Setting hospital infection control policy : a decision-making framework incorporating health economics and healthcare epidemiology

Background: Reducing rates of healthcare acquired infection has been identified by the Australian Commission on Safety and Quality in Health Care as a national priority. One of the goals is the prevention of central venous catheter-related bloodstream infection (CR-BSI). At least 3,500 cases of CR-BSI occur annually in Australian hospitals, resulting in unnecessary deaths and costs to the healthcare system between $25.7 and $95.3 million. Two approaches to preventing these infections have been proposed: use of antimicrobial catheters (A-CVCs); or a catheter care and management ‘bundle’. Given finite healthcare budgets, decisions about the optimal infection control policy require consideration of the effectiveness and value for money of each approach. Objectives: The aim of this research is to use a rational economic framework to inform efficient infection control policy relating to the prevention of CR-BSI in the intensive care unit. It addresses three questions relating to decision-making in this area: 1. Is additional investment in activities aimed at preventing CR-BSI an efficient use of healthcare resources? 2. What is the optimal infection control strategy from amongst the two major approaches that have been proposed to prevent CR-BSI? 3. What uncertainty is there in this decision and can a research agenda to improve decision-making in this area be identified? Methods: A decision analytic model-based economic evaluation was undertaken to identify an efficient approach to preventing CR-BSI in Queensland Health intensive care units. A Markov model was developed in conjunction with a panel of clinical experts which described the epidemiology and prognosis of CR-BSI. The model was parameterised using data systematically identified from the published literature and extracted from routine databases. The quality of data used in the model and its validity to clinical experts and sensitivity to modelling assumptions was assessed. Two separate economic evaluations were conducted. The first evaluation compared all commercially available A-CVCs alongside uncoated catheters to identify which was cost-effective for routine use. The uncertainty in this decision was estimated along with the value of collecting further information to inform the decision. The second evaluation compared the use of A-CVCs to a catheter care bundle. We were unable to estimate the cost of the bundle because it is unclear what the full resource requirements are for its implementation, and what the value of these would be in an Australian context. As such we undertook a threshold analysis to identify the cost and effectiveness thresholds at which a hypothetical bundle would dominate the use of A-CVCs under various clinical scenarios. Results: In the first evaluation of A-CVCs, the findings from the baseline analysis, in which uncertainty is not considered, show that the use of any of the four A-CVCs will result in health gains accompanied by cost-savings. The MR catheters dominate the baseline analysis generating 1.64 QALYs and cost-savings of $130,289 per 1.000 catheters. With uncertainty, and based on current information, the MR catheters remain the optimal decision and return the highest average net monetary benefits ($948 per catheter) relative to all other catheter types. This conclusion was robust to all scenarios tested, however, the probability of error in this conclusion is high, 62% in the baseline scenario. Using a value of $40,000 per QALY, the expected value of perfect information associated with this decision is $7.3 million. An analysis of the expected value of perfect information for individual parameters suggests that it may be worthwhile for future research to focus on providing better estimates of the mortality attributable to CR-BSI and the effectiveness of both SPC and CH/SSD (int/ext) catheters. In the second evaluation of the catheter care bundle relative to A-CVCs, the results which do not consider uncertainty indicate that a bundle must achieve a relative risk of CR-BSI of at least 0.45 to be cost-effective relative to MR catheters. If the bundle can reduce rates of infection from 2.5% to effectively zero, it is cost-effective relative to MR catheters if national implementation costs are less than $2.6 million ($56,610 per ICU). If the bundle can achieve a relative risk of 0.34 (comparable to that reported in the literature) it is cost-effective, relative to MR catheters, if costs over an 18 month period are below $613,795 nationally ($13,343 per ICU). Once uncertainty in the decision is considered, the cost threshold for the bundle increases to $2.2 million. Therefore, if each of the 46 Level III ICUs could implement an 18 month catheter care bundle for less than $47,826 each, this approach would be cost effective relative to A-CVCs. However, the uncertainty is substantial and the probability of error in concluding that the bundle is the cost-effective approach at a cost of $2.2 million is 89%. Conclusions: This work highlights that infection control to prevent CR-BSI is an efficient use of healthcare resources in the Australian context. If there is no further investment in infection control, an opportunity cost is incurred, which is the potential for a more efficient healthcare system. Minocycline/rifampicin catheters are the optimal choice of antimicrobial catheter for routine use in Australian Level III ICUs, however, if a catheter care bundle implemented in Australia was as effective as those used in the large studies in the United States it would be preferred over the catheters if it was able to be implemented for less than $47,826 per Level III ICU. Uncertainty is very high in this decision and arises from multiple sources. There are likely greater costs to this uncertainty for A-CVCs, which may carry hidden costs, than there are for a catheter care bundle, which is more likely to provide indirect benefits to clinical practice and patient safety. Research into the mortality attributable to CR-BSI, the effectiveness of SPC and CH/SSD (int/ext) catheters and the cost and effectiveness of a catheter care bundle in Australia should be prioritised to reduce uncertainty in this decision. This thesis provides the economic evidence to inform one area of infection control, but there are many other infection control decisions for which information about the cost-effectiveness of competing interventions does not exist. This work highlights some of the challenges and benefits to generating and using economic evidence for infection control decision-making and provides support for commissioning more research into the cost-effectiveness of infection control.

