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In addition hypertension emergency treatment purchase telmisartan 20mg mastercard, the lingual plate must compromised but may provide service for a time heart attack jack let it out discount telmisartan master card, these completely close the interproximal spaces to excel blood pressure chart 80 mg telmisartan overnight delivery the level of teeth may be supported by a lingual plate until extraction the contact points pulse pressure difference telmisartan 80mg without prescription. As teeth are lost, retentive loops may be aspect prevents food from being packed into these areas. The superior mar placement of prosthetic teeth without the expense of re gins of the scalloped metal should be knife edged to avoid making the prosthesis. Ledg When posterior teeth have been lost and there is a ing occurs when metal margins are thick or linear and pro need for additional indirect retention, the use of a lingual duces unnatural contours, which are annoying to the plate may be advantageous. Moderate relief must be provided plish this, the superior border of a lingual plate should during framework fabrication to prevent irritation of the cover the cingulum of the individual tooth. Fig 2-40 the superior border of a lingual plate major Fig 2-41 A lingual plate may include “step backs” to connector should display a scalloped appearance. Fig 2-42 A lingual plate must be supported by rests Fig 2-43 In certain applications, the lingual surfaces of (arrows) located no farther posterior than the mesial the anterior teeth may be covered, while the lingual surfaces of the first premolars. One of the greatest advantages of the lingual plate A lingual plate generally contacts the anterior teeth, major connector is its exceptional rigidity. In such applications, the tients often consider a well-fitting lingual plate more com lingual surfaces of the anterior teeth usually are covered, fortable than a lingual bar. The lingual plate’s exten proach as long as the resultant contours are self-cleansing. Ex surfaces and irritation of the soft tissues in patients with treme care must be taken to ensure that a lingual plate poor oral hygiene. Consequently, a thorough examination major connector does not create additional oral hygiene is essential to recognize those patients for whom a lingual challenges for a patient. Double lingual bar (Kennedy bar) contributes to horizontal stabilization of the prosthesis, A double lingual bar displays characteristics of both lingual since stress is transferred to those teeth contacted by the bar and lingual plate major connectors (Fig 2-44). These lower components of a double lingual bar are not joined factors may be critical in the long-term health of the re by a continuous sheet of metal. The principal disad the lower component of this major connector should vantage of a double lingual bar is its tendency to trap de display the same structural characteristics as does a lingual bris. It should be half-pear shaped in cross section, with its by mandibular anterior teeth. The upper bar cuts and makes accurate adaptation of the upper bar ex should be half oval in cross section. The upper bar should not tact with tooth surfaces, food entrapment and patient run straight across the lingual surfaces of the teeth but discomfort will generally occur. The minor connectors should be located Patients also may find a double lingual bar irritating in the interproximal spaces to disguise the thickness of the to the tongue. The presence of multiple borders and metal and to be less noticeable to the tongue. As a Rests should be placed at each end of the upper bar result, a modified lingual plate major connector may and should be located no farther posterior than the be preferred. Placement of these rests is intended to prevent the bar from moving inferiorly Labial bar and causing orthodontic movement of the remaining As its name suggests, a labial bar runs across the mucosa anterior teeth. Like A double lingual bar is indicated primarily when con other mandibular major connectors, a labial bar displays a tact with the remaining mandibular anterior teeth is indi half-pear shape when viewed in cross section. The upper bar should of its placement on the external curvature of the man exhibit a scalloped contour that extends from the contact dible, a labial bar is longer than a corresponding lingual bar, points to the cingula. When properly sup the only justification for using a labial bar is the pres ported by rests at each end, a double lingual bar effectively ence of a gross uncorrectable interference that makes the extends indirect retention in an anterior direction. Fig 2-46 the Swing-Lock removable partial denture represents a useful modification of the labial bar con cept. The labial component functions as a gate that may be closed and locked to provide retention. Patient acceptance of labial bar are (1) malpositioned or lingually inclined teeth and (2) bar major connectors generally is poor. The bulk of the large mandibular tori that preclude the use of a lingual bar major connector distorts the lower lip unless the lip is rel or lingual plate. Every attempt should be made to correct atively immobile, and the mere presence of metal be the condition by extraction of severely malpositioned tween the gingival tissues