Strategic risk appraisal. Comparing expert- and literature-informed consequence assessments for environmental policy risks receiving national attention.

Strategic risk appraisal (SRA) has been applied to compare diverse policy level risks to and from the environment in England and Wales. Its application has relied on expert-informed assessments of the potential consequences from residual risks that attract policy attention at the national scale. Here we compare consequence assessments, across environmental, economic and social impact categories that draw on 'expert'- and 'literature-based' analyses of the evidence for 12 public risks appraised by Government. For environmental consequences there is reasonable agreement between the two sources of assessment, with expert-informed assessments providing a narrower dispersion of impact severity and with median values similar in scale to those produced by an analysis of the literature. The situation is more complex for economic consequences, with a greater spread in the median values, less consistency between the two assessment types and a shift toward higher severity values across the risk portfolio. For social consequences, the spread of severity values is greater still, with no consistent trend between the severities of impact expressed by the two types of assessment. For the latter, the findings suggest the need for a fuller representation of socioeconomic expertise in SRA and the workshops that inform SRA output.

Engaging with Comparative Risk Appraisals: Public Views on Policy Priorities for Environmental Risk Governance.

Communicating the rationale for allocating resources to manage policy priorities and their risks is challenging. Here, we demonstrate that environmental risks have diverse attributes and locales in their effects that may drive disproportionate responses among citizens. When 2,065 survey participants deployed summary information and their own understanding to assess 12 policy-level environmental risks singularly, their assessment differed from a prior expert assessment. However, participants provided rankings similar to those of experts when these same 12 risks were considered as a group, allowing comparison between the different risks. Following this, when individuals were shown the prior expert assessment of this portfolio, they expressed a moderate level of confidence with the combined expert analysis. These are important findings for the comprehension of policy risks that may be subject to augmentation by climate change, their representation alongside other threats within national risk assessments, and interpretations of agency for public risk management by citizens and others.

U.K. Foot and Mouth Disease: A Systemic Risk Assessment of Existing Controls.

This article details a systemic analysis of the controls in place and possible interventions available to further reduce the risk of a foot and mouth disease (FMD) outbreak in the United Kingdom. Using a research-based network analysis tool, we identify vulnerabilities within the multibarrier control system and their corresponding critical control points (CCPs). CCPs represent opportunities for active intervention that produce the greatest improvement to United Kingdom's resilience to future FMD outbreaks. Using an adapted 'features, events, and processes' (FEPs) methodology and network analysis, our results suggest that movements of animals and goods associated with legal activities significantly influence the system's behavior due to their higher frequency and ability to combine and create scenarios of exposure similar in origin to the U.K. FMD outbreaks of 1967/8 and 2001. The systemic risk assessment highlights areas outside of disease control that are relevant to disease spread. Further, it proves to be a powerful tool for demonstrating the need for implementing disease controls that have not previously been part of the system.

Confluence and Contours: Reflexive Management of Environmental Risk.

Government institutions have responsibilities to distribute risk management funds meaningfully and to be accountable for their choices. We took a macro-level sociological approach to understanding the role of government in managing environmental risks, and insights from micro-level psychology to examine individual-level risk-related perceptions and beliefs. Survey data from 2,068 U.K. citizens showed that lay people's funding preferences were associated positively with beliefs about responsibility and trust, yet associations with perception varied depending on risk type. Moreover, there were risk-specific differences in the funding preferences of the lay sample and 29 policymakers. A laboratory-based study of 109 participants examined funding allocation in more detail through iterative presentation of expert information. Quantitative and qualitative data revealed a meso-level framework comprising three types of decisionmakers who varied in their willingness to change funding allocation preferences following expert information: adaptors, responders, and resistors. This research highlights the relevance of integrated theoretical approaches to understanding the policy process, and the benefits of reflexive dialogue to managing environmental risks.

Implementing quality improvement strategies to reduce healthcare-associated infections: A systematic review.

BACKGROUND: Comprehensive incidence estimates indicate that 1.7 million healthcare-associated infections (HAIs) and 99,000 HAI-associated deaths occur in US hospitals. Preventing HAIs could save $25.0 to $31.5 billion. Identifying effective quality improvement (QI) strategies for promoting adherence to evidence-based preventive interventions could reduce infections. METHODS: We searched MEDLINE, CINAHL, and EMBASE from 2006-2012 for English-language articles with ≥ 100 patients that described an implementation strategy to increase adherence with evidence-based preventive interventions and that met study design criteria. One reviewer abstracted and appraised study quality, with verification by a second. QI strategies included audit and feedback; financial incentives, regulation, and policy; organizational change; patient education; provider education; and provider reminder systems. RESULTS: We evaluated data on HAIs from 30 articles reporting adherence and infection rates that accounted for confounding or secular trends. Many of the measures improved significantly, especially adherence. Results varied by QI strategy(s). CONCLUSIONS: Moderate strength of evidence supports improvement in adherence and infection rates when audit and feedback plus provider reminder systems or audit and feedback alone is added to organizational change and provider education. Strength of evidence is low when provider reminder systems alone are added to organizational change and provider education. There were no studies on HAIs in nonhospital settings that met the selection criteria.

