The food in our future: where will we find ethics? / El alimento en nuestro futuro: ¿dónde encontraremos la ética?

Food and agricultural systems are in large part driven by technology. Together with public policy, the kinds of technologies that are induced into, or chosen by actors in, food systems, dictates their structure and activities. The "Big Story" or ideology which underlies research, development and adoption of technologies provides the justification for choices we make about the future of the food system. A combination of productionism -more is better, and "feed the world"- is what governs, and seems to be what will govern Western food systems. Important ethical questions include whether more is better and whether we will feed the world with our technology and policy. But a parallel question is how will we include critical consideration of the continued legitimacy of our Big Story? This system, after all, has worked well for the past century

Los sistemas alimentarios y agrícolas son, en gran parte, impulsados por la tecnología. Junto con la política pública, las tipologías de tecnologías que están introducidas, o elegidas por los sujetos en los sistemas alimentarios, imponen sus estructuras y actividades. La «Gran Historia» o ideología que subyace a la investigación, al desarrollo y a la adopción de las tecnologías, proporciona la justificación de las decisiones que tomamos sobre el futuro del sistema alimentario. Una combinación de produccionismo -"more is better", y "feed the world"- es lo que gobierna, y parece ser lo que sostendrá, los sistemas alimentarios occidentales. Las preguntas éticas importantes incluyen si «más es mejor» y si vamos a «alimentar al mundo» con nuestra tecnología y política. Sin embargo, una cuestión paralela es, ¿cómo vamos a incluir la consideración crítica de la legitimidad continua de nuestra «Gran Historia»? Este sistema, después de todo, ha funcionado bien durante el siglo pasado

The Food in our Future: Where Will We Find Ethics?

Food and agricultural systems are in large part driven by technology. Together with public policy, the kinds of technologies that are induced into, or chosen by actors in, food systems, dictates their structure and activities. The ″Big Story″ or ideology which underlies research, development and adoption of technologies provides the justification for choices we make about the future of the food system. A combination of productionism -more is better, and ″feed the world″- is what governs, and seems to be what will govern Western food systems. Important ethical questions include whether more is better and whether we will feed the world with our technology and policy. But a parallel question is how will we include critical consideration of the continued legitimacy of our Big Story? This system, after all, has worked well for the past century.

Cost implications of human and automated follow-up in ambulatory care.

OBJECTIVES: To compare the costs of human and automated follow-up processes in ambulatory care. STUDY DESIGN: Analysis of costs of nurse-initiated and interactive voice response (IVR) system follow-up interventions. METHODS: Using national cost data and data on follow-up processes and outcomes from a previous study, we examined the costs to the healthcare system and providers of developing a follow-up process using nurse-initiated telephone calls compared with calls made by an IVR. RESULTS: Whether using nurse-initiated telephone calls or IVR calls, costs over the first 2 years of follow-up for a practice assumed to have 4800 acute care patient visits per year are approximately the same. After 2 years, IVR follow-up is approximately $9000 per year less expensive than nurse follow-up. In addition, overall cost savings are greater with IVR. CONCLUSIONS: Follow-up of ambulatory care patients is a way to assess risks of future problems and associated costs and to improve quality of care. An automated follow-up process using IVR is more efficient than one based on nurse-initiated follow-up calls.

Examining financial performance indicators for acute care hospitals.

Measuring financial performance in acute care hospitals is a challenge for those who work daily with financial information. Because of the many ways to measure financial performance, financial managers and researchers must decide which measures are most appropriate. The difficulty is compounded for the non-finance person. The purpose of this article is to clarify key financial concepts and describe the most common measures of financial performance so that researchers and managers alike may understand what is being measured by various financial ratios.

Behavioral therapy with or without biofeedback and pelvic floor electrical stimulation for persistent postprostatectomy incontinence: a randomized controlled trial.