Exchange relationships in building services maintenance activity : a test of transaction cost economics and the resource dependency view

The firm is faced with a decision concerning the nature of intra-organizational exchange relationships with internal human resources and the nature or inter-organizational exchange relationships with market firms. In both situations, the firm can develop an exchange that ranges from a discrete exchange to a relational exchange. Transaction Cost Economics (TCE) and the Resource Dependency View (RDV) represent alternative efficiency-based explanations fo the nature of the exchange relationship. The aim of the paper is to test these two theories in respect of air conditioning maintenance in retail centres. Multiple sources of information are genereated from case studies of Australian retail centres to test these theories in respoect of internalized operations management (concerning strategic aspects of air conditioning maintenance) and externalized planned routine air conditioning maintenance. The analysis of the data centres on pattern matching. It is concluded that the data supports TCE - on the basis of a development in TCE's contractual schema. Further research is suggested towards taking a pluralistic stance and developing a combined efficiency and power hypothesis - upon which Williamson has speculated. For practice, the conclusions also offer a timely cautionary note concerning the adoption of one approach in all exchange relationships.

Economics and preventing healthcare acquired infection

The evolution of organisms that cause healthcare acquired infections (HAI) puts extra stress on hospitals already struggling with rising costs and demands for greater productivity and cost containment. Infection control can save scarce resources, lives, and possibly a facility’s reputation, but statistics and epidemiology are not always sufficient to make the case for the added expense. Economics and Preventing Healthcare Acquired Infection presents a rigorous analytic framework for dealing with this increasingly serious problem. ----- Engagingly written for the economics non-specialist, and brimming with tables, charts, and case examples, the book lays out the concepts of economic analysis in clear, real-world terms so that infection control professionals or infection preventionists will gain competence in developing analyses of their own, and be confident in the arguments they present to decision-makers. The authors: ----- Ground the reader in the basic principles and language of economics. ----- Explain the role of health economists in general and in terms of infection prevention and control. ----- Introduce the concept of economic appraisal, showing how to frame the problem, evaluate and use data, and account for uncertainty. ----- Review methods of estimating and interpreting the costs and health benefits of HAI control programs and prevention methods. ----- Walk the reader through a published economic appraisal of an infection reduction program. ----- Identify current and emerging applications of economics in infection control. ---- Economics and Preventing Healthcare Acquired Infection is a unique resource for practitioners and researchers in infection prevention, control and healthcare economics. It offers valuable alternate perspective for professionals in health services research, healthcare epidemiology, healthcare management, and hospital administration. ----- Written for: Professionals and researchers in infection control, health services research, hospital epidemiology, healthcare economics, healthcare management, hospital administration; Association of Professionals in Infection Control (APIC), Society for Healthcare Epidemiologists of America (SHEA)

Creative clusters and universities : the cluster concept in economics and geography

This paper considers the history of the cluster concept in urban economic geography, and its relationship to recent debates about creative cities. It then looks at the role that universities can play in the development of a creative cluster, as well as some of the potential pitfalls.

Operations research for mining : a classification and literature review

In this paper, we describe the main processes and operations in mining industries and present a comprehensive survey of operations research methodologies that have been applied over the last several decades. The literature review is classified into four main categories: mine design; mine production; mine transportation; and mine evaluation. Mining design models are further separated according to two main mining methods: open-pit and underground. Moreover, mine production models are subcategorised into two groups: ore mining and coal mining. Mine transportation models are further partitioned in accordance with fleet management, truck haulage and train scheduling. Mine evaluation models are further subdivided into four clusters in terms of mining method selection, quality control, financial risks and environmental protection. The main characteristics of four Australian commercial mining software are addressed and compared. This paper bridges the gaps in the literature and motivates researchers to develop more applicable, realistic and comprehensive operations research models and solution techniques that are directly linked with mining industries.

