Digital imaging technique has been a topic that is widely discussed and has much importance in the world of radiography.  Technique plays many roles in radiography such as image quality, diagnostic quality, and the most important; patient dose.  Technique is the number one factor that contributes to patient dose and is therefore of the utmost importance.  Throughout the rest of the paper, a brief history of digital imaging as it relates to technique and patient dose will be given as well as; different exposure systems, variance in recommended techniques from vendors, and collimation creep.

To truly understand how digital imaging technique is related to patient dose, a brief history must be given first.  After the discovery of x-rays, the first system to capture the image was film-screen radiography.  With film-screen radiography, things like techniques, patient positioning, imaging processing, and others needed to be precise in order to receive an optimal image.  If one, or many, of these things were off it could result in a repeat image that would cause more dose to the patient.  In 1980, digital imaging was introduced and quickly changed the world of radiography (Alexander, 2016, p. 55).  While techniques and patient positioning still needed to be precise, there was a little more wiggle room to play with.  Now there was no need for a repeat image if the chemicals to process the image were off, because chemicals were no longer used.  If an image with film-screen radiography was too over or under exposed it would be cause for a repeat.  Now images that are under or over exposed are so subtle that it’s hard to see if it really is, and there are also window and leveling options that give even more room for error.  It has been said that it is usually better to overexpose a patient than to underexpose, because there is more useful information in the image that is overexposed, and because there are window and leveling options to see more of what is on the image.  But with that new philosophy came a common problem of dose creep, where if a little is good a lot is better.  Radiologic technologists seem to get in the habit of erring on the side of overexposed and then continually increase the technique, so the patient receives more dose.  As Low As Reasonably Achievable (ALARA) is easy to ignore when a patient is overexposed and it is hardly noticeable on the image.  With that problem came the solution of an exposure index (EI) number that shows how much dose the imaging receptor (IR) has received.  The dose that the IR receives is comparable to how much a patient receives and is a good indicator for that.

Most systems have an EI range that is used to help determine how over or underexposed the image is and if the image is within acceptable range.  For example, a system using a range of 1300-1700 would have the ideal EI be close to 1500, signaling that it is an optimal image.  If it is above or below that range it could be cause for a repeat or as a signal that the technique needs to be changed for the next images that are taken.  These EI numbers help radiologic technologists know appropriate techniques for different sizes, age ranges, and body types.  There are also new systems being developed such as the DigiBit, that can accurately adjust exposure factors such as milliampere seconds (mAs), kilovoltage peak (kVp), and source-to-image distance (SID) for patients of differing size.  The DigiBit systems is specifically designed for when automatic exposure control (AEC) is not available.

The AEC device controls x-ray exposure during radiography.  It controls the amount of radiation and the time it takes to reach the detector by adjusting the milliampere seconds (mAs) at the x-ray tube and by terminating the exposure once a preset amount of radiation has been detected by the AEC chamber(s) (Ching, Robinson, & McEntee, 2015, p. 614-615).

Other factors such as kVp and SID are controlled by the radiologic technologist and may vary.  AEC exposure will also vary depending on patient size, if the patient is correctly positioned over the correct cells, and if the correct cells are chosen.

According to a study by Gibson and Davidson, the number of optimal exposure factors selected decreased over 2 years in intensive and critical care units and emergency departments where an AEC was not available.  This decrease occurred because radiographers overestimated the exposure factor adjustment required for changes in patient size.  According to a study by Mothiram et al, between 77% and 82% of mobile chest radiographs were overexposed compared to less than 2% of radiographs taken in a department where an AEC was available.  To avoid systematic overestimation of exposure when an AEC is unavailable, radiographers need a system to adjust exposure (Ching, Robinson, & McEntee, 2015, p. 615).

As was shown in the study, the common problem of dose creep is even more present without the help of things such as an AEC. That is why, making new systems to adjust exposure is just one way that can help reduce patient dose and over exposed images.

Other factors to consider with technique and EI are the vendor’s recommended techniques depending on body part and size.  A study was done to determine the amount of mAs acceptable for an anteroposterior (AP) pelvis and lumbar spine using a phantom model of each of them.  The AP pelvis was imaged using a fixed kVp of 81 and variable mAs of 6.3, 8, 12.5, 16, 20, 25, 32, 40, and 50.  The suggested mAs for the AP pelvis according to the manufacturers was 25.  For the AP lumbar spine, it was imaged at a fixed kVp of 81 and variable mAs of 16, 20, 25, 32, 40, 50, 63, 80, and 100.  The suggested mAs according to the manufacturers was 50.  Four images were acquired using the same technique and each image was reviewed by a selected group of radiologists.  After reviewing the images, it was found that the lowest mAs that could be used without compromising image quality was 16 mAs for the AP pelvis and 32 mAs for the AP lumbar spine (Seeram, Davidson, Bushong, & Swan, 2016, p. 380-381).  It is obvious to see that the difference between the recommended amounts and the amounts that could be used have a large difference. This difference in mAs saves patient dose while still receiving an optimal image.  When performing an exam, it is important to keep this in mind so appropriate techniques are chosen for patients and patient dose is kept to a minimum.

Another important thing to keep in mind is proper collimation.  With the use of digital radiography came another use of the cropping feature that is offered.  This cropping feature allows radiologic technologists to cut down on their image after it is has been taken, giving the appearance of a collimated image.  Some radiologic technologists have reported that they use the cropping feature to give their image a “neat” and “tidy” appearance, whereas others use it as a correction to an image that is not collimated enough (Casey, 2019, para. 9).  This creates a problem because radiologic technologists that leave the collimation open and then correct after, are giving their patients more dose and creating what is called ‘collimation creep’.  ‘Collimation creep’ happens when radiologic technologists are trying to create an ideal image by leaving the collimation open when exposing the patient, and then cropping the image after it has been taken to make it look more pleasing to the eye.  While some radiologic technologists report using the cropping feature, others think that it is a bad practice.  One reported saying ‘“If you do your radiography well, you know your positioning, you do your collimation right — why should you do the cropping?”’ (Casey, 2019, para. 11).  With the option of cropping the image after or correctly collimating in the first place, it is always important to remember to protect your patient by using ALARA and keeping dose creep and collimation creep to a minimum.

