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Dictionary of Acronyms in Healthcare

A Resource Curated by Meaningful Health IT

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Contents
Articles
Acronyms in healthcare Emergency department Accreditation Association for Ambulatory Health Care Association of American Medical Colleges American Academy of Otolaryngology Head and Neck Surgery Association of American Physicians and Surgeons American Association of Physicians of Indian Origin American Association for Respiratory Care Hematopoietic stem cell transplantation Patient Protection and Affordable Care Act Administration for Children and Families American College of Healthcare Executives American Congress of Obstetricians and Gynecologists American Cancer Society American College of Surgeons Academy of Nutrition and Dietetics American Dental Association American Diabetes Association Americans with Disabilities Act of 1990 Attention deficit hyperactivity disorder Activities of daily living Adverse drug reaction American Dental Society of Anesthesiology Automated external defibrillator Aid to Families with Dependent Children Atrial fibrillation American Hospital Association American Heart Association American Health Care Association American Health Information Management Association America's Health Insurance Plans Agency for Healthcare Research and Quality HIV/AIDS American Medical Association 1 14 22 24 24 25 29 31 33 42 80 82 83 85 89 92 100 103 110 122 135 138 144 147 153 157 169 171 173 175 177 180 184 202

African Malaria Network Trust American Medical Group Association American Medical Informatics Association American Nurses Association American Optometric Association American Osteopathic Association American Occupational Therapy Association Administrative Procedure Act American Psychiatric Association American Psychological Association American Pharmacists Association Ambulatory Payment Classification American Public Health Association American Physical Therapy Association Outpatient surgery American Society for Clinical Pathology Aspartate transaminase Wholesale Department of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy Balanced Budget Act of 1997 Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 Blue Cross Blue Shield Association Baby Friendly Hospital Initiative BI-RADS Bureau of Primary Health Care Behavioral Risk Factor Surveillance System Bachelor of Science in Nursing Coronary artery bypass surgery Coronary artery disease Consumer Assessment of Healthcare Providers and Systems Alternative medicine College of American Pathologists Community Action Agencies Community Access Program Commission on Accreditation of Rehabilitation Facilities X-ray computed tomography Blood glucose monitoring Congressional Budget Office

208 213 215 217 218 220 222 223 228 232 239 240 243 247 249 251 251 256 257 259 260 261 266 269 270 274 275 276 284 293 293 318 319 320 322 323 339 344

Certification Commission for Healthcare Information Technology Coronary care unit Intensive care unit Clinical Document Architecture Clostridium difficile Centers for Disease Control and Prevention Chargemaster Clinical data repository Acute assessment unit Tricare Veterans Health Administration Community health center College of Healthcare Information Management Executives Heart failure Community health worker Hospital information system Clinical Laboratory Improvement Amendments Cost-minimization analysis Continuing medical education Community mental health service Chief Medical Officer Centers for Medicare and Medicaid Services Unlicensed assistive personnel Central nervous system Consolidated Omnibus Budget Reconciliation Act of 1985 Council of governments Cost of living Certificate of need Chronic obstructive pulmonary disease Certified Public Accountant Consumer price index Computerized physician order entry Cardiopulmonary resuscitation Current Procedural Terminology Nurse anesthetist Special education Doctor of Chiropractic Developmental disability

346 349 350 353 355 367 373 375 375 377 381 388 389 392 406 410 413 414 415 417 423 424 425 427 430 434 436 438 439 452 458 468 473 482 487 496 507 512

Dental degree Drug Enforcement Administration Drug Enforcement Agency United States Department of Health and Human Services Durable medical equipment Do not resuscitate Doctor of Osteopathic Medicine Director of nursing Diagnosis-related group Disproportionate share hospital Diagnostic and Statistical Manual of Mental Disorders Direct-to-consumer advertising Veterinary physician Evidence-based medicine Electrocardiography Electronic data interchange Electroencephalography Electronic health record Electromyography Emergency medical technician Emergency medical services Emergency Medical Treatment and Active Labor Act Otolaryngology Explanation of benefits (insurance) United States Environmental Protection Agency Preferred provider organization Endoscopic retrograde cholangiopancreatography Employee Retirement Income Security Act End stage renal disease Federation of American Hospitals Food and Drug Administration Federal Employees Health Benefits Program Federal Food, Drug, and Cosmetic Act Medical classification Federal Insurance Contributions Act tax Federal Medical Assistance Percentages International medical graduate Family and Medical Leave Act of 1993

520 529 539 540 546 547 550 556 556 560 562 573 576 583 591 607 612 628 652 656 663 677 682 687 688 702 705 708 716 716 717 731 735 742 748 753 754 758

Nurse practitioner Poverty in the United States Federal Trade Commission Federally Qualified Health Center Fiscal year Flexible spending account Government Accountability Office Gross domestic product Human gastrointestinal tract Ophthalmology General practitioner Pediatrics Adolescent medicine Management of HIV/AIDS Healthcare Facilities Accreditation Program Healthcare Common Procedure Coding System Healthcare Cost and Utilization Project High-deductible health plan Healthcare Effectiveness Data and Information Set Home care Health information exchange Health information management Healthcare Information and Management Systems Society Health Insurance Portability and Accountability Act Bureau of Health Professions Health informatics Health information technology Health Information Technology for Economic and Clinical Health Act Healthcare Information Technology Standards Panel HIV Health Level 7 Health maintenance organization Health human resources HRHIS Health Resources and Services Administration Health savings account Health Service Executive Health Technology Assessment

764 769 783 789 792 800 806 810 827 833 841 851 855 859 867 868 869 878 879 884 889 892 899 901 911 914 927 932 936 938 949 959 963 966 969 972 980 983

Incurred but not reported International Statistical Classification of Diseases and Related Health Problems ICD-10 International Classification of Functioning, Disability and Health International Council of Nurses International Classification of Primary Care Indian Dental Association Integrated delivery system Irish Medical Organisation Independent practice association Interprofessional education JAMA (journal) The Journal of the American Osteopathic Association Joint Commission Lactate dehydrogenase Laboratory information management system Length of stay Licensed practical nurse Long-term acute care facility Long-term care Lung volume reduction surgery Left without being seen Medicare Advantage Medication Administration Record Medical College Admission Test Managed care Doctor of Medicine Medicare Payment Advisory Commission Medical Expenditure Panel Survey Magnetic resonance imaging Master of Science in Nursing Master of Social Work Medical laboratory scientist National Association of County and City Health Officials National Board for Respiratory Care The New England Journal of Medicine Non-communicable disease National Health Service

984 985 991 995 999 1001 1003 1003 1004 1006 1007 1010 1013 1015 1019 1027 1033 1033 1037 1038 1043 1044 1044 1048 1049 1054 1060 1073 1073 1078 1096 1097 1099 1104 1107 1110 1115 1120

National Institutes of Health National Institute of Mental Health National Institute for Occupational Safety and Health United States National Library of Medicine Omnibus Budget Reconciliation Act of 1993 Drug overdose Post-anesthesia care unit Personal Care Assistant NHS primary care trust Primary health care Protected health information United States Public Health Service Peripherally inserted central catheter Prospective payment system Quality-adjusted life year Quality improvement organizations Resource-based relative value scale Radiology information system Robert Wood Johnson Foundation Registered nurse Registered Health Information Technician Regional Health Information Organization Substance Abuse and Mental Health Services Administration Birth attendant State Children's Health Insurance Program State Food and Drug Administration Medicare Sustainable Growth Rate Nursing home Special needs plan Supplemental Security Income Selective serotonin reuptake inhibitor Temporary Assistance for Needy Families Transcranial Doppler Third-party administrator Tension headache Therapy UnitingCare Health UNICEF

1123 1134 1140 1143 1147 1150 1154 1155 1157 1158 1163 1165 1169 1172 1172 1174 1177 1180 1181 1183 1185 1186 1190 1194 1195 1202 1204 1207 1216 1216 1225 1239 1249 1254 1256 1259 1261 1262

United States Agency for International Development United States Pharmacopeia URAC World Health Organization Walter Reed Army Institute of Research

1269 1286 1288 1291 1302

References
Article Sources and Contributors Image Sources, Licenses and Contributors 1306 1335

Article Licenses
License 1344

Acronyms in healthcare

Acronyms in healthcare
The following is a partial list of initialisms and acronyms commonly used in health care. The terms listed are used in the English language within the health care systems of various countries.[1] A B C D E F G H I J K L M N O P Q R S T U V W X Y Z This list is incomplete; you can help by expanding it [2].

A
A&E Accident and Emergency Department AAAHC Accreditation Association for Ambulatory Health Care AAHSA American Association of Homes and Services for the Aging AAMA American Association of Medical Assistants AAMC American Association of Medical Colleges AAO-HNS American Academy of Otolaryngology - Head and Neck Surgery AAPC American Academy of Professional Coders AAPCC Adjusted Average per Capita Cost AAPS American Association of Physicians and Surgeons AAPI American Association of Physicians of Indian Origin

AARC American Association of Respiratory Care ABMT Autologous Bone Marrow Transplant ACA Affordable Care Act of 2010

Acronyms in healthcare ACF Administration for Children and Families ACHE American College of Healthcare Executives ACIIP Association of Clinical IVR and IWR Professionals ACO Accountable Care Organization ACOG American Congress of Obstetricians and Gynecologists ACS American Cancer Society ACS American College of Surgeons ADA American Dietetic Association ADA American Dental Association ADA American Diabetes Association ADA Americans with Disabilities Act ADHD Attention-Deficit Hyperactivity Disorder ADL Activities of Daily Living ADR Adverse Drug Reaction ADSA American Dental Society of Anesthesiology ADT Admission, Discharge, Transfer AED Automated External Defibrillator AEP Accredited Exercise Physiologist AFDC Aid to Families with Dependent Children AF Atrial Fibrillation AFMA African Medical Association AHA American Hospital Association AHA American Heart Association AHCA American Health Care Association AHDI Association for Healthcare Documentation Integrity AHEC Area Health Education Center AHIMA American Health Information Management Association AHIP America's Health Insurance Plans AHRQ Agency for Healthcare Research and Quality AIDS Acquired Immunodeficiency Syndrome AIN Assistant In Nursing AMA American Medical Association AMANET African Malaria Network Trust AMGA American Medical Group Association AMIA American Medical Informatics Association ANA American Nurses Association AOA American Optometric Association AOA American Osteopathic Association AOTA American Occupational Therapy Association APA Administrative Procedures Act APA American Psychiatric Association APA American Pharmaceutical Association APA American Psychological Association APC Ambulatory Payment Classification APDRG All Patient Diagnosis Related Groups

APHA American Public Health Association APHA American Protestant Hospital Association

Acronyms in healthcare APTA American Physical Therapy Association ASA American Society of Anesthesiology ASC Ambulatory Surgery Center ASCP American Society for Clinical Pathology ASHICE Reporting patient's condition Age Sex History Injury/Illness Consciousness ETA ASHRM American Society for Healthcare Risk Management ASO Administrative Service Organization AST Aspartate Aminotransferase ASTHO Association of State and Territorial Health Officials AWP Average Wholesale Price AYUSH Department of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy

B
BBA Balanced Budget Act of 1997 BBRA Balanced Budget Refinement Act of 1999 BCA Blue Cross Association BCBSA Blue Cross Blue Shield Association BCMA Bar Code Medication Administration BFHI Baby Friendly Hospital Initiative BHCS Baylor Health Care System, Dallas, TX BI-RADS Breast Imaging-Reporting and Data System Atlas BP Blood Pressure BPM Beats Per Minute BPHC Bureau of Primary Health Care BPOC Bar Code Enabled Point of Care BRFSS Behavioral Risk Factor Surveillance System BSN Bachelor of Science in Nursing

C
CABG Coronary artery bypass grafting CAD Coronary Artery Disease CAH Critical Access Hospital CAHPS Consumer Assessment of Healthcare Providers and Systems CAM Complementary and Alternative Medicine CAP College of American Pathologists, Community Action Program, or Community Access Program CARF Commission on Accreditation of Rehabilitation Facilities CAT Computerized Axial Tomography CBG Capillary Blood Glucose CBO Congressional Budget Office CCA Cost Consequence Analysis CCBTI Certified Cognitive Behavioral Training Instructor [3] CCHIT Certification Commission for Healthcare Information Technology CCHP Consumer Choice Health Plan CCM Certified Case Manager

CCRN Critical Care Registered Nurse CCU Coronary Care Unit

Acronyms in healthcare CCU Critical Care Unit CDA Clinical Document Architecture CDif Clostridium Difficile CDC Centers for Disease Control and Prevention CDM Charge Description Master CDR Clinical Data Repository CDR Chronic Disease Register CDU Clinical Decisions Unit CERTs Centers for Education and Research on Therapeutics CEO Campaign to End Obesity CHAMPUS Civilian Health and Medical Program of the Uniformed Services CHAMPVA Civilian Health and Medical Program - Veterans Administration CHC Community Health Center CHER Community Health Education & Resources CHHA Certified Home Health Agency CHIME College of Health Information Management Executives CHF Congestive Heart Failure CHI Consolidated Health Informatics CHMIS Community Health Management Information System CHS Certified in Healthcare Security CHW Community health worker CICU Cardiac Intensive Care Unit CIS Clinical information system CLIA Clinical Laboratory Improvement Amendments Act CMA Cost Minimization Analysis CME Continuing Medical Education CMHC Community Mental Health Center CMO Career Medical Officer CMO Chief Medical Officer CMP Competitive Medical Plan CMS Centers for Medicare and Medicaid Services CMT Certified Medical Transcriptionist CN Clinical Nurse CNA Certified Nursing Assistant CNC Clinical Nurse Consultant CNS Central Nervous System COB Coordination of Benefits COBRA Consolidated Omnibus Budget Reconciliation Act COG Council of Governments COI Cost of Illness Analysis COLA Cost of Living Allowance COMPASS Community Participation for Action in the Social Sector (Nigeria) CON Certificate of Need CONQUEST Computerized Needs-Oriented Quality Measurement Evaluation System COPC Community Oriented Primary Care

COPD Chronic Obstructive Pulmonary Disease COTH Council of Teaching Hospitals

Acronyms in healthcare CPA Certified Public Accountant CPHA Commission on Professional and Hospital Activities CPI Consumer Price Index CPOE Computerized Physician Order Entry CPOE Computerized Prescription Order Entry CPR Customary, Prevailing, and Reasonable CPR Cardiopulmonary Resuscitation CPT-4 Current Procedural Terminology, Fourth Edition CQuIPS Center for Quality Improvement and Patient Safety CRNA Certified Registered Nurse Anesthetist CRVS California Relative Value Studies CT Computerized Tomographic (scanners) CCRAS Central Council for Research in Ayurveda and Siddha CWSN Children with Special Needs

D
DC Doctor of Chiropractic DD Developmental Disability DDS Doctor of Dental Surgery DEA Drug Enforcement Administration DEA Drug Enforcement Agency DDM Doctor of Dental Medicine DHHS Department of Health and Human Services DME Durable Medical Equipment DMO Disease Management Organization DNR Do Not Resuscitate DO Doctor of Osteopathic Medicine DOA Dead On Arrival DON Director Of Nursing DOS Date Of Service DOU Direct Observation Unit DR ABC Primary Survey Danger Response Airway Breathing Circulation DRG Diagnosis Related Group DSH Disproportionate Share Hospital DSM-IV Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition DTC Direct to Consumer DUR Drug Utilization Review DVM Doctor of Veterinary Medicine

Acronyms in healthcare

E
EBM Evidence-Based Medicine ECF Extended Care Facility ECG Electrocardiogram ED Emergency Department EDI Electronic Data Interchange EDON Executive Director Of Nursing EEG Electroencephalogram EEN Endorsed Enrolled Nurse EHR Electronic health record EKG Electrocardiogram ELS Emergency Life Support EMG Electromyogram EMR Electronic medical record EMS Emergency Medical Services EMT Emergency Medical Technician EMTALA Emergency Medical Treatment and Active Labor Act ENT Ear, Nose and Throat EOB explanation of benefits (insurance) EPA Exclusive Provider Arrangement EPA Environmental Protection Agency EPC Evidence-Based Practice Center EPO Exclusive provider organization EPSDT Early and Periodic Screening, Diagnosis, and Treatment Program ER Emergency Room ERCP Endoscopic Retrograde Cholangiopancreatography ERISA Employee Retirement Income Security Act ESI Employer-sponsored Insurance ESRD End Stage Renal Disease ET Expenditure Target ETA Estimated Time of Arrival

F
FACCT The Foundation for Accountability FACS Fellow, American College of Surgeons FAH Federation of American Hospitals FAHIMA Fellow of the American Health Information Management Association FDA Food and Drug Administration FEHBP Federal Employees Health Benefits Program FFDCA Federal Food, Drug, and Cosmetic Act FIC Family of International Classifications, World Health Organization FICA Federal Insurance Contributions Act FIPH Fellow International Public Health, honoris FMAP Federal Medical Assistance Percentages

FMC Foundation for Medical Care FMG Foreign Medical Graduate

Acronyms in healthcare FMLA Family and Medical Leave Act of 1993 FNP Family Nurse Practitioner FPL Federal poverty level FTC Federal Trade Commission FQHC Federally Qualified Health Center FY Fiscal Year FSA Flexible spending account FHT Fetal Heart Tones

G
GAO Government Accountability Office GDP Gross Domestic Product GHAA Group Health Association of America GI Gastrointestinal GME Graduate Medical Education GOS General Ophthalmic Services GP General Practitioner

GPAM General Pediatrics and Adolescent Medicine

H
HAART Highly active antiretroviral therapy HC Healthcare HCBS Home and Community Based Services HCFAP Healthcare Facilities Accreditation Program HCPCS Healthcare Common Procedure Coding System HCUP Healthcare Cost and Utilization Project HCQ Healthcare Quality HDHP High Deductible Health Plan HEDIS Healthcare Effectiveness Data and Information Set HH Home Health HIE Health Information Exchange HIFA Health Insurance Flexibility and Accountability HIM Health information management HIMSS Healthcare Information and Management Systems Society HIPAA Health Insurance Portability and Accountability Act HIPC Health Insurance Purchasing Cooperative HIPDB Healthcare Integrity and Protection Data Bank HIPPS Health information prospective payment system HISP Health Information Service Provider [4] HISPC Health Information Security and Privacy Collaboration HIS Health Information System HIT Health Information Technology HITECH Health Information Technology for Economic and Clinical Health Act HITSP Healthcare Information Technology Standards Panel

HAV, HBV, HCV Hepatitis A, B, C, respectively. HIV Human immunodeficiency virus

Acronyms in healthcare HL7 Health Level 7 HME Home Medical Equipment HMO Health Maintenance Organization HMSA Health Manpower Shortage Area HOPPS Hospital Outpatient Prospective Payment System HPI History of Present Illness HPSAs Health Professional Shortage Areas HRQL Health Related Quality of Life HRA Health Risk Assessment HRA Health Reimbursement Account HRH Human resources for health HRHIS Human resources for health information system HRSA Health Resources and Services Administration HSA Health Savings Account HSA Health Service Area HSA Health Systems Agency HSE Health Service Executive

HTA Health Technology Assessment Hx History

I
IADL Instrumental Activities of Daily Living IBNR Incurred But Not Reported ICD International Statistical Classification of Diseases and Related Health Problems ICD-9-CM International Classification of Diseases, Ninth Revision, Clinical Modifications ICD-10-CM International Classification of Diseases, Tenth Revision, Clinical Modifications ICD-10-PCS International Classification of Diseases, Ninth Revision, Procedure Coding System ICDA International Classification of Diseases, Adopted ICF International Classification of Functioning, Disability and Health ICF Intermediate Care Facility ICN International Council of Nurses ICNP International Classification for Nursing Practice ICU Intensive Care Unit ICF/MR Intermediate Care Facility for the Mentally Retarded ICPC International Classification of Primary Care IDA Indian Dental Association IDN Integrated Delivery Network IDS Integrated Delivery System IHI Institute for Healthcare Improvement IMG International Medical Graduate IMO Irish Medical Organisation INHS Inland Northwest Health Services IOM Institute of Medicine of the National Academy of the Sciences IPA Independent Practice Association

IPE Interprofessional Education IPHF International Public Health Forum IRM Information Resource Management

Acronyms in healthcare ISN Integrated Services Network ITU Intensive Treatment Unit

J
JAMA Journal of the American Medical Association JAOAJournal of the American Osteopathic Association JCAHO Joint Commission on the Accreditation of Healthcare Organizations JIPHF Journal of International Public Health Forum

K
KPM Key Performance Measures

L
LDH Lactic dehydrogenase LIS Low Income Subsidy or Laboratory Information System LMT Licensed Massage Therapist LOS Length of Stay LPN Licensed Practical Nurse LSC Life Safety Code LSIT Life Sciences Information Technology LTAC Long-Term Acute Care facility LTC Long Term Care LUPA Low Utilization Payment Adjustment LVN Licensed Vocational Nurse LVRS Lung volume reduction surgery LWBS Left without being seen

M
MA Medical Assistant; Medicare Advantage MAAC Maximum Allowable Actual Charge MAF Medical Assistance Facility MAP Medical Audit Program MAPD Medicare Advantage Prescription Drug Plan MAR Medication Administration Record MCAT Medical College Admission Test MCH Maternal and Child Health Program MCI Medical Council of India MCO Managed Care Organization MD Doctor of Medicine MEDLARS Medical Literature and Analysis Retrieval System MedPAC Medicare Payment Advisory Commission MEPS Medical Expenditure Panel Survey MET Multiple Employer Trust

MEWA Multiple Employer Welfare Arrangement MDH Medicare-dependent Hospital

Acronyms in healthcare MHC Managed Health Care MHA Master's in Health Care Administration MI Myocardial Infarction MLR Medical Loss Ratio MLT Medical Laboratory Technician MMIS Medicaid Management Information System MMRA Metropolitan Medical Response System MPH Master of Public Health MRHFP Medicare Rural Hospital Flexibility Program MRI Magnetic Resonance Imaging MRSA Methicillin-resistant ''Staphylococcus aureus'' infections MSA Medical Savings Account or Metropolitan Statistical Area MSN Master of Science in Nursing MSW Master of Social Work or Medical Social Worker MT Medical Technologist MU Meaningful Use measurement/objective of HITECH Act MUA/MUPs Medically Under-served Areas/Populations

10

N
NACo National Association of Counties NACCHO National Association of County and City Health Officials NASHP National Academy for State Health Policy NASMD National Association of State Medicaid Directors NBRC National Board for Respiratory Care NCD Non-communicable disease NCHS National Center for Health Statistics NCQA National Committee for Quality Assurance NDC National Drug Code NEJM New England Journal of Medicine (standard PubMed abbreviation is N Engl J Med) NGA National Governors Association NGC National Guidelines Clearinghouse NwHIN Nationwide Health Information Network[5] NHS National Health Service NHSC National Health Savings Corps NICU Neonatal Intensive Care Unit NIH National Institutes of Health NIMH National Institute of Mental Health NIOSH National Institute of Occupational Safety and Health NKDA No Known Drug Allergies NLM National Library of Medicine NMA Nigerian Medical Association NMF Nigerian Medical Forum NP Nurse Practitioner NPRM Notice of Proposed Rule-making

NPS National Pharmaceutical Stockpile NRHA National Rural Health Association NUM Nurse Unit Manager

Acronyms in healthcare

11

O
OAA Old Age Assistance OASDHI Old Age Survivors, Disability, and Health Insurance Program OB/GYN Obstetrician/Gynecologist OBRA Omnibus Budget Reconciliation Act OD Overdose or the right eye (from the Latin oculus dexter) ODS Organized Delivery System OMB Office of Management and Budget OPD Outpatient Department OPHP Office of Public Health Preparedness OS the left eye (from the Latin oculus sinister) OSHA Occupational Health and Safety Administration

P
PA Physician Assistant PACU Post Anesthesia Care Unit PAHO Pan American Health Organization PBM Pharmacy Benefits Manager PCA Personal Care Assistant or Patient Controlled Anesthesia PCCM Primary Care Case Management PCMH - Patient-Centered Medical Home PCP Primary Care Physician PCT NHS Primary Care Trust PDI Professional Development Institute PDP Prescription Drug Plan PDQS Partnership Defined Quality of Service PFP Patient Flow Platform PHC Primary health care PHI Protected Health Information PHO Physician-Hospital Organization PHS Public Health Service PIAPHP Partners in Information Access for Public Health Professionals PICC Peripherally Inserted Central Catheter PICU Pediatric Intensive Care Unit POC Point of Care POS Place of Service or Point of Service PMPM Per Member Per Month PMP Per Million Population PPA Preferred Provider Arrangement PPO Preferred Provider Organization PPG Physician Provider Group PPS Prospective Payment System PSN Provider Sponsored Network PSO Provider Sponsored Organization

Acronyms in healthcare

12

Q
QALY Quality-Adjusted Life Year QAPI Quality Assessment and Performance Improvement Program QARI Quality Assurance Reform Initiative QD Each day, usually in prescriptions. QIO Quality Improvement Organization QISMC Quality Improvement System for Managed Care QuIC Quality Inter agency Coordination Task Force

R
RAN Rural Area Computer Network RAP Request for Anticipated Payment RBRVS Resource-Based Relative Value Scale RCT Randomized Clinical Trial or Randomized Controlled Trial RD Registered Dietician RFE Reason For Encounter RHC Rural Health Clinic RICE Rest, Ice, Compression, Elevation (Alternatively) Rest, Immobilize, Cool, Elevate RIS Radiology Information System RRC Rural Referral Centers RUG Resource Utilization Groups RWJF Robert Wood Johnson Foundation RN Registered Nurse RMO Resident Medical Officer RHIT Registered Health Information Technician RHIA Registered Health Information Administrator RHIO Regional Health Information Organization

S
SAMPLE Signs/Symptoms, Allergies, Medications, Past history, Last meal, Events leading up to (First aid secondary survey questions) SAMSHA Substance Abuse and Mental Health Services Administration SBA Skilled Birth Attendant SCH Sole Community Hospitals SCHIP State Children's Health Insurance Program SEP Special Enrollment Period SDMC Statistical and Data Management Center SFDA State Food and Drug Administration SGR Sustainable Growth Rate SHEA State Health Expenditure Account SJA St John Ambulance SOB Shortness of Breath SNF Skilled Nursing Facility SNIP Strategic National Implementation Process SNP Special Needs Plan SSF Sjgren's Syndrome Foundation

Acronyms in healthcare SSI Supplemental Security Income SSRI Selective Serotonin Reuptake Inhibitor Sx Symptoms

13

T
TANF Temporary Assistance for Needy Families TCD Transcranial Doppler TPA Third Party Administrator or tissue plasminogen activator TTHs tension type headaches Tx Treatment Txp Transport (by ambulance)

U
UAP Unlicensed assistive personnel UCH UnitingCare Health UNICEF United Nations Children's Fund USAID United States Agency for International Development USP U.S. Pharmacopeia URAC Utilization Review Accreditation Commission

V
VIRHN Vertically Integrated Rural Health Network

W
WHO World Health Organization WHRN Whole Health Resource Network WISN Workload Indicators of Staffing Needs WRAIR Walter Reed Army Institute of Research

References
[1] [2] [3] [4] [5] Health Care Acronyms (http:/ / www. all-acronyms. com/ tag/ health_care), All Acronyms, Accessed 19/11/08 http:/ / en. wikipedia. org/ w/ index. php?title=Acronyms_in_healthcare& action=edit http:/ / www. NBSEmpowers. com http:/ / wiki. directproject. org/ http:/ / healthit. hhs. gov/ portal/ server. pt?open=512& objID=1142& parentname=CommunityPage& parentid=4& mode=2

External links
Smart Define (http://www.smartdefine.org/healthcare/abb/r) - Healthcare Related Abbreviations

Emergency department

14

Emergency department
An emergency department (ED), also known as accident & emergency (A&E), emergency room (ER), or casualty department, is a medical treatment facility specializing in acute care of patients who present without prior appointment, either by their own means or by ambulance. The emergency department is usually found in a hospital or other primary care center. Due to the unplanned nature of patient attendance, the department must provide initial treatment for a broad spectrum of illnesses and injuries, some of which may be life-threatening and require immediate attention. In some countries, emergency departments have become important entry points for those without other means of access to medical care.

A clearly marked emergency department at the The Royal Infirmary of Edinburgh.

The emergency departments of most hospitals operate 24 hours a day, although staffing levels may be varied in an attempt to mirror patient volume.

History
Accident services were already provided by workmen's compensation plans, railway companies, and municipalities in Europe and the United States by the late mid-nineteenth century, but the first specialized trauma care center in the world was opened in 1911 in the United States at the University of Louisville Hospital in Louisville, Kentucky, and was developed by surgeon Arnold Griswold during the 1930s. Griswold also equipped police and fire vehicles with medical supplies and trained officers to give emergency care while en route to the hospital.[1][2][3]

Department operation
Today, a typical hospital has its emergency department in its own section of the first floor of the campus, with its own dedicated entrance. As patients can present at any time and with any complaint, a key part of the operation of an emergency department is the prioritization of cases based on clinical need. This process is called triage.

The emergency department entrance at Mayo Clinic's Saint Marys Hospital. The red-and-white emergency sign is clearly visible.

Triage is normally the first stage the patient passes through, and consists of a brief assessment, including a set of vital signs, and the assignment of a "chief complaint" (i.e. chest pain, abdominal pain, difficulty breathing, etc.). Most emergency departments have a dedicated area for this process to take place, and may have staff dedicated to performing nothing but a triage role. In most departments, this role is fulfilled by a nurse, although dependent on training levels in the country and area, other health care professionals may perform the triage sorting, including paramedics or physicians (DOs or MDs). Triage is typically conducted face-to-face when the patient presents, or a form of triage may be conducted via radio with an ambulance crew; in this method, the paramedics will call the hospital's triage center with a short update about an incoming patient, who will then be triaged to the appropriate level of care.

Emergency department Most patients will be initially assessed at triage and then passed to another area of the department, or another area of the hospital, with their waiting time determined by their clinical need. However, some patients may complete their treatment at the triage stage, for instance if the condition is very minor and can be treated quickly, if only advice is required, or if the emergency department is not a suitable point of care for the patient. Conversely, patients with evidently serious conditions, such as cardiac arrest, will bypass triage altogether and move straight to the appropriate part of the department. The resuscitation area, commonly referred to as "Trauma" or "Resus", is a key area in most departments. The most seriously ill or injured patients will be dealt with in this area, as it contains the equipment and staff required for dealing with immediately life threatening illnesses and injuries. Typical resuscitation staffing involves at least one attending physician (DO or MD), and at least one and usually two nurses with trauma and Advanced Cardiac Life Support training. These personnel may be assigned to the resuscitation area for the entirety of the shift, or may be "on call" for resuscitation coverage (i.e. if a critical case presents via walk-in triage or ambulance, the team will be paged to the resuscitation area to deal with the case immediately). Resuscitation cases may also be attended by residents, medical students, nursing students, emergency medical technicians, respiratory therapists, and/or hospital pharmacists, depending upon the skill mix needed for any given case and whether or not the hospital provides teaching services. Patients who exhibit signs of being seriously ill but are not in immediate danger of life or limb will be triaged to "acute care" or "majors," where they will be seen by a physician and receive a more thorough assessment and treatment. Examples of "majors" include chest pain, difficulty breathing, abdominal pain and neurological complaints. Advanced diagnostic testing may be conducted at this stage, including laboratory testing of blood and/or urine, ultrasonography, CT or MRI scanning. Medications appropriate to manage the patient's condition will also be given. Depending on underlying causes of the patient's chief complaint, he or she may be discharged home from this area or admitted to the hospital for further treatment. Patients whose condition is not immediately life threatening will be sent to an area suitable to deal with them, and these areas might typically be termed as a prompt care or minors area. Such patients may still have been found to have significant problems, including fractures, dislocations, and lacerations requiring suturing. Children can present particular challenges in treatment. Some departments have dedicated pediatrics areas, and some departments employ a play therapist whose job is to put children at ease to reduce the anxiety caused by visiting the emergency department, as well as provide distraction therapy for simple procedures. Many hospitals have a separate area for evaluation of psychiatric problems. These are often staffed by psychiatrists and mental health nurses and social workers. There is typically at least one room for people who are actively a risk to themselves or others (e.g. suicidal). Fast decisions on life-and-death cases are critical in hospital emergency rooms. As a result, doctors face great pressures to overtest and overtreat. The fear of missing something often leads to extra blood tests and imaging scans for what may be harmless chest pains, run-of-the-mill head bumps, and non-threatening stomach aches, with a high cost on the Health Care system.[4]

15

Emergency department

16

Nomenclature in English
Emergency department became the preferred termWikipedia:WikiProject Countering systemic bias when emergency medicine was recognised as a medical speciality and hospitals and medical centres developed Departments of emergency medicine to provide services. Other common variations include 'emergency ward,' 'emergency centre' or 'emergency unit.' Historic terminology still exists across the English-speaking world, especially in vernacular usage. The previously accepted formal term 'Accident and Emergency' or 'A&E' is still widely known in countries such as the United Kingdom, the Commonwealth and Hong Kong (former British colony and Commonwealth member), as are earlier terms such as 'Casualty', or 'Casualty Ward' which continue to be used informally. The same applies to 'Emergency Room' or 'ER' in North America, originating when emergency facilities were provided in a single room of the hospital by the Department of Surgery.

Signage
Regardless of naming convention, there is a widespread usage of directional signage in white text on a red background across the world, which indicates the location of the emergency department, or a hospital with such facilities. Signs on emergency departments may contain additional information. In some American states there is close regulation of the design and content of such signs. For example, California requires wording such as "Comprehensive Emergency Medical Service" and "Physician On Duty",[5] to prevent persons in need of critical care from presenting to facilities that are not fully equipped and staffed.
An example of California hospital signage. In some countries, including the United States and Canada, a smaller facility that may provide assistance in medical emergencies is known as a clinic. Larger communities often have walk-in clinics where people with medical problems that would not be considered serious enough to warrant an emergency department visit can be seen. These clinics often do not operate on a 24 hour basis. Very large clinics may operate as "free-standing emergency centres," which are open 24 hours and can manage a very large number of conditions. However, if a patient presents to a free-standing clinic with a condition requiring hospital admission, he or she must be transferred to an actual hospital, as these facilities do not have the capability to provide inpatient care.

United States
Many U.S. emergency departments are exceedingly busy. A study found that in 2009, there were an estimated 128,885,040 ED encounters in U.S. hospitals. Approximately one-fifth of ED visits in 2010 were for patients under the age of 18 years.[6] Most encounters (82.8 percent) resulted in treatment and release; 17.2 percent were admitted to inpatient care.[7] A survey of New York area doctors in February 2007 found that injuries and even deaths have been caused by excessive waits for hospital beds by ED patients.[8] A 2005 patient survey found an average ED wait time from 2.3 hours in Iowa to 5.0 hours in Arizona.[9] One inspection of Los Angeles area hospitals by Congressional staff found the EDs operating at an average of 116% of capacity (meaning there were more patients than available treatment spaces) with insufficient beds to accommodate victims of a terrorist attack the size of the 2004 Madrid train bombings. Three of the five Level I

Emergency department trauma centres were on "diversion", meaning ambulances with all but the most severely injured patients were being directed elsewhere because the ED could not safely accommodate any more patients.[10] This controversial practice was banned in Massachusetts (except for major incidents, such as a fire in the ED), effective January 1, 2009; in response, hospitals have devoted more staff to the ED at peak times and moved some elective procedures to non-peak times.[11][12] In 2009, there were 1,800 EDs in the country.[13]

17

United Kingdom
All A&E departments throughout the United Kingdom are financed and managed publicly by the NHS of each constituent country (England, Scotland, Wales and A&E sign common in the UK. Northern Ireland). As with most other NHS services, emergency care is provided to all, both resident citizens and those not ordinarily resident in the UK, free at the point of need and regardless of any ability to pay. Historically, waits for assessment in A&E were very long in some areas of the UK. In October 2002, the Department of Health introduced a four-hour target in emergency departments that required departments in England to assess and treat patients within four hours of arrival, with referral and assessment by other departments if deemed necessary. Present policy is that 95% of all patient cases do not "breach" this four-hour wait. The busiest departments in the UK outside London include University Hospital of Wales in Cardiff, The North Wales Regional Hospital in Wrexham and the Edinburgh Royal Infirmary. The 4-hour target triggered the introduction of the acute assessment unit (also known as the medical assessment unit), which works alongside the emergency department but is outside it for statistical purposes in the bed management cycle. It is claimed that though A&E targets have resulted in significant improvements in completion times, the current target would not have been possible without some form of patient re-designation or re-labeling taking place, so true improvements are somewhat less than headline figures might suggest and it is doubtful that a single target (fitting all A&E and related services) is sustainable.[14]

Critical conditions handled


Cardiac arrest
Cardiac arrest may occur in the ED/A&E or a patient may be transported by ambulance to the emergency department already in this state. Treatment is basic life support and advanced life support as taught in advanced life support and advanced cardiac life support courses. This is an immediately life-threatening condition which requires immediate action in salvageable cases.

Heart attack
Patients arriving to the emergency department with a myocardial infarction (heart attack) are likely to be triaged to the resuscitation area. They will receive oxygen and monitoring and have an early ECG; aspirin will be given if not contraindicated or not already administered by the ambulance team; morphine or diamorphine will be given for pain; sub lingual (under the tongue) or buccal (between cheek and upper gum) glyceryl trinitrate (nitroglycerin) (GTN or NTG) will be given, unless contraindicated by the presence of other drugs, such as drugs that treat erectile dysfunction. An ECG that reveals ST segment elevation or new left bundle branch block suggests complete blockage of one of the main coronary arteries. These patients require immediate reperfusion (re-opening) of the occluded vessel. This can be achieved in two ways: thrombolysis (clot-busting medication) or percutaneous transluminal coronary angioplasty

Emergency department (PTCA). Both of these are effective in reducing significantly the mortality of myocardial infarction. Many centres are now moving to the use of PTCA as it is somewhat more effective than thrombolysis if it can be administered early. This may involve transfer to a nearby facility with facilities for angioplasty.

18

Trauma
Major trauma, the term for patients with multiple injuries, often from a road traffic accident or a major fall, is initially handled in the Emergency Department. However, trauma is a separate (surgical) specialty from emergency medicine (which is a medical specialty, and has certifications in the United States from the American Board of Emergency Medicine). Trauma is treated by a trauma team who have been trained using the principles taught in the internationally recognized Advanced Trauma Life Support (ATLS) course of the American College of Surgeons. Some other international training bodies have started to run similar courses based on the same principles. The services that are provided in an emergency department can range from simple x-rays and the setting of broken bones to those of a full-scale trauma centre. A patient's chance of survival is greatly improved if the patient receives definitive treatment (i.e. surgery or reperfusion) within one hour of an accident (such as a car accident) or onset of acute illness (such as a heart attack). This critical time frame is commonly known as the "golden hour". Some emergency departments in smaller hospitals are located near a helipad which is used by helicopters to transport a patient to a trauma centre. This inter-hospital transfer is often done when a patient requires advanced medical care unavailable at the local facility. In such cases the emergency department can only stabilize the patient for transport.

Mental illness
Some patients arrive at an emergency department for a complaint of mental illness. In many jurisdictions (including many U.S. states), patients who appear to be mentally ill and to present a danger to themselves or others may be brought against their will to an emergency department by law enforcement officers for psychiatric examination. The emergency department conducts medical clearance rather than treats acute behavioral disorders. From the emergency department, patients with significant mental illness may be transferred to a psychiatric unit (in many cases involuntarily).

Asthma and COPD


Acute exacerbations of chronic respiratory diseases, mainly asthma and chronic obstructive pulmonary disease (COPD), are assessed as emergencies and treated with oxygen therapy, bronchodilators, steroids or theophylline, have an urgent chest X-ray and arterial blood gases and are referred for intensive care if necessary. Noninvasive ventilation in the ED has reduced the requirement for tracheal intubation in many cases of severe exacerbations of COPD.

Special facilities, training, and equipment


An ED requires different equipment and different approaches than most other hospital divisions. Patients frequently arrive with unstable conditions, and so must be treated quickly. They may be unconscious, and information such as their medical history, allergies, and blood type may be unavailable. ED staff are trained to work quickly and effectively even with minimal information. ED staff must also interact efficiently with pre-hospital care providers such as EMTs, paramedics, and others who are occasionally based in an ED. The pre-hospital providers may use equipment unfamiliar to the average physician, but ED physicians must be expert in using (and safely removing) specialized equipment, since devices such as Military Anti-Shock Trousers ("MAST") and traction splints require special procedures. Among other reasons, given that they must be able to handle specialized equipment, physicians can now specialize in emergency medicine, and

Emergency department EDs employ many such specialists. ED staff have much in common with ambulance and fire crews, combat medics, search and rescue teams, and disaster response teams. Often, joint training and practice drills are organized to improve the coordination of this complex response system. Busy EDs exchange a great deal of equipment with ambulance crews, and both must provide for replacing, returning, or reimbursing for costly items. Cardiac arrest and major trauma are relatively common in EDs, so defibrillators, automatic ventilation and CPR machines, and bleeding control dressings are used heavily. Survival in such cases is greatly enhanced by shortening the wait for key interventions, and in recent years some of this specialized equipment has spread to pre-hospital settings. The best-known example is defibrillators, which spread first to ambulances, then in an automatic version to police cars, and most recently to public spaces such as airports, office buildings, hotels, and even shopping malls. Because time is such an essential factor in emergency treatment, EDs typically have their own diagnostic equipment to avoid waiting for equipment installed elsewhere in the hospital. Nearly all have an X-ray room, and many now have full radiology facilities including CT scanners and ultrasonography equipment. Laboratory services may be handled on a priority basis by the hospital lab, or the ED may have its own "STAT Lab" for basic labs (blood counts, blood typing, toxicology screens, etc.) that must be returned very rapidly. The use of Electronic Medical Records in U.S. EDs has increased rapidly as a result of the 2009 HITECH Act. Companies such as MEDHOST, Inc. and Wellsoft Corporation provide Emergency Department Information Systems (EDIS) that help hospitals meet HITECH requirements.[15] Functionality typically offered by these software systems include real-time patient tracking, clinical charting and clinician order entry, charge capture, and comprehensive reporting capabilities.[16] MEDHOST, Inc. was named Best In KLAS [17] in the Emergency Department Market Segment for Software & Services in early 2012.[18]

19

Non-emergency use
Metrics applicable to the ED can be grouped into three main categories, volume, cycle time, and patient satisfaction. Volume metrics including arrivals per hour, percentage of ED beds occupied and age of patients are understood at a basic level at all hospitals as an indication for staffing requirements. Cycle time metrics are the mainstays of the evaluation and tracking of process efficiency and are less widespread since an active effort is needed to collect and analyze this data. Patient satisfaction metrics, already commonly collected by physician groups and hospitals, are useful in demonstrating the impact of changes in patient perception of care over time. Since patient satisfaction metrics are derivative and subjective, they are less useful in primary process improvement. In all Primary Care Trusts there are out of hours doctor services provided by general practitioners. In the United States, and many other countries, hospitals are beginning to create areas in their emergency rooms for people with minor injuries. These are commonly referred as Fast Track or Minor Care units. These units are for people with non-life-threatening injuries. The use of these units within a department have been shown to significantly improve the flow of patients through a department and to reduce waiting times. Urgent care clinics are another alternative, where patients can go to receive immediate care for non-life-threatening conditions. To reduce the strain on limited ED resources, American Medical Response created a checklist that allows EMTs to identify intoxicated individuals who can be safely sent to detoxification facilities instead. [19]

Emergency department

20

Doctors in training
Doctors in training provide a large portion of the medical care in emergency departments. In the United States, they are called residents and most are supervised by ABEM or AOBEM board certified attending physicians. In the United Kingdom, many doctors rotate through the emergency department, such as during their second foundation year (F2), or as part of a rotational specialty training programme in General Practice or Acute Care Common Stem training (Emergency Medicine, Acute medicine, Anaesthetics, and Intensive Care). There are also many other professional positions filled in the ED for those wishing to become doctors; one could become a Scribe (ER), a volunteer, or one could shadow a doctor. All of these positions provide experience and perspective to the future medical student.

Overcrowding
Emergency department overcrowding is when function of a department is hindered by an inability to treat all patients in an adequate manner. This is a common occurrence in emergency departments world wide.[] Overcrowding causes inadequate patient care which leads to poorer patient outcomes.[][] To address this problem, Lakeland Regional Medical Center successfully implemented several techniques in 2011 to improve emergency department efficiencies. The emergency department reorganized space into pods, made staffing changes to facilitate patient flow, required emergency medical service personnel to provide advance notice of ambulance arrivals so that a bed could be preassigned, and had a multidisciplinary team develop and use care plans for nonemergent patients who repeatedly present with chronic pain issues.[20]

Frequent presenters
Frequent presenters are persons who will present themselves at a hospital multiple times, usually those with complex medical requirements or with psychological issues complicating medical management.[] These persons contribute to overcrowding and typically use require more hospital resources although they do not account for a significant amount of visits.[]

Emergency departments in the military


Emergency departments in the military benefit from the added support of enlisted personnel who are capable of performing any task they have been trained for, regardless of actual education obtained from civilian schooling. For example, in Naval hospitals, Hospital Corpsmen perform tasks that fall under the scope of practice of both doctors (i.e. sutures and incision and drainages) and nurses (i.e. medication administration and foley catheter insertion). Often, some civilian education and/or certification will be required such as an EMT certification, in case of the need to provide care outside of the base where the member is actually stationed.

Violence against health care workers


According to a survey at an urban inner-city tertiary care centre in Vancouver,[] 57% of health care workers were physically assaulted in 1996. 73% were afraid of patients as a result of violence, almost half, 49%, hid their identities from patients, 74% had reduced job satisfaction. Over one-fourth of the respondents took days off because of violence. Of respondents no longer working in the emergency department, 67% reported that they had left the job at least partly owing to violence. Twenty-four hour security and a workshop on violence prevention strategies were felt to be the most useful potential interventions. Physical exercise, sleep and the company of family and friends were the most frequent coping strategies.[]

Emergency department

21

Notes
[1] [2] [3] [4] [5] [6] url=http:/ / books. google. com/ books?id=HbZMAQAAIAAJ& pg=PA1809#v=onepage url=http:/ / books. google. com/ books?id=ltcEPWDHIkMC& pg=PA212 url=http:/ / www. louisville. edu/ ur/ ucomm/ mags/ summer2000/ cover_story. htm http:/ / news. yahoo. com/ s/ ap/ 20100621/ ap_on_bi_ge/ us_med_overtreated_er Title 22, California Code of Regulations, Section 70453(j). Wier LM, Hao Y, Owens P, Washington R. Overview of Children in the Emergency Department, 2010. HCUP Statistical Brief #157. Agency for Healthcare Research and Quality, Rockville, MD. May 2013. (http:/ / hcup-us. ahrq. gov/ reports/ statbriefs/ sb157. jsp) [7] Kindermann D, Mutter R, Pines JM. Emergency Department Transfers to Acute Care Facilities, 2009. HCUP Statistical Brief #155. Agency for Healthcare Research and Quality. May 2013. (http:/ / hcup-us. ahrq. gov/ reports/ statbriefs/ sb155. jsp) [8] http:/ / abcnews. go. com/ print?id=3322309 [9] http:/ / www. medicalnewstoday. com/ articles/ 44453. php [10] http:/ / oversight. house. gov/ documents/ 20080505102428. pdf [15] "Wellsoft KLAS Performance Ratings Overview" (http:/ / www. klasresearch. com/ Vendor/ 550?ReturnURL=/ Vendor/ 550), KLAS, Retrieved January 12, 2012 [16] "Emergency Department KLAS Performance Ratings" (http:/ / www. klasresearch. com/ Segment/ 13), KLAS, Retrieved January 30, 2013 [17] http:/ / www. klasresearch. com/ [18] "MEDHOST Attains No. 1 "Best in KLAS" Ranking" (http:/ / www. reuters. com/ article/ 2012/ 01/ 12/ idUS162786+ 12-Jan-2012+ BW20120112), REUTERS, Retrieved January 30, 2013

References
John B Bache, Carolyn Armitt, Cathy Gadd, Handbook of Emergency Department Procedures, ISBN 0-7234-3322-4 Swaminatha V Mahadevan, An Introduction To Clinical Emergency Medicine: Guide for Practitioners in the Emergency Department, ISBN 0-521-54259-6 Academic Emergency Medicine (http://www.aemj.org/), ISSN: 1069-6563, Elsvier

External links
Use of emergency departments for less- or non-urgent care (http://secure.cihi.ca/cihiweb/dispPage. jsp?cw_page=media_14sep2005_e) (Canada) (Canadian Institute for Health Information) Overuse of Emergency Departments Among Insured Californians (http://www.chcf.org/topics/hospitals/ index.cfm?itemID=126089) (US) (California HealthCare Foundation, October 2006) ED visits (http://www.cdc.gov/nchs/fastats/ervisits.htm) (US) (National Center for Health Statistics) Academic Emergency Medicine (http://www.aemj.org/), ISSN: 1069-6563, Elsvier Physicians on Call: California's Patchwork Approach to Emergency Department Coverage (http://www.chcf. org/publications/2011/02/physicians-on-call-ca-patchwork)

Accreditation Association for Ambulatory Health Care

22

Accreditation Association for Ambulatory Health Care


Accreditation Association for Ambulatory Health Care
Industry Founded Accreditation 1979

Headquarters Skokie, Ill. Website http:/ / www. aaahc. org

The Accreditation Association for Ambulatory Health Care (AAAHC), founded in 1979, is an American organization which accredits ambulatory health care organizations, including ambulatory surgery centers, office-based surgery centers, endoscopy centers, and college student health centers, as well as health plans, such as health maintenance organizations and preferred provider organizations.[1]:550 AAAHC has been granted "deemed status" to certify ambulatory surgery centers for Medicare by the Centers for Medicare and Medicaid Services. In 2009, the AAAHC added the Medical home to the types of organizations that it accredits. It offers on-site surveys for organizations seeking Medical Home accreditation or certification.[2] The AAAHC survey model is one of cooperation and education. It is unique in offering accreditation surveys that are conducted by professionals who are actively involved in ambulatory care and have first-hand understanding of the specific issues facing the facilities they survey. Surveyors assess how an organization meets prevailing Standards and share their knowledge and experience with others to help ambulatory service providers maintain high standards. AAAHC is one of three organizations that accredits office-based surgery practices, the others being the Joint Commission on Accreditation of Healthcare Organizations and the American Association for Accreditation of Ambulatory Surgery Facilities.[3] In 2010, the organization extended its accreditation services internationally, beginning with Costa Rica. The program has since expanded to Peru and further expansion is planned. AAAHC announced the launch of a new accreditation program for hospitals in 2012, which will focus on small hospitals and will be offered through a new entity established by AAAHC, the Accreditation Association for Hospitals/Health Systems Inc. (AAHHS). AAAHC continuously reviews its standards and revises current standards and adds new standards as required by the constantly changing health care arena. Each year in August there is a public comment period where these revisions and additions are presented for review and comment by interested parties. Facebook: http://www.facebook.com/AccreditationAssn Twitter: http://twitter.com/aaahc_quality

Accreditation Association for Ambulatory Health Care

23

History
The Accreditation Association was formed in 1979 by six member organizations including the American College Health Association, the ASC Association, and the Medical Group Management Association.[1]:549 The Accreditation Association has 18 Association Members:[4] Ambulatory Surgery Foundation American Academy of Cosmetic Surgery American Academy of Dental Group Practice American Academy of Dermatology American Academy of Facial Plastic and Reconstructive Surgery American Association of Oral and Maxillofacial Surgeons American College of Gastroenterology American College Health Association American College of Mohs Surgery American College of Obstetricians and Gynecologists American Dental Association American Gastroenterological Association American Society of Anesthesiologists American Society for Dermatologic Surgery American Society for Gastrointestinal Endoscopy Association of periOperative Registered Nurses Medical Group Management Association Society of Ambulatory Anesthesia

Accreditation Process
Standards are reviewed and updated annually to keep up with current trends and technologies in the health care arena. AAAHC surveyors are volunteers: physicians, dentists, podiatrists, pharmacists, nurses and administrators who are actively involved with ambulatory health care. AAAHC offers a three year term of accreditation. An organization may also receive a deferral or denial of accreditation if compliance is not met.

Institute for Quality Improvement


In 1999, the AAAHC founded its non-profit subsidiary, the AAAHC Institute for Quality Improvement (AAAHC Institute) to offer performance measurement opportunities and related quality improvement/educational programs to ambulatory health care organizations. The AAAHC Institute has conducted and published more than 70 studies.

References
[1] Kongstvedt, Peter R. Essentials of Managed Health Care. Jones and Bartlett: Boston, 2007 [2] Accreditation Association for Ambulatory Health Care. Medical Home Accreditation (http:/ / www. aaahc. org/ eweb/ dynamicpage. aspx?webcode=mha). Accessed 2010 March 30. [3] Preventing errors in the outpatient setting: A tale of three states (http:/ / www. medscape. com/ viewarticle/ 439794_print). Lapetina, Elizabeth M. and Armstrong, Elizabeth M. 2002. Health Affairs 1(4):26-39. [4] AAAHC Member Organizations/Board of Directors (http:/ / www. aaahc. org/ eweb/ dynamicpage. aspx?site=aaahc_site& webcode=mbr_orgs_and_board). Accreditation Association for Ambulatory Health Care web site. Retrieved on 2008-12-05.

Accreditation Association for Ambulatory Health Care

24

External links
Accreditation Association for Ambulatory Health Care (http://www.aaahc.org)

Association of American Medical Colleges


The Association of American Medical Colleges (AAMC) is a non-profit organization based in Washington, DC and established in 1876. It administers the Medical College Admission Test. The AAMC operates the American Medical College Application Service and the Electronic Residency Application Service which facilitate students applying to medical schools and residency programs, respectively. Since 2006, the AAMC president has been Darrell Kirch.[1]

References
[1] Darrell G. Kirch, M.D. (https:/ / www. aamc. org/ download/ 45150/ data/ kirchbiolong. pdf) AAMC. Accessed October 4, 2011.

External links
Official website (http://www.aamc.org)

American Academy of Otolaryngology Head and Neck Surgery


The American Academy of Otolaryngology Head and Neck Surgery, originally started in the 1924, is the world's largest organization of over 13,000 specialists related to the area of ears, nose, and throat.[1]

History
Reference[2] Though it was not official at the time, the AAO began in 1896 when Dr. Hal Foster wrote a letter to invite specialists in the areas of ophthalmology and otolaryngology to gather for a meeting in Kansas City. This began the Western Ophthalmological, Otological, Laryngological and Rhinological Association. It was not until 82 years later that it adopted its official name. Then later it would add Head and Neck Surgery to identify its broader medical view of the foundation from just the ears, nose and throat. In 1982 The AAO merged with the ACO as to "speak with a single voice" for the special field of medicine.

References
[1] About the AAO (http:/ / www. entnet. org/ about/ index. cfm) [2] A Brief History of the AAO-HNS/F (http:/ / www. entlink. net/ academy/ mission/ history. cfm)

External links
Official Website of the American Academy of Otolaryngology-Head and Neck Surgery (http://www.entnet.org/ )

Association of American Physicians and Surgeons

25

Association of American Physicians and Surgeons


Association of American Physicians and Surgeons
Type Founded Political advocacy group May 1944

Headquarters Tucson, Arizona, United States Focus(es) Opposes abortion, Medicare/Medicaid, universal health care, and government involvement in health care; publishes the Journal of American Physicians and Surgeons omnia pro aegroto ("All for the patient") http:/ / www. aapsonline. org/

Motto Website

The Association of American Physicians and Surgeons (AAPS) is a politically conservative non-profit association founded in 1943 to "fight socialized medicine and to fight the government takeover of medicine."[][] The group was reported to have approximately 4,000 members in 2005, and 3,000 in 2011.[][1] Notable members include Ron Paul and John Cooksey;[2] the executive director is Jane Orient, a member of the Oregon Institute of Science and Medicine. The AAPS motto, "omnia pro aegroto" is Latin for "all for the patient."[3] AAPS also publishes the Journal of American Physicians and Surgeons (formerly known as the Medical Sentinel). The Journal is not indexed by mainstream scientific databases such as the Web of Science or MEDLINE.[4] The quality and scientific validity of articles published in the Journal has been criticized by others. Many of the political and scientific viewpoints advocated by AAPS are considered extreme or dubious by other medical groups.[]

History
During the winter of 1943, the Lake County (Indiana) Medical Committee opposed the Wagner-Murray-Dingell Bill, proposed legislation that would provide government health care for most U.S. citizens. Also opposed to the bill was the conservative National Physicians Committee. The committee began a membership drive in February 1944. By May 1944, the AAPS claimed members from all 48 states.[] In 1944, Time reported that the group's aim was the "defeat of any Government group medicine."[] In 1966, the New York Times described AAPS as an "ultra-right-wing... political-economic rather than a medical group," and noted that some of its leaders were members of the John Birch Society.[]

Positions
While it describes itself as "non-partisan",[5] AAPS is generally recognized as politically conservative.[][6][7][] According to Mother Jones, "despite the lab coats and the official-sounding name, the docs of the AAPS are hardly part of mainstream medical society. Think Glenn Beck with an MD."[] The organization opposes mandatory vaccination,[8] a single-payer healthcare system[9] and government intervention in healthcare.[][10] The AAPS has characterized the effects of the Social Security Act of 1965, which established Medicare and Medicaid, as "evil" and "immoral",[11] and encouraged member physicians to boycott Medicare and Medicaid.[12] AAPS argues that individuals should purchase medical care directly from doctors, and that there is no right to medical care.[13] The organization requires its members to sign a "declaration of independence" pledging that they will not work with Medicare, Medicaid, or even private insurance companies.[] AAPS opposes mandated evidence-based medicine and practice guidelines, criticizing them as a usurpation of physician autonomy and a fascist merger of state and corporate power where the biggest stakeholder is the

Association of American Physicians and Surgeons pharmaceutical industry.[14] Other procedures that AAPS opposes include abortion[15] and over-the-counter access to emergency contraception.[16] AAPS also opposes electronic medical records[] as well as any "direct or de facto supervision or control over the practice of medicine by federal officers or employees."[17] On Oct 25, 2008 the AAPS website published an editorial implying that Barack Obama was using Neuro-linguistic Programming, "a covert form of hypnosis", to coerce people to vote for him in his 2008 presidential campaign.[18]

26

Political activity
Gun control
In 1996, Dr Miguel A. Faria, Jr., a retired neurosurgeon and former Clinical Professor of Surgery (Neurosurgery, ret.) at Mercer University School of Medicine as well as founding editor of Medical Sentinel, the AAPS's journal, was involved in a gun control debate regarding the CDC's National Center for Injury Prevention and Control (NCIPC). Faria and other critics felt the NCIPC's program on gun violence was biased against gun owners, and was part of a 'public health' political strategy by gun control advocates. They testified before a US House Subcommittee on Appropriations to that effect.[19][20][21] Faria wanted to defund the NCIPC entirely.[22][23] The CDC was forbidden by Congress to use taxpayers' money for gun control research and from participating in lobbying activities.[24][25] Faria left AAPS in 2002 to pursue other interests.[] He was subsequently appointed by the administration of President George W. Bush to oversee the NCIPC as member of the grant review committee of the CDC, which he did until 2005.[26] He is the World Affairs editor of Surgical Neurology International.[27] Dr. Jane Orient remains the Executive Director of AAPS.[28]

Legal activity
Social Security In 1975, AAPS went to court to block enforcement of a new Social Security amendment that would monitor the treatment given Medicare and Medicaid patients.[29] AAPS v. Hillary Clinton With several other groups, AAPS filed a lawsuit in 1993 against Hillary Clinton and Secretary of Health and Human Services Donna Shalala over closed-door meetings related to the 1993 Clinton health care plan. The AAPS sued to gain access to the list of members of President Clinton's health care taskforce. Judge Royce C. Lamberth found in favor of the plaintiffs and awarded $285,864 to the AAPS for legal costs; Lamberth also harshly criticized the Clinton administration and Clinton aide Ira Magaziner in his ruling.[30] Subsequently, a federal appeals court overturned the award and the initial findings on the basis that Magaziner and the administration had not acted in bad faith.[31]

Health Insurance Portability and Accountability Act


The AAPS was involved in litigation against Health Insurance Portability and Accountability Act (HIPAA), arguing that it violates the Fourth Amendment to the United States Constitution by allowing government access to certain medical data without a warrant.[32] (Title II of HIPAA, known as the Administrative Simplification (AS) provisions, requires the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers, and is intended to improve the efficiency and effectiveness of the US's health care system by encouraging the widespread use of electronic data interchange in the health care system.)

