The need for cost-effectiveness analyses of antimicrobial stewardship programmes: A structured review

The cost effectiveness of antimicrobial stewardship (AMS) programmes was reviewed in hospital settings of Organisation for Economic Co-operation and Development (OECD) countries, and limited to adult patient populations. In each of the 36 studies, the type of AMS strategy and the clinical and cost outcomes were evaluated. The main AMS strategy implemented was prospective audit with intervention and feedback (PAIF), followed by the use of rapid technology, including rapid polymerase chain reaction (PCR)-based methods and matrix-assisted laser desorption/ionisation time-of-flight (MALDI-TOF) technology, for the treatment of bloodstream infections. All but one of the 36 studies reported that AMS resulted in a reduction in pharmacy expenditure. Among 27 studies measuring changes to health outcomes, either no change was reported post-AMS, or the additional benefits achieved from these outcomes were not quantified. Only two studies performed a full economic evaluation: one on a PAIF-based AMS intervention; and the other on use of rapid technology for the selection of appropriate treatment for serious Staphylococcus aureus infections. Both studies found the interventions to be cost effective. AMS programmes achieved a reduction in pharmacy expenditure, but there was a lack of consistency in the reported cost outcomes making it difficult to compare between interventions. A failure to capture complete costs in terms of resource use makes it difficult to determine the true cost of these interventions. There is an urgent need for full economic evaluations that compare relative changes both in clinical and cost outcomes to enable identification of the most cost-effective AMS strategies in hospitals.

The clinical effectiveness and cost-effectiveness of exercise referral schemes: A systematic review and economic evaluation

- Background Exercise referral schemes (ERS) aim to identify inactive adults in the primary-care setting. The GP or health-care professional then 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 individual. - Objective To assess the clinical effectiveness and cost-effectiveness of ERS for people with a diagnosed medical condition known to benefit from physical activity (PA). The scope of this report was broadened to consider individuals without a diagnosed condition who are sedentary. - Data sources MEDLINE; EMBASE; PsycINFO; The Cochrane Library, ISI Web of Science; SPORTDiscus and ongoing trial registries were searched (from 1990 to October 2009) and included study references were checked. - Methods Systematic reviews: the effectiveness of ERS, predictors of ERS uptake and adherence, and the cost-effectiveness of ERS; and the development of a decision-analytic economic model to assess cost-effectiveness of ERS. - Results Seven randomised controlled trials (UK, n = 5; non-UK, n = 2) met the effectiveness inclusion criteria, five comparing ERS with usual care, two compared ERS with an alternative PA intervention, and one to an ERS plus a self-determination theory (SDT) intervention. In intention-to-treat analysis, compared with usual care, there was weak evidence of an increase in the number of ERS participants who achieved a self-reported 90-150 minutes of at least moderate-intensity PA per week at 6-12 months' follow-up [pooled relative risk (RR) 1.11, 95% confidence interval 0.99 to 1.25]. There was no consistent evidence of a difference between ERS and usual care in the duration of moderate/vigorous intensity and total PA or other outcomes, for example physical fitness, serum lipids, health-related quality of life (HRQoL). There was no between-group difference in outcomes between ERS and alternative PA interventions or ERS plus a SDT intervention. None of the included trials separately reported outcomes in individuals with medical diagnoses. Fourteen observational studies and five randomised controlled trials provided a numerical assessment of ERS uptake and adherence (UK, n = 16; non-UK, n = 3). Women and older people were more likely to take up ERS but women, when compared with men, were less likely to adhere. The four previous economic evaluations identified suggest ERS to be a cost-effective intervention. Indicative incremental cost per quality-adjusted life-year (QALY) estimates for ERS for various scenarios were based on a de novo model-based economic evaluation. Compared with usual care, the mean incremental cost for ERS was £169 and the mean incremental QALY was 0.008, with the base-case incremental cost-effectiveness ratio at £20,876 per QALY in sedentary people without a medical condition and a cost per QALY of £14,618 in sedentary obese individuals, £12,834 in sedentary hypertensive patients, and £8414 for sedentary individuals with depression. Estimates of cost-effectiveness were highly sensitive to plausible variations in the RR for change in PA and cost of ERS. - Limitations We found very limited evidence of the effectiveness of ERS. The estimates of the cost-effectiveness of ERS are based on a simple analytical framework. The economic evaluation reports small differences in costs and effects, and findings highlight the wide range of uncertainty associated with the estimates of effectiveness and the impact of effectiveness on HRQoL. No data were identified as part of the effectiveness review to allow for adjustment of the effect of ERS in different populations. - Conclusions There remains considerable uncertainty as to the effectiveness of ERS for increasing activity, fitness or health indicators or whether they are an efficient use of resources in sedentary people without a medical diagnosis. We failed to identify any trial-based evidence of the effectiveness of ERS in those with a medical diagnosis. Future work should include randomised controlled trials assessing the cinical effectiveness and cost-effectivenesss of ERS in disease groups that may benefit from PA. - Funding The National Institute for Health Research Health Technology Assessment programme.