As reviewed, technique plays a critical role in patient dose as do many other things such as ideal EI’s, new exposure systems, and collimation.  While it is the radiation from the x-rays that gives patients their dose, it is the radiologic technologist that sets the technique and is therefore their responsibility to determine how much is received. Throughout all of these things, it is ultimately up to the radiologic technologist to properly use the systems that are available, set correct techniques, and protect their patients.  Radiologic technologists must always remember the importance of their duties to their patients and do all that they can to keep them safe.

Reference

• Alexander, S. (2016). Image Acquisition and Quality in Digital Radiography.
  
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• Casey, B. (2019, June 25).
  
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• Ching, W., Robsinson, J., & McEntee, M. (2015). DigiBit: A System for Adjusting Radiographic Exposure Factors in the Digital Era.
  
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• Seeram, E., Davidson, R., Bushong, S., &Swan, H. (2016). Optimizing the Exposure Indicator as a Dose Management Strategy in Computed Radiography.
  
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Congenital Heart Defects (CHD) and Angiotensin Converting Enzyme (ACE) Inhibitors

Congenital Heart Defects (CHD) are abnormalities that occur during the development of a fetus’s heart during gestation (Children’s Hospital of Philadelphia, 2019a; Ni, Lv, Ding & Yao, 2019).  Because of the advances in medical technology, individuals with CHD are surviving into adulthood at larger rates (Centers for Disease Control and Prevention, 2018a; Lantin-Hermoso et al., 2017).  The Centers for Disease Control and Prevention (2018a) reported that as of the 2010 census, about 2 million infants, children, adolescents, and adults in the United States were living with CHD.  Of those 2 million, about 1 million of those were children and 1.4 million were adults; moreover, as these children age, they need more coordinated and specialized medical care (Centers for Disease Control and Prevention, 2018a; Lantin-Hermoso et al., 2017).  After life-saving surgical interventions are utilized, medications like ACE inhibitors may be needed (Feinstein et al., 2012; Wilson et al., 2016; Yimgang, Sorkin, Evans, Abraham, & Rosenthal, 2018).

Congenital Heart Defects (CHD)

Congenital Heart Defects are the leading birth defect, affecting about 1 in 120 babies born every year in the United States (Children’s Hospital of Philadelphia, 2019a; Lantin-Hermoso et al., 2017).  Although CHD is prevalent, the causes are relatively unknown. According the Children’s Hospital of Philadelphia (2019a), there are certain steps that are taken during gestation that cause the heart to form correctly.  Unfortunately, in someone with CHD, there is some misstep that causes an abnormality of the heart.  Research has tried to ascertain the why, with limited success.  Sometimes, links can be drawn between CHD and genetics or the utilization of certain medications while pregnant, but most of the time there is no distinguishable cause (Centers for Disease Control and Prevention, 2018b; Children’s Hospital of Philadelphia, 2019a).

These abnormalities are usually detected by a Fetal Echocardiogram that is performed between 18-22 weeks’ gestation (Lantin-Hermoso et al., 2017).  The survival rates of individuals with CHD improve when these abnormalities are found earlier, allowing for definitive plans and steps to be created for treatment (Centers for Disease Control and Prevention, 2018b; Pace et al., 2018).  That being said, some defects evade basic screening measures or develop later in gestational age (Lantin-Hermoso et al., 2017); moreover, understanding the severity index of Congenital Heart Defects is integral for understanding utilized treatments.

CHD vary in severity from mild to severe (Centers for Disease Control and Prevention, 2018b; Pace et al., 2018).  The Children’s Hospital of Philadelphia (2019a) outline the different abnormalities into three different areas: 1. Problems that cause too much blood to pass through the lungs (Patent Ductus Arteriosus (PDA), Atrial Septal Defect (ASD), Ventricular Septal Defect (VSD), Atrioventricular Canal (AVC or AV Canal)), 2. Problems that cause too little blood to pass through the lungs (Tricuspid Atresia, Pulmonary Atresia, Transposition of the Great Arteries (TGA), Tetralogy of Fallot (TOF), Double Outlet Right Ventricle (DORV), and Truncus Arteriosus) and 3. Problems that cause too little blood to travel to the body (Coarctation of the Aorta (CoA), Aortic Stenosis (AS) and Hypoplastic Left Heart Syndrome (HLHS)).  These qualitative categorizations allow for the person to understand the severity of each malformation based on its end result and the necessary treatment.

Treatment changes based on the severity of the defect.  Simple CHD may be able to be managed with medication and the child may even outgrow the defect (Children’s Hospital of Philadelphia, 2019a).  On the other end of the spectrum, more complex CHD may require surgery and ongoing care throughout the life span (Centers for Disease Control and Prevention, 2018b; Children’s Hospital of Philadelphia, 2019a; Pace et al., 2018).  These surgeries are utilized to extend the first year of life and are needed, but also can cause residual effects on the heart and other body systems; moreover, continued cardiac care will be needed through coordination between both a pediatric cardiologist and the child’s primary care physician (Pace et al., 2018).  One of the most severe CHD is Hypoplastic Left Heart Syndrome (HLHS).  HLHS requires rapid surgical intervention after birth and continued care throughout the lifespan (Yimgang, et al., 2018).

Hypoplastic Left Heart Syndrome (HLHS)

Focusing on one type of severe heart defect can be helpful in understanding treatment and mechanisms of action for drugs.  Hypoplastic Left Heart Syndrome is a congenital heart defect where the left side of the heart is underdeveloped (Children’s Hospital of Philadelphia, 2019a; Children’s Hospital of Philadelphia, 2019b).  This causes issues with systemic blood flow, since the responsibility of the left side of the heart is to pump oxygen-rich blood to the rest of the body (Children’s Hospital of Philadelphia, 2019b; Yimgang et al., 2018).  As compared to 25 years ago, there has been many advancements in the identification and treatment of HLHS (Feinstein et al., 2012).