Association of American Physicians and Surgeons

27

Seizure of Rush Limbaugh's medical records


In 2004, AAPS filed a brief on behalf of conservative talk show host Rush Limbaugh in Florida's Fourth District Court of Appeal, opposing the seizure of his medical files in an investigation of drug charges for Limbaugh's alleged misuse of prescription drugs. The AAPS stated the seizure was a violation of state law and that 'It is not a crime for a patient to be in pain and repeatedly seek relief, and doctors should not be turned against patients they tried to help.'"[4][33] Patient Protection and Affordable Care Act (PPACA) On March 26, 2010 AAPS filed suit to invalidate the new health care bill.[34]

Other cases
In 2006 the group criticised what it called sham peer review, claiming it was a device used to punish whistleblowers.[35] The next year, AAPS helped appeal the conviction of Virginia internist William Hurwitz, who was sentenced to 25 years in federal prison for prescribing excessive quantities of narcotic drugs after 16 former patients testified against him.[36] Hurwitz was granted a retrial in 2006, and his 25-year prison sentence was reduced to 4 years and 9 months.[37]

Journal of American Physicians and Surgeons


The Journal of American Physicians and Surgeons (JPandS), until 2003 named the Medical Sentinel,[][38] is the journal of the association. Its mission statement includes " a commitment to publishing scholarly articles in defense of the practice of private medicine, the pursuit of integrity in medical research Political correctness, dogmatism and orthodoxy will be challenged with logical reasoning, valid data and the scientific method." The publication policy of the journal states that articles are subject to a double-blind peer-review process.[39] The Journal of American Physicians and Surgeons is not listed in major academic literature databases such as MEDLINE/PubMed[] nor the Web of Science.[40] The U.S. National Library of Medicine declined repeated requests from AAPS to index the journal, citing unspecified concerns.[] Articles and commentaries published in the journal have argued a number of non-mainstream or scientifically discredited claims,[] including: that human activity has not contributed to climate change, and that global warming will be beneficial and thus not a cause for concern;[41] that HIV does not cause AIDS;[42][43] that the "gay male lifestyle" shortens life expectancy by 20 years.[44] A series of articles by pro-life authors published in the journal argued for a link between abortion and breast cancer.[45][46] Such a link has been rejected by the scientific community, including the U.S. National Cancer Institute,[47] the American Cancer Society,[] and the World Health Organization,[] among other major medical bodies.[] A 2003 paper published in the journal, claiming that vaccination was harmful, was criticized for poor methodology, lack of scientific rigor, and outright errors by the World Health Organization[48] and the American Academy of Pediatrics.[] A National Public Radio piece mentioned inaccurate information published in the Journal and said: "The journal itself is not considered a leading publication, as it's put out by an advocacy group that opposes most government involvement in medical care."[49] The Journal has also published articles advocating politically and socially conservative policy positions[citation needed] , including: that the Food and Drug Administration and Centers for Medicare and Medicaid Services are unconstitutional;[50] that "humanists" have conspired to replace the "creation religion of Jehovah" with evolution;[51] that "anchor babies" are valuable to undocumented immigrants, particularly if the babies are disabled.[]

Association of American Physicians and Surgeons Quackwatch lists JPandS as an untrustworthy, non-recommended periodical.[52] An editorial in Chemical & Engineering News described JPandS as a "purveyor of utter nonsense."[53] Investigative journalist Brian Deer wrote that the journal is the "house magazine of a right-wing American fringe group [AAPS]" and "is barely credible as an independent forum."[54]

28

Leprosy error
In a 2005 article published in the Journal, Madeleine Cosman argued that illegal immigrants were carriers of disease, and that immigrants and "anchor babies" were launching a "stealthy assault on [American] medicine."[55] In the article, Cosman claimed that "Suddenly, in the past 3 years America has more than 7,000 cases of leprosy" because of illegal aliens.[55] The journal's leprosy claim was cited and repeated by Lou Dobbs as evidence of the dangers of illegal immigration.[49][56] However, publicly available statistics show that the 7,000 cases of leprosy occurred during the past 30 years, not the past three as Cosman claimed.[57] James L. Krahenbuhl, director of the U.S. government's leprosy program, stated that there had been no significant increase in leprosy cases, and that "It [leprosy] is not a public health problemthats the bottom line."[56] National Public Radio reported that the Journal article "had footnotes that did not readily support allegations linking a recent rise in leprosy rates to illegal immigrants."[49] The article's erroneous leprosy claim was pointed out by 60 Minutes,[58] National Public Radio,[49] and the New York Times[56] but has not been corrected by the Journal.[citation needed]

References
[4] Erik M. Conway, Naomi Oreskes, Merchants of Doubt, 2010, p.245 [7] "...an ultra-conservative political-action group" [14] The Standard of Care (http:/ / www. aapsonline. org/ newsletters/ jan06. php), from the AAPS website. Retrieved March 10, 2007. [15] Resolution passed by the Assembly Affirming the Sanctity of Human Life (http:/ / www. aapsonline. org/ resolutions/ 2003-2. htm), from the AAPS website. Retrieved March 12, 2007. [16] Comments re: Docket No. 2005N-0345, RIN 0910-AF72 (http:/ / www. aapsonline. org/ testimony/ fda-ab. php), from the AAPS website. Retrieved March 12, 2007. [19] Departments of Labor, Health and Human Services, Education, and Related Agencies Appropriations for 1997: Testimony of members of Congress and other interested individuals and organizations. Hearings Before a House Subcommittee of the Committee on Appropriations, House of Representatives, One Hundred Fourth Congress, Second Session, March 6, 1996, Hearing Volume, Part 7:935-970. U.S. Government Printing Office, Washington, DC. [20] Faria MA: The Perversion of Science and Medicine (Part III): Public Health and Gun Control Research. Medical Sentinel 1997;2(3):81-82. http:/ / haciendapublishing. com/ medicalsentinel/ perversion-science-and-medicine-part-iii-public-health-and-gun-control-research [21] Faria MA: The Perversion of Science and Medicine (Part IV): The Battle Continues. Medical Sentinel 1997;2(3):83-86. http:/ / www. haciendapub. com/ medicalsentinel/ perversion-science-and-medicine-part-iv-battle-continues [23] Faria MA: The Tainted Public-Health Model of Gun Control. Ideas on Liberty, April 2001. http:/ / www. thefreemanonline. org/ featured/ the-tainted-public-health-model-of-gun-control/ [24] Rochell A. Funding ends for study that drew fire of gun lobby. Atlanta Journal Constitution, May 2, 1996, p. A13. [25] Department of Health and Human Services, Centers for Disease Control and Prevention. Funding Opportunity Announcements, Additional Requirements AR-13: Prohibition on Use of CDC Funds for Certain Gun Control Activities in DHS-CDC. http:/ / www. cdc. gov/ od/ pgo/ funding/ grants/ additional_req. shtm#ar13 [27] Faria MA. The Russian political turmoil (2012): An American perspective. Surg Neurol Int 2012;3:28. http:/ / www. surgicalneurologyint. com/ content/ 3/ 1/ 28 [28] Orient J. Healthcare is personal, it's not for sharing. http:/ / www. aapsonline. org/ index. php/ site/ article/ healthcare_is_personal_its_not_for_sharing/ [34] http:/ / www. aapsonline. org/ hhslawsuit/ aaps-v-sebelius-03-26-2010. php [37] Washington Post story (http:/ / www. washingtonpost. com/ wp-dyn/ content/ article/ 2007/ 07/ 13/ AR2007071301035. html), July 14, 2007. [41] Environmental Effects of Increased Atmospheric Carbon Dioxide (http:/ / www. jpands. org/ vol12no3/ robinson. pdf) by Arthur B. Robinson, Noah E. Robinson, and Willie Soon. Published in The Journal of American Physicians and Surgeons, 2007; 12(3), 79. [42] Questioning HIV/AIDS: Morally Reprehensible or Scientifically Warranted? (http:/ / www. jpands. org/ vol12no4/ bauer. pdf), by Henry Bauer. Published in the Journal of American Physicians and Surgeons 2007: Vol 12, No. 4, p. 116.

Association of American Physicians and Surgeons


[43] AIDS A Heterosexual Epidemic? by Michael Fumento and AIDS Inventing a Virus? Commentary by Peter H. Duesberg, PhD (http:/ / www. haciendapub. com/ v2n3. html). From Medical Sentinel, Volume 2, No. 3, Summer 1997. duesberg.com (http:/ / www. duesberg. com/ ) [44] Homosexuality: Some Neglected Considerations (http:/ / www. jpands. org/ vol10no3/ lehrman. pdf), by Nathaniel S. Lehrman, MD. Published in Journal of American Physicians and Surgeons, Volume 10, Number 3 (Fall 2005), pp. 8082. [49] Broken Borders? CBS Lambastes, Hires Dobbs (http:/ / www. npr. org/ templates/ story/ story. php?storyId=10141647), by David Folkenflik. From All Things Considered, National Public Radio, May 11, 2007. Retrieved August 29, 2008. [50] The FDA and HCFA (Part II): Unconstitutional Regulatory Agencies (http:/ / www. haciendapub. com/ albright2. html), by James A. Albright, MD. Published in Medical Sentinel, 2000;5(6):205208. [51] Conspiracy --- Part III (http:/ / www. jpands. org/ hacienda/ caine6. html), by Curtis W. Caine, MD. Published in Medical Sentinel, 1999;4(6):224. [55] Illegal Aliens and American Medicine (http:/ / www. jpands. org/ vol10no1/ cosman. pdf), by Madeleine Cosman. Published in the Journal of American Physicians and Surgeons, Spring 2005 (Vol. 10, No. 1, pp. 610). [56] Truth, Fiction, and Lou Dobbs (http:/ / www. nytimes. com/ 2007/ 05/ 30/ business/ 30leonhardt. html), by David Leonhardt. Published in the New York Times on May 30, 2007; accessed August 29, 2008. [57] New U.S. Reported Hansen's Disease (Leprosy) Cases by Year, 19762005 (http:/ / hrsa. gov/ hansens/ 30yeartrend. htm), from the U.S. National Hansen's Disease (Leprosy) Program. Retrieved August 29, 2008. [58] Lou Dobbs' Opinion (http:/ / www. cbsnews. com/ sections/ i_video/ main500251. shtml?id=2765343n), from 60 Minutes. Originally broadcast on May 17, 2007; accessed August 29, 2008.

29

External links
AAPSonline.org (http://www.aapsonline.org/) Association of American Physicians and Surgeons home page Medical Sentinel (http://haciendapublishing.com/medicalsentinel) The first journal published by AAPS, now renamed to the Journal of American Physicians and Surgeons http://www.jpands.org. Rachel Maddow (November 18, 2009). "Special Interests Rally for Senate Health Bill" (http://www.msnbc. msn.com/id/26315908/vp/34029631#34029631). MSNBC: The Rachel Maddow Show.

American Association of Physicians of Indian Origin


The American Association of Physicians of Indian Origin (AAPI) is a professional association for Indian American physicians. The association is based in Chicago and was founded in 1984. It claims a membership of 52,000 physician.

Doctors of Indian Origin


There are currently (as of 2005) 40,838 doctors of Indian origin in the United States of America and they account for 5% of all doctors in the USA and 20% of all International Medical Graduates employed in the US workforce. It is noteworthy that India provides the largest number of International Medical Graduates to the US in absolute numbers. With 59,523 Physicians of Indian Origin working in the English speaking Western world (the US, UK, Australia and Canada combined), India is by far the single largest source of emigre physicians in the world.[1]

American Association of Physicians of Indian Origin

30

Jagdish Tytler Controversy


In June 2004, AAPI became involved in a controversy for its invitation to Indian Minister for NRI Affairs Jagdish Tytler to be honored at a dinner gala.[citation needed] Various human rights and Sikh groups threatened to hold demonstrations at the venue and the invitation to Jagdish Tytler was withdrawn.[2] Tytler resigned from the Indian government after being indicted by the official Nanavati Commission of inciting mobs for violence.[3][4][5]

References
[1] [2] [3] [4] [5] http:/ / www. nejm. org/ doi/ pdf/ 10. 1056/ NEJMsa050004 I n d i a P o s t . c o m (http:/ / www. indiapost. com/ members/ story. php?story_id=3187) http:/ / www. witness84. com/ doc/ aapi. doc Nanavati report: Credible evidence against Tytler (http:/ / in. rediff. com/ news/ 2005/ aug/ 08nanavati1. htm) "United States Should Not Let Tytler Enter Country" - Statement by [[New York (http:/ / thomas. loc. gov/ cgi-bin/ query/ R?r108:FLD001:E51218)] Representative Edolphus Towns in US Congress]

External links
American Association of Physicians of Indian Origin (http://www.aapiusa.org/) AAPIO website (http://www.aapio.org/)

American Association for Respiratory Care

31

American Association for Respiratory Care


American Association for Respiratory Care
Type Industry Non-profit organization Health care

Predecessor(s) American Association for Respiratory Therapy Founded Founder(s) March 16, 1947 Edwin R. Levine

Headquarters Irving, TX, United States Area served Website United States http:/ / www. aarc. org/

The American Association for Respiratory Care (AARC) is a non profit organization and is the only professional organization supporting Respiratory Care in the United States. In addition to attempting to help lobby for beneficial legislation nationally and locally, the AARC is trying to promote the profession as a whole to increase interest and membership.[1] The AARC began in 1943, as the Inhalation Technician Association and has evolved rapidly and repeatedly since.[2]

Mission
"The American Association for Respiratory Care (AARC) will continue to be the leading national and international professional association for respiratory care. The AARC will encourage and promote professional excellence, advance the science and practice of respiratory care, and serve as an advocate for patients, their families, the public, the profession and the respiratory therapist."[3]

Publications
Respiratory Care AARC Times Magazine

History
1946 - University of Chicago Hospital forms the Inhalation Therapy Association (ITA). 1947 - The ITA is chartered as a non-profit entity in the state of Illinois. 1954 - The ITA is renamed American Association of Inhalation Therapists (AAIT). 1966 - The AAIT is renamed American Association of Inhalation Therapy (AAIT). 1956 - The AAIT begins publishing a journal called Inhalation Therapy. 1973 - The AAIT is renamed the American Association of Respiratory Therapy. 1986 - The AART is renamed the American Association of Respiratory Care.

American Association for Respiratory Care

32

Affiliations
The AARC has several organizations with which they have an affiliation;Wikipedia:Please clarify some of these include: AMA Allied Health Careers American Academy of Allergy, Asthma & Immunology American Academy of Pediatrics American Association of Cardiovascular and Pulmonary Rehabilitation American Association of Critical-Care Nurses American College of Allergy, Asthma & Immunology American Heart Association American Hospital Association American Society of Anesthesiologists American Society for Testing and Materials American Thoracic Society Campaign for Tobacco-Free kids Canadian Society of Respiratory Therapists COARC, The Committee on Accreditation for Respiratory Care Council on Licensure, Enforcement, and Regulation Joint Commission on Accreditation of Healthcare Organizations Lambda Beta Society National Association for Medical Direction of Respiratory Care National Association for the Support of Long Term Care National Board for Respiratory Care National Coalition for Health Professional Education in Genetics National Committee for Clinical Laboratory Standards National Lung Health Education Program Neonatal Resuscitation Program Respiratory Therapy Society of Ontario Society of Critical Care Medicine

References External links


National Board of Respiratory Care, Inc. (http://www.nbrc.org)

Hematopoietic stem cell transplantation

33

Hematopoietic stem cell transplantation


Hematopoietic stem cell transplantation
Intervention

Bone marrow transplant ICD-9-CM MeSH MedlinePlus 41.0 [1] [2]

D018380 003009

[3]

Hematopoietic stem cell transplantation (HSCT) is the transplantation of multipotent hematopoietic stem cells, usually derived from bone marrow, peripheral blood, or umbilical cord blood. It is a medical procedure in the fields of hematology and oncology, most often performed for patients with certain cancers of the blood or bone marrow, such as multiple myeloma or leukemia. In these cases, the recipient's immune system is usually destroyed with radiation or chemotherapy before the transplantation. Infection and graft-versus-host disease is a major complication of allogenic HSCT. Hematopoietic stem cell transplantation remains a dangerous procedure with many possible complications; it is reserved for patients with life-threatening diseases. As the survival of the procedure increases, its use has expanded beyond cancer, such as autoimmune diseases.[4][5]

History
Georges Math, a French oncologist, performed the first European bone marrow transplant in 1959 on five Yugoslavian nuclear workers whose own marrow had been damaged by irradiation caused by a Criticality accident at the Vina Nuclear Institute, but all of these transplants were rejected.[6][7][8][9][10] Math later pioneered the use of bone marrow transplants in the treatment of leukemia.[10] Stem cell transplantation was pioneered using bone-marrow-derived stem cells by a team at the Fred Hutchinson Cancer Research Center from the 1950s through the 1970s led by E. Donnall Thomas, whose work was later recognized with a Nobel Prize in Physiology or Medicine. Thomas' work showed that bone marrow cells infused intravenously could repopulate the bone marrow and produce new blood cells. His work also reduced the likelihood of developing a life-threatening complication called graft-versus-host disease.[11]

Hematopoietic stem cell transplantation The first physician to perform a successful human bone marrow transplant on a disease other than cancer was Robert A. Good at the University of Minnesota in 1968.[12]

34

Medical uses
Many recipients of HSCTs are multiple myeloma[13] or leukemia patients[14] who would not benefit from prolonged treatment with, or are already resistant to, chemotherapy. Candidates for HSCTs include pediatric cases where the patient has an inborn defect such as severe combined immunodeficiency or congenital neutropenia with defective stem cells, and also children or adults with aplastic anemia[15] who have lost their stem cells after birth. Other conditions[] treated with stem cell transplants include sickle-cell disease, myelodysplastic syndrome, neuroblastoma, lymphoma, Ewing's sarcoma, desmoplastic small round cell tumor, chronic granulomatous disease and Hodgkin's disease. More recently non-myeloablative, or so-called "mini transplant," procedures have been developed that require smaller doses of preparative chemo and radiation. This has allowed HSCT to be conducted in the elderly and other patients who would otherwise be considered too weak to withstand a conventional treatment regimen.

Number of procedures
A total of 50,417 first hematopoietic stem cell transplants were reported as taking place worldwide in 2006, according to a global survey of 1327 centers in 71 countries conducted by the Worldwide Network for Blood and Marrow Transplantation. Of these, 28,901 (57%) were autologous and 21,516 (43%) were allogenetic (11,928 from family donors and 9,588 from unrelated donors). The main indications for transplant were lymphoproliferative disorders (54.5%) and leukemias (33.8%), and the majority took place in either Europe (48%) or the Americas (36%).[] In 2009, according to the world marrow donor association, stem cell products provided for unrelated transplantation worldwide had increased to 15,399 (3,445 bone marrow donations, 8,162 peripheral blood stem cell donations, and 3,792 cord blood units).[16]

Graft types
Autologous
Autologous HSCT requires the extraction (apheresis) of haematopoietic stem cells (HSC) from the patient and storage of the harvested cells in a freezer. The patient is then treated with high-dose chemotherapy with or without radiotherapy with the intention of eradicating the patient's malignant cell population at the cost of partial or complete bone marrow ablation (destruction of patient's bone marrow function to grow new blood cells). The patient's own stored stem cells are then transfused into his/her bloodstream, where they replace destroyed tissue and resume the patient's normal blood cell production. Autologous transplants have the advantage of lower risk of infection during the immune-compromised portion of the treatment since the recovery of immune function is rapid. Also, the incidence of patients experiencing rejection (graft-versus-host disease) is very rare due to the donor and recipient being the same individual. These advantages have established autologous HSCT as one of the standard second-line treatments for such diseases as lymphoma.[17] However, for others such as Acute Myeloid Leukemia, the reduced mortality of the autogenous relative to allogeneic HSCT may be outweighed by an increased likelihood of cancer relapse and related mortality, and therefore the allogeneic treatment may be preferred for those conditions.[18] Researchers have conducted small studies using non-myeloablative hematopoietic stem cell transplantation as a possible treatment for type I (insulin dependent) diabetes in children and adults. Results have been promising; however, as of 2009[19] it was premature to speculate whether these experiments will lead to effective treatments for diabetes.[20]

Hematopoietic stem cell transplantation

35

Allogeneic
Allogeneic HSCT involves two people: the (healthy) donor and the (patient) recipient. Allogeneic HSC donors must have a tissue (HLA) type that matches the recipient. Matching is performed on the basis of variability at three or more loci of the HLA gene, and a perfect match at these loci is preferred. Even if there is a good match at these critical alleles, the recipient will require immunosuppressive medications to mitigate graft-versus-host disease. Allogeneic transplant donors may be related (usually a closely HLA matched sibling), syngeneic (a monozygotic or 'identical' twin of the patient - necessarily extremely rare since few patients have an identical twin, but offering a source of perfectly HLA matched stem cells) or unrelated (donor who is not related and found to have very close degree of HLA matching). Unrelated donors may be found through a registry of bone marrow donors such as the National Marrow Donor Program. People who would like to be tested for a specific family member or friend without joining any of the bone marrow registry data banks may contact a private HLA testing laboratory and be tested with a mouth swab to see if they are a potential match.[21] A "savior sibling" may be intentionally selected by preimplantation genetic diagnosis in order to match a child both regarding HLA type and being free of any obvious inheritable disorder. Allogeneic transplants are also performed using umbilical cord blood as the source of stem cells. In general, by transfusing healthy stem cells to the recipient's bloodstream to reform a healthy immune system, allogeneic HSCTs appear to improve chances for cure or long-term remission once the immediate transplant-related complications are resolved.[][][22] A compatible donor is found by doing additional HLA-testing from the blood of potential donors. The HLA genes fall in two categories (Type I and Type II). In general, mismatches of the Type-I genes (i.e. HLA-A, HLA-B, or HLA-C) increase the risk of graft rejection. A mismatch of an HLA Type II gene (i.e. HLA-DR, or HLA-DQB1) increases the risk of graft-versus-host disease. In addition a genetic mismatch as small as a single DNA base pair is significant so perfect matches require knowledge of the exact DNA sequence of these genes for both donor and recipient. Leading transplant centers currently perform testing for all five of these HLA genes before declaring that a donor and recipient are HLA-identical. Race and ethnicity are known to play a major role in donor recruitment drives, as members of the same ethnic group are more likely to have matching genes, including the genes for HLA.[23]

Sources and storage of cells


To limit the risks of transplanted stem cell rejection or of severe graft-versus-host disease in allogeneic HSCT, the donor should preferably have the same human leukocyte antigens (HLA) as the recipient. About 25 to 30 percent of allogeneic HSCT recipients have an HLA-identical sibling. Even so-called "perfect matches" may have mismatched minor alleles that contribute to graft-versus-host disease.

Bone marrow
In the case of a bone marrow transplant, the HSC are removed from a large bone of the donor, typically the pelvis, through a large needle that reaches the center of the bone. The technique is referred to as a bone marrow harvest and is performed under general anesthesia.

Peripheral blood stem cells


Peripheral blood stem cells[] are now the most common source of stem cells for allogeneic HSCT. They are collected from the blood through a process known as apheresis. The donor's blood is withdrawn through a
Bone marrow harvest.

Hematopoietic stem cell transplantation sterile needle in one arm and passed through a machine that removes white blood cells. The red blood cells are returned to the donor. The peripheral stem cell yield is boosted with daily subcutaneous injections of Granulocyte-colony stimulating factor, serving to mobilize stem cells from the donor's bone marrow into the peripheral circulation.

36

Amniotic fluid
It is also possible to extract hematopoietic stem cells from amniotic fluid for both autologous or heterologous use at the time of childbirth.

Umbilical cord blood


Umbilical cord blood is obtained when a mother donates her infant's Umbilical Cord and Placenta after birth. Cord blood has a higher concentration of HSC than is normally found in adult blood. However, the small quantity of blood obtained from an Umbilical Cord (typically about 50 mL) makes it more suitable for transplantation into small children than into adults. Newer techniques using ex-vivo expansion of cord blood units or the use of two cord blood units from different donors allow cord blood transplants to be used in adults. Cord blood can be harvested from the Umbilical Cord of a child being born after preimplantation genetic diagnosis (PGD) for human leucocyte antigen (HLA) matching (see PGD for HLA matching) in order to donate to an ill sibling requiring HSCT.

Storage of HSC
Unlike other organs, bone marrow cells can be frozen (cryopreserved) for prolonged periods without damaging too many cells. This is a necessity with autologous HSC because the cells must be harvested from the recipient months in advance of the transplant treatment. In the case of allogeneic transplants, fresh HSC are preferred in order to avoid cell loss that might occur during the freezing and thawing process. Allogeneic cord blood is stored frozen at a cord blood bank because it is only obtainable at the time of childbirth. To cryopreserve HSC, a preservative, DMSO, must be added, and the cells must be cooled very slowly in a controlled-rate freezer to prevent osmotic cellular injury during ice crystal formation. HSC may be stored for years in a cryofreezer, which typically uses liquid nitrogen.

Conditioning regimens
Myeloablative transplants
The chemotherapy or irradiation given immediately prior to a transplant is called the conditioning regimen, the purpose of which is to help eradicate the patient's disease prior to the infusion of HSC and to suppress immune reactions. The bone marrow can be ablated (destroyed) with dose-levels that cause minimal injury to other tissues. In allogeneic transplants a combination of cyclophosphamide with total body irradiation is conventionally employed. This treatment also has an immunosuppressive effect that prevents rejection of the HSC by the recipient's immune system. The post-transplant prognosis often includes acute and chronic graft-versus-host disease that may be life-threatening. However, in certain leukemias this can coincide with protection against cancer relapse owing to the graft versus tumor effect.[24] Autologous transplants may also use similar conditioning regimens, but many other chemotherapy combinations can be used depending on the type of disease.

Hematopoietic stem cell transplantation

37

Non-myeloablative allogeneic transplants


This is a newer treatment approach using lower doses of chemotherapy and radiation, which are too low to eradicate all the bone marrow cells of a recipient. Instead, non-myeloablative transplants run lower risks of serious infections and transplant-related mortality while relying upon the graft versus tumor effect to resist the inherent increased risk of cancer relapse.[25][] Also significantly, while requiring high doses of immunosuppressive agents in the early stages of treatment, these doses are less than for conventional transplants.[26] This leads to a state of mixed chimerism early after transplant where both recipient and donor HSC coexist in the bone marrow space. Decreasing doses of immunosuppressive therapy then allows donor T-cells to eradicate the remaining recipient HSC and to induce the graft versus tumor effect. This effect is often accompanied by mild graft-versus-host disease, the appearance of which is often a surrogate marker for the emergence of the desirable graft versus tumor effect, and also serves as a signal to establish an appropriate dosage level for sustained treatment with low levels of immunosuppressive agents. Because of their gentler conditioning regimens, these transplants are associated with a lower risk of transplant-related mortality and therefore allow patients who are considered too high-risk for conventional allogeneic HSCT to undergo potentially curative therapy for their disease. These new transplant strategies are still somewhat experimental, but are being used more widely on elderly patients unfit for myeloablative regimens and for whom the higher risk of cancer relapse may be acceptable.[]

Engraftment
After several weeks of growth in the bone marrow, expansion of HSC and their progeny is sufficient to normalize the blood cell counts and reinitiate the immune system. The offspring of donor-derived hematopoietic stem cells have been documented to populate many different organs of the recipient, including the heart, liver, and muscle, and these cells had been suggested to have the abilities of regenerating injured tissue in these organs. However, recent research has shown that such lineage infidelity does not occur as a normal phenomenon [citation needed].

Complications
HSCT is associated with a high treatment-related mortality in the recipient (10% or higher)[citation needed], which limits its use to conditions that are themselves life-threatening. Major complications are veno-occlusive disease, mucositis, infections (sepsis), graft-versus-host disease and the development of new malignancies.

Infection
Bone marrow transplantation usually requires that the recipient's own bone marrow be destroyed ("myeloablation"). Prior to "engraftment" patients may go for several weeks without appreciable numbers of white blood cells to help fight infection. This puts a patient at high risk of infections, sepsis and septic shock, despite prophylactic antibiotics. However, antiviral medications, such as acyclovir and valacyclovir, are quite effective in prevention of HSCT-related outbreak of herpetic infection in seropositive patients.[] The immunosuppressive agents employed in allogeneic transplants for the prevention or treatment of graft-versus-host disease further increase the risk of opportunistic infection. Immunosuppressive drugs are given for a minimum of 6-months after a transplantation, or much longer if required for the treatment of graft-versus-host disease. Transplant patients lose their acquired immunity, for example immunity to childhood diseases such as measles or polio. For this reason transplant patients must be re-vaccinated with childhood vaccines once they are off immunosuppressive medications.

Hematopoietic stem cell transplantation

38

Veno-occlusive disease
Severe liver injury can result from hepatic veno-occlusive disease (VOD). Elevated levels of bilirubin, hepatomegaly and fluid retention are clinical hallmarks of this condition. There is now a greater appreciation of the generalized cellular injury and obstruction in hepatic vein sinuses, and hepatic VOD has lately been referred to as sinusoidal obstruction syndrome (SOS). Severe cases of SOS are associated with a high mortality rate. Anticoagulants or defibrotide may be effective in reducing the severity of VOD but may also increase bleeding complications. Ursodiol has been shown to help prevent VOD, presumably by facilitating the flow of bile.

Mucositis
The injury of the mucosal lining of the mouth and throat is a common regimen-related toxicity following ablative HSCT regimens. It is usually not life-threatening but is very painful, and prevents eating and drinking. Mucositis is treated with pain medications plus intravenous infusions to prevent dehydration and malnutrition.

Graft-versus-host disease
Graft-versus-host disease (GVHD) is an inflammatory disease that is peculiar to allogeneic transplantation. It is an attack of the "new" bone marrow's immune cells against the recipient's tissues. This can occur even if the donor and recipient are HLA-identical because the immune system can still recognize other differences between their tissues. It is aptly named graft-versus-host disease because bone marrow transplantation is the only transplant procedure in which the transplanted cells must accept the body rather than the body accepting the new cells. Acute graft-versus-host disease typically occurs in the first 3 months after transplantation and may involve the skin, intestine, or the liver. High-dose corticosteroids such as prednisone are a standard treatment; however this immuno-suppressive treatment often leads to deadly infections. Chronic graft-versus-host disease may also develop after allogeneic transplant. It is the major source of late treatment-related complications, although it less often results in death. In addition to inflammation, chronic graft-versus-host disease may lead to the development of fibrosis, or scar tissue, similar to scleroderma; it may cause functional disability and require prolonged immunosuppressive therapy. Graft-versus-host disease is usually mediated by T cells, which react to foreign peptides presented on the MHC of the host[citation needed].

Graft-versus-tumor effect
Graft-versus-tumor effect (GVT) or "graft versus leukemia" effect is the beneficial aspect of the Graft-versus-Host phenomenon. For example, HSCT patients with either acute and in particular chronic graft-versus-host disease after an allogeneic transplant tend to have a lower risk of cancer relapse.[27][28] This is due to a therapeutic immune reaction of the grafted donor T lymphocytes against the diseased bone marrow of the recipient. This lower rate of relapse accounts for the increased success rate of allogeneic transplants, compared to transplants from identical twins, and indicates that allogeneic HSCT is a form of immunotherapy. GVT is the major benefit of transplants that do not employ the highest immuno-suppressive regimens. Graft versus tumor is mainly beneficial in diseases with slow progress, e.g. chronic leukemia, low-grade lymphoma, and some cases multiple myeloma. However, it is less effective in rapidly growing acute leukemias.[29] If cancer relapses after HSCT, another transplant can be performed, infusing the patient with a greater quantity of donor white blood cells.[29]

Hematopoietic stem cell transplantation

39

Oral carcinoma
Patients after HSCT are at a higher risk for oral carcinoma. Post-HSCT oral cancer may have more aggressive behavior with poorer prognosis, when compared to oral cancer in non-HSCT patients.[]

Prognosis
Prognosis in HSCT varies widely dependent upon disease type, stage, stem cell source, HLA-matched status (for allogeneic HCST) and conditioning regimen. A transplant offers a chance for cure or long-term remission if the inherent complications of graft versus host disease, immuno-suppressive treatments and the spectrum of opportunistic infections can be survived.[][] In recent years, survival rates have been gradually improving across almost all populations and sub-populations receiving transplants.[30] Mortality for allogeneic stem cell transplantation can be estimated using the prediction model created by Sorror et al.,[] using the Hematopoietic Cell Transplantation-Specific Comorbidity Index (HCT-CI). The HCT-CI was derived and validated by investigators at the Fred Hutchinson Cancer Research Center (Seattle, WA). The HCT-CI modifies and adds to a well-validated comorbidity index, the Charlson Comorbidity Index (CCI) (Charlson et al.[]) The CCI was previously applied to patients undergoing allogeneic HCT but appears to provide less survival prediction and discrimination than the HCT-CI scoring system.

Risks to donor
The risks of a complication depend on patient characteristics, health care providers and the apheresis procedure, and the colony-stimulating factor used (G-CSF, GM-CSF). G-CSF drugs include filgrastim (Neupogen, Neulasta), and lenograstim (Graslopin).

Drug risks
Filgrastim is typically dosed in the 10 microgram/kg level for 45 days during the harvesting of stem cells. The documented adverse effects of filgrastim include splenic rupture (indicated by left upper abdominal or shoulder pain, risk 1 in 40000), Adult respiratory distress syndrome (ARDS), alveolar hemorrage, and allergic reactions (usually expressed in first 30 minutes, risk 1 in 300).[31][][] In addition, platelet and hemoglobin levels dip post-procedure, not returning to normal until one month.[] The question of whether geriatrics (patients over 65) react the same as patients under 65 has not been sufficiently examined. Coagulation issues and inflammation of atherosclerotic plaques are known to occur as a result of G-CSF injection.[] G-CSF has also been described to induce genetic changes in mononuclear cells of normal donors.[] There is evidence that myelodysplasia (MDS) or acute myeloid leukaemia (AML) can be induced by GCSF in susceptible individuals.[]

Access risks
Blood was drawn peripherally in a majority of patients, but a central line to jugular/subclavian/femoral veins may be used in 16% of women and 4% of men. Adverse reactions during apheresis were experienced in 20% of women and 8% of men, these adverse events primarily consisted of numbness/tingling, multiple line attempts, and nausea.[]

Clinical observations
A study involving 2408 donors (1860 years) indicated that bone pain (primarily back and hips) as a result of filgrastim treatment is observed in 80% of donors by day 4 post-injection.[] This pain responded to acetaminophen or ibuprofen in 65% of donors and was characterized as mild to moderate in 80% of donors and severe in 10%.[] Bone pain receded post-donation to 26% of patients 2 days post-donation, 6% of patients one week post-donation, and <2% 1 year post-donation. Donation is not recommended for those with a history of back pain.[] Other symptoms

Hematopoietic stem cell transplantation observed in more than 40% of donors include myalgia, headache, fatigue, and insomnia.[] These symptoms all returned to baseline 1 month post-donation, except for some cases of persistent fatigue in 3% of donors.[] . In one metastudy that incorporated data from 377 donors, 44% of patients reported having adverse side effects after peripheral blood HSCT.[] Side effects included pain prior to the collection procedure as a result of GCSF injections, post-procedural generalized skeletal pain, fatigue and reduced energy.[]

40

Severe reactions
A study that surveyed 2408 donors found that serious adverse events (requiring prolonged hospitalization) occurred in 15 donors (at a rate of 0.6%), although none of these events were fatal.[] Donors were not observed to have higher than normal rates of cancer with up to 48 years of follow up.[] One study based on a survey of medical teams covered approximately 24,000 peripheral blood HSCT cases between 1993 and 2005, and found a serious cardiovascular adverse reaction rate of about 1 in 1500.[] This study reported a cardiovascular-related fatality risk within the first 30 days HSCT of about 2 in 10000. For this same group, severe cardiovascular events were observed with a rate of about 1 in 1500. The most common severe adverse reactions were pulmonary edema/deep vein thrombosis, splenic rupture, and myocardial infarction. Haematological malignancy induction was comparable to that observed in the general population, with only 15 reported cases within 4 years.[]

Donor registration and recruitment


At the end of 2010, 14.9 million people had registered their willingness to be a bone marrow donor with one of the 64 registries from 45 countries participating in Bone Marrow Donors Worldwide. 12.2 million of these registered donors had been ABDR typed, allowing easy matching. A further 453,000 cord blood units had been received by one of 44 cord blood units from 26 countries participating. The highest total number of bone marrow donors registered were those from the USA (6.4 million), and the highest number per capita were those from Cyprus (10.6% of the population).[32] Within the United States, racial minority groups are the least likely to be registered and therefore the least likely to find a potentially life-saving match. In 1990, only six African-Americans were able to find a bone marrow match, and all six had common European genetic signatures.[] Africans are more genetically diverse than people of European descent, which means that more registrations are needed to find a match.[] Bone marrow and cord blood banks exist in South Africa, and a new program is beginning in Nigeria.[]

Research
HIV
In 2007, a team of doctors in Berlin, Germany, including Gero Htter, performed a stem cell transplant for leukemia patient Timothy Ray Brown, who was also HIV-positive.[] From 60 matching donors, they selected a [CCR5]-32 homozygous individual with two genetic copies of a rare variant of a cell surface receptor. This genetic trait confers resistance to HIV infection by blocking attachment of HIV to the cell. Roughly one in 1000 people of European ancestry have this inherited mutation, but it is rarer in other populations.[33][34] The transplant was repeated a year later after a relapse. Over three years after the initial transplant and despite discontinuing antiretroviral therapy, researchers cannot detect HIV in the transplant recipient's blood or in various biopsies.[35] Levels of HIV-specific antibodies have also declined, leading to speculation that the patient may have been functionally cured of HIV. However, scientists emphasise that this is an unusual case.[36] Potentially fatal transplant complications (the "Berlin patient" suffered from graft-versus-host disease and leukoencephalopathy) mean that the procedure could not be performed in others with HIV, even if sufficient numbers of suitable donors were found.[][37]

Hematopoietic stem cell transplantation In 2012, Daniel Kuritzkes reported results of two stem cell transplants in patients with HIV. They did not, however, use donors with the 32 deletion. One of the men has been followed for two years and the other for three and a half years. While both are still on HIV treatment, neither shows traces of HIV in their blood plasma and purified CD4 T cells using a sensitive culture method (less than 3 copies/ml). They are also showing a significant decline in HIV antibodies, suggesting a lack of HIV replication.[38]Wikipedia:Verifiability In mid 2013 it was reported that the two patients had been 15 and 7 weeks respectively without treatment, and still showing no signs of HIV returning.[39]

41

Multiple sclerosis
Since McAllister's 1997 report on a patient with multiple sclerosis (MS) who received a bone marrow transplant for CML,[40] there have been over 600 reports of HSCTs performed primarily for MS.[] These have been shown to "reduce or eliminate ongoing clinical relapses, halt further progression, and reduce the burden of disability in some patients" that have aggressive highly active multiple sclerosis, "in the absence of chronic treatment with disease-modifying agents".[]

References
[1] http:/ / icd9cm. chrisendres. com/ index. php?srchtype=procs& srchtext=41. 0& Submit=Search& action=search [2] http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2011/ MB_cgi?field=uid& term=D018380 [3] http:/ / www. nlm. nih. gov/ medlineplus/ ency/ article/ 003009. htm [6] McLaughlin et al. page 96, "Radiation doses were intense, being estimated at 205, 320, 410, 415, 422, and 433 rem.74 Of the six persons present, one died and the other five recovered after severe cases of radiation sickness." [8] Vinca reactor accident, 1958 (http:/ / www. johnstonsarchive. net/ nuclear/ radevents/ 1958YUG1. html), compiled by Wm. Robert Johnston [9] Nuove esplosioni a Fukushima: danni al nocciolo. Ue: "In Giappone lapocalisse" (http:/ / www. ilfattoquotidiano. it/ 2011/ 03/ 14/ giappone-due-esplosioni-di-idrogeno-a-fukushima-bloccato-un-altro-reattore/ 97466/ ), 14 marzo 2011 [16] Charts from [19] http:/ / en. wikipedia. org/ w/ index. php?title=Hematopoietic_stem_cell_transplantation& action=edit [21] "Getting Tested: Bone Marrow Donor Options" (http:/ / www. bonemarrowtest. com/ marrowdonoroptions. htm) [22] CLL article (http:/ / clltopics. org/ BMT/ OnlyRealCure. htm) [23] http:/ / www. marrow. org/ DONOR/ ABCs/ index. html [29] Memorial Sloan-Kettering Cancer Center > Blood & Marrow Stem Cell Transplantation > The Graft-versus-Tumor Effect (http:/ / www. mskcc. org/ mskcc/ html/ 15927. cfm) Last Updated: 20 Nov. 2003. Retrieved on 6 April 2009 [30] Data analysis slides by Center for International Blood and Marrow Transplant Research (https:/ / campus. mcw. edu/ AngelUploads/ Content/ CS_IBMTR2/ _assoc/ ECCBED0AF0A4492BB667FB6227DC7C06/ SummarySet06_Pt2_files/ frame. htm) [31] Neupogen Prescription information provided by Amgen http:/ / pi. amgen. com/ united_states/ neupogen/ neupogen_pi_hcp_english. pdf [32] Bone Marrow Donors Worldwide Annual Report 2010 http:/ / bmdw. org/ uploads/ media/ BMDW2010_01. pdf [34] http:/ / biology. plosjournals. org/ perlserv/ ?request=get-document& doi=10. 1371/ journal. pbio. 0030339 [36] http:/ / www. aidsmeds. com/ articles/ hiv_aids_stemcell_2042_14199. shtml [38] (primary source) [39] Bone marrow 'frees men of HIV drugs'

External links
Media related to Hematopoietic stem cell transplantation at Wikimedia Commons

Patient Protection and Affordable Care Act

42

Patient Protection and Affordable Care Act


Patient Protection and Affordable Care Act

Long title Colloquial acronym(s) Nickname(s)

The Patient Protection and Affordable Care Act PPACA Affordable Care Act, Health Insurance Reform, Healthcare Reform, Obamacare 111th United States Congress March 23, 2010 Most major provisions phased in by January 2014; remaining provisions phased in by 2020 Citations

Enacted by the Effective

Public Law Stat.

111148

[1]

124 Stat. 119 through 124 Stat. 1025 (906 pages) Legislative history [2] [3] ) by Charles Rangel (DNY) on

Introduced in the House as the "Service Members Home Ownership Tax Act of 2009" (H.R. 3590 September 17, 2009 Committee consideration by: Ways and Means Passed the House on October 8, 2009 (4160 [4] )

Passed the Senate as the "Patient Protection and Affordable Care Act" on December 24, 2009 (6039 House agreed to Senate amendment on March 21, 2010 (219212 Signed into law by President Barack Obama on March 23, 2010 Major amendments [6] )

[5]

) with amendment

Health Care and Education Reconciliation Act of 2010 Comprehensive 1099 Taxpayer Protection and Repayment of Exchange Subsidy Overpayments Act of 2011 United States Supreme Court cases National Federation of Independent Business v. Sebelius

The Patient Protection and Affordable Care Act (PPACA),[7] commonly called Obamacare[][8] or the Affordable Care Act (ACA), is a United States federal statute signed into law by President Barack Obama on March 23, 2010. Together with the Health Care and Education Reconciliation Act, it represents the most significant government expansion and regulatory overhaul of the country's healthcare system since the passage of Medicare and Medicaid in 1965.[] The ACA aims to increase the quality, affordability, and rate of health insurance coverage for Americans, and reduce the costs of health care for individuals and the government. It provides a number of mechanismsincluding mandates, subsidies, and insurance exchangesto increase coverage and affordability.[][9] The law also requires

Patient Protection and Affordable Care Act insurance companies to cover all applicants within new minimum standards and offer the same rates regardless of pre-existing conditions or sex.[10][11] Additional reforms aim to reduce costs and improve healthcare outcomes by shifting the system towards quality over quantity through increased competition, regulation, and incentives to streamline the delivery of health care. The Congressional Budget Office projected that the ACA will lower both future deficits[12] and Medicare spending.[13] On June 28, 2012, the United States Supreme Court upheld the constitutionality of most of the ACA in the case National Federation of Independent Business v. Sebelius. However, the Court held that states cannot be forced to participate in the ACA's Medicaid expansion under penalty of losing their current Medicaid funding.[14][15]

43

Overview
Provisions
The ACA includes numerous provisions to take effect over several years beginning in 2010. There is a grandfather clause on policies issued before then that exempt them from many of these provisions, but other provisions may affect existing policies. Guaranteed issue will require policies to be issued regardless of any medical condition, and partial community rating will require insurers to offer the same premium to all applicants of the same age and geographical location without regard to gender or most pre-existing conditions (excluding tobacco use).[][][] A shared responsibility requirement, commonly called an individual mandate,[][] requires all individuals not covered by an employer sponsored health plan, Medicaid, Medicare or other public insurance programs, to secure an approved private-insurance policy or pay a penalty, unless the applicable individual is a member of a recognized religious sect exempted by the Internal Revenue Service, or waived in cases of financial hardship.[] This was included on the rationale that - without such a mandate, a form of community rating, and coverage standards - the guaranteed issue provision would likely exacerbate adverse selection: if people could not be denied insurance by companies they

The President and White House Staff react to the House of Representatives passing the bill on March 21, 2010.

Obama signing the bill at the White House

Patient Protection and Affordable Care Act might put-off insuring themselves until they got sick, causing insurers to resort to larger premium increases on sick individuals and more extensive coverage limits to afford the remaining insured population, which could result in an insurance death spiral.[][][16] This led to the inclusion of subsidies (see below) so people with low-incomes can comply when the mandate goes into effect.[] Health insurance exchanges will commence operation in each state, offering a marketplace where individuals and small businesses can compare policies and premiums, and buy insurance (with a government subsidy if eligible).[]

44

Maximum Out-of-Pocket Premium as Percentage of Family Income and federal [] poverty level (Source: CRS)

Low-income individuals and families above 100% and up to 400% of the federal poverty level will receive federal subsidies[] on a sliding scale if they choose to purchase insurance via an exchange (those from 133% to 150% of the poverty level would be subsidized such that their premium cost would be 3% to 4% of income).[] The text of the law expands Medicaid eligibility to include all individuals and families with incomes up to 133% of the poverty level, and simplifies the CHIP enrollment process. In National Federation of Independent Business v. Sebelius, the Supreme Court effectively allowed states to opt out of the Medicaid expansion, and some states have stated their intention to do so. States that choose to reject the Medicaid expansion can set their own Medicaid eligibility thresholds, which in many states are significantly below 133% of the poverty line; in addition, many states do not make Medicaid available to childless adults at any income level. Because subsidies on insurance plans purchased through exchanges are not available to those below 100% of the poverty line, this may create a coverage gap in those states.[][][] Minimum standards for health insurance policies are to be established[] (an 'essential health benefits'[]), and annual and lifetime coverage caps will be banned.[][][] Firms employing 50 or more people but not offering health insurance will also pay a shared responsibility requirement if the government has had to subsidize an employee's health care.[17][] Very small businesses will be able to get subsidies if they purchase insurance through an exchange.[] Co-payments, co-insurance, and deductibles are to be eliminated for select health care insurance benefits considered to be part of the "essential benefits package"[] for Level A or Level B preventive care.[][] Changes are enacted that allow a restructuring of Medicare reimbursement from "fee-for-service" to "bundled payment."[18][19] A single payment is paid to a hospital and a physician group, for example, for a defined episode of care (such as a hip replacement), rather than individual payments to individual service-providers.

Funding
The ACA's provisions are funded by a variety of taxes and offsets. Major sources of new revenue include a much-broadened Medicare tax on incomes over $200,000 and $250,000, for individual and joint filers respectively, an annual fee on insurance providers, and a 40% excise tax on "Cadillac" insurance policies. The income levels are not adjusted for inflation, leaving the possibility of increased taxes on incomes over 250,000 inflation-adjusted dollars after more than two decades without indexing through.[20] There are also taxes on pharmaceuticals, high-cost diagnostic equipment, and a 10% federal sales tax on indoor tanning services. Offsets are from intended cost savings

Patient Protection and Affordable Care Act such as changes in the Medicare Advantage program relative to traditional Medicare.[21] Summary of tax increases: (ten-year projection) Increase Medicare tax rate by 0.9% and impose added tax of 3.8% on unearned income for high-income taxpayers: $210.2billion Charge an annual fee on health insurance providers: $60billion Impose a 40% excise tax on health insurance annual premiums in excess of $10,200 for an individual or $27,500 for a family: $32billion Impose an annual fee on manufacturers and importers of branded drugs: $27billion Impose a 2.3% excise tax on manufacturers and importers of certain medical devices:$20billion Raise the 7.5% Adjusted Gross Income floor on medical expenses deduction to 10%: $15.2billion Limit annual contributions to flexible spending arrangements in cafeteria plans to $2,500: $13billion All other revenue sources: $14.9billion Summary of spending offsets: (ten-year projection) Reduce funding for Medicare Advantage policies: $132billion Reduce Medicare home health care payments: $40billion Reduce certain Medicare hospital payments: $22billion Original budget estimates included a provision to require information reporting on payments to corporations, which had been projected to raise $17billion, but the provision was repealed.[22]

45

Provisions by effective date


The ACA is divided into 10 titles[23] and contains provisions that became effective immediately, 90 days after enactment, and six months after enactment, as well as provisions phased in through to 2020.[][] Below are some of the key provisions of the ACA. For simplicity, the amendments in the Health Care and Education Reconciliation Act of 2010 are integrated into this timeline.[24][]

Effective at enactment
The Food and Drug Administration is now authorized to approve generic versions of biologic drugs and grant biologics manufacturers 12years of exclusive use before generics can be developed.[] The Medicaid drug rebate (paid by drug manufacturers to the states) for brand name drugs is increased to 23.1% (except the rebate for clotting factors and drugs approved exclusively for pediatric use increases to 17.1%), and the rebate is extended to Medicaid managed care plans; the Medicaid rebate for non-innovator, multiple source drugs is increased to 13% of average manufacturer price.[] A non-profit Patient-Centered Outcomes Research Institute is established, independent from government, to undertake comparative effectiveness research.[] This is charged with examining the "relative health outcomes, clinical effectiveness, and appropriateness" of different medical treatments by evaluating existing studies and conducting its own. Its 19-member board is to include patients, doctors, hospitals, drug makers, device manufacturers, insurers, payers, government officials and health experts. It will not have the power to mandate or even endorse coverage rules or reimbursement for any particular treatment. Medicare may take the Institute's research into account when deciding what procedures it will cover, so long as the new research is not the sole justification and the agency allows for public input.[25] The bill prohibits the Institute from developing or employing "a dollars per quality adjusted life year" (or similar measure that discounts the value of a life because of an individual's disability) as a threshold to establish what type of health care is cost effective or recommended. This makes it different from the UK's National Institute for Health and Clinical Excellence, which determines cost-effectiveness directly based on quality-adjusted life year valuations.

