Tuesday, January 28, 2020

Comparison of Pneumonia Management Methods

Comparison of Pneumonia Management Methods INTRODUCTION 1.1 Background: Pneumonia is the inflammation and consolidation of lung tissue due to an infectious agent (Marrie TJ, 1994). Pneumonia has the highest mortality rate among infectious diseases and represents the fifth leading cause of death (Brandstetter, 1993). Pneumonia causes excess morbidity, hospitalization, and mortality, especially among the elderly, the fastest growing sector of the population.According to first- or second-listed diagnosis, approximately 1 million persons were discharged from short-stay hospitals after treatment for pneumoniain the United States in 1990, and elderly persons aged 65 years or more accounted for 52% of all pneumonia discharges (Fedson Musher, 1994). Pneumonia has the highest mortality rate among infectious diseases and represents the fifth cause of death (Brandstltter, 1993). In addition fine (2000) reported that lower respiratory tract infections affect three million persons annually and is the leading cause of death of infection in the United States. †¢ Pneumonia represented one of the 10th leading causes of hospitalization and deaths in Malaysia through 1999-2006 (Ministry of Health, Malaysia, 1999, 2000, 2001, 2002b, 2003, 2004, 2005band 2006b) Because of differences in pathogenesis and causative micro-organisms, pneumonia is often divided into: hospital acquired and community-acquired pneumonia.Community acquired pneumonia (CAP) is caused mainly by streptococcus pneumoniae. Its symptoms include coughing (with or without sputum production), change in colour of respiratory secretion, fever, and pleuritic chest pain (Fine, 2000). Nosocomial pneumonia or hospital acquired pneumonia is the second most common nosocomial infection in the United States and it causes the highest rates of morbidity and mortality. It is caused mainly by streptococcus pneumoniae and pseudomonas aeruginosa. The highest mortality rates occurred in patients with pseudomonas aeruginosa or acineobacter infection. It is characterized by fever and purulent respiratory secretion. Nosocomial pneumonia results in increase length of hospitalization and cost of treatment (Kashuba, 1999; Levison, 2003; Wilks et al., 2003). The clinical criteria for the diagnosis o f pneumonia include chest pain, cough, or auscultatory findings such as rales or evidence of pulmonary consolidation, fever or leucocytosis. In addition, there must be radiographic evidence, such as the presence of new infiltrates on chest radiograph, and laboratory evidence that supports the diagnosis. Because of differences in pathogenesis and causative micro-organisms, pneumonia is often divided in hospital acquired and community-acquired pneumonia. Pneumonia developing outside the hospital is referred to as community-acquired pneumonia (CAP). Pharmacoeconomic study Pharmacoeconomics is defined as the description and analysis of costs of drug therapy or clinical service to health care systems and society (Bootman et al., 1996). It has risen up as the discipline with the increase interst in calculating the value and costs of medicines (Sanches, 1994). Cost is defined as the value of resources consumed by the program or drug therapy of interest while a consequence is defined as the effect, outputs, or outcomes of a program. When identifying the costs associated with a product or service, all possible costs that include or related to the study are calculated (Sanchez, 1994). With the increase in financial pressure to hospitals to minimize their medical care costs, pharmacoeconomics can define costs and benefits of both expensive drug therapies and pharmacy based clinical services (Destache, 1993; Touw, 2005).Furthermore pharmacoeconomics can assist practitioners in balancing cost and quality that may result in improving patient care and cost saving to the institution (Sanches, 1994). Bootman and Harison (1997) stated that pharmacoeconomics and outcome research are very important to determine the efficient way to present a quality care at realistic rate. They suggested that pharmacoeconomics should have a remarkable authority on the delivery and financing of health care throughout the world. Different methods have been used to perform pharmacoeconomics analysis which includes: Cost-benefit analysis: Cost-benefit analysis two or more alternatives that do not have the same outcome measures. It measures all costs and benefits of a program in monetary terms (Bootman et al., 1996; Fleurence, 2003). Cost-benefit analysis could play a major role in identifying the specific costs and benefits associated with the pneumonia. Cost-effective analysis Cost-effective analysis compares alternatives that differ in safety, efficacy and outcome. Cost is measured in monetary terms, while outcome is measured in specific objectives or natural units. The outcome are expressed in terms of the cost per unit of success or effect (Bootman et al., 1996). Cost-utility analysis Cost-utility analysis compares treatment alternatives; benefits are measured in terms of quality of life, willingness to pay, and patient preference for one intervention over another, while cost is measured in monetary terms. It has some similarity to cost-effectivness with more concentration on patient view. As an example, looking for new druig therapy; benefits can built-in together with expected risks. Cost-minimization analysis Cost-minimization analysis is one of the simplest forms of pharmacoeconomics analysis. It is used when two or more alternatives are assumed to be equivalent in terms of outcomes but differ in the cost which is measured in monetary terms (Fleurence, 2003). Cost of illness analysis Cost of illness analysis is the determination of all costs of aparticular disease, which include both direct and indirect costs. Since both costs were calculated, an economic evaluation for the disease can be performed successfully. It has been used for evaluating many diseases (Bootman et al., 1996). 1.2 Study problems and rationale The management of pneumonia is very straight forward. However this is not always true for the diagnosis and selection of therapy. As there are some issues related to pneumonia that need to be addressed : The first issue pertains to the inappropriate diagnosis of the pneumonia. Some physicians do not properly identify the causative organism, I.e, whether, it is bacterial or viral. Bartlet et al (1998) found that the viral infections have been associated with at least 10% to 15 % of CAP in hospitalized adults (Bartlet et al, 1998). Secondly is the use of inappropriate medications. The prescription of inappropriate or un-indicated drug therapy such as the prescription of antibiotics for pneumonia caused by nonbacterial infection may increase the incidence of bacterial resistance (Steinman, 2003). Thirdly the adherence to guidelines improves quality of care and reduces the length of hospital stay (Marrie TJ et al, 2000). Fourthly the adherence to guidelines reduces the cost of treating pneumonia (Feagan BG, 2001). Fifthly Teaching hospitals are widely perceived to provide good outcome, and that reputation is thought to justify these institutions comparatively higher charges relative to non-teaching (general) hospitals. Despite their reputation for specialized care, teaching hospitals have traditionally relied on revenue from routine services, such as treatment of pneumonia, and the costs of specialized services and medical training. However, with managed care and competition creating pressures for cost containment, these higher costs have come into question: Do a teaching hospital provide good outcome for management of pneumonia, or do a general hospital provide comparable outcome at lower costs? 1.3 Significance of the Study This study has the following important issues: To the researchers: Several studies have compare the management of pneumonia in a university hospital versus a general hospital, but most of these studies were conducted in the USA and other parts of the world. There are no published studies in Malaysia or Asia to our knowledge. This study also provides the difference in the outcome, cost and cost-effectivness of treating pneumonia between a university hospital and a general hospital. To the practitioners: This study will provide information about the adherence to guidelines will reduce the length of hospital stay, reduce the cost of treating pneumonia and improve outcomes of treating pneumonia. To the patients: This study attempts to highlight the benefits associated with adherence to the guidelines. To the policy makers: This study will help policy makers to develop new strategies for management of pneumonia. This study will help policy makers to develop new guideline for management of pneumonia according to the microorganisms and the population in Malaysia. This study also provides the difference in the management of pneumonia between a university hospital and a general hospital. This study will provide information about how we can reduce the length of hospital stay, reduce the cost of treating pneumonia and improve outcomes of treating pneumonia. The results of this study will help in improving the management of pneumonia. It is the time to know whether a university hospital (H-USM) provide good outcome for treating pneumonia or do a general hospital (Penang-GH) provide comparable outcome at lower costs. By analyzing the cost and effectiveness of the regimens being used, the most effective therapy can be defined and the information can be offered to the policy makers to improve the deciosion making in treating pneumonia. The study will be able to help on: How we can make the drug therapy cost effective keeping effectiveness and outcome in our mind and try to suggest the best and most appropriate drug therapy which should be cost effective which help to decrease the financial burden on patients as well as Ministry Of health. This study will help to suggest how we can reduce the cost of therapy of treating pneumonia. The study will be able to provide data on: The incidence of pneumonia in (H-USM and Penang-GH). The most common organisms causing pneumonia in (H-USM and Penang-GH). The pattern of drugs used and management of pneumonia in in (H-USM and Penang-GH). The outcome of treating pneumonia in (H-USM and Penang-GH). The cost of treating pneumonia in (H-USM and Penang-GH). The cost-effectivness of treating pneumonia in (H-USM and Penang-GH). Whether a university hospital provide a good outcome for management of pneumonia, or a general hospital provide comparable quality at lower costs. 1.4 Hypothesis of the Study: H0: There is no significant difference of the management of pneumonia between a universiry hospital (H-USM) and a general hospital (Penang-GH). H1: There is a significant difference of the management of pneumonia between a universiry hospital (H-USM) and a general hospital (Penang-GH). 1.5 Aim of the study The aim of this study is to compare the management of pneumonia in a university hospital (H-USM) versus a general hospital (Pinanag-GH). 1.6 Objectives The objectives of this study are: To compare the incidence of pneumonia at a university hospital (H-USM) versus a general hospital (Penang-GH). To compare the most common organisms associated with pneumonia at a university hospital (H-USM) versus a general hospital (Penang-GH). To compare the drug therapy for pneumonia at a university hospital (H-USM) versus a general hospital (Penang-GH). To compare the outcome of treating pneumonia (mortality rate, length of hospitalization, pneumonia related symptoms at discharge and complications of pneumonia) at a university hospital (H-USM) versus a general hospital (Penang-GH). To compare the cost of treating pneumonia at a university hospital (H-USM) versus a general hospital (Penang-GH). To compare the cost-effectivness of treating pneumonia at a university hospital (H-USM) versus a general hospital (Penang-GH). 