Fichas
aug 12th
Fichas del conjunto (200)
- 1Neisseria and MoraxellaGram-negative
Diplococci
Oxidase positive
Catalase positive
Naturally competent - 2Species associated with humans:Neisseria gonorrhoeae
Neisseria meningitidis
– ~11 species in normal flora
Moraxella catarrhalis
• Pathogen of upper respiratory
tract - 3Neisseria gonorrhoeae diseasesGonorrhea (urethritis/cervicitis)
PID (pelvic inflam disease)
Disseminated infection
(arthritis, skin lesions)
Conjunctivitis (neonates)
Pharyngitis - 4• Neisseria meningitidis diseaseMeningitis
Meningococcemia (bacteremia)
Rarely pneumonia, arthritis, otitis
media and epiglottitis - 5Moraxella catarrhalis– “Emerging” pathogen in 2000’s
Common childhood infection and
immunocompromised adults - 6Moraxella catarrhalis diseqseUpper respiratory tract infections
COPD exasperation
Immunocompromised: pneumonia,
bacteremia - 7Primary Diseases Caused by N. gonorrhoeaeLower male and female reproductive tract infections
Upper male and female reproductive tract infections
Proctitis
Pharyngitis
Opthalmia neonatorum
Disseminated infection - 8Lower male and female reproductive tract infectionsCervicitis
Urethritis - 9Upper male and female reproductive tract infectionsEndometritis
Epididymitis
Pelvic inflammatory disease (PID) - 10Disseminated infectionDermatitis-arthritis-tenosynovitis syndrome: fever, polyarthritis,
tenosynovitis and skin lesions
Monoarticular septic arthritis (one joint—often knee)
Rarely endocarditis or meningitis - 11Neisseria gonorrhoeae mechanismInvades mucosal surfaces and causes inflammation thru sexual contact
• Localized
– Genital tract
– Rectal
– Oropharyngea - 12AsymptomaticPurulent discharge and
irritation
Chronic: fibrosis - 13Virulence factorspilli
IgA protease
omp
LOS-endotoxin - 14Disseminated Infection: Purulent or septic arthritisInfection in the joints “septic arthritis” = culture positive
Swelling
Pain
Typically afebrile - 15EpidemiologySexually transmitted
so most people who are younger teens - 16preventionCondom use, abstinence
No vaccines
Screening and treatment
Treatment of partners - 17DiagnosisSpecimen
Microscopy
Culture
Biochemical Tests
Nucleic Acid Amplification Tests (NAAT) - 18SpecimenCervical or urethral discharge
Anal/rectal
Oropharyngeal
Joint aspiration - 19NAATVariety with different levels of specificity and sensitivity
Drawback: cannot perform drug resistance testing - 20MicroscopyGram Stain
Gram Negative diplococci often found
in neutrophils (pathogens)
Commensal flora - 21CultureFastidious (needs special media or special
incubation conditions)
Culturing important for drug sensitivity
screening
Selective media:
– Thayer-Martin Medium - 22Thayer-Martin MediumChocolate agar containing vancomycin, colistin, nystatin, and sometimes trimethoprim
The left side of the plane is chocolate agar; the right side contains chocolate agar plus
antibiotics, which block growth of normal flora and allow the gonococcus to grow - 23Differential DiagnosisAcid production with sugar utilization
– Glucose, Lactose, Maltose, Sucrose
N. gonorrhoeae is positive for glucose
but not maltose, lactose, or sucrose
Negative for Dnases - 24Moraxellanegative for all sugars, +
for Dnase and – beta lactamase - 25TreatmentDrug resistance common
– Penicillin resistance common due to mutations in penicillin binding proteins and beta-lactamases
• CDC recommends 2 antibiotics
– Ceftriaxone and azithromycin - 26Neisseria meningitidisNormal flora ~10%
people
symbiote but can be invasive for other people: Acute, rapid meningitis and/or sepsis (blood stream infection)
Rarely chronic infection: recurrent fever,
arthralgias, cutaneous eruptions - 27MeningitisMeningitis is a disease caused by the
inflammation of the protective membranes
covering the brain and spinal cord known as the meninges. The inflammation is usually caused by an infection of the fluid surrounding the brain and spinal cord. - 28Meningitis symtoms• Headache
• Fever
• Vomiting
• Photophobia
• Lethargy
• Neck stiffness
• Seizures - 29Bacterial meningitis doesnt occur innewborns