Using Hidden Markov Models to Determine Changes in Subject Data over Time, Studying the Immunoregulatory effect of Mesenchymal Stem Cells.

A novel application of Hidden Markov Models is used to help research intended to test the immunuregulatory effects of mesenchymal stem cells in a cynomolgus monkey model of islet transplantation. The Hidden Markov Model, an unsupervised learning data mining technique, is used to automatically determine the postoperative day (POD) corresponding to a decrease of graft function, a possible sign of transplant rejection, on nonhuman primates after isolated islet cell transplant. Currently, decrease of graft function is being determined solely on experts' judgment. Further, information gathered from the evaluation of construted Hidden Markov Models is used as part of a clustering method to aggregate the nonhuman subjects into groups or clusters with the objective of finding similarities that could potentially help predict the health outcome of subjects undergoing postoperative care. Results on expert labeled data show the HMM to be accurate 60% of the time. Clusters based on the HMMs further suggest a possible correspondence between donor haplotypes matching and loss of function outcomes.

A systems approach to the policy-level risk assessment of exotic animal diseases: network model and application to classical swine fever.

Exotic animal diseases (EADs) are characterized by their capacity to spread global distances, causing impacts on animal health and welfare with significant economic consequences. We offer a critique of current import risk analysis approaches employed in the EAD field, focusing on their capacity to assess complex systems at a policy level. To address the shortcomings identified, we propose a novel method providing a systematic analysis of the likelihood of a disease incursion, developed by reference to the multibarrier system employed for the United Kingdom. We apply the network model to a policy-level risk assessment of classical swine fever (CSF), a notifiable animal disease caused by the CSF virus. In doing so, we document and discuss a sequence of analyses that describe system vulnerabilities and reveal the critical control points (CCPs) for intervention, reducing the likelihood of U.K. pig herds being exposed to the CSF virus.

Closing the quality gap: revisiting the state of the science (vol. 6: prevention of healthcare-associated infections).

OBJECTIVES: To update the Agency for Healthcare Research and Quality (AHRQ) Evidence Report Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies: Volume 6-Prevention of Healthcare-Associated Infections on quality improvement (QI) strategies to increase adherence to preventive interventions and/or reduce infection rates for central line-associated bloodstream infections (CLABSI), ventilator-associated pneumonia (VAP), surgical site infections (SSI), and catheter-associated urinary tract infections (CAUTI). DATA SOURCES: MEDLINE®, CINAHL®, and Embase® were searched from January 2006 to January 2012 for English-language studies with sample size ≥100 patients, a defined baseline period, and reported statistical analysis for adherence and/or infection rates. Articles from the previous report were screened and those meeting selection criteria were included. REVIEW METHODS: We sought studies that evaluated the following QI strategies to improve adherence to evidence-based preventive interventions and/or reduce healthcare-associated infection (HAI) rates: audit and feedback; financial incentives, regulation, and policy; organizational change; patient education; provider education; and provider reminder systems. Data were abstracted by a single reviewer and fact-checked by a second. Outcomes were adherence to preventive interventions, infection rates, adverse outcomes, and cost savings. Study quality was assessed using relative rankings based on study design, adequacy of statistical analysis, length of followup, reporting and analysis of baseline and postintervention adherence and infection rates, and implementation of the intervention independent of other QI efforts. Combinations of QI strategies were assessed, not individual strategies. Strength of evidence was judged according to the AHRQ Methods Guide. RESULTS: Sixty-one articles yielded 71 analyses at the infection level, including 9 articles (10 analyses) from the 2007 report, which evaluated the use of one or more QI strategies to improve adherence or infection rates and also controlled for confounding or secular trend. Twenty-six analyses were performed on CLABSI, 19 on VAP, 15 on SSI, and 11 on CAUTI. There were 34 analyses on adherence, of which 31 (91%) showed significant improvement. There were 63 analyses of infection rates, of which 42 (67%) showed significant improvement. CONCLUSIONS: There is moderate strength of evidence across all four infections that both adherence and infection rates improve when either audit and feedback plus provider reminder systems or audit and feedback alone is added to the base strategies of organizational change and provider education. There is low strength of evidence that adherence and infection rates improve when provider reminder systems alone are added to the base strategies. There was insufficient evidence for reduction of HAI in nonhospital settings, cost savings for QI strategies, and the nature and impact of the clinical contextual factors.

Character of environmental harms: overcoming implementation challenges with policy makers and regulators.

Policy makers and regulators are charged with the daunting task of comparing incommensurate environmental risks to inform strategic decisions on interventions. Here we present a policy-level framework intended to support strategic decision processes concerning environmental risks within the Department for Environment, Food and Rural Affairs (Defra). The framework provides the structure by which risk-based evidence may be collated and by assessing the value of harm expressed by different environmental policy areas against a consistent objective (e.g., sustainable development), we begin to form a basis for relative comparison. This research integrates the prior art, examples of best practice, and intimate end-user input to build a qualitative assessment informed by expert judgment. Supported by contextual narratives, the framework has proven successful in securing organizational support and stimulating debate about proportionate mitigation activity, resource allocation, and shifts in current risk thinking.

