Cost-Benefit Model System of Chronic Diseases in Australia to Assess and Rank Prevention and Treatment Options

Chronic diseases - eg heart disease, cancer, diabetes, mental disorders - affect around 80% of older Australians, are the main causes of disability and premature death, and account for 70% of total health expenditures. Because lifestyle patterns are major risk factors, chronic disease prevention and treatment are not only of medical concern, but also of considerable social, family-level and personal interest. While this makes microsimulation approaches particularly suitable for assessing intervention costs and benefits, such approaches will need to be combined with disease-progression models if health status and treatment choices are also to be simulated. AIMS: Describe methodological and technical proposals for the development of a cost-benefit model-system. METHODS: Several chronic disease progression models are to be linked to an ‘Umbrella’ microsimulation model representing the Australian population. To project 20 years ahead, use of reweighting techniques are proposed for population projections, disease-specific predictions and for health-related projections. The model-system is to account simultaneously for Australians’ demographic, socioeconomic and health-risk-factor characteristics; progression of their health status; the number of chronic diseases (comorbidities) they accumulate over time; health-related expenditures; and changes in quality of life. Standard methods are proposed to estimate costs versus benefits of simulated policy interventions and related quality of life improvements. KEY OUTCOME: Proposal of novel methods for modelling comorbidities - a task rarely attempted, although quality of life is known to decline and health expenditures to increase well above what a linear addition of the effects of individual chronic diseases would predict.Chronic Disease, Comorbidities, Cost-Benefit Model, Australia

The healthiness of food and beverage advertising on Sydney train stations: regulation and policy implications

The results of this study highlight the inadequacy of Australia’s voluntary self-regulatory system in protecting train commuters from exposure to unhealthy food and beverage advertising. Regulatory action by state government, such as placing a cap on the number of discretionary food advertisements per station, is required to address this issue

The Carnivore Connection Hypothesis: Revisited

The “Carnivore Connection” hypothesizes that, during human evolution, a scarcity of dietary carbohydrate in diets with low plant : animal subsistence ratios led to insulin resistance providing a survival and reproductive advantage with selection of genes for insulin resistance. The selection pressure was relaxed at the beginning of the Agricultural Revolution when large quantities of cereals first entered human diets. The “Carnivore Connection” explains the high prevalence of intrinsic insulin resistance and type 2 diabetes in populations that transition rapidly from traditional diets with a low-glycemic load, to high-carbohydrate, high-glycemic index diets that characterize modern diets. Selection pressure has been relaxed longest in European populations, explaining a lower prevalence of insulin resistance and type 2 diabetes, despite recent exposure to famine and food scarcity. Increasing obesity and habitual consumption of high-glycemic-load diets worsens insulin resistance and increases the risk of type 2 diabetes in all populations

Scaling up Type 2 Diabetes Prevention Programs: National and State Interventions in Australia

Australia has one of the world's largest systematic, government-funded diabetes prevention programs. This chapter describes a federally-funded national program, a state-funded program in Victoria and an implementation trial in New South Wales. A coincidence of events, influential individuals and policy directions has led to these initiatives

Insulin Intensification for People with Type 2 Diabetes

BackgroundType 2 diabetes is a progressive disorder and with time, it is appropriate for insulin therapy to be initiated in the majority of people. Insulin is commonly initiated with once-daily basal insulin. However, when glycaemic control becomes unsatisfactory despite the introduction of basal insulin, no clear guidelines exist for intensifying the insulin regimen. In this article we aim to provide a clinician’s approach to both the optimisation of the basal insulin dose, and strategies to intensify insulin therapy.MethodsAn expert consensus panel, consisting of the authors, was convened to review the current practice of insulin intensification in people with type 2 diabetes and to develop a pragmatic algorithm for clinicians. The panel reviewed the published literature on the use of insulin in clinical practice, the evidence for different intensification strategies, and the potential impact of patient-related factors on insulin choices. ResultsInsulin intensification should only be considered after the basal insulin dose has been optimised. This is achieved by taking into account basal and prandial (pre and post) blood glucose levels, individualised target HbA1c, and dietary factors. If optimal basal insulin together with oral medications is not sufficient to reach glycaemic targets, the next step is to introduce a basal plus 1 regimen or switch to twice-daily premixed insulin. Each has advantages and disadvantages and existing guidelines do not emphasise or support any particular regimen. Therefore, it is important to individualise the choice according to the individual’s needs. A practical algorithm has been developed to help clinicians choose an appropriate second-line regimen.ConclusionAs beta-cell failure progresses in people with type 2 diabetes, basal insulin regimens need to be optimised and then intensified when necessary to maintain agreed glycaemic targets

