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In 17 unconfounded trials of pharmacological treatment involving almost 50,000 individuals with mean follow up of 4.9 years, the average treatment induced fall in diastolic BP of 5–6 mm Hg was associated with highly significant reductions in fatal and non-fatal stroke (38%), and fatal and non-fatal heart attacks (16%); there were no significant differences among the individual trials. 124 Non-vascular deaths were evenly distributed among treatment groups and therefore all cause mortality was also reduced (12%). This overview provides direct and highly significant evidence that just a few years of BP lowering prevents the proportion of stroke events anticipated from prospective epidemiological data, although there may have been a shortfall in prevention of CHD events (16% observed v 20–25% expected). Uncertainties about the value of antihypertensive therapy in preventing CHD events may reflect the limited power of individual trials for a statistically reliable assessment of treatment effect. It is likely that the benefits of antihypertensive treatment have been underestimated in most of the randomised controlled trials because, overall, up to 25% of patients randomised to placebo—those with the highest pressures—were switched to active therapy. 64-66 125 In addition, most trials were short term, and relatively low risk patients were included preferentially (those with other major concomitant risk factors or target organ damage were excluded), reducing the likelihood of absolute risk reduction. 126 127

Although cardiovascular risk increases across the whole BP range, 128 recommendations for the threshold of intervention are based on the level of BP above which treatment has been shown to reduce cardiovascular risk in randomised controlled trials. Evidence from both observational studies and randomised control trials suggest that cardiovascular risk is at least as closely associated with systolic BP as with diastolic BP. sOliver BLACK LABEL Classic heels copper RsskRhoLe6
130 However, because entry into the randomised controlled trials was based on diastolic BP level, 124 with two exceptions, KARL LAGERFELD SKOOL SIGNIA LACE LO Trainers black wQPaFbLfK
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thresholds for intervention have usually been based on diastolic BP. In addition to BP the threshold for therapeutic intervention with antihypertensive drugs should also be influenced by an assessment of all cardiovascular risk factors, and not simply the level of BP.

Diastolic BP measurements of 110 mm Hg or greater should be repeated over one to two weeks to confirm a sustained increase, despite lifestyle intervention, after which drug treatment should be started. Individuals with diastolic BP in the range 100–109 mm Hg, but with no evidence of target organ damage, should be given lifestyle advice and observed, initially weekly and thereafter monthly. If there is a downward trend in BP (diastolic less than 100 mm Hg), observations should be continued together with reinforced lifestyle advice. If diastolic BP is sustained at or above 100 mm Hg during this three to six month period, drug treatment should be started. 5

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Executive Summary

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A health care revolution is under way, and doctors must be part of it. But many are deeply anxious and angry about the transformation, fearing loss of autonomy, respect, and income. Given their resistance, how can health system leaders engage them in redesigning care? In this article, Dr. Thomas H. Lee, Press Ganey’s chief medical officer, and Dr. Toby Cosgrove, the CEO of the Cleveland Clinic, describe a framework they’ve developed for encouraging buy-in.

Adapting Max Weber’s “typology of motives,” and applying behavioral economics and other motivational principles, they describe four tactics leadership must apply in concert: engaging doctors in a noble shared purpose; addressing their economic self-interest; leveraging their desire for respect; and appealing to their sense of tradition.

Drawing from experiences at the Mayo Clinic, Geisinger Health System, Partners HealthCare, the Cleveland Clinic, Ascension Health, and others, the authors show how the four motivational levers work together to bring this critical group of stakeholders on board.

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Despite wondrous advances in medicine and technology, health care regularly fails at the fundamental job of any business: to reliably deliver what its customers need. In the face of ever-increasing complexity, the hard work and best intentions of individual physicians can no longer guarantee efficient, high-quality care. Fixing health care will require a radical transformation, moving from a system organized around individual physicians to a team-based approach focused on patients. Doctors, of course, must be central players in the transformation: Any ambitious strategy that they do not embrace is doomed.

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A s humans, we can’t help but be goal-oriented. We love to move forward. We love to feel a sense of momentum. And, more than anything, we love to tick things off a list.

This manifests as something called completion bias , a happy-making hit of dopamine that we get whenever we recognize a task as complete. And because we are hard-wired to crave completion, there are few things that keep us more engaged at work — and in life — than feeling a sense of progress.

In a fascinating study , Harvard researcher Teresa Amabile tracked emotions, motivations and perceptions of 238 knowledge workers over the course of 4 months, ultimately collecting over 12,000 diary entries. The results were unequivocal:

Of all the things that can boost emotions, motivation, and perceptions during a workday, the single most important is making progress in meaningful work. And the more frequently people experience that sense of progress, the more likely they are to be creatively productive in the long run. Whether they are trying to solve a major scientific mystery or simply produce a high-quality product or service, everyday progress—even a small win—can make all the difference in how they feel and perform.

Making progress in meaningful work is the key to staying engaged. And, as Amabile notes, progress doesn’t necessarily mean great, bounding leaps forward – in fact, it usually doesn’t. A palpable sense of progress typically emerges from studiously tracking our “small wins.” Here’s Amabile again:

When we think about progress, we often imagine how good it feels to achieve a long-term goal or experience a major breakthrough. These big wins are great—but they are relatively rare. The good news is that even small wins can boost inner work life tremendously. Many of the progress events our research participants reported represented only minor steps forward. Yet they often evoked outsize positive reactions. Consider this diary entry from a programmer in a high-tech company, which was accompanied by very positive self-ratings of her emotions, motivations, and perceptions that day: “I figured out why something was not working correctly. I felt relieved and happy because this was a minor milestone for me.”

The good news is that even small wins can boost inner work life tremendously. Many of the progress events our research participants reported represented only minor steps forward.

However, if you want to feel progress, you have to track it. Most of us make advances small and large every single day, but we fail to notice them because we lack a method for acknowledging our progress. This is a huge loss.

A pervasive sense of overwhelm is common these days. We feel like we have too many things to do, and not enough time to do them. We work tirelessly but rarely feel like we’re accomplishing anything of import. What’s wrong?

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