- 30Meningococcemia (sepsis or septicemiaOverwhelming systemic inflammatory reaction to endotoxin
Very rapid progression (hours)
Fever
Tachycardia/tachypnea
Bleeding under the skin
Disseminated intravascular coagulation (clotting cascade)
Hypotension
Multiple organ failure and tissue
necrosis - 31sepsis symtomsFever
Tachycardia/tachypnea
Bleeding under the skin
Disseminated intravascular coagulation (clotting cascade)
Hypotension
Multiple organ failure and tissue
necrosis - 32Virulence factors: Neisseria meningitidisCapsule
Endotoxin (LOS)
Pili and outermembrane proteins
IgA protease (mucosal colonization) - 33Capsule– Prevents phagocytosis
– Used in serotyping
– Vaccines based on capsular
antigens - 34Risk FactorsAge
Crowding
Immune function
Deficiency in “late” complement (C5-C9)
Complement inhibitors (i.e. eculizumab)
Travel (Meningitis belt in Africa) - 35Deficiency in “late” complement (C5-C9)– Likely associated with a nonfunctional membrane
attack complex - 36Vaccine for Neisseria meningitidis2 types of meningococcal vaccines based on capsular antigens
– MenACWY (protects against types A,C,W,Y)
– MenB (protects against type B) - 37CDC recommendations for U.S.Babies and Children
• Only if immunodeficient or have increased risk
Preteens and teens
• All 11-12 year olds get MenACWY (booster at 16)
• Now MenB recommended at age 16
Adults
• Only if have risk factors - 38DiagnosisSpecimen
– Cerebrospinal fluid
– Blood
NAATs
Expect Gram negative diplococcus
Culturing
Biochemical tests - 39Biochemical testsOX+, Catalase+
Acid production with sugar utilization
– Glucose, Lactose, Maltose, Sucrose
Deoxyribonuclease - 40TreatmentRapid progression, treat quickly
Penetrate to meninges
Intravenous antibiotics
Typically broad-spectrum antibiotic regimen given severity and rapid progression - 41antibioticsEmpiric treatment with ceftriaxone or cefotaxime (3rd gen cephalosporins: inhibit cell wall synthesis by binding to the
enzymes that crosslink the cell wall) - 42Antibiotic resistance newly emergingBeta-lactamase positive isolates
Penicillin and ciprofloxacin now not recommended without susceptibility testing - 43Moraxella catarrhalisEmerging pathogen in 80’s-90’s
Now established. Vaccination against S. pneumoniae has changed colonization patterns
Normal flora in nasopharynx of ~5% population
Third most common cause of upper respiratory tract infections in children
Infections of the pulmonary tract in older adults especially those with COPD (Pneumonia, chronic bronchitis) - 44upper respiratory tract infections– Otitis media, bronchitis, sinusitis, laryngitis
- 45DiagnosisGram negative diplococcus in neutrophils
• Looks like Neisseria
• Lots of commensals in nasopharynx/respiratory tract
– Culture on blood agar
– Biochemical testing
• Negative for sugar tests
• Positive for DNAse - 46TreatmentDrug resistance common
– Produce beta-lactamases
– Amoxicillin + clavulanate or trimethroprimsulfamethoxasole or second or third generation cephalosporin - 47The EnterobacteriaceaeEscherichia coli
Shigella
Salmonella
Klebsiella
Enterobacter
Serratia
Proteus - 48Enterobacteriaceae characteristicslarge family of bacteria
Gram negative rods
Facultative anaerobes
Oxidase negative
Reduce nitrate to nitrite
Many found in the lower GI of humans and animals
Also found widely in the environment
Cause a variety of diseases - 49Cause a variety of diseasesPathogens
Opportunistic pathogens - 50Enterobacteriaceae SerotypingO, H, K antigens
• O = outer polysaccharide portion of
lipopolysaccharide
• H = flagellar protein
• K = capsular polysaccharide - 51capsular polysaccharide identified byquelling reaction (antibodies bind to
capsule and appears to be swelling) - 52Enterobacteriaceae DiagnosticsAll species are easy to
culture: Lactose fermentation is
a key characteristic
20+ biochemical tests for differentiation
Selective and indicator agars for lactose
fermentation - 53Selective and indicator agars for lactose fermentationMacConkeys
Eosin Methylene Blue (EMB)
Shigella-salmonella agar
(Hektoins agar) - 54Lactose Fermentation positivs.
- 55Lactose Fermentation negative.
