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Carolyn Popp and JoAnn Rajewski are MyMichigan Medical Center Midland’s Gift Shop coordinators.Volunteers from MyMichigan Medical Center Midland’s Gift Shop recently fulfilled ventolin online usa their 2021-22 pledge of support to the Medical Center http://natalievartanian.com/buy-ventolin-pills-online/. The volunteers donated more than $130,000 toward the purchase of equipment to support patient care, as well as $50,000 to support the future James T. And Elsa ventolin online usa U. Pardee Cancer Center (Pardee Cancer Center).

Equipment purchased through the Gift Shop Volunteers’ donation included pieces that support the Inpatient and Outpatient Rehabilitation Departments, Behavioral Health Unit, surgical floor, as well as cardiovascular testing ventolin online usa to support the Medical Center’s new Special Care Nursery. In addition, the volunteers donated $50,000 toward the Pardee Cancer Center. €œThe Gift Shop volunteers are so pleased that our efforts provide needed equipment in multiple departments,” said Cathy Strong, ventolin online usa Gift Shop chairman. €œIt’s very exciting each year just how successful our work is in the amount we’re able to give and support MyMichigan Health.

We are so thankful for our many customers and supporters.” The 115,000-square-foot Pardee Cancer Center ventolin online usa is currently under construction on the campus of MyMichigan Medical Center Midland and will bring cancer care into one convenient location for patients who are undergoing diagnosis, treatment or who need support for cancer. The Cancer Center is slated to open in 2024. MyMichigan has available volunteer positions that range from a few hours a week ventolin online usa to a few days a week, including in the Gift Shop, reception services and patient services. Those who are interested in becoming a volunteer at MyMichigan Health may visit www.mymichigan.org/volunteer, or contact Diana Brookens, manager of volunteer service, at diana.brookens@mymichigan.org, or (989) 839-3340..

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Common medical issues that require cognition and language therapy include brain injuries, stroke and dementia, while voice treatment is often helpful for patients with vocal cord paralysis, spasmodic dysphonia and Parkinson’s disease, among others. So how do you know if you would benefit from seeing ventolin online usa a speech-language pathologist?. Some things to look out for include.

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Their experiences in nature to overcome ventolin online usa anxiety of the modern world and trauma from childhood is well documented in their writings and encouraged others to use wilderness experience for similar healing. Over the decades since, millions of people have had similar healing experiences in nature without the need of any scientific evidence of its effectiveness. For those in the ventolin online usa medical community who prefer scientific evidence before recommending a treatment, evidence is now available.

Annette McGivney, writer, outdoors enthusiast and anxiety sufferer, summarizes this research in her 2018 Backpacker Magazine article. “In an effort to make this brand of wilderness medicine a reality, the Sierra Club has teamed up with scientists at the University of California, Berkeley, to create the Great Outdoors Lab, which compiles research to quantify the effects nature has on chronic health conditions. €˜We hope to make public lands part of a common health care prescription,’ says Sierra Club Outdoors director Stacy Bare, who is also an Iraq War veteran diagnosed with PTSD.” Over a three-year period, ventolin online usa researchers took 180 people, war veterans and children from underserved communities, and took them on whitewater rafting trips.

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The greater the level of awe that a person experienced, the longer the positive results lasted ventolin online usa. McGivney quotes UC Berkeley psychology professor Dacher Keltner, who co-authored the GO Lab study, “Time outdoors changes people’s nervous systems. It is as effective as any PTSD interventions we have.” The results of the GO Lab study were published in Emotions, a publication of the American Psychological Association.

In a separate study, Nooshin Razani, a pediatrician and director of the Center of ventolin online usa Nature and Health at Children’s Hospital Oakland in California, took 78 pairs of parents and traumatized children into nature for one full day three times a week for three weeks. They saw positive changes on the participants’ responses on surveys on psychological wellbeing, as well as parasympathetic nervous system markers such as cortisol and alpha amylase (obtained through saliva samples), heart rate and blood pressure, before, during, and after the outings. Razani is ventolin online usa calling it the “park prescription,” and says that it decreases the trauma response, improves cognitive function, promotes healing and increases resilience in children.

For anyone who has spent much time in nature these results are not surprising. Best of all, no one needs a doctor’s prescription to use this treatment for anxiety, and, if appropriate footwear and good judgement about one’s ability are used, there are little to no negative side effects. Nature is ventolin online usa waiting to help in the healing process.

If those in need can get out in nature on a regular basis, they will likely feel more at ease. For those who need more intense treatment for mental health conditions, MyMichigan Health ventolin online usa provides an intensive outpatient program called Psychiatric Partial Hospitalization Program at MyMichigan Medical Center Gratiot. Those interested in more information about the PHP program may call (989) 466-3253.

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Longtime physician leader to transition to new role in hop over to this web-site December 2022Lydia Watson, ventolin reviews M.D., C.P.E.President and CEO MyMichigan HealthThe MyMichigan Health Board of Directors has named senior vice president and chief medical officer Lydia A. Watson, M.D., C.P.E., as president and CEO of MyMichigan Health with an effective date of Dec. 1, 2022 ventolin reviews. Dr.

Watson will succeed Greg Rogers, longtime health ventolin reviews care administrator for the organization.“Lydia is a well-respected and trusted leader in the industry and here at home. She has been instrumental in guiding our system through the ventolin, is a steadfast advocate for quality care and patient, employee and physician satisfaction, and accomplished in establishing and maintaining cultures of excellence,” said Rogers, who will serve in an advisory role to Dr. Watson for the month ventolin reviews of December. €œWith her foresight and clinical background experience, she will play a pivotal role in the continued growth and development of MyMichigan Health.”Dave Midkiff, MyMichigan Health board member and chair of the selection committee, shared, “The process our team used to assess Dr.

Watson’s qualifications was both ventolin reviews objective and thorough. We believe that our Board’s unanimous support of Dr. Watson as our next president and CEO should reinforce confidence with our employees, our patients, and our communities that she is uniquely qualified to lead MyMichigan Health into ventolin reviews the future.”While serving with MyMichigan Health, Dr. Watson’s career has included roles as chief quality and patient safety officer for MyMichigan Health, as well as chief of staff, vice president of medical affairs, and board member of MyMichigan Medical Center Midland.

She is on the MHA Physicians in Healthcare Leadership ventolin reviews Council serving as chair in 2021-2022. Prior to joining the administrative staff for MyMichigan in 2013, Dr. Watson cared for thousands of women as a practicing obstetrician-gynecologist at the Medical Center ventolin reviews in Midland. Before this, she was an active staff member at Saginaw General Hospital from 1988 to 1996.Board certified in obstetrics and gynecology, Dr.

Watson received both her undergraduate and medical degrees from Wayne State University School of ventolin reviews Medicine. Throughout her education period, she also served six years in the Army National Guard 207th EVAC Hospital of which she was honorably discharged as a captain in 1992. Today she maintains her ventolin reviews position as the assistant clinical professor in the Department of Obstetrics/Gynecology and Reproductive Biology at Michigan State University.Dr. Watson is active in her community and currently serves on the Strosacker Family Foundation Board of Trustees.

She is a member of the Michigan Health Improvement Alliance/THRIVE Safety Taskforce, Midland ventolin reviews 100 Women’s Club, as well as serves as medical director for the SANE (Sexual Assault Nurse Examiner) Program. She has also volunteered her leadership to the American Heart Association’s Go Red for Women event and the Midland Public Schools Sex Advisory Council. In addition, ventolin reviews she is an author of several textbook chapters and co-author of a book. She also has received numerous accolades, including the Midland Area Chamber of Commerce Athena Award, and, most recently, the 2020 YWCA Woman of the Year in Healthcare Award.

Dr. Watson is married with two grown children.“While MyMichigan Health has experienced much change over the past six months following the unexpected passing of Diane Postler-Slattery and her husband, Don, what hasn’t changed is the commitment and care provided to patients,” said Jenee Velasquez, board chair, MyMichigan Health. €œThe leadership and direction provided by Greg, Dr. Watson and the entire leadership team has been nothing short of exceptional.

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Dr. Watson will succeed Greg Rogers, longtime ventolin online usa health care administrator for the organization.“Lydia is a well-respected and trusted leader in the industry and here at home. She has been instrumental in guiding our system through the ventolin, is a steadfast advocate for quality care and patient, employee and physician satisfaction, and accomplished in establishing and maintaining cultures of excellence,” said Rogers, who will serve in an advisory role to Dr.

Watson for the month of ventolin online usa December. €œWith her foresight and clinical background experience, she will play a pivotal role in the continued growth and development of MyMichigan Health.”Dave Midkiff, MyMichigan Health board member and chair of the selection committee, shared, “The process our team used to assess Dr. Watson’s qualifications was both ventolin online usa objective and thorough.

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She is on the MHA Physicians in Healthcare Leadership ventolin online usa Council serving as chair in 2021-2022. Prior to joining the administrative staff for MyMichigan in 2013, Dr. Watson cared for thousands of women as a ventolin online usa practicing obstetrician-gynecologist at the Medical Center in Midland.

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Today she maintains her position as the assistant clinical professor in the Department of Obstetrics/Gynecology and Reproductive Biology at Michigan State ventolin online usa University.Dr. Watson is active in her community and currently serves on the Strosacker Family Foundation Board of Trustees. She is a member of the Michigan Health Improvement Alliance/THRIVE Safety Taskforce, Midland 100 Women’s Club, as ventolin online usa well as serves as medical director for the SANE (Sexual Assault Nurse Examiner) Program.

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Dr. Watson is married with two grown children.“While MyMichigan Health has experienced much change over the past six months following the unexpected passing of Diane Postler-Slattery and her husband, Don, what hasn’t changed is the commitment and care provided to patients,” said Jenee Velasquez, board chair, MyMichigan Health. €œThe leadership and direction provided by Greg, Dr.

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Abstract Background ventolin generic name. Empathy plays a role not only in pathophysiology but also in planning management strategies for alcohol dependence. However, few ventolin generic name studies have looked into it. No data are available regarding the variation of empathy with abstinence and motivation. Assessment based on cognitive and affective dimensions of empathy ventolin generic name is needed.Aim.

This study aimed to assess cognitive and affective empathy in men with alcohol dependence and compared it with normal controls. Association of empathy ventolin generic name with disease-specific variables, motivation, and abstinence was also done.Methods. This was a cross-sectional observational study conducted in the outpatient department of a tertiary care center. Sixty men with alcohol dependence and 60 healthy controls ventolin generic name were recruited and assessed using the Basic Empathy Scale for cognitive and affective empathy. The University of Rhode Island Change Assessment Scale was used to assess motivation.

Other variables were ventolin generic name assessed using a semi-structured pro forma. Comparative analysis was done using unpaired t-test and one-way ANOVA. Correlation was done using Pearson's correlation test.Results ventolin generic name. Cases with alcohol dependence showed lower levels of cognitive, affective, and total empathy as compared to controls. Affective and total ventolin generic name empathy were higher in abstinent men.

Empathy varied across various stages of motivation, with a significant difference seen between precontemplation and action stages. Empathy correlated negatively with number of relapses and positively with ventolin generic name family history of addiction.Conclusions. Empathy (both cognitive and affective) is significantly reduced in alcohol dependence. Higher empathy ventolin generic name correlates with lesser relapses. Abstinence and progression in motivation cycle is associated with remission in empathic deficits.Keywords.

Abstinence, alcohol, empathy, motivationHow to cite this article:Nachane HB, ventolin generic name Nadadgalli GV, Umate MS. Cognitive and affective empathy in men with alcohol dependence. Relation with clinical ventolin generic name profile, abstinence, and motivation. Indian J Psychiatry 2021;63:418-23How to cite this URL:Nachane HB, Nadadgalli GV, Umate MS. Cognitive and affective empathy in men ventolin generic name with alcohol dependence.

