Assessing cost-effectiveness of drug interventions for schizophrenia

Objective: To assess from a health sector perspective the incremental cost-effectiveness of eight drug treatment scenarios for established schizophrenia.

Method: Using a standardized methodology, costs and outcomes are modelled over the lifetime of prevalent cases of schizophrenia in Australia in 2000. A two-stage approach to assessment of health benefit is used. The first stage involves a quantitative analysis based on disability-adjusted life years (DALYs) averted, using best available evidence. The robustness of results is tested using probabilistic uncertainty analysis. The second stage involves application of 'second filter' criteria (equity, strength of evidence, feasibility and acceptability) to allow broader concepts of benefit to be considered.

Results: Replacing oral typicals with risperidone or olanzapine has an incremental costeffectiveness ratio (ICER) of A$48 000 and A$92 000/DALY respectively. Switching from low-dose typicals to risperidone has an ICER of A$80 000. Giving risperidone to people experiencing side-effects on typicals is more cost-effective at A$20 000. Giving clozapine to people taking typicals, with the worst course of the disorder and either little or clear deterioration, is cost-effective at A$42 000 or A$23 000/DALY respectively. The least costeffective intervention is to replace risperidone with olanzapine at A$160 000/DALY.

Conclusions: Based on an A$50 000/DALY threshold, low-dose typical neuroleptics are indicated as the treatment of choice for established schizophrenia, with risperidone being reserved for those experiencing moderate to severe side-effects on typicals. The more expensive olanzapine should only be prescribed when risperidone is not clinically indicated. The high cost of risperidone and olanzapine relative to modest health gains underlie this conclusion. Earlier introduction of clozapine however, would be cost-effective. This work is limited by weaknesses in trials (lack of long-term efficacy data, quality of life and consumer satisfaction evidence) and the translation of effect size into a DALY change. Some stakeholders, including SANE Australia, argue the modest health gains reported in the literature do not adequately reflect perceptions by patients, clinicians and carers, of improved quality of life with these atypicals.

The employers' perspective of the impact of RICS education reform on building surveying

Purpose: This paper seeks to present the second part of research funded by the RICS Education Trust to investigate the impact of the 2001 education reforms on Building Surveying. The first part of the research involved the collection of data from university course leaders.

Design/methodology/approach: This research involved the collection of data from large national, mainly London-based, employers of building surveyors at a focus group meeting.

Findings: The paper finds that issues of concern to these employers include the extent of construction technology knowledge of graduates, the delivery of contract administration, the placement year, post-graduate conversion courses and the high referral rate for the Assessment of Professional Competence (APC). Recommendations include advice to universities on the design of building surveying undergraduate and conversion courses, a call for further research on the high APC referral rate, and greater liaison between industry and universities.

Research limitations/implications: The main limitation of the research is that the employers from whom data were collected were mainly large, national firms. Further research would be required to elicit the views of smaller regional organisations.

Practical implications: Both parts of this RICS Education Trust funded research provides a foundation for the Building Surveying Faculty of the RICS to complete their review of the education and training of building surveyors.

Originality/value: The research provides useful data on the impact of RICS education reform on building surveying, but mainly large, national firms.

Advance directives and the persistent vegetative state in Victoria: a human rights perspective

With advances in medical technology, it is now possible to sustain the life of a person in a persistent vegetative state (PVS) until a decision is made to withhold or withdraw life-sustaining treatment. Who makes that decision? Under the Medical Treatment Act 1988 (Vic) there is no legally enforceable right for a person to choose, in advance, what intervention that person will and will not accept if he or she ends up in a PVS. The best that can be achieved is that a person can appoint an agent who is empowered to refuse medical treatment on the person's behalf in the event of incompetence. It is suggested that this mechanism ignores two fundamental human rights: self-determination and the inherent right to dignity. This article proposes the development of an advance directive mechanism that provides for a person to refuse, in advance, specified intervention, thereby respecting fundamental human rights and alleviating the existing need for an agent to second-guess a person's desires and best interests.

