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.

Implementation of a better choice healthy food and drink supply strategy for staff and visitors in government owned health facilities in Queensland, Australia

Objective The present paper reports on a quality improvement activity examining implementation of A Better Choice Healthy Food and Drink Supply Strategy for Queensland Health Facilities (A Better Choice). A Better Choice is a policy to increase supply and promotion of healthy foods and drinks and decrease supply and promotion of energy-dense, nutrient-poor choices in all food supply areas including food outlets, staff dining rooms, vending machines, tea trolleys, coffee carts, leased premises, catering, fundraising, promotion and advertising. Design An online survey targeted 278 facility managers to collect self-reported quantitative and qualitative data. Telephone interviews were sought concurrently with the twenty-five A Better Choice district contact officers to gather qualitative information. Setting Public sector-owned and -operated health facilities in Queensland, Australia. Subjects One hundred and thirty-four facility managers and twenty-four district contact officers participated with response rates of 48·2 % and 96·0 %, respectively. Results Of facility managers, 78·4 % reported implementation of more than half of the A Better Choice requirements including 24·6 % who reported full strategy implementation. Reported implementation was highest in food outlets, staff dining rooms, tea trolleys, coffee carts, internal catering and drink vending machines. Reported implementation was more problematic in snack vending machines, external catering, leased premises and fundraising. Conclusions Despite methodological challenges, the study suggests that policy approaches to improve the food and drink supply can be implemented successfully in public-sector health facilities, although results can be limited in some areas. A Better Choice may provide a model for improving food supply in other health and workplace settings.

Odometry-driven inference to link multiple exemplars of a location

A major challenge for robot localization and mapping systems is maintaining reliable operation in a changing environment. Vision-based systems in particular are susceptible to changes in illumination and weather, and the same location at another time of day may appear radically different to a system using a feature-based visual localization system. One approach for mapping changing environments is to create and maintain maps that contain multiple representations of each physical location in a topological framework or manifold. However, this requires the system to be able to correctly link two or more appearance representations to the same spatial location, even though the representations may appear quite dissimilar. This paper proposes a method of linking visual representations from the same location without requiring a visual match, thereby allowing vision-based localization systems to create multiple appearance representations of physical locations. The most likely position on the robot path is determined using particle filter methods based on dead reckoning data and recent visual loop closures. In order to avoid erroneous loop closures, the odometry-based inferences are only accepted when the inferred path's end point is confirmed as correct by the visual matching system. Algorithm performance is demonstrated using an indoor robot dataset and a large outdoor camera dataset.

Sampling designs on stream networks using the pseudo-Bayesian approach

Monitoring stream networks through time provides important ecological information. The sampling design problem is to choose locations where measurements are taken so as to maximise information gathered about physicochemical and biological variables on the stream network. This paper uses a pseudo-Bayesian approach, averaging a utility function over a prior distribution, in finding a design which maximizes the average utility. We use models for correlations of observations on the stream network that are based on stream network distances and described by moving average error models. Utility functions used reflect the needs of the experimenter, such as prediction of location values or estimation of parameters. We propose an algorithmic approach to design with the mean utility of a design estimated using Monte Carlo techniques and an exchange algorithm to search for optimal sampling designs. In particular we focus on the problem of finding an optimal design from a set of fixed designs and finding an optimal subset of a given set of sampling locations. As there are many different variables to measure, such as chemical, physical and biological measurements at each location, designs are derived from models based on different types of response variables: continuous, counts and proportions. We apply the methodology to a synthetic example and the Lake Eacham stream network on the Atherton Tablelands in Queensland, Australia. We show that the optimal designs depend very much on the choice of utility function, varying from space filling to clustered designs and mixtures of these, but given the utility function, designs are relatively robust to the type of response variable.

