The need for cost-effectiveness analyses of antimicrobial stewardship programmes: A structured review

The cost effectiveness of antimicrobial stewardship (AMS) programmes was reviewed in hospital settings of Organisation for Economic Co-operation and Development (OECD) countries, and limited to adult patient populations. In each of the 36 studies, the type of AMS strategy and the clinical and cost outcomes were evaluated. The main AMS strategy implemented was prospective audit with intervention and feedback (PAIF), followed by the use of rapid technology, including rapid polymerase chain reaction (PCR)-based methods and matrix-assisted laser desorption/ionisation time-of-flight (MALDI-TOF) technology, for the treatment of bloodstream infections. All but one of the 36 studies reported that AMS resulted in a reduction in pharmacy expenditure. Among 27 studies measuring changes to health outcomes, either no change was reported post-AMS, or the additional benefits achieved from these outcomes were not quantified. Only two studies performed a full economic evaluation: one on a PAIF-based AMS intervention; and the other on use of rapid technology for the selection of appropriate treatment for serious Staphylococcus aureus infections. Both studies found the interventions to be cost effective. AMS programmes achieved a reduction in pharmacy expenditure, but there was a lack of consistency in the reported cost outcomes making it difficult to compare between interventions. A failure to capture complete costs in terms of resource use makes it difficult to determine the true cost of these interventions. There is an urgent need for full economic evaluations that compare relative changes both in clinical and cost outcomes to enable identification of the most cost-effective AMS strategies in hospitals.

Modern energy access to all in rural India: An integrated implementation strategy

Expanding energy access to the rural population of India presents a critical challenge for its government. The presence of 364 million people without access to electricity and 726 million who rely on biomass for cooking indicate both the failure of past policies and programs, and the need for a radical redesign of the current system. We propose an integrated implementation framework with recommendations for adopting business principles with innovative institutional, regulatory, financing and delivery mechanisms. The framework entails establishment of rural energy access authorities and energy access funds, both at the national and regional levels, to be empowered with enabling regulatory policies, capital resources and the support of multi-stakeholder partnership. These institutions are expected to design, lead, manage and monitor the rural energy interventions. At the other end, trained entrepreneurs would be expected to establish bioenergy-based micro-enterprises that will produce and distribute energy carriers to rural households at an affordable cost. The ESCOs will function as intermediaries between these enterprises and the international carbon market both in aggregating carbon credits and in trading them under CDM. If implemented, such a program could address the challenges of rural energy empowerment by creating access to modern energy carriers and climate change mitigation. (C) 2011 Elsevier Ltd. All rights reserved.

Low cost calibrated mechanical noisemaker for hearing screening of neonates in resource constrained settings

Background & objectives: There is a need to develop an affordable and reliable tool for hearing screening of neonates in resource constrained, medically underserved areas of developing nations. This study valuates a strategy of health worker based screening of neonates using a low cost mechanical calibrated noisemaker followed up with parental monitoring of age appropriate auditory milestones for detecting severe-profound hearing impairment in infants by 6 months of age. Methods: A trained health worker under the supervision of a qualified audiologist screened 425 neonates of whom 20 had confirmed severe-profound hearing impairment. Mechanical calibrated noisemakers of 50, 60, 70 and 80 dB (A) were used to elicit the behavioural responses. The parents of screened neonates were instructed to monitor the normal language and auditory milestones till 6 months of age. This strategy was validated against the reference standard consisting of a battery of tests - namely, auditory brain stem response (ABR), otoacoustic emissions (OAE) and behavioural assessment at 2 years of age. Bayesian prevalence weighted measures of screening were calculated. Results: The sensitivity and specificity was high with least false positive referrals for. 70 and 80 dB (A) noisemakers. All the noisemakers had 100 per cent negative predictive value. 70 and 80 dB (A) noisemakers had high positive likelihood ratios of 19 and 34, respectively. The probability differences for pre- and post- test positive was 43 and 58 for 70 and 80 dB (A) noisemakers, respectively. Interpretation & conclusions: In a controlled setting, health workers with primary education can be trained to use a mechanical calibrated noisemaker made of locally available material to reliably screen for severe-profound hearing loss in neonates. The monitoring of auditory responses could be done by informed parents. Multi-centre field trials of this strategy need to be carried out to examine the feasibility of community health care workers using it in resource constrained settings of developing nations to implement an effective national neonatal hearing screening programme.

