Quality assurance of rectal cancer diagnosis and treatment - phase 3 : statistical methods to benchmark centres on a set of quality indicators

In 2004, the Belgian Section for Colorectal Surgery, a section of the Royal Belgian Society for Surgery, decided to start PROCARE (PROject on CAncer of the REctum), a multidisciplinary, profession-driven and decentralized project with as main objectives the reduction of diagnostic and therapeutic variability and improvement of outcome in patients with rectal cancer. All medical specialties involved in the care of rectal cancer established a multidisciplinary steering group in 2005. They agreed to approach the stated goal by means of treatment standardization through guidelines, implementation of these guidelines and quality assurance through registration and feedback. In 2007, the PROCARE guidelines were updated (Procare Phase I, KCE report 69). In 2008, a set of 40 process and outcome quality of care indicators (QCI) was developed and organized into 8 domains of care: general, diagnosis/staging, neoadjuvant treatment, surgery, adjuvant treatment, palliative treatment, follow-up and histopathologic examination. These QCIs were tested on the prospective PROCARE database and on an administrative (claims) database (Procare Phase II, KCE report 81). Afterwards, 4 QCIs were added by the PROCARE group. Centres have been receiving feedback from the PROCARE registry on these QCIs with a description of the distribution of the unadjusted centre-averaged observed measures and the centre’s position therein. To optimize this feedback, centres should ideally be informed of their risk-adjusted outcomes and be given some benchmarks. The PROCARE Phase III study is devoted to developing a methodology to achieve this feedback

Examination of the impact and effectiveness of herd health and welfare assessment in im-proving animal welfare on organic dairy farms, using qualitative interviews.

During winter 2002-03, 15 organic dairy farms in SW England participated in a herd health and welfare assessment and benchmarking study. A second assessment was carried out on 14 of the original 15 farms and on 14 new farms during winter 2003-04. The effectiveness of the herd health and welfare as-sessments and benchmarking in delivering animal health and welfare improvements was investigated by means of qualitative research interviews. The inter-views were conducted between August and November 2004. The average length of interview was one hour and fifteen minutes. Five common themes were iden-tified and headed ‘Sensitivities and misgivings’; ‘Ac-ceptability of scoring methodology and indicators assessed’; ‘Raised awareness and motivation to im-prove’; ‘Veterinary support and herd health planning’ and ‘Value of assessment and benchmarking’. It was apparent that farmers, who took part voluntarily in the study, took the results of the herd health and welfare assessments very seriously and were clearly motivated by the process. The main focus for change was related to housing issues. The main constraints to welfare improvement were a shortage of finance to affect change beyond relatively simple alterations and a lack of information on the identification of changes likely to improve animal welfare in given situations

Outsourcing: guidelines for a structured approach

Outsourcing is a management approach by which an organization delegates some noncore functions to specialized and ef®cient service providers. In the era of ªglobal marketº and ªe-economyº, outsourcing is one of the main pillars of the new way to conceive the relationships among companies. Despite outsourcing large diffusion, huge business cases and big deals of documentation available on network or press, there is no structured procedure able to support the govern of the evolution of a generic outsourcing process. In accordance with the principles of total quality management, this paper describes a proposal of a new approach for managing outsourcing processes. The model, which can be easily adapted to different application ®elds, has been conceived with the main aim of managing strategic decisions, economic factors and human resources. The approach is supported by different decision and analysis tools, such as benchmarking techniques, multiple criteria decision aiding (MCDA) methods, cost analysis, and other process-planning methodologies. An application of the method to a real case is also provide

Welfare benchmarking and herd health plans on organic dairy farms (OF0343)

