Health Care

This means we have at least 60 “true” measles at present. Measles is said to be eliminated if we have 1 case per million or below 100 cases in a year Maternal and Neonatal Tetanus Elimination 10 areas were classified as highest risk for neonatal tetanus (NT). Figure 3 shows the areas categorized as low risk, at risk and highest risk based on the NT urveillance, skilled birth attendants and facility based delivery and the tetanus toxoid 2+ (TT 2+) vaccination. Figure 3: Level of Risk for NT, Philippines Three (3) rounds of TT vaccination are currently on-going in the 10 highest risk areas.

An estimated 1,010,751 women age 15 – 40 year old women regardless of their TT immunization will receive the vaccine during these rounds. This is funded by the Kiwanis International through UNICEF and World Health Organization. Control of other common vaccine-preventable diseases (Diphtheria, Pertussis, Hepatitis B and Meningitis/Encephalitis secondary to H. influenzae type B) Continuous vaccination for infants and children with the DPT or the combination DPT-HepB-HiB Type B. Annexl EPI Annual Accomplishment Report. DOH procures all the vaccines and needles and syringes for the immunization activities targeted to infants/children/mothers.

Hepatitis B Control Republic Act No. 101 52 has been signed. It is otherwise known as the “Mandatory Infants and Children Health Immunization Act of 2011, which requires that all children under five years old be given basic immunization against vaccine- preventable diseases. Specifically, this bill provides for all infants to be given the irth dose of the Hepatitis-B vaccine within 24 hours of birth. One strategy to strengthen Hepatitis B coverage is to integrate birth dose in the Essential Intrapartum and Newborn Care Package (EINC).

In 2011, 11 tertiary hospitals are already EINC compliant. The goal of Hepatitis B control is to reduce the chronic hepatitis B infection rate as measured by HBsAg prevalence to less than 1% in five- year-olds born atter routine vaccination start Hepa it’s a birth vaccination. Figure 4 Hepatitis B Coverage. Philippines, 2001-2011 Timing of administration/dose 2009 2010* 2011* 4 hours62% 24% Hep B 3rd dose *both 2010

Summary of the case

General Electric Healthcare in the international leading producer of diagnostic imaging equipments, offering medical clinics around the globe a wide variety of products and services designed to improve the quality of medical diagnosis and treatments. In 2005, GE Healthcare had a market share of 34% of the entire diagnosis imaging equipment in the world.

Along time, the producer had undergone major structural changes, all assisted by current Chief Executive Officer Joe Hogan. Founded as Global Product Company (GPC), the company was reorganized as General Electric Medical Systems (GEMS or modified GPC) and then as General Electric Healthcare (GE Healthcare).

During the GPC era, the company was characterized by intense efforts to reduce costs and even swifted production from the United States to other countries that offered less expensive work force. Under the name GEMS, the producer registered immense growth and development, and by the year 2000, had become the leader in the market of diagnosis devices.

Following the model launched by CEO Jeffrey R. Immelt, Global Product Company, excelled in domains such as manufacturing, research and development, product design, sales, marketing and human resources.

The manufacturing of diagnosis devices was generally characterized by managerial attempts to increase efficiency and reduce costs which led to the formation of “Centers of Excellence” in foreign countries. Up to 90% of the products designed in these centers were being sold abroad. The materials used in production comprised 80% of the total costs, and the labor force was payed with the 20% remaining. The primary goals of GPC were to decrease material costs by 30% and labor costs by 50%.

R&D and product design developed new monitoring and diagnosis technologies, but encountered difficulties in efficiently using their human resources. Revenues increased by 60% due to sales of produced devices and services (repairs and healthcare IT systems). The marketing strategies promoted by GPC revolved around customizing their products to best meet the needs of the buying countries. In regard to the human resource policy promoted by GPC, they placed great emphasis on the technical competences of the managers.

Under the name of GEMS, the producer implemented the program In Country for Country which insured that the majority of devices produced within the Centers of Excellence in one country remained in that country. The largest such program was In China for China.

In 2001, GEMS commenced treaties to purchase Amersham, producer recognized for their equipments of early detection of cancer. The newly formed company took the name of General Electric Healthcare. GE Healthcare placed great emphasis on the rapid technological development and stressed out the strong connection between medical research and information technology’s both software applications as well as hardware devices.

Along its existence, General Electric Healthcare has undergone numerous mergers and acquisitions that sustained the manufacturers’ growth. The acquisition of Amersham, finalized in 2004, made GE Healthcare the international leader of produced medical equipments. The new elements brought by the merger regarded an increased sensitivity and specificity, which automatically generated better diagnosis capabilities. Furthermore, the acquisition of Amersham resulted in intense cooperations with pharmaceutical companies, most of them being former partners of Amersham’s.

