Framing pandemic management: New governance, science or culture?

Management of a pandemic engages multiple sites where previously settled or uncontroversial understandings may be transformed by global and domestic forces. This article examines the iconography of social distancing implicated in the discourses of ‘quarantine’ and ‘risk control’ in public health, and the tension between scientific and popular media readings of the contours of acceptable public health models for managing particular pandemics. The role of culture in shaping and reshaping borders at an operational level is explored as a basis for explaining the apparent paradoxes in the way historic and contemporary pandemics are actually managed, and the different ways particular pandemics are framed. The article argues that a rational-scientific approach to pandemic management is insufficient and that a more nuanced socio-political blend of science, culture and public perceptions offers a more substantial basis for public health policy.

Emergency health services : demand and service delivery models. Monograph 1: literature review and activity trends

Emergency Health Services (EHS), encompassing hospital-based Emergency Departments (ED) and pre-hospital ambulance services, are a significant and high profile component of Australia’s health care system and congestion of these, evidenced by physical overcrowding and prolonged waiting times, is causing considerable community and professional concern. This concern relates not only to Australia’s capacity to manage daily health emergencies but also the ability to respond to major incidents and disasters. EHS congestion is a result of the combined effects of increased demand for emergency care, increased complexity of acute health care, and blocked access to ongoing care (e.g. inpatient beds). Despite this conceptual understanding there is a lack of robust evidence to explain the factors driving increased demand, or how demand contributes to congestion, and therefore public policy responses have relied upon limited or unsound information. The Emergency Health Services Queensland (EHSQ) research program proposes to determine the factors influencing the growing demand for emergency health care and to establish options for alternative service provision that may safely meet patient’s needs. The EHSQ study is funded by the Australian Research Council (ARC) through its Linkage Program and is supported financially by the Queensland Ambulance Service (QAS). This monograph is part of a suite of publications based on the research findings that examines the existing literature, and current operational context. Literature was sourced using standard search approaches and a range of databases as well as a selection of articles cited in the reviewed literature. Public sources including the Australian Institute of Health and Welfare (AIHW), the Council of Ambulance Authorities (CAA) Annual Reports, Australian Bureau of Statistics (ABS) and Department of Health and Ageing (DoHA) were examined for trend data across Australia.

Incentivising private health insurance through the income tax regime : Capitalising on behavioural models

The Australian income tax regime is generally regarded as a mechanism by which the Federal Government raises revenue, with much of the revenue raised used to support public spending programs. A prime example of this type of spending program is health care. However, a government may also decide that the private sector should provide a greater share of the nation's health care. To achieve such a policy it can bring about change through positive regulation, or it can use the taxation regime, via tax expenditures, not to raise revenue but to steer or influence individuals in its desired direction. When used for this purpose, tax expenditures steer taxpayers towards or away from certain behaviour by either imposing costs on, or providing benefits to them. Within the context of the health sector, the Australian Federal Government deploys social steering via the tax system, with the Medicare Levy Surcharge and the 30 percent Private Health Insurance Rebate intended to steer taxpayer behaviour towards the Government’s policy goal of increasing the amount of health provision through the private sector. These steering mechanisms are complemented by the ‘Lifetime Health Cover Initiative’. This article, through the lens of behavioural economics, considers the ways in which these assorted mechanisms might have been expected to operate and whether they encourage individuals to purchase private health insurance.

How do allied health professionals evaluate new models of care? What are we measuring and why?

The aim of this study was to identify what outcome measures or quality indicators are being used to evaluate advanced and new roles in nine allied health professions and whether the measures are evaluating outcomes of interest to the patient, the clinician, or the healthcare provider. A systematic search strategy was used. Medical and allied health databases were searched and relevant articles extracted. Relevant studies with at least 1 outcome measure were evaluated. A total of 106 articles were identified that described advanced roles, however, only 23 of these described an outcome measure in sufficient detail to be included for review. The majority of the reported measures fit into the economic and process categories. The most reported outcome related to patients was satisfaction surveys. Measures of patient health outcomes were infrequently reported. It is unclear from the studies evaluated whether new models of allied healthcare can be shown to be as safe and effective as traditional care for a given procedure. Outcome measures chosen to evaluate these services often reflect organizational need and not patient outcomes. Organizations need to ensure that high-quality performance measures are chosen to evaluate the success of new health service innovations. There needs to be a move away from in-house type surveys that add little or no valid evidence as to the effect of a new innovation. More importance needs to be placed on patient outcomes as a measure of the quality of allied health interventions.

