By I. Pranck. Drew University.

From the states’ per- be expressed as the difference between observed and spective generic zanaflex 2 mg without prescription, buying private long-term care can reduce the expected outcomes discount zanaflex 2mg mastercard. Hence many access to data that can describe the clinical course asso- states have tried to create inducements for older people ciated with typical care and with the care actually being to buy such coverage 2 mg zanaflex for sale, usually offering to exclude more rendered zanaflex 2 mg on-line. It LTC workers may readily become discouraged and dis- offers a means to assure that assets will not be depleted satisfied from seeing decline in so many of their clients effective zanaflex 2 mg. Without some means of appreciating the differences their The better the LTC coverage offered under Medicaid, care is making on the lives of those they care for, they the fewer the incentives to purchase LTC insurance. It may assume a reaction of learned helplessness, feeling would be perverse public policy, however, to make that their efforts cannot change the course of their Medicaid-covered care so unattractive to induce more charges. As new forms of care emerge, such as the nursing home model, which combines room and assisted living, those in the nursing home arena cry foul, board with services. An alternative formulation would claiming that assisted living is allowed to live under a dif- have public funds cover only the services component of ferent (i. On the other hand, if assisted LTC, leaving the responsibility for the housing aspect to living is required to meet all the mandates of nursing the individual. This formulation has several potential home care, it will inevitably become nursing home advantages. It could lay the groundwork for a universal care and any possible benefits will be lost. It could allow a the emphasis away from mandating components and more even footing for comparing the costs and value of methods of care to accountability for case-mix-adjusted different modalities of LTC. The Long and the Short of Long-Term Care 109 to offer a reasonable living situation as well as the req- Table 10. All care would LTC expenditures to HCBS (%) offer the same range of services to people living in a Total Medicaid variety of settings with varying levels of amenities. The latter would reflect their affluence but would not affect Alaska 47 14 Oregon 46 44 the receipt of care. Idaho 37 28 Another direction being explored is to translate public New York 34 34 obligations for financing LTC into strict accounts. Those California 33 21 eligible for such payments would be given the option of West Virginia 28 28 in effect cashing out their benefits by receiving a cash North Carolina 28 27 Texas 28 25 payment in lieu of services. This arrangement has been Arkansas 26 24 used in several European countries, most notably Maryland 9 6 Germany, which has a universal long-term care insurance New Hampshire 9 8 program. Traditionally, it has Ohio 8 6 South Dakota 7 3 been quite deeply discounted (paying only about 65% of Rhode Island 7 6 estimated costs). People’s willingness to accept such a Mississippi 7 5 deep discount raises interesting questions. Either the cost Louisiana 7 6 of LTC is overpriced or many people expect that they can North Dakota 7 3 obtain these services less expensively from informal Pennsylvania 7 0. These cash and counseling programs raise a number of Source: State LTC Profiles Report, 1996. Historically, public agencies have had a much harder time relinquishing responsibility compared to the relationship between private agencies and clients. The extent of balance in current long- this vulnerability, public agencies are reluctant to simply term care programs varies widely across the states. Instead, they prefer to provide some vanguard states, such as Oregon and Washington, have sort of vouchers that would limit the range of services made deliberate efforts to redirect Medicaid expendi- that could be bought or to insist on some sort of coun- tures from nursing homes to community care, including seling to enhance the likelihood of wise decisions. The institutional options like assisted living, but most states other large concern is the so-called woodwork effect. The range in expenditures on However, the offer of cash should prompt more people home- and community-based services (HCBS) as a to demand care (or its cash equivalent) and hence raise percentage of total LTC expenditures runs from 47% the overall costs. The proportion of expendi- tures is generally quite similar for Medicaid funds, but there are some exceptions (e. If long-term care is acknowledged as a social construct, A commitment to a balanced LTC program requires then the goal should be to improve the lives of the people both the creation of options for care and the flexibility to served. From this starting point, planning the future spend money on a variety of services. While one might would better start from the vantage point of the type of expect the market to respond to more flexible payment care we want rather than how to revise what we have. We policies, some proactive effort from the state seems to be need a wider array of choices that can provide care required to provide assurance of demand as an induce- at varying levels of intensity, combined with housing ment for innovation. The housing can be the client’s The debate goes on as to whether LTC should continue or congregate housing may be needed, either to meet a to be a state-level issue or should move toward a more person’s needs for housing or because colocation is national standard.

