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Elon Musk on Friday unveiled a coin-sized prototype of a brain implant developed by his startup Neuralink to enable people who are paralyzed to operate smartphones and robotic limbs with their thoughts — and said the company had worked to “dramatically simplify” the device since presenting an earlier version buy propecia uk last summer.In an event live-streamed on YouTube to more than 150,000 viewers at one point, the company staged a demonstration in which it trotted out a pig named Gertrude that was said to have had the company’s device implanted in its head two months ago. The live stream showed what Musk claimed to be Gertrude’s real-time brain activity as it sniffed around a pen. At no point, though, did he provide evidence that the signals — rendered in beeps and bright blue wave patterns on screen — were, in fact, emanating from the pig’s brain.A pig presented at a Neuralink demonstration was said buy propecia uk to have one of the company’s brain implants in its head. YouTube screenshot“This is obviously sounding increasingly like a Black Mirror episode,” Musk said at one point during the event as he responded affirmatively to a question about whether the company’s implant could eventually be used to save and replay memories. €œThe future’s going to be buy propecia uk weird.”advertisement Musk said that in July Neuralink received a breakthrough device designation from the Food and Drug Administration — a regulatory pathway that could allow the company to soon start a clinical trial in people with paraplegia and tetraplegia.

The big reveal came after four former Neuralink employees told STAT that the company’s leaders have long fostered an internal culture characterized by rushed timelines and the “move fast and break things” ethos of a tech company — a pace sometimes at odds with the slow and incremental pace that’s typical of medical device development. Advertisement Friday’s event began, 40 minutes late, with a glossy video about the company’s work — and then panned to Musk, standing in front of a blue curtain beside a gleaming new version buy propecia uk of the company’s surgical “sewing machine” robot that could easily have been mistaken for a giant Apple device. Musk described the event as a “product demo” and said its primary purpose was to recruit potential new employees. It was unclear whether the demonstration was taking place at the company’s Fremont, Calif., headquarters buy propecia uk or elsewhere. Musk proceeded to reveal the new version of Neuralink’s brain implant, which he said was designed to fit snugly into the top of the skull.

Neuralink’s technological design buy propecia uk has changed significantly since its last big update in July 2019. At that time, the company’s brain implant system involved a credit-card sized device designed to be positioned behind the back of a person’s ear, with several wires stretching to the top of the skull. After demonstrating the pig’s brain activity at Friday’s event, Musk showed video footage of a pig walking on a treadmill and said Neuralink’s device could be used to “predict the position of limbs with high accuracy.” That capability would be critical to allowing someone using the device to do something like controlling a prosthetic limb, for example.Neuralink for months has signaled that it initially plans to develop its device for buy propecia uk people who are paralyzed. It said at its July 2019 event that it wanted to start human testing by the end of 2020. Receiving the breakthrough device designation from the FDA — designed to speed up the lengthy regulatory process — is buy propecia uk a step forward, but it by no means guarantees that a device will receive a green light, either in a short or longer-term time frame.

After Musk’s presentation, a handful of the company’s employees — all wearing masks, but seated only inches apart — joined him to take questions submitted on Twitter or from the small audience in the room.In typical fashion for a man who in 2018 sent a Tesla Roadster into space, Musk didn’t hesitate to use the event to cross-promote his electric car company. Asked whether the Neuralink chip would allow people to summon their buy propecia uk Tesla telepathically, Musk responded. €œDefinitely — of course.”Matthew MacDougall, the company’s head neurosurgeon, appearing in scrubs, said the company had so far only implanted its technology into the brain’s cortical surface, the coaster-width layer enveloping the brain, but added that it hoped to go deeper in the future. Still, Musk said buy propecia uk. €œYou could solve blindness, you could solve paralysis, you could solve hearing — you can solve a lot just by interfacing with the cortex.”Musk and MacDougall said they hoped to eventually implant Neuralink’s devices — which they referred to on stage simply as “links” — in the deeper structures of the brain, such as in the hypothalamus, which is believed to play a critical role in mental illnesses including depression, anxiety, and PTSD.There were no updates at the event of Neuralink’s research in monkeys, which the company has been conducting in partnership with the University of California, Davis since 2017.

At last buy propecia uk July’s event, Musk said — without providing evidence — that a monkey had controlled a computer with its brain.At that same July 2019 event, Neuralink released a preprint paper — published a few months later — that claimed to show that a series of Neuralink electrodes implanted in the brains of rats could record neural signals. Critically, the work did not show where in the brain the implanted electrodes were recording from, for how long they were recording, or whether the recordings could be linked to any of the rats’ bodily movements.In touting Friday’s event — and Neuralink’s technological capabilities — on Twitter in recent weeks, Musk spoke of “AI symbiosis while u wait” and referenced the “matrix in the matrix” — a science-fiction reference about revealing the true nature of reality. The progress the company reported on Friday fell far short buy propecia uk of that. Neuralink’s prototype is ambitious, but it has yet to show evidence that it can match up to the brain-machine interfaces developed by academic labs and other companies. Other groups have shown that they can listen in on neural activity and allow primates and people to control a computer cursor with their brain — so-called “read-out” technology — and have also shown that they can use electrical stimulation buy propecia uk to input information, such as a command or the heat of a hot cup of coffee, using “write-in” technology.

Neuralink said on Friday that its technology would have both read-out and write-in capabilities.Musk acknowledged that Neuralink still has a long way to go. In closing the event buy propecia uk after more than 70 minutes, Musk said. €œThere’s a tremendous amount of work to be done to go from here to a device that is widely available and affordable and reliable.”Following the news this week of what appears to have been the first confirmed case of a hair loss treatment re, other researchers have been coming forward with their own reports. One in buy propecia uk Belgium, another in the Netherlands. And now, one in Nevada.What caught experts’ attention about the case of the 25-year-old Reno man was not that he appears to have contracted hair loss (the name of the propecia that causes hair loss treatment) a second time.

Rather, it’s that his second bout was more serious than his buy propecia uk first.Immunologists had expected that if the immune response generated after an initial could not prevent a second case, then it should at least stave off more severe illness. That’s what occurred with the first known re case, in a 33-year-old Hong Kong man.advertisement Still, despite what happened to the man in Nevada, researchers are stressing this is not a sky-is-falling situation or one that should result in firm conclusions. They always presumed people would become vulnerable to hair loss treatment again some time after recovering from an initial case, based on how our immune buy propecia uk systems respond to other respiratory propeciaes, including other hair losses. It’s possible that these early cases of re are outliers and have features that won’t apply to the tens of millions of other people who have already shaken off hair loss treatment.“There are millions and millions of cases,” said Michael Mina, an epidemiologist at Harvard’s T.H. Chan School of Public Health buy propecia uk.

The real question that should get the most focus, Mina said, is, “What happens to most people?. €advertisement But buy propecia uk with more re reports likely to make it into the scientific literature soon, and from there into the mainstream press, here are some things to look for in assessing them.What’s the deal with the Nevada case?. The Reno resident in question first tested positive for hair loss in April after coming down with a sore throat, cough, and headache, as well as nausea and diarrhea. He got better over time and later tested negative twice buy propecia uk. But then, some 48 days later, the man started experiencing headaches, cough, and other symptoms again.

Eventually, he became so sick that he had to be hospitalized and was found to have pneumonia.Researchers sequenced propecia samples from both of his s and found they were different, providing evidence that this was a new distinct from the first. What happens when we buy propecia uk get hair loss treatment in the first case?. Researchers are finding that, generally, people who get hair loss treatment develop a healthy immune response replete with both antibodies (molecules that can block pathogens from infecting cells) and T cells (which help wipe out the propecia). This is what happens buy propecia uk after other viral s.In addition to fending off the propecia the first time, that immune response also creates memories of the propecia, should it try to invade a second time. It’s thought, then, that people who recover from hair loss treatment will typically be protected from another case for some amount of time.

With other hair losses, protection is thought to last for perhaps a little less than a buy propecia uk year to about three years.But researchers can’t tell how long immunity will last with a new pathogen (like hair loss) until people start getting reinfected. They also don’t know exactly what mechanisms provide protection against hair loss treatment, nor do they know what levels of antibodies or T cells are required to signal that someone is protected through a blood test. (These are called the “correlates of buy propecia uk protection.”) Why do experts expect second cases to be milder?. With other propeciaes, protective immunity doesn’t just vanish one day. Instead, it buy propecia uk wanes over time.

Researchers have then hypothesized that with hair loss, perhaps our immune systems might not always be able to prevent it from getting a toehold in our cells — to halt entirely — but that it could still put up enough of a fight to guard us from getting really sick. Again, this buy propecia uk is what happens with other respiratory pathogens.And it’s why some researchers actually looked at the Hong Kong case with relief. The man had mild to moderate hair loss treatment symptoms during the first case, but was asymptomatic the second time. It was a demonstration, experts said, of what you would want your immune system to do buy propecia uk. (The case was only detected because the man’s sample was taken at the airport when he arrived back in Hong Kong after traveling in Europe.)“The fact that somebody may get reinfected is not surprising,” Malik Peiris, a virologist at the University of Hong Kong, told STAT earlier this week about the first re.

€œBut the re didn’t cause disease, so that’s the first point.”The Nevada case, then, provides a buy propecia uk counterexample to that. What kind of immune response did the person who was reinfected generate initially?. Earlier, we described the robust immune response that most people who have hair loss treatment buy propecia uk seem to mount. But that was a generalization. s and the immune responses they induce in different people are “heterogeneous,” said Sarah Cobey, an epidemiologist and evolutionary biologist at the University of Chicago.Older people often generate weaker immune responses than younger people buy propecia uk.

Some studies have also indicated that milder cases of hair loss treatment induce tamer immune responses that might not provide as lasting or as thorough of a defense as stronger immune responses. The man in Hong Kong, for example, did not generate antibodies to the propecia after his first , at least to the level that could be detected by blood tests buy propecia uk. Perhaps that explains why he contracted the propecia again just about 4 1/2 months after recovering from his initial .In the Nevada case, researchers did not test what kind of immune response the man generated after the first case.“ is not some binary event,” Cobey said. And with re, “there’s going to be some viral replication, but the question is how much is the buy propecia uk immune system getting engaged?. €What might be broadly meaningful is when people who mounted robust immune responses start getting reinfected, and how severe their second cases are.

Are people who have hair loss treatment a second buy propecia uk time infectious?. As discussed, immune memory can prevent re. If it buy propecia uk can’t, it might stave off serious illness. But there’s a third aspect of this, too.“The most important question for re, with the most serious implications for controlling the propecia, is whether reinfected people can transmit the propecia to others,” Columbia University virologist Angela Rasmussen wrote in Slate this week.Unfortunately, neither the Hong Kong nor the Reno studies looked at this question. But if most buy propecia uk people who get reinfected don’t spread the propecia, that’s obviously good news.

What happens when people broadly become susceptible again?. Whether it’s six months after the first or nine months or a year buy propecia uk or longer, at some point, protection for most people who recover from hair loss treatment is expected to wane. And without the arrival of a treatment and broad uptake of it, that could change the dynamics of local outbreaks.In some communities, it’s thought that more than 20% of residents have experienced an initial hair loss treatment case, and are thus theoretically protected from another case for some time. That is still below the point of herd immunity — when enough people are immune that transmission doesn’t occur — but buy propecia uk still, the fewer vulnerable people there are, the less likely spread is to occur.On the flip side though, if more people become susceptible to the propecia again, that could increase the risk of transmission. Modelers are starting to factor that possibility into their forecasts.A crucial question for which there is not an answer yet is whether what happened to the man in Reno, where the second case was more severe than the first, remains a rare occurrence, as researchers expect and hope.

As the Nevada researchers wrote, “the generalizability of this finding is unknown.”An advocacy group has asked the Department of Defense to investigate what it called “an apparent failure” by Moderna (MRNA) to disclose millions of dollars in awards received from the Defense Advanced Research Projects Agency in patent applications the company filed for treatments.In a letter to the agency, Knowledge Ecology International explained that a review buy propecia uk of dozens of patent applications found the company received approximately $20 million from the federal government in grants several years ago and the funds “likely” led to the creation of its treatment technology. This was used to develop treatments to combat different propeciaes, such as Zika and, later, the propecia that causes hair loss treatment.In arguing for an investigation, the advocacy group maintained Moderna is obligated under federal law to disclose the grants that led to nearly a dozen specific patent applications and explained the financial support means the U.S. Government would have certain rights buy propecia uk over the patents. In other words, U.S. Taxpayers would have an ownership stake in treatments developed by the company.advertisement “This clarifies the public’s right buy propecia uk in the inventions,” said Jamie Love, who heads Knowledge Ecology International, a nonprofit that tracks patents and access to medicines issues.

€œThe disclosure (also) changes the narrative about who has financed the inventive activity, often the most risky part of development.” advertisement One particular patent assigned to Moderna concerns methods and compositions that can be used specifically against hair losses, including hair loss treatment. The patent names a Moderna scientist and a former Moderna scientist as inventors, both of which acknowledged performing work under the DARPA awards in two academic papers, according to the report by the advocacy group.The group examined the 126 patents assigned to Moderna or ModernaTx as well as 154 patent applications. €œDespite the evidence that multiple inventions were conceived in the course of research supported by the DARPA awards, not a single one of the patents or applications assigned to Moderna buy propecia uk disclose U.S. Federal government funding,” the report stated.We asked Moderna and the Department of Defense for comment and will update you accordingly.The missive to the Department of Defense follows a recent analysis by Public Citizen, another advocacy group, indicating the National Institutes of Health may own mRNA-1273, the Moderna treatment candidate for hair loss treatment. The advocacy group noted the federal government filed multiple patents covering the treatment and two patent applications, in particular, list federal scientists as co-inventors.The analyses are part of a larger campaign among advocacy groups and others buy propecia uk in the U.S.

And elsewhere to ensure that hair loss treatment medical products are available to poor populations around the world. The concern reflects the unprecedented global demand for therapies and treatments, and a race among buy propecia uk wealthy nations to snap up supplies from treatment makers. In the U.S., the effort has focused on the extent to which the federal government has provided taxpayer dollars to different companies to help fund their discoveries. In some cases, advocates argue that federal funding matters because it buy propecia uk clarifies the rights that the U.S. Government has to ensure a therapy or treatment is available to Americans on reasonable terms.One example has been remdesivir, the Gilead Sciences (GILD) treatment being given to hospitalized hair loss treatment patients.

The role played by the buy propecia uk U.S. Government in developing remdesivir to combat hair losses involved contributions from government personnel at such agencies as the U.S. Army Medical Research Institute of Infectious Diseases.As for the Moderna treatment, earlier this month, the company was awarded buy propecia uk a $1.525 billion contract by the Department of Defense and the Department of Health and Human Services to manufacture and deliver 100 million doses of its hair loss treatment. The agreement also includes an option to purchase another 400 million doses, although the terms were not disclosed. In announcing the agreement, the government said it buy propecia uk would ensure Americans receive the hair loss treatment at no cost, although they may be charged by health care providers for administering a shot.In this instance, however, Love said the “letter is not about price or profits.

It’s about (Moderna) not owning up to DARPA funding inventions. If the U.S buy propecia uk. Wants to pay for all of the development of Moderna’s treatment, as Moderna now acknowledges, and throw in a few more billion now, and an option to spend billions more, it’s not unreasonable to have some transparency over who paid for their inventions.”This is not the first time Moderna has been accused of insufficient disclosure. Earlier this month, Knowledge buy propecia uk Ecology International and Public Citizen maintained the company failed to disclose development costs in a $955 million contract awarded by BARDA for its hair loss treatment. In all, the federal government has awarded the company approximately $2.5 billion to develop the treatment.The coming few weeks represent a crucial moment for an ambitious plan to try to secure hair loss treatments for roughly 170 countries around the world without the deep pockets to compete for what will be scarce initial supplies.Under the plan, countries that want to pool resources to buy treatments must notify the World Health Organization and other organizers — Gavi, the treatment Alliance, as well as the Coalition for Epidemic Preparedness Innovations — of their intentions by Monday.

That means it’s fish-or-cut-bait time for the so-called COVAX facility.Already, wealthy countries — the United States, the United Kingdom, Japan, Canada, and Australia, among others, as well as the European Union — have opted to buy their own treatment, signing bilateral contracts with manufacturers that have secured billions of doses buy propecia uk of treatment already. That raises the possibility that less wealthy countries will be boxed out of supplies.advertisement And yet Richard Hatchett, the CEO of CEPI, insists there is a path to billions of doses of treatment for the rest of the world in 2021. STAT spoke with Hatchett this buy propecia uk week. A transcript of the conversation, lightly edited for clarity and length, follows. You said this is a buy propecia uk critical time for CEPI.

Can you explain what needs to happen between now and mid-September for this joint purchasing approach to be a success?. Advertisement The critical buy propecia uk moment is now for countries to commit to the COVAX facility, because that will enable us to secure ample quantities of treatment and then to be able to convey when that treatment is likely to become available based on current information.What we’re now here asking countries to do is to indicate their intent to participate by Aug. 31, and to make a binding commitment by Sept. 18. And to provide funds in support of that binding commitment by early October.

Our negotiations with companies are already taking place and it will be important for us from a planning purpose that countries indicate their intent to participate.Those binding commitments we think will be sufficient to allow us to then secure the advance purchase agreements, particularly with those companies that don’t have a prior contractual obligation to COVAX. And then obviously, we need the funds to live up to those advance purchase agreements.Is it possible this thing could still fall apart?. There appears to be some concern COVAX has been boxed out by rich countries. There was always a possibility that there wouldn’t be sufficient uptake. But I think we’re very encouraged at this point by the level of commitment, both from countries that would be beneficiaries of the advance market commitment — that’s the lower-income, lower-middle-income countries — as well as the self-financing countries.