Are lower fasting plasma glucose levels at diagnosis of type 2 diabetes associated with improved outcomes? U.K. Prospective Diabetes Study 61

WSTĘP. Cukrzyca typu 2 może się rozwijać przez wiele lat przed postawieniem diagnozy. W tym czasie u wielu osób dochodzi już do rozwoju jej powikłań. Wczesne wykrycie i leczenie cukrzycy może temu zapobiec, ale jak dotąd brakuje dowodów na poparcie tej tezy. MATERIAŁ I METODY. U 5088 spośród 5102 uczestników badania UKDPS (United Kingdom Prospective Diabetes Study) dokonano porównania kontroli glikemii oraz klinicznych i pośrednich kryteriów badania w zależności od glikemii na czczo (FPG, fasting plasma glucose) w momencie rozpoznania choroby. Grupy porównywane cechowały się niską ( 140 do < 180 mg/dl [7,8 do < 10,0 mmol/l]) lub wysoką (ł 180 mg/dl [ł 10,0 mmol/l]) glikemią. Porównano również grupy pacjentów różniące się objawami klinicznymi cukrzycy. WYNIKI. W grupie pacjentów z niższymi stężeniami glukozy na czczo stwierdzono rzadsze występowanie retinopatii cukrzycowej, nieprawidłowych wyników biotezjometrii oraz deklarowanych zaburzeń erekcji. Stopień wzrostu FPG i HbA1c podczas badania był identyczny we wszystkich trzech grupach, chociaż obserwowano przetrwanie pierwotnych różnic. U osób mieszczących się w grupie z najniższą glikemią na czczo ryzyko wystąpienia każdego z określonych wcześniej klinicznych kryteriów badania, wyłączywszy udar mózgu, było istotnie niższe. W grupie o średnich wartościach glikemii ryzyko wszystkich kryteriów badania, poza udarem i zawałem serca, było istotnie zmniejszone. Grupy o niskiej i średniej FPG charakteryzowało istotnie zmniejszone ryzyko progresji retinopatii, zmniejszenia czucia wibracji i rozwoju mikroalbuminurii. WNIOSKI. Chorzy, u których rozpoznaje się cukrzycę typu 2 z niższymi wartościami glikemii na czczo, znajdują się na wczesnym etapie rozwoju choroby i ryzyko rozwoju klinicznych kryteriów badania jest u nich mniejsze mimo progresji cukrzycy. Ponieważ większość pacjentów w momencie rozpoznania nie ma wyraźnych objawów klinicznych, do ich identyfikacji pożądane jest wprowadzenie programów aktywnego wykrywania cukrzycyINTRODUCTION. Type 2 diabetes may be present for several years before diagnosis, by which time many patients have already developed diabetic complications. Earlier detection and treatment may reduce this burden, but evidence to support this approach is lacking. MATERIAL AND METHODS. Glycemic control and clinical and surrogate outcomes were compared for 5,088 of 5,102 U.K. Diabetes Prospective Study participants according to whether they had low (< 140 mg/dl [< 7.8 mmol/l]), intermediate (140 to < 180 mg/dl [7.8 to < 10.0 mmol/l]), or high (&#8805; 180 mg/dl [&#8805; 10 mmol/l]) fasting plasma glucose (FPG) levels at diagnosis. Individuals who presented with and without diabetic symptoms were also compared. RESULTS. Fewer people with FPG in the lowest category had retinopathy, abnormal biothesiometer measurements, or reported erectile dysfunction. The rate of increase in FPG and HbA1c during the study was identical in all three groups, although absolute differences persisted. Individuals in the low FPG group had a significantly reduced risk for each predefined clinical outcome except stroke, whereas those in the intermediate group had significantly reduced risk for each outcome except stroke and myocardial infarction. The low and intermediate FPG groups had a significantly reduced risk for progression of retinopathy, reduction in vibration sensory threshold, or development of microalbuminuria. CONCLUSIONS. People presenting with type 2 diabetes with lower initial glycemia who may be earlier in the course of their disease had fewer adverse clinical outcomes despite similar glycemic progression. Since most such people are asymptomatic at diagnosis, active case detection programs would be required to identify them

