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.

Estimating the cost of health care–associated infections : mind your p’s and q’s

Monetary valuations of the economic cost of health care–associated infections (HAIs) are important for decision making and should be estimated accurately. Erroneously high estimates of costs, designed to jolt decision makers into action, may do more harm than good in the struggle to attract funding for infection control. Expectations among policy makers might be raised, and then they are disappointed when the reduction in the number of HAIs does not yield the anticipated cost saving. For this article, we critically review the field and discuss 3 questions. Why measure the cost of an HAI? What outcome should be used to measure the cost of an HAI? What is the best method for making this measurement? The aim is to encourage researchers to collect and then disseminate information that accurately guides decisions about the economic value of expanding or changing current infection control activities.

Elements of an environmental offsets policy : a working paper towards a policy for an environmental banking scheme appropriate for Queensland

In the past eight years, Australia has adopted the use of environmental offsets as a means to compensate for environmental degradation from development. Queensland has more environmental offsetting policies than any other Australian State or Territory. The methodology has profound effects on development companies, landowners (both private and public), regional land planning, organizations, government agencies, monetary banking institutions and environmental conservation bodies.

Home sustainability policy and mandatory disclosure. a survey of buyer and seller participation and awareness in Qld

Sustainability Declarations were introduced by the Queensland State Government on 1 January 2010 as a mandatory disclosure measure for all dwelling sales in the State. The purpose of this paper is to assess the impact this policy decision has had in the homebuyer decision-making process in the first year since its introduction and to consider the effectiveness of the legislation in meeting its policy objectives. This quantitative research comprised a two-part process: the first stage surveyed the level of compliance by the real estate industry with the legislative requirements. Stage two comprised an online survey of Real Estate Institute of Queensland members to determine what impact the Sustainability Declaration has had on home buyer decision making and how effective the legislative mechanisms have been in achieving the policy objectives. This paper assesses the initial impact of this initiative over its first year in operation. These preliminary findings indicate a high level of compliance from the real estate industry, however results confirm that sustainability is yet to become a criterion of relevance to the majority of homebuyers in Queensland. These quantitative findings support anecdotal evidence that the objectives of the legislation to increase homebuyer awareness and relevance of sustainability issues in the home are not being achieved. Sustainability Declarations are a first step in raising homebuyer awareness of the importance of sustainability in housing. Further monitoring of this impact will be carried out over time. This is the first research undertaken to assess the impact of this new mandatory disclosure legislation in Queensland, Australia. The findings will inform policy makers and assist them to assess the effectiveness of the current legislation in achieving its policy objectives.

Comments on the Australian Accounting Research Foundation's Legislation Policy Discussion Paper NO.4 (A framework for financial reporting by incorporated associations)

The Australian Accounting Research Foundation (AARF) recently issued Legislative Policy Discussion Paper No.4 which proposes a framework for financial reporting by Australian incorporated associations.This paper comments on both the merits and deficiencies of the proposal. In particular it notes that the proposal simply advocates that the application of differential reporting, accounting standards, and the conceptual framework be imposed on incorporated associations by amended statutes. It is noted that in light of long experience in the corporate sector, he espoused benefits of such a move may not eventuate. Further, concern is expressed that the proposal is a blank cheque one because of the inadequacy of existing relevant accounting standards and the proposal to introduce new relevant standards. Another major defect in the proposal is that it emanates from accountants who acknowledge in their conceptual framework, the need for external reports to report on performance through both financial and non-financial reporting methods. Despite that acknowledgment, the standard set of external reports prepared by accountants do not measure performance as defined in their own conceptual framework (SAC 2) and in their auditing pronouncements (AUP 33), and they have restricted their domain to financial reporting (SAC 2). Accordingly the proposal appears to be seriously deficient and it is suggested that it be rejected and a new proposal be prepared by a multi-party group free from vested interests.

A parcel-scale assessment tool to measure sustainability through urban ecosystem components : the MUSIX model

In recent years a number of urban sustainability assessment frameworks are developed to better inform policy formulation and decision-making processes. This paper introduces one of these attempts in developing a comprehensive assessment tool—i.e., Micro-level Urban-ecosystem Sustainability IndeX (MUSIX). Being an indicator-based indexing model, MUSIX investigates the environmental impacts of land-uses on urban sustainability by measuring urban ecosystem components in local scale. The paper presents the methodology of MUSIX and demonstrates the performance of the model in a pilot test-bed—i.e., in Gold Coast, Australia. The model provides useful insights on the sustainability performance of the test-bed area. The parcel-scale findings of the indicators are used to identify local problems considering six main issues of urban development—i.e., hydrology; ecology; pollution; location; design, and; efficiency. The composite index score is used to propose betterment strategies to guide the development of local area plans in conjunction with the City's Planning Scheme. In overall, this study has shown that parcel-scale environmental data provides an overview of the local sustainability in urban areas as in the example of Gold Coast, which can also be used for setting environmental policy, objectives and targets.

