OSCE online : making assessment of clinical competencies transparent, accountable & authentic

Creating an authentic assessment which at once assesses competencies, scene management, communication and overall patient care is challenging in the competitive tertiary education market. Increasing student numbers and the cost of evaluating scenario based competencies serve to ensure the need for consistent objectivity and need for timely feedback to students on their performance. Objective structured clinical examination (OSCE) is currently the most flexible approach to competency based formative and summative assessment and widely used within paramedic degree programs. Students are understandably compelled to perform well and can be frustrated by not receiving timely and appropriate feedback. Increasingly a number of products aimed at providing a more efficient and paperless approach have begun to enter the market. These products, it is suggested are aimed at medicine programs and not at allied health professions and limited to one operating system and therefore ignore issues surrounding equity and accessibility. OSCE Online aims to address this gap in the market and is tailored to these disciplines. The application will provide a service that can be both tailored and standardised from a pre-written bank, depending upon requirement to fit around the needs of clinical competency assessment. Delivering authentic assessments to address student milestones in their training to become paramedics is the cornerstone of OSCE Online. By not being restricted to a specific device it will address issues of functionality, adaptability, accessibility, authenticity and importantly: transparency and accountability by producing contemporaneous data allowing issues to be easily identified and rectified.

A preliminary study into the environmental and economic consequences of a sugar factory depithing operation

Bagasse stockpile operations have the potential to lead to adverse environmental and social impacts. Dust releases can cause occupational health and safety concerns for factory workers and dust emissions impact on the surrounding community. Preliminary modelling showed that bagasse depithing would likely reduce the environmental risks, particularly dust emissions, associated with large-scale bagasse stockpiling operations. Dust emission properties were measured and used for dispersion modelling with favourable outcomes. Modelling showed a 70% reduction in peak ground level concentrations of PM10 dust (particles with an aerodynamic diameter less than 10 μm) from operations on depithed bagasse stockpiles compared to similar operations on stockpiles of whole bagasse. However, the costs of a depithing operation at a sugar factory were estimated to be approximately $2.1 million in capital expenditure to process 100 000 t/y of bagasse and operating costs were 200 000 p.a. The total capital cost for a 10 000 t/y operation was approximately $1.6 million. The cost of depithing based on a discounted cash flow analysis was $5.50 per tonne of bagasse for the 100 000 t/y scenario. This may make depithing prohibitively expensive in many situations if installed exclusively as a dust control measure.

Analysis of temporary traffic control cost items in transportation construction bidding process

Temporary Traffic Control Plans (TCP’s), which provide construction phasing to maintain traffic during construction operations, are integral component of highway construction project design. Using the initial design, designers develop estimated quantities for the required TCP devices that become the basis for bids submitted by highway contractors. However, actual as-built quantities are often significantly different from the engineer’s original estimate. The total cost of TCP phasing on highway construction projects amounts to 6–10% of the total construction cost. Variations between engineer estimated quantities and final quantities contribute to reduced cost control, increased chances of cost related litigations, and bid rankings and selection. Statistical analyses of over 2000 highway construction projects were performed to determine the sources of variation, which later were used as the basis of development for an automated-hybrid prediction model that uses multiple regressions and heuristic rules to provide accurate TCP quantities and costs. The predictive accuracy of the model developed was demonstrated through several case studies.

Curse or cure? Revisiting state, capital and resources

WA’s experience, as portrayed in this volume, not only highlights the changeable nature of the mining industry, the volatility of global commodity markets and the impact of global capital on people and place, it also draws into question the promise of lasting value derived from resource development as currently practiced. It is in this context that Chapter 18 revisits WA's resource boom and assesses the sustainability of resource-led development in the state, to arrive at an answer to the question of ‘curse or cure?’. Opening up the discourse beyond the dominant developmentalist narrative invites discussion on new perspectives of economic sustainability that include well-being, equity and the protection of people, culture and place.