Constructing a frame of cube : connecting 3D shapes with direction, location and movement

With the advancement of new technologies, this author has in 2010 started to engineer an online learning environment for investigating the nature and development of spatial abilities, and the teaching and learning of geometry. This paper documents how this new digital learning environment can afford the opportunity to integrate the learning about 3D shapes with direction, location and movement, and how young children can mentally and visually construct virtual 3D shapes using movements in both egocentric and fixed frames of reference (FOR). Findings suggest that year 4 (aged 9) children can develop the capacity to construct a cube using egocentric FOR only, fixed FOR only or a combination of both FOR. However, these young participants were unable to articulate the effect of individual or combined FOR movements. Directions for future research are proposed.

A question of agency : applying Sen’s theory of human capability to the concept of secondary school student career ‘choice’

In this paper, we seek to operationalize Amartya Sen's concept of human capability to guide a scholarly investigation of student career choice capability. We begin by outlining factors affecting youth labour markets in Australia; a prosperous country that is affected by a ‘two-speed’ national economy. We then examine recent government initiatives that have been designed to combat youth unemployment and cyclical disadvantage by enhancing the aspirations and career knowledge of secondary school students. We argue that these policy measures are based on four assumptions: first, that career choice capability is a problem of individual agency; second, that the dissemination of career information can empower students to act as ‘consumers’ in an unequal job market; third, that agency is simply a question of will; and finally, that school education and career advice – as a means to freedom in the space of career development – is of equal quality, distribution and value to an increasingly diverse range of upper secondary school students. The paper concludes by outlining a conceptual framework capable of informing an empirical research project that aims to test these assumptions by measuring and comparing differences between groups in the range of freedom to achieve and, therefore, to choose.

Who struggles most in making a career choice and why?Findings from a cross-sectional survey of highschool students

This paper reports findings from an empirical study examining the influence of student background and educational experiences on the development of career choice capability. Secondary school students attending years 9-12 (N = 706) in New South Wales (NSW), Australia, were invited to participate in an online survey that sought to examine factors influencing their career choices. The survey included questions relating to student demographics, parental occupation, attitudes to school and to learning, student aspirations, and students’ knowledge of the further education or skills required to achieve their desired goal. We found no significant differences in the proportions of students who were “uncertain” of their future career aspirations with respect to their socio-educational background. There were, however, significantly more students struggling with career decision making from an English-speaking background in comparison to households where children spoke a language other than English. Those students were proportionally present in government and non-government schools and had some behavioural and attitudinal characteristics in common.

Editorial : Action research, action learning and community services

This edition of ALARj has a focus on the contribution of action learning and action research to the development of community services, particularly nonprofits. The landscape of community services has been changing rapidly in recent decades, and can be typified by the notion of complexity. Complexity in the nature of issues that services seek to respond to, complexity in the policy environment and systems of support that have tended to silo and compartmentalise problems and people, and complexity in the institutional location non-profit services occupy in ‘helping’ those who are seen as ‘in need’ or marginalised. In addition to being typified by complexity the environment in which community services are located is dynamic, undergoing profound and ongoing change as neo-liberal approaches to understanding and responding to human need, which emphasise the individualisation of risk, and market principles such as choice, competition and innovation, drive social policy. How can long held values of empowerment, care, inclusivity and benefit to individuals and communities have expression in community services as they grapple with the challenges of being viable and relevant in such a dynamically changing environment? This edition brings together a range of contributions which speak to these challenges. The thematic through these is that processes are needed which engage services and communities in ongoing processes of inquiry about how they can best proceed in contexts typified by complexity and change. Action learning and action research can provide processes of this character.

Identifying steganographic payload location in binary image

In this paper, we propose a steganalysis method that is able to identify the locations of stego bearing pixels in the binary image. In order to do that, our proposed method will calculate the residual between a given stego image and its estimated cover image. After that, we will compute the local entropy difference between these two versions of images as well. Finally, we will compute the mean of residual and mean of local entropy difference across multiple stego images. From these two means, the locations of stego bearing pixels can be identified. The presented empirical results demonstrate that our proposed method can identify the stego bearing locations of near perfect accuracy when sufficient stego images are supplied. Hence, our proposed method can be used to reveal which pixels in the binary image have been used to carry the secret message.