Emergency Health Services (EHS) : demand and service delivery models. [Monograph 2 : Queensland EHS users’ profile]

Emergency health is a critical component of Australia’s health system and one which is increasingly congested from growing demand and blocked access to inpatient beds. The Emergency Health Services Queensland (EHSQ) study aims to identify the factors driving increased demand for emergency health and to evaluate strategies which may safely reduce the future demand growth. This monograph addresses the characteristics of users of emergency health services with an aim to identify those that appear to contribute to demand growth. This study utilises data on patients treated by Emergency Departments (ED) and Queensland Ambulance Service (QAS) across Queensland. ED data was derived from the Emergency Department Information System (EDIS) for the period 2001-02 through to 2010-11. Ambulance data was extracted from the QAS’ Ambulance Information Management System (AIMS) and electronic Ambulance Report Form (eARF) for the period 2001-02 through to 2009-10. Due to discrepancies and comparability issues for ED data, this monograph compares data from the 2003-04 time period with 2010-11 data for 21 of the reporting EDs. Also a snapshot of users for the 2010-11 financial year for 31 reporting EDs is used to describe the characteristics of users and to compare those characteristics with population demographics. For QAS data, the 2002-03 and 2009-10 time periods were selected for detailed analyses to identify trends. • Demand for emergency health care services is increasing, representing both increased population and increased relative utilisation. Per capita demand for ED attention has increased by 2% per annum over the last decade and for ambulance attention by 3.7% per annum. • The growth in ED demand is prominent in more urgent triage categories with actual decline in less urgent patients. An estimated 55% of patients attend hospital EDs outside of normal working hours. There is no evidence that patients presenting out of hours are significantly different to those presenting within working hours; they have similar triage assessments and outcomes. • Patients suffering from injuries and poisoning comprise 28% of the ED workload (an increase of 65% in the study period), whilst declines of 32% in cardiovascular and circulatory conditions, and musculoskeletal problems have been observed. • 25.6% of patients attending EDs are admitted to hospital. 19% of admitted patients and 7% of patients who die in the ED are triage category 4 or 5 on arrival. • The average age of ED patients is 35.6 years. Demand has grown in all age groups and amongst both men and women. Men have higher utilisation rates for ED in all age groups. The only group where the growth rate in women has exceeded men is in the 20-29 age group; this growth is particularly in the injury and poisoning categories. • Considerable attention has been paid publicly to ED performance criteria. It is worth noting that 50% of all patients were treated within 33 minutes of arrival. • Patients from lower socioeconomic areas appear to have higher utilisation rates and the utilisation rate for indigenous people appears to exceed those of European and other backgrounds. The utilisation rates for immigrant people is generally less than that of Australian born however it has not been possible to eliminate the confounding impact of different age and socioeconomic profiles. • Demand for ambulance service is also increasing at a rate that exceeds population growth. Utilisation rates have increased by an average of 5% per annum in Queensland compared to 3.6% nationally, and the utilisation rate in Queensland is 27% higher than the national average. • The growth in ambulance utilisation has also been amongst the more urgent categories of dispatch and utilisation rates are higher in rural and regional areas than in the metropolitan area. The demand for ambulance increases with age but the growth in demand for ambulance service has been more prominent in younger age groups. These findings contribute significantly to an understanding of the growth in demand for emergency health. It shows that the growth is amongst patients in genuine need of emergency healthcare and public rhetoric that the congestion of emergency health services is due to inappropriate attendees is unable to be substantiated. The consistency of the growth in demand over the last decade reflects not only the changing demographics of the Australian population but also the changes in health status, standards of acute health care and other social factors. The growth is also amongst patients with acute injury and poisoning which is inconsistent with rates of chronic disease as a fundamental driver. We have also interviewed patients in regard to their decision making choices for acute health care and the factors that influence these decisions and this will be the subject of a third Monograph and publications.