1.7 Research Questions What are the difference between the organisms that is commonly associated with pneumonia at H-USM and Penang-GH? What are the difference between the antibiotics that is commonly used for the treatment of pneumonia at H-USM and Penang-GH? What are the difference between the outcome of treating pneumonia (mortality rate, length of hospitalization, pneumonia related symptoms at discharge and complications of pneumonia) at H-USM and Penang-GH? What are the difference between the cost of treating pneumonia at H-USM and Penang-GH? And how can these costs be reduced? What are the difference between the cost-effectivness of treating pneumonia at H-USM and Penang-GH? Do a university hospital (H-USM) provide good outcome for treating pneumonia or do a general hospital (Penang-GH) provide comparable outcome at lower costs? CHPTER 2 LITERATURE REVIEW 2.1 Community-acquired pneumonia 2.1.1 Introduction Community-acquired pneumonia (CAP) is defined as an acute infection of the pulmonary parenchyma that is associated with at least some symptoms of acute infection, a new infiltrate on chest x-ray or auscultatory findings such as altered breath sounds and/or localized rales in community-dwelling patients (Infectious Diseases Society of America 2000). It is a common condition that carries a high burden of mortality and morbidity, particularly in elderly populations. Although most patients recover without sequellae, CAP can take a very severe course, requiring admission to an intensive care unit (ICU) and even leading to death. According to US data, it is the most important cause of death from infectious causes and the sixth most important cause of death overall (Adams et al. 1996). Even though the mortality from pneumonia decreased rapidly in the 1940s after the introduction of antibiotic therapy, it has remained essentially unchanged since then or has even increased slightly (MMWR 1995 ). Furthermore, significant costs are associated with the diagnosis and management of CAP. Between 22% and 42% of adults with CAP are admitted to hospital, and of those, 5% to 10% need to be admitted to an ICU (British Thoracic Society 2001). In the US, it is estimated that the total cost of treating an episode of CAP in hospital is about USD $ 7500, which is approximately 20 times more than the cost of treating a patient on an outpatient basis (Lave et al. 1999). CAP also contributes significantly to antibiotic use, which is associated with well-known problems of resistance. In treating patients with CAP, the choice of antibiotic is a difficult one. Factors to be considered are the possible etiologic pathogen, the efficacy of the substance, potential side-effects, the treatment schedule and its effect on adherence to treatment as well as the particular regional resistance profile of the causative organism and the co-morbidities that might influence the range of potential pathogens (such as in cystic fibrosis) or the dosage (as in the case of renal insufficiency). It may be a primary disease occurring at random in healthy individuals or may be secondary to a predisposing factor such as chronic lung disease or diabetes mellitus. CAP represents a broad spectrum of severity, ranging from mild pneumonia that can be managed by general practitioners outside the hospital to severe pneumonia with septic shock needing treatment in intensive care unit. Depending on severity of illness, about 20% of patients with pneumonia need hospitalization and approximately 1% of all CAP patients require treatment in ICU. Elderly persons and those with underlying conditions, such as cerebro and cardiovascular diseases, chronic obstructive pulmonary disease (COPD) and alcoholism, are at increased risk for developing lower respiratory tract infections and complicated courses of infection. 2.1.2 Definition: Community-Acquired pneumonia (CAP) is defined as inflammation and consolidation of lung tissue induced by infectious microbes such as bacteria, viruses, or parasites. When the onset of symptoms and signs of this disease is before or within 48 hours after admission, it is considered as CAP (Bartlett JG et al., 1995). 2.1.3 Epidemiology Incidence: In the industrialized world, the annual incidence of CAP in community dwelling adults is estimated at 5 to 11 cases per 1000 adult population (British Thoracic Society 2001). The incidence is known to vary markedly with age, being higher in the very young and the elderly. In one Finnish study, the annual incidence for people aged 16-59 years was 6 cases per 1000 population, for those 60 years and older it was 20 per 1000, and for people aged 75 and over, 34 per 1000 (Jokinen et al. 1993). Annual incidences of 30-50 per 1000 population have been reported for infants below 1 year of age (Marrie 2001). Seasonal variations in incidence are also significant, with a peak in the winter months (Marrie 2001). The annual incidence of CAP requiring hospitalisation has been estimated at 1 to 4 patients per 1000 population (Marrie 1990, Fine et al. 1996). The proportion of patients requiring hospitalisation varies from country to country and across studies and has been estimated as ranging anywhe re between 15% and 56% (Foy et al. 1973, Minogue et al. 1998). Of those, 5% to 10% required admission to an intensive care unit (ICU) (British Thoracic Society Research Committee and Public Health Laboratory Service 1992, Torres et al. 1991). Conversely, about 8% to 10% of admissions to a medical ICU are due to severe CAP (Woodhead et al. 1985). Community acquired pneumonia (CAP) is a leading infectious disease cause of death throughout the world (WHO Statistical Information System (WHOSIS). WHO Mortality Database. Released: January 2005; Health, United States, 2005; Annual Report, Hong Kong, 2003/2004). Adult community-acquired pneumonia is a serious, life-threatening illness that affects more than 3 million people each year and accounts for more than half a million annual hospital admissions in the United States alone (Lynch JP, 1992). Each year, more than 900 000 cases of pneumonia occur in the United States, accounting for nearly 3% of all hospital admissions,(National Hospital Discharge Survey, 1988) and about 50 000 people die as a result of community-acquired pneumonia (Farr BM et al 203). Bartlet et al (1998) found that viral infections have been associated with at least 10% to 15 % of CAP in hospitalized adults. Adult community-acquired pneumonia is a serious, life-threatening illness that affects more than 3 million people each year and accounts for more than half a million annual hospital admissions in the United States alone. Each year, more than 900 000 cases of pneumonia occur in the United States, accounting for nearly 3% of all hospital admissions, and about 50 000 people die as a result of community-acquired pneumonia. In the USA, community acquired pneumonia is the fifth leading cause of death in people over the age of 65 years and an estimated 60 000 seniors die annually. Most of the excess deaths and hospitalizations due to lower respiratory infections occur in older adults, as reflected by the more than 44 000 hospitalizations for pneumonia and influenza in people aged 65 and older in 1997 in Canada. It is estimated that the age-specific incidence of pneumonia increases from 15.4 cases per 1000 in those aged 60-74 years to 34.2 for those 75 years and older. Residents of long-term care facilities, a distinct subpopulation of elderly people, are at particularly high risk for developing nursing-home acquired pneumonia. Health costs for this sector are growing at an accelerated rate as the age of dea th increases. Thirteen percent of the population is over the age of 65 in the United States and this is expected to increase to 20% by 2030. In Canada, the proportion of individuals over the age of 65 is expected to rise to 20% in the year 2021. Presently, while making up 12% of the Canadian population, older adults account for 31% of acute hospital days and half of all hospital stays. To meet their health-care needs and alleviate the burden onthe health-care system, we must improve our understanding of the management and prevention of pneumonia in this age group. Elderly people constitute an ever-increasing proportion of the population. CAP has traditionally been recognized as problems that particularly affect the older individuals. According to western studies, the overall rate of pneumonia requiring hospitalization increase with age, from 1 per 1,000 persons in the general population but increases to 12 per 1,000 persons for those over age 75 years3. As the population of those ov er age 65 years is predicted to rise from its current level of 11% to 25 % of the total population in the year 20504, respiratory tract infection will assume a greater degree of importance to the overall public health. In Hong Kong, pneumonia was the fourth leading death from a specific diagnosis in 2001. A total of 3026 people died of pneumonia in 2001 which 1526 cases were male. Out of the 3026 deaths, 2794 patients were 65 or older which accounted for more than 90% of the total death. Pneumonia in the elderly population is a major cause of morbidity and mortality and in some series represents the leading cause of death. The annual cost of treating patients age > 65 years with pneumonia to be $4.8 billion, compared with $3.6 billion for those 85 years need help with bathing and 10% need help in using the toilet and transferring. The present of any or all of following identifies elderly persons at greatest risk for functional decline: pressure ulcer, cognitive impairment, functiona l impairment, and low level of social activity. The attack rate for pneumonia is highest among those in nursing homes. It is found that 33 of 1,000 nursing home residents per year required hospitalization for treatment of pneumonia, compared with 1.14 of 1,000 adults living in the community. Pneumonia is a major cause of morbidity and mortality worldwide. In the UK as a whole, pneumonia is responsible for over 10% of all deaths (66,581 deaths in 2001), the majority of which occur in the elderly. Community-acquired pneumonia (CAP) remains a common cause of morbidity. Because CAP also is a potentially fatal disease, even in previously healthy persons, early appropriate antibiotic treatment is vital. In Japan, pneumonia is the fourth leading cause of death, and from 57 to 70 persons per 100,000 populations died per year of this disease in the last decade. Community acquired pneumonia (CAP) is a leading infectious disease cause of death throughout the world, including Hong Kong, Pneumonia is the second most common infectious disease in Thailand. Whereas diarrhea is more common, pneumonia is associated with more fatalities. CAP remains the leading cause of death due to infectious diseases, with an annual incidence ranging 1.6-10.6 per 1,000 adult populations in Europe According to the Ministry of Health Malaysia (MOH), pneumonia is the 5th cause of death in Malaysia and the 4th cause of hospitalization. A prospective observational study by Jae et al (2007) of 955 cases of adult CAP in 14 hospitals in eight Asian countries found that the overall 30-day mortality rate was 7.3%. A prospective study by Liam CK et al (2001) of 127 cases of CAP in Malaysia found that the Mortality from CAP is more likely in patients with comorbidity and in those who are bacteraemic. A prospective study by LOH et al (2004) of 108 cases of adult CAP in urban-based university teaching hospital in Malaysia found that the mortality rate from CAP in hospital was 12%. 