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

Dissemination of management into politics: Michael Porter and the political uses of management consulting

The article contributes to the literature on management dissemination by looking at how management fashions are diffused into and circulated in politics. The ideas of management have been increasingly disseminated into the realm of politics during recent decades. To illustrate how this takes place, this article examines the spread of Michael Porter’s ideas on national politics. Porter’s work is considered a management fashion that has been skilfully packaged; a new form of the 20th-century tradition of state-led social engineering which takes the form of management fashion-style packaging. For this he is seen as a global guru in national politics, and this development is regarded as a new form of consultocracy in the realm of democracies. In consultocracy, the ideas of management consulting are often adopted into politics as a common justifying rationality of power for the political elites. Thus we call for further research on the underlying dynamics of the power involved as management fashions are disseminated into the realm of politics

Annual pastures, seed mixtures and supplementary feeding in organic milk production

The current study was aiming to evaluate annual legume-grass-cereal mixture as a basal feed for dairy cows under organic or other low fertiliser input systems in Nordic conditions. In additional aim was to evaluate the effect of concentrate feeding regimen in order to simplify grazing management

Effects of replacing different proportions of barley grain by barley fibre on performance of dairy bulls

The objective of the present experiment was to study the effects of partial replacement of barley grain with barley fibre (BF) on animal performance, carcass traits and diet digestibility of growing dairy bulls. The feeding experiment comprised 20 Finnish Ayrshire bulls and 12 Holstein-Friesian bulls, and four treatments (8 bulls per treatment). There were four diets with two offered at stage 1 (from the initiation of the study to 450 kg live weight) and four at stage 2 (from 450 kg live weight to slaughter). The control diet (BF0) included grass silage (460 g kg–1 dry matter) and barley grain (540), BF25 diet included grass silage (460), barley grain (405) and BF (135), BF50 diet included grass silage (460), barley grain (270) and BF (270), and BF75 diet included grass silage (460), barley grain (135) and BF (405). At stage 1 there were only two treatments (BF0 and BF50) and at stage 2, all four treatments were included. All bulls were fed total mixed ration ad libitum. The mean initial live weight of the bulls was 261 kg and the mean final live weight 650 kg. At stage 1 there were no significant treatment differences in dry matter, energy or protein intakes or in live weight gain. At stage 2, replacing barley grain with BF led to a linear decrease of daily live weight gain (P < 0.05) and a linearly reduced feed conversion (kg dry matter kg–1 live weight gain) (P < 0.05). The apparent digestibility of the organic matter and neutral detergent fibre decreased linearly with increasing BF supplementation (P < 0.001). The dressing proportion and the carcass fat score decreased linearly (P < 0.05) with partial replacement of barley grain with BF. On carcass conformation, treatment had a significant (P < 0.05) quadratic effect: the BF25 and BF50 diets were classified highest. The results indicate that 50% of barley starch can be replaced with BF without affecting growth, but feed efficiency factors may decrease when barley starch is replaced with BF. At 75% replacement, feed intake was reduced, which resulted in a lower energy intake and reduced level of performance

Need for protein supplementation in the diet of growing dairy bulls fed total mixed ration based on moderate digestible grass silage and barley

The objective of the present experiment was to study the need for the protein supplementation in the diet of growing dairy bulls (initial live weight 272 ± 28.5 kg and final live weight 666 ± 31.2 kg, on average) fed total mixed ration based on moderate digestible grass silage and barley. The experiment comprised 24 Finnish Ayrshire bulls and 8 Holstein-Friesian bulls and included four treatments. The control diet (C) consisted of moderate digestible (653 g digestible organic matter in dry matter (DM) grass silage (450 g kg-1 DM), barley grain (275) and barley fibre (275) without protein supplementation. Three isonitrogenous experimental diets included also extra protein, i.e. (1) rapeseed meal (RSM) (supplementation 530 g DM per animal day-1), (2) wet distillers’ solubles (WDS) (600 g) and (3) a mixture of barley protein (90% of fresh weight) and wet distillers’ solubles (10) (BPWDS) (480 g). In all isonitrogenous diets the crude protein content of concentrate increased from 137 to 150 g kg-1 DM (9%) compared with the C diet. All bulls were fed total mixed ration ad libitum. The energy content of all diets was 11.6 MJ kg-1 DM. The live weight gain of the bulls tended to be higher with the BPWDS diet than with the C diet (C 1214 vs. BPWDS 1301 g d-1; p = 0.10), but the treatments had no significant effect on carcass gain, feed conversion or slaughter parameters. Only the BPWDS diet differed significantly from the C diet in DM (C 9.69 vs. BPWDS 10.38 kg DM d-1; p < 0.01) and energy intake (C 112.4 vs. BPWDS 120.3 MJ d-1; p < 0.05). The apparent organic matter digestibility (OMD) was 5% higher in the BPWDS diet than in the C diet (p < 0.001), but the RSM and WDS diets did not differ from the C diet in OMD. The results indicate that the supply of protein in dairy bulls is most probably adequate with moderate digestible, well-preserved grass silage and barley-based concentrates when intake of digestible organic matter is high enough to support microbial protein synthesis in the rumen