Patient Protection and Affordable Care Act Creation of the Prevention and Public Health Fund to fund programs and research designed to increase chronic disease prevention.[26][27][28] Creation of task forces on Preventive Services and Community Preventive Services to develop, update, and disseminate evidenced-based recommendations on the use of clinical and community prevention services.[] The Indian Health Care Improvement Act is reauthorized and amended.[] Chain restaurants and food vendors with 20 or more locations are required to display the caloric content of their foods on menus, drive-through menus, and vending machines. Additional information, such as saturated fat, carbohydrate, and sodium content, must also be made available upon request.[] But first, the Food and Drug Administration has to come up with regulations, and as a result, calories disclosures may not appear until 2013 or 2014.Wikipedia:Manual of Style/Dates and numbers#Precise language[] States can apply for a 'State Plan Amendment" to expand family planning eligibility to the same eligibility as pregnancy related care (above and beyond Medicaid level eligibility), through a state option rather than having to apply for a federal waiver.[][29][30]

46

Effective June 21, 2010


Adults with existing conditions became eligible to join a temporary high-risk pool, which will be superseded by the health care exchange in 2014.[][31] To qualify for coverage, applicants must have a pre-existing health condition and have been uninsured for at least the past six months.[] There is no age requirement.[] The new program sets premiums as if for a standard population and not for a population with a higher health risk. Allows premiums to vary by age (3:1), geographic area, family composition and tobacco use (1.5:1). Limit out-of-pocket spending to $5,950 for individuals and $11,900 for families, excluding premiums.[][32][33]

Effective July 1, 2010


The President established, within the Department of Health and Human Services (HHS), a council to be known as the National Prevention, Health Promotion and Public Health Council to help begin to develop a National Prevention and Health Promotion Strategy. The Surgeon General shall serve as the Chairperson of the new Council.[][34] A 10% sales tax on indoor tanning took effect.[35]

Effective September 23, 2010


Insurers are prohibited from imposing lifetime dollar limits on essential benefits, like hospital stays, in new policies issued.[] Dependents (mainly children) will be permitted to remain on their parents' insurance plan until their 26th birthday,[36] and regulations implemented under the ACA include dependents that no longer live with their parents, are not a dependent on a parent's tax return, are no longer a student, or are married.[][] Insurers are prohibited from excluding pre-existing medical conditions (except in grandfathered individual health insurance plans) for children under the age of 19.[37][] All new insurance plans must cover preventive care and medical screenings[] rated Level A or B [38] by the U.S. Preventive Services Task Force.[39] Insurers are prohibited from charging co-payments, co-insurance, or deductibles for these services.[] Individuals affected by the Medicare Part D coverage gap will receive a $250 rebate, and 50% of the gap will be eliminated in 2011.[] The gap will be eliminated by 2020. Insurers' abilities to enforce annual spending caps will be restricted, and completely prohibited by 2014.[] Insurers are prohibited from dropping policyholders when they get sick.[] Insurers are required to reveal details about administrative and executive expenditures.[] Insurers are required to implement an appeals process for coverage determination and claims on all new plans.[]

Patient Protection and Affordable Care Act Enhanced methods of fraud detection are implemented.[] Medicare is expanded to small, rural hospitals and facilities.[] Medicare patients with chronic illnesses must be monitored/evaluated on a 3-month basis for coverage of the medications for treatment of such illnesses. Companies which provide early retiree benefits for individuals aged 5564 are eligible to participate in a temporary program which reduces premium costs.[] A new website installed by the Secretary of Health and Human Services will provide consumer insurance information for individuals and small businesses in all states.[] A temporary credit program is established to encourage private investment in new therapies for disease treatment and prevention.[] All new insurance plans must cover childhood immunizations and adult vaccinations recommended by the Advisory Committee on Immunization Practices (ACIP) without charging co-payments, co-insurance, or deductibles when provided by an in-network provider.[]

47

Effective January 1, 2011


Insurers must spend 80% (for individual or small group insurers) or 85% (for large group insurers) of premium dollars on health costs and claims, leaving only 20% or 15% respectively for administrative costs and profits, subject to various waivers and exemptions. If an insurer fails to meet this requirement, there is no penalty, but a rebate must be issued to the policy holder. This policy is known as the 'Medical Loss Ratio'.[40][][][] The Centers for Medicare and Medicaid Services is responsible for developing the Center for Medicare and Medicaid Innovation and overseeing the testing of innovative payment and delivery models.[41] Flexible spending accounts, Health reimbursement accounts and health savings accounts cannot be used to pay for over-the-counter drugs, purchased without a prescription, except insulin.[]

Effective September 1, 2011


All health insurance companies must inform the public when they want to increase health insurance rates for individual or small group policies by an average of 10% or more. This policy is known as 'Rate Review'. States are provided with Health Insurance Rate Review Grants to enhance their rate review programs and bring greater transparency to the process.[42][43]

Effective January 1, 2012


Employers must disclose the value of the benefits they provided beginning in 2012 for each employee's health insurance coverage on the employee's annual Form W-2's.[44] This requirement was originally to be effective January 1, 2011, but was postponed by IRS Notice 201069 on October 23, 2010.[45] Reporting is not required for any employer that was required to file fewer than 250 Forms W-2 in the preceding calendar year.[46] New tax reporting changes were to come in effect. Lawmakers originally felt these changes would help prevent tax evasion by corporations. However, in April 2011, Congress passed and President Obama signed the Comprehensive 1099 Taxpayer Protection and Repayment of Exchange Subsidy Overpayments Act of 2011 repealing this provision, because it was burdensome to small businesses.[47][] Before the ACA, businesses were required to notify the IRS on form 1099 of certain payments to individuals for certain services or property over a reporting threshold of $600.[][] Under the repealed law, reporting of payments to corporations would also be required.[48][49] Originally it was expected to raise $17billion over 10years.[50] The amendments made by Section 9006 of the ACA were designed to apply to payments made by businesses after December 31, 2011, but will no longer apply because of the repeal of the section.[][]

Patient Protection and Affordable Care Act

48

Effective August 1, 2012


All new plans must cover certain preventive services such as mammograms and colonoscopies without charging a deductible, co-pay or coinsurance. Women's Preventive Services including: well-woman visits; gestational diabetes screening; human papillomavirus (HPV) DNA testing for women age 30 and older; sexually transmitted infection counseling; human immunodeficiency virus (HIV) screening and counseling; FDA-approved contraceptive methods and contraceptive counseling; breastfeeding support, supplies and counseling; and domestic violence screening and counseling - will be covered without cost sharing.[] The requirement to cover FDA-approved contraceptive methods is also known as the contraceptive mandate.[][51][]

Effective October 1, 2012


The Centers for Medicare & Medicaid Services (CMS) will begin the Readmissions Reduction Program, which requires CMS to reduce payments to IPPS hospitals with excess readmissions, effective for discharges beginning on October 1, 2012. The regulations that implement this provision are in subpart I of 42 CFR part 412 (412.150 through 412.154).[52] Starting in October, an estimated total of 2,217 hospitals across the nation will be penalized; however, only 307 of these hospitals will receive this year's maximum penalty, i.e., 1 percent off their base Medicare reimbursements. The penalty will be deducted from reimbursements each time a hospital submits a claim starting Oct. 1. The maximum penalty will increase after this year, to 2 percent of regular payments starting in October 2013 and then to 3 percent the following year. As an example, if a hospital received the maximum penalty of 1 percent and it submitted a claim for $20,000 for a stay, Medicare would reimburse it $19,800. Together, these 2,217 hospitals will forfeit more than $280 million in Medicare funds over the next year, i.e., until October 2013, as Medicare and Medicaid begin a wide-ranging push to start paying health care providers based on the quality of care they provide. The $280 million in penalties comprises about 0.3 percent of the total amount hospitals are paid by Medicare.[53]

Effective January 1, 2013


Income from self-employment and wages of single individuals in excess of $200,000 annually will be subject to an additional tax of 0.9%. The threshold amount is $250,000 for a married couple filing jointly (threshold applies to joint compensation of the two spouses), or $125,000 for a married person filing separately.[54] In addition, an additional Medicare tax of 3.8% will apply to unearned income, specifically the lesser of net investment income or the amount by which adjusted gross income exceeds $200,000 ($250,000 for a married couple filing jointly; $125,000 for a married person filing separately.)[55] Beginning January 1, 2013, the limit on pre-tax contributions to healthcare flexible spending accounts will be capped at $2,500 per year.[56][57][58] Most medical devices become subject to a 2.3% excise tax collected at the time of purchase. (Reduced by the reconciliation act from 2.6% to 2.3%.)[59] This tax will also apply to some medical devices, such as examination gloves and catheters, that are used in veterinary medicine.[] Insurance companies are required to use simpler, more standardized paperwork, with the intention of helping consumers make apples-to-apples comparisons between the prices and benefits of different health plans.[60]

Effective August 1, 2013


Religious organizations that were given an extra year to implement the contraceptive mandate are no longer exempt. Certain non-exempt, non-grandfathered group health plans established and maintained by non-profit organizations with religious objections to covering contraceptive services may take advantage of a one-year enforcement safe harbor (i.e., until the first plan year beginning on or after August 1, 2013) by timely satisfying certain requirements set forth by the U.S. Department of Health & Human Services.[61]

Patient Protection and Affordable Care Act

49

Effective October 1, 2013


Individuals may enroll in subsidized health insurance plans offered through state-based health insurance exchanges. Coverage begins on January 1, 2014.[62][63][64]

Effective January 1, 2014


Insurers are prohibited from discriminating against or charging higher rates for any individual based on pre-existing medical conditions or gender.[] Insurers are prohibited from establishing annual spending caps of dollar amounts on essential health benefits.[] Under the mandatory coverage provision, individuals who are not covered by an acceptable insurance policy will be charged an annual penalty of $95, or up to 1% of Maximum Out-of-Pocket Premium Payments Under PPACA by Family Size and federal [] income over the filing minimum,[65] poverty level. (Source: CRS) whichever is greater; this will rise to a minimum of $695 ($2,085 for families),[66] or 2.5% of income over the filing minimum,[65] by 2016.[][] Exemptions are permitted for religious reasons, members of health care sharing ministries, or for those for whom the least expensive policy would exceed 8% of their income.[67] In 2010, the Commissioner speculated that insurance providers would supply a form confirming essential coverage to both individuals and the IRS; individuals would attach this form to their Federal tax return. Those who aren't covered will be assessed the penalty on their Federal tax return. In the wording of the law, a taxpayer who fails to pay the penalty "shall not be subject to any criminal prosecution or penalty", and cannot have liens or levies placed on their property, but the IRS will be able to withhold future tax refunds from them.[68] In participating states, Medicaid eligibility is expanded; all individuals with income up to 133% of the poverty line qualify for coverage, including adults without dependent children.[][] The law also provides for a 5% "income disregard", making the effective income eligibility limit 138% of the poverty line.[] States may choose to increase the income eligibility limit beyond this minimum requirement.[] As written, the ACA withheld all Medicaid funding from states declining to participate in the expansion. However, the Supreme Court ruled in National Federation of Independent Business v. Sebelius (2012) that this withdrawal of funding was unconstitutionally coercive and that individual states had the right to opt out of the Medicaid expansion without losing pre-existing Medicaid funding from the federal government. As of April 25, 2013, fifteen statesAlaska, Alabama, Georgia, Idaho, Indiana, Iowa, Louisiana, Mississippi, Nebraska, North Carolina, Oklahoma, South Carolina, Texas, Wisconsin, and Virginiawere not participating in the Medicaid expansion, with ten moreKansas, Maine, Michigan, Montana, Missouri, Ohio, Pennsylvania, South Dakota, Utah, and Wyomingleaning towards not participating.[69] Health insurance exchanges are established, and subsides for insurance premiums are given to individuals who buy a plan from an exchange and have a household income between 133% and 400% of the poverty line.[][70][][71] Section 1401(36B) of PPACA explains that each subsidy will be provided as an advanceable, refundable tax credit[] and gives a formula for its calculation.[72] A refundable tax credit is a way to provide government benefits to individuals who may have no tax liability[73] (such as the Earned Income Tax Credit). The formula was

Patient Protection and Affordable Care Act changed in the amendments (HR 4872) passed March 23, 2010, in section 1001. To qualify for the subsidy, the beneficiaries cannot be eligible for other acceptable coverage. The U.S. Department of Health and Human Services (DHHS) and Internal Revenue Service (IRS) on May 23, 2012, issued joint final rules regarding implementation of the new state-based health insurance exchanges to cover how the exchanges will determine eligibility for uninsured individuals and employees of small businesses seeking to buy insurance on the exchanges, as well as how the exchanges will handle eligibility determinations for low-income individuals applying for newly expanded Medicaid benefits.[74][] According to DHHS and CRS, in 2014 the income-based premium caps for a "silver" healthcare plan for a family of four will be the following:

50

Health Insurance Premiums and Cost Sharing under PPACA for Average Family of 4[][][75][76][]
Income % of federal poverty level 133% 150% 200% 250% 300% 350% 400% Premium Cap as a Share of Income Max Annual Income $ (family of a Out-of-Pocket Premium 4) $31,900 $33,075 $44,100 $55,125 $66,150 $77,175 $88,200 $992 $1,323 $2,778 $4,438 $6,284 $7,332 $8,379 Premium Savingsb Additional Cost-Sharing Subsidy

3% of income 4% of income 6.3% of income 8.05% of income 9.5% of income 9.5% of income 9.5% of income

$10,345 $9,918 $8,366 $6,597 $4,628 $3,512 $2,395

$5,040 $5,040 $4,000 $1,930 $1,480 $1,480 $1,480

[][] a.^ Note: In 2016, the FPL is projected to equal about $11,800 for a single person and about $24,000 for family of four. See Subsidy Calculator [] for specific dollar amount. b.^ DHHS and CBO estimate the average annual premium cost in 2014 to be $11,328 for family of 4 without the [75] reform.

Two federally regulated "multi-state plans" (MSP), one of which is required to be offered by a non-profit insurer and the other is forbidden from providing coverage for abortion services, become available in some state health insurance exchanges. The MSPs will have to abide by the same federal regulations as required by an individual state's qualified health plans available on the exchanges and must provide the same identical cover privileges and premiums in all states. MSPs will be phased in nationally, being available in 60% of all states in 2014, 70% in 2015, 85% in 2016, and 100% in 2017.[] Section 2708 to the Public Health Service Act becomes effective, which prohibits patient eligibility waiting periods in excess of 90 days for group health plan coverage. The 90-day rule applies to all grandfathered and non-grandfathered group health plans and group health insurance issuers, including multiemployer health plans and single-employer group health plans pursuant to collective bargaining arrangements.[77] Plans will still be allowed to impose eligibility requirements based on factors other than the lapse of time; for example, a health plan can restrict eligibility to employees who work at a particular location or who are in an eligible job classification. The waiting period limitation means that coverage must be effective no later than the 91st day after the employee satisfies the substantive eligibility requirements.[78] Two years of tax credits will be offered to qualified small businesses. To receive the full benefit of a 50% premium subsidy, the small business must have an average payroll per full-time equivalent ("FTE") employee of no more than $50,000 and have no more than 25 FTEs. For the purposes of the calculation of FTEs, seasonal employees, and owners and their relations, are not considered. The subsidy is reduced by 3.35 percentage points per additional employee and 2 percentage points per additional $1,000 of average compensation. As an example, a 16 FTE firm with a $35,000 average salary would be entitled to a 10% premium subsidy.[79]

Patient Protection and Affordable Care Act A $2,000 per employee penalty will be imposed on employers with more than 50 full-time employees who do not offer health insurance to their full-time workers (as amended by the reconciliation bill).[][] "Full-time" is defined as, with respect to any month, an employee who is employed on average at least 30 hours of service per week.[] In July 2013, the Obama administration announced this penalty would not be enforced until January 1, 2015.[80][81] For employer-sponsored plans, a $2,000 maximum annual deductible is established for any plan covering a single individual or a $4,000 maximum annual deductible for any other plan (see 111HR3590ENR, section 1302). These limits can be increased under rules set in section 1302. To finance part of the new spending, spending and coverage cuts are made to Medicare Advantage, the growth of Medicare provider payments are slowed (in part through the creation of a new Independent Payment Advisory Board), Medicare and Medicaid drug reimbursement rates are decreased, and other Medicare and Medicaid spending is cut.[][82] Revenue is increased from a new $2,500 limit on tax-free contributions to flexible spending accounts (FSAs), which allow for payment of health costs.[83] Members of Congress and their staff are only offered health care plans through the exchanges or plans otherwise established by the bill (instead of the Federal Employees Health Benefits Program that they currently use).[84] A new excise tax goes into effect that is applicable to pharmaceutical companies and is based on the market share of the company; it is expected to create $2.5billion in annual revenue.[] Health insurance companies become subject to a new excise tax based on their market share; the rate gradually rises between 2014 and 2018 and thereafter increases at the rate of inflation. The tax is expected to yield up to $14.3billion in annual revenue.[] The qualifying medical expenses deduction for Schedule A tax filings increases from 7.5% to 10% of adjusted gross income (AGI).[85] Consumer Operated and Oriented Plans (CO-OP), which are member-governed non-profit insurers, entitled to a 5-year federal loan, are permitted to start providing health care coverage.[86] The CLASS Act provision would have created a voluntary long-term care insurance program, but in October 2011 the Department of Health and Human Services announced that the provision was unworkable and would be dropped.[87][88] The CLASS Act was repealed January 1, 2013.[89]

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Effective October 1, 2014


Federal payments to "disproportionate share hospitals", which are hospitals that treat large numbers of indigent patients, are reduced. The payments will subsequently be allowed rise based on the percentage of the population that is uninsured in each state.[]

Effective January 1, 2015


CMS begins using the Medicare fee schedule to give larger payments to physicians who provide high-quality care compared with cost.[90]

Patient Protection and Affordable Care Act

52

Effective October 1, 2015


States are allowed to shift children eligible for care under the Children's Health Insurance Program to health care plans sold on their exchanges, as long as HHS approves.[]

Effective January 1, 2016


States are permitted to form health care choice compacts and allows insurers to sell policies in any state participating in the compact.[] The threshold for itemizing medical expenses increases from 7.5% of income to 10% for seniors.[91]

Effective January 1, 2017


A state may apply to the Secretary of Health & Human Services for a "waiver for state innovation" provided that the state passes legislation implementing an alternative health care plan meeting certain criteria. The decision of whether to grant the waiver is up to the Secretary (who must annually report to Congress on the waiver process) after a public comment period.[] A state receiving the waiver would be exempt from some of the central requirements of the ACA, including the individual mandate, the creation by the state of an insurance exchange, and the penalty for certain employers not providing coverage.[][] The state would also receive compensation equal to the aggregate amount of any federal subsidies and tax credits for which its residents and employers would have been eligible under the ACA plan, but which cannot be paid out due to the structure of the state plan.[] To qualify for the waiver, the state plan must provide insurance at least as comprehensive and as affordable as that required by the ACA, must cover at least as many residents as the ACA plan would, and cannot increase the federal deficit. The coverage must continue to meet the consumer protection requirements of the ACA, such as the prohibition on increasing premiums because of pre-existing conditions.[] A bipartisan bill sponsored by Senators Ron Wyden and Scott Brown, and supported by President Obama, proposes making waivers available in 2014 rather than 2017, so that, for example, states that wish to implement an alternative plan need not set up an insurance exchange only to dismantle it a short time later.[] In April 2011 Vermont announced its intention to pursue a waiver to implement the single-payer system enacted in May 2011.[][92][][] In September 2011 Montana announced it would also be seeking a waiver to set up its own single payer healthcare system.[93] States may allow large employers and multi-employer health plans to purchase coverage in the health insurance exchange. The two federally regulated "multi-state plans" (MSPs) that began being phased into state health insurance exchanges on January 1, 2014, become available in every state.[]

Effective January 1, 2018


All existing health insurance plans must cover approved preventive care and checkups without co-payment.[] A 40% excise tax on high cost ("Cadillac") insurance plans is introduced. The tax (as amended by the reconciliation bill)[] is on insurance premiums in excess of $27,500 (family plans) and $10,200 (individual plans), and it is increased to $30,950 (family) and $11,850 (individual) for retirees and employees in high risk professions. The dollar thresholds are indexed with inflation; employers with higher costs on account of the age or gender demographics of their employees may value their coverage using the age and gender demographics of a national risk pool.[][94]

Patient Protection and Affordable Care Act

53

Effective January 1, 2019


Medicaid extends coverage to former foster care youths who were in foster care for at least six months and are under 25 years old.[]

Effective January 1, 2020


The Medicare Part D coverage gap (commonly called the "donut hole") will be completely phased out and hence closed.

Legislative history
Background
The plan that ultimately became the Patient Protection and Affordable Care Act consists of a combination of measures to control health care costs and an insurance expansion through public insurance (expanded Medicaid eligibility and Medicare coverage) and subsidized, regulated private insurance. The latter of these ideas forms the core of the law's insurance expansion, and it has been included in bipartisan reform proposals in the past. In particular, the idea of an individual mandate coupled with subsidies for private insurance, as an alternative to public insurance, was considered a way to get Universal Health Insurance that could win the support of the Senate. Many healthcare policy experts have pointed out that the individual mandate requirement to buy health insurance was contained in many previous proposals by Republicans for healthcare legislation, going back as far as 1989, when it was initially proposed by the politically conservative Heritage Foundation as an alternative to single-payer health care.[] The idea of an individual mandate was championed by Republican politicians as a market-based approach to health-care reform, on the basis of individual responsibility: because the Emergency Medical Treatment and Active Labor Act (EMTALA), passed in 1986 by a bipartisan Congress and signed by Ronald Reagan, requires any hospital participating in Medicare (nearly all do) to provide emergency care to anyone who needs it, the government often indirectly bore the cost of those without the ability to pay.[][][] When, in 1993, President Bill Clinton proposed a health-care reform bill which included a mandate for employers to provide health insurance to all employees through a regulated marketplace of health maintenance organizations, Republican Senators proposed a bill that would have required individuals, and not employers, to buy insurance, as an alternative to Clinton's plan.[] Ultimately the Clinton plan failed amid concerns that it was overly complex or unrealistic, and in the face of an unprecedented barrage of negative advertising funded by politically conservative groups and the health-insurance industry.[] (After failing to obtain a comprehensive reform of the health care system, Clinton did however negotiate a compromise with the 105th Congress to instead enact the State Children's Health Insurance Program (SCHIP) in 1997). The 1993 Republican alternative, introduced by Senator John Chafee (R-RI) as the Health Equity and Access Reform Today Act, contained a "Universal Coverage" requirement with a penalty for non-compliance.[95][] Advocates for the 1993 bill which contained the individual mandate included prominent Republicans who today oppose the mandate, such as Orrin Hatch (R-UT), Charles Grassley (R-IA), Bob Bennett (R-UT), and Christopher Bond (R-MO).[96][97] Of the 43 Republicans Senators from 1993, almost half - 20 out of 43 - supported the HEART Act.[][] And in 1994 Senator Don Nickles (R-OK) introduced the Consumer Choice Health Security Act which also contained an individual mandate with a penalty provision[98] - however, subsequently, he did remove the mandate from the act after introduction stating that they had decided "that government should not compel people to buy health insurance."[99] At the time of these proposals, Republicans did not raise constitutional issues with the mandate; Mark Pauly, who helped develop a proposal that included an individual mandate for George H.W. Bush, remarked, "I dont remember that being raised at all. The way it was viewed by the Congressional Budget Office in 1994 was, effectively, as a tax... So Ive been surprised by that argument."[]

Patient Protection and Affordable Care Act An individual health-insurance mandate was also enacted at the state-level in Massachusetts: In 2006, Republican Mitt Romney, then governor of Massachusetts, signed an insurance expansion bill with an individual mandate into law with strong bipartisan support (including that of Ted Kennedy (D-MA)). Romney's success in installing an individual mandate in Massachusetts was at first lauded by Republicans. During Romney's 2008 Presidential campaign, Senator Jim DeMint (R-SC) praised Romney's ability to "take some good conservative ideas, like private health insurance, and apply them to the need to have everyone insured." Romney himself said of the individual mandate: "I'm proud of what we've done. If Massachusetts succeeds in implementing it, then that will be the model for the nation."[] The following year (2007), Senators Bob Bennett (R-UT) and Ron Wyden (D-OR) introduced the Healthy Americans Act, a bill that also featured an individual mandate, and which attracted bipartisan support.[][] Among the Republican co-sponsors still in Congress during the health care debate: Senators Chuck Grassley (R-IA), Lindsey Graham (R-SC), Bob Bennett (R-UT), Mike Crapo (R-ID), Bob Corker (R-TN), Lamar Alexander (R-TN), and Arlen Specter (R-PA).[100][101] Given the history of bipartisan support for the idea, and its track record in Massachusetts; by 2008 Democrats were considering it as a basis for comprehensive, national health care reform: Experts have pointed out that the legislation that eventually emerged from Congress in 2009 and 2010 bears many similarities to the 2007 bill;[] and that it was deliberately patterned after former Republican Governor of Massachusetts Mitt Romney's state healthcare plan (which contains an individual mandate).[102] Jonathan Gruber, a key architect of the Massachusetts reform, advised the Clinton and Obama Presidential campaigns on their health care proposals, served as a technical consultant to the Obama Administration, and helped Congress draft the ACA.

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Health care debate, 20082010


Health care reform was a major topic of discussion during the 2008 Democratic presidential primaries. As the race narrowed, attention focused on the plans presented by the two leading candidates, New York Senator Hillary Clinton and the eventual nominee, Illinois Senator Barack Obama. Each candidate proposed a plan to cover the approximately 45million Americans estimated to be without health insurance at some point during each year. One point of difference between the plans was that Clinton's plan was to require all Americans to obtain coverage (in effect, an individual health insurance mandate), while Obama's was to provide a subsidy but not create a direct requirement. During the general election campaign between Obama and the Republican nominee, Arizona Senator John McCain, Obama said that fixing health care would be one of his top four priorities if he won the presidency.[] After his inauguration, Obama announced to a joint session of Congress in February 2009 that he would begin working with Congress to construct a plan for health care reform.[] On March 5, 2009, Obama formally began the reform process and held a conference with industry leaders to discuss reform.[] By July, a series of bills were approved by committees within the House of [] Representatives. On the Senate side, beginning June 17, 2009, and extending through September 14, 2009, three Democratic and three Republican Senate Finance Committee Members met for a

President Obama addressing Congress regarding health care reform, September 9, 2009.

Patient Protection and Affordable Care Act series of 31 meetings to discuss the development of a health care reform bill. Over the course of the next three months, this group, Senators Max Baucus (D-MT), Chuck Grassley (R-IA), Kent Conrad (D-ND), Olympia Snowe (R-ME), Jeff Bingaman (D-NM), and Mike Enzi (R-WY), met for more than 60 hours, and the principles that they discussed (in conjunction with the other Committees) became the foundation of the Senate's health care reform bill.[103] The meetings were held in public and broadcast by C-SPAN and can be seen on the C-SPAN web site[104] or at the Committee's own web site.[105] With universal health insurance as one of the stated goals of the Obama Administration, Congressional Democrats and health policy experts like Jonathan Gruber and David Cutler argued that guaranteed issue would require both a (partial) community rating and an individual health insurance mandate to prevent either adverse selection and/or free riding from creating an insurance death spiral.[] They convinced Obama that this was necessary, which persuaded the Administration to accept Congressional proposals that included a mandate.[] This approach was preferred because the President and Congressional leaders concluded that more liberal plans (such as Medicare-for-all) could not win filibuster-proof support in the Senate. By deliberately drawing on bipartisan ideas - the same basic outline was supported by former Senate Majority Leaders Howard Baker (R-TN), Bob Dole (R-KS), Tom Daschle (D-SD) and George Mitchell (D-ME) - the bill's drafters hoped to increase the chances of getting the necessary votes for passage.[106][107][] However, following the adoption of an individual mandate as a central component of the proposed reforms by Democrats, Republicans began to oppose the mandate and threaten to filibuster any bills that contained it.[] Senate Minority Leader Mitch McConnell (R-KY), who lead the Republican Congressional strategy in responding to the bill, calculated that Republicans should not support the bill, and worked to keep party discipline and prevent defections:[]

55

It was absolutely critical that everybody be together because if the proponents of the bill were able to say it was bipartisan, it tended to convey [108] to the public that this is O.K., they must have figured it out.

Republican Senators (including those who had supported previous bills with a similar mandate) began to describe the mandate as "unconstitutional". Writing in The New Yorker, Ezra Klein stated that "the end result was... a policy that once enjoyed broad support within the Republican Party suddenly faced unified opposition."[] The New York Times subsequently noted: "It can be difficult to remember now, given the ferocity with which many Republicans assail it as an attack on freedom, but the provision in President Obama's health care law requiring all Americans to buy health insurance has its roots in conservative thinking."[][] The reform negotiations also attracted a great deal of attention from lobbyists,[109] including deals among certain lobbies and the advocates of the law to win the support of groups who had opposed past reform efforts, such as in 1993.[110][111] The Sunlight Foundation documented many of the reported ties between "the healthcare lobbyist complex" and politicians in both major parties.[112] During the August 2009 summer congressional recess, many members went back to their districts and entertained town hall meetings to solicit public opinion on the proposals. Over the recess, the Tea Party Tea Party protesters at the Taxpayer March on Washington, movement organized protests and many conservative September 12, 2009. groups and individuals targeted congressional town hall meetings to voice their opposition to the proposed reform bills.[] There were also many threats made against members of Congress over the course of the Congressional debate, and many were assigned extra protection.[]

Patient Protection and Affordable Care Act To maintain the progress of the legislative process, when Congress returned from recess, in September 2009 President Obama delivered a speech to a joint session of Congress supporting the ongoing Congressional negotiations, to re-emphasize his commitment to reform and again outline his proposals.[] In it he acknowledged the polarization of the debate, and quoted a letter from the late-Senator Ted Kennedy urging on reform: "what we face is above all a moral issue; that at stake are not just the details of policy, but fundamental principles of social justice and the character of our country."[113] On November 7, the House of Representatives passed the Affordable Health Care for America Act on a 220215 vote and forwarded it to the Senate for passage.[]

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Senate
The Senate began work on its own proposals while the House was still working on its bill (the Affordable Health Care for America Act); it instead took up H.R. 3590, a bill regarding housing tax breaks for service members.[] As the United States Constitution requires all revenue-related bills to originate in the House,[114] the Senate took up this bill since it was first passed by the House as a revenue-related modification to the Internal Revenue Code. The bill was then used as the Senate's vehicle for their health care reform proposal, completely revising the content of the bill.[115] The bill as amended would ultimately incorporate elements of proposals that were reported favorably by the Senate Health and Finance committees. With the Republican minority in the Senate vowing to filibuster any bill that they did not support, requiring a cloture vote to end debate, 60 votes would be necessary to get passage in the Senate.[116] At the start of the 111th Congress, Democrats had only 58 votes (the Senate seat in Minnesota that would be won by Al Franken was still undergoing a recount, and Arlen Specter was still a Republican). To reach 60 votes, negotiations were undertaken to satisfy the demands of moderate Democrats, and to try to bring aboard several Republican Senators (particular attention was given to Bob Bennett, Chuck Grassley, Mike Enzi, and Olympia Snowe). Negotiations continued even after July 7 when Al Franken was sworn into office and by which time Arlen Specter had switched parties because of disagreements over the substance of the bill, which was still being drafted in committee, and because moderate Democrats hoped to win bipartisan support. However, on August 25, before the bill could come up for a vote, Ted Kennedy a long-time advocate for health care reform died, depriving Democrats of their 60th vote. Whilst Paul Kirk was appointed as Senator Kennedy's temporary replacement on September 24 (regaining the Democrats' 60th vote); attention was drawn to Senator Snowe because of her vote in favor of the draft bill in the Finance Committee on October 15, however she explicitly stated that this did not mean she would support the final bill.[] Following the Finance Committee vote, negotiations turned to the demands of moderate Democrats to finalize their support, whose votes would be necessary to break the Republican filibuster. Majority Leader Harry Reid focused on satisfying the centrist members of the Democratic caucus until the hold-outs narrowed down to Connecticut's Joe Lieberman (an independent who caucused with Democrats) and Nebraska's Ben Nelson. Lieberman, despite intense negotiations in search of a compromise by Reid, refused to support a public option; a concession granted only after Lieberman agreed to commit to voting for the bill if the provision was not included,[][] even though it had majority support in Congress.[] There was debate among supporters of the bill about the importance of the public option,[117] although the vast majority of supporters concluded that the it was a minor part of the reform overall,[] and that Congressional Democrats' fight for it won various concessions (including conditional waivers allowing states to set up state-based public options,[] for example Vermont's Green Mountain Care).[118]

Patient Protection and Affordable Care Act

57

With every other Democrat now in favor and every other Republican now overtly opposed, the White House and Reid moved on to addressing Senator Nelson's concerns in order to win filibuster-proof support for the bill;[119] they had by this point concluded that "it was a waste of time dealing with [Snowe]"[120] because, after her vote for the draft bill in the Finance Committee, Snowe had come under intense pressure from the Republican Senate Leadership who opposed reform.[][121][122] Senate vote by state. Two Democratic yeasOne Democratic yea, one Republican (Snowe retired at the end of her term, citing nayOne Republican nay, one Republican not votingTwo Republican nays [123] partisanship and polarization). After a final 13-hour negotiation, Nelson's support for the bill was won after two concessions: a compromise on abortion, modifying the language of the bill "to give states the right to prohibit coverage of abortion within their own insurance exchanges" (requiring consumers to pay for the procedure out-of-pocket, if the state decided it); and an amendment to offer a higher rate of Medicaid reimbursement for Nebraska.[][124] The latter half of the compromise was derisively referred to as the "Cornhusker Kickback"[125] (and was later repealed by the subsequent reconciliation amendment bill). On December 23, the Senate voted 6039 to end debate on the bill (a cloture vote to end the filibuster by opponents). The bill then passed by a vote of 6039 on December 24, 2009, with all Democrats and two independents voting for, and all Republicans voting against except one (Jim Bunning (R-KY), not voting).[] The bill was endorsed by the AMA and AARP.[126] Several weeks after the vote, on January 19, 2010, Massachusetts Republican Scott Brown was elected to the Senate in a special election to replace the late Ted Kennedy, having campaigned on giving the Republican minority the 41st vote needed to sustain filibusters, even signing autographs as "Scott 41."[][127][128] The special election had become significant to the reform debate because of its effects on the legislative process. The first was a psychological one: given not only how democratic (blue) Massachusetts is, but also the symbolic importance of losing the seat formerly held by Ted Kennedy (a staunch support of reform); the loss made many Congressional Democrats concerned about the political cost of passing a bill that had become controversial.[129][] The second effect was more practical: the loss of their supermajority complicated the legislative strategy of reform proponents (see below).[]

Patient Protection and Affordable Care Act

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House
The election of Scott Brown meant Democrats could no longer break a filibuster in the Senate. In response, White House Chief of Staff Rahm Emanuel argued the Democrats should scale-back for a less ambitious bill; House Speaker Nancy Pelosi pushed back, dismissing Emanuel's scaled-down approach as "Kiddie Care."[][] Obama also remained insistent on comprehensive reform, and the news that Anthem Blue Cross in California intended to raise premium rates for its patients by as much as 39% gave him a new line of argument to reassure nervous Democrats after Scott Brown's win.[][] On February 22 Obama laid out a "Senate-leaning" proposal to consolidate the bills.[130] He also held a meeting, on February 25, with leaders of both parties urging passage of a reform bill.[] The summit proved successful in shifting the political narrative away from the Massachusetts loss back to health care policy.[]

House vote by congressional district. Democratic yeaDemocratic nayRepublican nayNo representative seated

With Democrats having lost a filibuster-proof supermajority in the Senate, but having already passed the Senate bill with 60 votes on December 24; the most President Obama signing the Patient Protection and Affordable Care Act on March viable option for the proponents of 23, 2010. comprehensive reform was for the House to abandon its own health reform bill, the Affordable Health Care for America Act, and pass the Senate's bill (The Patient Protection and Affordable Care Act) instead. Various health policy experts encouraged the House to pass the Senate version of the bill.[131] However, House Democrats were not happy with the content of the Senate bill and had expected to be able to negotiate changes in a (House-Senate) Conference before passing a final bill.[] With that option off the table (as any bill that emerged from Conference that differed from the Senate bill would have to be passed in the Senate over another Republican filibuster);[] most House Democrats agreed to pass the Senate bill on condition that it be amended by a subsequent bill (ultimately the Health Care and Education Reconciliation Act), which could be passed via the reconciliation process.[][][] Unlike the regular order, reconciliation is not subject to a filibuster (which requires 60 votes to break), but the process is limited to budget changes, which is why it was never able to be used to pass a comprehensive reform bill (with its inherently non-budgetary regulations as in the ACA) in the first place.[132][133] Whereas the already passed Senate bill could not have been put through reconciliation, most of House Democrats' demands were budgetary: "these changes -- higher subsidy levels, different kinds of taxes to pay for them, nixing the Nebraska Medicaid deal -- mainly involve taxes and spending. In other words, they're exactly the kinds of policies that are well-suited for reconciliation."[]

Patient Protection and Affordable Care Act The remaining obstacle was a pivotal group of pro-life Democrats, initially reluctant to support the bill, led by Congressman Bart Stupak. The group found the possibility of federal funding for abortion would be substantive enough to warrant opposition. The Senate bill had not included language that satisfied their abortion concerns, but they could not include additional such language in the reconciliation bill, as it would be outside the scope of the process with its budgetary limits. Instead, President Obama issued Executive Order 13535, reaffirming the principles in the Hyde Amendment.[134] This concession won the support of Stupak and members of his group and assured passage of the bill.[][135] The House passed the bill with a vote of 219 to 212 on March 21, 2010, with 34 Democrats and all 178 Republicans voting against it.[] The following day, Republicans introduced legislation to repeal the bill.[] Obama signed the original bill (the ACA) into law on March 23, 2010.[136] The amendment bill (the Health Care and Education Reconciliation Act) was also passed by the House on March 21, then by the Senate via reconciliation on March 25, and finally signed by President Obama on March 30.

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Impact
Public policy
Change in number of uninsured CBO originally estimated the legislation will reduce the number of uninsured residents by 32million, leaving 23million uninsured residents in 2019 after the bill's provisions have all taken effect.[][][][] A July 2012 CBO estimate raised the expected number of uninsured by 3 million, reflecting the successful legal challenge to PPACA's expansion of Medicaid.[][] Among the people in this uninsured group will be: Illegal immigrants, estimated to be around eight million they will be ineligible for insurance subsidies and Medicaid;[][137][138] they will also be exempt from the health insurance mandate and will remain eligible for emergency services under the 1986 Emergency Medical Treatment and Active Labor Act (EMTALA). Citizens not enrolled in Medicaid despite being eligible.[] Citizens not otherwise covered and opting to pay the annual penalty instead of purchasing insurance mostly younger and single Americans.[] Citizens whose insurance coverage would cost more than 8% of household income and are exempt from paying the annual penalty.[] Citizens who live in states that opt out of the Medicaid expansion and who qualify for neither existing Medicaid coverage nor subsidized coverage through the states' new insurance exchanges.[] ACA drafters believed that increasing insurance coverage would not only improve quality of life but also help reduce medical bankruptcies (currently the leading cause of bankruptcy in America[139]) and job lock;[140][][] in addition, many believed that expanding coverage was necessary to help ensure cost controls function - the reforms to the payment systems that incentivize value over quantity would be more likely to succeed if the costs of health care providers could be reduced by limiting uncompensated emergency care, and if there was a larger risk pool to distribute costs among.[][] Early experience under PPACA was that, as a result of the tax credit for small businesses, some businesses offered health insurance to their employees for the first time.[141] A later report from the Government Accountability Office in 2012 found that of the 4 million small businesses that were offered the tax credit only 170,300 businesses claimed it.[142][143] In part due to the new regulations of guaranteed issue and ensuring children could remain included on their parents plans until age 26; in September 2010 some insurance companies announced that in response to the law, they would end the issuance of new child-only policies.[144][145][146] An August 2011 Congressional report backed up the finding that passage of the health care law prompted health insurance carriers to stop selling new child-only health

Patient Protection and Affordable Care Act plans in many states.[] Of the 50states, 17 reported that there were currently no carriers selling child only health plans to new enrollees.[] Thirty-nine states indicated at least one insurance carrier exited the child-only market following enactment of the health care laws.[] At the same time, the Census Bureau released a report on September 13, 2011, showing that the number of uninsured 19- to 25-year-olds (now eligible to stay on their parents' policies) had declined by 393,000, or 1.6%.[147] Insurance exchanges and the individual mandate The ACA has two predominant means for increasing insurance coverage (as summarized above): One involves the expansion of already-existing, public insurance programs: expanding the coverage of Medicare (such as eliminating the 'donut hole'), and increasing the eligibility of the Medicaid program to expand enrollment. The other primary mechanism for providing insurance is the creation of state-based insurance exchanges: regulated, virtual marketplaces, administered by either federal or state government, where private insurers may sell plans to individuals and small business starting January 2014.[][148][] Those purchasing insurance plans may, if eligible, use subsidies provided through the exchanges.[] These exchanges will take the form of websites where the private plans allowed on sale within them will be regulated and comparable: Consumers will be able to visit these websites, compare the plans on offer, fill out a form to the government that will determine their eligibility for subsidies, and then purchase the insurance of their choice from the options available.[149][] (Members of Congress and their staff will participate in this system: they will be required to obtain health insurance through the exchanges - or plans otherwise approved by the bill, such as Medicare - instead of the Federal Employees Health Benefits Program that they currently use.[84]) The insurance exchanges are a method designed to create a market for private insurance in a way that addresses market failures in the current system (such as the high number of uninsured, medical bankruptcies, coverage limits, unaffordability, inflation, etc.[150]) through regulations:[][][151] Only approved plans that meet certain standards (see details below) will be allowed to be sold on the exchanges, and insurers will be prohibited from denying insurance, on the basis of pre-existing conditions, to consumers who are willing to and can afford a plan on offer in the exchanges.[][] Several methods will be employed to make these plans affordable: Subsidies will be provided to those eligible.[][] Regulations intended to increase competition (to reduce prices) will make plans and prices more transparent and price comparisons more accessible for consumers with online information;[152][153][154][155] as well as the phase-in of federally approved, multi-state plans on state exchanges[] (to help guarantee enough options, given that the number of plans on offer varies by state[156]). And price regulations will be implemented, including a minimum medical loss ratio,[] and partial community rating that prevents individuals from being priced out of the market by price discrimination (through unaffordable plans for the uninsured, or premium increases on the insured)[][] - namely poor and sick individuals who are more expensive to cover for insurers motivated either by profit maximization and/or the economics of insurance (specifically, the risk of an insurance pool not providing enough net-premiums to offset net-pay-outs).[][16] The aforementioned regulations are enabled to function due to the requirement to buy insurance (the penalty for forgoing insurance known as the individual mandate[]), without which healthy people might put-off insuring themselves until they got sick; in such a situation, to afford the remaining (relatively sicker and thus more expensive) population, insurers would have to raise their premiums,[][][][] which could drive more people to drop their coverage, creating a vicious cycle that could ultimately result in an insurance death spiral.[16][] Alternatively, the process could settle at a stable equilibrium relying on relatively high premiums for the insured and less coverage (and thus more illness and medical bankruptcy) for the uninsured.[][][] Either way, the absence of the mandate would likely cause the exchanges as a whole to malfunction, and ultimately perform similarly to the current private insurance market,[][][157] as studies by the CBO, Jonathan Gruber, and Rand Health have concluded.[158][][159] Conversely, the inclusion of the mandate increases the size and diversity of the insured population, broadening the risk pool to spread the cost of insurance in a sustainable manner.[][][] Policy experience in New Jersey on the one hand and Massachusetts on the other offers evidence of such divergent outcomes.[][][]

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Patient Protection and Affordable Care Act The Congressional Budget Office estimates that "about 4 million" (3.9 million or 1.2% of the population) will pay the penalty in 2016.[160] In September 2012, an updated CBO estimate concluded that nearly six million will pay a $1,200penalty in 2016. Also, nearly 80percent of those who will face the penalty would be making up to or less than five times the federal poverty level. This would work out to $55,850or less for an individual and $115,250or less for a family of four.[161] Under the law, setting-up an exchange gives a state partial discretion on standards and prices of insurance (beyond those specifics set-out in the ACA):[][162] For example, those administering the exchange will be able to determine which plans are sold on or excluded from the exchanges, adjust (through limits on and negotiations with private insurers) the prices on offer, and impose higher or state-specific coverage requirements including whether plans offered in the Insurance exchanges by state as of May, 2013.States creating fully state-operated state are prohibited from covering exchangesStates establishing state-federal partnership exchangesStates defaulting to abortion (making the procedure an federally facilitated exchanges out-of-pocket expense) or mandated to cover abortions that a physician determines to be medically necessary (in either case, federal subsidies are prohibited from being used to fund the procedure).[163] If a state does not set-up an exchange itself, they lose that discretion; and the responsibility to set-up exchanges for such states defaults to the federal government, whereby the Department of Health and Human Services assumes the authority and legal obligation to operate all functions in these 'federally facilitated exchanges'.[] As of May 2013, 23 states and the District of Columbia plan to operate state-based exchanges themselves (7 of which are doing so in partnership with the federal government, an arrangement where they retain discretionary management but the federal government executes various functions), whereas the remaining 27 states default to federally facilitated exchanges.[] The law is also designed to be flexible by allowing states, from 2017 onwards, to apply for a "waiver for state innovation" from the federal government that will enable them to experiment with their own state-based system, on condition that it meets certain criteria.[] To obtain a waiver, a state must pass legislation setting-up an alternative health system that provides insurance at least as comprehensive and as affordable as that the ACA would, covers at least as many residents, and does not increase the federal deficit.[] Provided a state meets these conditions; receiving a waiver can exempt states from some of the central requirements of the ACA, including the individual mandate, the provision of an insurance exchange, and the employer mandate.[] The state would also receive compensation equal to the aggregate amount of any federal subsidies and tax credits for which its residents and employers would have been eligible under the ACA plan, if they cannot be paid out due to the structure of the state plan.[] So far, only Vermont, in May 2011, has enacted an alternative plan - a state-based single-payer system for which they intend to pursue a waiver to implement.[][][]

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Patient Protection and Affordable Care Act Change in insurance standards The ACA includes new regulations setting standards for insurance,[] some set-out in the law, others subsequently established by the Secretary of Health and Human Services. The standards specified in the law include banning price discrimination on the basis of pre-existing conditions or sex through a partial community rating, prohibiting annual or lifetime limits on health care, making it illegal to drop policy holders if and when they become sick, and allowing dependents (mainly children) to remain on their parents' insurance plan until their 26th birthday. The essential health benefits[] that were defined by the Secretary of Health and Human Services include: "ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care."[][164] In determining what qualified as an essential benefit, the law required that the scope of standard benefits should equal that of a "typical employer plan."[] States have some discretion in determining what should be considered the benchmark plan (beyond what is required by the law), and may include services beyond those set-out by the Secretary as essential benefits.[165] For certain services that are included in the essential benefits package, co-payments, co-insurance, and deductibles will be eliminated - they will be covered by an insurance plan's premiums.[][][] The law also establishes four tiers of coverage: bronze, silver, gold, and platinum. All categories offer the same set of essential health benefits. What the categories specify is the division of premiums and out-of-pocket costs: bronze plans will have the lowest monthly premiums and higher out-of-pocket costs, and vice versa for platinum plans.[][166] The percentages of care that plans are expected to cover through premiums (as opposed to out-of-pocket costs) are, on average: 60% (Bronze), 70% (Silver), 80% (Gold), and 90% (Platinum).[167] By the time the law is fully implemented (scheduled for 2020), the following list of specific standards will have taken effect: Effective September 23, 2010 Insurers are prohibited from imposing lifetime dollar limits on essential benefits, like hospital stays, in new policies issued.[] Dependents (mainly children) will be permitted to remain on their parents' insurance plan until their 26th birthday,[36] and regulations implemented under the ACA include dependents that no longer live with their parents, are not a dependent on a parent's tax return, are no longer a student, or are married.[][] Insurers are prohibited from excluding pre-existing medical conditions (except in grandfathered individual health insurance plans) for children under the age of 19.[][168] All new insurance plans must cover preventive care and medical screenings[] rated Level A or B [38] by the U.S. Preventive Services Task Force.[39] Insurers are prohibited from charging co-payments, co-insurance, or deductibles for these services.[] Insurers' abilities to enforce annual spending caps will be restricted, and completely prohibited by 2014.[] Insurers are prohibited from dropping policyholders when they get sick.[] Insurers are required to reveal details about administrative and executive expenditures.[] Insurers are required to implement an appeals process for coverage determination and claims on all new plans.[] All new insurance plans must cover childhood immunizations and adult vaccinations recommended by the Advisory Committee on Immunization Practices (ACIP) without charging co-payments, co-insurance, or deductibles when provided by an in-network provider.[] Effective January 1, 2011 Insurers must spend 80% (for individual or small group insurers) or 85% (for large group insurers) of premium dollars on health costs and claims, leaving only 20% or 15% respectively for administrative costs and profits, subject to various waivers and exemptions. If an insurer fails to meet this requirement, there is no penalty, but

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Patient Protection and Affordable Care Act a rebate must be issued to the policy holder. This policy is known as the 'Medical Loss Ratio'.[169][][][] Effective August 1, 2012 All new plans must cover certain preventive services such as mammograms and colonoscopies without charging a deductible, co-pay or coinsurance. Women's Preventive Services including: well-woman visits; gestational diabetes screening; human papillomavirus (HPV) DNA testing for women age 30 and older; sexually transmitted infection counseling; human immunodeficiency virus (HIV) screening and counseling; FDA-approved contraceptive methods and contraceptive counseling; breastfeeding support, supplies and counseling; and domestic violence screening and counseling - will be covered without cost sharing.[] The requirement to cover FDA-approved contraceptive methods is also known as the contraceptive mandate.[][170][] Effective January 1, 2014 Insurers are prohibited from discriminating against or charging higher rates for any individual based on pre-existing medical conditions or gender.[] Insurers are prohibited from establishing annual spending caps.[] Coverage for contraceptives The ACA includes a contraceptive coverage mandate that, with the exception of churches and houses of worship, applies to all employers and educational institutions. These regulations[] made under PPACA rely on the recommendations of the Institute of Medicine, which concluded that access to contraception is medically necessary "to ensure women's health and well-being."[171] The initial regulations proved controversial among Christian hospitals, Christian charities, Catholic universities, and other enterprises owned or controlled by religious organizations that oppose contraception on doctrinal grounds.[172] To accommodate those concerns whilst still guaranteeing access to contraception, the regulations were adjusted to "allow religious organizations to opt out of the requirement to include birth control coverage in their employee insurance plans. In those instances, the insurers themselves will offer contraception coverage to enrollees directly, at no additional cost."[173] Temporary waivers during implementation, 2010-2011 During the implementation of the law, there were interim regulations put in place for a specific type of employer-funded insurance, the so-called "mini-med" or limited-benefit plans, which are low-cost to employers who buy them for their employees, but cap coverage at a very low level. The waivers allowed employers to temporarily avoid the regulations ending annual and lifetime limits on coverage, and were put in place to encourage employers and insurers offering mini-med plans not to withdraw medical coverage before those regulations come into force (by which time small employers and individuals will be able to buy non-capped coverage through the exchanges) and were granted only if the employer could show that complying with the limit would mean a significant decrease in employees' benefits coverage or a significant increase in employees' premiums.[174] By January 26, 2011, HHS said it had granted a total of 733 waivers for 2011, covering 2.1million people, or about 1% of the privately insured population.[175] In June 2011, the Obama Administration announced that all applications for new waivers and renewals of existing ones have to be filed by September 22 of that year, and no new waivers would be approved after this date.[176]
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Patient Protection and Affordable Care Act

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The limited-benefit plans were sometimes offered to low-paid and part-time workers, for example in fast food restaurants or purchased direct from an insurer. Most company-provided health insurance policies starting on or after September 23, 2010, and before September 23, 2011, may not set [174] an annual coverage cap lower than $750,000, a lower limit that is raised in stages until 2014, by which time no insurance caps are allowed at all. By 2014, no health insurance, whether sold in the individual or group market, will be allowed to place an annual cap on coverage. Among those receiving waivers were employers, large insurers, such as Aetna and Cigna, and union plans covering about one million employees. McDonald's, one of the employers that received a waiver, has 30,000 hourly employees whose plans have annual caps of $10,000. The waivers are [][177] issued for one year and can be reapplied for. Referring to the adjustments as "a balancing act", Nancy-Ann DeParle, director of the Office of [] Health Reform at the White House, said, "The president wants to have a smooth glide path to 2014."

Effects on insurance premiums Several studies on insurance premiums expect that with the subsidies offered under the ACA, more people will pay less (than they did prior to the reforms) than those who will pay more, and that those premiums will be more stable (even in changing health circumstances) and transparent, thanks to the regulations on insurance.[][178][179] As of July 2013, the average monthly premium scheduled to be on offer in the exchanges has come in below CBO expectations which, if it holds up, will not only be cheaper for consumers, but will reduce the overall cost of the subsidies.[180] For the effect on health insurance premiums, the CBO referred[] to its November 2009 analysis[] and stated that the effects would "probably be quite similar" to that earlier analysis. The analysis forecasts that by 2016, for the non-group market comprising 17% of the market, premiums per person would increase by 10 to 13% but that over half of these insureds would receive subsidies that would decrease the premium paid to "well below" premiums charged under current law. For the small group market, 13% of the market, premiums would be impacted 1 to 3% and 8 to 11% for those receiving subsidies; for the large group market comprising 70% of the market, premiums would be impacted 0 to 3%, with insureds under high premium plans subject to excise taxes being charged 9 to 12%. The analysis was affected by various factors, including increased benefits particularly for the nongroup markets, more healthy insureds due to the mandate, administrative efficiencies related to the health exchanges, and insureds under high-premium plans reducing benefits in response to the tax.[] The Associated Press reported that, as a result of PPACA's provisions concerning the Medicare Part D coverage gap (between the initial coverage limit and the catastrophic coverage threshold in the Medicare Part D prescription drug program), individuals falling in this "donut hole" would save about 40 percent.[] Almost all of the savings came because, with regard to brand-name drugs, PPACA secured a discount from pharmaceutical companies.[] The change benefited more than two million people, most of them in the middle class.[] In January 2013, the Internal Revenue Service ruled that only the cost of covering the individual employee but not their family can be used for determining whether the cost of employer-based health coverage exceeds 9.5 percent of the workers household income, which is necessary to obtain taxpayer-subsidized coverage on the new health insurance exchanges starting in 2014. The New York Times said this could leave millions of Americans unable to afford family coverage under their employers plans and ineligible for subsidies to buy coverage elsewhere.[181] Larry Levitt, a health policy analyst from the Kaiser Family Foundation, noted that the individual market compromises just 6% of those under 65 currently, and said, in contrast, "I don't think anyone expects significant [cost] increases in the employer market," where the majority of Americans get their health insurance. Secretary of Health and Human Services Kathleen Sebelius also indicated that some cost increase in the individual market was expected because the standard of insurance allowed in the health care exchanges (run by the states or the federal government) would be higher quality than that generally available currently (and thus more expensive), and that the government subsidies provided to make insurance affordable are intended to more than offset this effect.[] In June 2013, a study by the Kaiser Family Foundation focused on actual experience under the Act as it affected individual market consumers (those buying insurance on their own). The study found that the Medical Loss Ratio provision of the Act had saved this group of consumers $1.2 billion in 2011 and $2.1 billion in 2012, reducing their 2012 costs by 7.5%.[] The bulk of the savings were in reduced premiums for individual insurance, but some came from premium rebates paid to consumers by insurance companies that had failed to meet the requirements of the Act.

Patient Protection and Affordable Care Act Health care cost trends (health care cost inflation) In a May 2010 presentation on "Health Costs and the Federal Budget", CBO stated:

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Rising health costs will put tremendous pressure on the federal budget during the next few decades and beyond. In CBO's judgment, the health legislation enacted earlier this year does not substantially diminish that pressure.

CBO further observed that "a substantial share of current spending on health care contributes little if anything to people's health" and concluded, "Putting the federal budget on a sustainable path would almost certainly require a significant reduction in the growth of federal health spending relative to current law (including this year's health legislation)."[182] Jonathan Cohn, a noted health policy analyst, commented that:

CBO doesn't produce estimates of how reform will affect overall health care spending--that is, the amount of money our society, as a whole, will devote to health care. But the official actuary for Medicare does. The actuary determined that... the long-term trend is towards less spending: Inflation after ten years would be lower than it is now. And it's the long-term trend that matters most... [The Affordable Care Act] [][183] will reduce the cost of care--not by a lot and not by as much as possible in theory, but as much as is possible in this political universe.

He and fellow The New Republic editor Noam Scheiber further noted the CBO didn't include in its estimate various cost-saving provisions intended to reduce health inflation,[] and that historically the CBO has consistently underestimated the impact of health legislation.[] Jonathan Gruber, an influential consultant who helped develop both the Affordable Care Act and the Massachusetts Health Care reform that preceded it, acknowledges that the Affordable Care Act is not guaranteed to significantly 'bend the curve' of rising health care costs:[184]

The real question is how far the ACA will go in slowing cost growth. Here, there is great uncertaintymostly because there is such uncertainty in general about how to control cost growth in health care. There is no shortage of good ideas for ways of doing so... There is, however, a shortage of evidence regarding which approaches will actually workand therefore no consensus on which path is best to follow. In the face of such uncertainty, the ACA pursued the path of considering a range of different approaches to controlling health care costs... Whether these policies by themselves can fully solve the long run health care cost problem in the United States is doubtful. They may, [185] however, provide a first step towards controlling costsand understanding what does and does not work to do so more broadly.