- 56MacConkey AgarSelective
– Bile salts/crystal violet inhibit gram positives and most others besides Enterobacteriaceae and Pseudomonas
• Indicator
– Neutral red
– Ferment lactose (acid=pink)
– No fermentation - colorless - 57Eosin Methylene Blue AgarSelective—only Gram negatives
(mostly)(eosin and methylene blue)
Lactose fermenters = dark purple
High lactose = green metallic sheen (E.
coli) - 58TransmissionFecal contamination
– Food
– Water
– Objects (fomites)
Animal reservoir hosts
Food processing - 59Escherichia coliHighly diverse with various “pathotypes”
- 60Major groups of pathogensUTI: UPEC Uropathogenic E. coli
GI infection: diarrheal or dysentery disease
• ETEC Enterotoxigenic
• EHEC Enterohemorrhagic - 61diseasesNeonatal meningitis
Sepsis - 62ETECExotoxin causes diarrhea
Common worldwide where sanitation is not adequate
Self limiting diarrhea 1-3 days
Treatment often not necessary
– Prevent dehydration - 63ETEC Enterotoxinsheat labile toxin (LT)
heat stabile toxin (ST) - 64heat labile toxin (LT)A-B toxin
similar to cholera toxin (although not as severe)
Increases cAMP levels in cells, which
phosphorylates ion transporters causing
outpouring of Na+ and Cl- and water - 65Enterohemorrhagic E. coliCauses diarrhea and bloody diarrhea
• ~265,000 cases in the US each year
Many strains which all produce Shiga toxin
(verotoxin) STEC (E. coli O157:H7)
Can lead to hemolytic uremic syndrome (HUS)
World wide distribution - 66EHEC reservoircattle
- 67EHEC Clinical PictureWatery diarrhea, cramping (typically no fever)
Some progress to hemorrhagic colitis
usually self limiting (in ~1 week)
5-10% progress to (HUS) hemolytic uremic
syndrome
5-10 days after diarrheal symptoms - 685-10 days after diarrheal symptoms1.) Hemolytic anemia
2.) thrombocytopenia
3.) Acute renal failure - 69Shiga ToxinSTX1, STX2, Shiga-like toxin
Present in species of Shigella and E. coli
Derived from Lambda bacteriophage
A-B toxin - 70A-B toxin mechanismBinding
• Gb3 receptor
– Vascular endothelium (high density in kidney)
– Colonic epithelial cells
Inhibits protein synthesis
• Cleaves a nucleobase from the 28S RNA of the 60S subunit of the ribosome - 71EHEC DiagnosticsCDC recommends that patients presenting
with acute community acquired diarrhea be tested for EHEC 0157 and also shiga toxins
Test for Shiga toxin: ELISA or PCR for toxin
genes
Culture
Serotyping - 72EHEC CultureMacConkeys agar—pink
EMB—Green - 73Sorbitol MacConkey Agar for EHEC O157:H7EHEC O157:H7
remains colorless— does not ferment
sorbitol (ferments slowly - 74EHEC Treatmentantibiotics may cause the release toxin and
increase risk of HUS….they are contraindicated
supportive therapy
Monitor for HUS - 75E. coli Neonatal MeningitisExposure of neonates at birth to E. coli in the vaginal tract
Can lead to meningitis and sepsis
Typically have capsule
• “Group B” Streptococci also major cause of neonatal meningitis - 76ShigellaEnterocolitis or inflammatory diarrhea
Shigellosis, bacillary dysentery (bloody
diarrhea)
Very low ID50
Very contagious, person to person
transmission likely - 77Highlighted species– Shigella dysenteriae
• Shiga toxin
– Shigella sonnei
• Most common in the U.S. - 78Shigella DiagnosticsLactose non-fermenter
– Colorless on MacConkeys or EMB
Grow on Hektoen’s agar or Salmonella-Shigella agar
– Differentiates Salmonella and Shigella - 79Salmonella enterica ---2Gastroenteritis (Salmonella enterica Typhimurium)
Typhoid fever (Salmonella enterica Typhi) - 80Salmonella Gastroenteritis trasmission----Contaminated Food
