Economics and preventing healthcare acquired infection

The evolution of organisms that cause healthcare acquired infections (HAI) puts extra stress on hospitals already struggling with rising costs and demands for greater productivity and cost containment. Infection control can save scarce resources, lives, and possibly a facility’s reputation, but statistics and epidemiology are not always sufficient to make the case for the added expense. Economics and Preventing Healthcare Acquired Infection presents a rigorous analytic framework for dealing with this increasingly serious problem. ----- Engagingly written for the economics non-specialist, and brimming with tables, charts, and case examples, the book lays out the concepts of economic analysis in clear, real-world terms so that infection control professionals or infection preventionists will gain competence in developing analyses of their own, and be confident in the arguments they present to decision-makers. The authors: ----- Ground the reader in the basic principles and language of economics. ----- Explain the role of health economists in general and in terms of infection prevention and control. ----- Introduce the concept of economic appraisal, showing how to frame the problem, evaluate and use data, and account for uncertainty. ----- Review methods of estimating and interpreting the costs and health benefits of HAI control programs and prevention methods. ----- Walk the reader through a published economic appraisal of an infection reduction program. ----- Identify current and emerging applications of economics in infection control. ---- Economics and Preventing Healthcare Acquired Infection is a unique resource for practitioners and researchers in infection prevention, control and healthcare economics. It offers valuable alternate perspective for professionals in health services research, healthcare epidemiology, healthcare management, and hospital administration. ----- Written for: Professionals and researchers in infection control, health services research, hospital epidemiology, healthcare economics, healthcare management, hospital administration; Association of Professionals in Infection Control (APIC), Society for Healthcare Epidemiologists of America (SHEA)

Sustainable urban futures : an ecological approach to sustainable urban development

In recent years, cities show increasing signs of environmental problems due to the negative impacts of urban activities. The degradation and depletion of natural resources, climate change and development pressure on green areas have become major concerns for cities. In response to these problems, urban planning policies have shifted to a sustainable focus and authorities have begun to develop new strategies for improving the quality of urban ecosystems. An extremely important function of an urban ecosystem is to provide healthy and sustainable environments for both natural systems and communities. Therefore, ecological planning is a functional requirement in the establishment of sustainable built environment. With ecological planning human needs are supplied while natural resources are used in the most effective and sustainable manner. And the maintenance of ecological balance is sustained. Protecting human and environmental health, having healthy ecosystems, reducing environmental pollution and providing green spaces are just a few of the many benefits of ecological planning. In this context, the paper briefly presents a short overview of the importance of the implementation of ecological planning into sustainable urban development. Furthermore, the paper defines the conceptual framework of a new method for developing sustainable urban ecosystems through ecological planning approach. In the future of the research, this model will be developed as a guideline for the assessment of the ecological sustainability in built environments.

Creative clusters and universities : the cluster concept in economics and geography

This paper considers the history of the cluster concept in urban economic geography, and its relationship to recent debates about creative cities. It then looks at the role that universities can play in the development of a creative cluster, as well as some of the potential pitfalls.

Ecological perspectives and wellness

Since the industrial revolution, the development of a lifestyle lived predominantly indoors has resulted in less contact with nature. Research over the last twenty years has gradually been identifying the human health benefits attributed to re-connecting with the natural environment. The significance of feeling connected to natural environments, families and friends are described as a foundational requirement for human health and wellbeing (Maller et al., 2008). Also, the early findings of Schultz‟s (2002) work indicated that by feeling connected to the natural world a person is more likely to be committed to positively interact with and protect the natural world. Research on young people has indicated that young people are even more disconnected from the natural world. Leading some writers to call this disconnection a crisis termed “Nature Deficit Disorder.” Participants (n = 131) from 1st year university Physical Education and Human Movement Studies were asked to complete two questionnaires the Connectedness to Nature scale (CNS) (Mayer & Frantz, 2004) and the New Ecological Paradigm Scale (NEP) (Dunlap, Van Liere, Mertig, & Jones, 2000). The NEP and CNS are two scales most commonly used to explore beliefs and feelings of connectedness to the natural world (Schultz, 2002). The NEP was developed over thirty years ago by Dunlap and Van Liere (1978) and originally termed the New Environmental Paradigm. The NEP is now the foremost International tool for measuring beliefs about the natural world (Dunlap, 2008). The CNS measures an individual‟s trait levels of emotional connection to the natural world. It is a relatively new tool for understanding ecological behaviour based on ecopsychology theory and employed to predict behaviour (Mayer and Frantz, 2004). Both questionnaires are based on a 1-5 scale (Strongly disagree to Strongly agree). By combing both scales the researchers aim to develop a snap shot of beliefs and emotional feelings towards the natural world and therefore an idea of intended behaviour. The two questionnaires were combined as one online survey with additional material asking for demographics and self assessments of type of leader included before the surveys. An email inviting outdoor leaders to participate was sent out to networks and interest groups. A basic descriptive statistical analysis was used to interpret data.