Built to last or meant to end : intertemporal choice in strategic alliance portfolios

A salient but rarely explicitly studied characteristic of interfirm relationships is that they can intentionally be formed for finite periods of time. What determines firms' intertemporal choices between different alliance time horizons? Shadow of the future theorists suggest that when an alliance has an explicitly set short-term time frame, there is an increased risk that partners may behave opportunistically. This does not readily explain the high incidence of time-bound alliances being formed. Reconciling insights from the shadow of the future perspective with nascent research on the flexibility of temporary organizations, and shifting the focus from the level of individual transactions to that of strategic alliance portfolios, we argue that firms may be willing to accept a higher risk of opportunism when there are offsetting gains in strategic flexibility in managing their strategic alliance portfolio. Consequently, we hypothesize that environmental factors that increase the need for strategic flexibility—namely, dynamism and complexity in the environment—are likely to increase the relative share of time-bound alliances in strategic alliance portfolios. Our analysis of longitudinal data on the intertemporal alliance choices of a large sample of small and medium-sized enterprises provides support for this argument. Our findings fill an important gap in theory about time horizons in interfirm relationships and temporary organizations and show the importance of separating planned terminations from duration-based performance measures.

Location of hydrogen atoms in hydronium jarosite

Various models for the crystal structure of hydronium jarosite were determined from Rietveld refinements against neutron powder diffraction patterns collected at ambient temperature and also single-crystal X-ray diffraction data. The possibility of a lower symmetry space group for hydronium jarosite that has been suggested by the literature was investigated. It was found the space group is best described as R3¯m, the same for other jarosite minerals. The hydronium oxygen atom was found to occupy the 3¯m site (3a Wyckoff site). Inadequately refined hydronium bond angles and bond distances without the use of restraints are due to thermal motion and disorder of the hydronium hydrogen atoms across numerous orientations. However, the acquired data do not permit a precise determination of these orientations; the main feature up/down disorder of hydronium is clear. Thus, the highest symmetry model with the least disorder necessary to explain all data was chosen: The hydronium hydrogen atoms were modeled to occupy an m (18 h Wyckoff site) with 50 % fractional occupancy, leading to disorder across two orientations. A rigid body description of the hydronium ion rotated by 60° with H–O–H bond angles of 112° and O–H distances of 0.96 Å was optimal. This rigid body refinement suggests that hydrogen bonds between hydronium hydrogen atoms and basal sulfate oxygen atoms are not predominant. Instead, hydrogen bonds are formed between hydronium hydrogen atoms and hydroxyl oxygen atoms. The structure of hydronium alunite is expected to be similar given that alunite supergroup minerals are isostructural.

Substrate choice of membrane-type 1 matrix metalloproteinase is dictated by tissue inhibitor of metalloproteinase-2 levels

Although tissue inhibitor of metalloproteinase-2 (TIMP-2) is known to be not only an inhibitor of matrix metalloproteinases (MMP) but also a cofactor for membrane-type 1 MMP (MT1-MMP)-mediated MMP-2 activation, it is still unclear how TIMP-2 regulates MMP-2 activation and cleavage of substrates by MT1-MMP. In the present study we examined the levels of cell-surface MT1-MMP, MMP-2 activation and cleavage of MT1-MMP substrates in 293T cells transfected with the MT1-MMP and TIMP-2 genes. Co-expression of TIMP-2 at an appropriate level increased the level of cell-surface MT1-MMP, both the TIMP-2-bound and free forms, and generated processed MMP-2 with gelatin-degrading activity. In contrast, MT1-MMP substrates testican-1 and syndecan-1 were cleaved by the cells expressing MT1-MMP, which was inhibited by TIMP-2 even at levels that stimulate MMP-2 activation. These results suggest that TIMP-2 environment determines MT1-MMP substrate choice between direct cleavage of its own substrates and MMP-2 activation.

