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Regular use of an antibacterial mouthwash does not prevent oropharyngeal gonococcal The double-blind Oral Mouthwash use to Eradicate GonorrhoeA (OMEGA) trial randomised men who have sex with men to rinse and gargle at where can i buy kamagra least once daily for 60 s with either an antibacterial mouthwash (Listerine. N=219) or where can i buy kamagra a mouth lubricant as control (Biotène. N=227) for a total of 12 weeks.1 2 Oropharyngeal swabs were collected 6-weekly and saliva 3-weekly. The number of incident cases of oropharyngeal gonorrhoea was 15 (7%) in the Listerine group and where can i buy kamagra 10 (4%) in the Biotène group.

At week 12, the adjusted risk difference in the cumulative incidence of oropharyngeal gonorrhoea where can i buy kamagra between the two groups was 3.1% (95% CI −1.4 to 7.7). While the large CI indicates the need for further data, these initial findings do not support a protective effect of Listerine against oropharyngeal gonorrhoea.Transient impact of erectile dysfunction treatment on HIV care in four African countriesInvestigators analysed data from the African Cohort Study, which prospectively collects information from 12 clinics across 5 HIV care programmes in Tanzania, Uganda, Kenya and Nigeria.3 Parameters including HIV clinic visit adherence, virological suppression and food security were compared between the periods January 2019–March 2020 (prekamagra phase) and May 2020–February 2021 (kamagra phase). After adjusting for age, sex and HIV care programme, both attendance of scheduled clinic visits and where can i buy kamagra food security were significantly reduced in the early kamagra phase, but not after 7 September 2020. There were no detrimental effects on treatment adherence and virological suppression rates.

The findings provide reassurance, although they are not fully representative of where can i buy kamagra the general HIV population across Africa. There remains a need to investigate the impact of the erectile dysfunction treatment kamagra on HIV care globally.Expedited partner therapy does not improve eradication of Chlamydia trachomatis before deliveryExpedited partner therapy (EPT) enables providers to prescribe treatment for partners of patients diagnosed with an STI, without the partner having to establish direct care.4 This cohort study evaluated a prenatal EPT programme in Dallas, Texas, a high where can i buy kamagra Chlamydia trachomatis (CT) prevalence area. Investigators evaluated the effect of EPT on rates of CT before delivery compared with the traditional partner referral, testing and treatment approach used the year before. The rate of was 15% (61 of 419) with EPT vs where can i buy kamagra 13% (60 of 471) with the standard approach (OR 0.86.

95% CI 0.58 to 1.26). EPT on its own is unlikely to be enough to successfully eradicate CT before delivery.Homelessness and housing instability increase the risk of HIV and hepatitis C kamagra among people who inject drugsPeople who inject drugs (PWID) are at where can i buy kamagra increased risk of HIV and hepatitis C kamagra (HCV) and have high levels of homelessness and unstable housing.5 This systematic review and meta-analysis included studies published between 2017 and 2020 that estimated HIV or HCV incidence, or both, among community-recruited PWID. In the pooled estimates, recent homelessness or unstable housing (current or within 1 year) increased the risk of where can i buy kamagra acquiring HIV and HCV compared with stable housing, with an adjusted relative risk of 1.39 (95% CI 1.06 to 1.84. P=0.019) for HIV and 1.64 (95% CI 1.43 to 1.89.

P<0.0001) for HCV where can i buy kamagra. Risk reduction for PWID must include interventions to support housing stability.Unrecognised oral and anal shedding of Treponema pallidum in MSM with early syphilisMouth, anus, urethra and semen samples were systematically collected in 200 men who have sex with men (MSM) (31% living with HIV) to investigate Treponema pallidum shedding from asymptomatic sites relative to lesion sites.6 Across all stages of early syphilis, comprising primary, secondary and early latent, 91%, 74% and 8%, respectively, had T. Pallidum at any site, and 20%, 26% and 0% had detection at two or more sites, with the highest detection where can i buy kamagra in the mouth (24%) and anus (23%). Oral and anal where can i buy kamagra shedding of T.

Pallidum was most frequent during secondary syphilis and often occurred in the absence of overt syphilis lesions, independently of HIV status. Studies are where can i buy kamagra needed to demonstrate bacteria viability from asymptomatic shedding sites and whether its detection might improve syphilis control.Published in Sexually Transmitted s - The Editor’s Choice. The combination of dolutegravir/rilpivirine used in HIV and neuropsychiatric adverse effectsPooling data from 20 randomised trials with a minimum duration of 48 weeks, this meta-analysis investigated the risk of neurotoxicity (defined as the occurrence of depression, anxiety, insomnia, dizziness or suicidal behaviour) in adults treated with rilpivirine, dolutegravir or the combination dolutegravir/rilpivirine versus comparator regimens.7 Twelve trials were in treatment-naive and eight in treatment-experienced participants, totalling 10 998 individuals. Depression was the most common neuropsychiatric event, where can i buy kamagra whereas suicidal behaviour was the least common.

The relative where can i buy kamagra risk (RR) of depression was not different with dolutegravir or rilpivirine versus comparator. In contrast, dolutegravir/rilpivirine showed a synergistic effect on depression, with an RR of 2.82 (95% CI 1.12 to 7.10. P=0.03), although no study where can i buy kamagra directly compared dolutegravir/rilpivirine with efavirenz. While further studies are needed, the occurrence of depression should be monitored during dolutegravir/rilpivirine therapy..

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Clear evidence for a weekend effect was first demonstrated by Bell and Redelmeier1 who examined 3.8 million emergency admissions between kamagra oral jelly buy online 1988 http://dsdtips.com/how-to-set-up-windows-fax-service-and-fax-forms-in-paperless-office-for-sage-mas-90-and-200/ and 1997 in an acute care hospital in Ontario. They had noted that staffing levels were lower in acute care hospitals at weekends and hypothesised that this might lead to poorer care kamagra oral jelly buy online and higher mortality. To test this hypothesis, they identified three conditions (ruptured abdominal aortic aneurysm, acute epiglottitis and pulmonary embolism) for which lower staffing on admission was expected to have consequences in outcomes, as well as three control conditions for which this would not be the case. In addition, they kamagra oral jelly buy online conducted an analysis without a prespecified hypothesis, examining the 100 conditions responsible for most deaths.

After adjustment for illness severity, they found higher mortality for conditions expected to be affected by lower staffing and no increase for control conditions. From the 100 medical conditions examined, 23 had significantly increased mortality risk for weekend kamagra oral jelly buy online admissions. These two sets of findings provided strong evidence for a weekend effect, suggesting that for some conditions lower staffing on admission affected standards of care and thereby patient outcomes.Since then, dozens of studies of the weekend effect have been conducted, mostly in the UK and the USA.2 In Britain, the issue became much more high profile after an intervention in 2015 by the Secretary of State who suggested that 11 000 patients were unnecessarily dying at the weekend.3 4 This claim was challenged at the time,5 and many pointed out that the National Health Service (NHS) was already a 7-day service.6 7 However, concern about the weekend led eventually to the introduction of ‘7 day services’ in the NHS in England. A new set of 10 clinical standards was introduced to reduce differences between weekend and weekday services, including increased involvement of consultants in the first 24 hours of admission.8 9 A cross-sectional analysis covering the period before introduction showed no association between specialist intensity and weekend admission mortality.10 Nevertheless, the programme did lead to many NHS hospital kamagra oral jelly buy online trusts reorganising services to reduce differences in care delivery across the 7-day week.

The reorganisation of services did not affect clinical outcomes11 nor was adoption of the clinical standards associated with any significant change in the magnitude of the weekend effect.12Possible underlying mechanisms. The weekend as proxy variableRecent systematic reviews have concluded that the weekend effect does exist, but the explanation for the finding is unclear.2 4 kamagra oral jelly buy online 13–17 Patients admitted to hospital at the weekend are more likely to die than those during weekdays with ORs of 1.16 (all studies)2 and 1.07 (UK studies),4 with reviews for some specific disease categories reporting higher ORs.2 13 The quality of studies is highly variable, with findings being influenced by methodological, clinical and service configuration factors2 with ongoing debate about likely mechanisms. Why has it been so difficult to elucidate possible mechanisms?. To go more deeply into this, we need to consider what role the weekend is playing in the design of all these studies.Bell and Redelmeier1 used two distinct designs in their original investigation, which might best be defined as an kamagra oral jelly buy online investigation of staffing levels and mortality.