CONTEXT: Although behavioral therapy has been shown to improve postoperative recovery of continence, there have been no controlled trials of behavioral therapy for postprostatectomy incontinence persisting more than 1 year. OBJECTIVE: To evaluate the effectiveness of behavioral therapy for reducing persistent postprostatectomy incontinence and to determine whether the technologies of biofeedback and pelvic floor electrical stimulation enhance the effectiveness of behavioral therapy. DESIGN, SETTING, AND PARTICIPANTS: A prospective randomized controlled trial involving 208 community-dwelling men aged 51 through 84 years with incontinence persisting 1 to 17 years after radical prostatectomy was conducted at a university and 2 Veterans Affairs continence clinics (2003-2008) and included a 1-year follow-up after active treatment. Twenty-four percent of the men were African American; 75%, white. INTERVENTIONS: After stratification by type and frequency of incontinence, participants were randomized to 1 of 3 groups: 8 weeks of behavioral therapy (pelvic floor muscle training and bladder control strategies); behavioral therapy plus in-office, dual-channel electromyograph biofeedback and daily home pelvic floor electrical stimulation at 20 Hz, current up to 100 mA (behavior plus); or delayed treatment, which served as the control group. MAIN OUTCOME MEASURE: Percentage reduction in mean number of incontinence episodes after 8 weeks of treatment as documented in 7-day bladder diaries. RESULTS: Mean incontinence episodes decreased from 28 to 13 per week (55% reduction; 95% confidence interval [CI], 44%-66%) after behavioral therapy and from 26 to 12 (51% reduction; 95% CI, 37%-65%) after behavior plus therapy. Both reductions were significantly greater than the reduction from 25 to 21 (24% reduction; 95% CI, 10%-39%) observed among controls (P = .001 for both treatment groups). However, there was no significant difference in incontinence reduction between the treatment groups (P = .69). Improvements were durable to 12 months in the active treatment groups: 50% reduction (95% CI, 39.8%-61.1%; 13.5 episodes per week) in the behavioral group and 59% reduction (95% CI, 45.0%-73.1%; 9.1 episodes per week) in the behavior plus group (P = .32). CONCLUSIONS: Among patients with postprostatectomy incontinence for at least 1 year, 8 weeks of behavioral therapy, compared with a delayed-treatment control, resulted in fewer incontinence episodes. The addition of biofeedback and pelvic floor electrical stimulation did not result in greater effectiveness. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00212264.

Out of pocket cost comparison between Caucasian and minority breast cancer survivors in the Breast Cancer Education Intervention (BCEI).

The purpose of this article is to: (1) describe out of pocket (OOP) costs among minority and Caucasian participants in the BCEI, the Breast Cancer Education Intervention, a randomized clinical trial of psychoeducational quality of life interventions for breast cancer survivors (BCS); and (2) examine the OOP burden, as measured by the proportion of income spent OOP, between the two racial/ethnic groups. We examined baseline OOP costs reported by 261 early-stage I and II breast cancer survivors who participated in the BCEI trial. Data were collected using the Breast Cancer Finances Survey and the Breast Cancer Sociodemographic and Treatment Tool. OOP costs averaged $316 per month since diagnosis. Direct medical costs were $281, and direct non-medical were $66. There were no significant differences in total OOP costs or direct medical and non-medical OOP costs between minority and Caucasian BCS. Minority BCS with incomes of $40,000 or less spent a greater proportion of income in total OOP and direct medical OOP costs (31.4 and 27% for BCS with incomes ≤ $20,000; 19.5 and 18.8% for BCS with incomes $20,001-40,0000) compared to their Caucasian counterparts (12.6 and 9.2% for BCS with incomes ≤ $20,000; 8.7 and 8.2% for BCS with incomes $20,001-40,0000). OOP costs can be a considerable burden for breast cancer survivors representing as much as 31% of monthly income depending on BCS' income levels. Future studies can investigate how this burden affects the quality of life of breast cancer survivors, especially minorities.

An application of longitudinal analysis with skewed outcomes.

BACKGROUND: Longitudinal designs are indispensable to the study of change in outcomes over time and have an important role in health, social, and behavioral sciences. However, these designs present statistical challenges particularly related to accounting for the variance and covariance of the repeated measurements on the same participants and to modeling outcomes that are not normally distributed. OBJECTIVES: The purpose of this study was to introduce a general methodology for longitudinal designs to address these statistical challenges and to present an example of an analysis conducted with data collected in a randomized clinical trial. In this example, the outcome of interest-monthly health-related out-of-pocket expenses incurred by breast cancer survivors-had a skewed distribution. METHODS: Common statistical approaches are for longitudinal analysis using linear and generalized linear mixed models are reviewed, and the discussed methods are applied to analyze monthly health-related out-of-pocket expenses. DISCUSSION: Although standard statistical software is available to conduct longitudinal analyses, training is necessary to understand and to take advantage of the various options available for model fitting. However, knowledge of the basics of the methodology allows assimilation and incorporation into practice of evidence from the numerous studies that use these designs.

