Drug administration guides in dysphagia

Aim: The aim of this evaluation was to evaluate the use of Individualised Medication Administration Guides (IMAGs) for patients with dysphagia on one stroke ward over a 6month period. Background: Patients with dysphagia (PWD) are more likely to suffer an administration error than patients without swallowing difficulties. To both standardise and improve medicines administration to patients with dysphagia I-MAGs were introduced on one stroke ward over a 6 month period. Methods: A software package supported with data on current national guidelines on the administration of medicines to PWD was designed by a specialised pharmacist in dysphagia to enable him to create individualised medication administration guides for patients with dysphagia which stated how each medicine should be optimally prepared and administered. On completion of the pilot service a questionnaire was given to all nurses, pharmacist and speech and language therapists who had experienced the I-MAGs. All the professionals received the same questionnaire but questions relevant only to their practice were added to the nurse’s questionnaire. Results: Of 26 Healthcare professionals (HCPs) approached, 19 returned completed questionnaires. Higher variability was found in the 13 responses from the nurse respondents than in the ones from the 3 pharmacist and the 3 SALTs. 8 (61%) of the nurses felt more confident in their practice when I-MAGs were in place. 10 (76%) of the nurses admitted that the guides could sometimes increase the time of the administration, but saw that it made practice safer. All the pharmacists considered the recommendations in the guides useful and all the respondents with the exception of one nurse (12:13) would like this service to continue. Conclusion: I-MAGs were well received on the ward and they support individualised care for patients with dysphagia. But the guides needed additional pharmacist input and greater nursing time. Research to determine the cost effectiveness of I-MAGs is needed.

Implementing improvements to health care services in the US

In a previous blog I was critical of the US health care system for not using cost-effectiveness information to plan their services. Today I’m going to talk about the implementation of innovation in health services, something the US does really well compared to Australia.

Magnetic nanoparticles boosting the osmotic efficiency of a polymeric FO draw agent: Effect of polymer conformation

Poly sodium acrylate (PSA)-coated Magnetic Nanoparticles (PSA-MNPs) were synthesized as smart osmotic draw agent (SMDA) for water desalination by forward osmosis (FO) process. The PSA-coated MNPs demonstrated significantly higher osmotic pressure (~ 30 fold) as well as high FO water flux (~ 2–3 fold) when compared to their polymer (polyelectrolyte) counterpart, even at a very low concentration of ~ 0.13 wt.% in the draw solution. The PSA polymer chain conformation – coiled to extended – demonstrates a significant impact on the availability of the polymer hydrophilic groups in solution which is the driving force to attain higher osmotic pressure and water flux. When an optimum concentration of the polymer was anchored to a NP surface, the polymer chains assume an extended open conformation making the functional hydrophilic groups available to attract water molecules. This in turn boosts the osmotic pressure and FO water flux of the PSA-MNP draw agents. The low concentration of the PSA-MNP osmotic agent and the associated high water flux enhances the cost-effectiveness of our proposed SMDA system. In addition, easier magnetic separation and regeneration of the SMDA also improves its usability making it efficient, cost-effective and environment-friendly.

Priority threat management of non-native plants to maintain ecosystem integrity across heterogeneous landscapes

Invasive non-native plants have negatively impacted on biodiversity and ecosystem functions world-wide. Because of the large number of species, their wide distributions and varying degrees of impact, we need a more effective method for prioritizing control strategies for cost-effective investment across heterogeneous landscapes. Here, we develop a prioritization framework that synthesizes scientific data, elicits knowledge from experts and stakeholders to identify control strategies, and appraises the cost-effectiveness of strategies. Our objective was to identify the most cost-effective strategies for reducing the total area dominated by high-impact non-native plants in the Lake Eyre Basin (LEB). We use a case study of the ˜120 million ha Lake Eyre Basin that comprises some of the most distinctive Australian landscapes, including Uluru-Kata Tjuta National Park. More than 240 non-native plant species are recorded in the Lake Eyre Basin, with many predicted to spread, but there are insufficient resources to control all species. Lake Eyre Basin experts identified 12 strategies to control, contain or eradicate non-native species over the next 50 years. The total cost of the proposed Lake Eyre Basin strategies was estimated at AU$1·7 billion, an average of AU$34 million annually. Implementation of these strategies is estimated to reduce non-native plant dominance by 17 million ha – there would be a 32% reduction in the likely area dominated by non-native plants within 50 years if these strategies were implemented. The three most cost-effective strategies were controlling Parkinsonia aculeata, Ziziphus mauritiana and Prosopis spp. These three strategies combined were estimated to cost only 0·01% of total cost of all the strategies, but would provide 20% of the total benefits. Over 50 years, cost-effective spending of AU$2·3 million could eradicate all non-native plant species from the only threatened ecological community within the Lake Eyre Basin, the Great Artesian Basin discharge springs. Synthesis and applications. Our framework, based on a case study of the ˜120 million ha Lake Eyre Basin in Australia, provides a rationale for financially efficient investment in non-native plant management and reveals combinations of strategies that are optimal for different budgets. It also highlights knowledge gaps and incidental findings that could improve effective management of non-native plants, for example addressing the reliability of species distribution data and prevalence of information sharing across states and regions.

