Cost-effectiveness of an intervention to reduce emergency re-admissions to hospital among older patients

Background. The objective is to estimate the cost-effectiveness of an intervention that reduces hospital readmission among older people at high risk. A cost-effectiveness model to estimate the costs and health benefits of the intervention was implemented. Methodology/Principal Findings. The model used data from a randomised controlled trial conducted in an Australian tertiary metropolitan hospital. Participants were acute medical admissions aged >65 years with at least one risk factor for readmission: multiple comorbidities, impaired functionality, aged >75 years, 30 recent multiple admissions, poor social support, history of depression. The intervention was a comprehensive nursing and physiotherapy assessment and an individually tailored program of exercise strategies and nurse home visits with telephone follow-up; commencing in hospital and continuing following discharge for 24 weeks. The change to cost outcomes, including the costs of implementing the intervention and all subsequent use of health care services, and, the change to health benefits, represented by quality adjusted life years, were estimated for the intervention as compared to existing practice. The mean change to total costs and quality 38 adjusted life years for an average individual over 24 weeks participating in the intervention were: cost savings of $333 (95% Bayesian credible interval $-1,932:1,282) and 0.118 extra quality adjusted life years (95% Bayesian credible interval 0.1:0.136). The mean net41 monetary-benefit per individual for the intervention group compared to the usual care condition was $7,907 (95% Bayesian credible interval $5,959:$9,995) for the 24 week period. Conclusions/Significance. The estimation model that describes this intervention predicts cost savings and improved health outcomes. A decision to remain with existing practices causes unnecessary costs and reduced health. Decision makers should consider adopting this 46 program for elderly hospitalised patients.

Leading indigenous education in a remote location : reflections on teaching to be "proud and deadly"

This thesis is a critical reflection of the author’s time as a Principal of an Indigenous state school from 2003-2004. The purpose is to reassess the impact of her principalship in terms of the staff, students and Community change that affected learning outcomes at the school and to reanalyse to what actions and to whom positive changes could be attributed. This thesis reflects and identifies, in light of the literature, strategies which were effective in enhancing student learning outcomes. The focus of this thesis was the Doongal State School*, its students, staff and facilities. The author will attempt to draw out theoretical frameworks in terms of: (1) what changed educationally in Doongal State School, (2) what seemed to be important in the Principal’s role, (3) the processes that took place, and (4) the effect of being non- Indigenous and a female. Overall, the author undertook this critical reflection in order to understand and embrace educational practices that will (a) lessen the gap between the academic outcomes achieved by Indigenous and non-Indigenous students, and (b) enhance life choices for Indigenous children. The findings indicate that principal leadership is critical for success in Indigenous schools and is the centrepiece of the models developed to explain improvement at Doongal State School. School factors, Principal Leadership factors, Change factors and factors relating to being a non-Indigenous female principal, which, when implemented, will lead to improved educational outcomes for Indigenous students, have evolved as a result of this thesis. Principal Leadership factors were found to be the enablers for the effective implementation of the key components for success.

Quality issues for the National Bowel Cancer Screening Program (NBCSP)