2.1.4 Syndromes of CAP The presence of various signs and symptoms and physical findings varies according to the age of the patients, therapy with antibiotics before presentation, and the severity of illness. Patients with pneumonia usually present with cough (>90%), dyspnea (66%), sputum production (66%% pleuritic chest pain (50%), and chills is present in 40-70% and rigor in 15%. However, a variety of nonrespiratory symptoms can also predominate in pneumonia cases, including fatigue (91%), anorexia (71%), sweating (69%), and nausea (41%). Metlay et al. (1997c) divided 1812 patients with CAP into four age groups: 18 through 44 years (43%), 45 through 64 years (25%), 65 through 74 years (17%), and 75 years or older (15%). For 17 of the 18 recorded symptoms there were significant decreases in reported prevalence with increasing age (p 37 °C at presentation. Crackles were present on auscultation in 80% of patients, and rhonchi in 34% to 47% (more common in the nursing home patients). About 25% had the physical findings of dullness to percussion, bronchial breathing, whispered pectoriloquy, and aegophony. Alteration in mental status was common. Marrie and coworkers (1989) reported confusion in 48% of the patients with nursing home-acquired pneumonia and in 30% of the other patients with CAP. Fine and colleagues (1998) define altered mental status as stupor, coma, or confusion representing an acute change from the usual state prior to presentation with pneumonia. This was present in 17.3% of the hospitalized patients. The decrease in symptoms with increasing age, tachypnea increased with increasing age (Metlay et al., 1997c). Thirty-six percent of 780 patients with CAP in the 18-44 year age group had tachypnea on admission versus 65% of the 280 patients who were = 75 years old. There were minimal differences in the proportion of patients with tachycardia and hyperthermia in the different age groups Pneumonia in the elderly are quite different from that in a younger population. These differences are due to age-related alterations in immunology, different epidemiology and bacteriology. It is important to remember that pneumonia in the elderly may report fewer respiratory signs and symptoms. The clinical presentation may be more subtle than in younger population, with more gradual onset, less frequent complaints of chill and rigors, and less fever. The classical finding of cough, fever, and dyspnea may be absent in over half of elderly patients8. Instead they may be manifest as delirium, a decline in f unctional status, weakness, anorexia, abdominal pain, or decrease general condition. The incidence of fever may decline with age, and the degree of fever appears lower in old population10. Tachypnea which respiration rate greater than 24-30 breaths per minute is noted more frequently in up to 69% of patients. Although rales are common and are noted in 78% of patients, signs of true consolidation are found in only 29%. Bacteremia, metastatic foci of infection and death are more frequent in older populations. As many elderly present with non-specific clinical symptoms and nonspecific functional decline that makes an accurate diagnosis difficult and may lead a life-threatening delay of diagnosis and therapy. Metlay et al. compared the prevalence of symptoms and signs of pneumonia in a cohort of 1812 patients and found that patients aged 65-74 years and over 75 years had 2.9 and 3.3 fewer symptoms, respectively, than those aged 18 through 44 years. The reduced prevalence of symptoms was most pronounced for symptoms related to febrile response (chills and sweats) and pain (chest, headache, and myalgia). These findings are consistent with those of Marrie et al. demonstrating reduced prevalence of non-respiratory symptoms among elderly patients. In a retrospective chart review by Johnson et al., the presence of dementia seemed to account for non-specific symptoms. However the sample size of the study was small and precluded a multivariable analysis. Roghmann et al found a significant inverse correlation between age and initial temperature in 320 older patients hospitalized for pneumonia. Evidence therefore does exist for a less distinct presentation of nonrespiratory symptoms and signs of pneumonia in the elderly. 2.1.5 Radiographic findings in CAP Radiographic changes usually cannot be used to distinguish bacterial from nonbacterial pneumonia, but they are often important for diagnosis of CAP, evaluating the severity of illness, determining the need for diagnostic studies, and selecting antibiotic agents. A chest radiograph usually shows lobar or segmental opacification in bacterial pneumonias and in the majority of atypical infections. Patchy peribronchial shadowing or more diffuse nodular or ground-glass opacification is seen less commonly, particularly in viral and atypical infections. The lower lobes are most commonly affected in all types of pneumonia. Small pleural effusions can be detected in about one-quarter of cases. Multilobar pneumonia is a feature of severe disease, and spread to other lobes despite appropriate antibiotics is seen in Legionella and M. pneumoniae infection. Hilar lymphadenopathy is unusual except in Mycoplasma pneumonia, particularly in children. Cavitation is uncommon but is a classic feature of S . aureus and S. pneumoniae infections. False negative results can be attributed to dehydration, evaluation during the first 24 hours, pneumonia due to Pneumocystis carinii, or pneumonia with profound neutropenia. 2.1.6 Etiology: More than 100 microorganisms have been identified so far as potential causative agents of CAP (Marrie 2001). They can be classified according to their biological characteristics as either bacteria, mycoplasma and other intracellular organisms, viruses, fungi and parasites. The most common causative agent of CAP is the bacteriumStreptococcus pneumoniae, which is implicated in 20% to 75% of cases of CAP (Marrie 2001) and about 66% of bacteremic pneumonia (Infectious Diseases Society of America 2000). Another causative bacterium is Haemophilus influenzae. So called â€Å"atypical† organisms have also been implicated as causal agents. These include Chlamydia pneumoniae, Mycoplasma pneumoniae and Legionella pneumophila (Marrie 2001). Influenza is the most common serio Comparison of Pneumonia Management Methods Comparison of Pneumonia Management Methods INTRODUCTION 1.1 Background: Pneumonia is the inflammation and consolidation of lung tissue due to an infectious agent (Marrie TJ, 1994). Pneumonia has the highest mortality rate among infectious diseases and represents the fifth leading cause of death (Brandstetter, 1993). Pneumonia causes excess morbidity, hospitalization, and mortality, especially among the elderly, the fastest growing sector of the population.According to first- or second-listed diagnosis, approximately 1 million persons were discharged from short-stay hospitals after treatment for pneumoniain the United States in 1990, and elderly persons aged 65 years or more accounted for 52% of all pneumonia discharges (Fedson Musher, 1994). Pneumonia has the highest mortality rate among infectious diseases and represents the fifth cause of death (Brandstltter, 1993). In addition fine (2000) reported that lower respiratory tract infections affect three million persons annually and is the leading cause of death of infection in the United States. †¢ Pneumonia represented one of the 10th leading causes of hospitalization and deaths in Malaysia through 1999-2006 (Ministry of Health, Malaysia, 1999, 2000, 2001, 2002b, 2003, 2004, 2005band 2006b) Because of differences in pathogenesis and causative micro-organisms, pneumonia is often divided into: hospital acquired and community-acquired pneumonia.Community acquired pneumonia (CAP) is caused mainly by streptococcus pneumoniae. Its symptoms include coughing (with or without sputum production), change in colour of respiratory secretion, fever, and pleuritic chest pain (Fine, 2000). Nosocomial pneumonia or hospital acquired pneumonia is the second most common nosocomial infection in the United States and it causes the highest rates of morbidity and mortality. It is caused mainly by streptococcus pneumoniae and pseudomonas aeruginosa. The highest mortality rates occurred in patients with pseudomonas aeruginosa or acineobacter infection. It is characterized by fever and purulent respiratory secretion. Nosocomial pneumonia results in increase length of hospitalization and cost of treatment (Kashuba, 1999; Levison, 2003; Wilks et al., 2003). The clinical criteria for the diagnosis o f pneumonia include chest pain, cough, or auscultatory findings such as rales or evidence of pulmonary consolidation, fever or leucocytosis. In addition, there must be radiographic evidence, such as the presence of new infiltrates on chest radiograph, and laboratory evidence that supports the diagnosis. Because of differences in pathogenesis and causative micro-organisms, pneumonia is often divided in hospital acquired and community-acquired pneumonia. Pneumonia developing outside the hospital is referred to as community-acquired pneumonia (CAP). Pharmacoeconomic study Pharmacoeconomics is defined as the description and analysis of costs of drug therapy or clinical service to health care systems and society (Bootman et al., 1996). It has risen up as the discipline with the increase interst in calculating the value and costs of medicines (Sanches, 1994). Cost is defined as the value of resources consumed by the program or drug therapy of interest while a consequence is defined as the effect, outputs, or outcomes of a program. When identifying the costs associated with a product or service, all possible costs that include or related to the study are calculated (Sanchez, 1994). With the increase in financial pressure to hospitals to minimize their medical care costs, pharmacoeconomics can define costs and benefits of both expensive drug therapies and pharmacy based clinical services (Destache, 1993; Touw, 2005).Furthermore pharmacoeconomics can assist practitioners in balancing cost and quality that may result in improving patient care and cost saving to the institution (Sanches, 1994). Bootman and Harison (1997) stated that pharmacoeconomics and outcome research are very important to determine the efficient way to present a quality care at realistic rate. They suggested that pharmacoeconomics should have a remarkable authority on the delivery and financing of health care throughout the world. Different methods have been used to perform pharmacoeconomics analysis which includes: Cost-benefit analysis: Cost-benefit analysis two or more alternatives that do not have the same outcome measures. It measures all costs and benefits of a program in monetary terms (Bootman et al., 1996; Fleurence, 2003). Cost-benefit analysis could play a major role in identifying the specific costs and benefits associated with the pneumonia. Cost-effective analysis Cost-effective analysis compares alternatives that differ in safety, efficacy and outcome. Cost is measured in monetary terms, while outcome is measured in specific objectives or natural units. The outcome are expressed in terms of the cost per unit of success or effect (Bootman et al., 1996). Cost-utility analysis Cost-utility analysis compares treatment alternatives; benefits are measured in terms of quality of life, willingness to pay, and patient preference for one intervention over another, while cost is measured in monetary terms. It has some similarity to cost-effectivness with more concentration on patient view. As an example, looking for new druig therapy; benefits can built-in together with expected risks. Cost-minimization analysis Cost-minimization analysis is one of the simplest forms of pharmacoeconomics analysis. It is used when two or more alternatives are assumed to be equivalent in terms of outcomes but differ in the cost which is measured in monetary terms (Fleurence, 2003). Cost of illness analysis Cost of illness analysis is the determination of all costs of aparticular disease, which include both direct and indirect costs. Since both costs were calculated, an economic evaluation for the disease can be performed successfully. It has been used for evaluating many diseases (Bootman et al., 1996). 