In their first analysis, the weekend is used as a proxy measure for differences in staffing. They targeted specific conditions such as ruptured abdominal aortic aneurysm for which staffing on admission was deemed likely to have an important impact on kamagra oral jelly buy online patient outcomes. Their second analysis took the opposite approach, by examining overall outcomes at the weekend and then speculating about which factors might explain any observed differences. Most subsequent studies have kamagra oral jelly buy online used the second approach, which has made it difficult to make progress on identifying the relevant factors driving any effect.

If we do not define the questions and hypothesised relationships precisely, then we will not be able to identify how care delivered to patients is affected and which factors are responsible for poorer outcomes. Critically, if we cannot identify the factors, then we cannot intelligently propose interventions to improve patient care.We therefore need to examine how the weekend kamagra oral jelly buy online as a proxy variable for staffing levels fits into the conceptual model. Is the proxy only associated with the determinant, often assumed to be staffing levels, or also with other possible confounders or factors that affect the outcome in question?. We recognise there are multiple possible sets of relationships, but examining three of them is sufficient kamagra oral jelly buy online to make the general argument.

Figure 1 displays three possible sets of relationships, which correspond with three broad hypotheses about potential mechanisms and hence the interpretation of the weekend effect.Proxy measures in the context of studying a determinant - outcome relationship, applied to the weekend as a proxy variable for staffing." data-icon-position data-hide-link-title="0">Figure 1 Proxy measures in the context of studying a determinant - outcome relationship, applied to the weekend as a proxy variable for staffing.Levels of staffing on admission is the dominant influence on quality of care and mortality (panel A)This shows the ‘ideal’ and simplest situation when the proxy weekend/weekday variable is primarily associated with staffing in the first hours or days. The implied mechanism is that lower numbers of staff, particularly senior staff, lead to poorer care and increased mortality kamagra oral jelly buy online. In that situation, weekend–weekday mortality differences, after adjustment for patient mix, can be presumed to be due to staffing differences. Bell and kamagra oral jelly buy online Redelmeier specifically tested this scenario by selecting those conditions for which the first few days of admission are critical, that are treatable and where death may be rapid.

For these conditions, insufficient staffing levels at admission (determinant) might cause delay in care processes (intermediate variable) and higher mortality (outcome).Patients at weekends are sicker and more likely to die (panel B)As many studies have shown, the weekend is associated with confounding variables. Patients admitted at the weekend are known to be sicker18 19 and are less likely to be admitted from emergency departments despite attendance rates being similar.16 20 Studies attempt to control for severity of condition and other confounders, kamagra oral jelly buy online but there is general agreement that it is simply not possible to control for all potential factors (and confounding by indication). There is always the possibility that, even after adjustment kamagra oral jelly buy online for severity of illness and other patient variables, that differences in outcome are due to other patient factors that, for whatever reason, could not be included in the calculations. So for many conditions, this is an important alternative pathway to consider.Multiple factors affect care at the weekend, which in turn increases mortality (panel C)This model underlies the second approach by Bell and Redelmeier and many subsequent studies.

The basic hypothesis is that patient outcomes differ between kamagra oral jelly buy online weekend and weekday, but this may be due to multiple relationships and multiple interrelated variables. For instance, the average seniority or specialty level may differ between the groups of nurses and medical staff working during weekdays and weekends, and such differences in skill-mix may affect patient outcomes.21–23 Access to diagnostic tests or other ancillary services might also differ between weekends and weekdays, or there may be factors further along the patient pathway (in subsequent days after admission) such as how quickly any deterioration on the ward is detected. In this scenario, uncertainty about the mechanisms of the weekend effect makes it very difficult to identify targeted interventions to improve outcomes for patients admitted at the weekend.The assumed intermediate variable of worse kamagra oral jelly buy online quality of careHypotheses 1 and 3 have the same intermediate variable, that quality of care is poorer at the weekend—although for different reasons—and that this is the reason for higher mortality. Investigating this particular proposal requires, as many have noted, ‘painstaking detective work’,24 but few studies have directly examined the quality of care provided during weekdays and at weekends.

In this issue of BMJ Quality kamagra oral jelly buy online &. Safety, Bion and colleagues therefore add crucial evidence with their impressive and comprehensive study.25 They reviewed the quality of care delivered by examining case records from 4000 non-operative medical emergency admissions in 20 acute hospital trusts before and after introduction of the ‘7-day services’ in England. Records were randomly sampled from each trust, equally kamagra oral jelly buy online divided between the two time periods and weekend versus weekday admissions. They found that rates of errors and adverse events were not significantly different between weekdays and weekends and that this was the case both before and after introduction of the ‘7-day services’.

They also made a direct assessment of intensity of senior medical staffing by comparing hours of consultant time kamagra oral jelly buy online per 10 emergency admissions between Sundays and Wednesdays. This specialist intensity ratio was much lower at weekends (0.51 overall) and improved slightly (from 0.47 to 0.58) across periods. Their study therefore does not offer support for quality of care being worse at the weekend or that senior staff involvement at an kamagra oral jelly buy online early point in the patient’s admission is significantly associated with overall quality of care. We should note, however, that operative patients were excluded, so it remains possible that care is poorer for some other groups of patients.The implicit assumption in many previous studies, and most political discourse, is that the weekend is simply a reflection and proxy for lower levels of skilled staff, particularly medical staff.

Proxy variables are of course used all the time in research and can be very helpful if they are ‘close’ kamagra oral jelly buy online to the variable of interest. For instance, we might use the prescription record of a medication as a proxy for the actual medication administered to the patient. We are then confident of what the proxy means kamagra oral jelly buy online and how it relates to the actual variable of interest. Even though some patients may decide not to collect their medication or be non-adherent in taking it, interpreting the proxy is relatively straightforward.In contrast, the weekend/weekday comparison is a distant and complex proxy.

Care could potentially be different for a whole variety of kamagra oral jelly buy online reasons, which are only partly dependent on levels of skilled medical staff. Diagnostic tests and investigations may not be readily available. Coordination between kamagra oral jelly buy online different specialties may be problematic within the hospital or between primary and secondary care and so on. Each of these may cause delay in a care process that may (in combination) affect patient outcomes.

In addition, conditions vary in the extent to which kamagra oral jelly buy online delays in the first few days are critical in preventing death. Some primarily require skilled staff on admission, while others are more vulnerable to kamagra oral jelly buy online later deterioration on wards and need care from experienced nurses in the days following admission.Should we continue studying the weekend effect?. We do not doubt that studies of the weekend effect buy kamagra next day delivery have been worthwhile. Clearly, the higher mortality at weekends originally identified 20 years ago merited kamagra oral jelly buy online investigation.

The question is whether it is worthwhile to continue to conduct similar studies in the future given the limited funding and research time available. What avenues of kamagra oral jelly buy online inquiry are most likely to benefit patients?. The ultimate aim of all concerned is to improve care given to patients. The weekend kamagra oral jelly buy online effect is only important as a potential marker of other problems.

Local reviews of mortality or other indices of quality should always be alert to variations in the quality of care over the week, and consider whether care is poorer at weekends or indeed at any particular time of the day, week or year. However, we consider that there is no reason to carry out further studies that simply demonstrate kamagra oral jelly buy online a weekend effect. We need instead to turn our attention to the factors directly influencing quality of care for which the weekend has been a proxy.Bion and colleagues provide a valuable illustration of research that examines the presumed causal relationships, looking at the actual care processes and so give a clearer indication of what kind of intervention might most benefit patients. Their study found that care had improved over time but that about 15% of patients received partial care and a small percentage received very poor care.25 These problems occurred throughout the week, affecting the larger kamagra oral jelly buy online volume of patients treated on weekdays.

Following the example of the study by Bion et al, future studies could directly assess standards of care and the factors that most powerfully influence quality. A notable example is the study by Jayawardana and colleagues,26 showing that the increased mortality for out-of-hours admissions kamagra oral jelly buy online with ST-elevation acute myocardial infarction was explained by differences in door-to-needle time, identifying the specific care process on which interventions should be targeted. To improve clinical practice, we need evidence that will help us design targeted interventions to influence the quality of care delivered and thereby patient outcomes.The ‘7-day services’ initiative was introduced in England without a clear understanding of the causes of the weekend effect. The intervention, while well intentioned, was therefore poorly targeted kamagra oral jelly buy online.

Rather than a one-size-fits all initiative to increase consultant intensity, we should consider the much harder question on how to spend the same money to maximum effect. Consultant time is scarce kamagra oral jelly buy online and so should be tailored to the time, place and particular conditions where it is most beneficial over the week as a whole. For some patients though, more rapid access to diagnostic tests or the increased use of skilled nurses during recovery may be much more critical to improving outcomes. Studies of the weekend effect drew attention to potentially dangerous kamagra oral jelly buy online levels of staffing that undoubtedly posed risks to patients.

