Bayesian hierarchical models in statistical quality control methods to improve healthcare in hospitals

Quality oriented management systems and methods have become the dominant business and governance paradigm. From this perspective, satisfying customers’ expectations by supplying reliable, good quality products and services is the key factor for an organization and even government. During recent decades, Statistical Quality Control (SQC) methods have been developed as the technical core of quality management and continuous improvement philosophy and now are being applied widely to improve the quality of products and services in industrial and business sectors. Recently SQC tools, in particular quality control charts, have been used in healthcare surveillance. In some cases, these tools have been modified and developed to better suit the health sector characteristics and needs. It seems that some of the work in the healthcare area has evolved independently of the development of industrial statistical process control methods. Therefore analysing and comparing paradigms and the characteristics of quality control charts and techniques across the different sectors presents some opportunities for transferring knowledge and future development in each sectors. Meanwhile considering capabilities of Bayesian approach particularly Bayesian hierarchical models and computational techniques in which all uncertainty are expressed as a structure of probability, facilitates decision making and cost-effectiveness analyses. Therefore, this research investigates the use of quality improvement cycle in a health vii setting using clinical data from a hospital. The need of clinical data for monitoring purposes is investigated in two aspects. A framework and appropriate tools from the industrial context are proposed and applied to evaluate and improve data quality in available datasets and data flow; then a data capturing algorithm using Bayesian decision making methods is developed to determine economical sample size for statistical analyses within the quality improvement cycle. Following ensuring clinical data quality, some characteristics of control charts in the health context including the necessity of monitoring attribute data and correlated quality characteristics are considered. To this end, multivariate control charts from an industrial context are adapted to monitor radiation delivered to patients undergoing diagnostic coronary angiogram and various risk-adjusted control charts are constructed and investigated in monitoring binary outcomes of clinical interventions as well as postintervention survival time. Meanwhile, adoption of a Bayesian approach is proposed as a new framework in estimation of change point following control chart’s signal. This estimate aims to facilitate root causes efforts in quality improvement cycle since it cuts the search for the potential causes of detected changes to a tighter time-frame prior to the signal. This approach enables us to obtain highly informative estimates for change point parameters since probability distribution based results are obtained. Using Bayesian hierarchical models and Markov chain Monte Carlo computational methods, Bayesian estimators of the time and the magnitude of various change scenarios including step change, linear trend and multiple change in a Poisson process are developed and investigated. The benefits of change point investigation is revisited and promoted in monitoring hospital outcomes where the developed Bayesian estimator reports the true time of the shifts, compared to priori known causes, detected by control charts in monitoring rate of excess usage of blood products and major adverse events during and after cardiac surgery in a local hospital. The development of the Bayesian change point estimators are then followed in a healthcare surveillances for processes in which pre-intervention characteristics of patients are viii affecting the outcomes. In this setting, at first, the Bayesian estimator is extended to capture the patient mix, covariates, through risk models underlying risk-adjusted control charts. Variations of the estimator are developed to estimate the true time of step changes and linear trends in odds ratio of intensive care unit outcomes in a local hospital. Secondly, the Bayesian estimator is extended to identify the time of a shift in mean survival time after a clinical intervention which is being monitored by riskadjusted survival time control charts. In this context, the survival time after a clinical intervention is also affected by patient mix and the survival function is constructed using survival prediction model. The simulation study undertaken in each research component and obtained results highly recommend the developed Bayesian estimators as a strong alternative in change point estimation within quality improvement cycle in healthcare surveillances as well as industrial and business contexts. The superiority of the proposed Bayesian framework and estimators are enhanced when probability quantification, flexibility and generalizability of the developed model are also considered. The empirical results and simulations indicate that the Bayesian estimators are a strong alternative in change point estimation within quality improvement cycle in healthcare surveillances. The superiority of the proposed Bayesian framework and estimators are enhanced when probability quantification, flexibility and generalizability of the developed model are also considered. The advantages of the Bayesian approach seen in general context of quality control may also be extended in the industrial and business domains where quality monitoring was initially developed.