Purpose: This two-part research project was undertaken as part of the planning process by Queensland Health (QH), Cancer Screening Services Unit (CSSU), Queensland Bowel Cancer Screening Program (QBCSP), in partnership with the National Bowel Cancer Screening Program (NBCSP), to prepare for the implementation of the NBCSP in public sector colonoscopy services in QLD in late 2006. There was no prior information available on the quality of colonoscopy services in Queensland (QLD) and no prior studies that assessed the quality of colonoscopy training in Australia. Furthermore, the NBCSP was introduced without extra funding for colonoscopy service improvement or provision for increases in colonoscopic capacity resulting from the introduction of the NBCSP. The main purpose of the research was to record baseline data on colonoscopy referral and practice in QLD and current training in colonoscopy Australia-wide. It was undertaken from a quality improvement perspective. Implementation of the NBCSP requires that all aspects of the screening pathway, in particular colonoscopy services for the assessment of positive Faecal Occult Blood Tests (FOBTs), will be effective, efficient, equitable and evidence-based. This study examined two important aspects of the continuous quality improvement framework for the NBCSP as they relate to colonoscopy services: (1) evidence-based practice, and (2) quality of colonoscopy training. The Principal Investigator was employed as Senior Project Officer (Training) in the QBCSP during the conduct of this research project. Recommendations from this research have been used to inform the development and implementation of quality improvement initiatives for provision of colonoscopy in the NBCSP, its QLD counterpart the QBCSP and colonoscopy services in QLD, in general. Methods – Part 1 Chart audit of evidence-based practice: The research was undertaken in two parts from 2005-2007. The first part of this research comprised a retrospective chart audit of 1484 colonoscopy records (some 13% of all colonoscopies conducted in public sector facilities in the year 2005) in three QLD colonoscopy services. Whilst some 70% of colonoscopies are currently conducted in the private sector, only public sector colonoscopy facilities provided colonoscopies under the NBCSP. The aim of this study was to compare colonoscopy referral and practice with explicit criteria derived from the National Health & Medical Research Council (NHMRC) (1999) Clinical Practice Guidelines for the Prevention, Early Detection and Management of Colorectal Cancer, and describe the nature of variance with the guidelines. Symptomatic presentations were the most common indication for colonoscopy (60.9%). These comprised per rectal bleeding (31.0%), change of bowel habit (22.1%), abdominal pain (19.6%), iron deficiency anaemia (16.2%), inflammatory bowel disease (8.9%) and other symptoms (11.4%). Surveillance and follow-up colonoscopies accounted for approximately one-third of the remaining colonoscopy workload across sites. Gastroenterologists (GEs) performed relatively more colonoscopies per annum (59.9%) compared to general surgeons (GS) (24.1%), colorectal surgeons (CRS) (9.4%) and general physicians (GPs) (6.5%). Guideline compliance varied with the designation of the colonoscopist. Compliance was lower for CRS (62.9%) compared to GPs (76.0%), GEs (75.0%), GSs (70.9%, p<0.05). Compliance with guideline recommendations for colonoscopic surveillance for family history of colorectal cancer (23.9%), polyps (37.0%) and a past history of bowel cancer (42.7%), was by comparison significantly lower than for symptomatic presentations (94.4%), (p<0.001). Variation with guideline recommendations occurred more frequently for polyp surveillance (earlier than guidelines recommend, 47.9%) and follow-up for past history of bowel cancer (later than recommended, 61.7%, p<0.001). Bowel cancer cases detected at colonoscopy comprised 3.6% of all audited colonoscopies. Incomplete colonoscopies occurred in 4.3% of audited colonoscopies and were more common among women (76.6%). For all colonoscopies audited, the rate of incomplete colonoscopies for GEs was 1.6% (CI 0.9-2.6), GPs 2.0% (CI 0.6-7.2), GS 7.0% (CI 4.8-10.1) and CRS 16.4% (CI 11.2-23.5). 