At this point, however, we need more precise studies that directly examine standards of care and the factors that influence the care delivered. We can then define and target interventions effectively and make best use of scarce resources.Ethics statementsPatient consent for publicationNot required.The Harvard Medical Practice Study brought the issue of patient safety into the public eye kamagra oral jelly buy online and demonstrated that patients are often harmed by the care they receive.1 It used retrospective chart review to identify adverse events. Since its publication in 1991, considerable focus has been placed on trying to improve the methods for understanding the prevalence of harm in hospitals. These efforts have led to deeper understanding of the relative strengths and weaknesses of the tools we currently have for adverse kamagra oral jelly buy online event identification.

Still, most organisations do not have robust approaches for tracking all types of harm routinely. Other efforts have sought to assess safety not just in hospitals but across national health systems, and at one point in time, and to track and trend.Developing better approaches for measuring safety routinely kamagra oral jelly buy online is critical if we are to understand how many patients are being harmed, what the primary causes are and whether care is getting safer or less safe. However, it is also work that needs to kamagra oral jelly buy online be contextualised and the limitations of our tools must be appreciated.2 3The Irish National Adverse Event Study 2 (INAES-2) is presented in this issue.4 In this study, Connolly and colleagues used retrospective chart review to find adverse events at eight Irish hospitals in 2015 and compare these to previously reported data from 2009. Retrospective chart review was the first method used in this space5 6 and is still a mainstay for national studies assessing rates of adverse events,7–12 although approaches using claims data are also used widely and are much less expensive though much less sensitive.13 The original approach using retrospective chart review relied on information exclusively gathered from retrospective review of randomly selected medical records, but it has since been bolstered by the creation of standardised triggers,14 and more rigorous methods for chart review which make it more sensitive for finding adverse events, and more reliable.

Despite this, retrospective chart review has many limitations, most notably the level of agreement between abstractors and its reliance on the completeness of documentation in medical charts.15The issue of reliance on kamagra oral jelly buy online documentation is especially important. There have been well-conceived critiques that have raised concern related to underdocumentation of errors that occur in hospitals, as well as those that have raised concern that the findings from longitudinal studies looking at trends may be confounded by improved documentation resulting in an overestimation of the true (comparative) incidence of events. These are both kamagra oral jelly buy online legitimate concerns. The INAES-2 study, as in prior similar work looking at multi-institution adverse event rates over time,16 17 showed an increase in events over time but no change in preventable harm.

We are left not knowing if this represents a change in safety or a change in documentation.These concerns have led other investigators to develop adverse event identification approaches to enable more real-time identification, leveraging a broader set of kamagra oral jelly buy online data for the interpretation of the preventability and impact of these events.18 19 Prospective event identification, or the near real-time application of triggers, can also incorporate the perspectives of staff in the clinical environment around the time of the event to provide additional insights. Even with this more comprehensive, contemporaneous collection of data however, agreement continues to be variable between reviewers.20–22Looking to spontaneous reporting from front-line staff, rather than retrospectively or prospectively monitoring for triggers, is another method that has been proposed as a mechanism for identifying the prevalence of adverse events over time. Similar to documentation, however, concerns exist about the under-reporting of events by front-line staff in safety reporting systems.23 24 Moreover, spontaneous reporting routinely underestimates the incidence of adverse events for some types of events by a factor of 20.25The inverse is also likely true that advances in safety culture may increase reporting, kamagra oral jelly buy online without any change in the frequency of actual events. Indeed, in the INAES-2 study, the researchers found that although safety reports increased threefold, adverse event rates did not change.

This highlights the kamagra oral jelly buy online challenge of using safety reports alone as a proxy for adverse events. Instead, the insights from safety reporting may hold promise for other uses in the safety space, such as providing a signal for the degree of staff engagement in safety, enabling the identification of near misses and facilitating the identification of significant events that require root cause analysis.Because of the variability that exists in the methods mentioned, many investigators have attempted to identify more reliable ways to identify adverse events. Several studies have employed reimbursement codes (in the USA, International Classification of Diseases Ninth Revision codes) as a mechanism to screen for adverse events.26–28 These systems, which aim to identify complications of medical care by looking for codes that are highly associated with adverse events, have largely been shown to be ineffective.29 30 This is likely to be multifactorial, with an inability to identify which conditions predated the current healthcare encounter, a lack of incentives to use coding to identify adverse events and their limited ability to accurately capture the full kamagra oral jelly buy online clinical picture all contributing to their limited efficacy.31Other approaches have leveraged information systems to screen for adverse events, which is almost certainly how this will be done in the future.32 This works better for some categories of events than for others. Identification for some events is relatively straightforward, for example, for the development of acute kidney injury in which there is a biomarker to track (rise in creatinine), which routinely appears when the event is present.

However, the identification kamagra oral jelly buy online of newly altered mental status, for example, is much more challenging. For events such as falls, which are almost always documented in electronic health record (EHR) systems, this also works well. Commercial products that sift through data from the EHR are available to find adverse events for inpatients, while the situation regarding adverse event detection is much less advanced kamagra oral jelly buy online in the ambulatory setting, even though EHR use is widespread in developed countries. Among the main types of inpatient adverse events, hospital-acquired s, adverse drug events and falls can readily be detected in inpatients, while the situation is more complex for deep venous thromboses/pulmonary emboli, surgical injuries, specific types of pressure ulcers and missed diagnoses.32 Novel approaches that are highly effective for identifying wrong patient errors have been developed, such as ‘retract and reorder’ detection, which identifies these errors effectively.33 This has led to interventions such as showing the photograph of a patient to the ordering clinician, which reduced the likelihood of a wrong patient order by 43% in one study.34 Still, most organisations do not have a robust sense of how often their patients experience adverse events across the spectrum of care.The challenge of adverse event identification is multiplied by the importance of understanding one moment in time and, as the authors in the INAES-2 study aim to do, trying to look at trends.

This will be essential as we continue to mobilise kamagra oral jelly buy online large efforts to improve safety and as these compete with other priorities. As with all work in quality, having robust metrics is vital. In safety, however, we have in many ways been ‘flying blind’—initiating large-scale efforts to decrease the rate of adverse events without having reliable ways to measure their prevalence over time.It is important to emphasise that this lack of insight into performance is not equally distributed across all categories of adverse events.3 In fact, as proposed recently by Shojania and Marang-van de Mheen, the incidence of adverse events may be best understood as a kamagra oral jelly buy online composite measure—with all of the limitations that come with looking at a measure with many composite parts.35 When broken apart, what we come to understand is that some of our mechanisms for identifying certain types of events are likely much more reliable than others. In the USA, for example, where the Agency for Healthcare Research and Quality has leveraged standardised methods for collecting and reporting national performance on a set of specific healthcare-associated s, we have much better insight into performance over time related to such healthcare-associated s than we do, for instance, with diagnostic error.Lastly, the challenge of interpreting national adverse event data over time is complicated by the nuances associated with the interfaces between politics and science.

In our personal experience, we have encountered challenges reporting results of safety studies that are tied to ministries of health.36 Related to the INAES-2 study specifically, Ireland has kamagra oral jelly buy online a long history of sensationalised media coverage of data pointing to opportunities for improved care, further complicating researchers’ ability to conduct this work free of influence.37Ultimately, the work presented by Connolly and colleagues is critically important work and we suggest that all health systems should be monitoring adverse event rates over time. The mechanisms for doing this, though, should rapidly evolve. With hospitals kamagra oral jelly buy online increasingly leveraging EHRs, data being collected in more uniform ways and advances in natural language processing and artificial intelligence, a future in which we have reliable measures of adverse events that are stable over time is likely within our reach. To get from here to there, an ongoing investment in research with evaluation including leveraging artificial intelligence and natural language processing, and a commitment to transparent data reporting and enabling collaboration between organisations and governments focused on this work is essential.38 If we can achieve this, we could reasonably expect a future in which we have access to publicly available meaningful data on how many people are being harmed, and in what context, which could in turn transform safety.Ethics statementsPatient consent for publicationNot required..

Clear evidence for a weekend effect was first demonstrated by Bell and where can i buy kamagra Redelmeier1 who examined 3.8 million emergency admissions between 1988 and 1997 in an acute care hospital in Ontario. They had noted that staffing levels were lower in acute care hospitals at weekends and hypothesised that this might lead to poorer care where can i buy kamagra and higher mortality. To test this hypothesis, they identified three conditions (ruptured abdominal aortic aneurysm, acute epiglottitis and pulmonary embolism) for which lower staffing on admission was expected to have consequences in outcomes, as well as three control conditions for which this would not be the case. In addition, they conducted an where can i buy kamagra analysis without a prespecified hypothesis, examining the 100 conditions responsible for most deaths. After adjustment for illness severity, they found higher mortality for conditions expected to be affected by lower staffing and no increase for control conditions.

