Bayesian hierarchical models in statistical quality control methods to improve healthcare in hospitals

Quality oriented management systems and methods have become the dominant business and governance paradigm. From this perspective, satisfying customers’ expectations by supplying reliable, good quality products and services is the key factor for an organization and even government. During recent decades, Statistical Quality Control (SQC) methods have been developed as the technical core of quality management and continuous improvement philosophy and now are being applied widely to improve the quality of products and services in industrial and business sectors. Recently SQC tools, in particular quality control charts, have been used in healthcare surveillance. In some cases, these tools have been modified and developed to better suit the health sector characteristics and needs. It seems that some of the work in the healthcare area has evolved independently of the development of industrial statistical process control methods. Therefore analysing and comparing paradigms and the characteristics of quality control charts and techniques across the different sectors presents some opportunities for transferring knowledge and future development in each sectors. Meanwhile considering capabilities of Bayesian approach particularly Bayesian hierarchical models and computational techniques in which all uncertainty are expressed as a structure of probability, facilitates decision making and cost-effectiveness analyses. Therefore, this research investigates the use of quality improvement cycle in a health vii setting using clinical data from a hospital. The need of clinical data for monitoring purposes is investigated in two aspects. A framework and appropriate tools from the industrial context are proposed and applied to evaluate and improve data quality in available datasets and data flow; then a data capturing algorithm using Bayesian decision making methods is developed to determine economical sample size for statistical analyses within the quality improvement cycle. Following ensuring clinical data quality, some characteristics of control charts in the health context including the necessity of monitoring attribute data and correlated quality characteristics are considered. To this end, multivariate control charts from an industrial context are adapted to monitor radiation delivered to patients undergoing diagnostic coronary angiogram and various risk-adjusted control charts are constructed and investigated in monitoring binary outcomes of clinical interventions as well as postintervention survival time. Meanwhile, adoption of a Bayesian approach is proposed as a new framework in estimation of change point following control chart’s signal. This estimate aims to facilitate root causes efforts in quality improvement cycle since it cuts the search for the potential causes of detected changes to a tighter time-frame prior to the signal. This approach enables us to obtain highly informative estimates for change point parameters since probability distribution based results are obtained. Using Bayesian hierarchical models and Markov chain Monte Carlo computational methods, Bayesian estimators of the time and the magnitude of various change scenarios including step change, linear trend and multiple change in a Poisson process are developed and investigated. The benefits of change point investigation is revisited and promoted in monitoring hospital outcomes where the developed Bayesian estimator reports the true time of the shifts, compared to priori known causes, detected by control charts in monitoring rate of excess usage of blood products and major adverse events during and after cardiac surgery in a local hospital. The development of the Bayesian change point estimators are then followed in a healthcare surveillances for processes in which pre-intervention characteristics of patients are viii affecting the outcomes. In this setting, at first, the Bayesian estimator is extended to capture the patient mix, covariates, through risk models underlying risk-adjusted control charts. Variations of the estimator are developed to estimate the true time of step changes and linear trends in odds ratio of intensive care unit outcomes in a local hospital. Secondly, the Bayesian estimator is extended to identify the time of a shift in mean survival time after a clinical intervention which is being monitored by riskadjusted survival time control charts. In this context, the survival time after a clinical intervention is also affected by patient mix and the survival function is constructed using survival prediction model. The simulation study undertaken in each research component and obtained results highly recommend the developed Bayesian estimators as a strong alternative in change point estimation within quality improvement cycle in healthcare surveillances as well as industrial and business contexts. The superiority of the proposed Bayesian framework and estimators are enhanced when probability quantification, flexibility and generalizability of the developed model are also considered. The empirical results and simulations indicate that the Bayesian estimators are a strong alternative in change point estimation within quality improvement cycle in healthcare surveillances. The superiority of the proposed Bayesian framework and estimators are enhanced when probability quantification, flexibility and generalizability of the developed model are also considered. The advantages of the Bayesian approach seen in general context of quality control may also be extended in the industrial and business domains where quality monitoring was initially developed.