To have over 170 countries expressing interest in participating — they see the value.We’re much more encouraged now that it’s not going to fall apart. We still need to bring it off to maximize its value. And we’re right at the crunch moment where countries are going to have to make these commitments. So, the next month is really absolutely critical to the facility. I am confident at this point that the world recognizes the value and wants it to work.I’ve been keeping tabs on advance purchase agreements that have been announced.

And at this point, a small number of rich countries have nailed down a lot of treatment — more than 3 billion doses. How hard does that make your job?. The fact that they’re doing it creates anxiety among other countries. And that in itself can accelerate the pace. So, I’m not going to say that we’re not watching that with concern.I will say that for COVAX and the facility, this is absolutely critical moment.

I think we still have a window of opportunity between now and mid-September — when we’re asking that the self-financing countries to make their commitments — to make the facility real and to make it work. Between doses that are committed to COVAX through the access agreements and other agreements — these are discussions with partners that CEPI has funded as well as partners that CEPI has not funded — we still see a pathway for COVAX to well over 3 billion doses in 2021.I think it’s really important to bear in mind is that there are at least a few countries — and I think the U.S. And the U.K. Most publicly — that may be in a situation of significant oversupply. I believe the U.S.

And U.K. Numbers, if you add them together, would result in enough treatment for 600 million people to receive two doses of treatment each. And, you know, there is no possible way that the U.S. Or the U.K. Can use that much treatment.So, there may be a lot of extra supply that looks like it’s been tied up sloshing around later.

I don’t think that the bilateral deals that have been struck are going to prevent COVAX from achieving its goals.But if so much treatment has been pre-ordered by rich countries, can countries in the COVAX pool get enough for their needs?. One of the things that we’ve argued through COVAX is that to control the propecia or to end the acute phase of the propecia to allow normalcy to start to reassert itself, you don’t have to vaccinate 100% of your population.You need to vaccinate those at greatest risk for bad outcomes and you need to vaccinate certain critical workers, particularly your health care workforce. And if you can achieve that goal, which for most countries means vaccinating between 20% and maybe 30% of the population, then you can transform the propecia into something that is much more manageable. Then you can buy yourself time to vaccinate everybody who wants to be vaccinated.We’ve argued the COVAX facility really offers the world the best shot at doing that globally in the fastest possible way, as well as providing for equitable access. This is a case where doing the equitable thing is also doing the efficient thing.CEPI has provided funding to nine treatments.

Is it true that all those manufacturers aren’t required to provide the COVAX facility with treatment?. That is correct. One of the things that we did, and I think it was an important role that CEPI played early on, was that we moved money very, very quickly, in small increments. You know, some of the early contracts were only $5 million or $10 million, to get programs up and running while we potentially put in place much larger-scale, longer-term contracts.If you were doing it over again, would you have given money without strings attached?. Yes, I think I would have.

I think that was critically important to initiating programs.Our contract with Moderna was established in about 48 hours. And that provided critical funding to them to manufacture doses that got them into clinical trials within nine weeks of the genetic sequences [of the hair loss propecia] being released.And if you look at the nine programs that we’ve invested in, seven are in clinical trials. Two — the AstraZeneca program now and the Moderna program — are among the handful in Phase 3 clinical trials. And, I think the number of projects that that we funded initially, which started in kind of a biotech or academic phase that have now been picked up by large multinational corporations, there’s at least four. The Themis program being picked up by Merck, Oxford University by AstraZeneca, the University of Queensland by CSL, and Clover being in partnership with GSK, I think that speaks to the quality of the programs that we selected.So, I think that combination of rapid review, speed of funding, getting those programs started, getting them oriented in the right direction, I think all of that is critical to where we are now.Companies that got money from CEPI to build out production capacity — that money came with strings attached, right?.

Yes, exactly. So, where CEPI has made investments that create manufacturing, or secure manufacturing capacity, the commitment has been that the capacity that is attributable to the CEPI investment is committed — at least right of first refusal — to the global procurement facility.WASHINGTON — The Trump administration removed a top Food and Drug Administration communications official from her post on Friday in the wake of several controversial agency misstatements, a senior administration official confirmed to STAT.The spokeswoman, Emily Miller, had played a lead role in defending the FDA commissioner, Stephen Hahn, after he misrepresented data regarding the use of blood plasma from recovered hair loss treatment patients. The New York Times first reported Miller’s ouster. Miller’s tenure at as the top FDA spokeswoman lasted only 11 days. Her appointment was viewed with alarm by agency officials who felt her presence at the agency was emblematic of broader political pressure from the Trump administration, STAT first reported earlier this week.advertisement Before joining the FDA, Miller had no experience in health or medicine.

Her former role as assistant commissioner for media affairs is typically not an appointment filled by political appointees. The FDA’s communications arm typically maintains a neutral, nonpolitical tone.Miller’s appointment particularly alarmed FDA staff and outside scientists given her history in right-wing political advocacy and conservatism journalism. Her résumé included a stint as a Washington Times columnist, where she penned columns with titles that include “New Obamacare ads make young women look like sluts,” and a 2013 book on gun rights titled “Emily Gets Her Gun. But Obama Wants to Take Yours.”advertisement She also worked as a reporter for One America News Network, a right-wing cable channel that frequently espouses conspiracy theories and has declared an open alliance with President Trump.Miller quickly made her presence known at the FDA. In the wake of Hahn’s misstatements on blood plasma, she aggressively defended the commissioner, falsely claiming in a tweet that the therapy “has shown to be beneficial for 35% of patients.” An FDA press release on blood plasma, issued less than a week after her appointment, similarly alarmed agency insiders by trumpeting the emergency authorization as “Another Achievement in Administration’s Fight Against [the] propecia.”.

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The federal government must aggressively bolster primary care and connect more Americans with a dedicated source of care, the National Academies of Sciences, Engineering and Medicine warn in a http://bethlehemroofrepairs.com/time-to-clean-your-gutters/ major report that sounds the alarm about an endangered foundation of propecia canada shoppers drug mart the U.S. Health system. The urgently worded report, which comes as internists, family doctors and pediatricians nationwide struggle with the economic propecia canada shoppers drug mart fallout of the hair loss propecia, calls for a broad recognition that primary care is a “common good” akin to public education. The authors recommend that all Americans select a primary care provider or be assigned one, a landmark step that could reorient how care is delivered in the nation’s fragmented medical system.

And the report calls on major government health plans such as Medicare and Medicaid to shift money to primary care and away from the medical specialties that have long commanded the biggest fees in the U.S. System. €œHigh-quality primary care is the foundation of a robust health care system, and perhaps more importantly, it is the essential element for improving the health of the U.S. Population,” the report concludes.

€œYet, in large part because of chronic underinvestment, primary care in the United States is slowly dying.” The report, which is advisory, does not guarantee federal action. But reports from the national academies have helped support major health initiatives over the years, such as curbing tobacco use among children and protecting patients from medical errors. Strengthening primary care has long been seen as a critical public health need. And research dating back more than half a century shows that robust primary care systems save money, improve people’s health and even save lives.

€œWe know that better access to primary care leads to more timely identification of problems, better management of chronic disease and better coordination of care,” said Melinda Abrams, executive vice president of the Commonwealth Fund, a New York-based foundation that studies health systems around the world. Recognizing the value of this kind of care, many nations — from wealthy democracies like the United Kingdom and the Netherlands to middle-income countries such as Costa Rica and Thailand — have deliberately constructed health systems around primary care. And many have reaped significant rewards. Europeans with chronic illnesses such as diabetes, high blood pressure, cancer and depression reported significantly better health if they lived in a country with a robust primary care system, a group of researchers found.

For decades, experts here have called for this country to make a similar commitment. But only about 5% of U.S. Health care spending goes to primary care, versus an average of 14% in other wealthy nations, according to data collected by the Organization for Economic Co-operation and Development. Other research shows that primary spending has declined in many U.S.

States in recent years. The situation grew even more dire as the propecia forced thousands of primary care physicians — who didn’t receive the government largesse showered on major medical systems — to lay off staff members or even close their doors. Reversing this slide will require new investment, the authors of the new report conclude. But, they argue, that should yield big dividends.

€œIf we increase the supply of primary care, more people and more communities will be healthier, and no other part of health care can make this claim,” said Dr. Robert Phillips, a family physician who co-chaired the committee that produced the report. Phillips also directs the Center for Professionalism and Value in Health Care at the American Board of Family Medicine. The report urges new initiatives to build more health centers, especially in underserved areas that are frequently home to minority communities, and to expand primary care teams, including nurse practitioners, pharmacists and mental health specialists.

And it advocates new efforts to shift away from paying physicians for every patient visit, a system that critics have long argued doesn’t incentivize doctors to keep patients healthy. Potentially most controversial, however, is the report’s recommendation that Medicare and Medicaid, as well as commercial insurers and employers that provide their workers with health benefits, ask their members to declare a primary care provider. Anyone who does not, the report notes, should be assigned a provider. €œSuccessfully implementing high-quality primary care means everyone should have access to the ‘sustained relationships’ primary care offers,” the report notes.

This idea of formally linking patients with a primary care office — often called empanelment — isn’t new. Kaiser Permanente, consistently among the nation’s best-performing health systems, has long made primary care central. (KHN is not affiliated with Kaiser Permanente.) But the model, which was at the heart of managed-care health plans, suffered in the backlash against HMOs in the 1990s, when some health plans forced primary care providers to act as “gatekeepers” to keep patients away from costlier specialty care. More recently, however, a growing number of experts and primary care advocates have shown that linking patients with a primary care provider need not limit access to care.

Indeed, a new generation of medical systems that rely on primary care to look after elderly Americans on Medicare with chronic medical conditions has demonstrated great success in keeping patients healthier and costs down. These “advanced primary care” systems include ChenMed, Iora Health and Oak Street Health. €œIf you don’t have empanelment, you don’t really have continuity of care,” said Dr. Tom Bodenheimer, an internist who founded the Center for Excellence in Primary Care at the University of California-San Francisco and has called for stronger primary care systems for decades.

Bodenheimer added. €œWe know that continuity of care is linked to everything good. Better preventive care, higher patient satisfaction, better chronic care and lower costs. It is really fundamental.” Noam N.

Levey. nlevey@kff.org, @NoamLevey Related Topics Contact Us Submit a Story TipIf you are uninsured because health coverage seemed too expensive the last time you looked, it’s time to look again. A new federal law could make it a whole lot cheaper to buy your own insurance if you don’t get coverage through an employer or a government insurance program such as Medicare or Medicaid. The law, the American Rescue Plan, provides billions of federal dollars to reduce premiums for people who buy their coverage through the insurance exchanges established by the Affordable Care Act.

The aid expands a federal tax credit created by the ACA that you can take upfront as a discount on your premium or claim when you file your taxes the following year. It is not available for those who buy individual or family policies in the open market outside an ACA exchange. So, if you are in an off-exchange health plan, you might save a lot of money by switching to one inside the exchange. Covered California, the state’s ACA exchange, opened a special enrollment period on April 12 for people who want to take advantage of the new aid by enrolling or switching coverage.

The period runs through December — 4½ months later than the Aug. 15 special enrollment end date on the federally run exchanges. Covered California estimates the new money will reduce its customers’ monthly premium bills by an average of $180 per household. Nearly 90% of Covered California enrollees already get financial aid, and many will now get more.

Some enrollees who didn’t previously qualify for tax credits may now be eligible. Darci Gutierrez, an insurance agent in Dublin, California, says a client with a large family saved $425 a month on a Blue Shield PPO at the silver tier — the second-lowest level in the ACA’s four-tier system of coverage. €œI was shocked at the amount of reduction in cost. I was like, ‘Holy cow,’” Gutierrez says.

The additional federal aid is slated to stop after 2022, which means your insurance could cost you more after that. But there is talk in Congress about extending the enhanced tax credits for longer. The new law follows the lead of California, which provided groundbreaking state-funded tax credits starting last year to augment the ACA credits and push eligibility for aid well into the middle class. The new federal dollars will provide assistance even further up the income scale.

Covered California estimates 100,000 consumers with incomes too high to qualify for federal or state credits under prior law will now be eligible for subsidies averaging $500 a month per household. The share of the new money going to California could be about four times as much as those state-funded subsidies and will completely replace them, saving the state about $761 million this fiscal year and next. The newly enhanced federal tax credits take effect with coverage that starts May 1. To get coverage for the first of any month, you need only sign up by the day before.

If you are currently enrolled in Covered California, you can keep your plan and take the savings, or you could shop around and save even more — or switch to a higher level of coverage without increasing your monthly bill. €œIt’s critical that anybody who buys coverage as an individual take a look, because they may be leaving hundreds if not thousands of dollars on the table,” says Anthony Wright, executive director of Health Access, a Sacramento-based consumer advocacy group. The new law, signed by President Joe Biden in March, also allocates money to provide virtually premium-free coverage — in 2021 only — for anyone, regardless of income, who receives unemployment benefits at any point during the year. California is projected to get about $3 billion of the new federal money.

Officials at Covered California think the state can get even more, and the exchange is spending more than $20 million on a television, radio and social media advertising blitz to drum up business. It is targeting in particular the approximately 810,000 uninsured Californians who are eligible for federal support under the new law. €œWe need to rattle uninsured people to look again and realize this is new and different,” says Peter Lee, Covered California’s executive director. €œIf they think it’s just the same old same old, they ain’t going to check.” Covered California is also marketing itself to an additional 270,000 people who are enrolled in health plans outside the exchange and would qualify for subsidized coverage if they switched to Covered California.

In an example used by Covered California in its promotional campaign, an Oakland couple making $77,580 a year, both 45 years old, pay the full monthly premium of $1,271 for a silver plan outside the exchange. By switching to the same plan in Covered California, they would pay only $550 — a monthly saving of $721. If you are a current enrollee, Covered California — unlike the federally run exchanges — will automatically calculate your lower premium, and you will see a credit for May on your June bill. You will also reap that saving retroactively for the first four months of 2021 in the form of an additional premium reduction, in equal monthly installments, over the rest of the year.

If you are uninsured or in an off-exchange health plan, however, you need to take action. The money won’t just come to you. Research your options and enroll. To find out if you qualify for federal assistance, log on to www.coveredca.com.

Click the “shop and compare” button to find the health plans available to you in your area, along with the monthly premium you will pay after your tax credit. You can also click a button to get a call from a licensed health insurance agent who can help you figure it all out — without charging you. If you don’t have a computer, call Covered California at 800-300-1506. In contrast to the federally operated exchanges, Covered California requires that people switching from off-exchange health plans into exchange-based ones be allowed to apply any deductible paid so far this year against the new policy, as long as they don’t change insurance companies.

That flexibility also applies if you are exchanging one Covered California plan for another, but with more restrictions, so ask your health plan before you make any changes. If you are coming to Covered California from the open market, it should be easy to keep doctors you like, since most off-exchange plans mirror ones in Covered California and have the same networks. But there are cases in which you would not be able to keep your doctors, so be sure to ask your insurer about it before making a final decision. Another notable feature of the new federal tax credits is that they no longer carry upper-income limits for eligibility.

Instead, the amount people pay in premiums is limited to a fixed percentage of their income, ranging from zero for low-income consumers to 8.5% for the most affluent. For the 2020 tax year, the new law overrides a requirement that consumers whose incomes exceeded their original estimate pay back any subsidy amounts to which they are not entitled. Tom Freker, an insurance agent in Huntington Beach, California, says one of his clients made a big profit on a property sale last year, which raised his income to a level that would have required paying back the $10,000 subsidy he received in 2020. €œBut the new American Rescue Plan waived that repayment,” Freker says.

€œThat’s a big deal.” This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. Bernard J. Wolfson. bwolfson@kff.org, @bjwolfson Related Topics Contact Us Submit a Story TipAfter spending much of the past year tending to elderly patients, doctors are seeing a clear demographic shift.

Young and middle-aged adults make up a growing share of the patients in hair loss treatment hospital wards. It’s both a sign of the country’s success in protecting the elderly through vaccination and an urgent reminder that younger generations will pay a heavy price if the outbreak is allowed to simmer in communities across the country. €œWe’re now seeing people in their 30s, 40s and 50s — young people who are really sick,” said Dr. Vishnu Chundi, a specialist in infectious diseases and chair of the Chicago Medical Society’s hair loss treatment task force.

€œMost of them make it, but some do not. €¦ I just lost a 32-year-old with two children, so it’s heartbreaking.” Nationally, adults under 50 now account for the most hospitalized hair loss treatment patients in the country — about 36% of all hospital admissions. Those ages 50 to 64 account for the second-highest number of hospitalizations, or about 31%. Meanwhile, hospitalizations among adults 65 and older have fallen significantly.

About 32% of the U.S. Population is now fully vaccinated, but the vast majority are people older than 65 — a group that was prioritized in the initial phase of the treatment rollout. Although new s are gradually declining nationwide, some regions have contended with a resurgence of the hair loss in recent months — what some have called a “fourth wave” — propelled by the B.1.1.7 variant, first identified in the United Kingdom, which is estimated to be somewhere between 40% and 70% more contagious. As many states ditch propecia precautions, this more virulent strain still has ample room to spread among the younger population, which remains broadly susceptible to the disease.