Relation with clinical profile, abstinence, and motivation. Indian J Psychiatry [serial online] 2021 [cited 2022 ventolin generic name Nov 13];63:418-23. Available from. Https://www.indianjpsychiatry.org/text.asp?. 2021/63/5/418/328088 Introduction Alcohol dependence is as much a social challenge as it is a clinical one.[1] Clinicians have faced several challenges in helping subjects with alcohol dependence stay in treatment and maintain abstinence.[2] In substance abuse treatment, clients' motivation to change has often been the focus of both clinical interest and frustration.[3],[4] Motivation has been described as a prerequisite for treatment, without which the clinician can do little.[5] Similarly, lack of motivation has been used to explain the failure of individuals to begin, continue, comply with, and succeed in treatment.[6],[7] Treatment modalities have focused on various aspects of motivation enhancement – such as locus of control, social support, and networking.[8] Recent literature is focusing on the role empathy plays in pathogenesis and treatment seeking in alcohol dependence.[9] However, the way in which empathy is perceived has recently undergone drastic changes, specifically its role in both emotion processing and social interactions.[10]Broadly speaking, empathy is believed to be constituted of two components – cognitive and affective (or emotional).[9] Affective empathy (AE) deals with the ability of detecting and experiencing the others' emotional states, whereas cognitive empathy (CE) relates to perspective-taking ability allowing to understand and predict the other's various mental states (sometimes used synonymously with theory of mind).[11] Empathy constitutes an essential emotional competence for interpersonal relations and has been shown to be highly impaired in various psychiatric disorders including alcohol dependence.[9],[12] Empathy is crucial for maintaining interpersonal relations, which are frequently impaired in alcoholics and prove to be a source of frequent relapses.[9] However, research pertaining to empathy in alcohol has generated varied results.[9] Factors such as lapses, retaining in treatment, and abstinence have also been linked to subjects' empathy.[9],[13] However, few of these have assessed CE and AE separately.[9],[13] Previous literature has demonstrated that empathy correlates with the motivation to help others.[14] No study however addresses the role empathy may play in self-help, a crucial step in the management of alcohol dependence.

A link between an alcoholic's empathy and motivation is lacking. It is imperative to highlight changes in empathy with changes in motivation, over and above the dichotomy of abstinence and dependence.Detailed understanding of empathy, or a lack thereof, and its fate during the natural course of the illness, particularly with each step of the motivation cycle, will prove fruitful in planning better strategies for alcohol dependence. This will, in turn, lead to better handling of its social consequences and reduction in its burden on society and healthcare. The present study was thus formulated, which aimed at comparing CE, AE, and total empathy (TE) between subjects of alcohol dependence and normal controls. Differences in CE, AE and TE with abstinence and stage of motivation were also assessed.

We also correlated CE, AE, and TE with disease-specific variables. Materials and Methods The present study is a cross-sectional observational study done in the outpatient psychiatric department of a tertiary care center. Ethical clearance was obtained from the institutional ethics committee (IEC/Pharm/RP/102/Feb/2019). The study was conducted over a period of 6 months (March 2019–August 2019) and purposive sampling method was used. Sixty subjects, between the ages of 18–65 years, diagnosed with alcohol dependence as per the International Classification of Diseases-10 criteria were included in the study as cases.

Subjects with comorbid psychiatric and medical disorders (four subjects) and those dependent on more than one substance (six subjects) were excluded. As all the available cases were male, the study was restricted to males. Sixty normal healthy male controls who were not suffering from any medical or psychiatric illness (five subjects excluded) were recruited from the normal population (these were healthy relatives of patients attending our outpatient department). Subjects were explained about the nature of the study and written informed consent was obtained from them. A semi-structured pro forma was devised to include sociodemographic variables, such as age, marital status, family structure, education, and employment status and disease-specific variables in the cases, such as total duration of illness, number of relapses, number of hospital admissions, and family history of psychiatric illness/substance dependence.

Empathy was assessed using the Basic Empathy Scale for Adults for both cases and controls and motivation was assessed in the cases using the University of Rhode Island Change Assessment Scale (URICA). The scales were translated into the vernacular languages (Hindi and Marathi) and the translated versions were used. The scales were administered by a single rater in one sitting. The entire interview was completed in 20–30 min.InstrumentsThe Basic Empathy Scale for AdultsIt is a 20-item scale which was developed by Jolliffe and Farrington.[15] Each question is rated on a five point Likert type scale. We used the two-factor model where nine items assess CE (Items 3, 6, 9, 10, 12, 14, 16, 19, and 20) and 11 items assess AE (Items 1, 2, 4, 5, 7, 8, 11, 13, 15, 17, and 18).

The total score gives TE, which can range from 20 (deficit in empathy) to 100 (high level of empathy).The University of Rhode Island Change Assessment Scale (URICA)This scale is based on the transtheoretical model of motivation given by Prochaska and DiClemente, which divides the readiness to change temporally into four stages. Precontemplation (PC), contemplation (C), action (A), and maintenance (M).[16] The URICA is a 32-item self-report measure that grades responses on a 5-point Likert scale ranging from one (strong disagreement) to five (strong agreement). The subscales can be combined arithmetically (C + A + M − PC) to yield a second-order continuous readiness to change score that is used to assess readiness to change at entrance to treatment. Based on this score, the individual is classified into the stage of motivation (precontemplation, contemplation, action, and maintenance)Statistical analysisSPSS 20.0 software was used for carrying out the statistical analysis. (IBM SPSS Statistics for Windows, Version 20.0, released 2011, Armonk, NY.

IBM Corp.). Data were expressed as mean (standard deviation) for continuous variables and frequencies and percentages for categorical variables. Comparative analyses were done using unpaired Student's t-test and one-way ANOVA with post hoc Bonferroni's test wherever appropriate. The correlation was done using Pearson's correlation test and point biserial correlation test for continuous and dichotomous categorical variables, respectively. The effect size was determined by calculating Cohen's d (d) for t-test, partial eta square (ηp2) for ANOVA, and correlation coefficient (r) for Pearson's correlation/point biserial correlation test.

P <0.05 was considered statistically significant. Results A total of 120 subjects consisting of 60 cases and 60 controls who satisfied the inclusion and exclusion criteria were considered for the analysis. The mean age of cases was 40.80 (8.69) years, whereas that of controls was 39.02 (10.12) years. About 80% of the cases and 88% of the controls were married. Only 58% of the cases and 57% of the controls were educated.

Almost 80% of the cases versus 95% of the controls were employed at the time of assessment. Majority of the cases (75%) and controls (83%) belonged to nuclear families. None of the sociodemographic variables varied significantly across cases and controls. Comparison of empathy between cases and controls using unpaired t-test showed cognitive (t(118) =2.59, P = 0.01), affective (t(118) =2.19, P = 0.03), and total empathy (t(118) =2.39, P = 0.02) to be significantly lower in cases [Table 1]. The analysis showed the difference to be most significant for CE (d = 0.48), followed by TE (d = 0.44), and then AE (d = 0.40), implying that it is CE that is most significantly lowered in men with alcohol dependence.

[Table 2] shows the correlation between empathy and disease-related variables amng the cases using Pearson's correlation/point biserial correlation tests. Number of relapses negatively correlated with all three measures of empathy, most with CE (r = −0.42, P = 0.001), followed by TE (r = −0.39, P = 0.002) and least with AE (r = −0.31, P = 0.016). This means that men with alcohol dependence who are more empathic tend to have lesser relapses. Having a family history of mental illness/substance use was seen to have a positive correlation with CE (r = 0.43, P = 0.001) and TE (r = 0.30, P = 0.02) but not AE (P = 0.17). As the coefficients of correlation for all the relations were <0.5, the strength of correlations in our sample was mild–moderate.Table 2.

Relation of disease related variables with total empathy in casesClick here to viewMotivation and readiness to change was assessed in the cases using the URICA scale, which had a mean score of 8.78 (4.09). About 50% of the subjects were currently consuming alcohol (30 out of 60) and the remaining were completely abstinent. Comparing empathy scores among those subjects still consuming and those subjects completely abstinent using unpaired t-test [Figure 1] showed that abstinent patients had significantly higher AE (t(58) =2.72, mean difference = 5.10 [95% confidence interval [CI]. 1.34–8.86], P = 0.009) and TE (t(58) =2.88, mean difference = 8.60 [95% CI. 2.63–14.57], P = 0.006) as compared to those still consuming but not CE (t(58) =1.93, mean difference = 2.83 [95% CI.

0.09–5.77], P = 0.058). This difference was most marked in TE (d = 0.77), followed by AE (d = 0.71). Dividing the cases into their respective stages of motivation showed that 20 out of 60 (33%) subjects were in precontemplation stage, 10 out of 60 (17%) in contemplation stage and 30 out of 60 (50%) in action stage. None were seen to be in maintenance phase. Using one-way ANOVA to assess the difference in empathy across the various stages of motivation [Table 3], it was found that AE (F (2,57) = 5.03, P = 0.01) and TE (F (2, 57) = 4.25, P = 0.02) varied across the motivation cycle but not CE (F (2,57) = 2.26, P = 0.11).

Difference was more significant for affective empathy (ηp2 = 0.15) as compared to total empathy (ηp2 = 0.13), although a small one. In both cases of affective and total empathy, it can be seen that empathy increases gradually with each stage in motivation cycle [Figure 2]. However, using the post hoc Bonferroni test [Table 4] revealed that significant difference in both cases was seen between precontemplation and action stages only (P <. 0.05).Figure 1. Difference in cognitive, affective, and total empathy among dependent and abstinent subjects.

Data expressed as mean (standard deviation)Click here to viewFigure 2. Cognitive, affective, and total empathy in cases across precontemplation, contemplation, and action stages of motivation. Data expressed as mean (standard deviation)Click here to viewTable 4. Comparison of cognitive, affective and total empathy in individual stages of motivation using post hoc Bonferroni testClick here to view Discussion Role of empathy in addictive behaviors is a pivotal one.[17] The present analysis shows that subjects dependent on alcohol lack empathic abilities as compared to healthy controls. This translates to both cognitive and affective components of empathy.

Earlier research appears divided in this aspect. Massey et al. Elucidated reduction in both CE and AE by behavioral, neuroanatomical, and self-report methods.[18] Impairment in affect processing system in alcohol dependence was cited as the reason behind the so-called “cognitive-affective dissociation of empathy” in alcoholics, which resulted in a changed AE, with relatively intact CE.[9],[17] However, there is enough evidence to suggest the lack of social cognition, emotional cognition, and related cognitive deficits in alcohol-dependent subjects.[19] Cognitive deficits responsible for dampening of CE seen in addictions have been attributed to frontal deficits.[19] In fact, it is a combined deficit which leads to impaired social and interpersonal functioning in alcoholics.[20] Hence, our primary finding is in keeping with this hypothesis.Empathy may relate to various aspects of the psychopathological process.[21] Disorders have also been classified based on which aspect of empathy is deficient – cognitive, affective, or general.[21] On such a spectrum, alcohol dependence should definitely be classified as a general empathic deficit disorder. It is also known that within a disorder, the two components of empathy may show variation, depending upon various factors.[21] Addiction processes may have impulsivity, antisocial personality traits, externalizing behaviors, and internalizing behaviors as a part of their presentations, all factors which effect empathy.[22],[23] Hence, it is likely that difference in empathy could be attributable to these factors, even though it has been shown that empathy operates independent of them to impact the disease process.[18]Abstinence period is associated with several physiological and psychological changes and is a key experience in the life of patients with alcohol use disorder.[24] The present analysis shows that abstinence period is associated with higher empathy than the active phase of illness. It has been demonstrated that empathy correlates significantly with abstinence and retention in treatment.[13],[23] A study has described improvement in empathy, attributable to personality changes with abstinence, in subjects following up for treatment in self-help groups.[13] A causative effect of improvement in empathy due to the 12-step program and abstinence has been hypothesized,[13] and our findings support this.

Empathy is a key factor in motivation to help others and oneself when in distress. This suggests a role for it in motivation to quit and treatment seeking. Yet still, few studies have made this assessment. Across the motivation cycle, we found that TE and AE were significantly higher for subjects in action phase than for precontemplation and contemplation phases. CE showed no significant changes.

Thus, it appears that AE is more amenable to change and instrumental in motivation enhancement. Treatment modalities for dependence should inculcate methods addressing empathy, especially AE as this would be more beneficial. It is also possible that these patients may innately have higher empathy and hence are motivated to quit alcohol, as has been previously demonstrated.[9]It is clear that in adults who have developed alcohol dependence, deficits in empathic processing remit in recovery and this finding is crucial to optimize long-term outcomes and minimize the likelihood of relapse. Altered empathic abilities have been shown to impair future problem solving in social situations, thus impacting the prognosis of the illness.[25] Similarly, it also hampers treatment seeking in alcoholics. CE played a greater role in our sample as compared to AE, contrary to what most literature states.[26] This is furthered by the fact that CE and TE correlated with number of relapses and having a family history of mental illness in our subjects, whereas AE correlated with only number of relapses.

Subjects with higher empathy had significantly lesser relapses, suggesting a role for empathy, particularly CE in maintaining abstinence, even though it is least likely to change. This relation has been demonstrated by other researchers also.[13],[23] Having a positive family history of mental illness/addictions was associated with higher CE and TE. Genes have shown to influence development and dynamicity of empathy in healthy individuals and as genetics play a major role in heredity of addictions, levels of empathy may also vary accordingly.[21],[27] As AE did not show this relation, it appears CE and AE may not be “equally heritable.” However, more research in this area is needed.Our study was not without limitations. Factors such as premorbid personality and baseline empathy were not considered. As all cases and controls were males, gender differences could not be assessed.