Letter: Brain natriuretic peptide is a potentially useful screening tool for the detection of cardiovascular disease in patients with rheumatoid arthritis

Patients with rheumatoid arthritis (RA) have a significantly higher risk of coronary heart disease, despite being less likely to report symptoms of angina, and are more likely to experience unrecognised myocardial infarction and sudden cardiac death than non-RA controls.1 Furthermore, left ventricular diastolic dysfunction has been described in up to 40% of patients with RA.2...

Research around practice partnerships: An example of building partnerships to address overweight and obesity in children

Prevention and management of childhood overweight and obesity is a health priority for governments and communities throughout the developed world. A conceptual model, Research around Practice in Childhood Obesity (RAPICO), has been developed to guide capacity building in a coordinated 'bench to fieldwork' initiative to address this public health problem. Translation of research findings into sustainable responses with optimal fit requires consideration of context-specific relevance, cost-effectiveness, feasibility and levels of available support. The RAPICO model uses program theory to describe a framework for progressing practitionercommunityresearch partnerships to address low, medium and high levels of risk for childhood overweight and obesity within community settings. A case study describing the development of a logic model to inform risk-linked responses to childhood overweight and obesity is presented for the Ipswich community in south-east Queensland.

Whole exome sequencing is an efficient and sensitive method for detection of germline mutations in patients with phaeochromcytomas and paragangliomas

Background Genetic testing is recommended when the probability of a disease-associated germline mutation exceeds 10%. Germline mutations are found in approximately 25% of individuals with phaeochromcytoma (PCC) or paraganglioma (PGL); however, genetic heterogeneity for PCC/PGL means many genes may require sequencing. A phenotype-directed iterative approach may limit costs but may also delay diagnosis, and will not detect mutations in genes not previously associated with PCC/PGL. Objective To assess whether whole exome sequencing (WES) was efficient and sensitive for mutation detection in PCC/PGL. Methods Whole exome sequencing was performed on blinded samples from eleven individuals with PCC/PGL and known mutations. Illumina TruSeq™ (Illumina Inc, San Diego, CA, USA) was used for exome capture of seven samples, and NimbleGen SeqCap EZ v3.0 (Roche NimbleGen Inc, Basel, Switzerland) for five samples (one sample was repeated). Massive parallel sequencing was performed on multiplexed samples. Sequencing data were called using Genome Analysis Toolkit and annotated using annovar. Data were assessed for coding variants in RET, NF1, VHL, SDHD, SDHB, SDHC, SDHA, SDHAF2, KIF1B, TMEM127, EGLN1 and MAX. Target capture of five exome capture platforms was compared. Results Six of seven mutations were detected using Illumina TruSeq™ exome capture. All five mutations were detected using NimbleGen SeqCap EZ v3.0 platform, including the mutation missed using Illumina TruSeq™ capture. Target capture for exons in known PCC/PGL genes differs substantially between platforms. Exome sequencing was inexpensive (<$A800 per sample for reagents) and rapid (results <5 weeks from sample reception). Conclusion Whole exome sequencing is sensitive, rapid and efficient for detection of PCC/PGL germline mutations. However, capture platform selection is critical to maximize sensitivity.