Similar to other congenital heart defects, HLHS is most likely diagnosed with a Fetal Echocardiogram (Children’s Hospital of Philadelphia, 2019b).  It is integral that that diagnosis is made prior to birth so that surgical plans can be made because, with the absence of any surgical interventions, HLHS is lethal to the neonate (Children’s Hospital of Philadelphia, 2019b; Yimgang et al., 2018).  With the influx of modern technology and research on HLHS, a 3-stage model of surgical interventions is the most widely accepted route for palliation and care (Children’s Hospital of Philadelphia, 2019b; Feinstein et al., 2012; Yimgang et al., 2018).  These procedures are called the Norwood Procedure, the Glenn (or Hemi-Fontan) Procedure and the Fontan Procedure (Children’s Hospital of Philadelphia, 2019b; Feinstein et al., 2012).  The goal of all of these procedures, called “Staged Reconstruction” is to re-route the right side of the heart to perform the function of the left: pumping oxygen-rich blood to the body (Children’s Hospital of Philadelphia, 2019b).  Therefore, the Norwood procedure, performed at about one-week old, starts the process by creating a viable source of oxygen-rich blood to the body (Yimgang et al., 2018).  The Glenn or Hemi-Fontan procedure, performed between 4-6 months old, reduces stress on the heart and improve circulatory system efficiency (Yimgang et al., 2018).  The final step is the Fontan Procedure, which is performed between 3 years and 5 years old, and results in the child having “Fontan Circulation,” where the blood from the lower extremities goes directly to the lungs where it picks up oxygen (Bingler, 2018; Children’s Hospital of Philadelphia, 2019b; Yimgang et al., 2018).  This results in less strain on the heart (Bingler, 2018).  Although these procedures are a life-saving necessity, there are some effects on the heart as well as other organ systems; moreover, continued cardiac care and the utilization of medications, like ACE inhibitors, may be needed (Feinstein et al., 2012; Wilson et al., 2016; Yimgang et al., 2018).

Angiotensin Converting Enzyme (ACE) Inhibitors

Studies have documented the use of Angiotensin Converting Enzyme (ACE) Inhibitors since the late 1980s and early 1990s (Casas, Álvarez & Lucero, 2015; Frishman, 1992; McMurray et al., 2014; SOLVD Investigators, 1991).  ACE inhibitors can be prescribed for a variety of issues including diabetic nephropathy, heart failure, hypertension, nondiabetic kidney disease, left ventricular dysfunction and myocardial infarction (Bowling et al., 2011; British Heart Foundation, 2018; DynaMed, 2018; Kechagia, Kalantzi & Dokoumetzidis, 2015; Ku et al., 2017; Mayo Clinic Staff, 2019; Stage et al., 2017; Thabet, Walsh & Breitkreutz, 2018).

Types

There are also a variety of different types of ACE inhibitors (Casas et al., 2015; DynaMed, 2018; Mayo Clinic Staff, 2019).  The first ACE inhibitor to be discovered was captopril (Casas et al., 2015).  From there a variety of different ACE Inhibitors were synthesized such as benazepril, enalapril, fosinopril, lisinopril, moexipril, perindopril, quinapril, ramipril and trandolapril (Frishman, 1992; Mayo Clinic Staff, 2019).  These ACE inhibitors are taken by mouth, with the exception of enalapril, which also has the option of being  given intravenously (Herman & Bashir, 2019).  Depending on the type of ACE inhibitor and the route of administration, the dosing may change, but the overall mechanism of action within the body stays constant

Mechanisms of Action

The exact mechanism of action of ACE inhibitors has evaded researchers throughout the years (Herman & Bashir, 2019; Mayo Clinic Staff, 2019).  What is known is that ACE inhibitors work within the renin-angiotensin-aldosterone system (RAAS) within the body (Herman & Bashir, 2019; Mayo Clinic Staff, 2019).  This system resides within the endocrine system and helps to regulate long-term blood pressure and extracellular volume within the body (Mechanisms in Medicine, 2012).  There are many different facets within this system that require further description in order to understand the entirety of the known mechanisms of action of ACE inhibitors.

The key components include Angiotensinogen, renin, Angiotensin I, Angiotensin Converting Enzyme (ACE) and Angiotensin II.  Angiotensinogen is released in response to low-blood pressure and interacts with renin, which is secreted by the kidneys (Mechanisms of Medicine, 2012).  This interaction causes the production of Angiotensin I (Mechanisms of Medicine, 2012).  Angiotensin I is a relatively inactive enzyme in the blood stream, until it interacts with the Angiotensin Converting Enzyme (ACE) (British Heart Foundation, 2018; Herman & Bashir, 2019; Mechanisms of Medicine, 2012).  ACE can be found in a multitude of areas within the body including the pulmonary circulation (lungs) and the vascular endothelium of many tissues like the kidney, adrenal glands, brain and heart (Mechanisms of Medicine, 2012).  ACE converts Angiotensin I into the very active enzyme Angiotensin II (British Heart Foundation, 2018; Casas et al., 2015; Herman & Bashir, 2019; Kechagia et al., 2015; Mayo Clinic Staff, 2019; Mechanisms of Medicine, 2012).  Angiotensin II causes a multitude of effects within the body.  Angiotensin II is a vasoconstrictor, meaning it narrows the blood vessels (British Heart Foundation, 2018; Frishman, 1992; Herman & Bashir, 2019).  It also is responsible for inhibiting the reuptake of norepinephrine, stimulating the release of catecholamines from the adrenal medulla, reducing the urinary excretion of sodium and water, stimulating the synthesis and release of aldosterone (which results in sodium retention) and stimulating hypertrophy (enlargement) of both vascular and smooth muscle cells and cardiac myocytes (Herman & Bashir, 2019).  Between its vasoconstrictive and sodium retention effects, Angiotensin II raises the blood pressure of the individual (Mechanisms of Medicine, 2012).  The creation of ACE inhibitors allow for pharmacological control of this system because they interrupt this process (British Heart Foundation, 2018; Ferreira, 2000; Frishman, 1992; Herman & Bashir, 2019; Mayo Clinic Staff, 2019). Analyzing a specific ACE inhibitor, enalapril, can provide further details about the mechanism of action of ACE inhibitors.