18.6% (n=55) of patients with a documented family history of bowel cancer had colonoscopy performed against guidelines recommendations (for general (category 1) population risk, for reasons of patient request or family history of polyps, rather than for high risk status for colorectal cancer). In general, family history was inadequately documented and subsequently applied to colonoscopy referral and practice. Methods - Part 2 Surveys of quality of colonoscopy training: The second part of the research consisted of Australia-wide anonymous, self-completed surveys of colonoscopy trainers and their trainees to ascertain their opinions on the current apprenticeship model of colonoscopy in Australia and to identify any training needs. Overall, 127 surveys were received from colonoscopy trainers (estimated response rate 30.2%). Approximately 50% of trainers agreed and 27% disagreed that current numbers of training places were adequate to maintain a skilled colonoscopy workforce in preparation for the NBCSP. Approximately 70% of trainers also supported UK-style colonoscopy training within dedicated accredited training centres using a variety of training approaches including simulation. A collaborative approach with the private sector was seen as beneficial by 65% of trainers. Non-gastroenterologists (non-GEs) were more likely than GEs to be of the opinion that simulators are beneficial for colonoscopy training (χ2-test = 5.55, P = 0.026). Approximately 60% of trainers considered that the current requirements for recognition of training in colonoscopy could be insufficient for trainees to gain competence and 80% of those indicated that ≥ 200 colonoscopies were needed. GEs (73.4%) were more likely than non-GEs (36.2%) to be of the opinion that the Conjoint Committee standard is insufficient to gain competence in colonoscopy (χ2-test = 16.97, P = 0.0001). The majority of trainers did not support training either nurses (73%) or GPs in colonoscopy (71%). Only 81 (estimated response rate 17.9%) surveys were received from GS trainees (72.1%), GE trainees (26.3%) and GP trainees (1.2%). The majority were males (75.9%), with a median age 32 years and who had trained in New South Wales (41.0%) or Victoria (30%). Overall, two-thirds (60.8%) of trainees indicated that they deemed the Conjoint Committee standard sufficient to gain competency in colonoscopy. Between specialties, 75.4% of GS trainees indicated that the Conjoint Committee standard for recognition of colonoscopy was sufficient to gain competence in colonoscopy compared to only 38.5% of GE trainees. Measures of competency assessed and recorded by trainees in logbooks centred mainly on caecal intubation (94.7-100%), complications (78.9-100%) and withdrawal time (51-76.2%). Trainees described limited access to colonoscopy training lists due to the time inefficiency of the apprenticeship model and perceived monopolisation of these by GEs and their trainees. Improvements to the current training model suggested by trainees included: more use of simulation, training tools, a United Kingdom (UK)-style training course, concentration on quality indicators, increased access to training lists, accreditation of trainers and interdisciplinary colonoscopy training. Implications for the NBCSP/QBCSP: The introduction of the NBCSP/QBCSP necessitates higher quality colonoscopy services if it is to achieve its ultimate goal of decreasing the incidence of morbidity and mortality associated with bowel cancer in Australia. This will be achieved under a new paradigm for colonoscopy training and implementation of evidence-based practice across the screening pathway and specifically targeting areas highlighted in this thesis. Recommendations for improvement of NBCSP/QBCSP effectiveness and efficiency include the following: 1. Implementation of NBCSP and QBCSP health promotion activities that target men, in particular, to increase FOBT screening uptake. 2. Improved colonoscopy training for trainees and refresher courses or retraining for existing proceduralists to improve completion rates (especially for female NBCSP/QBCSP participants), and polyp and adenoma detection and removal, including newer techniques to detect flat and depressed lesions. 3. Introduction of colonoscopy training initiatives for trainees that are aligned with NBCSP/QBCSP colonoscopy quality indicators, including measurement of training outcomes using objective quality indicators such as caecal intubation, withdrawal time, and adenoma detection rate. 4. Introduction of standardised, interdisciplinary colonoscopy training to reduce apparent differences between specialties with regard to compliance with guideline recommendations, completion rates, and quality of polypectomy. 5. Improved quality of colonoscopy training by adoption of a UK-style training program with centres of excellence, incorporating newer, more objective assessment methods, use of a variety of training tools such as simulation and rotations of trainees between metropolitan, rural, and public and private sector training facilities. 6. Incorporation of NHMRC guidelines into colonoscopy information systems to improve documentation, provide guideline recommendations at the point of care, use of gastroenterology nurse coordinators to facilitate compliance with guidelines and provision of guideline-based colonoscopy referral letters for GPs. 7. Provision of information and education about the NBCSP/QBCSP, bowel cancer risk factors, including family history and polyp surveillance guidelines, for participants, GPs and proceduralists. 8. Improved referral of NBCSP/QBCSP participants found to have a high-risk family history of bowel cancer to appropriate genetics services.