• Several animal reservoirs (chickens and eggs)
• Outbreaks from peanut butter, and vegetables and fruits (fruit juices)
--- Asymptomatic carriers
-----Pets (especially reptiles and turtles) • ~90% of reptiles carry the bacteria
• birds, rodents, dogs, and cats are also potential reservoirs - 81Pathogenesis: Enteric DiseaseEnterocolitis or Inflammatory diarrhea
Invades cells
Dissemination to other parts of the body
– Osteomyelitis in those with Sickle cell disease - 82Invades cells– Inflammation
– Blood in stool
– Leukocytes in stool - 83Diagnosisnon-lactose fermenting
– (Colorless on MacConkey Agar)
Motile (Shigella is not)
Produces H2S
Hektoen agar or Shigellasalmonella agar = black colonies
– Differentiate from Shigella - 84Hektoen’s Agar (differentiates Salmonella from Shigella from other enterics)H2S production ---> black (thiosulfate)
Black=Salmonella
Clear = Shigella - 85Typhoid Fever and Paratyphoid Fever locationsGlobal Health Problem
Low income areas with inadequate sanitation
Animal reservoirs play a role in paratyphi
transmission - 86Typhoid Fever and Paratyphoid Fever diseasesFebrile illness (2-3 weeks)
Rose spots (Week 2)
Complications: Intestinal perforation, dissemination of infection - 87Febrile illness (2-3 weeks)– High fever, delirium
– Tender abdomen
– Enlarged spleen
– Weakness, fatigue, loss of appetite
– Diarrhea or constipation - 88**Rose spots (Week 2)rash of flat, rose-colored spots on the abdomen – Light colored skin
Not very common - 89Klebsiellapathogen in humans:Klebsiella pneumoniae
Capsule
Infections
Patients have predisposing condition
such as diabetes, respiratory disease,
alcoholism - 90InfectionsPneumonia
UTI
Wound and surgical sites
Can spread to other parts of the body - 91Diagnosisculture: Lactose fermenting
Mucoid colonies due to capsule
Pneumonia: sputum thick due to capsule
and bloody = currant jelly sputum - 92**klebsia is becoming very drug reistsant becus gram neg enteric.
- 93EnterobacterOpportunistic and nosocomial pathogen
-lower respiratory tract infections
– UTI
Highly drug resistant
Lactose positive - 94Spread from thereBacteremia
• skin and soft-tissue infections
• Endocarditis
• Osteomyelitis
• CNS infections - 95Serratia marcescensOpportunistic and nosocomial pathogen
-lower respiratory tract infections
– UTI
HIV/AIDS associated diarrhea
May cause diarrhea in some healthy patients
Drug resistance - 96Spread from thereBacteremia
• skin and soft-tissue infections
• Endocarditis
• Osteomyelitis
• CNS infections - 97serratic diagnosisculture
Produces red pigment
especially at lower temperatures (25C) - 98ProteusProteus mirabilis
UTI infections
Highly motile, swarming
Produces urease
Non-lactose fermenting, swarming - 99Produces urease– Hydrolyzes urea to form ammonia,
raising pH
– Encourages formation of stones
• Struvite stones of magnesium and
ammonium phosphate
• Bacteria can remain in the stones - 100Rare relatives of ProteusMorganella
Providencia
• Opportunisticpathogens
• Lactose negative
• Urease positive - 101Primary careCommon health problems (e.g., sore throats, diabetes, arthritis, depression, or hypertension) and preventive measures (e.g., vaccinations or mammograms) that account for 80% to 90% of visits to a physician or other caregiver
- 102Secondary careProblems that require more specialized clinical expertise such as hospital care for a patient with acute renal failure
- 103Tertiary careLies at the apex of the organizational pyramid, involves the management of rare disorders such as pituitary tumors and congenital malformations.
