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.

Comparison of robust criteria for D-optimal design

This study compared the performance of a local and three robust optimality criteria in terms of the standard error for a one-parameter and a two-parameter nonlinear model with uncertainty in the parameter values. The designs were also compared in conditions where there was misspecification in the prior parameter distribution. The impact of different correlation between parameters on the optimal design was examined in the two-parameter model. The designs and standard errors were solved analytically whenever possible and numerically otherwise.

A Reliability test system for educational purposes-basic data

The IEEE Subcommittee on the Application of Probability Methods (APM) published the IEEE Reliability Test System (RTS) [1] in 1979. This system provides a consistent and generally acceptable set of data that can be used both in generation capacity and in composite system reliability evaluation [2,3]. The test system provides a basis for the comparison of results obtained by different people using different methods. Prior to its publication, there was no general agreement on either the system or the data that should be used to demonstrate or test various techniques developed to conduct reliability studies. Development of reliability assessment techniques and programs are very dependent on the intent behind the development as the experience of one power utility with their system may be quite different from that of another utility. The development and the utilization of a reliability program are, therefore, greatly influenced by the experience of a utlity and the intent of the system manager, planner and designer conducting the reliability studies. The IEEE-RTS has proved to be extremely valuable in highlighting and comparing the capabilities (or incapabilities) of programs used in reliability studies, the differences in the perception of various power utilities and the differences in the solution techniques. The IEEE-RTS contains a reasonably large power network which can be difficult to use for initial studies in an educational environment.

Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010 : a systematic analysis for the Global Burden of Disease Study 2010

Background Non-fatal health outcomes from diseases and injuries are a crucial consideration in the promotion and monitoring of individual and population health. The Global Burden of Disease (GBD) studies done in 1990 and 2000 have been the only studies to quantify non-fatal health outcomes across an exhaustive set of disorders at the global and regional level. Neither effort quantified uncertainty in prevalence or years lived with disability (YLDs). Methods Of the 291 diseases and injuries in the GBD cause list, 289 cause disability. For 1160 sequelae of the 289 diseases and injuries, we undertook a systematic analysis of prevalence, incidence, remission, duration, and excess mortality. Sources included published studies, case notification, population-based cancer registries, other disease registries, antenatal clinic serosurveillance, hospital discharge data, ambulatory care data, household surveys, other surveys, and cohort studies. For most sequelae, we used a Bayesian meta-regression method, DisMod-MR, designed to address key limitations in descriptive epidemiological data, including missing data, inconsistency, and large methodological variation between data sources. For some disorders, we used natural history models, geospatial models, back-calculation models (models calculating incidence from population mortality rates and case fatality), or registration completeness models (models adjusting for incomplete registration with health-system access and other covariates). Disability weights for 220 unique health states were used to capture the severity of health loss. YLDs by cause at age, sex, country, and year levels were adjusted for comorbidity with simulation methods. We included uncertainty estimates at all stages of the analysis. Findings Global prevalence for all ages combined in 2010 across the 1160 sequelae ranged from fewer than one case per 1 million people to 350 000 cases per 1 million people. Prevalence and severity of health loss were weakly correlated (correlation coefficient −0·37). In 2010, there were 777 million YLDs from all causes, up from 583 million in 1990. The main contributors to global YLDs were mental and behavioural disorders, musculoskeletal disorders, and diabetes or endocrine diseases. The leading specific causes of YLDs were much the same in 2010 as they were in 1990: low back pain, major depressive disorder, iron-deficiency anaemia, neck pain, chronic obstructive pulmonary disease, anxiety disorders, migraine, diabetes, and falls. Age-specific prevalence of YLDs increased with age in all regions and has decreased slightly from 1990 to 2010. Regional patterns of the leading causes of YLDs were more similar compared with years of life lost due to premature mortality. Neglected tropical diseases, HIV/AIDS, tuberculosis, malaria, and anaemia were important causes of YLDs in sub-Saharan Africa. Interpretation Rates of YLDs per 100 000 people have remained largely constant over time but rise steadily with age. Population growth and ageing have increased YLD numbers and crude rates over the past two decades. Prevalences of the most common causes of YLDs, such as mental and behavioural disorders and musculoskeletal disorders, have not decreased. Health systems will need to address the needs of the rising numbers of individuals with a range of disorders that largely cause disability but not mortality. Quantification of the burden of non-fatal health outcomes will be crucial to understand how well health systems are responding to these challenges. Effective and affordable strategies to deal with this rising burden are an urgent priority for health systems in most parts of the world. Funding Bill & Melinda Gates Foundation.