The emergence of more dangerous strains of the propecia in the U.S. €” including variants first discovered in South Africa and Brazil — has made the vaccination effort all the more urgent. €œWe are in a whole different ballgame,” said Judith Malmgren, an epidemiologist at the University of Washington. Rising s among young adults create a “reservoir of disease” that eventually “spills over into the rest of society” — one that has yet to reach herd immunity — and portends a broader surge in cases, she said.

Fortunately, the chance of dying of hair loss treatment remains very small for people under 50, but this age group can become seriously ill or experience long-term symptoms after the initial . People with underlying conditions such as obesity and heart disease are also more likely to become seriously ill. €œB.1.1.7 doesn’t discriminate by age, and when it comes to young people, our messaging on this is still too soft,” Malmgren said. Hospitals Filled With Younger, Sicker People Across the country, the influx of younger patients with hair loss treatment has startled clinicians who describe hospital beds filled with patients, many of whom appear sicker than what was seen during previous waves of the propecia.

€œA lot of them are requiring ICU care,” said Dr. Michelle Barron, head of prevention and control at UCHealth, one of Colorado’s large hospital systems, as compared with earlier in the propecia. The median age of hair loss treatment patients at UCHealth hospitals has dropped by more than 10 years in the past few weeks, from 59 down to about 48 years old, Barron said. €œI think we will continue to see that, especially if there’s not a lot of treatment uptake in these groups,” she said.

While most hospitals are far from the onslaught of illness seen during the winter, the explosion of cases in Michigan underscores the potential fallout of loosening restrictions when a large share of adults are not yet vaccinated. There’s strong evidence that all three treatments being used in the U.S. Provide good protection against the U.K. Variant.

One study suggests that the B.1.1.7 variant doesn’t lead to more severe illness, as was previously thought. However, patients infected with the variant appear more likely to have more of the propecia in their bodies than those with the previously dominant strain, which may help explain why it spreads more easily. €œWe think that this may be causing more of these hospitalizations in younger people,” said Dr. Rachael Lee at the University of Alabama-Birmingham hospital.

Lee’s hospital also has observed an uptick in younger patients. As in other Southern states, Alabama has a low rate of treatment uptake. But even in Washington state, where much of the population is opting to get the treatment, hospitalizations have been rising steadily since early March, especially among young people. In the Seattle area, more people in their 20s are now being hospitalized for hair loss treatment than people in their 70s, according to Dr.

Jeff Duchin, public health chief officer for Seattle and King County. €œWe don’t yet have enough younger adults vaccinated to counteract the increased ease with which the variants spread,” said Duchin at a recent press briefing. Nationwide, about 32% of people in their 40s are fully vaccinated, compared with 27% of people in their 30s. That share drops to about 18% for 18- to 29-year-olds.

€œI’m hopeful that the death curve is not going to rise as fast, but it is putting a strain on the health system,” said Dr. Nathaniel Schlicher, an emergency physician and president of the Washington State Medical Association. Schlicher, also in his late 30s, recalls with horror two of his recent patients — close to his age and previously healthy — who were admitted with new-onset heart failure caused by hair loss treatment. €œI’ve seen that up close and that’s what scares the hell out of me,” he said.

€œI understand young people feeling invincible, but what I would just tell them is — don’t be afraid of dying, be afraid of heart failure, lung damage and not being able to do the things that you love to do.” Will Younger Adults Get Vaccinated?. Doctors and public health experts hope that the troubling spike in hospitalizations among the younger demographic will be temporary — one that treatments will soon counteract. It was only on April 19 that all adults became eligible for a hair loss treatment, although they were available in some states much sooner. But some concerning national polls indicate a sizable portion of teens and adults in their 20s and 30s don’t necessarily have plans to get vaccinated.

€œWe just need to make it super easy — not inconvenient in any way,” said Malmgren, the Washington epidemiologist. €œWe have to put our minds to it and think a little differently.” This story is part of a partnership that includes NPR and KHN. Related Topics Contact Us Submit a Story TipOne of the few surprises in President Joe Biden’s social safety-net proposal, the American Families Plan, was something that didn’t make it into the final version. Any mention of reining in the price of prescription drugs.

The American Families Plan, the second part of Biden’s expansive “infrastructure” agenda, includes sweeping programs aimed at boosting access to child care, higher education and paid family leave. But despite White House signals in March that health also would be a major part of the package, the only health proposal was one that would make permanent the temporary subsidy increases, passed as part of the hair loss treatment relief bill earlier this spring, on insurance purchased through the Affordable Care Act’s health exchanges. Initial reports suggest that Biden and his aides did not want to pick a fight now with the powerful prescription drug industry, which is riding high in public opinion after producing hair loss treatments in record time. They worry that the industry’s impressive lobbying clout could endanger the rest of the program.

But there is likely another big reason Democrats are loath to address drug prices, despite broad bipartisan support. After nearly a year of uncharacteristically being on the same page when it comes to health care, Democratic lawmakers are reverting to a more familiar position. They are at loggerheads about what to do next. Most Democrats agree the time is ripe to tackle high drug prices.

In 2019 the Democratic-led House passed a broad drug price bill that was reintroduced just days ago with the backing of Speaker Nancy Pelosi. Senate Democrats have also been working on drug price legislation. There is some difference between liberals and moderates on how far to push the drug industry for savings, but the consensus is that drugs cost too much and the government needs to step in. The real problem is what to do with the considerable budget savings that would be produced by policies like allowing Medicare to negotiate drug prices.

That’s something that pits the more liberal Democratic backers of a “Medicare for All” insurance system against moderates who would instead put the savings into expanding the benefits of the Affordable Care Act. Biden is, for the moment at least, taking both sides. Savings from drug price reforms “can go to strengthen the Affordable Care Act and expand Medicare coverage and benefits — without costing taxpayers one additional penny,” he said in his speech to a joint session of Congress on Wednesday night. But the factions are taking shape in Congress.

On hearing reports that Biden’s families plan would leave major health items on the cutting-room floor, Medicare for All sponsor Sen. Bernie Sanders (I-Vt.) and 16 Senate Democratic colleagues urged Biden not just to include Medicare drug price negotiation authority in his package, but also to use the proceeds to lower the Medicare eligibility age (a Biden campaign promise) and add hearing, vision and dental benefits to Medicare. House Democrats in their 2019 bill opted to use the savings to provide those added health benefits to current Medicare beneficiaries. €œWe have an historic opportunity to make the most significant expansion of Medicare since it was signed into law,” wrote the senators.

A similar letter went to the president signed by 80 House members, led by Medicare for All backer Rep. Pramila Jayapal (D-Wash.). But at the same time, more than 50 members of the “New Democrat Coalition,” a more moderate group of House Democrats, also wrote to Biden, urging him to use the package to enhance the ACA. €œOver a decade after the passage of the Obama-Biden administration’s landmark health care legislation, we are eager to work with the Biden-Harris administration to fortify and build on the ACA to achieve universal coverage with access to affordable, quality care,” they wrote.

This particular disagreement harks back to the 1980s and ’90s, when generations were pitted against each other in a sometimes ugly way. Younger Americans, worried about rising rates of the uninsured, accused Medicare beneficiaries who wanted better benefits of being “greedy geezers.” A law Congress passed in 1988 that would have boosted Medicare benefits and added a cap on catastrophic expenses caused a backlash when Congress decided wealthier seniors should pay for it themselves via added taxes. Seniors angry that younger people would not help foot the bill rebelled, and the entire program was repealed in 1989 before it ever took effect. €œIt’s a very American debate,” said Jonathan Oberlander, a health policy professor at the University of North Carolina-Chapel Hill who has written extensively about Medicare.

€œIt’s a function of the fact that we have a fragmented health insurance system and it’s fragmented by age. You don’t have this conversation in Canada or France or anywhere else.” Loren Adler, associate director of the USC-Brookings Schaeffer Initiative for Health Policy, said the obvious next step is to make the new ACA subsidies permanent. €œIt’s simple, it’s all winners, and certainly affordable in the context,” he said. In other words, there are no deep-pocketed stakeholders, like health insurers or drug companies, who would step in to fight the plan.

But neither plan, she said, gets to the biggest need, which is to help those caught in the “Medicaid gap” — at least 2.2 million people in states that didn’t expand Medicaid who are still uninsured. They don’t qualify for ACA marketplace coverage, because they earn too little, or for Medicaid, because they earn too much. €œMy general preference is to create a public program for those folks to enroll,” Adler said. Oberlander and Adler said it’s likely this fight will be settled the old-fashioned way.

Rather than pick one pathway, lawmakers will do both, expanding the ACA and Medicare. €œIf you try to do these policies in a somewhat frugal manner, there are some opportunities here,” said Adler. But Oberlander warned that Congress shouldn’t spend the drug price bounty before it’s passed. In the 1990s the fight was over whether to expand health insurance for younger Americans or provide more long-term care options for seniors.

Said Oberlander, “In the end, they did neither.” HealthBent, a regular feature of Kaiser Health News, offers insight and analysis of policies and politics from KHN’s chief Washington correspondent, Julie Rovner, who has covered health care for more than 30 years. Julie Rovner. jrovner@kff.org, @jrovner Related Topics Contact Us Submit a Story TipUna mañana de verano en 2019, Debbie Cook estaba todavía en pijamas cuando recibió una llamada de su hijo. €œAlgo malo le pasa a la abuela”.

Por el miedo en la voz de su hijo supo que se trataba de algo serio. Marcó el 911 de inmediato, sabiendo que una ambulancia podría tardar un buen tiempo en recorrer las carreteras rurales del condado de Fentress, en Tennessee. Se vistió y condujo a través de la granja familiar, dos puentes y un riachuelo, hasta la casa de su madre. Cook rezó para que una de las tres ambulancias que cubrían su condado de aproximadamente 500 millas cuadradas estuviera cerca.

Cuando llegó, encontró a su madre, Lottie Crouch, en el baño, incapaz de pararse o caminar. Cook, quien es enfermera licenciada, reconoció rápidamente los signos. Cara torcida, un lado de la boca caído. Su mamá estaba sufriendo un accidente cerebrovascular (ACV, también llamado ataque cerebral).

€œMe quedé petrificada”, recordó Cook, quien comenzó su carrera trabajando con pacientes en rehabilitación tras accidentes cerebrovasculares, y sabía que obtener la atención adecuada rápidamente podría hacer la diferencia entre la vida o la muerte. O una gran diferencia en la calidad de vida de su madre. Crouch tenía 75 años, todavía estaba enérgica y le encantaba hacer cosas como prepararse sopa. Para seguir viviendo la vida que Crouch conocía, cada paso hacia la atención adecuada, en un área rural, tenía que salir bien.

Cuando llegaron los paramédicos, la pregunta crucial fue. ¿A dónde llevarían a Crouch para que recibiera atención?. Cuando Lottie Crouch (izq.) tuvo un accidente cerebrovascular en agosto de 2019, su hija (der.), supo que obtener la atención correcta rápido podía hacer la diferencia entre la vida y la muerte.(Owen Hornstein / InvestigateTV) En todo el país, cerca de 800,000 personas sufren accidentes cerebrovasculares cada año. El problema es particularmente grave en las regiones de los Apalaches y el delta del Mississippi, donde más del 80% de los condados tienen tasas de muerte por ACV superiores al promedio nacional.

Muchos de estos condados también enfrentan altos índices de pobreza y albergan a poblaciones de adultos mayores vulnerables. Tienen escasez de proveedores médicos o han visto cerrar hospitales locales. En Tennessee, 2 millones de personas, casi un tercio del estado, están en la situación de Crouch. Viven a más de 45 minutos de un hospital certificado para el tratamiento de accidentes cerebrovasculares y capaz de brindar la atención más avanzada, según un nuevo análisis de KHN e InvestigateTV.

Y las tasas son aún más altas en los estados del delta como Arkansas y Mississippi, donde más de la mitad de los residentes deben conducir más de 45 minutos hasta estos centros especializados. El análisis es parte de un proyecto de un año llamado Bridging the Great Health Divide, durante el cual KHN y el equipo de investigación nacional de Gray Television, InvestigateTV, investigan los problemas de salud que históricamente han plagado a estas regiones. Y los accidentes cerebrovasculares son los principales. A pesar de los avances médicos en la atención de estos ataques, enviar a los pacientes de las zonas rurales de los Apalaches y el delta del Mississippi a las instalaciones adecuadas es un intrincado rompecabezas.

"No existe una única respuesta correcta para todos los pacientes", dijo el doctor Raul Nogueira, neurólogo intervencionista del Grady Memorial Hospital en Atlanta, Georgia. El lugar donde se debe cuidar a un paciente "realmente depende del tiempo de viaje", dijo. "Todo es cuestión de tiempo". Durante años, el consejo para los pacientes con ACV ha sido llegar al hospital más cercano lo antes posible.

Esta emergencia interrumpe el flujo sanguíneo a una parte del cerebro y, cuanto antes se lo pueda restaurar, mejor. Entonces, la idea ha sido llevar a los pacientes a un médico, cualquier médico, rápidamente. Pero ahora, ese consejo está evolucionando. Investigaciones muestran que algunos pacientes con ACV se benefician más de los procedimientos avanzados que suelen realizar especialistas en grandes centros médicos.

Por eso, el nuevo objetivo es llevar a los pacientes al médico adecuado en el hospital adecuado lo antes posible. En algunos casos, eso no significa la instalación más cercana. Para los pacientes con accidentes cerebrovasculares graves, en los que un coágulo está bloqueando a una de las arterias principales del cerebro, las asociaciones médicas recomiendan viajar hasta 30 minutos adicionales en áreas urbanas y 60 minutos en áreas rurales para llegar a un hospital con capacidad de tratar un ataque cerebral con técnicas avanzadas. Si bien eso es bastante fácil en una ciudad donde hay muchos hospitales, en áreas rurales como el condado de Fentress, la cuestión de dónde llevar a un paciente se ha vuelto cada vez más complicada.

Grandes decisiones, poco tiempo Cuando Lottie Crouch tuvo su accidente cerebrovascular, el que habría sido el hospital más cercano, a menos de 20 minutos, había cerrado dos meses antes. Es uno de los 136 hospitales rurales en todo el país que han cerrado desde 2010, incluidos casi tres docenas en Appalachia y el delta. Eso significaba que, para Crouch, el hospital estatal más cercano estaba a casi 45 minutos en auto, y los centros médicos con la atención más avanzada estaban a más de una hora. Eso hizo que los servicios de emergencias médicas se esforzaran por transportar a los pacientes más lejos.

Cada paso en el proceso para conseguir que alguien que había sufrido un derrame cerebral recibiera la atención adecuada en el tiempo adecuado se había vuelto más complejo. Las decisiones del momento rara vez son claras, dijo Nogueira. Si un paciente tiene un accidente cerebrovascular severo, podría beneficiarse de ir a un centro médico grande donde pueda someterse a una cirugía de inmediato, agregó. Detenerse en un hospital más pequeño que no puede realizar ese procedimiento podría retrasar innecesariamente la atención.

Pero si el ataque es menos grave, podría ser mejor ir primero a un centro más cercano en donde el paciente podría recibir medicamentos para disolver el coágulo antes, dijo Nogueira. Así, evitaría facturas médicas innecesarias por un viaje largo, desde $500 por un viaje en la parte trasera de una ambulancia regular hasta $50,000 por un helicóptero. Y la familia podría ahorrar el tiempo y el dinero que implica visitar al paciente en un hospital lejano. El problema es que los socorristas no necesariamente pueden saber qué tan grave es un derrame cerebral con solo mirar a alguien.

Por lo tanto, se basan en una evaluación de los síntomas del paciente para tomar la mejor decisión. A Jamey Beaty, un paramédico en el condado de Fentress que respondió a la casa de Lottie Crouch, le pesan la gravedad de estas decisiones. "Cuando estás solo en la parte trasera de una ambulancia y tienes un paciente que se está muriendo, lo único en lo que puedes pensar es. ¿Cómo puedo mantener vivo a este paciente hasta que pueda llevarlo a alguna parte?.

", dijo Beaty. "Eso es todo lo que se te pasa por la cabeza". Cada vez que Beaty recibe una llamada por un ataque cerebral, su primera respuesta es mirar al cielo. Desde que cerró el hospital local, una ambulancia aérea es la forma más rápida para que el paciente llegue al lugar del tratamiento.

Afortunadamente, el día que Lottie Crouch tuvo su ataque, el cielo de Tennessee estaba azul claro. Crouch fue trasladada casi 100 millas a un hospital en Knoxville con servicios avanzados para accidentes cerebrovasculares. Cuando Lottie Crouch tuvo un accidente cerebrovascular en agosto de 2019, en Fentress County, Tennessee, los paramédicos locales la llevaron a un campo abierto en donde fue trasladada en una ambulancia aérea. El helicóptero la llevó a un hospital a 100 millas de distancia.(Haelee Stockton) Viajes largos hacia la atención avanzada Durante las últimas dos décadas, dos tratamientos principales han hecho que avanzara la atención de los accidentes cerebrovasculares causados ​​por un bloqueo, el tipo de ataque más común en Estados Unidos.

El primero es un medicamento administrado por vía intravenosa para disolver los coágulos en los vasos sanguíneos de los pacientes. El medicamento debe administrarse dentro de las 4½ horas posteriores al inicio de los síntomas. El segundo es un procedimiento que utiliza un catéter para remover físicamente el coágulo de los vasos de un paciente. Este tratamiento se puede realizar hasta 24 horas después del comienzo de los síntomas, pero generalmente se usa solo para accidentes cerebrovasculares graves.