A potential HIV epidemic among male street laborers in urban Vietnam

Background: Mass migration to Asian cities is a defining phenomenon of the present age, as hundreds of millions of people move from rural areas or between cities in search of economic prosperity. Although many do prosper, large numbers of people experience significant social disadvantage. This is especially the case among poorly educated, migrant unskilled unregistered male laborers who do much of the manual work throughout the cities. These men are at significant risk for many health problems, including HIV infection. However, to date there has been little research in developing countries to explain the determinants of this risk, and thereby to suggest feasible preventive strategies. Objectives and Methodology: Using combined qualitative and quantitative methods, the aim of this study was to explore the social contexts that affect health vulnerabilities and to develop conceptual models to predict risk behaviors for HIV [illicit drug use, unsafe sex, and non-testing for HIV] among male street laborers in Hanoi, Vietnam. Qualitative Research: Sixteen qualitative interviews revealed a complex variety of life experiences, beliefs and knowledge deficits that render these mostly poor and minimally educated men vulnerable to health problems including HIV infection. This study formed a conceptual model of numerous stressors related to migrants’ life experiences in urban space, including physical, financial and social factors. A wide range of coping strategies were adopted to deal with stressors – including problem-focused coping (PFC) and emotion-focused coping (EFC), pro-social and anti-social, active and passive. These men reported difficulty in coping with stressors because they had weak social networks and lacked support from formal systems. A second conceptual model emerged that highlighted equivalent influences of individual psychological factors, social integration, social barriers, and accessibility regarding drug use and sexual risk behavior. Psychological dimensions such as tedium, distress, fatalism and revenge, were important. There were strong effects of collective decision-making and fear of social isolation on shaping risk behaviors. These exploratory qualitative interviews helped to develop a culturally appropriate instrument for the quantitative survey and informed theoretical models of the factors that affect risk behaviors for HIV infection. Quantitative Research: The Information-Motivation-Behavioral Skills (IMB) model was adopted as the theoretical framework for a large-scale survey. It was modified to suit the contexts of these Vietnamese men. By doing a social mapping technique, 450 male street laborers were interviewed in Hanoi, Vietnam. The survey revealed that the risk of acquiring and transmitting HIV was high among these men. One in every 12 men reported homosexual or bisexual behavior. These men on average had 3 partners within the preceding year, and condom use was inconsistent. One third had had sex with commercial sex workers (CSW) and only 30% of them reported condom use; 17% used illicit drugs sometimes, with 66.7% of them frequently sharing injecting equipment with peers. Despite the risks, only 19.8% of men had been tested for HIV during the previous 12 months. These men have limited HIV knowledge and only moderate motivation and perceived behavioral skills for protective behavior. Although rural-to-urban migration was not associated with sexual risk behavior, three elements of the IMB model and depression associated with the process of mobility were significant determinants of sexual behavior. A modified model that incorporated IMB elements and psychosocial stress was found to be a better fit than the original IMB model alone in predicting protected sex behavior among the men. Men who were less psychologically and socially stressed, better informed and motivated for HIV prevention were more likely to demonstrate behavioral skills, and in turn were more likely to engage in safer sexual behavior. With regard to drug use, although the conventional model accounted for slightly less variance than the modified IMB model, data were of better fit for the conventional model. Multivariate analyses revealed that men who originated from urban areas, those who were homo- or bi-sexually identified and had better knowledge and skills for HIV prevention were more likely to access HIV testing, while men who had more sexual partners and those who did not use a condom for sex with CSW were least likely to take a test. The modified IMB model provided a better fit than the conventional model, as it explained a greater variance in HIV testing. Conclusions and Implications: This research helps to highlight a potential hidden HIV epidemic among street male, unskilled, unregistered laborers. This group has multiple vulnerabilities to HIV infection through both their partners and peers. However, most do not know their HIV status and have limited knowledge about preventing infection. This is the first application of a modified IMB model of risk behaviors for HIV such as drug use, condom use, and uptake of HIV testing to research with male street laborers in urban settings. The study demonstrated that while the extended IMB model had better fit than the conventional version in explaining the behaviors of safe sex and HIV testing, it was not so for drug use. The results provide interesting directions for future research and suggest ways to effectively design intervention strategies. The findings should shed light on culturally appropriate HIV preventive education and support programs for these men. As Vietnam has much in common with other developing countries in Southeast Asia, this research provides evidence for policy and practice that may be useful for public health systems in similar countries.