Comprehensive standardized data definitions for acute coronary syndrome research in emergency departments in Australasia

Patients with chest discomfort or other symptoms suggestive of acute coronary syndrome (ACS) are one of the most common categories seen in many Emergency Departments (EDs). While the recognition of patients at high-risk of ACS has improved steadily, identifying the majority of chest pain presentations who fall into the low-risk group remains a challenge. Research in this area needs to be transparent, robust, applicable to all hospitals from large tertiary centres to rural and remote sites, and to allow direct comparison between different studies with minimum patient spectrum bias. A standardised approach to the research framework using a common language for data definitions must be adopted to achieve this. The aim was to create a common framework for a standardised data definitions set that would allow maximum value when extrapolating research findings both within Australasian ED practice, and across similar populations worldwide. Therefore a comprehensive data definitions set for the investigation of non-traumatic chest pain patients with possible ACS was developed, specifically for use in the ED setting. This standardised data definitions set will facilitate ‘knowledge translation’ by allowing extrapolation of useful findings into the real-life practice of emergency medicine.

Negative mood regulation expectancies, frontal lobe related behaviors and alcohol use

Negative mood regulation (NMR) expectancies have been linked to substance problems in previous research, but the neurobiological correlates of NMR are unknown. In the present study, NMR was examined in relation to self-report indices of frontal lobe functioning, mood and alcohol use in 166 volunteers of both genders who ranged in age from 17 to 43 years. Contrary to expectations based on previous findings in addicts and problem drinkers, scores on the NMR scale did not differ between Low Risk and High Risk drinkers as defined by the Alcohol Use Disorders Identification Test (AUDIT). However, NMR scores were significantly negatively correlated with all three indices of frontal lobe dysfunction on the Frontal Systems Behavior Scale (FrSBe) Self-Rating Form as well as with all three indices of negative mood on the Depression Anxiety Stress Scales (DASS), which in turn were all positively correlated with FrSBe. Path analyses indicated that NMR partially mediated the direct effects of frontal lobe dysfunction (as indexed by FrSBe) on DASS Stress and DASS Depression. Further, the High Risk drinkers scored significantly higher on the Disinhibition and Executive Dysfunction indices of the FrSBe than did Low Risk drinkers. Results are consistent with the notion that NMR is a frontal lobe function.

Masculinity, rurality and violence

The assumption that the size, anonymity and weakened social controls of urban living generates social conflict, disorganization and higher rates of crime and violence has been an article of faith in much criminological and social scientific inquiry since the nineteenth century (i.e. Tönnies 1897; Shaw and McKay 1931; Levin and Lindesmith 1937; Nisbet 1970; Baldwin and Bottoms 1976; Felson 1994). The paper challenges this article of criminological faith and questions the utility of urban centric criminological theorizing about the causes of violence in rural settings. Drawing on descriptive data that show that rural men present a relatively high risk of inflicting harm upon themselves and others, this paper explores the larger socio-criminological question as to why this might be. The question is examined in relation to the processes of community formation that shape the everyday architecture of rural life. We explore how that architecture has historically valorized violent expressions of masculinity grounded in a relationship between men's bodies and the rural landscapes they inhabit - but how the legitimacy of these violent expressions are being challenged by sweeping social, economic and political changes. One psycho-social response to these sweeping social changes to rural life, we conclude, is a resort to violence as a largely strategic practice deployed to recreate an imagined rural gender order.

Human papillomavirus DNA detected in peripheral blood samples from healthy Australian male blood donors

Recent studies have shown that human papillomavirus (HPV) DNA can be found in circulating blood, including peripheral blood mononuclear cells (PBMCs), sera, plasma, and arterial cord blood. In light of these findings, DNA extracted from PBMCs from healthy blood donors were examined in order to determine how common HPV DNA is in blood of healthy individuals. Blood samples were collected from 180 healthy male blood donors (18-76 years old) through the Australian Red Cross Blood Services. Genomic DNA was extracted and specimens were tested for HPV DNA by PCR using a broad range primer pair. Positive samples were HPV-type determined by cloning and sequencing. HPV DNA was found in 8.3% (15/180) of the blood donors. A wide variety of different HPV types were isolated from the PBMCs; belonging to the cutaneous beta and gamma papillomavirus genera and mucosal alpha papillomaviruses. High-risk HPV types that are linked to cancer development were detected in 1.7% (3/180) of the PBMCs. Blood was also collected from a healthy HPV-positive 44-year-old male on four different occasions in order to determine which blood cell fractions harbor HPV. PBMCs treated with trypsin were negative for HPV, while non-trypsinized PBMCs were HPV-positive. This suggests that the HPV in blood is attached to the outside of blood cells via a protein-containing moiety. HPV was also isolated in the B cells, dendritic cells, NK cells, and neutrophils. To conclude, HPV present in PBMCs could represent a reservoir of virus and a potential new route of transmission.