Fertility in Australia: The role of policy and the labour market

One of the most discussed topics in labour and demographic studies, population ageing and stability, is closely related to fertility choices. This thesis explores recent developments in the fertility literature in the context of Australia. We investigate individual preferences for child bearing, the determinants of fertility decisions and the effectiveness of policies implemented by the government aimed at improving total fertility. The first study highlights the impact of monetary incentives on the decision to bear children in light of potentially differential responses across the native and immigrant population. The second study analyses the role of unemployment and job stability on the fertility choices of women. The final study examines whether the quality-quantity trade-off exists for Australian families and explores the impact of siblings on a child's health and educational outcomes.

Transportation disadvantage impedance indexing: A methodological approach to reduce policy shortcomings

Access to transport systems and the connection to such systems provided to essential economic and social activities are critical to determine households' transportation disadvantage levels. In spite of the developments in better identifying transportation disadvantaged groups, the lack of effective policies resulted in the continuum of the issue as a significant problem. This paper undertakes a pilot case investigation as test bed for a new approach developed to reduce transportation policy shortcomings. The approach, ‘disadvantage-impedance index’, aims to ease transportation disadvantages by employing representative parameters to measure the differences between policy alternatives run in a simulation environment. Implemented in the Japanese town of Arao, the index uses trip-making behaviour and resident stated preference data. The results of the index reveal that even a slight improvement in accessibility and travel quality indicators makes a significant difference in easing disadvantages. The index, integrated into a four-step model, proves to be highly robust and useful in terms of quick diagnosis in capturing effective actions, and developing potentially efficient policies.

Allied health growth: What we do not measure we cannot manage

Background Data describing the Australian allied health workforce is inadequate and so insufficient for workforce planning. National health policy reform requires that health-care models take into account future workforce requirements, the distribution and work contexts of existing practitioners, training needs, workforce roles and scope of practice. Good information on this workforce is essential for managing services as demands increase, accountability of practitioners, measurement of outcomes and benchmarking against other jurisdictions. A comprehensive data set is essential to underpin policy and planning to meet future health workforce needs. Discussion Some data on allied health professions is managed by the Australian Health Practitioner Regulation Agency; however, there is limited information regarding several core allied health professions. A global registration and accreditation scheme recognizing all allied health professions might provide safeguards and credibility for professionals and their clients. Summary Arguments are presented about inconsistencies and voids in the available information about allied health services. Remedying these information deficits is essential to underpin policy and planning for future health workforce needs. We make the case for a comprehensive national data set based on a broad and inclusive sampling process across the allied health population.

The enhanced Russell-based directional distance measure with undesirable outputs: Numerical example considering CO2 emissions

Following the spirit of the enhanced Russell graph measure, this paper proposes an enhanced Russell-based directional distance measure (ERBDDM) model for dealing with desirable and undesirable outputs in data envelopment analysis (DEA) and allowing some inputs and outputs to be zero. The proposed method is analogous to the output oriented slacks-based measure (OSBM) and directional output distance function approach because it allows the expansion of desirable outputs and the contraction of undesirable outputs. The ERBDDM is superior to the OSBM model and traditional approach since it is not only able to identify all the inefficiency slacks just as the latter, but also avoids the misperception and misspecification of the former, which fails to identify null-jointness production of goods and bads. The paper also imposes a strong complementary slackness condition on the ERBDDM model to deal with the occurrence of multiple projections. Furthermore, we use the Penn Table data to help us explore our new approach in the context of environmental policy evaluations and guidance for performance improvements in 111 countries.

Medicalising Prohibition : Harm reduction in Finnish and International Drug Policy

The increase in drug use and related harms in the late 1990s in Finland has come to be referred to as the second drug wave. In addition to using criminal justice as a basis of drug policy, new kinds of drug regulation were introduced. Some of the new regulation strategies were referred to as "harm reduction". The most widely known practices of harm reduction include needle and syringe exchange programmes for intravenous drug users and medicinal substitution and maintenance treatment programmes for opiate users. The purpose of the study is to examine the change of drug policy in Finland and particularly the political struggle surrounding harm reduction in the context of this change. The aim is, first, to analyse the content of harm reduction policy and the dynamics of its emergence and, second, to assess to what extent harm reduction undermines or threatens traditional drug policy. The concept of harm reduction is typically associated with a drug policy strategy that employs the public health approach and where the principal focus of regulation is on drug-related health harms and risks. On the other hand, harm reduction policy has also been given other interpretations, relating, in particular, to human rights and social equality. In Finland, harm reduction can also be seen to have its roots in criminal policy. The general conclusion of the study is that rather than posing a threat to a prohibitionist drug policy, harm reduction has come to form part of it. The implementation of harm reduction by setting up health counselling centres for drug users with the main focus on needle exchange and by extending substitution treatment has implied the creation of specialised services based on medical expertise and an increasing involvement of the medical profession in addressing drug problems. At the same time the criminal justice control of drug use has been intensified. Accordingly, harm reduction has not entailed a shift to a more liberal drug policy nor has it undermined the traditional policy with its emphasis on total drug prohibition. Instead, harm reduction in combination with a prohibitionist penal policy constitutes a new dual-track drug policy paradigm. The study draws on the constructionist tradition of research on social problems and movements, where the analysis centres on claims made about social problems, claim-makers, ways of making claims and related social mobilisation. The research material mainly consists of administrative documents and interviews with key stakeholders. The doctoral study consists of five original articles and a summary article. The first article gives an overview of the strained process of change of drug policy and policy trends around the turn of the millennium. The second article focuses on the concept of harm reduction and the international organisations and groupings involved in defining it. The third article describes the process that in 1996 97 led to the creation of the first Finnish national drug policy strategy by reconciling mutually contradictory views of addressing the drug problem, at the same as the way was paved for harm reduction measures. The fourth article seeks to explain the relatively rapid diffusion of needle exchange programmes after 1996. The fifth article assesses substitution treatment as a harm reduction measure from the viewpoint of the associations of opioid users and their family members.