THE meaning of effectiveness

As the Industry Commission prepares to engage in its examination of the Australian nonprofit sector as defined in its draft terms of reference, it confronts what it should regard as a fundamental dilemma; the meaning of the construct `effectiveness'. I should at this point state clearly that the potential difficulties are not unique to the task of the Commission, but have instead plagued human service evaluation for many a long year. At the level of human service or welfare practice, a favoured method of resolving the conundrum has been to dismiss it as irrelevant to the human services as it pursues its task of working for human betterment however understood. Such a response highlights a fundamental characteristic of the human services generally, not only in the nonprofit arena: their relative freedom from evaluation. While there are many reasons for this, some of which we will canvass later in this paper, one stems from a lack of clarity about the meaning of effectiveness coupled with a lack of consensus about its purpose.

Normative influences across cultures : conceptual differences and potential confounders among drivers in Australia and China

Normative influences on road user behaviour have been well documented and include such things as personal, group, subjective and moral norms. Commonly, normative factors are examined within one cultural context, although a few examples of exploring the issue across cultures exist. Such examples add to our understanding of differences in perceptions of the normative factors that may exert influence on road users and can assist in determining whether successful road safety interventions in one location may be successful in another. Notably, the literature is relatively silent on such influences in countries experiencing rapidly escalating rates of motorization. China is one such country where new drivers are taking to the roads in unprecedented numbers and authorities are grappling with the associated challenges. This paper presents results from qualitative and quantitative research on self-reported driving speeds of car drivers and related issues in Australia and China. Focus group interviews and questionnaires conducted in each country examined normative factors that might influence driving in each cultural context. Qualitative findings indicated perceptions of community acceptance of speeding were present in both countries but appeared more widespread in China, yet quantitative results did not support this difference. Similarly, with regard to negative social feedback from speeding, qualitative findings suggested no embarrassment associated with speeding among Chinese participants and mixed results among Australian participants, yet quantitative results indicated greater embarrassment for Chinese drivers. This issue was also examined from the perspective of self-identity and findings were generally similar across both samples and appear related to whether it is important to be perceived as a skilled/safe driver by others. An interesting and important finding emerged with regard to how Chinese drivers may respond to questions about road safety issues if the answers might influence foreigners’ perceptions of China. In attempting to assess community norms associated with speeding, participants were asked to describe what they would tell a foreign visitor about the prevalence of speeding in China. Responses indicated that if asked by a foreigner, people may answer in a manner that portrayed China as a safe country (e.g., that drivers do not speed), irrespective of the actual situation. This ‘faking good for foreigners’ phenomenon highlights the importance of considering ‘face’ when conducting research in China – a concept absent from the road safety literature. An additional noteworthy finding that has been briefly described in the road safety literature is the importance and strength of the normative influence of social networks (guanxi) in China. The use of personal networks to assist in avoiding penalties for traffic violations was described by Chinese participants and is an area that could be addressed to strengthen the deterrent effect of traffic law enforcement. Overall, the findings suggest important considerations for developing and implementing road safety countermeasures in different cultural contexts.