A prospective study of personality features predictive of early adolescent alcohol misuse

Personality factors implicated in alcohol misuse have been extensively investigated in adult populations. Fewer studies have clarified the robustness of personality dimensions in predicting early onset alcohol misuse in adolescence. The aim of this study was to examine the predictive utility of two prominent models of personality (Cloninger, 1987; Eysenck & Eysenck, 1975) in emergent alcohol misuse in adolescence. One hundred and 92 secondary school students (mean age = 13.8 years, SD = 0.5) were administered measures of personality (Revised Junior Eysenck Personality Questionnaire – abbreviated; Temperament scale of Junior Temperament and Character Inventory) and drinking behavior (quantity and frequency of consumption, Alcohol Use Disorders Identification Test) at Time 1. At 12-month follow-up, 170 students (88.5%) were retained. Hierarchical multiple regressions revealed the dimensions of psychoticism, extraversion, and Novelty-Seeking to be the most powerful predictors of future alcohol misuse in adolescents. Results provide support for the etiological relevance of these dimensions in the development of early onset alcohol misuse. Findings can be used to develop early intervention programs that target personality risk factors for alcohol misuse in high-risk youth.

Basin analysis and economic geology of the Northern Mount Isa Basin

The Mount Isa Basin is a new concept used to describe the area of Palaeo- to Mesoproterozoic rocks south of the Murphy Inlier and inappropriately described presently as the Mount Isa Inlier. The new basin concept presented in this thesis allows for the characterisation of basin-wide structural deformation, correlation of mineralisation with particular lithostratigraphic and seismic stratigraphic packages, and the recognition of areas with petroleum exploration potential. The northern depositional margin of the Mount Isa Basin is the metamorphic, intrusive and volcanic complex here referred to as the Murphy Inlier (not the "Murphy Tectonic Ridge"). The eastern, southern and western boundaries of the basin are obscured by younger basins (Carpentaria, Eromanga and Georgina Basins). The Murphy Inlier rocks comprise the seismic basement to the Mount Isa Basin sequence. Evidence for the continuity of the Mount Isa Basin with the McArthur Basin to the northwest and the Willyama Block (Basin) at Broken Hill to the south is presented. These areas combined with several other areas of similar age are believed to have comprised the Carpentarian Superbasin (new term). The application of seismic exploration within Authority to Prospect (ATP) 423P at the northern margin of the basin was critical to the recognition and definition of the Mount Isa Basin. The Mount Isa Basin is structurally analogous to the Palaeozoic Arkoma Basin of Illinois and Arkansas in southern USA but, as with all basins it contains unique characteristics, a function of its individual development history. The Mount Isa Basin evolved in a manner similar to many well described, Phanerozoic plate tectonic driven basins. A full Wilson Cycle is recognised and a plate tectonic model proposed. The northern Mount Isa Basin is defined as the Proterozoic basin area northwest of the Mount Gordon Fault. Deposition in the northern Mount Isa Basin began with a rift sequence of volcaniclastic sediments followed by a passive margin drift phase comprising mostly carbonate rocks. Following the rift and drift phases, major north-south compression produced east-west thrusting in the south of the basin inverting the older sequences. This compression produced an asymmetric epi- or intra-cratonic clastic dominated peripheral foreland basin provenanced in the south and thinning markedly to a stable platform area (the Murphy Inlier) in the north. The fmal major deformation comprised east-west compression producing north-south aligned faults that are particularly prominent at Mount Isa. Potential field studies of the northern Mount Isa Basin, principally using magnetic data (and to a