En todo el país, los hospitales están certificados por niveles, en gran parte en función de su capacidad para proporcionar estos tratamientos con regularidad. Algunos hospitales no tienen certificación. Entre los hospitales certificados para accidentes cerebrovasculares, el primer nivel son los que están preparados para accidentes cerebrovasculares agudos, que pueden evaluar a los pacientes con accidente cerebrovascular, mantenerlos estables y proporcionar medicamentos anticoagulantes. En el otro extremo del espectro están los centros integrales de accidentes cerebrovasculares, que cuentan con equipos especializados de neurólogos y neurocirujanos.

Además de administrar los medicamentos anticoagulantes, estos centros pueden remover los coágulos con cirugía. La gran pregunta es ¿a qué centro se puede y se debe llevar primero a los pacientes con ACV para que reciban la atención adecuada en un tiempo adecuado?. En Appalachia, aproximadamente el 11% de los residentes deben conducir más de 45 minutos para llegar a cualquier tipo de centro de accidentes cerebrovasculares, según el análisis de KHN e InvestigateTV. Esa proporción es aún mayor en el delta, donde casi un tercio de los residentes tienen que conducir más de 45 minutos para llegar a uno de estos centros.

Otro tercio solo tiene centros de atención básica para accidentes cerebrovasculares dentro de esa distancia y necesitaría conducir más lejos para cirugías avanzadas. Y en las partes rurales más remotas de estas dos regiones, es menos probable que las personas estén cerca de un centro de atención avanzada para accidentes cerebrovasculares. El Jamestown Regional Medical Center era el único hospital en Fentress County, Tennessee. Cerró en junio de 2019, sumándose a la lista de más de 100 hospitales rurales que han dejado de funcionar desde 2010.(Kevin Hughes for InvestigateTV) Rural y mayoritariamente afroamericano Si bien para muchos estadounidenses rurales como Crouch, que es blanca no hispana, es difícil llegar a tiempo al lugar adecuado para recibir la atención, las preocupaciones se agravan en los lugares con una gran población de raza negra.

Los afroamericanos tienen accidentes cerebrovasculares con más frecuencia y a edades más tempranas que sus contrapartes caucásicas. También es menos probable que reciban medicamentos anticoagulantes porque generalmente llegan al hospital fuera de la ventana del tratamiento. En el condado de Sumter, Alabama, varias personas entrevistadas, desde el dueño de un negocio local hasta un profesor universitario y el juez de distrito, pudieron nombrar a alguien que había tenido un ataque cerebral. Más del 70% de la población del condado es de raza negra, y es una de las áreas más pobres del estado.

El único hospital dentro de las fronteras del condado no tiene certificación para ACV. Loretta Wilson, directora ejecutiva del Hospital Hill del condado de Sumter, quisiera que su centro pudiera hacer más por los pacientes con ACV. Pero los medicamentos anticoagulantes pueden costar $8,000 por dosis y el hospital no siempre puede permitirse el lujo de tenerlos a mano, dijo. A la mayoría de los pacientes con accidente cerebrovascular se los traslada a hospitales más grandes, al menos a 30 o 40 minutos de distancia.

Ese puede ser un viaje largo y costoso para muchos residentes, agregó Wilson. Por eso, Wilson se centra principalmente en los esfuerzos de prevención. Dirige una organización sin fines de lucro que aborda problemas como la presión arterial alta, la obesidad y la diabetes, que aumentan el riesgo de una persona de sufrir un ACV. Su organización tiene alianzas con iglesias para educar a las personas sobre alimentación saludable y ejercicio, y distribuye monitores de presión arterial para que los feligreses puedan tomarse la presión ellos mismos.

"Tenemos una alta población afroamericana", dijo Wilson, quien también es afroamericana, "y esos son los que realmente necesitan los servicios". Otras organizaciones en el condado también trabajan para educar a las personas sobre la salud cardíaca y cuándo llamar al 911. El programa de enfermería de la universidad local tiene una beca destinada a atraer a más proveedores médicos al área. Usando telestroke para impulsar la atención rural En los hospitales rurales, incluso si los médicos tienen acceso a medicamentos anticoagulantes, pueden dudar en administrarlos por temor a dañar al paciente.

En raras ocasiones, alrededor del 2% al 7% de los casos, los medicamentos pueden causar sangrado cerebral. Pero no usar las drogas también puede tener consecuencias. Un estudio nacional publicado en 2020 encontró que los pacientes con accidente cerebrovascular tenían menos probabilidades de recibir esos medicamentos en hospitales rurales que en los urbanos, y los pacientes con estos ataques tenían más probabilidades de morir en hospitales rurales. Los programas de telestroke pueden ayudar a cerrar esa brecha, explicó la doctora Amelia Adcock, neuróloga de WVU Medicine en West Virginia y jefa de la red de telestroke del sistema.

Al conectar a médicos de hospitales más pequeños, a menudo rurales, con un especialista de guardia en un gran centro médico, los programas permiten que las personas “compartan la carga de la toma de decisiones”, dijo Adcock. Y la responsabilidad. El doctor Michael Gould es médico de medicina de emergencia en el Hospital Potomac Valley de 25 camas en la zona rural del norte de West Virginia. Su hospital no está certificado para accidentes cerebrovasculares y no cuenta con un neurólogo de planta.

Dijo que administrar medicamentos anticoagulantes es "una de las decisiones de la medicina que me pone más nervioso". Pero consultar con neurólogos en el centro de Medicina de WVU a unas 80 millas de distancia en Morgantown le ha dado más confianza, dijo. Gould estimó que ahora administra los medicamentos una o dos veces al mes. Un estudio de la red de telestroke de WVU Medicine halló que el número de pacientes con accidente cerebrovascular que recibieron medicamentos anticoagulantes casi se duplicó durante los primeros tres años del programa.

El otoño pasado, Christopher Green estaba haciendo las compras cuando de repente sintió un fuerte dolor de cabeza y perdió la visión periférica. Green, un veterano paramédico, reconoció de inmediato lo que estaba sucediendo. "Oh, Dios mío, estoy sufriendo un ataque cerebral", recuerda haber pensado. Lo llevaron al hospital de Gould y el personal de emergencias inmediatamente puso en marcha el programa de telestroke.

Christopher Green ha trabajado en servicios médicos de emergencia por cerca de 30 años. Dijo que tener él mismo un ataque cerebral cambió su perspectiva sobre cómo responder a las llamadas al 911 por estas emergencias.(Tara Butler) En 30 minutos, Green consiguió medicamentos para disolver el coágulo en sus vasos. "Un resultado de libro de texto", dijo Green, quien ha respondido a muchas llamadas al 911 por accidentes cerebrovasculares. Rememorando, Green dijo que probablemente habría llevado a un paciente en su situación a un hospital más lejano que estuviera certificado para accidentes cerebrovasculares.

Pero experimentar el programa de telestroke en carne propia cambió su perspectiva. "Ahora veo que retrasar el tratamiento de 20 a 30 minutos marca la diferencia entre tener una solución completa o algún tipo de efecto residual", dijo. €œÂ¿Qué pudo haber sido?. € De vuelta en Tennessee, Debbie Cook estaba agradecida de que a su madre la hubieran llevado al centro de atención avanzada para accidentes cerebrovasculares en Knoxville.

Le permitió a Lottie Crouch recibir el tratamiento que necesitaba para poder llevar una vida mayormente independiente. Pero la distancia le pasó factura a la familia. Cook, su hermana y su hija se turnaron para conducir casi dos horas de ida y dos de vuelta para pasar la noche con Crouch en el hospital. Después de 10 días, cuando Crouch fue trasladada a un centro de rehabilitación más cercano a su casa, la familia sintió una sensación de alivio.

Podrían llevarle pastel de carne y dumplings de moras silvestres para la cena. Y "un montón de caramelos de menta", recuerda Crouch, su favorito. Aunque Crouch ahora está sana, y en casa, su nieta de 27 años, Haelee Stockton, todavía está obsesionada de solo pensar lo que podría haber sucedido ese día. Si los paramédicos no hubieran llegado a tiempo o si el mal tiempo hubiera impedido que el helicóptero volara, es posible que su abuela no estuviera viva.

"¿Qué pudo haber sido?. ", se preguntó Stockton. €œÂ¿Qué tanta suerte tuvo?. ¿Y cuántas personas van a tener esa suerte en el futuro?.

". La abuela de Haelee Stockton, Lottie Crouch, sobrevivió a un accidente cerebrovascular en 2019, pero a Stockton le preocupa que otros en el condado no tengan tanta suerte.(Owen Hornstein/InvestigateTV) Aneri Pattani lideró las entrevistas y la redacción de esta historia. Hannah Recht lideró el análisis de datos y los gráficos. Daniela Molina de InvestigateTV colaboraron con la historia.

Aneri Pattani. apattani@kff.org, @aneripattani Hannah Recht. hrecht@kff.org, @hannah_recht Related Topics Contact Us Submit a Story Tip.

The federal government must aggressively bolster primary care and connect more Americans with a http://ephratahservicecenter.com/?page_id=20 dedicated source of care, the National Academies of Sciences, Engineering and Medicine warn in a major report that sounds the alarm about buy propecia uk an endangered foundation of the U.S. Health system. The urgently worded report, which comes as internists, family doctors and pediatricians nationwide struggle with the economic fallout of the hair loss buy propecia uk propecia, calls for a broad recognition that primary care is a “common good” akin to public education. The authors recommend that all Americans select a primary care provider or be assigned one, a landmark step that could reorient how care is delivered in the nation’s fragmented medical system. And the report calls on major government health plans such as Medicare and Medicaid to shift money to primary care and away from the medical specialties that have long commanded the biggest fees in the U.S.

System. €œHigh-quality primary care is the foundation of a robust health care system, and perhaps more importantly, it is the essential element for improving the health of the U.S. Population,” the report concludes. €œYet, in large part because of chronic underinvestment, primary care in the United States is slowly dying.” The report, which is advisory, does not guarantee federal action. But reports from the national academies have helped support major health initiatives over the years, such as curbing tobacco use among children and protecting patients from medical errors.

Strengthening primary care has long been seen as a critical public health need. And research dating back more than half a century shows that robust primary care systems save money, improve people’s health and even save lives. €œWe know that better access to primary care leads to more timely identification of problems, better management of chronic disease and better coordination of care,” said Melinda Abrams, executive vice president of the Commonwealth Fund, a New York-based foundation that studies health systems around the world. Recognizing the value of this kind of care, many nations — from wealthy democracies like the United Kingdom and the Netherlands to middle-income countries such as Costa Rica and Thailand — have deliberately constructed health systems around primary care. And many have reaped significant rewards.

Europeans with chronic illnesses such as diabetes, high blood pressure, cancer and depression reported significantly better health if they lived in a country with a robust primary care system, a group of researchers found. For decades, experts here have called for this country to make a similar commitment. But only about 5% of U.S. Health care spending goes to primary care, versus an average of 14% in other wealthy nations, according to data collected by the Organization for Economic Co-operation and Development. Other research shows that primary spending has declined in many U.S.

States in recent years. The situation grew even more dire as the propecia forced thousands of primary care physicians — who didn’t receive the government largesse showered on major medical systems — to lay off staff members or even close their doors. Reversing this slide will require new investment, the authors of the new report conclude. But, they argue, that should yield big dividends. €œIf we increase the supply of primary care, more people and more communities will be healthier, and no other part of health care can make this claim,” said Dr.

Robert Phillips, a family physician who co-chaired the committee that produced the report. Phillips also directs the Center for Professionalism and Value in Health Care at the American Board of Family Medicine. The report urges new initiatives to build more health centers, especially in underserved areas that are frequently home to minority communities, and to expand primary care teams, including nurse practitioners, pharmacists and mental health specialists. And it advocates new efforts to shift away from paying physicians for every patient visit, a system that critics have long argued doesn’t incentivize doctors to keep patients healthy. Potentially most controversial, however, is the report’s recommendation that Medicare and Medicaid, as well as commercial insurers and employers that provide their workers with health benefits, ask their members to declare a primary care provider.

Anyone who does not, the report notes, should be assigned a provider. €œSuccessfully implementing high-quality primary care means everyone should have access to the ‘sustained relationships’ primary care offers,” the report notes. This idea of formally linking patients with a primary care office — often called empanelment — isn’t new. Kaiser Permanente, consistently among the nation’s best-performing health systems, has long made primary care central. (KHN is not affiliated with Kaiser Permanente.) But the model, which was at the heart of managed-care health plans, suffered in the backlash against HMOs in the 1990s, when some health plans forced primary care providers to act as “gatekeepers” to keep patients away from costlier specialty care.

More recently, however, a growing number of experts and primary care advocates have shown that linking patients with a primary care provider need not limit access to care. Indeed, a new generation of medical systems that rely on primary care to look after elderly Americans on Medicare with chronic medical conditions has demonstrated great success in keeping patients healthier and costs down. These “advanced primary care” systems include ChenMed, Iora Health and Oak Street Health. €œIf you don’t have empanelment, you don’t really have continuity of care,” said Dr. Tom Bodenheimer, an internist who founded the Center for Excellence in Primary Care at the University of California-San Francisco and has called for stronger primary care systems for decades.

Bodenheimer added. €œWe know that continuity of care is linked to everything good. Better preventive care, higher patient satisfaction, better chronic care and lower costs. It is really fundamental.” Noam N. Levey.

nlevey@kff.org, @NoamLevey Related Topics Contact Us Submit a Story TipIf you are uninsured because health coverage seemed too expensive the last time you looked, it’s time to look again. A new federal law could make it a whole lot cheaper to buy your own insurance if you don’t get coverage through an employer or a government insurance program such as Medicare or Medicaid. The law, the American Rescue Plan, provides billions of federal dollars to reduce premiums for people who buy their coverage through the insurance exchanges established by the Affordable Care Act. The aid expands a federal tax credit created by the ACA that you can take upfront as a discount on your premium or claim when you file your taxes the following year. It is not available for those who buy individual or family policies in the open market outside an ACA exchange.

So, if you are in an off-exchange health plan, you might save a lot of money by switching to one inside the exchange. Covered California, the state’s ACA exchange, opened a special enrollment period on April 12 for people who want to take advantage of the new aid by enrolling or switching coverage. The period runs through December — 4½ months later than the Aug. 15 special enrollment end date on the federally run exchanges. Covered California estimates the new money will reduce its customers’ monthly premium bills by an average of $180 per household.

Nearly 90% of Covered California enrollees already get financial aid, and many will now get more. Some enrollees who didn’t previously qualify for tax credits may now be eligible. Darci Gutierrez, an insurance agent in Dublin, California, says a client with a large family saved $425 a month on a Blue Shield PPO at the silver tier — the second-lowest level in the ACA’s four-tier system of coverage. €œI was shocked at the amount of reduction in cost. I was like, ‘Holy cow,’” Gutierrez says.

The additional federal aid is slated to stop after 2022, which means your insurance could cost you more after that. But there is talk in Congress about extending the enhanced tax credits for longer. The new law follows the lead of California, which provided groundbreaking state-funded tax credits starting last year to augment the ACA credits and push eligibility for aid well into the middle class. The new federal dollars will provide assistance even further up the income scale. Covered California estimates 100,000 consumers with incomes too high to qualify for federal or state credits under prior law will now be eligible for subsidies averaging $500 a month per household.

The share of the new money going to California could be about four times as much as those state-funded subsidies and will completely replace them, saving the state about $761 million this fiscal year and next. The newly enhanced federal tax credits take effect with coverage that starts May 1. To get coverage for the first of any month, you need only sign up by the day before. If you are currently enrolled in Covered California, you can keep your plan and take the savings, or you could shop around and save even more — or switch to a higher level of coverage without increasing your monthly bill. €œIt’s critical that anybody who buys coverage as an individual take a look, because they may be leaving hundreds if not thousands of dollars on the table,” says Anthony Wright, executive director of Health Access, a Sacramento-based consumer advocacy group.

The new law, signed by President Joe Biden in March, also allocates money to provide virtually premium-free coverage — in 2021 only — for anyone, regardless of income, who receives unemployment benefits at any point during the year. California is projected to get about $3 billion of the new federal money. Officials at Covered California think the state can get even more, and the exchange is spending more than $20 million on a television, radio and social media advertising blitz to drum up business. It is targeting in particular the approximately 810,000 uninsured Californians who are eligible for federal support under the new law. €œWe need to rattle uninsured people to look again and realize this is new and different,” says Peter Lee, Covered California’s executive director.

€œIf they think it’s just the same old same old, they ain’t going to check.” Covered California is also marketing itself to an additional 270,000 people who are enrolled in health plans outside the exchange and would qualify for subsidized coverage if they switched to Covered California. In an example used by Covered California in its promotional campaign, an Oakland couple making $77,580 a year, both 45 years old, pay the full monthly premium of $1,271 for a silver plan outside the exchange. By switching to the same plan in Covered California, they would pay only $550 — a monthly saving of $721. If you are a current enrollee, Covered California — unlike the federally run exchanges — will automatically calculate your lower premium, and you will see a credit for May on your June bill. You will also reap that saving retroactively for the first four months of 2021 in the form of an additional premium reduction, in equal monthly installments, over the rest of the year.

If you are uninsured or in an off-exchange health plan, however, you need to take action. The money won’t just come to you. Research your options and enroll. To find out if you qualify for federal assistance, log on to www.coveredca.com. Click the “shop and compare” button to find the health plans available to you in your area, along with the monthly premium you will pay after your tax credit.