A new framework of measuring national nutrients balance for international and global comparison

Nutrients balance such as nitrogen and phosphorus balance are increasingly used as an indicator of the environmental performance of agricultural sector in international and global context. However there still is a lack of harmony in the use of methods for estimating the nutrients balance among countries. This is because of the disagreement regarding the accuracy and uncertainty of different accounting methods. The lack of harmony in the methods used in different countries further increases the uncertainty in the context of the international comparisons. This paper provides a new framework for nutrients balance calculation using the farm-gate accounting method. The calculation under this new framework takes advantage of availability of data from FAO and other reliable national and international sources. Due to this, the proposed framework is highly adaptable in many countries, making the global comparison feasible. The paper also proposes three criteria including adaptability, accuracy and interpretability to assess the appropriateness of nutrients accounting method. Based on these criteria, the paper provides a comprehensive comparison of the farm-gate and soil-surface methods in accounting country-level nutrients balance of agricultural production. The paper identifies some shortcomings of the soil-surface balance and shows that the farm-gate method has a greater potential of providing a more accurate and meaningful estimation of national nutrients balance.

Assessing the Impact of Sensor Accuracy and Sensor Choice on Air Traffic Conflict Risk Estimation using Risk-Ratio Concepts

One of the primary desired capabilities of any future air traffic separation management system is the ability to provide early conflict detection and resolution effectively and efficiently. In this paper, we consider the risk of conflict as a primary measurement to be used for early conflict detection. This paper focuses on developing a novel approach to assess the impact of different measurement uncertainty models on the estimated risk of conflict. The measurement uncertainty model can be used to represent different sensor accuracy and sensor choices. Our study demonstrates the value of modelling measurement uncertainty in the conflict risk estimation problem and presents techniques providing a means of assessing sensor requirements to achieve desired conflict detection performance.

Speaker diarization : "who spoke when"

Speaker diarization is the process of annotating an input audio with information that attributes temporal regions of the audio signal to their respective sources, which may include both speech and non-speech events. For speech regions, the diarization system also specifies the locations of speaker boundaries and assign relative speaker labels to each homogeneous segment of speech. In short, speaker diarization systems effectively answer the question of ‘who spoke when’. There are several important applications for speaker diarization technology, such as facilitating speaker indexing systems to allow users to directly access the relevant segments of interest within a given audio, and assisting with other downstream processes such as summarizing and parsing. When combined with automatic speech recognition (ASR) systems, the metadata extracted from a speaker diarization system can provide complementary information for ASR transcripts including the location of speaker turns and relative speaker segment labels, making the transcripts more readable. Speaker diarization output can also be used to localize the instances of specific speakers to pool data for model adaptation, which in turn boosts transcription accuracies. Speaker diarization therefore plays an important role as a preliminary step in automatic transcription of audio data. The aim of this work is to improve the usefulness and practicality of speaker diarization technology, through the reduction of diarization error rates. In particular, this research is focused on the segmentation and clustering stages within a diarization system. Although particular emphasis is placed on the broadcast news audio domain and systems developed throughout this work are also trained and tested on broadcast news data, the techniques proposed in this dissertation are also applicable to other domains including telephone conversations and meetings audio. Three main research themes were pursued: heuristic rules for speaker segmentation, modelling uncertainty in speaker model estimates, and modelling uncertainty in eigenvoice speaker modelling. The use of heuristic approaches for the speaker segmentation task was first investigated, with emphasis placed on minimizing missed boundary detections. A set of heuristic rules was proposed, to govern the detection and heuristic selection of candidate speaker segment boundaries. A second pass, using the same heuristic algorithm with a smaller window, was also proposed with the aim of improving detection of boundaries around short speaker segments. Compared to single threshold based methods, the proposed heuristic approach was shown to provide improved segmentation performance, leading to a reduction in the overall diarization error rate. Methods to model the uncertainty in speaker model estimates were developed, to address the difficulties associated with making segmentation and clustering decisions with limited data in the speaker segments. The Bayes factor, derived specifically for multivariate Gaussian speaker modelling, was introduced to account for the uncertainty of the speaker model estimates. The use of the Bayes factor also enabled the incorporation of prior information regarding the audio to aid segmentation and clustering decisions. The idea of modelling uncertainty in speaker model estimates was also extended to the eigenvoice speaker modelling framework for the speaker clustering task. Building on the application of Bayesian approaches to the speaker diarization problem, the proposed approach takes into account the uncertainty associated with the explicit estimation of the speaker factors. The proposed decision criteria, based on Bayesian theory, was shown to generally outperform their non- Bayesian counterparts.