The law created the Center for Medicare and Medicaid Innovation and requires numerous pilots and demonstrations to be conducted which may have an impact on the cost of healthcare in the long-run.[186] Although these cost reductions have not been factored into CBO cost estimates, the experiments cover nearly every idea healthcare experts advocate, except malpractice/tort reform.[] The Business Roundtable, an association of CEOs, commissioned a report from the consulting company Hewitt Associates that found that the legislation "could potentially reduce that trend line by more than $3,000 per employee, to $25,435" with respect to insurance premiums. It also stated that the legislation "could potentially reduce the rate of future health care cost increases by 15% to 20% when fully phased in by 2019". The group cautioned that this is all assuming that the cost-saving government pilot programs both succeed and then are wholly copied by the private market, which is uncertain.[187] The Centers for Medicare and Medicaid Services reported in 2013 that, while costs per capita continue to rise, the rate of increase in annual healthcare costs (health care inflation) has fallen since 2002. Per capita cost increases have averaged 5.4% annually since 2000. Costs relative to GDP, which had been rising, has stagnated since 2009.[188] Several studies have attempted to explain the reduction in the rate of annual increase. Reasons include, among others: Higher unemployment due to the 2008-2010 recession, which has limited the ability of consumers to purchase healthcare;

Patient Protection and Affordable Care Act Out-of-pocket payments and deductibles (the amount a person pays of their health costs before insurance begins to cover claims) have risen, which generally causes less consumption of health care.[189] And the proportion of workers with employer-sponsored health insurance that requires a deductible has climbed to about three-quarters in 2012 from about half in 2006;[][] And structural changes[] from ACA programs and regulations aiming to shift the system from paying-for-quantity to paying-for-quality (like incentives to use electronic medical records, accountable care organizations and bundled payments to coordinate care and prioritize quality over quantity, and reduce hospital infections, etc.),[] including health care providers acting in anticipation of future implementation of reforms.[][] Whilst there is uncertainty about which causes are responsible to what extent for the recent reduction in health care inflation (and accompanying reduction in long-term deficit projections due to reduced health care costs), and about the durability of the trend; several studies have found that the temporary effects of the recession can not account for all of the slowdown, and that structural changes therefore likely share (partial) credit.[][][][190] One study estimated the changes to the health system to be responsible for about a quarter of the recent reduction in inflation.[191] Even if the cost controls succeed in lowering what is spent on health care (relative to having done nothing), such efforts on their own may not be sufficient to outweigh the long-term burden placed by demographic changes.[192] Federal deficit

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U.S. Healthcare Costs as a Percentage of GDP 2000-2011 - Centers for Medicare and Medicaid Services

Patient Protection and Affordable Care Act

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U.S. Healthcare Cost Inflation 2000-2011 - Centers for Medicare and Medicaid Services

CBO estimates of impact on deficit The 2011 comprehensive CBO estimate projected a net-deficit reduction of more than $200 billion during the 20122021 period:[][] it calculated the law would result in $604 billion in total outlays (expenditure) offset by $813 billion in total receipts (revenue), resulting in a $210 billion net-reduction in the deficit.[] The CBO separately noted that whilst most of the spending provisions don't begin until 2014,[][] revenue will still exceed spending in those subsequent years.[] CBO also stated that the bill would "substantially reduce the growth of Medicare's payment rates for most CBO Deficit reduction under ACA services; impose an excise tax on insurance plans with relatively high premiums; and make various other changes to the federal tax code, Medicare, Medicaid, and other programs."[] Although the CBO generally does not provide cost estimates beyond the 10-year budget projection period (because of the degree of uncertainty involved in the projection) it decided to do so in this case at the request of lawmakers, and estimated a second decade deficit reduction of $1.2trillion.[][] CBO predicted deficit reduction around a broad range of one-half percent of GDP over the 2020s while cautioning that "a wide range of changes could occur".[193] A commonly heard criticism of the CBO cost estimates is that CBO was required to exclude from its initial estimates the effects of likely "doc fix" legislation that would increase Medicare payments by more than $200billion from 2010 to 2019.[194][195][196][197][198] However, the doc fix remains a separate issue that would have existed whether or not the ACA became law - omitting its cost from the ACA is no different than omitting the cost of the Bush tax

Patient Protection and Affordable Care Act cuts.[199][200] In 2012, the CBO updated its cost estimates for a portion of the bill, but did not update its estimate of the net deficit impact of the whole bill (which was still estimated to reduce budget deficits overall).[] The ACA's provisions related to insurance coverage were projected earlier in 2012 to have a net cost of $1,252 billion over the 20122022 period; that amount represented a gross cost to the federal government of $1,762 billion, offset in part by $510 billion in receipts and other budgetary effects (primarily revenues from penalties and other sources). The addition of 2022 to the projection period had the effect of increasing the costs of the coverage provisions of the ACA relative to those projected in March 2011 for the 2012-2021 period because that change added a year in which the expansion of eligibility for Medicaid and the subsidies for health insurance purchased through the exchanges would have been in effect. This estimate was made prior to the Supreme Court's ruling regarding the expansion of Medicaid program to the individual states however.[] CBO and JCT now estimate that the insurance coverage provisions of the ACA will have a net cost of $1,168 billion over the 20122022 periodcompared with $1,252 billion projected in March 2012 for that 11-year periodreducing the cost estimate by $84 billion. (Those figures do not include the budgetary impact of other provisions of the ACA, which in the aggregate reduce budget deficits.)[][][201] Opinions on CBO projections There was mixed opinion about the CBO estimates. Uwe Reinhardt, a health economist at Princeton, wrote that "The rigid, artificial rules under which the Congressional Budget Office must score proposed legislation unfortunately cannot produce the best unbiased forecasts of the likely fiscal impact of any legislation", but went on to say "But even if the budget office errs significantly in its conclusion that the bill would actually help reduce the future federal deficit, I doubt that the financing of this bill will be anywhere near as fiscally irresponsible as was the financing of the Medicare Modernization Act of 2003."[202] Douglas Holtz-Eakin, CBO director during the George W. Bush administration, who later served as the chief economic policy adviser to U.S. Senator John McCain's 2008 presidential campaign, alleged that the bill would increase the deficit by $562billion because, he argued, it front-loaded revenue and back-loaded benefits.[203] The New Republic editors Noam Scheiber (an economist) and Jonathan Cohn (a health care policy analyst), countered critical assessments of the law's deficit impact, arguing that it is as likely, if not more so, for predictions to have underestimated deficit reduction than to have overestimated it. They noted that it is easier, for example, to account for the cost of definite levels of subsidies to specified numbers of people than account for savings from preventive health care, and that the CBO has a track record of consistently overestimating the costs of, and underestimating the savings of health legislation;[][] "innovations in the delivery of medical care, like greater use of electronic medical records[204] and financial incentives for more coordination of care among doctors, would produce substantial savings while also slowing the relentless climb of medical expenses... But the CBO would not consider such savings in its calculations, because the innovations hadn't really been tried on such large scale or in concert with one another and that meant there wasn't much hard data to prove the savings would materialize."[] David Walker, former U.S. Comptroller General now working for The Peter G. Peterson Foundation, has stated that the CBO estimates are not likely to be accurate, because it is based on the assumption that Congress is going to do everything they say they're going to do.[] The Center on Budget and Policy Priorities objected: in its analysis, Congress has a good record of implementing Medicare savings. According to their study, Congress followed through on the implementation of the vast majority of provisions enacted in the past 20years to produce Medicare savings.[205][206] Republican House leadership and the Republican majority on the House Budget Committee estimate the law would increase the deficit by more than $700billion in its first 10years.[207][208] Democratic House leadership and the Democratic minority on the House Budget Committee say the claims of budget gimmickry are false[209] and that repeal of the legislation would increase the deficit by $230billion over the same period,[210] pointing to the CBO's 2011 analysis of the impact of repeal.[211]

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Patient Protection and Affordable Care Act Employer mandate and part-time working hours Not to be confused with the individual mandate[] The employer mandate is a penalty that will be incurred by employers with more than 50 employees, if they do not offer health insurance to their full-time workers.[] This provision was included as a disincentive for employers considering dropping their current insurance plans once the insurance exchanges begin operating as an alternative source of insurance.[] Proponents of the reform law wanted to address the parts of the health care system they believed to not be working well, whilst causing minimal disruption to those happy with the coverage they have, and the employer mandate was a part of this attempt.[212][] Lawmakers recognized that approximately 80% of Americans already have insurance, of whom 54% are covered directly or indirectly through an employer (44% of the total population) another 29% of those covered (23% of the total population) are covered by the government (mainly Medicare, Medicaid).[213] And 73% of the total population reported themselves satisfied with their insurance situation; however significant minorities (even among those that reported favorably) had medically related financial troubles and/or dissatisfaction with aspects of their insurance coverage, especially among the poor and sick.[212] The intent of the employer mandate is to help ensure that existing employer-sponsored insurance plans that people like will stay in place. However, because a company will not face the penalty if it has less than 50 full-time employees, many are concerned that the employer mandate creates a perverse incentive for business to employ people part-time instead of full-time.[][] Several businesses and the State of Virginia have clarified the contracts of their part-time employees by adding a 29-hour a week cap,[214][215][216][217] to reflect the 30-hour threshold for full-time hours, as defined by the law.[] As of yet, however, only a small percent of companies have shifted their workforce towards more part-time hours (4% in a survey from the Federal Reserve Bank of Minneapolis).[] And labour market experts note that such shifts are not clearly attributable to the implementation of the ACA: pre-existing, long-term trends in working hours,[] and the effects of the Great Recession correlate with part-time working hour patterns.[218] The impact of this provision on employers decision-making is partially offset by other factors: offering health care helps attract and retain employees, while increasing productivity and reducing absenteeism; and to trade a smaller full-time workforce for a larger part-time work force carries costs of training and administration for a business.[][][219] In addition, the amount of employers with over 50 employees is relatively small,[] and over 90% of them already offer insurance,[] so changes in employer plans from this provision are expected to be small.[] Workers who dont receive insurance from an employer plan will still be able to purchase insurance on the exchanges. Regardless of the political rationale (of maintaining existing insurance arrangements for those happy with them), most policy analysts (on both the right and left) are critical of the employer mandate provision on the policy merits.[][] They argue that the perverse incentives regarding part-time hours (even if they dont change many existing insurance plans) are real and harmful; that the raised marginal cost of the 50th worker for businesses could limit companies growth; that the costs of reporting and administration (the paperwork for businesses and the state enforcement) are not worth the trade-off of incentivizing the maintenance of current employer plans; and note that the employer mandate (unlike the individual mandate) is a non-essential part of the law.[][][220][] (At the same time, though, some analysts have noted that it is possible to design an employer mandate that partially avoids these problems, by instead taxing business that don't offer insurance by a percentage of their payroll, known as 'pay-or-play,' rather than using the 50-employee and 30-hour cut-offs).[][] Furthermore, many health care policy analysts think it would be better to transition away from the employer-based system to systems (whether state- or market-based) where insurance is more portable and stable, and hence think that it is a bad idea to even try to maintain existing employer insurance systems.[221] The effects of the provision have also generated vocal opposition from several business and unions.[][222] On July 2, 2013, the Obama Administration announced on the Treasury Departments website that it would delay the employer mandate for one year, until 2015.[][] In the statement, the Administration said that they were delaying implementation in order to meet two goals: First, it will allow us to consider ways to simplify the new reporting

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Patient Protection and Affordable Care Act requirements consistent with the law. Second, it will provide time to adapt health coverage and reporting systems while employers are moving toward making health coverage affordable and accessible for their employees."[] The announcement was met with strong criticism by some who claimed that the authority to delay the implementation of the law lay with Congress.[][][] Senate Minority Leader Mitch McConnell argued that President Obamas authorization to delay the provision exceeded the limits of his executive power.[] House Republicans brought two bills to a vote to draw attention to the issue: The Authority for Mandate Delay Act; and the Fairness for American Families Act, which would apply the same delay to the individual mandate, arguing that the individual mandate should be treated the same way an action which the Obama Administration opposes.[] Constitutional scholar Simon Lazarus countered critics, saying that the delay was a lawful discretion of Executive power: "In effect, the Administration explains the delay as a sensible adjustment to phase-in enforcement, not a refusal to enforce To be sure, the federal Administrative Procedure Act authorizes federal courts to compel agencies to initiate statutorily required actions that have been unreasonably delayed. But courts have found delays to be unreasonable only in rare cases where, unlike this one, inaction had lasted for several years, and the recalcitrant agency could offer neither a persuasive excuse nor a credible end to its dithering."[223] Critics of the House Republicans comparison of the employer and individual mandate also pointed out that the two provisions are qualitatively different.[][]

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Political
Public opinion Polls indicate support of health care reform in general, but became more negative in regards to specific plans during the legislative debate over 2009 and 2010, and the Act that was ultimately signed in 2010 remains controversial with opinions falling along party lines: Democrats favor the law, while Republicans and most Independents do not. Polling averages show a plurality with negative opinions of the law, with those in favor trailing by single digits.[][] USA Today found opinions were starkly divided by age, with a solid majority of seniors opposing the bill and a solid majority of those younger than 40 in favor.[224] Specific elements are very popular across the political spectrum, with the notable exception of the mandate to purchase insurance. FiveThirtyEight, describing public opinion of the law, said, "while surveys have consistently found that a plurality of Americans have an overall negative view of the Affordable Care Act, they have just as consistently shown that large majorities of Americans favor individual elements of the law."[] For example, a Reuters-Ipsos poll during June 2012 indicated the following: 56% of Americans overall were against the law, with 44% supporting it. By party affiliation, 75% of Democrats, 27% of Independents, and 14% of Republicans favored the law overall. 82% favored banning insurance companies from denying coverage to people with pre-existing conditions. 61% favored allowing children to stay on their parents' insurance until age 26. 72% supported requiring companies with more than 50 employees to provide insurance for their employees. 61% opposed requiring all U.S. residents to own health insurance. By party affiliation, 19% of Republicans, 27% of Independents, and 41% of Democrats favored the mandate that all Americans buy health insurance.[] Other polls showed additional provisions receiving majority support among all three affiliations included: creation of insurance pools so small businesses and the uninsured had access to insurance exchanges to take advantage of large group pricing benefits; and providing subsidies on a sliding scale to aid individuals and families who cannot afford health insurance.[225][226] Other specific ideas that were not enacted but which showed majority support included importing prescription drugs from Canada (with its lower, government-controlled prices),[227] limiting malpractice awards, reducing the age to qualify for Medicare, and the public option.[]

Patient Protection and Affordable Care Act Pollsters probed the reasons for opposition.[228] In a CNN poll, 62% of respondents said they thought the ACA would "increase the amount of money they personally spend on health care," 56% said the bill "gives the government too much involvement in health care," and only 19% said they thought they and their families would be better off with the legislation.[229] In The Wall Street Journal, pollsters Scott Rasmussen and Doug Schoen wrote, "81% of voters say it's likely the plan will end up costing more than projected, [and 59%] say that the biggest problem with the health-care system is the cost: They want reform that will bring down the cost of care."[230] However, a June 2012 Reuters-Ipsos poll indicated that part of the opposition to the law was because some Americans did not believe the reform went far enough and wanted more done, not less. Among those opposed to the bill, 71% of Republican opponents reject it overall, while 29% believed it did not go far enough, while independent opponents are divided 67% to 33%. Among (the relative much smaller group of) Democratic opponents, 49% reject it overall, and 51% wanted the measure to go further.[] A majority (5234) indicated that they want "Congress to implement or tinker with the law rather than repeal it."[231] Many Democrats believe that the ACA will grow more popular over time, as Medicare did after its implementation,[232] as the benefits of the law take effect and close the information gap about the contents of the bill.[][233][234] Following the Supreme Court decision upholding the Act, a poll released in July 2012 showed that "most Americans (56%) want to see critics of President Obama's health care law drop efforts to block it and move on to other national issues."[235] Term "Obamacare" The term "Obamacare" was originally coined by opponents, notably Mitt Romney in 2007, as a pejorative term. According to The New York Times, the term was first put in print in March 2007, when health care lobbyist Jeanne Schulte Scott penned it in a health industry journal. "We will soon see a 'Giuliani-care' and 'Obama-care' to go along with 'McCain-care,' 'Edwards-care,' and a totally revamped and remodeled 'Hillary-care' from the 1990s", Schulte Scott wrote.[][] The expression Obamacare first was used in early 2007 generally by writers describing the candidates proposal for expanding coverage for the uninsured according to research by Elspeth Reeve at The Atlantic magazine.[] The word was first uttered in a political campaign by Mitt Romney in May 2007 in Des Moines, Iowa. Romney said: "In my state, I worked on health care for some time. We had half a million people without insurance, and I said, 'How can we get those people insured without raising taxes and without having government take over health care'. And let me tell you, if we don't do it, the Democrats will. If the Democrats do it, it will be socialized medicine; it'll be government-managed care. It'll be what's known as Hillarycare or Barack Obamacare, or whatever you want to call it."[] By mid-2012, Obamacare had become the most common colloquial term to refer to the law by both supporters and opponents (in contrast to the use of 'Patient Protection and Affordable Care Act' or 'Affordable Care Act' in more formal and official use).[] Use of the term in a positive sense was suggested by Democratic politicians such as John Conyers (D-MI).[236] President Obama endorsed the nickname, saying, "I have no problem with people saying Obama cares. I do care."[237] Because of the number of "Obamacare" search engine queries, the Department of Health and Human Services purchased Google advertisements, triggered by the term, to direct people to the official HHS site.[] In March 2012, the Obama reelection campaign embraced the term "Obamacare", urging Obama's supporters to post Twitter messages that begin, "I like #Obamacare because...".[] After its debut as a phrase on Capitol Hill, according to an analysis by the Sunlight Foundation, from July 2009 to June 2012 the term "Obamacare" was used nearly 3,000 times in congressional speeches.[]

71

Patient Protection and Affordable Care Act Myths On August 7, 2009, Sarah Palin falsely claimed that the proposed legislation would create death panels that would decide if sick and elderly Americans were "worthy" of medical care.[] By 2010, the Pew Research Center reported that 85% of Americans were familiar with the claim, and that 30% of Americans believed it was true, with three contemporaneous polls finding similar results.[238] The allegation was named PolitiFact's "Lie of the Year",[][239] one of FactCheck's "whoppers",[240][241] and the most outrageous term by the American Dialect Society.[242] The AARP described such rumors as "rife with gross - and even cruel - distortions."[] A poll in August 2012 found that 39% of Americans still believed the "death panels" claim.[243] The 'death panel' rumors and comparable myths (similarly false) distort two issues related to the ACA to claim that seniors are either able to be denied care due to their age under the law,[244] or will be advised by the government to end their own lives instead of receiving due care.[] Such rumors first allude to the Independent Payment Advisory Board (IPAB), which has the authority to make cost-saving changes to the Medicare program by implementing the adoption of cost-effective treatments, and finding savings in administration of the program. However, the IPAB is also prohibited from limiting what Medicare covers or raising the costs on beneficiaries.[245] The other related issue concerns advance care planning consultation: a section of an initial House reform proposal would have reimbursed physicians for providing voluntary consultations of Medicare recipients on end-of-life health planning (which is also covered by many private plans), enabling patients to specify, on request, the kind of care they wish to receive in their old age.[246] As described by the site Snopes.com, "This provision would allow patients (if they so choose) to prepare for the day when they might be seriously ill and unable to make medical decisions for themselves by engaging in consultations with doctors to discuss the full range of end-of-life care options available to them, and to have the cost of such consultations covered by Medicare... [including] directives to accept or refuse extreme life-saving measures, selection of hospice care programs, appointment of relatives" to act on the patient's behalf, etc.[] However, due to the public concern, this provision was not included in the final draft of the bill that was enacted into law.[] In 2010, more false rumors spread on the Internet, claiming that the bill would require all Americans or those covered by public insurance to have a microchip implanted.[] These were sometimes associated with the number of the beast (666) in Christian eschatology.[247] These rumors echo similar 'Big Brother' conspiracy myths, and in this case were based on language in draft bills of the law that would have enabled the Department of Health and Human Services to collect data "about medical devices 'used in or on a patient' (such as pacemakers or hip replacements) for purposes that included tracking the effectiveness of such devices and facilitating the distribution of manufacturer recall notices."[] These provisions did not mandate or authorize the government to implant devices in patients, and were not included in the final bill that became law.[]

72

Opposition and resistance


Efforts to oppose, undermine, and repeal the legislation have drawn support from prominent conservative advocacy groups, Congressional and many State Republicans, certain small business organizations, and the Tea Party movement.[248] These groups believe the law will lead to disruption of existing health plans, increased costs from new insurance standards, and that it will increase the deficit.[249] Some also are against the idea of universal health insurance, viewing insurance as similar to other commodities to which people are not entitled.[250][251]

Legal challenges
Opponents of the Patient Protection and Affordable Care Act turned to the federal courts to challenge the constitutionality of the legislation.[252][253] In National Federation of Independent Business v. Sebelius, decided on June 28, 2012, the Supreme Court upheld most of the law; ruling the individual mandate (5-4) is constitutional on the basis that is a tax rather than being authorized by the Commerce Clause, but determined that States could not be forced to participate in the Medicaid expansion, effectively allowing states to opt out of this provision. As written, the ACA withheld all Medicaid funding from states declining to participate in the expansion. However, the Supreme

Patient Protection and Affordable Care Act Court ruled that this withdrawal of funding was unconstitutionally coercive, and that individual states had the right to opt out of the Medicaid expansion without losing pre-existing Medicaid funding from the federal government. All provisions of PPACA will continue in effect or will take effect as scheduled subject to States determination on Medicaid expansion.[254]

73

State rejections of Medicaid expansion


Following the NFIB v. Sebelius ruling, several states with legislatures and governorships controlled by Republicans have opted to reject the expanded Medicaid coverage provided for by the act. Over half of the uninsured live in those states. They include Texas,[] Florida,[] Kansas,[] Georgia,[] Louisiana,[] Alabama,[] and Mississippi.[] As of May 24, 2013, a number of states had not made final decisions, and lists of states which have opted out or were considering Medicaid expansion by state as of July 1, 2013.States expanding MedicaidStates not opting out varied,[][] but Alaska,[] expanding MedicaidStates still debating Medicaid expansion Idaho,[] South Dakota,[] Nebraska,[] Iowa,[] Wisconsin,[] Indiana,[] Pennsylvania,[] Maine,[] North Carolina,[] South Carolina,[] Oklahoma,[] and Missouri[] seemed to have decided to reject expanded coverage.[] As of July 17, with the addition of Arizona,[] 24 states and the District of Columbia have adopted the Medicaid expansion.[256] The drafters of the ACA had intended for Medicaid to cover individuals and families with incomes up to 133% (138% under certain definitions of income[]) of the poverty level by expanding Medicaid eligibility and simplifying the CHIP enrollment process. Low-income individuals and families above 100% and up to 400% of the federal poverty level will receive federal subsidies[] on a sliding scale if they choose to purchase insurance via an exchange (those from 133% to 150% of the poverty level would be subsidized such that their premium cost would be 3% to 4% of income);[] However the SCOTUS ruling created the potential for a coverage gap: States that choose to reject the Medicaid expansion can maintain the pre-existing Medicaid eligibility thresholds that they have set, which in many states are significantly below 133% of the poverty line (many states do not make Medicaid available to childless adults at any income level); because subsidies on insurance plans purchased through exchanges are not available to those below 100% of the poverty line, this will create a coverage gap in those states between the state Medicaid threshold and the subsidy eligibility threshold.[][][][257] For example, in Kansas, where only those able-bodied adults with children with an income below 32% of the poverty line are eligible for Medicaid, those with incomes from 32 percent to 100 percent of the poverty level ($6,250 to $19,530 for a family of three) would be ineligible for both Medicaid and federal subsidies to buy insurance. If they have no children, able-bodied adults are not eligible for Medicaid in Kansas.[] Studies of the impact of state decisions (as of July 2013) to reject the Medicaid expansion calculate that up to 6.4 million Americans could fall into this coverage gap.[258]

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74

Noncooperation
Missouri, has not only declined to expand Medicaid or establish a health insurance marketplace but also is engaged in an active program of noncooperation, enacting a statute forbidding any state or local official to render any aid not specifically required by federal law to functioning of the Affordable Care Act.[] Other Republican politicians have tried to discourage efforts to advertise the benefits of the law, and some conservative political groups are launching ad campaigns to discourage enrollment.[259]

Congressional obstruction
As with all complex legislation, the act contains small errors and provisions which need to be tweaked in order to make the legislation work well in practice and avoid unintended consequences. Strong opposition in Congress by Republicans opposed to the act has resulted in gridlock, preventing these routine adjustments to programs.[][] Many Congressional Republicans and supporters argue that improving the law will weaken the arguments for repeal.[][] In addition to refusing to make routine technical corrections that would improve the law, Republicans have also attempted to defund its implementation,[][260] and block appointments to relevant agencies (like the IPAB[261] and CMS[262][263]).[264]

Repeal efforts
The ACA has been the subject of repeal efforts by Republicans in the 111th, 112th, and 113th Congresses: Reps. Steve King of Iowa and Michele Bachmann of Minnesota, both Republicans, introduced bills in the House to repeal PPACA shortly after it was passed, as did Sen. Jim DeMint in the Senate.[265] None of the three bills were considered by either body. In 2011, the Republican-controlled House of Representatives voted 245189 to approve a bill entitled "Repealing the Job-Killing Health Care Law Act" (H.R.2),[266] which, if enacted, would repeal the Patient Protection and Affordable Care Act and the health care-related text of the Health Care and Education Reconciliation Act of 2010. All Republicans and 3 Democrats voted for repeal.[267] In the Senate, the bill was offered as an amendment to an unrelated bill, and was subsequently voted down.[268] Before votes in both houses of the Congress took place, President Obama stated that he would veto the bill should it pass both chambers.[269] Democrats in the House proposed that repeal not take effect until a majority of the Senators and Representatives had opted out of the Federal Employees Health Benefits Program. The Republicans voted down this measure.[270] On June 28, 2012, following the law being ruled as constitutional by the Supreme Court, House Majority Leader Eric Cantor stated that the House would again vote to repeal the law in July when Congress returns from recess.[271][272][273] On July 11, 2012, the House of Representatives voted to repeal the law with 5 Democrats and all 239 Republicans voting in favor of the repeal.[][] This was the 31st effort by the House of Representatives to repeal the law.[] With President Obama's reelection and the Democrats expanding their majority in the Senate following the 2012 elections, many Republicans conceded that repeal almost certainly will not occur.[274] Job consequences of repeal One argument put forth in favor of repeal was that, as stated by a spokesman for House Majority Leader Eric Cantor, "This is a job-killing law, period."[] The House Republican leadership justified its use of the term "job killing" by contending that PPACA would lead to a loss of 650,000 jobs, and attributing that figure to a report by the Congressional Budget Office.[] However, FactCheck noted the 650,000 figure was not included in the CBO report that was referred to, and said that the Republican statement "badly misrepresents what the Congressional Budget Office has said about the law. In fact, CBO is among those saying the effect [on employment] 'will probably be small.'"[] PolitiFact also rated the Republican statement as False.[275] Jonathan Cohn, citing the projections of the CBO, summarized that the primary employment effect of the ACA is to alleviate job lock: "people who are only working because they desperately need employer-sponsored health

Patient Protection and Affordable Care Act insurance will no longer do so."[] He concluded that "reforms only significant employment impact was a reduction in the labor force, primarily because people holding onto jobs just to keep insurance could finally retire"[] once they have health insurance outside of their jobs. Effect of repeal proposals on federal budget projections The non-partisan Congressional Budget Office (CBO) estimated that repealing the entire PPACA (including both its taxing and spending provisions) would increase the net 20112021 federal deficit by $210billion.[211] In May 2011, CBO analyzed proposals to prevent the use of appropriated funds to implement the legislation, and wrote that "a temporary prohibition, extending through the remainder of fiscal year 2011, would reduce the budget deficit by about $1.4billion in 2011 but would increase deficits by almost $6billion over the 20112021 period... CBO cannot determine whether changes in spending under a permanent prohibition would produce net costs or net savings relative to its baseline projection, which assumes full implementation."[] Revised CBO accounting, based on the latest repeal effort passed in the House of Representatives (H.R.6079) on July 11, 2012, and taking into account the Supreme Court's ruling concerning the expansion of Medicaid by the States, that, on balance, the direct spending and revenue effects of enacting the Repeal of Obamacare Act legislation would cause a net increase in federal budget deficits of $109billion over the 20132022 period. Specifically, CBO estimates that H.R.6079 would reduce direct spending by $890billion and reduce revenues by $1trillion between 2013 and 2022, thus adding $109billion to federal budget deficits over that period.[][]

75

References
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Patient Protection and Affordable Care Act


(II) offered through an Exchange established under this Act (or an amendment made by this Act)." [96] "History of the Individual Health Insurance Mandate, 1989-2010 Republican Origins of Democratic Health Care Provision" (http:/ / healthcarereform. procon. org/ view. resource. php?resourceID=004182) [100] Cosponsors of S.334 (http:/ / thomas. loc. gov/ cgi-bin/ bdquery/ z?d110:SN00334:@@@P) from the Library of Congress THOMAS website [101] Bipartisan Senate Coalition Introduces First Comprehensive Health Reform Bill of 2009 (http:/ / wyden. senate. gov/ newsroom/ record. cfm?id=307848), from Senator Wyden's website [102] "RomneyCare vs. ObamaCare" (http:/ / www. boston. com/ bostonglobe/ editorial_opinion/ oped/ articles/ 2011/ 06/ 28/ romneycare_vs_obamacare/ ) [104] (http:/ / www. c-spanvideo. org/ videoLibrary/ search-results. php?organization="Finance"& organization="Senate+ Committee"& date-from=01/ 06/ 2009& date-to=01/ 02/ 2011) Senate Finance Committee Hearings for the 111th Congress recorded by C-SPAN [114] U.S. Const. art. I, 7, cl. 1. [126] AARP, AMA Announce Support For Health Care Bill: Largest Doctors And Retiree Groups Backing Legislation (http:/ / www. huffingtonpost. com/ 2010/ 03/ 19/ aarp-ama-announce-support_n_506060. html). The Huffington Post. [134] Executive Order 13535 of March 24, 2010 Ensuring Enforcement and Implementation of Abortion Restrictions in the Patient Protection and Affordable Care Act, Vol.75, No.59,, March 29, 2010. [142] Ellmers, R. (2012, May 31). Small business subcommittee on healthcare & technology chairwoman Renee Ellmers: Need a job: support small businesses. Congressional Documents and Publications. Retrieved online from http:/ / www. dowjones. com/ factiva [143] Lawrimore, E. (2012, June 27). Barrasos 2nd opinion: Obamacare small business tax credit is a bust. Congressional Documents and Publications. Retrieved from http:/ / www. dowjones. com/ factiva [144] Insurers to Bail on Child-Only Policies as Health Care Law Looms (http:/ / www. cbsnews. com/ 8301-504744_162-20017272-10391703. html), CBS News, September 22, 2010 [145] Big health insurers to stop selling new child-only policies (http:/ / www. latimes. com/ health/ la-fi-kids-health-insurance-20100921,0,799167. story), Los Angeles Times, September 21, 2010 [160] Congressional Budget Office, " Selected CBO Publications Related to Health Care Legislation, 2009-2010 (http:/ / cbo. gov/ sites/ default/ files/ cbofiles/ ftpdocs/ 120xx/ doc12033/ 12-23-selectedhealthcarepublications. pdf)," Congress of the United States, December 2010, pp 71,73. [168] Note: Language in the law concerning this provision has been described as ambiguous, but representatives of the insurance industry have indicated they will comply with regulations to be issued by the Secretary of Health and Human Services reflecting this interpretation. [174] The Affordable Care Act: Eliminating Limits on Your Benefits (http:/ / www. healthcare. gov/ law/ provisions/ limits/ limits. html) HHS web site [175] " Annual Limits Policy: Protecting Consumers, Maintaining Options, and Building a Bridge to 2014 (http:/ / cciio. cms. gov/ resources/ files/ approved_applications_for_waiver. html)", HHS-CMS-CCIIO, see section "Applications for Waiver of the Annual Limits Requirements" [181] "A Cruel Blow to American Families" (http:/ / www. nytimes. com/ 2013/ 02/ 03/ opinion/ sunday/ a-cruel-blow-to-american-families. html) New York Times, February 2, 2013 [186] Kuraitis V. (2010). Pilots, Demonstrations & Innovation in the ACA Healthcare Reform Legislation (http:/ / e-caremanagement. com/ pilots-demonstrations-innovation-in-the-ppaca-healthcare-reform-legislation/ ). e-CareManagement.com. [188] Centers for Medicare and Medicaid Services-Statistics, Trends and Reports-Retrieved June 9, 2013 (http:/ / www. cms. gov/ Research-Statistics-Data-and-Systems/ Statistics-Trends-and-Reports/ NationalHealthExpendData/ NationalHealthAccountsHistorical. html) [210] Health Care Repeal Balloons Deficit, Hurts Economy and Families (http:/ / democrats. budget. house. gov/ press-release/ health-care-repeal-balloons-deficit-hurts-economy-and-families) Committee on the Budget | United States House of Representatives [211] Heavey, Susan (February 18, 2011), "Repealing healthcare law would cost $210 bln: CBO" (http:/ / www. reuters. com/ article/ 2011/ 02/ 18/ us-usa-healthcare-cbo-idUSTRE71H77N20110218), Reuters, retrieved March 13, 2011 [214] "Va. workers' part-time hours capped due to health law" (http:/ / hamptonroads. com/ 2013/ 02/ state-workers-parttime-hours-capped-due-health-law) The Virginian-Pilot, February 8, 2013 [215] "Colleges roll back faculty hours in response to Obamacare" MSNBC (http:/ / tv. msnbc. com/ 2013/ 01/ 14/ colleges-roll-back-faculty-hours-in-response-to-obamacare/ ) [216] "Virginia Cuts State Employees Hours To Avoid Providing Obamacare Coverage" (http:/ / thinkprogress. org/ health/ 2013/ 02/ 11/ 1568291/ virginia-employees-obamacare/ ) ThinkProgress, February 11, 2013 [217] "Four Public Colleges Will Cut Adjunct Faculty Hours To Avoid Providing Health Coverage Under Obamacare" ThinkProgress, January 14, 2013 (http:/ / thinkprogress. org/ health/ 2013/ 01/ 14/ 1445301/ four-public-colleges-obamacare/ ) [222] Union Letter: Obamacare Will Destroy The Very Health and Wellbeing of Workers (http:/ / blogs. wsj. com/ corporate-intelligence/ 2013/ 07/ 12/ union-letter-obamacare-will-destroy-the-very-health-and-wellbeing-of-workers/ ), Wall St. Journal, July 12, 2013 [229] http:/ / i2. cdn. turner. com/ cnn/ 2010/ images/ 03/ 22/ rel5a. pdf [235] Jackson, David. Poll: Most oppose blocking Obama health care law (http:/ / content. usatoday. com/ communities/ theoval/ post/ 2012/ 07/ poll-most-oppose-blocking-obama-health-care-law/ 1#. T_m-ZJGmW_J) USA Today. Retrieved: 8 July 2012. [247] E.g.

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[274] Baker, Sam. (2012-11-07) Conservatives begin to admit defeat in their 3-year war against 'ObamaCare' - The Hill's Healthwatch (http:/ / thehill. com/ blogs/ healthwatch/ health-reform-implementation/ 266689-conservatives-are-begin-to-admit-defeat-in-their-three-year-war-against-obamacare). Thehill.com. Retrieved on 2013-07-17.

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Further reading
Barr, Donald A. (2011). Introduction to U.S. Health Policy: The Organization, Financing, and Delivery of Health Care in America (http://books.google.com/books?id=yZLJrmNoEzkC). JHU Press. CCH (2010). Law, Explanation and Analysis of the Patient Protection and Affordable Care Act: Including Reconciliation Act Impact (http://books.google.com/books?id=tCTt0sq2vaEC). CCH Incorporated. 1183pp Feldman, Arthur M. (2011). Understanding Health Care Reform: Bridging the Gap Between Myth and Reality (http://books.google.com/books?id=dSszUQPKSZIC). CRC Press. Jacobs, Lawrence R.; Theda Skocpol (2010). Health Care Reform and American Politics (http://books.google. com/books?id=VcsmJybD32wC). Oxford U.P. John E. McDonough (September 2011). Inside National Health Reform. University of California Press. ISBN9780520270190. Preliminary CBO documents Patient Protection And Affordable Care Act, Incorporating The Manager's Amendment (http://www.cbo.gov/ doc.cfm?index=10868) December 19, 2009 Effects Of The Patient Protection And Affordable Care Act On The Federal Budget And The Balance In The Hospital Insurance Trust Fund (December 23, 2009) Estimated Effect Of The Patient Protection And Affordable Care Act (Incorporating The Manager's Amendment) On The Hospital Insurance Trust Fund (December 23, 2009) Base Analysis H.R. 3590, Patient Protection and Affordable Care Act (http://cbo.gov/doc. cfm?index=10731), November 18, 2009. (The Additional and/or Related CBO reporting that follows can be accessed from the above link) Estimated Distribution Of Individual Mandate Penalties (November 20, 2009) Estimated Effects On Medicare Advantage Enrollment And Benefits Not Covered By Medicare (November 21, 2009) Estimated Effects On The Status Of The Hospital Insurance Trust Fund (November 21, 2009) Estimated Average Premiums Under Current Law (December 5, 2009) Additional Information About Employment-Based Coverage (December 7, 2009) Budgetary Treatment Of Proposals To Regulate Medical Loss Ratios (December 13, 2009) Centers for Medicare and Medicaid Services (CMS) Estimates of the impact of P.L. 111-148 Estimated Financial Effects of the "Patient Protection and Affordable Care Act," as Amended (https://www. cms.gov/ActuarialStudies/downloads/PPACA_2010-04-22.pdf). April 22, 2010. Estimated Effects of the "Patient Protection and Affordable Care Act," as Amended, on the Year of Exhaustion for the Part A Trust Fund, Part B Premiums, and Part A and Part B Coinsurance Amounts (https://www.cms. gov/ActuarialStudies/Downloads/PPACA_Medicare_2010-04-22.pdf). April 22, 2010. Centers for Medicare and Medicaid Services (CMS) Estimates of the impact of H.R. 3590 Estimated Financial Effects of the "Patient Protection and Affordable Care Act of 2009," as Proposed by the Senate Majority Leader on November 18, 2009 (http://www.cms.gov/ActuarialStudies/Downloads/ S_PPACA_2009-12-10.pdf). December 10, 2009. Estimated Effects of the "Patient Protection and Affordable Care Act" on the Year of Exhaustion for the Part A Trust Fund, Part B Premiums, and Part A and Part B Coinsurance Amounts (http://www.cms.gov/ ActuarialStudies/Downloads/S_PPACA_Medicare_2009-12-10.pdf). December 10, 2009.

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External links
Video: Obama signs Healthcare Bill (http://www.wtsp.com/video/1711079319001/1/ Archive-video-Obama-signs-health-care-bill) Supreme Court Ruling on the ACA-June 28, 2012 (http://www.supremecourt.gov/opinions/11pdf/ 11-393c3a2.pdf) Remarks by the President on Supreme Court Ruling on the Affordable Care Act-June 28, 2012 (http://www. whitehouse.gov/the-press-office/2012/06/28/remarks-president-supreme-court-ruling-affordable-care-act) HealthCare.gov (http://www.healthcare.gov/) Department of Health and Human Services website on the law Affordable Care Act (http://topics.nytimes.com/top/reference/timestopics/organizations/s/supreme_court/ affordable_care_act//index.html) collected news and commentary at The New York Times Health Reform (http://topics.wsj.com/subject/H/health-reform/1662) collected news and commentary at The Wall Street Journal Basics: Health care reform issues (http://edition.cnn.com/2012/03/26/health/health-care-reform-interactive/ index.html?iid=article_sidebar) as provided by Emily Smith from CNN' June 25, 2012 Timeline of the health care law (http://edition.cnn.com/2012/06/17/politics/health-care-timeline/index. html?iid=article_sidebar) as provided by CNN June 17, 2012 Kaiser Family Foundation: Health Reform Subsidy Calculator Premium Assistance for Coverage in Exchanges/Gateways (http://healthreform.kff.org/SubsidyCalculator.aspx) Three Days of Argument: Obamacare On Trial Audiobook (http://www.castlibrary.com/free_books) Complete coverage of the arguments to the Supreme Court regarding Obamacare Supreme Court ruling caps a century of American debate over how to get medical care for all (http://www. washingtonpost.com/politics/federal_government/ supreme-court-ruling-caps-a-century-of-american-debate-over-how-to-get-medical-care-for-all/2012/06/28/ gJQA6XmP8V_story.html?tid=pm_politics_pop) An Associated Press timeline published on June 28, 2012, by The Washington Post about key events in a century of debate over what role the government should play in helping people in the United States afford medical care HealthReformGPS.org (http://www.healthreformgps.org/) Tracking and explanation of the law as it is implemented by analysts at the Hirsh Health Law and Policy program of the George Washington University School of Public Health and Health Services. Ambinder, Marc (March 22, 2010). "Has Romney Lost The RomneyCare = ObamaCare Argument?" (http:// www.theatlantic.com/politics/archive/2010/03/has-romney-lost-the-romneycare-obamacare-argument/37842/ ). The Atlantic. Retrieved 2011-04-07. Copies of the proposed bill hosted online or readily downloadable PDF (http://docs.house.gov/energycommerce/ppacacon.pdf) of the Patient Protection and Affordable Care Act ("PPACA"; Public Law 111148) after consolidating the amendments made by Title X of PPACA itself and by the Health Care and Education Reconciliation Act of 2010 ("HCERA"; Public Law 111152) into one revision. Plain Text or PDF formats of H. R. 3590 (Public Law 111-148) (http://www.gpo.gov/fdsys/search/ pagedetails.action?packageId=PLAW-111publ148), as engrossed or passed by the Senate and printed via FDsys. The Patient Protection and Affordable Care Act (http://dpc.senate.gov/dpcissue-sen_health_care_bill.cfm), full text, summary, background, provisions and more, via Democratic Policy Committee (Senate.gov) Summary of H.R. 3590 (http://thomas.loc.gov/cgi-bin/bdquery/z?d111:HR03590:@@@L&summ2=m& summary) (March 23, 2010) via THOMAS. Entry for H.R. 3590 (http://www.govtrack.us/congress/bill.xpd?bill=h111-3590) at GovTrack The law as published by the U.S. Government Printing Office (http://www.gpo.gov/fdsys/pkg/ PLAW-111publ148/pdf/PLAW-111publ148.pdf)

Patient Protection and Affordable Care Act "Lines Crossed: Separation of Church and State. Has the Obama Administration Trampled on Freedom of Religion and Freedom of Conscience?" Hearing before the Congressional Committee on Oversight and Government Reform February 16, 2012 Lines Crossed: Separation of Church and State Part 1 (http://www.youtube.com/watch?v=9nJRUxj-HUY) Lines Crossed: Separation of Church and State Part 2 (http://www.youtube.com/watch?v=uj1l8suFE68) '"Where Are the Women?": Lawmakers Walk Out on Contraception Rule Hearing After Female Witness Barred' (https://www.democracynow.org/2012/2/17/where_are_the_women_lawmakers_walk) Democracy Now! February 17, 2012

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Administration for Children and Families

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Administration for Children and Families


Administration for Children & Families
Agency overview Agency executive George Sheldon, Assistant Secretary (Acting) Parent Agency United States Department of Health and Human Services Website
http:/ / www. acf. hhs. gov/

The Administration for Children and Families (ACF) is a division of the United States Department of Health and Human Services (HHS). It is headed by the Assistant Secretary for Children and Families. It has a $58.8 billion budget for 65 programs that target children, youth and families.[1] These programs include assistance with welfare, child support enforcement, adoption assistance, foster care, child care, and child abuse.

Mission statement
"The Administration for Children and Families (ACF), within the United States Department of Health and Human Services (HHS), provides national leadership and creates opportunities for families to lead economically and socially productive lives. ACF's programs are designed to help children to develop into healthy adults and communities to become more prosperous and supportive of their members."[2]

Major Goals
"ACF is responsible for federal programs that promote the economic and social well-being of families, children, individuals and communities. ACF programs aim to achieve the following: families and individuals empowered to increase their own economic independence and productivity; strong, healthy, supportive communities that have a positive impact on the quality of life and the development of children; partnerships with individuals, front-line service providers, communities, American Indian tribes, Native communities, states, and Congress that enable solutions which transcend traditional agency boundaries; services planned, reformed, and integrated to improve needed access; a strong commitment to working with people with developmental disabilities, refugees, and migrants to address their needs, strengths, and abilities."[2]

Major Programs
Administration for Native Americans (ANA) Administration on Children, Youth and Families (ACYF) Administration on Developmental Disabilities (ADD) Assets for Independence (AFI) Child Care Bureau (CCB) Office of Child Support Enforcement (OCSE) Children's Bureau (CB) Family and Youth Services Bureau (FYSB) Office of Head Start (OHS) Healthy Marriage Initiative (HMI)

Administration for Children and Families Office of Community Services (OCS) Low Income Home Energy Assistance Program (LIHEAP) Community Services Block Grant (CSBG) Social Services Block Grant (SSBG) Office of Family Assistance (OFA) / Temporary Assistance for Needy Families (TANF) Office of Refugee Resettlement (ORR) President's Committee for People with Intellectual Disabilities (PCPID)

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Other Initiatives, Clearinghouses and Resources


Center for Faith-Based and Community Initiatives (CFBCI) Child Welfare Information Gateway [3] Fatherhood Initiative "Insure Kids Now!" Campaign National Child Care Information and Technical Assistance Center (NCCIC) [4] National Clearinghouse on Families and Youth (NCFY) National Healthy Marriage Resource Center (NHMRC) [5] Office of Child Support Enforcement Tribal Resources

Abstinence education
For fiscal year 2006, ending September 30, 2006, Congress appropriated $50 million for state grants for abstinence education programs. Such programs teach that abstaining from sex is the only effective or acceptable method to prevent pregnancy or disease, and give no instruction on birth control or safe sex. In October 2006, revised guidelines by ACF specified that states seeking grants are "to identify groups ... most likely to bear children out-of-wedlock, targeting adolescents and/or adults within the 12- through 29-year-old age range." Previous guidelines didn't mention specific ages, and programs focused on preteens and teens.[6] ACF also administers the Community-Based Abstinence Education Program, which is focused on funding public and private entities that provide abstinence-until-marriage education for adolescents from 12 to 18 years old. For fiscal year 2005, 63 grants were awarded, totaling $104 million to organizations and other entities; in fiscal 2001, grants totaled only $20 million. In October 2006, the Government Accountability Office reported that ACF does not review its grantees education materials for scientific accuracy and does not require grantees of either program to review their own materials for scientific accuracy. GAO also reported that most of the efforts to evaluate the effectiveness of abstinence-until-marriage education programs included in GAOs review have not met certain minimum scientific criteria.[7]

Notes
[1] ACF Office of Legislative Affairs and Budget: Budget Information (http:/ / www. acf. hhs. gov/ programs/ olab/ budget/ index. html) [2] ACF Office of Public Affairs (OPA): Fact Sheet - Administration for Native Americans (ANA) (http:/ / www. acf. hhs. gov/ opa/ fact_sheets/ acf_factsheet. html) [3] http:/ / childwelfare. gov [4] http:/ / nccic. acf. hhs. gov [5] http:/ / www. healthymarriageinfo. org [6] Abstinence message goes beyond teens - USATODAY.com (http:/ / www. usatoday. com/ news/ washington/ 2006-10-30-abstinence-message_x. htm) [7] "Abstinence Education: Efforts to Assess the Accuracy and Effectiveness of Federally Funded Programs" (http:/ / www. gao. gov/ new. items/ d0787. pdf), U.S. Government Accountability Office, October 2006

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External links
Administration For Children and Families official web page (http://www.acf.hhs.gov)

American College of Healthcare Executives


The American College of Healthcare Executives
Motto To be the premier professional society for healthcare leaders by providing exceptional value to our members. 1933 Healthcare Association Chicago, Illinois, USA worldwide approx 40,000 Thomas C Dolan

Formation Type Headquarters Location Membership President and Chief Executive Officer Staff Website

approx. 100 www.ache.org [1]

The American College of Healthcare Executives (ACHE) is an international professional association of healthcare executives (high-level hospital administrators, CEOs, COOs, health system officers, etc.) Its central offices are located at 1 N. Franklin Street in Chicago, Illinois, USA. ACHE was described by Modern Healthcare as one of the healthcare industry's top professional associations.[2] Its President and Chief Executive Officer is Thomas C Dolan.

Credentialing
Currently in the United States, the practice of healthcare management does not require licensure. ACHE's credential, the FACHE, is a voluntary credential which healthcare managers can pursue to demonstrate their knowledge and experience. The credential was restructured in 2007 to streamline the process, which made it easier to achieve [2]

Divisions
ACHE itself is made up of a number of divisions, including membership, education, research and publications.

Education
Ongoing education for ACHE's members (designated as "Member" or "Fellow") is an element of ACHE's program. In 2005, these offerings included a two-day conference for Chief Operating Officers, a Canadian seminar offered in partnership with the Canadian College of Health Service Executives, and the annual Congress on Healthcare Leadership, which draws more than 4,000 participants each year.[3]

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Publications
Health Administration Press (HAP), founded at the University of Michigan in 1972, is ACHE's publisher and subsidiary. In 2005 HAP sold 54,000 publications, published 18 books, and published 10 issues of their two journals; the Journal of Healthcare Management and Frontiers of Health Services Management.[3]

Research
ACHE conducts research in a number of healthcare management areas. Factors affecting the career attainments of healthcare executives as well as trends and recommended practices affecting the profession are studied. Reports on the extent of hospital CEO turnover are routine produced as well.[4]

References
[1] [2] [3] [4] http:/ / www. ache. org Evans, Melanie. "Paying Dues by Doing Less". Modern Healthcare August 20, 2007. pp. 6, 7, 16. ACHE. About ACHE (http:/ / www. ache. org/ aboutache. cfm) ACHE. Research Publications (http:/ / www. ache. org/ pubs/ research/ research. cfm)

External links
Official homepage (http://www.ache.org) 2007 Annual Report (http://www.ache.org/ABT_ACHE/07_Annual_Report/ar07_tableofcontents.cfm) Health Administration Press (http://www.ache.org/hap.cfm)

American Congress of Obstetricians and Gynecologists


The American Congress of Obstetricians and Gynecologists (ACOG), formerly the American College of Obstetricians and Gynecologists, is a professional association of medical doctors specializing in obstetrics and gynecology in the United States. It has a membership of over 55,000[1] and represents 90 percent of U.S. board-certified obstetrician-gynecologists.[] Members are referred to as fellows and use the post-nominal letters FACOG to indicate their status. To become a fellow, candidates must become certified by the American Board of Obstetrics and Gynecology and then nominated to the college by another fellow. Board certification involves a two-part exam, usually taken over a two-year period. The first part is a written exam, which is taken the first year the candidate is "eligible" (typically in the final year of obstetrics and gynecology residency training). The second part is an oral exam, taken the year after the written exam is passed. The oral examination is based largely on a collection of a year's worth of medical and surgical cases known as the "case list". Obstetrics & Gynecology is the official publication of the ACOG. It is popularly known as "The Green Journal".[2] In 1986, the organization successfully challenged an anti-abortion law in Pennyslvania before the U.S. Supreme Court in Thornburgh v. American College of Obstetricians and Gynecologists.[3]

American Congress of Obstetricians and Gynecologists

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References
[1] About ACOG (http:/ / www. acog. org/ About_ACOG) [2] SCImago Journal and Country rank > Obstetrics and Gynecology (http:/ / www. scimagojr. com/ journalsearch. php?q=28089& tip=sid& clean=0) Retrieved on April 15, 2010 [3] Greenhouse, Linda. Becoming Justice Blackmun. Times Books. 2005. Page 183.

External links
Official ACOG website (http://www.acog.org/) ACOG, District IX - California (http://www.acog.org/About_ACOG/ACOG_Districts/District_IX) Journal site (http://journals.lww.com/greenjournal/pages/default.aspx)

American Cancer Society

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American Cancer Society


American Cancer Society
Founded 1913

Headquarters American Cancer Society Center Atlanta, Georgia Origins Key people New York, New York John R. Seffrin, PhD, Chief Executive Officer Otis Webb Brawley, MD, Chief Medical Officer W. Phil Evans, MD, FACR, President Cynthia M. LeBlanc, EdD, Chair United States and Puerto Rico. "To save lives by helping people stay well, helping people get well, by finding cures, and fighting back." Cancer research, Endowments, Public policy, and Education. cancer.org [1] [] []

Area served Focus(es) Method(s) Website

The American Cancer Society (ACS) is a nationwide voluntary health organization dedicated to eliminating cancer. Established in 1913, the society is organized into twelve[2] geographical divisions of both medical and lay volunteers operating in more than 900 offices throughout the United States, including Puerto Rico.[] Its home office is located in the American Cancer Society Center in Atlanta, Georgia. As the official journals the ACS publishes Cancer, CA: A Cancer Journal For Clinicians and Cancer Cytopathology. [3] In 1994, the Chronicle of Philanthropy, an industry publication, released the results of the largest study of charitable and non-profit organization popularity and credibility conducted by Nye Lavalle & Associates. The study showed that the American Cancer Society was ranked as the 10th "most popular charity/non-profit in America" of over 100 charities researched with 38% of Americans over the age of 12 choosing Love and Like A lot for the American Cancer Society.[4] [5]

History
The society was originally founded on May 22, 1913 by 15 physicians and businessmen in New York City under the name American Society for the Control of Cancer (ASCC). The current name was adopted in 1945.[6][7] In that time of founding it was not considered appropriate to mention the word cancer in public. Information concerning this illness was cloaked in a climate of fear and denial. Over 75,000 people died each year of cancer in just the United States. The top item on the founders agenda was to raise awareness of cancer, before any other progress could be made in funding research. Therefore a frenetic writing campaign was undertaken to educate doctors, nurses, patients and family members about cancer. Articles were written for popular magazines and professional journals. The ASCC undertook to publish their own journal, Campaign Notes, which was a monthly bulletin with information about cancer. They began recruiting doctors from all over the United States to help educate the public about cancer. Marjorie Illig was an ASCC field representative in 1936. She suggested creating a large network of new volunteers whose purpose was to wage war on cancer. In 1935 there were 15,000 people involved in cancer control in the U.S. By 1938 there was ten times that number. The Womens Field Army, those volunteers working on behalf of the ASCC were responsible for this increase more than anything else.[8]

American Cancer Society The sword symbol, adopted by the American Cancer Society in 1928, was designed by George E. Durant of Brooklyn, New York. According to Durant, the two serpents forming the handle represent the scientific and medical focus of the societys mission and the blade expresses the crusading spirit of the cancer control movement."[9] In the spring of 2013 the American Cancer Society reorganized nationally. The organization centralized and consolidated its operations and required all employees too reapply for their jobs. [10]

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Activities and Fund allocation


Its activities include providing grants to researchers, icluding funding 46 Nobel Laureate researchers, discovering the link between smoking and cancer, and serving one million callers every year through its National Cancer Information Center. The 46 Nobel Prize laureates include James D. Watson, Mario Capecchi, Oliver Smithies, Paul Berg, E. Donnall Thomas, and Walter Gilbert.[11] It also runs public health advertising campaigns, and organizes projects such as the Relay For Life and the Great American Smokeout. It operates a series of thrift stores to raise money for its operations. Notable endorsements include the 4K for Cancer, a 4000-mile bike ride from Baltimore to San Francisco to raise money for the society's Hope Lodge.[12] The societys allocation of funds for the fiscal year ending August 31, 2010, lists 72% of funds for Program Services (Patient Support 28%, Research 16%, Prevention 16%, Detection and Treatment 12%). The remaining 28% are allocated for supporting services (Fundraising 21%, and Management, General administration 7%) meeting the Better Business Bureau's Standards for Charity Accountability (At least 65% to program services and no more than 35% to overhead and fundraising expenses).[13] In 2012 the American Cancer Society raised $934 million and spent $943 million prompting a national consolidation and cost-cutting reorganization. [14] John R. Seffrin, CEO of the American Cancer Society, received $2,401,112 salary/compensation from the charity for the 2009-2010 fiscal year.[15] This is the second most money given by any charity to the head of that charity, according to Charity Watch. The money included $1.5 million in a retention benefit approved in 2001, to preserve management stability.[16]

1938 American Society for the Control of Cancer poster.

Evaluations
Charity Navigator rates the society two of four stars.[17] According to Charity Navigator the society is directed to "eliminating cancer" and destroying it. The American Cancer Society's website contains a chronological listing of specific accomplishments in the fight against cancer, for example the unipod technological device of UTD, that the ACS had a hand in, including the funding of various scientists who went on to discover life-saving cancer treatments, and advocating for increased use of preventative techniques.[18] Charity Watch rates American Cancer Society a "C".[19]
ACS Hope Lodge in Manhattan

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Scandals
New York embezzlement
In the 1980s, an employee of a New York branch was indicted for a tax fraud scheme that allowed individuals to fraudulently claim contributions, much of which had been returned to them.[20]

Ohio embezzlement
In 2000, Dan Wiant, the chief administrative officer of the American Cancer Society of Ohio, pled guilty to embezzling $7 million from the organization.[21]

Lack of control over state affiliates


In 1995, the Arizona chapter of the American Cancer Society was targeted for its extremely high overhead. Two economists, James Bennett and Thomas DiLorenzo, issued a report analyzing the chapter's financial statements and demonstrating that the Arizona chapter used about 95% of its donations for paying salaries and other overhead costs, resulting in a 22 to 1 ratio of overhead to actual money spent on the cause. The report also asserted that the Arizona chapter's annual ACS offices in Washington, D.C. report had grossly misrepresented the amount of money spent on patient services, inflating it by more than a factor of 10. The American Cancer Society responded by alleging that the two economists issuing the report were working for a group funded by the tobacco industry.[22]

Controversy
Declined participation of atheist organization in Relay For Life National Team program
The American Cancer Society was criticized for turning down participation from the Foundation Beyond Belief in its Relay For Life "National Team" program, worth more than $500,000. The ACS responded to the criticism by stating the "National Team" was to become a corporate sponsorship program and that non-profits and advocacy groups were no longer going to be included in this sponsorship program. This change in policy occurred after the ACS had already agreed that Foundation Beyond Belief could have a team under the Relay non-corporate National Team program.[23][24]

References
[1] http:/ / www. cancer. org/ [2] American Cancer Society: Fact Sheet (http:/ / www. cancer. org/ docroot/ AA/ content/ AA_1_2_ACS_Fact_Sheet. asp) [4] The Charities Americans Like Most And Least, The Chronicle of Philanthropy, December 13, 1996 And USA Today, December 20, 1994, "Charity begins with health", FINAL 01D [5] http:/ / www. workingtogive. org/ charities/ disease-research/ american-cancer-society/ history History [6] name="charitynavigator.org" [7] http:/ / journaltimes. com/ news/ today-in-history-american-cancer-society-is-founded-strongest-ever/ article_8d048ba8-c17b-11e2-ba4e-001a4bcf887a. html Journal Times [8] http:/ / www. workingtogive. org/ charities/ disease-research/ american-cancer-society/ history History [10] http:/ / www. timesunion. com/ business/ article/ Cancer-Society-chapters-facing-reorganization-4446222. php Times Union, Cancer Society Reorg [14] http:/ / www. timesunion. com/ business/ article/ Cancer-Society-chapters-facing-reorganization-4446222. php Times Union, Cancer Society Reorg [19] Charity Rating Guide and Watchdog Report, Volume Number 59, December 2011

American Cancer Society


[20] Ex-Fund-Raiser At Cancer Society Indicted In $4 MillionTax Fraud (http:/ / query. nytimes. com/ gst/ fullpage. html?sec=health& res=9504E6D9153BF93AA25751C1A963948260). The New York Times. Retrieved on February 9, 2007. [21] Cancer Society Executive Surrenders to the F.B.I. (http:/ / query. nytimes. com/ gst/ fullpage. html?sec=health& res=990CEFD7163EF932A25755C0A9669C8B63& n=Top/ Reference/ Times Topics/ Organizations/ A/ American Cancer Society). The New York Times. Retrieved on February 9, 2007.

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External links
American Cancer Society (http://www.cancer.org/) Relay For Life (http://www.relayforlife.org/) Making Strides Against Breast Cancer (http://makingstrides.acsevents.org/) DetermiNation (http://determination.acsevents.org/) Relay Recess (http://www.relayrecess.org/) More Birthdays (http://morebirthdays.com/) Guidestar Report on American Cancer Society including financial data (http://www.guidestar.org/ pqShowGsReport.do?partner=networkforgood&ein=13-1788491) Charity Navigator's Rating of the American Cancer Society (http://www.charitynavigator.org/index.cfm/bay/ search.summary/orgid/6495.htm) American Cancer Society YouTube Channel (http://www.youtube.com/amercancersociety)

American College of Surgeons

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American College of Surgeons


American College of Surgeons
Formation Type Headquarters Location Membership 78,000 1913 Professional Association Chicago, IL

Officiallanguages English President Key people Website A. Brent Eastman EVP David B. Hoyt www.facs.org [1]

The American College of Surgeons is an educational association of surgeons created in 1913.[2] Headquartered in Chicago, Illinois, the College provides membership for doctors worldwide specializing in surgery who pass a set of rigorous qualifications.