From the 100 medical conditions examined, 23 had significantly increased mortality risk for weekend where can i buy kamagra admissions. These two sets of findings provided strong evidence for a weekend effect, suggesting that for some conditions lower staffing on admission affected standards of care and thereby patient outcomes.Since then, dozens of studies of the weekend effect have been conducted, mostly in the UK and the USA.2 In Britain, the issue became much more high profile after an intervention in 2015 by the Secretary of State who suggested that 11 000 patients were unnecessarily dying at the weekend.3 4 This claim was challenged at the time,5 and many pointed out that the National Health Service (NHS) was already a 7-day service.6 7 However, concern about the weekend led eventually to the introduction of ‘7 day services’ in the NHS in England. A new set of 10 clinical standards was introduced to where can i buy kamagra reduce differences between weekend and weekday services, including increased involvement of consultants in the first 24 hours of admission.8 9 A cross-sectional analysis covering the period before introduction showed no association between specialist intensity and weekend admission mortality.10 Nevertheless, the programme did lead to many NHS hospital trusts reorganising services to reduce differences in care delivery across the 7-day week. The reorganisation of services did not affect clinical outcomes11 nor was adoption of the clinical standards associated with any significant change in the magnitude of the weekend effect.12Possible underlying mechanisms. The weekend as proxy variableRecent systematic reviews have concluded that the weekend effect does exist, but the explanation for the finding is unclear.2 4 13–17 Patients admitted to hospital at the weekend are more likely to die than those during weekdays with ORs of 1.16 (all studies)2 and 1.07 (UK studies),4 with reviews for where can i buy kamagra some specific disease categories reporting higher ORs.2 13 The quality of studies is highly variable, with findings being influenced by methodological, clinical and service configuration factors2 with ongoing debate about likely mechanisms.

Why has it been so difficult to elucidate possible mechanisms?. To go more deeply into this, we need to consider what role the weekend is playing in the design of all these studies.Bell and Redelmeier1 used two distinct designs in their original investigation, which might best be defined as an investigation of staffing levels where can i buy kamagra and mortality. In their first analysis, the weekend is used as a proxy measure for differences in staffing. They targeted specific conditions such as ruptured abdominal aortic aneurysm for which staffing on admission was deemed likely to have an where can i buy kamagra important impact on patient outcomes. Their second analysis took the opposite approach, by examining overall outcomes at the weekend and then speculating about which factors might explain any observed differences.

Most subsequent studies have used the second approach, which has made it difficult to where can i buy kamagra make progress on identifying the relevant factors driving any effect. If we do not define the questions and hypothesised relationships precisely, then we will not be able to identify how care delivered to patients is affected and which factors are responsible for poorer outcomes. Critically, if where can i buy kamagra we cannot identify the factors, then we cannot intelligently propose interventions to improve patient care.We therefore need to examine how the weekend as a proxy variable for staffing levels fits into the conceptual model. Is the proxy only associated with the determinant, often assumed to be staffing levels, or also with other possible confounders or factors that affect the outcome in question?. We recognise there are multiple possible sets of relationships, but examining three of them is sufficient to make the general where can i buy kamagra argument.

Figure 1 displays three possible sets of relationships, which correspond with three broad hypotheses about potential mechanisms and hence the interpretation of the weekend effect.Proxy measures in the context of studying a determinant - outcome relationship, applied to the weekend as a proxy variable for staffing." data-icon-position data-hide-link-title="0">Figure 1 Proxy measures in the context of studying a determinant - outcome relationship, applied to the weekend as a proxy variable for staffing.Levels of staffing on admission is the dominant influence on quality of care and mortality (panel A)This shows the ‘ideal’ and simplest situation when the proxy weekend/weekday variable is primarily associated with staffing in the first hours or days. The implied mechanism is that where can i buy kamagra lower numbers of staff, particularly senior staff, lead to poorer care and increased mortality. In that situation, weekend–weekday mortality differences, after adjustment for patient mix, can be presumed to be due to staffing differences. Bell and Redelmeier specifically tested this scenario where can i buy kamagra by selecting those conditions for which the first few days of admission are critical, that are treatable and where death may be rapid. For these conditions, insufficient staffing levels at admission (determinant) might cause delay in care processes (intermediate variable) and higher mortality (outcome).Patients at weekends are sicker and more likely to die (panel B)As many studies have shown, the weekend is associated with confounding variables.

Patients admitted at the weekend are known to be sicker18 19 and are less likely to be admitted from emergency departments despite attendance rates being similar.16 20 Studies attempt to control for severity of condition and other confounders, where can i buy kamagra but there is general agreement that it is simply not possible to control for all potential factors (and confounding by indication). There is where can i buy kamagra always the possibility that, even after adjustment for severity of illness and other patient variables, that differences in outcome are due to other patient factors that, for whatever reason, could not be included in the calculations. So for many conditions, this is an important alternative pathway to consider.Multiple factors affect care at the weekend, which in turn increases mortality (panel C)This model underlies the second approach by Bell and Redelmeier and many subsequent studies. The basic hypothesis is that patient outcomes where can i buy kamagra differ between weekend and weekday, but this may be due to multiple relationships and multiple interrelated variables. For instance, the average seniority or specialty level may differ between the groups of nurses and medical staff working during weekdays and weekends, and such differences in skill-mix may affect patient outcomes.21–23 Access to diagnostic tests or other ancillary services might also differ between weekends and weekdays, or there may be factors further along the patient pathway (in subsequent days after admission) such as how quickly any deterioration on the ward is detected.

In this scenario, uncertainty about the mechanisms of the weekend effect makes it very difficult to identify targeted interventions to improve outcomes for patients admitted at the weekend.The assumed intermediate variable of worse quality of careHypotheses 1 and 3 have the same intermediate variable, that quality of care is poorer at the weekend—although for different reasons—and that this is the reason where can i buy kamagra for higher mortality. Investigating this particular proposal requires, as many have noted, ‘painstaking detective work’,24 but few studies have directly examined the quality of care provided during weekdays and at weekends. In this issue of BMJ Quality & where can i buy kamagra. Safety, Bion and colleagues therefore add crucial evidence with their impressive and comprehensive study.25 They reviewed the quality of care delivered by examining case records from 4000 non-operative medical emergency admissions in 20 acute hospital trusts before and after introduction of the ‘7-day services’ in England. Records were randomly sampled where can i buy kamagra from each trust, equally divided between the two time periods and weekend versus weekday admissions.

They found that rates of errors and adverse events were not significantly different between weekdays and weekends and that this was the case both before and after introduction of the ‘7-day services’. They also made a direct assessment of where can i buy kamagra intensity of senior medical staffing by comparing hours of consultant time per 10 emergency admissions between Sundays and Wednesdays. This specialist intensity ratio was much lower at weekends (0.51 overall) and improved slightly (from 0.47 to 0.58) across periods. Their study therefore does not offer support for quality of care being worse at the weekend or that senior staff involvement at an early point where can i buy kamagra in the patient’s admission is significantly associated with overall quality of care. We should note, however, that operative patients were excluded, so it remains possible that care is poorer for some other groups of patients.The implicit assumption in many previous studies, and most political discourse, is that the weekend is simply a reflection and proxy for lower levels of skilled staff, particularly medical staff.

Proxy variables are of course used all the time in research where can i buy kamagra and can be very helpful if they are ‘close’ to the variable of interest. For instance, we might use the prescription record of a medication as a proxy for the actual medication administered to the patient. We are then confident of what the proxy means and where can i buy kamagra how it relates to the actual variable of interest. Even though some patients may decide not to collect their medication or be non-adherent in taking it, interpreting the proxy is relatively straightforward.In contrast, the weekend/weekday comparison is a distant and complex proxy. Care could potentially be different for a whole variety where can i buy kamagra of reasons, which are only partly dependent on levels of skilled medical staff.

Diagnostic tests and investigations may not be readily available. Coordination between different specialties may be problematic where can i buy kamagra within the hospital or between primary and secondary care and so on. Each of these may cause delay in a care process that may (in combination) affect patient outcomes. In addition, conditions vary in the extent to which where can i buy kamagra delays in the first few days are critical in preventing death. Some primarily require skilled staff on admission, while others are more where can i buy kamagra vulnerable to later deterioration on wards and need care from experienced nurses in the days following admission.Should we continue studying the weekend effect?.

We do not doubt that studies of the weekend effect have been worthwhile. Clearly, the where can i buy kamagra higher mortality at weekends originally identified 20 years ago merited investigation. The question is whether it is worthwhile to continue to conduct similar studies in the future given the limited funding and research time available. What avenues of inquiry are most likely where can i buy kamagra to benefit patients?. The ultimate aim of all concerned is to improve care given to patients.