Top-k retrieval using facility location analysis

The top-k retrieval problem aims to find the optimal set of k documents from a number of relevant documents given the user’s query. The key issue is to balance the relevance and diversity of the top-k search results. In this paper, we address this problem using Facility Location Analysis taken from Operations Research, where the locations of facilities are optimally chosen according to some criteria. We show how this analysis technique is a generalization of state-of-the-art retrieval models for diversification (such as the Modern Portfolio Theory for Information Retrieval), which treat the top-k search results like “obnoxious facilities” that should be dispersed as far as possible from each other. However, Facility Location Analysis suggests that the top-k search results could be treated like “desirable facilities” to be placed as close as possible to their customers. This leads to a new top-k retrieval model where the best representatives of the relevant documents are selected. In a series of experiments conducted on two TREC diversity collections, we show that significant improvements can be made over the current state-of-the-art through this alternative treatment of the top-k retrieval problem.

The impact of a congestion charging exemption on the demand for new low‐emission vehicles

Numerous initiatives have been employed around the world in order to address rising greenhouse gas (GHG) emissions originating from the transport sector. These measures include: travel demand management (congestion‐charging), increased fuel taxes, alternative fuel subsidies and low‐emission vehicle (LEV) rebates. Incentivizing the purchase of LEVs has been one of the more prevalent approaches in attempting to tackle this global issue. LEVs, whilst having the advantage of lower emissions and, in some cases, more efficient fuel consumption, also bring the downsides of increased purchase cost, reduced convenience of vehicle fuelling, and operational uncertainty. To stimulate demand in the face of these challenges, various incentive‐based policies, such as toll exemptions, have been used by national and local governments to encourage the purchase of these types of vehicles. In order to address rising GHG emissions in Stockholm, and in line with the Swedish Government’s ambition to operate a fossil free fleet by 2030, a number of policies were implemented targeting the transport sector. Foremost amongst these was the combination of a congestion charge – initiated to discourage emissions‐intensive travel – and an exemption from this charge for some LEVs, established to encourage a transition towards a ‘green’ vehicle fleet. Although both policies shared the aim of reducing GHG emissions, the exemption for LEVs carried the risk of diminishing the effectiveness of the congestion charging scheme. As the number of vehicle owners choosing to transition to an eligible LEV increased, the congestion‐reduction effectiveness of the charging scheme weakened. In fact, policy makers quickly recognized this potential issue and consequently phased out the LEV exemption less than 18 months after its introduction (1). Several studies have investigated the demand for LEVs through stated‐preference (SP) surveys across multiple countries, including: Denmark (2), Germany (3, 4), UK (5), Canada (6), USA (7, 8) and Australia (9). Although each of these studies differed in approach, all involved SP surveys where differing characteristics between various types of vehicles, including LEVs, were presented to respondents and these respondents in turn made hypothetical decisions about which vehicle they would be most likely to purchase. Although these studies revealed a number of interesting findings in regards to the potential demand for LEVs, they relied on SP data. In contrast, this paper employs an approach where LEV choice is modelled by taking a retrospective view and by using revealed preference (RP) data. By examining the revealed preferences of vehicle owners in Stockholm, this study overcomes one of the principal limitations of SP data, namely that stated preferences may not in fact reflect individuals’ actual choices, such as when cost, time, and inconvenience factors are real rather than hypothetical. This paper’s RP approach involves modelling the characteristics of individuals who purchased new LEVs, whilst estimating the effect of the congestion charging exemption upon choice probabilities and subsequent aggregate demand. The paper contributes to the current literature by examining the effectiveness of a toll exemption under revealed preference conditions, and by assessing the total effect of the policy based on key indicators for policy makers, including: vehicle owner home location, commuting patterns, number of children, age, gender and income. Extended Abstract Submission for Kuhmo Nectar Conference 2014 2 The two main