We did not have any patients in the maintenance phase of motivation and hence this difference could not be assessed. It also might be more prudent to have a prospective study design wherein patients are followed throughout their motivation cycle to derive a more robust relation between empathy and motivation. As our study was a cross-sectional study, it was not possible.To mention a few strengths, our analysis adds to the need for studying CE and AE separately, as they may impact different aspects of the illness and show varied dynamicity over the natural course of alcohol dependence owing to their difference in neural substrates.[28] While many risk factors for alcohol dependence are difficult if not impossible to change,[29] some components of empathy may be modifiable,[13] particularly AE. Abstinence is associated with an increase in AE and TE and thus empathy may be crucial in propelling an individual along the motivation cycle. Our analysis stands out in being one of the few to establish a relation between stages of motivation and components of empathy in alcohol dependence, which will definitely have further research and therapeutic implications.

Conclusions Empathic deficits in alcohol dependence are well established, being more for CE than AE although both being affected. Even though psychotherapeutic approaches have hitherto targeted therapist's empathy,[30] we suggest that a detailed understanding of patient's empathy is equally crucial in the management. Increment in AE and TE is seen with abstinence and improvement in subject's motivation. Relapses are lesser in individuals with higher empathy and it is possible that those who relapse develop low empathy. The present analysis is associational and causality inference should be done with caution.

Modalities of treatment which focus on empathy and its subsequent advancement, such as brief intervention and self-help groups, have met with ample success in clinical practice.[13],[31] Adding to existing factors that have proved successful for abstinence,[32] focusing on improving empathy at specific points in the motivation cycle (contemplation to action) may motivate individuals better to stay in treatment and reduce further relapses.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.Caetano R, Cunradi C. Alcohol dependence. A public health perspective. Addiction 2002;97:633-45.

2.Willenbring ML. The past and future of research on treatment of alcohol dependence. Alcohol Res Health 2010;33:55-63. 3.DiClemente CC. Conceptual models and applied research.

The ongoing contribution of the transtheoretical model. J Addict Nurs 2005;16:5-12. 4.Velasquez MM, Crouch C, von Sternberg K, Grosdanis I. Motivation for change and psychological distress in homeless substance abusers. J Subst Abuse Treat 2000;19:395-401.

5.Beckman LJ. An attributional analysis of Alcoholics Anonymous. J Stud Alcohol 1980;41:714-26. 6.Appelbaum A. A critical re-examination of the concept of “motivation for change” in psychoanalytic treatment.

Int J Psychoanal 1972;53:51-9. 7.Miller WR. Motivation for treatment. A review with special emphasis on alcoholism. Psychol Bull 1985;98:84-107.

8.Murphy PN, Bentall RP. Motivation to withdraw from heroin. A factor-analytic study. Br J Addict 1992;87:245-50. 9.Maurage P, Grynberg D, Noël X, Joassin F, Philippot P, Hanak C, et al.

Dissociation between affective and cognitive empathy in alcoholism. A specific deficit for the emotional dimension. Alcohol Clin Exp Res 2011;35:1662-8. 10.de Vignemont F, Singer T. The empathic brain.

How, when and why?. Trends Cogn Sci 2006;10:435-41. 11.Reniers RL, Corcoran R, Drake R, Shryane NM, Völlm BA. The QCAE. A questionnaire of cognitive and affective empathy.

J Pers Assess 2011;93:84-95. 12.Martinotti G, Di Nicola M, Tedeschi D, Cundari S, Janiri L. Empathy ability is impaired in alcohol-dependent patients. Am J Addict 2009;18:157-61. 13.McCown W.

The relationship between impulsivity, empathy and involvement in twelve step self-help substance abuse treatment groups. Br J Addict 1989;84:391-3. 14.Krebs D. Empathy and auism. J Pers Soc Psychol 1975;32:1134-46.

15.Jolliffe D, Farrington DP. Development and validation of the basic empathy scale. J Adolesc 2006;29:589-611. 16.McConnaughy EA, Prochaska JO, Velicer WF. Stages of change in psychotherapy.

Measurement and sample profiles. Psychol Psychother 1983;20:368-75. 17.Ferrari V, Smeraldi E, Bottero G, Politi E. Addiction and empathy. A preliminary analysis.

Neurol Sci 2014;35:855-9. 18.Massey SH, Newmark RL, Wakschlag LS. Explicating the role of empathic processes in substance use disorders. A conceptual framework and research agenda. Drug Alcohol Rev 2018;37:316-32.

19.Uekermann J, Daum I. Social cognition in alcoholism. A link to prefrontal cortex dysfunction?. Addiction 2008;103:726-35. 20.Uekermann J, Channon S, Winkel K, Schlebusch P, Daum I.

Theory of mind, humour processing and executive functioning in alcoholism. Addiction 2007;102:232-40. 21.Gonzalez-Liencres C, Shamay-Tsoory SG, Brüne M. Towards a neuroscience of empathy. Ontogeny, phylogeny, brain mechanisms, context and psychopathology.

Neurosci Biobehav Rev 2013;37:1537-48. 22.Miller PA, Eisenberg N. The relation of empathy to aggressive and externalizing/antisocial behavior. Psychol Bull 1988;103:324-44. 23.McCown W.

The effect of impulsivity and empathy on abstinence of poly-substance abusers. A prospective study. Br J Addict 1990;85:635-7. 24.Pitel AL, Beaunieux H, Witkowski T, Vabret F, Guillery-Girard B, Quinette P, et al. Genuine episodic memory deficits and executive dysfunctions in alcoholic subjects early in abstinence.

Alcohol Clin Exp Res 2007;31:1169-78. 25.Thoma P, Friedmann C, Suchan B. Empathy and social problem solving in alcohol dependence, mood disorders and selected personality disorders. Neurosci Biobehav Rev 2013;37:448-70. 26.Marinkovic K, Oscar-Berman M, Urban T, O'Reilly CE, Howard JA, Sawyer K, et al.

Alcoholism and dampened temporal limbic activation to emotional faces. Alcohol Clin Exp Res 2009;33:1880-92. 27.Smith A. Cognitive empathy and emotional empathy in human behavior and evolution. Psychol Rec 2006;56:3-21.

28.Decety J, Jackson PL. A social-neuroscience perspective on empathy. Curr Dir Psychol Sci 2006;15:54-8. 29.Tarter RE, Edwards K. Psychological factors associated with the risk for alcoholism.

Alcohol Clin Exp Res 1988;12:471-80. 30.Moyers TB, Miller WR. Is low therapist empathy toxic?. Psychol Addict Behav 2013;27:878-84. 31.Heather N.

Psychology and brief interventions. Br J Addict 1989;84:357-70. 32.Cook S, Heather N, McCambridge J. Posttreatment motivation and alcohol treatment outcome 9 months later. Findings from structural equation modeling.

J Consult Clin Psychol 2015;83:232-7. Correspondence Address:Hrishikesh Bipin Nachane63, Sharmishtha, Tarangan, Thane West, Thane - 400 606, Maharashtra IndiaSource of Support. None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_1101_2 Figures [Figure 1], [Figure 2] Tables [Table 1], [Table 2], [Table 3], [Table 4].

Abstract Background ventolin online usa who can buy ventolin. Empathy plays a role not only in pathophysiology but also in planning management strategies for alcohol dependence. However, few studies have looked into ventolin online usa it.

No data are available regarding the variation of empathy with abstinence and motivation. Assessment based on ventolin online usa cognitive and affective dimensions of empathy is needed.Aim. This study aimed to assess cognitive and affective empathy in men with alcohol dependence and compared it with normal controls.

Association of empathy with disease-specific variables, ventolin online usa motivation, and abstinence was also done.Methods. This was a cross-sectional observational study conducted in the outpatient department of a tertiary care center. Sixty men with alcohol ventolin online usa dependence and 60 healthy controls were recruited and assessed using the Basic Empathy Scale for cognitive and affective empathy.

The University of Rhode Island Change Assessment Scale was used to assess motivation. Other variables were assessed using a semi-structured ventolin online usa pro forma. Comparative analysis was done using unpaired t-test and one-way ANOVA.

Correlation was done ventolin online usa using Pearson's correlation test.Results. Cases with alcohol dependence showed lower levels of cognitive, affective, and total empathy as compared to controls. Affective and total empathy were higher in ventolin online usa abstinent men.

Empathy varied across various stages of motivation, with a significant difference seen between precontemplation and action stages. Empathy correlated negatively with number of relapses and positively with family history of ventolin online usa addiction.Conclusions. Empathy (both cognitive and affective) is significantly reduced in alcohol dependence.

Higher empathy correlates ventolin online usa with lesser relapses. Abstinence and progression in motivation cycle is associated with remission in empathic deficits.Keywords. Abstinence, alcohol, empathy, ventolin online usa motivationHow to cite this article:Nachane HB, Nadadgalli GV, Umate MS.

Cognitive and affective empathy in men with alcohol dependence. Relation with ventolin online usa clinical profile, abstinence, and motivation. Indian J Psychiatry 2021;63:418-23How to cite this URL:Nachane HB, Nadadgalli GV, Umate MS.

Cognitive and affective empathy in men with ventolin online usa alcohol dependence. Relation with clinical profile, abstinence, and motivation. Indian J Psychiatry [serial online] 2021 [cited ventolin online usa 2022 Nov 13];63:418-23.

Available from. Https://www.indianjpsychiatry.org/text.asp?. 2021/63/5/418/328088 Introduction Alcohol dependence is as much a social challenge as it is a clinical one.[1] Clinicians have faced several challenges in helping subjects with alcohol dependence stay in treatment and maintain abstinence.[2] In substance abuse treatment, clients' motivation to change has often been the focus of both clinical interest and frustration.[3],[4] Motivation has been described as a prerequisite for treatment, without which the clinician can do little.[5] Similarly, lack of motivation has been used to explain the failure of individuals to begin, continue, comply with, and succeed in treatment.[6],[7] Treatment modalities have focused on various aspects of motivation enhancement – such as locus of control, social support, and networking.[8] Recent literature is focusing on the role empathy plays in pathogenesis and treatment seeking in alcohol dependence.[9] However, the way in which empathy is perceived has recently undergone drastic changes, specifically its role in both emotion processing and social interactions.[10]Broadly speaking, empathy is believed to be constituted of two components – cognitive and affective (or emotional).[9] Affective empathy (AE) deals with the ability of detecting and experiencing the others' emotional states, whereas cognitive empathy (CE) relates to perspective-taking ability allowing to understand and predict the other's various mental states (sometimes used synonymously with theory of mind).[11] Empathy constitutes an essential emotional competence for interpersonal relations and has been shown to be highly impaired in various psychiatric disorders including alcohol dependence.[9],[12] Empathy is crucial for maintaining interpersonal relations, which are frequently impaired in alcoholics and prove to be a source of frequent relapses.[9] However, research pertaining to empathy in alcohol has generated varied results.[9] Factors such as lapses, retaining in treatment, and abstinence have also been linked to subjects' empathy.[9],[13] However, few of these have assessed CE and AE separately.[9],[13] Previous literature has demonstrated that empathy correlates with the motivation to help others.[14] No study however addresses the role empathy may play in self-help, a crucial step in the management of alcohol dependence.

A link between an alcoholic's empathy and motivation is lacking. It is imperative to highlight changes in empathy with changes in motivation, over and above the dichotomy of abstinence and dependence.Detailed understanding of empathy, or a lack thereof, and its fate during the natural course of the illness, particularly with each step of the motivation cycle, will prove fruitful in planning better strategies for alcohol dependence. This will, in turn, lead to better handling of its social consequences and reduction in its burden on society and healthcare.

The present study was thus formulated, which aimed at comparing CE, AE, and total empathy (TE) between subjects of alcohol dependence and normal controls. Differences in CE, AE and TE with abstinence and stage of motivation were also assessed. We also correlated CE, AE, and TE with disease-specific variables.

Materials and Methods The present study is a cross-sectional observational study done in the outpatient psychiatric department of a tertiary care center. Ethical clearance was obtained from the institutional ethics committee (IEC/Pharm/RP/102/Feb/2019). The study was conducted over a period of 6 months (March 2019–August 2019) and purposive sampling method was used.

Sixty subjects, between the ages of 18–65 years, diagnosed with alcohol dependence as per the International Classification of Diseases-10 criteria were included in the study as cases. Subjects with comorbid psychiatric and medical disorders (four subjects) and those dependent on more than one substance (six subjects) were excluded. As all the available cases were male, the study was restricted to males.

Sixty normal healthy male controls who were not suffering from any medical or psychiatric illness (five subjects excluded) were recruited from the normal population (these were healthy relatives of patients attending our outpatient department). Subjects were explained about the nature of the study and written informed consent was obtained from them. A semi-structured pro forma was devised to include sociodemographic variables, such as age, marital status, family structure, education, and employment status and disease-specific variables in the cases, such as total duration of illness, number of relapses, number of hospital admissions, and family history of psychiatric illness/substance dependence.