lesser extent gravity data, satellite images and aerial photographs) exhibit remarkable correlation with the reflection seismic data. The potential field data contributed significantly to the unravelling of the northern Mount Isa Basin architecture and deformation. Structurally, the Mount Isa Basin consists of three distinct regions. From the north to the south they are the Bowthorn Block, the Riversleigh Fold Zone and the Cloncurry Orogen (new names). The Bowthom Block, which is located between the Elizabeth Creek Thrust Zone and the Murphy Inlier, consists of an asymmetric wedge of volcanic, carbonate and clastic rocks. It ranges from over 10 000 m stratigraphic thickness in the south to less than 2000 min the north. The Bowthorn Block is relatively undeformed: however, it contains a series of reverse faults trending east-west that are interpreted from seismic data to be down-to-the-north normal faults that have been reactivated as thrusts. The Riversleigh Fold Zone is a folded and faulted region south of the Bowthorn Block, comprising much of the area formerly referred to as the Lawn Hill Platform. The Cloncurry Orogen consists of the area and sequences equivalent to the former Mount Isa Orogen. The name Cloncurry Orogen clearly distinguishes this area from the wider concept of the Mount Isa Basin. The South Nicholson Group and its probable correlatives, the Pilpah Sandstone and Quamby Conglomerate, comprise a later phase of now largely eroded deposits within the Mount Isa Basin. The name South Nicholson Basin is now outmoded as this terminology only applied to the South Nicholson Group unlike the original broader definition in Brown et al. (1968). Cored slimhole stratigraphic and mineral wells drilled by Amoco, Esso, Elf Aquitaine and Carpentaria Exploration prior to 1986, penetrated much of the stratigraphy and intersected both minor oil and gas shows plus excellent potential source rocks. The raw data were reinterpreted and augmented with seismic stratigraphy and source rock data from resampled mineral and petroleum stratigraphic exploration wells for this study. Since 1986, Comalco Aluminium Limited, as operator of a joint venture with Monument Resources Australia Limited and Bridge Oil Limited, recorded approximately 1000 km of reflection seismic data within the basin and drilled one conventional stratigraphic petroleum well, Beamesbrook-1. This work was the first reflection seismic and first conventional petroleum test of the northern Mount Isa Basin. When incorporated into the newly developed foreland basin and maturity models, a grass roots petroleum exploration play was recognised and this led to the present thesis. The Mount Isa Basin was seen to contain excellent source rocks coupled with potential reservoirs and all of the other essential aspects of a conventional petroleum exploration play. This play, although high risk, was commensurate with the enormous and totally untested petroleum potential of the basin. The basin was assessed for hydrocarbons in 1992 with three conventional exploration wells, Desert Creek-1, Argyle Creek-1 and Egilabria-1. These wells also tested and confrrmed the proposed basin model. No commercially viable oil or gas was encountered although evidence of its former existence was found. In addition to the petroleum exploration, indeed as a consequence of it, the association of the extensive base metal and other mineralisation in the Mount Isa Basin with hydrocarbons could not be overlooked. A comprehensive analysis of the available data suggests a link between the migration and possible generation or destruction of hydrocarbons and metal bearing fluids. Consequently, base metal exploration based on hydrocarbon exploration concepts is probably. the most effective technique in such basins. The metal-hydrocarbon-sedimentary basin-plate tectonic association (analogous to Phanerozoic models) is a compelling outcome of this work on the Palaeo- to Mesoproterozoic Mount lsa Basin. Petroleum within the Bowthom Block was apparently destroyed by hot brines that produced many ore deposits elsewhere in the basin.