Issues confronting the company and recommendations

One of the most critical challenges GE Healthcare is currently faced with is keeping up with the developments that occur in the IT and medical domains. A revolutionary discovery of the medical research teams at Harvard Medical School is related to genomics and regards the efficiency of a treatment prior to its commence on a patient. Relevant examples of this challenges are the effects of chemotherapy on cancer patients.

Due to assiduous studies, medicine has proven that genomics could inform doctors of a patient’s response to a certain type of treatment, based on their genes. For instance, a chemotherapy treatment has an efficiency somewhere between 20 and 30 percent. But there is a certain gene mutation (present in about 10% of the population) that increases the efficiency of chemotherapy up to 95%. The current problem is that the tests that identify the certain gene mutation and foresee the efficiency of the treatment are time consuming and a large majority of the terminally ill patients dies before the investigations are complete.

All in all, the problem is that the new innovations in incurable diseases are extremely time consuming, and time is a luxury these patients do not have. There are two directions specialists could follow in order to resolve this problem. First of all, the medical team could work on developing new methods and alternatives to prolong the life expectancy of cancer patients until the genomics test are completed and an informed decision can be made in regard to the treatment.

Secondly, the IT team could work on developing new software applications that speed up the genomics process in order to get the test results as soon as possible. A third measure that could be taken is sustaining a continuous process of informing the population in regard to their health and the importance of

Another issue confronting General Electronic Healthcare is the increased need to develop new equipments that identify the diseases in the patients’ body prior to symptomatic manifestations, task impossible for the current X-rays and MRI devices. In order to meet this growing need, the medical and IT teams have to work together and develop means of increasing the machines sensitivity and specificity while performing tests. The increased sensitivity and specificity would insure a more comprehensive analysis of the patients’ body and would expand the number of early diagnosed illnesses. The acquisition of Amersham has generated better chances of developing equipments with increased sensitivity and specificity, and the struggle to produce the best devices continues to be the main occupation of GE Healthcare.

The following issue confronting GE Healthcare regards the way in which medical doctors perceive the equipments, in the meaning that they do not care for high technology gadgets, but for the functionality of the devices and their assistance in detecting and curing diseases. This again implies a strong work connection between the medical and IT team in order to perfectly combine their skills and retrieve equipments that perfectly meet both technological as well as medical functionality.

And probably the ultimate challenge of GE Healthcare is their current intend to step into the healthcare domain with additional products and services. The manufacturer wants to launch new programs regarding innovative drugs. This desire generates the necessity to develop new business partnerships and emphasize on the existing ones with the pharmaceutical companies. This approach would integrate the pharmaceutical business model into the company’s IT/physics/engineering profile, says Dr. Bill Clarke, former head of the R;D division.

In United States the Congress had passed the Medicare Prescription Drug, Improvement and Modernization Act of 2003 or MMA and with this imposed a stoppage for 18 months on the starting of new physician owned specialty hospitals. At the same time, they also wanted to know the position regarding certain matters of physician owned heart, orthopedic and surgical specialty hospitals through MedPAC. The team visited sites, made legal analysis and met the share owners in these hospitals and finally presented a report to the Congress. It had also gone through the cost reports received from Medicare and inpatient claims of 2002, which was the most recent at that time. This will naturally form the basis of such hospitals being permitted or not. (Physician-owned specialty hospitals)

The findings of this committee showed that:-

Physician owned hospitals generally treated patients who had less severe problems and concentrated on specific diagnosis related groups and the reason for both of this was that these were expected to be more profitable than other patients.

These hospitals do not treat as many Medicaid patients as community hospitals.

Regarding the costs of patients in these hospitals for the patients, the Medicare patients did not get benefits of lower costs though the inpatients had shorter periods of stay.

There was no appreciable impact of physician owned specialty hospitals on the community hospitals as seen in 2002, and there was also no impact on the financial performance of the community hospitals.

Most of the differences in profitability can be rectified by improving the prospective patient system for inpatients that are made by Medicare.

Thus according to the findings there are not major differences between the community hospitals and physician owned specialty hospitals in terms of costs or capability for services. (Physician-owned specialty hospitals)

Differences among types of hospitals:

We shall make comparison of the hospitals in India and USA. In India, apart from the government hospitals, there are a number of large hospitals run by trusts or large corporations. In the city of Bombay or Mumbai, the hospitals named Jaslok or Hinduja are run by trusts and Wockhardt Heart Hospital is run by a major pharmaceutical company. Even when the hospital has been promoted by a physician, still the hospital is run like a corporation as is seen in the case of Apollo Hospitals.