The out of pocket cost of breast cancer survivors: a review.

INTRODUCTION: Out of pocket (OOP) costs add to the burden facing breast cancer survivors but remain an understudied area of costs. Current turbulent economic climate increases the urgency to better understand this burden. Few studies or systematic reviews focus on OOP costs. METHODS: PubMed search was conducted for articles in English containing: (1) MESH terms breast neoplasms and economics, and (2) words "breast cancer" and "cost" or "costs," "expenditure," or "out of pocket." Limits included: publication dates from January 1, 1980 to December 16, 2009, and populations aged > or = 45 years old. Articles were excluded based on title, abstract, and full text reviews. Citation searches and searches of reference lists were also conducted. Three articles were selected for this review. RESULTS: Medical direct OOP costs (e.g., for physician fees) ranged from $300 to $1,180 per month during active treatment, and were about $500 per month 1 year post diagnosis. Non-medical direct OOP costs (e.g., for transportation to doctor's office, parking etc.) ranged from $137 to $174 per month in the year post diagnosis; and $200-$509 per month 1 year or more after diagnosis. Different types of costs were identified. CONCLUSION: OOP costs represent a significant burden for survivors even after initial treatment. The nature and extent of OOP costs need further evaluation. IMPLICATIONS FOR CANCER SURVIVORS: OOP costs are rarely considered. However, as OOP costs affect the well being of cancer survivors, they should be understood more fully and possibly addressed in interventions aimed at improving quality of life.

Physician opinions of the importance, accessibility, and quality of health information and their use of the information.

This study compared physicians' perceptions of the importance, accessibility, and quality of different types of patient information that could potentially be available with Health Information Exchange (HIE) with how they use patient information. The results showed that while the physicians rated the majority of 11 data types as very important, accessible, and of high quality, they regularly used only a few data types before having access to a new HIE system. The three major types of information regularly used by the physicians were diagnoses, current medication lists, and allergy information. This study provides new data about how opinions on the importance of information relate to reported information use. Our findings suggest that having important, accessible, and high quality information does not necessarily lead to routine use, but that much of the early value of HIE may lie in improving access to a few data areas.

In vitro metabolism of the analgesic bicifadine in the mouse, rat, monkey, and human.

The in vitro metabolism of [(14)C]bicifadine by hepatic microsomes and hepatocytes from mouse, rat, monkey, and human was compared using radiometric high-performance liquid chromatography and liquid chromatography/tandem mass spectrometry. Two main metabolic pathways were identified in all four species. One pathway was an NADPH-dependent pathway in which the methyl group was oxidized to form a hydroxymethyl metabolite (M2). Its formation was inhibited in human microsomes only by quinidine, a CYP2D6 inhibitor. In incubations with individual cDNA-expressed human cytochromes P450, M2 was formed only by CYP2D6 and CYP1A2, with CYP2D6 activity 6-fold greater than that of CYP1A2. M2 was oxidized further to the carboxylic acid metabolite (M3) by hepatocytes from all four species. The second major metabolic pathway was an NADPH-independent oxidation at the C2 position of the pyrrolidine ring, forming a lactam metabolite (M12). This reaction was almost completely inhibited in human hepatic microsomes and mitochondria by the monoamine oxidase (MAO)-B-specific inhibitor selegiline. Clorgyline, a specific inhibitor of MAO-A, was less effective in inhibiting M12 formation. Other metabolic pathways of variable significance among the four species included the formation of carbamoyl-O-glucuronide, hydroxymethyl lactam, and carboxyl lactam. Overall, the data indicate that the primary enzymes responsible for the primary metabolism of bicifadine in humans are MAO-B and CYP2D6.

To outsource or not to outsource: Examining the effects of outsourcing IT functions on financial performance in hospitals.

BACKGROUND: Outsourcing of information technology (IT) functions is a popular strategy with both potential benefits and risks for hospitals. Anecdotal evidence, based on case studies, suggests that outsourcing may be associated with significant cost savings. However, no generalizable evidence exists to support such assertions. PURPOSE: This study examines whether outsourcing IT functions is related to improved financial performance in hospitals. METHODOLOGY: Primary survey data on IT outsourcing behavior were combined with secondary data on hospital financial performance. Regression analyses examined the relationship between outsourcing and various measures of financial performance while controlling for bed size, average patient acuity, geographic location, and overall IT adoption. FINDINGS: Complete data from a total of 83 Florida hospitals were available for analyses. Findings suggest that the decision to outsource IT functions is not related to any of the hospital financial performance measures that were examined. Specifically, outsourcing of IT functions did not correlate with net inpatient revenue, net patient revenue, hospital expenses, total expenses, cash flow ratio, operating margin, or total margin. PRACTICE IMPLICATIONS: In most cases, IT outsourcing is not necessarily a cost-lowering strategy, but instead, a cost-neutral manner in which to accomplish an organizational strategy.

