The health loss from ischemic stroke and intracerebral hemorrhage : evidence from the North East Melbourne Stroke Incidence Study (NEMESIS)

Background People suffering different types of stroke have differing demographic characteristics and survival. However, current estimates of disease burden are based on the same underlying assumptions irrespective of stroke type. We hypothesized that average Quality Adjusted Life Years (QALYs) lost from stroke would be different for ischemic stroke and intracerebral hemorrhage (ICH).

Methods We used 1 and 5-year data collected from patients with first-ever stroke participating in the North East Melbourne Stroke Incidence Study (NEMESIS). We calculated case fatality rates, health-adjusted life expectancy, and quality-of-life (QoL) weights specific to each age and gender category. Lifetime 'health loss' for first-ever ischemic stroke and ICH surviving 28-days for the 2004 Australian population cohort was then estimated. Multivariable uncertainty analyses and sensitivity analyses (SA) were used to assess the impact of varying input parameters e.g. case fatality and QoL weights.

Results Paired QoL data at 1 and 5 years were available for 237 NEMESIS participants. Extrapolating NEMESIS rates, 31,539 first-ever strokes were expected for Australia in 2004. Average discounted (3%) QALYs lost per first-ever stroke were estimated to be 5.09 (SD 0.20; SA 5.49) for ischemic stroke (n = 27,660) and 6.17 (SD 0.26; SA 6.45) for ICH (n = 4,291; p < 0.001). QALYs lost also differed according to gender for both subtypes (ischemic stroke: males 4.69 SD 0.38, females 5.51 SD 0.46; ICH: males 5.82 SD 0.67, females 6.50 SD 0.40).

Discussion People with ICH incurred greater loss of health over a lifetime than people with ischemic stroke. This is explained by greater stroke related case fatality at a younger age, but longer life expectancy with disability after the first 12 months for people with ICH. Thus, studies of disease burden in stroke should account for these differences between subtype and gender. Otherwise, in countries where ICH is more common, health loss for stroke may be underestimated. Similar to other studies of this type, the generalisability of the results may be limited. Sensitivity and uncertainty analyses were used to provide a plausible range of variation for Australia. In countries with demographic and life expectancy characteristics comparable to Australia, our QoL weights may be reasonably applicable.

Organized blood pressure control programs to prevent stroke in Australia : would they be cost-effective?

Background and Purpose—: High blood pressure (BP) is the most important modifiable stroke risk factor. Worldwide high BP in many people is uncontrolled or people are unaware of their BP status. We aimed to assess whether a program of organized multidisciplinary care and medication would be cost-effective for improving BP control for the prevention of stroke.

Methods—: A novel aspect was to simulate the intervention to match recent primary care initiatives (eg, new Medicare reimbursement items) to ensure policy relevance. Current practice and additional costs of each intervention were included using the best available evidence. The differences in the cost per quality-adjusted life year (QALY) gained for the interventions were compared against current practice. Cost-effectiveness was defined as cost per QALY gained was less than Australian dollars (AUD) 50 000 (societal perspective; reference year 2004). The robustness of estimates was assessed with probabilistic multivariable uncertainty analysis.

Results—: For primary prevention, the median cost per QALY gained was AUD11 068 (95% uncertainty interval AUD5201 to AUD18 696) in those aged 75 years or older and was AUD17 359 (95% uncertainty interval AUD10 516 to AUD26 036) in those aged 55 to 84 years with >=15% absolute risk of stroke. Primary prevention interventions were not cost-effective if aged younger than 50 years. The median cost per QALY gained for secondary prevention was AUD1811 and AUD4704, depending on which medications were modeled.

Conclusions—: Organized care for BP control targeted at specific populations offers excellent value over current practice. Organized care for secondary prevention provided the greatest benefits and strongest cost-effectiveness. Translation into clinical practice requires improved use of relevant Medicare policy in Australia.

