Assessment of the learning curve in health technologies: a systematic review

Objective: We reviewed and appraised the methods by which the issue of the learning curve has been addressed during health technology assessment in the past. Method: We performed a systematic review of papers in clinical databases (BIOSIS, CINAHL, Cochrane Library, EMBASE, HealthSTAR, MEDLINE, Science Citation Index, and Social Science Citation Index) using the search term "learning curve:" Results: The clinical search retrieved 4,571 abstracts for assessment, of which 559 (12%) published articles were eligible for review. Of these, 272 were judged to have formally assessed a learning curve. The procedures assessed were minimal access (51%), other surgical (41%), and diagnostic (8%). The majority of the studies were case series (95%). Some 47% of studies addressed only individual operator performance and 52% addressed institutional performance. The data were collected prospectively in 40%, retrospectively in 26%, and the method was unclear for 31%. The statistical methods used were simple graphs (44%), splitting the data chronologically and performing a t test or chi-squared test (60%), curve fitting (12%), and other model fitting (5%). Conclusions: Learning curves are rarely considered formally in health technology assessment. Where they are, the reporting of the studies and the statistical methods used are weak. As a minimum, reporting of learning should include the number and experience of the operators and a detailed description of data collection. Improved statistical methods would enhance the assessment of health technologies that require learning

Assessing the learning curve effect in health technologies: Lessons from the non-clinical literature

Introduction: Many health technologies exhibit some form of learning effect, and this represents a barrier to rigorous assessment. It has been shown that the statistical methods used are relatively crude. Methods to describe learning curves in fields outside medicine, for example, psychology and engineering, may be better. Methods: To systematically search non–health technology assessment literature (for example, PsycLit and Econlit databases) to identify novel statistical techniques applied to learning curves. Results: The search retrieved 9,431 abstracts for assessment, of which 18 used a statistical technique for analyzing learning effects that had not previously been identified in the clinical literature. The newly identified methods were combined with those previously used in health technology assessment, and categorized into four groups of increasing complexity: a) exploratory data analysis; b) simple data analysis; c) complex data analysis; and d) generic methods. All the complex structured data techniques for analyzing learning effects were identified in the nonclinical literature, and these emphasized the importance of estimating intra- and interindividual learning effects. Conclusion: A good dividend of more sophisticated methods was obtained by searching in nonclinical fields. These methods now require formal testing on health technology data sets

Out of the Mouths of Babes: Vocal Production in Infant Siblings of Children with ASD

Background: Younger siblings of children with autism spectrum disorders (ASD) are at higher risk for acquiring these disorders than the general population. Language development is usually delayed in children with ASD. The present study examines the development of pre-speech vocal behavior in infants at risk for ASD due to the presence of an older sibling with the disorder. Methods: Infants at high risk (HR) for ASD and those at low risk, without a diagnosed sibling (LR), were seen at 6, 9, and 12 months as part of a larger prospective study of risk for ASD in infant siblings. Standard clinical assessments were administered, and vocalization samples were collected during play with mother and a standard set of toys. Infant vocal behavior was recorded and analyzed for consonant inventory, presence of canonical syllables, and of non-speech vocalizations, in a cross-sectional design. Children were seen again at 24 months for provisional diagnosis. Results: Differences were seen between risk groups for certain vocal behaviors. Differences in vocal production in the first year of life were associated with outcomes in terms of autistic symptomotology in the second year. Conclusions: Early vocal behavior is a sensitive indicator of heightened risk for autistic symptoms in infants with a family history of ASD

Utilizing the mental health nursing workforce:A scoping review of mental health nursing clinical roles and identities

Despite rising international needs for mental health practitioners, the mental health nursing workforce is underutilized. This is in part due to limited understandings of their roles, identities, and capabilities. This paper aimed to collate and synthesize published research on the clinical roles of mental health nurses in order to systematically clarify their professional identity and potential. We searched for eligible studies, published between 2001 and 2021, in five electronic databases. Abstracts of retrieved studies were independently screened against exclusion and inclusion criteria (primarily that studies reported on the outcomes associated with mental health nursing roles). Decisions of whether to include studies were through researcher consensus guided by the criteria. The search yielded 324 records, of which 47 were included. Retained papers primarily focused on three themes related to mental health nursing clinical roles and capabilities. Technical roles included those associated with psychotherapy, consumer safety, and diagnosis. Non-technical roles and capabilities were also described. These included emotional intelligence, advanced communication, and reduction of power differentials. Thirdly, the retained papers reported the generative contexts that influenced clinical roles. These included prolonged proximity with consumers with tensions between therapeutic and custodial roles. The results of this scoping review suggest the mental health nurses (MHNs) have a wide scope of technical skills which they employ in clinical practice. These roles are informed by a distinctive cluster of non-technical capabilities to promote the well-being of service users. They are an adaptable and underutilized component of the mental health workforce in a context of escalating unmet needs for expert mental health care

Prediction of cardiovascular disease risk by cardiac biomarkers in 2 United Kingdom cohort studies: does utility depend on risk thresholds for treatment?

