Evaluation of financial incentives as a quality improvement strategy in the public hospital context : clinician attitudes, design variables, and economic costs

In 2008, a three-year pilot ‘pay for performance’ (P4P) program, known as ‘Clinical Practice Improvement Payment’ (CPIP) was introduced into Queensland Health (QHealth). QHealth is a large public health sector provider of acute, community, and public health services in Queensland, Australia. The organisation has recently embarked on a significant reform agenda including a review of existing funding arrangements (Duckett et al., 2008). Partly in response to this reform agenda, a casemix funding model has been implemented to reconnect health care funding with outcomes. CPIP was conceptualised as a performance-based scheme that rewarded quality with financial incentives. This is the first time such a scheme has been implemented into the public health sector in Australia with a focus on rewarding quality, and it is unique in that it has a large state-wide focus and includes 15 Districts. CPIP initially targeted five acute and community clinical areas including Mental Health, Discharge Medication, Emergency Department, Chronic Obstructive Pulmonary Disease, and Stroke. The CPIP scheme was designed around key concepts including the identification of clinical indicators that met the set criteria of: high disease burden, a well defined single diagnostic group or intervention, significant variations in clinical outcomes and/or practices, a good evidence, and clinician control and support (Ward, Daniels, Walker & Duckett, 2007). This evaluative research targeted Phase One of implementation of the CPIP scheme from January 2008 to March 2009. A formative evaluation utilising a mixed methodology and complementarity analysis was undertaken. The research involved three research questions and aimed to determine the knowledge, understanding, and attitudes of clinicians; identify improvements to the design, administration, and monitoring of CPIP; and determine the financial and economic costs of the scheme. Three key studies were undertaken to ascertain responses to the key research questions. Firstly, a survey of clinicians was undertaken to examine levels of knowledge and understanding and their attitudes to the scheme. Secondly, the study sought to apply Statistical Process Control (SPC) to the process indicators to assess if this enhanced the scheme and a third study examined a simple economic cost analysis. The CPIP Survey of clinicians elicited 192 clinician respondents. Over 70% of these respondents were supportive of the continuation of the CPIP scheme. This finding was also supported by the results of a quantitative altitude survey that identified positive attitudes in 6 of the 7 domains-including impact, awareness and understanding and clinical relevance, all being scored positive across the combined respondent group. SPC as a trending tool may play an important role in the early identification of indicator weakness for the CPIP scheme. This evaluative research study supports a previously identified need in the literature for a phased introduction of Pay for Performance (P4P) type programs. It further highlights the value of undertaking a formal risk assessment of clinician, management, and systemic levels of literacy and competency with measurement and monitoring of quality prior to a phased implementation. This phasing can then be guided by a P4P Design Variable Matrix which provides a selection of program design options such as indicator target and payment mechanisms. It became evident that a clear process is required to standardise how clinical indicators evolve over time and direct movement towards more rigorous ‘pay for performance’ targets and the development of an optimal funding model. Use of this matrix will enable the scheme to mature and build the literacy and competency of clinicians and the organisation as implementation progresses. Furthermore, the research identified that CPIP created a spotlight on clinical indicators and incentive payments of over five million from a potential ten million was secured across the five clinical areas in the first 15 months of the scheme. This indicates that quality was rewarded in the new QHealth funding model, and despite issues being identified with the payment mechanism, funding was distributed. The economic model used identified a relative low cost of reporting (under $8,000) as opposed to funds secured of over $300,000 for mental health as an example. Movement to a full cost effectiveness study of CPIP is supported. Overall the introduction of the CPIP scheme into QHealth has been a positive and effective strategy for engaging clinicians in quality and has been the catalyst for the identification and monitoring of valuable clinical process indicators. This research has highlighted that clinicians are supportive of the scheme in general; however, there are some significant risks that include the functioning of the CPIP payment mechanism. Given clinician support for the use of a pay–for-performance methodology in QHealth, the CPIP scheme has the potential to be a powerful addition to a multi-faceted suite of quality improvement initiatives within QHealth.

