Marie Germain

           With the elderly population living longer, the rise of polypharmacy is becoming more common.  Polypharmacy, the state of being in more than 5 medications causes high risk in the health of the patient and consequently becomes a huge concern for medical practitioners (Golchin, Frank, Vince, Isham & Meropol, 2015). Polypharmacy is common among the elderly people especially because of high morbidity factors. As a result, it becomes medically necessary to be on multiple medications, although it is not advisable especially given the high risk the patient is put into. The question becomes does the benefits outweigh the consequences? It is important to understand these risks and possible interventions to prevent, treat and respond to polypharmacy risks in order to improve patient outcomes.

           Among the risk associated with polypharmacy are reactions between drug to drug reactions and increased risk of morbidity. Approximately 40% of the older adults are on multiple prescription drugs, while half of these are at a high risk of experiencing the risks associated with polypharmacy (Rossi, Feske, Shaffer & Kreutzer, 2017). Reaction to drugs can cause effects such as allergic reactions and other serious adverse effects that can be fatal (Azhagesan, 2017). Also, drugs may react with each other resulting in one having a greater effect than the other, and possibly hindering it from the intended action. Morbidity is the ultimate and most unprecedented risk as death may occur on the patient following immunity weakening.

           As a health concern, practitioners need to respond to this issue. The first response is to examine the patient’s accurate medical history upon any given discharge. This is important in examining previous medications and how they fared well with the particular patient. This also helps to inspire the most accurate medication (Rossi, Feske, Shaffer & Kreutzer, 2017). Secondly, the medical practitioners need to reconcile medications given to the patient (Azhagesan, 2017). This helps to prevent the risk of drug to drug interactions, while adhering to early intervention to help to prevent or deal with medical issues.

Maritza Cosme

Risk Factors for Polypharmacy

          Polypharmacy entails taking of 5 or more medicines. Generally, polypharmacy in the elderly occurs because of three factors: demographic factors, health factors, and access to healthcare. It is more common among older patients and has potential harms such as drug interactions and drug toxicity. Polypharmacy is an area of concern for elderly because of several reasons. Elderly people are at a greater risk for adverse drug reactions (ADRs) because of the metabolic changes and reduced drug clearance associated with ageing; this risk is furthermore exacerbated by increasing the number of drugs used. Polypharmacy is linked to increased risk of adverse drug events in older people due to increased risk of drug interactions, lack of adherence to medication regimes, susceptibility of older people to side effects of medications, and physical changes related to ageing causing difficulties in taking medications as  prescribed. One of the risk factors is frailty. Patients who are frail are more likely to be having many health conditions that can contribute to excessive polypharmacy. Another risk factor is multimorbidity (Card, 2016; Ersoy, 2018).  Patients who have many chronic conditions may be have to take 5 or more medicines to manage their conditions. Obesity is another risk factor. Obese people may have risk factors for many health conditions such as diabetes, heart disease, and high blood pressure, among others (Ersoy, 2018). These conditions may make them to take many medicines to manage them, therefore resulting to polypharmacy. In the elderly, disorders that occur as a result of ageing, frequently require treatment, resulting in increased use of medications. Polypharmacy is common among the elderly and although it can be therapeutic in nature, is linked to adverse events such as falls.

Interventions to prevent polypharmacy and its complications

          A nurse practitioner is central to the administration of healthcare services. The nurse can play certain roles to prevent polypharmacy and its complications. One intervention may entail assessing for drug-drug interactions. If there are interactions, there may be a need to eliminate some medicines. Another intervention may include reviewing dosages. The effects of the medicines may be due to excess dosages. The reviewing of dosages can lead to a reduction in the number of medicines that one takes. Another intervention is eliminating duplicate medications (Johansson, 2017). Some medications may serve the same purpose; and therefore, it is necessary to eliminate some to reduce the burden on the patient. Exploring non-pharmacological approaches may also be necessary. For instance, if a patient has depression or anxiety, use of psychotherapy and exercise may be a useful alternative to medicines and therefore reduce the number of medicines that one takes.

Guillermo

Polypharmacy

Indeed, polypharmacy in which patients take several medicines to an extent that they result in complexities is a common experience among the old people. Such a situation is as a result of particular aspects which is discovered can solve the issue. The common risk factors for polypharmacy among the older individuals are gastric disturbances as well as gastrointestinal diseases that induce a lot of adverse reactions which make patients opt to taking gastrointestinal drugs. The intake of such drugs them result in cascading of treatments and increment in DDC. Additionally, painful conditions which the older adults suffer including arthropathic, chronic, and neuropathic pain. According to Word Health Organization (2019) chronic pain is related with behavioral and somatic comorbidities encourages the old adults to consume excess analgesic. Indeed, risk factors such as the ones mentioned above trigger the increased cases of polypharmacy.