We tested the predictive ability of cardiac biomarkers N-terminal pro B-type natriuretic peptide (NT-proBNP), high-sensitivity troponin T, and midregional pro adrenomedullin for cardiovascular disease (CVD) events using the British Regional Heart Study (BRHS) of men aged 60 to 79 years, and the MIDSPAN Family Study (MFS) of men and women aged 30 to 59 years. They included 3757 and 2226 participants, respectively, and during median 13.0 and 17.3 years follow-up the primary CVD event rates were 16.6 and 5.3 per 1000 patient-years, respectively. In Cox models adjusted for basic classical risk factors, 1 SD increases in log-transformed NT-proBNP, high-sensitivity troponin T, and midregional pro adrenomedullin were generally associated with increased primary CVD risk in both the studies (P<0.006) except midregional pro adrenomedullin in MFS (P=0.10). In BRHS, QRISK2 risk factors yielded a C-index of 0.657, which was improved by 0.017 (P=0.005) by NT-proBNP, but not by other biomarkers. Using 28% 14-year risk as a proxy for 20% 10-year risk, NT-proBNP improved risk classification for primary CVD cases (case net reclassification index, 5.9%; 95% confidence interval, 2.8%–9.2%), but only improved classification of noncases at a 14% 14-year risk threshold (4.6%; 2.9%–6.3%). In MFS, ASSIGN risk factors yielded a C-index of 0.752 for primary CVD; none of the cardiac biomarkers improved the C-index. Improvements in risk classification were only seen using NT-proBNP and high-sensitivity troponin T among cases using the 28% 14-year risk threshold (4.7%; 1.0%–9.2% and 2.6%; 0.0%–5.8%, respectively). In conclusion, the improvement in treatment allocation gained by adding cardiac biomarkers to risk scores seems to depend on the risk threshold chosen for commencing preventative treatments

An analysis of penalties under ASIC administered legislation: scoping the issues

This working paper is the first published output of an eighteen month (December 2014 – June 2016) research project conducted by staff at the Melbourne Law School that examines enforcement and penalties regimes under legislation administered by the Australian Securities and Investments Commission (ASIC). During 2015 and early 2016 the project will conduct a review of selected penalties over a ten year period from 2005 to 2014. This paper is an introductory publication that scopes the issues that will be examined in the course of the project. The paper begins with a brief overview of the project and identifies topics that will be considered as the project progresses. Part II discusses key findings in ASIC’s Report 387: Penalties for Corporate Wrongdoing which compares the penalties available to ASIC in relation to comparable regulators in other jurisdictions. Part III examines current debates about corporate wrongdoing and the adequacy of penalties, including the impact of recent parliamentary inquiries. Part IV explains ASIC’s regulatory and enforcement functions and briefly discusses the policy rationales that underlie such functions. Part V presents a preliminary set of data on ASIC’s enforcement activity sourced from its six monthly Enforcement Reports. Part VI makes initial observations in relation to comparable financial market regulatory agencies in other jurisdictions by reference to various criteria, including funding models. Part VII concludes the working paper

Using ecosystem engineers as tools in habitat restoration and rewilding: beaver and wetlands

Potential for habitat restoration is increasingly used as an argument for reintroducing ecosystem engineers. Beaver have well known effects on hydromorphology through dam construction, but their scope to restore wetland biodiversity in areas degraded by agriculture is largely inferred. Our study presents the first formal monitoring of a planned beaver-assisted restoration, focussing on changes in vegetation over 12 years within an agriculturally-degraded fen following beaver release, based on repeated sampling of fixed plots. Effects are compared to ungrazed exclosures which allowed the wider influence of waterlogging to be separated from disturbance through tree felling and herbivory. After 12 years of beaver presence mean plant species richness had increased on average by 46% per plot, while the cumulative number of species recorded increased on average by 148%. Heterogeneity, measured by dissimilarity of plot composition, increased on average by 71%. Plants associated with high moisture and light conditions increased significantly in coverage, whereas species indicative of high nitrogen decreased. Areas exposed to both grazing and waterlogging generally showed the most pronounced change in composition, with effects of grazing seemingly additive, but secondary, to those of waterlogging.  Our study illustrates that a well-known ecosystem engineer, the beaver, can with time transform agricultural land into a comparatively species-rich and heterogeneous wetland environment, thus meeting common restoration objectives. This offers a passive but innovative solution to the problems of wetland habitat loss that complements the role of beavers in water or sediment storage and flow attenuation. The role of larger herbivores has been significantly overlooked in our understanding of freshwater ecosystem function; the use of such species may yet emerge as the missing ingredient in successful restoration