1.2 Study problems and rationale The management of pneumonia is very straight forward. However this is not always true for the diagnosis and selection of therapy. As there are some issues related to pneumonia that need to be addressed : The first issue pertains to the inappropriate diagnosis of the pneumonia. Some physicians do not properly identify the causative organism, I.e, whether, it is bacterial or viral. Bartlet et al (1998) found that the viral infections have been associated with at least 10% to 15 % of CAP in hospitalized adults (Bartlet et al, 1998). Secondly is the use of inappropriate medications. The prescription of inappropriate or un-indicated drug therapy such as the prescription of antibiotics for pneumonia caused by nonbacterial infection may increase the incidence of bacterial resistance (Steinman, 2003). Thirdly the adherence to guidelines improves quality of care and reduces the length of hospital stay (Marrie TJ et al, 2000). Fourthly the adherence to guidelines reduces the cost of treating pneumonia (Feagan BG, 2001). Fifthly Teaching hospitals are widely perceived to provide good outcome, and that reputation is thought to justify these institutions comparatively higher charges relative to non-teaching (general) hospitals. Despite their reputation for specialized care, teaching hospitals have traditionally relied on revenue from routine services, such as treatment of pneumonia, and the costs of specialized services and medical training. However, with managed care and competition creating pressures for cost containment, these higher costs have come into question: Do a teaching hospital provide good outcome for management of pneumonia, or do a general hospital provide comparable outcome at lower costs? 1.3 Significance of the Study This study has the following important issues: To the researchers: Several studies have compare the management of pneumonia in a university hospital versus a general hospital, but most of these studies were conducted in the USA and other parts of the world. There are no published studies in Malaysia or Asia to our knowledge. This study also provides the difference in the outcome, cost and cost-effectivness of treating pneumonia between a university hospital and a general hospital. To the practitioners: This study will provide information about the adherence to guidelines will reduce the length of hospital stay, reduce the cost of treating pneumonia and improve outcomes of treating pneumonia. To the patients: This study attempts to highlight the benefits associated with adherence to the guidelines. To the policy makers: This study will help policy makers to develop new strategies for management of pneumonia. This study will help policy makers to develop new guideline for management of pneumonia according to the microorganisms and the population in Malaysia. This study also provides the difference in the management of pneumonia between a university hospital and a general hospital. This study will provide information about how we can reduce the length of hospital stay, reduce the cost of treating pneumonia and improve outcomes of treating pneumonia. The results of this study will help in improving the management of pneumonia. It is the time to know whether a university hospital (H-USM) provide good outcome for treating pneumonia or do a general hospital (Penang-GH) provide comparable outcome at lower costs. By analyzing the cost and effectiveness of the regimens being used, the most effective therapy can be defined and the information can be offered to the policy makers to improve the deciosion making in treating pneumonia. The study will be able to help on: How we can make the drug therapy cost effective keeping effectiveness and outcome in our mind and try to suggest the best and most appropriate drug therapy which should be cost effective which help to decrease the financial burden on patients as well as Ministry Of health. This study will help to suggest how we can reduce the cost of therapy of treating pneumonia. The study will be able to provide data on: The incidence of pneumonia in (H-USM and Penang-GH). The most common organisms causing pneumonia in (H-USM and Penang-GH). The pattern of drugs used and management of pneumonia in in (H-USM and Penang-GH). The outcome of treating pneumonia in (H-USM and Penang-GH). The cost of treating pneumonia in (H-USM and Penang-GH). The cost-effectivness of treating pneumonia in (H-USM and Penang-GH). Whether a university hospital provide a good outcome for management of pneumonia, or a general hospital provide comparable quality at lower costs. 1.4 Hypothesis of the Study: H0: There is no significant difference of the management of pneumonia between a universiry hospital (H-USM) and a general hospital (Penang-GH). H1: There is a significant difference of the management of pneumonia between a universiry hospital (H-USM) and a general hospital (Penang-GH). 1.5 Aim of the study The aim of this study is to compare the management of pneumonia in a university hospital (H-USM) versus a general hospital (Pinanag-GH). 1.6 Objectives The objectives of this study are: To compare the incidence of pneumonia at a university hospital (H-USM) versus a general hospital (Penang-GH). To compare the most common organisms associated with pneumonia at a university hospital (H-USM) versus a general hospital (Penang-GH). To compare the drug therapy for pneumonia at a university hospital (H-USM) versus a general hospital (Penang-GH). To compare the outcome of treating pneumonia (mortality rate, length of hospitalization, pneumonia related symptoms at discharge and complications of pneumonia) at a university hospital (H-USM) versus a general hospital (Penang-GH). To compare the cost of treating pneumonia at a university hospital (H-USM) versus a general hospital (Penang-GH). To compare the cost-effectivness of treating pneumonia at a university hospital (H-USM) versus a general hospital (Penang-GH). 1.7 Research Questions What are the difference between the organisms that is commonly associated with pneumonia at H-USM and Penang-GH? What are the difference between the antibiotics that is commonly used for the treatment of pneumonia at H-USM and Penang-GH? What are the difference between the outcome of treating pneumonia (mortality rate, length of hospitalization, pneumonia related symptoms at discharge and complications of pneumonia) at H-USM and Penang-GH? What are the difference between the cost of treating pneumonia at H-USM and Penang-GH? And how can these costs be reduced? What are the difference between the cost-effectivness of treating pneumonia at H-USM and Penang-GH? Do a university hospital (H-USM) provide good outcome for treating pneumonia or do a general hospital (Penang-GH) provide comparable outcome at lower costs? CHPTER 2 LITERATURE REVIEW 2.1 Community-acquired pneumonia 2.1.1 Introduction Community-acquired pneumonia (CAP) is defined as an acute infection of the pulmonary parenchyma that is associated with at least some symptoms of acute infection, a new infiltrate on chest x-ray or auscultatory findings such as altered breath sounds and/or localized rales in community-dwelling patients (Infectious Diseases Society of America 2000). It is a common condition that carries a high burden of mortality and morbidity, particularly in elderly populations. Although most patients recover without sequellae, CAP can take a very severe course, requiring admission to an intensive care unit (ICU) and even leading to death. According to US data, it is the most important cause of death from infectious causes and the sixth most important cause of death overall (Adams et al. 1996). Even though the mortality from pneumonia decreased rapidly in the 1940s after the introduction of antibiotic therapy, it has remained essentially unchanged since then or has even increased slightly (MMWR 1995 ). Furthermore, significant costs are associated with the diagnosis and management of CAP. Between 22% and 42% of adults with CAP are admitted to hospital, and of those, 5% to 10% need to be admitted to an ICU (British Thoracic Society 2001). In the US, it is estimated that the total cost of treating an episode of CAP in hospital is about USD $ 7500, which is approximately 20 times more than the cost of treating a patient on an outpatient basis (Lave et al. 1999). CAP also contributes significantly to antibiotic use, which is associated with well-known problems of resistance. In treating patients with CAP, the choice of antibiotic is a difficult one. Factors to be considered are the possible etiologic pathogen, the efficacy of the substance, potential side-effects, the treatment schedule and its effect on adherence to treatment as well as the particular regional resistance profile of the causative organism and the co-morbidities that might influence the range of potential pathogens (such as in cystic fibrosis) or the dosage (as in the case of renal insufficiency). It may be a primary disease occurring at random in healthy individuals or may be secondary to a predisposing factor such as chronic lung disease or diabetes mellitus. CAP represents a broad spectrum of severity, ranging from mild pneumonia that can be managed by general practitioners outside the hospital to severe pneumonia with septic shock needing treatment in intensive care unit. Depending on severity of illness, about 20% of patients with pneumonia need hospitalization and approximately 1% of all CAP patients require treatment in ICU. Elderly persons and those with underlying conditions, such as cerebro and cardiovascular diseases, chronic obstructive pulmonary disease (COPD) and alcoholism, are at increased risk for developing lower respiratory tract infections and complicated courses of infection. 2.1.2 Definition: Community-Acquired pneumonia (CAP) is defined as inflammation and consolidation of lung tissue induced by infectious microbes such as bacteria, viruses, or parasites. When the onset of symptoms and signs of this disease is before or within 48 hours after admission, it is considered as CAP (Bartlett JG et al., 1995). 