As a Nurse Practitioner, I would proactively teach the community especially old patients about sustainable and suitable medication as well as lifestyle. According to WHO (2019) unhealthy lifestyle causes multimorbidity among many patients, hence educating the ole people on healthy foods, proper health care, and housing as well as exercising helps reduce polypharmacy and its effects. The second intervention is to involve the patients into understanding the effect of using too many medications, reporting side effects immediately they happen, and using medication in the correct manner.    Molokhia & Majeed (2017) Opines that involving patients in the process of medication, monitoring them as they start and continue using the medication, as well as informing them on the right way to take drugs and report on impacts serves in reducing risks of polypharmacy. Therefore, the two interventions would suit me well.

Daylamis

Risk Factor for Polypharmacy

Polypharmacy may lead to comorbidities mostly to elderly people since its strongly related to age. Most of the aged people suffers from multiple illness at the same time leading to the taking more than one medication to cater for different sickness (Cantlay, Glyn, & Barton, 2016). Patients with multiple comorbidities have a high risk of polypharmacy since treating the patient with various illnesses has become a general practice in the health sector. In addition, most of the clinical officer’s focus on the single disease at a time, excluding patients with multiple conditions. 

Polypharmacy increases the risk of poor behavior and misunderstanding on medication to the patient. Most of the patient lack proper knowledge of drugs and reliable on available information or experience. This led to duplication or unnecessary medication prescribed by medical staff who have no previous medical history of the patient. The patient also accesses medication from multiple providers that do not know his other health condition. 

Intervention to Prevent Polypharmacy

First is through identify the indication strategy that should be implemented by any therapist and physician. The approach involves identification or diagnosis before the medication is given out to avoid the increased case of misappropriating prescriptions in healthcare facilities (Fasipe, Akhideno, Ibiyemi-Fasipe, & Idowu, 2018). It also the role of the patient to ensure the information given is clearly communicated and in the direction of use. 

Another method is the integration of START (screening tool to alert the doctor to the right treatment) technology in health care facilities. The technology provides the physician with an opportunity to evaluate and discontinues any prescribed medication that poses a risk to polypharmacy. 

Dailyn Gonzalez

Advanced Pharmacology

Polypharmacy refers to the use of more than one medication by a patient. The exact number of medications that define polypharmacy vary from one person to another and ranges from five to ten drugs. There are various risk factors associated with the condition. The first one is age. Polypharmacy is common in old people. The elderly are more susceptible to experiencing the condition since they have multiple diseases which require varying prescriptions. The elderly are also at risk since their bodies have high chances of experiencing drug events as a result of metabolic changes and a reduction in drug clearance capabilities (Abdulraheem, 2013). 

According to Slater, White, Venables, & Frisher (2018), another risk factor associated with polypharmacy is poverty or lower wealth. People from lower social classes tend to use over the counter drugs to treat themselves due to lack of funds to take them to hospitals. As a result, they take more than one medication for their conditions. Obesity is also believed to increase the risk of polypharmacy. Obesity is usually associated with a series of chronic heart diseases such as hypertension. Therefore, obese people use multiple medications to treat various diseases.

The first intervention towards preventing polypharmacy involves drawing from palliative care. The intervention is mostly applicable in very old people, and it entails discontinuation of drugs being administered on the patient. Another method entails conducting medication training during transition care. An example of a transition case is discharging a patient. Duplicate medications also need be to eliminated (Dagli, & Sharma, 2014). The last method entails assessing a patient for the presence of drug-drug interactions before administering any medication. Therefore, as a practitioner, the interventions which I would take to prevent polypharmacy include training patients before they are discharged and assessing them for drug-drug interactions before administering medications.