Negotiating life choices : living with motor neurone disease

Motor neurone disease (MND) is an uncommon neurodegenerative disease that is terminal and has an insidious onset. With no known cause or cure, the disease triggers progressive death of motor neurones that causes increasing difficulties with mobility, communication, breathing and nutrition. Most research focuses on the disease process, but little is known of the illness experience from the perspective of those diagnosed with the disease. The aim of this study was to explore what it is like to live with MND and how people with the disease negotiate with others to exercise choice over the way they live. A grounded theory methodology was used to explore the life world of people diagnosed and living with MND. Data were collected via in-depth interviews, their stories and photographs, poems and books participants identified as important and fieldnotes. The textual data were analysed using constant comparative analysis. The majority of participants experienced difficulty with verbal communication. Some invited a third person to interpret their speech and others used assistive technologies such as Lightwriters and computers. Analysis revealed three constructs that, together, told the story of the MND illness experience. First, was the “diagnosis story” that described the devastating process of repeated tests had on the participants, shattering their trust in the competence of the health care system. The second construct revealed the process of living with MND as cyclical and repetitive requiring constant decision-making to adapt to the ongoing changes connected with the disease. The core theme and basic social process of “maintaining personal integrity” evolved as the third construct. This process underpinned and explained participants’ decision-making. Finally a substantive theory was conceptualised as the illness experience: “maintaining personal integrity in the face of ongoing change and adaptation”. This theory illustrates that the basic social process of maintaining personal integrity is central to decision and choice making while living with MND. The findings have implications for people with MND, their carers, health professionals and service providers. Recommendations include improved counselling services for people at the time of diagnosis; the introduction of nurse specialists to support health professionals, people diagnosed with the disease and their families; open, accessible, realistic health and funding policies.

Multi-type maltreatment : relationships between familial characteristics, maltreatment and adjustment of children and adults

This thesis examines the nature, extent and impact of multiple forms of maltreatment (multi-type maltreatment) from within a developmental victimological framework. The interrelationships between sexual abuse, physical abuse, psychological maltreatment, neglect, and witnessing family violence are assessed. The role of family variables in predicting maltreatment and the relative contribution of child maltreatment and family variables to adjustment are evaluated. Risk factors for multi-type maltreatment, and the relationship between multi-type maltreatment and adjustment are explored. The major theories of child development are reviewed. As well as exploring the relevance of developmental theories to understanding the impact of child maltreatment, factors influencing the emergence of child psychopathology are reviewed from a developmental psychopathology perspective. Ecological and developmental perspectives on how child maltreatment translates into the behavioural and emotional adjustment problems of children are integrated in the Child Maltreatment: Risk and Protection Model. After exploring some of the relevant conceptual issues, the literature on the prevalence and impact of each maltreatment type is reviewed, and the literature on multi-type maltreatment critiqued. Methodological and ethical concerns with the conduct of research in the field of child maltreatment using direct assessment of children led to the need for an instrument to assess parent perceptions of each of the types of abuse and neglect, as well as adult retrospective reports. Data are presented from two cross-sectional questionnaire-based studies using the Parent and Adult versions of the Family and Life Experiences Questionnaire which was designed to assess perceptions of children's experiences of sexual abuse, physical abuse, psychological maltreatment, neglect and witnessing family violence. Problems with the isolated focus of research on single forms of child maltreatment are addressed by the inclusion of each of these forms of child maltreatment within a single research design. Respondents for both studies were volunteers recruited from counselling agencies, medical, community health, child care and fitness centres and a first year psychology course. Parents (N=50) described their perceptions of primary school children's family characteristics, experiences of maltreatment and adjustment. Children's behavioural adjustment (internalising and externalising), sexual behaviours, emotions, self-esteem, gender identity, family adaptability and cohesion, parental traditionality, parental sexual punitiveness, interparental relationship satisfaction, and demographic characteristics are assessed in the study of Parents' perceptions. A large degree of overlap between the different types of abuse and neglect was found, with a high proportion of parents describing children's experiences of multiple forms of child maltreatment. Using both maltreatment and family characteristics to predict internalising behaviour problems, neglect and family cohesion were the only unique predictors. Family adaptability and cohesion were the only unique predictors of externalising behaviour problems. Physical and sexual abuse were not predicted from family characteristics; neglect was predicted, but no variables provided unique prediction. Unique predictors of psychological maltreatment were family cohesion, parental sexual punitiveness and divorce. Divorce was the only variable with significant unique prediction of the child witnessing family violence. Family background and family functioning were found to predict some forms of maltreatment, but to also be important factors mediating the adjustment of children, independent of maltreatment. The results are interpreted within an ecological framework, integrating risk factors for maltreatment with experiences of abuse and neglect and subsequent adjustment in childhood. Retrospective reports of adults' (N=175) own childhood family characteristics, experiences of maltreatment, and reports of their current adjustment are also studied. Included with the adult version of the FLEQ were the Trauma Symptom Checklist-40, Rosenberg's Self-esteem Scale, and the Family and Adaptability and Cohesion Evaluation Scale-II. Similar results were found in the in the Adult Study. As hypothesised, adult retrospective reports of the five different types of child maltreatment were found to be highly intercorrelated. Family characteristics predicted maltreatment and adjustment scores and discriminated between single and multi-type maltreatment. Maltreatment scores also predicted adult adjustment. As the number of maltreatment types increased, there was an increase in the number of adjustment problems reported. Alternate hypotheses regarding the possible operation of mediating and moderating processes in the relationships between family characteristics, maltreatment and the adjustment of adults were assessed. Finally, the results of these investigations are discussed and interpreted in the light of extant findings previously reviewed. Data from the two major empirical studies are used to demonstrate the overlap between different child maltreatment categories, and the extent and impact of multi-type maltreatment. The results show that children are vulnerable to more than one type of maltreatment. Individuals who experience a number of different forms of maltreatment had greater adjustment problems than those experiencing only one or two different types of abuse or neglect. Dysfunctional families place children at risk of child maltreatment. Negative family characteristics lead to adjustment problems in children and adults. The type of maltreatment having the most damaging effect on children was neglect, and in the long-term, sexual abuse. A multi-dimensional approach to prevention and intervention needs to be adopted, based on the co-morbidity of maltreatment types, and the likelihood of children experiencing further abuse or neglect of a different type. Dysfunctional family dynamics which place children at risk of multi-type maltreatment, and mediate the effects of maltreatment on adjustment, need to be specifically targeted with support and family intervention strategies. Risk-assessment measures used by Child Protection workers must include adequate knowledge of the inter-relationships between maltreatment types, and the particularly negative impact on adjustment of experiencing many forms of abuse or neglect. Suggestions for future clinical and research work in the area of child maltreatment are developed. The importance of assessing all forms of maltreatment when examining the relationships of maltreatment to adjustment is emphasised. It is recommended that prevention and intervention strategies acknowledge the interrelationships between maltreatment types.