Enalapril.

Enalapril is an ACE inhibitor that is commonly used because of its effectiveness in in treating hypertension and reducing hospitalizations of individuals with congestive heart failure (Bowling et al., 2011).  Enalapril also has been preferred over other ACE inhibitors because of the research supporting its use in pediatric settings and the capability for once-daily dosing, which improves patient compliance (Casas et al., 2015).

Enalapril works by interrupting the Angiotensin Converting Enzyme (ACE) (British Heart Foundation, 2018; Casas et al., 2015; Frishman, 1992; Herman & Bashir, 2019).  When this enzyme is inhibited, angiotensin I cannot be transformed into angiotensin II (British Heart Foundation, 2018; Herman & Bashir, 2019).  As a result, less angiotensin II is available in the body, which leads to a relaxation of the blood vessels (British Heart Foundation, 2018).  Since angiotensin II also stimulates the synthesis and release of aldosterone the decrease of angiotensin II means that more sodium and water are filtered through the kidneys, which increases their excretion through the urine and decreases the amount of fluids in a person’s body (British Heart Foundation, 2018; DynaMed, 2018).  The combination of a relaxation of the blood vessels and less fluid retention leads to a decrease in blood pressure (British Heart Foundation, 2018; DynaMed, 2018).  When an individual’s blood pressure is low, there is less strain on the heart because there is less volume of blood that the heart needs to pump (British Heart Foundation, 2018).

Enalapril can be taken by mouth or administered intravenously (Herman & Bashir, 2019).  All ACE inhibitors share a number of pharmacokinetic properties and enalapril is no different.  For example, these medications are rapidly absorbed from the gastrointestinal traction, show a wide distribution in most tissues in the body and are excreted through the kidneys (Frishman, 1992).  For an oral dose of enalapril, absorption is about 60-70% and the presence of food does not complicate the absorption (DynaMed, 2018; Frishman, 1992; Moffett, DiSanto, Espinosa, Hou & Colabuono, 2014).  Once enalapril is absorbed, it is metabolized into its active form enalaprilat (Frishman, 1992).  The conversion of enalapril into enalaprilat occurs in the liver via carboxylesterase 1 (CES1) (Frishman, 1992; Stage et al., 2017).  It is in this active form of enalaprilat that the mechanism of inhibiting ACE occurs.  Once the enalaprilat has completed its job, it is excreted through the kidneys (Frishman, 1992).  Understanding the mechanism of action is important when doctors are contemplating the varying doses that can be given.

Dosing.

Dosing requires intimate knowledge of the mechanisms of action and the pharmacokinetics of enalapril and the other ACE inhibitors.  When discussing appropriate dosages, one area to consider is the root of administration of the drug.  For example, enalapril can be offered by mouth as a tablet (either a solid capsule or an orodispersible minitablet (ODMT)), liquid formula (Epaned) or intravenously (Faisal, Cawello, Burckhardt & Laer, 2019; Herman & Bashir, 2019; Moffett et al., 2014; Thabet et al., 2018).  The absorption of these modes of administration vary and needs to be taken into account when prescribing.  For example, Faisal and colleagues (2019) assessed the pharmacokinetic properties of the ODMT form of enalapril versus the capsules.  These researchers found that the OMDT appeared in systemic circulation four minutes faster than the capsules, possibly because of their faster disintegration and dissolution upon entrance to the gastrointestinal tract (Faisal et al., 2019).  The route of administration is not the only area which effects the pharmacokinetics of enalapril.  Another area to be considered is the research about pediatric versus adult dosages.

The pharmacokinetics and pharmacodynamics are different in children than in adults; moreover, dosing regimens for ACE inhibitors are different for children (Faisal et al., 2019). Although ACE inhibitors have the largest amount of evidence to support their use in a pediatric population, dosages for children are also renegotiated based on body weight (Casas et al., 2015).  Therefore, size of the child must be taken into account when making decisions on the use of enalapril and other ACE inhibitors.  ACE inhibitors like enalapril are a treatment regimen that can be utilized in response to medical complications with CHD, like HLHS.

HLHS and ACE Inhibitors

HLHS is one of the most severe congenital heart anomalies and needs lifelong cardiac care (Children’s Hospital of Philadelphia, 2019b).  The surgical interventions that are utilized as a treatment for HLHS are necessary, but they also cause different pressure and circulation issues and different hemodynamics (Heusch, Kahl, Hensel & Calaminus, 2017).  Moreover, ACE inhibitors may be utilized as a treatment to release pressure on the heart (Wilson et al., 2016; Yimgang et al., 2018).

The use of ACE inhibitors for individuals with HLHS is not wholly accepted and seems to be decided on a case-by-case basis (Wilson et al., 2016).  There has been documentation of the use of ACE inhibitors after the Norwood Procedure (Yimgang et al., 2018).  Since the Norwood Procedure is utilized for increased blood flow, the prescription of ACE inhibitors during this period helps to reduce the cardiac afterload, or the tension that the heart must work against in order to pump blood to the body, increasing cardiac output (Yimgang et al., 2018).  There has also been evidence to support their use in individuals with Fontan circulation (Feinstein et al., 2012; Wilson et al., 2016).  Since individuals with Fontan circulation are in a state of heart failure and ACE inhibitors are used to treat heart failure in individuals with two ventricles, their use is hypothesized for individuals with a single ventricle or Fontan circulation (Wilson et al., 2016).  As seen in their use between the Norwood and Glenn procedures, ACE inhibitors may decrease the individual’s cardiac afterload, allowing for better contraction of the heart for those with Fontan Circulation (Feinstein et al., 2012).  As stated previously, Fontan circulation has effects on other organ systems; moreover, the use of ACE inhibitors with HLHS has shown better neurodevelopmental outcomes, improved endothelial function and reduced renal injury (Feinstein et al., 2012).  There is still more research to be done in order to help the increase of individuals that are living with a CHD, particularly those with Fontan circulation (Feinstein et al., 2012; Wilson et al., 2016).