research questions motivating this study were:  Which individuals chose to purchase a new LEV in Stockholm in 2008?; and,  How did the congestion charging exemption affect the aggregate demand for new LEVs in Stockholm in 2008? In order to answer these research questions the analysis was split into two stages. Firstly, a multinomial logit (MNL) model was used to identify which demographic characteristics were most significantly related to the purchase of an LEV over a conventional vehicle. The three most significant variables were found to be: intra‐cordon residency (positive); commuting across the cordon (positive); and distance of residence from the cordon (negative). In order to estimate the effect of the exemption policy on vehicle purchase choice, the model included variables to control for geographic differences in preferences, based on the location of the vehicle owners’ homes and workplaces in relation to the congestion‐charging cordon boundary. These variables included one indicator representing commutes across the cordon and another indicator representing intra‐cordon residency. The effect of the exemption policy on the probability of purchasing LEVs was estimated in the second stage of the analysis by focusing on the groups of vehicle owners that were most likely to have been affected by the policy i.e. those commuting across the cordon boundary (in both directions). Given the inclusion of the indicator variable representing commutes across the cordon, it is assumed that the estimated coefficient of this variable captures the effect of the exemption policy on the utility of choosing to purchase an exempt LEV for these two groups of vehicle owners. The intra‐cordon residency indicator variable also controls for differences between the two groups, based upon direction of travel across the cordon boundary. A counter‐hypothesis to this assumption is that the coefficient of the variable representing commuting across the cordon boundary instead only captures geo‐demographic differences that lead to variations in LEV ownership across the different groups of vehicle owners in relation to the cordon boundary. In order to address this counter‐hypothesis, an additional analysis was performed on data from a city with a similar geodemographic pattern to Stockholm, Gothenburg ‐ Sweden’s second largest city. The results of this analysis provided evidence to support the argument that the coefficient of the variable representing commutes across the cordon was capturing the effect of the exemption policy. Based upon this framework, the predicted vehicle type shares were calculated using the estimated coefficients of the MNL model and compared with predicted vehicle type shares from a simulated scenario where the exemption policy was inactive. This simulated scenario was constructed by setting the coefficient for the variable representing commutes across the cordon boundary to zero for all observations to remove the utility benefit of the exemption policy. Overall, the procedure of this second stage of the analysis led to results showing that the exemption had a substantial effect upon the probability of purchasing and aggregate demand for exempt LEVs in Stockholm during 2008. By making use of unique evidence of revealed preferences of LEV owners, this study identifies the common characteristics of new LEV owners and estimates the effect of Stockholm's congestion charging exemption upon the demand for new LEVs during 2008. It was found that the variables that had the greatest effect upon the choice of purchasing an exempt LEV included intra‐cordon residency (positive), distance of home from the cordon (negative), and commuting across the cordon (positive). It was also determined that owners under the age of 30 years preferred non‐exempt LEVs (low CO2 LEVs), whilst those over the age of 30 years preferred electric vehicles. In terms of electric vehicles, it was apparent that those individuals living within the city had the highest propensity towards purchasing this vehicle type. A negative relationship between choosing an electric vehicle and the distance of an individuals’ residency from the cordon was also evident. Overall, the congestion charging exemption was found to have increased the share of exempt LEVs in Stockholm by 1.9%, with, as expected, a much stronger effect on those commuting across the boundary, with those living inside the cordon having a 13.1% increase, and those owners living outside the cordon having a 5.0% increase. This increase in demand corresponded to an additional 538 (+/‐ 93; 95% C.I.) new exempt LEVs purchased in Stockholm during 2008 (out of a total of 5 427; 9.9%). Policy makers can take note that an incentive‐based policy can increase the demand for LEVs and appears to be an appropriate approach to adopt when attempting to reduce transport emissions through encouraging a transition towards a ‘green’ vehicle fleet.