Thoracoscopic scoliosis surgery – a cheaper option? A cost analysis of 189 consecutive cases

INTRODUCTION: Increasing health care costs, limited resources and increased demand makes cost effective and cost-efficient delivery of Adolescent Idiopathic Scoliosis (AIS) management paramount. Rising implant costs in deformity correction surgery have prompted analysis of whether high implant densities are justified. The objective of this study was to analyse the costs of thoracoscopic scoliosis surgery, comparing initial learning curve costs with those of the established technique and to the costs involved in posterior instrumented fusion from the literature. METHODS: 189 consecutive cases from April 2000 to July 2011 were assessed with a minimum of 2 years follow-up. Information was gathered from a prospective database covering perioperative factors, clinical and radiological outcomes, complications and patient reported outcomes. The patients were divided into three groups to allow comparison; 1. A learning curve cohort, 2. An intermediate cohort and 3. A third cohort of patients, using our established technique. Hospital finance records and implant manufacturer figures were corrected to 2013 costs. A literature review of AIS management costs and implant density in similar curve types was performed. RESULTS: The mean pre-op Cobb angle was 53°(95%CI 0.4) and was corrected postop to mean 22.9°(CI 0.4). The overall complication rate was 20.6%, primarily in the first cohort, with a rate of 5.6% in the third cohort. The average total costs were $46,732, operating room costs of $10,301 (22.0%) and ICU costs of $4620 (9.8%). The mean number of screws placed was 7.1 (CI 0.04) with a single rod used for each case giving average implant costs of $14,004 (29.9%). Comparison of the three groups revealed higher implant costs as the technique evolved to that in use today, from $13,049 in Group 1 to $14577 in Group 3 (P<0.001). Conversely operating room costs reduced from $10,621 in Group 1 to $7573 (P<0.001) in Group 3. ICU stay was reduced from an average of 1.2 to 0 days. In-patient stay was significantly (P=0.006) lower in Groups 2 and 3 (5.4 days) than Group 1 (5.9 days) (i.e. a reduction in cost of approximately $6,140). CONCLUSIONS: The evolution of our thoracoscopic anterior scoliosis correction has resulted in an increase in the number of levels fused and reduction in complication rate. Implant costs have risen as a result, however, there has been a concurrent decrease in those costs generated by operating room use, ICU and in-patient stay with increasing experience. Literature review of equivalent curve types treated posteriorly shows similar perioperative factors but higher implant density, 69-83% compared to the 50% in this study. Thoracoscopic Scoliosis surgery presents a low density, reliable, efficient and effective option for selected curves. A cost analysis of Thoracoscopic Scoliosis Surgery using financial records and a prospectively collected database of all patients since 2000, demonstrating a clear cost advantage compared to equivalent posterior instrumentation and fusion.

Dynamic modelling of long-term care decisions

This paper describes and analyzes research on the dynamics of long-term care and the policy relevance of identifying the sources of persistence in caregiving arrangements (including the effect of dynamics on parameter estimates, implications for family welfare, parent welfare, child welfare, and cost of government programs). We discuss sources and causes of observed persistence in caregiving arrangements including inertia/state dependence (confounded by unobserved heterogeneity) and costs of changing caregivers. We comment on causes of dynamics including learning/human capital accumulation; burnout; and game-playing. We suggest how to deal with endogenous geography; dynamics in discrete and continuous choices; and equilibrium issues (multiple equilibria, dynamic equilibria). We also present an overview of commonly used longitudinal data sets and evaluate their relative advantages/disadvantages. We also discuss other data issues related to noisy measures of wealth and family structure. Finally, we suggest some methods to handle econometric problems such as endogeneous geography. © 2014 Springer Science+Business Media New York.

The activation, appropriation and practices of student-equity policy in Australian higher education

