Submission to KPMG review of the Federal Government Initiative to “analyse dementia program and services funded by the Department of Social Services"

The comments I make are based on my nearly twenty years involvement in the dementia cause at both a national and international level. In preparation, I read two papers namely the Ministerial Dementia Forum – Option Paper produced by KPMG Management Consultants (2014) and Analysis of Dementia Programmes and Services Funded by the Department of Social Services: Conversation Starter prepared by KPMG as a preparation document for those attending a workshop in Brisbane on April 22nd 2015. Dementia is a complex “syndrome” and as is often said, “when you meet one person with dementia, you have met one” meaning that no two persons with dementia are the same. Even in dementia care, Australia is a “lucky country” and there is much to be said for the quality and diversity of dementia care available for people living with dementia. Despite this, I agree with the many views expressed in the material I read that there is scope for improvement, especially in the way that services are coordinated. In saying that, I do not purport to have all the solutions nor claim to have the knowledge required to comment on all the programs covered by this review. If I appear to be a “biased” advocate for Alzheimer’s Australia across the States and Territories, it is because I have seen constant evidence of ordinary people doing extraordinary things with inadequate resources. Dementia care is not cheap and if those funding dementia services are primarily only interested in economic outcomes and benefits, the real purpose of this consultation will be defeated. In addition, nowhere in the material I have read is there any recognition that in many instances program funding is a complex mix of government (at all levels) and private funding. This makes reviewing those programs more complex and less able to be coordinated at a Departmental level. It goes without saying therefore that the Federal Government is not” the only player in this game”. Of all those participating in this review, Alzheimer’s Australia is best placed to comment on programs as it is more connected to people living with dementia and has probably the best record of consulting with them. It would appear however that their role has been reduced to that of a “bit player”. Without wanting to be critical, the Forum Report which deals with the comments made at a gathering of 70 individuals and organisations, only three (3) or 4.28% were actual carers of people living with dementia. Even if it is argued that a number of organisations present represented consumers, the percentage goes up only marginally to 8.57% which is hardly an endorsement of the forum being “consumer driven”. The predominance of those present were service providers, each with their own agenda and each seeking advantage for their “business”. The final point I want to make before commenting on more specific, program related issues, is that many programs being reviewed have a much longer history than is reflected in the material I have read. Their growth and development was pioneered by Alzheimer’s Australia organisations across the country often with no government funding. Attempts to bring about better coordination of programs were often at the behest of Alzheimer’s Australia but in the main were ignored. The opportunity to now put this right is long overdue.

Costing the Australian National Hand Hygiene Initiative

Background The Australian National Hand Hygiene Initiative (NHHI) is a major patient safety programme co-ordinated by Hand Hygiene Australia (HHA) and funded by the Australian Commission for Safety and Quality in Health Care. The annual costs of running this programme need to be understood to know the cost-effectiveness of a decision to sustain it as part of health services. Aim To estimate the annual health services cost of running the NHHI; the set-up costs are excluded. Methods A health services perspective was adopted for the costing and collected data from the 50 largest public hospitals in Australia that implemented the initiative, covering all states and territories. The costs of HHA, the costs to the state-level infection-prevention groups, the costs incurred by each acute hospital, and the costs for additional alcohol-based hand rub are all included. Findings The programme cost AU$5.56 million each year (US$5.76, £3.63 million). Most of the cost is incurred at the hospital level (65%) and arose from the extra time taken for auditing hand hygiene compliance and doing education and training. On average, each infection control practitioner spent 5 h per week on the NHHI, and the running cost per annum to their hospital was approximately AU$120,000 in 2012 (US$124,000, £78,000). Conclusion Good estimates of the total costs of this programme are fundamental to understanding the cost-effectiveness of implementing the NHHI. This paper reports transparent costing methods, and the results include their uncertainty.