MayleePolypharmacySome of the definitions concerning polypharmacy that can be encountered in my readings can be more than one definition aspect. The first description of polypharmacy is the utilization of numerous pharmacies, which is a chief public health concern. This happens as the multiple prescribers in the industry, the ever readily available of supplements, and the use of OTC medications are some of the experienced challenges affecting the prescription for the aged population ( Chamberlain College of Nursing, 2018). Secondly, numerous prescribers, as well as care providers, the use of OTC drugs, the cost adherence, the availability of supplements as well as the herbals, are still problems affecting the prescriptions for the adults (Terrery & Nicoteri, 2016). Moreover, the use of several medicine drugs is what is referred to as polypharmacy, which usually affects the older population experiencing multi-morbidity, results as one or more medicine drugs can be employed as a therapeutic modality to treat each condition experienced (Masnoon, Skakib, & Caughey, 2017).The self-medication is a risk factor which contributes to the polypharmacy in most of the cases. The primary rationale here is evidenced based on that most of the patients usually buy medicine from the nearest local places as they do self-prescriptions and purchase, and this increases the risk factors of polypharmacy. Moreover, due to the rising status of the economy and the escalation of the cost of medicinal drugs the patients are often like to use the medicines that had been prescribed for them in the past and this enhances the risks of polypharmacy as a result of the self-medications (Maher, Hanlon, & Hajjar, 2014),The aspect of chronic comorbidities is a risk factor that results in the use of polypharmacy. For example, if the patient has been diagnosed with conditions such as diabetes, cancer, dementia, cardiorespiratory illness, infectious diseases, these patients are likely to be subjected to polypharmacy. Sometimes, when patients have different care providers with separate chart sheets, they are likely to subject the patient to polypharmacy (Maher, Hanlon, & Hajjar, 2014).Some of the interventions that I can take as nursing practitioner is enhance a comprehensive review of the patient treatment sheet to avoid an element of medication duplicate which might occur during the transmission of the patient from one facility to another one or even correctly check the information given to the patient by the chemist to avoid polypharmacy issues. The brown bag review technique is the strategy where the patient is encouraged, carrying all medical history to allow the comprehensive review to prevent the element of subjecting the patient into polypharmacy (McGrath et al., 2017). Another intervention strategy is to create a thorough follow up with the patients. The planning aid at the time of doing a prescription of medication as it provides a complete developed plan to monitor and assess the patient regularly. The comprehensive follow up method enables the patient to understand the effects and symptoms that may results due to medication withdrawal as it provides the necessary, which can cause the return of the condition if the medication is not taken as per the prescription.

 

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Reply to the following two classmates’ posts. In your reply posts, include your analysis of the impact on quality of care generated by these generated by these coverage gaps and the non-financial barriers to access described in your readings and in your own research. Each reply should be 200 to 300 words.