Current national reforms in Australian higher education have prioritised efforts to reduce educational disadvantage within a vernacular expression of neoliberal education policy. Student-equity policy in universities is enmeshed in a set of competitive student recruitment relations. This raises practice-based tensions as universities strive to meet specific institutional targets for low-socio-economic status (SES) and Indigenous student participation, whilst broadening participation more generally within the sector. This paper seeks empirically to trace the activation and appropriation of federal policy through two sites of higher education policy practices: a state government-sponsored equity practitioner body and two differently positioned universities, Dawson and McIllwraith, as they engage with low-SES schools. Working together Dorothy Smith’s insights into the textually mediated activation of local practices, Levinson and colleagues’ concept of the local appropriation of authorised policy, and Bourdieu’s notion of the contested field, we demonstrate that the generation of state level and institutionally specific policies for student-equity practices not only articulates to federal policy, but also appropriates the ruling relations of mandated policy. Further, the scope of these creative local appropriations is organised within a hierarchical academic field through which particular institutional imperatives, as well as the needs of low-SES students, are negotiated. The analysis demonstrates the vernacularisation of policy in the national rearticulation of global discourses, in appropriation at the level of the state body and in the practices of equity workers.

The value of tail risk hedging in defined contribution plans: What does history tell us

Hedging against tail events in equity markets has been forcefully advocated in the aftermath of recent global financial crisis. Whether this is beneficial to long horizon investors like employees enrolled in defined contribution (DC) plans, however, has been subject to criticism. We conduct historical simulation since 1928 to examine the effectiveness of active and passive tail risk hedging using out of money put options for hypothetical equity portfolios of DC plan participants with 20 years to retirement. Our findings show that the cost of tail hedging exceeds the benefits for a majority of the plan participants during the sample period. However, for a significant number of simulations, hedging result in superior outcomes relative to an unhedged position. Active tail hedging is more effective when employees confront several panic-driven periods characterized by short and sharp market swings in the equity markets over the investment horizon. Passive hedging, on the other hand, proves beneficial when they encounter an extremely rare event like the Great Depression as equity markets go into deep and prolonged decline.

Informal caring networks for people at end of life: Building social capital in Australian communities

The care of a person living at home near the end of their life is predominantly provided by family carers with the support of health services such as palliative care. In addition, informal caring networks also contribute at times to the support to the dying person and their carer. In this way, these networks can promote social capital in the communities from which they are drawn. This social approach to end of life care enhances community capacity to provide support to those dying at home and their carers. This article examines relevant published literature to explore the conceptual foundations of informal caring networks, examining the place of social capital and community development in the provision of end of life care at home, particularly in the Australian context.

Rural dispositions of floating children within the field of Beijing schools: can disadvantaged rural habitus turn into recognised cultural capital?

The rapid pace of urbanisation in China has seen a massive increase in the movement of the rural population to work and live in urban regions. In this large-scale migration context, the educational, health, and psychological problems of floating children are becoming increasingly visible. Different from extant studies, we focus our investigation on the rural dispositions of floating children through interviews with leaders, teachers, and students in four schools in Beijing. Drawing on Bourdieu’s key notions of habitus, capital, and field, our study indicates that the rural habitus of floating children can differentiate these children from their urban peers. This habitus can be marginalised and stigmatised in certain fields but can be recognised and valued as capital in other fields. Our paper offers some implications for research and practice in relation to the schooling of floating children.

The cost and time effectiveness of osseointegration compared to the traditional socket prosthesis

Individuals with limb amputation fitted with conventional socket-suspended prostheses often experience socket related discomfort leading to a significant decrease in quality of life.[1-14] Most of these concerns can be overcome with osseointegration, a direct skeletal fixation method where the prosthetic componentry are directly attached to the fixation, resulting in the redundancy of the traditional socket system. There are two stages of osseointegration; Stage one, a titanium implant is inserted into the marrow space of residual limb bone and Stage two, a titanium extension is attached to the fixture. This surgical procedure is currently blooming worldwide, particularly within Queensland. Whilst providing improvements in quality of life, this new method also has potential to minimise the cost required for an amputee to ambulate during daily living. Thus, the aim of this project was to compare the differences in mean cost of services, cost of componentry and labour hours when using osseointegration compared to traditional socket-based prostheses. Data were extracted from Queensland Artificial Limb Services (QALS) database to determine cost of services, type of services and labour hours required to maintain a prosthetic limb. Five trans-femoral amputee male participants (age 46.4±10.1 yrs; height 175.4±16.3 cm; mass 83.8±14.0 kg; time since second stage 22.0± 8.1 mths) met inclusion criteria which was patient had to be more than 12 months post stage two osseointegration procedure. The socket and osseointegration prosthesis variables examined were the mean hours of labour, mean cost of services and mean cost of prosthetic componentry. Statistical analyses were conducted using an ANOVA. The results identified that there were only significant differences in the number of labour hours (p = 0.005) and cost of services (p = 0.021) when comparing the socket and osseointegration prosthetic type. These results identified that the cost of componentry were comparable between the two methods.