- 104OutpatientAmbulatory health care
Types
Private Practice
Community Health Center
Emergency Department
Urgent Care Center
Patient-Centered Medical Home - 105Regionalized ModelDifferent types of personnel and facilities are assigned to distinct tiers in the primary, secondary, and tertiary levels
Flow of patients across levels occurs in an orderly, regulated fashion
Emphasizes the primary care base and a population-oriented framework for health planning
Example: British National Health Service (NHS) - 106Primary care levelDomain of general practitioners (GPs) who practice in small- to medium-sized groups and whose main responsibility is ambulatory care
Half of all physicians in the UK are GPs. - 107Secondary care levelIncludes specialties such as internal medicine, pediatrics, neurology, psychiatry, obstetrics and gynecology, and general surgery
Physicians are located at hospital-based clinics
Serve as consultants for outpatient referrals from GPs
Provide care to hospitalized patients - 108Tertiary care levelSubspecialists such as cardiac surgeons, immunologists, and pediatric hematologists
Physicians are located at a few tertiary care medical centers - 109Dispersed ModelLess structured approach to levels of care than in British NHS
Example: US
Patients may directly access specialist of choice
Internists and pediatricians provide primary care
Primary care accounts for 1/3rd of physician workforce vs ½ in UK
Overlapping roles among primary care physicians and specialists
Overlapping care among community and tertiary care hospitals - 110ProsEnhanced coordination
Emphasis on primary care and prevention - 111ConsLack of direct access and less flexibility
Lack of specialty care - 112ProsFlexibility and convenience
Emphasis on specialization and technology
Direct access - 113ConsToo many specialists and too much emphasis on tertiary care orientation
Lack of organizational coherence that may contribute to higher cost and decreased quality of care - 114Vertically Integrated ModelPolicy analysts predicted that the organizational efficiency and coherence of vertically integrated, first-generation HMOs would position these systems of care to prevail as health care entered a more competitive era
More regionally based
Differs significantly from dispersed industry model - 115Virtually Integrated ModelEnrollment in virtually integrated systems has surpassed that of traditional HMOs
Nonprofit commercial insurers that operate nationally
More like dispersed industry model - 116Preferred Provider Organization (PPO)Like an HMO, but not as tightly controlled
Patients have more flexibility in choosing care from providers that are not in the PPO network, but pay have higher cost-sharing - 117Patient-Centered Medical HomeA model of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety
Can reside in the medical neighborhood, which also includes the secondary, tertiary, community, and related services; care is functionally integrated vs structurally or vertically integrated - 118Accountable Care OrganizationsLarge organizations that integrate primary care, specialty services and inpatient hospital care
Includes doctors, hospitals and other health care providers
Similar to PCMH (i.e. coordination of care), but expand beyond primary care
Payment is tied to quality metrics and cost of care - 119Important aspects of ACOs:When physicians share financial risk with other physicians, and physicians share risk with hospitals, they are all motivated to work together to achieve common performance goals
Because the global payment target is applied to a defined group of beneficiaries, it moves ACOs toward a population health model - 120There are four basic modes of paying for health careOut-of-pocket payment
Individual private insurance
Employment-based group private insurance
Government funded insurance - 121Out-of-Pocket PaymentSimplest mode of financing—direct purchase by the consumer of goods and services
Health care is the foremost example of asymmetry of information between providers and consumers - 122Individual Private InsuranceWith private health insurance, a third party, the insurer is added to the patient and the health care provider relationship
Requires two transactions
a premium payment from the individual to an insurance plan (also called a health plan)
a payment from the insurance plan to the provider - 123Employment-Based Private InsuranceThe rapid growth of employment-based private insurance was spurred by an accident of history
During World War II, wage and price controls prevented companies from granting wage increases, but allowed the growth of fringe benefits
Employers usually pay much of the premium that purchases health insurance for their employees - 124Government Financed Health InsuranceThe government had subsidized municipal hospitals and dispensaries to care for the poor and state-operated mental hospitals
- 125Medicare65 years of age or older and a US citizen or permanent resident for more than 5 years and have paid taxes for at least 10 years
Under the age of 65 and permanently disabled, have ALS or require dialysis - 126MedicaidJointly administered by the federal and state governments, with the federal government contributing at least 50% of the funding to match state expenses
Although designed for low-income Americans, not all poor people have traditionally been eligible
In addition to being poor, Medicaid required that people also meet “categorical” eligibility criteria such as being a young child, pregnant, elderly, or disabled - 127With government-financed health plans, the taxpayer can interact with the health care consumer in two distinct ways:The social insurance model, exemplified by Medicare, allows only those who have paid a certain amount of social security taxes to be eligible for Part A and only those who pay a monthly premium to receive benefits from Part B. As with private insurance, social insurance requires people to make a contribution in order to receive benefits
