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.

Population aging in a globalizing labour market: implications for older workers

Against a background of population aging, and with it, warnings about the sustainability of social welfare systems and problems associated with declining labour supply, there is an increasing policy emphasis on extending working lives of older workers among the industrialised nations (Hirsch, 2003; Keese, 2005; Taylor, 2006). However, recent commentaries have tended to focus on the relationship between population aging and the labour market, largely ignoring other critical factors that are affecting older workers’ relationship with the labour market. This contrasts with extensive research undertaken in the 1980s and 1990s when the forces acting upon older workers at that time were thoroughly elucidated (e.g. Kohli et al., 1991). The focus of this paper is on the labour supply challenges for employers and nations arising from demographic trends, in combination with social and technological changes and the wider forces of globalisation, how each is responding, and how these trends are affecting older workers’ trying to secure or maintain footholds in a labour market but facing, as Richard Sennett (2006) puts it, the ‘spectre of uselessness’ as jobs they could do have either migrated to other parts of the world or have been destroyed in the wake of industry failure.

Revisiting Industrial Relations

In 1999 I convened Industrial Relations, the annual ADSA Conference hosted by QUT in Brisbane. This event was promoted as ‘a conference exploring the links between theatre scholarship and professional theatre practice’. As well as academics, there was to be substantial representation by ‘industry professionals’, although interest from the latter category turned out to be modest. One day of the conference was designated a special ‘Links with Industry’ day, during which the Association launched its now defunct ADSAIL (ADSA Industry Links) initiative. Keynote speaker Wesley Enoch commented on ‘the very strong resistance in “the industry” to acknowledging any role of academics’. ‘What is the practical role of having them?’ he asked the ‘them’ gathered before him. In a letter declining our invitation to speak (he later changed his mind), David Williamson remarked that he always felt ‘uneasy at such conferences’: My view of my work is that I’ve successfully filled theatres for 30 years now, something dramatists are supposed to do. I suppose there’s part of me that hopes this will be celebrated. It often is, but rarely in academic drama departments …. Perhaps in fifty years time someone in academe will realise that I wasn’t just reinforcing the attitudes of the Anglo Celtic ruling class. Several years on it seems timely to revisit Industrial Relations; to look again at the extent to which problems of intercultural communication between industry and academy are being addressed. And what are the implications of this for the ADSA History project, which seeks to investigate ADSA’s contribution to the development of theatre / performance studies in Australasia? What are the ‘external’ impacts of ADSA’s ongoing conference enterprise, and how might these be measured? Reflections from delegates on these and other questions will be warmly encouraged.

Small Business and entrepreneurship policy

There are two key approaches to entrepreneurship, each of which has different implications for small business policy (Danson 2002). The first conceives of entrepreneurship as an economic process and can be traced to the work of Joseph Schumpeter who developed the concept of creative destruction to describe the entrepreneurial process that led to the simultaneous elimination of old industries and activities and the creation of new activities through the commercial application of new ideas. While entrepreneurship as a process of creative destruction might include start up activity amongst small firms, it does not exclusively involve small firms as large firms may contribute to the entrepreneurial process through the generation of new knowledge and by assisting in financing the development of new ideas amongst small firms. Although innovation occurs in large as well as small firms, the literature on small enterprise innovation draws heavily on Schumpeter’s depiction of the central role of the entrepreneur in the process of creative destruction, whereby the economic system is transformed from within and new cycles in economic life emerge in which new industries and markets replace old industries and markets. Schumpeter argued that entrepreneurs drove the process of innovation and that innovation was a stimulus to economic development and involved the development of new products, processes, methods of production or new forms of commercial or financial organisation (Schumpeter 1911). At a time when technological development and structuraleconomic change are occurring at a rapid pace, small firm innovation is seen to be critically important because empirical evidence, although not undisputed, indicates that SMEs make an important contribution to radical innovations in new industries (Nooteboom 1994). The second view of entrepreneurship focuses on the individual entrepreneur more than the entrepreneurial process. The entrepreneur is depicted as an owner of small businesses, and is regarded as having particular personal characteristics such as self-reliance, individual initiative and self-motivation. Entrepreneurs are also considered to have a behavioural orientation towards the exploitation of new ideas and opportunities. They are the risk takers who are able to see an opportunity and pursue it commercially despite the uncertainty of rewards. The capacity to plan, manage and lead is also seen to be identifying characteristics of entrepreneurs. Different small business policy approaches arise from these different perspectives on entrepreneurship. Small business policy approaches that emphasise the process by which new ideas are generated and applied commercially arise from the first and broader view of entrepreneurship. Policies designed to generate a population of risk taking and self-motivated individuals with highly developed management and commercial skills are more in keeping with the second approach, which is focused on the individual entrepreneur rather than the entrepreneurial process.