Justice in Society

Australia has always made claims to being a just and fair society. It is a land of opportunity, where anyone can make it, and where mateship rather than class underpins social relations. Why is it, then, that our criminal justice system is host to the most disadvantaged and disenfranchised in our community? Why do certain groups of people continue to experience the worst forms of injustice in our society? And why do these injustices continue, despite numerous attempts by researchers and activists to address them? By exploring the ways in which we think about justice in the wider Australian society, this book considers these questions. As disciplines that have the most to say about justice and injustice, it analyses the contributions of political philosophy and sociology, and examines how their ideas have come to dominate discussion on issues ranging from asylum seeking to homophobic violence. By examining the shared assumptions about justice and injustice that underpin these discussions, this book also charts a course between and beyond these debates, and seeks to engage, challenge, and offer new possibilities for justice in Australian society. Relevant contemporary social issues like sex trafficking, homelessness, mental illness and Indigenous policing are examined throughout, placed in their historical, social and cultural context, and linked to local, national and global debates. Such analyses examine the broader implications of these criminological, social and legal issues for those excluded from justice in Australian society.

Upwave cities, creative cities : the case of London

The saddest book on cities I have read in a long time is The Lost City of Stoke-on-Trent by Matthew Rice (2010). Rice, who is married to the pottery owner Emma Bridgewater, charts the long decline of the potteries since the 1970s, when many brands closed local potteries to move overseas to Indonesia. There are now only a dozen or so potteries left in Stoke and many jobs that once were there have simply vanished. Yet at one time, Stoke was a place of great wealth creation, innovation and industriousness. The lesson is that once a local economy loses its dynamism, the place itself stagnates and may even die. Stoke is to the UK what Detroit is to the USA. Rice also shows that successive attempts at urban renewal have largely failed to make any impact in reversing Stoke’s declining fortunes. Economic stagnation and decline occurs in real places, leaving multiple economic, social and cultural problems in its wake. Over a period of years, local communities and residents gradually grow poorer, as wealth leaks away to other places.

Understanding QC and EQA : an authentic learning model for undergraduate students (Conference Abstract)

Introduction QC and EQA are integral to good pathology laboratory practice. Medical Laboratory Science students undertake a project exploring internal QC and EQA procedures used in chemical pathology laboratories. Each student represents an individual lab and the class group represents the peer group of labs performing the same assay using the same method. Methods Using a manual BCG assay for serum albumin, normal and abnormal controls are run with a patient sample over 7 weeks. The QC results are assessed each week using calculated z-scores and both 2S & 3S control rules to determine whether a run is ‘in control’. At the end of the 7 weeks a completed LJ chart is assessed using the Westgard Multirules. Students investigate causes of error and the implications for both lab practice and patient care if runs are not ‘in control’. Twice in the 7 weeks two EQA samples (with target values unknown) are assayed alongside the weekly QC and patient samples. Results from each student are collated and form the basis of an EQA program. ALP are provided and students complete a Youden Plot, which is used to analyse the performance of each ‘lab’ and the method to identify bias. Students explore the concept of possible clinical implications of a biased method and address the actions that should be taken if a lab is not in consensus with the peer group. Conclusion This project is a model of ‘real world’ practice in which student demonstrate an understanding of the importance of QC procedures in a pathology laboratory, apply and interpret statistics and QC rules and charts, apply critical thinking and analytical skills to quality performance data to make recommendations for further practice and improve their technical competence and confidence.

Wife abuse : are we detecting it?