The effects of gas and air flow distributions on the performance of the Farleigh No. 3 boiler

As more raw sugar factories become involved in the manufacture of by-products and cogeneration, bagasse is becoming an increasingly valuable commodity. However, in most factories, most of the bagasse produced is used to generate steam in relatively old and inefficient boilers. Efficient bagasse fired boilers are a high capital cost item and the cost of supplying the steam required to run a sugar factory by other means is prohibitive. For many factories a more realistic way to reduce bagasse consumption is to increase the efficiency of existing boilers. The Farleigh No. 3 boiler is a relatively old low efficiency boiler. Like many in the industry, the performance of this boiler has been adversely affected by uneven gas and air flow distributions and air heater leaks. The combustion performance and efficiency of this boiler have been significantly improved by making the gas and air flow distributions through the boiler more uniform and repairing the air heater. The estimated bagasse savings easily justify the cost of the boiler improvements.

Assessing the cost-effectiveness of water quality interventions in South-East Queensland

The focus of this article is on the cost-effectiveness of mitigation strategies to reduce pollution loads and improve water quality in South-East Queensland. Scenarios were developed about the types of catchment interventions that could be considered, and the resulting changes in water quality indicators that may result. Once these catchment scenarios were modelled, the range of expected outcomes was assessed and the costs of mitigation interventions were estimated. Strategies considered include point and non-point source interventions. Predicted reductions in pollution levels were calculated for each action based on the expected population growth. The cost of the interventions included the full investment and annual running costs as well as planned public investment by the state agencies. Cost-effectiveness of strategies is likely to vary according to whether suspended sediments, nitrogen or phosphorus loads are being targeted.

Impact of control strategies on bellyache bush (Jatropha gossypiifolia L.) mortality, seedling recruitment, population dynamics, pasture yield and cost analysis

Bellyache bush (Jatropha gossypiifolia L.) is an invasive weed that has the potential to greatly reduce biodiversity and pasture productivity in northern Australia’s rangelands. This paper reports an approach to develop best practice options for controlling medium to dense infestations of bellyache bush using combinations of control methods. The efficacy of five single treatments including foliar spraying, slashing, stick raking, burning and do nothing (control) were compared against 15 combinations of these treatments over 4 successive years. Treatments were evaluated using several attributes, including plant mortality, changes in population demographics, seedling recruitment, pasture yield and cost of treatment. Foliar spraying once each year for 4 years proved the most cost-effective control strategy, with no bellyache bush plants recorded at the end of the study. Single applications of slashing, stick raking and to a lesser extent burning, when followed up with foliar spraying also led to significantly reduced densities of bellyache bush and changed the population from a growing one to a declining one. Total experimental cost estimates over 4 successive years for treatments where burning, stick raking, foliar spraying, and slashing were followed with foliar spraying were AU$408, AU$584, AU$802 and AU$789 ha–1, respectively. Maximum pasture yield of 5.4 t ha–1 occurred with repeated foliar spraying. This study recommends that treatment combinations using either foliar spraying alone or as a follow up with slashing, stick raking or burning are best practice options following consideration of the level of control, changes in pasture yield and cost effectiveness.