You can also click a button to get a call from a licensed health insurance agent who can help you figure it all out — without charging you. If you don’t have a computer, call Covered California at 800-300-1506. In contrast to the federally operated exchanges, Covered California requires that people switching from off-exchange health plans into exchange-based ones be allowed to apply any deductible paid so far this year against the new policy, as long as they don’t change insurance companies. That flexibility also applies if you are exchanging one Covered California plan for another, but with more restrictions, so ask your health plan before you make any changes. If you are coming to Covered California from the open market, it should be easy to keep doctors you like, since most off-exchange plans mirror ones in Covered California and have the same networks.

But there are cases in which you would not be able to keep your doctors, so be sure to ask your insurer about it before making a final decision. Another notable feature of the new federal tax credits is that they no longer carry upper-income limits for eligibility. Instead, the amount people pay in premiums is limited to a fixed percentage of their income, ranging from zero for low-income consumers to 8.5% for the most affluent. For the 2020 tax year, the new law overrides a requirement that consumers whose incomes exceeded their original estimate pay back any subsidy amounts to which they are not entitled. Tom Freker, an insurance agent in Huntington Beach, California, says one of his clients made a big profit on a property sale last year, which raised his income to a level that would have required paying back the $10,000 subsidy he received in 2020.

€œBut the new American Rescue Plan waived that repayment,” Freker says. €œThat’s a big deal.” This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. Bernard J. Wolfson. bwolfson@kff.org, @bjwolfson Related Topics Contact Us Submit a Story TipAfter spending much of the past year tending to elderly patients, doctors are seeing a clear demographic shift.

Young and middle-aged adults make up a growing share of the patients in hair loss treatment hospital wards. It’s both a sign of the country’s success in protecting the elderly through vaccination and an urgent reminder that younger generations will pay a heavy price if the outbreak is allowed to simmer in communities across the country. €œWe’re now seeing people in their 30s, 40s and 50s — young people who are really sick,” said Dr. Vishnu Chundi, a specialist in infectious diseases and chair of the Chicago Medical Society’s hair loss treatment task force. €œMost of them make it, but some do not.

€¦ I just lost a 32-year-old with two children, so it’s heartbreaking.” Nationally, adults under 50 now account for the most hospitalized hair loss treatment patients in the country — about 36% of all hospital admissions. Those ages 50 to 64 account for the second-highest number of hospitalizations, or about 31%. Meanwhile, hospitalizations among adults 65 and older have fallen significantly. About 32% of the U.S. Population is now fully vaccinated, but the vast majority are people older than 65 — a group that was prioritized in the initial phase of the treatment rollout.

Although new s are gradually declining nationwide, some regions have contended with a resurgence of the hair loss in recent months — what some have called a “fourth wave” — propelled by the B.1.1.7 variant, first identified in the United Kingdom, which is estimated to be somewhere between 40% and 70% more contagious. As many states ditch propecia precautions, this more virulent strain still has ample room to spread among the younger population, which remains broadly susceptible to the disease. The emergence of more dangerous strains of the propecia in the U.S. €” including variants first discovered in South Africa and Brazil — has made the vaccination effort all the more urgent. €œWe are in a whole different ballgame,” said Judith Malmgren, an epidemiologist at the University of Washington.

Rising s among young adults create a “reservoir of disease” that eventually “spills over into the rest of society” — one that has yet to reach herd immunity — and portends a broader surge in cases, she said. Fortunately, the chance of dying of hair loss treatment remains very small for people under 50, but this age group can become seriously ill or experience long-term symptoms after the initial . People with underlying conditions such as obesity and heart disease are also more likely to become seriously ill. €œB.1.1.7 doesn’t discriminate by age, and when it comes to young people, our messaging on this is still too soft,” Malmgren said. Hospitals Filled With Younger, Sicker People Across the country, the influx of younger patients with hair loss treatment has startled clinicians who describe hospital beds filled with patients, many of whom appear sicker than what was seen during previous waves of the propecia.

€œA lot of them are requiring ICU care,” said Dr. Michelle Barron, head of prevention and control at UCHealth, one of Colorado’s large hospital systems, as compared with earlier in the propecia. The median age of hair loss treatment patients at UCHealth hospitals has dropped by more than 10 years in the past few weeks, from 59 down to about 48 years old, Barron said. €œI think we will continue to see that, especially if there’s not a lot of treatment uptake in these groups,” she said. While most hospitals are far from the onslaught of illness seen during the winter, the explosion of cases in Michigan underscores the potential fallout of loosening restrictions when a large share of adults are not yet vaccinated.

There’s strong evidence that all three treatments being used in the U.S. Provide good protection against the U.K. Variant. One study suggests that the B.1.1.7 variant doesn’t lead to more severe illness, as was previously thought. However, patients infected with the variant appear more likely to have more of the propecia in their bodies than those with the previously dominant strain, which may help explain why it spreads more easily.

€œWe think that this may be causing more of these hospitalizations in younger people,” said Dr. Rachael Lee at the University of Alabama-Birmingham hospital. Lee’s hospital also has observed an uptick in younger patients. As in other Southern states, Alabama has a low rate of treatment uptake. But even in Washington state, where much of the population is opting to get the treatment, hospitalizations have been rising steadily since early March, especially among young people.

In the Seattle area, more people in their 20s are now being hospitalized for hair loss treatment than people in their 70s, according to Dr. Jeff Duchin, public health chief officer for Seattle and King County. €œWe don’t yet have enough younger adults vaccinated to counteract the increased ease with which the variants spread,” said Duchin at a recent press briefing. Nationwide, about 32% of people in their 40s are fully vaccinated, compared with 27% of people in their 30s. That share drops to about 18% for 18- to 29-year-olds.

€œI’m hopeful that the death curve is not going to rise as fast, but it is putting a strain on the health system,” said Dr. Nathaniel Schlicher, an emergency physician and president of the Washington State Medical Association. Schlicher, also in his late 30s, recalls with horror two of his recent patients — close to his age and previously healthy — who were admitted with new-onset heart failure caused by hair loss treatment. €œI’ve seen that up close and that’s what scares the hell out of me,” he said. €œI understand young people feeling invincible, but what I would just tell them is — don’t be afraid of dying, be afraid of heart failure, lung damage and not being able to do the things that you love to do.” Will Younger Adults Get Vaccinated?.

Doctors and public health experts hope that the troubling spike in hospitalizations among the younger demographic will be temporary — one that treatments will soon counteract. It was only on April 19 that all adults became eligible for a hair loss treatment, although they were available in some states much sooner. But some concerning national polls indicate a sizable portion of teens and adults in their 20s and 30s don’t necessarily have plans to get vaccinated. €œWe just need to make it super easy — not inconvenient in any way,” said Malmgren, the Washington epidemiologist. €œWe have to put our minds to it and think a little differently.” This story is part of a partnership that includes NPR and KHN.

Related Topics Contact Us Submit a Story TipOne of the few surprises in President Joe Biden’s social safety-net proposal, the American Families Plan, was something that didn’t make it into the final version. Any mention of reining in the price of prescription drugs. The American Families Plan, the second part of Biden’s expansive “infrastructure” agenda, includes sweeping programs aimed at boosting access to child care, higher education and paid family leave. But despite White House signals in March that health also would be a major part of the package, the only health proposal was one that would make permanent the temporary subsidy increases, passed as part of the hair loss treatment relief bill earlier this spring, on insurance purchased through the Affordable Care Act’s health exchanges. Initial reports suggest that Biden and his aides did not want to pick a fight now with the powerful prescription drug industry, which is riding high in public opinion after producing hair loss treatments in record time.

They worry that the industry’s impressive lobbying clout could endanger the rest of the program. But there is likely another big reason Democrats are loath to address drug prices, despite broad bipartisan support. After nearly a year of uncharacteristically being on the same page when it comes to health care, Democratic lawmakers are reverting to a more familiar position. They are at loggerheads about what to do next. Most Democrats agree the time is ripe to tackle high drug prices.

In 2019 the Democratic-led House passed a broad drug price bill that was reintroduced just days ago with the backing of Speaker Nancy Pelosi. Senate Democrats have also been working on drug price legislation. There is some difference between liberals and moderates on how far to push the drug industry for savings, but the consensus is that drugs cost too much and the government needs to step in. The real problem is what to do with the considerable budget savings that would be produced by policies like allowing Medicare to negotiate drug prices. That’s something that pits the more liberal Democratic backers of a “Medicare for All” insurance system against moderates who would instead put the savings into expanding the benefits of the Affordable Care Act.

Biden is, for the moment at least, taking both sides. Savings from drug price reforms “can go to strengthen the Affordable Care Act and expand Medicare coverage and benefits — without costing taxpayers one additional penny,” he said in his speech to a joint session of Congress on Wednesday night. But the factions are taking shape in Congress. On hearing reports that Biden’s families plan would leave major health items on the cutting-room floor, Medicare for All sponsor Sen. Bernie Sanders (I-Vt.) and 16 Senate Democratic colleagues urged Biden not just to include Medicare drug price negotiation authority in his package, but also to use the proceeds to lower the Medicare eligibility age (a Biden campaign promise) and add hearing, vision and dental benefits to Medicare.

House Democrats in their 2019 bill opted to use the savings to provide those added health benefits to current Medicare beneficiaries. €œWe have an historic opportunity to make the most significant expansion of Medicare since it was signed into law,” wrote the senators. A similar letter went to the president signed by 80 House members, led by Medicare for All backer Rep. Pramila Jayapal (D-Wash.). But at the same time, more than 50 members of the “New Democrat Coalition,” a more moderate group of House Democrats, also wrote to Biden, urging him to use the package to enhance the ACA.

€œOver a decade after the passage of the Obama-Biden administration’s landmark health care legislation, we are eager to work with the Biden-Harris administration to fortify and build on the ACA to achieve universal coverage with access to affordable, quality care,” they wrote. This particular disagreement harks back to the 1980s and ’90s, when generations were pitted against each other in a sometimes ugly way. Younger Americans, worried about rising rates of the uninsured, accused Medicare beneficiaries who wanted better benefits of being “greedy geezers.” A law Congress passed in 1988 that would have boosted Medicare benefits and added a cap on catastrophic expenses caused a backlash when Congress decided wealthier seniors should pay for it themselves via added taxes. Seniors angry that younger people would not help foot the bill rebelled, and the entire program was repealed in 1989 before it ever took effect. €œIt’s a very American debate,” said Jonathan Oberlander, a health policy professor at the University of North Carolina-Chapel Hill who has written extensively about Medicare.

€œIt’s a function of the fact that we have a fragmented health insurance system and it’s fragmented by age. You don’t have this conversation in Canada or France or anywhere else.” Loren Adler, associate director of the USC-Brookings Schaeffer Initiative for Health Policy, said the obvious next step is to make the new ACA subsidies permanent. €œIt’s simple, it’s all winners, and certainly affordable in the context,” he said. In other words, there are no deep-pocketed stakeholders, like health insurers or drug companies, who would step in to fight the plan. But neither plan, she said, gets to the biggest need, which is to help those caught in the “Medicaid gap” — at least 2.2 million people in states that didn’t expand Medicaid who are still uninsured.

They don’t qualify for ACA marketplace coverage, because they earn too little, or for Medicaid, because they earn too much. €œMy general preference is to create a public program for those folks to enroll,” Adler said. Oberlander and Adler said it’s likely this fight will be settled the old-fashioned way. Rather than pick one pathway, lawmakers will do both, expanding the ACA and Medicare. €œIf you try to do these policies in a somewhat frugal manner, there are some opportunities here,” said Adler.

But Oberlander warned that Congress shouldn’t spend the drug price bounty before it’s passed. In the 1990s the fight was over whether to expand health insurance for younger Americans or provide more long-term care options for seniors. Said Oberlander, “In the end, they did neither.” HealthBent, a regular feature of Kaiser Health News, offers insight and analysis of policies and politics from KHN’s chief Washington correspondent, Julie Rovner, who has covered health care for more than 30 years. Julie Rovner. jrovner@kff.org, @jrovner Related Topics Contact Us Submit a Story TipUna mañana de verano en 2019, Debbie Cook estaba todavía en pijamas cuando recibió una llamada de su hijo.

€œAlgo malo le pasa a la abuela”. Por el miedo en la voz de su hijo supo que se trataba de algo serio. Marcó el 911 de inmediato, sabiendo que una ambulancia podría tardar un buen tiempo en recorrer las carreteras rurales del condado de Fentress, en Tennessee. Se vistió y condujo a través de la granja familiar, dos puentes y un riachuelo, hasta la casa de su madre. Cook rezó para que una de las tres ambulancias que cubrían su condado de aproximadamente 500 millas cuadradas estuviera cerca.

Cuando llegó, encontró a su madre, Lottie Crouch, en el baño, incapaz de pararse o caminar. Cook, quien es enfermera licenciada, reconoció rápidamente los signos. Cara torcida, un lado de la boca caído. Su mamá estaba sufriendo un accidente cerebrovascular (ACV, también llamado ataque cerebral). €œMe quedé petrificada”, recordó Cook, quien comenzó su carrera trabajando con pacientes en rehabilitación tras accidentes cerebrovasculares, y sabía que obtener la atención adecuada rápidamente podría hacer la diferencia entre la vida o la muerte.

O una gran diferencia en la calidad de vida de su madre. Crouch tenía 75 años, todavía estaba enérgica y le encantaba hacer cosas como prepararse sopa. Para seguir viviendo la vida que Crouch conocía, cada paso hacia la atención adecuada, en un área rural, tenía que salir bien. Cuando llegaron los paramédicos, la pregunta crucial fue. ¿A dónde llevarían a Crouch para que recibiera atención?.

Cuando Lottie Crouch (izq.) tuvo un accidente cerebrovascular en agosto de 2019, su hija (der.), supo que obtener la atención correcta rápido podía hacer la diferencia entre la vida y la muerte.(Owen Hornstein / InvestigateTV) En todo el país, cerca de 800,000 personas sufren accidentes cerebrovasculares cada año. El problema es particularmente grave en las regiones de los Apalaches y el delta del Mississippi, donde más del 80% de los condados tienen tasas de muerte por ACV superiores al promedio nacional. Muchos de estos condados también enfrentan altos índices de pobreza y albergan a poblaciones de adultos mayores vulnerables. Tienen escasez de proveedores médicos o han visto cerrar hospitales locales. En Tennessee, 2 millones de personas, casi un tercio del estado, están en la situación de Crouch.

Viven a más de 45 minutos de un hospital certificado para el tratamiento de accidentes cerebrovasculares y capaz de brindar la atención más avanzada, según un nuevo análisis de KHN e InvestigateTV. Y las tasas son aún más altas en los estados del delta como Arkansas y Mississippi, donde más de la mitad de los residentes deben conducir más de 45 minutos hasta estos centros especializados. El análisis es parte de un proyecto de un año llamado Bridging the Great Health Divide, durante el cual KHN y el equipo de investigación nacional de Gray Television, InvestigateTV, investigan los problemas de salud que históricamente han plagado a estas regiones. Y los accidentes cerebrovasculares son los principales. A pesar de los avances médicos en la atención de estos ataques, enviar a los pacientes de las zonas rurales de los Apalaches y el delta del Mississippi a las instalaciones adecuadas es un intrincado rompecabezas.

"No existe una única respuesta correcta para todos los pacientes", dijo el doctor Raul Nogueira, neurólogo intervencionista del Grady Memorial Hospital en Atlanta, Georgia. El lugar donde se debe cuidar a un paciente "realmente depende del tiempo de viaje", dijo. "Todo es cuestión de tiempo". Durante años, el consejo para los pacientes con ACV ha sido llegar al hospital más cercano lo antes posible. Esta emergencia interrumpe el flujo sanguíneo a una parte del cerebro y, cuanto antes se lo pueda restaurar, mejor.

Entonces, la idea ha sido llevar a los pacientes a un médico, cualquier médico, rápidamente. Pero ahora, ese consejo está evolucionando. Investigaciones muestran que algunos pacientes con ACV se benefician más de los procedimientos avanzados que suelen realizar especialistas en grandes centros médicos. Por eso, el nuevo objetivo es llevar a los pacientes al médico adecuado en el hospital adecuado lo antes posible. En algunos casos, eso no significa la instalación más cercana.

Para los pacientes con accidentes cerebrovasculares graves, en los que un coágulo está bloqueando a una de las arterias principales del cerebro, las asociaciones médicas recomiendan viajar hasta 30 minutos adicionales en áreas urbanas y 60 minutos en áreas rurales para llegar a un hospital con capacidad de tratar un ataque cerebral con técnicas avanzadas. Si bien eso es bastante fácil en una ciudad donde hay muchos hospitales, en áreas rurales como el condado de Fentress, la cuestión de dónde llevar a un paciente se ha vuelto cada vez más complicada. Grandes decisiones, poco tiempo Cuando Lottie Crouch tuvo su accidente cerebrovascular, el que habría sido el hospital más cercano, a menos de 20 minutos, había cerrado dos meses antes. Es uno de los 136 hospitales rurales en todo el país que han cerrado desde 2010, incluidos casi tres docenas en Appalachia y el delta. Eso significaba que, para Crouch, el hospital estatal más cercano estaba a casi 45 minutos en auto, y los centros médicos con la atención más avanzada estaban a más de una hora.