Bayesian methodology for genetics of complex diseases

Genetic research of complex diseases is a challenging, but exciting, area of research. The early development of the research was limited, however, until the completion of the Human Genome and HapMap projects, along with the reduction in the cost of genotyping, which paves the way for understanding the genetic composition of complex diseases. In this thesis, we focus on the statistical methods for two aspects of genetic research: phenotype definition for diseases with complex etiology and methods for identifying potentially associated Single Nucleotide Polymorphisms (SNPs) and SNP-SNP interactions. With regard to phenotype definition for diseases with complex etiology, we firstly investigated the effects of different statistical phenotyping approaches on the subsequent analysis. In light of the findings, and the difficulties in validating the estimated phenotype, we proposed two different methods for reconciling phenotypes of different models using Bayesian model averaging as a coherent mechanism for accounting for model uncertainty. In the second part of the thesis, the focus is turned to the methods for identifying associated SNPs and SNP interactions. We review the use of Bayesian logistic regression with variable selection for SNP identification and extended the model for detecting the interaction effects for population based case-control studies. In this part of study, we also develop a machine learning algorithm to cope with the large scale data analysis, namely modified Logic Regression with Genetic Program (MLR-GEP), which is then compared with the Bayesian model, Random Forests and other variants of logic regression.

Optimal control of distributed generators and capacitors by hybrid DPSO

In this paper, a comprehensive planning methodology is proposed that can minimize the line loss, maximize the reliability and improve the voltage profile in a distribution network. The injected active and reactive power of Distributed Generators (DG) and the installed capacitor sizes at different buses and for different load levels are optimally controlled. The tap setting of HV/MV transformer along with the line and transformer upgrading is also included in the objective function. A hybrid optimization method, called Hybrid Discrete Particle Swarm Optimization (HDPSO), is introduced to solve this nonlinear and discrete optimization problem. The proposed HDPSO approach is a developed version of DPSO in which the diversity of the optimizing variables is increased using the genetic algorithm operators to avoid trapping in local minima. The objective function is composed of the investment cost of DGs, capacitors, distribution lines and HV/MV transformer, the line loss, and the reliability. All of these elements are converted into genuine dollars. Given this, a single-objective optimization method is sufficient. The bus voltage and the line current as constraints are satisfied during the optimization procedure. The IEEE 18-bus test system is modified and employed to evaluate the proposed algorithm. The results illustrate the unavoidable need for optimal control on the DG active and reactive power and capacitors in distribution networks.

Utility of routine data sources for feedback on the quality of cancer care: an assessment based on clinical practice guidelines

Background Not all cancer patients receive state-of-the-art care and providing regular feedback to clinicians might reduce this problem. The purpose of this study was to assess the utility of various data sources in providing feedback on the quality of cancer care. Methods Published clinical practice guidelines were used to obtain a list of processes-of-care of interest to clinicians. These were assigned to one of four data categories according to their availability and the marginal cost of using them for feedback. Results Only 8 (3%) of 243 processes-of-care could be measured using population-based registry or administrative inpatient data (lowest cost). A further 119 (49%) could be measured using a core clinical registry, which contains information on important prognostic factors (e.g., clinical stage, physiological reserve, hormone-receptor status). Another 88 (36%) required an expanded clinical registry or medical record review; mainly because they concerned long-term management of disease progression (recurrences and metastases) and 28 (11.5%) required patient interview or audio-taping of consultations because they involved information sharing between clinician and patient. Conclusion The advantages of population-based cancer registries and administrative inpatient data are wide coverage and low cost. The disadvantage is that they currently contain information on only a few processes-of-care. In most jurisdictions, clinical cancer registries, which can be used to report on many more processes-of-care, do not cover smaller hospitals. If we are to provide feedback about all patients, not just those in larger academic hospitals with the most developed data systems, then we need to develop sustainable population-based data systems that capture information on prognostic factors at the time of initial diagnosis and information on management of disease progression.

Nursing Sans Frontieres: A Three Year Case Study of Multi-State Registration of Support Nursing Practice Using Information Technology

Objective: To highlight the registration issues for nurses who wish to practice nationally, particularly those practicing within the telehealth sector. Design: As part of a national clinical research study, applications were made to every state and territory for mutual recognition of nursing registration and fee waiver for telenursing cross boarder practice for a period of three years. These processes are described using a case study approach. Outcome: The aim of this case study was to achieve registration in every state and territory of Australia without paying multiple fees by using mutual recognition provisions and the cross-border fee waiver policy of the nurse regulatory authorities in order to practice telenursing. Results: Mutual recognition and fee waiver for cross-border practice was granted unconditionally in two states: Victoria (Vic) and Tasmania (Tas), and one territory: the Northern Territory (NT). The remainder of the Australian states and territories would only grant temporary registration for the period of the project or not at all, due to policy restrictions or nurse regulatory authority (NRA) Board decisions. As a consequence of gaining fee waiver the annual cost of registration was a maximum of $145 per annum as opposed to the potential $959 for initial registration and $625 for annual renewal. Conclusions: Having eight individual nurses Acts and NRAs for a population of 265,000 nurses would clearly indicate a case for over regulation in this country. The structure of regulation of nursing in Australia is a barrier to the changing and evolving role of nurses in the 21st century and a significant factor when considering workforce planning.