Traceability : retracing law and public policy on measurement standards

This presentation outlines key aspects of public policy in broad terms insofar as they relate to establishment, implementation and compliance with legal measurement standards. It refers in particular to traceability of a legal measurement unit from its source in a single international standard as a compliance issue. It comments on accreditation of legal measurement and liability concerned with errors in measurement.

Youth identities : time, space and social exclusion : exploring youth policy and practice in Sheffield, 1999-2003

The type and quality of youth identities ascribed to young people living in residual housing areas present opportunities for action as well as structural constraints. In this book three ethnographies, based on a youth work practitioner's observations, interviews and participation in local networks, identify young people's resistant identities. Through an analysis of social exclusion, youth policies and interviews with young people, youth workers and their managers, the book outlines a contingent network of relationships that hinder informal learning. Globalisation, individualisation, welfare/education reform and the rise of cultural social movements act upon youth identities and steer youth policies to subordinate the notion of informal group learning. Drawing on Castells' and Touraine's sociological models of identity, the book explores youth as a category of time and residual housing areas as a category of space, as they pertain to local dynamics of social exclusion.

The planning of airport regions and National Aviation Policy Issues and challenges in the Australian experience 2008-2009

The planning of airports has long been contentious because of their localisation of negative impacts. The globalisation, commercialisation and deregulation of the aviation industry has unleashed powerful new economic forces both on and offairport. Over the last two decades, many airports have evolved into airport cities located at the heart of the wider aerotropolis region. This shifts the appropriate scale of planning analysis towards broader regional concerns. However,governments have been slow to respond and airport planning usually remains poorly integrated with local, city and regional planning imperatives. The Australian experience exemplifies the divide. The privatization of major Australian airports from 1996 has seen billions of dollars spent on new airside and landside infrastructure but with little oversight from local and state authorities because the ultimate authority for on-airport development is the Federal Minister for Transport. Consequently, there have been growing tensions in many major airport regions between the private airport lessee and the broader community, exacerbated by both the building of highly conspicuous non-aeronautical developments and growing airport area congestion. This paper examines the urban planning content of Australia’s national aviation policy review (2008-09) with reference to current and potential opportunities for all-of-region collaboration in the planning process.

Making literacy policy and practice with a difference : generational change, professionalisation and literate futures

This article has been edited from a transcript of the keynote address to the combined ALEA/MTE National Conference, Hobart, Tasmania, August 2001. In this talk Allan reflects on some of the difficulties facing makers of literacy policy in 'New Times'. His reflections are informed by some important research that is having an impact· on literacy teaching in Australia and he raises various issues, ranging from what he sees as a 'dumbing down' of curriculum, to addressing the needs of'at risk' students, to issues of lifelong education in a rapidly changing world.

Disrupting the new orthodoxy : emergency intervention and Indigenous social policy

This article develops a critical analysis of the ideological framework that informed the Australian Federal government’s 2007 intervention into Northern Territory Indigenous communities (ostensibly to address the problem of child sexual abuse). Continued by recently elected Prime Minister, Kevin Rudd, the NT ‘emergency response’ has aroused considerable public debate and scholarly inquiry. In addressing what amounts to a broad bi-partisan approach to Indigenous issues we highlight the way in which Indigenous communities are problematised and therefore subject to interventionist regimes that override differentiated Indigenous voices and intensify an internalised sense of rage occasioned by disempowering interventionist projects. We further argue that in rushing through the emergency legislation and suspending parts of the Racial Discrimination Act, the Howard and Rudd governments have in various ways perpetuated racialised and neo-colonial forms of intervention that override the rights of Indigenous people. Such policy approaches require critical understanding on the part of professions involved most directly in community practice, particularly when it comes to mounting effective opposition campaigns. The article offers a contribution to this end.

