Patients who attend a private practice vs a university outpatient clinic: how do they differ?

Although interpersonal continuity is commonly assumed to be essential for care, some patients prefer to attend a university outpatient clinic where physicians change regularly and interpersonal continuity of care is not ensured. The aim of this exploratory study was to evaluate the differences between patients attending a university outpatient clinic and patients frequenting a private practice, explore their patterns of care-seeking and their understanding of continued care. We conducted a cross-sectional study of patients attending the university medical outpatient clinic (OC) in Lausanne, Switzerland and ten randomly selected private general practices (PP). Eligible patients were >30 years, Swiss nationals or long term residents, with one or more chronic conditions and attending the same practice for >3 years. They were asked to complete a questionnaire on sociodemographic data, use of medical resources and reasons for choosing and remaining at the same practice. Semi-structured interviews were conducted with a randomly selected subset of 26 patients to further explore their preferences. 329 patient questionnaires were completed, 219 by PP and 110 by OC patients. OC patients tended to be of lower socioeconomic status than PP patients. The main reason for choosing a PP were personal recommendation, while a higher percentage of patients chose the OC because they could obtain a first appointment quickly. A higher percentage of PP patients accorded importance to physician communication skills and trust, whereas a higher percentage of OC patients favoured investigation facilities. Qualitative data suggested that although OC and PP patients reported different reasons for consulting, their expectations on the medical and relationship level were similar. Our study suggests that the two groups of patients belong to different social backgrounds, have different patterns of care-seeking and attach importance to different aspects of care continuity. However, patients' expectations and perceptions of the physician-patient relationship are similar.

The Role of an Enterprise Portal in Knowledge Management Strategy, Case: Private Equity Investor

Työ tutkii yritysportaalin roolia organisaation tietojohtamisessa. Tutkimusongelman ratkaisemiseksi luodaan viitekehys, jossa yritysportaalin ja tietojohtamisen teoriat linkittyvät. Työn empiirisessä osassa viitekehys on pohjana case-yritykselle rakennettavalle yritysportaalille. Laadullinen tutkimus käsittää teoriaosuuden sekä osallistuvaan case-tutkimukseen perustuvan empiriaosuuden. Työn runko muodostuu kahden vastakkaisen tietojohtamisajattelun vuoropuhelusta, jotka ovat informaatioteknologiaan- ja strategiseen johtamiseen perustuvat näkökulmat. Toimivan tietojohtamismallin täytyy sisältää molemmat aspektit. Jokainen organisaatio tarvitsee informaation hallintaan liittyviä toiminnallisuuksia ja täten eksplisiittisen tiedon hallinta tietojärjestelmien avulla on onnistuneen tietojohtamisen kulmakiviä. Tätä perusinfrastruktuuria on mahdollista laajentaa hiljaisen tiedon hallintaan perustuvilla tietojohtamismenetelmillä. Työn ratkaisu näiden kahden näkemyksen, 'kovan' informaatioteknogiaan painottuvan sekä 'pehmeän' ihmisnäkökulman integrointiin, on yritysportaali. Työssä käytettävä yritysportaalin viitekehys rakentuu kolmeen päätoiminnallisuuteen; sisällönhallintaan, yhteistyöominaisuuksiin ja liiketoimintatiedon hallintaan. Työ todistaa yhteyden viitekehyksen sekä tietojohtamisen perusmallien, kuten tietojohtamisen prosessimallin sekä tietoympäristöjen välillä. Yritysportaali voi täten toimia, ei ainoastaan yksittäisten tietojohtamistyökalujen implementoinnissa, vaan tietojohtamisstrategian luomisen apuna tarjoten alustan tai 'katalyytin' kokonaisvaltaiselle tietojohtamiselle.