Empathy was assessed using the Basic Empathy Scale for Adults for both cases and controls and motivation was assessed in the cases using the University of Rhode Island Change Assessment Scale (URICA). The scales were translated into the vernacular languages (Hindi and Marathi) and the translated versions were used. The scales were administered by a single rater in one sitting.

The entire interview was completed in 20–30 min.InstrumentsThe Basic Empathy Scale for AdultsIt is a 20-item scale which was developed by Jolliffe and Farrington.[15] Each question is rated on a five point Likert type scale. We used the two-factor model where nine items assess CE (Items 3, 6, 9, 10, 12, 14, 16, 19, and 20) and 11 items assess AE (Items 1, 2, 4, 5, 7, 8, 11, 13, 15, 17, and 18). The total score gives TE, which can range from 20 (deficit in empathy) to 100 (high level of empathy).The University of Rhode Island Change Assessment Scale (URICA)This scale is based on the transtheoretical model of motivation given by Prochaska and DiClemente, which divides the readiness to change temporally into four stages.

Precontemplation (PC), contemplation (C), action (A), and maintenance (M).[16] The URICA is a 32-item self-report measure that grades responses on a 5-point Likert scale ranging from one (strong disagreement) to five (strong agreement). The subscales can be combined arithmetically (C + A + M − PC) to yield a second-order continuous readiness to change score that is used to assess readiness to change at entrance to treatment. Based on this score, the individual is classified into the stage of motivation (precontemplation, contemplation, action, and maintenance)Statistical analysisSPSS 20.0 software was used for carrying out the statistical analysis.

(IBM SPSS Statistics for Windows, Version 20.0, released 2011, Armonk, NY. IBM Corp.). Data were expressed as mean (standard deviation) for continuous variables and frequencies and percentages for categorical variables.

Comparative analyses were done using unpaired Student's t-test and one-way ANOVA with post hoc Bonferroni's test wherever appropriate. The correlation was done using Pearson's correlation test and point biserial correlation test for continuous and dichotomous categorical variables, respectively. The effect size was determined by calculating Cohen's d (d) for t-test, partial eta square (ηp2) for ANOVA, and correlation coefficient (r) for Pearson's correlation/point biserial correlation test.

P <0.05 was considered statistically significant. Results A total of 120 subjects consisting of 60 cases and 60 controls who satisfied the inclusion and exclusion criteria were considered for the analysis. The mean age of cases was 40.80 (8.69) years, whereas that of controls was 39.02 (10.12) years.

About 80% of the cases and 88% of the controls were married. Only 58% of the cases and 57% of the controls were educated. Almost 80% of the cases versus 95% of the controls were employed at the time of assessment.

Majority of the cases (75%) and controls (83%) belonged to nuclear families. None of the sociodemographic variables varied significantly across cases and controls. Comparison of empathy between cases and controls using unpaired t-test showed cognitive (t(118) =2.59, P = 0.01), affective (t(118) =2.19, P = 0.03), and total empathy (t(118) =2.39, P = 0.02) to be significantly lower in cases [Table 1].

The analysis showed the difference to be most significant for CE (d = 0.48), followed by TE (d = 0.44), and then AE (d = 0.40), implying that it is CE that is most significantly lowered in men with alcohol dependence. [Table 2] shows the correlation between empathy and disease-related variables amng the cases using Pearson's correlation/point biserial correlation tests. Number of relapses negatively correlated with all three measures of empathy, most with CE (r = −0.42, P = 0.001), followed by TE (r = −0.39, P = 0.002) and least with AE (r = −0.31, P = 0.016).

This means that men with alcohol dependence who are more empathic tend to have lesser relapses. Having a family history of mental illness/substance use was seen to have a positive correlation with CE (r = 0.43, P = 0.001) and TE (r = 0.30, P = 0.02) but not AE (P = 0.17). As the coefficients of correlation for all the relations were <0.5, the strength of correlations in our sample was mild–moderate.Table 2.

Relation of disease related variables with total empathy in casesClick here to viewMotivation and readiness to change was assessed in the cases using the URICA scale, which had a mean score of 8.78 (4.09). About 50% of the subjects were currently consuming alcohol (30 out of 60) and the remaining were completely abstinent. Comparing empathy scores among those subjects still consuming and those subjects completely abstinent using unpaired t-test [Figure 1] showed that abstinent patients had significantly higher AE (t(58) =2.72, mean difference = 5.10 [95% confidence interval [CI].

1.34–8.86], P = 0.009) and TE (t(58) =2.88, mean difference = 8.60 [95% CI. 2.63–14.57], P = 0.006) as compared to those still consuming but not CE (t(58) =1.93, mean difference = 2.83 [95% CI. 0.09–5.77], P = 0.058).

This difference was most marked in TE (d = 0.77), followed by AE (d = 0.71). Dividing the cases into their respective stages of motivation showed that 20 out of 60 (33%) subjects were in precontemplation stage, 10 out of 60 (17%) in contemplation stage and 30 out of 60 (50%) in action stage. None were seen to be in maintenance phase.

Using one-way ANOVA to assess the difference in empathy across the various stages of motivation [Table 3], it was found that AE (F (2,57) = 5.03, P = 0.01) and TE (F (2, 57) = 4.25, P = 0.02) varied across the motivation cycle but not CE (F (2,57) = 2.26, P = 0.11). Difference was more significant for affective empathy (ηp2 = 0.15) as compared to total empathy (ηp2 = 0.13), although a small one. In both cases of affective and total empathy, it can be seen that empathy increases gradually with each stage in motivation cycle [Figure 2].

However, using the post hoc Bonferroni test [Table 4] revealed that significant difference in both cases was seen between precontemplation and action stages only (P <. 0.05).Figure 1. Difference in cognitive, affective, and total empathy among dependent and abstinent subjects.

Data expressed as mean (standard deviation)Click here to viewFigure 2. Cognitive, affective, and total empathy in cases across precontemplation, contemplation, and action stages of motivation. Data expressed as mean (standard deviation)Click here to viewTable 4.

Comparison of cognitive, affective and total empathy in individual stages of motivation using post hoc Bonferroni testClick here to view Discussion Role of empathy in addictive behaviors is a pivotal one.[17] The present analysis shows that subjects dependent on alcohol lack empathic abilities as compared to healthy controls. This translates to both cognitive and affective components of empathy. Earlier research appears divided in this aspect.

Massey et al. Elucidated reduction in both CE and AE by behavioral, neuroanatomical, and self-report methods.[18] Impairment in affect processing system in alcohol dependence was cited as the reason behind the so-called “cognitive-affective dissociation of empathy” in alcoholics, which resulted in a changed AE, with relatively intact CE.[9],[17] However, there is enough evidence to suggest the lack of social cognition, emotional cognition, and related cognitive deficits in alcohol-dependent subjects.[19] Cognitive deficits responsible for dampening of CE seen in addictions have been attributed to frontal deficits.[19] In fact, it is a combined deficit which leads to impaired social and interpersonal functioning in alcoholics.[20] Hence, our primary finding is in keeping with this hypothesis.Empathy may relate to various aspects of the psychopathological process.[21] Disorders have also been classified based on which aspect of empathy is deficient – cognitive, affective, or general.[21] On such a spectrum, alcohol dependence should definitely be classified as a general empathic deficit disorder. It is also known that within a disorder, the two components of empathy may show variation, depending upon various factors.[21] Addiction processes may have impulsivity, antisocial personality traits, externalizing behaviors, and internalizing behaviors as a part of their presentations, all factors which effect empathy.[22],[23] Hence, it is likely that difference in empathy could be attributable to these factors, even though it has been shown that empathy operates independent of them to impact the disease process.[18]Abstinence period is associated with several physiological and psychological changes and is a key experience in the life of patients with alcohol use disorder.[24] The present analysis shows that abstinence period is associated with higher empathy than the active phase of illness.

It has been demonstrated that empathy correlates significantly with abstinence and retention in treatment.[13],[23] A study has described improvement in empathy, attributable to personality changes with abstinence, in subjects following up for treatment in self-help groups.[13] A causative effect of improvement in empathy due to the 12-step program and abstinence has been hypothesized,[13] and our findings support this. Empathy is a key factor in motivation to help others and oneself when in distress. This suggests a role for it in motivation to quit and treatment seeking.

Yet still, few studies have made this assessment. Across the motivation cycle, we found that TE and AE were significantly higher for subjects in action phase than for precontemplation and contemplation phases. CE showed no significant changes.

Thus, it appears that AE is more amenable to change and instrumental in motivation enhancement. Treatment modalities for dependence should inculcate methods addressing empathy, especially AE as this would be more beneficial. It is also possible that these patients may innately have higher empathy and hence are motivated to quit alcohol, as has been previously demonstrated.[9]It is clear that in adults who have developed alcohol dependence, deficits in empathic processing remit in recovery and this finding is crucial to optimize long-term outcomes and minimize the likelihood of relapse.

Altered empathic abilities have been shown to impair future problem solving in social situations, thus impacting the prognosis of the illness.[25] Similarly, it also hampers treatment seeking in alcoholics. CE played a greater role in our sample as compared to AE, contrary to what most literature states.[26] This is furthered by the fact that CE and TE correlated with number of relapses and having a family history of mental illness in our subjects, whereas AE correlated with only number of relapses. Subjects with higher empathy had significantly lesser relapses, suggesting a role for empathy, particularly CE in maintaining abstinence, even though it is least likely to change.

This relation has been demonstrated by other researchers also.[13],[23] Having a positive family history of mental illness/addictions was associated with higher CE and TE. Genes have shown to influence development and dynamicity of empathy in healthy individuals and as genetics play a major role in heredity of addictions, levels of empathy may also vary accordingly.[21],[27] As AE did not show this relation, it appears CE and AE may not be “equally heritable.” However, more research in this area is needed.Our study was not without limitations. Factors such as premorbid personality and baseline empathy were not considered.

As all cases and controls were males, gender differences could not be assessed. We did not have any patients in the maintenance phase of motivation and hence this difference could not be assessed. It also might be more prudent to have a prospective study design wherein patients are followed throughout their motivation cycle to derive a more robust relation between empathy and motivation.

As our study was a cross-sectional study, it was not possible.To mention a few strengths, our analysis adds to the need for studying CE and AE separately, as they may impact different aspects of the illness and show varied dynamicity over the natural course of alcohol dependence owing to their difference in neural substrates.[28] While many risk factors for alcohol dependence are difficult if not impossible to change,[29] some components of empathy may be modifiable,[13] particularly AE. Abstinence is associated with an increase in AE and TE and thus empathy may be crucial in propelling an individual along the motivation cycle. Our analysis stands out in being one of the few to establish a relation between stages of motivation and components of empathy in alcohol dependence, which will definitely have further research and therapeutic implications.

Conclusions Empathic deficits in alcohol dependence are well established, being more for CE than AE although both being affected. Even though psychotherapeutic approaches have hitherto targeted therapist's empathy,[30] we suggest that a detailed understanding of patient's empathy is equally crucial in the management. Increment in AE and TE is seen with abstinence and improvement in subject's motivation.

Relapses are lesser in individuals with higher empathy and it is possible that those who relapse develop low empathy. The present analysis is associational and causality inference should be done with caution. Modalities of treatment which focus on empathy and its subsequent advancement, such as brief intervention and self-help groups, have met with ample success in clinical practice.[13],[31] Adding to existing factors that have proved successful for abstinence,[32] focusing on improving empathy at specific points in the motivation cycle (contemplation to action) may motivate individuals better to stay in treatment and reduce further relapses.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest.

References 1.Caetano R, Cunradi C. Alcohol dependence. A public health perspective.

Addiction 2002;97:633-45. 2.Willenbring ML. The past and future of research on treatment of alcohol dependence.

Alcohol Res Health 2010;33:55-63. 3.DiClemente CC. Conceptual models and applied research.

The ongoing contribution of the transtheoretical model. J Addict Nurs 2005;16:5-12. 4.Velasquez MM, Crouch C, von Sternberg K, Grosdanis I.

Motivation for change and psychological distress in homeless substance abusers. J Subst Abuse Treat 2000;19:395-401. 5.Beckman LJ.

An attributional analysis of Alcoholics Anonymous. J Stud Alcohol 1980;41:714-26. 6.Appelbaum A.

A critical re-examination of the concept of “motivation for change” in psychoanalytic treatment. Int J Psychoanal 1972;53:51-9. 7.Miller WR.

Motivation for treatment. A review with special emphasis on alcoholism. Psychol Bull 1985;98:84-107.

8.Murphy PN, Bentall RP. Motivation to withdraw from heroin. A factor-analytic study.