A Diffusion-Based Processor Reallocation Strategy for Tracking Multiple Dynamically Varying Weather Phenomena

Many meteorological phenomena occur at different locations simultaneously. These phenomena vary temporally and spatially. It is essential to track these multiple phenomena for accurate weather prediction. Efficient analysis require high-resolution simulations which can be conducted by introducing finer resolution nested simulations, nests at the locations of these phenomena. Simultaneous tracking of these multiple weather phenomena requires simultaneous execution of the nests on different subsets of the maximum number of processors for the main weather simulation. Dynamic variation in the number of these nests require efficient processor reallocation strategies. In this paper, we have developed strategies for efficient partitioning and repartitioning of the nests among the processors. As a case study, we consider an application of tracking multiple organized cloud clusters in tropical weather systems. We first present a parallel data analysis algorithm to detect such clouds. We have developed a tree-based hierarchical diffusion method which reallocates processors for the nests such that the redistribution cost is less. We achieve this by a novel tree reorganization approach. We show that our approach exhibits up to 25% lower redistribution cost and 53% lesser hop-bytes than the processor reallocation strategy that does not consider the existing processor allocation.

Make or buy decision in the context of manufacturing strategy

This paper describes an approach to structuring the make or buy decision process, basing it firmly in the context of an overall manufacturing strategy. The work has been carried out jointly by the University of Cambridge Manufacturing Engineering Group and Lucas Industries. A review of the current state of ideas surrounding the linked issues of vertical integration and make or buy decisions is presented. Important features of the approach include identification of core manufacturing capabilities, assessment of the role of technology in manufacturing, the development of a cost model to support make or buy decisions and a review of the strategic implications of varying degrees of vertical integration.

A modelling approach to the development of an active management strategy for the Queen Elizabeth II reservoir

This article outlines the outcome of work that set out to provide one of the specified integral contributions to the overarching objectives of the EU- sponsored LIFE98 project described in this volume. Among others, these included a requirement to marry automatic monitoring and dynamic modelling approaches in the interests of securing better management of water quality in lakes and reservoirs. The particular task given to us was to devise the elements of an active management strategy for the Queen Elizabeth II Reservoir. This is one of the larger reservoirs supplying the population of the London area: after purification and disinfection, its water goes directly to the distribution network and to the consumers. The quality of the water in the reservoir is of primary concern, for the greater is the content of biogenic materials, including phytoplankton, then the more prolonged is the purification and the more expensive is the treatment. Whatever good that phytoplankton may do by way of oxygenation and oxidative purification, it is eventually relegated to an impurity that has to be removed from the final product. Indeed, it has been estimated that the cost of removing algae and microorganisms from water represents about one quarter of its price at the tap. In chemically fertile waters, such as those typifying the resources of the Thames Valley, there is thus a powerful and ongoing incentive to be able to minimise plankton growth in storage reservoirs. Indeed, the Thames Water company and its predecessor undertakings, have a long and impressive history of confronting and quantifying the fundamentals of phytoplankton growth in their reservoirs and of developing strategies for operation and design to combat them. The work to be described here follows in this tradition. However, the use of the model PROTECH-D to investigate present phytoplankton growth patterns in the Queen Elizabeth II Reservoir questioned the interpretation of some of the recent observations. On the other hand, it has reinforced the theories underpinning the original design of this and those Thames-Valley storage reservoirs constructed subsequently. The authors recount these experiences as an example of how simulation models can hone the theoretical base and its application to the practical problems of supplying water of good quality at economic cost, before the engineering is initiated.

Background Concepts for a Rotating Harvesting Strategy with Particular Reference to the Mediterranean Red Coral, Corallium rubrum

A simple cohort model was used as the basis for selecting the appropriate periodicity and number of separate unit areas in a rotating harvest scheme for a sedentary species, the red coral, Corallium rubrum, in the General Fisheries Management Council for the Mediterranean area. The rotation period in years, and hence the minimum number of unit areas involved, was determined on the basis of the time to maximum biomass by a simple calculation of the yield-per-recruit type, requiring a knowledge of natural mortality and growth rates. Other criteria may be more important, however, and in general for a long-lived species, will result in shorter rotation periods. These criteria may include economic factors, criteria based on the preferred size or quality of product, or criteria that take into account the cumulative risk of illegal fishing of closed areas with time, hence the growing cost of enforcement as harvestable product accumulates. For red coral, although maximum biomass is predicted to be reached after some 15-44 years, the above considerations suggest that a rotation period ofsome 9-15 years would be close to optimal, taking into account a range ofthe above considerations. This article discusses the relative merits of rotating harvest schemes in contrast to quota management for sedentary and semi-sedentary resources or geographically isolated substocks ofa mobile resource, and concludes that this approach may have considerable potential as an alternative approach to resource management.