Women, religion and social change in the Philippines : refractions of the past in urban filipinas' religious practices today

This research is an exploration of the place of religious beliefs and practices in the life of contemporary, predominantly Catholic, Filipinas in a large Quezon City Barangay in Metro Manila. I use an iterative discussion of the present in the light of historical studies, which point to women in pre-Spanish ‘Filipino’ society having been the custodians of a rich religious heritage and the central performers in a great variety of ritual activities. I contend that although the widespread Catholic evangelisation, which accompanied colonisation, privileged male religious leadership, Filipinos have retained their belief in feminine personages being primary conduits of access to spiritual agency through which the course of life is directed. In continuity with pre-Hispanic practices, religious activities continue to be conceived in popular consciousness as predominantly women’s sphere of work in the Philippines. I argue that the reason for this is that power is not conceived as a unitary, undifferentiated entity. There are gendered avenues to prestige and power in the Philippines, one of which directly concerns religious leadership and authority. The legitimacy of religious leadership in the Philippines is heavily dependent on the ability to foster and maintain harmonious social relations. At the local level, this leadership role is largely vested in mature influential women, who are the primary arbiters of social values in their local communities. I hold that Filipinos have appropriated symbols of Catholicism in ways that allow for a continuation and strengthening of their basic indigenous beliefs so that Filipinos’ religious beliefs and practices are not dichotomous, as has sometimes been argued. Rather, I illustrate from my research that present day urban Filipinos engage in a blend of formal and informal religious practices and that in the rituals associated with both of these forms of religious practice, women exercise important and influential roles. From the position of a feminist perspective I draw on individual women’s articulation of their life stories, combined with my observation and participation in the religious practices of Catholic women from different ethnic and socio-economic backgrounds, to discuss the role of Filipinas in local level community religious leadership. I make interconnections between women’s influence in this sphere, their positioning in family social relations, their role in the celebration of All Saints and All Souls Days in Metro Manila’s cemeteries and the ubiquity and importance of Marian devotions. I accompany these discussions with an extensive body of pictorial plates.