Language, Literacy and Literature

"Language, Literacy and Literature combines concepts of language, literature and literacy within a pedagogical framework that leads readers through a series of learning processes. In other words, it is as much a book about teaching English as it is a book about learning how to learn about teaching. The book provides models for pre-service teachers to help identify the kinds of dispositions towards learning that a teacher needs to develop, such as curiosity, collaboration and willingness to ‘give things a go’. It further challenges the pre-service teacher to question what they think they know, as well as discover what they need to know. A range of practical and relevant exercises and activities assist in building habits of reflexive practice."-- publisher website

Exploring Indigenous representations in Australian film and literature for the Australian Curriculum

The Australian Curriculum: English, v.5 (ACARA, 2013) now being implemented in Queensland asks teachers and curriculum designers to incorporate the cross curriculum priority (CCP)of Indigenous issues through Aboriginal and Torres Strait Islander histories and cultures. In the Australian Curriculum English, (AC:E) one way to address this CCP is by including texts by and about Aboriginal and Torres Strait Islander people. With the rise of promising and accomplished young, Indigenous filmmakers such as Ivan Sen, Rachael Perkins, Wayne Blair and Warwick Thornton, this guide focuses on the suitable films for schools implementing the Australian Curriculum in terms of cultural representations. This annotated guide suggests some films suitable for inclusion in classroom study and suggests some companion texts (novels, plays, television series and animations, documentaries, poetry and short stories) that may be studied alongside the films. Some of these are by Indigenous filmmakers and writers, and others features Aboriginal and Torres Strait Island representations in character and/or themes.

Public Economics and the Assessment of Tourism Developments and Policies

Public economics covers both topics in welfare economic of social (as opposed to private) interest and aspects of public finance. This chapter considers the application of two methods of social economic evaluation of tourist developments, namely, social cost-benefit analysis and economic impact analysis. The role of social cost-benefit analysis in the assessment of tourism is illustrated by its application to the evaluation of inbound tourism. This is followed by a discussion of taxes on tourism and subsidies to promote it. The principle focus is on hotel room taxes. The analysis of taxes on tourism involves both public finance and welfare economics issues. The scope for and desirability of applying the user-pays principle to tourism is then examined.

Investigating early childhood education for sustainability : insights from history and literature

Seemingly straightforward tasks often have a way of becoming complex. This was the case for our guest editorial team charged with creating Early Childhood Australia’s Best of Sustainability publication drawn from the the Australasian Journal of Early Childhood and Every Child. The complexities we encountered ranged from the varied terminologies and understandings of constructs such as education for sustainable development, environmental education and education for sustainability, through to the fundamental lack of published research on which to draw as the basis for a special issue. It is timely to explore these complexities as we face the global challenges of The Critical Decade (DCCEE, 2011) including rising sea levels, extreme weather events and food security. At a local level, the early childhood field in Australia is seeking to interpret sustainability with systemic support from the National Quality Standards(NQS) (ACECQA, 2011), while elsewhere environmental/sustainability education is encouraged through national curricula documents (for example, Singapore Ministry of Education, 2008; Swedish National Agency for Education,2010; Ministry of Education of Korea, 2011). Both The Critical Decade and the NQS provide imperatives to drive early childhood education’s engagement with sustainability. In other words, sustainability in early childhood education is no longer optional, but essential (Elliott, 2010). While some twenty years of advocacy has led to this somewhat subdued celebratory position, in this publication we do recognise the historical contexts that have led to early childhood education for sustainability (ECEfS), as we (Elliott & Davis) phrase it, becoming almost ‘mainstream not marginal’ (Davis, 1999)— a stitching together of the isolated ‘patches of green’, first identified a decade ago by Elliott (NSW EPA, 2003). Here we weave together, through these articles, a story of the evolving history of ECEfS from our particular perspective. In so doing, we also acknowledge that there are other perspectives or ‘paths’ for this field as identified by Edwards and Cutter-McKenzie in their concluding paper to this compilation.

Geo-economics and considerations on the tourism industry with emphasis on historical cities tourism and ecotourism in Iran

Considering its many potentials in the tourism industry, Iran has constantly been among the leading countries seeking development in this industry. Iran is a country with many attractions in different tourism sections including cultural, urban, and monument tourism, and ancient places as well as ecotourism, and water tourism etc. for tourists. However, Iran has never economically prospered regarding its potentials in this industry as compared to its rivals. Thus, the main objective of this work is to list the main necessities of harnessing economic power and required instruments to fulfill this goal. In addition, the tourism industry is discussed as an important strategy for reaching this power, and the Iranian wildlife is introduced as an intact environment. It is also discussed that what economic benefits are obtained through using this tourism industry. It must be noted that the main emphasis of this work is on urban, monument tourism, ancient places, and ecotourism as a case study in two Iranian provinces. Finally, the required analyses are performed considering the affinity between these two sections and two provinces. Results indicated that while Iran having the highest percent of growth compared to the two other countries active in this area, however this advantage has not significantly affected the GDP in Iran, and Iran has not been able to improve its geo-economic capacity in this area.

Licensing system in Oman and literature review. Report to the Research Council of Oman, Muscat

This document reviews the existing literature in the area of novice driver behaviour and the impact of Graduated Driver Licencing (GDL) as a key response to young driver management. The document focuses on consolidating the available research evidence and identifying existing gaps in the current knowledge. The chapter reviews novice driver crash risk, the factors that influence novice driver behaviour, countermeasures used to address the problem, the learner phase, the provisional phase, The Australian example of GDL, compliance with the road laws and parental involvement in the GDL process...