Lakes - Classification & Monitoring: a strategy for the classification of lakes

This is the report on Lakes – Classification and Monitoring, a strategy for the classification of lakes by the National Rivers Authority. This report describes a scheme for the assessment and monitoring of water and ecological quality in standing waters, greater than about 1ha in area, in England and Wales although it is generally relevant to Northwest Europe. Thirteen hydrological, chemical and biological variables are used to characterize the standing water body in any current sampling. Statistical testing on the chemical variables showed that at least six samples during a year would be needed to produce a representative sampling mean; but in this scheme the choice of variables minimizes logistic cost by not using boat sampling and time costs by not demanding extensive taxonomic work. Standing waters are classified in a state-changed system in which the contemporary values of the variables are compared with a reference baseline state and then placed in categories of percentage change from this baseline. The scheme is presently designed for use at about five year intervals on all lakes greater than 2ha area plus additional lakes of significant amenity or conservation interest.

Translocation as a strategy to rehabilitate the queen conch (Strombus gigas) population in the Florida Keys

Queen conch (Strombus gigas) stocks in the Florida Keys once supported commercial and recreational fisheries, but overharvesting has decimated this once abundant snail. Despite a ban on harvesting this species since 1985, the local conch population has not recovered. In addition, previous work has reported that conch located in nearshore Keys waters are incapable of spawning because of poor gonadal condition, although reproduction does occur offshore. Queen conch in other areas undergo ontogenetic migrations from shallow, nearshore sites to offshore habitats, but conch in the Florida Keys are prevented from doing so by Hawk Channel. The present study was initiated to determine the potential of translocating nonspawning nearshore conch to offshore sites in order to augment the spawning stock. We translocated adult conch from two nearshore sites to two offshore sites. Histological examinations at the initiation of this study confirmed that nearshore conch were incapable of reproduction, whereas offshore conch had normal gonads and thus were able to reproduce. The gonads of nearshore females were in worse condition than those of nearshore males. However, the gonadal condition of the translocated nearshore conch improved, and these animals began spawning after three months offshore. This finding suggests that some component of the nearshore environment (e.g., pollutants, temperature extremes, poor food or habitat quality) disrupts reproduction in conch, but that removal of nearshore animals to suitable offshore habitat can restore reproductive viability. These results indicate that translocations are preferable to releasing hatchery-reared juveniles because they are more cost-effective, result in a more rapid increase in reproductive output, and maintain the genetic integrity of the wild stock. Therefore, translocating nearshore conch to offshore spawning aggregations may be the key to expediting the recovery of queen conch stocks in the Florida Keys.

Policy entrepreneurship in the development of public sector strategy: the case of London health reform

The development of health policy is recognized as complex; however, there has been little development of the role of agency in this process. Kingdon developed the concept of policy entrepreneur (PE) within his ‘windows’ model. He argued inter-related ‘policy streams' must coincide for important issues to become addressed. The conjoining of these streams may be aided by a policy entrepreneur. We contribute by clarifying the role of the policy entrepreneur and highlighting the translational processes of key actors in creating and aligning policy windows. We analyse the work in London of Professor Sir Ara Darzi as a policy entrepreneur. An important aspect of Darzi's approach was to align a number of important institutional networks to conjoin related problems. Our findings highlight how a policy entrepreneur not only opens policy windows but also yokes together a network to make policy agendas happen. Our contribution reveals the role of clinical leadership in health reform.

Dynamic technology leadership: The adaptive role of the CTO

OVERVIEW: The importance of the chief technology officer role is widely accepted, particularly in today's turbulent, global conditions. However, not enough is known about the key activities of CTOs or the factors that influence their priorities. Thirty in-depth interviews conducted with the CTOs in global firms identified key activities: aligning technology and corporate strategy and business models, determining technology entry and exit points, and preparing business cases to secure funding for technology development. The research also showed that priority areas for CTOs are related to technology transition points-major contextual and business discontinuities that impact the focus of the CTO. We conclude that the determination of priorities at these technology transition points is highly idiosyncratic and closely related to whether the CTO functions more or less strategically.

The development of a scanning strategy for the manufacture of porous biomaterials by selective laser melting.

Porous structures are used in orthopaedics to promote biological fixation between metal implant and host bone. In order to achieve rapid and high volumes of bone ingrowth the structures must be manufactured from a biocompatible material and possess high interconnected porosities, pore sizes between 100 and 700 microm and mechanical strengths that withstand the anticipated biomechanical loads. The challenge is to develop a manufacturing process that can cost effectively produce structures that meet these requirements. The research presented in this paper describes the development of a 'beam overlap' technique for manufacturing porous structures in commercially pure titanium using the Selective Laser Melting (SLM) rapid manufacturing technique. A candidate bone ingrowth structure (71% porosity, 440 microm mean pore diameter and 70 MPa compression strength) was produced and used to manufacture a final shape orthopaedic component. These results suggest that SLM beam overlap is a promising technique for manufacturing final shape functional bone ingrowth materials.