Comparison of two modes of delivery of first aid training including basic life support

Aims: Flexible-learning first aid courses are increasingly common due to reduced classroom contact time. This study compared retention of first aid knowledge and basic life support (BLS) skills three months after a two-day, classroom-based first aid course (STD) to one utilizing on-line theory learning at home followed by one day of classroom training (FLEX).
Methods: In this prospective randomized controlled trial, 256 participants with internet access and no first aid related training for at least five years were randomly allocated to a STD or FLEX course. Assessment was conducted immediately after training and again three months later. Each participant was allocated a theory and a BLS score, which were summed and averaged to create an equally-weighted ‘combined score’
of first aid knowledge and skills.
Results: There was no significant difference in theory scores between the STD and FLEX groups immediately after training and after three months. STD participants had significantly higher BLS scores immediately after training (p = 0.001) and three months later (p = 0.046). Males had significantly higher BLS scores after training (p < 0.001), but not three months later (p = 0.02). Participants older than 46 years had significantly lower BLS scores than younger participants (p < 0.001). There was no significant difference in combined scores between the STD and FLEX groups or between genders, education or age groups either immediately after training or three months later.
Conclusion: After replacing one day of classroom-based training with on-line theory training, there was no significant difference in the first aid competencies of the study population, as measured by an equallyweighted
combined score of basic life support and first aid theory.

Recovering from an acute cardiac event – the relationship between depression and life satisfaction

Aims. This study sought to measure the rates and trajectory of depression over six months following admission for an acute cardiac event and describe the relationship between depression and life satisfaction.
Background. Co-morbid depression has an impact on cardiac mortality and is associated with the significant impairment of quality of life and well-being, impairments in psychosocial function, decreased medication adherence and increased morbidity.
Design. This was a descriptive, correlational study.
Method. The study was undertaken at a large public hospital in Melbourne. Participants were asked to complete a survey containing the cardiac depression scale (CDS) and the Personal Well-being Index.
Results. This study mapped the course of depression over six months of a cohort of patients admitted for an acute cardiac event. Significant levels of depressive symptoms were found, at a level consistent with the literature. A significant correlation between depressive symptoms as measured by the CDS and the Personal Well-being Index was found.
Conclusions. Depression remains a significant problem following admission for an acute coronary event. The Personal Wellbeing Index may be a simple, effective and non-confrontational initial screening tool for those at risk of depressive symptoms in this population. Relevance to clinical practice. Despite the known impact of depression on coronary heart disease (CHD), there is limited research describing its trajectory. This study makes a compelling case for the systematic screening for depression in patients with CHD and the importance of the nursing role in identifying at risk individuals.

Young adults’ management of Type 1 diabetes during life transitions

Aim. To identify life transitions likely to impact diabetes self-care among young adults with Type 1 diabetes and their coping strategies during transition events.
Background. Relationships among psychosocial stress, adjustment, coping and metabolic control affect clinical outcomes and mental health. Life transitions represent major change and are associated with stress that temporarily affects individuals’ problem-solving, coping abilities and blood glucose levels.
Design. A qualitative interpretive inquiry.
Method. Semi-structured interviews were conducted with 20 young adults with Type 1 diabetes and a constant comparative analysis method. Data and analysis was managed using QSR NVIVO 7 software.
Results. Participants identified two significant transition groups: life development associated with adolescence, going through the education system, entering new relationships, motherhood and the workforce and relocating. Diabetes-related transitions included being diagnosed, developing diabetes complications, commencing insulin pump treatment and going on diabetes camps. Participants managed transitions using ‘strategic thinking and planning’ with strategies of ‘self-negotiation to minimise risks’; ‘managing diabetes using previous experiences’; ‘connecting with others with diabetes’; ‘actively seeing information to ‘patch’ knowledge gaps’; and ‘putting diabetes into perspective’.
Conclusions. Several strategies are used to manage diabetes during transitions. Thinking and planning strategically was integral to glycaemic control and managing transitions. The impact of transitions on diabetes needs to be explored in larger and longitudinal studies to identify concrete strategies that assist diabetes care during life transitions.
Relevance to clinical practice. It is important for health professionals to understand the emotional, social and cognitive factors operating during transitions to assist young adults with Type 1 diabetes to achieve good health outcomes by prioritising goals and plan flexible, timely, individualised and collaborative treatment.