Ecological sustainability : what role for public health education?

This article explores the notion of ecological sustainability in the context of public health education and the contribution Universities can make in creating environments that include ecologically sustainable practices. It considers the important role of environmental health in building a sustainable future for the population as a central plank of public health. It presents the evidence for the need for comprehensive approaches to ecological sustainability within the University and offers suggestions about how this can take place. It concludes by arguing that to date there is a substantial gap between the rhetoric and the reality in the University context.

Obesity in pregnancy : outcomes and economics

Maternal obesity is an important aspect of reproductive care. It is the commonest risk factor for maternal mortality in developed countries and is also associated with a wide spectrum of adverse pregnancy outcomes. Maternal obesity may have longer-term implications for the health of the mother and infant, which in turn will have economic implications. Efforts to prevent, manage and treat obesity in pregnancy will be costly, but may pay dividends from reduced future economic costs, and subsequent improvements to maternal and infant health. Decision-makers working in this area of health services should understand whether the problem can be reduced, at what cost; and then, what cost savings and health benefits will accrue in the future from a reduction of the problem.

The importance of ecological scale for wildlife conservation in naturally fragmented environments: A case study of the Brush-Tailed Rock-Wallaby (Petrogale Penicillata)

Determining the ecologically relevant spatial scales for predicting species occurrences is an important concept when determining species–environment relationships. Therefore species distribution modelling should consider all ecologically relevant spatial scales. While several recent studies have addressed this problem in artificially fragmented landscapes, few studies have researched relevant ecological scales for organisms that also live in naturally fragmented landscapes. This situation is exemplified by the Australian rock-wallabies’ preference for rugged terrain and we addressed the issue of scale using the threatened brush-tailed rock-wallaby (Petrogale penicillata) in eastern Australia. We surveyed for brush-tailed rock-wallabies at 200 sites in southeast Queensland, collecting potentially influential site level and landscape level variables. We applied classification trees at either scale to capture a hierarchy of relationships between the explanatory variables and brush-tailed rock-wallaby presence/absence. Habitat complexity at the site level and geology at the landscape level were the best predictors of where we observed brush-tailed rock-wallabies. Our study showed that the distribution of the species is affected by both site scale and landscape scale factors, reinforcing the need for a multi-scale approach to understanding the relationship between a species and its environment. We demonstrate that careful design of data collection, using coarse scale spatial datasets and finer scale field data, can provide useful information for identifying the ecologically relevant scales for studying species–environment relationships. Our study highlights the need to determine patterns of environmental influence at multiple scales to conserve specialist species such as the brush-tailed rock-wallaby in naturally fragmented landscapes.

Setting hospital infection control policy : a decision-making framework incorporating health economics and healthcare epidemiology