The weekend effect is where can i buy kamagra only important as a potential marker of other problems. Local reviews of mortality or other indices of quality should always be alert to variations in the quality of care over the week, and consider whether care is poorer at weekends or indeed at any particular time of the day, week or year. However, we consider that there is no reason to carry out further studies that simply demonstrate a weekend effect where can i buy kamagra. We need instead to turn our attention to the factors directly influencing quality of care for which the weekend has been a proxy.Bion and colleagues provide a valuable illustration of research that examines the presumed causal relationships, looking at the actual care processes and so give a clearer indication of what kind of intervention might most benefit patients. Their study found that care had improved over time but that about 15% of patients received partial care and a small percentage received very poor care.25 These problems occurred throughout the week, affecting the larger volume of where can i buy kamagra patients treated on weekdays.

Following the example of the study by Bion et al, future studies could directly assess standards of care and the factors that most powerfully influence quality. A notable example is the study by Jayawardana and colleagues,26 showing that the increased mortality for out-of-hours admissions where can i buy kamagra with ST-elevation acute myocardial infarction was explained by differences in door-to-needle time, identifying the specific care process on which interventions should be targeted. To improve clinical practice, we need evidence that will help us design targeted interventions to influence the quality of care delivered and thereby patient outcomes.The ‘7-day services’ initiative was introduced in England without a clear understanding of the causes of the weekend effect. The intervention, while well intentioned, was where can i buy kamagra therefore poorly targeted. Rather than a one-size-fits all initiative to increase consultant intensity, we should consider the much harder question on how to spend the same money to maximum effect.

Consultant time is scarce and so should be tailored to the time, place and where can i buy kamagra particular conditions where it is most beneficial over the week as a whole. For some patients though, more rapid access to diagnostic tests or the increased use of skilled nurses during recovery may be much more critical to improving outcomes. Studies of the weekend effect drew attention to potentially where can i buy kamagra dangerous levels of staffing that undoubtedly posed risks to patients. At this point, however, we need more precise studies that directly examine standards of care and the factors that influence the care delivered. We can then define and target interventions effectively and make best use of scarce where can i buy kamagra resources.Ethics statementsPatient consent for publicationNot required.The Harvard Medical Practice Study brought the issue of patient safety into the public eye and demonstrated that patients are often harmed by the care they receive.1 It used retrospective chart review to identify adverse events.

Since its publication in 1991, considerable focus has been placed on trying to improve the methods for understanding the prevalence of harm in hospitals. These efforts have led to deeper understanding of the relative strengths and weaknesses of where can i buy kamagra the tools we currently have for adverse event identification. Still, most organisations do not have robust approaches for tracking all types of harm routinely. Other efforts have sought to assess safety not just in hospitals but across national health systems, and at one point in time, and to track and trend.Developing better approaches for measuring safety routinely is critical if we are to understand how many patients are where can i buy kamagra being harmed, what the primary causes are and whether care is getting safer or less safe. However, it is also work that needs to be contextualised and the limitations of our tools must be appreciated.2 3The Irish National Adverse Event Study 2 (INAES-2) is presented in this issue.4 In this study, Connolly and colleagues used retrospective chart review to find adverse events at eight Irish where can i buy kamagra hospitals in 2015 and compare these to previously reported data from 2009.

Retrospective chart review was the first method used in this space5 6 and is still a mainstay for national studies assessing rates of adverse events,7–12 although approaches using claims data are also used widely and are much less expensive though much less sensitive.13 The original approach using retrospective chart review relied on information exclusively gathered from retrospective review of randomly selected medical records, but it has since been bolstered by the creation of standardised triggers,14 and more rigorous methods for chart review which make it more sensitive for finding adverse events, and more reliable. Despite this, retrospective chart review has many limitations, most notably the level of agreement between abstractors and its where can i buy kamagra reliance on the completeness of documentation in medical charts.15The issue of reliance on documentation is especially important. There have been well-conceived critiques that have raised concern related to underdocumentation of errors that occur in hospitals, as well as those that have raised concern that the findings from longitudinal studies looking at trends may be confounded by improved documentation resulting in an overestimation of the true (comparative) incidence of events. These are both legitimate where can i buy kamagra concerns. The INAES-2 study, as in prior similar work looking at multi-institution adverse event rates over time,16 17 showed an increase in events over time but no change in preventable harm.

We are left not knowing if this represents a change in safety or a change in documentation.These concerns have led other investigators to develop adverse event identification approaches to enable more real-time identification, leveraging a broader set of data for where can i buy kamagra the interpretation of the preventability and impact of these events.18 19 Prospective event identification, or the near real-time application of triggers, can also incorporate the perspectives of staff in the clinical environment around the time of the event to provide additional insights. Even with this more comprehensive, contemporaneous collection of data however, agreement continues to be variable between reviewers.20–22Looking to spontaneous reporting from front-line staff, rather than retrospectively or prospectively monitoring for triggers, is another method that has been proposed as a mechanism for identifying the prevalence of adverse events over time. Similar to documentation, however, concerns where can i buy kamagra exist about the under-reporting of events by front-line staff in safety reporting systems.23 24 Moreover, spontaneous reporting routinely underestimates the incidence of adverse events for some types of events by a factor of 20.25The inverse is also likely true that advances in safety culture may increase reporting, without any change in the frequency of actual events. Indeed, in the INAES-2 study, the researchers found that although safety reports increased threefold, adverse event rates did not change. This highlights the challenge of using safety reports alone as where can i buy kamagra a proxy for adverse events.

Instead, the insights from safety reporting may hold promise for other uses in the safety space, such as providing a signal for the degree of staff engagement in safety, enabling the identification of near misses and facilitating the identification of significant events that require root cause analysis.Because of the variability that exists in the methods mentioned, many investigators have attempted to identify more reliable ways to identify adverse events. Several studies have employed reimbursement codes (in the USA, International Classification of Diseases Ninth Revision codes) as a mechanism to screen for adverse events.26–28 These systems, which aim to identify complications of medical care by looking for codes that are highly associated with adverse events, have largely been shown to be ineffective.29 30 This is likely to be multifactorial, with an inability to identify which conditions predated the current healthcare encounter, a lack of incentives to use coding to identify adverse events and their limited ability to accurately capture the full clinical picture all contributing to their limited efficacy.31Other approaches have leveraged information systems to where can i buy kamagra screen for adverse events, which is almost certainly how this will be done in the future.32 This works better for some categories of events than for others. Identification for some events is relatively straightforward, for example, for the development of acute kidney injury in which there is a biomarker to track (rise in creatinine), which routinely appears when the event is present. However, the identification where can i buy kamagra of newly altered mental status, for example, is much more challenging. For events such as falls, which are almost always documented in electronic health record (EHR) systems, this also works well.

Commercial products that sift through data from the EHR are available to find adverse events for inpatients, while the situation regarding adverse event detection is much less advanced in the ambulatory setting, even though where can i buy kamagra EHR use is widespread in developed countries. Among the main types of inpatient adverse events, hospital-acquired s, adverse drug events and falls can readily be detected in inpatients, while the situation is more complex for deep venous thromboses/pulmonary emboli, surgical injuries, specific types of pressure ulcers and missed diagnoses.32 Novel approaches that are highly effective for identifying wrong patient errors have been developed, such as ‘retract and reorder’ detection, which identifies these errors effectively.33 This has led to interventions such as showing the photograph of a patient to the ordering clinician, which reduced the likelihood of a wrong patient order by 43% in one study.34 Still, most organisations do not have a robust sense of how often their patients experience adverse events across the spectrum of care.The challenge of adverse event identification is multiplied by the importance of understanding one moment in time and, as the authors in the INAES-2 study aim to do, trying to look at trends. This will where can i buy kamagra be essential as we continue to mobilise large efforts to improve safety and as these compete with other priorities. As with all work in quality, having robust metrics is vital. In safety, however, we have in many ways been ‘flying blind’—initiating large-scale efforts to decrease the rate of adverse events without having reliable ways to measure their prevalence over time.It is important to emphasise that this lack of insight into performance is not equally distributed across all categories of adverse events.3 In fact, as proposed recently by Shojania and Marang-van de Mheen, the incidence of adverse events may be best understood as a composite measure—with all of the limitations that come with looking at a measure with many composite parts.35 When broken apart, what we come to understand is that some of our mechanisms for identifying certain types of events are likely much more reliable than others where can i buy kamagra.

