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.

Improvement of stability and load sharing in an autonomous microgrid using supplementary droop control loop

This paper investigates the problem of appropriate load sharing in an autonomous microgrid. High gain angle droop control ensures proper load sharing, especially under weak system conditions. However it has a negative impact on overall stability. Frequency domain modeling, eigenvalue analysis and time domain simulations are used to demonstrate this conflict. A supplementary loop is proposed around a conventional droop control of each DG converter to stabilize the system while using high angle droop gains. Control loops are based on local power measurement and modulation of the d-axis voltage reference of each converter. Coordinated design of supplementary control loops for each DG is formulated as a parameter optimization problem and solved using an evolutionary technique. The sup-plementary droop control loop is shown to stabilize the system for a range of operating conditions while ensuring satisfactory load sharing.

Prevalence of Staphylococcus aureus strains in an Australian cohort, 1989-2003 : evidence for the low prevalence of the toxic shock toxin and Panton-Valentine leukocidin genes

The purpose of this paper is to determine the prevalence of the toxic shock toxin gene (tst) and to enumerate the circulating strains of methicillin-sensitive Staphylococcus aureus (MSSA) and methicillin-resistant S. aureus (MRSA) in Australian isolates collected over two decades. The aim was to subtype these strains using the binary genes pvl, cna, sdrE, pUB110 and pT181. Isolates were assayed using real-time polymerase chain reaction (PCR) for mecA, nuc, 16 S rRNA, eight single-nucleotide polymorphisms (SNPs) and for five binary genes. Two realtime PCR assays were developed for tst. The 90 MRSA isolates belonged to CC239 (39 in 1989, 38 in 1996 and ten in 2003), CC1 (two in 2003) and CC22 (one in 2003). The majority of the 210 MSSA isolates belonged to CC1 (26), CC5 (24) and CC78 (23). Only 18 isolates were tst-positive and only 15 were pvl-positive. Nine MSSA isolates belonged to five binary types of ST93, including two pvlpositive types. The proportion of tst-positive and pvl-positive isolates was low and no significant increase was demonstrated. Dominant MSSA clonal complexes were similar to those seen elsewhere, with the exception of CC78. CC239 MRSA (AUS-2/3) was the predominant MRSA but decreased significantly in prevalence, while CC22 (EMRSA-15) and CC1 (WA-1) emerged. Genetically diverse ST93 MSSA predated the emergence of ST93- MRSA (the Queensland clone).

A psychometric comparison of the Toronto Alexithymia Scale (TAS-20) and the Observer Alexithymia Scale (OAS) in an alcohol-dependent sample

Alexithymia is characterised by deficits in emotional insight and self reflection, that impact on the efficacy of psychological treatments. Given the high prevalence of alexithymia in Alcohol Use Disorders, valid assessment tools are critical. The majority of research on the relationship between alexithymia and alcohol-dependence has employed the self-administered Toronto Alexithymia Scale (TAS-20). The Observer Alexithymia Scale (OAS) has also been recommended. The aim of the present study was to assess the validity and reliability of the OAS and the TAS-20 in an alcohol-dependent sample. Two hundred and ten alcohol-dependent participants in an outpatient Cognitive Behavioral Treatment program were administered the TAS-20 at assessment and upon treatment completion at 12 weeks. Clinical psychologists provided observer assessment data for a subsample of 159 patients. The findings confirmed acceptable internal consistency, test-retest reliability and scale homogeneity for both the OAS and TAS-20, except for the low internal consistency of the TAS-20 EOT scale. The TAS-20 was more strongly associated with alcohol problems than the OAS.

Difference and dispersion : educational research in a postmodern context

Difference and Dispersion is the fourth in a series of annual research papers produced by doctoral students from The Graduate School of Education, The University of Queensland, following their presentation at the School’s annual Postgraduate Research Conference in Education. The work featured herein celebrates the diversity of cultural and disciplinary backgrounds of education researchers who come from as far afield as Germany, Hong Kong, China, Nigeria, Russia, Singapore, Thailand and of course different parts of Australia. In keeping with a postmodern epistemology, ‘difference’ and ‘dispersion’ are key themes in apprehending the multiplicity of their research topics, methodologies, methods and speaking/writing positions. From widely differing contexts and situations, these writers address the consequences, implications and possibilities for education at the beginning of the third millennium. Their interest ranges from location-specific issues in schools and classrooms, change in learning contexts and processes, educational discourses and relations of power in diverse geographical settings, and the differing articulations of the local and the global in situated policy contexts. Conceived and developed in a spirit of ongoing dialogue with and insight to alternative views and visions of education and society, this edited collection exemplifies the quality in diversity and the high levels of scholarship and supervision at one of Australia’s finest Graduate Schools of Education.