Bayesian survival analysis using gene expression

This thesis developed and applied Bayesian models for the analysis of survival data. The gene expression was considered as explanatory variables within the Bayesian survival model which can be considered the new contribution in the analysis of such data. The censoring factor that is inherent of survival data has also been addressed in terms of its impact on the fitting of a finite mixture of Weibull distribution with and without covariates. To investigate this, simulation study were carried out under several censoring percentages. Censoring percentage as high as 80% is acceptable here as the work involved high dimensional data. Lastly the Bayesian model averaging approach was developed to incorporate model uncertainty in the prediction of survival.

Rough set based approach to text classification

Textual document set has become an important and rapidly growing information source in the web. Text classification is one of the crucial technologies for information organisation and management. Text classification has become more and more important and attracted wide attention of researchers from different research fields. In this paper, many feature selection methods, the implement algorithms and applications of text classification are introduced firstly. However, because there are much noise in the knowledge extracted by current data-mining techniques for text classification, it leads to much uncertainty in the process of text classification which is produced from both the knowledge extraction and knowledge usage, therefore, more innovative techniques and methods are needed to improve the performance of text classification. It has been a critical step with great challenge to further improve the process of knowledge extraction and effectively utilization of the extracted knowledge. Rough Set decision making approach is proposed to use Rough Set decision techniques to more precisely classify the textual documents which are difficult to separate by the classic text classification methods. The purpose of this paper is to give an overview of existing text classification technologies, to demonstrate the Rough Set concepts and the decision making approach based on Rough Set theory for building more reliable and effective text classification framework with higher precision, to set up an innovative evaluation metric named CEI which is very effective for the performance assessment of the similar research, and to propose a promising research direction for addressing the challenging problems in text classification, text mining and other relative fields.

Motion planning and stochastic control with experimental validation on a planetary rover

Motion planning for planetary rovers must consider control uncertainty in order to maintain the safety of the platform during navigation. Modelling such control uncertainty is difficult due to the complex interaction between the platform and its environment. In this paper, we propose a motion planning approach whereby the outcome of control actions is learned from experience and represented statistically using a Gaussian process regression model. This model is used to construct a control policy for navigation to a goal region in a terrain map built using an on-board RGB-D camera. The terrain includes flat ground, small rocks, and non-traversable rocks. We report the results of 200 simulated and 35 experimental trials that validate the approach and demonstrate the value of considering control uncertainty in maintaining platform safety.

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.

Projecting the impact of climate change on the transmission of Ross River virus : methodological challenges and research needs

Ross River virus (RRV) is the most common vector-borne disease in Australia. It is vitally important to make appropriate projections on the future spread of RRV under various climate change scenarios because such information is essential for policy-makers to identify vulnerable communities and to better manage RRV epidemics. However, there are many methodological challenges in projecting the impact of climate change on the transmission of RRV disease. This study critically examined the methodological issues and proposed possible solutions. A literature search was conducted between January and October 2012, using the electronic databases Medline, Web of Science and PubMed. Nineteen relevant papers were identified. These studies demonstrate that key challenges for projecting future climate change on RRV disease include: (1) a complex ecology (e.g. many mosquito vectors, immunity, heterogeneous in both time and space); (2) unclear interactions between social and environmental factors; and (3) uncertainty in climate change modelling and socioeconomic development scenarios. Future risk assessments of climate change will ultimately need to better understand the ecology of RRV disease and to integrate climate change scenarios with local socioeconomic and environmental factors, in order to develop effective adaptation strategies to prevent or reduce RRV transmission.

