Improving chronic disease prevention and screening in primary care: results of the BETTER pragmatic cluster randomized controlled trial.

BackgroundPrimary care provides most of the evidence-based chronic disease prevention and screening services offered by the healthcare system. However, there remains a gap between recommended preventive services and actual practice. This trial (the BETTER Trial) aimed to improve preventive care of heart disease, diabetes, colorectal, breast and cervical cancers, and relevant lifestyle factors through a practice facilitation intervention set in primary care.MethodsPragmatic two-way factorial cluster RCT with Primary Care Physicians' practices as the unit of allocation and individual patients as the unit of analysis. The setting was urban Primary Care Team practices in two Canadian provinces. Eight Primary Care Team practices were randomly assigned to receive the practice-level intervention or wait-list control; 4 physicians in each team (32 physicians) were randomly assigned to receive the patient-level intervention or wait-list control. Patients randomly selected from physicians' rosters were stratified into two groups: 1) general and 2) moderate mental illness. The interventions involved a multifaceted, evidence-based, tailored practice-level intervention with a Practice Facilitator, and a patient-level intervention involving a one-hour visit with a Prevention Practitioner where patients received a tailored 'prevention prescription'. The primary outcome was a composite Summary Quality Index of 28 evidence-based chronic disease prevention and screening actions with pre-defined targets, expressed as the ratio of eligible actions at baseline that were met at follow-up. A cost-effectiveness analysis was conducted.Results789 of 1,260 (63%) eligible patients participated. On average, patients were eligible for 8.96 (SD 3.2) actions at baseline. In the adjusted analysis, control patients met 23.1% (95% CI: 19.2% to 27.1%) of target actions, compared to 28.5% (95% CI: 20.9% to 36.0%) receiving the practice-level intervention, 55.6% (95% CI: 49.0% to 62.1%) receiving the patient-level intervention, and 58.9% (95% CI: 54.7% to 63.1%) receiving both practice- and patient-level interventions (patient-level intervention versus control, P < 0.001). The benefit of the patient-level intervention was seen in both strata. The extra cost of the intervention was $26.43CAN (95$16 to $44) per additional action met.ConclusionsA Prevention Practitioner can improve the implementation of clinically important prevention and screening for chronic diseases in a cost-effective manner

Real world costs and cost-effectiveness of Rituximab for diffuse large B-cell lymphoma patients: a population-based analysis.

BackgroundCurrent treatment of diffuse-large-B-cell lymphoma (DLBCL) includes rituximab, an expensive drug, combined with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) chemotherapy. Economic models have predicted rituximab plus CHOP (RCHOP) to be a cost-effective alternative to CHOP alone as first-line treatment of DLBCL, but it remains unclear what its real-world costs and cost-effectiveness are in routine clinical practice.MethodsWe performed a population-based retrospective cohort study from 1997 to 2007, using linked administrative databases in Ontario, Canada, to evaluate the costs and cost-effectiveness of RCHOP compared to CHOP alone. A historical control cohort (n = 1,099) with DLBCL who received CHOP before rituximab approval was hard-matched on age and treatment intensity and then propensity-score matched on sex, comorbidity, and histology to 1,099 RCHOP patients. All costs and outcomes were adjusted for censoring using the inverse probability weighting method. The main outcome measure was incremental cost per life-year gained (LYG).ResultsRituximab was associated with a life expectancy increase of 3.2 months over 5 years at an additional cost of $16,298, corresponding to an incremental cost-effectiveness ratio of$61,984 (95% CI $34,087-$135,890) per LYG. The probability of being cost-effective was 90% if the willingness-to-pay threshold was $100,000/LYG. The cost-effectiveness ratio was most favourable for patients less than 60 years old ($31,800/LYG) but increased to $80,600/LYG for patients 60-79 years old and$110,100/LYG for patients ≥ 80 years old. We found that post-market survival benefits of rituximab are similar to or lower than those reported in clinical trials, while the costs, incremental costs and cost-effectiveness ratios are higher than in published economic models and differ by age.ConclusionsOur results showed that the addition of rituximab to standard CHOP chemotherapy was associated with improvement in survival but at a higher cost, and was potentially cost-effective by standard thresholds for patients <60 years old. However, cost-effectiveness decreased significantly with age, suggesting that rituximab may be not as economically attractive in the very elderly on average. This has important clinical implications regarding age-related use and funding decisions on this drug