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.

Measuring cost and affordability of healthy and less healthy diet globally

The INFORMAS food prices module proposes a step-wise framework to measure the cost and affordability of population diets. The price differential and the tax component of healthy and less healthy foods, food groups, meals and diets will be benchmarked and monitored over time. Results can be used to model or assess the impact of fiscal policies, such as ‘fat taxes’ or subsidies. Key methodological challenges include: defining healthy and less healthy foods, meals, diets and commonly consumed items; including costs of alcohol, takeaways, convenience foods and time; selecting the price metric; sampling frameworks; and standardizing collection and analysis protocols. The minimal approach uses three complementary methods to measure the price differential between pairs of healthy and less healthy foods. Specific challenges include choosing policy relevant pairs and defining an anchor for the lists. The expanded approach measures the cost of a healthy diet compared to the current (less healthy) diet for a reference household. It requires dietary principles to guide the development of the healthy diet pricing instrument and sufficient information about the population’s current intake to inform the current (less healthy) diet tool. The optimal approach includes measures of affordability and requires a standardised measure of household income that can be used for different countries. The feasibility of implementing the protocol in different countries is being tested in New Zealand, Australia and Fiji. The impact of different decision points to address challenges will be investigated in a systematic manner. We will present early insights and results from this work.

A Low Cost Controller Board for Teaching Robotics

This paper presents the Smarty Board; a new micro-controller board designed specifically for the robotics teaching needs of Australian schools. The primary motivation for this work was the lack of commercially available and cheap controller boards that would have all their components including interfaces on a single board. Having a single board simplifies the construction of programmable robots that can be used as platforms for teaching and learning robotics. Reducing the cost of the board as much as possible was one of the main design objectives. The target user groups for this device are the secondary and tertiary students, and hobbyists. Previous studies have shown that equipment cost is one of the major obstacles for teaching robotics in Australia. The new controller board was demonstrated at high-school seminars. In these demonstrations the new controller board was used for controlling two robots that we built. These robots are available as kits. Given the strong demand from high-school teachers, new kits will be developed for the next robotic Olympiad to be held in Australia in 2006.

The impact of planning delays and other holding costs on housing affordability

Housing affordability is gaining increasing prominence in the Australian socioeconomic landscape, despite strong economic growth and prosperity. It is a major consideration for any new development. However, it is multi-dimensional, has many facets, is complex and interwoven. One factor widely held to impact housing affordability is holding costs. Although it is only one contributor, the nature and extent of its impact requires clarification. It is certainly more multifarious than simple calculation of the interest or opportunity cost of land holding. For example, preliminary analysis suggests that even small shifts in the regulatory assessment period can significantly affect housing affordability. Other costs associated with “holding” also impact housing affordability, however these costs cannot always be easily identified. Nevertheless it can be said that ultimately the real impact is felt by those whom can least afford it - new home buyers whom can be relatively easily pushed into the realms of un-affordability.