Little evidence that condition, stress indicators, sex ratio, or homozygosity are related to landscape or habitat attributes in declining woodland birds

Habitat loss, fragmentation and degradation are drivers of major declines in biodiversity and species extinctions. The actual causes of species population declines following habitat change are more difficult to discern and there is typically high covariation among the measures used to infer the causes of decline. The causes of decline may act directly on individual fitness and survival, or through disruption of population processes. We examined the relationships among configuration, extent and status of native vegetation and three commonly used indicators of individual body condition and chronic stress (haemoglobin level, haematocrit, residual body mass condition index) in 13 species of woodland-dependent birds in south-eastern Australia. We also examined two measures of changes to population processes (sex ratio and individual homozygosity) in ten species and alleic richness in five species. We found little support for relationships between site or landscape characteristics and individual or population response variables, notwithstanding that our simulations showed we had sufficient power to detect relatively small effects. We discuss possible causes of the absence of detectable habitat effects in this system and the implications for the usefulness of individual body condition and easily measured haematological indices as indicators of the response of avian populations to habitat change. © 2012 The Authors.

Performance indicators and the deeper foundations of performance

Critics of Key Performance Indicators (KPIs) argue that KPIs culture rewards the immediate production of tangible outcomes sometimes at the expense of social engagement and cooperative behaviour. The need to gain immediate outcomes in the current KPIs performance culture focuses many individuals onto forms of productivity that gain high KPIs but at what cost? What effect does this single minded focus have on developing organisational loyalties and commitments? Some scholars have suggested that a singular focus on performance indicator success may crowd out other positive social capital in institutions.

Urban growth in arid environments : developing water sustainability indicators for Abu Dhabi (UAE)

The United Arab Emirates (UAE) face a serious water problem. It has a very dry climate, high evaporation rate, combined with large water consumption from fast growing population, economic activities and uncontrolled uses of water for irrigation. Currently, UAE has one of the largest water footprints in the world. Groundwater is overexploited. Waste water is increasingly being treated to supply non-drinking water, but it still cover a small proportion of the demand. Desalination of sea water is the main source of potable water in UAE, but the high economic cost of desalination, its intensive energy demand and the adverse effects of its effluents on the marine life are a major concern. Other factors contributing to the problem are the focus of water management policies on keep supplying the growing demand for water, the increase of the per capita water consumption, and the free water charge for most of population. This research goal is to develop a water sustainability set of indicators for the challenging context of UAE. This paper presents the first stage of the research. Based on a review of the literature, the proposed framework involves 19 indicators, divided into four categories: water availability; water quality; water use efficiency; and policy and governance. Using an integrated cause-effect approach (DSR - Driving force, State, Response), the indicators were related in terms of their interdependencies, with a holistic view of the city water cycle. A preliminary test of the indicators to Abu Dhabi as a case study allowed an evaluation of the main 'Driving force' on the system, such as the scarcity of water due to natural constraints of the region, and increasing water consumption patterns of modern society; an assessment of the current 'state', which is under serious water stress. Also it indicated some potential 'responses', such as implementing policies for increasing efficient use.

Indicators of the impact of climate change on migratory species

The Bonn Convention on the Conservation of Migratory Species of Wild Animals adopted a Resolution in 2005 recognising the impacts of climate change on migratory species. It called on Contracting Parties to undertake more research to improve our understanding of these impacts and to implement adaptation measures to reduce foreseeable adverse effects. Given the large diversity of taxa and species affected by climate change, it is impossible to monitor all species and effects thereof. However, it is likely that many of the key ecological and physical processes through which climate change may impact wildlife could be monitored using a suite of indicators, each comprising parameters of species/populations or groups of species as proxies for wider assemblages, habitats and ecosystems. Herein, we identify a suite of 17 indicators whose attributes could reveal negative impacts of climate change on the global status of migratory species: 4 for birds, 4 for marine mammals, 2 for sea turtles, 1 for fish, 3 for land mammals and 3 for bats. A few of these indicators would be relatively straightforward to develop, but most would require additional data collation, and in many cases methodological development. Choosing and developing indicators of the impacts of climate change on migratory species is a challenge, particularly with endangered species, which are subject to many other pressures. To identify and implement conservation measures for these species, indicators must account for the full ensemble of pressures, and link to a system of alerts and triggers for action.