Our objective was to measure the prevalence of wife abuse in an urban teaching hospital family practice unit and compare this to the frequency of documentation by family physicians. A modified Conflicts Tactics Scale Questionnaire was administered to all female patients either married or common-law older than 16 years during the study period. The respective patients' charts were reviewed for documentation of wife abuse. Three hundred eighty-three charts were reviewed, and 275 surveys were completed (72% response rate). Physical and mental abuse were reported in 8% and 23%, respectively, of the respondents. Four percent of respondents had considered suicide. One percent of the charts had wife assault documented (p = 0.0001). Wife abuse is reported in at least 8% of our patients. There appear to be significant health risks to these women, including homicide, suicide, and rape. Family physician documentation of wife abuse was poor.

Supporting the development of inclusive products : the effects of everyday ambient illumination levels and contrast on older adults' near visual acuity

Current older adult capability data-sets fail to account for the effects of everyday environmental conditions on capability. This article details a study that investigates the effects of everyday ambient illumination conditions (overcast, 6000 lx; in-house lighting, 150 lx and street lighting, 7.5 lx) and contrast (90%, 70%, 50% and 30%) on the near visual acuity (VA) of older adults (n= 38, 65-87 years). VA was measured at a 1-m viewing distance using logarithm of minimum angle of resolution (LogMAR) acuity charts. Results from the study showed that for all contrast levels tested, VA decreased by 0.2 log units between the overcast and street lighting conditions. On average, in overcast conditions, participants could detect detail around 1.6 times smaller on the LogMAR charts compared with street lighting. VA also significantly decreased when contrast was reduced from 70% to 50%, and from 50% to 30% in each of the ambient illumination conditions. Practitioner summary: This article presents an experimental study that investigates the impact of everyday ambient illumination levels and contrast on older adults' VA. Results show that both factors have a significant effect on their VA. Findings suggest that environmental conditions need to be accounted for in older adult capability data-sets/designs.

The Politics of Sex Trafficking : a Moral Geography

This book offers a unique insight into the moral politics behind the making of human trafficking policy in Australia and the United States of America. As governments around the world rush to meet their international obligations to combat human trafficking, a heated debate has emerged over the rights, wrongs, and harms of prostitution, and its relationship to sex trafficking. The Politics of Sex Trafficking identifies and challenges intrinsic notions of moral harm that have pervaded trafficking discourse and resulted in a distinctly anti-prostitution agenda in trafficking policy in recent decades. Including rare interviews with key political actors, this book charts the competing perspectives of feminist, faith-based, and sex-worker activists, and their efforts to influence policy-makers. This critical account of the creation of anti-trafficking policy challenges the sex trafficking narrative dominant in US Congressional and Australian Parliamentary hearings, and demonstrates the power of a moral politics in shaping policy. This book will appeal to academics across the fields of criminology, criminal justice, law, human rights and gender studies, as well as policy-makers.

Constitutional Law

"This book systematically explores and clarifies the complexities of Austrealian Constitutional law and provides valuable critical analysis suitable for students, academics and government departments." -- book cover "Constitutional Law examines the foundational principles and concepts of this area of law. Written by practicing lawyers and lecturers in the subject, this book aims to provide an accessible yet comprehensive introductory text for Australian students. In eight parts this book systematically explores and clarifies the complexities of Australian Constitutional law and provides valuable critical analysis suitable for students, academics and government departments. An excellent resource for law students, Constitutional Law provides visual summaries in the form of flow charts, and each chapter includes key concepts and end-of-chapter discussion questions, further reading and useful websites and links. It also introduces students to key examinable areas, legal style essays, problems and assessment." -- publisher website

Queer criminology, critique, and the "art of not being governed"

This article builds on previous work that argues that a useful path for a ‘‘queer/ed criminology’’ to follow is one that takes ‘‘queer’’ to denote a position. It suggests that one way of developing such an approach is to adopt a particular understanding of critique—specifically one that draws from Michel Foucault’s view of critique as ‘‘the art of not being governed.’’ It then charts some of the possible directions for such a ‘‘queer/ed criminology.’’ While such an approach to critique has previously been discussed within critical criminologies, this article suggests that it is useful for queer criminologists to explore the opportunities that it affords, particularly in order to better appreciate how ‘‘queer/ed criminology’’ might connect to, draw from, or push against other currents among critical criminologies, and help to delineate the unique contribution that this kind of ‘‘queer/ed criminology’’ might make.