Transnational private authority and the participation of workers' organizations in the regulatory space surrounding the employment relationship

Most corporate codes of conduct and multi-stakeholder sustainability standards guarantee workers' rights to freedom of association and collective bargaining, but many authors are sceptical about the concrete impact of codes and standards of this kind. In this paper we use Hancher and Moran's (1998) concept of 'regulatory space' to assess the potential of private transnational regulation to support the growth of trade union membership and collective bargaining relationships, drawing on some preliminary case study results from a project on the impact of the International Finance Corporation's (IFC) social conditionality on worker organization and social dialogue. One of the major effects of neoliberal economic and industrial policy has been the routine exclusion of workers' organizations from regulatory processes on the grounds that they introduce inappropriate 'political' motives into what ought to be technical decision-making processes. This, rather than any direct attack on their capacity to take action, is what seems best to explain the global decline in union influence (Cradden 2004; Howell 2007; Howe 2012). The evidence we present in the paper suggests that private labour regulation may under certain conditions contribute to a reversal of this tendency, re-establishing the legitimacy of workers' organizations within regulatory processes and by extension the legitimacy of their use of economic and social power. We argue that guarantees of freedom of association and bargaining rights within private regulation schemes are effective to the extent that they can be used by workers' organizations in support of a claim for access to the regulatory space within which the terms and conditions of the employment relationship are determined. Our case study evidence shows that certain trade unions in East Africa have indeed been able to use IFC and other private regulation schemes as levers to win recognition from employers and to establish collective bargaining relationships. Although they did not attempt to use formal procedures to make a claim for the enforcement of freedom of association rights on behalf of their members, the unions did use enterprises' adherence to private regulation schemes as a normative point of reference in argument and political exchange about worker representation. For these unions, the regulation was a useful addition to the range of arguments that they could deploy as means to justify their demand for recognition by employers. By contrast, the private regulation that helps workers' organizations to win access to regulatory processes does little to ensure that they are able to participate meaningfully, whether in terms of technical capacity or of their ability to mobilize social power as a counterweight to the economic power of employers. To the extent that our East African unions were able to make an impact on terms and conditions of employment via their participation in regulatory space it was solely on the basis of their own capacities and resources and the application of national labour law.

The Effectiveness of Currency Hedging Strategies. Case: Imatra Boards Business Unit of Stora Enso Corp.

Tutkimus tarkastelee vaihtoehtoisia termiinisuojaustrategioita metsäteollisuuden alan tulosyksikössä. Jälkitestauksen tarkoituksena on arvioida vaihtoehtoisten strategioiden tuloksellisuutta suojata case-yrityksen kassavirtoja seuraavan kolmen arviointikriteerin avulla: yksittäisten vieraan valuutan määräisten kassavirtojen vaihtelu; koko vieraan valuutan määräisen kassavirran vaihtelu; suojausvoitot ja -tappiot. Tutkimuksen teoreettinen viitekehys tarkastelee yrityksen päätöksentekoa, valuuttariskien suojausprosessia sekä esittelee yrityksen vaihtoehtoisia suojausstrategioita. Tutkimuksen empiirinen aineisto pohjautuu case- yrityksen historiallisiin myyntilukuihin ja on kerätty yrityksen tietojärjestelmästä. Muu tutkimuksessa käytetty dataon kerätty eri tietokannoista. Tutkimuksen tulokset osoittavat, että suojaaminen vähentää kassavirtojen vaihtelua. Suojaamisen taloudelliset tulokset ovat kuitenkin erittäin riippuvaisia valitusta suojausstrategiasta, joka voi johtaa merkittäviin suojausvoittoihin, mutta yhtä hyvin myos merkittäviin tappioihin. Johdon näkemykset ja riskitoleranssi määrittelevät mitä strategiaa yrityksessä tullaan viime kädessä noudattamaan.

Effectiveness of antioxidants in preventing oxidation of palm oil enriched with heme iron: A model for iron fortification in baked products

Bakery products such as biscuits, cookies, and pastries represent a good medium for iron fortification in food products, since they are consumed by a large proportion of the population at risk of developing iron deficiency anemia, mainly children. The drawback, however, is that iron fortification can promote oxidation. To assess the extent of this, palm oil added with heme iron and different antioxidants was used as a model for evaluating the oxidative stability of some bakery products, such as baked goods containing chocolate. The palm oil samples were heated at 220°C for 10 min to mimic the conditions found during a typical baking processing. The selected antioxidants were a free radical scavenger (tocopherol extract (TE), 0 and 500 mg/kg), an oxygen scavenger (ascorbyl palmitate (AP), 0 and 500 mg/kg), and a chelating agent (citric acid (CA), 0 and 300 mg/kg). These antioxidants were combined using a factorial design and were compared to a control sample, which was not supplemented with antioxidants. Primary (peroxide value and lipid hydroperoxide content) and secondary oxidation parameters (p-anisidine value, p-AnV) were monitored over a period of 200 days in storage at room temperature. The combination of AP and CA was the most effective treatment in delaying the onset of oxidation. TE was not effective in preventing oxidation. The p-AnV did not increase during the storage period, indicating that this oxidation marker was not suitable for monitoring oxidation in this model.

