Utility of routine data sources for feedback on the quality of cancer care: an assessment based on clinical practice guidelines

Background Not all cancer patients receive state-of-the-art care and providing regular feedback to clinicians might reduce this problem. The purpose of this study was to assess the utility of various data sources in providing feedback on the quality of cancer care. Methods Published clinical practice guidelines were used to obtain a list of processes-of-care of interest to clinicians. These were assigned to one of four data categories according to their availability and the marginal cost of using them for feedback. Results Only 8 (3%) of 243 processes-of-care could be measured using population-based registry or administrative inpatient data (lowest cost). A further 119 (49%) could be measured using a core clinical registry, which contains information on important prognostic factors (e.g., clinical stage, physiological reserve, hormone-receptor status). Another 88 (36%) required an expanded clinical registry or medical record review; mainly because they concerned long-term management of disease progression (recurrences and metastases) and 28 (11.5%) required patient interview or audio-taping of consultations because they involved information sharing between clinician and patient. Conclusion The advantages of population-based cancer registries and administrative inpatient data are wide coverage and low cost. The disadvantage is that they currently contain information on only a few processes-of-care. In most jurisdictions, clinical cancer registries, which can be used to report on many more processes-of-care, do not cover smaller hospitals. If we are to provide feedback about all patients, not just those in larger academic hospitals with the most developed data systems, then we need to develop sustainable population-based data systems that capture information on prognostic factors at the time of initial diagnosis and information on management of disease progression.

The Chronic Heart-Failure Assistance by Telephone (CHAT) Study: Assessment of Telephone Support for Vulnerable Patients with Chronic Disease

Aim: To determine whether telephone support using an evidence-based protocol for chronic heart failure (CHF) management will improve patient outcomes and will reduce hospital readmission rates in patients without access to hospital-based management programs. Methods: The rationale and protocol for a cluster-design randomised controlled trial (RCT) of a semi-automated telephone intervention for the management of CHF, the Chronic Heart-failure Assistance by Telephone (CHAT) Study is described. Care is coordinated by trained cardiac nurses located in Heartline, the national call center of the National Heart Foundation of Australia in partnership with patients’ general practitioners (GPs). Conclusions: The CHAT Study model represents a potentially cost-effective and accessible model for the Australian health system in caring for CHF patients in rural and remote areas. The system of care could also be readily adapted for a range of chronic diseases and health systems. Key words: chronic disease management; chronic heart failure; integrated health care systems; nursing care, rural health services; telemedicine; telenursing

Assessment for learning - Why the theory needs the practice

Assessment for Learning is a pedagogical practice with anticipated gains of increased student motivation, mastery and autonomy as learners develop their capacity to monitor and plan their own learning progress. Assessment for Learning (AfL) differs from Assessment of learning in its timing, occurring within the regular flow of learning rather than end point, in its purpose of improving student learning rather than summative grading and in the ownership of the learning where the student voice is heard in judging quality. Since Black and Wiliam (1998) highlighted the achievement gains that AfL practices seem to bring to all learners in classrooms, it has become part of current educational policy discourse in Australia, yet teacher adoption of the practices is not a straightforward implementation of techniques within an existing classroom repertoire. As can be seen from the following meta-analysis, recent research highlights a more complex interrelationship between teacher and student beliefs about learning and assessment, and the social and cultural interactions in and contexts of the classroom. More research is needed from a sociocultural perspective that allows meaning to emerge from practice. Before another policy push, we need to understand better the many factors within the assessment relationship. We need to hear from teachers and students through long-term AfL case studies both to inform AfL theory and to shed light on the complexities of pedagogical change for enhancing learner autonomy.

