Paediatric quality of life instruments: a review of the impact of the conceptual framework on outcomes

With an increasing number of paediatric quality of life (QOL) instruments being developed, it is becoming difficult for researchers and clinicians to select the most appropriate instrument. Reviews of QOL instruments tend to report only basic properties of the instruments such as domains and psychometric properties. This paper seeks to appraise critically the conceptual underpinnings of paediatric QOL instruments. A systematic review was conducted to identify QOL instruments for children aged 0 to 12 years, and to examine and compare their conceptual frameworks, definitions employed, and structure. Both generic and condition-specific measures were reviewed. Fourteen generic and 25 condition-specific QOL instruments were identified. Eleven types of definition of QOL and health-related QOL and three theories of QOL were identified. QOL was measured by a variety of domains including emotional, social and physical health, and well-being. Items commonly assessed difficulties, or intensity/frequency of feelings/symptoms, in contrast to positive aspects of life and happiness. The findings highlight the diversity that is apparent in the conceptualization of paediatric QOL and draw attention to the lack of empirical evidence for many of the fundamental assumptions. The impact of the conceptual underpinnings of the instruments on the resulting QOL scores is discussed.

Development and application of model of resource utilization, costs, and outcomes for stroke (MORUCOS): an Australian economic model for stroke.

Objectives: To outline the development, structure, data assumptions, and application of an Australian economic model for stroke (Model of Resource Utilization, Costs, and Outcomes for Stroke [MORUCOS]). Methods: The model has a linked spreadsheet format with four modules to describe the disease burden and treatment pathways, estimate prevalence-based and incidence-based costs, and derive life expectancy and quality of life consequences. The model uses patient-level, community-based, stroke cohort data and macro-level simulations. An interventions module allows options for change to be consistently evaluated by modifying aspects of the other modules. To date, model validation has included sensitivity testing, face validity, and peer review. Further validation of technical and predictive accuracy is needed. The generic pathway model was assessed by comparison with a stroke subtypes (ischemic, hemorrhagic, or undetermined) approach and used to determine the relative cost-effectiveness of four interventions. Results: The generic pathway model produced lower costs compared with a subtypes version (total average first-year costs/case AUD$15,117 versus AUD$17,786, respectively). Optimal evidence-based uptake of anticoagulation therapy for primary and secondary stroke prevention and intravenous thrombolytic therapy within 3 hours of stroke were more cost-effective than current practice (base year, 1997). Conclusions: MORUCOS is transparent and flexible in describing Australian stroke care and can effectively be used to systematically evaluate a range of different interventions. Adjusting results to account for stroke subtypes, as they influence cost estimates, could enhance the generic model.

Trial application of a model of resource utiliztion, costs, and outcomes for stroke (MORUCOS) to assist priority setting in stroke.

Background and Purpose— Cost-effectiveness data for stroke interventions are limited, and comparisons between studies are confounded by methodological inconsistencies. The aim of this study was to trial the use of the intervention module of the economic model, a Model of Resource Utilization, Costs, and Outcomes for Stroke (MORUCOS) to facilitate evaluation and ranking of the options.

Methods— The approach involves using an economic model together with added secondary considerations. A consistent approach was taken using standard economic evaluation methods. Data from the North East Melbourne Stroke Incidence Study (NEMESIS) were used to model "current practice" (base case), against which 2 interventions were compared. A 2-stage process was used to measure benefit: health gains (expressed in disability-adjusted life years [DALYs]) and filter analysis. Incremental cost-effectiveness ratios (ICERs) were calculated, and probabilistic uncertainty analysis was undertaken.

Results— Aspirin, a low-cost intervention applicable to a large number of stroke patients (9153 first-ever cases), resulted in modest health benefits (946 DALYs saved) and a mean ICER (based on incidence costs) of US $1421 per DALY saved. Although the health gains from recombinant tissue-type plasminogen activator (rtPA) were less (155 DALYs saved), these results were impressive given the small number of persons (256) eligible for treatment. rtPA dominates current practice because it is more effective and cost-saving.

Conclusions— If used to assess interventions across the stroke care continuum, MORUCOS offers enormous capacity to support decision-making in the prioritising of stroke services.

Is more better? The relationship between outcomes achieved by problem gamblers and the number of counselling sessions attended

This paper addresses the question of how much intervention is necessary for the effective treatment of problem gambling by exploring the relationship between the number of counselling sessions attended and the degree of problem resolution achieved for 613 individuals who attended problem gambling counselling services in Victoria. While those who achieved partial or full resolution of presenting problems attended more sessions than those who finished counselling with their problems still unresolved, problems were typically reported as being resolved in fewer than five sessions. It is concluded that for some problem gamblers a relatively brief intervention may be sufficient.