Emergency Health Services (EHS) : demand and service delivery models. monograph 3 : patients’ reasons and perceptions

Executive Summary Emergency health is a critical component of Australia’s health system and emergency departments (EDs) are increasingly congested from growing demand and blocked access to inpatient beds. The Emergency Health Services Queensland (EHSQ) study aims to identify the factors driving increased demand for emergency health and to evaluate strategies which may safely reduce the future demand growth. This monograph addresses the perspectives of users of both ambulance services and EDs. The research reported here aimed to identify the perspectives of users of emergency health services, both ambulance services and public hospital Emergency Departments and to identify the factors that they took into consideration when exercising their choice of location for acute health care. A cross-sectional survey design was used involving a survey of patients or their carers presenting to the EDs of a stratified sample of eight hospitals. A specific purpose questionnaire was developed based on a novel theoretical model which had been derived from analysis of the literature (Monograph 1). Two survey versions were developed: one for adult patients (self-complete); and one for children (to be completed by parents/guardians). The questionnaires measured perceptions of social support, health status, illness severity, self-efficacy; beliefs and attitudes towards ED and ambulance services; reasons for using these services, and actions taken prior to the service request. The survey was conducted at a stratified sample of eight hospitals representing major cities (four), inner regional (two) and outer regional and remote (two). Due to practical limitations, data were collected for ambulance and ED users within hospital EDs, while patients were waiting for or under treatment. A sample size quota was determined for each ED based on their 2009/10 presentation volumes. The data collection was conducted by four members of the research team and a group of eight interviewers between March and May 2011 (corresponding to autumn season). Of the total of 1608 patients in all eight emergency departments the interviewers were able to approach 1361 (85%) patients and seek their consent to participate in the study. In total, 911 valid surveys were available for analysis (response rate= 67%). These studies demonstrate that patients elected to attend hospital EDs in a considered fashion after weighing up alternatives and there is no evidence of deliberate or ill-informed misuse. • Patients attending ED have high levels of social support and self-efficacy that speak to the considered and purposeful nature of the exercise of choice. • About one third of patients have new conditions while two thirds have chronic illnesses • More than half the attendees (53.1%) had consulted a healthcare professional prior to making the decision. • The decision to seek urgent care at an ED was mostly constructed around the patient’s perception of the urgency and severity of their illness, reinforced by a strong perception that the hospital ED was the correct location for them (better specialised staff, better care for my condition, other options not as suitable). • 33% of the respondent held private hospital insurance but nevertheless attended a public hospital ED. Similarly patients exercised considered and rational judgements in their choice to seek help from the ambulance service. • The decision to call for ambulance assistance was based on a strong perception about the severity of the illness (too severe to use other means of transport) and that other options were not considered appropriate. • The decision also appeared influenced by a perception that the ambulance provided appropriate access to the ED which was considered most appropriate for their particular condition (too severe to go elsewhere, all facilities in one spot, better specialised and better care). • In 43.8% of cases a health care professional advised use of the ambulance. • Only a small number of people perceived that ambulance should be freely available regardless of severity or appropriateness. These findings confirm a growing understanding that the choice of professional emergency health care services is not made lightly but rather made by reasonable people exercising a judgement which is influenced by public awareness of the risks of acute health and which is most often informed by health professionals. It is also made on the basis of a rational weighing up of alternatives and a deliberate and considered choice to seek assistance from a service which the patient perceived was most appropriate to their needs at that time. These findings add weight to dispensing with public perceptions that ED and ambulance congestion is a result of inappropriate choice by patients. The challenge for health services is to better understand the patient’s needs and to design and validate services that meet those needs. The failure of our health system to do so should not be grounds for blaming the patient, claiming inappropriate patient choices.

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.