Fast pyrolysis for better utilization of tamarind seed from renewable energy point of view

The conversion of tamarind seeds into pyrolytic oil by fixed bed fire-tube heating reactor has been taken into consideration in this study. The major components of the system were fixed bed fire-tube heating reactor, liquid condenser and collectors. The raw and crushed tamarind seed in particle form was pyrolized in an electrically heated 10 cm diameter and 27 cm high fixed bed reactor. The products are oil, char and gases. The parameters varied were reactor bed temperature, running time, gas flow rate and feed particle size. The parameters were found to influence the product yields significantly. The maximum liquid yield was 45 wt% at 4000C for a feed size of 1.07cm3 at a gas flow rate of 6 liter/min with a running time of 30 minute. The pyrolysis oil was obtained at these optimum process conditions were analyzed for physical and chemical properties to be used as an alternative fuel.

A rhetorical study of in-flight real estate advertisements as a potential site of ethical transformation in Chinese cities

Real estate markets in Chinese cities are in transition. Advertising for new developments in these markets often reflects changing city aspirations and branding rather than environmental and social experience. This paper investigates real estate marketing as a site of potential ethical transformation of values related to new urban development. It uses Kenneth Burke’s rhetorical analysis as an approach to coding real estate representations from in-flight magazine advertisements as a means of capturing environmental and social viewpoints in China during 2008 - 2009. Both Chinese and foreign participants coded representations into four code modalities. These were based on anthropocentric - non-anthropocentric environmental orientations and nationalistic - universal social orientations. The results suggested that new developments in China are more likely to be understood as based on environmental resource use for continued national economic expansion rather than for a more sustainable world. Emerging patterns in coded representations have opened up the possibility of greater social choices that were however difficult to unambiguously decode from Chinese real estate advertising. From this it is concluded that it may take some time before real estate demand shifts in response to representations of Chinese eco-cities being promoted by Chinese policy makers in the 2000s.

Antibiotics overuse in children with upper respiratory tract infections in Saudi Arabia : risk factors and potential interventions

Background: Antibiotics misuse is currently one of the major public health issues worldwide. This misuse can lead to the development of bacterial resistance, increasing the burden of chronic diseases, rising costs of health services, and the development of side effects. Several factors may influence this pattern of overuse. Objectives:This article will review the pertinent factors contributing to the overuse of antibiotics worldwide, and to assess the intervention strategies to limit this overuse. Methods: studies about antibiotics use in children were reviewed from several electronic databases, such as MEDLINE and Pubmed. Results: Factors contributing to the overuse of antibiotics could include psychosocial factors, such as behaviors and attitudes (e.g. self-medication, over-the-counter medication, or patients/parents pressure), and demographic factors, such as socio-economic status and education level. Several intervention strategies were reported to be effective in reducing the overuse of antibiotics, such as health education, doctor-patient communication, and policies change. Multifaceted interventions were found to be the most effective in reducing the antibiotics overuse.

Silk fibroin in ocular surface reconstruction : what is its potential as a biomaterial in ophthalmics?

Hardly a month goes by within the scientific literature without some new material “X” being reported as a suitable material on which to grow cell type “Y”, for the potential purpose of treating disease “Z”. Thus when fibroin, a protein found in silk, was first proposed as a biomaterial for cell growth [1] it joined a long list of other materials of both natural as well as synthetic origin. Nevertheless, in the second decade of the Asian Century it is perhaps befitting that a material of so much importance to the continent’s cultural and economic history, should become the focus of cutting-edge biomedical research. Sentiments aside, however, silk fibroin possesses quite a unique combination of properties which make it a promising candidate for repairing the eye and especially for treating damage to the cornea, the transparent window at the front of the eye.

Point-to-point speed enforcement

This report reviews the use of point-to-point speed enforcement internationally in order to provide principles for better practice for its use in Australia and New Zealand. Point-to-point enforcement is a relatively new technological approach to speed enforcement which involves measuring the average speed of vehicles passing a series of cameras, by using automatic number plate recognition (ANPR) and other technologies. The approach has been implemented or trialled in a number of countries including Australia, New Zealand, the United Kingdom, the Netherlands, Austria, Italy, Switzerland and France. The major research activities were undertaken for the preparation of this report included: (1) an extensive review of the international literature; (2) stakeholder consultation with international and domestic organisations. To date, there have been no formal evaluations of point-to- point speed enforcement in Australia or New Zealand.