and the lip causes significant dis teeth, orthodontic correction of lingually inclined teeth, comfort. In addition, the labial vestibule usually is not deep placement of crowns, or surgical intervention to remove enough to permit a sufficiently rigid connector without en tori. Because of the position and bulk of a labial bar, the croaching on the free gingival margins. Review of indications for mandibular the Swing-Lock removable partial denture represents major connectors a useful modification of the labial bar (Fig 2-46). Instead, the modified labial bar has a hinge at lingual bar normally is the mandibular major connector one end and a locking device at the opposite end. When there is insufficient room between the floor of the framework may be positioned in the mouth with the the mouth and the gingival margins (< 8 mm), a lingual gate in the open position. This permits the re indicated for patients with large inoperable tori and pa movable partial denture to reach otherwise inaccessible tients with high lingual frenum attachments. When the anterior teeth have reduced periodontal Swing-Lock removable partial denture is discussed at support and require stabilization, a lingual plate is length in chapter 20. When the remaining support and large interproximal spaces, a modified mandibular teeth are tipped so far lingually that a more lingual plate (ie, step-back design) or double lingual bar conventional major connector cannot be used, a labial bar should be used. When a removable partial denture will replace all avoiding the use of a labial bar should be entertained be mandibular posterior teeth, a lingual plate should be fore it is incorporated into the design of a partial denture. A minor connector should never be the primary function of a minor connector is to join the positioned on the convex lingual surface of a tooth where remaining components of a removable partial denture to its bulk will be evident. Minor connectors also are responsi ble for distribution of applied forces to the supporting Minor connectors joining indirect retainers teeth and oral tissues. Therefore, rigidity is an essential or auxiliary rests to major connectors characteristic of all minor connectors. The broad distribu tion of forces prevents any one tooth or any one portion Minor connectors that support indirect retainers or aux of an edentulous ridge from bearing a destructive amount iliary rests are often used in removable partial denture of stress. These minor connectors should form right angles connector may result in stress concentration and damage with the corresponding major connectors, but junctions to the supporting teeth and soft tissues. As previously noted, minor connectors should be positioned in lingual embrasures to disguise their bulk Types of minor connectors and promote patient comfort. They may be described as follows: Minor connectors joining denture bases to major connectors 1. Minor connectors that join clasp assemblies to major connectors (Fig 2-47) Minor connectors that join a denture base to a major con 2. Minor connectors that join indirect retainers or auxil nector may be described as follows: iary rests to major connectors (Fig 2-48) 3. Bead, wire, or nailhead components on a metal base vertical projection/bar-type clasps (Fig 2-50) these minor connectors must be strong enough to Minor connectors joining clasp assemblies anchor a denture base to the removable partial denture framework. They must be rigid enough to resist fracture to major connectors and displacement. In addition, these components must Minor connectors that join clasp assemblies to major con provide minimal interference with the arrangement of nectors must be rigid, because they support the active artificial teeth. They also support the rests, which prevent ver tend the entire length of the ridge and should cover the tical movement of a prosthesis toward the underlying tuberosity. As a result, minor connectors must have sufficient extended as far posteriorly as is practical. In many in bulk to ensure rigidity, yet they must be positioned so they stances, the minor connector may extend beyond the do not irritate the oral tissues. In Most minor connectors that support clasp assemblies other cases, the minor connector must be terminated an are located on proximal surfaces of teeth adjacent to terior to this area. These minor connectors should be In the mandibular arch, a distal extension base must broad buccolingually, but thin mesiodistally (Fig 2-51). Therefore, the minor connector resultant shape makes it easier to place a prosthetic tooth should extend two-thirds the length of the edentulous in a natural position. This provides adequate support and In many instances, a clasp assembly must be positioned retention for the associated resin base. When this occurs, a minor connector should be posi tioned in the associated lingual embrasure (Fig 2-52). Fig 2-49 A minor connector (arrows) that joins a resin Fig 2-50 A minor connector (arrow) that serves as denture base to the major connector. Fig 2-51 A minor connector that joins a clasp assem Fig 2-52 A minor connector may be positioned in a bly to the major connector must be broad buccolin lingual embrasure to disguise its thickness. This allows the minor con nector to be strong, yet does not interfere with prosthetic tooth placement.

