Transitioning to routine breast cancer risk assessment and management in primary care: what can we learn from cardiovascular disease?

To capitalise on advances in breast cancer prevention, all women would need to have their breast cancer risk formally assessed. With ~85% of Australians attending primary care clinics at least once a year, primary care is an opportune location for formal breast cancer risk assessment and management. This study assessed the current practice and needs of primary care clinicians regarding assessment and management of breast cancer risk. Two facilitated focus group discussions were held with 17 primary care clinicians (12 GPs and 5 practice nurses (PNs)) as part of a larger needs assessment. Primary care clinicians viewed assessment and management of cardiovascular risk as an intrinsic, expected part of their role, often triggered by practice software prompts and facilitated by use of an online tool. Conversely, assessment of breast cancer risk was not routine and was generally patient- (not clinician-) initiated, and risk management (apart from routine screening) was considered outside the primary care domain. Clinicians suggested that routine assessment and management of breast cancer risk might be achieved if it were widely endorsed as within the remit of primary care and supported by an online risk-assessment and decision aid tool that was integrated into primary care software. This study identified several key issues that would need to be addressed to facilitate the transition to routine assessment and management of breast cancer risk in primary care, based largely on the model used for cardiovascular disease.

Intensive case management for high-risk patients with first-episode psychosis: service model and outcomes

Background : The first episode of psychosis is a crucial period when early intervention can alter the trajectory of the young person's ongoing mental health and general functioning. After an investigation into completed suicides in the Early Psychosis Prevention and Intervention Centre (EPPIC) programme, the intensive case management subprogramme was developed in 2003 to provide assertive outreach to young people having a first episode of psychosis who are at high risk owing to risk to self or others, disengagement, or suboptimal recovery. We report intensive case management model development, characterise the target cohort, and report on outcomes compared with EPPIC treatment as usual.

Methods : Inclusion criteria, staff support, referral pathways, clinical review processes, models of engagement and care, and risk management protocols are described. We compared 120 consecutive referrals with 50 EPPIC treatment as usual patients (age 15–24 years) in a naturalistic stratified quasi-experimental real-world design. Key performance indicators of service use plus engagement and suicide attempts were compared between EPPIC treatment as usual and intensive case management, and psychosocial and clinical measures were compared between intensive case management referral and discharge.

Findings : Referrals were predominately unemployed males with low levels of functioning and educational attainment. They were characterised by a family history of mental illness, migration and early separation, with substantial trauma, history of violence, and forensic attention. Intensive case management improved psychopathology and psychosocial outcomes in high-risk patients and reduced risk ratings, admissions, bed days, and crisis contacts.

Interpretation : Characterisation of intensive case management patients validated the clinical research focus and identified a first episode of psychosis high-risk subgroup. In a real-world study, implementation of an intensive case management stream within a well-established first episode of psychosis service showed significant improvement in key service outcomes. Further analysis is needed to determine cost savings and effects on psychosocial outcomes. Targeting intensive case management services to high-risk patients with unmet needs should reduce the distress associated with pathways to care for patients, their families, and the community.

iPrevent®: a tailored, web-based, decision support tool for breast cancer risk assessment and management

We aimed to develop a user-centered, web-based, decision support tool for breast cancer risk assessment and personalized risk management. Using a novel model choice algorithm, iPrevent(®) selects one of two validated breast cancer risk estimation models (IBIS or BOADICEA), based on risk factor data entered by the user. Resulting risk estimates are presented in simple language and graphic formats for easy comprehension. iPrevent(®) then presents risk-adapted, evidence-based, guideline-endorsed management options. Development was an iterative process with regular feedback from multidisciplinary experts and consumers. To verify iPrevent(®), risk factor data for 127 cases derived from the Australian Breast Cancer Family Study were entered into iPrevent(®), IBIS (v7.02), and BOADICEA (v3.0). Consistency of the model chosen by iPrevent(®) (i.e., IBIS or BOADICEA) with the programmed iPrevent(®) model choice algorithm was assessed. Estimated breast cancer risks from iPrevent(®) were compared with those attained directly from the chosen risk assessment model (IBIS or BOADICEA). Risk management interventions displayed by iPrevent(®) were assessed for appropriateness. Risk estimation model choice was 100 % consistent with the programmed iPrevent(®) logic. Discrepant 10-year and residual lifetime risk estimates of >1 % were found for 1 and 4 cases, respectively, none was clinically significant (maximal variation 1.4 %). Risk management interventions suggested by iPrevent(®) were 100 % appropriate. iPrevent(®) successfully integrates the IBIS and BOADICEA risk assessment models into a decision support tool that provides evidence-based, risk-adapted risk management advice. This may help to facilitate precision breast cancer prevention discussions between women and their healthcare providers.