Introduction In response to the recommendations of recent studies on the health and welfare of dairy cattle (Whay et al. 2003) and to assist farmers to meet legislative requirements, promoting farm animal welfare and meeting consumer demand, this study investigated, by means of farmer interviews, the effectiveness of herd health and welfare assessment and benchmarking as a farm management tool. The aims of the study were to • offer support to the organic farming sector and provide detail relevant to all dairy farms utilising herd health plans; • provide information to both organic dairy farmers and their veterinary advisors on the most important elements of herd health plans and the benefits of their effective implementation; and • identify the benefits and constraints to the use and adoption of comparative animal health and welfare assessment as a herd health management tool. From this information, recommendations for practical application and future research would be developed. Other DEFRA funded projects would benefit from findings relevant to their objectives, the development of herd health planning and improvement of farm animal welfare. Objectives As part of a larger study with an objective to carry out health and welfare assessment and benchmarking on organic dairy farms in order to assist farmers and their advisors to identify strengths and weaknesses in herd health and welfare performance, the objectives of this study were to • use qualitative research interviews to a. evaluate farmer responses to the welfare assessment and benchmarking, b. assess the impact and evaluate the effectiveness of the intervention in delivering animal health and welfare improvements and c. as a tool to develop herd health plans for organic systems; • ensure that the results are effectively disseminated to farmers, veterinarians and advisors. Background Benchmarking of production performance has been actively used by many farmers to compare their achievements with those of others and to target areas for improvement with the aim of increasing financial returns from dairy, beef, sheep and other farm enterprises. A protocol to apply this benchmarking concept to farm animal health and welfare has been developed using animal based observations. By observing the animals it becomes possible to compare production systems with different resource provisions, such as quality of flooring, amount of trough space and stocking density, and management approaches. This approach facilitates the identification of strengths and weaknesses in the different management systems assessed and through comparison with others, can demonstrate what it is possible to achieve and where improvements might be made. Qualitative research interviews enable the researcher to gather insights on the interviewee’s perception and opinion. They allow the beliefs and concerns of interviewees to be explored and enable the consistency and weight of the story told to be evaluated. This technique has been used in a range of subject areas including in a farm animal welfare context. However this method for collection of information provides a descriptive account based upon the observations and interpretation of the interview material by the researcher, rather than attempting to quantify opinion or experience. It cannot be used to provide statistically valid numerical data. Summary of assessment and benchmarking process a) Phase 1 During winter 2002 to 2003, 15 organic dairy farms in SW England took part in a herd health and welfare assessment and benchmarking project. The response to the benchmarking process was evaluated by qualitative research interviews. Farmers had implemented changes and requested that there should be a repeat assessment to identify any effect of the changes on cow welfare on their farms. b) Phase 2 In response to this farmer request, fourteen of the fifteen organic dairy farms which had participated in Phase 1 were recruited to Phase 2 of a herd health and welfare assessment and benchmarking study in September 2003. The sample size was increased by the recruitment of a further fourteen new farms following the award of additional funding for the study. On-farm health and welfare assessment and benchmarking of the 28 organic dairy herds was carried out during winter housing period 2003 to 2004. Methodology Semi-structured qualitative research interviews were used to obtain farmer feedback on their participation in comparative assessment of herd health and welfare. Interviews were conducted with all participating farmers between August and November 2004, on a one to one basis on farm either in the house or in the farm office, by the same interviewer. The interviews were recorded onto mini-discs then transcribed in full. Data were analysed using a ‘Grounded Theory’ approach in which common themes across interviews were identified. Results The average length of the research interviews was one hour and fifteen minutes (range thirty minutes to two hours and thirty minutes). Five common and inter-related themes were identified from the farmer interviews: 1. Sensitivities and misgivings Some participants admitted to experiencing feelings of exposure and vulnerability as a result of allowing such a process to be carried out on their herds. Others experienced feelings of shock, failure and disappointment as a result of the assessment outcome. There was considerable concern about the potential for mis-interpretation and mis-use of the results by others outside farming and research circles, particularly if taken out of context and without clear explanation and understanding of the assessment process. Some expressed concerns that that the findings from the assessment and benchmarking might be used in the development of new legislation or that the process might become a requirement of farm quality assurance schemes. 2. Acceptability of scoring methodology and indicators assessed On the whole, the measures used for the assessment were considered to be relevant to herd health and welfare. Farmers were critical of the way in which scores were applied and questioned the relevance, at low/mild levels, of indicators assessed to animal health and welfare. This was particularly true of some scores for mild degrees of dirtiness, lameness and injuries from the environment where the assessment was considered to have been marked ‘severely’, ‘overly critically’ or ‘harshly’. Some were particularly distressed that their efforts to keep their animals clean had apparently failed and were at a loss as to what steps could be taken to improve the situation further. Whilst farmers acknowledged that lameness was a major herd health problem, their initial reactions were of shock and disbelief at the percentage of their cows that were classified as lame on the day of the assessment. Some were of the opinion that if detection of very mild lameness was so difficult, the measure at such a mild level was impractical and had no relevance to day to day management of herd health and welfare. Others considered that where detection and investigation of very mild cases of lameness was possible, it might have some value as a management tool in preventing more serious problems from developing. Injury to hocks, ranging in severity from slight rubbing of the hair to swelling and ulceration was a main focus of farmers’ attention. Although scores given were again at three levels of severity, interestingly there was greater acceptance of the significance of mild levels of incidence of hock injury. Furthermore, the links between hock damage, aspects of the housing environment and lameness were clearly recognised. It was suggested that the assessment should include all dairy animals, from calves, rearing and in calf heifers, dry and milking cows, to bulls. Respondents also considered that the addition of medicine use, fertility and calving indices and mastitis management to the assessment and benchmarking would add value to the process. 