The effectiveness of a short-term group music therapy intervention for parents who have a child with a disability

The relationship between the quality of parent-child interactions and positive child developmental trajectories is well established (Guralnick, 2006; Shonkoff & Meissels, 2000; Zubrick et al., 2008). However, a range of parental, family, and socio-economic factors can pose risks to parents’ capacity to participate in quality interactions with their children. In particular, families with a child with a disability have been found to have higher levels of parenting stress, and are more likely to experience economic disadvantage, as well as social isolation. The importance of early interventions to promote positive parenting and child development for these families is widely recognised (Shonkoff & Meissels, 2000). However, to date, there is a lack of evidence about the effectiveness of early parenting programs for families who have a young child with a disability. This thesis investigates the impact of a music therapy parenting program, Sing & Grow, on 201 parent-child dyads who attended programs specifically targeted to parents who had a young child with a disability. Sing & Grow is an Australian national early parenting intervention funded by the Australian Government Department of Families, Housing, Community Services and Indigenous Affairs and delivered by Playgroup Queensland. It is designed and delivered by Registered Music Therapists for families with children aged from birth to three years. It aims to improve parenting skills and confidence, improve family functioning (positive parent-child interactions), enhance child development, and provide social networking opportunities to socially isolated families. The intervention targets a range of families in circumstances that have the potential to impact negatively on family functioning. This thesis uses data from the National Evaluation Study of Sing & Grow from programs which were targeted at families who had a young child with a disability. Three studies were conducted to address the objectives of this thesis. Study 1 examines the effects of the Sing & Grow intervention on parent reported pre and post parent mental health, parenting confidence, parenting skills, and child development, and other parent reported outcomes including social support, use of intervention resources, satisfaction with the intervention and perceived benefits of and barriers to participation. Significant improvements from pre to post were found for parent mental health and parent reported child communication and social skills, along with evidence that parents were very satisfied with the program and that it brought social benefits to families. Study 2 explored the pre to post effects of the intervention on children’s developmental skills and parent-child interactions using observational ratings made by clinicians. Significant pre to post improvements were found for parenting sensitivity, parental engagement with child and acceptance of child as well as for child responsiveness to parent, interest, and participation in the intervention, and social skills. Study 3 examined the nature of child and family characteristics that predicted better outcomes for families while taking account of the level of participation in the program. An overall outcome index was calculated and served as the dependent variable in a logistic regression analysis. Families who attended six or more sessions and mothers who had not completed high school were more likely to have higher outcome scores at post intervention than those who attended fewer sessions and those with more educated mothers respectively. The findings of this research indicate that the intervention had a positive impact on participants’ mental health, parenting behaviours and child development and that level of attendance was associated with better outcomes. There was also evidence that the program reached its target of high risk families (i.e., families in which mothers had lower educational levels) and that for these families better outcomes were achieved. There were also indications that the program was accessible and highly regarded by families and that it promoted social connections for participants. A theoretical model of how the intervention is currently working for families is proposed to explain the connections between early parenting, child development and maternal wellbeing. However, more research is required to further elucidate the mechanisms by which the intervention creates change for families. This research presents promising evidence that a short term group music therapy program can elicit important therapeutic benefits for families who have a child with a disability.

Expected safety performance of rural signalized intersections in South Korea

Understanding the expected safety performance of rural signalized intersections is critical for (a) identifying high-risk sites where the observed safety performance is substantially worse than the expected safety performance, (b) understanding influential factors associated with crashes, and (c) predicting the future performance of sites and helping plan safety-enhancing activities. These three critical activities are routinely conducted for safety management and planning purposes in jurisdictions throughout the United States and around the world. This paper aims to develop baseline expected safety performance functions of rural signalized intersections in South Korea, which to date have not yet been established or reported in the literature. Data are examined from numerous locations within South Korea for both three-legged and four-legged configurations. The safety effects of a host of operational and geometric variables on the safety performance of these sites are also examined. In addition, supplementary tables and graphs are developed for comparing the baseline safety performance of sites with various geometric and operational features. These graphs identify how various factors are associated with safety. The expected safety prediction tables offer advantages over regression prediction equations by allowing the safety manager to isolate specific features of the intersections and examine their impact on expected safety. The examination of the expected safety performance tables through illustrated examples highlights the need to correct for regression-to-the-mean effects, emphasizes the negative impacts of multicollinearity, shows why multivariate models do not translate well to accident modification factors, and illuminates the need to examine road safety carefully and methodically. Caveats are provided on the use of the safety performance prediction graphs developed in this paper.

Identifying large truck hot spots using crash counts and PDOEs

Large trucks are involved in a disproportionately small fraction of the total crashes but a disproportionately large fraction of fatal crashes. Large truck crashes often result in significant congestion due to their large physical dimensions and from difficulties in clearing crash scenes. Consequently, preventing large truck crashes is critical to improving highway safety and operations. This study identifies high risk sites (hot spots) for large truck crashes in Arizona and examines potential risk factors related to the design and operation of the high risk sites. High risk sites were identified using both state of the practice methods (accident reduction potential using negative binomial regression with long crash histories) and a newly proposed method using Property Damage Only Equivalents (PDOE). The hot spots identified via the count model generally exhibited low fatalities and major injuries but large minor injuries and PDOs, while the opposite trend was observed using the PDOE methodology. The hot spots based on the count model exhibited large AADTs, whereas those based on the PDOE showed relatively small AADTs but large fractions of trucks and high posted speed limits. Documented site investigations of hot spots revealed numerous potential risk factors, including weaving activities near freeway junctions and ramps, absence of acceleration lanes near on-ramps, small shoulders to accommodate large trucks, narrow lane widths, inadequate signage, and poor lighting conditions within a tunnel.