LMP estimation considering the uncertainty of wind power

One of the impediments to large-scale use of wind generation within power system is its variable and uncertain real-time availability. Due to the low marginal cost of wind power, its output will change the merit order of power markets and influence the Locational Marginal Price (LMP). For the large scale of wind power, LMP calculation can't ignore the essential variable and uncertain nature of wind power. This paper proposes an algorithm to estimate LMP. The estimation result of conventional Monte Carlo simulation is taken as benchmark to examine accuracy. Case study is conducted on a simplified SE Australian power system, and the simulation results show the feasibility of proposed method.

The mobile phone : the new communication drum of Papua New Guinea

This thesis examines the role of mobile telephony in rural communities in Papua New Guinea (PNG). It is a threshold study which reports on research conducted in the earliest stages of mobile phone adoption in these areas. It explores the ways in which this new technology changes people’s lives, social structures and relationships. The research focuses on non-urban communities, which previously had little or no access to modern communication technologies, but which are in some cases still using traditional forms of communication such as drums. It has found that the introduction of mobile telecommunications has generally been viewed positively, although several negative concerns have been strongly felt. Specific benefits related to enhanced communication with relatives and friends living away from home villages, and use of the technology in time-critical emergencies or crises. Difficulties have arisen with respect to the cost of owning and operating a handset, as well as financial and logistical challenges when recharging handset batteries, particularly in areas with no mains electricity supply. Perceived damaging effects of mobile phone access related to sex, crime and pornography. The changes taking place are described through a social lens, by foregrounding the perceptions of villagers. The perspectives of key informants, such as telecommunication company managers, are also discussed. Employing the technique of triangulation (using different methods and sources) has helped to validate the findings of the research project. The sources constantly overlap and agree on the main themes, such as those outlined above. PNG is a developing country which performs poorly on a wide range of development indicators. A large majority of the people live outside of the major towns and cities. It is therefore worthwhile investigating the introduction of mobile phone technology in rural areas. These areas often have poor access to services, including transport, health, education and banking. Until 2007, communities in such regions fell outside of mobile phone coverage areas. In the case of all ten villages discussed in this thesis, there has never been any landline telephone infrastructure available. Therefore, this research on mobile phones is in effect documenting the first ever access to any kind of phone in these communities. This research makes a unique contribution to knowledge about the role of communication in PNG, and has implications for policy, practice and theory. In the policy arena, the thesis aids understanding of the impact which communication sector competition and regulation can have on rural and relatively isolated communities. There are three practical problems which have emerged from the research: cost, battery recharging difficulties and breakage are all major obstacles to uptake and use of mobile telephony in rural communities. Efforts to reduce usage costs, enable easier recharging, and design more robust handsets would allow for increased utilisation of mobile phones for a range of purposes. With respect to the realm of theory, this research sits amongst the most recent scholarship in the mobile phone field, located within the broader communication theory area. It recommends cautionary reading of any literature which suggests that mobile phones will reduce poverty and increase incomes in poor, rural communities in developing countries. Nonetheless, the present research adds weight to mobile phone studies which suggest that the primary advantages of mobile phones in such settings are for the satisfactions of communication of itself, and for social interaction among loved ones.

The motivation and structure of corrupt police networks : theorising the dark side of the ‘thin blue line’

In recent times considerable research attention has been directed to understanding dark networks, especially criminal and terrorist networks. Dark networks are those in which member motivations are self rather than public interested, achievements come at the cost of other individuals, groups or societies and, in addition, their activities are both ‘covert and illegal’ (Raab & Milward, 2003: 415). This ‘darkness’ has implications for the way in which these networks are structured, the strategies adopted and their recruitment methods. Such entities exhibit distinctive operating characteristics including most notably the tension between creating an efficient network structure while retaining the ability to hide from public view while avoiding catastrophic collapse should one member cooperate with authorities (Bouchard 2007). While theoretical emphasis has been on criminal and terrorist networks, recent work has demonstrated that corrupt police networks exhibit some distinctive characteristics. In particular, these entities operate within the shadows of a host organisation - the Police Force and distort the functioning of the ‘Thin Blue Line’ as the interface between the law abiding citizenry and the criminal society. Drawing on data derived from the Queensland Fitzgerald Commission of Enquiry into Police Misconduct and related documents, this paper examines the motivations, structural properties and operational practices of corrupt police networks and compares and contrasts these with other dark networks with ‘bright’ public service networks. The paper confirms the structural differences between dark corrupt police networks and bright networks and suggests. However, structural embeddedness alone is found to be an insufficient theoretical explanation for member involvement in networks and that a set of elements combine to impact decision-making. Although offering important insights into network participation, the paper’s findings are especially pertinent in identifying additional points of intervention for police corruption networks.