2.1.3 Epidemiology Incidence: In the industrialized world, the annual incidence of CAP in community dwelling adults is estimated at 5 to 11 cases per 1000 adult population (British Thoracic Society 2001). The incidence is known to vary markedly with age, being higher in the very young and the elderly. In one Finnish study, the annual incidence for people aged 16-59 years was 6 cases per 1000 population, for those 60 years and older it was 20 per 1000, and for people aged 75 and over, 34 per 1000 (Jokinen et al. 1993). Annual incidences of 30-50 per 1000 population have been reported for infants below 1 year of age (Marrie 2001). Seasonal variations in incidence are also significant, with a peak in the winter months (Marrie 2001). The annual incidence of CAP requiring hospitalisation has been estimated at 1 to 4 patients per 1000 population (Marrie 1990, Fine et al. 1996). The proportion of patients requiring hospitalisation varies from country to country and across studies and has been estimated as ranging anywhe re between 15% and 56% (Foy et al. 1973, Minogue et al. 1998). Of those, 5% to 10% required admission to an intensive care unit (ICU) (British Thoracic Society Research Committee and Public Health Laboratory Service 1992, Torres et al. 1991). Conversely, about 8% to 10% of admissions to a medical ICU are due to severe CAP (Woodhead et al. 1985). Community acquired pneumonia (CAP) is a leading infectious disease cause of death throughout the world (WHO Statistical Information System (WHOSIS). WHO Mortality Database. Released: January 2005; Health, United States, 2005; Annual Report, Hong Kong, 2003/2004). Adult community-acquired pneumonia is a serious, life-threatening illness that affects more than 3 million people each year and accounts for more than half a million annual hospital admissions in the United States alone (Lynch JP, 1992). Each year, more than 900 000 cases of pneumonia occur in the United States, accounting for nearly 3% of all hospital admissions,(National Hospital Discharge Survey, 1988) and about 50 000 people die as a result of community-acquired pneumonia (Farr BM et al 203). Bartlet et al (1998) found that viral infections have been associated with at least 10% to 15 % of CAP in hospitalized adults. Adult community-acquired pneumonia is a serious, life-threatening illness that affects more than 3 million people each year and accounts for more than half a million annual hospital admissions in the United States alone. Each year, more than 900 000 cases of pneumonia occur in the United States, accounting for nearly 3% of all hospital admissions, and about 50 000 people die as a result of community-acquired pneumonia. In the USA, community acquired pneumonia is the fifth leading cause of death in people over the age of 65 years and an estimated 60 000 seniors die annually. Most of the excess deaths and hospitalizations due to lower respiratory infections occur in older adults, as reflected by the more than 44 000 hospitalizations for pneumonia and influenza in people aged 65 and older in 1997 in Canada. It is estimated that the age-specific incidence of pneumonia increases from 15.4 cases per 1000 in those aged 60-74 years to 34.2 for those 75 years and older. Residents of long-term care facilities, a distinct subpopulation of elderly people, are at particularly high risk for developing nursing-home acquired pneumonia. Health costs for this sector are growing at an accelerated rate as the age of dea th increases. Thirteen percent of the population is over the age of 65 in the United States and this is expected to increase to 20% by 2030. In Canada, the proportion of individuals over the age of 65 is expected to rise to 20% in the year 2021. Presently, while making up 12% of the Canadian population, older adults account for 31% of acute hospital days and half of all hospital stays. To meet their health-care needs and alleviate the burden onthe health-care system, we must improve our understanding of the management and prevention of pneumonia in this age group. Elderly people constitute an ever-increasing proportion of the population. CAP has traditionally been recognized as problems that particularly affect the older individuals. According to western studies, the overall rate of pneumonia requiring hospitalization increase with age, from 1 per 1,000 persons in the general population but increases to 12 per 1,000 persons for those over age 75 years3. As the population of those ov er age 65 years is predicted to rise from its current level of 11% to 25 % of the total population in the year 20504, respiratory tract infection will assume a greater degree of importance to the overall public health. In Hong Kong, pneumonia was the fourth leading death from a specific diagnosis in 2001. A total of 3026 people died of pneumonia in 2001 which 1526 cases were male. Out of the 3026 deaths, 2794 patients were 65 or older which accounted for more than 90% of the total death. Pneumonia in the elderly population is a major cause of morbidity and mortality and in some series represents the leading cause of death. The annual cost of treating patients age > 65 years with pneumonia to be $4.8 billion, compared with $3.6 billion for those 85 years need help with bathing and 10% need help in using the toilet and transferring. The present of any or all of following identifies elderly persons at greatest risk for functional decline: pressure ulcer, cognitive impairment, functiona l impairment, and low level of social activity. The attack rate for pneumonia is highest among those in nursing homes. It is found that 33 of 1,000 nursing home residents per year required hospitalization for treatment of pneumonia, compared with 1.14 of 1,000 adults living in the community. Pneumonia is a major cause of morbidity and mortality worldwide. In the UK as a whole, pneumonia is responsible for over 10% of all deaths (66,581 deaths in 2001), the majority of which occur in the elderly. Community-acquired pneumonia (CAP) remains a common cause of morbidity. Because CAP also is a potentially fatal disease, even in previously healthy persons, early appropriate antibiotic treatment is vital. In Japan, pneumonia is the fourth leading cause of death, and from 57 to 70 persons per 100,000 populations died per year of this disease in the last decade. Community acquired pneumonia (CAP) is a leading infectious disease cause of death throughout the world, including Hong Kong, Pneumonia is the second most common infectious disease in Thailand. Whereas diarrhea is more common, pneumonia is associated with more fatalities. CAP remains the leading cause of death due to infectious diseases, with an annual incidence ranging 1.6-10.6 per 1,000 adult populations in Europe According to the Ministry of Health Malaysia (MOH), pneumonia is the 5th cause of death in Malaysia and the 4th cause of hospitalization. A prospective observational study by Jae et al (2007) of 955 cases of adult CAP in 14 hospitals in eight Asian countries found that the overall 30-day mortality rate was 7.3%. A prospective study by Liam CK et al (2001) of 127 cases of CAP in Malaysia found that the Mortality from CAP is more likely in patients with comorbidity and in those who are bacteraemic. A prospective study by LOH et al (2004) of 108 cases of adult CAP in urban-based university teaching hospital in Malaysia found that the mortality rate from CAP in hospital was 12%. 2.1.4 Syndromes of CAP The presence of various signs and symptoms and physical findings varies according to the age of the patients, therapy with antibiotics before presentation, and the severity of illness. Patients with pneumonia usually present with cough (>90%), dyspnea (66%), sputum production (66%% pleuritic chest pain (50%), and chills is present in 40-70% and rigor in 15%. However, a variety of nonrespiratory symptoms can also predominate in pneumonia cases, including fatigue (91%), anorexia (71%), sweating (69%), and nausea (41%). Metlay et al. (1997c) divided 1812 patients with CAP into four age groups: 18 through 44 years (43%), 45 through 64 years (25%), 65 through 74 years (17%), and 75 years or older (15%). For 17 of the 18 recorded symptoms there were significant decreases in reported prevalence with increasing age (p 37 °C at presentation. Crackles were present on auscultation in 80% of patients, and rhonchi in 34% to 47% (more common in the nursing home patients). About 25% had the physical findings of dullness to percussion, bronchial breathing, whispered pectoriloquy, and aegophony. Alteration in mental status was common. Marrie and coworkers (1989) reported confusion in 48% of the patients with nursing home-acquired pneumonia and in 30% of the other patients with CAP. Fine and colleagues (1998) define altered mental status as stupor, coma, or confusion representing an acute change from the usual state prior to presentation with pneumonia. This was present in 17.3% of the hospitalized patients. The decrease in symptoms with increasing age, tachypnea increased with increasing age (Metlay et al., 1997c). Thirty-six percent of 780 patients with CAP in the 18-44 year age group had tachypnea on admission versus 65% of the 280 patients who were = 75 years old. There were minimal differences in the proportion of patients with tachycardia and hyperthermia in the different age groups Pneumonia in the elderly are quite different from that in a younger population. These differences are due to age-related alterations in immunology, different epidemiology and bacteriology. It is important to remember that pneumonia in the elderly may report fewer respiratory signs and symptoms. The clinical presentation may be more subtle than in younger population, with more gradual onset, less frequent complaints of chill and rigors, and less fever. The classical finding of cough, fever, and dyspnea may be absent in over half of elderly patients8. Instead they may be manifest as delirium, a decline in f unctional status, weakness, anorexia, abdominal pain, or decrease general condition. The incidence of fever may decline with age, and the degree of fever appears lower in old population10. Tachypnea which respiration rate greater than 24-30 breaths per minute is noted more frequently in up to 69% of patients. Although rales are common and are noted in 78% of patients, signs of true consolidation are found in only 29%. Bacteremia, metastatic foci of infection and death are more frequent in older populations. As many elderly present with non-specific clinical symptoms and nonspecific functional decline that makes an accurate diagnosis difficult and may lead a life-threatening delay of diagnosis and therapy. Metlay et al. compared the prevalence of symptoms and signs of pneumonia in a cohort of 1812 patients and found that patients aged 65-74 years and over 75 years had 2.9 and 3.3 fewer symptoms, respectively, than those aged 18 through 44 years. The reduced prevalence of symptoms was most pronounced for symptoms related to febrile response (chills and sweats) and pain (chest, headache, and myalgia). These findings are consistent with those of Marrie et al. demonstrating reduced prevalence of non-respiratory symptoms among elderly patients. In a retrospective chart review by Johnson et al., the presence of dementia seemed to account for non-specific symptoms. However the sample size of the study was small and precluded a multivariable analysis. Roghmann et al found a significant inverse correlation between age and initial temperature in 320 older patients hospitalized for pneumonia. Evidence therefore does exist for a less distinct presentation of nonrespiratory symptoms and signs of pneumonia in the elderly. 2.1.5 Radiographic findings in CAP Radiographic changes usually cannot be used to distinguish bacterial from nonbacterial pneumonia, but they are often important for diagnosis of CAP, evaluating the severity of illness, determining the need for diagnostic studies, and selecting antibiotic agents. A chest radiograph usually shows lobar or segmental opacification in bacterial pneumonias and in the majority of atypical infections. Patchy peribronchial shadowing or more diffuse nodular or ground-glass opacification is seen less commonly, particularly in viral and atypical infections. The lower lobes are most commonly affected in all types of pneumonia. Small pleural effusions can be detected in about one-quarter of cases. Multilobar pneumonia is a feature of severe disease, and spread to other lobes despite appropriate antibiotics is seen in Legionella and M. pneumoniae infection. Hilar lymphadenopathy is unusual except in Mycoplasma pneumonia, particularly in children. Cavitation is uncommon but is a classic feature of S . aureus and S. pneumoniae infections. False negative results can be attributed to dehydration, evaluation during the first 24 hours, pneumonia due to Pneumocystis carinii, or pneumonia with profound neutropenia. 2.1.6 Etiology: More than 100 microorganisms have been identified so far as potential causative agents of CAP (Marrie 2001). They can be classified according to their biological characteristics as either bacteria, mycoplasma and other intracellular organisms, viruses, fungi and parasites. The most common causative agent of CAP is the bacteriumStreptococcus pneumoniae, which is implicated in 20% to 75% of cases of CAP (Marrie 2001) and about 66% of bacteremic pneumonia (Infectious Diseases Society of America 2000). Another causative bacterium is Haemophilus influenzae. So called â€Å"atypical† organisms have also been implicated as causal agents. These include Chlamydia pneumoniae, Mycoplasma pneumoniae and Legionella pneumophila (Marrie 2001). Influenza is the most common serio

