Barriers to Improving Primary Care of Depression: Perspectives of Medical Group Leaders

Using clinical trials, researchers have demonstrated effective methods for treating depression in primary care, but improvements based on these trials are not being implemented. This might be because these improvements require more systematic organizational changes than can be made by individual physicians. We interviewed 82 physicians and administrative leaders of 41 medical groups to learn what is preventing those organizational changes. The identified barriers to improving care included external contextual problems (reimbursement, scarce resources, and access to/communication with specialty mental health), individual attitudes (physician and patient resistance), and internal care process barriers (organizational and condition complexity, difficulty standardizing and measuring care). Although many of these barriers are challenging, we can overcome them by setting clear priorities for change and allocating adequate resources. We must improve primary care of depression if we are to reduce its enormous adverse social and economic impacts

Addressing alcohol and tobacco harms in remote Indigenous communities and rapid responses to mental health crises in regional centres

Alcohol Management Plans (AMPs) were initially designed as part of a wide range of innovative and significant Queensland Government reforms. As well as supply control, these promised to reduce alcohol and substance misuse and violence through demand reduction by addressing key social determinants: economic development; education and training, land and sustainable natural resource management, housing, and health 3, 4. The limited available evidence in the peer-reviewed published literature points to some favourable impacts of restrictions 5, 6, including a reduction in indicators of serious injury in some communities to historically low levels 7. These favourable findings were reflected in an internal Queensland Government review 4. However, the evidence that these initial positive effects were experienced in all communities, or that they have been sustained, particularly after the most recent round of restrictions in 2008, has become equivocal 8. This paper was the first in a unique evaluation research program designed to examine the health and social effects of Queensland�s AMPs 1, 9. It investigates issues surrounding implementation of the designed AMP intervention components, specifically their perceived impacts on alcohol supply and consumption, violence, injury and community health and well-being. Perceptions and experiences are reported of the community leaders, service providers and relevant organisations with a mandate or responsibility for alcohol-related matters in the affected AMP communities and nearby towns.The research reported in this paper is a project of the Australian Primary Health Care Research Institute, which is supported by a grant from the Australian Government Department of Health and Ageing under the Primary Health Care Research, Evaluation and Development Strategy

Validation of thermal-mechanical modeling of stainless steel forgings

A constitutive model for recrystallization has been developed within the framework of an existing dislocation-based rate and temperature-dependent plasticity model. The theory has been implemented and tested in a finite element code. Material parameters were fit to data from monotonic compression tests on 304L steel for a wide range of temperatures and strain rates. The model is then validated by using the same parameter set in predictive thermal-mechanical simulations of experiments in which wedge forgings were produced at elevated temperatures. Model predictions of the final yield strengths compare well to the experimental results

Study Protocol - Alcohol Management Plans (AMPs) in remote indigenous communities in Queensland: their impacts on injury, violence, health and social indicators and their cost-effectiveness

BACKGROUND: In 2002/03 the Queensland Government responded to high rates of alcohol-related harm in discrete Indigenous communities by implementing alcohol management plans (AMPs), designed to include supply and harm reduction and treatment measures. Tighter alcohol supply and carriage restrictions followed in 2008 following indications of reductions in violence and injury. Despite the plans being in place for over a decade, no comprehensive independent review has assessed to what level the designed aims were achieved and what effect the plans have had on Indigenous community residents and service providers. This study will describe the long-term impacts on important health, economic and social outcomes of Queensland’s AMPs. METHODS/DESIGN: The project has two main studies, 1) outcome evaluation using de-identified epidemiological data on injury, violence and other health and social indicators for across Queensland, including de-identified databases compiled from relevant routinely-available administrative data sets, and 2) a process evaluation to map the nature, timing and content of intervention components targeting alcohol. Process evaluation will also be used to assess the fidelity with which the designed intervention components have been implemented, their uptake and community responses to them and their perceived impacts on alcohol supply and consumption, injury, violence and community health. Interviews and focus groups with Indigenous residents and service providers will be used. The study will be conducted in all 24 of Queensland’s Indigenous communities affected by alcohol management plans. DISCUSSION: This evaluation will report on the impacts of the original aims for AMPs, what impact they have had on Indigenous residents and service providers. A central outcome will be the establishment of relevant databases describing the parameters of the changes seen. This will permit comprehensive and rigorous surveillance systems to be put in place and provided to communities empowering them with the best credible evidence to judge future policy and program requirements for themselves. The project will inform impending alcohol policy and program adjustments in Queensland and other Australian jurisdictions.The study was funded by the National Health and Medical Research Council of Australia (NHMRC, Project Grant #APP1042532), with additional support from the Australian Primary Health Care Research Institute-funded Centre for Research Excellence for the Prevention of Chronic Conditions in Rural and Remote High Risk Populations at James Cook University & University Adelaide. Dr Caryn West is a National Health and Medical Research Council of Australia Early Career Research Post – Doctoral Fellow (NHMRC ECR, #APP1070931).Associate Professor Clough holds a NHMRC Career Development Award (#APP1046773)