Instead of the time-worn "testing cheap zanaflex 2mg on line, one purchase zanaflex 2mg visa, two cheap zanaflex 2mg without a prescription, three generic 2mg zanaflex amex, testing" generic zanaflex 2 mg on-line, I would recommend "Peter Piper picked a peck of pickled pepper" to sort out the pops from the snaps and crackles. The lapel microphone may be a marvel of miniaturisation, but it can cause tons of trouble. First, there’s the agony of where to clip it – a particular challenge for presenters without lapels. Women often find themselves in this awkward situation – and occasionally have to resort to holding the thing in position. With a radio microphone, the box of works can provide an even more difficult problem. But if there is no podium, or if you’re standing at the overhead projector, you could find yourself with both hands full. I remember one particular female presenter who performed a remarkably nimble impromptu juggling act with a clip-on microphone, its black box, and a profusion of wildly haphazard overheads. And then there is the pitfall of failing to disconnect 47 HOW TO PRESENT AT MEETINGS yourself at the end of your talk. This can either result in half your apparel being yanked away as you attempt to leave the podium, or, with a radio mike, the much more disastrous consequence of inadvertently leaving the thing switched on and accidentally telling everyone what dumb questions you felt you’d just been asked. By that I don’t mean you have to don your best Armani – which might provoke antibodies in some quarters. I mean looking self-assured and confident, knowing how to stand and move, and generally having poise and style. If you appear to be comfortably in command of the situation it will help people focus more on what you have to say rather than the struggle you’re having saying it. What would be appropriate for a small informal lunchtime session for GPs might not be at all right for an international conference. My advice is to try to strike a balance between what you perceive is expected by the organisers, and what you feel comfortable in. If there is a golden rule, I would say it’s not to wear anything that either distracts or detracts from the message or impression you want to put across. So, fight temptation and leave that favourite ultra-loud tie or those knock-’em-dead sparklers firmly at home. Standing and moving It was once rather unfairly observed of the accident-prone US ex-President Gerald Ford that he couldn’t walk down stairs and chew gum at the same time. Certainly many speakers do develop acute dystaxia when they get up on stage and have to cope with talking, following their notes, pressing buttons, changing overheads and pointing at things on the screen, all more-or-less simultaneously. I’ve already mentioned being familiar with the set-up, so that you know exactly which buttons to press. It also pays to have your notes (if you have any) clearly page-numbered, with bold headings, so that you can quickly navigate your way through them and instantly find your place again when you look up at your 48 HOW TO APPEAR ON STAGE audience. Overheads should have their backing sheets already removed (to avoid them looking too freshly made), and be interleaved with plain paper (so you can see what they are, and also to prevent them sticking together). They should be numbered (just in case you drop the lot) and, if possible, already placed in position on the OHP projector side-table, with a space to stack them again after use. As soon as you hear yourself being introduced, go straight into successful presenter mode and walk confidently up those steps, smiling at the chairman who hopefully has said a few nice things about you. When you reach your position, place your notes, check the microphone, smile at the audience, and launch forth. If you’re using slides or computer graphics, the chances are you’ll be speaking from the podium. Not only does it conveniently hold your notes, but it also gives you something to lean on in a casual, relaxed fashion, emanating calm professionalism. And it’s a shield that you can literally and metaphorically hide behind, so that you don’t feel so exposed. They much prefer the freedom to move about, made possible either by a radio microphone or a very loud voice. This provides a wonderful opportunity to be more expressive, engaging and even dramatic. If you do too much strutting and fretting, it can divert attention from what you’re trying to communicate.