There is now a new hospital named as Asian Heart Hospital in Bombay which has been promoted by a physician team and they have a large stake in the hospital. The team of physician is led by one Mr. Panda who is now the CEO of the hospital. These physicians have all invested their own funds, and to get more funds, they have even asked for more contributions from other physicians who are now not resident in India. The hospital is the result of a plan by these physicians in 1993-94. The hospital took about 10 years to complete. Thus one should realize that a hospital takes a long time to take shape up. (Doctors in arms)

The biggest problems in the management of hospitals come from physicians and renowned physicians are sought for empanelment by hospitals. The physicians then continually force the hospitals to upgrade their infrastructure and also charge heavy fees from the patients. At the end of the services by the physicians, it is they who get the biggest returns. It is also difficult to retain the physicians as they leave at the earliest opportunity, and this statement is from one of the promoters of the hospital, GW Capital. They are now investing money in the concept of physician managed private hospitals. This resulted in its investment of Rs 150 million or about 3 million dollars in buying a 26 percent stake in another hospital group in Hyderabad, in 2000 called the Care Group.

That group has expanded very fast and now has over a 1000 beds in its operations in six centers. (Doctors in arms) Thus the costs of the hospitals will require about 12 million dollars for a 1000 bed operation. At the same time, not all hospitals are made with money in mind and there are hospitals in Chennai or Madras in India which have 150 physicians, 500 nurses and 371 Para-medical staff. The entire team works within a budget of Rs 120 million or 2.4 million dollars. (Healing Ministry of the Madras Diocesan Medical Board) This hospital is run by a religious mission and its objective is to provide service to the people and this hospital does not want to make money, but run at break even costs.

In United States, during 2002 there were 48 hospitals found to be physician owned hospitals. Of them 12 were heart hospitals, 25 were orthopedic hospitals and 11 were surgical hospitals. These hospitals are generally very small with average capacities of orthopedic hospitals being 16 beds, the surgical specialty hospitals being 14 beds and heart hospitals are the largest with average capacity being 52 beds. The general conditions of these hospitals are not full fledged as they do not have emergency departments, whereas 93 percent of the community hospitals have emergency departments. The reason for existence of these hospitals is the physician control over the hospitals. (Physician-owned specialty hospitals) At the same time, one of these hospitals has been named as one of country’s top 100 heart hospitals. (Parkwest Medical Center)

Financial position of private hospitals:

According to available reports, the private hospitals are in a position to take on patients who are capable of paying for them, and not take on patients who have to depend on managed care organizations. This increases the incomes of the hospitals by 20 to 50 percent. This reduces the cost of a bypass surgery at one of the hospitals in India, Care to about Rs 80,000 or $1,700. The cost in India is higher by about 30 to 40 percent in corporate hospitals.

Even the new hospital, Asian Heart has predicted a cash break even during the second year of operations, and by the end of the second year it expects to pay a 15 percent dividend to the investor. Thus on an investment of $50 million, the returns would be $7.5 million from the second year. (Doctors in arms) The position in United States is the same, and in spite of some private specialty hospitals not having made any distributions to stockholders, the study showed that the margin in these hospitals was about 13 percent in 2002 as compared to 3 to 6 percent that was seen for community hospitals. (Physician-owned specialty hospitals)

The advantages of physician owned specialty hospitals:

To find this aspect out, there were discussions with the physicians who were investing in these hospitals. The cardiologists and surgeons want to admit their patients, perform the required procedures and have the patients recover with minimum disturbance. They believe that community hospitals cannot match their services as those hospitals have a variety of services and missions that they have to undertake.

The direct control by the physicians help to increase productivity through less disturbances to the schedules in operating room which come from the emergency cases that come about, decreasing the down time between operations between two different surgeries and this is due to cleaning the operating room more efficiently, increased ability to work between two operating rooms even when the operating rooms are blocked due to some other work and better efficiencies through direct control of operating room staff.

As mentioned earlier, they also like to form specialty hospitals as they have increases in income. There is some increase due to productivity, but they are able to collect a share of the profits from the facility for themselves and other associated physicians. They concentrate on providing services that are profitable, on treating patients who are less sick and thus more profitable. (Physician-owned specialty hospitals) Even in India the same situation exists and most of the physicians who have now started developing hospitals have been working together earlier, and one of the main aims is to remove the pressure from managed health care systems that they have to face otherwise.

There is now a distinct change in the formation of hospitals and new hospitals are being formed by physicians. The total costs have been discussed to some extent, but without the participation of physicians, the hospitals are unlikely to be successful.

The deliberative model in healthcare is expected to meet quite a few of the needs of the American public regarding the general area of healthcare. Of the many areas that may decide to look at this problem, an attempt is made here to look at two specific problems. One is the need of patients taking medicine properly and the other is the needs of patient care among all Americans. The problems in taking medication have been taken up on the issue of individual needs of patients for education on medicine taking. The education needs of patients in this area are not being met by healthcare providers.