Effectiveness of antioxidants in preventing oxidation of palm oil enriched with heme iron: A model for iron fortification in baked products

Bakery products such as biscuits, cookies, and pastries represent a good medium for iron fortification in food products, since they are consumed by a large proportion of the population at risk of developing iron deficiency anemia, mainly children. The drawback, however, is that iron fortification can promote oxidation. To assess the extent of this, palm oil added with heme iron and different antioxidants was used as a model for evaluating the oxidative stability of some bakery products, such as baked goods containing chocolate. The palm oil samples were heated at 220°C for 10 min to mimic the conditions found during a typical baking processing. The selected antioxidants were a free radical scavenger (tocopherol extract (TE), 0 and 500 mg/kg), an oxygen scavenger (ascorbyl palmitate (AP), 0 and 500 mg/kg), and a chelating agent (citric acid (CA), 0 and 300 mg/kg). These antioxidants were combined using a factorial design and were compared to a control sample, which was not supplemented with antioxidants. Primary (peroxide value and lipid hydroperoxide content) and secondary oxidation parameters (p-anisidine value, p-AnV) were monitored over a period of 200 days in storage at room temperature. The combination of AP and CA was the most effective treatment in delaying the onset of oxidation. TE was not effective in preventing oxidation. The p-AnV did not increase during the storage period, indicating that this oxidation marker was not suitable for monitoring oxidation in this model.

Cost-effectiveness of a new combined immunosuppressive and anti-infectious regimen in kidney transplantation.

OBJECTIVES: The aims of this study were to assess the 1-year cost-effectiveness of a new combined immunosuppressive and anti-infectious regimen in kidney transplantation to prevent both rejection and infectious complications. METHODS: Patients (pts) transplanted from January 2000 to March 2003 (Group A) and treated with a conventional protocol were compared with pts submitted to a combined regimen including universal cytomegalovirus (CMV) prophylaxis between April 2003 and July 2005 (Group B). Costs were computed from the hospital accounting system for hospital stays, and official tariffs for outpatient visits. Patients with incomplete costs data were excluded from analysis. RESULTS: Fifty-three patients were analyzed in Group A, and 60 in Group B. Baseline characteristics including CMV serostatus were not significantly different between the two groups. Over 12 months after transplantation, acute rejections decreased from 41.5 percent in Group A to 6.7 percent in Group B (p < .001), and CMV infections from 47 percent to 15 percent (p < .001). Overall, readmissions decreased from 68 percent to 55 percent (p = .160), and average hospital days from 28 +/- 19 to 20 +/- 11 days (p < .007). The average number of outpatient visits decreased from 49 +/- 10 to 39 +/- 8 (p < .001). Average 1-year immunosuppressive and CMV prophylaxis costs (per patient) increased from CHF20,402 +/- 7,273 to 27,375 +/- 6,063 (p < .001), graft rejection costs decreased from CHF4,595 +/- 10,182 to 650 +/- 3,167 (p = .005), CMV treatment costs from CHF2,270 +/- 6,161 to 101 +/- 326 (p = .008), and outpatient visits costs from CHF8,466 +/- 1'721 to 6,749 +/- 1,159 (p < .001). Altogether, 1-year treatment costs decreased from CHF39'957 +/- 16,573 to 36,204 +/- 6,901 (p = .115). CONCLUSIONS: The new combined regimen administered in Group B was significantly more effective, and its additional costs were more than offset by savings associated with complications avoidance.