Evidence-based recommendations for the diagnosis of ankylosing spondylitis: Results from the Australian 3E initiative in rheumatology

• As part of the 3E program, we conducted a systematic literature review and gathered consensus from 23 practising Australian rheumatologists to develop guidelines for early identification of ankylosing spondylitis and specialist referral. • In three rounds of break-out sessions followed by discussion and voting, the specialist panel addressed three questions related to diagnosis of ankylosing spondylitis: In individuals with back pain, what are the early clinical features that suggest ankylosing spondylitis? How useful is imaging in identifying early ankylosing spondylitis? Based on which clinical features should a general practitioner refer a patient to a rheumatologist for further evaluation? • The panel agreed on six recommendations related to the three questions: 1a. Early clinical features to suggest ankylosing spondylitis include inflammatory back pain and age at symptom onset < 45 years. 1b. The absence of symptomatic response to an appropriate course of non-steroidal anti-inflammatory drugs makes the diagnosis of ankylosing spondylitis less likely. 1c. Raised inflammatory markers are supportive, but their absence does not rule out the diagnosis of ankylosing spondylitis. 2a. Despite low sensitivity to detect changes of early ankylosing spondylitis, plain radiographs of the pelvis and spine are appropriate initial imaging techniques. 2b. Magnetic resonance imaging is a useful imaging modality for detecting early changes of ankylosing spondylitis. 3. Individuals with inflammatory back pain should be referred to a rheumatologist for further evaluation. • Effective dissemination and implementation of these recommendations are important to standardise the approach to early diagnosis of ankylosing spondylitis.

Evidence-based recommendations for the monitoring and treatment of ankylosing spondylitis: Results from the Australian 3E initiative in rheumatology

Aim: To develop a set of Australian recommendations for the monitoring and treatment of ankylosing spondylitis (AS) through systematic literature review combined with the opinion of practicing rheumatologists. Methods: A set of eight questions, four in each domain of monitoring and treatment, were formulated by voting and the Delphi method. The results of a systematic literature review addressing each question were presented to the 23 participants of the Australian 3E meeting. All participants were clinical rheumatologists experienced in the daily management of AS. Results: After three rounds of breakout sessions to discuss the findings of the literature review, a set of recommendations was finalized after discussion and voting. The category of evidence and strength of recommendation were determined for each proposal. The level of agreement among participants was excellent (mean 84%, range 64-100%). Conclusions: The 12 recommendations developed from evidence and expert opinion provide guidance for the daily management of AS patients. For most recommendations, we found a paucity of supportive evidence in the literature highlighting the need for additional clinical studies.

Understanding the determinants of Australian hospital nurses' hand hygiene decisions following the implementation of a national hand hygiene initiative

Hand hygiene is the primary measure in hospitals to reduce the spread of infections, with nurses experiencing the greatest frequency of patient contact. The ‘5 critical moments’ of hand hygiene initiative has been implemented in hospitals across Australia, accompanied by awareness-raising, staff training and auditing. The aim of this study was to understand the determinants of nurses’ hand hygiene decisions, using an extension of a common health decision-making model, the theory of planned behaviour (TPB), to inform future health education strategies to increase compliance. Nurses from 50 Australian hospitals (n = 2378) completed standard TPB measures (attitude, subjective norm, perceived behavioural control [PBC], intention) and the extended variables of group norm, risk perceptions (susceptibility, severity) and knowledge (subjective, objective) at Time 1, while a sub-sample (n = 797) reported their hand hygiene behaviour 2 weeks later. Regression analyses identified subjective norm, PBC, group norm, subjective knowledge and risk susceptibility as the significant predictors of nurses’ hand hygiene intentions, with intention and PBC predicting their compliance behaviour. Rather than targeting attitudes which are already very favourable among nurses, health education strategies should focus on normative influences and perceptions of control and risk in efforts to encourage hand hygiene adherence.

Mapping quantitative trait loci for resistance to Pratylenchus thornei from synthetic hexaploid wheat in the International Triticeae Mapping Initiative (ITMI) population

Root-lesion nematode (Pratylenchus thornei) is a serious pathogen of wheat in many countries. The International Triticeae Mapping Initiative (ITMI) population of recombinant inbred lines (RILs) was assessed for resistance to P. thornei to determine the chromosome locations of the resistance genes. The ITMI population is derived from a cross between the resistant synthetic hexaploid wheat W-7984 and a susceptible bread wheat cultivar Opata 85. Two years of phenotypic data for resistance to P. thornei were obtained in replicated glasshouse trials. Quantitative trait locus (QTL) analysis was performed using available segregation and map data for 114 RILs. A QTL on chromosome 6DS showed consistent effects for reduced nematode numbers (partial resistance) across years and accounted for 11% and 23% of the phenotypic variation. A second QTL for P. thornei resistance on chromosome 2BS accounted for an additional 19% and 5%. Restriction fragment length polymorphism (RFLP) and simple sequence repeat (SSR) markers associated with the QTLs are physically located in regions rich in major genes at the distal ends of the short chromosome arms of 6D and 2B. SSR markers with potential for marker-assisted selection of P. thornei resistance effective in different genetic backgrounds have been identified.