Background: Reducing rates of healthcare acquired infection has been identified by the Australian Commission on Safety and Quality in Health Care as a national priority. One of the goals is the prevention of central venous catheter-related bloodstream infection (CR-BSI). At least 3,500 cases of CR-BSI occur annually in Australian hospitals, resulting in unnecessary deaths and costs to the healthcare system between $25.7 and $95.3 million. Two approaches to preventing these infections have been proposed: use of antimicrobial catheters (A-CVCs); or a catheter care and management ‘bundle’. Given finite healthcare budgets, decisions about the optimal infection control policy require consideration of the effectiveness and value for money of each approach. Objectives: The aim of this research is to use a rational economic framework to inform efficient infection control policy relating to the prevention of CR-BSI in the intensive care unit. It addresses three questions relating to decision-making in this area: 1. Is additional investment in activities aimed at preventing CR-BSI an efficient use of healthcare resources? 2. What is the optimal infection control strategy from amongst the two major approaches that have been proposed to prevent CR-BSI? 3. What uncertainty is there in this decision and can a research agenda to improve decision-making in this area be identified? Methods: A decision analytic model-based economic evaluation was undertaken to identify an efficient approach to preventing CR-BSI in Queensland Health intensive care units. A Markov model was developed in conjunction with a panel of clinical experts which described the epidemiology and prognosis of CR-BSI. The model was parameterised using data systematically identified from the published literature and extracted from routine databases. The quality of data used in the model and its validity to clinical experts and sensitivity to modelling assumptions was assessed. Two separate economic evaluations were conducted. The first evaluation compared all commercially available A-CVCs alongside uncoated catheters to identify which was cost-effective for routine use. The uncertainty in this decision was estimated along with the value of collecting further information to inform the decision. The second evaluation compared the use of A-CVCs to a catheter care bundle. We were unable to estimate the cost of the bundle because it is unclear what the full resource requirements are for its implementation, and what the value of these would be in an Australian context. As such we undertook a threshold analysis to identify the cost and effectiveness thresholds at which a hypothetical bundle would dominate the use of A-CVCs under various clinical scenarios. Results: In the first evaluation of A-CVCs, the findings from the baseline analysis, in which uncertainty is not considered, show that the use of any of the four A-CVCs will result in health gains accompanied by cost-savings. The MR catheters dominate the baseline analysis generating 1.64 QALYs and cost-savings of $130,289 per 1.000 catheters. With uncertainty, and based on current information, the MR catheters remain the optimal decision and return the highest average net monetary benefits ($948 per catheter) relative to all other catheter types. This conclusion was robust to all scenarios tested, however, the probability of error in this conclusion is high, 62% in the baseline scenario. Using a value of $40,000 per QALY, the expected value of perfect information associated with this decision is $7.3 million. An analysis of the expected value of perfect information for individual parameters suggests that it may be worthwhile for future research to focus on providing better estimates of the mortality attributable to CR-BSI and the effectiveness of both SPC and CH/SSD (int/ext) catheters. In the second evaluation of the catheter care bundle relative to A-CVCs, the results which do not consider uncertainty indicate that a bundle must achieve a relative risk of CR-BSI of at least 0.45 to be cost-effective relative to MR catheters. If the bundle can reduce rates of infection from 2.5% to effectively zero, it is cost-effective relative to MR catheters if national implementation costs are less than $2.6 million ($56,610 per ICU). If the bundle can achieve a relative risk of 0.34 (comparable to that reported in the literature) it is cost-effective, relative to MR catheters, if costs over an 18 month period are below $613,795 nationally ($13,343 per ICU). Once uncertainty in the decision is considered, the cost threshold for the bundle increases to $2.2 million. Therefore, if each of the 46 Level III ICUs could implement an 18 month catheter care bundle for less than $47,826 each, this approach would be cost effective relative to A-CVCs. However, the uncertainty is substantial and the probability of error in concluding that the bundle is the cost-effective approach at a cost of $2.2 million is 89%. Conclusions: This work highlights that infection control to prevent CR-BSI is an efficient use of healthcare resources in the Australian context. If there is no further investment in infection control, an opportunity cost is incurred, which is the potential for a more efficient healthcare system. Minocycline/rifampicin catheters are the optimal choice of antimicrobial catheter for routine use in Australian Level III ICUs, however, if a catheter care bundle implemented in Australia was as effective as those used in the large studies in the United States it would be preferred over the catheters if it was able to be implemented for less than $47,826 per Level III ICU. Uncertainty is very high in this decision and arises from multiple sources. There are likely greater costs to this uncertainty for A-CVCs, which may carry hidden costs, than there are for a catheter care bundle, which is more likely to provide indirect benefits to clinical practice and patient safety. Research into the mortality attributable to CR-BSI, the effectiveness of SPC and CH/SSD (int/ext) catheters and the cost and effectiveness of a catheter care bundle in Australia should be prioritised to reduce uncertainty in this decision. This thesis provides the economic evidence to inform one area of infection control, but there are many other infection control decisions for which information about the cost-effectiveness of competing interventions does not exist. This work highlights some of the challenges and benefits to generating and using economic evidence for infection control decision-making and provides support for commissioning more research into the cost-effectiveness of infection control.