Post # 1: Michael

When we discuss access to health care, we are primarily referring to health insurance (Harvard University, 2014a). Thus, when we are referring to gaps in health care, we are referring to gaps in insurance coverage. In the U.S., gaps in health insurance significantly affect vulnerable sub-populations, which include women, children, low-income (and homeless), migrants, the mentally ill, elderly persons who retire prior to age 65, people living in rural areas, and persons with HIV/AIDS (Shi & Singh, 2019). Prior to the passage of Affordable Care Act (ACA), persons with pre-existing conditions were considerably affected by denial of health insurance coverage (Levitt, Damico, Claxton, Cox, & Politz, 2017). Less emergent gaps, although not less significant or potentially financially distressful, include access to long-term care, dental, and caregiver support (Reinhard, Feinberg, Houser, Choula, & Evans, 2019; Shi et al., 2019). Since the passage of the ACA, a new gap in coverage has emerged and that is the underinsured (Collins, Bhupal, & Doty, 2019). Despite the ACA’s ability to reduce the number of Americans uninsured, significant gaps persist, especially for lower income earners and racial/ethnic minorities (Sommers, McMurtry, Blendon, Benson, & Sayde, 2017).  In the United States, ethnic minorities are more likely to lack health insurance than whites, particularly in the western and southern areas (Shi et al., 2019). Per Shi and Singh (2019), people who are uninsured have a higher prevalence to having poor health. A couple of possible reasons for this are the uninsured tend to avoid accessing preventative services resulting in more expensive emergency health services and the uninsured tend to postpone obtaining essential prescriptions due to cost concerns (Shi et al., 2019). For those who assert that the poor bring it upon themselves and argue that society should not share the cost of their health misfortunes, Shi and Singh (2019) assert that Americans paid $85 billion in uncompensated care in 2013. Aside from the moral and ethical implications, ignoring these health care disparities among these vulnerable populations incurs a cost of approximately $1.5 trillion to the entire system every three years (Murphy, 2020).  Collins et al. (2019) report that the most significant deterioration in health quality and comprehensive insurance exists among Americans with employer-based plans. Collins et al. (2019) claimed that 45%, or 87 million, Americans qualify as under-insured. Per Collins et al. (2019), under-insured is defined as those who spend more than 5% of their annual income on out-of-pocket costs, not including their premiums. Due to rising deductibles, co-pays, and other out-of-pocket expenses, covered Americans are increasingly avoiding obtaining necessary medical attention when ill, did not fill a prescription, skipped prescribed tests and treatments, and failed to follow through with follow-up appointments or seeing a specialist (Collins et al., 2019). Now we are back to the beginning of this conversation where avoiding obtaining early medical interventions due to lack of money results in seeking more costly emergent care, which is, in turn, affecting the shared pocketbooks of all Americans (Murphy, 2020). However, these exorbitant costs could be better controlled if states expanded their Medicaid programs and better informed the public, including those insured by their employers, of their options (Collins et al., 2019; Murphy, 2020).  References Collins, S. R., Bhupal, H. K., & Doty, M. M. (2019). Health insurance coverage eight years after the ACA. The Commonwealth Fund. Retrieved from https://www.commonwealthfund.org/publications/issue-briefs/2019/feb/health-insurance-coverage-eight-years-after-aca Harvard University. (2014a). Topic 3: Access, Quality and Cost. Retrieved from https://courses.edx.org/courses/HarvardX/PH210x/1T2014/courseware/6ce98f482d6247c3aa65e260ea95bb3d/dc71cfef257548e28e5345af205c6000/1?activate_block_id=i4x%3A%2F%2FHarvardX%2FPH210x%2Fvertical%2F642e414f4862439fa0da074bf1d0f320  Levitt, L., Damico, A., Claxton, G., Cox, C., & Politz, K. (2017). Gaps in coverage among people with pre-existing conditions. KFF. Retrieved from https://www.kff.org/health-reform/issue-brief/gaps-in-coverage-among-people-with-pre-existing-conditions/ Murphy, M. (2020, January 28). Gaps in care: What you need to know. Medical Scribe Journal. Retrieved from https://www.scribeamerica.com/blog/gaps-in-care-what-you-need-to-know/ Reinhard, S. C., Feinberg, L. F., Houser, A., Choula, R., & Evans, M. (2019). Valuing the Invaluable: 2019 Update: Charting a Path Forward. AARP. Retrieved from https://www.aarp.org/ppi/info-2015/valuing-the-invaluable-2015-update.html Shi, L., & Singh, D. (2019). Delivering Health Care in America (7th ed.). Sudbury, MA: Jones and Bartlett. Sommers, B. D., McMurtry, C. L., Blendon, R. J., Benson, J. M., & Sayde, J. M. (2017). Beyond Health Insurance: Remaining Disparities in US Health Care in the Post-ACA Era. The Milbank Quarterly, 95(1), 43-69. Retrieved from doi:10.1111/1468-0009.12245

Post # 2: Molly

The purpose of this discussion is to analyze the major current contributors to insurance coverage gaps. More than half of Americans under age 65 receive health insurance through an employer (Collins et al., 2019). Two major contributors to gaps in coverage is loss of employment and the state does not expand Medicare eligibility. This means “individuals have an income above the Medicare eligibility but below the limit for Marketplace premium tax credits” (Garfield et al., 2020). The main contributor to no coverage is that individuals cannot afford the insurance. All these factors contribute to the insurance coverage gaps in America. Loss of employment can be a form of being released from your employer or voluntarily leaving your employer. Some jobs will have different timings on when insurance coverage stops, for example coverage could last one month after leaving your job. Some jobs don’t activate health insurance coverage until 90 days into the job. Options for a person with a gap in coverage to get coverage are through a spouse’s plan, COBRA, ACA or individual insurance, short-term plans, and Medicaid (Masterson, 2020). It is important to plan ahead to know when your gap in coverage will be and get insurance accordingly, although if released from your employer this could be a major problem.  If states expanded their programs and adopt the Medicaid expansion, 2.3 million adults with gain Medicaid edibility (Garfield et al., 2020). People in the coverage gap are usually people with limited family income and live below poverty level, therefore these people will not be able to afford ACA coverage (Garfield et al., 2020). For example, in 2020 the premium for a 40-year-old non-smoking individual purchasing coverage through the Marketplace was $331 per month for the lowest plan (Garfield et al., 2020). This is sometime half of an individual’s income, which ends up relating to the reason of not getting coverage because people cannot afford it. This is huge problem for people because they will face barriers to needed health services or if they do require and receive medical care, they will have financial consequences (Garfield et al., 2020). If states expand Medicaid eligibility this might prevent these problems. As discussed earlier, another problem is no coverage due to not being able to afford insurance coverage. Two of the contributors discussed apply to this as well because if you do not have employment you don’t have income and if you live below the poverty level, income is low. Some of the worries with health care costs are difficulty affording routine costs of insurance, costs stop people from getting needed care or filling prescriptions, and difficulty paying medical bills and having consequences on families (Kirzinger et al., 2019). Twice as many people with insurance from employers say cost-related concerns are the most important feature to them when choosing a health plan compared to coverage-related concerns (Kirzinger et al., 2019). Ultimately this means people will only look at the cost of health insurance and not worry if it covers what they need medically. Health care coverage is extremely important and when someone can’t afford it or has a gap in coverage this is a critical time in their life.    References