Trends in colon cancer screening procedures in the US Medicare and Tricare populations: 1999-2001.

BACKGROUND: This study examined trends in the numbers of double contrast barium enemas, flexible sigmoidoscopies, and colonoscopies and trends in the choices of colorectal cancer screening service providers. METHODS: Descriptive statistics were used to examine Medicare and Tricare data for the years 1999 to 2001. RESULTS: The total volume of procedures increased 5% and 14%, respectively, in Tricare and Medicare. Tricare and Medicare, respectively, saw 32% and 33% reductions in barium enemas and 28% and 41% reductions in flexible sigmoidoscopies. Colonoscopies increased by 45% and 34% in Tricare and Medicare, respectively. Gastroenterologists provided the majority of colonoscopies for both groups each year. CONCLUSIONS: The volume of colonoscopies increased from 1999 to 2001 for both groups while the volumes of barium enemas and flexible sigmoidoscopies decreased. Gastroenterologists appear to be the preferred providers of colonoscopies.

Hospital information technology and positive financial performance: a different approach to finding an ROI.

This empirical study examined the relationship between information technology (IT) utilization and hospital financial performance. Using primary and secondary data, we specified and tested a series of regression models that examined this relationship in Florida hospitals. In addition, we employed performance group analysis for a select group of operational performance indicators. Findings suggested a significant and positive relationship between increased levels of IT use and various measures of financial performance, even after controlling for case-mix acuity and bed size. Regardless of the analysis or method employed, the results indicated that IT adoption is consistently related to improved financial outcomes both overall and operationally. This relationship was present when examining IT collectively and for clinical IT, administrative IT, and strategic IT as individual measures. Lastly, although higher IT use was associated with a higher level of revenues, income, or cash flow, higher use was also associated with ratios based on higher expenses. This probably reflects the relatively high acquisition costs associated with obtaining and maintaining sophisticated IT systems. Given that a true return on investment is so difficult to obtain for many individual hospitalwide IT systems, our data can serve as a proxy for hospital leaders and policymakers who want to understand the potential financial effects of investing in IT in the acute care setting.

Comparing the costs of radiation therapy and radical prostatectomy for the initial treatment of early-stage prostate cancer.

PURPOSE: Radical prostatectomy and external-beam radiation are the most common treatments for localized prostate cancer. Given the absence of clinical consensus in favor of one treatment or the other, relative costs may be a significant factor. This study compares the direct medical costs during the month before and 9 months after diagnosis for patients treated primarily with external-beam radiation or radical prostatectomy for early-stage prostate cancer. METHODS: Patients age 65 or older and coded by the Surveillance, Epidemiology, and End Results (SEER) registry as having been diagnosed with adenocarcinoma of the prostate treated primarily with external-beam radiation or radical prostatectomy during 1992 and 1993 were identified. The initial treatment costs, as measured by Medicare-approved payment amounts, for each strategy were analyzed using linked SEER-Medicare claims data after adjusting for differences in comorbidity and age. An intent-to-treat analysis was also performed to adjust for differences in staging between the two groups. RESULTS: For patients in the treatment-received analysis, the average costs were significantly different; $14,048 (95% confidence interval [CI], $13,765 to $14,330) for radiation therapy and $17,226 (95% CI, $16,891 to $17,560) for radical prostatectomy (P <.001). The average costs for patients in the intent-to-treat analysis were also significantly less for radiation therapy patients ($14,048; 95% CI, $13,765 to $14,330) than for those who underwent radical prostatectomy ($17,516; 95% CI, $17,195 to $17,837; P <.001). CONCLUSION: For patients with early-stage prostate cancer, average costs during the initial treatment interval were at least 23% greater for radical prostatectomy than for external-beam radiation. Major limitations of the research include not studying costs after the initial treatment interval and questionable current applicability, given changes in management of early prostate cancer.