Assessment of Nanoscience and Nanotechnology Initiatives in India

Nanotechnology is a new technology which is generating a lot of interest among academicians, practitioners and scientists. Critical research is being carried out in this area all over the world.Governments are creating policy initiatives to promote developments it the nanoscale science and technology developments. Private investment is also seeing a rising trend. Large number of academic institutions and national laboratories has set up research centers that are workingon the multiple applications of nanotechnology. Wide ranges of applications are claimed for nanotechnology. This consists of materials, chemicals, textiles, semiconductors, to wonder drug delivery systems and diagnostics. Nanotechnology is considered to be a next big wave of technology after information technology and biotechnology. In fact, nanotechnology holds the promise of advances that exceed those achieved in recent decades in computers and biotechnology. Much interest in nanotechnology also could be because of the fact that enormous monetary benefits are expected from nanotechnology based products. According to NSF, revenues from nanotechnology could touch $ 1 trillion by 2015. However much of the benefits are projected ones. Realizing claimed benefits require successful development of nanoscience andv nanotechnology research efforts. That is the journey of invention to innovation has to be completed. For this to happen the technology has to flow from laboratory to market. Nanoscience and nanotechnology research efforts have to come out in the form of new products, new processes, and new platforms.India has also started its Nanoscience and Nanotechnology development program in under its 10(th) Five Year Plan and funds worth Rs. One billion have been allocated for Nanoscience and Nanotechnology Research and Development. The aim of the paper is to assess Nanoscience and Nanotechnology initiatives in India. We propose a conceptual model derived from theresource based view of the innovation. We have developed a structured questionnaire to measure the constructs in the conceptual model. Responses have been collected from 115 scientists and engineers working in the field of Nanoscience and Nanotechnology. The responses have been analyzed further by using Principal Component Analysis, Cluster Analysis and Regression Analysis.

Worksite Fitness Policy in an Intellectual Capital Framework

In a framework of Intellectual Capital (IC), the effects and interactions of a Worksite Fitness Program (WFP) policy was studied with a multidisciplinary approach. In a preliminary study, indicators for physical activity (PAI), physical fitness (PFI), activity in WFP on a regular (WFPI) and on a events basis (WFPE) were created in line with positive findings regarding the associations between physical activity and fitness patterns and sick leave, perceived health, and self-assessed work ability. The intensity of physical activity was found to be the most important variable to predict positive associations with the above mentioned wellness parameters. In four case study follow-up settings, the effects and interactions of physical activity and fitness patterns and the company’s WFP-policy on different elements of IC were studied. Qualitative methods were applied in constructing indicators and a descriptive IC measure for each case company. In cross-sectional and follow-up settings, several findings with respect to IC were found regarding physical activity in general and activity in WFP in particular. Findings were relatively strong in health and wellness related indicators in Human Capital, where, as also in Structural Capital indicators such as the company climate and employee-superior relationship, revealed positive associations. Physical activity patterns were found to act in minor role in Relational Capital. Overall, WFP was seen to be an integrated part of Structural Capital. From the viewpoint of Worksite Fitness Program as a phenomenon, this study positioned WFP as an active element of Intellectual Capital. The literature in the field of WFP emphasizes the role of WFP as an instrument to activate employees in physical activity, and thus promote their health and wellbeing. With the wider perspective the active and long range WFP policy can support a company’s Structural and Relational Capital in line with the fundamental role it has on Human Capital.

The New Keynesian Monetary Model: Does it Show the Comovement Between Output and Inflation in the U.S.?

Published as article in: Journal of Economic Dynamics and Control (2008), 32(May), pp. 1466-1488.

Should Fiscal Policy be different in a Non-Competitive Framework?

Published as an article in: Journal of Monetary Economics, 2003, vol. 50, issue 6, pages 1311-1331.