Towards learner autonomy : an assessment for learning approach

Using Assessment for Learning (AfL) may develop learner autonomy however, very often AfL is reduced to a set of strategies that do not always achieve the desired outcome. This research adopted a different approach that examined AfL as a cultural practice, situated within influential social relationships that shape learner identity. The study addressed the question “What are the qualities of the teacher-student relationship that support student learning autonomy in an AfL context?” Three case studies of the interactions of Queensland middle school teachers and their classes of Year 7, 8 and 9 were developed over one year. Data were collected from field notes and video recordings of classroom interactions and individual and focus group interviews with teachers and students. The analysis began with a close look at the field data. Interpretations that emerged from a sociocultural theoretical understanding were helpful in informing the process of analysis. Themes and patterns of interrelationships were identified through thematic coding using a constant comparative approach. Validation was achieved through methodological triangulation. Four findings that inform an understanding of AfL and the development of learner autonomy emerged. Firstly, autonomy is theorised as a context-specific identity mediated through the teacher-student relationship. Secondly, it was observed that learners negotiated their identities as knowers through AfL practices in various tacit, explicit, group and individual ways in a ‘generative dance’ of knowing in action (Cook & Brown, 2005). Thirdly, teachers and learners negotiated their participation by drawing from identities in multiple communities of practice. Finally it is proposed that a new participative identity or narrative for assessment is needed. This study contributes to understandings about teacher AfL practices that can help build teacher assessment capacity. Importantly, autonomy is understood as an identity that is available to all learners. This study is also significant as it affirms the importance of teacher assessment to support learners in developing autonomy, a focus that challenges the singular assessment policy focus on measuring performance. Finally this study contributes to a sociocultural theoretical understanding of AfL.

Assessment policy change in relation to English language teaching and learning in China : a study of perspectives from two universities

In response to concerns about the quality of English Language Learning (ELL) education at tertiary level, the Chinese Ministry of Education (CMoE) launched the College English Reform Program (CERP) in 2004. By means of a press release (CMoE, 2005) and a guideline document titled College English Curriculum Requirements (CECR) (CMoE, 2007), the CERP proposed two major changes to the College English assessment policy, which were: (1) the shift to optional status for the compulsory external test, the College English Test Band 4 (CET4); and (2) the incorporation of formative assessment into the existing summative assessment framework. This study investigated the interactions between the College English assessment policy change, the theoretical underpinnings, and the assessment practices within two Chinese universities (one Key University and one Non-Key University). It adopted a sociocultural theoretical perspective to examine the implementation process as experienced by local actors of institutional and classroom levels. Systematic data analysis using a constant comparative method (Merriam, 1998) revealed that contextual factors and implementation issues did not lead to significant differences in the two cases. Lack of training in assessment and the sociocultural factors such as the traditional emphasis on the product of learning and hierarchical teacher/students relationship are decisive and responsible for the limited effect of the reform.

Continuous and pedagogically sound assessment : A new economy of power relations in Australian Law schools

In recent decades, assessment practices within Australian law schools have moved from the overwhelming use of end-of-year closed-book examinations to an increase in the use of a wider range of techniques. This shift is often characterised as providing a ‘better’ learning environment for students, contributing more positively to their own ‘personal development’ within higher education, or, considered along the lines of critical legal thought, as ‘liberating’ them from the ‘conservatising’ and ‘indoctrinating’ effects of the power relations that operate in law schools. This paper seeks to render problematic such liberal-progressive narratives about these changes to law school assessment practices. It will do so by utilising the work of French historian and philosopher Michel Foucault on power, arguing that the current range of assessment techniques demonstrates a shift in the ‘economy’ of power relations within the law school. Rather than ‘liberating’ students from relations of power, these practices actually extend the power relations through which students are governed. This analysis is intended to inform legal education research and assessment practice by providing a far more nuanced conceptual framework than one that seeks to ‘free’ law students from these ‘repressive’ practices, or hopes to ‘objectively’ contribute to their ‘personal development’.

Preliminary development of a sewerage infrastructure buffer assessment tool for engineering risk and strategic land use planning

Urban expansion continues to encroach on once isolated sewerage infrastructure. In this context,legislation and guidelines provide limited direction to the amenity allocation of appropriate buffer distances for land use planners and infrastructure providers. Topography, wind speed and direction,temperature, humidity, existing land uses and vegetation profiles are some of the factors that require investigation in analytically determining a basis for buffer separations. This paper discusses the compilation and analysis of six years of Logan sewerage odour complaint data. Graphically,relationships between the complaints, topographical features and meteorological data are presented. Application of a buffer sizing process could assist planners and infrastructure designers alike, whilst automatically providing extra green spaces. Establishing a justifiable criterion for buffer zone allocations can only assist in promoting manageable growth for healthier and more sustainable communities.