Alcohol management plans in Aboriginal and Torres Strait Islander (Indigenous) Australian communities in Queensland: community residents have experienced favourable impacts but also suffered unfavourable ones

Background: In Australia, 'Alcohol Management Plans' (AMPs) provide the policy infrastructure for State and Commonwealth Governments to address problematic alcohol use among Aboriginal and Torres Strait Islanders. We report community residents' experiences of AMPs in 10 of Queensland's 15 remote Indigenous communities.\ud \ud Methods: This cross-sectional study used a two-stage sampling strategy: N = 1211; 588 (48%) males, 623 (52%) females aged ≥18 years in 10 communities. Seven propositions about 'favourable' impacts and seven about 'unfavourable' impacts were developed from semi-structured interviews. For each proposition, one-sample tests of proportions examined participant agreement and multivariable binary logistic regressions assessed influences of gender, age (18–24, 25–44, 45–64, ≥65 years), residence (≥6 years), current drinking and Indigenous status. Confirmatory factor analyses estimated scale reliability (ρ), item loadings and covariances.\ud \ud Results: Slim majorities agreed that: AMPs reduced violence (53%, p = 0.024); community a better place to live (54%, 0.012); and children were safer (56%, p < 0.001). More agreed that: school attendance improved (66%, p < 0.001); and awareness of alcohol's harms increased (71%, p < 0.001). Participants were equivocal about improved personal safety (53%, p = 0.097) and reduced violence against women (49%, p = 0.362). The seven 'favourable' items reliably summarized participants' experiences of reduced violence and improved community amenity (ρ = 0.90).\ud \ud Stronger agreement was found for six 'unfavourable' items: alcohol availability not reduced (58%, p < 0.001); drinking not reduced (56%, p < 0.001)); cannabis use increased (69%, p < 0.001); more binge drinking (73%, p < 0.001); discrimination experienced (77%, p < 0.001); increased fines, convictions and criminal records for breaching restrictions (90%, p < 0.001). Participants were equivocal (51% agreed, p = 0.365) that police could enforce restrictions effectively. 'Unfavourable' items were not reliably reflected in one group (ρ = 0.48) but in: i) alcohol availability and consumption not reduced and ii) criminalization and discrimination.\ud \ud In logistic regressions, longer-term (≥ 6 years) residents more likely agreed that violence against women had reduced and that personal safety had improved but also that criminalization and binge drinking had increased. Younger people disagreed that their community was a better place to live and strongly agreed about discrimination. Current drinkers' views differed little from the sample overall.\ud \ud Conclusions: The present Government review provides an opportunity to reinforce 'favourable' outcomes while targeting: illicit alcohol, treatment and diversion services and reconciliation of criminalization and discrimination issues.\ud \u

Primary health care services for the aged in the United Arab Emirates: a comparison of two models of care