Indoor environments : design, productivity and health

In a typical large office block, by far the largest lifetime expense is the salaries of the workers - 84% for salaries compared with : office rent (14%), total energy (1%), and maintenance (1%). The key drive for business is therefore the maximisation of the productivity of the employees as this is the largest cost. Reducing total energy use by 50% will not produce the same financial return as 1% productivity improvement? The aim of the project which led to this review of the literature was to understand as far as possible the state of knowledge internationally about how the indoor environment of buildings does influence occupants and the impact this influence may have on the total cost of ownership of buildings. Therefore one of the main focus areas for the literature has been identifying whether there is a link between productivity and health of building occupants and the indoor environment. Productivity is both easy to define - the ratio of output to input - but at the same time very hard to measure in a relatively small environment where individual contributions can influence the results, in particular social interactions. Health impacts from a building environment are also difficult to measure well, as establishing casual links between the indoor environment and a particular health issue can be very difficult. All of those issues are canvassed in the literature reported here. Humans are surprisingly adaptive to different physical environments, but the workplace should not test the limits of human adaptability. Physiological models of stress, for example, accept that the body has a finite amount of adaptive energy available to cope with stress. The importance of, and this projects' focus on, the physical setting within the integrated system of high performance workplaces, means this literature survey explores research which has been undertaken on both physical and social aspects of the built environment. The literature has been largely classified in several different ways, according to the classification scheme shown below. There is still some inconsistency in the use of keywords, which is being addressed and greater uniformity will be developed for a CD version of this literature, enabling searching using this classification scheme.

Initial steps in optimal planning of a distribution system

This paper reports the initial steps of research on planning of rural networks for MV and LV. In this paper, two different cases are studied. In the first case, 100 loads are distributed uniformly on a 100 km transmission line in a distribution network and in the second case, the load structure become closer to the rural situation. In case 2, 21 loads are located in a distribution system so that their distance is increasing, distance between load 1 and 2 is 3 km, between 2 and 3 is 6 km, etc). These two models to some extent represent the distribution system in urban and rural areas, respectively. The objective function for the design of the optimal system consists of three main parts: cost of transformers, and MV and LV conductors. The bus voltage is expressed as a constraint and should be maintained within a standard level, rising or falling by no more than 5%.

Open Specification for BIM : Sydney Opera House Case Study

Executive Summary The objective of this report was to use the Sydney Opera House as a case study of the application of Building Information Modelling (BIM). The Sydney opera House is a complex, large building with very irregular building configuration, that makes it a challenging test. A number of key concerns are evident at SOH: • the building structure is complex, and building service systems - already the major cost of ongoing maintenance - are undergoing technology change, with new computer based services becoming increasingly important. • the current “documentation” of the facility is comprised of several independent systems, some overlapping and is inadequate to service current and future services required • the building has reached a milestone age in terms of the condition and maintainability of key public areas and service systems, functionality of spaces and longer term strategic management. • many business functions such as space or event management require up-to-date information of the facility that are currently inadequately delivered, expensive and time consuming to update and deliver to customers. • major building upgrades are being planned that will put considerable strain on existing Facilities Portfolio services, and their capacity to manage them effectively While some of these concerns are unique to the House, many will be common to larger commercial and institutional portfolios. The work described here supported a complementary task which sought to identify if a building information model – an integrated building database – could be created, that would support asset & facility management functions (see Sydney Opera House – FM Exemplar Project, Report Number: 2005-001-C-4 Building Information Modelling for FM at Sydney Opera House), a business strategy that has been well demonstrated. The development of the BIMSS - Open Specification for BIM has been surprisingly straightforward. The lack of technical difficulties in converting the House’s existing conventions and standards to the new model based environment can be related to three key factors: • SOH Facilities Portfolio – the internal group responsible for asset and facility management - have already well established building and documentation policies in place. The setting and adherence to well thought out operational standards has been based on the need to create an environment that is understood by all users and that addresses the major business needs of the House. • The second factor is the nature of the IFC Model Specification used to define the BIM protocol. The IFC standard is based on building practice and nomenclature, widely used in the construction industries across the globe. For example the nomenclature of building parts – eg ifcWall, corresponds to our normal terminology, but extends the traditional drawing environment currently used for design and documentation. This demonstrates that the international IFC model accurately represents local practice for building data representation and management. • a BIM environment sets up opportunities for innovative processes that can exploit the rich data in the model and improve services and functions for the House: for example several high-level processes have been identified that could benefit from standardized Building Information Models such as maintenance processes using engineering data, business processes using scheduling, venue access, security data and benchmarking processes using building performance data. The new technology matches business needs for current and new services. The adoption of IFC compliant applications opens the way forward for shared building model collaboration and new processes, a significant new focus of the BIM standards. In summary, SOH current building standards have been successfully drafted for a BIM environment and are confidently expected to be fully developed when BIM is adopted operationally by SOH. These BIM standards and their application to the Opera House are intended as a template for other organisations to adopt for the own procurement and facility management activities. Appendices provide an overview of the IFC Integrated Object Model and an understanding IFC Model Data.