In the USA, for example, where the Agency for Healthcare Research and Quality has leveraged standardised methods for collecting and reporting national performance on a set of specific healthcare-associated s, we have much better insight into performance over time related to such healthcare-associated s than we do, for instance, with diagnostic error.Lastly, the challenge of interpreting national adverse event data over time is complicated by the nuances associated with the interfaces between politics and science. In our personal experience, we have encountered challenges reporting results of safety studies that are tied to ministries of health.36 Related to the INAES-2 where can i buy kamagra study specifically, Ireland has a long history of sensationalised media coverage of data pointing to opportunities for improved care, further complicating researchers’ ability to conduct this work free of influence.37Ultimately, the work presented by Connolly and colleagues is critically important work and we suggest that all health systems should be monitoring adverse event rates over time. The mechanisms for doing this, though, should rapidly evolve. With hospitals increasingly leveraging EHRs, data being collected in more uniform ways and advances in natural language processing and artificial intelligence, a future in which we have reliable measures of where can i buy kamagra adverse events that are stable over time is likely within our reach. To get from here to there, an ongoing investment in research with evaluation including leveraging artificial intelligence and natural language processing, and a commitment to transparent data reporting and enabling collaboration between organisations and governments focused on this work is essential.38 If we can achieve this, we could reasonably expect a future in which we have access to publicly available meaningful data on how many people are being harmed, and in what context, which could in turn transform safety.Ethics statementsPatient consent for publicationNot required..

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As the Congressional debate over budget reconciliation legislation intensifies, stakeholders are keeping a close eye on a proposal to allow the federal government to negotiate drug prices in Medicare, which is currently prohibited under federal law can you take kamagra through customs. The so-called “non-interference clause” prohibits the federal government from “interfering” in negotiations between can you take kamagra through customs drug companies and the private plans that deliver Part D coverage, and also prohibits the government from requiring a particular formulary or price structure for drugs. The proposal under consideration amends the non-interference clause by adding an exception that would allow the government to negotiate prices with drug companies for a relatively small number of high-cost drugs, with an excise tax levied on drug companies that do not agree to participate in the negotiation process or comply with the negotiated price. This proposal would yield savings upwards of $450 billion, based on an earlier estimate from the Congressional Budget Office.The pharmaceutical industry’s latest ad campaign claims that drug price negotiation would “restrict access to medicines in Medicare” by removing “a provision that protects access to medicines” and that patients “would be stuck can you take kamagra through customs with whatever medicines the government says you can have.” Another drug industry ad says that allowing the government to negotiate drug prices means “politicians…[will] decide which medicines you can and can’t get.”This is not accurate.

In fact, the proposed drug price negotiation program does not authorize the federal government to decide which medications people on Medicare can and cannot get and does not establish or require a particular prescription drug formulary. Insurers that offer Medicare prescription drug plans would continue can you take kamagra through customs to make decisions about which drugs to cover, or not, subject to protections provided under current law and regulations. The legislation under consideration leaves in place the non-interference clause and its specific restrictions with the exception of the proposed drug price negotiation program. Under this program, the negotiation process would not apply to most prescription drugs, instead focusing on a relatively small number with the highest spending and lacking generic or can you take kamagra through customs biosimilar competitors.While there is nothing in the proposed legislation that would allow the federal government to dictate which drugs Medicare beneficiaries can access, it is possible that downward pressure on prices from negotiation could lead drug companies to bring fewer drugs to market.

The Congressional Budget Office has estimated that reductions in future profits of 15% to 25% for high revenue drugs, which CBO expects would be similar to the effect of the current drug price negotiation proposal, would lead to 2 fewer drugs in the first decade (a reduction of 0.5%), 23 fewer drugs over the next decade (a reduction of 5%), and 34 fewer drugs in the third decade (a reduction of 8%). But the effect of lower can you take kamagra through customs prices on the number and type of new drugs that do and don’t come to market in the future is impossible to know with certainty. CBO does not forecast whether the drugs that don’t come to market would be innovative lifesaving treatments or “me too” drugs that offer little value in terms of improved health. CBO also notes that lower prices could potentially improve affordability and access to drugs for patients, leading to improved health.Allowing the federal government to negotiate drug prices, which is supported by a large majority of the public, would lower cost sharing and premiums can you take kamagra through customs for Medicare beneficiaries and produce significant savings for the federal government that could be used to cover the costs of other spending priorities, such as adding new Medicare dental, hearing, and vison benefits, filling the Medicaid “coverage gap”, and making permanent subsidy enhancements for people in Marketplace plans.

With much at stake in the outcome of the debate over this proposal, it’s no surprise that the rhetoric is getting heated. But while the pharmaceutical industry may want to frame the debate over drug price negotiation by focusing on the federal government limiting access to medications, this framing doesn’t accurately reflect what’s can you take kamagra through customs in the current legislative proposal. There are trade-offs involved in the proposal to negotiate drug prices, but that is not one of them.Many Medicare beneficiaries face high annual out-of-pocket costs for dental and hearing care — services that generally aren’t covered in traditional Medicare, but typically are covered by Medicare Advantage plans though the scope and value of these benefits vary, finds a new KFF analysis.The analysis shows that, among beneficiaries who used each type of service, average annual out-of-pocket spending was $914 for hearing care and $874 for dental care in 2018, but considerably less ($230) for vision care. Among those who were in the top 10 percent in terms of their out-of-pocket costs for such services, 2.7 can you take kamagra through customs million beneficiaries spent $2,136 or more on their dental care, while 360,000 beneficiaries spent $3,600 or more on hearing services.Beneficiaries can face high out-of-pocket costs whether they are in traditional Medicare or privately-run Medicare Advantage plans, the analysis finds.

Among users of dental services, for instance, average out-of-pocket spending was $766 among beneficiaries in Medicare Advantage and $992 among those in traditional Medicare in 2018.The analysis also finds that people on Medicare in communities of color, with disabilities, or with low incomes are disproportionately likely to have difficulty getting these services. About 16 percent of all Medicare beneficiaries reported in 2019 that there was a time in the last year can you take kamagra through customs that they could not get dental, hearing, or vision care, but this was reported by a greater percentage of beneficiaries under age 65 with long-term disabilities (35%). Those enrolled in both Medicare and Medicaid (35%). With low incomes (e.g., 31% for those with income under can you take kamagra through customs $10,000).

And Black and Hispanic beneficiaries (25% and 22%, respectively).The new analysis also provides an overview of coverage of dental, hearing, and vision services in Medicare Advantage plans. While most plans offer coverage for these services, the extent of coverage varies and has limits.Nearly all Medicare Advantage enrollees with access to dental coverage can you take kamagra through customs have preventive care benefits, and most have access to more extensive dental benefits. Cost sharing for more extensive dental services is typically 50 percent for in-network care, and typically is subject to an annual dollar cap on plan payments.Similarly, almost all Medicare Advantage enrollees have access to hearing exams and hearing aid coverage. The coverage generally is subject to either a maximum annual dollar cap and/or frequency limits on how often plans cover the service.Virtually all Medicare Advantage enrollees have access to vision exams and eyewear coverage, typically subject to maximum annual limits averaging about $160 per year.The findings come as can you take kamagra through customs policymakers in Congress are considering adding dental, hearing, and vision benefits to Medicare as part of the budget reconciliation bill, one of several competing spending priorities in the debate.

It would be the largest expansion of Medicare benefits since the Part D drug benefit was launched in 2006. (A similar 2019 proposal would have increased Medicare spending by more than $300 billion over 10 years according to the Congressional Budget Office.)For can you take kamagra through customs the full analysis and other KFF data and analyses about Medicare, including the recent Medicare and Dental Coverage. A Closer Look, visit kff.org.

As the Congressional debate over budget reconciliation legislation intensifies, stakeholders are keeping a close eye on a http://cheaper-hotels.dk/get-kamagra-prescription-online/ proposal to allow the federal government to negotiate drug prices where can i buy kamagra in Medicare, which is currently prohibited under federal law. The so-called “non-interference clause” prohibits the federal government from “interfering” in negotiations between drug companies and the private plans that deliver Part D coverage, and also prohibits the government from requiring a particular formulary or price structure for drugs where can i buy kamagra. The proposal under consideration amends the non-interference clause by adding an exception that would allow the government to negotiate prices with drug companies for a relatively small number of high-cost drugs, with an excise tax levied on drug companies that do not agree to participate in the negotiation process or comply with the negotiated price. This proposal would yield savings upwards where can i buy kamagra of $450 billion, based on an earlier estimate from the Congressional Budget Office.The pharmaceutical industry’s latest ad campaign claims that drug price negotiation would “restrict access to medicines in Medicare” by removing “a provision that protects access to medicines” and that patients “would be stuck with whatever medicines the government says you can have.” Another drug industry ad says that allowing the government to negotiate drug prices means “politicians…[will] decide which medicines you can and can’t get.”This is not accurate. In fact, the proposed drug price negotiation program does not authorize the federal government to decide which medications people on Medicare can and cannot get and does not establish or require a particular prescription drug formulary.