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By communicating our sustainability performance blood pressure juicing recipes buy cheap telmisartan 20mg, we foster stakeholder trust and confdence blood pressure quizlet telmisartan 40mg free shipping. The corresponding assessment and topics determined to blood pressure 220 cheap 20 mg telmisartan mastercard be material are presented on p arrhythmia overview order 20mg telmisartan with mastercard. The topics listed are relevant for Straumann’s operations, shareholders and employees, as they can infuence cost, brand reputation, and ultimately business success. Economic, social and environmental topics are also relevant for the communities in which we operate. Product related topics are relevant for our customers and the patients they serve. Human resources topics infuence the competence of our team and ultimately the confdence and peace-of-mind we provide to our customers. This report is based on information for the whole Straumann Group, unless stated otherwise. Strategic oversight of our fnancial performance is 201, 203, 205, 206 provided by the Board of Directors. Central to our approach is a strong commitment to innovation, quality and service in all the regions where we do business. We are positioned as a supplier of premium products and services and have a clear focus on cost control. We plan to maintain our position through prompt execution of strategic goals and by upholding our commitment to developing new products in the replacement, restorative, regenerative, esthetic and preventive dental markets, as well as for digital dentistry. Our main indirect economic impacts include the provision of jobs in the communities in which we operate and our charitable and social engagement initiatives to make dental treatment and education about oral hygiene available to the underprivileged. Straumann’s charitable and social engagement programs around the world are a key part of our culture. They are typically managed by the teams located in each region where we do business. Our charitable programs relate, for example, to ectodermal dysplasia or basic dental care and oral hygiene. Our products and services are, by their nature, designed to improve the human condition and thus inherently beneft society. It requires Straumann employees to comply with applicable laws and regulations at all times. Employees are obligated to report any violation or suspected violation, or any other suspected misconduct. With regard to supply chain administration, our Strategic Procurement & Direct Spend team is responsible for procuring raw materials. They are overseen by plant managers who in turn report to our Head of Operations or the Head of our Digital Business Unit. To track our performance, we regularly collect and evaluate data from our production sites to understand our environmental impact and continuously identify measures for improvement. Minimizing our impact on the environment also falls within the responsibility of our employees. Our Code of Conduct obliges every individual in the Straumann Group to comply with all laws and internal regulations regarding environmental matters. We continuously refne products and processes and seek ways to improve the conservation of resources. Economical use of resources and efcient production as well as recycling eforts minimize efuents and waste. We closely monitor our greenhouse gas emissions to quantify our impact on climate change. We are aware that our supply chain also infuences our environmental impact and we strive for a thorough environmental assessment of suppliers. Our expectations regarding environmental protection in the supply chain are clearly specifed in our Code of Conduct for Suppliers. On a strategic level, the Human Resources & Compensation Committee of the Board of Directors reviews Straumann’s human resources policies and oversees the recruitment of Executive Board Members as well as the compensation of the Board and the Executive Management Board. We base our approach to employment on principles of employee development, open dialogue and fair and attractive employment conditions. Collective bargaining agreements and freedom of association are allowed throughout the company in compliance with laws and regulations. However, there is a general preference for informal employee