Objective
The American College of Surgeons is a scientific and educational association of surgeons that was founded in 1913 to improve the quality of care for the surgical patient by setting high standards for surgical education and practice.[2]

Membership
American College of Surgeons members are referred to as Fellows. Members abbreviate their membership status in the American College of Surgeons by using the letters FACS (Fellow, American College of Surgeons). Those letters after a surgeons name mean that the surgeons education and training, professional qualifications, surgical competence, and ethical conduct have passed a rigorous evaluation, and have been found to be consistent with the high standards established and demanded by the College. Associate Fellow is another category of American College of Surgeons membership. Associate Fellowship provides an opportunity for surgeons who are beginning surgical practice and who meet specific requirements to assume an active role in the College at an early stage in their careers. In order to provide education and other benefits for allied professionals who deal with surgical patients, but who are not surgeons, the Affiliate Member category was created. Currently, there are approximately 78,000 members, including more than 58,000 Fellows in the U.S. and Canada and more than 4,000 Fellows in other countries, which makes the American College of Surgeons the largest organization of surgeons in the world. There are presently more than 3,900 Associate Fellows.

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Administration
22 members make up a Board of Regents, who govern the College. The Board of Regents is selected by an elected Board of Governors representing different specialties and geographical locations (the number of governors is based on the amount of Fellows in a region). While the Board of Regents is an administrative body, the Board of Regents serve as the representative body of the ACS between Fellows and the Board of Regents.[3] Within the ACS are numerous committees and advisory councils, studying and serving as a liaison for different specialties and aspects of the surgical profession.[4][5] Examples include the Committee on Trauma, the Patient Education Committee, and the Advisory Council on General Surgery. There are currently 103 chapters into which ACS Fellows are organized: 64 chapters in the United States, 2 in Canada, and 37 in other countries around the world.

Major activities
Through its Inspiring Quality initiative, the American College of Surgeons drives awareness of its quality improvement programs such as the ACS National Surgical Quality Improvement Program (ACS NSQIP) and ACS NSQIP Pediatric. The initiative is intended to enable the College to have a dialogue and work together with health care leaders around the nation, to continue to have a tremendous impact on improving surgical care, and to lead our health care system in the right direction. By administering myriad continuing medical education offerings, reflecting technology advancements and distance-learning options; accrediting simulation institutes that offer surgeons and surgical residents opportunities to learn new procedures and emerging technology; and providing surgeons with opportunities to record and obtain information they need for American surgical specialty board Maintenance of Certification requirements, the College "promotes high quality educational programs designed to educate surgeons and directly improve the health and safety of surgical patients." By means of standard setting and rigorous review processes through its Commission on Cancer, National Accreditation Program for Breast Centers, Committee on Trauma, and Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, the American College of Surgeons accredits and verifies facilities to help ensure that surgical patients get high-quality care. In an effort to provide surgeons with the best scientific evidence available through evidence-based data, ACS works to improve the quality of surgical care through the ACS National Surgical Quality Improvement Program, National Cancer Data Base, National Trauma Data Bank, and Trauma Quality Improvement Program. ACS monitors and analyzes socioeconomic, legislative, and regulatory issues affecting the practice of surgery through its Division of Advocacy and Health Policy based in Washington, DC, and the ACS Professional Association. The College participates in health policy development on these issues, prepares responses to Congress and federal agencies, and serves as a liaison between the ACS and Congress and federal agencies, as well as the offices of other surgical and medical associations regarding health policy matters of importance to surgeons and surgical patients.

The Murphy Auditorium


In 1919, the headquarters of the ACS were a former private residence at 40 East Erie Street near downtown Chicago, the Samuel M. Nickerson House. In 1923, on property adjacent to the Nickerson House, the ACS commissioned the creation of the John B. Murphy Memorial Auditorium from the architectural firm of Marshall and Fox.[6] By 2003, the organization grew larger than the space offered by these two buildings and moved to the present location at 633 N. Saint Clair. While the Nickerson House was sold and eventually founded as a museum, the Murphy Auditorium was renovated and in June 2006 reopened as an event venue open to the public. The ACS still maintains ownership of the building.

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Publications
The American College of Surgeons distributes numerous publications, including peer-reviewed journals. They include: The Bulletin of the American College of Surgeons, the monthly news magazine for its Fellows and other constituents A monthly official scientific journal, the Journal of the American College of Surgeons (JACS) ACS NewsScope, the Colleges weekly e-newsletter Surgery News, the Colleges monthly newspaper

Fictional portrayals
Membership as a Fellow of the American College of Surgeons has been the subject of many fictional or fictionalized portrayals in popular culture, including: Drs. Brackett and Early on the television series Emergency! Drs. Altman, Burke, Hahn, Hunt, Montgomery, Robbins, Shepherd, Sloan, and Webber on the television series Grey's Anatomy. Dr. Lee on the television series Addicted to Beauty. Dr. Knowles-Teller on the television series Sons of Anarchy

References
[1] http:/ / www. facs. org/ [2] American College of Surgeons Online - "What is the American College of Surgeons?" (http:/ / www. facs. org/ about/ corppro. html)

External links
Official Website (http://www.facs.org/) ACS Foundation (http://www.facs.org/acsfoundation/index.html) ACS Archives (http://www.facs.org/archives/index.html) Journal of the American College of Surgeons (http://www.journalacs.org/) ACS Professional Association (http://www.facs.org/acspa/index.html) ACS Political Contributions (opensecrets.org) (http://www.opensecrets.org/orgs/summary.php?cycle=2012& id=D000043294)

Academy of Nutrition and Dietetics

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Academy of Nutrition and Dietetics


Academy of Nutrition and Dietetics
Formation Legalstatus 1917 Foundation

Purpose/focus Nutrition Headquarters Chicago, IL, U.S. Regionserved United States Mainorgan Budget Website Board of Delgates $34 million in 2011 eatright.org [1] []

The Academy of Nutrition and Dietetics is the United States' largest organization of food and nutrition professionals, with close to 72,000 members. After nearly 100 years as the American Dietetic Association (ADA), the organization officially changed its name to the Academy of Nutrition and Dietetics (A.N.D.) in 2012.[2] The organizations members are primarily registered dietitians (RDs) and dietetic technicians as well as many researchers, educators, students, nurses, physicians, pharmacists, clinical and community dietetics professionals, consultants and food service managers.[3]

Origins
The Academy was founded in 1917 in Cleveland, Ohio, by a group of women led by Lenna F. Cooper and the Academy's first president, Lulu G. Graves, who were dedicated to helping the government conserve food and improve public health during World War I.[4] It is now headquartered in Chicago, Illinois.[5] The original mission of the Academy was in part to help make maximal use of America's food resources during wartime.[6] In its first year, the Academy attracted 58 members.[7] It remained a small organization, remaining under the 1,000 member mark until the 1930s.[7] As the group's scope expanded, so did its membership numbers. Between the 1930s and 1960s, membership skyrocketed to more than than 60,000.[7] Growth trajectory has since stabilized, and the Academy marked its 70,000th member when a female dietitian in Texas rejoined the Academy in May 2009.[7] Since its founding in 1917, the Academy has gained members in every decade.[7] In 1973, the Academy created National Nutrition Week. The theme the first year was "Invest in Yourself...Buy Nutrition.[8] On May 9, 2010, the AND proclaimed Registered Dietitian's Day to honor the indispensable providers of food and nutrition services and to recognize RDs for their commitment to helping people enjoy healthy lives.[] The association also sponsors National Nutrition Month in March in the U.S.[9] According to current Academy president Sylvia Escott Stump, the group changed their name to the Academy of Nutrition and Dietetics in 2012 to reflect the scientific and academic expertise of its members.[10]

Academy of Nutrition and Dietetics

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Finances and Organization


In 2011, the Academy had disclosed net assets of $44 million, the bulk of which was in cash and investments.[] It took in $11M in annual membership dues, and an additional $5M in registration and examination fees. In 2011, it took in $33.9 million in revenue on expenses of $34.8M for a slight operating loss of $875,000. Due to successful investments, it posted a surplus of $6M for the 2011 fiscal year and $4.6M for 2010.[] In the same year, they received $1.2 million in corporate sponsorships from companies like General Mills, Coca Cola and PepsiCo via donations, joint initiatives, and programs.[11] The Academy has offices both in Chicago and Washington DC. In addition to the Academy, the organization maintains several other organizations and entities, including the Commission on Dietetic Registration, Commission on Accreditation for Dietetics Education, Dietetic Practice Groups, Academy Political Action Committee, and Academy Foundation. There are also several member interest groups which include more than 1,600 members with common interests or specialties including Fifty Plus in Nutrition and Dietetics; Filipino Americans in Dietetics and Nutrition; Muslims in Dietetics and Nutrition; and National Organization of Blacks in Dietetics and Nutrition.[]

Academy of Nutrition and Dietetics Foundation


In 1966, the Academy established the Foundation as a 501(C)(3) public charity. According to its mission statement, the Foundation is the only charitable organization devoted exclusively to promoting good nutrition. Its mission is to advance public health and nutrition with focus on three initiatives: scholarships, Healthy Weight for Kids and food and nutrition research.[12] In 2011, the Foundation had charitable contributions and revenues of $4.23 million, of which $1.7 million went to program expenses, $540,000 went to administrative expenses, and $289,000 went to fund raising expenses. Its executive director, Mary Beth Whalen, is paid $215,000 per year. These figures earned the Foundation a 60.95/70 score by CharityNavigator.com (four stars for transparency, three stars for its financials).[12] In 2011, the Foundation received corporate contributions totaling around $1.2 million from organizations such as Nestle, Kelloggs, Mars, Inc Coca Cola and the National Cattlemen's Beef Association,[2] as well as a $500,000 donation industrial food giant General Mills to promote healthy eating for kids.[13]

Influence and positions


Through its research journal, the Academy shapes and influences the public and legislative discussion about health, food safety and nutrition. Academy RDs are regularly quoted in world publications such as New York Times, Wall Street Journal, USA Today, Los Angeles Times Mens Fitness, O Magazine, Consumer Reports, Forbes and Huffington Post. In 2010, the organization received approximately 30 billion media impressions.[14] As an organization and research institute, the Academy holds a variety of influential health positions, including: The Academy "maintains that the only way to lose weight is through a healthy, well-balanced diet and exercise."[15] The Academys stated position is that there are no good or bad foods, only good and bad diets. According to the Academy such labeling or bumpers confuse the public.[16] The Academy states that "exclusive breastfeeding provides optimal nutrition and health protection for the rst 6 months of life and breastfeeding with complementary foods from 6 months until at least 12 months of age is the ideal feeding pattern for infants."[17] The Academy "believes that up to two servings of soy per day for adults could be part of a healthy diet."[18] The Academy has stated that a "well planned vegan diet" (no meat, dairy or animal products) is appropriate and healthy for babies.[19]

Academy of Nutrition and Dietetics The Academy states that to combat the obesity epidemic, adults and children need access to healthy foods, education on eating well, and preventative health services, including counseling by registered dietitians.[20][21] They support the White House and Michelle Obamas efforts to end the childhood obesity epidemic within a generation.[22] The Academy opposed mandated labeling of "trans fats" on food packaging.[23] The Academy has given low ratings to the high-protein no-carb diet (known as the Atkins Diet), insisting that the diet is "unhealthy and the weight loss is temporary."[24] The Academy maintains that carbohydrates are not responsible for weight gain any more than other forms of calories.[25] The Academy states that children who eat breakfast have better concentration, problem-solving skills, and eye hand coordination. Children who do not eat breakfast are tired at school and eat more junk food.[26][27]

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Research and Publications


The Academy publishes position papers on public health regarding pediatric (children's) health, food technology, food safety, geriatrics (elderly) health, health-care reform, obesity and the full range of food and nutrition topics through the Journal of the Academy of Nutrition and Dietetics (ANDJ). Considered the premier scholarly nutritional journal, it is a monthly peer-reviewed publication involved in the dietetics field, with original research, critical reviews, and reports on dietetics and human nutrition.[28] In 2012, its name changed along with the organization, becoming the "Journal of the Academy of Nutrition and Dietetics."[28] The Academy has also published 3 editions of the bestselling, award-winning 668-page book American Dietetic Association Complete Food and Nutrition Guide.[29] Through its publishing arm, the Academy has published such books and guides as Easy Gluten-Free, ADA Pocket Guide to Eating Disorders, ADA Pocket Guide to Lipid Disorders, Hypertension, Diabetes and Weight Management, ADA Quick Guide to Drug-Supplement Interactions and Making Nutrition Your Business.[] It also maintains the site eatright.org. In the 1980s, the Academy published the magazine Food/2 which had originally been created by the Department of Agriculture. In response pressure from meat, egg, and dairy industries, the Department of Agriculture decided not publish it, after which the Academy negotiated with the government to publish it itself, omitting the controversial chapters on fat and cholesterol.[30] The decision was widely criticized, with participating dietitians stating "it is just incredible that they would publish it without the most important part."[30]

Certification
The AND certification process offers two career options: Registered Dietitian (RD) and Dietetic Technician, Registered (DTR). Both are educated nutrition professionals qualified to work in hospitals, academia and private practice, and differ mostly in the hours of training and level of college degree required. A Registered Dietitian must complete a bachelor's degree or higher and more than 900 hours of training, while a Dietetic Technician is required to complete and associate level degree and 450 hours of training.[31] About 72% of the ANDs members are Registered Dietitians, and 2% are Dietetic Technicians.[3] Members are granted these accredited titles by fulfilling the ANDs strenuous certification requirements in addition to any state or local regulations. Through its ADAF foundation, the AND issued nearly $500,000 in certification scholarships in 2011, $100,000 of which went to doctoral students.[] The terms Registered Dietitian and Dietetic Technician are legally protected titles and can be used only by someone who has completed coursework approved by the AND.[32] In recent years, the AND has lobbied for stricter regulation over the professional licensing of dietitian and nutrition professionals and supported state regulations that would include heavy fines for the dispensing of nutritional advice without the proper license.[33][34] AND's Commission on Accreditation for Dietetics Education (CADE) is the organizations accrediting agency for education programs that prepare individuals for careers as dietetics professionals. In 2011, CADE changed its name

Academy of Nutrition and Dietetics to Accreditation Council for Education in Nutrition and Dietetics (ACEND).[35] The Accreditation Council is recognized by the Department of Education and is a member of the Association of Specialized and Professional Accreditors. The councils fees earn the AND about $1.1 million per year.[36]

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Registered Dietitian (RD)


According to the AND, a Registered Dietitian is a is a food and nutrition expert who has fulfilled the minimum requirements for the titled RD.[31] Requirements include the following items: Earning a bachelors degree with course work approved by ANDs Commission on Accreditation for Dietetics Education. Coursework typically includes food and nutrition sciences, foodservice systems management, business, economics, computer science, sociology, biochemistry, physiology, microbiology and chemistry. Completing an accredited, supervised practice program at a health-care facility, community agency or foodservice corporation. Passing a national examination administered by the Commission on Dietetic Registration. Completing continuing professional educational requirements to maintain registration. In addition to the costs of the college coursework, the AND charges a $200 application fee for registered dietitians.[37] Students must complete a 1,200 hour internship to sit for the Registered Dietitian exam.[38] Approximately 50% of RDs hold advanced degrees. Some RDs also hold additional certifications in specialized areas of practice, such as pediatric or renal nutrition, nutrition support and diabetes education.[3] In addition to any AND requirements (and often with some overlap), many states have laws for dietitians and nutrition practitioners.[39]

Dietetic Technician, Registered (DTR)


According to the AND, DTRs are a food and nutrition practitioner who has fulfilled the minimum requirements for the title DTR.[31] These requirements, while similar to an RD, differ in that they require: A minimum of an Associate's degree. At least 450 hours of supervised practice accredited by CADE. Successful pass a national DTR examination administered by CDR. Complete continuing professional educational requirements to maintain registration.

DTRs typically work closely with RD in numerous employment settings such as hospitals, health care facilities, private practice, day care centers, correctional facilities and weight loss centers.[31] The AND application fee to become an DTR is $120.[40]

Lobbying efforts and competitive protections


To help better communications with the US government, the AND has offices in Washington, DC. They also operate their own political action committee, the AND Political Action Committee.[] The AND spent $5.8 million lobbying at the state and national level from 2000-2010.[41] A 1985 report noted the AND has supported licensing for dispensing nutritional advice.[42] In addition to supporting legislation regulating the professional nutrition field in states like Colorado, Wyoming, Hawaii, New Jersey and New York, the AND has also applied for patents for its certification titles such as: Certified Nutrition Coach, Certified Nutrition Professional, Registered Nutrition Professional, and Certified Nutrition Educator.[33][43] The AND states that by regulating who can provide nutritional counseling, they can protect their registered members and the public from unregulated advice or possibly inaccurate advice from less qualified dietary practitioners such as chiropractors, yoga instructors, homeopaths, and personal trainers.[33] The ANDs support of this legislation has

Academy of Nutrition and Dietetics generated strong opposition from alternative health practitioners and libertarian groups, who state that "highly restrictive bills could create a monopoly for one school of traditional nutrition thought" and that the primary intent of the bill is "not to protect the public, but to give clout and recognition to a single segment of dietitians, increasing their chances of obtaining reimbursement from insurance companies."[33][42]

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Kids Eat Right


AND and the ADA Foundation launched their first joint initiative, Kids Eat Right, in November 2010. This member-driven campaign is dedicated to supporting the efforts of the White House to end the childhood obesity epidemic within a generation.[22] Kids Eat Right is a two-tiered campaign aimed to mobilize AND members to participate in community and school childhood obesity prevention efforts, and also to educate families, communities, and policy makers about the importance of quality nutrition. Kids Eat Right has a website that gives families healthy eating tips, articles, videos, and recipes from registered dietitians.[44] Kids Eat Right also has scientifically-based health information centered around the theme "Shop-Cook-Eat" which has information about how to shop for healthy foods, how to cook foods with the most nutrient value, and gives the benefits of eating together at home and away from home.[45]

Controversy
The AND has been criticized for its connections to the pharmaceutical industry, including an inquiry from Senator Chuck Grassley.[46][47] In 1982, the organization faced mass resignations from members over a decision to support President Ronald Reagans cuts in food stamps and school lunch programs.[30] The decision was largely a political trade-off; the Reagan administration agreed to drop its proposal to deregulate nursing homes in exchange for the ANDs support of the school lunch and food stamp cuts.[30]

Criticism of partnerships with food companies


A 1995 report noted the AND received funding from companies like McDonald's, PepsiCo, The Coca Cola Company, Sara Lee, Abbott Nutrition, General Mills, Kellogg's, Mars, McNeil Nutritionals, SOYJOY, Truvia, Unilever, and The Sugar Association as corporate sponsorship.[16] The AND also partners with ConAgra Foods, which produces Orville Redenbacker, Slim Jims, Hunts Ketchup, SnackPacks, and Hebrew National hot dogs, to maintain the American Dietetic Association/ConAgra Foods Home Food Safety...It's in Your Hands program.[48] Additionally, the AND earns revenue from corporations by selling space at its booth during conventions, doing this for soft drinks and candy makers.[16][49] In April 2013, a dietitian working on a panel charged with setting policy on genetically modified foods for the academy contended she was removed for pointing out that two of its members had ties to Monsanto, one of the biggest makers of genetically modified seeds.[50] The resulting controversy highlighted the fact that Ms. Smith Edge, chairwoman of the committee charged with developing the GMO policy, is a senior vice president at the International Food Information Council, which is largely financed by food, beverage and agriculture businesses, including companies like DuPont, Bayer CropScience and Cargill, companies that were among the biggest financial opponents of a State of California GMO labeling initiative.[51] The AND maintains that being at the "same table" with food companies is important in order to exert a positive influence over their products and message, although critics describe this as an unhealthy alliance between the AND and junk food companies.[49][] The accusation is that despite what good may come of such programs, it ultimately whitewashes (similar to the greenwashing efforts of environmentally irresponsible companies) the brands role in the countrys food ecosystem. Watchdogs note that the AND rarely criticizes food companies, believing it to be out of fear of "biting the hand that feeds them."[52][53][54] Nutrition expert Marion Nestle opined that she believed that as

Academy of Nutrition and Dietetics long as the AND partners with the makers of food and beverage products, its opinions about diet and health will never be believed [to be] independent.[49] A 2011 survey found that 80% of Academy members are critical of the Academy's position. They believe that the Academy is endorsing corporate sponsors and their products when it allows their sponsorship.[55]

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Additional publications
The Journal of the Academy of Nutrition and Dietetics (JADA)[56] is a monthly peer-reviewed publication involved in the dietetics field, with original research, critical reviews, and reports on dietetics and human nutrition.

References
[1] [2] [3] [4] http:/ / eatright. org Eat Right (http:/ / www. eatright. org/ ). Academy of Nutrition and Dietetics. Who We Are and What We Do (http:/ / www. eatright. org/ About/ Content. aspx?id=7530). Eat Right. Barber, Mary I. History of the American Dietetic Association, 1917-1959 (http:/ / books. google. com/ books/ about/ History_of_the_American_Dietetic_Associa. html?id=GIw_AAAAYAAJ). Lippincott: 1959. [5] Mayer, Jean and Dr. Johanna Dwyer. Careers in Dietetics (http:/ / news. google. com/ newspapers?id=L90NAAAAIBAJ& sjid=M20DAAAAIBAJ& pg=4967,3418792& dq=american+ dietetic+ association& hl=en). Pittsburgh Post-Gazette. February 27, 1978. [6] Foer, Jonathan Safran. Food industry dictates nutrition policy (http:/ / edition. cnn. com/ 2009/ OPINION/ 10/ 30/ eating. meat. jonathan. foer/ index. html). CNN. October 30, 2009. [7] American Dietetic Association Reaches Membership Milestone, Surpassing 70,000 Members for the First Time (http:/ / www. eatright. org/ Media/ content. aspx?id=1254). Eat Right. April 7, 2009. [8] Diatetic Association tells of Natl Nutrition Week (http:/ / news. google. com/ newspapers?id=iVgzAAAAIBAJ& sjid=WlIDAAAAIBAJ& pg=5360,4029238& dq=american+ dietetic+ association& hl=en). The Bryan Times. March 2, 1973. [9] Grotto, Dave. National Nutrition Month: Dave Grotto (http:/ / www. usatoday. com/ community/ chat/ 2002-03-21-grotto. htm). USA Today. January 21, 2005. [10] Stein, Jeannine. The American Dietetic Assn. gets a new name (http:/ / articles. latimes. com/ 2012/ jan/ 04/ news/ la-heb-american-dietetic-association-name-change-20120103). The Los Angeles Times. January 4, 2012. [11] pg. 7: ADA Parnters: ARAMARK, The Coca-Cola Company, Hershey Center for Health & Nutrition, National Dairy Council. Premier Sponsors: Abbott Nutrition, CoroWise brand, General Mills, Kellogg Company, Mars, Incorporated, McNeil Nutritionals, LLC, PepsiCo, SOYJOY, Truvia natural sweetener, Unilever. 2010 FNCE Event Sponsors: Campbell Soup Company, Chobani, ConAgra Foods, Nature Made, Safeway, Target [12] American Dietetic Association Foundation (http:/ / www. charitynavigator. org/ index. cfm?bay=search. summary& orgid=8467). Charity Navigator. [13] General Mills Partners With American Dietetic Association To Help Kids Adopt Healthy Eating And Exercise Habits (http:/ / www. thestreet. com/ story/ 10789235/ 1/ general-mills-partners-with-american-dietetic-association-to-help-kids-adopt-healthy-eating-and-exercise-habits. html?cm_ven=GOOGLEFI). The Street. June 22, 2010. [14] pg. 2: Coverage of ADA totaled more than 30 billion media impressions, including stories in the New York Times, Wlal Street Journal, USA Today, Los Angeles Times and Chicago Sun-Times. Consumer magazine coverage of ADA appeared in Men's Fitness, O Magazine, Consumer Reports, US News & World Report, Prevention, Self, Forbes, and Huffington Post, among others. [15] The American Dietetic Association maintains that the only way to lose weight is through a healthy, well-balanced diet and exercise (http:/ / news. google. com/ newspapers?id=bLtNAAAAIBAJ& sjid=Uf0DAAAAIBAJ& pg=4799,6361178& dq=american+ dietetic+ association& hl=en). Lakeland Ledger. October 20, 1999. [16] Groups Pursuit of Cash Draws Fire (http:/ / news. google. com/ newspapers?id=rW8aAAAAIBAJ& sjid=Ei0EAAAAIBAJ& pg=6759,219809& dq=american+ dietetic+ association& hl=en). Milwaukee Journal Sentinel. December 6, 1995. [17] Position of the American Dietetic Association: Promoting and Supporting Breastfeeding (http:/ / www. cdphe. state. co. us/ ps/ bf/ Resources/ American Dietetic Assocation SupportingPromotingBreastfeeding TAB 2. pdf). American Dietetic Association. November 2009. [18] Eng, Monica. Soy in Illinois prison diets prompts lawsuit over health effects (http:/ / articles. chicagotribune. com/ 2009-12-21/ news/ 0912200121_1_soy-protein-soy-cheeses-soyfoods-association). Chicago Tribune. December 21, 2009. [19] Planck, Nina. A Choice With Definite Risks (http:/ / www. nytimes. com/ roomfordebate/ 2012/ 04/ 17/ is-veganism-good-for-everyone/ a-choice-with-definite-risks). The New York Times. April 17, 2012. [20] Spector, Kaye. Motivation, information needed to combat obesity, American Dietetic Association says (http:/ / www. cleveland. com/ healthy-eating/ index. ssf/ 2010/ 06/ motivation_information_needed_to_combat_obesity_american_dietetic_association_says. html). Cleveland Live. June 30, 2010. [21] Obesity (http:/ / www. eatright. org/ Public/ content. aspx?id=5549). Eat Right.

Academy of Nutrition and Dietetics


[22] ADA Supports Michelle Obama's Childhood Obesity Initiative (http:/ / www. eatright. org/ Public/ content. aspx?id=4294967969). Eat Right. [23] Squires, Sally. FDA Wants Food LabelsTo List Trans Fatty Acids (http:/ / pqasb. pqarchiver. com/ washingtonpost/ access/ 46329006. html?dids=46329006:46329006& FMT=ABS& FMTS=ABS:FT& type=current& date=Nov+ 13,+ 1999& author=Sally+ Squires& pub=The+ Washington+ Post& desc=FDA+ Wants+ Food+ LabelsTo+ List+ Trans+ Fatty+ Acids& pqatl=google). The Washington Post. November 13, 1999. "This is one more thing on the food label," said Connie Diekman, a national spokeswoman for the American Dietetic Association, which opposes the regulation [24] Low-carb, high-protein diets popular, but not with adults (http:/ / news. google. com/ newspapers?id=YQVBAAAAIBAJ& sjid=YKgMAAAAIBAJ& pg=6607,3286289& dq=american+ dietetic+ association& hl=en). Harlan Daily Enterprise. November 3, 1999. [25] Question of the Day: Do Carbohydrates Cause Weight Gain? (http:/ / www. eatright. org/ Public/ content. aspx?id=10645) Eat Right. [26] Start Your Day with Greatness - Inland Valley News (http:/ / www. inlandvalleynews. com/ 2012/ 08/ 15/ start-your-day-with-greatness/ ) [27] Dietitians prime parents on nutrition before start of school | The Columbus Dispatch (http:/ / www. dispatch. com/ content/ stories/ food/ 2012/ 08/ 15/ 1-backtoschool-art-ga6io1o1-1. html) [28] Journal of American Dietetic Association becomes Journal of the Academy of Nutrition and Dietetics (http:/ / phys. org/ wire-news/ 88949712/ journal-of-american-dietetic-association-becomes-journal-of-the. html). Phys Org. January 25th, 2012. [30] MAGAZINE WITHHELD BY U.S. MAY REVIVE (http:/ / www. nytimes. com/ 1982/ 05/ 19/ garden/ magazine-withheld-by-us-may-revive. html). The New York Times. May 19, 1982. [31] Frequently Asked Questions (http:/ / www. llu. edu/ allied-health/ nutrition/ faqs. page). What is the difference between a Registered Dietitian (RD) and a Dietetic Technician Registered (DTR) and what career opportunities are available for each? (Information is provided by the Academy of Nutrition and Dietetics (AND) FAQs web page) [32] What is the difference between a registered dietitian or dietetic technician, registered, and a nutritionist? (http:/ / www. eatright. org/ ACEND/ content. aspx?id=146#Mike_1) EatRight.org. Registered dietitian or RD and dietetic technician, registered or DTR can only be used by dietetics practitioners who are currently authorized to use the credential by the Commission on Dietetic Registration of the Academy of Nutrition and Dietetics. These are legally protected titles. Individuals with these credentials have completed specific academic and supervised practice requirements, successfully completed a registration examination and maintained requirements for recertification. [33] Ellsberg, Michael. Is the American Dietetic Association Attempting to Limit Market Competition in Nutrition Counseling? (http:/ / www. forbes. com/ sites/ michaelellsberg/ 2012/ 04/ 05/ american-dietetic-association/ ) Forbes. April 5, 2012. [34] Full Text of SB2936 (http:/ / www. ilga. gov/ legislation/ fulltext. asp?DocName=& SessionId=84& GA=97& DocTypeId=SB& DocNum=2936& GAID=11& LegID=63811& SpecSess=& Session=). Illinois General Assembly. [35] About ACEND (http:/ / www. eatright. org/ ACEND/ ). Eat Right. [36] Commission on Accredation for Dietetics Education (CADE). Education Program: 1,193,009 [37] National Requirements to Become a Registered Dietitian from the American Dietetic Associations (ADA) Commission on Dietetic Registration (CDR) (http:/ / www. nutritionist-world. com/ ADA_registered_dietitian_regs. html). Nutritionist World. [38] Graduates cooking up new ways to utilize degrees in dietetics - Chicago Tribune (http:/ / articles. chicagotribune. com/ 2012-08-07/ special/ chi-adveducation-dietetics-20120807_1_dietetics-nutrition-world-degree-program) [39] What Is the Academy of Nutrition and Dietetics? (http:/ / www. eatright. org/ Media/ content. aspx?id=6442467510). Eat Right. [40] National Requirements to Become a Registered Dietitian from the American Dietetic Associations (ADA) Commission on Dietetic Registration (CDR) (http:/ / www. nutritionist-world. com/ ADA_registered_dietitian_regs. html). Loma Linda University. [41] American Dietetic Assn (http:/ / www. opensecrets. org/ lobby/ clientsum. php?id=D000023948& year=2010). Open Secrets. [42] Sugarman, Carole. "Licensing Nutrition Advisers." The Washington Post via LexisNexis (http:/ / www. lexisnexis. com). May 5, 1985. "And they want to make it illegal for individuals to offer nutrition advice without proper credentials [...] According to Catherine Babington, director of government affairs of the American Dietetic Association, dietitians in 36 states are pursuing mandatory licensure, although details of the proposed laws vary from state to state. A bill awaits the governor's signature in Maryland, while dietetic associations in Virginia and the District of Columbia are in the beginning stages of drafting such bills. [...] Opponents such as the National Health Federation, chaired by Donsbach, and the National Nutritional Foods Association, which represents more than 3,500 health food stores, contend that highly restrictive bills could create a monopoly for one school of traditional nutrition thought, limiting the free market and consumer choice, and that their primary intent is not to protect the public, but to give clout and recognition to a single segment of dietitians, increasing their chances of obtaining reimbursement from insurance companies." [43] RD Licensure (http:/ / www. wyomingdieteticassociation. com/ rd_licensure. asp). Wyoming Dietetic Association. [44] School's Out! Help Your Kids Eat Right All Summer Long (http:/ / www. newswise. com/ articles/ school-s-out-help-your-kids-eat-right-all-summer-long). NewsWire. May 24, 2011. [45] Kids Eat Right - About Kids Eat Right (http:/ / www. eatright. org/ kids/ content. aspx?id=6442459728) [46] Grassley renews call for voluntary disclosure by influential disease and medical advocacy groups (http:/ / www. grassley. senate. gov/ news/ Article. cfm?customel_dataPageID_1502=34350). Senator Chuck Grassley of Iowa. May 5, 2011. [47] American Dietetic Association (http:/ / www. propublica. org/ documents/ item/ 87299-american-dietetic-association). Propublica. December 18, 2009. [48] Timely Turkey Tips from Buying to Baking; American Dietetic Association/ConAgra Foods offer Home Food Safety Help for Thanksgiving Cooks (http:/ / www. businesswire. com/ news/ home/ 20051110005755/ en/ Timely-Turkey-Tips-Buying-Baking-American-Dietetic). Business Wire. November 10, 2005.

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[49] Nestle, Marion. The ADA and Corporate Sponsors: An Unhealthy Alliance? (http:/ / www. thedailygreen. com/ healthy-eating/ blogs/ healthy-food/ marion-nestle-ADA-politics-44031808). The Daily Green. March 18, 2008. [50] http:/ / www. nytimes. com/ 2013/ 04/ 11/ business/ a-dismissal-raises-questions-about-objectivity-on-food-policy. html [51] http:/ / www. motherjones. com/ tom-philpott/ 2013/ 04/ gmo-dieticians-monsanto-california [53] Who Is the Dairy Coalition? PR Watch.org (http:/ / www. prwatch. org/ prwissues/ 2000Q4/ dairy. html). [54] American Dietetic Association at SourceWatch (http:/ / www. sourcewatch. org/ index. php?title=American_Dietetic_Association). [55] An Error Occurred Setting Your User Cookie (http:/ / www. tandfonline. com/ doi/ abs/ 10. 1080/ 19320248. 2012. 704748#preview) [56] Journal of the American Dietetic Association (JADA) (http:/ / www. adajournal. org)

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External links
American Dietetic Association (http://www.eatright.org) official site American Dietetic Association (http://adajournal.org) official peer-reviewed journal American Dietetic Association Foundation (http://eatright.org/foundation)

American Dental Association

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American Dental Association


American Dental Association
Formation Type Headquarters Location Membership 1859 Professional association Chicago, Illinois United States 159,000

Officiallanguages English President Key people Staff Website Dr. Robert A. Faiella William Henry Atkinson (Founder) 400 ada.org [1]

The American Dental Association (ADA) is an American professional association established in 1859 which has more than 155,000 members. Based in the American Dental Association Building in the Near North Side of Chicago,[2] the ADA is the world's largest and oldest national dental association and promotes good oral health to the public while representing the dental profession. The ADA publishes a monthly journal of dental related articles named the Journal of the American Dental Association.

Overview
The ADA was founded August 1859, at Niagara Falls, New York, by twenty-six dentists who represented various dental societies in the United States. Today, the ADA has more than 152,000 members, 55 constituent (state-territorial) and 545 component (local) dental societies. It is the largest and oldest national dental association in the world and is committed to both the public and the dental profession. The Association has more than 400 employees at its headquarters in Chicago and its office in Washington, D.C. The Paffenbarger Research Center (PRC), located on the campus of the National Institute of Standards and Technology (NIST) in Gaithersburg, Maryland, an agency of the American Dental Association Foundation (ADAF) and a Department of the Division of Science. PRC scientists conduct basic and applied studies in clinical research, dental chemistry, polymer chemistry and cariology, and are the crown jewels of the ADA. The ADA established rigorous guidelines for testing and advertising of dental products and the first ADA Seal of Acceptance was awarded in 1931. Today, about 350 manufacturers participate in the voluntary program and more than 1300 products have received the Seal of Acceptance. The Board of Trustees, the administrative body of the Association, is composed of the President, the President-elect, two Vice Presidents and 17 trustees from each of the 17 trustee districts in the United States. The Treasurer and Executive Director serve as ex officio members. The House of Delegates, the legislative body of the Association, is composed of 460 delegates representing 53 constituent societies, five federal dental services and the American Student Dental Association. The House meets once a year during the Association's annual session. The Association's 11 councils serve as policy recommending agencies. Each council is assigned to study issues relating to its special area of interest and to make recommendations on those matters to the Board of Trustees and the House of Delegates.

American Dental Association The Association's official publication is The Journal of the American Dental Association. Other publications include the ADA News and the ADA Guide to Dental Therapeutics. The Commission on Dental Accreditation, which operates under the auspices of the ADA, is recognized by the U.S. Department of Education as the national accrediting body for dental, advanced dental and allied dental education programs in the United States. It is also recognized by 47 individual states. The ADA formally recognizes 9 specialty areas of dental practice: dental public health, endodontics, oral and maxillofacial pathology, oral and maxillofacial surgery, orthodontics and dentofacial orthopedics, pediatric dentistry, periodontics, prosthodontics, and oral and maxillofacial radiology. The ADA library has an extensive collection of dental literature with approximately 33,000 books and 17,500 bound journal volumes. The ADA library also subscribes to more than 600 journal titles. The ADA Foundation is the charitable arm of the Association. The Foundation provides grants for dental research, education, scholarships, access to care and charitable assistance programs such as relief grants to dentists and their dependents who are unable to support themselves due to injury, a medical condition or advanced age; and grants to those who are victims of disasters.

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Advocacy
The ADA advocates several positions to legislators in the U.S. Congress. Its agenda includes funding dental research into the safety and effectiveness of amalgam and fluoride, supporting student loans and residency programs for future dentists, increased dental coverage from Medicaid and CHIP programs, reducing dental costs through reform of insurance and medical liability and through health information technology, and improving public health through water fluoridation, tobacco control, and disaster planning and response.[3]

Advertising
Dudley the Dinosaur is an advertising character from the ADA. He's an anthropomorphic T. rex. He lives with his mom, little sister Dee Dee, Grandpa, and baby brother Digby. His friends are other dinosaurs and prehistoric creatures like mammoths and saber tooth tigers. He, his friends, and family teaches children how to have healthy teeth and good oral hygiene in the form of a cartoon character. The character Dudley the Dinosaur was hatched in winter of 1991 and became the nation's first bilingual (English and Spanish) public service campaign for kids. Dudley has appeared in numerous public service announcements on TV, a dozen National Children's Dental Health Month Campaigns, several coloring books and patient education booklets, four animated shorts produced by the ADA and on 2,500 outdoor billboards around the country. Dudley has won over 100 major awards, appeared on mugs and as a doll. He stars in comic books and DVDs available from the ADA.

Significant events
1840: First dental college, the Baltimore College of Dental Surgery; The American Society of Dental Surgeons (ASDS) is established. 1845: American Society of Dental Surgeons ask members to sign a mandatory pledge promising not to use mercury amalgam fillings. 1856: American Society of Dental Surgeons, because of its stance against dental amalgam, is disbanded in 1856 due to loss of membership. 1859: Twenty-six dentists meet in Niagara Falls, New York to form a professional society. 1860: First ADA constitution and bylaws are adopted. 1897: ADA merges with the Southern Dental Association to form the National Dental Association (NDA). 1908: NDA publishes the first patient dental education pamphlet.

American Dental Association 1913: NDA adopts a new constitution and bylaws, establishing the House of Delegates and Board of Trustees. 1913: The Journal of the National Dental Association is first published under the title, Bulletin of the National Dental Association 1922: NDA is renamed the American Dental Association (ADA). 1928: ADA affiliates with the NBS; National Board of Dental Examiners is established. 1930: Council of Dental Therapeutics established to oversee the evaluation of dental products. The Council establishes the ADA's Seal Program. 1931: First ADA Seal of Approval awarded; ADA headquarters located on north side of Chicago. 1936: ADA Council on Dental Education is formed. 1948: The National Institute of Dental Research (NIDR) is established (since renamed the NIDCR (National Institute of Dental and Craniofacial Research)). 1950: ADA works with Congress to proclaim February 6 as National Children's Dental Health Day; ADA endorses fluoridation. 1964: ADA produces the first color television Public Service Announcement by a non-profit health agency; ADA establishes the ADA Health Foundation, a501 (c)(3) non-profit organization for the purpose of engaging in dental health research and educational programs. 1970: ADA News is first published. 1978: Council on Dental Practice established. 1979: The Commission on Dental Accreditation established. 1987: ADA Commission on the Young Professional is formed (later becomes the Committee on the New Dentist). 1991: First female ADA president, Dr. Geraldine Morrow. 1995: ADA Web site, ADA ONLINE, created (later becomes ADA.org) 2002: First minority ADA president, Dr. Eugene Sekiguchi (he is Japanese-American). 2003: First Give Kids a Smile day held as part of National Childrens Dental Health Month. 2009: First female ADA executive director, Dr. Kathleen O'Loughlin.

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References
[1] http:/ / www. ada. org/ [2] " Contact Us (http:/ / www. ada. org/ 22. aspx)." American Dental Association. Retrieved on December 23, 2011. "211 East Chicago Ave. Chicago, IL 60611-2678"

External links
"American Dental Association website" (http://www.ada.org).

American Diabetes Association

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American Diabetes Association


American Diabetes Association
Founded 1940

Headquarters Alexandria, Virginia, U.S. Key people Larry Hausner, Chief Executive Officer Karen Talmadge, Chair of the Board To prevent and cure diabetes and improve the lives of all people affected by diabetes. http:/ / www. diabetes. org

Mission Website

The American Diabetes Association (ADA) is a United States-based association working to fight the consequences of diabetes and to help those affected by diabetes. The Association funds research to manage, cure and prevent diabetes (including type 1 diabetes, type 2 diabetes, gestational diabetes, and pre-diabetes); delivers services to hundreds of communities; provides information for both patients and health care professionals; and advocates on behalf of people denied their rights because of diabetes.[1] In 2011 it was estimated that 25.8 million Americans have diabetes, and another 79 million have prediabetes.[1]

History and mission


Formed in 1940, the ADA was founded by 28 physicians.[2] During its first 30 years, the Association limited its membership to physicians, health professionals and corporations. In 1970, the Association underwent a reorganization during which membership was expanded to include general members. Now the ADA is a volunteer-driven organization based in Alexandria, Virginia, with about 90 local offices across the United States.[3] The mission of the ADA is to prevent and cure diabetes and to improve the lives of all people affected by diabetes.[1] To fulfill this mission, the Association funds research, publishes scientific findings, provides information and other services to people with diabetes, their families, health professionals and the public. The Association is also actively involved in advocating for scientific research and for the rights of people with diabetes.[1] The Association acts on its mission through a number of critical programs and activities that are directed to a broad range of constituents, including consumers, research scientists, health care professionals, corporations and communities. In 1994, the Chronicle of Philanthropy, an industry publication, study showed that the American Diabetes Association was ranked as the 18th "most popular charity/non-profit in America" from over 100 charities researched with 33.8% of Americans over the age of 12 choosing Love and Like A Lot for the American Diabetes Association.[4]

Fund-raising
The ADA is America's leading 501(c)3 nonprofit charity providing diabetes research, information and advocacy.[5] The ADA raises most monies themselves and their overall fundraising expenses are 27%, with 73 cents of every dollar raised being used for research and programs.[6] However, they engage telemarketers at very large costs in order to bring new donors into their rolls. In one instance, the ADA entered into contract with InfoCision, a telemarketing firm that works closely with nonprofits, whereby only 15% of the expected funds raised would be given to the ADA with the other 85% being kept by the telemarketing firm. Furthermore, the telemarketers are instructed to lie to prospective donors regarding how much of their donation will go to the ADA.[7] When questioned by NBC's Lisa Myers about this campaign, a representative from the ADA expressed no regrets saying in part that "this program is a teenie weenie part of what they do; it's about bringing more people into the organization," and

American Diabetes Association stating that the program was not misleading despite the fact that prospective donors are being lied to regarding what percentage of their donation will be going to the ADA. As for what the ADA's response would be to donors who feel duped, the representative said that the ADA would say "thank you for the gift, it's making a difference, every single penny makes a positive impact." [8]

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Research
ADA-funded research
The ADA Research Program supports basic and clinical diabetes research aimed at preventing, treating, and curing diabetes. The diabetes research projects the Association supports cover the spectrum from islet cell biology and transplantation techniques, to studies in education and behavioral issues.[9] The Association has increased support for diabetes research from providing $18million in 1999 to making $34.6 million available for diabetes research in 2012.[10] The ADAs research funding program is designed to complement the National Institutes of Health (NIH) diabetes research program by supporting new investigators and new research ideas.[10] With support from the Association, investigators are often able to prove that their ideas are solid enough to get more substantial funding from the United States federal government.[10]

Research Foundation
Founded in October 1994, the ADA Research Foundation (also a 501(c)3 nonprofit) was created to substantially accelerate the Association's ability to raise major gifts to directly fund diabetes research.[11] The mission of the Research Foundation is to ensure the availability of funds necessary for the full exploration of all the scientific possibilities that diabetes research is generating.[11] Donations contributed to the Research Foundation help support more than 406 awards at more than 164 research institutions across the country, all working toward a day without diabetes. All non-research costs associated with the Research Program are paid through the Association's general fund.[11]

Scientific Sessions
Every year the ADA hosts the worlds largest scientific and medical diabetes meeting.[12] This meeting, known as Scientific Sessions, brings together thousands of clinicians, researchers, scientists and other medical professionals from all 50 states and 111 countries for five days of sessions, oral presentations, poster presentations and exhibits.[13]

Programs and activities


Center for Information and Community Support
On average, each year more than 300,000 people contact the Association with questions and concerns, or to seek support or direction regarding diabetes and its management.[14] In 2011, the Center for Information and Community Support (previously named the National Call Center) fielded an average of 20,000 calls per month. The Center for Information and Community Support is a free service staffed by highly-trained personnel, who answer non-medical questions in English or Spanish. Call Center hours of operation are Monday Friday, 8:30am to 8pm eastern time, with an automated phone system including basic information 24 hours a day, 7 days a week at 1-800-DIABETES (800-342-2383).[14] In 2009, the Center began to use online chat as a new means of communication with people who have questions about diabetes.[15]

American Diabetes Association

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Family Link
The ADA's Family Link program provides information to families about living with diabetes and managing diabetes at school, and links them to other families who are also living with diabetes.[16] With message boards, local Family Link events,[17] tool kits for families of children newly diagnosed with diabetes, parent-to-parent mentor programs, school initiatives that advocate and train safety at school,[18] and a safe online social networking site exclusively for youth with diabetes called Planet D,[19] Family Link provides comprehensive support.[16] The American Diabetes Association also provides diabetes camps nationwide and is the largest provider of diabetes camps in the world.[20]

Community initiatives
The ADA offers programs and resources specially designed to target high-risk communities, including African-American, Hispanic and Latino American, Native American, Asian American and Pacific Islander communities.[21] There are also programs for the workplace and in the neighborhood, as well as events and programs that are run by local offices.[22]

Events
Step Out: Walk to Stop Diabetes
Step Out: Walk to Stop Diabetes is the ADA's largest fund-raising event. Most walks take place in the fall, with more than 150 walks taking place in over 100 markets around the United States in 2009.[23][24] It raises about $20million annually.[25]

Tour de Cure
Tour de Cure is a series of fund-raising cycling events held in 40 states nationwide to benefit the ADA.[26] The Tour is a ride, not a race, with routes designed for everyone from the occasional rider to the experienced cyclist. In 2009, Tour de Cure events across the nation began to recognize participants who have diabetes by awarding them with red shirts or cycling jerseys to signify that they are Red Riders.[27]

Diabetes EXPO
Diabetes EXPO is a one-day tradeshow-like exposition for people with diabetes providing an array of diabetes-related products, services and information. In 2009, 21 Diabetes Expos have taken place or are planned in major markets throughout the United States.[28]

School Walk for Diabetes


School Walk for Diabetes is a K-12 educational school fundraising program that promotes healthy living, school spirit and community involvement. While raising money for the ADA, students learn about diabetes and the importance of making healthy choices including eating nutritious foods and exercising every day.[29]

BAD Ride
The Bikers Against Diabetes (BAD) Ride is a motorcycle fund-raising ride and family festival of the ADA.[30] This event brings bikers together to support the search for a cure for diabetes, with a full day of riding, entertainment, food and many other activities.

American Diabetes Association

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Father of the Year


Since 1999, the ADA has partnered with the National Father's Day Council to host the Father of the Year Awards dinner. Each year, approximately 80 men from across the nation are recognized for the outstanding strength, commitment and love they exhibit as fathers.[31]

Advocacy
Advocacy plays an integral role in the Association's efforts to fulfill its mission. Diabetes Advocates around the country work to increase funding to prevent, treat and cure diabetes; to improve access to health care; and to eliminate discrimination against people with diabetes at school, work or elsewhere in their lives.[32]

Discrimination
The ADA builds networks, hosts workshops, and engages with its volunteers to fight discrimination based on diabetes. This includes discrimination in school, in the workplace, obtaining private and commercial driver's licenses, in public accommodation settings and correctional institutions.[33] The ADA also works to improve access of diabetes patients to insulin by lobbying for non-medical professionals to be allowed to administer insulin (after receiving basic training), which has put it at odds with the American Nurses Association.

Federal government advocacy and state legislation


The Associations advocacy efforts span a broad range of issues that may or may not vary depending on geographic location. Advocacy initiatives include but are not limited to research funding, health care costs and reform, prevention initiatives and discrimination.[34][35]

Call to Congress
The Associations Call to Congress is a biennial event. Diabetes advocates from across the United States congregate in Washington, D.C. to meet with their U.S. Representatives and senators and discuss how diabetes affects their lives.[36] At the same time, advocates who are not able to come to Washington, D.C. participate in a call-in campaign directed toward members of Congress.[37] The next Call to Congress will take place from March 5 to March 7, 2013, in Washington, D.C.

Awareness campaigns
American Diabetes Month
November is American Diabetes Month, a time to bring even greater awareness and attention to the seriousness of diabetes, its deadly complications, and the importance of proper diabetes control. Throughout the month, the ADA conducts activities and encourages others across the country to get involved in efforts to raise awareness about diabetes.[38]

American Diabetes Alert Day


The American Diabetes Alert Day is an annual one-day "wake-up" call to inform the American public about the seriousness of diabetes. Observed each year on the fourth Tuesday of March, Alert Day is a time when the ADA encourages people to take the Diabetes Risk Test and find out if they, or their loved ones, are at risk for developing type 2 diabetes.[39]

American Diabetes Association

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Publications
The ADA works with experts to publish a variety of informational books, magazines and journals for both medical professionals and consumers.

Consumer publications
Diabetes Forecast magazine (ISSN 00958301 [40]) This is a monthly publication in its 63rd annual volume as of October 2010.[] Dr. Paris Roach, an Associate Professor at Indiana University School of Medicine, is Editor-in-Chief of the publication.[] The publication is printed in the United States.[] Consumer book choices include nutrition, self-care, weight management, and cookbooks to manage their disease. Professional health care books include clinical care, nutrition, meal planning, weight control, annual reviews, and diabetes educator curricula. ADA engages respected medical practitioners, diabetes educators, nutritionist, and other health care professionals to write our books providing this community with the most reliable information based on ADA diabetes guidelines. ADA is the oldest and largest publisher of books on diabetes.

Medical professional publications


Diabetes Diabetes Care, with an annual supplement of the Associations Clinical Practice Recommendations Clinical Diabetes Diabetes Spectrum

The ADA publishes a wide variety of books on the latest diabetes care for use by medical professionals, for example: Clinical care medical management series & references Therapy for Diabetes Mellitus and Related Disorders 5th ed. Medical Management of type 1 Diabetes 6th ed. Medical Management of type 2 Diabetes 7th ed. Complete Nurses Guide to Diabetes Care 2nd ed. Intensive Diabetes Management 5th Ed. Managing Pre-Existing Diabetes and Pregnancy Pregnancy Complicated by Diabetes 4th ed. ADA Guide to Nutrition Therapy for Diabetes, 2nd ed.

Clinical references Annual Review of Diabetes 2012 Clinical Practice Recommendations 2012 Clinical Practice Recommendations Pocket Charts Clinical Care of the Diabetic foot Practical Psychology for Diabetes Clinicians 2nd ed. Diabetes Ready Reference for Nurse Practitioners Diabetes & Hypoglycemia Diabetes & The Gut Diabetes & Cancer

Insulin/medications Practical Insulin 3rd ed. Putting Your Patients on the Pump Mental health

American Diabetes Association Practical Psychology for Diabetes Clinicians Cardiovascular disease Managing Pre-Existing Diabetes and Pregnancy Pregnancy Complicated by Diabetes 4th ed. Medical Management of Type 1 Diabetes 6th ed. Medical Management of Type 2 Diabetes 7th ed. Therapy for Diabetes Mellitus and Related Disorders 5th ed. Intensive Diabetes Management 5th ed. Complete Nurses Guide to Diabetes Care 2nd ed.

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Weight control/nutrition Practical Carbohydrate Counting 2nd ed. Behavioral Approaches to Obesity, 2nd ed. Managing Obesity: A Clinical Guide

Notes
[1] http:/ / www. diabetes. org/ aboutus. jsp?WTLPromo=HEADER_aboutus [2] American Diabetes Association: The Journey & the Dream: A history of the American Diabetes Association, page 23. American Diabetes Association, 1990. [3] http:/ / www. diabetes. org/ in-my-community/ [4] The Charities Americans Like Most And Least, The Chronicle of Philanthropy, December 13, 1996 [5] http:/ / www. diabetes. org/ donate/ [6] http:/ / www. diabetes. org/ about-us/ 2011-ada-annual-report. pdf [7] Bloomberg Markets, "Charities Deceive Donors Unaware Money Goes to a Telemarketer" (http:/ / www. bloomberg. com/ news/ 2012-09-12/ charities-deceive-donors-unaware-money-goes-to-a-telemarketer. html/ ). Retrieved 2012-09-16. [8] Myers, Lisa, "Donors unaware charity money goes to telemarketer" (http:/ / www. nbc. com/ news-sports/ today-show/ 2012/ 09/ donors-unaware-charity-money-goes-to-telemarketer/ ), NBC Today Show, September 12, 2012. Retrieved 2012-09-16. [9] http:/ / www. diabetes. org/ diabetes-research/ ada-funded. jsp? [10] http:/ / www. diabetes. org/ news-research/ research/ [11] http:/ / www. diabetes. org/ diabetes-research/ ADA-Research-Foundation/ researchfoundation. jsp [12] http:/ / professional. diabetes. org/ Congress_Display. aspx?TYP=9& CID=60976 [13] http:/ / professional. diabetes. org/ Meeting_ListByType. aspx?ctyp=1 [14] http:/ / www. diabetes. org/ about-us/ center-for-information-community-support. html [15] http:/ / www. diabetes. org/ about-us/ center-for-information-community-support. html [16] http:/ / www. diabetes. org/ family-link/ about-family-link. jsp [17] http:/ / www. diabetes. org/ family-link/ find-family-link. jsp [18] http:/ / www. diabetes. org/ advocacy-and-legalresources/ discrimination/ school/ scrights. jsp [19] http:/ / tracker. diabetes. org/ index. php [20] http:/ / www. diabetes. org/ diabetes-camp/ diabetes-camp. jsp [21] http:/ / www. diabetes. org/ communityprograms-and-localevents. jsp [22] http:/ / www. diabetes. org/ communityprograms-and-localevents/ waw-default. jsp [23] http:/ / stepout. diabetes. org/ site/ PageServer?pagename=OUT_lm_wherewewalk [24] http:/ / www. volunteermatch. org/ search/ opp452373. jsp [25] http:/ / mydiabetessocialnetwork. ning. com/ events/ step-out-walk-to-fight [26] http:/ / tour. diabetes. org/ site/ PageServer?pagename=TC_homepage [27] http:/ / tour. diabetes. org/ site/ PageServer?pagename=TC_redrider [28] http:/ / www. diabetes. org/ communityprograms-and-localevents/ diabetesexpo. jsp [29] http:/ / schoolwalk. diabetes. org/ site/ PageServer?pagename=SW_homepage [30] http:/ / badride. diabetes. org/ site/ PageServer?pagename=BR_homepage [31] http:/ / main. diabetes. org/ site/ PageServer?pagename=FOTY_landing& WTLpromo=hpflyout [32] http:/ / www. diabetes. org/ advocacy-and-legalresources/ advocacy. jsp [33] http:/ / www. diabetes. org/ advocacy-and-legalresources/ discrimination. jsp [34] http:/ / www. diabetes. org/ advocacy-and-legalresources/ federal_legislation/ overview. jsp [35] http:/ / www. diabetes. org/ advocacy-and-legalresources/ state-legislation/ overview. jsp [36] http:/ / www. forecast. diabetes. org/ magazine/ advocacy/ calling-congress

American Diabetes Association


[37] [38] [39] [40] http:/ / www. diabetes. org/ advocacy-and-legalresources/ action-center/ calltocongress. jsp http:/ / www. diabetes. org/ communityprograms-and-localevents/ americandiabetesmonth. jsp http:/ / www. diabetes. org/ communityprograms-and-localevents/ american-diabetes-alert. jsp http:/ / www. worldcat. org/ title/ diabetes-forecast/ oclc/ 1798678

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External links
Official website (http://www.diabetes.org/) American Diabetes Association Journals (http://professional.diabetes.org/Journals_search.aspx/) Diabetes Forecast magazine (http://forecast.diabetes.org/) On Facebook (http://www.facebook.com/AmericanDiabetesAssociation/) On Twitter (http://www.twitter.com/AmDiabetesAssn/) On Flickr (http://www.flickr.com/photos/25087746@N04/) On YouTube (http://www.youtube.com/user/AmericanDiabetesAssn/) Facts about Diabetes (http://apps.nccd.cdc.gov/DDTSTRS/default.aspx/CDC) Website for children (http://youthzone.diabetes.org) Advocacy Action Center (http://advocacy.diabetes.org)

Americans with Disabilities Act of 1990

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Americans with Disabilities Act of 1990


Americans with Disabilities Act of 1990

Long title

An Act to establish a clear and comprehensive prohibition of discrimination on the basis of disability ADA 101st United States Congress July 26, 1990 Citations

Colloquial acronym(s) Enacted by the Effective

Public Law Stat.