The contrasting model is the Medicaid public assistance model, in which those who contribute (taxpayers) may not be eligible for benefits - 128The Burden of Financing Health CareHealthy middle-income employees generally pay more in social security payments and other taxes than they receive in health services
Unemployed, disabled, and lower-income elderly persons tend to receive more in health services than they contribute in taxes - 129Different methods of financing health care place different burdens on the various income levels of society. Payments are classified asProgressive if they take a rising percentage of income as income increases
Regressive if they take a falling percentage of income as income increases
Proportional if the ratio of payment to income is the same for all income classes - 130A large proportion of health care expenditures are financed through out-of-pocket payments and premiumsThese are regressive
The poorest households spent a disproportionate amount of income on health care in comparison to the highest-income households - 131as health care cost increased more than earnings,
- 132Units of PaymentFee-for-service
Payment by episode of Illness
Per diem payments to hospitals
Capitation payment - 133Fee-for-servicebest for physcians and risks are for insurance
With fee-for-service payments, physicians have an economic incentive to perform more services because more services bring in more payments, which has contributed to the rapid rise in health care costs in the US - 134Payment per episode of illnessPhysicians usually receive a single payment for several services (the surgery itself and postoperative care) that have been grouped or bundled together
There is an economic incentive to limit the number of postoperative visits because there is no extra payment for extra visits
At the same time, there is still an incentive to perform more surgeries, as with the traditional fee-for-service system - 135Payment per patient: CapitationCapitation payments (per capita payments or payments “by the head”) are monthly payments made to a physician for each patient signed up to receive care from that physician
The essence of capitation is a shift in financial risk from insurers to providers - 136Payment per time: SalaryPhysicians in the public sector (municipal, Veterans Health Administration and military hospitals, state mental hospitals), and in community clinics are usually paid by salary
Managed care has brought salaried practice to the private sector, either using a staff or group model
Physicians paid purely by salary bear little if any individual financial risk; the HMO or physician group is at risk if expenses are too great - 137Hospital Payment Payment per day: Per DiemThe hospital receives a lump sum for each day the patient is in the hospital
Per diem bundling of services into one fee removes the hospital’s financial incentive because it loses, rather than profits, by performing expensive studies
With per diem payment, the insurer continues to be at risk for the number of days a patient stays in the hospital because it must pay for each additional day - 138Payment per episode of hospitalization: Diagnosis-related groupsWhile per diem payment lumps together all services performed during 1 day, DRG payment lumps together all services performed during one hospital episode
With the DRG system, the Medicare program is at risk for the number of admissions, but the hospital is at risk for the length of hospital stay and the resources used during the hospital stay - 139Global budgetHospitals are paid using a fixed payment that is made for all hospital services for 1 year
Includes Kaiser Health Plan and Veteran Health Administration
Hospital is entirely at risk because no matter how many patients are admitted and how many expensive services are performed, it must stay within its budget - 140Health Care ReformThe subject of national health insurance has seen six periods of intense activity, alternating with times of political inattention
- 141Massachusetts Individual Mandate Plan of 2006Following enactment of the Massachusetts Plan, the un-insurance rate among nonelderly adults in the state dropped from 14% in 2006 to 3.7% in 2014
It set the stage for a national plan enacted under the sponsorship of Barack Obama after his election as President in 2008 - 142The Patient Protection & Affordable Care Act of 2010ACA’s policy pedigree derives more from the proposals of a Republican President (Nixon), a Republican Governor (Romney), and a conservative think tank (the Heritage Foundation) than from the single-payer national health insurance tradition of Democratic Presidents Roosevelt and Truman
The pluralistic financing model of the ACA includes individual and employer mandates for private insurance and an expansion of the publicly financed Medicaid program - 143Individual mandateRequires virtually all US citizens and legal residents to have insurance coverage
Those who fail to purchase insurance and do not have employer-sponsored insurance, or do not qualify for Medicaid, Medicare, or veteran’s health care benefits, must pay a tax penalty
Established federal and state-based insurance exchanges to function as clearing houses to assist people seeking coverage under the individual mandate to shop for insurance plans meeting the federal standards - 144Employer mandateEmployers with 50 or more full-time employees face a financial penalty if:
(1) their employees are not enrolled in an employer-sponsored health plan and
(2) any of their employees apply for federal subsidies for individually purchased insurance - 145Does not technically mandate large employers to provide health benefits to their full-time workers, but it penalizes employers who do not provide insurance benefits and leave their employees to fend for themselves in the individual market,