An audit of first-aid treatment of pediatric burns patients and their clinical outcome

This study describes the first aid used and clinical outcomes of all patients who presented to the Royal Children's Hospital, Brisbane, Australia in 2005 with an acute burn injury. A retrospective audit was performed with the charts of 459 patients and information concerning burn injury, first-aid treatment, and clinical outcomes was collected. First aid was used on 86.1% of patients, with 8.7% receiving no first aid and unknown treatment in 5.2% of cases. A majority of patients had cold water as first aid (80.2%), however, only 12.1% applied the cold water for the recommended 20 minutes or longer. Recommended first aid (cold water for >or=20 minutes) was associated with significantly reduced reepithelialization time for children with contact injuries (P=.011). Superficial depth burns were significantly more likely to be associated with the use of recommended first aid (P=.03). Suboptimal treatment was more common for children younger than 3.5 years (P<.001) and for children with friction burns. This report is one of the few publications to relate first-aid treatment to clinical outcomes. Some positive clinical outcomes were associated with recommended first-aid use; however, wound outcomes were more strongly associated with burn depth and mechanism of injury. There is also a need for more public awareness of recommended first-aid treatment.

Perioperative medication management: expanding the role of the preadmission clinic pharmacist in a single centre, randomised controlled trial of collaborative prescribing

Objectives Current evidence to support non-medical prescribing is predominantly qualitative, with little evaluation of accuracy, safety and appropriateness. Our aim was to evaluate a new model of service for the Australia healthcare system, of inpatient medication prescribing by a pharmacist in an elective surgery preadmission clinic (PAC) against usual care, using an endorsed performance framework. Design Single centre, randomised controlled, two-arm trial. Setting Elective surgery PAC in a Brisbane-based tertiary hospital. Participants 400 adults scheduled for elective surgery were randomised to intervention or control. Intervention A pharmacist generated the inpatient medication chart to reflect the patient's regular medication, made a plan for medication perioperatively and prescribed venous thromboembolism (VTE) prophylaxis. In the control arm, the medication chart was generated by the Resident Medical Officers. Outcome measures Primary outcome was frequency of omissions and prescribing errors when compared against the medication history. The clinical significance of omissions was also analysed. Secondary outcome was appropriateness of VTE prophylaxis prescribing. Results There were significantly less unintended omissions of medications: 11 of 887 (1.2%) intervention orders compared with 383 of 1217 (31.5%) control (p<0.001). There were significantly less prescribing errors involving selection of drug, dose or frequency: 2 in 857 (0.2%) intervention orders compared with 51 in 807 (6.3%) control (p<0.001). Orders with at least one component of the prescription missing, incorrect or unclear occurred in 208 of 904 (23%) intervention orders and 445 of 1034 (43%) controls (p<0.001). VTE prophylaxis on admission to the ward was appropriate in 93% of intervention patients and 90% controls (p=0.29). Conclusions Medication charts in the intervention arm contained fewer clinically significant omissions, and prescribing errors, when compared with controls. There was no difference in appropriateness of VTE prophylaxis on admission between the two groups.

Lifestyle Journalism

Lifestyle journalism has experienced enormous growth in the media over the past two decades, but scholars in the fields of journalism and communication studies have so far paid relatively little attention to a field that is still sometimes seen as “not real journalism”. There is now an urgent need for in-depth exploration and contextualisation of this field, with its increasing relevance for 21st century consumer cultures. For the first time, this book presents a wide range of studies which have engaged with the field of lifestyle journalism in order to outline the various political, economic, social and cultural tensions within it. Taking a comparative view, the collection includes studies covering four continents, including countries such as Australia, China, Norway, Denmark, Singapore, the UK and the USA. While keeping the broader lifestyle field in mind, the chapters focus on a variety of sub-fields such as travel, music, food, health, fashion and personal technology journalism. This volume provides a fascinating account of the different facets of lifestyle journalism, and charts the way forward for a more sustained analysis of the field. This book was originally published as a special issue of Journalism Practice.

