Le rôle de l’évaluation économique dans la pratique des médecins de famille = The role of economic evaluation in the practice of family physicians

L’évaluation économique en santé consiste en l’analyse comparative d’alternatives de services en regard à la fois de leurs coûts et de leurs conséquences. Elle est un outil d’aide à la décision. La grande majorité des décisions concernant l’allocation des ressources sont prises en clinique; particulièrement au niveau des soins primaires. Puisque chaque décision est associée à un coût d’opportunité, la non-prise en compte des considérations économiques dans les pratiques des médecins de famille peut avoir un impact important sur l’efficience du système de santé. Il existe peu de connaissances quant à l’influence des évaluations économiques sur la pratique clinique. L’objet de la thèse est de comprendre le rôle de l’évaluation économique dans la pratique des médecins de famille. Ses contributions font l’objet de quatre articles originaux (philosophique, théorique, méthodologique et empirique). L’article philosophique suggère l’importance des questions de complexité et de réflexivité en évaluation économique. La complexité est la perspective philosophique, (approche générale épistémologique) qui sous-tend la thèse. Cette vision du monde met l’attention sur l’explication et la compréhension et sur les relations et les interactions (causalité interactive). Cet accent sur le contexte et le processus de production des données souligne l’importance de la réflexivité dans le processus de recherche. L’article théorique développe une conception nouvelle et différente du problème de recherche. L’originalité de la thèse réside également dans son approche qui s’appuie sur la perspective de la théorie sociologique de Pierre Bourdieu; une approche théorique cohérente avec la complexité. Opposé aux modèles individualistes de l’action rationnelle, Bourdieu préconise une approche sociologique qui s’inscrit dans la recherche d’une compréhension plus complète et plus complexe des phénomènes sociaux en mettant en lumière les influences souvent implicites qui viennent chaque jour exercer des pressions sur les individus et leurs pratiques. L’article méthodologique présente le protocole d’une étude qualitative de cas multiples avec niveaux d’analyse imbriqués : les médecins de famille (niveau micro-individuel) et le champ de la médecine familiale (niveau macro-structurel). Huit études de cas furent réalisées avec le médecin de famille comme unité principale d’analyse. Pour le niveau micro, la collecte des informations fut réalisée à l’aide d’entrevues de type histoire de vie, de documents et d’observation. Pour le niveau macro, la collecte des informations fut réalisée à l’aide de documents, et d’entrevues de type semi-structuré auprès de huit informateurs clés, de neuf organisations médicales. L’induction analytique fut utilisée. L’article empirique présente l’ensemble des résultats empiriques de la thèse. Les résultats montrent une intégration croissante de concepts en économie dans le discours officiel des organisations de médecine familiale. Cependant, au niveau de la pratique, l'économisation de ce discours ne semble pas être une représentation fidèle de la réalité puisque la très grande majorité des participants n'incarnent pas ce discours. Les contributions incluent une compréhension approfondie des processus sociaux qui influencent les schèmes de perception, de pensée, d’appréciation et d’action des médecins de famille quant au rôle de l’évaluation économique dans la pratique clinique et la volonté des médecins de famille à contribuer à une allocation efficiente, équitable et légitime des ressources.

Applications of Fractal Based Structures in Radar Cross Section Reduction

This thesis presents the Radar Cross Section measurements of different geometric structures such as flat plate,cylinder, corner reflector and circular cone loaded with fractal based metallo dielectric structures.Use of different fractal geometris,metallizations of different shapes as well as the frequency tanability is investigated for TE and TM polarization of the incident electromagnetic field.Application of fractal based metallo-dielectric structures results in RCS reduction over a wide range of frequency bands.RCS enhancement of dihedral corner is observed at certain acute and obtuse corner angles.The experimental results are validated using electromagnetic simulation softwares.

Interatomic potential structures in highly ionized scattering systems

The interatomic potential of the ion-atom scattering system I^N+-I at small intermediate internuclear distances is calculated for different charge states N from atomic Dirac-Focker-Slater (DFS) electron densities within a statistical model. The behaviour of the potential structures, due to ionized electronic shells, is studied by calculations of classical elastic differential scattering cross-sections.

Group preference structures in AHP–group decision making

This paper presents a procedure that allows us to determine the preference structures (PS) associated to each of the different groups of actors that can be identified in a group decision making problem with a large number of individuals. To that end, it makes use of the Analytic Hierarchy Process (AHP) (Saaty, 1980) as the technique to solve discrete multicriteria decision making problems. This technique permits the resolution of multicriteria, multienvironment and multiactor problems in which subjective aspects and uncertainty have been incorporated into the model, constructing ratio scales corresponding to the priorities relative to the elements being compared, normalised in a distributive manner (wi = 1). On the basis of the individuals’ priorities we identify different clusters for the decision makers and, for each of these, the associated preference structure using, to that end, tools analogous to those of Multidimensional Scaling. The resulting PS will be employed to extract knowledge for the subsequent negotiation processes and, should it be necessary, to determine the relative importance of the alternatives being compared using anyone of the existing procedures

Three substituted 4-pyrazolylbenzoates: hydrogen-bonded supramolecular structures in one, two and three dimensions