- 146Medicaid eligibility expansionTo qualify for Medicaid required not only low income, but also meeting “categorical” eligibility criteria such as being a young child, parent, pregnant, elderly, or disabled, leaving out nondisabled, nonpregnant adults without dependent children
The ACA eliminated the categorical eligibility requirement and required that states make all US citizens and legal residents below 138% of the Federal Poverty Level eligible for their Medicaid programs - 147Insurance market regulationPrivate health insurance plans are required to include young adults up to age 26 under their parents’ policies
Eliminates caps on total insurance benefits payouts
Prohibits denial of coverage based on preexisting conditions
Limits the extent of experience rating to a maximum ratio of three-to-one between a plan’s highest and lowest premium charge for the same benefit package - 148Value-based Payment key to why aca was sucessfulPay for Performance (P4P)
Types of reimbursement that look at outcomes in order to address both cost and quality of care being delivered
Component of the Affordable Care Act (ACA)
---Value based purchasing - 149Value based purchasingInvolves quality reporting by hospitals and physicians
Penalizes those providing below average care - 150Bundled PaymentsMedicare not only bundles payments into more aggregated units using an episode-based rather than fee-for-service method; the physician and hospital payments are also bundled together into a single payment
The hospital and physicians share the risk of potentially losing money relative to the traditional payment model if they cannot control the average total cost (e.g. joint replacement) - 151ProsMost logical way to raise enough funds to insure the uninsured without massive tax increases
If most people younger than 65 years now receive their health insurance through the workplace, it may be less disruptive to change this - 152ConsForcing small businesses to shoulder the fiscal burden of insuring the uninsured is inequitable and economically disastrous
Because millions of people change their jobs in a given year, job-linked health insurance is administratively cumbersome and insecure for employees
Changes in the health plans offered by employers often force employees and their families to change physicians - 153ProsFree employers of the obligation to provide health insurance
Grant individuals a stable source of health insurance whether they are employed, change jobs, or become disabled - 154ConsCriticized as inefficient, with each family having to purchase its own health insurance
Enforce a requirement that every person buy coverage could be even more difficult for health insurance than for automobile insurance
To reduce the price of their premiums, many families would purchase high-deductible plans with high cost-sharing, leaving lower- and middle-income families with unaffordable out-of-pocket costs - 155Electronic Health RecordsApplication of electronic systems to organize and use heath care related data
- 156Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009Incentivized the adoption of EHRs
Tied set of standards or objectives termed “Meaningful Use”
Meaningful use is using certified electronic health record (EHR) technology to: Improve quality, safety, efficiency, and reduce health disparities
***increases better health outcomes - 157Computerized Physician Order Entry (CPOE)Allows providers to prescribe medications, order tests and provide other types of electronic instructions
Aim to is improve safety and efficiency
Reduce mistakes with order entry - 158Clinical Decision Support (CDS)Assists providers in making decisions regarding patient care
Diagnosis
Medication prescribing
Guidelines - 159Interprofessional Care TeamTeam based medical care
Effective for patient with multiple complex medical conditions (diabetes, asthma, CVD)
Traditionally seen in ICU, Acute Inpatient Rehabilitation
Now part of ACOs and Patient Centered Medical Homes
Improve coordination and reduce cost - 160Ethical Principles of Contemporary PracticeAccess to health services means the timely use of personal health services to achieve the best health outcomes. It requires 3 distinct steps:
Gaining entry into the health care system
Accessing a health care location where needed services are provided
Finding a health care provider with whom the patient can communicate and trust - 161***acess to healthcare doesnt just mean u have healthcare but also itf its good service.
- 162Financial Barriers to Health CareACA gretaly decresed the number of insured
- 163Problems with employment-based health insurance coverageUnstable nature of employment
People who are laid off from their jobs or who leave jobs because of illness may also lose their benefits
Family members insured through the workplace of a spouse may lose their insurance in cases of divorce, job loss, or death of the working family member - 164Prior to the ACA, the uninsured were divided into two major categoriesEmployed uninsured: Jobs that are low paying, in small firms, and may be part time
Unemployed uninsured: Not eligible for Medicaid - 165While individuals enrolling in exchange plans are no longer uninsured, many are finding themselvesunderinsured due to the high out-of-pocket costs required under exchange plans
had insurance but the quality is not good and not that well insured - 166Effects of underinsuranceCost sharing (deductibles or copayments) reduces the rate of ambulatory care use, especially among the poor, and patients with cost-sharing plans demonstrate a reduction in both appropriate and inappropriate medical visits
- 167Lack of prompt accessFailure to provide patients with access at the time when patients need care
- 168Access and women’s healthAccess problems for women begin with finding a physician who provides womens’ health services