Nangkha Nangdrik in the land of the Thunder Dragon : psychology, religion and the potential of mediation in the Kingdom of Bhutan

This article will consider the role that Alternative Dispute Resolution (‘Dham Kha Chen Ki Khendum’ or ‘Nangkha Nangdrik’) currently plays in resolving legal conflict in Bhutan. With a Constitution that has committed to the pursuit of Gross National Happiness, non-adversarial dispute resolution processes that promote continuing relationships and goodwill assume greater importance. One difficulty for Bhutan is that alternative dispute resolution procedures such as mediation (Dhum Drik) are being referred to in enactments of the Bhutanese National Council and National Assembly (bicameral parliament), without a shared understanding as to the characteristics and functionality of these procedures. This article will focus particularly on the current practice of mediation in Bhutan and investigate whether particular models of mediation are more suited to the Bhutanese context, given the particularities of Bhutanese culture, the search for gross national happiness, psychological understandings of happiness and the omnipresent influence of Mahayana Buddhism.

The influence of oxygenated organic aerosols (OOA) and its volatile organic content on the oxidative potential of diesel particulate mater

Airborne particulate matter pollution is of concern for a number of reasons and has been widely recognised as an important risk factor to human health. A number of toxicological and epidemiological studies reported negative health effects on both respiratory and cardiovascular system. Despite the availability of a huge body of research, the underlying toxicological mechanisms by which particles induce adverse health effects are not yet entirely understood. The production of reactive oxygen species (ROS) has been shown to induce oxidative stress, which is proposed as a mechanism for many of the adverse health outcomes associated with exposure to particulate matter (PM). Therefore, it is crucial to introduce a technique that will allow rapid and routine screenings of the oxidative potential of PM.

A method for measuring the creative potential of computer games

This paper describes a method for measuring the creative potential of computer games. The research approach applies a behavioral and verbal protocol to analyze the factors that influence the creative processes used by people as they play computer games from the puzzle genre. Creative potential is measured by examining task motivation and domain-relevant and creativity-relevant skills. This paper focuses on the reliability of the factors used for measurement, determining those factors that are more strongly related to creativity. The findings show that creative potential may be determined by examining the relationship between skills required and the effect of intrinsic motivation within game play activities.

Risk-based approach to the management of on-site wastewater treatment facilities

Background On-site wastewater treatment system (OWTS) siting, design and management has traditionally been based on site specific conditions with little regard to the surrounding environment or the cumulative effect of other systems in the environment. The general approach has been to apply the same framework of standards and regulations to all sites equally, regardless of the sensitivity, or lack thereof, to the receiving environment. Consequently, this has led to the continuing poor performance and failure of on-site systems, resulting in environmental and public health consequences. As a result, there is increasing realisation that more scientifically robust evaluations in regard to site assessment and the underlying ground conditions are needed. Risk-based approaches to on-site system siting, design and management are considered the most appropriate means of improvement to the current standards and codes for on-site wastewater treatment systems. The Project Research in relation to this project was undertaken within the Gold Coast City Council region, the major focus being the semi-urban, rural residential and hinterland areas of the city that are not serviced by centralised treatment systems. The Gold Coast has over 15,000 on-site systems in use, with approximately 66% being common septic tank-subsurface dispersal systems. A recent study evaluating the performance of these systems within the Gold Coast area showed approximately 90% were not meeting the specified guidelines for effluent treatment and dispersal. The main focus of this research was to incorporate strong scientific knowledge into an integrated risk assessment process to allow suitable management practices to be set in place to mitigate the inherent risks. To achieve this, research was undertaken focusing on three main aspects involved with the performance and management of OWTS. Firstly, an investigation into the suitability of soil for providing appropriate effluent renovation was conducted. This involved detailed soil investigations, laboratory analysis and the use of multivariate statistical methods for analysing soil information. The outcomes of these investigations were developed into a framework for assessing soil suitability for effluent renovation. This formed the basis for the assessment of OWTS siting and design risks employed in the developed risk framework. Secondly, an assessment of the environmental and public health risks was performed specifically related the release of contaminants from OWTS. This involved detailed groundwater and surface water sampling and analysis to assess the current and potential risks of contamination throughout the Gold Coast region. Additionally, the assessment of public health risk incorporated the use of bacterial source tracking methods to identify the different sources of fecal contamination within monitored regions. Antibiotic resistance pattern analysis was utilised to determine the extent of human faecal contamination, with the outcomes utilised for providing a more indicative public health assessment. Finally, the outcomes of both the soil suitability assessment and ground and surface water monitoring was utilised for the development of the integrated risk framework. The research outcomes achieved through this project enabled the primary research aims and objects to be accomplished. This in turn would enable Gold Coast City Council to provide more appropriate assessment and management guidelines based on robust scientific knowledge which will ultimately ensure that the potential environmental and public health impacts resulting from on-site wastewater treatment is minimised. As part of the implementation of suitable management strategies, a critical point monitoring program (CPM) was formulated. This entailed the identification of the key critical parameters that contribute to the characterised risks at monitored locations within the study area. The CPM will allow more direct procedures to be implemented, targeting the specific hazards at sensitive areas throughout Gold Coast region.