Collins, R. S., Bhupal, K. H., & Doty, M. M. (2019). Health insurance coverage eight years after the ACA. The Commonwealth Fund. Retrieved from https://www.commonwealthfund.org/publications/issue-briefs/2019/feb/health-insurance-coverage-eight-years-after-aca Garfield, R., Orgera, K., & Damico, A. (2020). The coverage gap: Uninsured poor adults in states that do not expand Medicaid. KFF. Retrieved from https://www.kff.org/medicaid/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/ Kirzinger, A., Munana, C., Wu, B., & Brodie, M. (2019). Data note: Americans’ challenges with health care costs. KFF. Retreived from https://www.kff.org/health-costs/issue-brief/data-note-americans-challenges-health-care-costs/ Masterson, L. (2020). How to get health insurance if you’re unemployed or changing jobs. Insure.com. Retrieved from https://www.insure.com/health-insurance/job-change-and-obamacare.html

 

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A company has the opportunity to do any, none, or all of the projects for which the net cash flows per year are shown below. The company has a cost of capital of 12%. Which should the company do and why? You must use at least two capital budgeting methods. Show your work.

Year

A

B

C

0

-300

-150

-350

1

100

-50

100

2

100

100

100

3

100

100

100

4

100

100

100

5

100

100

100

6

50

100

100

7

-100

-200

0

 

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1. A bond has 5 years to maturity and has a YTM of 8%. Its par value is $1,000. Its semiannual coupons are $50. What is the bonds current market price? (Show workings)

2. A bond currently sells for $1,030 even though it has a par of $1,000. It was issued two years ago and had a maturity of 10 years. The coupon rate is 7% and the interest payments are made semiannually. What is its YTM? (Show workings)

3. If you were a manager of a company, which of the three right side components of the DuPont Identity would you want to increase and which would you want to decrease, other things being equal? Give a specific example for how to do that for each of the three.

4. A stock has just paid a dividend and will pay a dividend of $3.00 in a year. The dividend will stay constant for the rest of time. The return on equity for similar stocks is 14%. What is P0? (Show workings)

5. A stock has just paid a dividend and has declared an annual dividend of $2.00 to be paid one year from today. The dividend is expected to grow at a 5% annual rate. The return on equity for similar stocks is 12%. What is P0? (Show workings)

6. Using examples, explain the difference between systematic risk and nonsystematic risk. Explain why the distinction is important for both investors and issuers of stock.

7. A company has 30 million shares outstanding trading for $8 per share. It also has $90 million in outstanding debt. If its equity cost of capital is 15%, and its debt cost of capital is 9%, and its effective corporate tax rate is 40%, what is its weighted average cost of capital? (Show workings)

8. What is the difference between capital structure and capital budgeting? Explain and give an example of a capital structure decision and an example of a capital budgeting decision.

9. What is the Cash Conversion Cycle (CCC)? Name the components of the CCC and explain why the CCC is important to business.

 

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The Nazis used logical fallacies to manipulate the German people like an appeal to emotion.
In most of the propaganda when they see it you can feel many emotions from then. For example for the childrens book, it is showing how they manipulate kids to learn about Jews. This proves my claim because you can feel how they just had to learn about the Jews. They learned how bad the Jews were in mushroom context. In another source about girls belonging to fhrer. This propaganda shows that the girls belong to a leader, too. This shows that Hitler really wants the girls to join a youth group for them to be with the fhrer. The next propaganda is the German student saying fight for the Fhrer and people. All of these posters are not facts it’s trying to get people in Germany to do this without knowing because if you dont join the 
In conclusion, all of these posters appeal to emotions to people who just look at it. Also, these are not facts its just saying do this so you can look have a good future ahead
The Nazis used logical fallacies to manipulate the German people like an appeal to emotion.

 

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