From the Academy: Colloquium perspective. Toward cropping systems that enhance productivity and sustainability

The defining features of any cropping system are (i) the crop rotation and (ii) the kind or intensity of tillage. The trend worldwide starting in the late 20th century has been (i) to specialize competitively in the production of two, three, a single, or closely related crops such as different market classes of wheat and barley, and (ii) to use direct seeding, also known as no-till, to cut costs and save soil, time, and fuel. The availability of glyphosate- and insect-resistant varieties of soybeans, corn, cotton, and canola has helped greatly to address weed and insect pest pressures favored by direct seeding these crops. However, little has been done through genetics and breeding to address diseases caused by residue- and soil-inhabiting pathogens that remain major obstacles to wider adoption of these potentially more productive and sustainable systems. Instead, the gains have been due largely to innovations in management, including enhancement of root defense by antibiotic-producing rhizosphere-inhabiting bacteria inhibitory to root pathogens. Historically, new varieties have facilitated wider adoption of new management, and changes in management have facilitated wider adoption of new varieties. Although actual yields may be lower in direct-seed compared with conventional cropping systems, largely due to diseases, the yield potential is higher because of more available water and increases in soil organic matter. Achieving the full production potential of these more-sustainable cropping systems must now await the development of varieties adapted to or resistant to the hazards shown to account for the yield depressions associated with direct seeding.     

Cost effectiveness and cost utility analysis of multidisciplinary care in patients with rheumatoid arthritis: a randomised comparison of clinical nurse specialist care,inpatient team care,and day patient team care

OBJECTIVE: To assess the relative cost effectiveness of clinical nurse specialist care, inpatient team care, and day patient team care. METHODS: Incremental cost effectiveness analysis and cost utility analysis, alongside a prospective randomised controlled trial with two year follow up. Included were patients with rheumatoid arthritis (RA) with increasing difficulty in performing activities of daily living over the previous six weeks. Quality of life and utility were assessed by the Rheumatoid Arthritis Quality of Life questionnaire, the Short Form-6D, a transformed rating scale, and the time tradeoff. A cost-price analysis was conducted to estimate the costs of inpatient and day patient hospitalisations. Other healthcare and non-healthcare costs were estimated from cost questionnaires. RESULTS: 210 patients with RA (75% female, median age 59 years) were included. Aggregated over the two year follow up period, no significant differences were found on the quality of life and utility instruments. The costs of the initial treatment were estimated at euro 200 for clinical nurse specialist care, euro 5000 for inpatient team care, and euro 4100 for day patient team care. Other healthcare costs and non-healthcare costs were not significantly different. The total societal costs did not differ significantly between inpatients and day patients, but were significantly lower for the clinical nurse specialist patients by at least euro 5400. CONCLUSIONS: Compared with inpatient and day patient team care, clinical nurse specialist care was shown to provide equivalent quality of life and utility, at lower costs. Therefore, for patients with health conditions that allow for any of the three types of care, the preferred treatment from a health-economic perspective is the care provided by the clinical nurse specialist.     

Delivering effective primary care to older adults: a randomized, controlled trial of the senior resource team at group health cooperative

OBJECTIVES: To assess the effect of a team of geriatrics specialists on the practice style of primary care providers (PCPs) and the functioning of their patients aged 75 and older.
DESIGN: Randomized, controlled trial.
SETTING: Two primary care clinics in the Seattle, Washington, area.
PARTICIPANTS: Thirty-one PCPs and 874 patients aged 75 and older.
INTERVENTION: An interdisciplinary team of geriatrics specialists worked with patients and providers to enhance the geriatric focus of care.
MEASUREMENTS: Main outcomes were a practice style reflecting a geriatric orientation and patient scores on the physical and affect subscales of the Arthritis Impact Measurement Scale 2—Short Form. Secondary outcomes were hospitalizations, incident disability in activities of daily living (ADLs), and PCP perceptions of the intervention. Death rates were also assessed.
RESULTS: Intervention providers screened significantly more for geriatric syndromes at 12 months, but this finding did not persist at 24 months. There were no significant differences in adequate hypertension control or high-risk prescribing at 12 or 24 months of follow-up. There were no significant differences in patient functioning or significant differences in hospitalization rates at either time point. Meaningful differences were observed in ADL disability at 12 but not 24 months. PCPs viewed the intervention favorably. Seventy-eight participants died over the 24 months of follow-up; the proportion dying was higher in the intervention group (11.4% in intervention group vs 7.1% of controls, P =.03).
CONCLUSION: The addition of an interdisciplinary geriatric team was acceptable to PCPs and had some effect on care of geriatric conditions but little effect on patient function or the use of inpatient care and was associated with greater mortality.     