Insurers that offer Medicare prescription drug plans would continue to make decisions about which drugs to cover, or not, subject to protections provided where can i buy kamagra under current law and regulations. The legislation under consideration leaves in place the non-interference clause and its specific restrictions with the exception of the proposed drug price negotiation program. Under this program, the negotiation process would not apply to most prescription drugs, where can i buy kamagra instead focusing on a relatively small number with the highest spending and lacking generic or biosimilar competitors.While there is nothing in the proposed legislation that would allow the federal government to dictate which drugs Medicare beneficiaries can access, it is possible that downward pressure on prices from negotiation could lead drug companies to bring fewer drugs to market. The Congressional Budget Office has estimated that reductions in future profits of 15% to 25% for high revenue drugs, which CBO expects would be similar to the effect of the current drug price negotiation proposal, would lead to 2 fewer drugs in the first decade (a reduction of 0.5%), 23 fewer drugs over the next decade (a reduction of 5%), and 34 fewer drugs in the third decade (a reduction of 8%). But the effect of lower prices on the number and type of new drugs where can i buy kamagra that do and don’t come to market in the future is impossible to know with certainty.

CBO does not forecast whether the drugs that don’t come to market would be innovative lifesaving treatments or “me too” drugs that offer little value in terms of improved health. CBO also notes that lower prices could potentially improve affordability and access to drugs for patients, leading to improved health.Allowing the federal government to negotiate drug prices, which is supported where can i buy kamagra by a large majority of the public, would lower cost sharing and premiums for Medicare beneficiaries and produce significant savings for the federal government that could be used to cover the costs of other spending priorities, such as adding new Medicare dental, hearing, and vison benefits, filling the Medicaid “coverage gap”, and making permanent subsidy enhancements for people in Marketplace plans. With much at stake in the outcome of the debate over this proposal, it’s no surprise that the rhetoric is getting heated. But while the pharmaceutical industry may want to frame the debate over drug price negotiation by focusing on the federal government limiting access to medications, this where can i buy kamagra framing doesn’t accurately reflect what’s in the current legislative proposal. There are trade-offs involved in the proposal to negotiate drug prices, but that is not one of them.Many Medicare beneficiaries face high annual out-of-pocket costs for dental and hearing care — services that generally aren’t covered in traditional Medicare, but typically are covered by Medicare Advantage plans though the scope and value of these benefits vary, finds a new KFF analysis.The analysis shows that, among beneficiaries who used each type of service, average annual out-of-pocket spending was $914 for hearing care and $874 for dental care in 2018, but considerably less ($230) for vision care.

Among those who were in the top 10 percent in terms of their out-of-pocket costs for such services, 2.7 million beneficiaries spent $2,136 or more on their dental care, while 360,000 beneficiaries spent $3,600 or more on hearing services.Beneficiaries can face high out-of-pocket costs whether they are in traditional Medicare where can i buy kamagra or privately-run Medicare Advantage plans, the analysis finds. Among users of dental services, for instance, average out-of-pocket spending was $766 among beneficiaries in Medicare Advantage and $992 among those in traditional Medicare in 2018.The analysis also finds that people on Medicare in communities of color, with disabilities, or with low incomes are disproportionately likely to have difficulty getting these services. About 16 percent of all Medicare beneficiaries reported in 2019 that there was a time in the last year that they could not get dental, hearing, or vision care, where can i buy kamagra but this was reported by a greater percentage of beneficiaries under age 65 with long-term disabilities (35%). Those enrolled in both Medicare and Medicaid (35%). With low incomes (e.g., 31% for those with income under $10,000) where can i buy kamagra.

And Black and Hispanic beneficiaries (25% and 22%, respectively).The new analysis also provides an overview of coverage of dental, hearing, and vision services in Medicare Advantage plans. While most plans offer coverage for these services, the extent of coverage varies and has limits.Nearly all Medicare Advantage enrollees where can i buy kamagra with access to dental coverage have preventive care benefits, and most have access to more extensive dental benefits. Cost sharing for more extensive dental services is typically 50 percent for in-network care, and typically is subject to an annual dollar cap on plan payments.Similarly, almost all Medicare Advantage enrollees have access to hearing exams and hearing aid coverage. The coverage generally is subject to either a maximum annual dollar cap and/or where can i buy kamagra frequency limits on how often plans cover the service.Virtually all Medicare Advantage enrollees have access to vision exams and eyewear coverage, typically subject to maximum annual limits averaging about $160 per year.The findings come as policymakers in Congress are considering adding dental, hearing, and vision benefits to Medicare as part of the budget reconciliation bill, one of several competing spending priorities in the debate. It would be the largest expansion of Medicare benefits since the Part D drug benefit was launched in 2006.

(A similar 2019 proposal would have increased Medicare spending by more than $300 billion over 10 years according to where can i buy kamagra the Congressional Budget Office.)For the full analysis and other KFF data and analyses about Medicare, including the recent Medicare and Dental Coverage. A Closer Look, visit kff.org.

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Historic yet kamagra sex pills kamagra online shopping canada imperfect. That’s how I think of the World Health Organization’s recent endorsement of the long-awaited malaria kamagra sex pills treatment, officially known as RTS,S/AS01, or simply as RTS,S.This recommendation follows careful determination by two of the WHO’s high-level advisory panels, one on immunization and another on malaria, that RTS,S provides significant protection against disease and deaths and that it is safe and cost-effective.That’s a huge step forward for a disease with 230 million cases in 2019, the last year with compete statistics, one that killed 409,000 people. Although malaria is most common in sub-Saharan Africa, it is also endemic in southeast Asia, the eastern Mediterranean, western Pacific, and Central and South America.advertisement The WHO’s final recommendation follows an ongoing pilot program in Ghana, Malawi and Kenya, in which 2.3 million doses have already been given to more than 800,000 children. This program demonstrated that RTS,S can be delivered alongside other childhood kamagra sex pills treatments, and that its introduction does not interfere with other malaria intervention programs. Countries in which malaria is endemic can now include the treatment as one of the interventions for children starting at age 5 months.

It is set to kamagra sex pills be given in four doses, the first three given monthly and the last dose two years later to boost immunity against repeat s. Children in endemic areas typically suffer multiple s, so this booster dose is particularly crucial.advertisement Since RTS,S is the first-ever malaria treatment, and the first treatment against any parasitic disease, its approval is historic. A widely accepted treatment development roadmap currently has set targets of 75% protection against malaria cases and 50% protection against deadly forms of malaria kamagra sex pills. Both of these targets, however, are far above the protection that RTS,S offers — hardly exceeding 40% against malaria cases or 30% against deadly severe malaria — making RTS,S also imperfect.Although there has been talk in recent years about malaria elimination, actual progress has been slow. Starting in 2000, greater investments in fighting malaria have averted an estimated 1.5 billion malaria cases and 7.6 million deaths, yet population growth and a myriad of other challenges in sub-Saharan Africa have left the total malaria burden unchanged kamagra sex pills.

In fact, since 2015, many of the countries with the highest malaria burden have recorded increases in cases.This situation calls for transformational approaches to more drastically reduce the global burden of malaria and to sustain gains against concerns such as insecticide resistance and drug resistance.The WHO emphasized that this treatment should be viewed as just one component in the arsenal against malaria and must be considered in a broader context of ongoing malaria control efforts. Countries must kamagra sex pills continue using existing malaria interventions such as artemisinin combination treatments, insecticide-treated bed nets, and preventive treatments for pregnant women and children because RTS,S is no silver bullet.This raises questions about how the adoption of RTS,S may change the malaria control landscape, whether the treatment will be affordable, whether there will be adequate doses to go around, and who will finance the treatment programs. Countries adopting RTS,S may therefore wish to prioritize areas of highest burden, where the treatment is expected to yield maximum impact. No matter what malaria-prevention strategies countries select, the benefits of RTS,S will be accrued only if governments enhance the basic infrastructure of their kamagra sex pills health systems to enable effective treatment delivery. That it takes four doses per child will create an additional layer of complexity and potentially reduce overall effectiveness.