International practices in investment decision making in road sector

This document provides the findings of an international review of investment decision-making practices in road asset management. Efforts were concentrated on identifying the strategic objectives of agencies in road asset management, establishing and understanding criteria different organisations adopted and ascertaining the exact methodologies used by different countries and international organisations. Road assets are powerful drivers of economic development and social equity. They also have significant impacts on the natural and man-made environment. The traditional definition of asset management is “A systematic process of maintaining, upgrading and operating physical assets cost effectively. It combines engineering principles with sound business practices and economic theory and it provides tools to facilitate a more organised, logical approach to decision-making” (US Dept. of Transportation, 1999). In recent years, the concept has been broadened to cover the complexity of decision making, based on a wider variety of policy considerations as well as social and environmental issues rather than is covered by Benefit-Cost analysis and pure technical considerations. Current international practices are summarised in table 2. It was evident that Engineering-economic analysis methods are well advanced to support decision-making. A range of tools available supports performance predicting of road assets and associated cost/benefit in technical context. The need for considering triple plus one bottom line of social, environmental and economic as well as political factors in decision-making is well understood by road agencies around the world. The techniques used to incorporate these however, are limited. Most countries adopt a scoring method, a goal achievement matrix or information collected from surveys. The greater uncertainty associated with these non-quantitative factors has generally not been taken into consideration. There is a gap between the capacities of the decision-making support systems and the requirements from decision-makers to make more rational and transparent decisions. The challenges faced in developing an integrated decision making framework are both procedural and conceptual. In operational terms, the framework should be easy to be understood and employed. In philosophical terms, the framework should be able to deal with challenging issues, such as uncertainty, time frame, network effects, model changes, while integrating cost and non-cost values into the evaluation. The choice of evaluation techniques depends on the feature of the problem at hand, on the aims of the analysis, and on the underlying information base At different management levels, the complexity in considering social, environmental, economic and political factor in decision-making is different. At higher the strategic planning level, more non-cost factors are involved. The complexity also varies based on the scope of the investment proposals. Road agencies traditionally place less emphasis on evaluation of maintenance works. In some cases, social equity, safety, environmental issues have been used in maintenance project selection. However, there is not a common base for the applications.

Traps for the unwary : reform stories of private sector managers entering public service

The purpose of this research is to capture and interpret the stories of “outsider” managers who make the transition to the public sector. These experiences are considered in the context of efforts to shift public management culture in a direction consistent with meeting contemporary demands placed on public sector organisations. It is often noted that an important strategy for changing culture is the infusion of outsiders. Outsiders are thought to bring new perspectives that, through a dialectical process (Van de Ven 1995), create the potential for change. While there have been cross-sector comparisons (Broussine 1990; Silfvast 1994; Redman 1997), little attention has been given to the experience of those who make the transition in the context of efforts to reform public sector management culture. Not only is the infusion of private sector managers into the public sector a potential culture change strategy, it is also a personal experience for those who make the transition. Boundary crossing is typically an anxiety provoking experience (Van Maanen & Schein 1979) and the quality of this experience influences decisions to commit, engage, disengage or exit. The quality of the experience is likely to be affected by how the public organisation responds to people making this transition, that is, their investment in people processing (Saks 2007). The cost of recruitment and selection processes at middle and senior management levels warrants a greater research focus on this transition. In this paper we argue that the experiences of those who make the transition from private to public sectors has much to tell us about the traps that transition managers experience in making this change, the implications for injecting outsider managers as a strategy for achieving public management culture change, and how reform-oriented public organisations can manage the transitions of outsider managers into the public sector in order that best value might be achieved for both the individual and organisational change goals.

Optimal allocation of a cross-connection and sectionalizers in distribution systems

In this paper, the placement of sectionalizers, as well as, a cross-connection is optimally determined so that the objective function is minimized. The objective function employed in this paper consists of two main parts, the switch cost and the reliability cost. The switch cost is composed of the cost of sectionalizers and cross-connection and the reliability cost is assumed to be proportional to a reliability index, SAIDI. To optimize the allocation of sectionalizers and cross-connection problem realistically, the cost related to each element is considered as discrete. In consequence of binary variables for the availability of sectionalizers, the problem is extremely discrete. Therefore, the probability of local minimum risk is high and a heuristic-based optimization method is needed. A Discrete Particle Swarm Optimization (DPSO) is employed in this paper to deal with this discrete problem. Finally, a testing distribution system is used to validate the proposed method.