Management characteristics and the decision to internationalize : Exploration of exporters vs. non-exporters within the Chilean wine industry

The objective of this exploratory study was to identify the key factors that enhance and inhibit the export activities of wineries and identify differences between exporters and non-exporters. Based on data collected from Chilean wineries, the findings of this study suggest that the major constraints for non-exporters are the lack of financial resources, limited quantities of stocks for market expansion, management’s lack of knowledge and experience, and the high cost of travelling and participating in trade shows. In addition, the main international markets for Chilean wineries were not psychically close markets as has been found for Australian or other wine industries. For domestic market oriented wineries cellar door sales were an important source of revenue. Finally, the results show that managers have educational levels and international experience exceeding those of other comparable New World wineries.

Long-evans rats acquire operant self-administration of 20% ethanol without sucrose fading

A major obstacle in the development of new medications for the treatment of alcohol use disorders (AUDs) has been the lack of preclinical, oral ethanol consumption paradigms that elicit high consumption. We have previously shown that rats exposed to 20% ethanol intermittently in a two-bottle choice paradigm will consume two times more ethanol than those given continuous access without the use of water deprivation or sucrose fading (5-6 g/kg every 24 h vs 2-3 g/kg every 24 h, respectively). In this study, we have adapted the model to an operant self-administration paradigm. Long-Evans rats were given access to 20% ethanol in overnight sessions on one of two schedules: (1) intermittent (Monday, Wednesday, and Friday) or (2) daily (Monday through Friday). With the progression of the overnight sessions, both groups showed a steady escalation in drinking (3-6 g/kg every 14 h) without the use of a sucrose-fading procedure. Following the acquisition phase, the 20% ethanol groups consumed significantly more ethanol than did animals trained to consume 10% ethanol with a sucrose fade (1.5 vs 0.7 g/kg every 30 min) and reached significantly higher blood ethanol concentrations. In addition, training history (20% ethanol vs 10% ethanol with sucrose fade) had a significant effect on the subsequent self-administration of higher concentrations of ethanol. Administration of the pharmacological stressor yohimbine following extinction caused a significant reinstatement of ethanol-seeking behavior. Both 20% ethanol models show promise and are amenable to the study of maintenance, motivation, and reinstatement. Furthermore, training animals to lever press for ethanol without the use of sucrose fading removes a potential confound from self-administration studies. © 2010 Nature Publishing Group All rights reserved.

Development of a high-speed sensing and detection system for automatic removal of packages with leaky seals from a high-speed food processing and packaging line

Contamination of packaged foods due to micro-organisms entering through air leaks can cause serious public health issues and cost companies large amounts of money due to product recalls, consumer impact and subsequent loss of market share. The main source of contamination is leaks in packaging which allow air, moisture and microorganisms to enter the package. In the food processing and packaging industry worldwide, there is an increasing demand for cost effective state of the art inspection technologies that are capable of reliably detecting leaky seals and delivering products at six-sigma. The new technology will develop non-destructive testing technology using digital imaging and sensing combined with a differential vacuum technique to assess seal integrity of food packages on a high-speed production line. The cost of leaky packages in Australian food industries is estimated close to AUD $35 Million per year. Contamination of packaged foods due to micro-organisms entering through air leaks can cause serious public health issues and cost companies large sums of money due to product recalls, compensation claims and loss of market share. The main source of contamination is leaks in packaging which allow air, moisture and micro-organisms to enter the package. Flexible plastic packages are widely used, and are the least expensive form of retaining the quality of the product. These packets can be used to seal, and therefore maximise, the shelf life of both dry and moist products. The seals of food packages need to be airtight so that the food content is not contaminated due to contact with microorganisms that enter as a result of air leakage. Airtight seals also extend the shelf life of packaged foods, and manufacturers attempt to prevent food products with leaky seals being sold to consumers. There are many current NDT (non-destructive testing) methods of testing the seal of flexible packages best suited to random sampling, and for laboratory purposes. The three most commonly used methods are vacuum/pressure decay, bubble test, and helium leak detection. Although these methods can detect very fine leaks, they are limited by their high processing time and are not viable in a production line. Two nondestructive in-line packaging inspection machines are currently available and are discussed in the literature review. The detailed design and development of the High-Speed Sensing and Detection System (HSDS) is the fundamental requirement of this project and the future prototype and production unit. Successful laboratory testing was completed and a methodical design procedure was needed for a successful concept. The Mechanical tests confirmed the vacuum hypothesis and seal integrity with good consistent results. Electrically, the testing also provided solid results to enable the researcher to move the project forward with a certain amount of confidence. The laboratory design testing allowed the researcher to confirm theoretical assumptions before moving into the detailed design phase. Discussion on the development of the alternative concepts in both mechanical and electrical disciplines enables the researcher to make an informed decision. Each major mechanical and electrical component is detailed through the research and design process. The design procedure methodically works through the various major functions both from a mechanical and electrical perspective. It opens up alternative ideas for the major components that although are sometimes not practical in this application, show that the researcher has exhausted all engineering and functionality thoughts. Further concepts were then designed and developed for the entire HSDS unit based on previous practice and theory. In the future, it would be envisaged that both the Prototype and Production version of the HSDS would utilise standard industry available components, manufactured and distributed locally. Future research and testing of the prototype unit could result in a successful trial unit being incorporated in a working food processing production environment. Recommendations and future works are discussed, along with options in other food processing and packaging disciplines, and other areas in the non-food processing industry.