101-336 104 Stat. 327 Codification

Title(s) amended U.S.C. sections created

42 12101 et seq. Legislative history [1]

Introduced in the Senate as S.933 by Sen. Tom Harkin (D-IA) on May 9, 1989 Passed the Senate on September 7, 1989 (76-8) Passed the House of Representatives on May 22, 1990 (unanimous voice vote) Reported by the joint conference committee on July 12, 1990; agreed to by the House of Representatives on July 12, 1990 (37728) and by the Senate on July 13, 1990 (91-6) Signed into law by President George H. W. Bush on July 26, 1990 Major amendments

ADA Amendments Act of 2008 United States Supreme Court cases Bragdon v. Abbott Olmstead v. L.C. Toyota Motor Manufacturing, Kentucky, Inc. v. Williams

The Americans with Disabilities Act of 1990[2][3] (ADA) is a law that was enacted by the U.S. Congress in 1990. Senator Tom Harkin (D-IA), authored the bill and was its chief sponsor in the Senate. Harkin delivered part of his introduction speech in sign language so his deaf brother could understand. It was signed into law on July 26, 1990, by President George H. W. Bush, and later amended with changes effective January 1, 2009.[4] The ADA is a wide-ranging civil rights law that prohibits, under certain circumstances, discrimination based on disability. It affords similar protections against discrimination to Americans with disabilities as the Civil Rights Act of 1964,[5] which made discrimination based on race, religion, sex, national origin, and other characteristics illegal. Disability is defined by the ADA as "...a physical or mental impairment that substantially limits a major life activity." The determination of whether any particular condition is considered a disability is made on a case by case

Americans with Disabilities Act of 1990 basis. Certain specific conditions are excluded as disabilities, such as current substance abuse and visual impairment that is correctable by prescription lenses. On September 25, 2008, President George W. Bush signed the ADA Amendments Act of 2008 (ADAAA) into law. This was intended to give broader protections for disabled workers and "turn back the clock" on court rulings that Congress deemed too restrictive.[] The ADAAA includes a list of "major life activities."

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Titles
Title IEmployment
See 42 U.S.C. 12111 [6] 12117 [7]. The ADA states that a covered entity shall not discriminate against a qualified individual with a disability.[] This applies to job application procedures, hiring, advancement and discharge of employees, workers' compensation, job training, and other terms, conditions, and privileges of employment. Covered entity can refer to an employment agency, labor organization, or joint labor-management committee, and is generally an employer engaged in interstate commerce and having 15 or more workers.[8] Discrimination may include, among other things, limiting or classifying a job applicant or employee in an adverse way, denying employment opportunities to people who truly qualify, or not making reasonable accommodations to the known physical or mental limitations of disabled employees, not advancing employees with disabilities in the business, and/or not providing needed accommodations in training materials or policies, and the provision of qualified readers or interpreters. Employers can use medical entrance Speech cards used by President George H. W. examinations for applicants, after making the job offer, only if all Bush at the signing ceremony of the Americans [2] with Disabilities Act (ADA) on July 26, 1990. applicants (regardless of disability) must take it and it is treated as a confidential medical record. Qualified individuals do not include any employee or applicant who is currently engaging in the illegal use of drugs when that usage is the basis for the employer's actions.[9] Part of Title I was found unconstitutional by the United States Supreme Court as it pertains to states in the case of Board of Trustees of the University of Alabama v. Garrett as violating the sovereign immunity rights of the several states as specified by the Eleventh Amendment to the United States Constitution. The provision allowing private suits against states for money damages was invalidated.

Title IIPublic entities (and public transportation)


See 42 U.S.C. 12131 [10] 12165 [11]. Title II prohibits disability discrimination by all public entities at the local (i.e. school district, municipal, city, county) and state level. Public entities must comply with Title II regulations by the U.S. Department of Justice. These regulations cover access to all programs and services offered by the entity. Access includes physical access described in the ADA Standards for Accessible Design and programmatic access that might be obstructed by discriminatory policies or procedures of the entity.

Access sign

Americans with Disabilities Act of 1990 Title II applies to public transportation provided by public entities through regulations by the U.S. Department of Transportation. It includes the National Railroad Passenger Corporation, along with all other commuter authorities. This section requires the provision of paratransit services by public entities that provide fixed route services sign of Illuminate. Title II also applies to all state and local public housing, housing assistance, and housing referrals. The Office of Fair Housing and Equal Opportunity is charged with enforcing this provision.

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Title IIIPublic accommodations (and commercial facilities)


See 42 U.S.C. 12181 [12] 12189 [13]. Under Title III, no individual may be discriminated against on the basis of disability with regards to the full and equal enjoyment of the goods, services, facilities, or accommodations of any place of public accommodation by any person who owns, leases (or leases to), or operates a place of public accommodation. "Public accommodations" include most places of lodging (such as inns and hotels), recreation, transportation, education, and dining, along with stores, care providers, and places of public displays, among other things. Under Title III of the ADA, all "new construction" (construction, modification or alterations) after the effective date of the ADA (approximately July 1992) must be fully compliant with the Americans With Disabilities Act Accessibility Guidelines (ADAAG)[2] found in the Code of Federal Regulations at 28C.F.R., Part 36, Appendix A.
The ADA sets standards for construction of accessible public facilities. Shown is a sign indicating an accessible fishing platform at Drano Lake, Washington.

Title III also has application to existing facilities. One of the definitions of "discrimination" under Title III of the ADA is a "failure to remove" architectural barriers in existing facilities. See 42 U.S.C.12182(b)(2)(A)(iv) [14]. This means that even facilities that have not been modified or altered in any way after the ADA was passed still have obligations. The standard is whether "removing barriers" (typically defined as bringing a condition into compliance with the ADAAG) is readily achievable, defined as "...easily accomplished without much difficulty or expense." The statutory definition of readily achievable calls for a balancing test between the cost of the proposed "fix" and the wherewithal of the business and/or owners of the business. Thus, what might be "readily achievable" for a sophisticated and financially capable corporation might not be readily achievable for a small or local business. There are exceptions to this title; many private clubs and religious organizations may not be bound by Title III. With regard to historic properties (those properties that are listed or that are eligible for listing in the National Register of Historic Places, or properties designated as historic under State or local law), those facilities must still comply with the provisions of Title III of the ADA to the "maximum extent feasible" but if following the usual standards would "threaten to destroy the historic significance of a feature of the building" then alternative standards may be used. Nonetheless, as Frank Bowe predicted when he testified as the lead witness on Title III in the Senate hearings leading up to enactment[citation needed], the fact that Title III calls for accessibility in, and alterations to, thousands of stores, restaurants, hotels, etc., in thousands of communities across the U.S. means that this Title probably has had more effect on the lives of more Americans with disabilities than any other ADA title.[15] On September 15, 2010, the Department of Justice issued revised regulations for implementation of Titles II and III, effective March 15, 2011.[16] The rules contain many new requirements for public accommodations, as well as an "element by element safe harbor."[17] Public swimming pool owners and operators must gear up for compliance with the 2010 Standards for Accessible Design with regard to existing swimming pools, wading pools and spas by January 31, 2013.[18] The Department of Justice published ADA 2010 Revised Requirements: Accessible Pools Means of Entry and Exit to help pool owners and operators understand the new accessibility requirements,

Americans with Disabilities Act of 1990 application of the requirements, and longstanding obligations of pool owners and operators in connection with the new requirements.[19] The ADA Revised Requirements require that newly constructed or altered swimming pools, wading pools, and spas have an accessible means of entrance and exit to pools for disabled people. However, providing accessibility is conditioned on whether providing access through a fixed lift is readily achievable. The technical specifications for when a means of entry is accessible are available on the (DOJ website). [20] Other requirements exist, based on pool size, include providing a certain number of accessible means of entry and exit, which are outlined in Section 242 of the Standards. However, businesses should consider the differences in application of the rules depending on whether the pool is new or altered, or whether the swimming pool was in existence before the effective date of the new rule. Full compliance may not be required for existing facilities; Section 242 and 1009 of the 2010 Standards outline such exceptions.[21]

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Title IVTelecommunications
Title IV of the ADA amended the landmark Communications Act of 1934 primarily by adding section 47 U.S.C.225 [22]. This section requires that all telecommunications companies in the U.S. take steps to ensure functionally equivalent services for consumers with disabilities, notably those who are deaf or hard of hearing and those with speech impairments. When Title IV took effect in the early 1990s, it led to installation of public Teletypewriter (TTY) machines and other TDDs (Telecommunications Device for the Deaf). Title IV also led to creation, in all 50 States and the District of Columbia, of what were then called dual-party relay services and now are known as Telecommunications Relay Services (TRS), such as STS Relay. Today, many TRS-mediated calls are made over the Internet by consumers who use broadband connections. Some are Video Relay Service (VRS) calls, while others are text calls. In either variation, communication assistants translate between the signed/typed words of a consumer and the spoken words of others. In 2006, according to the Federal Communications Commission (FCC), VRS calls averaged two million minutes a month.

Title VMiscellaneous provisions


See 42 U.S.C. 12201 [23] 12213 [24]. Title V includes technical provisions. It discusses, for example, the fact that nothing in the ADA amends, overrides or cancels anything in Section 504.[25] Additionally, Title V includes an anti retaliation or coercion provision. The Technical Assistance Manual for the ADA explains it: "III-3.6000 Retaliation or coercion. Individuals who exercise their rights under the ADA, or assist others in exercising their rights, are protected from retaliation. The prohibition against retaliation or coercion applies broadly to any individual or entity that seeks to prevent an individual from exercising his or her rights or to retaliate against him or her for having exercised those rights ... Any form of retaliation or coercion, including threats, intimidation, or interference, is prohibited if it is intended to interfere.

Major life activities


The ADA defines a covered disability as "...a physical or mental impairment that substantially limits a major life activity." The Equal Employment Opportunity Commission (EEOC) was charged with interpreting the 1990 law with regard to discrimination in employment. Its regulations narrowed "substantially limits" to "significantly or severely restricts." [citation needed] In 2008, effective January 1, 2009, the ADAAA broadened the interpretations and added to the ADA examples of "major life activities" including, but not limited to, "caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working" as well as the operation of several specified major bodily functions.[] The Act overturns a 1999 U.S. Supreme Court case that held that an employee was not disabled if the impairment could be corrected by mitigating measures; it specifically provides that such impairment must be determined without considering such ameliorative measures. Another court restriction overturned is the interpretation that an impairment

Americans with Disabilities Act of 1990 that substantially limits one major life activity must also limit others to be considered a disability.[] The ADAAA will undoubtedly lead to broader coverage of impaired employees. The United States House Committee on Education and Labor states that the amendment "...makes it absolutely clear that the ADA is intended to provide broad coverage to protect anyone who faces discrimination on the basis of disability."[26] Required doctor visits may not be held against anyone with a disability.[citation needed]

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"Capitol Crawl"
Shortly before the Act was passed, disability rights activists with physical disabilities coalesced in front of the Capitol Building, shed their crutches, wheelchairs, powerchairs and any other assistive devices, and immediately proceeded to crawl and pull their bodies up all 100 of the Capitol's front steps, without warning. As the activists did so, many of them chanted "ADA Now!!" and "Vote! Now!!". Some activists who remained at the bottom of the steps held signs and yelled words of encouragement at the 'Capitol Crawlers'. One young child with cerebral palsy is videotaped as she pulls herself up the steps, using mostly her hands and arms, saying "I'll take all night if I have to!". This direct action is reported to have "inconvenienced" several Senators and to have pushed them to approve the Act. While there are those who do not attribute much overall importance to this action, the Capitol Crawl is seen by many present-day disability activists in the United States as being the single action most responsible for 'forcing' the ADA into law.[27] Today, the Capitol Crawl action is not very well-known amongst the US public when compared to other United States civil rights movement actions, partly owing to the US mainstream media of 1990 failing to highlight the story.

Opposition
Opposition from religious groups
The debate over the Americans with Disabilities Act led some religious groups to take opposite positions.[28] Some religious groups, such as the Association of Christian Schools International, opposed the ADA in its original form.[29] ACSI opposed the Act primarily because the ADA labeled religious institutions public accommodations, and thus would have required churches to make costly structural changes to ensure access for all.[30] The cost argument advanced by ACSI and others prevailed in keeping religious institutions from being labeled as public accommodations, and thus churches were permitted to remain inaccessible if they choose. In addition to opposing the ADA on grounds of cost, church groups like the National Association of Evangelicals testified against the ADA's Title I (employment) provisions on grounds of religious liberty. The NAE felt that the regulation of the internal employment of churches was "... an improper intrusion [of] the federal government."[28]

Opposition from business interests


Many members of the business community opposed the passage of the Americans with Disabilities Act. Testifying before Congress, Greyhound Bus Lines stated that the Act had the potential to "...deprive millions of people of affordable intercity public transportation and thousands of rural communities of their only link to the outside world." The US Chamber of Commerce argued that the costs of the ADA would be "enormous" and have "a disastrous impact on many small businesses struggling to survive."[31] The National Federation of Independent Businesses, an organization that lobbies for small businesses, called the ADA "a disaster for small business."[32] Pro-business conservative commentators joined in opposition, writing that the Americans with Disabilities Act was "an expensive headache to millions" that would not necessarily improve the lives of people with disabilities.[33]

Americans with Disabilities Act of 1990

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Quotations
On signing the measure, George H. W. Bush said: I know there may have been concerns that the ADA may be too vague or too costly, or may lead endlessly to litigation. But I want to reassure you right now that my administration and the United States Congress have carefully crafted this Act. We've all been determined to ensure that it gives flexibility, particularly in terms of the timetable of implementation; and we've been committed to containing the costs that may be incurred.... Let the shameful wall of exclusion finally come tumbling down.[34]

President Bush signs the Americans with Disabilities Act into law

On the debate of what it means to be disabled, American poet Joan Aleshire stated in the book Voices From the Edge: If the definition of disability is the inability to do the common daily tasks of lifegetting out of bed, washing, dressing, eating, going to the bathroomand working at one's age level in school, I've never really been disabled.[35] About the importance of making employment opportunities inclusive, Shirley Davis, director of global diversity and inclusion at the Society for Human Resource Management, said: People with disabilities represent a critical talent pool that is underserved and underutilized.[36]

Criticism
The ADA has been a frequent target of criticism, on the grounds of actually decreasing the employment rate for the disabled[37] and raising the cost of doing business for employers, in large part due to the additional legal risks, which employers avoid by quietly avoiding hiring people with disabilities. Some researchersWikipedia:Avoid weasel words believe that the law has been ineffectual.[38]

Employment
Multiple economic studies have shown that the law has had unintended consequences. Between 1991 (after its enactment) and 1995, the ADA caused a 7.8% drop in the employment rate of men with disabilities regardless of age, educational level, and type of disability, with the most affected being young, less-educated and mentally disabled men.[] In 2001, for men of all working ages and women under 40, Current Population Survey data showed a sharp drop in the employment of disabled workers, with the ADA as a likely cause.[39]

Abuse
For example, a common claim is that individuals who are diagnosed with one of the so-called "lesser disabilities" are being "accommodated" when they should not be.[citation needed] As one law review article pointed out, the perception that the ADA primarily helps freeloaders was harshly satirized by The Onion in 1998 in the form of an article about the Americans With No Abilities Act.[40] The fictional Act would have provided "benefits and protection for more than 135 million talentless Americans," and prohibited discriminatory questions such as "What can you bring to this organization?"[41][42]

Americans with Disabilities Act of 1990 On the other hand, court decisions have made necessary "an individualized assessment to prove that an impairment is protected under the ADA. Therefore, the plaintiff must offer evidence that the extent of the limitation caused by the impairment is substantial in terms of his or her own experience;" a medical diagnosis or physician's declaration of disability is no longer enough.[43]

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"Professional plaintiffs"
Since enforcement of the Act began in July 1992, it has quickly become a major component of employment law, with large numbers of frivolous lawsuits. Through the end of fiscal year 1998, 86% of the 106,988 ADA charges filed with and resolved by the Equal Employment Opportunity Commission, were either dropped or investigated and dismissed by EEOC but not without imposing opportunity costs and legal fees on employers.[] The ADA allows private plaintiffs to receive only injunctive relief (a court order requiring the public accommodation to remedy violations of the accessibility regulations) and attorneys' fees, and does not provide monetary rewards to private plaintiffs who sue non-compliant businesses. Unless a state law, such as the California Unruh Civil Rights Act,[] provides for monetary damages to private plaintiffs, persons with disabilities do not obtain direct financial benefits from suing businesses that violate the ADA. Thus, "professional plaintiffs" are typically found in states that have enacted state laws that allow private individuals to win monetary awards from non-compliant businesses.[] At least one of these plaintiffs in California has been barred by courts from filing lawsuits unless he receives prior court permission.[] The attorneys' fees provision of Title III does provide incentive for lawyers to specialize and engage in serial ADA litigation, but a disabled plaintiff does not obtain financial reward from attorneys' fees unless they act as their own attorney, or as mentioned above, a disabled plaintiff resides in a state that provides for minimum compensation and court fees in lawsuits. Moreover, there may be a benefit to these "private attorneys general" who identify and compel the correction of illegal conditions: they may increase the number of public accommodations accessible to persons with disabilities. "Civil rights law depends heavily on private enforcement. Moreover, the inclusion of penalties and damages is the driving force that facilitates voluntary compliance with the ADA."[44] Courts have noted: "As a result, most ADA suits are brought by a small number of private plaintiffs who view themselves as champions of the disabled. For the ADA to yield its promise of equal access for the disabled, it may indeed be necessary and desirable for committed individuals to bring serial litigation advancing the time when public accommodations will be compliant with the ADA."[45]

Case law
There have been some notable cases regarding the ADA. For example, two major hotel room marketers (Expedia.com and Hotels.com) with their business presence on the Internet were sued because its customers with disabilities could not reserve hotel rooms, through their websites without substantial extra efforts that persons without disabilities were not required to perform.[46] These represent a major potential expansion of the ADA in that this, and other similar suits (known as "bricks vs. clicks"), seeks to expand the ADA's authority to cyberspace, where entities may not have actual physical facilities that are required to comply. National Federation of the Blind v. Target Corporation This is a case where a major retailer, Target Corp., was sued because their web designers failed to design its website to enable persons with low or no vision to use it.[47] Board of Trustees of the University of Alabama v. Garrett Board of Trustees of the University of Alabama v. Garrett, 531 U.S. 356 (2001), was a United States Supreme Court case about Congress's enforcement powers under the Fourteenth Amendment to the Constitution. It decided that Title I of the Americans with Disabilities Act was unconstitutional insofar as it allowed private citizens to sue states for money damages. Barden v. The City of Sacramento

Americans with Disabilities Act of 1990 Another example, filed in March 1999, claimed that the City of Sacramento failed to comply with the ADA when, while making public street improvements, it did not bring its sidewalks into compliance with the ADA. Certain issues were resolved in Federal Court. One issue, whether sidewalks were covered by the ADA, was appealed to the 9th Circuit Court of Appeals, which ruled that sidewalks were a "program" under ADA and must be made accessible to persons with disabilities. The ruling was later appealed to the U.S. Supreme Court, which refused to hear the case, letting stand the ruling of the 9th Circuit Court.[48] Bates v. UPS This was the first equal opportunity employment class action brought on behalf of Deaf and Hard of Hearing (D/HH) workers throughout the country concerning workplace discrimination. It established legal precedence for D/HH Employees and Customers to be fully covered under the ADA. Key finding included (1) UPS failed to address communication barriers and to ensure equal conditions and opportunities for deaf employees; (2) Deaf employees were routinely excluded from workplace information, denied opportunities for promotion, and exposed to unsafe conditions due to lack of accommodations by UPS; (3) UPS also lacked a system to alert these employees as to emergencies, such as fires or chemical spills, to ensure that they would safely evacuate their facility; and (4) UPS had no policy to ensure that deaf applicants and employees actually received effective communication in the workplace. The outcome was that UPS agreed to pay a $5.8 million dollar award and agreed to a comprehensive accommodations program that was implemented in their facilities throughout the country. Spector v. Norwegian Cruise Line Ltd. This was a case that was decided by the United States Supreme Court in 2005. The defendant argued that as a vessel flying the flag of a foreign nation was exempt from the requirements of the ADA. This argument was accepted by a federal court in Florida and, subsequently, the Fifth Circuit Court of Appeals. However, the U.S. Supreme Court reversed the ruling of the lower courts on the basis that Norwegian Cruise Lines was a business headquartered in the United States whose clients were predominantly Americans and, more importantly, operated out of port facilities throughout the United States. Olmstead, Commissioner, Georgia Department of Human Resources, et al. v. L. C., by zimring, guardian ad litem and next friend, et al. (not to be confused with Olmstead v. United States, 277 U.S. 438 (1928), a case regarding wiretapping) This was a case before the United States Supreme Court in 1999. The two plaintiffs L.C. and E.W. were institutionalized in Georgia for diagnosed mental retardation and schizophrenia. Clinical assessments by the state determined that the plaintiffs could be appropriately treated in a community setting rather than the state institution. The plaintiffs sued the state of Georgia and the institution for being inappropriately treated and housed in the institutional setting rather than being treated in one of the state's community based treatment facilities. The Supreme Court decided under Title II of the ADA that mental illness is a form of disability and therefore covered under the ADA, and that unjustified institutional isolation of a person with a disability is a form of discrimination because it "...perpetuates unwarranted assumptions that persons so isolated are incapable or unworthy of participating in community life." The court added, "Confinement in an institution severely diminishes the everyday life activities of individuals, including family relations, social contacts, work options, economic independence, educational advancement, and cultural enrichment." Therefore, under Title II no person with a disability can be unjustly excluded from participation in or be denied the benefits of services, programs or activities of any public entity.[49] Michigan Paralyzed Veterans of America v. The University of Michigan This was a case filed before The United States District Court for the Eastern District of Michigan Southern Division on behalf of the Michigan Paralyzed Veterans of America against University of Michigan Michigan Stadium claiming that Michigan Stadium violated the Americans with Disabilities Act in its $226-million renovation by failing to add enough seats for disabled fans or accommodate the needs for disabled restrooms, concessions and

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Americans with Disabilities Act of 1990 parking. Additionally, the distribution of the accessible seating was at issue, with nearly all the seats being provided in the end-zone areas. The U.S. Department of Justice assisted in the suit filed by attorney Richard Bernstein of The Law Offices of Sam Bernstein in Farmington Hills, Michigan, which was settled in March 2008.[50] The settlement required the stadium to add 329 wheelchair seats throughout the stadium by 2010, and an additional 135 accessible seats in clubhouses to go along with the existing 88 wheelchair seats. This case was significant because it set a precedent for the uniform distribution of accessible seating and gave the DOJ the opportunity to clarify previously unclear rules.[51] The agreement now is a blueprint for all stadiums and other public facilities regarding accessibility.[52] Paralyzed Veterans of America (or "PVA") v. Ellerbe Becket Architects and Engineers One of the first major ADA lawsuits, Paralyzed Veterans of America (or "PVA") v. Ellerbe Becket Architects and Engineers, Inc., was focused on the wheelchair accessibility of a stadium project that was still in the design Phase, MCI Center in Washington, D.C. Previous to this case, which was filed only five years after the ADA was passed, the DOJ was unable or unwilling to provide clarification on the distribution requirements for accessible wheelchair locations in large assembly spaces. While Section 4.33.3 of ADAAG makes reference to lines of sight, no specific reference is made to seeing over standing patrons. The MCI Center, designed by Ellerbe Becket Architects & Engineers, was designed with too few wheelchair and companion seats, and the ones that were included did not provide sight lines that would enable the wheelchair user to view the playing area while the spectators in front of them were standing. This case and another related case established precedent on seat distribution and sight lines issues for ADA enforcement that continues to present day. Toyota Motor Manufacturing, Kentucky, Inc. v. Williams Toyota Motor Manufacturing, Kentucky, Inc. v. Williams, 534 U.S. 184 (2002) was a case in which the Supreme Court interpreted the meaning of the phrase "substantially impairs" as used in the Americans with Disabilities Act. It reversed a Sixth Court of Appeals decision to grant a partial summary judgment in favor of the respondent, Ella Williams that qualified her inability to perform manual job-related tasks as a disability. The Court held that the "major life activity" definition in evaluating the performance of manual tasks focuses the inquiry on whether Williams was unable to perform a range of tasks central to most people in carrying out the activities of daily living. The issue is not whether Williams was unable to perform her specific job tasks. Therefore, the determination of whether an impairment rises to the level of a disability is not limited to activities in the workplace solely, but rather to manual tasks in life in general. When the Supreme Court applied this standard, it found that the Court of Appeals had incorrectly determined the presence of a disability because it relied solely on her inability to perform specific manual work tasks, which was insufficient in proving the presence of a disability. The Court of Appeals should have taken into account the evidence presented that Williams retained the ability to do personal tasks and household chores, such activities being the nature of tasks most people do in their daily lives, and placed too much emphasis on her job disability. Since the evidence showed that Williams was performing normal daily tasks, it ruled that the Court of Appeals erred when it found that Williams was disabled.[][] This ruling is now, however, no longer good lawit was invalidated by the ADAAA. In fact, Congress explicitly cited Toyota v. Williams in the text of the ADAAA itself as one of its driving influences for passing the ADAAA. Access Now v. Southwest Airlines Access Now v. Southwest Airlines was a case where the District Court decided that the website of Southwest Airlines was not in violation of the Americans with Disability Act because the ADA is concerned with things with a physical existence and thus cannot be applied to cyberspace. Judge Patricia A. Seitz found that the "virtual ticket counter" of the website was a virtual construct, and hence not a "public place of accommodation." As such, "To expand the ADA to cover 'virtual' spaces would be to create new rights without well-defined standards."[] Ouellette v. Viacom International Inc. Ouellette v. Viacom International Inc. followed in Access Now's footsteps by holding that a mere online presence does not subject a website to the ADA guidelines. Thus Myspace and YouTube were not liable for a dyslexic man's

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Americans with Disabilities Act of 1990 inability to navigate the site regardless of how impressive the "online theater" is.

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Resources
Acemoglu, Daron & Angrist, Joshua D. (2001). Consequences of Employment Protection? The Case of the Americans with Disabilities Act. Journal of Political Economy, volume 109 (2001), pages 915957. Bush, George H. W., Remarks of President George Bush at the Signing of the Americans with Disabilities Act. Available on-line at Equal Employment Opportunity Commission [53]. DeLeire, Thomas. (Autumn, 2000). The Wage and Employment Effects of the Americans with Disabilities Act. Journal of Human Resources, Vol. 35, No. 4, pp.693715 Fielder, J. F. Mental Disabilities and the Americans with Disabilities Act. Westport, CT: Quorum Books, 2004. Hamilton Krieger, Linda, ed., Backlash Against the ADA: Reinterpreting Disability Rights Ann Arbor: University of Michigan Press, 2003. Johnson, Mary. (2000). Make Them Go Away: Clint Eastwood, Christopher Reeve & The Case Against Disability Rights. Louisville, KY: The Advocado Press. Schall, Carol M. (Jun 1998). The Americans with Disabilities ActAre We Keeping Our Promise? An Analysis of the Effect of the ADA on the Employment of Persons with Disabilities. Journal of Vocational Rehabilitation, v10 n3 pp.191203. Schwochau, Susan & Blanck, Peter David. The Economics of the Americans with Disabilities Act, Part III: Does the ADA Disable the Disabled? Berkeley Journal of Employment & Labor Law [Vol. 21:271] Switzer, Jacqueline Vaughn. Disabled Rights: American Disability Policy and the Fight for Equality. Washington, DC: Georgetown University Press, 2003... Weber, Mark C. Disability Harassment. New York, NY: NYU Press, 2007. O'Brien, Ruth, ed. Voices from the Edge: Narratives about the Americans with Disabilities Act. New York: Oxford, 2004. ISBN 0-19-515687-0 Pletcher, David and Ashlee Russeau-Pletcher History of the Civil Rights Movement for the Physically Disabled http://aabss.org/Perspectives2008/AABSS2008Article5DisabilityHistory.pdf

References
[1] [2] [3] [5] http:/ / thomas. loc. gov/ cgi-bin/ bdquery/ D?d101:3:. / temp/ ~bsslrwQ:: Americans with Disabilities Act of 1990 (http:/ / finduslaw. com/ americans_with_disabilities_act_of_1990_ada_42_u_s_code_chapter_126) , codified at Civil Rights Act of 1964 (http:/ / finduslaw. com/ civil_rights_act_of_1964_cra_title_vii_equal_employment_opportunities_42_us_code_chapter_21) [6] http:/ / www. law. cornell. edu/ uscode/ 42/ 12111. html [7] http:/ / www. law. cornell. edu/ uscode/ 42/ 12117. html [10] http:/ / www. law. cornell. edu/ uscode/ 42/ 12131. html [11] http:/ / www. law. cornell. edu/ uscode/ 42/ 12165. html [12] http:/ / www. law. cornell. edu/ uscode/ 42/ 12181. html [13] http:/ / www. law. cornell. edu/ uscode/ 42/ 12189. html [14] http:/ / www. law. cornell. edu/ uscode/ 42/ 12182. html#b_2_A_iv [16] U.S. Department of Justice (February 16, 2011), 2010 Revised ADA Requirements: Effective Date and Compliance Date (http:/ / www. ada. gov/ revised_effective_dates-2010. htm) [17] Kim R. Blackseth (July 20, 2011, UrbDeZine), How The New ADA Effects All of Us (http:/ / urbdezine. com/ 2011/ 07/ 20/ how-the-new-ada-effects-all-of-us) [20] http:/ / www. ada. gov/ 2010ADAstandards_index. htm [22] http:/ / www. law. cornell. edu/ uscode/ 47/ 225. html [23] http:/ / www. law. cornell. edu/ uscode/ 42/ 12201. html [24] http:/ / www. law. cornell. edu/ uscode/ 42/ 12213. html [27] http:/ / www. youtube. com/ watch?v=-cBGj-Mp8ww [28] Lawton, K.A. Christianity Today, 10/8/90, Vol. 34 Issue 14, p. 71 [29] "Should the Senate Approve the Americans with Disabilities Act of 1989?" Congressional Digest December (1989): 297

Americans with Disabilities Act of 1990


[30] "Should the Senate Approve the Americans with Disabilities Act of 1989?" Congressional Digest December (1989): 297. [31] "Should the Senate Approve the Americans with Disabilities Act of 1989?" Congressional Digest December (1989): 208. [32] Mandel, Susan. "Disabling the GOP," The National Review 6/11/1990, Vol. 42 Issue 11, pp. 23-24 [33] Doherty, Brian. Reason, AugSep 95, Vol. 27 Issue 4, p. 18 [34] The U.S. Equal Employment Opportunity Commission (http:/ / www. eeoc. gov/ ada/ bushspeech. html) [36] ( Targeted Development for Managers with Disabilities (http:/ / www. shrm. org/ hrdisciplines/ Diversity/ Articles/ Pages/ ManagerswithDisabilities. aspx) [37] (see Schwochau & Blanck for counter arguments) [38] (see Schall, 1998) [40] Gina M. Cook, "Article: When The Duty To Provide A Reasonable Accommodation Seems Unreasonable: Accommodating And Managing Employees With Episodic Impairments Or Impairments In Remission Under The ADA Amendments Act Of 2008", 32 N.C. Cent. L. Rev. 1 (2009). [41] Scott Dikkers and Robert Siegel, The Onion's Finest News Reporting, Vol. 1 (New York: Three Rivers Press, 2000), 155. [42] Anonymous, "Congress Passes Americans With No Abilities Act" (http:/ / www. theonion. com/ articles/ congress-passes-americans-with-no-abilities-act,541/ ), The Onion, June 24, 1998. [44] Parr v. L & L Drive-Inn Restaurant (D. Hawaii 2000) 96F.Supp.2d 1065, 1082, citing and quoting, Committee Print, Vol. II, 101st Cong., 2d Sess., at 1481-82 (1990); (b)(2); S.Rep. No. 101-116, at 15 (1989). [45] Molski v. Evergreen Dynasty Corp., (9th Cir. 2007) 500F.3d 1047, 1062; D'Lil v. Best Western Encina Lodge & Suites (9th Cir. 2008) 538F.3d 1031, 1040. [46] Smith v. Hotels.com (http:/ / www. dralegal. org/ cases/ private_business/ Smith_v_Hotels_com. php) at Disability Rights Advocates [47] National Federation for the Blind v. Target (http:/ / www. dralegal. org/ cases/ private_business/ nfb_v_target. php) at Disability Rights Advocates [48] Barden v. Sacramento (http:/ / www. dralegal. org/ cases/ public_entities/ barden_v_sacramento. php) from Disability Rights Advocates [49] OLMSTEAD V. L. C. (http:/ / supct. law. cornell. edu/ supct/ html/ 98-536. ZS. html) from Cornell University Law School - Syllabus for the Supreme Court Decision in 1999 [50] Erb, Robin. "U-M fans rave about new seats for disabled," Detroit Free Press. 9 September 2008. [51] Wolffe, Jerry. "New wheelchair seats will be full at U-M's Big House." The Oakland Press. 14 September 2008. [52] Wolffe, Jerry. "New wheelchair seats will be full at U-M's Big House," The Oakland Press. 14 September 2008. / [53] http:/ / www. eeoc. gov/ ada/ bushspeech. html

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External links
File a housing discrimination complaint (http://www.hud.gov/offices/fheo/online-complaint.cfm) Compliance tool kits from the ADA (http://www.ada.gov/pcatoolkit/toolkitmain.htm) Navigable text of the Americans with Disabilities Act of 1990 - 42 U.S. Code Chapter 126 (http://finduslaw. com/americans_with_disabilities_act_of_1990_ada_42_u_s_code_chapter_126) Office of Fair Housing and Equal Opportunity (http://portal.hud.gov/hudportal/HUD?src=/program_offices/ fair_housing_equal_opp) Searchable collection of over 7,000 Federal ADA documents (http://www.ADAPortal.org) Federally funded technical assistance network (http://www.adata.org) Overview of ADA, IDEA, and Section 504: Update 2001 (http://www.ericdigests.org/2002-1/ada.html) Overview of ADA, IDEA, and Section 504 (http://www.ericdigests.org/1996-3/ada.htm) Employment of People with Disabilities (http://www.ericdigests.org/2004-1/people.htm) Accessible Web Design (http://www.ericdigests.org/2000-3/web.htm) ADA Wheelchair Ramp Guidelines (http://www.adawheelchairramps.com/Modular_Ramps/ ADA_Modular_Ramp_Specs.aspx) Testing Students with Disabilities (http://www.ericdigests.org/1996-4/testing.htm) Congressional Research Service (CRS) Reports regarding the Americans with Disabilities Act (http://digital. library.unt.edu/govdocs/crs/search.tkl?q=ada&search_crit=title&search=Search&date1=Anytime& date2=Anytime&type=form) Paratransit Watch - Accessible Public Transportation News, Issues, and Resources. (http://paratransitwatch. blogspot.com/) U.S. Department of Justice (http://www.usdoj.gov/crt/ada/adahom1.htm). ADA Info

Americans with Disabilities Act of 1990 Americans with Disabilities Act Amendment (ADAAA) Information Center (http://blr.com/information-ada/). ADAAA Information for Employers ADA Amendment Information Resources (http://www.smarthrmanager.com/human-resources/ ada-amendments) SHRM's Disability Employment Resource Page (http://www.shrm.org/disabilityemployment) Americans with Disabilities Act (ADA) - law and higher education (http://lawhighereducation.org/ 14-americans-with-disabilities-act-ada.html)

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Attention deficit hyperactivity disorder

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Attention deficit hyperactivity disorder


Attention-deficit/hyperactivity disorder
Classification and external resources

Children with ADHD find it more difficult to focus and to complete their schoolwork. ICD-10 ICD-9 OMIM DiseasesDB MedlinePlus eMedicine MeSH F90 [1] [2] , 314.01 [3]

314.00 143465 6158

[4]

[5] [6] [7] ped/177 [8]

001551

med/3103 D001289

[9]

Attention deficit hyperactivity disorder (ADHD, similar to hyperkinetic disorder in the ICD-10) is a psychiatric disorder[] of the neurodevelopmental disorder class[10][] in which there are significant problems of attention and/or hyperactivity and acting impulsively that are not appropriate for a persons age.[11] These symptoms must begin before seven to twelve years of age and has been present for more than six months for a diagnosis to be made.[][] There are three subtypes: predominantly inattentive (ADHD-PI or ADHD-I), predominantly hyperactive-impulsive (ADHD-HI or ADHD-H), or the two combined (ADHD-C), which shows all three difficulties. Often people refer to ADHD-PI as "attention deficit disorder" (ADD), however, the latter has not been officially accepted since the 1994 revision of the DSM. In school-aged children the lack of focus may result in poor school performance. It is the most commonly studied and diagnosed psychiatric disorder in children and adolescents, affecting about 6 to 7 percent of children when diagnosed via the DSM-IV criteria[] and 1 to 2 percent when diagnosed via the ICD-10 criteria.[] Rates are similar between countries and depend mostly on how it is diagnosed.[] ADHD is diagnosed approximately three times more frequently in boys than in girls.[][] About 30 to 50 percent of people diagnosed in childhood continue to have symptoms into adulthood[] with between 2 and 5 percent of adults have the condition.[] The symptoms can be difficult to tell apart from other disorders as well as that of high normal activity.[] ADHD management usually involves some combination of counselling, lifestyle changes, and medications. Medications are only recommended as a first-line treatment in children who have severe symptoms and may also be considered for those with moderate symptoms who either refuse or fail to improve with counselling.[]:p.317 Adolescents and adults tend to develop coping mechanisms which make up for some or all of their impairments.[] ADHD and its diagnosis and treatment have been considered controversial since the 1970s.[] The controversies have involved clinicians, teachers, policymakers, parents and the media. Topics include ADHD's causes, and the use of

Attention deficit hyperactivity disorder stimulant medications in its treatment.[][] Most healthcare providers accept ADHD as a genuine disorder; debate in the scientific community centers mainly around how it is diagnosed and treated.[][][] The National Institute for Clinical Excellence, while acknowledging the controversy, states that the current treatments and methods of diagnosis are based on the dominant view of the academic literature.[]:p.133

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Signs and symptoms


Inattention, hyperactivity (restlessness in adults), disruptive behavior, and impulsivity are common in ADHD.[][12] Academic difficulties are also frequent and social skills difficulties are much more common in the ADHD population.[] The symptoms can be difficult to define because it is hard to draw a line at where normal levels of inattention, hyperactivity, and impulsivity end and significant levels requiring intervention begin.[]:p.26 To be diagnosed as ADHD, symptoms must be observed in two different settings for six months or more and to a degree that is greater than other children of the same age.[] The presenting symptom give three types of ADHDpredominantly inattentive type, predominantly hyperactive-impulsive type, or combined type if criteria for both subtypes are met:[]:p.4 An individual with symtoms of inattention may have some or all of the following symptoms:[] Be easily distracted, miss details, forget things, and frequently switch from one activity to another Have difficulty maintaining focus on one task Become bored with a task after only a few minutes, unless doing something enjoyable Have difficulty focusing attention on organizing and completing a task or learning something new Have trouble completing or turning in homework assignments, often losing things (e.g., pencils, toys, assignments) needed to complete tasks or activities Not seem to listen when spoken to Daydream, become easily confused, and move slowly Have difficulty processing information as quickly and accurately as others Struggle to follow instructions. Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework). Difficulty starting tasks Difficulty completing tasks within time limits

An individual with symtoms of hyperactivity may have some or all of the following symptoms:[] Fidget and squirm in their seats Talk nonstop Dash around, touching or playing with anything and everything in sight Have trouble sitting still during dinner, school, doing homework, and story time Be constantly in motion Have difficulty doing quiet tasks or activities Talking to yourself Is often "on the go" acting as if "driven by a motor".

An individual with symtoms of impulsivity may have some or all of the following symptoms:[] Be very impatient Blurt out inappropriate comments, show their emotions without restraint, and act without regard for consequences Blurts out comments better left unsaid Have difficulty waiting for things they want or waiting their turns in games

Often interrupt conversations or others' activities. Says whatever is on one's mind with little or no forethought

Attention deficit hyperactivity disorder Some children, adolescents, and adults with ADHD have an increased risk of experiencing difficulties with social skills, such as social interaction and forming and maintaining friendships due to impairments in processing verbal and nonverbal language. About half of children and adolescents with ADHD experience rejection by their peers compared to 1015 percent of non-ADHD children and adolescents. Training in social skills, behavioural modification and medication may have some limited beneficial effects. The most important factor in reducing emergence of later psychopathology, such as major depression, criminality, school failure, and substance use disorders is formation of friendships with people who are not involved in delinquent activities.[] Handwriting difficulties seem to be common in children with ADHD.[] Delays in speech and language as well as motor development occur more commonly in the ADHD population.[][] Although ADHD causes many impairments particularly in modern day society many children with ADHD are resourceful showing persistent behavior and commitment if they find something interesting.[]

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Associated disorders
Inattention and hyperactive behavior and other ADHD symptomatology are not necessarily the only problems in children with ADHD. ADHD exists alone in only about 1/3 of the children diagnosed with it.[] Some of the associated conditions are: Oppositional defiant disorder and conduct disorder, occur with ADHD in about half and 20% of cases respectively.[] They are characterized by antisocial behaviors such as stubbornness, aggression, frequent temper tantrums, deceitfulness, lying, or stealing,[] inevitably linking these comorbid disorders with antisocial personality disorder (ASPD); about half of those with hyperactivity and ODD or CD develop ASPD in adulthood.[13] Brain imaging indicates that conduct disorder and ADHD are distinct disorders.[] Primary disorder of vigilance, which is characterized by poor attention and concentration, as well as difficulties staying awake. These children tend to fidget, yawn and stretch and appear to be hyperactive in order to remain alert and active.[] Mood disorders (especially bipolar disorder and major depressive disorder). Boys diagnosed with the combined ADHD subtype have been shown to be more likely to suffer from a mood disorder.[] Adults with ADHD sometimes have co-morbid bipolar disorder, which requires careful assessment to accurately diagnose and treat both conditions.[] Anxiety disorders have been found to occur more commonly in the ADHD population.[] Obsessive-compulsive disorder. OCD can co-occur with ADHD and shares many of its characteristics.[] Substance use disorders. Adolescents and adults with ADHD are at a significantly increased risk of developing a substance abuse problem which can interfere with the evaluation and treatment of ADHD. The reason for this increased risk may be due to an altered reward pathway in the brains of ADHD individuals.[] The most commonly misused substances by the ADHD population are alcohol and cannabis; serious substance misuse problems are usually treated first due to substance use disorders having more serious risks of harm than ADHD,[]:p.38[] with long-term alcohol misuse and long-term cannabis misuse and other drug misuse. Restless legs syndrome has been found to be more common in ADHD affected individuals and is often due to iron deficiency anaemia.[][] However, restless legs can simply be a part of ADHD and requires careful assessment to differentiate between the two disorders.[] Sleep disorders commonly co-exist with ADHD or can be caused by side effects of medications used to treat ADHD; insomnia is the most common sleep disorder found in ADHD children. Behavioural therapy is preferred as a first line treatment of insomnia rather than medication in these children.[][] Melatonin is sometimes used in children who have sleep onset insomnia.[] obstructive sleep apnea syndrome, can be a cause of ADHD type neurocognitive and behavioural impairments in affected children.[] There is a strong association between persistent bed wetting and ADHD[] as well as developmental coordination disorder with up to 50 percent of dyspraxics having ADHD.[] There is an association between ADHD and language

Attention deficit hyperactivity disorder delay.[] Problems with sleep initiation are common among ADHD individuals but often they will be deep sleepers and have significant difficulty getting up in the morning.[]

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Cause
The causes of ADHD remain an area of controversy - risks factors before and around the time of birth such as exposure to lead and other environmental toxins, genetic contributions and social factors have been considered as possible causes. There is evidence that a combination of factors rather than a single cause explains ADHD.[]

Genetics
Twin studies indicate that the disorder is highly heritable and that genetics are a factor in about 75 percent of all cases.[] Environmental factors also contribute to ADHD symptoms. Genetic factors are also believed to be involved in determining whether ADHD persists into adulthood or ends in childhood or adolescence.[] A large majority of cases arise from a combination of various genes, many of which affect dopamine transporters.[] Candidate genes include DAT1, DRD4, DRD5, 5HTT, HTR1B, and SNAP25. There is also strong heterogeneity for the associations between ADHD and DAT1, DRD4, DRD5, dopamine beta hydroxylase, ADRA2A, 5HTT, TPH2, MAOA, and SNAP25.[] A common variant of a gene called LPHN3 is estimated to be responsible for about 9% of the incidence of ADHD, and ADHD cases where this gene is present are particularly responsive to stimulant medication.[]

Executive function
One of the primary neuropsychological theories of ADHD suggests that its symptoms arise from a primary deficit in executive functions.[] Executive functions refers to an array of cognitive processes that are required to regulate, control, and manage daily life tasks.[] The criteria for an executive function deficit are met in 3050% of children and adolescents with ADHD.[14] One study found that 80% of individuals with ADHD were impaired in at least one EF task, compared to 50% for individuals without ADHD.[] Due to the rates of brain maturation and the increasing demands for executive control as a person gets older ADHD impairments may not fully manifest themselves until adolescence or even early adulthood.[] Some of these executive impairments include, problems with organizational skills, time keeping, excessive procrastination, concentration problems, processing speed, regulating emotions. Other problems include utilizing working memory and short-term memory problems. - however, some ADHD people display a remarkable long-term memory. ADHD individuals also display impulsivity in decision making and often jump to inaccurate conclusions. Some people with ADHD display impairments with recognizing when they have hurt other people's feelings and fail to adjust their behavior accordingly. People without ADHD experience some of these impairments as well but it is the duration and frequency of these impairments which differentiates between people with ADHD versus people without ADHD. Individuals with ADHD can focus intently on a task which has strong personal meaning to the ADHD affected individual or if the task has been left to the last minute. Outside observers sometimes misinterpret this as evidence that the person is not impaired by ADHD and fail to understand that the reason for this is because the brain in the ADHD individual is stimulating itself under certain circumstance enough to overcome these executive impairments.[]

Attention deficit hyperactivity disorder

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Evolution
Researchers have proposed that the high prevalence of ADHD - more than 1 percent of the population - may be due to natural selection having favoured ADHD, possibly because the individual traits may be beneficial on their own, and only become dysfunctional when these traits combine to form ADHD.[] The high prevalence of ADHD may in part be because women in general are more attracted to males who are risk takers, thereby promoting ADHD in the gene pool.[] More recent research suggests that because it is more common in the children of anxious or stressed mothers, ADHD primes a child to face a stressful or dangerous environment withfor exampleincreased impulsivity and explorative behaviour.[] Further evidence that hyperactivity might be evolutionarily beneficial was put forth in a 2006 study finding that it may carry specific benefits for certain forms of society. In these societies, those with ADHD are hypothesized to have been more proficient in tasks involving risk, competition, and/or unpredictable behavior (i.e. exploring new areas, finding new food sources, etc.), where these societies may have benefited from confining impulsive or unpredictable behavior to a small subgroup. In these situations, ADHD would have been beneficial to society as a whole even while severely detrimental to the individual.[] However, some research suggests that ADHD itself in certain environments is a distinct advantage to the individual such as a more quick response to predators, superior hunting skills, better movement and settling skills among other benefits.[15] A genetic variant associated with ADHD (DRD4 48bp VNTR 7R allele) has been found to be at higher frequency in more nomadic populations and those with more of a history of migration.[] Consistent with this, another group of researchers observed that the health status of nomadic Ariaal men was higher if they had the ADHD associated genetic variant (7R alleles). However in recently sedentary (non-nomadic) Ariaal those with 7R alleles seemed to have slightly worse health.[16]

Environmental
ADHD is predominantly a genetic disorder with environmental factors contributing a small role to the etiology of ADHD. Twin studies have shown that ADHD is largely genetic with 76 percent of the phenotypic variance being explained by inherited genetic factors.[][] Alcohol intake during pregnancy can cause the child to have a fetal alcohol spectrum disorder which can include symptoms similar to ADHD.[] Exposure to tobacco smoke during pregnancy impairs normal development of the foetus including the central nervous system and can increase the risk of the child being diagnosed with ADHD.[] Many children exposed to tobacco do not develop ADHD or else only have mild symptoms which do not reach the threshold of a diagnosis of ADHD. A combination of a genetic vulnerability to developing ADHD as well as the toxic developmental effects of tobacco on the foetus explain why some children exposed to tobacco smoke in utero develop ADHD and others do not.[17] Children exposed to lead, even relatively low levels of lead develop neurocognitive deficits which resemble ADHD and these children can fulfill the diagnostic criteria for ADHD. There is also some evidence that exposure to polychlorinated biphenyls during childhood causes developmental damage and can cause ADHD type symptoms which are then diagnosed as ADHD.[] Exposure to the organophosphate insecticides chlorpyrifos and dialkyl phosphate is associated with an increased risk; however, the evidence is not definitive as 5 of 17 studies failed to find an association.[] Very low birth weight, premature birth and exceptional early adversity increase the risk of the child having ADHD.[] At least 30 percent of children who experience a pediatric traumatic brain injury develop ADHD.[] Infections during pregnancy, at birth, and in early childhood are linked to an increased risk of developing ADHD. These include various viruses (measles, varicella, rubella, enterovirus 71) and streptococcal bacterial infection.[18]

Attention deficit hyperactivity disorder Diet According to one researcher, Weiss, concerns were first raised by Benjamin Feingold, a pediatric allergist, that food colourings and additives may affect children's behaviour in 1973. There is evidence suggesting that some food colourings may make some children hyperactive. However, the evidence for a link between food colourings and hyperactive behaviour remains uncertain. The FDA interpreted the evidence as being inconclusive as to whether food colours caused hyperactivity or not. The FDA review of food colours has been criticised for only doing a very narrow investigation into food colourings and their possible association with causing hyperactivity instead of investigating their possible effect on neurobehaviour in general.[] It is possible that certain food colourings act as a trigger for ADHD symptoms in subgroup of children who have a genetic vulnerability. The U.K, followed by the European Union as a whole, took regulatory action on food colourings due to concerns about their possible adverse effects in children.[] According to the Food Standards Agency, the food regulatory agency in the UK, food manufacturers were encouraged to voluntarily phase out the use of most artificial food colors by the end of 2009. Sunset yellow FCF (E110), quinoline yellow (E104), carmoisine (E122), allura red (E129), tartrazine (E102) and ponceau 4R (E124) are collectively called the "Southampton six". Following the FSA's actions, the European Food Safety Authority ruled that any food products containing the contentious colourings must display warning labels on their packaging by 2010.[19]

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Social
The World Health Organization states that the diagnosis of ADHD can represent family dysfunction or inadequacies in the educational system rather than individual psychopathology.[20] Other researchers believe that relationships with caregivers have a profound effect on attentional and self-regulatory abilities. A study of foster children found that a high number of them had symptoms closely resembling ADHD.[21] Researchers have found behavior typical of ADHD in children who have suffered violence and emotional abuse.[] Social construction theory states that it is societies that determine where the line between normal and abnormal behavior is drawn. Thus society members including physicians, parents, teachers, and others are the ones who determine which diagnostic criteria are applied and, thus, determine the number of people affected.[22] This is exemplified in the fact that the DSM IV arrives at levels of ADHD three to four times higher than those obtained with use of the ICD 10.[] Thomas Szasz, a proponent of this theory, has argued that ADHD was "invented and not discovered."[23][24]

Pathophysiology
The pathophysiology of ADHD is unclear and there are a number of competing theories.[] Research on children with ADHD has shown a general reduction of brain volume, but with a proportionally greater reduction in the volume of the left-sided prefrontal cortex. These findings suggest that the core ADHD features of inattention, hyperactivity, and impulsivity may reflect frontal lobe dysfunction, but other brain regions in particular the cerebellum have also been implicated.[25] Neuroimaging studies in ADHD have not always given consistent results and as of 2008 are used only for research and not Diagram of the human brain diagnostic purposes.[26] Research using neuroimaging, neuropsychological genetics, and neurochemistry has found converging lines of evidence to suggest that a main brain system connecting the prefrontal cortex and the striatum is involved in the pathophysiology of ADHD. Nevertheless other brain systems related to attentional, but also other more basic cognitive processes, have also been found to differ between ADHD patients and healthy controls.[][]

Attention deficit hyperactivity disorder Previously it was thought that the elevated number of dopamine transporters seen in ADHD patients was part of the pathophysiology of ADHD but it now appears that the reason for elevated striatal dopamine transporter density in ADHD individuals is due to neuroadaptations occurring due to the continuous exposure to stimulants such as methylphenidate or dexamphetamine as the body tries to counter-act the effects of the stimulants by developing a tolerance to the stimulant medications.[] There is evidence that people with ADHD have a low arousal threshold and compensate for this with increased stimuli, which in turn results in disruption of attentional capacity and an increase in hyperactive behaviour. The reason for this is due to abnormalities in how the dopamine system in central nervous system responds to stimuli.[27] However, abnormalities in the dopamine system alone do not explain ADHD abnormalities in the functioning of adrenergic, serotoninergic and cholinergic or nicotinergic pathways can also be present and contribute to the pathophysiology of ADHD.[][]

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Diagnosis
ADHD is diagnosed via an assessment of a person's childhood behavioral and cognitive development; this assessment includes ruling out the effects of drugs, medications and other medical or psychiatric disorders as possible explanations for the signs and symptoms.[]:p.1927 It often takes into account feedback from both parents and teachers.[] Whether or not someone responds to medications does not confirm the diagnosis.[] Children with behavioral symptoms of ADHD which do not cause significant problems compared to their age-matched peers do not have ADHD.[] In North America, the DSM-IV criteria are often the basis for a diagnosis, while European countries usually use the ICD-10. If the DSM-IV criteria are used, rather than the ICD-10, a diagnosis of ADHD is 34 times more likely.[] Standardized rating scales can be used for screening and assessment of severity.[28] Factors other than those within the DSM or ICD have been found to affect the diagnosis in clinical practice. For example, a study found that the youngest children in a class are much more likely to be diagnosed as having ADHD compared to their older counterparts in the same year. This because younger children typically have greater hyperactivity, not because they necessarily have ADHD. It is estimated that about 20 percent of children given a diagnosis of ADHD are misdiagnosed because of the month they were born.[] The previously-used term ADD is not used in the most recent versions of the DSM, with ADHD being the current name used to describe the disorder.[]

Classification
ADHD may be seen as one or more continuous traits found normally throughout the general population.[] However, the definition of ADHD is based on behaviour and it does not imply a neurological disease.[] ADHD is a psychiatric disorder[] of the neurodevelopmental disorder class.[] It is additionally classified as a disruptive behavior disorder along with oppositional defiant disorder, conduct disorder and antisocial personality disorder.[] The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) classifies ADHD according to the predominance of symptoms of: 1. Inattention; 2. Hyperactivityimpulsivity; 3. or a combination of both (Combined type).[] This subdivision is based on presence of at least six out of nine long-term maladaptive symptoms (lasting at least 6 months) of either inattention, hyperactivityimpulsivity, or both. Thus, a child who is diagnosed with the inattention subtype may also show signs of hyperactivityimpulsivity, and vice-versa. To be considered, the symptoms must have appeared before the age of 6, manifest in more than one environment (e.g. at home and at school or work), and not be better explained by another mental disorder.[] Most children with ADHD have the combined type. Children with the inattention subtype are less likely to act out or have difficulties getting along with other children. They may sit quietly, but without paying attention to what they

Attention deficit hyperactivity disorder are doing. Therefore, the child may be overlooked, and parents and teachers may not notice symptoms of ADHD.[]

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Diagnostic and Statistical Manual


As with many other psychiatric and medical disorders, the formal diagnosis is made by a qualified professional in the field based on a set number of criteria. In the USA these criteria are laid down by the American Psychiatric Association in their Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Based on the DSM-V criteria listed below, three types of ADHD are classified:[] 1. ADHD, Combined Type is a combination of the two other ADHD subtypes.[] 2. ADHD Predominantly Inattentive Type presents with symptoms including being easily distracted, forgetful, daydreaming, disorganisation, poor concentration, and difficulty completing tasks.[] 3. ADHD, Predominantly Hyperactive-Impulsive Type presents with excessive fidgetiness and restlessness, hyperactivity, difficulty waiting and remaining seated, immature behaviour; destructive behaviors may also be present.[] For a diagnosis of ADHD to be made the signs must present before the age of 12 years old and be developmentally inappropriate for a child of that age. Additionally the signs cannot be due to the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and the signs are not better accounted for by another mental disorder (such as mood disorder, anxiety disorder, dissociative identity disorder, or a personality disorder).[] Finally having ADHD symptoms/traits on their own is insufficient for a diagnosis to be made - there must be clear evidence that the ADHD symptoms cause social, academic and occupational impairments.[]

International Classification of Diseases


In the tenth edition of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) the signs of ADHD are given the name "hyperkinetic disorders". When a conduct disorder (as defined by ICD-10[]) is present, the condition is referred to as "hperkinetic conduct disorder". Otherwise the disorder is classified as "disturbance of activity and attention", "other hyperkinetic disorders" or "hyperkinetic disorders, unspecified". The latter is sometimes referred to as, "hyperkinetic syndrome".[]

Other guidelines
The American Academy of Pediatrics' clinical practice guideline for children and adolescents with ADHD recommends the following:[] ADHD should be considered as a possible diagnosis in children and adolescents 418 years old who present with academic or behavioural problems of hyperactivity, impulsiveness and inattention. To aid in the diagnosis the DSM IV should be used in combination with gathering evidence from family members, guardians, teachers and mental health workers who know the child or adolescent. Before making a diagnosis causes for the symptoms other than ADHD should be considered. Co-morbid disorders such as anxiety, depression, oppositional defiant disorder, and conduct disorder, as well as learning and language disorders which often co-exist with ADHD should be looked for. Additionally, other neurodevelopmental disorders, as well as tics, sleep apnea should be screened for. Finally, the guidance recommends when substance use disorders are present that these are treated first before the ADHD and given priority. ADHD should be viewed as a chronic disorder that has special healthcare needs and treatments which can include behavioural, pharmacological or a combination of both, and should take into consideration the age of the patient. Adults often continue to be impaired by ADHD. Adults with ADHD are diagnosed under the same criteria, including the stipulation that their signs must have been present prior to the age of seven. Questioning parents or guardians as to how the person behaved and developed as a child also forms part of the clinical assessment of the individual; a

Attention deficit hyperactivity disorder family history of ADHD also adds weight to a diagnosis of adult ADHD due the strong heritability of ADHD.[] While the core symptoms of ADHD are similar in children and adults they often present differently in adults than in children, for example excessive physical activity seen in children may present as feelings of restlessness and constant mental activity in adults.[] The American Academy of Child and Adolescent Psychiatry (AACAP) considers it necessary that the following be present before attaching the label of ADHD to a child:[] The behaviors must appear before age 7. They must continue for at least six months. The symptoms must also create a real handicap in at least two of the following areas of the child's life: in the classroom, on the playground, at home, in the community, or in social settings.