Br J Addict 1992;87:245-50. 9.Maurage P, Grynberg D, Noël X, Joassin F, Philippot P, Hanak C, et al. Dissociation between affective and cognitive empathy in alcoholism.

A specific deficit for the emotional dimension. Alcohol Clin Exp Res 2011;35:1662-8. 10.de Vignemont F, Singer T.

The empathic brain. How, when and why?. Trends Cogn Sci 2006;10:435-41.

11.Reniers RL, Corcoran R, Drake R, Shryane NM, Völlm BA. The QCAE. A questionnaire of cognitive and affective empathy.

J Pers Assess 2011;93:84-95. 12.Martinotti G, Di Nicola M, Tedeschi D, Cundari S, Janiri L. Empathy ability is impaired in alcohol-dependent patients.

Am J Addict 2009;18:157-61. 13.McCown W. The relationship between impulsivity, empathy and involvement in twelve step self-help substance abuse treatment groups.

Br J Addict 1989;84:391-3. 14.Krebs D. Empathy and auism.

J Pers Soc Psychol 1975;32:1134-46. 15.Jolliffe D, Farrington DP. Development and validation of the basic empathy scale.

J Adolesc 2006;29:589-611. 16.McConnaughy EA, Prochaska JO, Velicer WF. Stages of change in psychotherapy.

Measurement and sample profiles. Psychol Psychother 1983;20:368-75. 17.Ferrari V, Smeraldi E, Bottero G, Politi E.

Addiction and empathy. A preliminary analysis. Neurol Sci 2014;35:855-9.

18.Massey SH, Newmark RL, Wakschlag LS. Explicating the role of empathic processes in substance use disorders. A conceptual framework and research agenda.

Drug Alcohol Rev 2018;37:316-32. 19.Uekermann J, Daum I. Social cognition in alcoholism.

A link to prefrontal cortex dysfunction?. Addiction 2008;103:726-35. 20.Uekermann J, Channon S, Winkel K, Schlebusch P, Daum I.

Theory of mind, humour processing and executive functioning in alcoholism. Addiction 2007;102:232-40. 21.Gonzalez-Liencres C, Shamay-Tsoory SG, Brüne M.

Towards a neuroscience of empathy. Ontogeny, phylogeny, brain mechanisms, context and psychopathology. Neurosci Biobehav Rev 2013;37:1537-48.

22.Miller PA, Eisenberg N. The relation of empathy to aggressive and externalizing/antisocial behavior. Psychol Bull 1988;103:324-44.

23.McCown W. The effect of impulsivity and empathy on abstinence of poly-substance abusers. A prospective study.

Br J Addict 1990;85:635-7. 24.Pitel AL, Beaunieux H, Witkowski T, Vabret F, Guillery-Girard B, Quinette P, et al. Genuine episodic memory deficits and executive dysfunctions in alcoholic subjects early in abstinence.

Alcohol Clin Exp Res 2007;31:1169-78. 25.Thoma P, Friedmann C, Suchan B. Empathy and social problem solving in alcohol dependence, mood disorders and selected personality disorders.

Neurosci Biobehav Rev 2013;37:448-70. 26.Marinkovic K, Oscar-Berman M, Urban T, O'Reilly CE, Howard JA, Sawyer K, et al. Alcoholism and dampened temporal limbic activation to emotional faces.

Alcohol Clin Exp Res 2009;33:1880-92. 27.Smith A. Cognitive empathy and emotional empathy in human behavior and evolution.

Psychol Rec 2006;56:3-21. 28.Decety J, Jackson PL. A social-neuroscience perspective on empathy.

Curr Dir Psychol Sci 2006;15:54-8. 29.Tarter RE, Edwards K. Psychological factors associated with the risk for alcoholism.

Alcohol Clin Exp Res 1988;12:471-80. 30.Moyers TB, Miller WR. Is low therapist empathy toxic?.

Psychol Addict Behav 2013;27:878-84. 31.Heather N. Psychology and brief interventions.

Br J Addict 1989;84:357-70. 32.Cook S, Heather N, McCambridge J. Posttreatment motivation and alcohol treatment outcome 9 months later.

Findings from structural equation modeling. J Consult Clin Psychol 2015;83:232-7. Correspondence Address:Hrishikesh Bipin Nachane63, Sharmishtha, Tarangan, Thane West, Thane - 400 606, Maharashtra IndiaSource of Support.

None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_1101_2 Figures [Figure 1], [Figure 2] Tables [Table 1], [Table 2], [Table 3], [Table 4].

How long does ventolin hfa last

Decision makers how long does ventolin hfa last in healthcare systems strive to implement evidence-based, high-quality care http://bobmackin.ca/?p=2320. A lack of economic data is often cited as a barrier to implementation, especially when decision makers are asked to allocate finite resources and face competing demands.1–3 Studies that evaluate the cost of implementation strategies remain rare, and often these studies only estimate the implementation costs without connecting those investments to patient outcomes. In this issue of BMJ how long does ventolin hfa last Quality &. Safety, in a cost-effectiveness evaluation of a quality improvement project to improve thrombolysis door-to-needle times in a large Norwegian stroke centre, Ajmi and colleagues4 report that their implementation strategies cost $44 802 (US$) in fixed costs and $2141 per month in recurring costs.

Further, they report an incremental cost per life-year saved that ranged from $4961–$10 543 (US$) over a 5-year period, with the how long does ventolin hfa last range reflecting different assumptions made in a sensitivity analysis.The authors should be commended for estimating the incremental cost per life-year saved, incorporating costs of implementation of the intervention. This information alone may help in allocating scarce resources. However, we suspect that many decision makers will remain uncertain about whether they should try to replicate these efforts in their own systems.One challenge with economic evaluations is providing enough context by how long does ventolin hfa last which other decision makers can easily determine the generalisability of the findings to their own systems. Such knowledge is necessary if there is a desire to spread and replicate this work in other systems.

In the study on which Ajmi and colleagues’ analysis is based, the door-to-needle time was cut in half (from a median of 27 min to 13 min) how long does ventolin hfa last. On one hand, that is a triumph, and on the other hand, these hospitals were already doing relatively well at the onset. In contrast, Get with the Guideline efforts in the USA reported door-to-needle time improvements from a median of 77 min to 67 min.5 We anticipate many decision-makers will want to know if they can reasonably expect a relative reduction in door-to-needle time of 50% by investing a similar amount of money ($44 802 in fixed costs, plus $2141 per month) in a how long does ventolin hfa last similar intervention.As Lewis and colleagues6 highlight, mechanisms that drive changes in short term and overall outcomes must be explicitly described for others to feel confident in implementing the intervention themselves. Other decision makers can then try to extrapolate from the model to guide decisions at their healthcare system.

However, using economic models to make individual decisions, whether that how long does ventolin hfa last is for a single patient or a whole hospital, is fraught with difficulty.7 In the paper, Ajmi and colleagues4 discuss reasons why they likely saw favourable outcomes as a result of their implementation efforts but stopped short of exploring in more detail how these outcomes may be affected by varying mechanisms. Efforts to link the economic results more tightly to mechanisms of action will help guide decision makers to decide whether replication is warranted. This depends, in part, on whether they can expect similar results if they invest in similar interventions and implementation strategies.The issue of context comes up again with the authors’ decision to exclude additional healthcare costs (eg, additional CT-scans, price of additional thrombolytic medication, how long does ventolin hfa last critical care stays). Ajmi and colleagues did not describe Norway’s approach to healthcare financing or whether cost containment is a priority.

However, implementation scientists should consider the incentives created by how long does ventolin hfa last the broader financial landscape. Health systems financed through a ‘fee for service’ model may not be concerned by the exclusion of these downstream costs, but those working in systems financed through capitation or global payments may feel differently. In the USA, a growing number of decision makers are asking for budget impact analyses to understand how potential interventions will affect the allocation of funds and resources in the near future given existing budget constraints.8 9Although the issues we discuss could be viewed as critiques, this is partly the learning curve for researchers who are grappling with economic evaluations applied to implementation research with little guidance of best practices. We hope how long does ventolin hfa last there will be more economic evaluations of implementation efforts cvs ventolin price in the future.

In that vein, we offer a few suggestions.First, jargon can be an impediment, especially in multidisciplinary areas such as implementation science. Readers with varying experience how long does ventolin hfa last with either implementation science or economic evaluation often talk past each other due to a lack of mutual understanding over discipline-specific language.10 The use of terms such as opportunity costs, and fixed and variable costs, should therefore always be defined.11 For example, fixed costs are costs that do not vary by the scale of production. Purchasing an X-ray machine represents a fixed cost—the cost is fixed for the life of the machine, regardless of how many scans it is used for. Personnel (ie, labour) typically how long does ventolin hfa last represents a variable cost because the cost varies by the scale of production.

Ajmi and colleagues4 reported that the majority of costs were fixed and attributable to personnel, which may confuse some readers. It is possible that Ajmi and colleagues used the terms programme costs how long does ventolin hfa last synonymously with fixed costs, but programme costs often vary at some level, and for interdisciplinary work, clearly explaining key terms will therefore pay dividends.Second, to estimate the cost of the implementation strategies, most researchers rely on microcosting approaches that involve identifying the quantities of inputs used in the production of a service. In this study, the authors used staff surveys, with input from programme directors, to estimate the total cost. Microcosting approaches how long does ventolin hfa last differ in precision and accuracy due to the timing and method of data collection.

As a field, we need to find more accurate ways to track staff effort. Periodic surveys asking staff to recall their effort in the past month may be feasible, but whether these estimates are accurate is unknown and untested how long does ventolin hfa last. Some researchers try to handle this uncertainty with sensitivity analyses, yet those ‘in the trenches’ often feel as though we are imputing a considerable amount of data in economic evaluations that cannot be easily addressed with a sensitivity analysis. Building time tracking systems into the how long does ventolin hfa last workflow is perhaps the best method to ensure accurate and precise time estimates.12 13 Time tracking systems are standard in many industries that bill clients for direct services (eg, legal services, fixed-price contracts) and integration of these into existing clinical management systems can reduce the additional burden of time tracking for health professionals.Finally, as noted above, studies should ideally shed light on the mechanisms of action.

Including more information on the implementation process—such as the time and effort spent changing the minds of stakeholders and delays due to staff turnover—to provide other decision makers with advanced insight on decision points that may require additional resources. For many how long does ventolin hfa last implementation activities, time tracking systems can also inform the kinds of implementation efforts needed for future implementation planning purposes, whether those efforts are small and steady or rare but large.Creating tables of implementation costs, while helpful, provides only part of the information needed to make thoughtful decisions about implementation. The other component is understanding the benefits gained. Rarely are healthcare systems solely how long does ventolin hfa last focused on costs or solely focused on the benefits.

Integrating economic information into implementation science is appreciatively difficult and made worse by the lack of guidance for researchers. As these details are worked out and best practices are identified, we look forward to more studies like those of Ajmi and colleagues, informing this growing and evolving field.Ethics statementsPatient consent for publicationNot applicable.AcknowledgmentsWe appreciate the comments from Bryony Dean Franklin and Robert E Burke on an earlier draft..

Decision makers in healthcare systems can i buy ventolin over the counter australia strive to implement ventolin online usa evidence-based, high-quality care. A lack of economic data is often cited as a barrier to implementation, especially when decision makers are asked to allocate finite resources and face competing demands.1–3 Studies that evaluate the cost of implementation strategies remain rare, and often these studies only estimate the implementation costs without connecting those investments to patient outcomes. In this issue of ventolin online usa BMJ Quality &. Safety, in a cost-effectiveness evaluation of a quality improvement project to improve thrombolysis door-to-needle times in a large Norwegian stroke centre, Ajmi and colleagues4 report that their implementation strategies cost $44 802 (US$) in fixed costs and $2141 per month in recurring costs. Further, they report an incremental cost per life-year saved that ranged from $4961–$10 543 (US$) over a 5-year period, with the range reflecting different assumptions made in a sensitivity analysis.The authors should ventolin online usa be commended for estimating the incremental cost per life-year saved, incorporating costs of implementation of the intervention.

This information alone may help in allocating scarce resources. However, we suspect that many decision makers will remain uncertain about whether they should try to replicate these efforts in their own ventolin online usa systems.One challenge with economic evaluations is providing enough context by which other decision makers can easily determine the generalisability of the findings to their own systems. Such knowledge is necessary if there is a desire to spread and replicate this work in other systems. In the study on which Ajmi and colleagues’ analysis is based, the door-to-needle time was cut in half ventolin online usa (from a median of 27 min to 13 min). On one hand, that is a triumph, and on the other hand, these hospitals were already doing relatively well at the onset.