Fortunately, the ongoing pilot studies suggest kamagra sex pills that the RTSS treatment can be readily integrated into the expanded programs of childhood immunizations (EPIs), without negatively impacting other malaria interventions. These EPI programs are already widely kamagra sex pills popular in Africa and are among the most cost-effective.Other than the governments of countries in which malaria is endemic, major financers of malaria control today include The Global Fund, created in 2002, and the U.S. President’s Malaria Initiative, created in 2005. Most of the funding may have already been earmarked for existing tools, so the introduction of RTS,S is expected to initiate in-depth negotiations for either additional fundraising or reprograming of available budgets.The Global treatment Alliance (GAVI), which has been an extraordinary champion of childhood vaccination — and most recently erectile dysfunction treatment vaccination — in low-income countries will also likely play a crucial role in negotiating the financing, procurement, and delivery of RTS,S.Beyond RTS,S, other candidate anti-malaria treatments are currently in advanced trials kamagra sex pills. These include the sporozoite treatments, which require injection with live malaria parasites followed by a prophylactic dose of chloroquine to ensure that the person does not develop actual disease but remains sufficiently protected against future s.

There is also the R21 treatment, which recently showed up to 77% protection kamagra sex pills in a small trial involving 450 children in west Africa, and is scheduled for larger trials. Perhaps most exciting has been the recent announcement by BioNTech that it will configure the mRNA technology behind its successful erectile dysfunction treatment to target the malaria parasite.These options have different advantages and disadvantages, and will be crucial next steps in the now-rejuvenated malaria treatment era. It is imperative that all promising options are accelerated to make up for all the years during which malaria innovation has been kamagra sex pills so excruciatingly slow. Malaria endemic countries must resist the temptation of seeing RTS,S as a one-and-done solution and instead consider multiple options and formulate context specific packages of interventions for maximum impact. They must continue building more holistic strategies consisting of stronger health systems and multi-sectorial initiatives necessary to kamagra sex pills sustain the gains.

As well as the pursuit of potentially transformative tools to accelerate anti-malaria efforts.As the first treatment against a parasitic disease, one that was evaluated widely by African scientists, RTS,S could inspire new interest in public health and herald greater commitments to malaria control. Going forward, African countries should marshal greater energies to advance innovation against priority health challenges.The journey toward zero kamagra sex pills must not end here and the WHO’s endorsement of RTS,S treatment must not drive complacency. Instead it should inspire greater focus on achieving malaria elimination as fast as possible and with as few deaths as possible using every available strategy.Fredros Okumu is mosquito biologist and public health expert, director of science at Ifakara Health Institute in Tanzania, and an Aspen Institute New Voices Fellow. He is kamagra sex pills a member of the WHO Malaria Policy Advisory Group, which evaluated RTS,S, and reports having received research funding from the Bill and Melinda Gates Foundation and the Wellcome Trust, among others. The views expressed here are his own, and not to be viewed as representing any of the organizations with which he is affiliated..

Historic yet where can i buy kamagra kamagra oral jelly buy online canada imperfect. That’s how I think of the World Health Organization’s recent endorsement of the long-awaited malaria treatment, officially known as RTS,S/AS01, or simply as RTS,S.This recommendation where can i buy kamagra follows careful determination by two of the WHO’s high-level advisory panels, one on immunization and another on malaria, that RTS,S provides significant protection against disease and deaths and that it is safe and cost-effective.That’s a huge step forward for a disease with 230 million cases in 2019, the last year with compete statistics, one that killed 409,000 people. Although malaria is most common in sub-Saharan Africa, it is also endemic in southeast Asia, the eastern Mediterranean, western Pacific, and Central and South America.advertisement The WHO’s final recommendation follows an ongoing pilot program in Ghana, Malawi and Kenya, in which 2.3 million doses have already been given to more than 800,000 children. This program demonstrated that where can i buy kamagra RTS,S can be delivered alongside other childhood treatments, and that its introduction does not interfere with other malaria intervention programs.

Countries in which malaria is endemic can now include the treatment as one of the interventions for children starting at age 5 months. It is set to be given in four doses, the first three given monthly and the last dose two years where can i buy kamagra later to boost immunity against repeat s. Children in endemic areas typically suffer multiple s, so this booster dose is particularly crucial.advertisement Since RTS,S is the first-ever malaria treatment, and the first treatment against any parasitic disease, its approval is historic. A widely accepted treatment development roadmap currently has set targets of 75% protection against malaria where can i buy kamagra cases and 50% protection against deadly forms of malaria.

Both of these targets, however, are far above the protection that RTS,S offers — hardly exceeding 40% against malaria cases or 30% against deadly severe malaria — making RTS,S also imperfect.Although there has been talk in recent years about malaria elimination, actual progress has been slow. Starting in 2000, greater investments in fighting malaria have averted an estimated 1.5 billion malaria cases and 7.6 million deaths, yet population growth and a where can i buy kamagra myriad of other challenges in sub-Saharan Africa have left the total malaria burden unchanged. In fact, since 2015, many of the countries with the highest malaria burden have recorded increases in cases.This situation calls for transformational approaches to more drastically reduce the global burden of malaria and to sustain gains against concerns such as insecticide resistance and drug resistance.The WHO emphasized that this treatment should be viewed as just one component in the arsenal against malaria and must be considered in a broader context of ongoing malaria control efforts. Countries must continue using existing malaria interventions such as artemisinin combination treatments, insecticide-treated bed nets, and preventive treatments for pregnant women and children because RTS,S is no silver bullet.This raises questions about how the adoption of RTS,S may change the malaria control landscape, whether the treatment will be affordable, whether there will where can i buy kamagra be adequate doses to go around, and who will finance the treatment programs.

Countries adopting RTS,S may therefore wish to prioritize areas of highest burden, where the treatment is expected to yield maximum impact. No matter what malaria-prevention strategies countries select, the benefits of RTS,S will be accrued only if governments enhance the basic infrastructure of their health where can i buy kamagra systems to enable effective treatment delivery. That it takes four doses per child will create an additional layer of complexity and potentially reduce overall effectiveness. Fortunately, the ongoing pilot studies suggest that the RTSS where can i buy kamagra treatment can be readily integrated into the expanded programs of childhood immunizations (EPIs), without negatively impacting other malaria interventions.

These EPI programs are already widely popular in Africa and are among the most cost-effective.Other than the governments of countries in where can i buy kamagra which malaria is endemic, major financers of malaria control today include The Global Fund, created in 2002, and the U.S. President’s Malaria Initiative, created in 2005. Most of the funding may have already been earmarked for existing tools, so the introduction of RTS,S is expected to initiate in-depth negotiations for either additional fundraising or reprograming of where can i buy kamagra available budgets.The Global treatment Alliance (GAVI), which has been an extraordinary champion of childhood vaccination — and most recently erectile dysfunction treatment vaccination — in low-income countries will also likely play a crucial role in negotiating the financing, procurement, and delivery of RTS,S.Beyond RTS,S, other candidate anti-malaria treatments are currently in advanced trials. These include the sporozoite treatments, which require injection with live malaria parasites followed by a prophylactic dose of chloroquine to ensure that the person does not develop actual disease but remains sufficiently protected against future s.

There is also the R21 treatment, which recently showed up to 77% protection in a small trial involving 450 children in west Africa, and is scheduled where can i buy kamagra for larger trials. Perhaps most exciting has been the recent announcement by BioNTech that it will configure the mRNA technology behind its successful erectile dysfunction treatment to target the malaria parasite.These options have different advantages and disadvantages, and will be crucial next steps in the now-rejuvenated malaria treatment era. It is imperative that all promising options where can i buy kamagra are accelerated to make up for all the years during which malaria innovation has been so excruciatingly slow. Malaria endemic countries must resist the temptation of seeing RTS,S as a one-and-done solution and instead consider multiple options and formulate context specific packages of interventions for maximum impact.

They must continue building more holistic strategies consisting of stronger health systems where can i buy kamagra and multi-sectorial initiatives necessary to sustain the gains. As well as the pursuit of potentially transformative tools to accelerate anti-malaria efforts.As the first treatment against a parasitic disease, one that was evaluated widely by African scientists, RTS,S could inspire new interest in public health and herald greater commitments to malaria control. Going forward, African countries should marshal greater energies to where can i buy kamagra advance innovation against priority health challenges.The journey toward zero must not end here and the WHO’s endorsement of RTS,S treatment must not drive complacency. Instead it should inspire greater focus on achieving malaria elimination as fast as possible and with as few deaths as possible using every available strategy.Fredros Okumu is mosquito biologist and public health expert, director of science at Ifakara Health Institute in Tanzania, and an Aspen Institute New Voices Fellow.

He is a member of the WHO Malaria Policy Advisory Group, which evaluated RTS,S, and reports having received research funding from the where can i buy kamagra Bill and Melinda Gates Foundation and the Wellcome Trust, among others. The views expressed here are his own, and not to be viewed as representing any of the organizations with which he is affiliated..