An epidemic of pain in an Australian radiology practice

This paper presents findings from a study of an organisationally mandated assimilation process of an enterprise-wide information system in a radiology practice in Australia. A number of interviews with radiologists, radiographers and administrative staff are used to explore the impact of institutional structures on the assimilation process. The case study develops an argument that culture within and outside the Australian Radiology Practice (ARP), social structures within the ARP and organisational-level management mandates have impacted on the assimilation process. The study develops a theoretical framework that integrates elements of social actor theory (Lamb & Kling, 2003) to provide a more fine-grained analysis concentrating on the relationship among the radiology practitioners, the technology (an enterprise-wide Health Information System) and a larger social milieu surrounding its use. This study offers several theoretical and practical implications for technology assimilation in the health and radiology industry regarding the important roles social interactions, individual self-perceptions, organisational mandates and policies can play in assimilating new ICTs.

Learning to avoid indoor obstacles from optical flow

Optical flow (OF) is a powerful motion cue that captures the fusion of two important properties for the task of obstacle avoidance − 3D self-motion and 3D environmental surroundings. The problem of extracting such information for obstacle avoidance is commonly addressed through quantitative techniques such as time-to-contact and divergence, which are highly sensitive to noise in the OF image. This paper presents a new strategy towards obstacle avoidance in an indoor setting, using the combination of quantitative and structural properties of the OF field, coupled with the flexibility and efficiency of a machine learning system.The resulting system is able to effectively control the robot in real-time, avoiding obstacles in familiar and unfamiliar indoor environments, under given motion constraints. Furthermore, through the examination of the networks internal weights, we show how OF properties are being used toward the detection of these indoor obstacles.

Safety implications of increased moped and scooter use in an Australian city

Drawing on two studies within a larger program of research into scooter and moped safety in Queensland, Australia, some key safety concerns specific to the use of these vehicles are discussed. A five phase observational study is used to identify distribution of powered two-wheeler (PTW) types in the city centre of Brisbane, Australia’s third largest city. Data were first collected in August 2008, and thereafter at six-monthly intervals. Stationary PTWs were directly observed in designated parking areas. Four focus groups involving 23 Brisbane riders were held in March 2009, aiming to explore perspectives on safety and transport planning in a semi-structured format. Information gathered in the focus groups informed development of a questionnaire targeting a larger sample of scooter and moped riders. The observations made to date indicate that 36% of all PTWs parked in Brisbane’s inner city are either mopeds or larger scooters, with the remaining 64% accounted for by motorcycles (n = 2037). These data suggest that mopeds and scooters are a significant transport mode in Brisbane, yet little is known about their safety relative to that of motorcycles. In focus groups, main motivating factors for scooter or moped use included parking availability, traffic congestion, cost, time-efficiency and enjoyment. Moped riders were generally younger and less experienced than other scooter riders, less likely to wear protective clothing, and less likely to have undertaken rider training. The focus groups have helped to identify some particular safety concerns regarding moped use in a jurisdiction requiring no motorcycle licence or rider training.

Therapeutic relationships in specialist palliative care nursing practice.

There has been limited research into the scope or standards of specialist palliative care nursing practice in an Australian context. This study sought to develop a competency framework that described the core domains of specialist palliative care nursing. This article explores one key domain of specialist palliative care nursing practice - therapeutic relationships - that was identified as underpinning other domains of practice. A mixed method was used, involving a literature review, a survey including practice exemplars and an interview of specialist palliative care nurses. Seventy-four registered nurses working in designated specialist palliative care nursing roles from each Australian state and mainland territory were involved. The nurses represented metropolitan, regional, rural and remote communities, various inpatient facilities and community practice settings. Five core domains of specialist palliative care nursing practice were identified: complex supportive care, collaborative practice, leadership, improving practice and therapeutic relationships. Therapeutic relationships were identified as the central domain of specialist palliative care nursing practice to which all other domains were inextricably linked.

Validation of the Drinking Refusal Self-Efficacy Questionnaire - Revised in an Adolescent Sample (DRSEQ-RA)

Adolescent drinking is a significant issue yet valid psychometric tools designed for this group are scarce. The Drinking Refusal Self-Efficacy Questionnaire—Revised Adolescent Version (DRSEQ-RA) is designed to assess an individual's belief in their ability to resist drinking alcohol. The original DRSEQ-R consists of three factors reflecting social pressure refusal self-efficacy, opportunistic refusal self-efficacy and emotional relief refusal self-efficacy. A large sample of 2020 adolescents aged between 12 and 19 years completed the DRSEQ and measures of alcohol consumption in small groups. Using confirmatory factor analysis, the three factor structure was confirmed. All three factors were negatively correlated with both frequency and volume of alcohol consumption. Drinkers reported lower drinking refusal self-efficacy than non-drinkers. Taken together, these results suggest that the adolescent version of the Drinking Refusal Self-Efficacy Questionnaire (DRSEQ-RA) is a reliable and valid measure of drinking refusal self-efficacy.

A confirmatory factor analysis of the Toronto Alexithymia Scale (TAS-20) in an alcohol-dependent sample

Confirmatory factor analyses were conducted to evaluate the factorial validity of the Toronto Alexithymia Scale in an alcohol-dependent sample. Several factor models were examined, but all models were rejected given their poor fit. A revision of the TAS-20 in alcohol-dependent populations may be needed.