In contrast, Get with the Guideline efforts in the USA reported door-to-needle time improvements from a median of 77 min to 67 ventolin online usa min.5 We anticipate many decision-makers will want to know if they can reasonably expect a relative reduction in door-to-needle time of 50% by investing a similar amount of money ($44 802 in fixed costs, plus $2141 per month) in a similar intervention.As Lewis and colleagues6 highlight, mechanisms that drive changes in short term and overall outcomes must be explicitly described for others to feel confident in implementing the intervention themselves. Other decision makers can then try to extrapolate from the model to guide decisions at their healthcare system. However, using economic models to ventolin online usa make individual decisions, whether that is for a single patient or a whole hospital, is fraught with difficulty.7 In the paper, Ajmi and colleagues4 discuss reasons why they likely saw favourable outcomes as a result of their implementation efforts but stopped short of exploring in more detail how these outcomes may be affected by varying mechanisms. Efforts to link the economic results more tightly to mechanisms of action will help guide decision makers to decide whether replication is warranted. This depends, in part, on whether they can expect similar results if they invest in similar interventions and implementation strategies.The issue of context comes up again with the authors’ decision to exclude ventolin online usa additional healthcare costs (eg, additional CT-scans, price of additional thrombolytic medication, critical care stays).

Ajmi and colleagues did not describe Norway’s approach to healthcare financing or whether cost containment is a priority. However, implementation scientists should consider the incentives created by the broader financial landscape ventolin online usa. Health systems financed through a ‘fee for service’ model may not be concerned by the exclusion of these downstream costs, but those working in systems financed through capitation or global payments may feel differently. In the USA, a growing number of decision makers are asking for budget impact analyses to understand how potential interventions will affect the allocation of funds and resources in the near future given existing budget constraints.8 9Although the issues we discuss could be viewed as critiques, this is partly the learning curve for researchers who are grappling with economic evaluations applied to implementation research with little guidance of best practices. We hope there will be more economic evaluations of ventolin online purchase implementation efforts in the ventolin online usa future.

In that vein, we offer a few suggestions.First, jargon can be an impediment, especially in multidisciplinary areas such as implementation science. Readers with varying experience with either implementation science or economic evaluation often talk past each other due to a lack of mutual ventolin online usa understanding over discipline-specific language.10 The use of terms such as opportunity costs, and fixed and variable costs, should therefore always be defined.11 For example, fixed costs are costs that do not vary by the scale of production. Purchasing an X-ray machine represents a fixed cost—the cost is fixed for the life of the machine, regardless of how many scans it is used for. Personnel (ie, labour) typically represents a variable cost because the cost varies by the scale ventolin online usa of production. Ajmi and colleagues4 reported that the majority of costs were fixed and attributable to personnel, which may confuse some readers.

It is possible that Ajmi and colleagues used the terms programme costs synonymously with fixed costs, but programme costs often vary ventolin online usa at some level, and for interdisciplinary work, clearly explaining key terms will therefore pay dividends.Second, to estimate the cost of the implementation strategies, most researchers rely on microcosting approaches that involve identifying the quantities of inputs used in the production of a service. In this study, the authors used staff surveys, with input from programme directors, to estimate the total cost. Microcosting approaches ventolin online usa differ in precision and accuracy due to the timing and method of data collection. As a field, we need to find more accurate ways to track staff effort. Periodic surveys asking staff to recall their effort in the past ventolin online usa month may be feasible, but whether these estimates are accurate is unknown and untested.

Some researchers try to handle this uncertainty with sensitivity analyses, yet those ‘in the trenches’ often feel as though we are imputing a considerable amount of data in economic evaluations that cannot be easily addressed with a sensitivity analysis. Building time tracking systems into the workflow is perhaps the best method to ensure accurate and precise time estimates.12 13 Time tracking systems are standard in many industries that bill clients for direct services (eg, legal services, fixed-price contracts) and integration of these into existing clinical management systems can reduce the ventolin online usa additional burden of time tracking for health professionals.Finally, as noted above, studies should ideally shed light on the mechanisms of action. Including more information on the implementation process—such as the time and effort spent changing the minds of stakeholders and delays due to staff turnover—to provide other decision makers with advanced insight on decision points that may require additional resources. For many implementation activities, time tracking systems can also inform the kinds of implementation efforts needed for future implementation planning purposes, ventolin online usa whether those efforts are small and steady or rare but large.Creating tables of implementation costs, while helpful, provides only part of the information needed to make thoughtful decisions about implementation. The other component is understanding the benefits gained.

Rarely are healthcare systems solely focused on costs or solely focused on ventolin online usa the benefits. Integrating economic information into implementation science is appreciatively difficult and made worse by the lack of guidance for researchers. As these details are worked out and best practices are identified, we look forward to more studies like those of Ajmi and colleagues, informing this growing and evolving field.Ethics statementsPatient consent for publicationNot applicable.AcknowledgmentsWe appreciate the comments from Bryony Dean Franklin and Robert E Burke on an earlier draft..

Ventolin coupon 2020

Concern about the link between opioid prescribing and preventable ventolin coupon 2020 adverse drug events has led to a series of initiatives to reduce opioid use, with opioids identified as one of three high-priority drug classes targeted to reduce patient harms in the United States (US)’s National Action Plan for Adverse Drug Event Prevention.1 Variation in look at here opioid prescribing practices by physicians has been observed, yet the reasons why these differences exist remain largely unknown. A better understanding of these differences ventolin coupon 2020 may help to improve prescribing practice for opioids. Sex and gender considerations in opioid prescribing practices have not been well studied and may help address this important knowledge gap.There is some evidence to suggest that sex and gender of physicians can affect prescribing practices for older adults.2 ventolin coupon 2020 Patient gender has also been related to the experience of health conditions, health-seeking behaviours and medication use.3–5 Sex (biologic), a term describing the physical characteristics and biological attributes of males, females and intersex individuals, influences biological manifestations of medical conditions and responses to drug therapy.5 In contrast, gender (sociocultural) refers to the socially constructed norms, behaviours and roles associated with being a man, woman or gender diverse person.6 While these concepts are related, they are often incorrectly interchanged. Considering sex and gender, and how they intersect with key identity factors such as age, culture, race and ethnicity, is an analytical approach7 that can be applied to systematically explore the influence of sex and gender on prescribing practices, revealing potentially important differences or trends that would otherwise remain obscured.

Such an approach provides the opportunity to ventolin coupon 2020 inform prescribing practices in general, and pain management strategies in particular. This will allow healthcare provision to be tailored to the unique needs ventolin coupon 2020 of women, men and gender diverse people, including those in different age groups, acknowledging the evolution of health and medication needs across the life span.The study by Tamblyn and colleagues,8 published in this edition of the journal, underscores the utility and value of considering patient and provider sex along with other key identity factors such as age, race and culture in all clinical research. This study also presents the opportunity to consider the wider role of patient and physician gender on prescribing, and why the inclusion of both sex and gender may be essential to uncovering important ventolin coupon 2020 variations in clinical practice, and to capturing the diversity of health needs and experiences in patient populations.In their study, Tamblyn8 set out to explore the impact of physician characteristics, including clinical competence, specialty and country of origin, on opioid prescribing for chronic non-cancer pain. The authors examined the opioid prescribing patterns of a cohort of international medical graduates in the US who completed their Clinical Skills Assessment requirement for the Educational Commission for Foreign Medical Graduates between 1998 and 2004.

They were managing older patients covered by the Medicare part D drug insurance programme who were receiving care in an ambulatory setting for chronic non-cancer ventolin coupon 2020 pain in 2014 and 2015. Logistic and linear regression were used to explore the association of the prescribing physician’s characteristics with opioid prescribing and the doses prescribed.Outcomes measured in the study included opioid prescribing within 90 days of the clinical evaluation, whether the patient received a non-opioid intervention (eg, physiotherapy treatment or a non-steroidal anti-inflammatory drug) prior to the opioid prescription, and the opioid dose that was prescribed.8 The former outcome is particularly important, as opioids are not first-line therapy for chronic pain.9Notably, even though it was not identified as one of the primary variables of interest, the Tamblyn study8 revealed the importance of routinely stratifying data by sex ventolin coupon 2020. Further, the study underlines the importance of the collection and use of sex and age disaggregated data to better understand health status.10 More specifically, this study illustrates why it is important to consider provider sex in opioid prescribing, as well as gender-related sociocultural factors. First, there are important physician and patient factors that ventolin coupon 2020 relate to their sex and others that are gender related.

Most (61%) of the prescribing physicians in this ventolin coupon 2020 study were men. This is in part because medicine itself is gendered.11 While the proportion of female ventolin coupon 2020 physicians has grown substantially over the past few decades, they remain under-represented in most specialties, especially those that are higher paying, including some of those explored within the present study.11 12Women are more likely than men to experience the chronic conditions that cause pain.13 The most common chronic non-cancer conditions being managed in this study were back and neck pain, migraine/headaches, rheumatoid or osteoarthritis, and neuropathic pain. Each of these conditions occur more commonly in older women than in older men. For example, compared with men of the same age, women aged 65 years and older in Canada are 1.9 times more likely to have been diagnosed ventolin coupon 2020 with rheumatoid arthritis and are 1.4 times more likely to have been diagnosed with osteoarthritis.14 Migraine headaches are experienced by almost twice as many women as men (7.4% of women compared with 3.4% of men)10 and neuropathic pain is similarly more prevalent among women.13 The predominance of older women experiencing these chronic non-cancer pain conditions may be one reason why more than 66% of the older patients being managed for chronic pain in the Tamblyn study were women.

Unless these differences are examined using sex and age disaggregated data, important patterns in the characteristics of the prescribers and the differences in pain experienced by older women and men will remain hidden in the data.A second salient finding of this study was that the odds of prescribing an opioid for non-cancer chronic conditions was 11% higher for male physicians (OR 1.11, 95% CI 1.03 to 1.19).8 Further, for every 10% increase in the clinical encounter score (used to measure clinical competence), the odds of prescribing an opioid decreased by 16% for female physicians (OR 0.84, 95% CI 0.75 to 0.94), but not for male physicians (OR 0.99, 95% CI 0.92 to 1.07).8 These ventolin coupon 2020 findings align with the existing literature that reports on correlations between physician gender-related sociocultural factors and prescribing behaviour, patient care and clinical outcomes. Female physicians have been shown to prescribe medications at lower doses than male physicians.15 The initiation of medications at low doses, using the ‘start low, go slow approach’, is a practice from geriatric medicine that minimises the risk of harm in older adults, as adverse events are often dose related.16 This was illustrated in a study of the initiation of drug therapy for the management ventolin coupon 2020 of dementia. Female prescribers were more likely than their male counterparts to initiate cholinesterase inhibitor therapy at a lower-than-recommended dose and for a shorter duration.15 Previous literature on the prescribing of opioids similarly finds that female physicians prescribe opioids more sparingly than their male counterparts.17 When it comes to patient–clinician interactions, female physicians have been characterised as providing more patient-centred and empathetic care.18 19 Compared with their male counterparts, they have been shown to spend more time with patients, engage in more communicative and active partnerships, and provide more psychosocial support and counselling.19 Female physicians have also been shown to adhere more closely to clinical guidelines20 and practise more evidence-based medicine.21 These differences in care delivery and treatment provision may be linked to the more conservative prescribing practices of female physicians demonstrated in the present study and elsewhere.15 17The differences in opioid prescribing practices between male and female physicians observed in the Tamblyn study are not isolated to pain management or opioid prescribing. Rather, this study contributes to recent evidence from different clinical settings and specialties, suggesting that patients cared for by female physicians may have better clinical outcomes ventolin coupon 2020 compared with their male colleagues.

For instance, when matched for patient, surgeon and hospital characteristics in a large population-based cohort study, patients of female surgeons identified as having 1 of 25 index procedures were found to experience lower risk of short-term postoperative death than those cared for by male surgeons.22 Similarly, female internists treating older adults hospitalised with a medical condition were found to provide significantly better outcomes than their male colleagues in terms of 30-day mortality and readmission rates.23Data on physician and patient sex or gender-related sociocultural factors are often not reported on or described in research studies, making further synthesis of findings through meta-analysis difficult.24 Consistent reporting of this information can allow for aggregation of ventolin coupon 2020 data and establishment of stronger correlations between prescriber sex and gender, and clinical outcomes.Finally, considering a sex-based and gender-based analytical approach that includes an intersection with cultural factors for both patients and prescribers may be key to a better understanding of opioid prescribing and pain management. Gender-based psychosocial patient factors have been related to behavioural responses and expressions of perceived pain, which often reflect societal norms.25 As a social construct, gender is understood to be context specific and thus varying cultural expectations for pain management, potentially linked to country of origin, may influence how a patient experiences pain and a physician’s likelihood of opioid prescribing for common pain problems. In the present study, Tamblyn found that while the prescriber’s country of origin did not influence the odds of opioid prescribing, US and Canadian physicians, both men and women, prescribed opioids at higher doses.8 Therefore, the potential influence of cultural norms and gender in relation to clinical treatment and diagnosis of pain may also reveal disproportionate cross-national impacts that would otherwise remain hidden.This study has highlighted the importance of considering patient and prescriber sex, gender and other key identity factors including age and culture, in all research studies ventolin coupon 2020 in order to better inform clinical care. Given the risks associated with potentially inappropriate opioid use in older adults, it is worth exploring further how the more cautious practices of female physicians could offer a learning opportunity to optimise health outcomes for all.Ethics statementsPatient consent for publicationNot required.Ensuring patient safety in low-and-middle-income countries (LMICs) requires tailored approaches that are appropriate to the unique challenges faced by ventolin coupon 2020 health systems in LMICs.