Clinical characteristics and management of bipolar disorder in women across the life span

Though prevalent in both genders, specific consideration needs to be given when treating a woman suffering from bipolar disorder over her lifetime. Bipolar disorder is a serious and incapacitating illness affecting an estimated 5% of women. The first episode of illness in women is usually a depressive episode. Female gender has been associated with greater axis-one comorbidity, more depressive episodes, rapid cycling and mixed affective states. Special consideration is required for the treatment of bipolar disorder during reproductive events. More studies are required to better understand the course, outcome and gender-specific treatment strategies of this disorder.

Living the good life : how content providers can better conceptualize the content requirements of the ubiquitous technology user

Content provision via ubiquitous technology platforms such as smart mobile phones and personal digital assistants raises interesting practical and research challenges. Many current theoretical frameworks and models are based on assumptions which may not necessarily be valid in the case of ubiquitous technologies, which users employ in a variety of contexts and for different reasons. In this research-in-progress paper we explore how content providers can better conceptualize the content requirements of ubiquitous technology users. We introduce the principle of Continuous Quality of Life Optimization as a theoretical concept to understand the content requirements of these users. We put forth a number of propositions to guide further research and provide details about our own research approach, in which we are exploring ubiquitous content provision from the perspective of content providers.

Quality of life in restless legs syndrome: A systematic review of clinical trials and a critical review of instruments

Restless legs syndrome (RLS) is a neurological movement disorder characterized by sensory symptoms and motor disturbances. While the underlying cause remains unknown, it is suggested that 20–25% of people with RLS are affected seriously enough to require pharmacological treatment. Dopamine agonists (DAs) are the most common treatment and act by increasing the low levels of dopamine to which RLS is often attributed. A growing literature highlights the debilitating and distressing nature of this condition from the patient's perspective. While sleep problems are most commonly reported, the impact of RLS on quality of life (QOL) is wide ranging, affecting relationships with partners, sex life, family life, social life, leisure activities, friendships, everyday activities, concentration, travel, career/work, sleep, and health.

We conducted a systematic review of clinical trials in which DAs have been evaluated in terms of RLS-specific QOL, i.e. their impact on the QOL of people with RLS, and critically reviewed the development history and measurement properties of RLS-specific QOL instruments.

A systematic search using terms synonymous with RLS, DAs and QOL was conducted using Scopus software, which includes MEDLINE, PsycINFO, EMBASE, and CINAHL. Our search covered publications from 2000 (prior to which RLS-specific QOL measures did not exist) to August 2009. Trials were included in our review if they evaluated DAs for the treatment of adults with RLS and reported evaluation using an RLS-specific QOL measure. We also ran citation searches to identify papers reporting the development history and measurement properties of the identified RLS-specific QOL instruments.

Three measures of RLS-specific QOL have been developed in recent years and are reviewed here: the Restless Legs Syndrome Quality of Life (RLSQOL) questionnaire, the Restless Legs Syndrome Quality of Life Instrument (RLS-QLI), and the Quality of Life Restless Legs Syndrome (QOL-RLS) measure. Critical review indicates that each has limitations (particularly in terms of published developmental history and content validity). Eleven trials of DAs were identified that included assessment of RLS-specific QOL (nine using the RLSQOL and two using the QOL-RLS). In all studies, significant improvements in RLS-specific QOL were observed, although these were mostly short term (12 weeks) and large placebo effects were also noted.

In people with RLS, the use of DAs has been shown to improve RLS-specific QOL. Longer-term, large-scale studies may be needed to confirm these findings and demonstrate statistically significant improvements in RLS-specific QOL at lower doses. Further development of the RLS-specific QOL measures is needed to ensure that the full impact of RLS (and the full benefit of new treatments) on aspects of life identified as important to individuals is captured in future studies.

