Charlotte Kelly

Sustainability Assessment: The Definition Deficit

ABSTRACT Much work has focused on the development of indicator sets to monitor changes in the sustainability of transport. Such indicator sets are however, often quite divorced from those used in decision-making and fail to include clear sustainability goals to work towards. This research describes the development of a sustainability appraisal framework in conjunction with a series of key decision-makers in England. A case study of a real set of strategy options tested in a metropolitan area is outlined and the results used to assess the extent to which current strategy development in the United Kingdom produces the information required to both assess and communicate progress towards sustainability. The results suggest that although sustainability exists as a concept, it is poorly defined. This definition deficit has serious implications for the types of strategies tested. First, information on some aspects of sustainability is not produced and so these aspects are marginalized. Secondly, the lack of policy goals and the dominant welfare economics assessment paradigm allow unsustainable strategies to be justified provided they perform better than an unsustainable ‘do-minimum’. The paper concludes with some recommendations for the policy and research communities to bridge the current gap in thinking.

Beta-Agonist Lung Injury Trial-2 (BALTI-2) : a multicentre, randomised, double-blind, placebo-controlled trial and economic evaluation of intravenous infusion of salbutamol versus placebo in patients with acute respiratory distress syndrome

BACKGROUND Acute respiratory distress syndrome (ARDS) is a major cause of mortality in intensive care patients and lacks effective treatments. A previous randomised controlled Phase II trial suggested that an intravenous (i.v.) infusion of salbutamol may be beneficial, as it reduced extravascular lung water and plateau airway pressure. The Beta-Agonist Lung injury TrIal-2 (BALTI-2) was initiated to evaluate the effects of this intervention on mortality in patients with ARDS. OBJECTIVES To evaluate whether or not, in patients with ARDS, an i.v. infusion of salbutamol given at 15 μg/kg ideal body weight (IBW)/hour for up to 7 days, compared with a placebo (0.9% sodium chloride) infusion, reduces 28-day all-cause mortality and other clinical outcomes. To evaluate salbutamols clinical effectiveness and its cost-effectiveness in subgroups of patients. DESIGN A multicentre, randomised, placebo-controlled trial. SETTING Forty-six intensive care units (ICUs) in the UK. PARTICIPANTS Patients were eligible if they (1) were intubated and mechanically ventilated patients in participating ICUs; (2) were within 72 hours of onset of ARDS; (3) fulfilled American-European Consensus Conference definition for ARDS {acute-onset, severe hypoxaemic respiratory failure [partial pressure of oxygen in arterial blood/fraction of inspired oxygen ≤ 26.7 kPa (200 mmHg)] and bilateral infiltrates on the chest radiograph in the absence of clinical evidence of left atrial hypertension}; and (4) were aged ≥ 16 years. INTERVENTIONS Intravenous infusion of salbutamol (15 μg/kg IBW/hour) or placebo (0.9% saline) for up to 7 days. MAIN OUTCOME MEASURES All-cause mortality 28 days after randomisation, mortality at (first) discharge from ICU, mortality at (first) discharge from hospital, number of ventilator-free days, number of organ failure-free days, mortality at 12 months post randomisation, side effects (tachycardia/new arrhythmia/lactic acidosis) sufficient to stop treatment with trial drug, health-related quality of life (European Quality of Life-5 Dimensions and Short Form questionnaire-12 items at 6 and 12 months after randomisation), length of stay in critical care unit and length of stay in hospital. RESULTS Forty-six ICUs recruited patients to the trial. A total of 326 patients were randomised; 162 were allocated to salbutamol and 164 to placebo. One patient in each group withdrew consent. Recruitment was stopped after the second interim analysis because of safety concerns. Salbutamol increased 28-day mortality: 55 (34%) of 161 patients died in the salbutamol group compared with 38 (23%) of 163 in the placebo group (risk ratio 1.47, 95% confidence interval 1.03 to 2.08). CONCLUSIONS Treatment with i.v. salbutamol early in the course of ARDS was poorly tolerated, is unlikely to be beneficial and could worsen outcomes. Further trials of β-agonists in patients with ARDS are unlikely to be conducted. Some questions remain, such as whether or not there may be benefit at a different dose or in specific populations, but any studies investigating these would require a very strong rationale. TRIAL REGISTRATION Current Controlled Trials ISRCTN38366450. FUNDING The National Institute for Health Research Health Technology Assessment programme.

Selecting Indicators for Strategic Performance Management

There is a growing emphasis on the use of indicators for performance measurement and management in the transport sector. In the United Kingdom all local authorities are now required to set out 5-year programs with commitments on progress over a range of mandatory and voluntary indicators linked to a series of key policy outcomes. Increasingly, the financial settlements that local authorities receive from the central government will be related to their performance against these targets. Different types of information are needed to fulfill different roles in the decision-making process. Research in the United Kingdom has indicated that there are too many indicators and yet too little clarity about what is being collected and reported on, at what level, and why. This paper reports on a study examining the use of indicators in 16 local and regional authorities in the United Kingdom. The results from a questionnaire and a series of follow-up interviews are combined with the findings of a desktop review of performance management in the public sector to propose a more logical and connected process for developing a suite of indicators that supports both strategy development and monitoring. The results suggest that the current indicator sets are not broad enough to ensure that the strategies proposed are consistent with sustainable transport goals. The lack of a comprehensive framework also increases the risk of negative impacts from monitoring programs, such as measure fixation and myopia. The more comprehensive approach proposed seeks to bring together the aspirations of strategy with the realities of measurement.