Management of open access gastrointestinal endoscopy and quality of care: collaboration between an improvement team and primary care

Objective

To create an improvement team within a healthcare quality improvement project of the Government of Aragon (Spain), aimed at increasing the quality of care and suitability of the indications of gastrointestinal endoscopy in the open access endoscopy system of a secondary hospital in Aragon.

Design

The team developed a consensus document indicating how to use oral endoscopy and colonoscopy correctly, and held information and training sessions with all the primary care physicians involved in this area.

Location

Sector I health centers and Royo Villanova Hospital, in Zaragoza.

Participants

The team consisted of a gastroenterologist and three primary care physicians and, from the outset received the support of the primary care administration and management in the health area.

Results

Inappropriate use of endoscopy, particularly colonoscopy, was reduced from 20% to 11.6%. Significant savings were achieved in health costs. The endoscopy waiting list was reduced. The quality of care and the safety of patients undergoing these examinations improved. Training of primary care physicians in these procedures was enhanced, and coordination between primary and specialized was implemented.

Conclusions

To ensure efficient running of an open access gastrointestinal endoscopy system, an interdisciplinary improvement team and the full involvement of the primary care staff managing this resource are required.     

Improving care and efficiency: appointment times in a haemodialysis unit

Shortage of nurses and dialysis spaces and the desire to improve patient care are the two main driving forces in the dialysis field today. This paper suggests that these issues can be addressed by organisational change. We describe a simple, dramatically effective but rarely used example - the effect on a haemodialysis unit of the introduction of patient appointment times. This paper will demonstrate that appointment times can be highly effective in reducing waiting times for patients and in utilizing staff and resources more efficiently, as long as there is commitment from key staff to implement and maintain them effectively     

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文章扼要介绍美国老年医学的新理念与医疗模式,前者包括从传统的亚专科以疾病为中心的单病诊疗转向以患者为中心的个体化医疗保健服务,强调整体性、系统性和连续性、多学科协作,以及功能评估与康复。后者包括老年病房、髋部骨折专诊、亚急性和过渡性医疗、全面的老年人服务项目以及退休养老社区连续性医疗保健服务。最后提及美国霍普金斯医院和北京协和医院的合作。     

Providing primary general medical care in university hospitals: efficiency and cost

Data on efficiency, costs, and profits of 15 internal medicine outpatient group practices in university hospitals were collected for 9 months from interviews, a time-motion study, observations, and reviews of bills. Charges for a follow-up visit were about 25% higher than Medicare's allowable charges, but differed threefold across practices. Physicians spent more than half their allocated patient care or supervision time in other activities and 14% of nursing time was used for direct patient care. Visits to second- and third-year residents cost one half of those to faculty. Faculty supervision of second- and third-year residents was limited; it was, on average, 2 minutes per follow-up visit. Despite these inefficiencies, bad debts, and educational costs, practices appeared to break even financially. We conclude it is financially feasible for university hospitals to provide primary care to disadvantaged populations.     

Driving and dementia: a prospective audit of clients referred to an aged care assessment team

Objective: Many people with dementia or cognitive Impairment continue to drive. Given Australia's ageing population, this raises safety concerns for the driver in the community. This paper presents data collected by the NS W Central Coast Aged Care Assessment Team (ACAT), outlining the extent of the problem on the Central Coast and offers some suggestions about dealing with this issue. Method: A prospective audit of clients referred to Central Coast ACAT over a seven month period. Data describing the clients' cognitive state and also their driving habits were collected during routine ACAT assessments. Results: 1203 people were referred to ACAT during the study period. 100 (8%) of these were driving and 34% of those driving had some form of cognitive impairment. In some cases the impairment was quite severe. Most of these drivers were male. In a majority of the cases, concerns were expressed by someone familiar with the person, regarding their capacity to drive safely. Conclusion: The results support findings from other studies, which suggest there is a small but significant number of elderly people with cognitive impairment who are still driving. We propose that a safety first policy should be adopted and where there is doubt about the persons ability to drive safely, an Occupationul Therapy driving test in conjunction with a detailed cognitive assessment needs to be performed.