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The overlap must be substantial in order to support a shared endeavor zanaflex 2mg generic, although absolute convergence does not seem necessary best zanaflex 2 mg. In fact purchase zanaflex 2mg on line, patients purchase zanaflex 2 mg overnight delivery, for instance buy cheap zanaflex 2mg on line, are often very forgiving toward doctors who have multiple responsibilities and cannot immerse themselves wholly in the patient’s particular situation. Such generosity represents an openness of patients to admit consideration of others as relevant. Similarly, physicians and other caregivers should recognize that patients have more than one concern; and in particular, that they have lives outside of their illnesses which not only are ongoing, but which in the large determine the very importance of dealing with the illness at all. We are not, despite what our doctors might think, illnesses with lives secondarily attached any more than we should be, for our dentists, teeth which coincidentally are in people. Mutual forbearance and accommodation of the differences for participants in overlapping situations helps minimize friction caused by incongruities. Any pretense that participants are not engaged in situations apart from the shared one at front and center is potentially counterproductive. The training and socialization of professionals and the structuring of institutions providing for their work is enhanced when it supports the shared identification of situations between them and their clients. Thus there needs to be constant vigilance regarding conflict of interest as well as encouragement (instead of the usual discouragement) of feedback from clients encouraging accountability, and emphasis on understanding the perspective of others. But no matter how well care systems and training (in the case of medicine) are designed to align the concerns of patients and caregivers, there will always be work to do in particular cases. On occasion, it is easy to step into a well-shared situation as happened once to me when I was walking in to begin my shift at the emergency room. A sweating middle aged man drove under the entrance canopy, opened his door and fell out of the car while clutching his chest and saying: "Help! FULL SPECTRUM MEANS AND ENDS REASONING 157 In other instances, however, mutual participation in a common situation is seriously incomplete, and efforts are needed to bring the parties into a workable alignment. For example, I once treated an older physician who came to the ward with congestive heart failure. He said, "I gave myself a shot of merc2 and it didn’t work, so I came here to die. As he saw it, he needed morphine – not for treatment – but to be comfortable and die in the hospital without excessively distressing his family. Sometimes such adjustments fail, and then either the enterprise must be abandoned or one party must take control coercively. The latter occurs when patients walk out "against medical advice" or physicians take them to court to impose treatment. It also occurs in cases of toxic delirium, psychotic thought disorder and panic, for example, when actions may be required to get the patient out of a situation which she or he cannot assess adequately. States of confusion, obtundation, paranoia and panic may preclude participation on the part of the patient in any constructive response. But for the most part, the appreciation of discordances in the apprehended situation is the job of reflective inquiry, while the matter of resolving them requires dialogue and flexibility. Cultivating the proper degree of mutuality is one task for informal reason in establishing concerted action. Remaining open to the emergence of unnoticed or novel factors which could be relevant is another. Indeed, there can be latent "actual" or highly important situations hidden behind the initially "apparent" ones. Indications that more is going on than we thought can supersede preliminary impressions. For example, a situation can be vastly different than it appears when a caregiver discovers that some of her own important assumptions are not shared by the patient: The patient might not share the physician’s "scientific" view of the causation of symptoms; the patient might have very limited resources–no financial support, no family and no home; the patient could be unusually suspicious and mistrustful;4 the expectations for what can be accomplished might be very discordant between caregiver and patient; differences of economic, cultural or religious background could cause unexpected offense; the patient might be far more expert and up to date on the science of his diagnosis than the physician; threats of violence or of lawsuits could crop up; it might come out that the patient had one of several agendas other than getting better; a family might have exhausted its ability to cope with relatively mundane symptoms or problems; a patient might not be able to communicate honestly in the presence of a friend or family member; and initial investigation could uncover unsuspected, medically serious problems so radically different from those expected that their finding would transform the situation for all concerned. The focus of judgment centered on ascertaining and redefining the relevant situation can be quiescent, but it is always potentially active. Judgments About the Problem5 Whereas a problematic situation is characterized by potential, latent or manifest unease and dissatisfaction, it takes further inquiry to specify the problem as well as what aspects of it can aptly be addressed. In the instances of prevention and discov- ering latent or incipient disease, it even takes inquiry to uncover an unsatisfactory situation about which there is no initial unease. We may actually have to generate worry (a very unpleasant process) to arouse interest in prevention. Just as perceptions of the situation are not usually entirely shared, perceptions of problems among physicians or other caregivers and patients do not entirely overlap. The parties involved must educate one another about unshared aspects of the problems as they see them. In general, patients want relief from symptoms and physicians want diagnoses, although both goals are often shared.