dialogue, and labor contracts are negotiated individually rather than by collective bargaining. Our commitment to maintaining a safe working environment is ensured by monitoring occupational health and safety. We continuously communicate health and safety procedures to employees through training and awareness programs, and we regularly monitor and report absence rates. In order to keep our employee’s skills up to date, training and education are of key importance. We extended our continuing training and education programs considerably, aligning them with our high-performance culture and cultural change, and continued to ofer informal educational sessions (‘Discover’ and ‘Lunch & Learn’). We believe a diverse workforce greatly contributes to team performance and to our ability to serve customers all around the world. We regularly monitor a variety of indicators in our workforce such as age, gender, nationality and educational background to ensure inclusiveness and diversity of perspectives. It is integrated in all our employment contracts, and new employees are made aware of it as part of our onboarding program. Straumann Group 189 Appendix 2018 Annual Report To foster an open, collaborative working environment, our employees are protected from discrimination by Straumann’s Code of Conduct. We defne discrimination as biased treatment based on gender, race, background, religion, or sexual orientation. A supplier social assessment is achieved through our Code of Conduct for Suppliers, the purpose of which is to ensure that working conditions and human rights are protected along our supply chain. We apply stringent requirements for safety and efectiveness in product design and production, and will never accept shortcuts to market in order to boost short-term sales. The ftness for use of our products is assured over the entire product lifecycle: from conceptualization to research, development, manufacturing, storage, distribution, and in-market support. Our approach towards customer health and safety as well as compliance of our products and services includes the following: In the rare case of a potentially serious safety issue, our Corporate Product Safety Ofcer is authorized to convene a Safety Board meeting at very short notice to initiate corrective actions. Furthermore, our implant and regenerative products undergo preclinical and clinical testing, which continues after market introduction. Results of these studies are often published in peer-reviewed scientifc journals and are presented by independent experts at scientifc meetings. Our commitment to truthful and accurate marketing and labeling is embedded in our global sales compliance program, which has been in place since 2009. It is one of several safeguards ensuring compliance with regulations relating to sales of our products and services. Finally, respecting laws and regulations concerning customer privacy is integrated in our Code of Conduct. Dear customers, As you surely noticed from the cover of this cata Even with our new look and name, we will remain logue, our name now is Kulzer. It is a name that has your reliable lifetime partner and continue to stood for reliable and innovative dental products expand upon our customer-oriented products and for more than 80 years – and we will stay true to services. Our goal is to provide you with customer service to help you take advantage of the best-in-class solutions that empower you to design opportunities that new technologies offer. If you production processes that are safe, more con are also interested in developing your professional venient, and at the same time cost-effective. We skills, you can benefit from our extensive training continuously expand our portfolio of dental mate programme. Together with you, we are giving a hand rials and technologies to reach these goals on to oral health. In the road ahead, an even stronger R&D department backed up by the innovating Rediscover a reliable partner – in this catalogue, power of our parent company, Mitsui Chemicals, at our events, and in a personal conversation. We create solutions that ensure smooth processes Yours sincerely in the laboratory. Our individualised approach to automated in-house production reveals the countless ways to combine and interconnect Kulzer products, such as: the model scanner cara Scan 4.