Experimental evaluation of hotspot identification methods

Identifying crash “hotspots”, “blackspots”, “sites with promise”, or “high risk” locations is standard practice in departments of transportation throughout the US. The literature is replete with the development and discussion of statistical methods for hotspot identification (HSID). Theoretical derivations and empirical studies have been used to weigh the benefits of various HSID methods; however, a small number of studies have used controlled experiments to systematically assess various methods. Using experimentally derived simulated data—which are argued to be superior to empirical data, three hot spot identification methods observed in practice are evaluated: simple ranking, confidence interval, and Empirical Bayes. Using simulated data, sites with promise are known a priori, in contrast to empirical data where high risk sites are not known for certain. To conduct the evaluation, properties of observed crash data are used to generate simulated crash frequency distributions at hypothetical sites. A variety of factors is manipulated to simulate a host of ‘real world’ conditions. Various levels of confidence are explored, and false positives (identifying a safe site as high risk) and false negatives (identifying a high risk site as safe) are compared across methods. Finally, the effects of crash history duration in the three HSID approaches are assessed. The results illustrate that the Empirical Bayes technique significantly outperforms ranking and confidence interval techniques (with certain caveats). As found by others, false positives and negatives are inversely related. Three years of crash history appears, in general, to provide an appropriate crash history duration.

Modeling crash types: New insights into the effects of covariates on crashes at rural intersections

Many studies focused on the development of crash prediction models have resulted in aggregate crash prediction models to quantify the safety effects of geometric, traffic, and environmental factors on the expected number of total, fatal, injury, and/or property damage crashes at specific locations. Crash prediction models focused on predicting different crash types, however, have rarely been developed. Crash type models are useful for at least three reasons. The first is motivated by the need to identify sites that are high risk with respect to specific crash types but that may not be revealed through crash totals. Second, countermeasures are likely to affect only a subset of all crashes—usually called target crashes—and so examination of crash types will lead to improved ability to identify effective countermeasures. Finally, there is a priori reason to believe that different crash types (e.g., rear-end, angle, etc.) are associated with road geometry, the environment, and traffic variables in different ways and as a result justify the estimation of individual predictive models. The objectives of this paper are to (1) demonstrate that different crash types are associated to predictor variables in different ways (as theorized) and (2) show that estimation of crash type models may lead to greater insights regarding crash occurrence and countermeasure effectiveness. This paper first describes the estimation results of crash prediction models for angle, head-on, rear-end, sideswipe (same direction and opposite direction), and pedestrian-involved crash types. Serving as a basis for comparison, a crash prediction model is estimated for total crashes. Based on 837 motor vehicle crashes collected on two-lane rural intersections in the state of Georgia, six prediction models are estimated resulting in two Poisson (P) models and four NB (NB) models. The analysis reveals that factors such as the annual average daily traffic, the presence of turning lanes, and the number of driveways have a positive association with each type of crash, whereas median widths and the presence of lighting are negatively associated. For the best fitting models covariates are related to crash types in different ways, suggesting that crash types are associated with different precrash conditions and that modeling total crash frequency may not be helpful for identifying specific countermeasures.

A policy case study of blood in Australia

In 2008 the Australian government decided to remove white blood cells from all blood products. This policy of universal leucodepletion was a change to the existing policy of supplying leucodepleted products to high risk patients only. The decision was made without strong information about the cost-effectiveness of universal leucodepletion. The aims for this policy analysis are to generate cost-effectiveness data about universal leucodepletion, and to add to our understanding of the role of evidence and the political reality of healthcare decision-making in Australia. The cost-effectiveness analysis revealed universal leucodepletion costs $398,943 to save one year of life. This exceeds the normal maximum threshold for Australia. We discuss this result within the context of how policy decisions are made about blood, and how it relates to the theory and process of policy making. We conclude that the absence of a strong voice for cost-effectiveness was an important omission in this decision.