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

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

Holding cost model for Greenfield Housing developments

Presentation provided to a PhD Colloquium between two Australian and one Malaysian University providing the opportunity to inform and critique progress of students concerning their selected topic. This presentation essentially involves "The conceptualisation, sensitivity and measurement of holding costs and other selected elements impacting housing affordability" as provided by Gary Owen Garner of QUT, with research objectives thus: 1. To establish the nature and composition of holding costs over time, as related to residential property in Australia, and internationally. 2. To examine the linkages that may exist between various planning instruments, the length of regulatory assessment periods, and housing affordability. 3. To develop a model that quantifies the impact of holding costs on housing affordability in Australia, with a particular focus on the consequences of extended assessment periods as a component of holding costs. Thus, provide clarification as to the impact of holding costs on overall housing affordability.

Composite load model decomposition : induction motor contribution

In this thesis, a new technique has been developed for determining the composition of a collection of loads including induction motors. The application would be to provide a representation of the dynamic electrical load of Brisbane so that the ability of the power system to survive a given fault can be predicted. Most of the work on load modelling to date has been on post disturbance analysis, not on continuous on-line models for loads. The post disturbance methods are unsuitable for load modelling where the aim is to determine the control action or a safety margin for a specific disturbance. This thesis is based on on-line load models. Dr. Tania Parveen considers 10 induction motors with different power ratings, inertia and torque damping constants to validate the approach, and their composite models are developed with different percentage contributions for each motor. This thesis also shows how measurements of a composite load respond to normal power system variations and this information can be used to continuously decompose the load continuously and to characterize regarding the load into different sizes and amounts of motor loads.

Approach to developing a 3D conceptual hydrogeology model, in a system with multiple bore logs, Howard East, Darwin, using in-house software (GVS)

The Howard East rural area has experienced a rapid growth of small block subdivisions and horticulture over the last 40 years, which has been based on groundwater supply. Early bores in the area provide part of the water supply for Darwin City and are maintained and monitored by NT Power & Water Corporation. The Territory government (NRETAS) has established a monitoring network, and now 48 bores are monitored. However, in the area there are over 2700 private bores that are unregulated.Although NRETAS has both FDM and FEM simulations for the region, community support for potential regulation is sought. To improve stakeholder understanding of the resource QUT was retained by the TRaCKconsortium to develop a 3D visualisation of the groundwater system.

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

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

The applicability of biased estimation in model and model order selection

Biased estimation has the advantage of reducing the mean squared error (MSE) of an estimator. The question of interest is how biased estimation affects model selection. In this paper, we introduce biased estimation to a range of model selection criteria. Specifically, we analyze the performance of the minimum description length (MDL) criterion based on biased and unbiased estimation and compare it against modern model selection criteria such as Kay's conditional model order estimator (CME), the bootstrap and the more recently proposed hook-and-loop resampling based model selection. The advantages and limitations of the considered techniques are discussed. The results indicate that, in some cases, biased estimators can slightly improve the selection of the correct model. We also give an example for which the CME with an unbiased estimator fails, but could regain its power when a biased estimator is used.

An administrative model for UCON

UCON is an emerging access control framework that lacks an administration model. In this paper we define the problem of administration and propose a novel administrative model. At the core of this model is the concept of attribute, which is also the central component of UCON. In our model, attributes are created by the assertions of subjects, which ascribe properties/rights to other subjects or objects. Through such a treatment of attributes, administration capabilities can be delegated from one subject to another and as a consequence UCON is improved in three aspects. First, immutable attributes that are currently considered as external to the model can be incorporated and thereby treated as mutable at- tributes. Second, the current arbitrary categorisation of users (as modifiers of attributes), to system and administrator can be removed. Attributes and objects are only modifiable by those who possess administration capability over them. Third, the delegation of administration over objects and properties that is not currently expressible in UCON is made possible.