Tertiary Treatment of Ayr Municipal Wastewater using Bioremediation: A Pilot-Scale Study. A Report Prepared for the Burdekin Shire Council and the Burdekin Rangeland Reef Initiative

This joint DPI/Burdekin Shire Council project assessed the efficacy of a pilot-scale biological remediation system to recover Nitrogen (N) and Phosphorous (P) nutrients from secondary treated municipal wastewater at the Ayr Sewage Treatment Plant. Additionally, this study considered potential commercial uses for by-products from the treatment system. Knowledge gained from this study can provide directions for implementing a larger-scale final effluent treatment protocol on site at the Ayr plant. Trials were conducted over 10 months and assessed nutrient removal from duckweed-based treatments and an algae/fish treatment – both as sequential and as stand-alone treatment systems. A 42.3% reduction in Total N was found through the sequential treatment system (duckweed followed by algae/fish treatment) after 6.6 days Effluent Retention Time (E.R.T.). However, duckweed treatment was responsible for the majority of this nutrient recovery (7.8 times more effective than algae/fish treatment). Likewise, Total P reduction (15.75% reduction after 6.6 days E.R.T.) was twice as great in the duckweed treatment. A phytoplankton bloom, which developed in the algae/fish tanks, reduced nutrient recovery in this treatment. A second trial tested whether the addition of fish enhanced duckweed treatment by evaluating systems with and without fish. After four weeks operation, low DO under the duckweed blanket caused fish mortalities. Decomposition of these fish led to an additional organic load and this was reflected in a breakdown of nitrogen species that showed an increase in organic nitrogen. However, the Dissolved Inorganic Nitrogen (DIN: ammonia, nitrite and nitrate) removal was similar between treatments with and without fish (57% and 59% DIN removal from incoming, respectively). Overall, three effluent residence times were evaluated using duckweed-based treatments; i.e. 3.5 days, 5.5 days and 10.4 days. Total N removal was 37.5%, 55.7% and 70.3%, respectively. The 10.4-day E.R.T. trial, however, was evaluated by sequential nutrient removal through the duckweed-minus-fish treatment followed by the duckweed-plus-fish treatment. Therefore, the 70.3% Total N removal was lower than could have been achieved at this retention time due to the abovementioned fish mortalities. Phosphorous removal from duckweed treatments was greatest after 10.4-days E.R.T. (13.6%). Plant uptake was considered the most important mechanism for this P removal since there was no clay substrate in the plastic tanks that could have contributed to P absorption as part of the natural phosphorous cycle. Duckweed inhibited phytoplankton production (therefore reducing T.S.S) and maintained pH close to neutral. DO beneath the duckweed blanket fell to below 1ppm; however, this did not limit plant production. If fish are to be used as part of the duckweed treatment, air-uplifts can be installed that maintain DO levels without disturbing surface waters. Duckweed grown in the treatments doubled its biomass on average every 5.7 days. On a per-surface area basis, 1.23kg/m2 was harvested weekly. Moisture content of duckweed was 92%, equating to a total dry weight harvest of 0.098kg/m2/week. Nutrient analysis of dried duckweed gave an N content of 6.67% and a P content of 1.27%. According to semi-quantitative analyses, harvested duckweed contained no residual elements from the effluent stream that were greater than ANZECC toxicant guidelines proposed for aquaculture. In addition, jade perch, a local aquaculture species, actively consumed and gained weight on harvested duckweed, suggesting potential for large-scale fish production using by-products from the effluent treatment process. This suggests that a duckweed-based system may be one viable option for tertiary treatment of Ayr municipal wastewater. The tertiary detention lagoon proposed by the Burdekin Shire Council, consisting of six bays approximately 290 x 35 metres (x 1.5 metres deep), would be suitable for duckweed culture with minor modification to facilitate the efficient distribution of duckweed plants across the entire available growing surface (such as floating containment grids). The effluent residence time resulting from this proposed configuration (~30 days) should be adequate to recover most effluent nutrients (certainly N) based on the current trial. Duckweed harvest techniques on this scale, however, need to be further investigated. Based on duckweed production in the current trial (1.23kg/m2/week), a weekly harvest of approximately 75 000kg (wet weight) could be expected from the proposed lagoon configuration under full duckweed production. A benefit of the proposed multi-bay lagoon is that full lagoon production of duckweed may not be needed to restore effluent to a desirable standard under the present nutrient load, and duckweed treatment may be restricted to certain bays. Restored effluent could be released without risk of contaminating the receiving waterway with duckweed by evacuating water through an internal standpipe located mid-way in the water column.