Educational interventions for preventing vascular catheter bloodstream infections in critical care: Evidence map, systematic review and economic evaluation

Background Bloodstream infections resulting from intravascular catheters (catheter-BSI) in critical care increase patients' length of stay, morbidity and mortality, and the management of these infections and their complications has been estimated to cost the NHS annually £19.1–36.2M. Catheter-BSI are thought to be largely preventable using educational interventions, but guidance as to which types of intervention might be most clinically effective is lacking. Objective To assess the effectiveness and cost-effectiveness of educational interventions for preventing catheter-BSI in critical care units in England. Data sources Sixteen electronic bibliographic databases – including MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, Cumulative Index to Nursing and Allied Health Literature (CINAHL), NHS Economic Evaluation Database (NHS EED), EMBASE and The Cochrane Library databases – were searched from database inception to February 2011, with searches updated in March 2012. Bibliographies of systematic reviews and related papers were screened and experts contacted to identify any additional references. Review methods References were screened independently by two reviewers using a priori selection criteria. A descriptive map was created to summarise the characteristics of relevant studies. Further selection criteria developed in consultation with the project Advisory Group were used to prioritise a subset of studies relevant to NHS practice and policy for systematic review. A decision-analytic economic model was developed to investigate the cost-effectiveness of educational interventions for preventing catheter-BSI. Results Seventy-four studies were included in the descriptive map, of which 24 were prioritised for systematic review. Studies have predominantly been conducted in the USA, using single-cohort before-and-after study designs. Diverse types of educational intervention appear effective at reducing the incidence density of catheter-BSI (risk ratios statistically significantly < 1.0), but single lectures were not effective. The economic model showed that implementing an educational intervention in critical care units in England would be cost-effective and potentially cost-saving, with incremental cost-effectiveness ratios under worst-case sensitivity analyses of < £5000/quality-adjusted life-year. Limitations Low-quality primary studies cannot definitively prove that the planned interventions were responsible for observed changes in catheter-BSI incidence. Poor reporting gave unclear estimates of risk of bias. Some model parameters were sourced from other locations owing to a lack of UK data. Conclusions Our results suggest that it would be cost-effective and may be cost-saving for the NHS to implement educational interventions in critical care units. However, more robust primary studies are needed to exclude the possible influence of secular trends on observed reductions in catheter-BSI.

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.

General ranked set sampling for efficient treatment comparisons

In treatment comparison experiments, the treatment responses are often correlated with some concomitant variables which can be measured before or at the beginning of the experiments. In this article, we propose schemes for the assignment of experimental units that may greatly improve the efficiency of the comparison in such situations. The proposed schemes are based on general ranked set sampling. The relative efficiency and cost-effectiveness of the proposed schemes are studied and compared. It is found that some proposed schemes are always more efficient than the traditional simple random assignment scheme when the total cost is the same. Numerical studies show promising results using the proposed schemes.

The impacts and management of foxes Vulpes vulpes in Australia

1. The successful introduction of the red fox Vulpes vulpes into Australia in the 1870s has had dramatic and deleterious impacts on both native fauna and agricultural production. Historical accounts detail how the arrival of foxes in many areas coincided with the local demise of native fauna. Recent analyses suggest that native fauna can be successfully reintroduced to their former ranges only if foxes have been controlled, and several replicated removal experiments have confirmed that foxes are the major agents of extirpation of native fauna. Predation is the primary cause of losses, but competition and transmission of disease may be important for some species. 2. In agricultural landscapes, fox predation on lambs can cause losses of 1–30%; variation is due to flock size, health and management, as well as differences in the timing and duration of lambing and the density of foxes. 3. Fox control measures include trapping, shooting, den fumigation and exclusion fencing; baiting using the toxin 1080 is the most commonly employed method. Depending on the baiting strategy, habitat and area covered, baiting can reduce fox activity by 50–97%. We review patterns of baiting in a large sheep-grazing region in central New South Wales, and propose guidelines to increase landholder awareness of baiting strategies, to concentrate and coordinate bait use, and to maximize the cost-effectiveness of baiting programs. 4. The variable reduction in fox density within the baited area, together with the ability of the fox to recolonize rapidly, suggest that current baiting practices in eastern Australia are often ineffective, and that reforms are required. These might include increasing landholder awareness and involvement in group control programs, and the use of more efficient broadscale techniques, such as aerial baiting.

How can warren destruction by ripping control European wild rabbits (Oryctolagus cuniculus) on large properties in the Australian arid zone?