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If a child seems too active on the playground but not elsewhere, the problem might not be ADHD. It might also not be ADHD if the behaviors occur in the classroom but nowhere else. A child who shows some symptoms would not be diagnosed with ADHD if his or her schoolwork or friendships are not impaired by the behaviors.[]

Differential
[] ADHD symptoms which are related to other disorders Depression feelings of guilt, hopelessness, low self-esteem, pessimism, unhappiness, or worthlessness Anhedonia or loss of interest in hobbies, regular activities, sex, or work fatigue Sleep problems including insomnia, dyssomnia, or hypersomnia difficulty maintaining attentional control change in appetite Irritability or hostility low tolerance for stress thoughts of death or suicidal ideation unexplained pain or symptoms unresponsive to treatment, such as headache or dyspepsia Anxiety disorder worry or any persistent feeling of anxiety experienced daily for 36 months Irritability occasional feelings of panic, fear, or angst inability to relax being hyperalert inability to pay attention tire easily low tolerance for stress difficulty maintaining attentional control Mania excessive happiness, euphoria, or exhuberance Hyperactivity Racing thoughts Aggression excessive talking Grandiose delusions decreased need for sleep inappropriate social behavior difficulty maintaining attentional control

Symptoms of ADHD such as low mood and poor self-image, mood swings, and irritability can be confused with dysthymia, cyclothymia or bipolar disorder as well as with borderline personality disorder.[] Some of the symptoms that are due to anxiety disorders, antisocial personality disorder, developmental disabilities or mental retardation or the effects of substance abuse such as intoxication and withdrawal symptoms can overlap with some ADHD symptoms. These various disorders which can mimic some ADHD symptoms, sometimes occur along with ADHD. Medical conditions which can cause ADHD type symptoms and require consideration for a differential diagnosis include hyperthyroidism, seizure disorder, lead toxicity, hearing deficits, hepatic disease, sleep apnea, drug interactions, and head injury.[] Primary sleep disorders play a role in symptoms of inattention and behavioral dysregulation. There are multilevel and bidirectional relationships among sleep, neurobehavioral functioning and the clinical syndrome of ADHD.[]

Attention deficit hyperactivity disorder Many sleep disorders are important causes of symptoms that may overlap with the core symptoms of ADHD; children with ADHD should be regularly and systematically assessed for sleep problems.[][29] Behavioral manifestations of sleepiness in children range from the classic ones (yawning, rubbing eyes), to externalizing behaviors (impulsivity, hyperactivity, aggressiveness), to mood lability and inattentiveness.[][30] Obstructive sleep apnea syndrome, can be a cause of ADHD type neurocognitive and behavioural impairments in affected children.[]

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Management
The management of ADHD typically involves psychotherapy or medications either alone or in combination. While treatment may improve long term outcomes it does not get rid of negative outcomes entirely.[31] Medications used include stimulants, atomoxetine, alpha-adrenergic agonists and sometimes antidepressants.[] Medications have at least some effect in about 80% of people.[32] Dietary modifications may also be of benefit[33] with evidence supporting a benefit from free fatty acids and reduced exposure to food coloring.[] Removing other foods from the diet is not currently supported by the evidence.[]

Psychosocial
The evidence is strong for the effectiveness of behavioral treatments in ADHD.[34] It is recommended first line in those who have mild symptoms and in preschool-aged children.[] Psychological therapies used include psychoeducational input, behavior therapy, cognitive behavioral therapy (CBT), interpersonal psychotherapy (IPT), family therapy, school-based interventions, social skills training, parent management training,[] and neurofeedback.[35] Parent training and education have been found to have short-term benefits.[36] There is a deficiency of good research on the effectiveness of family therapy for ADHD, but the evidence that exists shows that it is comparable in effectiveness to treatment as usual in the community and is superior to medication placebo.[37] Several ADHD specific support groups exist as informational sources and to help families cope with ADHD.

Medication
Stimulant medications are the pharmaceutical treatment of choice.[] There are a number of non-stimulant medications, such as atomoxetine, that may be used as alternatives.[] There are no good studies of comparative effectiveness between various medications, and there is a lack of evidence on their effects on academic performance and social behaviors.[] While stimulants and atomoxetine are generally safe, there are side-effects and contraindications to their use.[] Medications are not methylphenidate (Ritalin) 10 mg tablets recommended for preschool children, as their long-term effects in such young people are unknown.[][38] Research into the long-term effects of stimulants in ADHD have come to conflicting conclusions with one study finding benefit, another finding no benefit while another finding evidence of harm. The current research has methodological problems and more robust research has been recommended.[] Any drug used for ADHD may have adverse drug reactions such as psychosis and mania,[39] though methylphenidate-induced psychosis is uncommon. Regular monitoring of individuals receiving long-term stimulant therapy for possible treatment emergent psychosis has been recommended.[] Stimulant therapy is recommended to be discontinued periodically during protracted therapy to assess for continuing need for medication.[] Tolerance to the therapeutic effects of stimulants can occur,[] with rebound effects occurring when the dose wears off.[] Therefore due to the risk of discontinuation/rebound effects abrupt withdrawal of stimulants is not recommended.[40] Rebound effects are often the result of the stimulant dosage being too high or the individual not being able to tolerate stimulant medication. Signs that the stimulant dose is too high include irritability, feeling stimulated or blunting of

Attention deficit hyperactivity disorder affect and personality.[] People with ADHD have an increased risk of substance abuse, and research studies have found that stimulant medications reduce this risk or have no effect on substance abuse.[] Additionally, stimulant medications approved for treating ADHD have the potential for abuse and dependence.[41] Atomoxetine due to its lack of abuse potential may be preferred in individuals who are at risk of abusing stimulant medication.[] Guidelines on when to use medications vary internationally, with the UK's National Institute of Clinical Excellence, for example, recommending use only in severe cases, while most United States guidelines recommend medications in nearly all cases.[42] Deficiency in zinc has been associated with inattentive symptoms of ADHD and there is evidence that zinc supplementation can benefit ADHD children who have low zinc levels. There is also some evidence that zinc supplementation can lead to a reduction in the dosage of stimulants.[]

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Prognosis
A large study that followed children diagnosed with ADHD (combined type) over a period of 8 years found that they often have significant difficulties in adolescence, regardless of treatment or lack thereof.[] In the United States, 37 percent of those with ADHD do not get a high school diploma even though many of them will receive special education services.[] Also in the US, less than 5 percent of individuals with ADHD get a college degree[43] compared to 28 percent of the general population aged 25 years and older.[] The proportion of children meeting the diagnostic criteria for ADHD drops by about 50 percent over three years after the diagnosis. This occurs regardless of the treatments used and also occurs in untreated children with ADHD.[44][][] ADHD persists into adulthood in about 30 to 50 percent of cases.[] Those affected are likely to develop coping mechanisms as they mature, thus compensating for their previous ADHD.[]

Epidemiology
ADHD is estimated to affect about 6 to 7 percent of people aged 18 and under when diagnosed via the DSM-IV criteria.[] When diagnosed via the ICD-10 criteria rates in this age group are estimated at between 1 to 2 percent.[] Children in North America appear to have a higher rate of ADHD than children in Africa and the Middle East however, this is believed to be due to differing methods of diagnosis in different areas of the world.[] If the same diagnostic methods are used rates are more or less the same between countries.[45] ADHD is diagnosed approximately three times more commonly in boys than in girls.[][] This difference between genders may reflect either a difference in susceptibility or that females with ADHD are less likely to be diagnosed than males.[46] Rates of ADHD diagnosis and treatment have increased in both the United Kingdom and the United States since the 1970s. This is believed to be primarily due to changes in how the condition is diagnosed[] and how readily people are willing to treat it with medications rather than a true change in the frequency.[] It is believed that the changes to the diagnostic criteria in 2013 with the release of the DSMV will increase the percentage of people with ADHD especially among adults.[47]

History
Hyperactivity has long been part of the human condition. Sir Alexander Crichton describes "mental restlessness" in his book An inquiry into the nature and origin of mental derangement written in 1798.[48][49] ADHD was first described by George Still in 1902.[] The terminology used to describe the condition has changes over time and include: "minimal brain damage", "minimal brain dysfunction" (or disorder) in the DSM-I in the 1950s and 1960s,[] "learning/behavioral disabilities" and "hyperactivity". In the DSM-II (1968) it was the "Hyperkinetic Reaction of Childhood".[] In the DSM-III "ADD (Attention-Deficit Disorder) with or without hyperactivity" was introduced.[] In 1987 this was changed to ADHD in the DSM-III-R and in 1994 the DSM-IV split the ADHD diagnosis into three subtypes, ADHD inattentive type, ADHD hyperactive-impulsive type and ADHD combined type.[50] The use of

Attention deficit hyperactivity disorder stimulants to treat ADHD was first described in 1937.[51] Amphetamines (Benzedrine) was the first medication approved for use in the United States with methyphenidate introduced in the 1950s and dextroamphetamine (Dexadrine) in the 1970s.[]

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Society and culture


A number of notable individuals have given controversial opinions on ADHD. Scientologist Tom Cruise has referred to the ADHD medications Ritalin and Adderall as being "street drugs" - this viewpoint (as well as his other viewpoints on psychiatry) has received criticism - for example the doses of stimulants used in the treatment of ADHD do not cause behavioural addiction and there is some evidence of a reduced risk of later substance addiction in children who had their ADHD treated with stimulants.[] In England Baroness Susan Greenfield, a leading neuroscientist, spoke out publicly in 2007 in the House of Lords about the need for a wide-ranging inquiry into the dramatic increase in the diagnosis of ADHD in the UK and possible causes following a BBC Panorama programme that highlighted US research (The Multimodal Treatment Study of Children with ADHD by the University of Buffalo) suggesting drugs are no better than other forms of therapy for ADHD in the long term.[52] However, in 2010 the BBC Trust criticized the 2007 BBC Panorama programme for summarizing the US research as showing "no demonstrable improvement in children's behaviour after staying on ADHD medication for three years" when in actuality "the study found that medication did offer a significant improvement over time" although the long-term benefits of medication were found to be "no better than children who were treated with behaviour therapy."[53] As of 2009[54], eight percent of all US Major League Baseball players had been diagnosed with ADHD, making the disorder common among this population. The increase coincided with the League's 2006 ban on stimulants which has raised concern that some players are mimicking the symptoms of ADHD to get around the ban on the use of stimulants in sport.[55]

Controversies
ADHD and its diagnosis and treatment have been considered controversial since the 1970s.[][][56] The controversies have involved clinicians, teachers, policymakers, parents and the media. Opinions regarding ADHD range from not believing it exists at all[]:p.23[] to believing there are genetic and physiological bases for the condition as well as disagreement about the use of stimulant medications in treatment.[][] Some sociologists consider ADHD to be a "classic example of the medicalization of deviant behavior, defining a previously nonmedical problem as a medical one".[] Most healthcare providers accept that ADHD is a genuine disorder with debate in centering mainly around how it is diagnosed and treated.[][][] Possible overdiagnosis of ADHD, the use of stimulant medications in children, and the methods by which ADHD is diagnosed and treated are some of the main areas of controversy.[57] Possible long-term side-effects of stimulants and their usefulness are largely unknown because of a lack of long-term studies.[58] Some research raises questions about the long-term effectiveness and side-effects of medications used to treat ADHD.[59] With a "wide variation in diagnosis across states, races, and ethnicities" some investigators suspect that factors other than neurological conditions play a role when the diagnosis of ADHD is made.[]

Special populations
Adults
Between 2 and 5 percent of adults have ADHD.[] Around two thirds of ADHD children continue to have ADHD as adults, however, not all of these children will continue to have the full disorder. About 15 percent of ADHD children continue to have the full ADHD disorder as adults whereas 50 percent partially 'grow out' of it with the remainder not displaying ADHD symptomatology as adults.[] Most adults, however, remain untreated.[] Untreated adults with ADHD often have chaotic lifestyles, may appear to be disorganized and may rely on non-prescribed drugs and

Attention deficit hyperactivity disorder alcohol to get by.[] Other problems include relationship and job difficulties, and an increased propensity to become involved in criminal activities.[] They often have such associated psychiatric comorbidities as depression, anxiety disorder, substance abuse, or a learning disability.[] Some ADHD symptoms in adults differ from those seen in children for example whereas children with ADHD may climb and run about excessively, adults may experience an inability to relax and talk excessively in social situations. Adults with ADHD may start relationships impulsively and may display sensation seeking behaviour and be short-tempered. Addictive behaviour such as substance abuse and gambling are also very common. The DSM-IV criteria have been criticised for not being developmentally appropriate for adults as these impairments present differently to children thus leading to claims that adults are outgrowing the diagnostic criteria rather than the ADHD disorder itself and thus are not being properly diagnosed.[]

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High IQ children
The diagnosis of ADHD and the significance of its impact in children with a high intelligence quotient (IQ) has been controversial.[] Most studies have shown a similar profile of functional impairments to that found in ADHD children with a normal IQ.[] When compared with children without ADHD evidence supports an increased likelihood of repeating grades and more social and functional impairments. Additionally, more than half of high IQ ADHD people experience major depressive disorder or oppositional defiant disorder at some point in their lives. Generalised anxiety disorder, separation anxiety disorder and social phobia are also more common. However, there is some evidence that high IQ ADHD individuals have a lowered risk of substance abuse and anti-social behaviour compared to low and average IQ ADHD young people.[] Regarding testing, high IQ children and adolescents with ADHD can have their intelligence level missed when a standard evaluation is performed; high IQ ADHD people tend to require more comprehensive testing to detect their true intelligence level.[]

References
[1] http:/ / apps. who. int/ classifications/ icd10/ browse/ 2010/ en#/ F90 [2] http:/ / www. icd9data. com/ getICD9Code. ashx?icd9=314. 00 [3] http:/ / www. icd9data. com/ getICD9Code. ashx?icd9=314. 01 [4] http:/ / omim. org/ entry/ 143465 [5] http:/ / www. diseasesdatabase. com/ ddb6158. htm [6] http:/ / www. nlm. nih. gov/ medlineplus/ ency/ article/ 001551. htm [7] http:/ / www. emedicine. com/ med/ topic3103. htm [8] http:/ / www. emedicine. com/ ped/ topic177. htm# [9] http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2013/ MB_cgi?field=uid& term=D001289 [54] http:/ / en. wikipedia. org/ w/ index. php?title=Attention_deficit_hyperactivity_disorder& action=edit

External links
Attention deficit hyperactivity disorder (http://www.dmoz.org/Mental_Health/Disorders/ Neurodevelopmental/ADD_and_ADHD//) at the Open Directory Project National Institute of Mental Health on ADHD (http://www.nimh.nih.gov/topics/topic-page-adhd.shtml) "CG72 Attention deficit hyperactivity disorder (ADHD): full guideline" (http://www.nice.org.uk/nicemedia/ pdf/ADHDFullGuideline.pdf) (PDF). NHS. 9 March 2009. Retrieved 2009-01-08. New Zealand MOH Guidelines for the Assessment and Treatment of Attention-Deficit/Hyperactivity Disorder (http://www.moh.govt.nz/moh.nsf/c7ad5e032528c34c4c2566690076db9b/ 4e1c3cddf420bcaecc256a8e007f12d9/$FILE/ADHDGuidelines.pdf)

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Activities of daily living


Disability

Disability portal Category: Disability Category: Disability lists

Activities of daily living (ADLs) is a term used in healthcare to refer to daily self-care activities within an individual's place of residence, in outdoor environments, or both. Health professionals routinely refer to the ability or inability to perform ADLs as a measurement of the functional status of a person, particularly in regards to people with disabilities and the elderly.[1] Younger children often require help from adults to perform ADLs, as they have not yet developed the skills necessary to perform them independently. ADLs are defined as "the things we normally do...such as feeding ourselves, bathing, dressing, grooming, work, homemaking, and leisure."[2] A number of national surveys collect data on the ADL status of the U.S. population.[3] While basic categories of ADLs have been suggested, what specifically constitutes a particular ADL in a particular environment for a particular person may vary.

Basic ADLs
Basic ADLs (BADLs) consist of self-care tasks, including:[] Bathing and showering (washing the body) Bowel and bladder management (recognizing the need to relieve oneself) Dressing Eating (including chewing and swallowing) Feeding (setting up food and bringing it to the mouth) Functional mobility (moving from one place to another while performing activities) Personal device care Personal hygiene and grooming (including washing hair) Sexual activity Toilet hygiene (completing the act of relieving oneself)

Although not in wide general use, one mnemonic that some consider useful is DEATH: dressing, eating, ambulating (walking), toileting, hygiene.[]

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Instrumental ADLs
Instrumental activities of daily living (IADLs) are not necessary for fundamental functioning, but they let an individual live independently in a community:[4] Housework Taking medications as prescribed Managing money Shopping for groceries or clothing Use of telephone or other form of communication Using technology (as applicable) Transportation within the community is SHAFT: shopping, housekeeping, accounting, food preparation/meds,

A useful mnemonic telephone/transportation.

Occupational therapists often evaluate IADLs when completing patient assessments. The American Occupational Therapy Association identifies 12 types of IADLs that may be performed as a co-occupation with others:[] Care of others (including selecting and supervising caregivers) Care of pets Child rearing Communication management Community mobility Financial management Health management and maintenance Home establishment and maintenance Meal preparation and cleanup Religious observances Safety procedures and emergency responses Shopping

Evaluation of ADLs
There are several evaluation tools, such as the Katz ADL scale,[5] the Lawton IADL scale.[6] and the Bristol Activities of Daily Living Scale. Most models of health care service use ADL evaluations in their practice, including the medical (or institutional) models, such as the Roper-Logan-Tierney model of nursing, and the resident-centered models, such as the Program of All-Inclusive Care for the Elderly (PACE).

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References
[1] "Activities of Daily Living Evaluation." Encyclopedia of Nursing & Allied Health. ed. Kristine Krapp. Gale Group, Inc., 2002. eNotes.com. 2006. Enotes Nursing Encyclopedia (http:/ / www. enotes. com/ nursing-encyclopedia/ activities-daily-living-evaluation) Accessed on: 11 Oct, 2007 [2] MedicineNet.com Medical Dictionary (http:/ / www. medterms. com/ script/ main/ art. asp?articlekey=2152) [3] National Center for Health Statistics (http:/ / www. cdc. gov/ nchs/ datawh/ nchsdefs/ ADL. htm) [4] Bookman, A., Harrington, M., Pass, L., & Reisner, E. (2007). Family Caregiver Handbook. Cambridge, MA: Massachusetts Institute of Technology. [5] Katz ADL scale (http:/ / son. uth. tmc. edu/ coa/ FDGN_1/ RESOURCES/ ADLandIADL. pdf) [6] Lawton IADL scale (http:/ / www. abramsoncenter. org/ PRI/ documents/ IADL. pdf)

Adverse drug reaction

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Adverse drug reaction


Adverse drug reaction
Classification and external resources

Adverse drug reaction leading to hepatitis (drug-induced hepatitis) with granulomata. Other causes were excluded with extensive investigations. Liver biopsy. H&E stain. ICD-10 ICD-9 DiseasesDB MeSH T88.7 995.2 295 [1] [4] , Y40 [2] -Y59 [3] [6]

, E850

[5]

-E858

[7] [8]

D004362

An adverse drug reaction (abbreviated ADR) is an expression that describes harm associated with the use of given medications at a normal dosage during normal use. ADRs may occur following a single dose or prolonged administration of a drug or result from the combination of two or more drugs. The meaning of this expression differs from the meaning of "side effect", as this last expression might also imply that the effects can be beneficial.[] The study of ADRs is the concern of the field known as pharmacovigilance. An adverse drug event (abbreviated ADE) refers to any injury caused by the drug (at normal dosage and/or due to overdose) and any harm associated with the use of the drug (e.g. discontinuation of drug therapy).[9] ADRs are a special type of ADEs.

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Classification
ADRs may be classified by e.g. cause and severity.

Cause
Type A: Augmented pharmacologic effects - dose dependent and predictable Intolerance Side Effects Type B: Bizarre effects (or idiosyncratic) - dose independent and unpredictable Type C: Chronic effects Type D: Delayed effects Type E: End-of-treatment effects Type F: Failure of therapy Type G: Genetic reactions Type I: Idiosyncratic

Types A and B were proposed in the 1970s,[10] and the other types were proposed subsequently when the first two proved insufficient to classify ADRs.[11]

Seriousness and severity


The American Food and Drug Administration defines a serious adverse event as one when the patient outcome is one of the following:[12] Death Life-threatening Hospitalization (initial or prolonged) Disability - significant, persistent, or permanent change, impairment, damage or disruption in the patient's body function/structure, physical activities or quality of life. Congenital anomaly Requires intervention to prevent permanent impairment or damage Severity is a point on an arbitrary scale of intensity of the adverse event in question. The terms "severe" and "serious" when applied to adverse events are technically very different. They are easily confused but can not be used interchangeably, requiring care in usage. A headache is severe, if it causes intense pain. There are scales like "visual analog scale" that help usWikipedia:Avoid weasel words assess the severity. On the other hand, a headache is not usually serious (but may be in case of subarachnoid haemorrhage, subdural bleed, even a migraine may temporally fit criteria), unless it also satisfies the criteria for seriousness listed above.

Overall Drug Risk


While no official scale exists yet to communicate overall drug risk, the iGuard Drug Risk Rating System is a five color rating scale similar to the Homeland Security Advisory System:[13] Red (high risk) Orange (elevated risk) Yellow (guarded risk) Blue (general risk)

Green (low risk)

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Location
Adverse effects may be local, i.e. limited to a certain location, or systemic, where a medication has caused adverse effects throughout the systemic circulation. For instance, some ocular antihypertensives cause systemic effects,[14] although they are administered locally as eye drops, since a fraction escapes to the systemic circulation.

Mechanisms
As research better explains the biochemistry of drug use, fewer ADRs are Type B and more are Type A. Common mechanisms are: Abnormal pharmacokinetics due to genetic factors comorbid disease states Synergistic effects between either a drug and a disease two drugs

Abnormal pharmacokinetics
Comorbid disease states Various diseases, especially those that cause renal or hepatic insufficiency, may alter drug metabolism. Resources are available that report changes in a drug's metabolism due to disease states.[15] Genetic factors Abnormal drug metabolism may be due to inherited factors of either Phase I oxidation or Phase II conjugation.[][] Pharmacogenomics is the study of the inherited basis for abnormal drug reactions. Phase I reactions Inheriting abnormal alleles of cytochrome P450 can alter drug metabolism. Tables are available to check for drug interactions due to P450 interactions.[][] Inheriting abnormal butyrylcholinesterase (pseudocholinesterase) may affect metabolism of drugs such as succinylcholine[] Phase II reactions Inheriting abnormal N-acetyltransferase which conjugated some drugs to facilitate excretion may affect the metabolism of drugs such as isoniazid, hydralazine, and procainamide.[][] Inheriting abnormal thiopurine S-methyltransferase may affect the metabolism of the thiopurine drugs mercaptopurine and azathioprine.[] Interactions with other drugs The risk of drug interactions is increased with polypharmacy.

Adverse drug reaction Protein binding These interactions are usually transient and mild until a new steady state is achieved.[][16] These are mainly for drugs without much first-pass liver metabolism. The principal plasma proteins for drug binding are:[] 1. albumin 2. 1-acid glycoprotein 3. lipoproteins Some drug interactions with warfarin are due to changes in protein binding.[] Cytochrome P450 Patients have abnormal metabolism by cytochrome P450 due to either inheriting abnormal alleles or due to drug interactions. Tables are available to check for drug interactions due to P450 interactions.[]

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Synergistic effects
An example of synergism is two drugs that both prolong the QT interval.

Assessing causality
Causality assessment is used to determine the likelihood that a drug caused a suspected ADR. There are a number of different methods used to judge causation, including the Naranjo algorithm, the Venulet algorithm and the WHO causality term assessment criteria. Each have pros and cons associated with their use and most require some level of expert judgement to apply.[17] An ADR should not be labeled as 'certain' unless the ADR abates with a challenge-dechallenge-rechallenge protocol (stopping and starting the agent in question). The chronology of the onset of the suspected ADR is important, as another substance or factor may be implicated as a cause; co-prescribed medications and underlying psychiatric conditions may be factors in the ADR. A simple scale is available at http:/ / annals.org/cgi/content/full/140/10/795 [18].[] Assigning causality to a specific agent often proves difficult, unless the event is found during a clinical study or large databases are used. Both methods have difficulties and can be fraught with error. Even in clinical studies some ADRs may be missed as large numbers of test individuals are required to find that adverse drug reaction. Psychiatric ADRs are often missed as they are grouped together in the questionnaires used to assess the population.[][]

Monitoring bodies
Many countries have official bodies that monitor drug safety and reactions. On an international level, the WHO runs the Uppsala Monitoring Centre, and the European Union runs the European Medicines Agency (EMEA). In the United States, the Food and Drug Administration (FDA) is responsible for monitoring post-marketing studies. In Canada, the Marketed Health Products Directorate of Health Canada is responsible for the surveillance of marketed health products.

Examples of adverse effects associated with specific medications

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Condition Abortion, miscarriage or uterine hemorrhage

Substance misoprostol, a labor-inducing drug (this is a case where the adverse effect has been used legally and illegally for performing abortions) many sedatives and analgesics such as diazepam, morphine, etc. thalidomide and isotretinoin aspirin therapy COX-2 inhibitors (i.e. rofecoxib) gentamicin (an antibiotic) propofol interferon tetrabenazine, rimonabant and other CB1 antagonists orlistat many drugs, such as antidepressants vaccination (in the past, imperfectly manufactured vaccines, such as BCG and poliomyelitis, have caused the very disease they intended to fight). acarbose corticosteroid-based eye drops chemotherapy against cancer, leukemia, etc. spinal anesthesia ephedrine users, which prompted FDA to remove the status of dietary supplement of ephedra extracts atypical antipsychotic medications, such as clozapine and olanzapine stimulants (e.g. methylphenidate, amphetamine, etc.) indinavir, carbonic anhydrase inhibitors (such as topiramate) stavudine (an antiretroviral drug) or metformin (oral anti-diabetic medication) paracetamol estrogen-containing hormonal contraception such as the combined oral contraceptive pill dopamine agonists

Addiction Birth defects Bleeding of the intestine Cardiovascular disease Deafness and kidney failure Death, following sedation Depression or hepatic injury Depression Diarrhea Erectile dysfunction Fever

Flatulence Glaucoma Hair loss and anemia Headache Hypertension

Impaired glucose tolerance and diabetes Insomnia Kidney stones Lactic acidosis Liver failure Melasma and thrombosis Pathological addiction, like gambling, shopping; sexual and other intense urges Irreversible Peripheral neuropathy Rhabdomyolysis Seizures Stroke or heart attack Suicide, increased tendency Parkinsonism Tardive dyskinesia Spontaneous Tendon rupture

fluoroquinolone medications

[19][20][21]

statins (a class of lipid-lowering drugs) withdrawal from benzodiazepines sildenafil when used with nitroglycerine; COX-2 inhibitors antidepressants MPTP, a meperidine related drug considered highly neurotoxic long-term use of metoclopramide, cinnarizine and many antipsychotic medications fluoroquinolone drugs [23] terminated. [22] even occurring as late as 6 months after treatment had been

Weight loss Weight gain

some antidepressants, like fluoxetine and bupropion some antipsychotics (e.g. olanzapine and clozapine) and antidepressants (mirtazapine)

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References
[1] http:/ / apps. who. int/ classifications/ icd10/ browse/ 2010/ en#/ T88. 7 [2] http:/ / apps. who. int/ classifications/ icd10/ browse/ 2010/ en#/ Y40 [3] http:/ / apps. who. int/ classifications/ icd10/ browse/ 2010/ en#/ Y59 [4] http:/ / www. icd9data. com/ getICD9Code. ashx?icd9=995. 2 [5] http:/ / www. icd9data. com/ getICD9Code. ashx?icd9=E850 [6] http:/ / www. icd9data. com/ getICD9Code. ashx?icd9=E858 [7] http:/ / www. diseasesdatabase. com/ ddb295. htm [8] http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2013/ MB_cgi?field=uid& term=D004362 [10] Rawlins MD, Thompson JW. Pathogenesis of adverse drug reactions. In: Davies DM, ed. Textbook of adverse drug reactions. Oxford: Oxford University Press, 1977:10. [11] Aronson JK. Drug therapy. In: Haslett C, Chilvers ER, Boon NA, Colledge NR, Hunter JAA, eds. Davidson's principles and practice of medicine 19th ed. Edinburgh: Elsevier Science, 2002:147[14] Page 146 [16] OVID full text (http:/ / gateway. ovid. com/ ovidweb. cgi?T=JS& PAGE=linkout& SEARCH=11907485. ui) summary table at OVID (http:/ / gateway. ovid. com/ ovidweb. cgi?T=JS& NEWS=N& PAGE=image& IMAGE=00003098-200203000-00001|TT2& D=ovft) [18] http:/ / annals. org/ cgi/ content/ full/ 140/ 10/ 795#T2

External links
Research and Report Adverse Drug Events at RxISK.org (http://RxISK.org) ADR online tools (http://farmacologiaclinica.info/scoring-tools/files/category-clinical-pharmacology.html) Drug Toxicity (Citizendium) (http://en.citizendium.org/wiki/Drug_toxicity)

American Dental Society of Anesthesiology

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American Dental Society of Anesthesiology


American Dental Society of Anesthesiology
Formation Type Headquarters Location Membership Officiallanguages Website 1953 Professional association Chicago, Illinois United States 4,500 English adsahome.org [1]

The American Dental Society of Anesthesiology (ADSA) is an American professional association established in 1953 and based in Chicago.

Mission
The mission of the American Dental Society of Anesthesiology is to provide a forum for education, research, and recognition of achievement in order to promote safe and effective patient care for all dentists who have an interest in anesthesiology, sedation and the control of anxiety and pain.[2]

Publications
The ADSA publishes a quarterly scientific journal of dental sedation and anesthesia related articles named Anesthesia Progress: A Journal for Pain and Anxiety Control in Dentistry [3]. Anesthesia Progress is the official journal of the American Dental Society of Anesthesiology and has been published quarterly since 1954.[52] This peer-reviewed journal also serves as the official umbrella journal for: the American Society of Dentist Anesthesiologists, the Australian Society of Dental Anesthesiology, the Canadian Society of Dental Anesthesia, the European Federation for the Advancement of Anesthesia in Dentistry and the International Federation of Dental Anesthesiology Societies.[52] Anesthesia Progress is indexed in Excerpta Medica (EMBASE), MEDLINE, and Periodicals Digest in Dentistry.[52] Retrospective articles were prepared for Anesthesia Progress on the 25th[4] and 35th[5] Anniversaries of the Society. ADSA also publishes the bi-monthly newsletter Pulse.[6]

Members
ADSA Membership is open to all dental professionals who have an interest in sedation and anesthesia. From its inception, Oral and Maxillofacial Surgeons and Dentist Anesthesiologists were encouraged to attain Fellowship status to recognize their high level of training. Since 2001, Diplomates of the National Dental Board of Anesthesiology and the American Board of Anesthesiology have been allowed to obtain ADSA Fellowship without a second examination process. The American Dental Society of Anesthesiology established the College of Sedation in Dentistry in 2001 for General Dentists to attain either Member (Enteral) or Master (Parenteral) status in the College.

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History
Since its creation in 1953, the focus of the American Dental Society of Anaesthesiology has been to provide continuing education, recognize educational achievement and pursue research. Its active membership of over 4,500 dentists includes general dentists as well as members from all of the dental specialities with interest in sedation, anaesthesia and pain control.

Contributions to the Profession of Dentistry


First Workshop on Teaching Pain Control to Dental Students (1963)
In 1963 on its tenth anniversary, the American Dental Society of Anesthesiology held a Workshop on Teaching Pain Control to Dental Students. An objective of that meeting was to determine how to encourage dental schools to coordinate the parts of the curriculum that are concerned, directly or indirectly with pain control. The workshop papers were published in the Journal of Dental Education 1964.

Second Pain Control Conference (1965)


The Second Pain Control Conference was held in 1965 by the American Dental Society of Anesthesiology to further develop the predoctoral program in pain control. One of the purposes was to protect the inherent right and accept the corresponding responsibility to advance the field in the profession of dentistry. The report of this conference was sent to all dental schools and communities of interest.

Third Pain Control Conference (1970)


The purpose of this conference was to develop guidelines for pain control in dentistry. Representatives of 48 dental schools, all dental specialty societies, the various federal services, and the sponsoring organizations attended. A document providing a guide for the teaching of pain control at all levels (undergraduate, advanced [postgraduate and graduate]), and continuing education was developed. The approval of the sponsoring agencies created a comprehensive statement, official in nature, that reflected the posture of the entire dental profession. Ultimately, the guidelines were accepted by the ADA Council on Dental Education and the House of Delegates of the ADA.

Teaching of Pain Control in Continuing Education Programs (1977)


This conference resulted in the creation of the complete sequence of guidelines as they relate to pain control at all educational levels within the profession.

Workshop on Anesthesia Education (1989)


This workshop focused on an increased emphasis on quality assurance and risk management applicable to dentistry in general and the modalities of anxiety and pain control employed by dentists in particular. The sponsors of the workshop were also concerned about the decreasing number of opportunities available to dentists for advanced training beyond that provided in traditional dental education.[7]

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1991
Creation of specific, detailed monitoring standards with universal applicability in the dental setting Guidelines for Intraoperative Monitoring of Dental Patients Undergoing Conscious Sedation, Deep Sedation, and General Anesthesia[] The promulgation and adoption of intraoperative monitoring standards in medicine for anesthesia has resulted in early detection of untoward events during sedation and anesthesia, lowering of malpractice premiums, and an improvement in the quality of care. The American Dental Society of Anesthesiology has devised specific, detailed monitoring standards with universal applicability in the dental setting.[]

Workshop on Enteral Sedation in Dentistry (2003)


The American Dental Society of Anesthesiology and the Anesthesia Research Foundation helped organize the Workshop on Enteral Sedation in Dentistry that was held in Washington, D.C. on December 2 3, 2003. Co-sponsored by the United States Pharmacopeial Convention, Inc. (USP) and the Dental Anesthesia Research Group of the International Association for Dental Research, this conference brought together medical and dental communities of interest along with basic science and clinical experts to review the scientific basic and clinical practice and evidenced-based foundations of enteral sedation in dentistry.[8]

American Dental Association Council on Dental Education and Licensure's Committee on Anesthesiology (2003)
Representatives of the American Dental Society of Anesthesiology often grapple with issues pertaining to sedation and anesthesia by dentists in this forum.

2006
With representatives of the American Dental Association, American Academy of General Dentistry, American Association of Oral and Maxillofacial Surgeons, American Academy of Pediatric Dentistry, and the American Society of Dentist Anesthesiologists, the American Dental Society of Anesthesiology funded and organized a roundtable discussion of sedation/anesthesia issues facing dentistry and how to address them.

Town Hall Forum on Anesthesia and Dentistry


The ADSA Town Hall Anesthesia Forum was conceived by the ADSA to address the needs and concerns of the dental community regarding the ADA Guidelines approved in 2007. Dr. Mark Feldman, President of the American Dental Association, will present the Keynote Address. Representatives from the American Academy of Pediatric Dentists, Federal Services, Academy of General Dentistry, Canadian Academy of Dental Anaesthesia, American Association of Oral and Maxillofacial Surgeons, American Society of Dentist Anesthesiologists, Dental Organization of Conscious Sedation and the American Dental Society of Anesthesiology are scheduled to attend and address the group.[9]

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2008-2009
American Dental Society of Anesthesiology won a $100,000 ADA Foundation grant[10] to fund advanced training to manage rare dental emergencies. A number of pilot and proof-of-concept courses were held during 2008 and 2009, including a pilot testing program Dec. 8 in Chicago,[11] which enabled ADA representatives and staff to observe. After the course was developed and the grant finished, the ADA began a series of courses.[12][13][14]

2006-2012
In 2006 in Yokohama, Japan, the American Dental Society of Anesthesiology made a successful bid to hold the International Federation of Dental Anesthesia Societies' 13th Annual International Dental Congress on Modern Pain Control in Hawaii in 2012.[15]

References
[1] http:/ / www. adsahome. org [3] http:/ / www. anesthesiaprogress. org/

External links
Official website (http://www.adsahome.org)

Automated external defibrillator


An automated external defibrillator (AED) is a portable electronic device that automatically diagnoses the potentially life threatening cardiac arrhythmias of ventricular fibrillation and ventricular tachycardia in a patient,[] and is able to treat them through defibrillation, the application of electrical therapy which stops the arrhythmia, allowing the heart to reestablish an effective rhythm. With simple audio and visual commands, AEDs are designed to be simple to use for the layman, and the use of AEDs is taught in many first aid, first responder, and basic life support (BLS) level cardiopulmonary resuscitation (CPR) classes.[1]

An automated external defibrillator, open and ready for pads to be attached

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148

Usage
Conditions that the device treats
An automated external defibrillator is used in cases of life threatening cardiac arrhythmias which lead to cardiac arrest. The rhythms that the device will treat are usually limited to: 1. Pulseless Ventricular tachycardia (shortened to VT or V-Tach)[] 2. Ventricular fibrillation (shortened to VF or V-Fib) In each of these two types of shockable cardiac arrhythmia, the heart is active, but in a life-threatening, dysfunctional pattern. In ventricular tachycardia, the heart beats too fast to effectively pump blood. Ultimately, ventricular tachycardia leads to ventricular fibrillation. In ventricular fibrillation, the electrical activity of the heart becomes chaotic, preventing the ventricle from effectively pumping blood. The fibrillation in the heart decreases over time, and will eventually reach asystole. AEDs, like all defibrillators, are not designed to shock asystole ('flat line' patterns) as this will not have a positive clinical outcome. The asystolic patient only has a chance of survival if, through a combination of CPR and cardiac stimulant drugs, one of the shockable rhythms can be established, which makes it imperative for CPR to be carried out prior to the arrival of a defibrillator.

Effect of delayed treatment


Uncorrected, these cardiac conditions (ventricular tachycardia, ventricular fibrillation, asystole) rapidly lead to irreversible brain damage and death. After approximately three to five minutes,[2] irreversible brain/tissue damage may begin to occur. For every minute that a person in cardiac arrest goes without being successfully treated (by defibrillation), the chance of survival decreases by 7 percent per minute in the first 3 minutes, and decreases by 10 percent per minute as time advances beyond ~3 minutes.[3]

Requirements for use


AEDs are designed to be used by laypersons who ideally should have received AED training. However, sixth-grade students have been reported to begin defibrillation within 90 seconds, as opposed to a trained operator beginning within 67 seconds.[4] This is in contrast to more sophisticated manual and semi-automatic defibrillators used by health professionals, which can act as a pacemaker if the heart rate is too slow (bradycardia) and perform other functions which require a skilled operator able to read electrocardiograms. Bras with a metal underwire and piercings on the torso must be removed before using the AED on someone to avoid interference.[5][6] American TV show Mythbusters [7] found evidence that use of a defibrillator on a woman wearing an underwire bra can lead to arcing or fire but only in unusual and unlikely circumstances. A study analyzed the effects of having AEDs immediately present during Chicago's Heart Start program over a two-year period. Of 22 individuals 18 were in a cardiac arrhythmia which AEDs can treat (Vfib or Vtach). Of these 18, 11 survived. Of these 11 patients, 6 were treated by good Samaritan bystanders with absolutely no previous training in AED use.[8][9]

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Placement and availability


Automated external defibrillators are generally either held by trained personnel who will attend events or are public access units which can be found in places including corporate and government offices, shopping centres, airports, airplanes,[10] restaurants, casinos, hotels, sports stadium, schools and universities, community centers, fitness centers, health clubs, theme parks, workplaces and any other location where people may congregate. Maimonides Medical Center in Borough Park, Brooklyn was the first hospital in the United States to implement fully automated external defibrillators at the bedside. [citation needed] The location of a public access AED should take into account where large groups of people gather, regardless of age or activity. Children as well as adults may fall victim to sudden cardiac arrest (SCA). In many areas, emergency vehicles are likely to carry AEDs, with some ambulances carrying an AED in addition to manual defibrillators. Police or fire vehicles often carry an AED for first responder use. Some areas have dedicated community first responders, who are volunteers tasked with keeping an AED and taking it to any victims in their area. AEDs are also increasingly common on commercial airliners, cruise ships, and other transportation facilities. High-rise buildings are densely populated, but are more difficult to access[11] by emergency crews facing heavy traffic and security barriers. It has been suggested that AEDs carried on elevators could save critical minutes for cardiac arrest victims, and reduce their deployment cost. In order to make them highly visible, public access AEDs are often brightly colored, and are mounted in protective cases near the entrance of a building. When these protective cases are opened or the defibrillator is removed, some will sound a buzzer to alert nearby staff to their removal, though this does not necessarily summon emergency services; trained AED operators should know to phone for an ambulance when sending for or using an AED. In September 2008, the International Liaison Committee on Resuscitation issued a 'universal AED sign' to be adopted throughout the world to indicate the presence of an AED, and this is shown on the right.[12] A trend that is developing is the purchase of AEDs to be used in the home, particularly by those with known existing heart conditions.[13] The number of devices in the community has grown as prices have fallen to affordable levels. There has been some concern among medical professionals that these home users do not necessarily have appropriate training,[14] and many advocate the more widespread use of community responders, who can be appropriately trained and managed. Typically, an AED kit will contain a face shield for providing a barrier between patient and first aider during rescue breathing; a pair of nitrile rubber gloves; a pair of trauma shears for cutting through a patient's clothing to expose the chest; a small towel for wiping away any moisture on the chest, and a razor for shaving those with very hairy chests.[15]

An AED at a railway station in Japan.

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Preparation for operation


Most manufacturers recommend checking the AED before every period of duty or on a regular basis for fixed units. Some units need to be switched on in order to perform a self check; other models have a self check system built in with a visible indicator.[citation needed] All manufacturers mark their electrode pads with an expiration date, and it is important to ensure that the pads are in date. This is usually marked on the outside of the pads. Some models are designed to make this date visible through a 'window', although others will require the opening of the case to find the date stamp.[citation needed] It is also important to ensure that the AED unit's batteries have not expired. The AED manufacturer will specify how often the batteries should be replaced. Each AED has a different recommended maintenance schedule lined out in the user manual. Common checkpoints on every checklist, however, also include a monthly check of the battery power by checking the green indicator light when powered on, condition and cleanliness of all cables and the unit, and check for the adequate supplies [16]

Mechanism of operation
An AED is external because the operator applies the electrode pads to the bare chest of the victim, as opposed to internal defibrillators, which have electrodes surgically implanted inside the body of a patient. Automatic refers to the unit's ability to autonomously analyse the patient's condition, and to assist this, the vast majority of units have spoken prompts, and some may also have visual displays to instruct the user. When turned on or opened, the AED will instruct the user to connect the electrodes (pads) to the patient. Once the pads are attached, everyone should avoid touching the patient so as to avoid false readings by the unit. The pads allow the AED to examine the electrical output from the heart and determine if the patient is in a shockable rhythm (either ventricular fibrillation or ventricular tachycardia). If the device determines that a shock is warranted, it will use the battery to charge its internal capacitor in preparation to deliver the shock. This system is not only safer (charging only when required), but also allows for a faster delivery of the electrical current.

The use of easily visible status indicator and pad expiration date on one model of AED

When charged, the device instructs the user to ensure no one is touching the patient and then to press a button to deliver the shock; human intervention is usually required to deliver the shock to the patient in order to avoid the possibility of accidental injury to another person (which can result from a responder or bystander touching the patient at the time of the shock). Depending on the manufacturer and particular model, after the shock is delivered most devices will analyze the patient and either instruct CPR to be given, or administer another shock. Many AED units have an 'event memory' which store the ECG of the patient along with details of the time the unit was activated and the number and strength of any shocks delivered. Some units also have voice recording abilities[citation needed] to monitor the actions taken by the personnel in order to ascertain if these had any impact on the survival outcome. All this recorded data can be either downloaded to a computer or printed out so that the providing organisation or responsible body is able to see the effectiveness of both CPR and defibrillation. Some AED units even provide feedback on the quality of the compressions provided by the rescuer.[17] The first commercially available AEDs were all of a monophasic type, which gave a high-energy shock, up to 360 to 400 joules depending on the model. This caused increased cardiac injury and in some cases second and third-degree

Automated external defibrillator burns around the shock pad sites. Newer AEDs (manufactured after late 2003) have tended to utilise biphasic algorithms which give two sequential lower-energy shocks of 120 - 200 joules, with each shock moving in an opposite polarity between the pads. This lower-energy waveform has proven more effective in clinical tests, as well as offering a reduced rate of complications and reduced recovery time.[18]

151

Simplicity of use
Unlike regular defibrillators, an automated external defibrillator requires minimal training to use. It automatically diagnoses the heart rhythm and determines if a shock is needed. Automatic models will administer the shock without the user's command. Semi-automatic models will tell the user that a shock is needed, but the user must tell the machine to do so, usually by pressing a button. In most circumstances, the user cannot override a "no shock" advisory by an AED. Some AEDs may be used on children - those under 55lbs (25kg) in weight or under age 8. If a particular model of AED is approved for pediatric use, all that is required is the use of more appropriate pads. All AEDs approved for use in the United States use an electronic voice to prompt users through each step. Because the user of an AED may be hearing impaired, many AEDs now include visual prompts as well. Most units are designed for use by non-medical operators. Their ease of use has given rise to the notion of public access defibrillation (PAD), which experts agree has the potential to be the single greatest advance in the treatment of out-of-hospital cardiac arrest since the invention of CPR.[19]

Usual placement of pads on chest

The number of people who survive sudden cardiac arrest is increasing gradually, thanks to the use of AEDs. For this reason, the Sudden Cardiac Arrest Foundation developed the National SCA Survivor Network [20], which provides a platform for mutual support and for engaging in the mission to help save other lives.

Liability
Automated external defibrillators are now easy enough to use that most states in the United States include the "good faith" use of an AED by any person under Good Samaritan laws.[21] "Good faith" protection under a Good Samaritan law means that a volunteer responder (not acting as a part of one's occupation) cannot be held civilly liable for the harm or death of a victim by providing improper or inadequate care, given that the harm or death was not intentional and the responder was acting within the limits of their training and in good faith. In the United States, Good Samaritan laws provide some protection for the use of AEDs by trained and untrained responders.[22] AEDs create little liability if used correctly;[23] NREMT-B and many state Emergency Medical Technician (EMT) training and many CPR classes incorporate or offer AED education as a part of their program. In addition to Good Samaritan laws, Ontario, Canada also has the "Chase McEachern Act (Heart Defibrillator Civil Liability), 2007 (Bill 171 Subsection N)", passed in June, 2007,[24] which protects individuals from liability for damages that may occur from their use of an AED to save someone's life at the immediate scene of an emergency unless damages are caused by gross negligence.

Automated external defibrillator

152

Reliability
Automated external defibrillators are under recent scrutiny by the U.S. Food and Drug Administration (FDA) which is now considering reclassifying AEDs as class III premarket approval devices. The major reason for this appears to be technical malfunctions that may have been the cause for apparently hundreds of deaths between 2004 and 2009, in most cases by component failures or design errors. Over the last several years dozens of AED models have been recalled from nearly every manufacturer.[25]

References
[3] American Red Cross. CPR/AED for the Professional Rescuer (participant's manual). Yardley, PA: StayWell, 2006. (page 63). [7] http:/ / dsc. discovery. com/ fansites/ mythbusters/ db/ human-body/ underwire-bra-mess-with-defibrillator. html [9] http:/ / beavermedic. wordpress. com/ 2010/ 02/ 10/ look-for-me-in-airportshockey-arenas/ [10] http:/ / vlex. com/ vid/ krys-rebeca-lufthansa-german-airlines-36137815 Leonard Krys, Rebeca Krys, His Wife, Plaintiffs-Appellees, v. Lufthansa German Airlines, Defendant-Appellant., 119 F.3d 1515 (11th Cir. 1997) [11] BMJ.com (http:/ / www. bmj. com/ cgi/ content/ full/ 328/ 7438/ E271) [15] CPR/AED for the Professional Rescuer, supra, page 65 ("[a] safety surgical razor should be included in the AED kit.") The other items not directly mentioned in this text but are used in AED preparation, such as the gloves (used throughout patron assessment) and the towel, as the chest should be dried prior to AED pad attachment (id, at page 64). [17] Zoll AED Plus Provides Compression Feedback (http:/ / www. lifeassisttraining. com/ zollaedplus. html) [19] Introduction to the International Guidelines 2000 for CPR and ECC (http:/ / circ. ahajournals. org/ cgi/ content/ full/ 102/ suppl_1/ I-1?ijkey=0ea84b1fa73ef72b72aef923e0f1adc6d4fd6ba5& keytype2=tf_ipsecsha) [20] http:/ / www. sca-aware. org/ national-sca-survivor-network [21] Laws on Cardiac Arrest and Defibrillators, 2013 update. (http:/ / www. ncsl. org/ programs/ health/ aed. htm) National Conference of State Legislatures. Retrieved on 2013-03-18. [22] State Laws on Heart Attacks, Cardiac Arrest & Defibrillators (http:/ / www. ncsl. org/ programs/ health/ aed. htm) [23] Laws on Cardiac Arrest and Defibrillators (http:/ / www. ncsl. org/ default. aspx?tabid=14506) [24] Health System Improvement Act, 2007 (http:/ / www. e-laws. gov. on. ca/ DBLaws/ Source/ Statutes/ English/ 2007/ S07010_e. htm) Retrieved on 26 June 2007

External links
Sudden Cardiac Arrest Foundation (http://www.sca-aware.org) American Heart Association: Learn & Live (http://www.heart.org/HEARTORG/) American Red Cross: Saving a Life is as Easy as A-E-D (http://www.redcross.org/services/hss/courses/aed. html) FDA Heart Health Online: Automated External Defibrillator (AED) (http://www.fda.gov/hearthealth/ treatments/medicaldevices/aed.html) Resuscitation Council (UK) (http://www.resus.org.uk)

Aid to Families with Dependent Children

153

Aid to Families with Dependent Children


Aid to Families with Dependent Children (AFDC) was a federal assistance program in effect from 1935 to 1996 created by the Social Security Act and administered by the United States Department of Health and Human Services that provided financial assistance to children whose families had low or no income.[1] This program grew from a minor part of the social security system to a significant system of welfare administered by the states with federal funding. However, it was criticized for offering incentives for women to have children, and for providing disincentives for women to join the workforce. In 1996, AFDC was replaced by the more restrictive Temporary Assistance for Needy Families (TANF) program.

History
The program was created under the name Aid to Dependent Children (ADC) by the Social Security Act of 1935 as part of the New Deal. ADC dispensed scant relief to poor single mothers. The federal government authorized case workers, supervisors, and administrators with discretion to determine who received aid and how much. ADC was primarily created for white single mothers who were [2] The overall decline in welfare monthly benefits (in 2006 dollars) expected not to work. Black mothers who had always been in the labor force were not considered eligible to receive benefits.[3] The words "families with" were added to the name in 1962, partly due to concern that the program's rules discouraged marriage.[4] The Civil Rights Movement and the efforts of the National Welfare Rights Organization (NWRO) in the 1960's expanded the scope of welfare entitlements to include Black women. The welfare rolls racial demographics changed drastically. The majority of welfare recipients still remained white and most Black women recipients continued to work.[5] Starting in 1962, the Department of Health and Human Services allowed state-specific exemptions as long as the change was "in the spirit of AFDC" in order to allow some experimentation. By 1996 spending was $24 billion per year. When adjusted for inflation, the highest spending was in 1976, which exceeded 1996 spending by about 8%.[6]

Criticism
Early in the program, there were concerns about whether this program encouraged unwed motherhood.[4] In the 1960s through 1980s, Nobel Prize winning physicist William Shockley argued that AFDC and other similar programs tended to encourage childbirth, especially among less productive members of society (particularly blacks, whom he considered to be genetically inferior to whites[7]), causing a reverse evolution (dysgenic effect), founded on the premises that: there is a correlation between financial success and intelligence; and that intelligence is hereditary.[8] Shockley[9] was influential in bringing recognition to this hypothesis among the public and Congress.[8] Some advocates complained that the rule had the effect of breaking up marriages and promoting matriarchy (see also single-parent family).