To date, the evidence on how to effectively improve patient safety in LMICs is limited and although we can infer lessons from high-income countries (HICs), there are ventolin coupon 2020 meaningful differences between HICs and LMICs that require careful study. The study by Hall et al1 in this issue of BMJ Quality &. Safety, which used implementation science methods to study what helped or hindered the roll-out of a patient safety programme in Guatemala, is therefore a welcome addition to this evidence base.1 Based on the findings from Hall et al,1 and the growing focus in the field of implementation science to analyse mechanisms by which implementation strategies work (or do not work), we argue that patient safety endeavours globally should consider systems-level barriers and explicitly include tailored strategies to overcome them.2 ventolin coupon 2020 LMICs have unique contextual factors that require interventions to be adapted, rather than directly transported from HICs.Mixed-methods implementation science studies like those employed in Hall et al’s paper1 are particularly helpful for increasing our understanding of how to translate systems thinking into real-world practice. Hall et al1 used the Consolidated Framework for Implementation ventolin coupon 2020 Research (CFIR)3 to identify facilitators and barriers for implementation and inform the optimisation of patient safety implementation strategies in Guatemala.

They evaluated ventolin coupon 2020 implementation determinants acting across multiple levels, including the individual, inner organisational context, and external environment which led to several insights related to the overall health system and context. The authors found that clinical staff were intrinsically motivated to provide high-quality and safe care for their patients, but often faced systems barriers of insufficient time, resources and staff to implement known evidence-based protocols. Some of these are similar as experienced in HICs, ventolin coupon 2020 but others unique for the context of LMICs. In addition, due to the hierarchical structure of the system, staff mentioned the need for increased governance and system/organizational-level structures to support and encourage patient safety.While the CFIR framework proved to be a helpful tool in the Hall et al1 study for identifying individual determinants, many existing implementation science theories, models and frameworks fail to consider the characteristics of the overall health system within which a discrete implementation strategy ventolin coupon 2020 is embedded.

For example, the current Expert Recommendations for Implementing Change compilation of implementation strategies has generated a list of 73 discrete implementation strategies that can be adopted for patient safety.4 Yet, we question whether any discrete implementation strategy can—or should be—divorced from the overall system in which strategies operate. Our group recently proposed a modified version of the CFIR framework for ventolin coupon 2020 use in LMICs, which includes a new domain focused on ‘Characteristics of Systems’ to address this gap. Systems design features such as the degree of centralisation, availability ventolin coupon 2020 of supplies, public/private mix and renumeration mechanisms can strongly influence the degree to which policies and practice are taken up and need to be considered when studying implementation success. Although we strongly advocate for the inclusion of a systems domain in both high-income and low-income settings, LMICs face unique systems-level ventolin coupon 2020 contextual determinants, which warrant specific exploration in implementation science studies and local strategy adaptation to maximise implementation effectiveness.In contrast to many of the challenges facing high-income health systems, many health systems in LMICs are still focused on guaranteeing a minimum level of facilities, people and supplies, without which delivering high-quality care may be nearly impossible.

Facility readiness surveys across 10 LMICs have shown that only 1% of health centres have all the diagnostics tests and medicines required to perform basic patient services.5 A similar assessment in Mozambique found that essential medicines for primary care were stocked out 20% of the time and upwards of 50% for mental health medications.6 With very limited trained human resources for primary healthcare, nurses in Mozambique are often forced to deliver sub-standard care as they race to evaluate 60 or more patients in a day and patients wait hours in the heat to be seen.7 Similarly, throughout the asthma treatment ventolin, providers in India,8 Nigeria,9 Brazil and around the world10 have had the impossible job of trying to deliver safe and effective care when their health systems have failed to guarantee basic supplies like oxygen, resulting in numerous preventable deaths. Providers cannot be expected to focus on preventing unnecessary when they do not have latex gloves or ventolin coupon 2020 N95 masks to prevent themselves from contracting asthma treatment, Ebola or other infectious diseases. Similarly, we cannot expect ventolin coupon 2020 to achieve high-quality mental healthcare with only one psychiatrist per 2 million people and when the antipsychotic medication a patient was prescribed last month is now out of stock in an entire province.11 When health systems struggle to guarantee the basics needed to provide essential primary healthcare, providers cannot be expected to provide optimal care. Patient safety efforts must address underlying systems weaknesses and not only add burden—or worse—blame providers who are trying the best they can to provide quality care under circumstances designed by the systems in which they operate.The financing of patient safety programmes is also important to consider, as it reflects priorities, potential for scale, as well as possible interruptions or delays in implementation.

The Hall et al1 study identified the lack of financial support and organisational ventolin coupon 2020 incentives as a barrier to implementation effectiveness. LMICs continue to rely on significant contributions from donor assistance and are at greater risk of a mismatch in the priorities of funding agents compared with HICs.12 Donor-assisted funds also tend to be earmarked and time-bound, restricting health systems’ ability to flexibly use the funds and hampering a smooth transition from pilot stage to scaled ventolin coupon 2020 implementation. The modified CFIR that our group proposed includes these constructs, as well as the perceived ability for a programme to scale, particularly in LMICs where fragmented implementation efforts and pilots are rampant.It is also critical to consider the administrative design of health systems in ventolin coupon 2020 LMICs as a construct in the modified CFIR, as rolling out a patient safety programme in a highly centralised system versus one that is highly decentralised or even federated will influence implementation effectiveness. The Hall et al1 study found that providers were highly motivated on their own to focus on patient safety, but felt limited by their own decision-making autonomy, and lack of national or facility level policies and organisational support.

If patient safety efforts focus on isolated implementation ventolin coupon 2020 strategies that are divorced from an understanding of the system within which it will be integrated, the results will be poor.Patient safety efforts also require that adverse events are reliably monitored, reported and properly incentivised. According to WHO, ‘each year 134 million adverse events occur in hospitals in LMICs due to unsafe care, resulting in 2.6 million deaths,’13 yet those ventolin coupon 2020 figures only capture reported events. Providers who participated in the Hall et al1 study felt that patient safety would not progress in their Guatemalan setting without accurate patient outcome data, accountability, incentives aligned to outcomes and clear governing ventolin coupon 2020 policies. The strength of the health information system in LMICs, the culture around reporting and the way leaders use those data are therefore critical determinants that we argued should be included in a modified CFIR.

Taking a ventolin coupon 2020 systems lens would also highlight that data reporting is linked with financing. The variables collected to monitor effectiveness of health programmes in LMICs are often dictated by donor priorities leading to proprietary, siloed systems and inefficiencies for health workers,14 15 an issue which many donors are now trying to combat.16The field of implementation science can help us critically evaluate policies and norms that are considered ventolin coupon 2020 essential for ‘safe’ care in HICs, but which lack real-world evidence in LMICs. We need to recognise that HICs and LMICs may differ in their definition of ‘safe’ and the way to minimise errors and adverse events may differ across settings. For example, in Western countries, only physicians were initially allowed ventolin coupon 2020 to monitor HIV/AIDS treatment—it was considered ‘unsafe’ for anyone else to do so.

Yet, studies in LMICs have demonstrated that care can be effectively and safely administered by non-physician clinicians, such as nurses,17 an approach that may or may not ventolin coupon 2020 be accepted in HICs. We have seen the same pattern demonstrated with task-sharing in family planning,18 mental health,19 20 surgical equipment21 and other non-communicable diseases.22 Implementation science can continue to build our understanding ventolin coupon 2020 of what patient safety means in LMICs.How we achieve healthcare delivery with no adverse events in LMICs will differ across cultures and health systems contexts. Implementers, researchers, managers and policy-makers should consider building patient safety programmes that use implementation strategies targeting the numerous barriers that exist at the provider level and also at the level of the health system as a whole. Future implementation research efforts ventolin coupon 2020 to improve patient safety in LMICs should use frameworks, such as the expanded CFIR adapted for LMICs, to evaluate determinants of patient safety at all levels with a specific focus on the systems domain.

Without this ventolin coupon 2020 holistic focus, narrowly defined patient safety programmes will likely have limited effects to improve care for patients and their outcomes. Worse, these programmes could demoralise the limited number of trained health providers who are already overburdened as they work on the front lines to ensure ‘health for all’ across LMICs.Ethics statementsPatient consent for publicationNot required..

Concern about the link ventolin online usa between opioid prescribing and preventable adverse drug events has led to a series of initiatives to reduce opioid use, with opioids identified as one of three high-priority drug classes targeted to reduce patient harms in the United States (US)’s National Lasix 40mg price Action Plan for Adverse Drug Event Prevention.1 Variation in opioid prescribing practices by physicians has been observed, yet the reasons why these differences exist remain largely unknown. A better understanding of these differences may help to improve prescribing practice for ventolin online usa opioids. Sex and gender considerations in opioid prescribing practices have not been well studied and may help address this important knowledge gap.There is some evidence to suggest that sex and gender of physicians can affect prescribing practices for older adults.2 Patient gender has also been related to the experience of health conditions, health-seeking behaviours and medication use.3–5 Sex (biologic), a term describing the physical characteristics and biological attributes of males, females and intersex individuals, influences biological manifestations of medical conditions and ventolin online usa responses to drug therapy.5 In contrast, gender (sociocultural) refers to the socially constructed norms, behaviours and roles associated with being a man, woman or gender diverse person.6 While these concepts are related, they are often incorrectly interchanged. Considering sex and gender, and how they intersect with key identity factors such as age, culture, race and ethnicity, is an analytical approach7 that can be applied to systematically explore the influence of sex and gender on prescribing practices, revealing potentially important differences or trends that would otherwise remain obscured. Such an ventolin online usa approach provides the opportunity to inform prescribing practices in general, and pain management strategies in particular.

This will allow healthcare provision to be tailored to the unique needs of women, men and gender diverse people, including those in different age groups, acknowledging the evolution of health and medication needs across the life span.The study by Tamblyn and colleagues,8 published in this edition of the journal, underscores the utility and value of considering patient and provider sex along with other key identity factors such as age, race and culture in ventolin online usa all clinical research. This study also presents the opportunity to consider the wider role of patient and physician gender on prescribing, and why the inclusion of both ventolin online usa sex and gender may be essential to uncovering important variations in clinical practice, and to capturing the diversity of health needs and experiences in patient populations.In their study, Tamblyn8 set out to explore the impact of physician characteristics, including clinical competence, specialty and country of origin, on opioid prescribing for chronic non-cancer pain. The authors examined the opioid prescribing patterns of a cohort of international medical graduates in the US who completed their Clinical Skills Assessment requirement for the Educational Commission for Foreign Medical Graduates between 1998 and 2004. They were managing older patients covered by the Medicare part D drug insurance programme who were receiving care in an ambulatory setting for chronic non-cancer pain ventolin online usa in 2014 and 2015. Logistic and linear regression were used to explore the association of the prescribing physician’s characteristics with opioid prescribing and the doses prescribed.Outcomes measured in the study included opioid prescribing within 90 days of the clinical evaluation, whether the patient received a non-opioid intervention (eg, physiotherapy treatment or a non-steroidal anti-inflammatory drug) prior to the opioid prescription, and the opioid dose that was prescribed.8 The former outcome is particularly important, as opioids are not first-line ventolin online usa therapy for chronic pain.9Notably, even though it was not identified as one of the primary variables of interest, the Tamblyn study8 revealed the importance of routinely stratifying data by sex.

Further, the study underlines the importance of the collection and use of sex and age disaggregated data to better understand health status.10 More specifically, this study illustrates why it is important to consider provider sex in opioid prescribing, as well as gender-related sociocultural factors. First, there are important physician and ventolin online usa patient factors that relate to their sex and others that are gender related. Most (61%) of the prescribing physicians ventolin online usa in this study were men. This is in part because medicine itself is gendered.11 While the proportion of female physicians has grown substantially over the past few decades, they remain under-represented in most specialties, especially those that are higher paying, including some of those explored within the present study.11 12Women are more likely than men to experience ventolin online usa the chronic conditions that cause pain.13 The most common chronic non-cancer conditions being managed in this study were back and neck pain, migraine/headaches, rheumatoid or osteoarthritis, and neuropathic pain. Each of these conditions occur more commonly in older women than in older men.