The aptitudes of allied health professionals working in remote communities

This study aimed to identify the aptitudes required in allied health professionals working in three different service delivery models serving remote locations in Northern tropical Australia. Eighteen allied health professionals including," dietetics, diabetes educators, occupational therapy, physiotherapy, psychology, podiatry, social work and speech pathology participated in this exploratory study using a narrative approach. A range of aptitudes were identified and themed under the following headings: (1) being organized but flexible, (2) cooperation and mediation, (3) culturally aware and accepting communicators, (4) knowing the community (5) resourcefulness and resilience and (6) reflectivity. Limiting factors were also deduced. Three of the themes are discussed in this paper. The study found that allied health professionals working in remote settings identified as important personal attributes not necessarily valued in metropolitan settings. Recruitment processes and education programs need to recognize the importance of personal attributes as well as professional skills.

Estimating indoor air quality using integrated 3D CAD building models

The indoor air quality (IAQ) in buildings is currently assessed by measurement of pollutants during building operation for comparison with air quality standards. Current practice at the design stage tries to minimise potential indoor air quality impacts of new building materials and contents by selecting low-emission materials. However low-emission materials are not always available, and even when used the aggregated pollutant concentrations from such materials are generally overlooked. This paper presents an innovative tool for estimating indoor air pollutant concentrations at the design stage, based on emissions over time from large area building materials, furniture and office equipment. The estimator considers volatile organic compounds, formaldehyde and airborne particles from indoor materials and office equipment and the contribution of outdoor urban air pollutants affected by urban location and ventilation system filtration. The estimated pollutants are for a single, fully mixed and ventilated zone in an office building with acceptable levels derived from Australian and international health-based standards. The model acquires its dimensional data for the indoor spaces from a 3D CAD model via IFC files and the emission data from a building products/contents emissions database. This paper describes the underlying approach to estimating indoor air quality and discusses the benefits of such an approach for designers and the occupants of buildings.

Validation of 3D models of the outer and inner surfaces of an ovine femur

The validation of Computed Tomography (CT) based 3D models takes an integral part in studies involving 3D models of bones. This is of particular importance when such models are used for Finite Element studies. The validation of 3D models typically involves the generation of a reference model representing the bones outer surface. Several different devices have been utilised for digitising a bone’s outer surface such as mechanical 3D digitising arms, mechanical 3D contact scanners, electro-magnetic tracking devices and 3D laser scanners. However, none of these devices is capable of digitising a bone’s internal surfaces, such as the medullary canal of a long bone. Therefore, this study investigated the use of a 3D contact scanner, in conjunction with a microCT scanner, for generating a reference standard for validating the internal and external surfaces of a CT based 3D model of an ovine femur. One fresh ovine limb was scanned using a clinical CT scanner (Phillips, Brilliance 64) with a pixel size of 0.4 mm2 and slice spacing of 0.5 mm. Then the limb was dissected to obtain the soft tissue free bone while care was taken to protect the bone’s surface. A desktop mechanical 3D contact scanner (Roland DG Corporation, MDX 20, Japan) was used to digitise the surface of the denuded bone. The scanner was used with the resolution of 0.3 × 0.3 × 0.025 mm. The digitised surfaces were reconstructed into a 3D model using reverse engineering techniques in Rapidform (Inus Technology, Korea). After digitisation, the distal and proximal parts of the bone were removed such that the shaft could be scanned with a microCT (µCT40, Scanco Medical, Switzerland) scanner. The shaft, with the bone marrow removed, was immersed in water and scanned with a voxel size of 0.03 mm3. The bone contours were extracted from the image data utilising the Canny edge filter in Matlab (The Mathswork).. The extracted bone contours were reconstructed into 3D models using Amira 5.1 (Visage Imaging, Germany). The 3D models of the bone’s outer surface reconstructed from CT and microCT data were compared against the 3D model generated using the contact scanner. The 3D model of the inner canal reconstructed from the microCT data was compared against the 3D models reconstructed from the clinical CT scanner data. The disparity between the surface geometries of two models was calculated in Rapidform and recorded as average distance with standard deviation. The comparison of the 3D model of the whole bone generated from the clinical CT data with the reference model generated a mean error of 0.19±0.16 mm while the shaft was more accurate(0.08±0.06 mm) than the proximal (0.26±0.18 mm) and distal (0.22±0.16 mm) parts. The comparison between the outer 3D model generated from the microCT data and the contact scanner model generated a mean error of 0.10±0.03 mm indicating that the microCT generated models are sufficiently accurate for validation of 3D models generated from other methods. The comparison of the inner models generated from microCT data with that of clinical CT data generated an error of 0.09±0.07 mm Utilising a mechanical contact scanner in conjunction with a microCT scanner enabled to validate the outer surface of a CT based 3D model of an ovine femur as well as the surface of the model’s medullary canal.