Comparison of part-time grazing and indoor silage feeding on milk production

Cows were assigned randomly to indoor silage feeding (with 2 h outdoor exercise) or part-time grazing treatment in two different experiments. One group was kept in confinement with ad libitum grass silage within each experiment. The other group had ad libitum grass silage indoors and they were put out on grass pasture during part of the 24 hour period, 12 hours (night, Experiment 1) and 6 hours (day, Experiment 2) in June, July and August. In Experiment 2, the concentrate (9 kg d-1) was given at two crude protein levels: high crude protein [185 g kg-1 dry matter (DM)] and low crude protein (135 g kg-1 DM). In Experiment 1, night-time grazing increased total DM intake and milk (3.9 kg d-1) production. There was interaction between month and forage feeding strategy, the difference in milk yield being smallest between treatments in June. In Experiment 2, day-time grazing had no significant main effect on milk production but there was significant interaction between month and forage feeding strategy showing 2.5 kg d-1 difference between treatments in July. High-protein concentrate tended to increase the milk yield more on the silage diet compared with the group grazing during daytime. .The differences in milk yield between the forage feeding treatments were mainly due to the higher dry matter intake and higher metabolizable energy content of the pasture grass compared with silage. The lower milk responses to concentrate crude protein in the cows grazing during daytime compared with the silage group indicate a high protein value of pasture grass. It is concluded that part-time grazing increases the milk yield and decreases the need for supplementary concentrate protein

Sward and milk production response to early turnout of dairy cows to pasture in Finland

The timing of turnout is an important factor affecting the grazing management of dairy cows. However, its consequences are not well known in the short grazing season of northern Europe. Thus, the effect of the turnout date of dairy cows to pasture on sward regrowth, herbage mass production and milk production was studied in two experiments, 1) a grazing trial with 16 Holstein-Friesian dairy cows and 2) a plot trial where the treatments simulated the grazing trial. The treatments were early turnout (1 June) and normal turnout (6 June). Early turnout decreased the annual herbage mass (HM) production in the plot trial (P=0,005), but due to a higher average organic matter (OM) digestibility (P0,05). Although early turnout had no effect on milk yields it meant easier management of pastures

Fate of silver nanoparticles in constructed wetlands : a microcosm study

Nano-enabled materials are produced at growing volumes which increases the likelihood of nanoparticles being released into the environment. Constructed wetlands (CWs) are likely to receive wastewater containing nanoparticles leaching from products during usage. Therefore, we investigate the retention of silver nanoparticles (Ag-NPs) in microcosms simulating CWs treating domestic wastewater. The effects of aeration and organic matter content on the Ag-NP removal efficiencies are studied in particular. CWs remove most of the Ag (80-90%) and the largest fraction of Ag is found in/on the biofilm. Detailed electron microscopy analyses suggest that Ag-NPs are transformed into Ag2S in all microcosm experiments. The good correlation between total suspended solids (TSS) and the Ag concentration measured in the effluent indicates that Ag-NPs are bound to the solids in the effluent. Aeration of the microcosms does not affect the release of Ag-NPs from the systems but increasing organic matter leads to increased amounts of Ag passing the CWs, correlating with the increased release of TSS from the CWs. These results suggest that Ag-NPs are retained with the (suspended) solids in CWs and that the removal efficiency of TSS is an important factor determining the discharge of Ag-NPs from CWs

Fate of metallic engineered nanomaterials in constructed wetlands : prospection and future research perspectives

Metallic engineered nanomaterials (ENMs) undergo various transformations in the environment which affect their fate, toxicity and bioavailability. Although constructed wetlands (CWs) are applied as treatment systems for waste streams potentially containing metallic ENMs, little is known about the fate and effects of ENMs in CWs. Hence, literature data from related fields such as activated sludge wastewater treatment and natural wetlands is used to predict the fate and effects of ENMs in CWs and to analyze the risk of nanomaterials being released from CWs into surface waters. The ENMs are likely to reach the CW (partly) transformed and the transformations will continue in the CW. The main transformation processes depend on the type of ENM and the ambient environmental conditions in the CW. In general, ENMs are expected to undergo sorption onto (suspended) organic matter and plant roots. Although the risk of ENMs being released at high concentrations from CWs is estimated low, caution is warranted because of the estimated rise in the production of these materials. As discharge of (transformed) ENMs from CWs during normal operation is predicted to be low, future research should rather focus on the effects of system malfunctions (e.g. short-circuiting). Efficient retention in the CW and increasing production volumes in the future entail increasing concentrations within the CW substrate and further research needs to address possible adverse effects caused

Luottamus Lapin aikuiskoulutustoimijoiden verkostoyhteistyössä

Tutkimukseni käsittelee luottamuksen merkitystä verkostoyhteistyössä. Tutkimuksen empiirisessä osassa tarkastelun kohteena ovat henkilöihin kohdistuvassa luottamuksessa ja systeemisessä luottamuksessa ilmenevät piirteet (Luhmann 1979). Keskeisimpänä aineistona toimii neljä kesällä 2013 toteutettua puolistrukturoitua teemahaastattelua, jotka on analysoitu teoriaohjaavan sisällönanalyysin menetelmällä, Tuomen & Sarajärven (2009) ohjeita mukaillen. Tämä tutkimus on tehty Lapin aikuiskoulutuksen kehittämishankkeen yhteydessä, jossa toimin osana tutkimusryhmää, jonka tehtävänä oli tuottaa tieteellistä tietoa aikuiskoulutustoiminnan kehittämisen tueksi. Luottamuksen henkilötason piirteitä ovat kommunikaatio, toimijoiden tunteminen, persoonasta riippumattomat tekijät, persoonakohtaiset tekijät, aika, käytännön teot ja asenne. Systeemisen luottamuksen piirteiksi muodostui rikastuttava vaikutus, välttämättömyys, vaativuus, organisointi, käytännönläheisyys ja motivaatio. Tutkimalla luottamusta sekä henkilöiden välisenä, että systeemiin kohdistuvana ilmiönä saadaan uusia näkökulmia luottamuksen ilmiön ymmärtämiseen verkostoyhteistyön kontekstissa