Adverse cardiovascular events during treatment with pioglitazone and rosiglitazone: population based cohort study

Objective To compare the risk of acute myocardial infarction, heart failure, and death in patients with type 2 diabetes treated with rosiglitazone and pioglitazone

State Power and Economic Inefficiency : Explaining Political Failture in Africa

SUMMARY The problem of agricultural crisis in Africa has forced a review of the highly centralised and bureaucratised structures used to provide services to farmers since independence, and has resulted in a return to favour of decentralised market mechanisms. This article traces the historical evolution of the present system in the colonial period, and sets out the theoretical and political assumptions which lay behind its retention in the post?colonial period. It then attempts to account for current failures by examining the theoretical inconsistencies and actual conflicts of interest involved in the attempt to use these structures in the political, economic and social conditions prevailing in post?colonial Africa. It concludes by recommending a more flexible approach based upon the use of decentralised private and cooperative structures directly accountable to the farmers who use them. SOMMAIRE Le problème de la crise agricole en Afrique a forcé une révision des structures bureaucratìques et hautement centralisées, utilisées pour procurer des services aux fermiers depuis l'indépendance, ceci a eu pour résultat de plaider en faveur des mécanismes de marché décentralisées. Cet article trace révolution historique du système actuel dans la période coloniale, et présente les assomptions qui sont derrière son maintien dans la période post?coloniale. On tente ensuite d'expliquer les échecs récents en analysant les contradictions théoriques et les conflits d'intérêt actuels impliqués dans les tentatives d'utiliser ces structures sous des conditions politiques, économiques et sociales prévalant dans l'Afrique post?coloniale. L'article conclut en recommandant une approche plus flexible, basée sur l'utilisation de structures privées décentralisées et des structures coopératives imputables aux fermiers utilisateurs. RESUMEN El problema de la crisis agrícola en Africa ha forzado a una revisión de las estructuras altamente centralizadas y burocráticas utilizadas para proporcionar servicios a los agricultores, resultando en un retorno en favor de los mecanismos descentralizados del mercado. Este artículo describe la evolución histórica del sistema actual en el periodo colonial y establece las hipótesis teóricas y políticas que yacen por detrás de su persistencia en el periodo post?colonial. A continuación intenta explicar los fracasos actuales mediante el examen de las incoherencias teóricas y los conflictos de intereses involucrados en el propósito de utilizar estas estructuras en las condiciones políticas, sociales y económicas prevalecientes en Africa post?colonial. Concluye recomendando un enfoque más flexible basado en el uso de estructuras descentralizadas, tanto privadas como cooperativas, directamente responsables ante los granjeros que las utilizan

A Fuzzy Criticality Assessment System of Process Equipment for Optimized Maintenance Management.

yesIn modern chemical plants, it is essential to establish an effective maintenance strategy which will deliver financially driven results at optimised conditions, that is, minimum cost and time, by means of a criticality review of equipment in maintenance. In this article, a fuzzy logic-based criticality assessment system (FCAS) for the management of a local company’s equipment maintenance is introduced. This fuzzy system is shown to improve the conventional crisp criticality assessment system (CCAS). Results from case studies show that not only can the fuzzy logic-based system do what the conventional crisp system does but also it can output more criticality classifications with an improved reliability and a greater number of different ratings that account for fuzziness and individual voice of the decision-makers

A Decolonial Critique of the Racialized “Localwashing” of Extraction in Central Africa

Responding to calls for increased attention to actions and reactions “from above” within the extractive industry, we offer a decolonial critique of the ways in which corporate entities and multinational institutions propagate racialized rhetoric of “local” suffering, “local” consultation, and “local” fault for failure in extractive zones. Such rhetoric functions to legitimize extractive intervention within a set of practices that we call localwashing. Drawing from a decade of research on and along the Chad-Cameroon Oil Pipeline, we show how multi-scalar actors converged to assert knowledge of, responsibility for, and collaborations with “local” people within a racialized politics of scale. These corporate representations of the racialized “local” are coded through long-standing colonial tropes. We identify three interrelated and overlapping flexian elite rhetoric(s) and practices of racialized localwashing: (a) anguishing, (b) arrogating, and (c) admonishing. These elite representations of a racialized “local” reveal diversionary efforts “from above” to manage public opinion, displace blame for project failures, and domesticate dissent in a context of persistent scrutiny and criticism from international and regional advocates and activists