Chronic diseases and multi-morbidity - a conceptual modification to the WHO ICCC model for countries in health transition

Background: The burden of non-communicable diseases is rising, particularly in low and middle-income countries undergoing rapid epidemiological transition. In sub-Saharan Africa, this is occurring against a background of infectious chronic disease epidemics, particularly HIV and tuberculosis. Consequently, multi-morbidity, the co-existence of more than one chronic condition in one person, is increasing; in particular multimorbidity due to comorbid non-communicable and infectious chronic diseases (CNCICD). Such complex multimorbidity is a major challenge to existing models of healthcare delivery and there is a need to ensure integrated care across disease pathways and across primary and secondary care. Discussion: The Innovative Care for Chronic Conditions (ICCC) Framework developed by the World Health Organization provides a health systems roadmap to meet the increasing needs of chronic disease care. This framework incorporates community, patient, healthcare and policy environment perspectives, and forms the cornerstone of South Africa’s primary health care re-engineering and strategic plan for chronic disease management integration. However, it does not significantly incorporate complexity associated with multimorbidity and CNCICD. Using South Africa as a case study for a country in transition, we identify gaps in the ICCC framework at the micro-, meso-, and macro-levels. We apply the lens of CNCICD and propose modification of the ICCC and the South African Integrated Chronic Disease Management plan. Our framework incorporates the increased complexity of treating CNCICD patients, and highlights the importance of biomedicine (biological interaction). We highlight the patient perspective using a patient experience model that proposes that treatment adherence, healthcare utilization, and health outcomes are influenced by the relationship between the workload that is delegated to patients by healthcare providers, and patients’ capacity to meet the demands of this workload. We link these issues to provider perspectives that interact with healthcare delivery and utilization. Summary: Our proposed modification to the ICCC Framework makes clear that healthcare systems must work to make sense of the complex collision between biological phenomena, clinical interpretation, beliefs and behaviours that follow from these. We emphasize the integration of these issues with the socio-economic environment to address issues of complexity, access and equity in the integrated management of chronic diseases previously considered in isolation

PENERAPAN MODEL PEMBELAJARAN KOOPERATIF TIPE MAKE A MATCH DENGAN MEDIA FLASH CARD UNTUK MENINGKATKAN HASIL BELAJAR BAHASA INGGRIS PESERTA DIDIK KELAS V MI IRSYADUT THOLIBIN TUGU REJOTANGAN TULUNGAGUNG