Pilot Study of clinician attitudes to insulin pump therapy: international differences and the need for a greater understanding of the patient perspective

OBJECTIVES: To identify and survey health care professionals (HCPs) attitudes to insulin pump therapy (CSII).

METHODS: Eight specialists were interviewed to explore the attitudes and beliefs about CSII. Responses were analysed thematically and used to inform the design of a new 22-item questionnaire: the Attitudes to Pump Therapy (APT) Survey. The APT was pilottested among 95 HCPs (54% male; 75.5% diabetologists/DSNs, 13.8% general practitioners) at the International Diabetes Federation (IDF) conference, 2006. Results were analysed using non-parametric statistics with bonferroni correction.

RESULTS: Analyses of interview data identified 9 themes: biomedical, perceived control of care/diabetes, technology, quality of life, financial resources, training, education & support, suitability, and evidence-base. Items were designed to reflect these themes with responses scored on a 5-point Likert scale (strongly agree—strongly disagree). No statistically significant differences
were found by gender, HCP speciality, country (and continent) of origin or proportion of patients using CSII. Most notable differences were found in relation to gross domestic product (GDP) and the potential for pump therapy to achieve tight blood glucose control (lower GDP = more agreement: p = 0.001), and result in diabetic ketoacidosis (DKA) (lower GDP = less agreement: p < 0.005). Ranked mean scores showed a split between biomedical/clinical items (N = 11) and items concerned with patient experience (N = 11). Attitudes about biomedical/clinical issues were generally clear (i.e. for 7/11 items, the mean score was “agree”) but less decisive about patient experience (i.e. for 8/11 items, the mean score was “neither agree nor disagree”).

CONCLUSION: Few subgroup differences existed, but those that did may be explained by lack of access to treatment (directly corresponding to GDP). Clinicians’ were generally clear in their attitudes regarding biomedical aspects but less so regarding patient experience. Research focusing on patient-reported outcomes is likely to offer clinicians a greater understanding of the patients’ perspective of insulin pump therapy.

Classrooms, creativity and everyday life : a continuing inquiry

The Melbourne Declaration on Educational Goals for Young Australians, as well as documents published by the Australian Curriculum and Assessment Authority (ACARA) in the lead up to the implementation of the national curriculum, all highlight the importance of students becoming ‘confident and creative individuals’ who are capable of meeting the demands posed by the 21st Century. These texts have prompted us to think again about ‘creativity’ and how the knowledge and experience embodied in the traditions in which we operate as English teachers might provide a context for implementing the national curriculum and for continuing the work that we have always done in encouraging young people’s imagination and creativity. The essay breaks up into four parts, including a reflection on the Ghosts of Curriculums Past contained in an old filing cabinet, a dialogical analysis of ACARA rhetoric about ‘creativity’ and a narrative written by Douglas in which he examines the creativity of his Year 8 students when they explored the potential of the ‘Quest’ story as a literary genre. We wrap up by locating our thinking about creativity within what, in the course of our inquiry, has emerged for us as a salient theoretical framework for understanding the creativity that young people display in classroom settings, namely the work of Raymond Williams. The sections of this essay are more or less self-contained, but we hope that cumulatively they point beyond the circumscribed notion of creativity at the heart of the ACARA documentation. The fact that the publication of The Australian Curriculum: English has motivated us to conduct this inquiry suggests that the professional practice of English teachers will always be richer and more multifaceted than this document’s attempt to contain what happens in English classrooms. The best way for teachers to respond to the new curriculum is to continue to engage in reflective practice, exploring the disjunction that will inevitably emerge between the intended curriculum and the curriculum they enact in their local settings.

Life in PBL : two PBL teams

Problem-based learning (PBL) continues to challenge educational institutions in terms of demonstrating its effectiveness. Prior studies have offered insight into the methods, application, and experiences of teaching using PBL. However, student behaviours and the learning cultures that develop in PBL settings are also important. In this paper, we present the ways students of a first year engineering course at an Australian university approach PBL. A number of PBL teams in the same subject were observed throughout two semesters with their consent. This paper reports on two of these teams. Some observations were video taped to aid analysis. The purpose of this study was to analyse and compare learning approaches that help or hinder successful group outcomes. It is evident from the data that individuals in the groups have a strong influence on what is learnt. Some students also focus more on exploiting the assessment system than on maximising their learning.