Context: For over 100 years, control efforts have been unable to stop rabbits causing damage to cattle production and native plants and animals on large properties in arid parts of Australia. Warren destruction by ripping has shown promise, but doubts about long-term success and the perceived expense of treating vast areas have led to this technique not being commonly used. Aims: This study measured the long-term reduction in rabbit activity and calculated the potential cost saving associated with treating just the areas where rabbits are believed to survive drought. Wealso considered whether ripping should be used in a full-scale rabbit control program on a property where rabbits have been exceptionally resilient to the influence of biological and other control measures. Methods: Rabbits were counted along spotlight transects before warrens were ripped and during the two years after ripping, in treated and untreated plots. Rabbit activity was recorded to determine the immediate and long-term impact of ripping, up to seven years after treatment. The costs of ripping warrens within different distances from drought refuge areas were calculated. Key results: Destroying rabbit warrens by ripping caused an immediate reduction in rabbit activity and there were still 98% fewer rabbits counted by spotlight in ripped plots five months after ripping. Seven years after ripping no active warrens were found in ripped plots, whereas 57% of warrens in unripped plots showed signs of rabbit activity. The cost of ripping only the areas where rabbits were likely to seek refuge from drought was calculated to be less than 4%of the cost of ripping all warrens on the property. Conclusions: Destroying rabbit warrens by ripping is a very effective way of reducing rabbit numbers on large properties in arid Australia. Ripping should commence in areas used by rabbits to survive drought. It is possible that no further ripping will be required. Implications: Strategic destruction of warrens in drought refuge areas could provide an alternative to biological control for managing rabbits on large properties in the Australian arid zone.

Optimise efficacy of broiler house treatments for the management of lesser mealworm

The Australian chicken meat industry requires effective agents for the management of lesser mealworm in broiler houses. The only two appropriate insecticides currently registered are cyfluthrin and spinosad, with gamma cyhalothrin being developed for registration. The industry requires the efficacy of cyfluthrin to be investigated, with progress and adoption of the latter two chemicals. Optimising the efficacy of each chemical and studying them singly and in rotation will, in addition to improving their efficacy, reduce overall insecticide use and improve their cost effectiveness.

Robustness of the partitions in grouping multi-item inventories

A recent work obtained closed-form solutions to the.problem of optimally grouping a multi-item inventory into subgroups with a common order cycle per group, when the distribution by value of the inventory could be described by a Pareto function. This paper studies the sensitivity of the optimal subgroup boundaries so obtained. Closed-form expressions have been developed to find intervals for the subgroup boundaries for any given level of suboptimality. Graphs have been provided to aid the user in selecting a cost-effective level of aggregation and choosing appropriate subgroup boundaries for a whole range of inventory distributions. The results of sensitivity analyses demonstrate the availability of flexibility in the partition boundaries and the cost-effectiveness of any stock control system through three groups, and thus also provide a theoretical support to the intuitive ABC system of classifying the items.

A capability-based view of organisational renewal : Combining opportunity- and advantage-seeking growth in large, established European and North American wood-industry companies

The purpose of this study was to extend understanding of how large firms pursuing sustained and profitable growth manage organisational renewal. A multiple-case study was conducted in 27 North American and European wood-industry companies, of which 11 were chosen for closer study. The study combined the organisational-capabilities approach to strategic management with corporate-entrepreneurship thinking. It charted the further development of an identification and classification system for capabilities comprising three dimensions: (i) the dynamism between firm-specific and industry-significant capabilities, (ii) hierarchies of capabilities and capability portfolios, and (iii) their internal structure. Capability building was analysed in the context of the organisational design, the technological systems and the type of resource-bundling process (creating new vs. entrenching existing capabilities). The thesis describes the current capability portfolios and the organisational changes in the case companies. It also clarifies the mechanisms through which companies can influence the balance between knowledge search and the efficiency of knowledge transfer and integration in their daily business activities, and consequently the diversity of their capability portfolio and the breadth and novelty of their product/service range. The largest wood-industry companies of today must develop a seemingly dual strategic focus: they have to combine leading-edge, innovative solutions with cost-efficient, large-scale production. The use of modern technology in production was no longer a primary source of competitiveness in the case companies, but rather belonged to the portfolio of basic capabilities. Knowledge and information management had become an industry imperative, on a par with cost effectiveness. Yet, during the period of this research, the case companies were better in supporting growth in volume of the existing activity than growth through new economic activities. Customer-driven, incremental innovation was preferred over firm-driven innovation through experimentation. The three main constraints on organisational renewal were the lack of slack resources, the aim for lean, centralised designs, and the inward-bound communication climate.