A model for computer profiling

This paper discusses the use of models in automatic computer forensic analysis, and proposes and elaborates on a novel model for use in computer profiling, the computer profiling object model. The computer profiling object model is an information model which models a computer as objects with various attributes and inter-relationships. These together provide the information necessary for a human investigator or an automated reasoning engine to make judgements as to the probable usage and evidentiary value of a computer system. The computer profiling object model can be implemented so as to support automated analysis to provide an investigator with the information needed to decide whether manual analysis is required.

Enhancing in vivo vascularized bone formation by cobalt chloride-treated bone marrow stromal cells in a tissue engineered periosteum model

The periosteum plays an indispensable role in both bone formation and bone defect healing. In this study we constructed an artificial in vitro periosteum by incorporating osteogenic differentiated bone marrow stromal cells (BMSCs) and cobalt chloride (CoCl(2))-treated BMSCs. The engineered periostea were implanted both subcutaneously and into skull bone defects in SCID mice to investigate ectopic and orthotopic osteogenesis and vascularization. After two weeks in subcutaneous and four weeks in bone defect areas, the implanted constructs were assessed for ectopic and orthotopic osteogenesis and vascularization by micro-CT, histomorphometrical and immunohistochemical methods. The results showed that CoCl(2) pre-treated BMSCs induced higher degree of vascularization and enhanced osteogenesis within the implants in both ectopic and orthotopic areas. This study provided a novel approach using BMSCs sourced from the same patient for both osteogenic and pro-angiogenic purposes in constructing tissue engineered periosteum to enhance vascularized osteogenesis.

Towards a model of understanding strategic decision-making in micro-firms : exploring the Australian information technology sector

This study explores strategic decision-making (SDM) in micro-firms, an economically significant business subsector. As extant large- and small-firm literature currently proffers an incomplete characterization of SDM in very small enterprises, a multiple-case methodology was used to investigate how these firms make strategic decisions. Eleven Australian Information Technology service micro-firms participated in the study. Using an information-processing lens, the study uncovered patterns of SDM in micro-firms and derived a theoretical micro-firm SDM model. This research also identifies several implications for micro-firm management and directions for future research, contributing to the understanding of micro-firm SDM in both theory and practice.

The Revised Transactional Model (RTM) of occupational stress and coping : an improved process approach

Despite more than three decades of research, there is a limited understanding of the transactional processes of appraisal, stress and coping. This has led to calls for more focused research on the entire process that underlies these variables. To date, there remains a paucity of such research. The present study examined Lazarus and Folkman’s (1984) transactional model of stress and coping. One hundred and twenty nine Australian participants with full time employment (i.e. nurses and administration employees) were recruited. There were 49 male (age mean = 34, SD = 10.51) and 80 female (age mean = 36, SD = 10.31) participants. The analysis of three path models indicated that in addition to the original paths, which were found in Lazarus and Folkman’s transactional model (primary appraisal-->secondary appraisal-->stress-->coping), there were also direct links between primary appraisal and stress level time one and between stress level time one to stress level time two. This study has provided additional insights into the transactional process which will extend our understanding of how individuals appraise, cope and experience occupational stress.

Examination of social demographic status, disease status, health behaviours and quality of life in older Australians using the theory of planned behaviour model

The increase of life expectancy worldwide during the last three decades has increased age-related disability leading to the risk of loss of quality of life. How to improve quality of life including physical health and mental health for older people and optimize their life potential has become an important health issue. This study used the Theory of Planned Behaviour Model to examine factors influencing health behaviours, and the relationship with quality of life. A cross-sectional mailed survey of 1300 Australians over 50 years was conducted at the beginning of 2009, with 730 completed questionnaires returned (response rate 63%). Preliminary analysis reveals that physiological changes of old age, especially increasing waist circumference and co morbidity was closely related to health status, especially worse physical health summary score. Physical activity was the least adherent behaviour among the respondents compared to eating healthy food and taking medication regularly as prescribed. Increasing number of older people living alone with co morbidity of disease may be the barriers that influence their attitude and self control toward physical activity. A multidisciplinary and integrated approach including hospital and non hospital care is required to provide appropriate services and facilities toward older people.