The health disparities cancer collaborative: a case study of practice registry measurement in a quality improvement collaborative

<p>Abstract</p> <p>Background</p> <p>Practice registry measurement provides a foundation for quality improvement, but experiences in practice are not widely reported. One setting where practice registry measurement has been implemented is the Health Resources and Services Administration's Health Disparities Cancer Collaborative (HDCC).</p> <p>Methods</p> <p>Using practice registry data from 16 community health centers participating in the HDCC, we determined the completeness of data for screening, follow-up, and treatment measures. We determined the size of the change in cancer care processes that an aggregation of practices has adequate power to detect. We modeled different ways of presenting before/after changes in cancer screening, including count and proportion data at both the individual health center and aggregate collaborative level.</p> <p>Results</p> <p>All participating health centers reported data for cancer screening, but less than a third reported data regarding timely follow-up. For individual cancers, the aggregate HDCC had adequate power to detect a 2 to 3% change in cancer screening, but only had the power to detect a change of 40% or more in the initiation of treatment. Almost every health center (98%) improved cancer screening based upon count data, while fewer (77%) improved cancer screening based upon proportion data. The aggregate collaborative appeared to increase breast, cervical, and colorectal cancer screening rates by 12%, 15%, and 4%, respectively (p < 0.001 for all before/after comparisons). In subgroup analyses, significant changes were detectable among individual health centers less than one-half of the time because of small numbers of events.</p> <p>Conclusions</p> <p>The aggregate HDCC registries had both adequate reporting rates and power to detect significant changes in cancer screening, but not follow-up care. Different measures provided different answers about improvements in cancer screening; more definitive evaluation would require validation of the registries. Limits to the implementation and interpretation of practice registry measurement in the HDCC highlight challenges and opportunities for local and aggregate quality improvement activities.</p

Could resistance to insecticides in Plutella xylostella (Lepidoptera:Plutellidae) be overcome by insecticide mixtures?

To investigate if synergism occurs between pyrethroids, organophosphates and new insecticides, we tested representatives of these compounds (bifenthrin, chlorpyrifos, spinosad, indoxacarb and emamectin) against the diamondback moth (Plutella xylostella). Larvicidal activity of these insecticides was assessed separately and together on a susceptible strain (Lab-UK) of P. xylostella as well as a field population collected from Multan. The field population showed significant resistance to chlorpyrifos (331 100-fold), bifenthrin (45 200-fold), emamectin (1800-fold), spinosad (11-fold) and indoxacarb (5600-fold) when compared with the Lab-UK population. When insecticides were mixed based on LC50 and tested at serial concentrations against Lab-UK, significant synergy (CI &lt; 1) occurred between bifenthrin, spinosad and emamectin. In contrast, the interaction between bifenthrin and indoxacarb was additive (CI B&lt; 1). The toxicity of bifenthrin against the field population increased significantly (P &lt; 0.01) when combined with spinosad, emamectin and indoxacarb. Synergistic effects could be attributed to the complementary modes of action by these insecticide classes acting on different components of nerve impulse transmission (which are not identical forbifenthrin and indoxacarb either). However, chlorpyrifos/bifenthrin mixture was not significantly different either from bifenthrin or chlorpyrifos alone, indicating an additive affect. In combination with spinosad and emamectin, tested against the resistant field population, the toxicity of chlorpyrifos increased significantly and even more so with indoxacarb. Mixtures could also give rise to multiple resistance that may extend across other chemical classes and thus become difficult to manage. Therefore, alternative strategies such as mosaics or rotations should be considered. That is, though synergistic effects have been found, this should not be followed up as a strategy to manage resistant field populations