Conclusion

The survival rate of individuals with CHD is growing (Centers for Disease Control and Prevention, 2018a; Lantin-Hermoso et al., 2017).  Therefore, these individuals need continued cardiac care throughout the lifespan (Children’s Hospital of Philadelphia, 2019a).  The surgical interventions utilized for individuals with CHD cause varying effects on the heart and other organ systems; moreover, medications, like ACE inhibitors, may be utilized to assist in long-term care (Feinstein et al., 2012; Heusch et al., 2017; Wilson et al., 2016; Yimgang et al., 2018).  Since ACE inhibitors are utilized in the treatment of heart failure, it can be hypothesized that their use would show benefits in treating individuals with CHD, specifically those with HLHS (Feinstein et al., 2012; Wilson et al., 2016; Yimgang et al., 2018)

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ISSUE

Despite comparatively high levels of spending on healthcare, the health of the U.S. population continues to lag that of its counterparts (Alper, 2014). In this paper, we evaluate the current landscape of funding for public health initiatives, the lack of uniformity of financial accounting standards for public health spending, and our proposal to address the existing funding structures of the public health system. Our multi-faceted approach includes:

• Federal, state and local government funding through a tax on medical services, with an emphasis on developing predictable funding based on funding cost-effective, evidence-based interventions.
• Investment by the healthcare industry through accelerated payment reform that incentivizes initiatives in population health management.
• Increased contributions to NGOs working in the public health arena through provision of expanded tax credits for individual and corporate donations to these organizations.

ASSESSMENT


The U.S. faces an urgent need for fundamental structural reform of its public health funding. Current public health funding streams are highly erratic and generally inadequate, in part due to a “fixation” upon clinical spending (Teutsch et al., 2012). Therefore, while per capita spending on healthcare in the U.S. exceeds that of other wealthy countries, the U.S. continues to experience comparatively poor health outcomes (Teutsch, 2012).

LITERATURE REVIEW

Challenges in


Current Funding Methods

The federal government provides a significant portion of both state and local health public health spending. Federal agencies subsequently influence provision of public health services at the state and local levels (Ogden, 2012). In essence, by being a primary funder and policy driver, the federal government often substantially influences the priorities and policies used to implement health services at all levels (Ogden, 2012). Consequently, state and local health agencies are often confined to the directives set forth by the federal government, which can result in various distortions in expenditure and service provision. One example is the federal government’s sudden shift of attention and funding allocation at moments of acute concern regarding infectious disease crises, such as with SARS and the more recent Ebola outbreaks (Weintraub, 2014).

Aside from federal influence, there is considerable variation in sources and the amount of public health spending at the state and local level (Ogden, Sellars, et al., 2012). Additionally, a reliance on inconsistent formula-based funding allocations often results in ineffective and inequitable public health spending. Funding formulas are often hampered by low-quality data, inconsistent calculation methods, and the complex political realities that ultimately shape allocations decisions (Honore, 2007).

Challenges in Current Accounting Methods

In a recent IOM Roundtable, David Kindig notes the need for a reallocation of spending away from ineffective interventions, and the parallel need for new strategic alignment of the interests of multiple sectors to find what he informally calls the “sweet spot” (Alper, 2014). Kindig notes that one of the main challenges is deciding how to spend the money (Alper, 2014).

A significant barrier to deciding where to spend public health funding has been the historical lack of standardized financial accounting methods utilized in the public health sector. Honore et al. point out the relatively lack of financial transparency in public health and call for reforms including a uniform chart of accounts, uniform classification of expenses and revenues, creation of a professional public health financial managers association, and standardized electronic data reporting (Honore et al., 2007). Any funding organization making an investment in public health will increasingly require this greater transparency (Honore et al., 2007). Ogden et al. also calls for development of standardized accounting methods to facilitate comparisons across organizations (Ogden, Sellars, et al, 2012).

Additionally, evidenced-based public health (EBPH), a practice currently encouraged of public health organizations, insists on cost-effective interventions (Brownson, 2009). One component of EBPH is economic evaluation. Until we have robust and uniform financial accounting standards, it will be difficult to evaluate the success of various healthcare initiatives. Even in the arena of government funding, there is an increasing demand for close financial accounting of funds allocated to public health departments (Levi, 2007). Such demands include a demonstration of how monies are being spent to support the core functions of public health, these being assessment, policy development, and assurance (Turnock, 2012).

RECOMMENDATIONS

To overcome the current problems with fragmented and declining revenue streams for public health, we propose an alternative approach specifically intended as a sustainable funding model sufficient to support core public health functions at appropriate levels.

1. Sustained and coordinated government funding

.

As noted above, current government funding is highly fragmented and dependent on a mix of local resources combined with federal funds that are often restricted to specific programming (Ogden, 2012). Like Kindig, we call for a move from “grants and short term appropriations” to a more coordinated effort across government departments based on a comprehensive, long range focused public health effort (Alper 2014). Diminishing government revenue can be addressed through a small tax on clinical healthcare services (IOM, 2012). If a sustained, dedicated revenue stream in the form of a clinical medical services tax can be achieved, we believe that the nation’s overall public health infrastructure can substantially improve population-based outcomes across the U.S.