It may be worthwhile to take up a study to develop medication taking instructions for patients which can be used by health care providers in the long run. The aim should be to reach an approach which will be based on the view of patients regarding their needs of taking medicine and at the same time, also taking into account the concerned theories for health and education. The problem has been accentuated by the development of new medicines for the treatment of problems in diseases. This is clear when one notices that in Canada it self, 167 new drugs were introduced in the period from 1997 to 2001.

This has led to the total number of drugs in the market reaching a figure of over 3,000. This shows that there is no shortage of drugs, yet a large number of patients are not being able to get the benefits that the medicines are expected to give. In one study it was seen that about 12% of the cases of hospitalization that are taking place now could be avoided if the condition of the patient was properly managed when the patient was undergoing treatment at home. They could have been cared for by family physicians, nurses and pharmacists.

This is further accentuated with the knowledge given by another study that 43% of these avoidable admissions were in the area of some chronic diseases like asthma, diabetes or heart failure. These diseases require patients to use medicines over a long term. This shows clearly that patients with chronic diseases are being hospitalized regularly when they could have been cared for in the home by doctors working outside the hospitals. (Bajcar, 2003) When the patients are put on medicines, they should receive the maximum benefits from their medicines.

For this purpose, the first point is the correct procedure of prescribing the medicine for the patient along with the dosing requirements. The second part is that these medicines have to be taken and this has to be done properly. This is generally decided by the patient. It has been seen in many instances that the process of preparing the prescriptions is not linked correctly to the process of taking the medicines. This often leads to the future hospitalization of the patient. During an analysis that was done recently it was seen that pf the total number of admissions to hospitals in recent times, 7. % were directly caused by the medicines that were taken by the patient or the failure of the medicines to act or the medicines were not taken properly by the patients.

Further it was seen that 59% of these admissions could have been avoided as the causes were due to inappropriate care or errors in medication. In medical terms, the adverse effects on patients are called drug related morbidity and mortality. The cost of drug related morbidity and mortality in United States during 1995 to the healthcare system was $76. 6 billion. These costs have been rising at a very fast rate and the costs in 2000 went to a figure above the $177 billion mark.

This also showed that hospital admissions related to drug related morbidity and mortality was now above 70% of the total costs. (Bajcar, 2003) The major cause behind this problem is the shortcoming in patient education as felt by the patients, though the groups of healthcare professionals at different levels are trying to give a lot of importance to it. The patients say that they are not given enough information about the side effects of medication, risks of medication, the choices that they have about medication and the period for which the medication should be taken.

This problem has been realized and the differences which are being caused by the differences in the approach of the health care professional and patient requirements are being sorted out. The problem is the greatest for patients who are on long term medication. (Bajcar, 2003) The shortage of information to patients is because of not getting enough information, or not receiving the information they want, or not receiving the information in a manner that gives the patients a chance to ask questions or seek involvement from the patients, or providing them information that is suitable for their special needs.

The difference is in what information the patients want and what information the health care professionals feel they should be given. There is a clear change among patients that they are informed about their healthcare, and this is line with the present day thinking that healthcare is centered on the patient, increase the participation of the patient, and give the patients greater powers. This will enable the patients to take better decisions.

The problem is compounded by the fact that there is no proper literature regarding the education needs of patients, who are on long term medication. This does not permit an analysis of the education needs of these patients. At present the emphasis regarding education on medication taking by the patients has the greatest focus on the information to be provided by the healthcare professional and does not consider the educational aspect.

The teachings to the professionals consist of sets of guidelines given to professional or a set of questions to be asked of the patient. These are not related to the understanding of how the patient is taking the medicine. This is leading to a situation where the medication taking practices of patients on long term medication is remaining underdeveloped, and this is also keeping in dark the relationship between the actual medication consumption and the final effects that the medication is providing.

There are definite needs for the development of a model for education of patients regarding their taking of medicine, and for the present levels of knowledge are not adequate. (Bajcar, 2003) A similar area where there is a lack of communication between the doctors and the patients is in the area of health insurance. This is reflected from the continuous rise in numbers of Americans without insurance and these are causing poor access to health care systems in the country.

It is seen that about 20% of the people in the country are not able to pay healthcare bills, and an even higher proportion of 25% forgo medication based on cost. This ultimately results in deaths of the order of 18,000 a year as was seen in 2000. There are certainly troubles that are being caused to individuals, but even the society is suffering. The costs of care for the patient keep increasing, and the final cost has to be met by the government which is reflected on the average citizen. (Will Insured Citizens Give Up Benefit Coverage to Include the Uninsured? )

According to the Centers for Disease Control and Prevention, asthma is a complex disease on the rise in the United States. Most at risk include poor or inner city minorities that present with inordinately high rates of mortality resulting from the condition (CDC, 2005). Asthma may also be on the rise due to environmental factors including increased pollution and exposure to environmental toxins that may affect lung capacity (CDC, 2005; Hwang et. al, 2005; Yang, et. al, 1997; Wickman, et. al, 2003).