The potential influence of Neoliberalism on the capacity and form of spatial adaptation

Human spatial environments must adapt to climate change. Spatial planning is central to climate change adaptation and potentially well suited to the task, however neoliberal influences and trends threaten this capacity. This paper explores the potential interaction of emerging research areas, the first of which pursues climate change adaptation through spatial planning and the second of which has observed the neoliberalisation of urban planning, The potential capacity and form of spatial adaptation within the context a planning environment influenced by neoliberal principles is evaluated. This influence relates to the themes of spatial scale, temporal scale, responsibility for action, strategies and mechanisms, accrual of benefits, negotiation of priorities and approach to uncertainty. This paper presents a conceptual framework of the influence of neoliberalism on spatial adaptation and presents examples of this approach in documents which underpin adaptation in Australia. It identifies the potential characteristics and the challenges and opportunities of spatial adaptation under a neoliberal frame. The neoliberal frame does not entirely preclude spatial adaptation but significantly influence its form. Neoliberal approaches involve individual action in response to private incentives and near term impacts while collective action, regulatory mechanisms and long term planning is approached cautiously. Challenges concern the degree to which collective action and a long term orientation are necessary, how individual adaptation relates to collective vulnerability and the prioritisation of adaptation by markets. Opportunities might involve the operability of individual and local adaptation, the existence of private incentives to adapt and the potential to align adaptation with entrepreneurial projects.

Suicide rates in Shandong, China, 1991–2010 : rapid decrease in rural rates and steady increase in male–female ratio

Background China has one of the highest suicide rates in the world; however, the recent trends in suicide have not been adequately studied. This study aimed to examine the potential changes in the rates and characteristics in a Chinese population. Methods Data on suicide deaths in 1991–2010 were extracted from the Shandong Disease Surveillance Point (DSP) mortality dataset based on ICD-10 codes. The temporal trend in age-adjusted suicide rates for each subpopulation was tested using log-linear Poisson regression analysis. Results From 1991 to 2010, there was a marked decrease in the overall suicide rate in Shandong, with an average reduction of 8% per year. The decrease trend was stronger in rural than in urban areas and more evident in females than in males. Similar decreases were observed for all age groups. Pesticide ingestion and hanging remained the top two methods for suicide. Limitations There are likely quality concerns in the morality data, such as underreporting and misclassification, as well as low accuracy in determining the underlying causes of deaths. The representativeness of the DSP system may also be problematic due to the rapid changes in economy and demography. Conclusions Completed suicides in Shandong have sharply declined over the past 20 years. Higher rates in females versus males and in rural versus urban areas, which were previously considered to be distinguishing features of suicide in China, are becoming less pronounced.