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Associated Features One type of unexpected panic attack is a nocturnal panic attack blood pressure chart hypotension order 80mg telmisartan with amex. Panic attacks are related to heart attack 3 stents discount telmisartan 20 mg otc a higher rate of suicide attempts and suicidal ideation even when comorbid­ ity and other suicide risk factors are taken into account hypertension arterielle order telmisartan without prescription. Prevalence In the general population blood pressure cuff and stethoscope purchase telmisartan with a mastercard, 12-month prevalence estimates for panic attacks in the United States is 11. Twelve-month prevalence estimates do not appear to differ sig­ nificantly among African Americans, Asian Americans, and Latinos. Lower 12-month prevalence estimates for European countries appear to range from 2. Females are more frequently affected than males, although this gender difference is more pro­ nounced for panic disorder. Panic attacks can occur in children but are relatively rare until the age of puberty, when the prevalence rates increase. The prevalence rates decline in older individuals, possibly reflecting diminishing severity to subclinical levels. Development and Course the mean age at onset for panic attacks in the United States is approximately 22-23 years among adults. However, the course of panic attacks is likely influenced by the course of any co-occurring mental disorder(s) and stressful life events. Panic attacks are uncommon, and unexpected panic attacks are rare, in preadolescent children. Adolescents might be less willing than adults to openly discuss panic attacks, even though they present with ep­ isodes of intense fear or discomfort. Lower prevalence of panic attacks in older individuals may be related to a weaker autonomic response to emotional states relative to younger in­ dividuals. Older individuals may be less inclined to use the word "fear" and more inclined to use the word "discomfort" to describe panic attacks. Older individuals with "panicky feelings" may have a hybrid of limited-symptom attacks and generalized anxiety. In addition, older individuals tend to attribute panic attacks to certain situations that are stressful. This may result in un­ der-endorsement of unexpected panic attacks in older individuals. Most individuals report iden­ tifiable stressors in the months before their first panic attack. Culture-R elated Diagnostic issues Cultural interpretations may influence the determination of panic attacks as expected or unexpected. Cultural syndromes also influence the cross-cultural presentation of panic attacks, resulting in different symptom profiles across different cultural groups. Ex­ amples include khyal (wind) attacks, a Cambodian cultural syndrome involving dizziness, tinnitus, and neck soreness; and trunggio (wind-related) attacks, a Vietnamese cultural syndrome associated with headaches. Ataque de nervios (attack of nerves) is a cultural syn­ drome among Latin Americans that may involve trembling, uncontrollable screaming or crying, aggressive or suicidal behavior, and depersonalization or derealization, and which may be experienced for longer than only a few minutes. Some clinical presentations of ataque de nervios fulfill criteria for conditions other than panic attack. Also, cultural expectations may influence the classification of panic attacks as expected or unexpected, as cultural syndromes may create fear of certain situa­ tions, ranging from interpersonal arguments (associated with ataque de nervios), to types of exertion (associated with khyal attacks), to atmospheric wind (associated with trunggio at­ tacks). Clarification of the details of cultural attributions may aid in distinguishing ex­ pected and unexpected panic attacks. For more information about cultural syndromes, see "Glossary of Cultural Concepts of Distress" in the Appendix to this manual. Gender-Related Diagnostic Issues Panic attacks are more common in females than in males, but clinical features or symp­ toms of panic attacks do not differ between males and females. Diagnostic Markers Physiological recordings of naturally occurring panic attacks in individuals with panic disorder indicate abrupt surges of arousal, usually of heart rate, that reach a peak within minutes and subside within minutes, and for a proportion of these individuals the panic attack may be preceded by cardiorespiratory instabilities. Functional Consequences of Panic Attaclcs In the context of^co-occurring mental disorders, including anxiety disorders, depressive disorders, bipolar disorder, substance use disorders, psychotic disorders, and personality disorders, panic attacks are associated with increased symptom severity, higher rates of comorbidity and suicidality, and poorer treatment response. Also, full-symptom panic at­ tacks typically are associated with greater morbidity. Panic attacks should not be diag­ nosed if the episodes do not involve the essential feature of an abrupt