Asthma is a serious, potentially life threatening condition for the millions of sufferers worldwide. Doctors are still working to determine the cause of this disease and finding new ways to treat it. While there is no cure for asthma yet, researchers have uncovered multiple treatment alternatives that help patients with asthma effectively control their condition.

Education, public response and intervention are all critical success factors for predicting the quality of life for patients with asthma now and in the future. Research supports the use of a defined set of treatment protocols for assisting patients with asthma lead a better quality of life. The basis for treatment, anatomy and physiology of the respiratory tract and pathology of asthma in patients are all discussed in greater detail below.

Normal Lung Function and Respiratory System

The human body has two lungs located on either side of the chest. The lungs functions include passing oxygen from outside the body into our bloodstream and releasing waste materials in the form of carbon dioxide back into the environment (Gershwin & Klingelhofer, 1992). During each breath the body inhales oxygen and exhales carbon dioxide (Polk, 18). Oxygen combines with carbohydrates and fat in the body to product energy. During the process of creating energy water and carbon dioxide are formed that are expelled through breathing.

The lungs consist of several anatomical structures including the bronchial tubes that enable expansion and constriction of the muscles in the lungs and chest. These tubes consist of muscles that allow air to pass deep in to the lungs. Bronchial tubes consistently change width, increasing in girth as an individual inhales and becoming narrower upon exhalation. In a person with a well functioning respiratory system all parts of the airway function synergistically to ensure maximum intake of oxygen and exhalation of carbon dioxide with each breath.

Air enters the body through the nose and mouth. It passes through the pharynx, larynx and trachea, all important parts of the airway (Polk, 18). The noses and sinuses act as conditioners adjusting the air temperature as it passes through other structures in the airway. The pharynx or back of the throat allows liquids and solids entering the airway to “drop out before entering the lungs” (Polk, 19). Likewise the larynx helps prevent other unwanted particles in the air from entering the lungs (Polk, 19). It is here that the body’s cough reflex lies. If something unwanted is present in the air being inhaled, the larynx will stimulate a cough reflex to help expel the object. While the larynx isn’t the only trigger for a cough reflect it is very important to the entire breathing process (Polk, 19).

When a person inhales, the chest muscles in the body contract allowing the ribs to separate slightly. Air is then drawn into the lungs. The opposite happens when an individual exhales, allowing air to forcefully come out of the lungs. The abdomen is also involved in breathing. The abdomen attaches to the front and back of the ribs, pushing them up and out when breathing. Breathing thus incorporates the chest and abdomen. The more a person engages all the muscles and organs involved in respiration including the abdomen, the better able they are to take a full breath of air.

In times of old doctors ascribed asthma to anyone having difficulty breathing regardless of the cause; during the 20th century however researchers refined asthma to include difficult breathing “Because of a problem that begins in the bronchial tubes of the lungs” (Polk, 15). Asthma is a complex disorder that doctors are still working to fully understand. While doctors have uncovered many potential causes for asthma, they are still not certain what exactly causes it and how to prevent it 100 percent in all patients.

In patients with asthma, the ability of the bronchial tubes to adjust their width is often diminished, resulting in difficulty breathing. Children are often at increased risk for developing asthma, as their bronchial tubes are narrower to begin with than adult tubes, thus less change in width is evident even in healthy lungs.

Exercise induced asthma is a form of asthma that results when the air present in the nose and sinuses isn’t prepared appropriately to pass through other parts of the airway (Polk, 19). Normally this form of asthma is easier to treat than severe forms of asthma whose cause is unknown (Hogshead, 1989; Guyton, 1991).

During a bronchospasm attach involuntary spasms may prevent lung tissue from expanding to their normal size. Air can become trapped in the lungs. Cellular and structural changes often occur within the airway and lungs of patients with asthma, including thickening of the airway wall and inflammation (Saetta & Turato, 2001).

Normally as air passes through the lungs the bronchiols or airways get smaller. In a patient with uncontrolled asthma however, the sides of the airways typically become enlarged or inflamed (CDC, 2005). During an acute attack, the muscles or bronchiols surrounding the airways constrict, thus reducing the amount of air a person can pass in and out of their lungs (CDC, 2005). Once this constriction begins, mucus starts forming in the airways, causing even greater constriction and distress. Typical symptoms associated with an asthma attack include wheezing, chest pain and tightness, coughing and difficulty breathing (CDC, 2005).