For example, compared with men of the same age, women aged 65 years and older in Canada are 1.9 times more likely to have been diagnosed with rheumatoid arthritis and are 1.4 times more likely to have been diagnosed with osteoarthritis.14 Migraine headaches are experienced by almost twice as many women as men (7.4% of women compared with 3.4% of men)10 and neuropathic pain is similarly more prevalent among women.13 The predominance of older women experiencing these ventolin online usa chronic non-cancer pain conditions may be one reason why more than 66% of the older patients being managed for chronic pain in the Tamblyn study were women. Unless these differences are examined using sex and age disaggregated data, important patterns in the characteristics of the prescribers and the differences in pain experienced by older women and men will remain hidden in the data.A second salient finding of this study was that the odds of prescribing an opioid for non-cancer chronic conditions was 11% higher for male physicians (OR 1.11, 95% CI 1.03 to 1.19).8 Further, for every 10% increase in the clinical encounter score (used to measure clinical competence), the odds of prescribing an opioid decreased by 16% for female physicians (OR 0.84, 95% CI 0.75 to 0.94), but not for male physicians (OR 0.99, 95% CI ventolin online usa 0.92 to 1.07).8 These findings align with the existing literature that reports on correlations between physician gender-related sociocultural factors and prescribing behaviour, patient care and clinical outcomes. Female physicians have been shown to prescribe medications at lower doses than male physicians.15 The initiation of medications at low doses, using the ‘start low, go slow approach’, is a practice from geriatric medicine that minimises the risk of harm in older adults, as adverse events are often ventolin online usa dose related.16 This was illustrated in a study of the initiation of drug therapy for the management of dementia. Female prescribers were more likely than their male counterparts to initiate cholinesterase inhibitor therapy at a lower-than-recommended dose and for a shorter duration.15 Previous literature on the prescribing of opioids similarly finds that female physicians prescribe opioids more sparingly than their male counterparts.17 When it comes to patient–clinician interactions, female physicians have been characterised as providing more patient-centred and empathetic care.18 19 Compared with their male counterparts, they have been shown to spend more time with patients, engage in more communicative and active partnerships, and provide more psychosocial support and counselling.19 Female physicians have also been shown to adhere more closely to clinical guidelines20 and practise more evidence-based medicine.21 These differences in care delivery and treatment provision may be linked to the more conservative prescribing practices of female physicians demonstrated in the present study and elsewhere.15 17The differences in opioid prescribing practices between male and female physicians observed in the Tamblyn study are not isolated to pain management or opioid prescribing. Rather, this study contributes to recent evidence from different clinical settings and specialties, suggesting that patients cared for ventolin online usa by female physicians may have better clinical outcomes compared with their male colleagues.

For instance, when matched for patient, surgeon and hospital characteristics in a large population-based cohort study, patients of female surgeons identified as having 1 of 25 index procedures were found to experience lower risk of ventolin online usa short-term postoperative death than those cared for by male surgeons.22 Similarly, female internists treating older adults hospitalised with a medical condition were found to provide significantly better outcomes than their male colleagues in terms of 30-day mortality and readmission rates.23Data on physician and patient sex or gender-related sociocultural factors are often not reported on or described in research studies, making further synthesis of findings through meta-analysis difficult.24 Consistent reporting of this information can allow for aggregation of data and establishment of stronger correlations between prescriber sex and gender, and clinical outcomes.Finally, considering a sex-based and gender-based analytical approach that includes an intersection with cultural factors for both patients and prescribers may be key to a better understanding of opioid prescribing and pain management. Gender-based psychosocial patient factors have been related to behavioural responses and expressions of perceived pain, which often reflect societal norms.25 As a social construct, gender is understood to be context specific and thus varying cultural expectations for pain management, potentially linked to country of origin, may influence how a patient experiences pain and a physician’s likelihood of opioid prescribing for common pain problems. In the present study, Tamblyn found that while the prescriber’s country of origin did not influence the odds of opioid prescribing, US and Canadian physicians, both men and women, prescribed opioids at higher doses.8 ventolin online usa Therefore, the potential influence of cultural norms and gender in relation to clinical treatment and diagnosis of pain may also reveal disproportionate cross-national impacts that would otherwise remain hidden.This study has highlighted the importance of considering patient and prescriber sex, gender and other key identity factors including age and culture, in all research studies in order to better inform clinical care. Given the risks associated with potentially inappropriate opioid use in older adults, it is worth exploring further how the more cautious practices of female physicians could offer a learning opportunity to optimise health outcomes for all.Ethics statementsPatient consent for publicationNot required.Ensuring patient safety in low-and-middle-income countries (LMICs) requires tailored approaches that are appropriate to ventolin online usa the unique challenges faced by health systems in LMICs. To date, the evidence on how to effectively improve patient safety in LMICs is limited and although we can infer lessons from high-income countries (HICs), there are meaningful differences between HICs and LMICs that require careful ventolin online usa study.

The study by Hall et al1 in this issue of BMJ Quality &. Safety, which used implementation science methods to study what helped or hindered the roll-out of a patient safety programme in Guatemala, is therefore a welcome addition to this evidence base.1 Based on the findings from Hall et al,1 and the growing focus in the field of implementation science to ventolin online usa analyse mechanisms by which implementation strategies work (or do not work), we argue that patient safety endeavours globally should consider systems-level barriers and explicitly include tailored strategies to overcome them.2 LMICs have unique contextual factors that require interventions to be adapted, rather than directly transported from HICs.Mixed-methods implementation science studies like those employed in Hall et al’s paper1 are particularly helpful for increasing our understanding of how to translate systems thinking into real-world practice. Hall et al1 used the Consolidated Framework for Implementation Research (CFIR)3 to identify facilitators and barriers for implementation and inform the ventolin online usa optimisation of patient safety implementation strategies in Guatemala. They evaluated implementation determinants ventolin online usa acting across multiple levels, including the individual, inner organisational context, and external environment which led to several insights related to the overall health system and context. The authors found that clinical staff were intrinsically motivated to provide high-quality and safe care for their patients, but often faced systems barriers of insufficient time, resources and staff to implement known evidence-based protocols.

Some of these are similar as experienced in HICs, but others unique for the ventolin online usa context of LMICs. In addition, due to the hierarchical structure of the system, staff mentioned the need for increased governance and system/organizational-level structures to support and encourage patient safety.While the CFIR framework ventolin online usa proved to be a helpful tool in the Hall et al1 study for identifying individual determinants, many existing implementation science theories, models and frameworks fail to consider the characteristics of the overall health system within which a discrete implementation strategy is embedded. For example, the current Expert Recommendations for Implementing Change compilation of implementation strategies has generated a list of 73 discrete implementation strategies that can be adopted for patient safety.4 Yet, we question whether any discrete implementation strategy can—or should be—divorced from the overall system in which strategies operate. Our group recently proposed a ventolin online usa modified version of the CFIR framework for use in LMICs, which includes a new domain focused on ‘Characteristics of Systems’ to address this gap. Systems design features such as the degree of centralisation, availability of supplies, public/private mix and renumeration mechanisms can strongly influence the degree to which policies ventolin online usa and practice are taken up and need to be considered when studying implementation success.

Although we strongly advocate for the inclusion of a systems domain in both high-income and low-income settings, LMICs face unique systems-level contextual determinants, which warrant specific exploration in implementation science studies and local strategy adaptation to maximise implementation effectiveness.In contrast to many of the challenges facing high-income health ventolin online usa systems, many health systems in LMICs are still focused on guaranteeing a minimum level of facilities, people and supplies, without which delivering high-quality care may be nearly impossible. Facility readiness surveys across 10 LMICs have shown that only 1% of health centres have all the diagnostics tests and medicines required to perform basic patient services.5 A similar assessment in Mozambique found that essential medicines for primary care were stocked out 20% of the time and upwards of 50% for mental health medications.6 With very limited trained human resources for primary healthcare, nurses in Mozambique are often forced to deliver sub-standard care as they race to evaluate 60 or more patients in a day and patients wait hours in the heat to be seen.7 Similarly, throughout the asthma treatment ventolin, providers in India,8 Nigeria,9 Brazil and around the world10 have had the impossible job of trying to deliver safe and effective care when their health systems have failed to guarantee basic supplies like oxygen, resulting in numerous preventable deaths. Providers cannot be expected ventolin online usa to focus on preventing unnecessary when they do not have latex gloves or N95 masks to prevent themselves from contracting asthma treatment, Ebola or other infectious diseases. Similarly, we cannot expect to achieve high-quality mental healthcare with only one psychiatrist per 2 million people and when the antipsychotic medication a patient was prescribed last month is now out of stock ventolin online usa in an entire province.11 When health systems struggle to guarantee the basics needed to provide essential primary healthcare, providers cannot be expected to provide optimal care. Patient safety efforts must address underlying systems weaknesses and not only add burden—or worse—blame providers who are trying the best they can to provide quality care under circumstances designed by the systems in which they operate.The financing of patient safety programmes is also important to consider, as it reflects priorities, potential for scale, as well as possible interruptions or delays in implementation.

The Hall et al1 study identified the lack ventolin online usa of financial support and organisational incentives as a barrier to implementation effectiveness. LMICs continue to rely on significant contributions from donor assistance and are at greater risk of a mismatch in the priorities of funding ventolin online usa agents compared with HICs.12 Donor-assisted funds also tend to be earmarked and time-bound, restricting health systems’ ability to flexibly use the funds and hampering a smooth transition from pilot stage to scaled implementation. The modified CFIR that our group proposed includes these constructs, as well as the perceived ability for a programme to scale, particularly in LMICs where fragmented implementation efforts and pilots are rampant.It is also critical to consider the administrative design of health systems in LMICs as a construct in the modified CFIR, as rolling out a patient safety programme in a highly centralised system versus one that is highly decentralised or even federated will ventolin online usa influence implementation effectiveness. The Hall et al1 study found that providers were highly motivated on their own to focus on patient safety, but felt limited by their own decision-making autonomy, and lack of national or facility level policies and organisational support. If patient safety efforts focus on isolated implementation strategies that are divorced from an understanding of the system ventolin online usa within which it will be integrated, the results will be poor.Patient safety efforts also require that adverse events are reliably monitored, reported and properly incentivised.

According to WHO, ‘each year 134 million adverse ventolin online usa events occur in hospitals in LMICs due to unsafe care, resulting in 2.6 million deaths,’13 yet those figures only capture reported events. Providers who participated in the Hall et al1 study felt that patient safety would not progress in their Guatemalan setting without accurate patient ventolin online usa outcome data, accountability, incentives aligned to outcomes and clear governing policies. The strength of the health information system in LMICs, the culture around reporting and the way leaders use those data are therefore critical determinants that we argued should be included in a modified CFIR. Taking a systems lens would also ventolin online usa highlight that data reporting is linked with financing. The variables collected to monitor effectiveness of health programmes in LMICs are often dictated by donor priorities leading to proprietary, siloed systems and inefficiencies for health workers,14 15 an issue which many donors are now trying to combat.16The field of implementation science can help us critically evaluate policies and norms that are considered essential for ‘safe’ care in HICs, but which ventolin online usa lack real-world evidence in LMICs.

We need to recognise that HICs and LMICs may differ in their definition of ‘safe’ and the way to minimise errors and adverse events may differ across settings. For example, in Western countries, only physicians were initially allowed to monitor HIV/AIDS treatment—it was considered ‘unsafe’ for anyone else to do so ventolin online usa. Yet, studies in LMICs have demonstrated that care can be effectively and safely administered ventolin online usa by non-physician clinicians, such as nurses,17 an approach that may or may not be accepted in HICs. We have seen the same pattern demonstrated with task-sharing in family planning,18 mental health,19 20 surgical equipment21 and other non-communicable diseases.22 Implementation science can continue to build our understanding of what patient safety means ventolin online usa in LMICs.How we achieve healthcare delivery with no adverse events in LMICs will differ across cultures and health systems contexts. Implementers, researchers, managers and policy-makers should consider building patient safety programmes that use implementation strategies targeting the numerous barriers that exist at the provider level and also at the level of the health system as a whole.

Future implementation research efforts to improve patient safety in LMICs should use frameworks, such as the expanded ventolin online usa CFIR adapted for LMICs, to evaluate determinants of patient safety at all levels with a specific focus on the systems domain. Without this ventolin online usa holistic focus, narrowly defined patient safety programmes will likely have limited effects to improve care for patients and their outcomes. Worse, these programmes could demoralise the limited number of trained health providers who are already overburdened as they work on the front lines to ensure ‘health for all’ across LMICs.Ethics statementsPatient consent for publicationNot required..

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