surge of intense fear or intense discomfort, but rather other emotional states. Medical conditions that can cause or be misdiagnosed as panic attacks include hyperthyroidism, hyperparathyroidism, pheo chromocytoma, vestibular dysfunctions, seizure disorders, and cardiopulmonary con­ ditions. A detailed history should be taken to determine if the individual had panic attacks prior to excessive substance use. Features such as onset after age 45 years or the presence of atypical symptoms during a panic attack. Repeated unexpected panic attacks are required but are not sufficient for the diagnosis of panic disorder. Comorbidity Panic attacks are associated with increased likelihood of various comorbid mental dis­ orders, including anxiety disorders, depressive disorders, bipolar disorders, impulse­ control disorders, and substance use disorders. Panic attacks are associated with increased likelihood of later developing anxiety disorders, depressive disorders, bipolar disorders, and possibly other disorders. The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symp­ toms or other incapacitating or embarrassing symptoms. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The fear, anxiety, or avoidance is not better explained by the symptoms of another men­ tal disorder—for example, the symptoms are not confined to specific phobia, situational type; do not involve only social situations (as in social anxiety disorder): and are not re­ lated exclusively to obsessions (as in obsessive-compulsive disorder), perceived defects or flaws inphysical appearance (as in body dysmohic disorder), reminders of traumatic events (as in posttraumatic stress disorder), or fear of separation (as in separation anx­ iety disorder). If an indi­ vidual’s presentation meets criteria for panic disorder and agoraphobia, both diagnoses should be assigned. Diagnostic Features the essential feature of agoraphobia is marked, or intense, fear or anxiety triggered by the real or anticipated exposure to a wide range of situations (Criterion A). The diagnosis re­ quires endorsement of symptoms occurring in at least two of the following five situations: 1) using public transporation, such as automobiles, buses, trains, ships, or planes; 2) being in open spaces, such as parking lots, marketplaces, or bridges; 3) being in enclosed spaces, such as shops, theaters, or cinemas; 4) standing in line or being in a crowd; or 5) being out­ side of the home alone. The examples for each situation are not exhaustive; other situations may be feared. When experiencing fear and anxiety cued by such situations, individuals typically experience thoughts that something terrible might happen (Criterion B). Individ­ uals frequently believe that escape from such situations might be difficult. The amount of fear experienced may vary with proximity to the feared situation and may occur in anticipation of or in the actual presence of the agoraphobic situation. Also, the fear or anxiety may take the form of a full or limited-symptom panic attack. Fear or anxiety is evoked nearly every time the individual comes into contact with the feared situation (Criterion C). Thus, an individual who becomes anxious only occasionally in an agoraphobic situation. The in­ dividual actively avoids the situation or, if he or she either is unable or decides not to avoid it, the situation evokes intense fear or anxiety (Criterion D). Active avoidance means the in­ dividual is currently behaving in ways that are intentionally designed to prevent or min­ imize contact with agoraphobic situations. Often, an individual is better able to con­ front a feared situation when accompanied by a companion, such as a partner, friend, or health professional. The fear, anxiety, or avoidance must be out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context (Criterion E). Differentiating clinically significant agoraphobic fears from reasonable fears. First, what constitutes avoidance may be difficult to judge across cultures and sociocultural contexts. Second, older adults are likely to overattribute their fears to age-related constraints and are less likely to judge their fears as being out of pro­ portion to the actual risk. Third, individuals with agoraphobia are likely to overestimate danger in relation to panic-like or other bodily symptoms. Agoraphobia should be diag­ nosed only if the fear, anxiety, or avoidance persists (Criterion F) and if it causes clinically significant distress or impairment in social, occupational, or other important areas of func­ tioning (Criterion G).

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Syndromes

  • Try to stop smoking.
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  • Damage to nearby organs in the body
  • Central nervous system depressants include alcohol, barbiturates (amobarbital, pentobarbital, secobarbital), benzodiazepines (Valium, Ativan, Xanax), chloral hydrate, and paraldehyde. These substances produce a sedative and anxiety-reducing effect, which can lead to dependence.