Wastewater remediation options for prawn farms - Aquaculture Industry Development Initiative 2002-04.

There are many potential bioremediation approaches that may be suitable for prawn farms in Queensland. Although most share generally accepted bioremediation principles, advocacy for different methods tends to vary widely. This diversity of approach is particularly driven by the availability and knowledge of functional species at different localities around the world. In Australia, little is known about the abilities of many native species in this regard, and translocation and biosecurity issues prevent the use of exotic species that have shown potential in other countries. Species selected must be tolerant of eutrophic conditions and ecological shifts, because prawn pond nutrient levels and pathways can vary with different assemblages of autotrophic and heterotrophic organisms. Generally, they would be included in a constructed ecosystem because of their functional contributions to nutrient cycling and uptake, and to create nutrient sinks in forms of harvestable biomass. Wide salinity, temperature and water quality tolerances are also valuable attributes for selected species due to the sometimes-pronounced effects of environmental extremes, and to provide over-wintering options and adequate safety margins in avoiding mass mortalities. To practically achieve these bioremediation polycultures on a large scale, and in concert with the operations of a prawn farm, methods involving seed production, stock management, and a range of other farm engineering and product handling systems need to be reliably achievable and economically viable. Research funding provided by the Queensland Government through the Aquaculture Industry Development Initiative (AIDI) 2002-04 has enabled a number of technical studies into biological systems to treat prawn farm effluent for recirculation and improved environmental sustainability. AIDI bioremediation research in southern Queensland was based at the Bribie Island Aquaculture Research Centre (BIARC), and was conducted in conjunction with AIDI genetics and selection research, and a Natural Heritage Trust (NHT) funded program (Coast and Clean Seas Project No.717757). This report compilation provides a summary of some of the work conducted within these programs.

ACIAR Pacific Agribusiness Research for Development Initiative (PARDI)

PARDI provides a platform for stronger economic growth of Pacific island countries. The initiative aims to substantially improve the livelihoods of smallholder farmers in the Pacific. Benefit to Queensland includes: 1) looking at supply chain (value chain) innovations for tropical horticultural commodities in both Queensland and the South Pacific to maintain competitiveness. 2) undertaking research on a product called canarium nut which is grown in the Solomon Islands. It is a new potential high value speciality product (similar to macadamia) in which macadamia industry partners are participating. 3) involvement in specific targeted supply chain business improvement with industry partners.

Australian Herbicide Resistance Initiative (phase 4)

A national focus on strategic and applied research to minimise herbicide resistance in Australian cropping.

Building capacity for cancer nursing research and evidence based practice: The cancer nursing professorial precinct initiative

The demand for cancer care is growing due to the increasing incidence of cancer and the improved effectiveness of cancer treatments. It is important that cancer nurses continue to improve patient outcomes through research and the use of evidence in practice development, education and policy. This paper describes a case report of a collaborative academic healthcare model that creates capacity for cancer nursing research and evidence-based practice. The Cancer Nursing Professorial Precinct is a strategic collaboration between the Royal Brisbane and Women’s Hospital (RBWH) and Queensland University of Technology (QUT), in Brisbane Australia. The outcomes of this initiative has been remarkable. The principles and strategies used in this initiative may be useful for cancer services in other countries.