An ecological assessment of secondary poisoning risk in the Australian sugarcane industry

Rodenticide use in agriculture can lead to the secondary poisoning of avian predators. Currently the Australian sugarcane industry has two rodenticides, Racumin® and Rattoff®, available for in-crop use but, like many agricultural industries, it lacks an ecologically-based method of determining the potential secondary poisoning risk the use of these rodenticides poses to avian predators. The material presented in this thesis addresses this by: a. determining where predator/prey interactions take place in sugar producing districts; b. quantifying the amount of rodenticide available to avian predators and the probability of encounter; and c. developing a stochastic model that allows secondary poisoning risk under various rodenticide application scenarios to be investigated. Results demonstrate that predator/prey interactions are highly constrained by environmental structure. Rodents used crops that provided high levels of canopy cover and therefore predator protection and poorly utilised open canopy areas. In contrast, raptors over-utilised areas with low canopy cover and low rodent densities, but which provided high accessibility to prey. Given this pattern of habitat use, and that industry baiting protocols preclude rodenticide application in open canopy crops, these results indicate that secondary poisoning can only occur if poisoned rodents leave closed canopy crops and become available for predation in open canopy areas. Results further demonstrate that after in-crop rodenticide application, only a small proportion of rodents available in open areas are poisoned and that these rodents carry low levels of toxicant. Coupled with the low level of rodenticide use in the sugar industry, the high toxic threshold raptors have to these toxicants and the low probability of encountering poisoned rodents, results indicate that the risk of secondary poisoning events occurring is minimal. A stochastic model was developed to investigate the effect of manipulating factors that might influence secondary poisoning hazard in a sugarcane agro-ecosystem. These simulations further suggest that in all but extreme scenarios, the risk of secondary poisoning is also minimal. Collectively, these studies demonstrate that secondary poisoning of avian predators associated with the use of the currently available rodenticides in Australian sugar producing districts is minimal. Further, the ecologically-based method of assessing secondary poisoning risk developed in this thesis has broader applications in other agricultural systems where rodenticide use may pose risks to avian predators.

The economics of the FIFA Football World Cup

The expansion of economics to ‘non-market topics’ has received increased attention in recent years. The economics of sports (football) is such a sub-field. This paper reports empirical evidence of team and referee performances in the FIFA World Cup 2002. The results reveal that being a hosting nation has a significant impact on the probability of winning a game. Furthermore, the strength of a team measured with the FIFA World Ranking does not play the important role presumed, which indicates that the element of uncertainty is working. The findings also indicate that the influence of a referee on the game result should not be neglected. Finally, the previous World Cup experiences seem to have the strongest impact on referees' performances during the game.

Reading the environment : narrative constructions of ecological subjectivities in Australian children's literature

Ways in which humans engage with the environment have always provided a rich source of material for writers and illustrators of Australian children's literature. Currently, readers are confronted with a multiplicity of complex, competing and/or complementing networks of ideas, theories and emotions that provide narratives about human engagement with the environment at a particular historical moment. This study, entitled Reading the Environment: Narrative Constructions of Ecological Subjectivities in Australian Children's Literature, examines how a representative sample of Australian texts (19 picture books and 4 novels for children and young adults published between 1995 and 2006) constructs fictional ecological subjects in the texts, and offers readers ecological subject positions inscribed with contemporary environmental ideologies. The conceptual framework developed in this study identifies three ideologically grounded positions that humans may assume when engaging with the environment. None of these positions clearly exists independently of any other, nor are they internally homogeneous. Nevertheless they can be categorised as: (i) human dominion over the environment with little regard for environmental degradation (unrestrained anthropocentrism); (ii) human consideration for the environment driven by understandings that humans need the environment to survive (restrained anthropocentrism); and (iii) human deference towards the environment guided by understandings that humans are no more important than the environment (ecocentrism). iv The transdisciplinary methodological approach to textual analysis used in this thesis draws on ecocriticism, narrative theories, visual semiotics, ecofeminism and postcolonialism to discuss the difficulties and contradictions in the construction of the positions offered. Each chapter of textual analysis focuses on the construction of subjectivities in relation to one of the positions identified in the conceptual framework. Chapter 5 is concerned with how texts highlight the negative consequences of human dominion over the environment, or, in the words of this study, living with ecocatastrophe. Chapter 6 examines representations of restrained anthropocentrism in its contemporary form, that is, sustainability. Chapter 7 examines representations of ecocentrism, a radical position with inherent difficulties of representation. According to the analysis undertaken, the focus texts convey the subtleties and complexities of human engagement with the environment and advocate ways of viewing and responding to contemporary unease about the environment. The study concludes that these ways of viewing and responding conform to and/or challenge dominant socio-cultural and political-economic opinions regarding the environment. This study, the first extended work of its kind, makes an original contribution to ecocritical study of Australian children's literature. By undertaking a comprehensive analysis of how texts for children represent human engagement with the environment at a time when important environmental concerns pose significant threats to human existence, I hope to contribute new knowledge to an area of children's literature research that to date has been significantly under-represented.