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In this period average costs per episode steadily increased from around $12 blood pressure number meanings buy cheap telmisartan 20mg on-line,000 to blood pressure causes purchase telmisartan 80mg otc over $22 blood pressure chart english discount 80 mg telmisartan amex,000 arrhythmia getting worse purchase 40mg telmisartan visa. Southern Cross spinal fusion volumes varied over the period ranging from 184 to 257 per annum, with average costs showing a similar steady increase in average cost, from around $24,000 to $45,000. Assessment for Analgesia first and second line ‘red flags’ and ‘yellow flags’ Manual Therapies Vote:Health funded N = 49,000 per year Cost = $7. The reliability of the cost estimates vary, however, depending on the data sources and the assumptions that have had to be made. Currently, there is no full Model of Care approach that provides a clear pathway across acute and chronic. It appears the peak seems to have been reached and there has been a slight decline in recent years. Reasons for this decline are not known but may feasibly be accounted for by a change in clinical behaviour or provision of alternative treatments. Reasons to explain the historical increase in spinal surgical discharges are likely multifactorial; including improvements in diagnostic imaging identifying the likely cause of pain, the development of surgical techniques to treat a greater range of conditions, increased numbers of and access to orthopaedic spinal specialists, and patients desiring to remain active into old age. There has been an increasing trend over time in the procedure rate of spinal fusion, across all age groups, with the rate stabilising in more recent years. The use of spinal fusion has been expanded to include pain from degenerative diseases, with the majority of procedures now performed being for spondylosis (spinal degenerative diseases), disc disorders and spinal stenosis (in the absence of (32) deformities). The clinical outcomes of spinal fusion are variable, leading to continuing debate (32) about which patients might benefit from the procedure. It is estimated that the cost of fusion surgery for mechanical and non-specific low back problems was about $8 million for 2013/14. However, fusions are performed in conjunction with other spinal surgery, though the cost of fusion with laminectomy is similar to that without laminectomy. Page 64 National Health Committee – Low Back Pain: A Pathway to Prioritisation the appropriateness of surgery with reference to a patient’s clinical condition is more nuanced than can be considered from the analysis of administrative data. This could indicate that some patients are not receiving beneficial surgery or that some patents are receiving surgery that is less beneficial. Overuse of surgery may reflect variation in the assessment of clinical benefit but also could be a reflection on the inadequate provision of effective non-surgical management options. Effective treatment, earlier in the patient’s course, improves outcomes and prevents the development of chronicity and so provision earlier in the model of care may reduce the number of patients with more severe clinical conditions presenting to specialist services. There appears to be geographical variation in the provision and variation in the pain management components offered. In conjunction with assessing specialist pain services in secondary care, the provision of pain services in the primary care/community setting delivered earlier in the clinical course could also be assessed. The various components of pain services could be considered, their relative effectiveness within the service delivered and the transferability of these interventions to alternatives settings. Evidence suggests that manual therapies and structured exercise programmes improve health outcomes, and are considered modestly effective. Additionally structured exercise programmes are considered effective in reducing pain and disability though the effect is small but cost effective (12) compared to general care. A stratified approach to the provision of physiotherapy shows (15) improvement in disability, quality of life and cost savings compared to standard care. The New Zealand Council of Medical Colleges is spearheading the astute application of the New Zealand version of the ‘appropriate use of resources / Choosing Wisely’ thinking in this area. Patients who do not have surgery appear to be hospitalised for diagnostic reasons and for delivery of therapeutic injections. There are indications that access to diagnostic imaging for Page 66 National Health Committee – Low Back Pain: A Pathway to Prioritisation patients with chronic low back pain is sub-optimal and this may be a partial explanation of acute non-surgery related hospitalisations. Timely diagnostic imaging would facilitate improved stratification of patient need for more intensive treatment and so allow for the fast tracking of patients into specific care. Over the three year period 2011/12 to 2013/14 approximately 11% of spinal fusions done were not clinically indicated. In addition to unwarranted surgery costs, the patient benefit and return on investment from $321. Evidence presented in this assessment proposes that there are critical