Fewer than one-third of women of reproductive age have received counseling about emergency contraception, sexually transmitted diseases, or domestic violence
Patients of female physicians are almost twice as likely to receive a Pap smear and 1.4 times more likely to have a mammogram than the patients of male physicians - 169Race/ethnicity and access to health careLatino and African-American received poorer pain control than whites (Todd et al., 1993 & 2000)
Because a far higher proportion of minorities than whites is uninsured, has Medicaid coverage, or is poor, access problems are amplified for these groups - 170Patient EngagementConcept that combines a patient's knowledge, skills, ability and willingness to manage his own health and care with interventions designed to increase activation and promote positive patient behavior
- 171Shared Decision MakingKey component of patient-centered health care. It is a process in which clinicians and patients work together to make decisions and select tests, treatments and care plans based on clinical evidence that balances risks and expected outcomes with patient preferences and values
- 172Informed ConsentOccurs when communication between a patient and physician results in the patient’s authorization or agreement to undergo a specific medical intervention
Assess the patient’s ability to understand relevant medical information and the implications of treatment alternatives and to make an independent, voluntary decision - 173AccreditationA self-assessment and external peer assessment process used by health care organizations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve
- 174ErrorsTypically not due to negligence, rather breakdowns in a complex care delivery system
Types
Medication errors
Transition of care / hand-offs
Ineffective communication - 175Never EventErrors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a health care facility
- 176Quality ImprovementSystematic improvement
Improved communication
During transitions of care - 177Disease causedHaemophilus influenzae causes
meningitis and sepsis in children - 178Unique characteristics:Gram negative coccobacillus
• Encapsulated bacteria are invasive and
virulent
Among the six serotypes of Haemophilus
influenzae type B is considered to be the most virulent. The capsule in type B serotype has poly ribosyl phosphate - 179Non-encapsulated strains causeupper
respiratory tract infections such as sinusitis and otitis media in children - 180Haemophilus influenzae can also cause what in adultspneumonia in adults with obstructive lung
disease - 181Haemophilus influenzae can be grown inchocolate agar (agar+heated
blood) containing factor V (NAD) and factor X (heme compound) - 182Haemophilus influenzae producesIgA protease
- 183Transmission and epidemiologyInfection begins by inhaling aerosol droplets containing H. influenzae.
- 184PathogenesisInitial infection could either by asymptomatic or the organism can cause a
mild upper respiratory tract infection. The organisms produce IgA protease to degrade the host IgA and this allows them to firmly attach to the respiratory epithelial cells. After establishing the infection, the bacteria invade the lungs and go to different parts of the body to cause
meningitis and sepsis. - 185Capsulated strains causeinvasive meningitis
and sepsis. - 186Nonencapsulated strains are non-invasive and causeupper respiratory tract infections.
- 187Virulence factorsantiphagocytic capsule and endotoxin.
No exotoxin is produced. - 188Clinical findingsThe common symptoms for meningitis include headache, stiffness,
fever and drowsiness.
The symptoms for sinusitis include pain in the affected area and opacification of sinus. - 189PreventionThe vaccine that contains capsular polysaccharide of H. influenza
conjugated to carrier protein is highly effective vaccine and has reduced the incidence of meningitis in children by 90 %. Meningitis can be prevented in close contacts of the patients by treating with rifampicin. - 190Disease causedwhooping cough.
- 191Unique propertiesIt is a coccobacillus, encapsulated Gram negative bacteria, can be grown in BordetGengou media.
- 192Transmission and epidemiology:transmitted by inhalation
of aerosol particles. - 193Pathogenesisattaches to the ciliated epithelial
cells in the upper respiratory tract
but do not invade
The bacteria produce a toxin called pertussis toxin that induce ADP-ribosylation of inhibitory subunit of G protein leading to activation of adenyl cyclase.
Protein kinase induces
mucous production in the lungs - 194Clinical findingsWhooping cough begins with upper respiratory tract infections followed by severe paroxysmal cough for 1-4 weeks.
The paraoxysmal cough is
characterized by hacking cough followed by production of copious amounts of mucous
that end with an inspiratory whoop
when the air rushes through the
narrow glottis - 195Laboratory diagnosiThe organism can be cultured in
Bordet-Gengou medium.
Since the organisms grow slowly fluorescent antibody staining is often used in diagnosing the infection.
PCR and serology tests are also available. - 196PreventionTwo vaccines are available.
One is a heat killed vaccine and the other is
acellular vaccine (purified proteins). - 197The acellular vaccinemade of modified pertussis toxoid where the amino acids that induce ADP-ribosylation are replaced and other proteins in the acellular vaccine
include hemagglutinin.
The acellular vaccine is usually given along with diphtheria and tetanus (DTaP) beginning two months of age and at 4 months, 6 months between 15 to 18 months, ages and 4-6 years of age. - 198Disease causedAtypical pneumonia
- 199Unique characteristics:Gram negative, pleiomorphic and
motile
Can be grown in Charcoal-yeast
media supplemented with iron
and cysteine - 200TransmissionSpread by
contaminated water droplets
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