2. Increased population health spending by the healthcare industry.

Private, for-profit healthcare providers can play a major role in “transforming” their communities through a combination of health interventions (Alper, 2014). Gunderson notes it will require a shift from “reactive” spending to “proactive” spending (Alper, 2014). The current shift in basis for payment for medical care from episodic care to population “pay for performance” mechanisms has the potential to create the environment where healthcare systems see such community-based investments as financially attractive, perhaps even obligatory for their financial survival. However, the transition to “pay for performance” mechanisms presents several challenges. Slow pace of change, lack of experience by healthcare organizations in public health management, and threats to vital revenue for “critical access” organizations in resource poor communities all pose significant hurdles (Alper, 2014). A shift from medicalized spending to public health investment is critical, and progressive healthcare organizations can play a vital role in creating this awareness and facilitating and modeling transition steps.

3. Enhanced spending by NGOs in the public health arena.

The IOM roundtable notes the success of community development strategies in improving health (Alper, 2014). Many of these efforts can be best carried out by NGOs or other organizations that already maintain high levels of financial transparency. NGOs also offer a nimbleness that is often lacking in the government bureaucracy due to their governance structures and financial transparency. Additionally, as James Hester has noted, such organizations can play the role of “integrator” (Alper, 2014). As such, these organizations can help to manage and coordinate revenue streams, capital requirements, community resources, and local health needs. However, in order to have adequate funding, specifically for those non-profit entities that depend largely on private donations, NGOs must have a reliable donor pool. In order to encourage donations to NGOs, we recommend passage of legislation authorizing enhanced tax credits for individuals and entities contributing to these entities. Through such a mechanism, NGOs will have the resources to take a leadership role alongside public health departments in developing, managing, and evaluating community-based public health interventions.

CONCLUSION

Despite rising levels of healthcare spending, the U.S. continues to fall behind in most measures of health (Teustsch, 2012). The U.S. risks falling further behind in health status unless there is a shift in focus from spending on medical interventions to spending on the well-documented determinants of health, including community, social, economic, and built environments (Teustsch, 2012). Such investments will ensure the continued economic growth and competitiveness of the US in the global economy (Teustsch, 2012). The historically fragmented and financially opaque public health system requires immediate and comprehensive reform. Effective reform will propel a shift from reactive illness-based spending to proactive community-based public health preventative investment. As discussions focused on this critical problem continue, we recommend implementation of the specific measures set out above.

Works Cited

Alper, J, Baciu, A., IOM Roundtable on Population Health Improvement.

Financing Population Health Improvement: Workshop Summary

. (2014). IOM.

Brownson, R. C., Fielding, J. E., & Maylahn, C. M. (2009). Evidence-based public health: a fundamental concept for public health practice.

Annu Rev Public Health, 30

, 175-201.

Honore, P., Clarke, R., Mead, D., & Menditto, S. (2007). Creating Financial Transparency in Public Health: Examining Best Practices of System Partners.

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(2), 121-129.

IOM. Committee on Public health Strategies to Improve Health, Board on Population health and Public Health Practice.

For the Public’s Health: Investing in a Healthier Future

. (2012). Washington, D.C.: The National Academies Press.

Levi, J., Juliano, C., & Richardson, M. (2007). Financing Public Health: Diminished Funding for Core Needs and State-by-State Variation in Support.

Journal of Public Health Management and Practice,


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(2), 97-102.

Ogden, L. (2012). How Federalism Shapes Public health Financing, Policy, and Program Options.

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(4), 317-322.

Ogden, L., Sellers, K., Sammartino, C., Buehler, J., & Bernet, P. (2012). Funding Formulas for Public Health Allocations: Federal and State Strategies.

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(4), 309-316.

Teutsch, S., Baciu, A., Mays, G., Getzen, T., Hansen, M., & Geller, A. (2012). Wiser Investment for a Healthier Future.

Journal of Public Health Management and Practice,


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(4), 295-298.

Turnock, B. J. (2012). Public Health: What it is and How it Works (Fifth ed.). Burlington, MA: Jones & Bartlett Learning.

Weintraub, K. (October 6, 2014). Ebola outbreak a wake-up call to the world.

The Boston Globe

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http://www.bostonglobe.com/lifestyle/health-wellness/2014/10/05/ebola-shows-how-global-public-health-has-become-everyone-concern/vc8R92VHmtpd4vZVbqzYEP/story.html

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Health promotion has been defined as” the process of enabling people to increase control over their health and its detriments and thereby improve their health” (WHO 2005). Breast Health Promotion improves understanding and confidence among women. It can help to remove fear of breast cancer and it encourages early diagnosis (Breastcancer care 2008).Health promotion can be performed in various locations. The settings that have received special attention are the community, health care settings, schools and workplaces (Tilford et al 2001).

Breast cancer is a disease that affects almost 46,000 women and around 300 men in the United Kingdom every year. One in nine women in the U.K will develop breast cancer at some point in their lifetime (Cancer Research UK 2006).

The contents of this assignment will include the importance of health promotion, primary, secondary and tertiary levels in relation to breast cancer, legislation and barriers.

Breast cancer is a very frightening word and the detection of it harrowing therefore early detection in order to improve breast cancer outcomes and survival remains the cornerstone of breast cancer control (Anderson et al 2008).

Mortality from breast cancer is falling in all age groups and the reasons for this are not certain but early diagnosis through screening and improvements in treatment particularly greater use of adjuvant therapies (e.g. chemotheraphy or radiotherapy) undoubtedly contribute (Petro et al 2000). It is important that women have as much information about the benefits and the risks of potential treatments so that they are able to have an active role in their treatment plans. Treatment should be tailored to individual needs and circumstances (NICE 2009).

There are several types of breast cancer which can develop in different parts of the breast and the most common form is ductal breast cancer which develops in the cells that line the breast ducts. Ductal breast cancer accounts for approximately 80% of all cases of breast cancer. (NICE 2002). Breast cancer can spread to different parts of the body such as the bones, lymph nodes and the liver. (NHS Choices 2010).