treatment options that if in place could significantly improve outcomes for patients and the sector. It is imperative that treatment options to prevent the deterioration of the patient’s condition whereby surgery is necessary or indeed the only treatment available to be offered to the patient. These include: Improved access to community diagnostics Access to manual therapies and targeted exercise programmes Community based chronic pain management programmes Improved access to comprehensive specialist complex pain management Page 67 National Health Committee – Low Back Pain: A Pathway to Prioritisation these services are illustrated below in a proposed New Zealand Model of Care for chronic low back pain in Figure 17 below. Page 68 National Health Committee – Low Back Pain: A Pathway to Prioritisation Figure 17: Proposed New Zealand Model of Care for patients with low back pain. The second assessment will similarly investigate the optimal configuration of specialist multidisciplinary pain management services. Systematic reviews and consensus documents were used to provide additional information about specific interventions. Page 71 National Health Committee – Low Back Pain: A Pathway to Prioritisation Many people may have low back pain and access private primary care services, or publically funded private care services that we do not currently have easy access to data on, or algorithms for identifying whether someone is accessing the service for low back pain or something else. This can mean that a patient attends ‘Osteopaths’, but the provider is registered as a ‘Rehabilitation Professional’. For the purposes of our analysis Counsellor, Psychologist, Psychiatrist, and psychotherapist have been grouped into ‘Mental health’ – we acknowledge that the figures associated with this group are ‘untidy’, this is likely due to the grouping we have done. We have kept this in here as mental health is an important part of any pathway of care, however caution is advised when looking at these figures and further analysis should be done if mental health is a priority. We have grouped Rehabilitation Professional and Rehabilitation Medicine Specialist into ‘Rehabilitation’. We have grouped Occupational Medicine Specialist and Occupational Therapist into ‘Occupational’. Page 72 National Health Committee – Low Back Pain: A Pathway to Prioritisation Only adults 18 years and over were included as children have a different distribution of back pain causes to adults and are unlikely to be hospitalised. Lumbar and sacral regions are included and cervical, thoracic and unspecified are excluded. Specifically: open fracture are excluded spinal or nerve injury is excluded dislocation is excluded subluxation is included Neuropathic spondylopathy is excluded. This means that the cohort populations do not necessarily add up to the discharge rates. A patient may have been counted in 2011/12 although they had subsequent surgeries in 2012/13. This also means that a patient can be counted more than once across the various diagnostic categories, both because they can have more than one ‘primary diagnosis’ if they have transfers and because the surgical categories overlap (Table 23). Severe non Of claimants identified with an account or Using the definition described above, those surgical service description that includes who have had a ‘non-surgical’ admission. Severe surgical Of claimants identified with an account or Using the definition described above, those service description that includes who have had a ‘surgical’ admission. Private hospital data have only been included from facilities that have reported for every year of analysis. Some effort has been made in this analysis to account for these multiple entries and only ‘count’ actual discharges, while still taking into account information in a patient’s other entries. From the literature we have estimated that approximately five percent of people present with acute lower back pain each year. Using the New Zealand Health Tracker population of those aged 18+ years five percent equates to approximately 170,000 for 2012/13. The median number of ‘visits’ is the median number of payments to each type of provider for each claim in the acute cohort. The median price is the median price of payments to each type of provider for each claim in the acute cohort. Due to the way the data are categorised the Mean was not necessarily appropriate as the distributions of the cost data are often quite skewed. The ‘per person cost’ is the median price multiplied by the median number of ‘visits’. Given this, we have included the price of one 100 pack of paracetamol and one 30 pack of diclofenac sodium for 60% of acute patients, approximately two weeks of painkillers. Chronic subpopulation While the origin of the analysis of the chronic patients is the same as that done for the acute patients there are some differences that are outlined here. The New Zealand Health Survey is a population-representative survey of New Zealanders, in 2013/14 (53) it surveyed 13,309 of adults aged 15 years and over and asked them if they experience chronic pain (the intensity may vary) that is present almost every day and has, or is expected to last, for 24 more than six months.

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