Monday, January 20, 2020

Marriage Essay -- Married Relationships Family Families Essays

Marriage What does marriage mean? By definition, marriage is â€Å"the legal union of a man and a woman as husband and wife† (Webster’s Dictionary). Most people claim that they want their marriage to last a lifetime. Because over half of all marriages in the United States end in a divorce, most people lack the understanding of what it takes to stay married. I believe that couples should become more aware of the commitment that they are making when they enter into marriage. Men and women should get to know one another completely before deciding to get married. Important issues such as religion, finances, career, and whether or not to have children should be discussed so that the couple can learn each other’s views regarding the issues to determine compatibility. For example, Br...

Sunday, January 12, 2020

Ar 670-1 – Essay 5

?AR 670-1 There are many army regulations dealing with the army but the one that I am going to talk about today is army regulation 670-1. What is army regulation 670-1 covering in the United states army? Army Regulation 670-1 deals with the wear and appearance of military uniforms for my paper I will recite the way a person is supposed to wear their uniform in army text and then tell you what it means in my own words. Starting with the parts that deals with the reason I am writing this report right now. AR 670-1 starts off with Part 1 which is General information and responsibilities. Part one is made up of 19 sections they are listed as followed: †¢1–1. Purpose †¢1–2. References †¢1–3. Explanation of abbreviations and terms †¢1–4. General †¢1–5. How to recommend changes to Army uniforms †¢1–6. Classification of service and utility or field uniforms †¢1–7. Personal appearance policies †¢1–8. Hair and fingernail standards and grooming policies †¢1–9. Uniform appearance and fit †¢1–10. When the wear of the Army uniform is required or prohibited †¢1–11. Uniformity of material †¢1–12. Distinctive uniforms and uniform items †¢1–13. Wear of civilian clothing †¢1–14. Wear of jewelry †¢1–15. Wear of eyeglasses, sunglasses, and contact lenses 1–16. Wear of identification tags and security badges †¢1–17. Wear of personal protective or reflective clothing †¢1–18. Wear of organizational protective or reflective clothing †¢1–19. Restrictions on the purchase, possession, and reproduction of heraldic items Being that I am a female in the united states army not all of the regulation applies to me. For instance I am not a guy so I don't have to worry about how to keep my mustache trimmed or well groomed but that doesn't mean that I should not know these things because when I do become an NCO I will have soldiers that are male that I need to keep squared away. But since I am writing this paper on myself and AR 670-1 I will us write the stuff that relates to my punishment and to me. Starting with 1-1. 1-1 is written as follows: 1–1. Purpose This regulation prescribes the authorization for wear, composition, and classification of uniforms, and the occasions for wearing all personal (clothing bag issue), optional, and commonly worn organizational Army uniforms. It also prescribes the awards, insignia, and accouterments authorized for wear on the uniform, and how these items are worn. General information is also provided on the authorized material, design, and uniform quality control system. This paragraph named purpose states that AR 670-1 tells you the way you should wear, put together, and how the uniform should look when you have it on. It goes on to say that the way that the army or the unit wears their uniform should not be changed but put together in an organized group. It also talks about awards, insignia,and what is allowed whe n it comes to the material used the way the uniform is designed and how they should be worn at all times. With the soldiers in the same uniform the army has system control. The next section 1-2 is written as followed: 1–2. References Required and related publications are listed in appendix A. In this section of AR 670-1 it just tells us that if we need to see the publications that they are listed in the back of the book. The next section to look at is 1-3: 1–3. Explanation of abbreviations and terms Abbreviations and special terms used in this regulation are explained in the glossary. ?This section states that all abbreviated items throughout AR 670-1 will be in the back of the glossary. 1–4. General a. Only uniforms, accessories, and insignia prescribed in this regulation or in the common tables of allowance (CTA), or as approved by Headquarters, Department of the Army (HQDA), will be worn by personnel in the US Army. Unless specified in this regulation, the commander issuing the clothing and equipment will establish wear policies for organizational clothing and equipment. No item governed by this regulation will be altered in any way that changes the basic design or the intended concept of fit as described in TM 10–227 and AR 700–84, including plating, smoothing, or removing detail features of metal items, or otherwise altering the color or appearance. All illustrations in this regulation should coincide with the text. The written description will control any inconsistencies between the text and the illustration. b. AR 70–1 prescribes Department of the Army (DA) policies, responsibilities, and administrative procedures by which all clothing and individual equipment used by Army personnel are initiated, designed, developed, tested, approved, fielded, and modified. c. AR 385–10 prescribes DA policies, responsibilities, and administrative procedures and funding for protective clothing and equipment. d. In accordance with chapter 45, section 771, title 10, United States Code (10 USC 771), no person except a member of the US Army may wear the uniform, or a distinctive part of the uniform of the US Army unless otherwise authorized by law. Additionally, no person except a member of the US Army may wear a uniform, any part of which is similar to a distinctive part of the US Army uniform. This includes the distinctive uniforms and uniform items listed in paragraph 1–12 of this regulation. Further, soldiers are not authorized to wear distinctive uniforms or uniform items of the US Army or of other US Services with, or on civilian clothes, except as provided in chapters 27 through 30 of this regulation. This part states that only uniforms that are authorized by the CTA and HQDA will be allowed to be worn by the units in that military. But at the same time the commander that authorizes your clothing can tell you what to wear and what not to wear on it. For instance, when we were down range and the battalion commander told us that we we only allowed to wear the 172nd patch so we could be in unison and so that people could know who we deployed with he had the right to do that. But the commander could not go out of the regulations of AR 670-1. So if the commander decided to change the design of the flight vest because it looks cool and it is the way he wanted to look hat is against AR670-1 the commander can only add to the regulation but cannot take away from it. This section also states that only a person from The united sates army can wear the uniform that the military issues out. This section is stating that if I have a uniform and I don't want it and my brother does I cannot give it to him because it is property of the united states army and he is not. Also if I have a pair of ACU trousers and the knees are worn i n them I am not allowed to cut them off and wear them as civilian attire. 1–5. How to recommend changes to Army uniforms a. Army Ideas For Excellence Program (AIEP). If a major Army command (MACOM) recommends approval of an AIEP suggestion, the recommendation will be forwarded to the Project Manager-Soldier Systems (SEQ), Bldg. 328, 5901 Putnam Road, Fort Belvoir, VA 22060–5852, for consideration. Each suggestion forwarded to the project manager will reflect the MACOM position; contain all appropriate supporting documentation; and be signed by the commander, deputy commander, chief of staff, or comparable level official. Suggestions not recommended for adoption at any level will not be forwarded to PM-Soldier. Suggestions forwarded without a MACOM position will be returned to the MACOM for action. b. General comments and suggestions. Comments and suggestions regarding the policy, criteria, and administrative instructions concerning individual military decorations, the Good Conduct Medal, service medals and service ribbons, combat and special skill badges and tabs, and unit decorations will be processed in accordance with AR 600–8–22. This section talks about how to go about making changes to an army uniform. The only ways you can go about making changes to the uniform is if a major Army command entrust approval of the change suggested. Then it will then go to the project manager-soldier system to get looked at to see if they will consider the change. They will then get all documents or paperwork that supports the reason they recommended the change. But if it was not recommended on any level of the chain then to the PM-Soldier. The second part of 1-5 talks about General comments and suggestions regarding policy, criteria, and administrative instructions concerning ertain people such as the good conduct medal, service medals and ribbons, combat badges and special skill badges and tabs and unit decorations but they will be worn only by and in a manner that comply with the rules standards or laws of army regulation 600-8-22. 