Primary interventions should be considered in the promotion of health in reducing some of the risks of getting breast cancer; these include maintaining a healthy diet (particularly one low in fat but high in fibre and vegetables). A key feature of the government’s prevention strategy to reduce early deaths from cancers and coronary heart disease is action to improve diet and nutrition with the introduction of eating 5 A DAY and CHANGE 4 LIFE. Evidence has shown that higher fruit and vegetable consumption can reduce the risk of breast cancer (DH 2000). Being active and undertaking some exercise also reduces the risk and women with higher levels of physical exercise have around 30% lower risk of developing breast cancer than those that are least active. The higher the level of physical activity the lower the risk (Dorn et al 2003). Drinking more than two units of alcohol per day over a number of years can also increase the risk (Macmillan 2008).

In order to help promote the government’s programmes, it is essential that the nurse has sound knowledge of these plans so that she can raise awareness of health benefits, offer advice and educate patients about all the strategies that they can do to help promote a healthier life.

It is very important to become familiar with how the breasts look and feel at different times of the month. The breast awareness 5-point code was introduced as a way of caring for your body and being able to notice any unusual changes in your breasts (Breast Cancer care 2007).The practice nurse will offer guidance to show patients how to examine their breasts or offer a leaflet which contains all the necessary information.

School nurses are also helping to promote breast health and breast cancer prevention to young girls across the nation in schools where they talk openly with girls about breast development and the complex health and emotional issues and problems that may occur. The health promotion enables the young girls to face the future with confidence and with knowledge of breast cancer. (Breast cancer 2008).

Breast screening is offered to all women between the ages of 50-70 years and they will receive an appointment by letter to attend for breast screening, however, if any unusual changes in the breast are noticed, it is essential that an appointment to see a G.P or the practice nurse is made, where a full examination of the breasts will be given. Reassurance and support will be given by the nurse or G.P and they will try to alleviate some embarrassment by maintaining privacy and dignity by locking the door and by pulling the curtains around (NMC 2008).If the nurse or G.P is uncertain about the problem, or they think that cancer may be present then a referral to a breast specialist for advice or treatment will be necessary.

All patients that are referred to a specialist with breast symptoms, even if breast cancer is not suspected should be seen within two weeks of the referral (DH 2007).

Diagnosis in the breast clinic at the hospital is made by a triple assessment (clinical assessment, mammography and/ or ultrasound imaging, core biopsy and/ or fine needle aspiration cytology (NICE 2009).

The breast cancer nurse will introduce herself and she will explain everything fully to the patient before gaining relevant historical information off them, the nurse will also ask the patient if they have any questions before asking the patient to put on a gown (ensuring dignity and privacy is maintained).The nurse must use sensitivity, empathy and understanding as this can often be emotionally upsetting and distressing for women. The nurse will ensure that prior consent is always gained off the patient (NMC 2008).

Screening is carried out by using either ultrasound scans of the breasts or by mammograms which are x-rays that use very low doses of radiation. In some cases women have both of these.

A core biopsy may be used to take samples of cells from a lump or area of abnormality in the breast using a needle. This will be sent to the laboratory where it will be studied by a pathologist. The results of these tests can help determine if the lump contains cancerous cells. Local anaesthetic is used in biopsies and the breast may have some bruising or soreness afterwards. The nurse will be on hand to guide the patient through the experience and will offer advice in caring for the area afterwards and she will assist in making follow up appointments and further treatment plans. The nurse will also support the patient by trying to relieve anxieties, offering reassurances and by answering any concerns. Providing information by the nurse alongside all the support can empower the patient to retain or regain control over their lives (DH 2007).Lack of good, sensitive communication skills provokes poor patient care and it costs the NHS greatly in preventable loss of money, time and resources (DH 2000).

At tertiary level a number of treatments are available for early breast cancer. The patient will become part of a multidisciplinary team and the nurse specialist or consultant will discuss treatment plans with the patient ensuring that the patient is fully aware of what they are being told and that they understand. (Jefford 2002).

Breast surgery is often the first treatment for patients with breast cancer and this must be carried out by surgeons with a special interest and training in breast disease (BASO 2009).The nurse plays a vital role in the patient’s surgical experience and her role is to ensure that the patient is comfortable, pain free and that encouragement is give to promote independence by advising the patient on wound care, maintaining food and nutritional status, mobility, hygiene and the psychological effect that might be experienced.

Treatment given after surgery is known as adjuvant treatment and includes radiotherapy, chemotherapy, hormone therapy and targeted (biological) therapy. Understanding the fundamental principles of radiation therapy enables the oncology nurse to provide support both physically and psychologically by offering advice on nutritional needs, areas that may be affected by the treatment, side effects, practical problems such as money difficulties and transportation to the treatment centre. The oncology nurse will also provide strategies to ensure family members and friends are supported.

The delivery of chemotherapy is primarily the responsibility of the oncology nurse. The nurse must have sound knowledge of the pharmacology of the drugs used so that errors do not occur and that the patient is well informed of any possible side-effects. Patients can be very poorly because of the side-effects of chemotherapy so it essential that the oncology nurse gives the correct information to the patient and they should be informed and given guidance of who to contact if problems arise.

The use of any adjuvant therapy is frightening for most women but nurses can offer practical advice, emotional and physical support and direction throughout the patient’s journey The nurse will arrange follow-up appointments for any on-going treatments, and they will discuss with the patient where they would like the follow-up to be undertaken (NICE 2009).

As a healthcare professional, nurses are sometimes asked about a wide variety of complementary and alternative therapy as some 30% of women diagnosed with breast cancer visit a complementary therapist (Rees et al 2000). Nurses have a duty to be aware of the different types of therapies and in the aspect of health promotion they must be knowledgeable about safety issues, contra-indication and side effects before advising patients about alternative therapy. The nurse must always follow the NMC in working within ones own limits and using practice based evidence to support her actions (NMC 2008).