Eso hizo que los servicios de emergencias médicas se esforzaran por transportar a los pacientes más lejos. Cada paso en el proceso para conseguir que alguien que había sufrido un derrame cerebral recibiera la atención adecuada en el tiempo adecuado se había vuelto más complejo. Las decisiones del momento rara vez son claras, dijo Nogueira. Si un paciente tiene un accidente cerebrovascular severo, podría beneficiarse de ir a un centro médico grande donde pueda someterse a una cirugía de inmediato, agregó. Detenerse en un hospital más pequeño que no puede realizar ese procedimiento podría retrasar innecesariamente la atención.

Pero si el ataque es menos grave, podría ser mejor ir primero a un centro más cercano en donde el paciente podría recibir medicamentos para disolver el coágulo antes, dijo Nogueira. Así, evitaría facturas médicas innecesarias por un viaje largo, desde $500 por un viaje en la parte trasera de una ambulancia regular hasta $50,000 por un helicóptero. Y la familia podría ahorrar el tiempo y el dinero que implica visitar al paciente en un hospital lejano. El problema es que los socorristas no necesariamente pueden saber qué tan grave es un derrame cerebral con solo mirar a alguien. Por lo tanto, se basan en una evaluación de los síntomas del paciente para tomar la mejor decisión.

A Jamey Beaty, un paramédico en el condado de Fentress que respondió a la casa de Lottie Crouch, le pesan la gravedad de estas decisiones. "Cuando estás solo en la parte trasera de una ambulancia y tienes un paciente que se está muriendo, lo único en lo que puedes pensar es. ¿Cómo puedo mantener vivo a este paciente hasta que pueda llevarlo a alguna parte?. ", dijo Beaty. "Eso es todo lo que se te pasa por la cabeza".

Cada vez que Beaty recibe una llamada por un ataque cerebral, su primera respuesta es mirar al cielo. Desde que cerró el hospital local, una ambulancia aérea es la forma más rápida para que el paciente llegue al lugar del tratamiento. Afortunadamente, el día que Lottie Crouch tuvo su ataque, el cielo de Tennessee estaba azul claro. Crouch fue trasladada casi 100 millas a un hospital en Knoxville con servicios avanzados para accidentes cerebrovasculares. Cuando Lottie Crouch tuvo un accidente cerebrovascular en agosto de 2019, en Fentress County, Tennessee, los paramédicos locales la llevaron a un campo abierto en donde fue trasladada en una ambulancia aérea.

El helicóptero la llevó a un hospital a 100 millas de distancia.(Haelee Stockton) Viajes largos hacia la atención avanzada Durante las últimas dos décadas, dos tratamientos principales han hecho que avanzara la atención de los accidentes cerebrovasculares causados ​​por un bloqueo, el tipo de ataque más común en Estados Unidos. El primero es un medicamento administrado por vía intravenosa para disolver los coágulos en los vasos sanguíneos de los pacientes. El medicamento debe administrarse dentro de las 4½ horas posteriores al inicio de los síntomas. El segundo es un procedimiento que utiliza un catéter para remover físicamente el coágulo de los vasos de un paciente. Este tratamiento se puede realizar hasta 24 horas después del comienzo de los síntomas, pero generalmente se usa solo para accidentes cerebrovasculares graves.

En todo el país, los hospitales están certificados por niveles, en gran parte en función de su capacidad para proporcionar estos tratamientos con regularidad. Algunos hospitales no tienen certificación. Entre los hospitales certificados para accidentes cerebrovasculares, el primer nivel son los que están preparados para accidentes cerebrovasculares agudos, que pueden evaluar a los pacientes con accidente cerebrovascular, mantenerlos estables y proporcionar medicamentos anticoagulantes. En el otro extremo del espectro están los centros integrales de accidentes cerebrovasculares, que cuentan con equipos especializados de neurólogos y neurocirujanos. Además de administrar los medicamentos anticoagulantes, estos centros pueden remover los coágulos con cirugía.

La gran pregunta es ¿a qué centro se puede y se debe llevar primero a los pacientes con ACV para que reciban la atención adecuada en un tiempo adecuado?. En Appalachia, aproximadamente el 11% de los residentes deben conducir más de 45 minutos para llegar a cualquier tipo de centro de accidentes cerebrovasculares, según el análisis de KHN e InvestigateTV. Esa proporción es aún mayor en el delta, donde casi un tercio de los residentes tienen que conducir más de 45 minutos para llegar a uno de estos centros. Otro tercio solo tiene centros de atención básica para accidentes cerebrovasculares dentro de esa distancia y necesitaría conducir más lejos para cirugías avanzadas. Y en las partes rurales más remotas de estas dos regiones, es menos probable que las personas estén cerca de un centro de atención avanzada para accidentes cerebrovasculares.

El Jamestown Regional Medical Center era el único hospital en Fentress County, Tennessee. Cerró en junio de 2019, sumándose a la lista de más de 100 hospitales rurales que han dejado de funcionar desde 2010.(Kevin Hughes for InvestigateTV) Rural y mayoritariamente afroamericano Si bien para muchos estadounidenses rurales como Crouch, que es blanca no hispana, es difícil llegar a tiempo al lugar adecuado para recibir la atención, las preocupaciones se agravan en los lugares con una gran población de raza negra. Los afroamericanos tienen accidentes cerebrovasculares con más frecuencia y a edades más tempranas que sus contrapartes caucásicas. También es menos probable que reciban medicamentos anticoagulantes porque generalmente llegan al hospital fuera de la ventana del tratamiento. En el condado de Sumter, Alabama, varias personas entrevistadas, desde el dueño de un negocio local hasta un profesor universitario y el juez de distrito, pudieron nombrar a alguien que había tenido un ataque cerebral.

Más del 70% de la población del condado es de raza negra, y es una de las áreas más pobres del estado. El único hospital dentro de las fronteras del condado no tiene certificación para ACV. Loretta Wilson, directora ejecutiva del Hospital Hill del condado de Sumter, quisiera que su centro pudiera hacer más por los pacientes con ACV. Pero los medicamentos anticoagulantes pueden costar $8,000 por dosis y el hospital no siempre puede permitirse el lujo de tenerlos a mano, dijo. A la mayoría de los pacientes con accidente cerebrovascular se los traslada a hospitales más grandes, al menos a 30 o 40 minutos de distancia.

Ese puede ser un viaje largo y costoso para muchos residentes, agregó Wilson. Por eso, Wilson se centra principalmente en los esfuerzos de prevención. Dirige una organización sin fines de lucro que aborda problemas como la presión arterial alta, la obesidad y la diabetes, que aumentan el riesgo de una persona de sufrir un ACV. Su organización tiene alianzas con iglesias para educar a las personas sobre alimentación saludable y ejercicio, y distribuye monitores de presión arterial para que los feligreses puedan tomarse la presión ellos mismos. "Tenemos una alta población afroamericana", dijo Wilson, quien también es afroamericana, "y esos son los que realmente necesitan los servicios".

Otras organizaciones en el condado también trabajan para educar a las personas sobre la salud cardíaca y cuándo llamar al 911. El programa de enfermería de la universidad local tiene una beca destinada a atraer a más proveedores médicos al área. Usando telestroke para impulsar la atención rural En los hospitales rurales, incluso si los médicos tienen acceso a medicamentos anticoagulantes, pueden dudar en administrarlos por temor a dañar al paciente. En raras ocasiones, alrededor del 2% al 7% de los casos, los medicamentos pueden causar sangrado cerebral. Pero no usar las drogas también puede tener consecuencias.

Un estudio nacional publicado en 2020 encontró que los pacientes con accidente cerebrovascular tenían menos probabilidades de recibir esos medicamentos en hospitales rurales que en los urbanos, y los pacientes con estos ataques tenían más probabilidades de morir en hospitales rurales. Los programas de telestroke pueden ayudar a cerrar esa brecha, explicó la doctora Amelia Adcock, neuróloga de WVU Medicine en West Virginia y jefa de la red de telestroke del sistema. Al conectar a médicos de hospitales más pequeños, a menudo rurales, con un especialista de guardia en un gran centro médico, los programas permiten que las personas “compartan la carga de la toma de decisiones”, dijo Adcock. Y la responsabilidad. El doctor Michael Gould es médico de medicina de emergencia en el Hospital Potomac Valley de 25 camas en la zona rural del norte de West Virginia.

Su hospital no está certificado para accidentes cerebrovasculares y no cuenta con un neurólogo de planta. Dijo que administrar medicamentos anticoagulantes es "una de las decisiones de la medicina que me pone más nervioso". Pero consultar con neurólogos en el centro de Medicina de WVU a unas 80 millas de distancia en Morgantown le ha dado más confianza, dijo. Gould estimó que ahora administra los medicamentos una o dos veces al mes. Un estudio de la red de telestroke de WVU Medicine halló que el número de pacientes con accidente cerebrovascular que recibieron medicamentos anticoagulantes casi se duplicó durante los primeros tres años del programa.

El otoño pasado, Christopher Green estaba haciendo las compras cuando de repente sintió un fuerte dolor de cabeza y perdió la visión periférica. Green, un veterano paramédico, reconoció de inmediato lo que estaba sucediendo. "Oh, Dios mío, estoy sufriendo un ataque cerebral", recuerda haber pensado. Lo llevaron al hospital de Gould y el personal de emergencias inmediatamente puso en marcha el programa de telestroke. Christopher Green ha trabajado en servicios médicos de emergencia por cerca de 30 años.

Dijo que tener él mismo un ataque cerebral cambió su perspectiva sobre cómo responder a las llamadas al 911 por estas emergencias.(Tara Butler) En 30 minutos, Green consiguió medicamentos para disolver el coágulo en sus vasos. "Un resultado de libro de texto", dijo Green, quien ha respondido a muchas llamadas al 911 por accidentes cerebrovasculares. Rememorando, Green dijo que probablemente habría llevado a un paciente en su situación a un hospital más lejano que estuviera certificado para accidentes cerebrovasculares. Pero experimentar el programa de telestroke en carne propia cambió su perspectiva. "Ahora veo que retrasar el tratamiento de 20 a 30 minutos marca la diferencia entre tener una solución completa o algún tipo de efecto residual", dijo.

€œÂ¿Qué pudo haber sido?. € De vuelta en Tennessee, Debbie Cook estaba agradecida de que a su madre la hubieran llevado al centro de atención avanzada para accidentes cerebrovasculares en Knoxville. Le permitió a Lottie Crouch recibir el tratamiento que necesitaba para poder llevar una vida mayormente independiente. Pero la distancia le pasó factura a la familia. Cook, su hermana y su hija se turnaron para conducir casi dos horas de ida y dos de vuelta para pasar la noche con Crouch en el hospital.

Después de 10 días, cuando Crouch fue trasladada a un centro de rehabilitación más cercano a su casa, la familia sintió una sensación de alivio. Podrían llevarle pastel de carne y dumplings de moras silvestres para la cena. Y "un montón de caramelos de menta", recuerda Crouch, su favorito. Aunque Crouch ahora está sana, y en casa, su nieta de 27 años, Haelee Stockton, todavía está obsesionada de solo pensar lo que podría haber sucedido ese día. Si los paramédicos no hubieran llegado a tiempo o si el mal tiempo hubiera impedido que el helicóptero volara, es posible que su abuela no estuviera viva.

"¿Qué pudo haber sido?. ", se preguntó Stockton. €œÂ¿Qué tanta suerte tuvo?. ¿Y cuántas personas van a tener esa suerte en el futuro?. ".

La abuela de Haelee Stockton, Lottie Crouch, sobrevivió a un accidente cerebrovascular en 2019, pero a Stockton le preocupa que otros en el condado no tengan tanta suerte.(Owen Hornstein/InvestigateTV) Aneri Pattani lideró las entrevistas y la redacción de esta historia. Hannah Recht lideró el análisis de datos y los gráficos. Daniela Molina de InvestigateTV colaboraron con la historia. Aneri Pattani. apattani@kff.org, @aneripattani Hannah Recht.

hrecht@kff.org, @hannah_recht Related Topics Contact Us Submit a Story Tip.

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That depends on what type of hearing loss you have. Sensorineural hearing loss is caused by damage to the sensory hair cells of the inner ear. This damage can be caused by exposure to loud noise, illness, medication, injury or age. If your hearing healthcare professional determines you have sensorineural hearing loss, you will probably benefit from wearing a hearing aid. Age-related hearing loss, generally a subset of sensorineural, is the loss of hearing that occurs in most people as they age.

This condition, known medically as presbycusis, is common and can often be improved with hearing aids. Conductive hearing loss, however is usually caused by an obstruction in the ear canal, such as swelling due to an ear or a benign tumor. If your hearing healthcare professional determines your hearing loss is conductive, your hearing may return to normal once the obstruction has been removed. If your hearing does not return to normal, you may benefit from wearing a hearing aid, cochlear implant or bone-anchored hearing system. What should I look for when choosing a hearing aid?.

That depends on your lifestyle and your budget. An active person who enjoys traveling and athletic activities will most likely need a different model of hearing aid than someone who spends most of their time at home watching television. Your hearing healthcare professional will ask a variety of questions to help you determine what type of amplification you need, then work with you to make sure your hearing device works properly to help you hear the sounds that are most important to you. Remember that friend who told you they keep their hearing aids in the dresser drawer?. That just might be because they weren’t honest with their hearing healthcare professional about their expectations and lifestyle, or didn’t schedule follow-up visits as requested.

How long will it take for me to adjust to wearing hearing aids?. Wondering what to expect from new hearing aids?. Adjusting to hearing aids varies from person to person and depends upon how long you waited to treat your hearing loss as well as its severity. Although our ears collect noise from our environment, it’s actually our brain that translates it into recognizable sound. If hearing loss is left untreated, the auditory part of your brain can actually atrophy, in which case your rehabilitation may take a while longer.

You’ll also want to wear them as recommended. Following your doctor’s orders improves your chances for success. More. 7 tips for getting used to hearing aids How long do hearing aids last?. With proper use and maintenance, hearing aids typically last between three and five years.

Can I return my hearing aids if I’m not satisfied?. Many hearing centers offer a trial period to ensure you are satisfied. Be sure to ask your hearing healthcare professional about their policies before you purchase any hearing device. How can I find out if I need a hearing aid?. The best way to find out if you need a hearing aid is to have your hearing tested by a hearing healthcare professional.

A thorough hearing test will take approximately an hour of your time during which you will get propecia prescription online most likely be asked to provide your health history, undergo a series of hearing assessments, and discuss your lifestyle and expectations for better hearing. Afterward, a hearing healthcare professional will discuss the results of your test with you and, if its determined that your hearing can benefit from amplification, discuss next steps. If your hearing has changed recently or you suspect you have hearing loss, make an appointment to see a hearing healthcare professional in your community as soon as possible. There’s a lot to hear in this world – laughing children, music, the sound of someone you love calling your name – and hearing aids may be able to help you hear them.When deciding on a new pair of hearing aids, you should consider how long they will last. Just like buying a car, the actual mileage may vary.Most modern high-quality hearing aids have a life expectancy on average between three and seven years.

However, keep in mind that two people can buy exactly the same hearing aids and have them last vastly different amounts of time. Here's why. New hearing aids generally last aroundfive years, but this depends on a lotof different factors. Factors impacting how long hearing aids will last There are at least nine factors that impact the average lifespan of a hearing aid. Materials used to make hearing aids Frequency of cleaning Where hearing aids are worn How hearing aids are stored Hearing aid style A person's body physiology Frequency of maintenance Technological advancements Unique hearing needs 1.

Materials used to make hearing aids Although they are designed to be durable, hearing aids are made of plastic, metal, silicon, polymers and other materials that may be subject to some degree of structural degradation over time. Most hearing aids sold today have a protective nanocoating on them to resist water, dust and moisture, but you should still treat them gently to protect them from shock and impacts. 2. Frequency of cleaning Most people would never dream of going months without washing their hair, face or body. However, they forget their hearing aids are exposed to the same environment—moisture, dust, skin oils and sweat, extreme temperatures and sunlight.

All this occurs in addition to the earwax generated by your ear canal in its natural cleaning process. Some wearers only have their hearing aids professionally cleaned twice a year or so. This takes a toll on hearing aids and can significantly reduce their life expectancy. To help your hearing aids life expectancy, clean them daily as directed by your hearing care practitioner and have them professionally cleaned in the hearing clinic every three to four months. 3.

Where hearing aids are worn Hearing aids that are consistently in damp or dusty environments often have more performance issues than other hearing aids. If you’re concerned about the environments in which you wear your hearing aids, consult your hearing care professional for ideas about protective measures. You may need to use protective sleeves or schedule more frequent professional cleanings to extend the life of your hearing aids. 4. How hearing aids are stored The way hearing aids are stored when you’re not wearing them can also be a factor in hearing aid life expectancy.

For hearing aids with disposable batteries, storing hearing aids with the battery door open will keep them safer. A case with a dehumidifier will keep them drier as well, which will also help them last longer. Ask your hearing care practitioner what type of storage case or dehumidifier options would work best for your hearing aids. For rechargeable hearing aids, lithium batteries last about four to five years. Just like with smartphones, the battery lifespan gets shorter the longer you own the device.

If you notice your battery draining faster than usual, speak to your hearing care provider about whether new rechargeable batteries will help, or if you should get new devices. 5. Style of hearing aids Conventional wisdom in the hearing aid industry is that behind-the-ear (BTE) styles tend to have a long lifespan than in-the-ear (ITE) styles. The reason behind this wisdom is more of the electronic components sit in the damp environment of the ear canal with ITE styles. However, recent technical advancements in nanocoatings on internal and external components may soon make this durability difference a thing of the past.