Risk analysis in cost planning and its effect on efficiency in capital cost budgeting

Builds on earlier work which reported on the experience of the Hong Kong Government in using risk analysis techniques in capital cost estimating. In 1993 the Hong Kong Government implemented a methodology for capital cost estimating using risk analysis (ERA) in its public works planning. This calculated amount replaces the pre-1993 contingency allowance, which was merely a percentage addition on top of the base estimate of a project. Adopts a team approach to identify, classify and cost the uncertainties associated with a project. The sum of the average risk allowance for the identified risk events thus becomes the contingency. A study of the effect of ERA was carried out to compare the variability and consistency of the contingency estimates between non-ERA and ERA projects. The preliminary results of a survey showed a highly significant difference in variation and consistency between these groups. This analysis indicates the successful use of the ERA method for public works projects to reduce unnecessary and  exaggerated allowance for risk. However, the contingency allowance for ERA projects was also considered high. Adds data from the UK with descriptions of 41 private sector projects which fall into the non-ERA category and reflect better performance in the determining of contingency allowances.

Who, when and where? Identification of patients at risk of an in-hospital adverse event: Implications for nursing practice

Patients who suffer an adverse event (AE) are more likely to die or suffer permanent disability. Many AEs are preventable. Nurses have long played a pivotal role in the prevention of AEs. Much of the literature to date pertains to the role of nurses in the prevention of AEs such as falls, pressure areas and deep vein thrombosis. Prominent risk factors for AEs are the presence of physiological abnormality, failure to recognize or correct physiological abnormality, advanced patient age and location of patient room. Ongoing physiological assessment of patients is a nursing responsibility and the assessment findings of nurses underpin many patient care decisions. The early recognition and correction of physiological abnormality can improve patient outcomes by reducing the incidence of AEs, making nurses' ability to identify, interpret and act on physiological abnormality a fundamental factor in AE prediction and prevention. This paper will examine the role of nurses in AE prevention, using cardiac arrest as an example, from the perspective of physiological safety; that is, accurate physiological assessment and the early correction of physiological abnormality.

Terrify and control: the politics of risk society

The article presents information on the idea of risk management. The origins of the contemporary constructions of risk are found in the seventeenth century, with the development of maritime insurance. In the context of maritime trading, risk came to be seen in terms of the balance between acquisitive opportunities and potential dangers and calculations of future loss of a ship or cargo. Today perceptions of risk affect our actions and strategies in areas of our life as diverse as health, parenting, crime prevention, recreation and travel. Public policy tends to be focused around risk avoidance and risk management, particularly in areas of child protection and aged care. While most of the discussions of risk have focused on risks as bads in society, risk has also been identified as a good. Risk is deemed a good when it challenges people to think differently and creatively. From a neo-liberal perspective risk opens up opportunities for unleashing of entrepreneurial capacity. In the context of the modernist commitment to the idea that people have the potential to control their own destiny, identification of threats and dangers can energize people to be adventurous. The discourse of risk has framed all the reports of the outbreaks of new strains of infection and includes instructions on how to recognize the risk assessments of its spread and instructions on how to avoid its spread.

Mismanagement of delerium places patients at risk

Objective: This paper discusses the problem of delirium and the challenges of accurately assessing, preventing and managing patients with delirium in an acute care setting.