1–6. Classification of service and utility or field uniforms a. The male class A service uniform consists of the Army green (AG) coat and trousers, a short-or lon g-sleeved AG shade 415 shirt with a black four-in-hand tie, and other authorized accessories. b. The male class B service uniform is the same as class A, except the service coat is not worn. The black four-in-hand tie is required with the long-sleeved AG shade 415 shirt when the long-sleeved shirt is worn without the class A coat, as an outer garment; the tie is optional with the short-sleeved shirt. c. The female class A service uniform consists of the Army green coat and skirt or slacks, a short-or long-sleeved AG shade 415 shirt with a black neck tab, and other authorized accessories. The Army green maternity uniform (slacks or skirt) is also classified as a class A service uniform when the tunic is worn. When the tunic is worn, females will wear the neck tab with both the short- and long-sleeved maternity shirts. d. The female class B service uniform is the same as the class A, except that neither the service coat nor the maternity tunic are worn. The black neck tab is required only when wearing the long-sleeved AG shade 415 shirt or the long-sleeved maternity shirt without the class A coat or tunic; the neck tab is optional with the short-sleeved version of both shirts. e. Class C uniforms are the utility, field, hospital duty, food service, and other organizational uniforms. F. See the table of prescribed dress in appendix B. This section talks about the action or process of classifying something according to shared qualities or characteristics of service and utility field uniforms. But since I am a female I will only break down the portion that relates to me. So with that said I will break down sections C, D, and E. Section C talks about the class A's service uniforms. The service class a uniforms for females have the Army green coat and skirt or pants. Short and long sleeve light green shirts and a tunic which is a neck piece is worn. The female just like the males also have class B service uniforms. The class A's and the class B's don't really differ from each other. The only difference is that the female wears the tunic or neck piece with the long sleeve or short sleeve maternity shirts without the jacket or coat to go with it. Another difference is that with the class B's the neck tab is only worn with the long sleeve shirt and not the short sleeve one. And last the class C uniform is the uniform that you wear on a daily basis for work. Whether it is the utility, field, hospital duty, food service, and other uniforms that is used by the unit. –7. Personal appearance policies a. General. The Army is a uniformed service where discipline is judged, in part, by the manner in which a soldier wears a prescribed uniform, as well as by the individual’s personal appearance. Therefore, a neat and well-groomed appearance by all soldiers is fundamental to the Army and contributes to building the pride and esp rit essential to an effective military force. A vital ingredient of the Army’s strength and military effectiveness is the pride and self-discipline that American soldiers bring to their Service through a conservative military image. It is the responsibility of commanders to ensure that military personnel under their command present a neat and soldierly appearance. Therefore, in the absence of specific procedures or guidelines, commanders must determine a soldier’s compliance with standards in this regulation. Soldiers must take pride in their appearance at all times, in or out of uniform, on and off duty. Pride in appearance includes soldiers’ physical fitness and adherence to acceptable weight standards, in accordance with AR 600–9. b. Exceptions to appearance standards based on religious practices. 1) As provided by AR 600–20, paragraph 5–6, and subject to temporary revocation because of health, safety, or mission requirements, the following applies to the wear of religious apparel, articles, or jewelry. The term â€Å"religious apparel† is defined as articles of clothing worn as part of the observance of the religious faith practiced by the soldier. Religious articles include, but are not limited to, medallions, small booklets, pictures, or copies of religious symbols or writing carried by the individual in wallets or pockets. Except as noted below, personnel may not wear religious items if they do not meet the standards of this regulation, and requests for accommodation will not be entertained (see AR 600–20, para 5–6g(2)(d)). (a) Soldiers may wear religious apparel, articles, or jewelry with the uniform, to include the physical fitness uniform, if they are neat, conservative, and discreet. â€Å"Neat conservative, and discreet† is defined as meeting the uniform criteria of this regulation. In other words, when religious jewelry is worn, the uniform must meet the same standards of wear as if the religious jewelry were not worn. For example, a religious item worn on a chain may not be visible when worn with the utility, service, dress, or mess uniforms. When worn with the physical fitness uniform, the item should be no more visible than identification (ID) tags would be in the same uniform. The width of chains worn with religious items should be approximately the same size as the width of the ID tag chain. (b) Soldiers may not wear these items when doing so would interfere with the performance of their duties or present a safety concern. Soldiers may not be prohibited, however, from wearing religious apparel, articles, or jewelry meeting the criteria of this regulation simply because they are religious in nature, if wear is permitted of similar items of a nonreligious nature. A specific example would be wearing a ring with a religious symbol. If the ring meets the uniform standards for jewelry and is not worn in a work area where rings are prohibited because of safety concerns, then wear is allowed and may not be prohibited simply because the ring bears a religious symbol. c) During a worship service, rite, or ritual, soldiers may wear visible or apparent religious articles, symbols, jewelry, and apparel that do not meet normal uniform standards. Commanders, however, may place reasonable limits on the wear of non-subdued items of religious apparel during worship services, rites, or rituals conducted in the field for operational or safety reasons. When soldiers in uniform wear visible religious articles on such occasi ons, they must ensure that these articles are not permanently affixed or appended to any prescribed article of the uniform. d) Chaplains may wear religious attire as described in this regulation, CTA 50–909, and AR 165–1 in the performance of religious services and other official duties, as required. Commanders may not prohibit chaplains from wearing religious symbols that are part of the chaplain’s duty uniform. (See AR 600–20, para 5–6g(7). ) (2) Soldiers may wear religious headgear while in uniform if the headgear meets the following criteria. (a) It must be subdued in color (black, brown, green, dark or navy blue, or a combination of these colors). b) It must be of a style and size that can be completely covered by standard military headgear, and it cannot interfere with the proper wear or functioning of protective clothing or equipment. (c) The headgear cannot bear any writing, symbols, or pictures. (d) Personnel will not wear religious headge ar in place of military headgear when military headgear is required (Outdoors, or indoors when required for duties or ceremonies). (3) Personal grooming. Hair and grooming practices are governed by paragraph 1–8 of this regulation, and exceptions or accommodations based on religious practices will not be granted. As an exception, policy exceptions based on religious practice given to soldiers in accordance with AR 600–20 on or prior to 1 January 1986 remain in effect as long as the soldier remains otherwise qualified for retention. 1-7 is the way a person dresses in their uniform. Its their personal appearance. this section states that the army is judge based on the amount of discipline the manner and the way a soldier wears his or her owned uniform. And by the way a soldier looks in their uniform or their personal appearance. This is why a soldier should take pride in the way they look every morning. o matter how bad they feels when they are getting dressed in the morning. A soldier should always have on a clean uniform on and conducts good personal hygiene. Their uniform should not be hanging off of them or too tight. their hair should remain neatly done for females and for males should always be cut to standards. But that isn't the only thing that a female and males have to maintain in the united states military. Males and females have to maintain their weight at all times. Soldiers should always maintain a well groomed appearance because they never know who is watching them. Soldiers should maintain their military appearance whether they are in or out of uniform. When a soldier maintains their physical appearance and takes pride in the way that they look it not only makes them feel better about themselves as a soldier but it also shows that they take pride in their unit and also show the self discipline that was embedded in them. The commanders job is to make sure that as a soldier it is they have a neat and presentable appearance at all time. Soldiers can also wear jewelry but only under certain terms and conditions such as if it is a part of their religious beliefs. Religious apparel for the army is listed as such medallions, small booklets such as bibles, pictures, or copies of religious symbols or writing carried by the individual in wallets or pockets such as verses from a bible, or hyms from a religious song book and etc. but if the jewelry or religious items do not meet the standards of the army regulations they can not wear them. Take me for example, i work on weapons and say if i have a ring on that had a cross on it i could not wear it because with my job if i was to work on a weapon with the ring on and the ring gets snagged on the bolt of a 50 cal. s i go to charge it and i release the handle from the ring being snagged on the handle when i let go of it my finger could be ripped off. Any religious apparel that when worn can put your life at harm or threaten your ability to work can not be worn in the uniform according to the army regulation. Another example of an improper religious apparel that cannot be worn while in uniform is t-shir ts. Say that I have this t-shirt that has a picture of god on it and I wear it every sunday to church I would not be able to wear it in uniform because it could make my uniform look bulky and stick out. The shirt could stick out over or away from under my ACU top. It could make my uniform a little more form fitting then it should be and it would look bad on the unit if I was to present myself in public like that. So us to show you a couple of examples of why not all religious apparel cannot be worn in military uniform. Another thing to add to the the wear of jewelry in the united states military and it also includes the physical fitness uniform is if they are neat, conservative, and discreet. Meaning dressing the way that the army regulation wants you to dress. There are yet some jewelry that you can not wear while you are in the army such as stomach piercings also known as abdomen piercings, nipple piercings, ear piercings while you are in uniform and if you are a guy no piercings in your ear at all, facial piercings such as lip rings, tongue rings, noise rings, no piercings that start from the bottom of your ear and go to the top of your ear if you are a female you are only allowed to have one hole in your ear and thats it. 1–8. Hair and fingernail standards and grooming policies a. Hair. (1) General. The requirement for hair grooming standards is necessary to maintain uniformity within a military population. Many hairstyles are acceptable, as long as they are neat and conservative. It is not possible to address every acceptable hairstyle, or what constitutes eccentric or conservative grooming. Therefore, it is the