Health impacts of free bus travel for young people: evaluation of a natural experiment in London

Background We used the introduction of free bus travel for young people in London in 2005 as a natural experiment with which to assess its effects on active travel, car use, road traffic injuries, assaults, and on one measure of social inclusion, total number of trips made. Methods A controlled before–after analysis was conducted. We estimated trips by mode and distances travelled in the preintroduction and postintroduction periods using data from London Travel Demand Surveys. We estimated rates of road traffic injury and assault in each period using STATS19 data and Hospital Episode Statistics, respectively. We estimated the ratio of change in the target age group (12–17 years) to the change in adults (ages 25–59 years), with 95% CIs. Results The proportion of short trips travelled by bus by young people increased postintroduction. There was no evidence for an increase in the total number of bus trips or distance travelled by bus by young people attributable to the intervention. The proportion of short trips by walking decreased, but there was no evidence for any change to total distance walked. Car trips declined in both age groups, although distance travelled by car decreased more in young people. Road casualty rates declined, but the pre–post ratio of change was greater in young people than adults (ratio of ratios 0.84; 95% CI 0.82 to 0.87). Assaults increased and the ratio of change was greater in young people (1.20; 1.13 to 1.27). The frequency of all trips by young people was unchanged, both in absolute terms and relative to adults. Conclusions The introduction of free bus travel for young people had little impact on active travel overall and shifted some travel from car to buses that could help broader environmental objectives.

Integrated Transport Strategies

This chapter describes how there has been growing interest in recent years in the development of integrated transport strategies. Their origins can be traced to a growing realization that a “predict and provide” approach was unlikely to provide a solution to growing transport problems, an acceptance that efforts to improve the supply of transport had to be matched by measures in order to control transport demand, and heightened interest in the role of land use planning as complement to transport policy. This chapter provides a set of possible definitions and outlines the possible principles on the basis of which integration might be achieved. The chapter then considers in greater detail two possible approaches; the pursuit of synergy and the removal of barriers, and it illustrates these with a number of examples taken from predictive analyses. It then considers the role of sensitivity analysis as a means of identifying possible combinations of policy instruments. The chapter concludes with broad guidance on the ways in which pairs of policy instruments might be combined in order to achieve integration. The techniques for developing optimal transport strategies offer an analytical approach to the design of integrated strategies.

The cost-effectiveness of a mechanical compression device in out-of-hospital cardiac arrest

AIM To assess the cost-effectiveness of LUCAS-2, a mechanical device for cardiopulmonary resuscitation (CPR) as compared to manual chest compressions in adults with non-traumatic, out-of-hospital cardiac arrest. METHODS We analysed patient-level data from a large, pragmatic, multi-centre trial linked to administrative secondary care data from the Hospital Episode Statistics (HES) to measure healthcare resource use, costs and outcomes in both arms. A within-trial analysis using quality adjusted life years derived from the EQ-5D-3L was conducted at 12-month follow-up and results were extrapolated to the lifetime horizon using a decision-analytic model. RESULTS 4471 patients were enrolled in the trial (1652 assigned to the LUCAS-2 group, 2819 assigned to the control group). At 12 months, 89 (5%) patients survived in the LUCAS-2 group and 175 (6%) survived in the manual CPR group. In the vast majority of analyses conducted, both within-trial and by extrapolation of the results over a lifetime horizon, manual CPR dominates LUCAS-2. In other words, patients in the LUCAS-2 group had poorer health outcomes (i.e. lower QALYs) and incurred higher health and social care costs. CONCLUSION Our study demonstrates that the use of the mechanical chest compression device LUCAS-2 represents poor value for money when compared to standard manual chest compression in out-of-hospital cardiac arrest.

Chapter 8 A Policy Perspective on Transport and Climate Change Issues

Purpose – To provide a policy perspective on the relationship between transport and climate change. Methodology/approach – Two key themes are identified and discussed: the meaning of a major change in a policy perspective, covering the Climate Change Act and the development of a Low Carbon Transition Plan. A theoretically informed framework applies and highlights the importance of understanding policy change from a historical perspective. Originality/value – The largely incremental nature of the policy change is considered in terms of whether there are real prospects of a radical change in transport policy that will deliver a low carbon transport future, whilst also allowing transport to fulfil its many other roles. Findings – The chapter demonstrates that the current approach to climate change policy has seen only minor adjustments to existing policy tools which are not consistent with the more radical shift in policy targets. This incremental approach may reflect the significant uncertainty over technological change or a reluctance to tackle the difficult issue of travel behaviour. Whilst oil prices remain high this may not be problematic but more proactive steering will be necessary in the coming years.