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I analyze the impact of physician competition for patients on treatment selection and an insurer's ability to induce its preferences through a supply-side payment mechanism. Informed patients choose the physician whose treatment practice best fits their preferences, aligning physician incentives with patient preferences. An insurer's ability to counter these incentives is not monotonic in how informed patients are, however. When demand is either perfectly inelastic to treatment practices because patients are completely uninformed or a sufficient proportion of the market is informed relative to the number of physicians in the market, then an insurer can induce its preferences through supply-side payment rules. Otherwise, more intensive policy levers such as utilization review must be employed. Programs that increase patient information can therefore improve the efficiency despite generating stronger incentive to treat according to patient preferences. I also explore how noisy signals of illness type and diagnostic testing further complicate the insurer's problem

Aim This study aimed to determine the strategies used by dietitians to assess, treat and monitor elderly patients diagnosed with, or at increased risk of, malnutrition and to compare these with evidence-based guidelines and the current literature. Methods An online survey was distributed to members of the Dietitians Association of Australia (DAA) working in an inpatient/outpatient facility or private practice/consultancy. Dietitians working with elderly people (≥65 years old) were invited to participate. The survey was informed by DAA's evidence-based guidelines and was pre-tested. Responses of dietitians were analysed by years of experience, service setting and approaches taken to assess and manage malnutrition. Results One hundred sixty surveys were returned. Fourteen per cent of respondents worked in services that had no malnutrition policies. A Subjective Global Assessment tool was used by 59% of respondents and 95% recommended oral nutrition supplements when malnutrition or risk of malnutrition was diagnosed. Eighty-three per cent focused on increasing both energy and protein intake; however, 64% of respondents did not consider the nature of the protein source and only 62% discussed sarcopenia. Patients at risk of malnutrition were monitored slightly less frequently than those with diagnosed malnutrition. Conclusions Respondents generally use practices that align with current assessment and treatment practice guidelines and use validated assessment tools; however, at sites where no policies exist, protocols are needed. Treatment protocols exist in less than 50% of workplaces, suggesting that specific malnutrition treatment guidelines for the elderly may be needed.

Aim: To investigate whether recent Australian practice conforms to the draft 2009 National Health and Medical Research Council (NHMRC) guidelines on the management of attention deficit hyperactivity disorder. Methods: Data from the 2007 Special Review on Attention Deficit Hyperactivity Disorder in Children and Adolescents in New South Wales (NSW) were examined. Results: Two hundred seven approved stimulant prescribers in NSW responded to a detailed survey on treatment practice (including 121 paediatricians and 67 psychiatrists). Overall, the practice identified in this survey of NSW approved stimulant prescribers was consistent with that recommended in the draft NHMRC guidelines. Paediatricians were more likely to inform families of developmental therapies. Most prescribers (67%) considered stimulants to be the first line of treatment for at least half of their patients. Psychiatrists were more likely to use stimulants as first-line treatments, while those recently qualified were less likely to prescribe. Half of the prescribers were willing to consider prescribing for children 4 years of age and younger. Paediatricians were more likely to consider prescribing to this age group, while those recently qualified were less likely. There were no significant differences in prescribing practice between child and adult psychiatrists. Most prescribers (67–97%) routinely monitored patients on stimulants for weight, height, blood pressure and academic progress. Psychiatrists were less likely to review these parameters than paediatricians, with this difference being largely due to adult psychiatrists. Conclusions: There are significant differences in prescribing practice between paediatricians and psychiatrists. These variations may reflect differing training programs and patient populations, and merit close consideration in any review arising from the publication of the recent NHMRC guideline.

Without maintenance, the performance of any stormwater treatment practice will decline over time until it reaches an unacceptable level. Thus, every stormwater management plan should include an estimated schedule for maintenance activities, and funds should be budgeted to support this schedule. This chapter provides recommendations for maintenance activities based on the treatment practice and assessment results and also presents typical suggested corresponding frequencies of such activities. In addition, this chapter provides the results of a maintenance activity survey, again grouped by the type of practice, that offers insights on typical issues that trigger the need for maintenance, maintenance complexity, and maintenance frequency.

Batch experiments with two Texas surface waters were employed to study the removal of the precursors of trihalomethanes (THMs) and haloacetic acids (HAAs) by ozonation alone and with subsequent biodegradation. Ozone doses of 0.5 to 5 mg/mg total organic carbon (TOC) were tested. Little biodegradation of THM precursors occurred in the absence of preozonation, whereas 25-30 percent of HAA precursors were biodegraded without ozonation. Ozonation and biodegradation combined removed up to 50 percent of THM precursors and up to 70 percent of HAA precursors. In some cases, ozone dosages larger than that now used in practice (1 mg/mg TOC) enhanced removal by the two processes combined. HAA precursors appeared to be more biodegradable than THM precursors, and ozonation enhanced HAA precursor biodegradation more than precursor biodegradation. Halogenated disinfection by-products (DBPs) are of significant concern to the water industry and will become even more so as stricter regulation of these chemicals occurs during the 1990s. This concern is now causing a shift in treatment practice to non-halogen-based primary disinfectants, e.g., ozone, as well as additional emphasis on DBP precursor removal processes. Switching to ozone, however, has at least one disadvantage in that ozonation produces biodegradable organic matter (BOM) from the back

The EC Directive on urban wastewater treatment will have a considerable impact on the methods used for the treatment and disposal of sewage at coastal locations. The Directive requires the natural processes involved in marine treatment to be enhanced by the use of land-based treatment to meet the same standards. This paper discusses the implications of this change, in particular the problems involved in constructing and operating conventional treatment plants at coastal locations. Planning problems, both locally and on a catchment basis, are considered. It is concluded that these difficulties point to a need for new thinking in catchment planning and in the design and construction methods used for treating wastewaters in coastal communities. This is illustrated with UK and continental examples. In addition, the implications in terms of outfall design are discussed. It is shown that the change of emphasis towards land-based treatment does not necessarily reduce the need for a high degree of dilution and dispersion in the sea in order to meet environmental standards. As a result, sound planning, design and operation of long sea outfalls remain as important as ever.

Evidence-based medicine (EBM) is an important advance in health care. The Australian Safety and Efficacy Register of New Interventional Procedures - Surgical (ASERNIP-S), the Royal Australasian College of Surgeons, has been at the forefront of promoting EBM in surgery by developing systematic reviews and managing surgical audits. In EBM, uptake of evidence is just as important as establishing the evidence. The prospective, long-term data collection of surgical audits on treatment processes and outcomes often have a high patient and surgeon coverage and make them extremely valuable as a tool for assessing the uptake of evidence. Surgical audits can be used: (i) to assess practice trends and the impact of systematic reviews or clinical guidelines on treatment practice, (ii) to identify the disparities in the uptake of evidence, and (iii) to promote further research on how to bridge evidence-practice gaps and to overcoming possible barriers for the evidence uptake. The information gathered through the audit data assessment on evidence-uptake can be used to improve evidence dissemination and identify possible barriers to the uptake of evidence.