ABSTRAK Skripsi dengan judul “Penerapan Model Pembelajaran Kooperatif Tipe Make A Match Dengan Media Flash Card Untuk Meningkatkan Hasil Belajar Bahasa Inggris Peserta Didik Kelas V MI Irsyadut Tholibin Tugu Rejotangan Tulungagung”ini ditulis oleh Sufiya, Ulfa Ayu Ainin NIM. 2817133194, Jurusan Pendidikan Guru Madrasah Ibtidaiyah, Fakultas Tarbiyah dan Ilmu Keguruan, Institut Agama Islam Negeri Tulungagung, yang dibimbing oleh Bapak Dr. Susanto, M.Pd. Kata Kunci: Make A Match, Flash Card, Hasil Belajar, Bahasa Inggris. Penelitian ini dilatar belakangi oleh permasalahan pembelajaran Bahasa Inggris di MI Irsyadut Tholibin, Rejotangan Tulungagung. Berdasarkan hasil observasi awal permasalahan tersebut disebabkan oleh penggunaan metode pembelajaran yang kurang bervariatif bagi peserta didik, sehingga peserta didik menjadi lebih cepat bosan dan kurang aktif selama proses pembelajaran. Tentu saja hal tersebut menyebabkan hasil belajar peserta didik yang rendah. Rumusan masalah dalam penulisan skripsi ini adalah: 1) Bagaimana penerapan Model Pembelajaran Kooperatif Tipe Make A Match yang dikembangkan dengan media Flash Card pada mata pelajaran Bahasa Inggris pokok bahasan Shapes Kelas V MI Irsyadut Tholibin, Rejotangan Tulungagung? 2) Bagaimana peningkatan keaktifan pada mata pelajaran Bahasa Inggris materi Shapes melalui penerapan Model Pembelajaran Kooperatif Tipe Make A Match yang dikembangkan dengan media Flash Card pada peserta didik Kelas V MI Irsyadut Tholibin, Rejotangan Tulungagung? 3) Bagaimana peningkatan hasil belajar pada mata pelajaran Bahasa Inggris materi Shapes melalui penerapan Model Pembelajaran Kooperatif Tipe Make A Match yang dikembangkan dengan media Flash Card pada peserta didik Kelas V MI Irsyadut Tholibin, Rejotangan Tulungagung? Penelitian ini menggunakan penelitian tindakan kelas (PTK) sebanyak dua siklus. Setiap siklus terdiri dari empat tahap, yaitu perencanaan, pelaksanaan, pengamatan, dan refleksi. Adapun teknik pengumpulan datanya menggunakan tes, wawancara, observasi, catatan lapangan, dan dokumentasi. Tes digunakan untuk menggali data tentang hasil belajar peserta didik. Sedangkan observasi, wawancara, dan catatan lapangan digunakan untuk menggali data tentang proses pembelajaran Bahasa Inggris, respon peserta didik, keadaan peserta didik dan guru serta keaktifan peserta didik. Analisis data yang digunakan mencakup reduksi data, penyajian data, dan penarikan kesimpulan. Akhirnya dalam refleksi I dan II data yang terkumpul dianalisis untuk mengetahui apakah indikator yang telah ditentukan sebelumnya sudah dipenuhi apa tidak. Hasil penelitian menunjukkan bahwa penerapan Model Pembelajaran Kooperatif Tipe Make A Match yang dikembangkan dengan media Flash Card dengan langkah-langkahnya dapat meningkatkan keaktifan dan hasil belajar peserta didik. Keaktifan peserta didik dalam pembelajaran Bahasa Inggris meningkat dari Siklus I ke Siklus II yaitu pada Siklus I keaktifan peserta didik mencapai taraf keberhasilan 80% dengan kriteria baik dan pada Siklus II keaktifan peserta didik mencapai taraf keberhasilan 95% dengan kriteria sangat baik. Sedangkan hasil belajar Bahasa Inggris peserta didik meningkatkan, yaitu pada Pre Test rata-rata peserta didik yaitu 44,37 dengan ketuntasan belajar 4,17%, meningkat pada Siklus I rata- rata peserta didik 74,37 dengan ketuntasan belajar pada Siklus I 70,83%. Hasil belajar peserta didik meningkat pada Siklus II yaitu dengan rata-rata 96 dengan ketuntasan belajar 100%. Dari data tersebut terlihat bahwa penerapan Model Pembelajaran Kooperatif Tipe Make A Match dengan media Flash Card dapat meningkatkan hasil belajar Bahasa Inggris peserta didik Kelas V MI Irsyadut Tholibin, Tugu Rejotangan Tulungagung