The importance of modelling heterogeneity in complex disease: application to NIMH Schizophrenia Genetics Initiative data

As for other complex diseases, linkage analyses of schizophrenia (SZ) have produced evidence for numerous chromosomal regions, with inconsistent results reported across studies. The presence of locus heterogeneity appears likely and may reduce the power of linkage analyses if homogeneity is assumed. In addition, when multiple heterogeneous datasets are pooled, inter-sample variation in the proportion of linked families (alpha) may diminish the power of the pooled sample to detect susceptibility loci, in spite of the larger sample size obtained. We compare the significance of linkage findings obtained using allele-sharing LOD scores (LOD(exp))-which assume homogeneity-and heterogeneity LOD scores (HLOD) in European American and African American NIMH SZ families. We also pool these two samples and evaluate the relative power of the LOD(exp) and two different heterogeneity statistics. One of these (HLOD-P) estimates the heterogeneity parameter alpha only in aggregate data, while the second (HLOD-S) determines alpha separately for each sample. In separate and combined data, we show consistently improved performance of HLOD scores over LOD(exp). Notably, genome-wide significant evidence for linkage is obtained at chromosome 10p in the European American sample using a recessive HLOD score. When the two samples are combined, linkage at the 10p locus also achieves genome-wide significance under HLOD-S, but not HLOD-P. Using HLOD-S, improved evidence for linkage was also obtained for a previously reported region on chromosome 15q. In linkage analyses of complex disease, power may be maximised by routinely modelling locus heterogeneity within individual datasets, even when multiple datasets are combined to form larger samples.

Cost-effectiveness of a national initiative to improve hand hygiene compliance using the outcome of healthcare associated staphylococcus aureus bacteraemia

Background The objective is to estimate the incremental cost-effectiveness of the Australian National Hand Hygiene Inititiave implemented between 2009 and 2012 using healthcare associated Staphylococcus aureus bacteraemia as the outcome. Baseline comparators are the eight existing state and territory hand hygiene programmes. The setting is the Australian public healthcare system and 1,294,656 admissions from the 50 largest Australian hospitals are included. Methods The design is a cost-effectiveness modelling study using a before and after quasi-experimental design. The primary outcome is cost per life year saved from reduced cases of healthcare associated Staphylococcus aureus bacteraemia, with cost estimated by the annual on-going maintenance costs less the costs saved from fewer infections. Data were harvested from existing sources or were collected prospectively and the time horizon for the model was 12 months, 2011–2012. Findings No useable pre-implementation Staphylococcus aureus bacteraemia data were made available from the 11 study hospitals in Victoria or the single hospital in Northern Territory leaving 38 hospitals among six states and territories available for cost-effectiveness analyses. Total annual costs increased by $2,851,475 for a return of 96 years of life giving an incremental cost-effectiveness ratio (ICER) of $29,700 per life year gained. Probabilistic sensitivity analysis revealed a 100% chance the initiative was cost effective in the Australian Capital Territory and Queensland, with ICERs of $1,030 and $8,988 respectively. There was an 81% chance it was cost effective in New South Wales with an ICER of $33,353, a 26% chance for South Australia with an ICER of $64,729 and a 1% chance for Tasmania and Western Australia. The 12 hospitals in Victoria and the Northern Territory incur annual on-going maintenance costs of $1.51M; no information was available to describe cost savings or health benefits. Conclusions The Australian National Hand Hygiene Initiative was cost-effective against an Australian threshold of $42,000 per life year gained. The return on investment varied among the states and territories of Australia.

The Queensland Mango Genomics Initiative

Mango is an important industry for Queensland, Australia, with an annual value exceeding $80 million. The Kensington Pride cultivar, prized by consumers for desirable taste and colour characteristics, commands 60% of the domestic market though this market share has declined in recent years as new varieties, such as Calypso™, get established with consumers. In 2005, the Queensland Government's Department of Agriculture and Fisheries commenced the Mango Genomics Initiative. This project brought together multidisciplinary teams of breeders, pathologists, sensory scientists, flavour chemists and molecular biologists to develop a suite of tools and inter-related data sets to support the accelerated development of new commercial mango varieties. An overview of the Mango Genomics Initiative will be presented here culminating in the generation of a draft Kensington Pride mango genome sequence.