The influence of demographic, behavioural and treatments characteristics on problem gambling counselling outcomes

The paper considers the influence of client characteristics and gambling behaviour as well as treatment modality on the resolution of gambling behaviour for 591 clients who sought help from the publicly funded BreakEven counselling services in the state of Victoria between 1 July 1996 and 30 June 1997. Statistical data about clients and their consultations was collected in the form of a Minimum Data Set. On their own, client demographics accounting for 12% of the variance were identified as discriminating between problem gamblers who achieved some resolution of their gambling behaviour and those whose behaviour did not change. Variables associated with gambling behaviour accounted for 10% of variance and treatment variables for 12% of variance in treatment outcomes. Collectively, the three types of data could explain 26% of the variance in problem resolution. Importantly, these findings demonstrate that the resolution of problematic gambling behaviour is affected by a complex interplay of client characteristics, their gambling behaviour and the treatment they receive. It is argued that the evaluation of treatment programs for problem gambling, and potentially all counselling programs in the primary health arena, needs to include measures from each of these domains.

Complementary therapies in action - education and outcomes

A study investigated the use of aromatherapy hand and foot massage on 11 patients in a rural rehabilitation setting. An education programme for nurses, carers and family members was developed and implemented. Clinical outcomes - pain, anxiety, joint flexibility and skin condition were evaluated using Likert scales completed before, and after, treatment at three time points and open questions to ascertain patients' feelings about the treatments. Each patient had three treatments, making a total of 33 massages. A significant reduction in pain and anxiety was apparent after all three treatments (p=0.05). Changes in skin condition (softer and more resilient) were highly significant (p=0.01). However, there was no significant change in joint flexibility (p<0.05). The main themes emerging from patients' comments were that aromatherapy massage facilitated communication, allowed emotional release and aided relaxation. Nine people undertook the education programme. They indicated that it covered appropriate information and they felt confident to deliver the aromatherapy massages, but the non-nursing participants would have liked more practice before they entered the clinical setting.

Randomised controlled trial evaluating the effectiveness of behavioural interventions to modify cardiovascular risk factors in men and women with imparied glucose tolerance: outcomes at 6 months

Aims: To evaluate the efficacy of interventions to promote a healthy diet and physical activity in people with impaired glucose tolerance (IGT). Methods: A randomised controlled trial in Newcastle upon Tyne, UK, 1995–98. Participants included 67 adults (38 men; 29 women) aged 24–75 years with IGT. The intervention consisted of regular diet and physical activity counselling based on the stages of change model. Main outcome measures were changes between baseline and 6 months in nutrient intake; physical activity; anthropometric and physiological measurements including serum lipids; glucose tolerance; insulin sensitivity. Results: The difference in change in total fat consumption was significant between intervention and control groups (difference −21.8 (95% confidence interval (CI) −37.8 to −5.8) g/day, P=0.008). A significantly larger proportion of intervention participants reported taking up vigorous activity than controls (difference 30.1, (95% CI 4.3–52.7)%, P=0.021). The change in body mass index was significantly different between groups (difference −0.95 (95% CI −1.5 to −0.4) kg/m2, P=0.001). There was no significant difference in change in mean 2-h plasma glucose between groups (difference −0.19 (95% CI −1.1 to 0.71) mmol/l, NS) or in serum cholesterol (difference 0.02 (95% CI −0.26 to 0.31) mmol/l, NS). The difference in change in fasting serum insulin between groups was significant (difference −3.4 (95% CI −5.8 to −1.1) mU/l, P=0.005). Conclusions: After 6 months of intensive lifestyle intervention in participants with IGT, there were changes in diet and physical activity, some cardiovascular risk factors and insulin sensitivity, but not glucose tolerance. Further follow-up is in progress to investigate whether these changes are sustained or augmented over 2 years.

Reconceptualising outsourcing in the public sector : choices and outcomes

National Competition Policy’s introduction encouraged the use of outsourcing in the public sector, but variations in the extent and types of services outsourced were evident. Through reviewing the economic and political literature, this paper has uncovered six reasons for outsourcing that straddle the two paradigms. The desire to reduce costs and increase efficiency, focus on core competitive advantage, introduce workforce flexibility, manage industrial relations’ problems, satisfy decision-makers’ personal objectives and adhere to the neo-liberal government agenda are discussed. The paper puts forward a number of models which delve into the relationship between the theoretical factors which economic and political theorists have proposed as being important in making the decision to outsource and delineates between those factors which are perceived by decision-makers as important in their reasoning and those which are unperceived but impact on the outcomes. It concludes that is only by understanding the complex relationship between reasons, and perceived and unperceived factors, will outcomes be able to be predicted.