Measuring bitrate and quality trade-off in a fast region-of-interest based video coding

Prevailing video adaptation solutions change the quality of the video uniformly throughout the whole frame in the bitrate adjustment process; while region-of-interest (ROI)-based solutions selectively retains the quality in the areas of the frame where the viewers are more likely to pay more attention to. ROI-based coding can improve perceptual quality and viewer satisfaction while trading off some bandwidth. However, there has been no comprehensive study to measure the bitrate vs. perceptual quality trade-off so far. The paper proposes an ROI detection scheme for videos, which is characterized with low computational complexity and robustness, and measures the bitrate vs. quality trade-off for ROI-based encoding using a state-of-the-art H.264/AVC encoder to justify the viability of this type of encoding method. The results from the subjective quality test reveal that ROI-based encoding achieves a significant perceptual quality improvement over the encoding with uniform quality at the cost of slightly more bits. Based on the bitrate measurements and subjective quality assessments, the bitrate and the perceptual quality estimation models for non-scalable ROI-based video coding (AVC) are developed, which are found to be similar to the models for scalable video coding (SVC).

Performance enhancement of smart antennas with reduced element spacing

This paper addresses the problem of degradations in adaptive digital beam-forming (DBF) systems caused by mutual coupling between array elements. The focus is on compact arrays with reduced element spacing and, hence, strongly coupled elements. Deviations in the radiation patterns of coupled and (theoretically) uncoupled elements can be compensated for by weight-adjustments in DBF, but SNR degradation due to impedance mismatches cannot be compensated for via signal processing techniques. It is shown that this problem can be overcome via the implementation of a RF-decoupling-network. SNR enhancement is achieved at the cost of a reduced frequency bandwidth and an increased sensitivity to dissipative losses in the antenna and matching network structure.

Reducing Actuator Switchings for Motion Control of Autonomous Underwater Vehicles

A priority when designing control strategies for autonomous underwater vehicles is to emphasize their cost of implementation on a real vehicle. Indeed, due to the vehicles' design and the actuation modes usually under consideration for underwater plateforms the number of actuator switchings must be kept to a small value to insure feasibility and precision. This is the main objective of the algorithm presented in this paper. The theory is illustrated on two examples, one is a fully actuated underwater vehicle capable of motion in six-degrees-of freedom and one is minimally actuated with control motions in the vertical plane only.

An exploratory study of the factors enhancing and inhibiting export growth in the Chilean wine industry

The objective of this exploratory study is to investigate the main drivers that enhance and inhibit the export performance of Chilean wineries. Based on survey data collected from Chilean wineries, the findings of this study suggest that the main constraints within the Chilean wineries in developing exports is the lack of financial resources, limited quantities of stocks for market expansion, management’s lack of knowledge and experience, and the high cost of travelling and participating in trade shows. The main drivers of wine export performance according to the respondents are high quality of the wines, well established network of international distributors, and marketing skills. The major inhibitors of developing wine exports are exchange rate variability, problems in selecting a reliable international distributor, and limited government support to promote wine exports. This study also shows that export managers of Chilean wineries have high educational levels and have international experience. The findings have important implications for export development efforts of both governments and managers.