Routine Measurement of Health-Related Quality of Life in Assessing Cost-Effectiveness in Secondary Health Care

Aims: The aims of this study were 1) to identify and describe health economic studies that have used quality-adjusted life years (QALYs) based on actual measurements of patients' health-related quality of life (HRQoL); 2) to test the feasibility of routine collection of health-related quality of life (HRQoL) data as an indicator of effectiveness of secondary health care; and 3) to establish and compare the cost-utility of three large-volume surgical procedures in a real-world setting in the Helsinki University Central Hospital, a large referral hospital providing secondary and tertiary health-care services for a population of approximately 1.4 million. Patients and methods: So as to identify studies that have used QALYs as an outcome measure, a systematic search of the literature was performed using the Medline, Embase, CINAHL, SCI and Cochrane Library electronic databases. Initial screening of the identified articles involved two reviewers independently reading the abstracts; the full-text articles were also evaluated independently by two reviewers, with a third reviewer used in cases where the two reviewers could not agree a consensus on which articles should be included. The feasibility of routinely evaluating the cost-effectiveness of secondary health care was tested by setting up a system for collecting HRQoL data on approximately 4 900 patients' HRQoL before and after operative treatments performed in the hospital. The HRQoL data used as an indicator of treatment effectiveness was combined with diagnostic and financial indicators routinely collected in the hospital. To compare the cost-effectiveness of three surgical interventions, 712 patients admitted for routine operative treatment completed the 15D HRQoL questionnaire before and also 3-12 months after the operation. QALYs were calculated using the obtained utility data and expected remaining life years of the patients. Direct hospital costs were obtained from the clinical patient administration database of the hospital and a cost-utility analysis was performed from the perspective of the provider of secondary health care services. Main results: The systematic review (Study I) showed that although QALYs gained are considered an important measure of the effectiveness of health care, the number of studies in which QALYs are based on actual measurements of patients' HRQoL is still fairly limited. Of the reviewed full-text articles, only 70 reported QALYs based on actual before after measurements using a valid HRQoL instrument. Collection of simple cost-effectiveness data in secondary health care is feasible and could easily be expanded and performed on a routine basis (Study II). It allows meaningful comparisons between various treatments and provides a means for allocating limited health care resources. The cost per QALY gained was 2 770 for cervical operations and 1 740 for lumbar operations. In cases where surgery was delayed the cost per QALY was doubled (Study III). The cost per QALY ranges between subgroups in cataract surgery (Study IV). The cost per QALY gained was 5 130 for patients having both eyes operated on and 8 210 for patients with only one eye operated on during the 6-month follow-up. In patients whose first eye had been operated on previous to the study period, the mean HRQoL deteriorated after surgery, thus precluding the establishment of the cost per QALY. In arthroplasty patients (Study V) the mean cost per QALY gained in a one-year period was 6 710 for primary hip replacement, 52 270 for revision hip replacement, and 14 000 for primary knee replacement. Conclusions: Although the importance of cost-utility analyses has during recent years been stressed, there are only a limited number of studies in which the evaluation is based on patients own assessment of the treatment effectiveness. Most of the cost-effectiveness and cost-utility analyses are based on modeling that employs expert opinion regarding the outcome of treatment, not on patient-derived assessments. Routine collection of effectiveness information from patients entering treatment in secondary health care turned out to be easy enough and did not, for instance, require additional personnel on the wards in which the study was executed. The mean patient response rate was more than 70 %, suggesting that patients were happy to participate and appreciated the fact that the hospital showed an interest in their well-being even after the actual treatment episode had ended. Spinal surgery leads to a statistically significant and clinically important improvement in HRQoL. The cost per QALY gained was reasonable, at less than half of that observed for instance for hip replacement surgery. However, prolonged waiting for an operation approximately doubled the cost per QALY gained from the surgical intervention. The mean utility gain following routine cataract surgery in a real world setting was relatively small and confined mostly to patients who had had both eyes operated on. The cost of cataract surgery per QALY gained was higher than previously reported and was associated with considerable degree of uncertainty. Hip and knee replacement both improve HRQoL. The cost per QALY gained from knee replacement is two-fold compared to hip replacement. Cost-utility results from the three studied specialties showed that there is great variation in the cost-utility of surgical interventions performed in a real-world setting even when only common, widely accepted interventions are considered. However, the cost per QALY of all the studied interventions, except for revision hip arthroplasty, was well below 50 000, this figure being sometimes cited in the literature as a threshold level for the cost-effectiveness of an intervention. Based on the present study it may be concluded that routine evaluation of the cost-utility of secondary health care is feasible and produces information essential for a rational and balanced allocation of scarce health care resources.