Cartographic Strategies of Postmodernity : the Figure of the Map in Contemporary Theory and Fiction

The last fifty years have witnessed the growing pervasiveness of the figure of the map in critical, theoretical, and fictional discourse. References to mapping and cartography are endemic in poststructuralist theory, and, similarly, geographically and culturally diverse authors of twentieth-century fiction seem fixated upon mapping. While the map metaphor has been employed for centuries to highlight issues of textual representation and epistemology, the map metaphor itself has undergone a transformation in the postmodern era. This metamorphosis draws together poststructuralist conceptualizations of epistemology, textuality, cartography, and metaphor, and signals a shift away from modernist preoccupations with temporality and objectivity to a postmodern pragmatics of spatiality and subjectivity. Cartographic Strategies of Postmodernity charts this metamorphosis of cartographic metaphor, and argues that the ongoing reworking of the map metaphor renders it a formative and performative metaphor of postmodernity.

Physical activity in overweight and nonoverweight preschool children

OBJECTIVE To compare the physical activity levels of overweight and non overweight 3- to 5-y-old children while attending preschool. A secondary aim was to evaluate weight-related differences in hypothesized parental determinants of child physical activity behavior. DESIGN Cross-sectional study. SUBJECTS A total of 245, 3- to 5-y-olds ( 127 girls, 118 boys) and their parent(s) ( 242 mothers, 173 fathers) recruited from nine preschools. Overweight status determined using the age- and sex-specific 85th percentile for body mass index (BMI) from CDC Growth Charts. MEASUREMENTS Physical activity during the preschool day was assessed on multiple days via two independent objective measures-direct observation using the observation system for recording activity in preschools (OSRAP) and real-time accelerometry using the MTI/CSA 7164 accelerometer. Parents completed a take-home survey assessing sociodemographic information, parental height and weight, modeling of physical activity, support for physical activity, active toys and sporting equipment at home, child's television watching, frequency of park visitation, and perceptions of child competence. RESULTS Overweight boys were significantly less active than their nonoverweight peers during the preschool day. No significant differences were observed in girls. Despite a strong association between childhood overweight status and parental obesity, no significant differences were observed for the hypothesized parental influences on physical activity behavior. CONCLUSIONS Our results suggest that a significant proportion of overweight children may be at increased risk for further gains in adiposity because of low levels of physical activity during the preschool day.

Physical activity correlates in adolescent girls who differ by weight status

Objective This study compared correlates of physical activity (PA) among African-American and white girls of different weight groups to guide future interventions. Research Methods and Procedures Participants were 1015 girls (mean age, 14.6 years; 45% African-American) from 12 high schools in South Carolina who served as control subjects for a school-based intervention. Post-intervention measures obtained at the end of ninth grade were used. PA was measured using the Three-Day PA Recall, and a questionnaire measured social-cognitive and environmental variables thought to mediate PA. Height and weight were measured, and BMI was calculated. Girls were stratified by race and categorized into three groups, based on BMI percentiles for girls from CDC growth charts: normal (BMI < 85th percentile), at risk (BMI, 85th to 94th percentile), and overweight (BMI ≥ 95th percentile). Girls were further divided into active and low-active groups, based on a vigorous PA standard (average of one or more 30-minute blocks per day per 3-day period). Mixed-model ANOVA was used to compare factors among groups, treating school as a random effect Results None of the social-cognitive or environmental variables differed by weight status for African-American or white girls. Perceived behavioral control and sports team participation were significantly higher in girls who were more active, regardless of weight or race group. In general, social-cognitive variables seem to be more related to activity in white girls, whereas environmental factors seem more related to activity in African-American girls. Discussion PA interventions should be tailored to the unique needs of girls based on PA levels and race, rather than on weight status alone.