responsibility of leaders at all levels to exercise good judgment in the enforcement of Army policy. All soldiers will comply with the hair, fingernail, and grooming policies while in any military uniform or while in civilian clothes on duty. a) Leaders will judge the appropriateness of a particular hairstyle by the appearance of headgear when worn. Soldiers will wear headgear as described in the applicable chapters of this regulation. Headgear will fit snugly and comfortably, without distortion or excessive gaps. Hairstyles that do not allow soldiers to wear the headgear properly, or that interfere with the proper wear of the protective mask or other protective equipme nt, are prohibited. (b) Extreme, eccentric, or trendy haircuts or hairstyles are not authorized. If soldiers use dyes, tints, or bleaches, they must choose those that result in natural hair colors. Colors that detract from a professional military appearance are prohibited. Therefore, soldiers should avoid using colors that result in an extreme appearance. Applied hair colors that are prohibited include, but are not limited to, purple, blue, pink, green, orange, bright (fire-engine) red, and fluorescent or neon colors. It is the responsibility of leaders to use good judgment in determining if applied colors are acceptable, based upon the overall effect on soldiers’ appearance. (c) Soldiers who have a texture of hair that does not part naturally may cut a part into the hair. The part will be one straight line, not slanted or curved, and will fall in the area where the soldier would normally part the hair. Soldiers will not cut designs into their hair or scalp. (2) Male haircuts will conform to the following standards. (a) The hair on top of the head must be neatly groomed. The length and bulk of the hair may not be excessive or present a ragged, unkempt, or extreme appearance. The hair must present a tapered appearance. A tapered appearance is one where the outline of the soldier’s hair conforms to the shape of the head, curving inward to the natural termination point at the base of the neck. When the hair is combed, it will not fall over the ears or eyebrows, or touch the collar, except for the closely cut hair at the back of the neck. The block-cut fullness in the back is permitted to a moderate degree, as long as the tapered look is maintained. In all cases, the bulk or length of hair may not interfere with the normal wear of headgear (see para 1–8a(1)(a), above) or protective masks or equipment. Males are not authorized to wear braids, cornrows, or dreadlocks (unkempt, twisted, matted, individual parts of hair) while in uniform or in civilian clothes on duty. Hair that is clipped closely or shaved to the scalp is authorized. b) Males will keep sideburns neatly trimmed. Sideburns may not be flared; the base of the sideburn will be a clean-shaven, horizontal line. Sideburns will not extend below the lowest part of the exterior ear opening. (c) Males will keep their face clean-shaven when in uniform or in civilian clothes on duty. Mustaches are permitted; if worn, males will keep mustaches neatly trimmed, tapered, and tidy. Mustaches will not present a chopped off or bushy appearance, and no portion of the mustache will cover the upper lip line or extend sideways beyond a vertical line drawn upward from the corners of the mouth (see figure 1–1). Handlebar mustaches, goatees, and beards are not authorized. If appropriate medical authority prescribes beard growth, the length required for medical treatment must be specified. For example, â€Å"The length of the beard will not exceed 1? 4 inch† (see TB MED 287). Soldiers will keep the growth trimmed to the level specified by appropriate medical authority, but they are not authorized to shape the growth into goatees, or â€Å"Fu Manchu† or handlebar mustaches. d) Males are prohibited from wearing wigs or hairpieces while in uniform or in civilian clothes on duty, except to cover natural baldness or physical disfiguration caused by accident or medical procedure. When worn, wigs or hairpieces will conform to the standard haircut criteria as stated in 1–8a(2)(a), above. (3) Female haircuts will conform to the following standards. (a) Females will ensure their hair is neatly groomed, that the length and bulk of the hair are not excessive, and that the hair does n ot present a ragged, unkempt, or extreme appearance. Likewise, trendy styles that result in shaved portions of the scalp (other than the neckline) or designs cut into the hair are prohibited. Females may wear braids and cornrows as long as the braided style is conservative, the braids and cornrows lie snugly on the head, and any hair-holding devices comply with the standards in 1–8a(3)(d) below. Dreadlocks (unkempt, twisted, matted individual parts of hair) are prohibited in uniform or in civilian clothes on duty. Hair will not fall over the eyebrows or extend below the bottom edge of the collar at any time uring normal activity or when standing in formation. Long hair that falls naturally below the bottom edge of the collar, to include braids, will be neatly and inconspicuously fastened or pinned, Section 1-8 basically is explains the way a male and females nails hair make-up and facial hair should be. For a female their hair cannot touch their collar and can be only one color. And that one color that they have can only be a na tural color such as blonde, brown, and auburn color which is a reddish color and black. Any other color that isn't any one of those colors are not authorized in the united states army. Make-up for a girl can only be a natural color. Like the color of their skin or if it looks natural the female soldier is allowed to wear it. But some exceptions are made for females when it comes to their ma-up. For instance a female can have eyeliner on if it is a permeant thing so if a female went to the tattoo polar and got black ink tattooed on her in the place of eyeliner it is excepted in the army as long as it looks presentable. Nails on a female cannot have an off the wall color her nails can only be a natural color such as white manicured nails or clear as long as it looks natural. Also A females nails can only be a fourth of an inch long past the tip of her finger tips. The last section I am going to do is paragraph 1-14. Paragraph 1-14 reads as follows according to the army regulations 670-1: 1–14. Wear of jewelry a. Soldiers may wear a wristwatch, a wrist identification bracelet, and a total of two rings (a wedding set is considered one ring) with Army uniforms, unless prohibited by the commander for safety or health reasons. Any jewelry soldiers wear must be conservative and in good taste. Identification bracelets are limited to medical alert bracelets and MIA/POW identification bracelets. Soldiers may wear only one item on each wrist. b. No jewelry, other than that described in paragraph 1–14a, above, will appear exposed while wearing the uniform; this includes watch chains, or similar items, and pens and pencils. The only authorized exceptions are religious items described in para 1–7b, above; a conservative tie tack or tie clasp that male soldiers may wear with the black four-in-hand necktie; and a pen or pencil that may appear exposed on the hospital duty, food service, CVC, r flight uniforms. c. Body piercing. When on any Army installation or other places under Army control, soldiers may not attach, affix, or display objects, articles, jewelry, or ornamentation to or through the skin while they are in uniform, in civilian clothes on duty, or in civilian clothes off duty (this includes earrings for male soldiers). The only exception is for female sold iers, as indicated in paragraph 1–14d, below. (The term â€Å"skin† is not confined to external skin, but includes the tongue, lips, inside the mouth, and other surfaces of the body not readily visible. ) d. Females are authorized to wear prescribed earrings with the service, dress, and mess uniforms. (1) Earrings may be screw-on, clip-on, or post-type earrings, in gold, silver, white pearl, or diamond. The earrings will not exceed 6 mm or 1? 4 inch in diameter, and they must be unadorned and spherical. When worn, the earrings will fit snugly against the ear. Females may wear earrings only as a matched pair, with only one earring per ear lobe. (2) Females are not authorized to wear earrings with any class C (utility) uniform (BDU, hospital duty, food service, physical fitness, field, or organizational). 3) When on duty in civilian attire, female soldiers must comply with the specifications listed in (1) above when wearing earrings, unless otherwise authorized by the commander. When females are off duty, there are no restrictions on the wear of earrings. e. Ankle bracelets, necklaces (other than those described in para 1–7b), faddish (trendy) devices, medallions, amulets, and perso nal talismans or icons are not authorized for wear in any military uniform, or in civilian clothes on duty.

Friday, January 3, 2020

Lean Six Sigma And The Effects On Operations And...

Process Analysis on Lean Six Sigma and The Effects on Operations and Technology Strategy Lauren M. Nanney East Tennessee State University Abstract Do not indent/ need to add headings/subheadings, etc Process Analysis on Lean Six Sigma and The Effects on Operations and Technology Strategy Over the course of the past three decades, American industrial organizations have sought a wide variety of management programs in hopes to improve their competitiveness. The two most prevalent programs are lean management and Six Sigma. Lean management derived from Toyota in Japan and has since been applied by many major firms in America, including Harley-Davidson. Six Sigma was introduced by Motorola†¦show more content†¦For Six Sigma, the emphasis is on reducing variation, leading to more uniform process output. The belief here is that by focusing on reducing variation and achieving uniform process will lead to reduced waste, less throughput time, and less inventory. While each methodology seems to be targeting common tools and concepts, the approaches begin the journey from different perspectives (Nave, 2002). Lean Management When relating lean production to a process, there are three key principles that are considered. First, manufacturing performance adheres to the improving flow of material and information across business functions. Second, lean emphasizes customer pull rather than organization push. Last of all, lean develops the individuals of an organization to practice and pursue a commitment to continuous improvement (Lewis, 2000). Many researchers cite lean as constantly evolving, arguing that any definition of the concept would only be a snapshot of a moving target. Because of this, it is hard to give a consistent definition to the subject of lean. Researchers also argue that lean principles can be applied to any industry, regardless of the concept’s origin to the automobile industry. They encourage organizations to acknowledge the different perspectives that the concept comprises when embracing a lean approach within their processes (Pettersen, 2009). Six Sigma A project-driven management approach, the Six Sigma method’s purpose isShow MoreRelatedLean Manufacturing Six Sigma Manufacturing1228 Words   |  5 PagesDISCUSSION Lean manufacturing six sigma Manufacturing: Six sigma and lean system has the same way of approaching but uses different technology to achieve the goal. The both procedure lives up to expectations for to dispense with waste and expand the productivity of the procedure and convey the zero defect items. 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