6. Your body’s physiology Some body chemistries are harder on the plastic and metal components of hearing aids and tend to discolor or degrade parts much faster than others. Some people have very oily skin, produce a lot of earwax or sweat profusely–all of these factors can impact hearing aid life, too. You can’t control these things, of course, but if you have any of these issues you should discuss them with your hearing care practitioner when you’re selecting hearing aids. 7.

Frequency of maintenance Most hearing aids have some readily-replaceable parts, such as wax guards, earmold tubing and silicone dome earpiece tips. These parts are regularly replaced during routine maintenance visits with your hearing care practitioner. There are other parts which can usually be replaced or repaired in the clinic if they become damaged or nonfunctional, like battery doors, earmolds, external speakers and microphone covers. These types of maintenance activities are very important for making your hearing aids last as long as possible. 8.

Technological advancements Hearing aid technology changes often.Many new hearing aids can connectto phones via Bluetooth, for example. Obsolescence can become an issue for very old hearing aids. After several years (usually between five and 10), hearing aid manufacturers may stop making replacement parts for a particular aid, which may make repairs on old hearing aids difficult or impossible. Software used to program hearing aids also changes over time and eventually becomes obsolete. This often makes it difficult to reprogram very old hearing aids.

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Following your doctor’s orders improves your chances for success. More. 7 tips for getting buy propecia uk used to hearing aids How long do hearing aids last?. With proper use and maintenance, hearing aids typically last between three and five years. Can I return my hearing aids if I’m not satisfied?.

Many buy propecia uk hearing centers offer a trial period to ensure you are satisfied. Be sure to ask your hearing healthcare professional about their policies before you purchase any hearing device. How can I find out if I need a hearing aid?. The best way to find out if you need a hearing aid is to have your hearing buy propecia uk tested by a hearing healthcare professional. A thorough hearing test will take approximately an hour of your time during which you will most likely be asked to provide your health history, undergo a series of hearing assessments, and discuss your lifestyle and expectations for better hearing.

Afterward, a hearing healthcare professional will discuss the results of your test with you and, if its determined that your https://mytutorlab.com/nf_sub/1519/ hearing can benefit from amplification, discuss next steps. If your hearing has changed recently or you suspect you have hearing loss, make an appointment to see a hearing healthcare professional in your community as soon buy propecia uk as possible. There’s a lot to hear in this world – laughing children, music, the sound of someone you love calling your name – and hearing aids may be able to help you hear them.When deciding on a new pair of hearing aids, you should consider how long they will last. Just like buying a car, the actual mileage may vary.Most modern high-quality hearing aids have a life expectancy on average between three and seven years. However, keep in mind that two people can buy exactly the same hearing aids and have buy propecia uk them last vastly different amounts of time.

Here's why. New hearing aids generally last aroundfive years, but this depends on a lotof different factors. Factors impacting how long hearing aids will last There are at least nine buy propecia uk factors that impact the average lifespan of a hearing aid. Materials used to make hearing aids Frequency of cleaning Where hearing aids are worn How hearing aids are stored Hearing aid style A person's body physiology Frequency of maintenance Technological advancements Unique hearing needs 1. Materials used to make hearing aids Although they are designed to be durable, hearing aids are made of plastic, metal, silicon, polymers and other materials that may be subject to some degree of structural degradation over time.

Most hearing aids sold today have a buy propecia uk protective nanocoating on them to resist water, dust and moisture, but you should still treat them gently to protect them from shock and impacts. 2. Frequency of cleaning Most people would never dream of going months without washing their hair, face or body. However, they forget their hearing aids are exposed to the same environment—moisture, dust, skin oils and sweat, buy propecia uk extreme temperatures and sunlight. All this occurs in addition to the earwax generated by your ear canal in its natural cleaning process.

Some wearers only have their hearing aids professionally cleaned twice a year or so. This takes a toll on hearing aids and can significantly reduce their life buy propecia uk expectancy. To help your hearing aids life expectancy, clean them daily as directed by your hearing care practitioner and have them professionally cleaned in the hearing clinic every three to four months. 3. Where hearing aids are worn Hearing aids that are consistently in damp or dusty environments often have more performance issues than buy propecia uk other hearing aids.

If you’re concerned about the environments in which you wear your hearing aids, consult your hearing care professional for ideas about protective measures. You may need to use protective sleeves or schedule more frequent professional cleanings to extend the life of your hearing aids. 4. How hearing aids are stored The way hearing aids are stored when you’re not wearing them can also be a factor in hearing aid life expectancy. For hearing aids with disposable batteries, storing hearing aids with the battery door open will keep them safer.

A case with a dehumidifier will keep them drier as well, which will also help them last longer. Ask your hearing care practitioner what type of storage case or dehumidifier options would work best for your hearing aids. For rechargeable hearing aids, lithium batteries last about four to five years. Just like with smartphones, the battery lifespan gets shorter the longer you own the device. If you notice your battery draining faster than usual, speak to your hearing care provider about whether new rechargeable batteries will help, or if you should get new devices.

5. Style of hearing aids Conventional wisdom in the hearing aid industry is that behind-the-ear (BTE) styles tend to have a long lifespan than in-the-ear (ITE) styles. The reason behind this wisdom is more of the electronic components sit in the damp environment of the ear canal with ITE styles. However, recent technical advancements in nanocoatings on internal and external components may soon make this durability difference a thing of the past. 6.

Your body’s physiology Some body chemistries are harder on the plastic and metal components of hearing aids and tend to discolor or degrade parts much faster than others. Some people have very oily skin, produce a lot of earwax or sweat profusely–all of these factors can impact hearing aid life, too. You can’t control these things, of course, but if you have any of these issues you should discuss them with your hearing care practitioner when you’re selecting hearing aids. 7. Frequency of maintenance Most hearing aids have some readily-replaceable parts, such as wax guards, earmold tubing and silicone dome earpiece tips.

These parts are regularly replaced during routine maintenance visits with your hearing care practitioner. There are other parts which can usually be replaced or repaired in the clinic if they become damaged or nonfunctional, like battery doors, earmolds, external speakers and microphone covers. These types of maintenance activities are very important for making your hearing aids last as long as possible. 8. Technological advancements Hearing aid technology changes often.Many new hearing aids can connectto phones via Bluetooth, for example.

Obsolescence can become an issue for very old hearing aids. After several years (usually between five and 10), hearing aid manufacturers may stop making replacement parts for a particular aid, which may make repairs on old hearing aids difficult or impossible. Software used to program hearing aids also changes over time and eventually becomes obsolete. This often makes it difficult to reprogram very old hearing aids. Hearing aid performance and features advance very rapidly.

Can you buy over the counter propecia

Over the past 20 years, a large body of research has documented a relationship between higher nurse-to-patient staffing ratios and better patient outcomes, including shorter hospital stays, lower rates of failure to prevent mortality after an in-hospital complication, inpatient mortality for multiple types of patients, hospital-acquired pneumonia, unplanned extubation, respiratory failure and cardiac arrest.1–5 In addition, can you buy over the counter propecia patients report higher satisfaction when they are cared for in hospitals with higher staffing levels.6 7To date, most http://www.wolf-garden.nl/cost-of-cialis-5mg/ studies have not identified an ‘optimal’ nurse staffing ratio,8 which creates a challenge for determining appropriate staffing levels. If increasing nurse staffing always produces at least some improvement in the quality of care, how does one determine what staffing level is best?. This decision is ultimately an economic one, balancing the benefits of nurse staffing can you buy over the counter propecia with the other options for which those resources could be used. It is in this context that hospitals develop staffing plans, generally based on historical patterns of patient acuity.Practical challenges of nurse staffingHospital staffing plans provide the structure necessary for determining hiring and scheduling, but fall short for a number of reasons. First, there are multiple ways in which patient acuity can be measured, which can have measurable effects on the staffing levels resulting from acuity models.9 Second, patient volume and acuity can shift rapidly with changes in the volume of can you buy over the counter propecia admissions, discharges and transfers between units.

Third, staffing plans provide little guidance regarding the optimal mix of permanent staff, variable staff and externally contracted staff.The paper by Saville and colleagues10 in this issue of BMJ Quality &. Safety addresses the latter two issues by applying a simulation model to identify can you buy over the counter propecia the optimal target for baseline nurse staffing in order to minimise periods of understaffing. Included in this model is consideration of the extent to which hospitals should leverage temporary personnel (typically obtained through an external agency) to fill gaps. The model acknowledges the likelihood that a hospital can you buy over the counter propecia cannot realistically prevent all shifts from having a shortfall of nurses at all times, as well as the reality that hospital managers lack information about the best balance between permanent and temporary staff. In addition, the analysis includes a calculation of the costs of each staffing approach, drawing from the records of 81 inpatient wards in four hospital organisations.The application of sophisticated simulation models and other advanced analyticl approaches to analysis of nurse staffing has been limited to date, and this paper is an exemplar of the value of such research.

Recent studies have used machine learning methods to forecast hospital discharge volume,11 a discrete event simulation model to determine nursing staff needs in can you buy over the counter propecia a neonatal intensive care unit,12 and a prediction model using machine learning and hierarchical linear regression to link variation in nurse staffing with patient outcomes.13 This new study applied a unique Monte Carlo simulation model to estimate demand for nursing care and test different strategies to meet demand.The results of the analysis are not surprising in that hospitals are much less likely to experience understaffed patient shifts if they aim to have higher baseline staffing. The data demonstrate a notable leftward skew, indicating that hospitals are more likely to have large unanticipated increases in patient volume and acuity than to have unanticipated decreases. This results in hospitals being more likely to have shifts that are understaffed than shifts that are overstaffed, which inevitably can you buy over the counter propecia places pressure on hospitals to staff at a higher level and/or have access to a larger pool of temporary nurses. It also is not surprising that hospitals will need to spend more money per patient day if they aim to reduce the percent of shifts that are understaffed. What is surprising about the results is that hospitals do not necessarily achieve cost savings by relying on temporary personnel versus setting regular staffing at a higher level.Trade-offs between permanent and temporary staffThe temporary nursing workforce enables healthcare facilities to maintain flexible yet full care teams based on patient care needs.

Hospitals can use temporary nurses to address staffing gaps during leaves of absence, turnover or gaps between recruitment of permanent nurses, can you buy over the counter propecia as well as during high-census periods. Temporary personnel are typically more expensive on an hourly basis than permanent staff. In addition, can you buy over the counter propecia over-reliance on temporary staff can have detrimental effects on permanent nurses’ morale and motivation. Orientations prior to shifts are often limited, which leads to a twofold concern as temporary nurses feel ill-prepared for shifts and permanent staff feel flustered when required to bring the temporary nurse up to speed while being expected to continue normal operations.14 Agency nurses may be assigned to patients and units that are incongruent with their experience and skills—either to unfamiliar units, which affects their ability to confidently deliver care, or to less complex patients where they feel as if their skills are not used adequately.14 15 These issues can create tension between temporary and permanent nursing staff, which can be compounded by the wage disparity. Permanent staff might feel demoralised and expendable when working alongside temporary staff who are not integrated into the social fabric of the staff.16Hospital managers also must be cognisant of the potential quality impact can you buy over the counter propecia of relying heavily on temporary nursing staff.

Research on the impact of contingent nursing employment on costs and quality have often found negative effects on quality, including mortality, and higher costs.17 18 However, other studies have found that the association between temporary nursing staff and low quality result from general shortages of nursing staff, which make a hospital more likely to employ temporary staff, and not directly from the contingent staff.19–21 Thus, temporary nurses play an important role in alleviating staffing shortages that would otherwise lead to lower quality of care.22Charting a path forward in hospital management and healthcare researchThe maturation of electronic health records and expansion of computerised healthcare management systems provide opportunities both for improved decision making about workforce deployment and for advanced workforce research. In the area of workforce management, can you buy over the counter propecia nursing and other leaders have a growing array of workforce planning tools available to them. Such tools are most effective when they display clear information about predicted patient needs and staff availability, but managers still must rely on their on-the-ground understanding of their staff and their context of patient care.23 Integration of human resources data with patient outcomes data has revealed that individual nurses and their characteristics have important discrete effects on the quality of care.24 25 Future development of workforce planning tools should translate this evidence to practice. In addition, new technology platforms are emerging to facilitate direct matching between temporary healthcare personnel and can you buy over the counter propecia healthcare organisations. One recent study tested a smartphone-based application that allowed for direct matching of locum tenens physicians with a hospital in the English National Health Service, finding that the platform generated benefits including greater transparency and lower cost.26 Similar technologies for registered nurses could facilitate better matching between hospital needs and temporary nurses’ preparedness to meet those needs.Analytical methods that fully leverage the large datasets compiled through electronic health records, human resources systems and other sources can be applied to advance research on the composition of nursing teams to improve quality of care.

As noted above, prior research has applied machine learning and discrete event can you buy over the counter propecia simulation to analyses of healthcare staffing. Other recent studies have leveraged natural language processing of nursing notes to identify fall risk factors27 and applied data mining of human resources records to understand the job titles held by nurses.28 Linking these rapidly advancing analytical approaches that assess the outcomes and costs of nurse staffing strategies, such as the work by Saville and colleagues published in this issue, to data on the impact of nurse staffing on the long-term costs of patient care will further advance the capacity of hospital leaders to design cost-effective policies for workforce deployment.Guidelines aim to align clinical care with best practice. However, simply publishing a guideline rarely triggers behavioural changes to match guideline recommendations.1–3 We thus transform guideline recommendations into actionable tasks by introducing interventions that promote behavioural changes meant to produce guideline-concordant care. Unfortunately, not much has changed in the 25 years since Oxman and colleagues concluded that we have no ‘magic bullets’ when it comes to changing clinician behaviour.4 In fact, far from magic bullets, interventions aimed at increasing the degree to which patients receive care recommended in guidelines (eg, educational interventions, reminders, audit and feedback, financial incentives, computerised decision support) typically produce disappointingly small improvements in care.5–10Much improvement work aims to ‘make the right thing to do the can you buy over the counter propecia easy thing to do.’ Yet, design solutions which hardwire the desired actions remain few and far between. Further, improvement interventions which ‘softwire’ such actions—not guaranteeing that they occur, but at least increasing the likelihood that clinicians will deliver the care recommended in guidelines—mostly produce small improvements.5–9 Until this situation changes, we need to acknowledge the persistent reality that guidelines themselves represent a main strategy for promoting care consistent with current evidence, which means their design should promote the desired actions.11 12In this respect, guidelines constitute a type of clinical decision support.

And, like all can you buy over the counter propecia decision support interventions, guidelines require. (1) user testing to assess if the content is understood as intended and (2) empirical testing to assess if the decision support provided by the guideline does in fact promote the desired behaviours. While the processes for developing guidelines have received substantial attention over the years,13–18 surprisingly little attention has been paid can you buy over the counter propecia to empirically answering basic questions about the finished product. Do users understand guidelines as intended?. And, can you buy over the counter propecia what version of a given guideline engenders the desired behaviours by clinicians?.

In this issue of BMJ Quality and Safety, Jones et al19 address this gap by using simulation to compare the frequency of medication errors when clinicians administer an intravenous medication using an existing guideline in the UK’s National Health Service (NHS) versus a revised and user-tested version of the guideline that more clearly promotes the desired actions. Their findings can you buy over the counter propecia demonstrate that changes to guideline design (through addition of actionable decision supports) based on user feedback does in fact trigger changes in behaviour that can improve safety. This is an exciting use of simulation, which we believe should encourage further studies in this vein.Ensuring end users understand and use guidelines as intendedJones and colleagues’ approach affords an opportunity to reflect on the benefits of user testing and simulation of guidelines. The design and evaluation of can you buy over the counter propecia their revised guidelines provides an excellent example of a careful stepwise progression in the development and evaluation of a guideline as a type of decision support for clinicians. First, in a prior study,20 they user tested the original NHS guidelines to improve retrieval and comprehension of information.

The authors produced a revised guideline, which included reformatted sections as well as increased support for key calculations, such as for infusion rates. The authors again user tested the revised guideline, successfully showing can you buy over the counter propecia higher rates of comprehension. Note that user testing refers to a specific approach focused on comprehension rather than behaviour21 and is distinct from usability testing. Second, in the current study, Jones et al evaluated whether nurse and midwife end users exhibited the desired behavioural changes when given the revised guidelines (with addition can you buy over the counter propecia of actionable decision supports), compared with a control group working with the current version of the guidelines used in practice. As a result, Jones and colleagues verify that end users (1) understand the content in the guideline and (2) actually change their behaviour in response to using it.Simulation can play a particularly useful role in this context, as it can help identify problems with users’ comprehension of the guideline and also empirically assess what behavioural changes occur in response to design changes in the guidelines.

The level of methodological control and qualitative detail that simulation provides is difficult to feasibly replicate with real-world pilot studies, and therefore simulation fills a critical gap.Jones et al report successful changes in can you buy over the counter propecia behaviour due to the revised guidelines in which they added actionable decision supports. For example, their earlier user testing found that participants using the initial guidelines did not account for displacement volume when reconstituting the powdered drug, leading to dosing errors. A second error with the initial guidelines involved participants using the shortest infusion rate can you buy over the counter propecia provided (eg, guidelines state ‘1 to 3 hours’), without realising that the shortest rate is not appropriate for certain doses (eg, 1 hour is appropriate for smaller doses, but larger doses should not be infused over 1 hour because the drug would then be administered faster than the maximum allowable infusion rate of 3 mg/kg/hour). These two issues were addressed in the revised guidelines by providing key determinants for ‘action’ such as calculation formulas that account for displacement volume and infusion duration, thereby more carefully guiding end users to avoid these dose and rate errors. These changes to the guideline triggered specific behaviours (eg, calculations that account for all variables) can you buy over the counter propecia that did not occur with the initial guidelines.