Factors influencing participant enrolment in a diabetes prevention program in general practice: lessons from the Sydney diabetes prevention program

Background: The effectiveness of lifestyle interventions in reducing diabetes incidence has been well established. Little is known, however, about factors influencing the reach of diabetes prevention programs. This study examines the predictors of enrolment in the Sydney Diabetes Prevention Program (SDPP), a community-based diabetes prevention program conducted in general practice, New South Wales, Australia from 2008&ndash;2011.Methods: SDPP was an effectiveness trial. Participating general practitioners (GPs) from three Divisions of General Practice invited individuals aged 50&ndash;65 years without known diabetes to complete the Australian Type 2 Diabetes Risk Assessment tool. Individuals at high risk of diabetes were invited to participate in a lifestyle modification program. A multivariate model using generalized estimating equations to control for clustering of enrolment outcomes by GPs was used to examine independent predictors of enrolment in the program. Predictors included age, gender, indigenous status, region of birth, socio-economic status, family history of diabetes, history of high glucose, use of anti-hypertensive medication, smoking status, fruit and vegetable intake, physical activity level and waist measurement.Results: Of the 1821 eligible people identified as high risk, one third chose not to enrol in the lifestyle program. In multivariant analysis, physically inactive individuals (OR: 1.48, P = 0.004) and those with a family history of diabetes (OR: 1.67, P = 0.000) and history of high blood glucose levels (OR: 1.48, P = 0.001) were significantly more likely to enrol in the program. However, high risk individuals who smoked (OR: 0.52, P = 0.000), were born in a country with high diabetes risk (OR: 0.52, P = 0.000), were taking blood pressure lowering medications (OR: 0.80, P = 0.040) and consumed little fruit and vegetables (OR: 0.76, P = 0.047) were significantly less likely to take up the program.Conclusions: Targeted strategies are likely to be needed to engage groups such as smokers and high risk ethnic groups. Further research is required to better understand factors influencing enrolment in diabetes prevention programs in the primary health care setting, both at the GP and individual level.<br /

Healthcare expenditure on Indigenous and non-Indigenous Australians at high risk of cardiovascular disease

Background: In spite of bearing a heavier burden of death, disease and disability, there is mixed evidence as to whether Indigenous Australians utilise more or less healthcare services than other Australians given their elevated risk level. This study analyses the Medicare expenditure and its predictors in a cohort of Indigenous and non-Indigenous Australians at high risk of cardiovascular disease. Methods: The healthcare expenditure of participants of the Kanyini Guidelines Adherence with the Polypill (GAP) pragmatic randomised controlled trial was modelled using linear regression methods. 535 adult (48% Indigenous) participants at high risk of cardiovascular disease (CVD) were recruited through 33 primary healthcare services (including 12 Aboriginal Medical Services) across Australia. Results: There was no significant difference in the expenditure of Indigenous and non-Indigenous participants in non-remote areas following adjustment for individual characteristics. Indigenous individuals living in remote areas had lower MBS expenditure ($932 per year P< 0.001) than other individuals. MBS expenditure was found to increase with being aged over 65 years ($128, p=0.013), being female ($472, p=0.003), lower baseline reported quality of life ($102 per 0.1 decrement of utility p=0.004) and a history of diabetes ($324, p=0.001), gout ($631, p=0.022), chronic obstructive pulmonary disease ($469, p=0.019) and established CVD whether receiving guideline-recommended treatment prior to the trial ($452, p=0.005) or not ($483, p=0.04). When controlling for all other characteristics, morbidly obese patients had lower MBS expenditure than other individuals (-$887, p=0.002). Conclusion: The findings suggest that for the majority of participants, once individuals are engaged with a primary care provider, factors other than whether they are Indigenous determine the level of Medicare expenditure for each person. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN 126080005833347