Simulations of pollutant dispersion at toll plazas using three-dimensional CFD models

Toll plazas are particularly susceptible to build-ups of vehicle-emitted pollutants because vehicles pass through in low gear. To look at this, three-dimensional computational fluid dynamics simulations of pollutant dispersion are used on the standard k e turbulence model. The effects of wind speed, wind direction and topography on pollutant dispersion were discussed. The Wuzhuang toll plaza on the Hefei-Nanjing expressway is considered, and the effects of the retaining walls along both sides of the plaza on pollutant dispersion is analysed. There are greater pollutant concentrations near the tollbooths as the angle between the direction of the wind and traffic increases implying that retaining walls impede dispersion. The slope of the walls has little influence on the variations in pollutant concentration.

A review on degradation models in reliability analysis

With increasingly complex engineering assets and tight economic requirements, asset reliability becomes more crucial in Engineering Asset Management (EAM). Improving the reliability of systems has always been a major aim of EAM. Reliability assessment using degradation data has become a significant approach to evaluate the reliability and safety of critical systems. Degradation data often provide more information than failure time data for assessing reliability and predicting the remnant life of systems. In general, degradation is the reduction in performance, reliability, and life span of assets. Many failure mechanisms can be traced to an underlying degradation process. Degradation phenomenon is a kind of stochastic process; therefore, it could be modelled in several approaches. Degradation modelling techniques have generated a great amount of research in reliability field. While degradation models play a significant role in reliability analysis, there are few review papers on that. This paper presents a review of the existing literature on commonly used degradation models in reliability analysis. The current research and developments in degradation models are reviewed and summarised in this paper. This study synthesises these models and classifies them in certain groups. Additionally, it attempts to identify the merits, limitations, and applications of each model. It provides potential applications of these degradation models in asset health and reliability prediction.

A review on reliability models with covariates

Modern Engineering Asset Management (EAM) requires the accurate assessment of current and the prediction of future asset health condition. Suitable mathematical models that are capable of predicting Time-to-Failure (TTF) and the probability of failure in future time are essential. In traditional reliability models, the lifetime of assets is estimated using failure time data. However, in most real-life situations and industry applications, the lifetime of assets is influenced by different risk factors, which are called covariates. The fundamental notion in reliability theory is the failure time of a system and its covariates. These covariates change stochastically and may influence and/or indicate the failure time. Research shows that many statistical models have been developed to estimate the hazard of assets or individuals with covariates. An extensive amount of literature on hazard models with covariates (also termed covariate models), including theory and practical applications, has emerged. This paper is a state-of-the-art review of the existing literature on these covariate models in both the reliability and biomedical fields. One of the major purposes of this expository paper is to synthesise these models from both industrial reliability and biomedical fields and then contextually group them into non-parametric and semi-parametric models. Comments on their merits and limitations are also presented. Another main purpose of this paper is to comprehensively review and summarise the current research on the development of the covariate models so as to facilitate the application of more covariate modelling techniques into prognostics and asset health management.

Mental health issues and resources in rural and regional communities : an exploration of perceptions of service providers

Objective: To identify service providers’ and community organisations’ perceptions of the resources available to support people with mental illness and the unmet needs of this client group in rural Queensland. Design: An exploratory study was undertaken involving focus group interviews across the study sites. Setting: Five regional towns in rural Queensland. Participants: Ten to 14 members were recruited for each of the five focus groups. The groups represented a diverse mix of participants including health and community service providers and representatives from community organisations. Results: Participants identified gaps in services in relation to health, employment and education, housing and accommodation, transport and social inclusion and health promotion. Inter-service communication and inappropriate funding models were themes affecting service delivery. Conclusions: Specific service issues of housing and transport were identified to be particularly problematic for people with mental illness across all towns. Intersectoral communication and funding models require further research.