Relationship of pulmonary artery catheter use to mortality and resource utilization in patients with severe sepsis.

OBJECTIVE: To examine the relationship of pulmonary artery catheter (PAC) use to patient outcomes, including mortality rate and resource utilization, in patients with severe sepsis in eight academic medical centers. DESIGN: Case-control, nested within a prospective cohort study. SETTING: Eight academic tertiary care centers. PATIENTS: Stratified random sample of 1,010 adult admissions with severe sepsis. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The main outcome measures were in-hospital mortality, total hospital charge, and length of stay (LOS) for patients with and without PAC use. The case-matched subset of patients included 141 pairs managed with and without the use of a PAC. The mortality rate was slightly but not statistically significantly lower among the PAC use group compared with those not using a PAC (41.1% vs. 46.8%, p =.34). Even this trend disappeared after we adjusted for the Charlson comorbidity score and sepsis-specific Acute Physiology and Chronic Health Evaluation (APACHE) III (adjusted odds ratio, 1.02; 95% confidence interval, 0.61-1.72). In linear regression models adjusted for the Charlson comorbidity score, sepsis-specific APACHE III, surgical status, receipt of a steroid before sepsis onset, presence of a Hickman catheter, and preonset LOS, no significant differences were found for total hospital charges (139,207 US dollars vs. 148,190, adjusted mean comparing PAC and non-PAC group, p =.57), postonset LOS (23.4 vs. 26.9 days, adjusted mean, p =.32), or total LOS in intensive care unit (18.2 vs. 18.8 days, adjusted mean, p =.82). CONCLUSIONS: Among patients with severe sepsis, PAC placement was not associated with a change in mortality rate or resource utilization, although small nonsignificant trends toward lower resource utilization were present in the PAC group.

Severe sepsis: variation in resource and therapeutic modality use among academic centers.

BACKGROUND: Treatment of severe sepsis is expensive, often encompassing a number of discretionary modalities. The objective of the present study was to assess intercenter variation in resource and therapeutic modality use in patients with severe sepsis. METHODS: We conducted a prospective cohort study of 1028 adult admissions with severe sepsis from a stratified random sample of patients admitted to eight academic tertiary care centers. The main outcome measures were length of stay (LOS; total LOS and LOS after onset of severe sepsis) and total hospital charges. RESULTS: The adjusted mean total hospital charges varied from 69 429 dollars to US237 898 dollars across centers, whereas the adjusted LOS after onset varied from 15.9 days to 24.2 days per admission. Treatments used frequently after the first onset of sepsis among patients with severe sepsis were pulmonary artery catheters (19.4%), ventilator support (21.8%), pressor support (45.8%) and albumin infusion (14.4%). Pulmonary artery catheter use, ventilator support and albumin infusion had moderate variation profiles, varying 3.2-fold to 4.9-fold, whereas the rate of pressor support varied only 1.92-fold across centers. Even after adjusting for age, sex, Charlson comorbidity score, discharge diagnosis-relative group weight, organ dysfunction and service at onset, the odds for using these therapeutic modalities still varied significantly across centers. Failure to start antibiotics within 24 hours was strongly correlated with a higher probability of 28-day mortality (r2 = 0.72). CONCLUSION: These data demonstrate moderate but significant variation in resource use and use of technologies in treatment of severe sepsis among academic centers. Delay in antibiotic therapy was associated with worse outcome at the center level.

Resource utilization among patients with sepsis syndrome.

OBJECTIVE: To assess the resource utilization associated with sepsis syndrome in academic medical centers. DESIGN: Prospective cohort study. SETTING: Eight academic, tertiary-care centers. PATIENTS: Stratified random sample of 1,028 adult admissions with sepsis syndrome and all 248,761 other adult admissions between January 1993 and April 1994. The main outcome measures were length of stay (LOS) in total and after onset of sepsis syndrome (post-onset LOS) and total hospital charges. RESULTS: The mean LOS for patients with sepsis was 27.7 +/- 0.9 days (median, 20 days), with sepsis onset occurring after a mean of 8.1 +/- 0.4 days (median, 3 days). For all patients without sepsis, the LOS was 7.2 +/- 0.03 days (median, 4 days). In multiple linear regression models, the mean for patients with sepsis syndrome was 18.2 days, which was 11.0 days longer than the mean for all other patients (P < .0001), whereas the mean difference in total charges was $43,000 (both P < .0001). These differences were greater for patients with nosocomial as compared with community-acquired sepsis, although the groups were similar after adjusting for pre-onset LOS. Eight independent correlates of increased post-onset LOS and 12 correlates of total charges were identified. CONCLUSIONS: These data quantify the resource utilization associated with sepsis syndrome, and demonstrate that resource utilization is high in this group. Additional investigation is required to determine how much of the excess post-onset LOS and charges are attributable to sepsis syndrome rather than the underlying medical conditions.