between biological and quantum systems, motivating the development of a similar formalism that can be applied to the modelling of biological processes.

World's pre-eminent powers recent treatment to international law : a paradigm of interest served or harmed

The US's recent rejection of some international laws may have been done to ensure American interests but it may have the opposite effects. While its recent rejection of some international legal arrangements has meant an unpopular opinion of America, its interest has been served.

The knock-on from the knock-off : recent shifts within Australian mass market fashion design practice

Australia's mass market fashion labels have traditionally benefitted from their peripheral location to the world's fashion centres. Operating a season behind, Australian mass market designers and buyers were well-placed to watch trends play out overseas before testing them in the Australian marketplace. For this reason, often a designer's role was to source and oversee the manufacture of 'knock-offs', or close copies of northern hemisphere mass market garments. Both Weller and Walsh have commented on this practice.12 The knock-on effect from this continues to be a cautious, derivative fashion sensibility within Australian mass market fashion design, where any new trend or product is first tested and proved overseas months earlier. However, there is evidence that this is changing. The rapid online dissemination of global fashion trends, coupled with the Australian consumer’s willingness to shop online, has meant that the ‘knock-off’ is less viable. For this reason, a number of mass market companies are moving away from the practice of direct sourcing and are developing product in-house under a northern hemisphere model. This shift is also witnessed in the trend for mass market companies to develop collections in partnership with independent Australian designers. This paper explores the current and potential effects of these shifts within Australian mass market design practice, and discusses how they may impact on both consumers and on the wider culture of Australian fashion.

Copyright protections and disability rights : turning the page to a new international paradigm

This paper argues that governments around the world need to take immediate coordinated action to reverse the 'book famine.' There are over 129 million book titles in the world, but persons with print disabilities can obtain less than 7% of these titles in formats that they can read. The situation is most acute in developing countries, where less than 1% of books are accessible. Two recent international developments – the United Nations Convention on the Rights of Persons with Disabilities (‘CRPD’) and the new Marrakesh Treaty to Facilitate Access to Published Works for Persons who are Blind, Visually Impaired, or otherwise Print Disabled (somewhat ironically nicknamed the ‘VIP Treaty’) – suggest that nation states are increasingly willing to take action to reverse the book famine. The Marrakesh Treaty promises to level out some of the disparity of access between people in developed and developing nations and remove the need for each jurisdiction to digitise a separate copy of each book. This is a remarkable advance, and suggests the beginnings of a possible paradigm shift in global copyright politicsmade all the more remarkable in the face of heated opposition by global copyright industry representatives. Now that the Marrakesh Treaty has been concluded, however, we argue that a substantial exercise of global political will is required to (a) invest the funds required to digitise existing books; and (b) avert any further harm by ensuring that books published in the future are made accessible upon their release.

Mediation ethics in Australia : a case for rethinking the foundational paradigm

In contemporary Western society, including Australia, professional mediation practice has developed with a specifically defined foundational approach - a problem-solving, facilitative method, in which the mediator's intervention is centred on providing the parties with a series of formal steps to assist their communication and to steer them towards a self-determined and mutually agreeable resolution of the issues in dispute. Facilitative mediation developed, in part, as a response to the adversarial system of law and justice. In that system the parties are said to lose control of their dispute, and a decision is imposed on them which invariably puts one party in a losing position. Facilitative mediation has offered an alternative to this inevitable outcome by offering the parties a democratic, cost-effective, party-centred, empowering, interests-based and principled option for resolving their dispute.

Threat vigilance in child witnesses of domestic violence: a pilot study utilizing the ambiguous situations paradigm

Research has found that children exposed to family violence exhibit higher rates of maladjustment. We review relevant literature on family violence, marital conflict, and cognitive factors implicated in child behaviour problems. A bias toward perceiving threat in ambiguous contexts has been identified as one factor mediating both aggressive and anxious behaviour disorders. We conducted a study utilizing the ambiguous situations paradigm to assess whether children exposed to violent spousal conflict were more likely than children not exposed to violence (divided into children with an externalizing behaviour disorder and non-clinic children) to perceive threat in two classes of ambiguous situations: Peer and Inter-Parental. The results indicated that children exposed to violent spousal conflict perceived more threat in parental situations than either of the other two groups. A number of considerations were taken into account given the exploratory nature of the study, particularly sample limitations. We conclude with suggestions for improvements to the research design and the further relevance of exploring cognitive factors involved in the adjustment of children from backgrounds of violence.

Parenting from the outside-in : reflections on parent training during a potential paradigm shift

This article proposes that a paradigm shift that has implications for practitioners of parenting interventions is emerging. This shift represents a challenge to the dominant model of parent training. The Triple P Parenting Program is discussed as an example of parent training programme to highlight the relevant issues for practitioners, including common practitioner objections encountered in dissemination as identified, in part, by Mazzucchelli and Sanders. It is argued that apart fromthese objections, there are more essential concerns in relation to the adoption of parent training programmes by practitioners. Rather, the article argues that parent training is “mind-blind” and that approaches emerging from the field of interpersonal neurobiology represent developmentally sophisticated alternatives for intervention. The Circle of Security programme is discussed as one example of this emerging paradigm shift that integrates attachment, social neuroscience, and psychodynamic theory. Contrasts are highlighted between the models, and considerations for future issues in parent intervention conclude the article.

Cortisol shifts financial risk preferences

Risk taking is central to human activity. Consequently, it lies at the focal point of behavioral sciences such as neuroscience, economics, and finance. Many influential models from these sciences assume that financial risk preferences form a stable trait. Is this assumption justified and, if not, what causes the appetite for risk to fluctuate? We have previously found that traders experience a sustained increase in the stress hormone cortisol when the amount of uncertainty, in the form of market volatility, increases. Here we ask whether these elevated cortisol levels shift risk preferences. Using a double-blind, placebo-controlled, cross-over protocol we raised cortisol levels in volunteers over eight days to the same extent previously observed in traders. We then tested for the utility and probability weighting functions underlying their risk taking, and found that participants became more risk averse. We also observed that the weighting of probabilities became more distorted among men relative to women. These results suggest that risk preferences are highly dynamic. Specifically, the stress response calibrates risk taking to our circumstances, reducing it in times of prolonged uncertainty, such as a financial crisis. Physiology-induced shifts in risk preferences may thus be an under-appreciated cause of market instability.

Rethinking the effects paradigm in porn studies

It has been an assumption of most anti-pornography discourse that porn damages women (and children) in a variety of ways. In Porno? Chic!, the author interrogated this assumption by examining the correlation between the incidence of sexual violence and other indicators of misogyny, and the availability and accessibility of pornography within a number of societies. This article develops that work with a specific focus on the regulatory environment as it relates to pornography and sexual representation. Does a liberal regulatory regime in sexual culture correlate with a relatively advanced state of sexual politics in a given country? Conversely, does an illiberal regime, where pornography and other forms of sexual culture are banned or severely restricted, correlate with relatively strong patriarchal structures? A comparative cross-country analysis seeks to explain the correlations identified, and to assess the extent to which the availability of porn can be viewed as a causal or a consequential characteristic of those societies where feminism has achieved significant advances.