No one is immune from asthma. Children, adults and the elderly are all at risk. Some people are more at risk than others including people who smoke, those with seasonal allergies and anyone with recurring acute respiratory infections (CDC, 2005). Signs of asthma include physical qualities of the disease a patient, family member or doctor can easily identify such as dyspnea (trouble breathing) (Polk, 7). Symptoms include complaints generally associated with the condition, and may include headaches or chest pain, skin flushing and itching (Polk, 8). Dyspnea results from multiple conditions other than asthma including infections, allergies, foreign bodies present in the airway and associated factors (Polk, 8). It is important a clinician differentiate between asthma and other causes of the disease.

Basis Contemporary Treatments For Managing Asthma

The National Asthma Education and Prevention Panel consistently work with doctors to develop contemporary treatments to manage asthma (Moonie, et. al, 2005). Many of these treatments are based on empirical research that supports reduction of patients symptoms and prevention of chronic attacks. The goal of contemporary asthma care and treatment includes “control of asthma and good quality of life for asthmatic patients” (Gaga, et. al, 80). The basis for much of contemporary care is empirical based research, though trends are changing in an attempt to encourage doctors to improve patient awareness and education.

Many asthma drugs historically are administered through inhalation. Inhalers are often prescribed “on an empirical basis rather than on evidence based awareness: (Virchow, 24). Much of the asthma management guidelines currently available offer “non-specific advice regarding inhaler choice” (Virchow, 24). As such it is important that GP work with patients to decide what the ideal inhaler is for all patients involved. The ideal inhaler according to Virchow (2005) is one that

1. is breath activated, “releasing medication only when all prerequisites for successful inhalation are met,
2. has a low intrinsic airflow resistance so children and elderly patients may use it and
3. is one that provides a flow-independent deposition of drugs in the lungs as well as feedback that reassures patients whether the drugs has been inhaled properly.

Newman (2005) suggests the pressured metered-doze inhaler or pMDI delivers asthma medications in a reliable “multi-dose presentation” (1177). Key components of this devices help determine the amount of drug delivered to the patient. The researcher further suggests that pMDIs can be developed that are breath actuated and coordinated with “spray-velocity modifiers” to help patients unable to use “conventional press and breathe pMDI’s correctly” (Newman, 1177). Modern or contemporary pMDI’s according to Newman should also contain non-ozone depleting propellants, a sentiment confirmed by Virchow (2005) as well.

Patients with severe refractory asthma require more comprehensive treatment. High-doses of inhaled corticosteroids are often insufficient for treating this form of asthma. Most require contemporary treatments including oral corticosteroid administration and use of immunosuppressants (Sano, Adachi, Kiuchi & Miyamoto, 2005). Chronic use of these drugs however present a high risk for adverse side effects. A study conducted by Sano, et. al (2005) suggests that nebulized sodium cromoglycate “is expected to be a new second-line therapeutic option in severe asthma” (1).

Gaga, et. al (2005) suggests that many doctors are not achieving good quality of life and control of asthma for patients. Their study of treatment outcomes for asthmatic patients in specialized care suggests that contemporary treatments should include more patient education combined with increased use of LABAs (Long-acting beta2-agonists) and leukotriene antagonists to help prevent bronchoconstriction and improve quality of life for patients.

Despite multiple contemporary treatment choices, managing acute severe asthma attacks still present a tremendous health challenge to health care professionals (Barnard, 2005). Contemporary guidelines for treating acute emergency attacks currently include treatment with oxygen and inhaled beta 2 agonists, which can be administered continuously to help preserve life in acute patients (Barnard, 532). Patients discharged after such treatment should also engage in review of current medications and consider “a short course of oral steroids, a written asthma action plan and detailed advice about deterioration that may occur within 48 hours” (Barnard, 533).

Butz et. al, (2005) are among a growing body of contemporary researchers that suggests that self management and patient education are critical success factors for treating patients with asthma in modern society. Their studies suggested home based educational programs that focus on accurate symptom identification and demonstration of “asthma medication delivery services” may improve patient quality of life and assist children with asthma and asthma like conditions (Butz, et. al, 190).

Delaronde, Peruccio & Bauer (2005) find that “individualized telephonic case management” from registered nurses specifically trained in contemporary asthma treatment may improve asthma medication use and subsequent quality of life for patients with asthma (361). This research correlates with a growing body of evidence supporting patient education and direct support as practical contemporary treatment practices.

The basis for much of contemporary treatment lies in the gold standards or clinical practice guidelines outlined by the National Asthma Education and Prevention Program’s Expert Panel (CDC, 2005). These standards offer patients and health care practitioners specific guidelines for recognizing, diagnosis, treating and providing ongoing care to asthmatic patients. Because asthma is a difficult disease to diagnose, clinicians should utilize multiple diagnostic tools to determine whether airflow obstruction in patients results from asthma or other underlying conditions. Doctors should also acquire a comprehensive medical and family history and attempt to quantify the severity of a person’s condition (CDC, 2005).