Assessment of retinal structure and visual function in association with diabetic peripheral neuropathy

Diabetes is an increasingly prevalent disease worldwide. Providing early management of the complications can prevent morbidity and mortality in this population. Peripheral neuropathy, a significant complication of diabetes, is the major cause of foot ulceration and amputation in diabetes. Delay in attending to complication of the disease contributes to significant medical expenses for diabetic patients and the community. Early structural changes to the neural components of the retina have been demonstrated to occur prior to the clinically visible retinal vasculature complication of diabetic retinopathy. Additionally visual functionloss has been shown to exist before the ophthalmoscopic manifestations of vasculature damage. The purpose of this thesis was to evaluate the relationship between diabetic peripheral neuropathy and both retinal structure and visual function. The key question was whether diabetic peripheral neuropathy is the potential underlying factor responsible for retinal anatomical change and visual functional loss in people with diabetes. This study was conducted on a cohort with type 2 diabetes. Retinal nerve fibre layer thickness was assessed by means of Optical Coherence Tomography (OCT). Visual function was assessed using two different methods; Standard Automated Perimetry (SAP) and flicker perimetry were performed within the central 30 degrees of fixation. The level of diabetic peripheral neuropathy (DPN) was assessed using two techniques - Quantitative Sensory Testing and Neuropathy Disability Score (NDS). These techniques are known to be capable of detecting DPN at very early stages. NDS has also been shown as a gold standard for detecting 'risk of foot ulceration'. Findings reported in this thesis showed that RNFL thickness, particularly in the inferior quadrant, has a significant association with severity of DPN when the condition has been assessed using NDS. More specifically it was observed that inferior RNFL thickness has the ability to differentiate individuals who are at higher risk of foot ulceration from those who are at lower risk, indicating that RNFL thickness can predict late-staged DPN. Investigating the association between RNFL and QST did not show any meaningful interaction, which indicates that RNFL thickness for this cohort was not as predictive of neuropathy status as NDS. In both of these studies, control participants did not have different results from the type 2 cohort who did not DPN suggesting that RNFL thickness is not a marker for diagnosing DPN at early stages. The latter finding also indicated that diabetes per se, is unlikely to affect the RNFL thickness. Visual function as measured by SAP and flicker perimetry was found to be associated with severity of peripheral neuropathy as measured by NDS. These findings were also capable of differentiating individuals at higher risk of foot ulceration; however, visual function also proved not to be a maker for early diagnosis of DPN. It was found that neither SAP, nor flicker sensitivity have meaningful associations with DPN when neuropathy status was measured using QST. Importantly diabetic retinopathy did not explain any of the findings in these experiments. The work described here is valuable as no other research to date has investigated the association between diabetic peripheral neuropathy and either retinal structure or visual function.

Bioimpedance in the assessment of unilateral lymphedema of a limb: the optimal frequency

Background: Bioimpedance techniques provide a reliable method of assessing unilateral lymphedema in a clinical setting. Bioimpedance devices are traditionally used to assess body composition at a current frequency of 50 kHz. However, these devices are not transferable to the assessment of lymphedema, as the sensitivity of measuring the impedance of extracellular fluid is frequency dependent. It has previously been shown that the best frequency to detect extracellular fluid is 0 kHz (or DC). However, measurement at this frequency is not possible in practice due to the high skin impedance at DC, and an estimate is usually determined from low frequency measurements. This study investigated the efficacy of various low frequency ranges for the detection of lymphedema. Methods and Results: Limb impedance was measured at 256 frequencies between 3 kHz and 1000 kHz for a sample control population, arm lymphedema population, and leg lymphedema population. Limb impedance was measured using the ImpediMed SFB7 and ImpediMed L-Dex® U400 with equipotential electrode placement on the wrists and ankles. The contralateral limb impedance ratio for arms and legs was used to calculate a lymphedema index (L-Dex) at each measurement frequency. The standard deviation of the limb impedance ratio in a healthy control population has been shown to increase with frequency for both the arm and leg. Box and whisker plots of the spread of the control and lymphedema populations show that there exists good differentiation between the arm and leg L-Dex measured for lymphedema subjects and the arm and leg L-Dex measured for control subjects up to a frequency of about 30 kHz. Conclusions: It can be concluded that impedance measurements above a frequency of 30 kHz decrease sensitivity to extracellular fluid and are not reliable for early detection of lymphedema.