Primary Argument: Acute confusion, also known as delirium, is misdiagnosed and under-treated in up to 94% of older patients in hospitals. With the ageing population, this problem will increase dramatically in the Australian setting. Managing patients with delirium is challenging not only for the management of their basic nursing care needs but also because they are prone to adverse events such as falls and medication problems. In order to address this issue it is vital that health care professionals routinely assess patients for signs of delirium. The current 'gold standard' for assessing delirium is the use of the Confusion Assessment Method (CAM) which has been developed based on the diagnostic criteria set by the Diagnostic and Statistical Manual of Mental Disorders DSM-IV and can be used by non-psychiatrists. Further, increased attention should be given to the prevention and management of delirium and the use of orientation and validation therapy.

Conclusion: Research indicates that early identification and intervention can help to limit any negative effects or adverse events. Increasing knowledge and awareness of early detection and efficient management of delirium is the first step toward prevention.

Transitional labour markets : a social investment and risk mitigation strategy for social policy

Drawing on transitional labor market (TLM) theory, this introductory chapter highlights major themes, overviews the contributions to this volume and suggests a future agenda for policy makers. The focus of applied research projects has been the impact of post-modem social transformations on systems of social protection, looking through the lens of the labor market and shifts in household and family structure. The Transitional Labor Market project uses the TLM model as a means of developing new thinking on how flexibility and innovation might be paired with social investment and new forms of social protection. TLM theory emphasizes the importance of institutions and of the links between different institutions which frequently operate as policy silos, rather than integrated systems to buffer risks and support capability and enhance employability. The great advantage of the TLM model is that it draws attention to the right places for strategic reform. It does not offer a standard set of institutions to facilitate transitions however.

Trading in open marketplace using trust and risk

In this paper, we propose buying and selling models for agents to trade in the open multi-agent marketplace. Unlike auctions, we take into account of the fact that agents trading in such open environments has to maximize their profits and at the same time, protect themselves from fraud and deception. We attempt to address this issue by incorporating the element of trust and risk management into our proposed buying and selling model. During buying, agents learn to select their partners based on the trustworthiness of the potential partner as well as its personal risk attitude. During selling, agents learn to increase the chances of winning a deal by adjusting their profit rate, which is a measure that considers both trust and risk. The novelty of this proposal is that it ensures agents continuing to seek maximum expected utility in a dynamic trading environment. Our experimental results confirm the feasibility of our approach.

Risky doctorates : managing doctoral studies in Australia as managing risk

This paper draws on work by the author as part of a team undertaking an ARC Discovery project entitled: The Impact of Risk Management on Doctoral Research Policy and Pedagogy in Australian Universities. The team is Erica McWilliam, Peter Taylor, Terry Evans and Alan Lawson, with Eluned Lloyd and Karen Tregenza. Some of the ideas in this paper reflect our discussions, reading and other work as part of this project.

Arguably, part of any manager’s work involves the identification and assessment of risks and then working to minimise or manage them. However, never has this been more important than is the case today for the manager of doctoral studies in Australia. Partly this is related to the rising risk consciousness and risk aversion in contemporary societies, but more particularly it is related to the dangers and harms that have been infused by the Australian government into its policies on ‘research training’ (that is, principally doctoral education) and quality assurance. This article explores the consequences of these two trends, one general and one specific, on the management and nature of doctoral research in Australia.

Clinical risk managment and the ethics of open disclosure : part 2 : implications for the nursing profession

Patient safety experts and other authorities have strongly postulated the open disclosure of errors and adverse events to patients and their nominated support persons as an essential component of effective clinical risk management in health care. Commentators also contend that ‘when things go wrong’, openly disclosing such events to the patient is simply ‘the right thing to do’. Important questions about the ethics of open disclosure remain, however. Is openly disclosing errors and adverse events to patients necessarily ‘the right thing to do’? Do hospital authorities and health care professionals always have an overriding duty to openly communicate with patients and their families when thing go wrong? If patients do not suffer any material harm when a mistake is made, should they or their nominated support persons still be told? Are there overriding moral considerations that might justify non-disclosure in certain circumstances? Despite the obvious importance of these issues and their possible implications for the nursing profession, they have not been comprehensively explored in the nursing literature. An important aim of this article (the second of a two-part discussion) is to contribute to the positive project of redressing this oversight.