Effectiveness of early detection on breast cancer mortality reduction in Catalonia (Spain)

Background: At present, it is complicated to use screening trials to determine the optimal age intervals and periodicities of breast cancer early detection. Mathematical models are an alternative that has been widely used. The aim of this study was to estimate the effect of different breast cancer early detection strategies in Catalonia (Spain), in terms of breast cancer mortality reduction (MR) and years of life gained (YLG), using the stochastic models developed by Lee and Zelen (LZ). Methods: We used the LZ model to estimate the cumulative probability of death for a cohort exposed to different screening strategies after T years of follow-up. We also obtained the cumulative probability of death for a cohort with no screening. These probabilities were used to estimate the possible breast cancer MR and YLG by age, period and cohort of birth. The inputs of the model were: incidence of, mortality from and survival after breast cancer, mortality from other causes, distribution of breast cancer stages at diagnosis and sensitivity of mammography. The outputs were relative breast cancer MR and YLG. Results: Relative breast cancer MR varied from 20% for biennial exams in the 50 to 69 age interval to 30% for annual exams in the 40 to 74 age interval. When strategies differ in periodicity but not in the age interval of exams, biennial screening achieved almost 80% of the annual screening MR. In contrast to MR, the effect on YLG of extending screening from 69 to 74 years of age was smaller than the effect of extending the screening from 50 to 45 or 40 years. Conclusion: In this study we have obtained a measure of the effect of breast cancer screening in terms of mortality and years of life gained. The Lee and Zelen mathematical models have been very useful for assessing the impact of different modalities of early detection on MR and YLG in Catalonia (Spain).

Cost-effectiveness of early detection of breast cancer in Catalonia (Spain)

Background: Breast cancer (BC) causes more deaths than any other cancer among women in Catalonia. Early detection has contributed to the observed decline in BC mortality. However, there is debate on the optimal screening strategy. We performed an economic evaluation of 20 screening strategies taking into account the cost over time of screening and subsequent medical costs, including diagnostic confirmation, initial treatment, follow-up and advanced care. Methods: We used a probabilistic model to estimate the effect and costs over time of each scenario. The effect was measured as years of life (YL), quality-adjusted life years (QALY), and lives extended (LE). Costs of screening and treatment were obtained from the Early Detection Program and hospital databases of the IMAS-Hospital del Mar in Barcelona. The incremental cost-effectiveness ratio (ICER) was used to compare the relative costs and outcomes of different scenarios. Results: Strategies that start at ages 40 or 45 and end at 69 predominate when the effect is measured as YL or QALYs. Biennial strategies 50-69, 45-69 or annual 45-69, 40-69 and 40-74 were selected as cost-effective for both effect measures (YL or QALYs). The ICER increases considerably when moving from biennial to annual scenarios. Moving from no screening to biennial 50-69 years represented an ICER of 4,469€ per QALY. Conclusions: A reduced number of screening strategies have been selected for consideration by researchers, decision makers and policy planners. Mathematical models are useful to assess the impact and costs of BC screening in a specific geographical area.

Clinical effectiveness of direct anterior restorations-A meta-analysis.

OBJECTIVES: This is the first meta-analysis on the efficacy of composite resin restorations in anterior teeth. The objective of the present meta-analysis was to verify whether specific material classes, tooth conditioning methods and operational procedures influence the result for Class III and Class IV restorations. MATERIAL AND METHODS: The database SCOPUS and PubMed were searched for clinical trials on anterior resin composites without restricting the search to the year of publication. The inclusion criteria were: (1) prospective clinical trial with at least 2 years of observation; (2) minimal number of restorations at last recall=20; (3) report on drop-out rate; (4) report of operative technique and materials used in the trial, and (5) utilization of Ryge or modified Ryge evaluation criteria. For the statistical analysis, a linear mixed model was used with random effects to account for the heterogeneity between the studies. p-Values smaller than 0.05 were considered to be significant. RESULTS: Of the 84 clinical trials, 21 studies met the inclusion criteria, 14 of them for Class III restorations, 6 for Class IV restorations and 1 for closure of diastemata; the latter was included in the Class IV group. Twelve of the 21 studies started before 1991 and 18 before 2001. The estimated median overall success rate (without replacement) after 10 years for Class III composite resin restorations was 95% and for Class IV restorations 90%. The main reason for the replacement of Class IV restorations was bulk fractures, which occurred significantly more frequently with microfilled composites than with hybrid and macrofilled composites. Caries adjacent to restorations was infrequent in most studies and accounted only for about 2.5% of all replaced restorations after 10 years irrespective of the cavity class. Class III restorations with glass ionomer derivates suffered significantly more loss of anatomical form than did fillings with other types of material. When the enamel was acid-etched and no bonding agent was applied, significantly more restorations showed marginal staining and detectable margins compared to enamel etching with enamel bonding or the total etch technique; fillings with self-etching systems were in between of these two outcome variables. Bevelling of the enamel was associated with a significantly reduced deterioration of the anatomical form compared to no bevelling but not with less marginal staining or less detectable margins. The type of isolation (absolute/relative) had a statistically significant influence on marginal caries which, however, might be a random finding.