Market-pull and technology-push in manufacturing start-ups in emerging industries

Purpose - As traditional manufacturing, previously vital to the UK economy, is increasingly outsourced to lower-cost locations, policy makers seek leadership in emerging industries by encouraging innovative start-up firms to pursue competitive opportunities. Emerging industries can either be those where a technology exists but the corresponding downstream value chain is unclear, or a new technology may subvert the existing value chain to satisfy existing customer needs. Hence, this area shows evidence of both technology-push and market-pull forces. The purpose of this paper is to focus on market-pull and technology-push orientations in manufacturing ventures, specifically examining how and why this orientation shifts during the firm's formative years. Design/methodology/approach - A multiple case study approach of 25 UK start-ups in emerging industries is used to examine this seldom explored area. The authors offer two models of dynamic business-orientation in start-ups and explain the common reasons for shifts in orientation and why these two orientations do not generally co-exist during early firm development. Findings - Separate evolution paths were found for strategic orientation in manufacturing start-ups and separate reasons for them to shift in their early development. Technology-push start-ups often changed to a market-pull orientation because of new partners, new market information or shift in management priorities. In contrast, many of the start-ups beginning with a market-pull orientation shifted to a technology-push orientation because early market experiences necessitated a focus on improving processes in order to increase productivity or meet partner specifications, or meet a demand for complementary products. Originality/value - While a significant body of work exists regarding manufacturing strategy in established firms, little work has been found that investigates how manufacturing strategy emerges in start-up companies, particularly those in emerging industries. © Emerald Group Publishing Limited.

Cost-effectiveness analysis of the diagnosis of meniscus tears.

BACKGROUND: Diagnostic imaging represents the fastest growing segment of costs in the US health system. This study investigated the cost-effectiveness of alternative diagnostic approaches to meniscus tears of the knee, a highly prevalent disease that traditionally relies on MRI as part of the diagnostic strategy. PURPOSE: To identify the most efficient strategy for the diagnosis of meniscus tears. STUDY DESIGN: Economic and decision analysis; Level of evidence, 1. METHODS: A simple-decision model run as a cost-utility analysis was constructed to assess the value added by MRI in various combinations with patient history and physical examination (H&P). The model examined traumatic and degenerative tears in 2 distinct settings: primary care and orthopaedic sports medicine clinic. Strategies were compared using the incremental cost-effectiveness ratio (ICER). RESULTS: In both practice settings, H&P alone was widely preferred for degenerative meniscus tears. Performing MRI to confirm a positive H&P was preferred for traumatic tears in both practice settings, with a willingness to pay of less than US$50,000 per quality-adjusted life-year. Performing an MRI for all patients was not preferred in any reasonable clinical scenario. The prevalence of a meniscus tear in a clinician's patient population was influential. For traumatic tears, MRI to confirm a positive H&P was preferred when prevalence was less than 46.7%, with H&P preferred above that. For degenerative tears, H&P was preferred until the prevalence reaches 74.2%, and then MRI to confirm a negative was the preferred strategy. In both settings, MRI to confirm positive physical examination led to more than a 10-fold lower rate of unnecessary surgeries than did any other strategy, while MRI to confirm negative physical examination led to a 2.08 and 2.26 higher rate than H&P alone in primary care and orthopaedic clinics, respectively. CONCLUSION: For all practitioners, H&P is the preferred strategy for the suspected degenerative meniscus tear. An MRI to confirm a positive H&P is preferred for traumatic tears for all practitioners. Consideration should be given to implementing alternative diagnostic strategies as well as enhancing provider education in physical examination skills to improve the reliability of H&P as a diagnostic test. CLINICAL RELEVANCE: Alternative diagnostic strategies that do not include the use of MRI may result in decreased health care costs without harm to the patient and could possibly reduce unnecessary procedures.

Developing “middle leaders” in the public services? The realities of management and leadership development for public managers

Purpose – This paper aims to assess the actual contribution to organisational change of management and leadership development (MLD) activity for middle managers (MMs) in public service organisations (PSOs). Design/methodology/approach – Using the case study approach, the paper compares the content and outcomes of management and leadership training interventions for MMs in two large PSOs. The organisations, a fire brigade and a train operating company, are leaders in their sectors with respect to management development and “modernisation” of their services. Findings – The paper demonstrates how, in one case, MM development was largely an exercise in regulatory compliance, with little effect on individual MMs' performance or organisational outcomes. The second case demonstrates how MMs were effectively trained to enforce specific human resource policies which contributed to the successful implementation of top-down strategy yet paid little attention to the potential leadership role of MMs. Research limitations/implications – The paper highlights the need for further contextualised research at organisational level into the outcomes of MLD, especially in terms of different public service contexts. Practical implications – The paper demonstrates the dangers of designing and implementing development programmes without sufficient regard to professional practice and the realities of managerial discretion in PSOs. Originality/value – The paper provides an in-depth and contextualised insight into the conditions for success and failure in management development interventions in PSOs.