Palliative care offers a support system to help patients live as actively as possible until death. The palliative care nurse will provide relief from pain and she will offer advice on how to deal with symptoms for example vomiting, diarrhoea and fatigue by explaining to the patient how to rest, positioning when resting, how to use relaxation techniques, they will educate the patient about diet and nutrition and how this can help maintain health and well being. If the patient has oral problems then the nurse can advise the patient on alternative foods such as calorie packed drinks. The palliative care nurse will use her knowledge, skills and caring compassion to guide the patient and their family to the end stage of life by communicating with them effectively, supporting emotionally and physically, planning outcomes with the patient as patient choice over place of death should be a priority (NICE 2004), promoting advice on equipment, wound care whilst always focusing on autonomy, justice and the spiritual needs of the patient.

The NHS Breast Screening programme (DH 1988) was first set up and the role of the breast care nurse is invaluable to the patient in providing support for patients by advising the best options in terms of treatment, emotional and psychological support. The nurses are there as a familiar face for the patient and they will continue to be available for the patient for on going advice throughout treatment. The breast care nurse will offer best advice on diet, health and mental well being and she will give guidance and offer literature on issues relating to the patients illness.

With the introduction of the NHS Cancer Plan (DH 2000), new funding for cancer services and cancer specialists became available. Nurses working in hospital and community settings help to detect cancer earlier by educating people about diet, health, exercise and raising public awareness by facilitating posters and leaflets around the health departments. Health clinics were set up where patients can attend for check ups, screening and other health related issues.

The cancer Reform Strategy (2007) enhances nurses by implementing training initiatives so that nursing staff can become better educated in cancer care, they can spread good practice, have a better understanding of inequalities, have more face to face communication with patients. Nurses are able to promote health awareness and disseminate information down to the people whose health and mental well being matter e.g. advising patients about smoking cessation and raising awareness about other lifestyle factors that contribute to cancer.

The Liverpool Care Pathway (LCP) is a framework which allows the caring team to plan care using specific goals, guideline-based interventions and a flow sheet that outlines an expected course of a patients care (Ellershaw 2002). The framework is patient focused so the nurse involved will document a plan of care required that includes comfort measures, anticipatory prescribing and discontinuation of inappropriate interventions. The nurse will work very closely with the patient and family and she will ensure that any religious, cultural or spiritual beliefs are adhered to.

The Gold Standards Framework (Thomas 2003) was developed and was aimed at primary care teams including nurses and palliative care nurses to help patients live well until the end of life. It helps the team to focus on promoting the needs of patients, families and carers. The nurse can help to plan “good” death with the patient and the nurse can offer practical and emotional support which will help to maintain the health of the patient and their loved ones. The nurse will offer advice on claiming benefit and financial support as this may have a detrimental impact on family members, carers and their health if they are worried that they cannot cope financially. The nurse can share knowledge with the multidisciplinary team which will help to maximise patient benefit. (GSF 2006).

Communication can be a barrier to effective health promotion especially if the individual cannot understand terminology used by the professional or English is not the first language. Effective communication is central to promoting high-quality care and barriers can be overcome by demonstrating active listening skills, talking to individuals in a manner that they can understand, showing supprt, maintaining realistic hope, taking time to talk to patients, being friendly, open and honest .Demonstrating good body language is also very important and this is one barrier that patients will detect very early on.

Many departments and clinical settings now employ interpreters, which is beneficial to the patient whose first language is not English. The use of interpreters improves the quality of care for the patient (Dreger et al 2002). Leaflets containing information are also available in different language for the patient to access.

Many individuals are unenlightened to their health needs and they may ignore preventative advice off health care professionals. This barrier can be overcome by educating people about health matters, by having health promotion posters, leaflets and information displayed in public places where people can access them without actually having to make an appointment to see a G.P or practice nurse (unless they want/need to).

Lifestyle is a barrier to health promotion. Many people face inequalities such as poor diet, poor health and financial difficulties’ The Department of Health’s healthy eating strategies such as 5 A Day and Change 4 Life have tried to change attitudes and raise awareness about the health benefits of eating fruit and vegetables by introducing it into schools, communication programmes e.g. 5 A Day logo, and ensuring that people can have adequate access to affordable, good quality fruit and vegetables within the local community. (DH 2003). Change4Life (DH 2009) can try to eradicate barriers by promoting healthy eating, having more exercise and living longer to young children with the added participation of other family members. The whole family can work together to initiate a healthy future.

Transportation difficulties present barriers for many people as they may find it difficult to access G.P surgeries, health centres or the hospital if they do not have the means to get there. Also if the person has mobility difficulties, attending appointments could prove to be a challenge for them. To encounter this problem health care trusts have provided walk in centres, one stop shops and mobile health units( e.g. for mammogram screening) within communities which are easily accessible , open later and at the weekend.

To conclude, it is evident from the information discussed in the assignment that early detection of breast cancer can significantly reduce mortality. The care and treatment of women (and men) with breast cancer has evolved greatly over the last few years and although there is no cure for metastatic breast cancer, evidence has shown that women are able to live longer withy the use of different treatments.

Breast screening is very important and evidence shows that the earlier breast cancer is diagnosed and treated, the better the chance of successful treatment.

The Governments campaigns such as Breast Awareness, 5 A DAY and ACTIVE 4 LIFE have enriched many people’s lives and by having more accessible clinics, walk in centres and mobile health units all contribute to a healthier, more active lifestyle.

Many of the clinics are now nurse led and this has proved to provide a warm, caring and informative environment for patients that attend.

Cancer provokes stress, anxiety, fear and anger in patients and nurses on the forefront can attempt to soften these fears by offering psychological and emotional support, guidance and empathy to patients. Caring for patients with breast cancer tests all aspects of holistic nursing care and by having all the necessary skills nurses can build a trusting, therapeutic relationship with the patient which will lessen some worries and anxieties for the patient. Communicating well, providing accurate information, listening and having time for the patient enhances the patient journey.

It is essential that autonomy is respected regardless of culture, spiritual or ethnicity differences and that what ever treatment the patient requires is undertaken with the utmost sincerity whilst upholding maximum dignity and privacy for the patient.

Lastly, end of life care is now firmly established as an important aspect of care delivery and it is an effective means of improving end-of-life care for all patients. The frameworks allow the patients to have a peaceful and meaningful end to their life.