Traditional local medicines in the republic of Palau and non-communicable diseases (NCD), signs of effectiveness.

ETHNOPHARMACOLOGICAL RELEVANCE: The aim of this survey was to describe which traditional medicines (TM) are most commonly used for non-communicable diseases (NCD - diabetes, hypertension related to excess weight and obesity) in Pacific islands and with what perceived effectiveness. NCD, especially prevalent in the Pacific, have been subject to many public health interventions, often with rather disappointing results. Innovative interventions are required; one hypothesis is that some local, traditional approaches may have been overlooked. MATERIALS AND METHODS: The method used was a retrospective treatment-outcome study in a nation-wide representative sample of the adult population (about 15,000 individuals) of the Republic of Palau, an archipelago of Micronesia. RESULTS: From 188 respondents (61% female, age 16-87, median 48,), 30 different plants were used, mostly self-prepared (69%), or from a traditional healer (18%). For excess weight, when comparing the two most frequent plants, Morinda citrifolia L. was associated with more adequate outcome than Phaleria nishidae Kaneh. (P=0.05). In case of diabetes, when comparing Phaleria nishidae (=Phaleria nisidai) and Morinda citrifolia, the former was statistically more often associated with the reported outcome "lower blood sugar" (P=0.01). CONCLUSIONS: Statistical association between a plant used and reported outcome is not a proof of effectiveness or safety, but it can help select plants of interest for further studies, e.g. through a reverse pharmacology process, in search of local products which may have a positive impact on population health.

Cost-effectiveness of a community pharmacist intervention in patients with depression: a randomized controlled trial (PRODEFAR study)

Background: Non-adherence to antidepressants generates higher costs for the treatment of depression. Little is known about the cost-effectiveness of pharmacist's interventions aimed at improving adherence to antidepressants. The study aimed to evaluate the cost-effectiveness of a community pharmacist intervention in comparison with usual care in depressed patients initiating treatment with antidepressants in primary care. Methods: Patients were recruited by general practitioners and randomized to community pharmacist intervention (87) that received an educational intervention and usual care (92). Adherence to antidepressants, clinical symptoms, Quality-Adjusted Life-Years (QALYs), use of healthcare services and productivity losses were measured at baseline, 3 and 6 months. Results: There were no significant differences between groups in costs or effects. From a societal perspective, the incremental cost-effectiveness ratio (ICER) for the community pharmacist intervention compared with usual care was 1,866 for extra adherent patient and 9,872 per extra QALY. In terms of remission of depressive symptoms, the usual care dominated the community pharmacist intervention. If willingness to pay (WTP) is 30,000 per extra adherent patient, remission of symptoms or QALYs, the probability of the community pharmacist intervention being cost-effective was 0.71, 0.46 and 0.75, respectively (societal perspective). From a healthcare perspective, the probability of the community pharmacist intervention being cost-effective in terms of adherence, QALYs and remission was of 0.71, 0.76 and 0.46, respectively, if WTP is 30,000. Conclusion: A brief community pharmacist intervention addressed to depressed patients initiating antidepressant treatment showed a probability of being cost-effective of 0.71 and 0.75 in terms of improvement of adherence and QALYs, respectively, when compared to usual care. Regular implementation of the community pharmacist intervention is not recommended.