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In addition discount 2mg zanaflex, a small study of 676 subjects demonstrated that coronary artery calcification scores incrementally predicted cardiac events (13) cheap 2mg zanaflex free shipping. These studies purchase zanaflex 2 mg fast delivery, as with the aforementioned larger sample purchase zanaflex 2 mg with visa, were able to show that coronary artery calcification on CT predicted health out- comes (e cheap zanaflex 2mg without a prescription. But of all the studies that have been eval- uated, none has shown any extra value in risk stratification and patient management. Aside from the earlier described reports, there has been a multitude of similar studies with varying patient population that have reached the same conclusion concerning the ability of coronary artery calcium scoring to predict heart disease and mortality (14–19). Other investigators utilized calcium scoring in conjunction with laboratory tests, such as C-reactive protein to model the mortality of heart disease (20), but no interactive effects were noted, although each independently predicted coronary events and mortality. However, a review of the literature to date has failed to iden- tify any direct data suggesting that calcium scoring has any clinical benefit over the current Framingham risk model (21). Currently, coronary artery calcium scoring on CT is utilized as a risk stratification tool for CAD. The major proportion of the data to date has shown that calcium scoring can predict CAD as well as mortality related to heart disease among asymptomatic patients. A literature review did not uncover any data that show that calcium scoring adds any additional infor- mation over current clinical predictive models in the asymptomatic patient. In addition, there have been no studies specifically evaluating the cost- effectiveness of coronary calcium scoring as a screening tool. As a result, calcium scoring, while predictive of CAD and mortality, has yet to be shown to add any additional information over and above current clinical models. Therefore, at this time there is insufficient data to recommend calcium scoring as a screening or risk stratification tool in the asympto- matic population. However, the dearth of cost-effectiveness data precludes stating that calcium scoring should not be preformed as a screening test. Subsequently, additional cost-effectiveness studies should be instituted to evaluate the role of calcium scoring in the screening for CAD. Thus, among high-risk populations calcium scoring cannot be recommended for screening or risk stratification (Insufficient Evidence). Similarly, only the previously described studies could be found to eval- uate the cost-effectiveness of stress echocardiography (28,36,38). However, several other studies evaluating the cost-effectiveness of SPECT were iden- tified in the literature review. In a small patient sample ( 29), SPECT was found to increase the diagnostic ability in cardiologist who were treat- ing emergency room patients with acute chest pain (39). The study also found a decrease in hospitalizations and a savings of $800 per patient (39), although this study had a small sample size and did not rigorously eval- uate cost and outcomes. There was a lower hospitalization rate among patients without coronary ischemia who had undergone a SPECT in the emergency department (42%) versus usual care (52%). The results suggest that SPECT may have an effect on decision making and possibly lower the costs by reducing hospitaliza- tion; however, to date there is insufficient evidence to recommend SPECT in the emergency setting. In conclusion, multiple decision analyses and randomized studies agree that in a low-risk patient a noninvasive study should be preformed prior to an angiogram. Also, the models seem to support stress echocardiogra- phy as the most cost-effective, but also have suggested that SPECT may be as cost-effective depending on the institutional performance. Subsequently, there is little definitive data to use one of these studies over the other. Although there is an early suggestion that SPECT may be useful in the emergent chest pain setting for patient triage, there is not enough data at this time to support this position. Lastly, there is conflicting evidence con- cerning the cost-effectiveness of PET in the diagnosis of CAD and ischemia; more studies are needed to determine the role of PET in the cardiac eval- uation (insufficient evidence). In symptomatic post-MI patients or those at high risk for CAD, coronary angiography is the most cost-effective method to evaluate, diagnose, and plan treatments. But the research to date is somewhat unclear as to the utilization of the aforementioned modalities. The current literature is somewhat limited in the cost-effective evaluations of noninvasive studies. The current literature has limited data on the performance of MR and CT with respect to evaluation of the coronary arteries or for assessment of ath- erosclerosis aside from calcium scoring. However, our literature review found no reports evaluating the cost-effectiveness of either modality.

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