Other contemporary diagnostic criteria helpful for assessing a patients condition include lung function tests (also referred to as spirometry) (CDC, 2005). Because there is no cure for asthma at this time doctors must work to improve the quality of life for patients presenting with asthma as effectively treat acute attacks. Doctors also work with patients to prevent attacks and recurrent episodes. Not one treatment modality works for all people because every case of asthma is unique. Because of this doctors often use various medications including injections, oral medications, vapors and inhalers. Use of inhalers to expand airflow is currently one of the most common and effective long-term treatment choices for patients with asthma.

Contemporary long lasting medical treatments should include use of corticosteroids to help reduce inflammation in the lungs and airways. Most patients will inhale these medicines or take them orally. Long acting beta2-agonists are also identified as effective long-term treatments for patients with asthma. While inhalers, nebulizers and other medications all serve the asthmatic population, education should also form the foundation for modern treatment practices.

Multiple researchers have concluded that patient education is effective for improving the quality of life in patients with asthma. Education also ensures that patients understand how to use their medications and do use them to prevent acute attacks. Education may be particularly beneficial for children by helping them adopt healthy behaviors early on that can help control their condition.

Asthma is a complex disease involving structural and physiological components. Patients with asthma face a life long and often debilitating condition that under severe circumstances may result in increased morbidity. Fortunately there are many treatments currently available that effectively manage this condition. Contemporary management and treatment of asthma is based on empirical research that suggests multiple forms of medication for preventing and treating acute asthma attacks.

The most common forms of treatment include corticosteroid administration through inhalers or oral forms. There are other equally effective medical treatments however that may work well for patients depending on the severity of their illness. No two patients are alike with respect to the condition thus treatment must be tailored to the individual.

New research suggests that doctors and patients focus on prevention and education to help improve patients quality of life and experience of their disease (West, 1990). Education that starts early, as when patients are children, is likely to be more effective than education that starts years after an individual has attempted to manage their disease using other methods. Adequate evidence suggests that the manner of delivery for education does not impact a patients success rate. Thus information may be distributed in person, in the home or even over the telephone if necessary.

The currently body of literature available suggest that education in the classroom may also be an important avenue for teaching prevention and treatment in the future (West, 1990). It is important that researchers and doctors continue exploring new avenues for treating and preventing this insidious disease.

In the U. S. economy, when companies or organizations compete for consumers’ business, consumers usually win with lower prices and better quality product (Stossel, 2007). This idea has spread to the healthcare industry and is being encouraged as a way to increase value for patients (Rivers, 2008). With the healthcare industry being a very diverse industry, there are many different forms of competitions as well as benefits and shortfalls for competition in the healthcare market.

Traditional competition in healthcare involves one more elements of price, quality, convenience, superior products or services, new technology and innovations (Rivers, 2008). There are different forms of healthcare competition. One form of healthcare competition is the competition that exists between individuals who provide healthcare such as physicians and other healthcare practitioners (Rivers, 2008). These entities compete for patients who are able to pay on their own, or who have their own health insurance (Rivers, 2008). They also compete off of a non-price basis (Rivers, 2008).

This means they are competing with their location, their colleague referrals, and their reputations (Rivers, 2008). Physicians and other healthcare practitioners may also compete in the medical market by reducing competition from non-physicians like psychologist (Rivers, 2008). The benefits for this type of competition are that it forces the healthcare practitioner and physicians to be more patient-orientated. It also encourages prices to competitive since some of these individuals are paying for the services out of their own pocket and is price conscious (Stossel, 2007).

Another form of competition in the healthcare industry is healthcare organizations, such as hospitals (Rivers, 2008). These entities compete for physicians, third-party payers and patients (Rivers, 2008). They compete for patients by providing more services, better amenities and discounted prices (Rivers, 2008). They also compete for physicians by trying to maintain a cutting edge of competition with their technology and new medical discoveries (Rivers, 2008). The final form of competition in the healthcare industry is between organizations that provide healthcare financing, insurance and plans.

These entities compete with access, premiums, benefits, quality and different degrees of freedom in choosing a provider and the benefits or coverage services. The pitfall for this type of competition is that it can often be confusing for consumers who are comparing different insurance or financing plan. Competition in the healthcare industry is being encouraged to help better the quality of care patients receive as well as reduce medical costs. When patients have the choice of where they receive medical care, competition and having a competitive edge on opponents is important.