Indoor environment sustainability of residential industrial housing in Malaysia

The importance of sustainable development has been internationally recognized and the principles have been widely used as an impetus for promoting housing sustainability. In the situation of mixed-use urban development in close proximity to heavy industrial areas in Malaysia, rising incomes are developing hand in hand with higher expectations for better and more sustainable housing designs. Negative environmental impacts due current deficiency in Malaysia’s approach to the implementation of sustainable development principles can be seen in this case study of the Pasir Gudang Industrial Area in Malaysia. This study aimed to highlight the level of residents’ satisfaction with living near the industrial area, and to relate their awareness of the relevance of sustainable principles with indoor environmental conditions, which found that the residents’ has limited understanding of the environmental problems in their indoor living conditions and in their neighborhoods. This study has suggested that proactive and integrated involvement by housing authorities from all levels of government in Malaysia should be encouraged in order to rationalise the approaches to develop better planning solutions for such mixed-used urban developments. This initiative should then encourage housing vendors to provide innovative ‘smart’ technological changes to their projects and so, to achieve a new direction in sustainable housing development.

ePortfolio use by university students in Australia: Informing excellence in policy and practice

In mid 2007, the Australian Learning and Teaching Council (ALTC), formerly the Carrick Institute for Learning and Teaching in Higher Education, commissioned an intensive research project to examine the use of ePortfolios by university students in Australia. The project was awarded to a consortium of four universities: Queensland University of Technology as lead institution, The University of Melbourne, University of New England and University of Wollongong.---------- The overarching aim of the research project, which was given the working title of the Australian ePortfolio Project, was to examine the current levels of ePortfolio practice in Australian higher education. The principal project goals sought to provide an overview and analysis of the national and international ePortfolio contexts, document the types of ePortfolios used in Australian higher education, examine the relationship with the National Diploma Supplement project funded by the Federal government, identify any significant issues relating to ePortfolio implementation, and offer guidance about future opportunities for ePortfolio development. The research findings revealed that there was a high level of interest in the use of ePortfolios in the context of higher education, particularly in terms of the potential to help students become reflective learners who are conscious of their personal and professional strengths and weaknesses, as well as to make their existing and developing skills more explicit. There were some good examples of early adoption in different institutions, although this tended to be distributed across the sector. The greatest use of ePortfolios was recorded in coursework programs, rather than in research programs, with implementation generally reflecting subject-specific or program-based activity, as opposed to faculty- or university-wide activity. Accordingly, responsibility for implementation frequently rested with the individual teaching unit, although an alternative centralised model of coordination by ICT services, careers and employment or teaching and learning support was beginning to emerge. The project report concludes with a series of recommendations to guide the process, drawing on the need for open dialogue and effective collaboration between the stakeholders across the range of contexts: government policy, international technical standards, academic policy, and learning and teaching research and practice.

Characteristics of sustainable entrepreneurship : some early explorations from the CAUSEE study