The domain layer for mixed-initiative interaction in generative design

The design space exploration formalism has developed data structures and algorithms of sufficient complexity and scope to support conceptual layout, massing, and enclosure configurations. However, design remains a human enterprise. To support the user in designing with the formalism, we have developed an interaction model that addresses the interleaving of user actions with the formal operations of design space exploration. The central feature of our interaction model is the modeling of control based on mixed-initiative. Initiative is sometimes taken by the designer and sometimes by the formalism in working on a shared design task. The model comprises three layers, domain, task, and dialogue. In this paper we describe the formulation of the domain layer of our mixed-initiative interaction model for design space exploration. We present the view of the domain as understood in the formalism in terms of the three abstract concepts of state, move, and structure. In order to support mixed initiative, it is necessary to develop a shared view of the domain. The domain layer addresses this problem by mapping the designer's view onto the symbol substrate. First, we present the designer's view of the domain in terms of problems, solutions, choices, and history. Second, we show how this view is interleaved with the symbol-substrate through four domain layer constructs, problem state, solution state, choice, and exploration history. The domain layer presents a suitable foundation for integrating the role of the designer with a description formalism. It enables the designer to maintain exploration freedom in terms of formulating and reformulating problems, generating solutions, making choices, and navigating the history of exploration.

The role of computer assisted learning packages in determining learning outcomes of accounting students

This study examines the factors affecting student performance in an undergraduate financial accounting course, utilising Computer Assisted Learning (CAL) and use of a commercial software package. Multiple regression analysis was undertaken to examine the influences of perceptions of CAL and QuickBooks Pro, together with background variables such as gender, entry pathway and prior knowledge had on student performance. The results show that perceptions of CAL together with entry pathway were significant predictors of student performance. However, perceptions of the ,usefulness of QuickBooks Pro, prior studies of accounting and computing, together with gender, were not significant influences on performance. In terms of entry pathway it was found that International students, many of whom entered the university at the second year level having obtained advanced standing credits, had significantly poorer performance than local students. This result may be attributed to transitional problems experienced by these students, given their different pathways to university study.

The results have implications for accounting educators utilising CAL in courses as a means of improving students understanding of accounting concepts. The study also provides reflections on the use of CAL and a commercial software package as a means of providing efficient and effective educational instruction to maximise learning outcomes in accounting.

A comparison of the satisfaction of first year members with renewing members : differences in antecedents and outcomes

In membership organisations it is common for a large number of first year members not to renew. The research reported here looks at members of a professional sporting organisation and compares the responses to a satisfaction survey of first year members with those of longer-term members. The results show that although the level of overall satisfaction was no different between first year and longer-term members, their overall satisfaction was influenced by different aspects of the package. Specifically, communications from the club, on-field performance during the year and the perceived level of personal involvement with the club were the aspects of the membership service that had a distinguishing influence on overall satisfaction. These findings imply that the experience of new members is different from that of existing members, and that there is sense in managers distinguishing between first year and other members when developing marketing tactics aimed at increasing renewals.

Students perceptions of learning outcomes from group-based, problem-based teaching and learning activities

Objective: A study aimed at exploring the variation in perceptions of learning outcomes reported by undergraduate nursing students enrolled in a problem-based learning subject in a pre-registration Bachelor of Nursing course (BN).
Method: Students were asked to respond to four open-ended questions which focussed on their learning outcomes in the different teaching/learning modalities of the subject. Data were analysed in two phases using a modified phenomenographic analysis. In the first phase a set of categories of description were developed from the student responses to questions related to the learning modalities. In the second phase the individual responses were classified in terms of the categories. Finally, correlations between the learning modalities were identified. In this paper the approach to analysis, the process of category identification and the correlations between the learning modalities will be described and the implications for further research and teaching will be discussed.
Results: The findings indicated that there were two distinct groups of student responses. Inward focussed students who described outcomes in terms of their own learning and students whose focus was outward i.e. describing learning in terms of patient care and how learning relates to that care. Another important result shows the relationship between the learning modalities and outcomes. From the students' perspective, the most sophisticated outcomes of the lectures and laboratories were ideas and skills to be used and applied in clinical settings. Whereas, the group-based activities in which clinical problems were presented to the students in the form of Situation Improvement Packages (SIPS) focussed their attention on the clinical setting which constituted a preparation for the realities of clinical practice.
Conclusion: The findings from this study indicate that students perceive their learning in the group based teaching/learning modality (SIPS) as effective in focussing them on the reality of their role in the clinical practice environment while lectures and laboratories provided the skills and knowledge required for this setting.