Addressing issues in sparseness, ecological bias and formulation of the adjacency matrix in Bayesian spatio-temporal analysis of disease counts

The main objective of this PhD was to further develop Bayesian spatio-temporal models (specifically the Conditional Autoregressive (CAR) class of models), for the analysis of sparse disease outcomes such as birth defects. The motivation for the thesis arose from problems encountered when analyzing a large birth defect registry in New South Wales. The specific components and related research objectives of the thesis were developed from gaps in the literature on current formulations of the CAR model, and health service planning requirements. Data from a large probabilistically-linked database from 1990 to 2004, consisting of fields from two separate registries: the Birth Defect Registry (BDR) and Midwives Data Collection (MDC) were used in the analyses in this thesis. The main objective was split into smaller goals. The first goal was to determine how the specification of the neighbourhood weight matrix will affect the smoothing properties of the CAR model, and this is the focus of chapter 6. Secondly, I hoped to evaluate the usefulness of incorporating a zero-inflated Poisson (ZIP) component as well as a shared-component model in terms of modeling a sparse outcome, and this is carried out in chapter 7. The third goal was to identify optimal sampling and sample size schemes designed to select individual level data for a hybrid ecological spatial model, and this is done in chapter 8. Finally, I wanted to put together the earlier improvements to the CAR model, and along with demographic projections, provide forecasts for birth defects at the SLA level. Chapter 9 describes how this is done. For the first objective, I examined a series of neighbourhood weight matrices, and showed how smoothing the relative risk estimates according to similarity by an important covariate (i.e. maternal age) helped improve the model’s ability to recover the underlying risk, as compared to the traditional adjacency (specifically the Queen) method of applying weights. Next, to address the sparseness and excess zeros commonly encountered in the analysis of rare outcomes such as birth defects, I compared a few models, including an extension of the usual Poisson model to encompass excess zeros in the data. This was achieved via a mixture model, which also encompassed the shared component model to improve on the estimation of sparse counts through borrowing strength across a shared component (e.g. latent risk factor/s) with the referent outcome (caesarean section was used in this example). Using the Deviance Information Criteria (DIC), I showed how the proposed model performed better than the usual models, but only when both outcomes shared a strong spatial correlation. The next objective involved identifying the optimal sampling and sample size strategy for incorporating individual-level data with areal covariates in a hybrid study design. I performed extensive simulation studies, evaluating thirteen different sampling schemes along with variations in sample size. This was done in the context of an ecological regression model that incorporated spatial correlation in the outcomes, as well as accommodating both individual and areal measures of covariates. Using the Average Mean Squared Error (AMSE), I showed how a simple random sample of 20% of the SLAs, followed by selecting all cases in the SLAs chosen, along with an equal number of controls, provided the lowest AMSE. The final objective involved combining the improved spatio-temporal CAR model with population (i.e. women) forecasts, to provide 30-year annual estimates of birth defects at the Statistical Local Area (SLA) level in New South Wales, Australia. The projections were illustrated using sixteen different SLAs, representing the various areal measures of socio-economic status and remoteness. A sensitivity analysis of the assumptions used in the projection was also undertaken. By the end of the thesis, I will show how challenges in the spatial analysis of rare diseases such as birth defects can be addressed, by specifically formulating the neighbourhood weight matrix to smooth according to a key covariate (i.e. maternal age), incorporating a ZIP component to model excess zeros in outcomes and borrowing strength from a referent outcome (i.e. caesarean counts). An efficient strategy to sample individual-level data and sample size considerations for rare disease will also be presented. Finally, projections in birth defect categories at the SLA level will be made.