Interpreting risk allocation mechanism in public-private partnership projects : an empirical study in a transaction cost economics perspective

Risk allocation in public-private partnership (PPP) projects is currently claimed as capability driven. While lacking theoretical support, the claim is often 'violated' by current industrial practice. There is thus a need for formal mechanisms to interpret why a particular risk is retained by government in one project while transferred to private partners in another. From the viewpoint of transaction cost economics (TCE), integrated with the resource-based view (RBV) of organizational capabilities, this paper proposed a theoretical framework for understanding risk allocation practice in PPP projects. The theories underlying the major constructs and their links were articulated. Data gathered from an industry-wide survey were used to test the framework. The results of multiple linear regression (MLR) generally support the proposed framework. It has been found that partners' risk management routine, mechanism, commitment, cooperation history, and uncertainties associated with project risk management could serve to determine the risk allocation strategies adopted in a PPP project. This theoretical framework thus provides both government and private agencies with a logical and complete understanding of the process of selecting the allocation strategy for a particular risk in PPP projects. Moreover, it could be utilized to steer the risk allocation strategy by controlling certain critical determinants identified in the study. Study limitations and future research directions have also been set out.

Who's Dean today? Acting and interim management as paradoxes of the contemporary university

Interim, discontinuous or 'acting' management is an increasingly ubiquitous feature of universities. This paper asks: What are the implications of this for good academic governance? Should we understand this managerial dance as a symptom of the collapse of good managerial order or, by contrast, as a symptom of the robustness and flexibility of the organisational culture of the university? Or both? This paper answers 'all of the above' to these questions. It reaches that conclusion by examining relevant literature, theorising a methodology for reading the field of interim management, and by applying this theorising to an analysis of qualitative data collected as part of a national collaborative research project conducted in Australia.

Contextualizing risk in the assessment of intellectually disabled individuals

In this article we examine the idea of expanding structured clinical judgement from primarily offender variables to a broader framework in which environmental (including staff) variables are given equal consideration in a comprehensive risk appraisal conducted for risk management purposes of intellectually disabled individuals. It is posited that only by contextualizing the individual's risk within environmental variables can an accurate portrayal of current dynamic risk (and hence the management of that risk) be construed.

Continence prevalence and management in an acute hospital

Learning Objective 1: describe the prevalence of incontinence within an Australian acute care hospital

Learning Objective 2: describe the current management practices for incontinence with regard to patients in an acute care hospital
Introduction: In 1998 the World Health Organisation recognised the international problem of incontinence. However, incontinence remains a major problem that affects more than 3.8 million Australians. Currently, there are no Australian guidelines governing the management of continence within the acute healthcare setting. Cabrini Health sought to identify the prevalence of incontinence in the acute inpatient setting and pilot a Continence Management Program to improve patient safety and patient outcomes.

Aim: The aim of this study was to determine the prevalence of and current management practices for incontinence with regard to Cabrini Health inpatients.

Method: The sample comprised 392 inpatients across three campuses of Cabrini Health (mean age= 68.3 years). Continence prevalence was assessed using a validated Continence Point Prevalence Tool.

Results: Urinary incontinence prevalence was 14%. The resulting overall faecal incontinence prevalence was 7.4%. There were 113 (52.3%) patients who were not incontinent and were using a continence product/device. Fifteen (25.9%) patients were incontinent and were not using any form of continence product/device. There were 43 (74.1%) patients who were incontinent and were using a continence product/device. For the large majority of patients, the admission notes contained documentation of their bladder and bowel function. Specifically, 46 (11.8%) patients had no form of admission documentation relating to bowel function and 45 (11.5%) patients had no form of admission documentation regarding to bladder function.

Conclusions: This study provided baseline continence prevalence for Cabrini Health. There is a need for evidence-based guidelines to support the management of incontinent patients. These interventions will assist staff to educate patients on appropriate choice of continence products and enable patients to maintain or regain continence. Thereby, leading to improved outcomes for patients and improved risk management.