Principal Topic: For forward thinking companies, the environment may represent the ''biggest opportunity for enterprise and invention the industrial world has ever seen'' (Cairncross 1990). Increasing awareness of environmental and sustainability issues through media including the promotion of Al Gore's ''An Inconvenient Truth'' has seen increased awareness of environmental and sustainability issues and increased demand for business processes that reduce detrimental environmental impacts of global development (Dean & McMullen 2007). The increased demand for more environmentally sensitive products and services represents an opportunity for the development of ventures that seek to satisfy this demand through entrepreneurial action. As a consequence, increasing recent market developments in renewable energy, carbon emissions, fuel cells, green building, and other sectors suggest an increasing importance of opportunities for environmental entrepreneurship (Dean and McMullen 2007) and increasingly important area of business activity (Schaper 2005). In the last decade in particular, big business has sought to develop a more ''sustainability/ green friendly'' orientation as a response to public pressure and increased government legislation and policy to improve environmental performance (Cohen and Winn 2007). Whilst much of the literature and media is littered with examples of sustainability practices of large firms, nascent and young sustainability firms have only recently begun generating strong research and policy interest (Shepherd, Kuskova and Patzelt 2009): not only for their potential to generate above average financial performance and returns owing to a greater popularity and demand towards sustainability products and services offerings, but also for their intent to lessen environmental impacts, and to provide a more accurate reflection of the ''true cost'' of market offerings taking into account carbon and environmental impacts. More specifically, researchers have suggested that although the previous focus has been on large firms and their impact on the environment, the estimated collective impact of entries and exits of nascent and young firms in development is substantial and could outweigh the combined environmental impact of large companies (Hillary, 2000). Therefore, it may be argued that greater attention should be paid to nascent and young firms and researching sustainability practices, for both their impact in reducing environmental impacts and potential higher financial performance. Whilst acknowledging this research only uses the first wave of a four year longitudinal study of nascent and young firms, it can still begin to provide initial analysis on which to continue further research. The aim of this paper therefore is to provide an overview of the emerging literature in sustainable entrepreneurship and to present some selected preliminary results from the first wave of the data collection, with comparison, where appropriate, of sustainable and firms that do not fulfil this criteria. ''One of the key challenges in evaluating sustainability entrepreneurship is the lack of agreement in how it is defined'' (Schaper, 2005: 10). Some evaluate sustainable entrepreneurs simply as one category of entrepreneurs with little difference between them and traditional entrepreneurs (Dees, 1998). Other research recognises values-based sustainable enterprises requiring a unique perspective (Parrish, 2005). Some see the environmental or sustainable entrepreneurship is a subset of social entrepreneurship (Cohen & Winn, 2007; Dean & McMullen, 2007) whilst others see it as a separate, distinct theory (Archer 2009). Following one of the first definitions of sustainability developed by the Brundtland Commission (1987) we define sustainable entrepreneurship as firms which ''seek to meet the needs and aspirations of the present without compromising the ability to meet those of the future''. ---------- Methodology/Key Propositions: In this exploratory paper we investigate sustainable entrepreneurship using Cohen et al.'s (2008) framework to identify strategies of nascent and young entrepreneurial firms. We use data from The Comprehensive Australian Study of Entrepreneurial Emergence (CAUSEE). This study shares the general empirical approach with PSED studies in the US (Reynolds et al 1994; Reynolds & Curtin 2008). The overall study uses samples of 727 nascent (not yet operational) firms and another 674 young firms, the latter being in an operational stage but less than four years old. To generate the sub sample of sustainability firms, we used content analysis techniques on firm titles, descriptions and product descriptions provided by respondents. Two independent coders used a predefined codebook developed from our review of the sustainability entrepreneurship literature (Cohen et al. 2009) to evaluate the content based on terms such as ''sustainable'' ''eco-friendly'' ''renewable energy'' ''environment'' amongst others. The inter-rater reliability was checked and the Kappa's co-efficient was found to be within the acceptable range (0.746). 85 firms fulfilled the criteria given for inclusion in the sustainability cohort. ---------- Results and Implications: The results for this paper are based on Wave one of the CAUSEE survey which has been completed and the data is available for analysis. It is expected that the findings will assist in beginning to develop an understanding of nascent and young firms that are driven to contribute to a society which is sustainable, not just from an economic perspective (Cohen et al 2008), but from an environmental and social perspective as well. The CAUSEE study provides an opportunity to compare the characteristics of sustainability entrepreneurs with entrepreneurial firms without a stated environmental purpose, which constitutes the majority of the new firms created each year, using a large scale novel longitudinal dataset. The results have implications for Government in the design of better conditions for the creation of new business, firms who assist sustainability in developing better advice programs in line with a better understanding of their needs and requirements, individuals who may be considering becoming entrepreneurs in high potential arenas and existing entrepreneurs make better decisions.

Research training and national innovation systems in Australia, Finland and the United States : a policy and systems study supported by 30 case studies of research students in the fields of geospatial science, wireless communication, biosciences, and materials science and engineering

Reforms to the national research and research training system by the Commonwealth Government of Australia sought to effectively connect research conducted in universities to Australia's national innovation system. Research training has a key role in ensuring an adequate supply of highly skilled people for the national innovation system. During their studies, research students produce and disseminate a massive amount of new knowledge. Prior to this study, there was no research that examined the contribution of research training to Australia's national innovation system despite the existence of policy initiatives aiming to enhance this contribution. Given Australia's below average (but improving) innovation performance compared to other OECD countries, the inclusion of Finland and the United States provided further insights into the key research question. This study examined three obvious ways that research training contributes to the national innovation systems in the three countries: the international mobility and migration of research students and graduates, knowledge production and distribution by research students, and the impact of research training as advanced human capital formation on economic growth. Findings have informed the concept of a research training culture of innovation that aims to enhance the contribution of research training to Australia's national innovation system. Key features include internationally competitive research and research training environments; research training programs that equip students with economically-relevant knowledge and the capabilities required by employers operating in knowledge-based economies; attractive research careers in different sectors; a national commitment to R&D as indicated by high levels of gross and business R&D expenditure; high private and social rates of return from research training; and the horizontal coordination of key organisations that create policy for, and/or invest in research training.