Aim: To compare the quality of aged care provided by two different models of primary health care services in the United Arab Emirates. Methods: Cross sectional survey by chart review of 200 consecutive people aged 65 years and over attending two primary health care centers located in adjacent suburbs and serving populations with similar characteristics; a resource intensive center (RIC) and the other a resource thrifty center (RTC). Quality indicators were blood pressure levels in hypertensives and glycosylated hemoglobin (HbA1c) levels in diabetics. Results: There was no variation in age, sex or number of visits per year between the clinics. Osteoarthritis, hypertension, and diabetes were the most common diagnoses at both. The people attending the RIC had a substantially higher level of comorbidity (RIC=1.19±1.18, RTC=0.63 ± 0.68, p < 0.001), the average systolic and diastolic blood pressure for those diagnosed with hypertension was in the normal range at the RIC (138.5 ± 19.8/77.1 ± 9.9), whereas it was significantly higher and in the elevated range at the RTC (149.5 ± 17.7/85.2 ± 9.1, p < 0.001) and the HbA1c was significantly lower at the RIC (7.7 ± 1.4) than at the RTC (9.5 ± 2.0, p < 0.001). Conclusions:The quality of health outcomes for the two chronic diseases, hypertension and diabetes, appeared significantly higher at the RIC, when compared with the RTC. However, there may have been significant selection bias. Further studies are needed to determine if the RIC improves quality measures in other aspects of chronic disease care and provides a more cost effective health care service

MRI-targeted or standard biopsy for prostate-cancer diagnosis

Background Multiparametric magnetic resonance imaging (MRI), with or without targeted biopsy, is an alternative to standard transrectal ultrasonography-guided biopsy for prostate-cancer detection in men with a raised prostate-specific antigen level who have not undergone biopsy. However, comparative evidence is limited. Methods In a multicenter, randomized, noninferiority trial, we assigned men with a clinical suspicion of prostate cancer who had not undergone biopsy previously to undergo MRI, with or without targeted biopsy, or standard transrectal ultrasonography-guided biopsy. Men in the MRI-targeted biopsy group underwent a targeted biopsy (without standard biopsy cores) if the MRI was suggestive of prostate cancer; men whose MRI results were not suggestive of prostate cancer were not offered biopsy. Standard biopsy was a 10-to-12-core, transrectal ultrasonography-guided biopsy. The primary outcome was the proportion of men who received a diagnosis of clinically significant cancer. Secondary outcomes included the proportion of men who received a diagnosis of clinically insignificant cancer. Results A total of 500 men underwent randomization. In the MRI-targeted biopsy group, 71 of 252 men (28%) had MRI results that were not suggestive of prostate cancer, so they did not undergo biopsy. Clinically significant cancer was detected in 95 men (38%) in the MRI-targeted biopsy group, as compared with 64 of 248 (26%) in the standard-biopsy group (adjusted difference, 12 percentage points; 95% confidence interval [CI], 4 to 20; P=0.005). MRI, with or without targeted biopsy, was noninferior to standard biopsy, and the 95% confidence interval indicated the superiority of this strategy over standard biopsy. Fewer men in the MRI-targeted biopsy group than in the standard-biopsy group received a diagnosis of clinically insignificant cancer (adjusted difference, -13 percentage points; 95% CI, -19 to -7; P&lt;0.001). Conclusions The use of risk assessment with MRI before biopsy and MRI-targeted biopsy was superior to standard transrectal ultrasonography-guided biopsy in men at clinical risk for prostate cancer who had not undergone biopsy previously. (Funded by the National Institute for Health Research and the European Association of Urology Research Foundation; PRECISION ClinicalTrials.gov number, NCT02380027 .)

Market Hegemony and Economic Theory

It is central to standard economic theory that people act on their interests. People are interested in a variety of things, so a range of values should influence market behavior. When engaged in commerce, however, people generally act for personal gain; the influence of other values usually just disappears in the marketplace. What is missing from the standard account is that people often act on proper subsets of their interests. Economics can, however, be extended to capture this insight.Yeshttps://us.sagepub.com/en-us/nam/manuscript-submission-guideline