3. Raised awareness and motivation to improve Farmers commented that participation in the assessment, had raised their awareness about their animals’ health and welfare and of factors that might affect animal health and welfare within their individual farming systems. Most participants had been keen to affect improvements and had changed at least one element of their system with the aim of better health and welfare for the herd. The main foci for change were the causes of lameness, dirtyness, injuries from the environment mainly involving damage to hocks and necks and condition scoring. There was strong agreement amongst participants that the health and welfare of the cows and financial considerations were the main drivers for change on the farm. Most were of the opinion that the two were inextricably linked in that the health and welfare status of the cows would directly affect performance and therefore financial returns. Constraints to improving animal welfare on farm were largely related to housing issues and lack of finance to implement change in both old cubicle housing and in new and refurbished systems, representing considerable and often recent investment. 4. Veterinary support and herd health planning It was clear that some participants had a very good working relationship with their veterinary advisors. A number of these farms had actively sought out a new veterinary advisor in order to improve the quality of veterinary support for their organic system. Others reported that they were dissatisfied with the service they had received from their veterinary practices and had become reluctant to involve their veterinarians in routine aspects of herd health and welfare management. The degree to which Herd Health Plans had been developed as a useful management tool was clearly linked to the level of interest and quality of veterinary support available to the farmer. 5. Value of assessment and benchmarking With regard to benchmarking, the main focus of attention was on the identification of particular strengths and weaknesses and how improvements to weaker elements might be affected within individual farming systems. Keen to improve their own situation year on year, farmers were interested to learn if management or structural changes they had introduced translated into improvements to herd health and welfare and lead to improved performance within the benchmarking league table. Nevertheless, a number of participants suggested that breed, calving pattern, herd size, housing and other system differences made benchmarking between farms less useful than it might at first appear. Instead they considered that year on year within farm comparison was the more useful measure to determine where progress had been made. Implicit in these comments was the desire to participate in further on-farm health and welfare assessment and to continue the process of improvement into the future. Although farmers suggested a range of timescales from six months to five years, within which repeat assessments should occur, most considered that the interval should be greater than one year. Most considered that the ideal assessor would be a veterinarian with a farm and cattle background. Others thought that whilst a veterinary qualification was probably not essential, the assessor should have a clear understanding of farm animal health and welfare. Farmers voiced concerns over inter-observer reliability. Of utmost concern was that continuity and the validity of any comparison between farms and between years might be lost if more than one person carried out the assessments for a particular group of farms. Recommendations 1. It is recommended that the provision of clear explanation and support is built into all future development and implementation of on-farm welfare assessments to ensure that individuals and groups of farmers fully understand the process in which they participate. 2. It is recommended that • a system of acceptable tolerance levels of welfare indicators is developed in conjunction with a scoring system that applies positive scores to the assessment procedure which takes into account the difficulties of practical application on farm and establishes realistic and achievable goals in welfare improvement. • assessment protocols should only include indicators proven by sound scientific evidence to be appropriate to the goal of improved farm animal health and welfare. 3. There is a requirement for the development of an assessment protocol for calves in order that a complete picture of dairy herd health and welfare can be produced. 4. It is recommended that the need for investigation and clarification of which changes are likely to improve animal welfare and the timescale within which improvements can be expected to occur within farming systems is addressed before widespread implementation of farm animal health and welfare assessment is introduced. 5. It is strongly recommended that an animal welfare payment scheme is introduced to • assist in making improvements in animal welfare • act as an incentive and reward the achievement of improved welfare status, whilst at the same time, • ease the financial burden for farmers. This should be linked to the updating and redevelopment of farm buildings where such action is justified on animal health and welfare grounds. 6. To address this shortfall veterinary training should be expanded to include organic farming principles, preventative and reduced medicine use and homeopathy. 7. It is recommended that in order that such problematic issues are identified, the formation of assessment groups of farms should be supported and encouraged. It is further recommended that areas where difficulties in affecting welfare improvement are experienced should be targeted for further research. 8. A system of training and accreditation of assessors that includes regular monitoring of performance and updating of skills should be developed as an integral part of farm animal health and welfare assessment. 9. A system of training and accreditation of assessors that includes regular monitoring of performance and updating of skills should be developed as an integral part of farm animal health and welfare assessment. It is recommended that the evaluation of the consistency and reliability of welfare assessment over time, and the impacts of potential errors on farming businesses should be made the focus of future research. 10. What is now required is to develop simpler yet robust approaches that enable farmer perception and opinion to be included as key elements in future herd health and welfare endeavours. Clarity of purpose would appear to be an imperative. A starting point may be to examine the approach taken by other disciplines, such as human medicine and environmental management