Therefore, the simulation testing demonstrated the value of providing determinants for action, such as specific calculation formulas to support end users, by showing a clear reduction in dose and rate errors when using the revised guidelines compared with the initial guidelines.The authors also report that other types of medication-specific errors remained unaffected by the revised guidelines (eg, incorrect technique and flush errors)—the changes made did not facilitate the desired actions. The initial can you buy over the counter propecia guidelines indicate ‘DO NOT SHAKE’ in capital letters, and there is a section specific to ‘Flushing’. In contrast, the revised guidelines do not capitalise the warning about shaking the vial, but embed the warning with a numbered sequence in the medication preparation section, aiming to increase the likelihood of reading it at the appropriate time. The revised guidelines do not have a section specific to flushing, but embed the flushing instructions as an unnumbered step in the administration section. Thus, the value of embedding can you buy over the counter propecia technique and flushing information within the context of use was not validated in the simulation testing (ie, no significant differences in the rates of these errors), highlighting precisely the pivotal role that simulation can play in assessing whether attempts to improve usability result in actual behavioural changes.Finally, simulation can identify potential unintended consequences of a guideline.

For instance, Jones and colleagues observed an increase in errors (although not statistically significant) that were not medication specific (eg, non-aseptic technique such as hand washing, swabbing vials with an alcohol wipe). Given that the can you buy over the counter propecia revised guidelines were specific to the medication tested, it is unusual that we see a tendency toward a worsening effect on generic medication preparation skills. Again, this finding was not significant, but we highlight this to remind ourselves of the very real possibility that some interventions might introduce new and unexpected errors in response to changing workflow and practice6. Simulations offer an opportunity to spot these risks in advance.Now that Jones et al have seen how the revised guidelines change behaviour, they are optimally positioned to move forward can you buy over the counter propecia. On one hand, they have the option of revising the guidelines further in attempts to address these resistant errors, and on the other, they can consider designing other interventions to be implemented in parallel with their user-tested guidance.

At first glance, the errors that were resistant to change appear to be mechanical tasks that end users can you buy over the counter propecia might think of as applying uniformly to multiple medications (eg, flush errors, non-aseptic technique). Therefore, a second intervention that has a more general scope (rather than drug specific) might be pursued. Regardless of what they decide to pursue, we applaud their measured approach and highlight that the key takeaway is that their next steps are supported can you buy over the counter propecia with clearer evidence of what to expect when the guidelines are released—certainly a helpful piece of information to guide decisions as to whether broad implementation of guidelines is justified.Caveats and conclusionSimulation is not a panacea—it is not able to assess longitudinal adherence, and there are limitations to how realistically clinicians behave when observed for a few sample procedures when under the scrutiny of observers. Further, studies where interventions are implemented to assess whether they move the needle on the outcomes we care about (eg, adverse events, length of stay, patient mortality) are needed and should continue. However, having end users physically perform clinical tasks with the intervention can you buy over the counter propecia in representative environments represents an important strategy to assess the degree to which guidelines and other decision support interventions in fact promote the desired behaviours and to spot problems in advance of implementation.

Such simulation testing is not currently a routine step in intervention design. We hope it becomes a more common phenomenon, with more improvement work following the example of the approach so effectively demonstrated by Jones and colleagues..

Over the past http://www.wolf-garden.nl/cost-of-cialis-5mg/ 20 years, a large body of research has documented a relationship between higher nurse-to-patient staffing ratios and better patient outcomes, including shorter hospital stays, lower rates of failure to prevent mortality after an in-hospital complication, inpatient mortality for multiple types of patients, hospital-acquired pneumonia, unplanned extubation, respiratory failure and cardiac arrest.1–5 In addition, patients report higher satisfaction when buy propecia uk they are cared for in hospitals with higher staffing levels.6 7To date, most studies have not identified an ‘optimal’ nurse staffing ratio,8 which creates a challenge for determining appropriate staffing levels. If increasing nurse staffing always produces at least some improvement in the quality of care, how does one determine what staffing level is best?. This decision is ultimately an economic one, balancing the benefits of nurse staffing with the other options for buy propecia uk which those resources could be used. It is in this context that hospitals develop staffing plans, generally based on historical patterns of patient acuity.Practical challenges of nurse staffingHospital staffing plans provide the structure necessary for determining hiring and scheduling, but fall short for a number of reasons.

First, there are multiple ways in which patient acuity can buy propecia uk be measured, which can have measurable effects on the staffing levels resulting from acuity models.9 Second, patient volume and acuity can shift rapidly with changes in the volume of admissions, discharges and transfers between units. Third, staffing plans provide little guidance regarding the optimal mix of permanent staff, variable staff and externally contracted staff.The paper by Saville and colleagues10 in this issue of BMJ Quality &. Safety addresses the latter two issues by applying a simulation model to identify the optimal buy propecia uk target for baseline nurse staffing in order to minimise periods of understaffing. Included in this model is consideration of the extent to which hospitals should leverage temporary personnel (typically obtained through an external agency) to fill gaps.

The model acknowledges the likelihood that a buy propecia uk hospital cannot realistically prevent all shifts from having a shortfall of nurses at all times, as well as the reality that hospital managers lack information about the best balance between permanent and temporary staff. In addition, the analysis includes a calculation of the costs of each staffing approach, drawing from the records of 81 inpatient wards in four hospital organisations.The application of sophisticated simulation models and other advanced analyticl approaches to analysis of nurse staffing has been limited to date, and this paper is an exemplar of the value of such research. Recent studies have used machine learning methods to forecast hospital discharge volume,11 a discrete event simulation model to determine nursing staff needs in a neonatal intensive care buy propecia uk unit,12 and a prediction model using machine learning and hierarchical linear regression to link variation in nurse staffing with patient outcomes.13 This new study applied a unique Monte Carlo simulation model to estimate demand for nursing care and test different strategies to meet demand.The results of the analysis are not surprising in that hospitals are much less likely to experience understaffed patient shifts if they aim to have higher baseline staffing. The data demonstrate a notable leftward skew, indicating that hospitals are more likely to have large unanticipated increases in patient volume and acuity than to have unanticipated decreases.

This results in hospitals being more likely to have shifts that are understaffed than shifts that are overstaffed, which buy propecia uk inevitably places pressure on hospitals to staff at a higher level and/or have access to a larger pool of temporary nurses. It also is not surprising that hospitals will need to spend more money per patient day if they aim to reduce the percent of shifts that are understaffed. What is surprising about the results is that hospitals do not necessarily achieve cost savings by relying on temporary personnel versus setting regular staffing at a higher level.Trade-offs between permanent and temporary staffThe temporary nursing workforce enables healthcare facilities to maintain flexible yet full care teams based on patient care needs. Hospitals can use temporary nurses to address staffing gaps during leaves of absence, turnover or buy propecia uk gaps between recruitment of permanent nurses, as well as during high-census periods.

Temporary personnel are typically more expensive on an hourly basis than permanent staff. In addition, over-reliance on temporary staff can have detrimental effects on permanent nurses’ morale and buy propecia uk motivation. Orientations prior to shifts are often limited, which leads to a twofold concern as temporary nurses feel ill-prepared for shifts and permanent staff feel flustered when required to bring the temporary nurse up to speed while being expected to continue normal operations.14 Agency nurses may be assigned to patients and units that are incongruent with their experience and skills—either to unfamiliar units, which affects their ability to confidently deliver care, or to less complex patients where they feel as if their skills are not used adequately.14 15 These issues can create tension between temporary and permanent nursing staff, which can be compounded by the wage disparity. Permanent staff might feel demoralised and expendable when working alongside temporary staff who are not integrated into the social fabric of the staff.16Hospital managers also must be cognisant of the potential quality impact buy propecia uk of relying heavily on temporary nursing staff.

Research on the impact of contingent nursing employment on costs and quality have often found negative effects on quality, including mortality, and higher costs.17 18 However, other studies have found that the association between temporary nursing staff and low quality result from general shortages of nursing staff, which make a hospital more likely to employ temporary staff, and not directly from the contingent staff.19–21 Thus, temporary nurses play an important role in alleviating staffing shortages that would otherwise lead to lower quality of care.22Charting a path forward in hospital management and healthcare researchThe maturation of electronic health records and expansion of computerised healthcare management systems provide opportunities both for improved decision making about workforce deployment and for advanced workforce research. In the area of workforce management, nursing and other leaders have buy propecia uk a growing array of workforce planning tools available to them. Such tools are most effective when they display clear information about predicted patient needs and staff availability, but managers still must rely on their on-the-ground understanding of their staff and their context of patient care.23 Integration of human resources data with patient outcomes data has revealed that individual nurses and their characteristics have important discrete effects on the quality of care.24 25 Future development of workforce planning tools should translate this evidence to practice. In addition, new technology platforms are emerging to facilitate direct matching between buy propecia uk temporary healthcare personnel and healthcare organisations.

One recent study tested a smartphone-based application that allowed for direct matching of locum tenens physicians with a hospital in the English National Health Service, finding that the platform generated benefits including greater transparency and lower cost.26 Similar technologies for registered nurses could facilitate better matching between hospital needs and temporary nurses’ preparedness to meet those needs.Analytical methods that fully leverage the large datasets compiled through electronic health records, human resources systems and other sources can be applied to advance research on the composition of nursing teams to improve quality of care. As noted above, prior buy propecia uk research has applied machine learning and discrete event simulation to analyses of healthcare staffing. Other recent studies have leveraged natural language processing of nursing notes to identify fall risk factors27 and applied data mining of human resources records to understand the job titles held by nurses.28 Linking these rapidly advancing analytical approaches that assess the outcomes and costs of nurse staffing strategies, such as the work by Saville and colleagues published in this issue, to data on the impact of nurse staffing on the long-term costs of patient care will further advance the capacity of hospital leaders to design cost-effective policies for workforce deployment.Guidelines aim to align clinical care with best practice. However, simply publishing a guideline rarely triggers behavioural changes to match guideline recommendations.1–3 We thus transform guideline recommendations into actionable tasks by introducing interventions that promote behavioural changes meant to produce guideline-concordant care.

Unfortunately, not much has changed in the 25 years since Oxman and colleagues concluded that we have no ‘magic bullets’ when it comes to changing clinician behaviour.4 In fact, far from magic bullets, interventions aimed at increasing the degree to which patients receive care recommended in guidelines (eg, educational interventions, reminders, audit and feedback, financial incentives, computerised decision support) typically produce disappointingly small improvements in care.5–10Much improvement work aims to ‘make the right thing to do the easy thing to do.’ Yet, design buy propecia uk solutions which hardwire the desired actions remain few and far between. Further, improvement interventions which ‘softwire’ such actions—not guaranteeing that they occur, but at least increasing the likelihood that clinicians will deliver the care recommended in guidelines—mostly produce small improvements.5–9 Until this situation changes, we need to acknowledge the persistent reality that guidelines themselves represent a main strategy for promoting care consistent with current evidence, which means their design should promote the desired actions.11 12In this respect, guidelines constitute a type of clinical decision support. And, like all decision support interventions, guidelines buy propecia uk require. (1) user testing to assess if the content is understood as intended and (2) empirical testing to assess if the decision support provided by the guideline does in fact promote the desired behaviours.

While the processes for developing guidelines buy propecia uk have received substantial attention over the years,13–18 surprisingly little attention has been paid to empirically answering basic questions about the finished product. Do users understand guidelines as intended?. And, what version of a given guideline engenders buy propecia uk the desired behaviours by clinicians?. In this issue of BMJ Quality and Safety, Jones et al19 address this gap by using simulation to compare the frequency of medication errors when clinicians administer an intravenous medication using an existing guideline in the UK’s National Health Service (NHS) versus a revised and user-tested version of the guideline that more clearly promotes the desired actions.

Their findings buy propecia uk demonstrate that changes to guideline design (through addition of actionable decision supports) based on user feedback does in fact trigger changes in behaviour that can improve safety. This is an exciting use of simulation, which we believe should encourage further studies in this vein.Ensuring end users understand and use guidelines as intendedJones and colleagues’ approach affords an opportunity to reflect on the benefits of user testing and simulation of guidelines. The design buy propecia uk and evaluation of their revised guidelines provides an excellent example of a careful stepwise progression in the development and evaluation of a guideline as a type of decision support for clinicians. First, in a prior study,20 they user tested the original NHS guidelines to improve retrieval and comprehension of information.

The authors produced a revised guideline, which included reformatted sections as well as increased support for key calculations, such as for infusion rates. The authors again user tested the revised guideline, successfully showing buy propecia uk higher rates of comprehension. Note that user testing refers to a specific approach focused on comprehension rather than behaviour21 and is distinct from usability testing. Second, in the current study, Jones et al evaluated whether nurse and midwife end users exhibited the desired behavioural changes when given the revised guidelines (with addition of buy propecia uk actionable decision supports), compared with a control group working with the current version of the guidelines used in practice.

As a result, Jones and colleagues verify that end users (1) understand the content in the guideline and (2) actually change their behaviour in response to using it.Simulation can play a particularly useful role in this context, as it can help identify problems with users’ comprehension of the guideline and also empirically assess what behavioural changes occur in response to design changes in the guidelines. The level of buy propecia uk methodological control and qualitative detail that simulation provides is difficult to feasibly replicate with real-world pilot studies, and therefore simulation fills a critical gap.Jones et al report successful changes in behaviour due to the revised guidelines in which they added actionable decision supports. For example, their earlier user testing found that participants using the initial guidelines did not account for displacement volume when reconstituting the powdered drug, leading to dosing errors. A second error with the initial guidelines involved participants using the shortest infusion rate provided (eg, guidelines state ‘1 to 3 hours’), without realising that the shortest rate is not appropriate for certain doses (eg, 1 hour is appropriate for smaller doses, but larger doses should buy propecia uk not be infused over 1 hour because the drug would then be administered faster than the maximum allowable infusion rate of 3 mg/kg/hour).

These two issues were addressed in the revised guidelines by providing key determinants for ‘action’ such as calculation formulas that account for displacement volume and infusion duration, thereby more carefully guiding end users to avoid these dose and rate errors. These changes to the guideline triggered specific behaviours (eg, calculations that account for all variables) that did buy propecia uk not occur with the initial guidelines. Therefore, the simulation testing demonstrated the value of providing determinants for action, such as specific calculation formulas to support end users, by showing a clear reduction in dose and rate errors when using the revised guidelines compared with the initial guidelines.The authors also report that other types of medication-specific errors remained unaffected by the revised guidelines (eg, incorrect technique and flush errors)—the changes made did not facilitate the desired actions. The initial guidelines indicate ‘DO NOT buy propecia uk SHAKE’ in capital letters, and there is a section specific to ‘Flushing’.

In contrast, the revised guidelines do not capitalise the warning about shaking the vial, but embed the warning with a numbered sequence in the medication preparation section, aiming to increase the likelihood of reading it at the appropriate time. The revised guidelines do not have a section specific to flushing, but embed the flushing instructions as an unnumbered step in the administration section. Thus, the value of embedding technique and flushing information within the context of use was not validated in the simulation testing (ie, no significant differences in the rates of these errors), highlighting precisely the pivotal role that simulation can play in assessing whether attempts to improve usability result in actual behavioural changes.Finally, simulation can identify potential unintended consequences buy propecia uk of a guideline. For instance, Jones and colleagues observed an increase in errors (although not statistically significant) that were not medication specific (eg, non-aseptic technique such as hand washing, swabbing vials with an alcohol wipe).

Given that the revised guidelines were specific to buy propecia uk the medication tested, it is unusual that we see a tendency toward a worsening effect on generic medication preparation skills. Again, this finding was not significant, but we highlight this to remind ourselves of the very real possibility that some interventions might introduce new and unexpected errors in response to changing workflow and practice6. Simulations offer an opportunity to spot these risks in advance.Now that Jones et al have seen how the revised guidelines change behaviour, they are buy propecia uk optimally positioned to move forward. On one hand, they have the option of revising the guidelines further in attempts to address these resistant errors, and on the other, they can consider designing other interventions to be implemented in parallel with their user-tested guidance.

At first glance, the errors that were resistant to change appear to be mechanical tasks buy propecia uk that end users might think of as applying uniformly to multiple medications (eg, flush errors, non-aseptic technique). Therefore, a second intervention that has a more general scope (rather than drug specific) might be pursued. Regardless of what they decide to pursue, we applaud their measured approach and highlight that the key takeaway is that their buy propecia uk next steps are supported with clearer evidence of what to expect when the guidelines are released—certainly a helpful piece of information to guide decisions as to whether broad implementation of guidelines is justified.Caveats and conclusionSimulation is not a panacea—it is not able to assess longitudinal adherence, and there are limitations to how realistically clinicians behave when observed for a few sample procedures when under the scrutiny of observers. Further, studies where interventions are implemented to assess whether they move the needle on the outcomes we care about (eg, adverse events, length of stay, patient mortality) are needed and should continue.

However, having end users physically perform clinical tasks with the intervention buy propecia uk in representative environments represents an important strategy to assess the degree to which guidelines and other decision support interventions in fact promote the desired behaviours and to spot problems in advance of implementation. Such simulation testing is not currently a routine step in intervention design. We hope it becomes a more common phenomenon, with more improvement work following the example of the approach so effectively demonstrated by Jones and colleagues..

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