The molecules of ethyl 4-(5-amino-3-methyl-1H-pyrazol-1yl) benzoate, C13H15N3O2, are linked by two independent N-H center dot center dot center dot O hydrogen bonds into a chain of edge-fused and alternating R-4(2)(8) and R-2(2)(20) rings. A combination of N-H center dot center dot center dot N and N-H center dot center dot center dot O hydrogen bonds links the molecules of methyl 4-(5-amino-3-tert-butyl-1H-pyrazol-1-yl) benzoate, C15H19N3O2, into sheets of alternating R-2(2)(20) and R-6(6)(32) rings. In 4-(5-amino-3-methyl-1H-pyrazol-1-yl) benzoic acid monohydrate, C11H11N3O2 center dot H2O, the molecular components are linked into a three-dimensional framework structure by a combination of five independent hydrogen bonds, two of O-H center dot center dot center dot N type and one each of O-H center dot center dot center dot O, N-H center dot center dot center dot O and N-H center dot center dot center dot N types

Rethinking Polycentric Structures in the Postcolonial Church: Dangers of “Drone Missiology” or Afghanization of Christianity

In this brief essay I shall obviously draw from my reflections which I shared over the past three decades and to which I have provided some bibliographical references. It is clear from them that I had several opportunities to share my views beyond the Anglo-Saxon world, and some of them in events organized by K. Koschorke himself in the German academic circles as Munich-Freising Conferences. It is important that we do not get misled by words. We also need clarity of the concepts involved. Koschorke’s emphasis on “ploycentric structures” requires to be discussed and analysed critically to sort out its geographic components and its political-cultural implications, in order to be clear where lie the priorities. Without such exercise we will run the risk of hiding behind the ambiguity of words and concepts. My gut feelings make me believe that “polycentric structures” is just what the West needs in the postcolonial era to replace the control it has lost with decolonization.

Does experience in creative art influence the written self-expression of the deaf child?

This paper discusses whether participation in creative art affects the hearing impaired child's self expression in written language.

Convectively coupled equatorial waves: A new methodology for identifying wave structures in observational data

Convectively coupled equatorial waves are fundamental components of the interaction between the physics and dynamics of the tropical atmosphere. A new methodology, which isolates individual equatorial wave modes, has been developed and applied to observational data. The methodology assumes that the horizontal structures given by equatorial wave theory can be used to project upper- and lower-tropospheric data onto equatorial wave modes. The dynamical fields are first separated into eastward- and westward-moving components with a specified domain of frequency–zonal wavenumber. Each of the components for each field is then projected onto the different equatorial modes using the y structures of these modes given by the theory. The latitudinal scale yo of the modes is predetermined by data to fit the equatorial trapping in a suitable latitude belt y = ±Y. The extent to which the different dynamical fields are consistent with one another in their depiction of each equatorial wave structure determines the confidence in the reality of that structure. Comparison of the analyzed modes with the eastward- and westward-moving components in the convection field enables the identification of the dynamical structure and nature of convectively coupled equatorial waves. In a case study, the methodology is applied to two independent data sources, ECMWF Reanalysis and satellite-observed window brightness temperature (Tb) data for the summer of 1992. Various convectively coupled equatorial Kelvin, mixed Rossby–gravity, and Rossby waves have been detected. The results indicate a robust consistency between the two independent data sources. Different vertical structures for different wave modes and a significant Doppler shifting effect of the background zonal winds on wave structures are found and discussed. It is found that in addition to low-level convergence, anomalous fluxes induced by strong equatorial zonal winds associated with equatorial waves are important for inducing equatorial convection. There is evidence that equatorial convection associated with Rossby waves leads to a change in structure involving a horizontal structure similar to that of a Kelvin wave moving westward with it. The vertical structure may also be radically changed. The analysis method should make a very powerful diagnostic tool for investigating convectively coupled equatorial waves and the interaction of equatorial dynamics and physics in the real atmosphere. The results from application of the analysis method for a reanalysis dataset should provide a benchmark against which model studies can be compared.

Preferred structures in large-scale circulation and the effect of doubling greenhouse gas concentration in HadCM3

Preferred structures in the surface pressure variability are investigated in and compared between two 100-year simulations of the Hadley Centre climate model HadCM3. In the first (control) simulation, the model is forced with pre-industrial carbon dioxide concentration (1×CO2) and in the second simulation the model is forced with doubled CO2 concentration (2×CO2). Daily winter (December-January-February) surface pressures over the Northern Hemisphere are analysed. The identification of preferred patterns is addressed using multivariate mixture models. For the control simulation, two significant flow regimes are obtained at 5% and 2.5% significance levels within the state space spanned by the leading two principal components. They show a high pressure centre over the North Pacific/Aleutian Islands associated with a low pressure centre over the North Atlantic, and its reverse. For the 2×CO2 simulation, no such behaviour is obtained. At higher-dimensional state space, flow patterns are obtained from both simulations. They are found to be significant at the 1% level for the control simulation and at the 2.5% level for the 2×CO2 simulation. Hence under CO2 doubling, regime behaviour in the large-scale wave dynamics weakens. Doubling greenhouse gas concentration affects both the frequency of occurrence of regimes and also the pattern structures. The less frequent regime becomes amplified and the more frequent regime weakens. The largest change is observed over the Pacific where a significant deepening of the Aleutian low is obtained under CO2 doubling.