A practical and theoretical definition of very small field size for radiotherapy output factor measurements

Purpose This work introduces the concept of very small field size. Output factor (OPF) measurements at these field sizes require extremely careful experimental methodology including the measurement of dosimetric field size at the same time as each OPF measurement. Two quantifiable scientific definitions of the threshold of very small field size are presented. Methods A practical definition was established by quantifying the effect that a 1 mm error in field size or detector position had on OPFs, and setting acceptable uncertainties on OPF at 1%. Alternatively, for a theoretical definition of very small field size, the OPFs were separated into additional factors to investigate the specific effects of lateral electronic disequilibrium, photon scatter in the phantom and source occlusion. The dominant effect was established and formed the basis of a theoretical definition of very small fields. Each factor was obtained using Monte Carlo simulations of a Varian iX linear accelerator for various square field sizes of side length from 4 mm to 100 mm, using a nominal photon energy of 6 MV. Results According to the practical definition established in this project, field sizes < 15 mm were considered to be very small for 6 MV beams for maximal field size uncertainties of 1 mm. If the acceptable uncertainty in the OPF was increased from 1.0 % to 2.0 %, or field size uncertainties are 0.5 mm, field sizes < 12 mm were considered to be very small. Lateral electronic disequilibrium in the phantom was the dominant cause of change in OPF at very small field sizes. Thus the theoretical definition of very small field size coincided to the field size at which lateral electronic disequilibrium clearly caused a greater change in OPF than any other effects. This was found to occur at field sizes < 12 mm. Source occlusion also caused a large change in OPF for field sizes < 8 mm. Based on the results of this study, field sizes < 12 mm were considered to be theoretically very small for 6 MV beams. Conclusions Extremely careful experimental methodology including the measurement of dosimetric field size at the same time as output factor measurement for each field size setting and also very precise detector alignment is required at field sizes at least < 12 mm and more conservatively < 15 mm for 6 MV beams. These recommendations should be applied in addition to all the usual considerations for small field dosimetry, including careful detector selection.

A threshold concepts focus to curriculum design: supporting student learning through application of variation theory

This project develops and evaluates a model of curriculum design that aims to assist student learning of foundational disciplinary ‘Threshold Concepts’. The project uses phenomenographic action research, cross-institutional peer collaboration and the Variation Theory of Learning to develop and trial the model. Two contrasting disciplines (Physics and Law) and four institutions (two research-intensive and two universities of technology) were involved in the project, to ensure broad applicability of the model across different disciplines and contexts. The Threshold Concepts that were selected for curriculum design attention were measurement uncertainty in Physics and legal reasoning in Law. Threshold Concepts are key disciplinary concepts that are inherently troublesome, transformative and integrative in nature. Once understood, such concepts transform students’ views of the discipline because they enable students to coherently integrate what were previously seen as unrelated aspects of the subject, providing new ways of thinking about it (Meyer & Land 2003, 2005, 2006; Land et al. 2008). However, the integrative and transformative nature of such threshold concepts make them inherently difficult for students to learn, with resulting misunderstandings of concepts being prevalent...

Non-monotonic Reasoning and the Reversibility of Belief Change

Traditional approaches to nonmonotonic reasoning fail to satisfy a number of plausible axioms for belief revision and suffer from conceptual difficulties as well. Recent work on ranked preferential models (RPMs) promises to overcome some of these difficulties. Here we show that RPMs are not adequate to handle iterated belief change. Specifically, we show that RPMs do not always allow for the reversibility of belief change. This result indicates the need for numerical strengths of belief.