Since the healthcare industry is so large and diverse, there are different forms of competition between healthcare entities. Ultimately competition is supposed to benefit the consumer and patients. resources: Rivers, P. (2008). Healthcare competition, strategic mission and patietn satisfaction:research models and propositions. Retrieved on October 13, 2012 from www. ncbi. nlm. nib/gov/pmc/articles/PMC2865678 Stossel, J (2007). The Competitive Advantage. http://abcnews. go. com/2020/story? id=36026262&page=1

I definitely think that is justified by the Bank as a way to help peripheral countries to structure its economy, establishing a pattern of inalienable development. The bank’s proposal suggests deep changes In political Institutions, as In the case of market opening to foreign trade and prevarication of the economy (Granola, Jorgensen & Roach, 2011). The targeted investments in Brazil are in favor of programs directed to health, education and improvement of public services.

Another benefit is the social inclusion through participatory stimuli, as well as Increased productivity and economic stability Granola,Jorgensen & Roach, 201 1 With the definition of unilateralism that primary education becomes an education for all, which would ensure the sustainability of the debtor countries. However, at this time the design changed, because the concept of globalization in which they believe in equality between the countries began to be replaced by the concept of fairness, believing that only a part of could not develop.

Based on this new concept, it moved admit inequality in developing countries. Since the equity was comprised of a single action, this does not guarantee that equality twine men. About this context education has to be seen as a mechanism to has occurred in the area of education was the exclusive elementary school, one that came to be understood as being required for the population, and is funded by the government. In turn, secondary education was offered, as priority by the private sector.

The same was true in higher education, suggesting a system of scholarships aimed at students who have low income (Granola, Jorgensen & Roach, 2011). The World Bank perceived education as a way to offset the poverty that the country was gassing by economic adjustment. It emphasizes education as a key mechanism in the acquisition of a new pattern of accumulation of capital (Granola, Jorgensen & Roach, 2011). The world is witnessing a growing questioning of established paradigms in economics and also in the political culture.

The environmental crisis on the planet, when translated into climate change is a real threat to the full development of our potential (Granola, Jorgensen & Roach, 2011). I assume that Brazil has a privileged position to face the enormous challenges that accumulate. Harbors significant part of diversity and fresh water on the planet, large expanse of arable land, ethnic- cultural diversity, creativity and a rich variety of natural formations whose role is fundamental in preserving the natural basis of our development (Rather, 2010).

A sustainable economy requires consistent and predictable economic policies, which may soften abrupt changes in household products and prices. Moreover, sustainable economic growth must be compatible with the absorption of new low carbon technologies and the continuous increase of the quality of life for all (Rather, 2010). Brazil has a population of over 191 million inhabitants, formed by many people and distributed in its different biomass and various forms of land occupation. Currently, much of the population is considered urban, and trends point to continued growth of population in cities (Rather, 2010).

Megabits to small and emerging urban areas, opposing realities exist side by side: wealth and poverty, inclusion and exclusion, participation and marginality. The urban question must be regarded as strategic for Brazil in the short, medium and long term, in order to overcome deficits in sanitation ND housing, increase efficiency in city management through mechanisms to ensure resources for municipalities finance their urban development, where the federal government has an important role to induce policies and actions that integrate and articulate the promotion of human development and quality of life of its inhabitants (Rather, 2010).

Healthy cities, democratic and secure – sustainable cities and democracy are one of the great challenges of the 21st century, where the mobility guarantee and right to the city for all its inhabitants, the strengthening of social and ultra diversity and the pursuit of sustainable standards for use of natural resources should be core values. Induce the formulation of urban development policies that have the right to the city, sustainability and democracy as core values.

Promoting efficiency in management, planning and development of cities with the integration and coordination of policies for arbitration, sanitation, mobility, and climate change adaptation, watershed protection, promoting the development and well -being. Encourage the installation of metropolitan governance structures and optimization of urban centers. Ensure resources and training for municipalities to finance their development (Rather, 2010).

Sanitation integrated into the right to decent housing and quality of life – articulate access to basic sanitation actions to investments, progressive and better distributed in the country to increase the pace of deficit overshoot network access for collection and treatment of sewage (Rather, 2010). Create policy for access to drinking water and watershed protection water supply, incorporating human health, water quality and sustainable use as core values n the production chain of water supply.

Healthy urban mobility – reorder and direct investments and subsidies in transport to guide and structure the growth and mobility in cities, aimed systems suitable for different sizes and types of cities in the territory. Create incentives and enter the criteria for funding the establishment of regulatory institutions of public transport in metropolitan and urban areas. Embed the bicycle as a means of transportation and create conditions for their safe use (bike lanes, bike lanes, intermeddle connections). The health is also related to better educational experience, higher productivity and hence higher wages in old age.

Healthy children are able to learn better and achieve higher levels, since they are less affected by school absenteeism and the early withdrawal. It is estimated that the loss of income due to iron deficiency ranges from 2% of GAP in Brazil (Route, 2011). The importance of international trade – the trade should play an important role in the transition to a green economy, to reduce poverty and foster development by stimulating economic growth, create Jobs, reduce prices, increase the variety of reduces to consumers and help countries to acquire new technologies.