The Implications of Diverse Applications and Scalable Data Sets in Benchmarking Big Data Systems

Now we live in an era of big data, and big data applications are becoming more and more pervasive. How to benchmark data center computer systems running big data applications (in short big data systems) is a hot topic. In this paper, we focus on measuring the performance impacts of diverse applications and scalable volumes of data sets on big data systems. For four typical data analysis applications---an important class of big data applications, we find two major results through experiments: first, the data scale has a significant impact on the performance of big data systems, so we must provide scalable volumes of data sets in big data benchmarks. Second, for the four applications, even all of them use the simple algorithms, the performance trends are different with increasing data scales, and hence we must consider not only variety of data sets but also variety of applications in benchmarking big data systems.Comment: 16 pages, 3 figure

The Richmond-Tweed region: an economic profile

Examines the Richmond-Tweed region in New South Wales, looking at its administrative and productive structure and the influences that currently bear on it. Introduction The Richmond-Tweed region (also known as the Northern Rivers) has experienced substantial changes. During the nineteenth century the driving force in production and employment, throughout the region, was primary production. During the twentieth century, the region effectively divided into two: a relatively urbanised coastal strip growing faster in association with neighbouring Queensland, and an inland zone that retains more of the region’s rural origins. In both portions of the region, nevertheless, the services sector has emerged as the predominant area of employment. This e-brief examines the region, looking at its administrative and productive structure and the influences that currently bear on it. There are at least four outstanding features which define the region: the sub-tropical climate; the long length of coastline (around 120 kilometres); the significant tracts of rainforest (preserved in areas such as the Mount Warning, Nightcap and Border Ranges national parks); and its proximity to Queensland. In this e-brief the name “Richmond-Tweed” is used primarily because that is the nomenclature adopted by the Australian Bureau of Statistics (ABS) in its new regional geography, which is relied on here for labour force data. Geographically, this region is very nearly identical to the Regional Development Australia (RDA) Northern Rivers region: with the exception that the RDA region includes the Clarence Valley LGA, which the ABS “Richmond-Tweed” SA4 does not