Aid to Families with Dependent Children ... the AFDC program tended to treat households with a cohabiting male who was not the natural father of the children much more leniently than those with a resident spouse or father of the children. This feature created a clear disincentive for marriage and also a clear incentive for divorce, because women who married face the reduction or loss of their AFDC benefits.[10] Lucy A. Williams and Jean Hardisty point to the existence of policies reacting to this perceived problem in some states such as "man-in-the-house" rule: States had wide discretion to determine eligibility and many states conditioned the receipt of welfare on the sexual morality of the mother, using "suitable home" and "man in the house" rules to disqualify many African American single mothers. The Right's Campaign Against Welfare [11] The "man-in-the-house" rule was struck down by the Supreme Court in 1968 (see King v. Smith). In 1984, libertarian author Charles Murray suggested that welfare causes dependency. He argued that as welfare benefits increased, the number of recipients also increased; this behavior, he said, was rational: there is little reason to work if one can receive benefits for a long period of time without having to work.[12] His later work and that of Richard J. Herrnstein and others suggested possible merit to the theory of a dysgenic effect,[13] however, the data are not entirely clear.[14] Right or wrong, this argument was among the stepping stones leading to the modification of AFDC toward TANF.[15]

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Reform
In 1996, President Bill Clinton negotiated with the Republican-controlled Congress to pass the Personal Responsibility and Work Opportunity Act which drastically restructured the program. Among other changes, a lifetime limit of five years was imposed for the receipt of benefits, and the newly-limited nature of the replacement program was reinforced by calling AFDC's successor Temporary Assistance for Needy Families (TANF). Many Americans continue to refer to TANF as "welfare" or AFDC. TANF has remained controversial. In 2003, LaShawn Y. Warren, an ACLU Legislative Counsel, said that TANF gives states an incentive "to deny benefits to those who need it most. The solution to getting people out of the cycle of poverty is not to prematurely kick them off welfare. Too many have been denied aid unfairly, creating a false impression that the number of people who need help has decreased."[16] In 2006, The New Republic suggested, "A broad consensus now holds that welfare reform was certainly not a disasterand that it may, in fact, have worked much as its designers had hoped."[17] More recent results, notably taking into account the effects of the Financial crisis of 20072010 and taking place after the lifetime limits imposed by TANF may have been reached by many recipients, suggest instead that the reforms have not been as successful as originally claimed.[18]

Notes
[1] PBS.org (http:/ / www. pbs. org/ pov/ pov2001/ takeitfromme/ abouttheissues. html), Timeline of National Welfare Reform [2] 2008 Indicators of Welfare Dependence (http:/ / aspe. hhs. gov/ hsp/ indicators08/ apa. shtml#ftanf2) Figure TANF 2. [4] Blank, Susan W. and Barbara B. Blum, Welfare to Work Vol 7 No 1, Spring 1997. A Brief History of Work Expectations for Welfare Mothers (http:/ / www. princeton. edu/ futureofchildren/ publications/ docs/ 07_01_02. pdf)". [6] U.S. Department of Health and Human Services (website) (http:/ / aspe. hhs. gov/ hsp/ AFDC/ baseline/ 4spending. pdf) Federal and State Expenditures for AFDC [8] George Bush: The Unauthorized Biography --- by Webster G. Tarpley & Anton Chaitkin Chapter 11 [9] Joel N. Shurkin; "Broken Genius: The Rise and Fall of William Shockley, Creator of the Electronic Age". New York: Palgrave Macmillan. 2006. ISBN 1-4039-8815-3 [10] Marriage and the economy: theory and evidence from advanced industrial societies (http:/ / books. google. com/ books?id=2CQ46PgqyKsC& pg=PA77& lpg=PA77& dq=supreme+ court+ afdc+ presence+ cohabiting+ male& source=bl& ots=yGZyjXJoXD& sig=S7wjkdlykNRsmlg-XsPsDuU3jxQ& hl=en& sa=X& ei=rA8OT4ScINHE0AHMrISuDQ& ved=0CD4Q6AEwAg#v=onepage& q=supreme court afdc presence cohabiting male& f=false) - Shoshana Grossbard-Shechtman, Professor of Economics at San Diego State University

Aid to Families with Dependent Children


[11] http:/ / www. jeanhardisty. com/ essay_therightscampaignagainstwelfare. html#_ednref2 [12] Charles Murray, 1984. Losing Ground: American Social Policy, 1950-1980 [13] Herrnstein, R. J. and Murray, C. (1994). The Bell Curve: Intelligence and Class Structure in American Life. New York: Free Press. ISBN 0-02-914673-9 pgs 191-193 [14] The Bell Curve Flattened (http:/ / www. slate. com/ id/ 2416) by Nicholas Lemann in Slate (January 1996) [15] Transcendental goods, Reason (magazine), April 1, 2004 , by Gillespie, Nick "Losing Ground: American Social Policy, 1950-1980 was a devastating dissection of welfare programs and is widely credited with helping inspire the welfare reforms of the 1990s." This is also supported by "George Bush: The Unauthorized Biography", by Webster G. Tarpley & Anton Chaitkin Chapter 11 [16] ACLU Says Current Welfare Reform Measure Ineffective, Calls for Civil Rights Protections, Better Poverty Elimination Efforts (http:/ / www. aclu. org/ racial-justice_prisoners-rights_drug-law-reform_immigrants-rights/ aclu-says-current-welfare-reform-m) (September 10, 2003) [17] New Republic September 4, 2006, page 7 [18] As Progressives Predicted, Clinton Welfare Reform Law Fails Families (http:/ / www. beyondchron. org/ articles/ As_Progressives_Predicted_Clinton_Welfare_Reform_Law_Fails_Families_8029. html) by Randy Shaw in BeyondChron (April 19 2010)

155

Bibliography
Keith M. Kilty, Elizabeth A. Segal. The Promise of Welfare Reform: Political Rhetoric and the Reality of Poverty in the Twenty-First. (2006) Clarita A. Mrena and Patricia Elston. Welfare Reform: State Sanction Policies and Number of Families Affected (2000) Robert P Stoker and Laura A Wilson. When Work Is Not Enough: State and Federal Policies to Support Needy Workers 2006 Webster G. Tarpley and Anton Chaitkin. George Bush: The Unauthorized Biography Joel N. Shurkin. Broken Genius: The Rise and Fall of William Shockley, Creator of the Electronic Age. New York: Palgrave Macmillan. 2006. ISBN 1-4039-8815-3 Herrnstein, R. J. and Murray, C. (1994). The Bell Curve: Intelligence and Class Structure in American Life. New York: Free Press. ISBN 0-02-914673-9 Charles Murray, 1984. Losing Ground: American Social Policy. 1950-1980 Nick Gillespie. "Transcendental goods". Reason (magazine), April 1, 2004 "The Bell Curve Flattened" (http://www.slate.com/id/2416) by Nicholas Lemann, in Slate (magazine) (January 1996) "Is the Great Society to Blame? If Not, Why Have Problems Worsened Since '60s?" (http://www.fumento.com/ greatsociety.html) by Michael Fumento, Investor's Business Daily, June 19, 1992 "Cracked Bell" (http://www.reason.com/news/show/29636.html) by Professor James Heckman in Reason (March 1995) "Federal and State Expenditures for AFDC" (http://aspe.hhs.gov/hsp/AFDC/baseline/4spending.pdf) from the U.S. Department of Health and Human Services website "A Brief History of the AFDC Program" (http://aspe.hhs.gov/hsp/AFDC/baseline/1history.pdf) from the U.S. Department of Health and Human Services (website) "The New Child Care Block Grant, State Funding Choices and Their Implications" (http://www.urban.org/ publications/307043.html) by Sharon K. Long & Sandra J. Clark, posted to the Urban Institute website October 1, 1997 "Women, Children, and Poverty in America" (http://www.fordfound.org/eLibrary/documents/0183/010.cfm) by Prudence Brown, Ford Foundation website "Timeline of National Welfare Reform" (http://www.pbs.org/pov/pov2001/takeitfromme/abouttheissues. html) from PBS.org

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External links
Aid to Families with Dependent Children at HHS (http://www.acf.hhs.gov/programs/afdc/) The Future of Children (http://www.princeton.edu/futureofchildren/publications/docs/07_01_ExecSummary. pdf), Executive Summary, Center for the Future of Children, The David and Lucile Packard Foundation, at Princeton University website

Atrial fibrillation

157

Atrial fibrillation
Atrial fibrillation
Classification and external resources

Schematic diagram of normal sinus rhythm for a human heart as seen on ECG. In atrial fibrillation, however, the P waves, which represent depolarization of the atria, are absent. ICD-10 ICD-9 DiseasesDB MedlinePlus eMedicine MeSH I48 [1] [2]

427.31 1065

[3] [4] [5] [7] emerg/46 [6]

000184

med/184 D001281

Atrial fibrillation (AF or A-fib) is the most common cardiac arrhythmia (heart rhythm disorder). It may cause no symptoms, but it is often associated with palpitations, fainting, chest pain, or congestive heart failure. However, in some people atrial fibrillation is caused by otherwise idiopathic or benign conditions. AF increases the risk of stroke. The degree of increase can be substantial, depending on the presence of additional risk factors (such as high blood pressure). It may be identified clinically when taking a pulse, and the presence of AF can be confirmed with an electrocardiogram (ECG or EKG) which demonstrates the absence of P waves together with an irregular ventricular rate. In AF, the normal regular electrical impulses generated by the sinoatrial node are overwhelmed by disorganized electrical impulses usually originating in the roots of the pulmonary veins, leading to irregular conduction of impulses to the ventricles which generate the heartbeat. AF may occur in episodes lasting from minutes to days ("paroxysmal"), or be permanent in nature. A number of medical conditions increase the risk of AF, particularly mitral stenosis (narrowing of the mitral valve of the heart). Atrial fibrillation may be treated with medications to either slow the heart rate to a normal range ("rate control") or revert the heart rhythm back to normal ("rhythm control"). Synchronized electrical cardioversion can be used to convert AF to a normal heart rhythm. Surgical and catheter-based therapies may be used to prevent recurrence of AF in certain individuals. Depending on the risk of stroke and systemic embolism, people with AF may use anticoagulants such as warfarin, which substantially reduces the risk but may increase the risk of major bleeding,

Atrial fibrillation mainly in geriatric patients. The prevalence of AF in a population increases with age, with 8% of people over 80 having AF. Chronic AF leads to a small increase in the risk of death.

158

Classification
Classification system
AF Category First detected Paroxysmal Persistent Permanent Defining Characteristics only one diagnosed episode recurrent episodes that self-terminate in less than 7 days. recurrent episodes that last more than 7 days an ongoing long-term episode

The American College of Cardiology (ACC), American Heart Association (AHA), and the European Society of Cardiology (ESC) recommend in their guidelines the following classification system based on simplicity and clinical relevance.[] All atrial fibrillation patients are initially in the category called first detected AF. These patients may or may not have had previous undetected episodes. If a first detected episode self-terminates in less than 7days and then another episode begins later on, the case has moved into the category of paroxysmal AF. Although patients in this category have episodes lasting up to 7days, in most cases of paroxysmal AF the episodes will self-terminate in less than 24hours. If instead the episode lasts for more than 7days, it is unlikely to self-terminate,[8] and it is called persistent AF. In this case, the episode may be still terminated by cardioversion. If cardioversion is unsuccessful or it is not attempted, and the episode is ongoing for a long time (e.g., a year or more), the patient's AF is called permanent. Episodes that last less than 30seconds are not considered in this classification system. Also, this system does not apply to cases where the AF is a secondary condition that occurs in the setting of a primary condition that may be the cause of the AF. Using this classification system, it's not always clear what an AF case should be called. For example, a case may fit into the paroxysmal AF category some of the time, while other times it may have the characteristics of persistent AF. One may be able to decide which category is more appropriate by determining which one occurs most often in the case under consideration. In addition to the above four AF categories, which are mainly defined by episode timing and termination, the ACC/AHA/ESC guidelines describe additional AF categories in terms of other characteristics of the patient.[] Lone atrial fibrillation (LAF) absence of clinical or echocardiographic findings of other cardiovascular disease (including hypertension), related pulmonary disease, or cardiac abnormalities such as enlargement of the left atrium, and age under 60years Nonvalvular AF absence of rheumatic mitral valve disease, a prosthetic heart valve, or mitral valve repair Secondary AF occurs in the setting of a primary condition which may be the cause of the AF, such as acute myocardial infarction, cardiac surgery, pericarditis, myocarditis, hyperthyroidism, pulmonary embolism, pneumonia, or other acute pulmonary disease

Atrial fibrillation

159

Signs and symptoms


Atrial fibrillation is usually accompanied by symptoms related to a rapid heart rate. Rapid and irregular heart rates may be perceived as palpitations, exercise intolerance, and occasionally produce angina (if the rate is faster and puts the heart under strain) and congestive symptoms of shortness of breath or edema. Sometimes the arrhythmia will be identified only with the onset of a stroke or a transient ischemic attack (TIA). It is not uncommon for a patient to first become aware of AF from a routine physical examination or ECG, as it may be asymptomatic in many cases.[] As most cases of atrial fibrillation are secondary to other medical problems, the presence of chest pain or angina, symptoms of hyperthyroidism (an overactive thyroid gland) such as weight loss and diarrhea, and symptoms suggestive of lung disease would indicate an underlying cause. A history of stroke or TIA, as well as hypertension (high blood pressure), diabetes, heart failure and rheumatic fever, may indicate whether someone with AF is at a higher risk of complications.[] A higher risk of embolus can be assessed using the CHADS2 score.

Rapid heart rate


Presentation is similar to other forms of rapid heart rate (tachycardia), and in some cases may actually be asymptomatic. The patient may complain of palpitations or chest discomfort. The rapid heart rate may result in the heart being unable to provide adequate blood flow and oxygen delivery to the rest of the body. Therefore, common symptoms may include shortness of breath which often worsens with exertion (dyspnea on exertion), shortness of breath when lying flat (orthopnea), and sudden onset of shortness of breath during the night (paroxysmal nocturnal dyspnea), and may progress to swelling of the lower extremities (peripheral edema). Owing to inadequate blood flow, patients may also complain of light-headedness, may feel like they are about to faint (presyncope), or may actually lose consciousness (syncope). The patient may be in significant respiratory distress. Because of inadequate oxygen delivery, the patient may appear blue (cyanosis). By definition, the heart rate will be greater than 100 beats per minute. Blood pressure will be variable, and often difficult to measure as the beat-by-beat variability causes problems for most digital (oscillometric) non-invasive blood pressure monitors. It is most worrying if consistently lower than usual (hypotension). Respiratory rate will be increased in the presence of respiratory distress. Pulse oximetry may confirm the presence of hypoxia related to any precipitating factors such as pneumonia. Examination of the jugular veins may reveal elevated pressure (jugular venous distention). Lung exam may reveal crackles, which are suggestive of pulmonary edema. Heart exam will reveal an irregular but rapid rhythm.

Association with other conditions


Central sleep apnea (CSA) A study found that the prevalence of atrial fibrillation among patients with idiopathic central sleep apnea was significantly higher than the prevalence among patients with obstructive sleep apnea or no sleep apnea (27%, 1.7%, and 3.3%, respectively). There was a total of 180 subjects with 60 people in each of the 3 groups. Possible explanations for the association between CSA and AF are a causal relationship between the two conditions, or an abnormality of central cardiorespiratory regulation.[] Left atrial enlargement Mitral stenosis

Atrial fibrillation

160

Diagnosis
The evaluation of atrial fibrillation involves diagnosis, determination of the etiology of the arrhythmia, and classification of the arrhythmia. The minimal evaluation of atrial fibrillation is a history and physical examination, ECG, transthoracic echocardiogram, and case specific bloodwork. Depending upon given resources, afflicted individuals may benefit from an in-depth evaluation which may include correlation of the heart rate response to exercise, exercise stress testing, chest X-ray, trans-esophageal echocardiography, and other studies.

A 12 lead ECG showing atrial fibrillation at approximately 150 beats per minute

If a patient presents with a sudden onset of severe symptoms other forms of tachyarrhythmia must be ruled-out, as some may be immediately life threatening, such as ventricular tachycardia. While most patients will be placed on continuous cardiorespiratory monitoring, an electrocardiogram is essential for diagnosis. Provoking causes should be sought out. A common cause of any tachycardia is dehydration, as well as other forms of hypovolemia. Acute coronary syndrome should be ruled out. Intercurrent illness such as pneumonia may be present.

Screening
Screening for atrial fibrillation is not generally performed, although a study of routine pulse checks or ECGs during routine office visits found that the annual rate of detection of AF in elderly patients improved from 1.04% to 1.63%; selection of patients for prophylactic anticoagulation would improve stroke risk in that age category.[] This estimated sensitivity of the routine primary care visit is 64%. This low result probably reflects the pulse not being checked routinely or carefully.[] When ECGs are used for screening, the SAFE trial found that electronic software, primary care physicians and the combination of the two had the following sensitivities and specificities:[] Interpreted by software: sensitivity = 83%, specificity = 99% Interpreted by a primary care physician: sensitivity = 80%, specificity = 92% Interpreted by a primary care physician with software: sensitivity = 92%, specificity = 91%

Minimal evaluation
The minimal evaluation of atrial fibrillation should generally be performed in all individuals with AF. The goal of this evaluation is to determine the general treatment regimen for the individual. If results of the general evaluation warrant it, further studies may then be performed. History and physical examination The history of the individual's atrial fibrillation episodes is probably the most important part of the evaluation. Distinctions should be made between those who are entirely asymptomatic when they are in AF (in which case the AF is found as an incidental finding on an ECG or physical examination) and those who have gross and obvious symptoms due to AF and can pinpoint whenever they go into AF or revert to sinus rhythm.

Atrial fibrillation Routine bloodwork While many cases of AF have no definite cause, it may be the result of various other problems (see below). Hence, renal function and electrolytes are routinely determined, as well as thyroid-stimulating hormone (commonly suppressed in hyperthyroidism and of relevance if amiodarone is administered for treatment) and a blood count.[] In acute-onset AF associated with chest pain, cardiac troponins or other markers of damage to the heart muscle may be ordered. Coagulation studies (INR/aPTT) are usually performed, as anticoagulant medication may be commenced.[] Electrocardiogram Atrial fibrillation is diagnosed on an electrocardiogram (ECG), an investigation performed routinely whenever an irregular heart beat is suspected. Characteristic findings are the absence of P waves, with disorganized electrical activity in their place, and irregular R-R intervals due to irregular conduction of impulses to ECG of atrial fibrillation (top) and normal sinus rhythm (bottom). The purple arrow the ventricles.[] At very fast heart rates indicates a P wave, which is lost in atrial fibrillation. atrial fibrillation may look more regular which may make it more difficult to separate from SVT or ventricular tachycardia.[9] QRS complexes should be narrow, signifying that they are initiated by normal conduction of atrial electrical activity through the intraventricular conduction system. Wide QRS complexes are worrisome for ventricular tachycardia, although in cases where there is disease of the conduction system, wide complexes may be present in A-Fib with rapid ventricular response. If paroxysmal AF is suspected but an ECG during an office visit only shows a regular rhythm, AF episodes may be detected and documented with the use of ambulatory Holter monitoring (e.g. for a day). If the episodes are too infrequent to be detected by Holter monitoring with reasonable probability, then the patient can be monitored for longer periods (e.g. a month) with an ambulatory event monitor.[] Echocardiography A non-invasive transthoracic echocardiogram (TTE) is generally performed in newly diagnosed AF, as well as if there is a major change in the patient's clinical state. This ultrasound-based scan of the heart may help identify valvular heart disease (which may greatly increase the risk of stroke), left and right atrial size (which indicates likelihood that AF may become permanent), left ventricular size and function, peak right ventricular pressure (pulmonary hypertension), presence of left atrial thrombus (low sensivity), presence of left ventricular hypertrophy and pericardial disease.[] Significant enlargement of both the left and right atria is associated with long-standing atrial fibrillation and, if noted at the initial presentation of atrial fibrillation, suggests that the atrial fibrillation is likely to be of a longer duration than the individual's symptoms.

161

Atrial fibrillation

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Extended evaluation
An extended evaluation is generally not necessary in most individuals with atrial fibrillation, and is only performed if abnormalities are noted in the limited evaluation, if a reversible cause of the atrial fibrillation is suggested, or if further evaluation may change the treatment course. Chest X-ray A chest X-ray is generally only performed if a pulmonary cause of atrial fibrillation is suggested, or if other cardiac conditions are suspected (particularly congestive heart failure.) This may reveal an underlying problem in the lungs or the blood vessels in the chest.[] In particular, if an underlying pneumonia is suggested, then treatment of the pneumonia may cause the atrial fibrillation to terminate on its own. Transesophageal echocardiogram A normal echocardiography (transthoracic or TTE) has a low sensitivity for identifying thrombi (blood clots) in the heart. If this is suspected (e.g., when planning urgent electrical cardioversion) a transesophageal echocardiogram (TEE or TOE where British spelling is used) is preferred.[] The TEE has much better visualization of the left atrial appendage than transthoracic echocardiography. This structure, located in the left atrium, is the place where thrombus is formed in more than 90% of cases in non-valvular (or non-rheumatic) atrial fibrillation or flutter.[] TEE has a high sensitivity for locating thrombi in this area[] and can also detect sluggish bloodflow in this area that is suggestive of thrombus formation.[] If no thrombus is seen on TEE, the incidence of stroke, (immediately after cardioversion is performed), is very low.[citation needed] Ambulatory Holter monitoring A Holter monitor is a wearable ambulatory heart monitor that continuously monitors the heart rate and heart rhythm for a short duration, typically 24 hours. In individuals with symptoms of significant shortness of breath with exertion or palpitations on a regular basis, a holter monitor may be of benefit to determine if rapid heart rates (or unusually slow heart rates) during atrial fibrillation are the cause of the symptoms. Exercise stress testing Some individuals with atrial fibrillation do well with normal activity but develop shortness of breath with exertion. It may be unclear if the shortness of breath is due to a blunted heart rate response to exertion caused by excessive AV node blocking agents, a very rapid heart rate during exertion, or due to other underlying conditions such as chronic lung disease or coronary ischemia. An exercise stress test will evaluate the individual's heart rate response to exertion and determine if the AV node blocking agents are contributing to the symptoms.

Causes
AF is linked to several cardiac causes, but may occur in otherwise normal hearts. Known associations include: Hypertension (High blood pressure) Primary heart diseases including coronary artery disease, mitral stenosis (e.g., due to rheumatic heart disease or mitral valve prolapse), mitral regurgitation, hypertrophic cardiomyopathy (HCM), pericarditis, congenital heart disease, previous heart surgery Lung diseases (such as pneumonia, lung cancer, pulmonary embolism, sarcoidosis) Excessive alcohol consumption ("binge drinking" or "holiday heart syndrome"). Even otherwise healthy middle-aged women who consumed more than 2 drinks daily were 60% more likely to develop AF.[10] Hyperthyroidism Dual-chamber pacemakers in the presence of normal atrioventricular conduction.[11]

Atrial fibrillation A family history of AF may increase the risk of AF. A study of more than 2,200 AF patients found that 30 percent had parents with AF.[] Various genetic mutations may be responsible.[][]

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Pathophysiology
Morphology
The primary pathologic change seen in atrial fibrillation is the progressive fibrosis of the atria. This fibrosis is primarily due to atrial dilation, however genetic causes and inflammation may have a cause in some individuals. One study found that atrial dilation can occur as a consequence of AF,[] although another study found that AF by itself does not cause it.[] Dilation of the atria can be due to almost any structural abnormality of the heart that can cause a rise in the intra-cardiac pressures. This includes valvular heart disease (such as mitral stenosis, mitral regurgitation, and tricuspid regurgitation), hypertension, and congestive heart failure. Any inflammatory state that affects the heart can cause fibrosis of the atria. This is typically due to sarcoidosis but may also be due to autoimmune disorders that create autoantibodies against myosin heavy chains. Mutation of the lamin AC gene is also associated with fibrosis of the atria that can lead to atrial fibrillation. Once dilation of the atria has occurred, this begins a chain of events that leads to the activation of the renin aldosterone angiotensin system (RAAS) and subsequent increase in matrix metaloproteinases and disintegrin, which leads to atrial remodeling and fibrosis, with loss of atrial muscle mass. This process is not immediate, and experimental studies have revealed patchy atrial fibrosis may precede the occurrence of atrial fibrillation and may progress with prolonged durations of atrial fibrillation. Fibrosis is not limited to the muscle mass of the atria, and may occur in the sinus node (SA node) and atrioventricular node (AV node), correlating with sick sinus syndrome. Prolonged episodes of atrial fibrillation have been shown to correlate with prolongation of the sinus node recovery time,[][][] suggesting that dysfunction of the SA node is progressive with prolonged episodes of atrial fibrillation.

Electrophysiology
Conduction Sinus rhythm Atrial fibrillation

The normal electrical conduction system of the heart allows the impulse that is generated by the sinoatrial node (SA node) of the heart to be propagated to and stimulate the myocardium (muscle of the heart). When the myocardium is

Atrial fibrillation stimulated, it contracts. It is the ordered stimulation of the myocardium that allows efficient contraction of the heart, thereby allowing blood to be pumped to the body. There are multiple theories about the etiology of atrial fibrillation. An important theory is that in atrial fibrillation, the regular impulses produced by the sinus node for a normal heartbeat, are overwhelmed by rapid electrical discharges produced in the atria and adjacent parts of the pulmonary veins. Sources of these disturbances are either automatic foci, often localized at one of the pulmonary veins, or a small number of localized sources in the form of either reentrant electrical spiral waves (rotors) or repetitive focal beats; these localized sources may be found in the left atrium near the pulmonary veins or in a variety of other locations through both the left or right atrium. Because recovery of the atria from excitation is heterogeneous, the electrical waves generated by the AF sources undergo repetitive, spatially distributed breakup and fragmentation in a process known as "fibrillatory conduction". Another theory is the multiple wavelet theory first formulated by Moe,[] which was experimentally proven by Allessie et al. AF can be distinguished from atrial flutter (AFL), which appears as an organized electrical circuit usually in the right atrium. AFL produces characteristic saw-toothed F-waves of constant amplitude and frequency on an ECG whereas AF does not. In AFL, the discharges circulate rapidly at a rate of 300beats per minute (bpm) around the atrium. In AF, there is no regularity of this kind, except at the sources where the local activation rate can exceed 500 bpm. Although the electrical impulses of AF occur at a high rate, most of them do not result in a heart beat. A heart beat results when an electrical impulse from the atria passes through the atrioventricular (AV) node to the ventricles and causes them to contract. During AF, if all of the impulses from the atria passed through the AV node, there would be severe ventricular tachycardia resulting in severe reduction of cardiac output. This dangerous situation is prevented by the AV node since its limited conduction velocity reduces the rate at which impulses reach the ventricles during AF.[]

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Management
The main goals of treatment are to prevent circulatory instability and stroke. Rate or rhythm control are used to achieve the former, while anticoagulation is used to decrease the risk of the latter.[12] If cardiovascularly unstable due to uncontrolled tachycardia, immediate cardioversion is indicated.[]

Anticoagulation
Anticoagulation can be achieved through a number of means including the use of heparin, warfarin, dabigatran and rivaroxaban . Which method is used depends on a number issues including: cost, risk of stroke, risk of falls, compliance, and speed of desired onset of anticoagulation.[] Some other anticoagulants were discussed in a 2012 state-of-the-art paper but were not generally approved at that time for stroke prevention in AF: apixaban, and edoxaban.[]

Rate control versus rhythm control using drugs


AF can cause disabling and bothersome symptoms. Palpitations, chest discomfort, anxiety, and decreased exercise tolerance are related to rapid heart rate and inefficient cardiac output caused by AF. Furthermore, AF with a persistent rapid rate can cause a form of heart failure called tachycardia induced cardiomyopathy. This can significantly increase mortality and morbidity, which can be prevented by early and adequate treatment of the AF. There are two ways to approach these symptoms using drugs: rate control and rhythm control. Rate control lowers the heart rate closer to normal, usually 60 to 100bpm, without trying to convert to a regular rhythm. Rhythm control restores normal heart rhythm in a process called cardioversion and maintains the normal rhythm with drugs. Studies suggest that rhythm control is most important in the acute setting AF, while rate control is more important in the chronic phase. As far as mortality is concerned, the AFFIRM trial showed that there is lower mortality using rate

Atrial fibrillation control with anticoagulation treatment versus rhythm control treatment and the difference increases up to 5 years (end of study).[] There is no difference in risk of stroke in patients who have converted to a normal rhythm with anti-arrhythmic treatment compared to those who have only rate control.[] AF is associated with a reduced quality of life, and while some studies indicate that rhythm control leads to a higher quality of life, some did not find a difference.[13] A further study focused on rhythm control in patients with AF with concomitant heart failure, based on the hypothesis that AF confers a higher mortality risk in heart failure. In this setting, rhythm control offered no advantage compared to rate control.[14] However, the diagnosis and progression of atrial fibrillation and other cardiovascular disease requires further investigation. In patients with a fast ventricular response, intravenous magnesium significantly increases the chances of successful rate and rhythm control in the urgent setting without major side-effects.[15] A patient with fluctuating vital signs, mental status changes, preexcitation, or chest pain often will go to immediate treatment with synchronized DC cardioversion.[] Otherwise the decision of rate control versus rhythm control using drugs is made. This is based on a number of criteria that includes whether or not symptoms persist with rate control.

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Rate control
Rate control is achieved with medications that work by increasing the degree of block at the level of the AV node, effectively decreasing the number of impulses that conduct into the ventricles. This can be done with:[][] Beta blockers (preferably the "cardioselective" beta blockers such as metoprolol, atenolol, bisoprolol, nebivolol) Non-dihydropyridine calcium channel blockers (e.g., diltiazem or verapamil) Cardiac glycosides (e.g., digoxin) have limited use, apart from in the sedentary elderly patient In addition to these agents, amiodarone has some AV node blocking effects (particularly when administered intravenously), and can be used in individuals when other agents are contraindicated or ineffective (particularly due to hypotension). Diltiazem has been shown to be more effective than either digoxin or amiodarone.[16]

Cardioversion
Cardioversion is a noninvasive conversion of an irregular heartbeat to a normal heartbeat using electrical or chemical means.[] Electrical cardioversion involves the restoration of normal heart rhythm through the application of a DC electrical shock. Chemical cardioversion is performed with drugs, such as amiodarone, dronedarone,[17] procainamide, dofetilide, ibutilide, propafenone, or flecainide. Vernakalant, an investigational drug which is unavailable in the U.S., has been found to safely and rapidly convert new onset atrial fibrillation in one published study.[18] After successful cardioversion the heart may be in a stunned state, which means that there is a normal rhythm but restoration of normal atrial contraction has not yet occurred.[]

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Ablation
In young patients where rhythm control is desired and cannot be maintained by medication or cardioversion then radiofrequency ablation or cryoablation may be attempted and is preferred over years of drug therapy.[]

Maze Procedure
The Maze procedure, first performed in 1987, is an effective invasive surgical treatment that is designed to create electrical blocks or barriers in the atria of the heart, forcing electrical impulses that stimulate the heartbeat to travel down to the ventricles. The idea is to force abnormal electrical signals to move along one, uniform path to the lower chambers of the heart (ventricles), thus restoring the normal heart rhythm.[19]

Following surgery
AF often occurs after cardiac surgery and is usually self-limiting. It is strongly associated with age, pre-operative hypertension, and the number of vessels grafted. Measures should be taken to control hypertension pre-operatively to reduce the risk of AF. Also, patients with a higher risk of AF, e.g., patients with pre-operative hypertension, more than 3 vessels grafted, or greater than 70 years of age, should be considered for prophylactic treatment. Postoperative pericardial effusion is also suspected to be the cause of atrial fibrillation. Prophylaxis may include prophylactic post-operative rate and rhythm management. Some authors perform posterior pericardiotomy to reduce the incidence of postoperative AF.[] When AF occurs, management should primarily be rate and rhythm control. However, cardioversion may be employed if the patient is haemodynamically unstable, highly symptomatic, or persists for 6 weeks after discharge. In persistent cases anticoagulation should be used.

Prognosis
Thromboembolism
In atrial fibrillation, the lack of an organized atrial contraction can result in some stagnant blood in the left atrium (LA) or left atrial appendage (LAA). This lack of movement of blood can lead to thrombus formation (blood clotting). If the clot becomes mobile and is carried away by the blood circulation, it is called an embolus. An embolus proceeds through smaller and smaller arteries until it plugs one of them and prevents blood from flowing through the artery. This process results in end-organ damage due to loss of nutrients, oxygen, and removal of cellular waste products. Thrombus can form anywhere in the body, while emboli follow the blood circulation to specific points in the body. Emboli in the brain may result in an ischemic stroke or a transient ischemic attack (TIA). More than 90% of cases of thrombi associated with non-valvular atrial fibrillation evolve in the left atrial appendage.[] However, the LAA lies in close relation to the free wall of the left ventricle and thus the LAA's emptying and filling, which determines its degree of blood stagnation, may be helped by the motion of the wall of the left ventricle, if there is good ventricular function.[20] If the LA is enlarged, there is an increased risk of thrombi that originate in the LA. Moderate to severe, non-rheumatic, mitral regurgitation (MR) reduces this risk of stroke.[] This risk reduction may be due to a beneficial stirring effect of the MR blood flow into the LA.[]

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Mitral valve
Atrial fibrillation and a corresponding enlargement of the left atrium may cause an increase in the perimeter of the mitral valve. The somewhat circular perimeter of the mitral valve is defined by the mitral annulus.[] With a normal sinus rhythm, the mitral annulus undergoes dynamic changes during the cardiac cycle. For example, at the end of diastole the annular area is smaller than at the end of systole. A possible reason for this dynamic size difference is that the coordinated contraction of the left atrium acts like a sphincter about the mitral annulus and reduces its size. This may be important for mitral valve competence so that it does not leak when the left ventricle pumps blood. However, when the left atrium fibrillates, this sphincter action is not possible and may contribute to, or result in, mitral regurgitation in some cases.[]

Epidemiology
Atrial fibrillation is the most common arrhythmia found in clinical practice.[] It also accounts for 1/3 of hospital admissions for cardiac rhythm disturbances,[] and the rate of admissions for AF has risen in recent years.[] Strokes from AF account for 6-24% of all ischemic strokes.[] Between 311% of those with AF have structurally normal hearts.[] Approximately 2.2million individuals in the United States and 4.5million in the European Union have AF.[][21] The incidence of atrial fibrillation increases with age. The prevalence in individuals over the age of 80 is about 8%.[22] In developed countries, the number of patients with atrial fibrillation is likely to increase during the next 50years, owing to the growing proportion of elderly individuals.[23]

Genetics
Four type of genetic disorder are associated with atrial fibrillation:[24] familial AF as a monogenic disease familial AF presenting in the setting of another inherited cardiac disease (hypertrophic cardiomyopathy, dilated cardiomyopathy, familial amyloidosis) inherited arrhythmic syndromes (congenital long QT syndrome, short QT syndrome, Brugada syndrome) non-familial AF associated with genetic backgrounds (polymorphism in the ACE gene) that may predispose to atrial fibrillation

History
Because the diagnosis of atrial fibrillation requires measurement of the electrical activity of the heart, atrial fibrillation was not truly described until 1874, when Edm Flix Alfred Vulpian observed the irregular atrial electrical behavior that he termed "fremissement fibrillaire" in dog hearts.[25] In the mid-eighteenth century, Jean-Baptiste de Snac made note of dilated, irritated atria in people with mitral stenosis.[26] The irregular pulse associated with AF was first recorded in 1876 by Carl Wilhelm Hermann Nothnagel and termed "delirium cordis", stating that "[I]n this form of arrhythmia the heartbeats follow each other in complete irregularity. At the same time, the height and tension of the individual pulse waves are continuously changing".[27] Correlation of delirium cordis with the loss of atrial contraction as reflected in the loss of a waves in the jugular venous pulse was made by Sir James MacKenzie in 1904.[28] Willem Einthoven published the first ECG showing AF in 1906.[29] The connection between the anatomic and electrical manifestations of AF and the irregular pulse of delirium cordis was made in 1909 by Carl Julius Rothberger, Heinrich Winterberg, and Sir Thomas Lewis.[30][31][32]

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References
[1] http:/ / apps. who. int/ classifications/ icd10/ browse/ 2010/ en#/ I48 [2] http:/ / www. icd9data. com/ getICD9Code. ashx?icd9=427. 31 [3] http:/ / www. diseasesdatabase. com/ ddb1065. htm [4] http:/ / www. nlm. nih. gov/ medlineplus/ ency/ article/ 000184. htm [5] http:/ / www. emedicine. com/ med/ topic184. htm [6] http:/ / www. emedicine. com/ emerg/ topic46. htm# [7] http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2013/ MB_cgi?field=uid& term=D001281 [19] Northwestern Surgery for Atrial Fibrillation. Atrial Fibrillation Surgery (http:/ / www. nmh. org/ nm/ atrial-fibrillation-surgery) [24] Shimizu W (2013) Atrial fibrillation and genetic abnormalities. Nihon Rinsho 71(1):161-1666

External links
Atrial fibrillation (http://www.dmoz.org/Health/Conditions_and_Diseases/Cardiovascular_Disorders/ Heart_Disease/Arrhythmia/Atrial_Fibrillation//) at the Open Directory Project

American Hospital Association

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American Hospital Association


American Hospital Association
Founded 1898

Headquarters Chicago, Illinois and Washington, D.C. Origins Key people The Association of Hospital Superintendents of the United States and Canada Thomas M. Priselac, Chairman [1] Richard Umbdenstock, President & CEO health care health care 5,708 [2] [3]

Area served Services Members Website

American Hospital Association

The American Hospital Association (AHA) is an organization that promotes the quality provision of health care by hospitals and health care networks through such efforts as promoting effective public policy and providing information related to health care and health administration to health care providers and the public. Founded in 1898 and hosting offices in Chicago, Illinois and Washington, D.C., the AHA hosts a Resource Center with more than 47,000 books on health care (some services fee based) and maintains an extensive, frequently updated Health Planning and Administration (HEALTH) database, which provides information related to health care unrelated to clinical treatment.[][4] More than 5,600 organizations and 41,000 individuals are members of the AHA.[]

History
In 1870, there were only about a hundred general hospitals in the United States, but the institution was growing rapidly.[] Hospital administrators formed an organization called "The Association of Hospital Superintendents of the United States and Canada", which held its first meeting in 1899 in Cleveland, Ohio, in which city seven of the eight superintendents in attendance were based.[] The organization was promoted by publisher Del Sutton, whose journal The National Hospital Sanitarium Record was adopted by the new group in 1900, gradually coming under control of the organization until it was replaced by the organization's own publication, The Modern Hospital.[5] In 1906, the growing organization adopted its present name, with membership reaching 450 in 1908.[6] Records of early annual meetings detail some of the conflicts in the emerging hospital culture of Canada and the United States concerning whether hospitals should be governed by physicians or administrators, with laypersons representing a heavy majority.[7]

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Personal membership groups


Personal membership groups (PMGs) are affiliated societies which fall under the umbrella of the AHA: American Society for Healthcare Engineering (ASHE) American Society for Healthcare Environmental Services (ASHES) American Society for Healthcare Human Resources Administration (ASHHRA) American Society for Healthcare Risk Management (ASHRM) Association for Community Health Improvement (ACHI) Association for the Healthcare Environment (AHE)[8] Association for Healthcare Resource & Materials Management (AHRMM) Association for Healthcare Volunteer Resource Professionals (AHVRP) At Large AHA Membership for Healthcare Management/Consulting Professionals Society for Healthcare Consumer Advocacy (SHCA) Society for Healthcare Strategy and Market Development (SHSMD)[]

References
[1] Richard Umbdenstock Bio (http:/ / www. aha. org/ aha/ content/ 2010/ pdf/ RJU-bio-. pdf), accessed December 22, 2010 [2] http:/ / www. aha. org/ aha/ resource-center/ Statistics-and-Studies/ fast-facts. html [3] [5] [6] [7] [8] http:/ / www. aha. org/ aha_app/ index. jsp Vogel, 245. Vogel, 244, 245. Vogel, 252. http:/ / www. ahe. org/

External links
American Hospital Association homepage (http://www.aha.org/aha_app/index.jsp)

American Heart Association

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American Heart Association


American Heart Association
Founded Founder(s) 1924 Physicians

Headquarters 7272 Greenville Avenue Dallas, TX 75231-4596 Key people Mission Motto Website Nancy A. Brown- Chief Executive Officer, Kathy Rogers-Executive Vice President of Consumer Markets "Building healthier lives, free of cardiovascular diseases and stroke" Learn and Live Official Website [1]

The American Heart Association (AHA) is a non-profit organization in the United States that fosters appropriate cardiac care in an effort to reduce disability and deaths caused by cardiovascular disease and stroke. It is headquartered in Dallas, Texas. The American Heart Association is a national voluntary health agency whose mission is: "Building healthier lives, free of cardiovascular diseases and stroke." Its motto is "Learn and Live". Ralph L. Sacco, MD, MS, FAAN, FAHA, is the current President of the American Heart Association. He is the first neurologist to hold the position.

Mission
The American Heart Association publishes a standard for providing basic and advanced life support, including standards for proper performance of cardiopulmonary resuscitation (CPR). The AHA offers the most widely accepted certification for basic life support (BLS). The AHA is now also a provider of training for first aid, in addition to CPR. The AHA also operates an affiliated organization, the American Stroke Association, which focuses on care, research and prevention of strokes.

History and Reputation


In 1994, the Chronicle of Philanthropy, an industry publication, released the results of the largest study of charitable and non-profit organization popularity and credibility. The study showed that the American Heart Association was ranked as the 5th "most popular charity/non-profit in America" of over 100 charities researched with 95% of Americans over the age of 12 choosing Love and Like A lot for the American Heart Association.[2]

Recent Events and Activities


On October 28, 2009 The American Heart Association and the Ad Council launched a Hands Only CPR PSA and website.[3] On November 30, 2009, The American Heart Association announced a new cardiac arrest awareness campaign called Be the Beat.[4] The campaigns aim is to help create the next generation of lifesavers by teaching 12- to 15-year-olds fun ways to learn the basics of cardiopulmonary resuscitation and how to use an automated external defibrillator. The official site, BetheBeat.heart.org [5], contains interactive games, quizzes, and a playlist of 100-beat-per-minute songs, as well as a section for teachers and administrators who want to incorporate CPR and AED educational information into their schools.

American Heart Association In May 2010, the AHA endorsed the Nintendo Wii Console to encourage everyone to get involved in a level of fitness that would develop healthiness. The AHA Heart Icon is featured on the box of the console as well as on the Wii Fit Plus and Wii Sports Resort titles. In July 2011, new content was added to the website including a digital app that helps a user learn how to perform Hands-Only CPR.[6] It also carried out a campaign in 2012 to educate more people on how to carry out Hands-Only CPR.[][][] The 2012 campaign, which began in New York, had Jennifer Coolidge as the celebrity spokesperson.[] Various affiliates around the country hold annual fundraising events, such as Go Red for Women, Heart Ball and Heart Walk. In 2012, singer-songwriter and actress Michelle Williams became an ambassador for the Power to End Stroke campaign. In speaking of her role she said "I am honored to partner with the campaign [...] My father had a stroke in 2005 due to smoking, diabetes and an unhealthy diet, and my grandmother was diagnosed with having a stroke in 2006 when she went to her doctor for a simple outpatient procedure. I am bringing awareness to people so that strokes can be prevented. Lets take care of ourselvesthe first step is knowledge about your health."[]

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External links
Official website [7] American Stroke Association Web site [8] My.AmericanHeart.org Web site [9] American Heart Association Training Web Site [10] Be the Beat [5] Hands Only CPR [11] Stroke Heroes Act FAST Heart Walk site [12] Go Red for Women site [13]

References
[1] http:/ / www. heart. org [2] The Charities Americans Like Most And Least, The Chronicle of Philanthropy, December 13, 1996 And USA Today, December 20, 1994, "Charity begins with health", FINAL 01D [3] American Heart Association, Ad Council launch Hands-Only CPR campaign (http:/ / www. newsroom. heart. org/ index. php?s=43& item=852) [4] Association's Campaign Inspires Teens to Use CPR, AEDs to Save Lives (http:/ / www. prnewswire. com/ news-releases/ associations-campaign-inspires-teens-to-use-cpr-aeds-to-save-lives-78125492. html) [5] http:/ / betheBeat. heart. org/ [6] Americans can learn Hands-Only CPR with a new digital application (http:/ / www. multivu. com/ mnr/ 50577-ad-council-hands-only-cpr) [7] http:/ / www. heart. org/ [8] http:/ / www. strokeassociation. org/ [9] http:/ / www. my. americanheart. org/ [10] http:/ / www. onlineaha. org/ [11] http:/ / handsonlycpr. org/ [12] http:/ / www. heartwalk. org/ [13] http:/ / www. goredforwomen. org/

American Health Care Association

173

American Health Care Association


AHCA/NCAL
Motto Legalstatus Headquarters Location Membership Improving Lives by Delivering Solutions for Quality Care. trade association 1201 L Street NW Washington, DC 11,000 facilities

Officiallanguages English CEO/President Website Governor Mark Parkinson Official Site [1]

The American Health Care Association (AHCA) is non-profit federation of affiliated state health organizations, together representing more than 10,000 non-profit and for-profit assisted living, nursing facility, developmentally-disabled, and subacute care providers that care for more than 1.5 million elderly and disabled individuals nationally. AHCA was founded in 1949 and is based in Washington, D.C. The National Center for Assisted Living (NCAL) is part of AHCA. AHCA/NCAL's mission statement: Improving Lives by Delivering Solutions for Quality Care.[citation needed] AHCA/NCAL works with Congress and the Federal government to advocate for long term care services. Membership is open to small and large health care facilities as well as long term care administrators, directors of nursing, certified nursing assistants, and facility owners and operators. Currently, the CEO/President of AHCA is Mark Parkinson, former Governor of Kansas. NCAL's CEO/President is Dave Kyllo. AHCA publishes a weekly member-only email newsletter called Capitol Connection and a separate monthly magazine titled Provider. The publications include breaking news and legislative progress on regulations and issue affecting the long term care industry. The association also offers professional development, educational, and networking opportunities. AHCA/NCAL established their Advancing Excellence in Americas Nursing Homes campaign in 2007 to improve care quality in nursing homes.[citation needed] The AHCA established the National Nursing Home Week in 1967. This is a week long observance recognizing nursing homes. It is held in May and begins on Mother's Day, the second Sunday of May. AHCA/NCAL has an up-to-date blog on industry-related news called Long Term Care Provider as well as a Facebook Page, YouTube Channel, and Twitter handle.

Quality improvement
AHCA/NCAL serves skilled nursing care centers in improving the quality of care provided to residents. AHCA provides facilities with resources and solutions for quality improvement such as Quality Reports, the Quality Award Program, a Leadership Excellence program, Gero Nurse Prep, and Nurse Assistant Training. In February 2012, AHCA/NCAL introduced The Quality Initiative-an effort that builds upon existing work the long term and post-acute care field is doing by setting specific, measurable targest to further improve quality of care in American's nursing and assisted living centers. The four main goals of The Quality Initiative are: 1. Safely Reduce Hospital Readmissions: By March 2012, reduce the number of hospital readmissions within 30 days during a SNF stay by 15 percent.

American Health Care Association 2. Increase Staff Stability: By March 2015, reduce turnover among nursing staff (RN, LPN/LVN, CNA) by 15 percent. 3. Increase Customer Satisfaction: By March 2015, increase the number of customers who would recommend the facility to others up to 90 percent. 4. Safely Reduce the Off-Label Use of Antipsychotics: By December 2012, reduce the off-label use of antipsychotic drugs by 15 percent.

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Advocacy
AHCA/NCAL's current advocacy issues include: 1. Protect and Preserve Medicaid Funding for Long Term 2. Stable Medicare Funding Essential for Quality Care 3. Extended Observation Stays Constrain Medicare Beneficiaries' Access to Skilled Nursing Facility Services AHCA/NCAL also provides an Advocate Toolkit which includes: Guide to Political Action and Grassroots Lobbying, Crafting an Effective Message, Steps to a Successful Facility Tour, and Using Facebook to Connect with Congress.

Research and data


AHCA develops and compiles comprehensive research and data concerning the long term and post-acute care sector. Whether conducted by AHCA and research agencies or gathered from government agencies, AHCA tries to inform the public and policymakers about the state of skilled nursing centers. Research and Data tools and resources include: LTC Trend Tracker, LTC Stats, Funding, and Trends and Statistics.

Member resources
AHCA/NCAL members have access to various information and resources which include: Clinical Practice, Compliance Programs, Disaster Planning, Fire and Life Safety, Finance, Medicaid, Survey and Certification, and Medicare. Members also have access to various publications such as Capitol Connection, NCAL Focus, Provider Magazine, NFP Newsletter, and DD Digest.

Events
AHCA/NCAL Convention - This annual long term care industry event includes influential speakers, education programs, networking opportunities, and activities. Congressional Briefing - Members convene annually at the nation's capital in order to raise awareness of important issues affecting long term and post-acute care in addition to meeting with congressional representatives. NCAL Spring Conference - This stand-alone event for assisted living professionals had its first inaugural conference in spring of 2012. Independent Owner Conference - The AHCA/NCAL Independent Owner Leadership Conference is for independent owners (IOs) and not for profit operators of ten or fewer long term care facilities. Quality Symposium - This annual symposium is for long term care quality professionals and is an event that provides a broad spectrum of programming to quality practitioners at all levels. Included are individual sessions, poster sessions, keynote speakers, networking, and idea sharing.

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External links
American Health Care Association [2] National Center for Assisted Living [3] National Nursing Home Week official site [4] Provider Magazine [5] Care Conversations [6]

References
[1] [2] [3] [4] [5] [6] http:/ / www. ahcancal. org http:/ / www. ahca. org/ http:/ / www. ncal. org/ http:/ / www. nnhw. org/ http:/ / www. providermagazine. com/ Pages/ default. aspx http:/ / www. careconversations. org/

American Health Information Management Association


The American Health Information Management Association (AHIMA) is a professional organization for the field of medical record management. Traditionally practicing in hospitals and to referring paper files and records, the field presently refers to all healthcare systems and types of media. The organization traces its history back to 1928 when the American College of Surgeons established the Association of Record Librarians of North America (ARLNA) to "elevate the standards of clinical records in hospitals and other medical institutions." The organization has had three name changes in its history, all were justified with an e xplanation that reflected the progression of contemporary medical record use, practices and perceptions. In 1938 the association became the American Association of Medical Record Librarians (AAMRL). In 1970, the association became the American Medical Record Association (AMRA) and in 1991, the title American Health Information Management Association (AHIMA) was adopted. Incorporation occurred in 1943 and became effective the next year. AHIMA's stated mission is to be the professional community that improves healthcare by advancing best practices and standards for health information management and the trusted source for education, research, and professional credentialing.

American Health Information Management Association

Formation Type Headquarters Location Membership

1928 professional association Chicago, Illinois United States 64,000

Official Language English President Patty Thierry Sheridan

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As of 2011, the association has more than 64,000 members in four membership classifications. Each member subsequently belongs to a relevant state chapter. The association offers seven credentials pertaining to four areas of practice; HIM, Coding, Data Analysis and Privacy. Two credentials require formal education, the others are acquired by a combination of testing and work experience. AHIMA requires members obtain regular continuing education to maintain their credentials. The Journal of AHIMA has a circulation of 61,000 and publishes both peer-reviewed and non-peer-reviewed articles. The association's membership is overwhelmingly female. AHIMA describes its foundation as a sister organization and states the foundation has a charitable and educational nature. The foundation's stated mission is to be the pre-eminent foundation recognized for excellence in health information leadership, policy and research for the healthcare industry and the public. The foundation formulates and issues opinions, supports education, conducts research and compiles its contributions into the Body of Knowledge (BoK).

References
AHIMA entry - TheFreeDictionary (http://medical-dictionary.thefreedictionary.com/AHIMA)

External links
AHIMA.org is the American Health Information Management Association's official site (http://www.AHIMA. org) ArHIMA.org is the Arkansas Health Information Management Association's official site (http://www. ARHIMA.org) WHIMA.org is the Wisconsin Health Information Management Association's official site (http://www.WHIMA. org) TXHIMA.org is the Texas Health Information Management Association's official site (http://www.TXHIMA. org) WSHIMA.org is the Washington State Health Information Management Association's official site (http://www. WSHIMA.org) MNHIMA.org is the Minnesota Health Information Management Association's official site (http://www. MNHIMA.org) WVHIMA.org is the West Virginia Health Information Management Association's official site (http://www. WVHIMA.org)

America's Health Insurance Plans

177

America's Health Insurance Plans


America's Health Insurance Plans
Abbreviation Formation Type AHIP 2003 trade association

Purpose/focus political advocacy Location Washington, District of Columbia

Regionserved United States President Website Karen Ignagni ahip.org [1]

Americas Health Insurance Plans (AHIP) is a national political advocacy and trade association with about 1,300 member companies that sell health insurance coverage to more than 200 million Americans.[2] AHIP was formed through the merger of Health Insurance Association of America (HIAA) and American Association of Health Plans (AAHP).[3][4][5][6] AAHP was formed through a merger between two Health Maintenance Organization (HMO) trade associations, Group Health Association of America and American Managed Care and Review Association.[citation needed] AHIP is a member of CAQH, a coalition of healthcare trade associations and health plans that aims to simplify healthcare administration. The AHIP Center for Policy and Research is the trade association's research arm.[7] The center publishes research on a variety of forms of private health insurance, often based on survey data gathered from AHIP member companies. The forms of insurance studied include disability income and long-term care insurance as well as different types of medical expense insurance. AHIP President Karen M. Ignagni[8] frequently serves as a spokesperson for the views of the insurance industry.[9] On September 27, 2007, she appeared on The Oprah Winfrey Show opposite Michael Moore, the director of Sicko, to discuss health insurance.[10]

Health Care Reform


In December 2008, AHIP published its proposals for health care reform: 1. Soaring health care costs not needed to be brought under control. It admitted that lower spending typically did mean lower quality. It urged that public-private Advisory Group should be tasked with the job of restraining and reducing wasteful and unnecessary spending, changing the rewards structure to favor quality and outcomes rather than volume of work, and streamline administrative processes across the health care system. 2. Reforms should strive for higher value and reduce disparities in ethnic and other minorities by focusing on keeping people healthy and intervening earlier, It called for coordinated care for chronic conditions, and the setting of uniform standards for quality, reporting, and information technology. Also there should be more investment in research to better understand which treatments and therapies work best for both the nation as a whole and for specific patients and accountability for consistently delivered, high-quality care based on the best evidence. It advocated a national initiative to increase public awareness of the links between preventable conditions and chronic illness, and prevention programs in our schools, worksites, and communities.

America's Health Insurance Plans 3. All Americans should have affordable, portable coverage and that there should be an individual mandate requiring all Americans to have adequate insurance as a quid pro quo for insurance companies issuing policies with no pre-existing condition exclusions. There should be better tax equity between company plans and private market policies, and tax credits on a sliding scale basis for those earning less than 400 percent of the Federal Poverty Level (FPL). Small businesses should get assistance through the tax code and other measures to make premiums stable and encourage them to contribute to their employees' health insurance needs. It promoted an Essential Benefits Plan available nationwide, that providing coverage for prevention and wellness as well as acute and chronic care, and that is not subject to varying and conflicting state benefit mandates. The large group market (covering 160 million Americans) should be preserved. The new system should avoid the cost shifting that was inherent in the old system. Public programs should be strengthened supported such as Community Health Centers, SCHIP and the reformed system should prevent so called "Medical bankruptcies". 4. Regulatory reform. It said that the patchwork of federal and state regulations often hinder, rather than helps, efforts to improve care and contain costs. It therefore said that the federal government should create a streamlined and effective regulatory system and the states should enforce it. It said the states should continue to run SCHIP and Medicaid programs and that eligibility for Medicaid should be simplified to those on 100 percent of the federal poverty level without other conditions.[11]

178

Lobbying
AHIP has spent more than $31.4 million on lobbying from 2005 to 2009, according to the non-partisan Center for Responsive Politics. This includes $3.9 million alone in 2009, which paid for the work of 50 lobbyists at eight different lobbying firms.[12]

AHIP and "Sicko"


On the July 10, 2009 edition of Bill Moyers Journal, Wendell Potter, former Vice President of corporate communications at the health insurance corporation CIGNA, claimed that the industry was "afraid" of the Michael Moore documentary Sicko.[13] As a result, AHIP formed a strategy to "discredit this film".[14] As part of the reporting on this allegation, Bill Moyers Journal provides May 2007 and June 2007 drafts of a memo entitled "Ensuring Accurate Perceptions of the Health Insurance Industry".[15][16] This memo outlines the strategy the health insurance industry would use to battle Moores documentary. The later draft lists the following as the "5 Strategies We Reached Consensus On": 1. 2. 3. 4. 5. "Debate the System, not the Anecdotes. Set the record straight then get off Moores turf and on to ours." "Reframe the Debate: Mount Campaign against a Government-run Health Care system." "Define the Health Insurance as Part of the Solution." "Caution Democrats Against Aligning with Moores Extremist Agenda." "Game Plan for Various Potential Scenarios."

The AHIP memos do not list any factual errors in Sicko. The memos instead focus primarily on media messaging in terms of influencing politicians and public opinion.

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179

Controversy
AHIP's 2005 television ad "Shark Bait" drew harsh criticism for its claim that "lawsuit abuse" by American trial lawyers cost the typical American family $1,200 a year.[17] On August 27, 2009, Michael Tuffin a spokesman for AHIP, told CNNs Lou Dobbs program that every survey shows strong satisfaction for private health insurance, as part of the organizations campaign against health care reform. The non-partisan Politfact watchdog organization found that his words were "half-true." In fact, Politifact said polls have found that often the majority of consumers have varying degrees of satisfaction, but are not strongly satisfied. For instance, an ABC News poll in June 2009 about the cost of health insurance premiums found 23 percent were very satisfied, but a combined 75 percent of consumers were somewhat satisfied, somewhat dissatisfied or very dissatisfied (31 percent somewhat satisfied, 19 percent somewhat dissatisfied and 25 percent very dissatisfied.) [18]

References
[1] http:/ / www. ahip. org [2] AHIP (http:/ / www. ahip. org/ content/ default. aspx?bc=31) Accessed 6 April 2007. [3] Press Release (http:/ / www. prnewswire. com/ cgi-bin/ stories. pl?ACCT=104& STORY=/ www/ story/ 12-11-2003/ 0002074162& EDATE=) dated December 11, 2003 (retrieved November 13, 2007) [4] AHIP "Smartbrief" announcing merger (http:/ / www. smartbrief. com/ news/ ahip/ storyDetails. jsp?issueid=AC500438-A63A-41EF-B4F0-BFFC93B584C3& copyid=46A67C43-F08A-478D-AB02-C382FA2B3A20) [5] "Health insurers gain a huge new lobby," (http:/ / query. nytimes. com/ gst/ fullpage. html?res=9504E4DB1F3AF930A1575AC0A9659C8B63) New York Times, September 23, 2003 [6] SARAH LUECK, "Two health trade groups to merge," (http:/ / online. wsj. com/ article/ SB106426654381679800. html?mod=home_whats_news_us), Wall Street Journal, September 23, 2003 [7] AHIP Center for Policy and Research (http:/ / www. ahipresearch. org/ ) [8] ROBERT PEAR (http:/ / www. nytimes. com/ 2007/ 09/ 16/ us/ politics/ 16clinton. html?_r=1& hp& oref=slogin) New York Times September 16, 2007. [9] Sam Youngman, "Clinton plan sparks frenzy," TheHill.com September 18, 2007 (http:/ / thehill. com/ leading-the-news/ clinton-plan-sparks-frenzy-2007-09-18. html) [10] Aoife McCarthy, "Suite Talk: Making room for new faces: A bad day at the office for AHIP?", Politico.com, September 26, 2007 (http:/ / www. politico. com/ news/ stories/ 0907/ 6030. html) [11] http:/ / www. americanhealthsolution. org/ assets/ Uploads/ ahipreformpolicyproposal. pdf [12] http:/ / www. opensecrets. org/ lobby/ clientsum. php?lname=America%27s+ Health+ Insurance+ Plans& year=2009 AHIP profile, Center for Responsive Politics [13] http:/ / www. pbs. org/ moyers/ journal/ 07102009/ transcript2. html [14] http:/ / www. pbs. org/ moyers/ journal/ 07102009/ transcript2. html [15] http:/ / www. pbs. org/ moyers/ journal/ 07102009/ ahip1. pdf [16] http:/ / www. pbs. org/ moyers/ journal/ 07102009/ ahip2. pdf [17] FactCheck.org: Insurance Industry Ad Makes Fishy Claim About Lawyers (http:/ / www. factcheck. org/ politics/ insurance_industry_ad_makes_fishy_claim_about. html) [18] http:/ / www. politifact. com/ truth-o-meter/ statements/ 2009/ sep/ 01/ americas-health-insurance-plans/ strong-satisfaction-health-insurance-coverage/ Politifact, 1 Sept 2009

America's Health Insurance Plans

180

External links
America's Health Insurance Plans (AHIP) Website (http://www.ahip.org/) Sourcewatch profile (http://www.sourcewatch.org/index.php?title=America's_Health_Insurance_Plans) Center for Responsive Politics profile (http://www.opensecrets.org/lobby/clientsum.php?lname=American+ Health+Insurance+Plans&year=2008) American Medical News story on AHIP annual meeting (http://www.ama-assn.org/amednews/2009/08/10/ bisa0810.htm) FCIC: Guide To Health Insurance (http://www.pueblo.gsa.gov/cic_text/health/guidehealth/guidehealth.htm)

Agency for Healthcare Research and Quality


The Agency for Healthcare Research and Quality (AHRQ) (formerly known as the Agency for Health Care Policy and Research) is one of 12 agencies within the United States Department of Health and Human Services (HHS).[1] AHRQ is one of three organizational focuses for HHS along with the National Institutes of Health and the Centers for Disease Control.[2] AHRQ's mission is to improve the quality, safety, efficiency and effectiveness of healthcare for Americans. Led by Director Carolyn M. Clancy, M.D.,[3] AHRQ sponsors, conducts, and disseminates research to aid in informed decision-making and improve the quality of health care services. Working with the public and private sectors, AHRQ research evaluates the effectiveness of health care interventions and aims to translate this knowledge into everyday practice and policymaking.

Medical cost-effectiveness research


AHRQ's patient-centered outcomes research aims to improve health care quality by providing patients and physicians with evidence-based information on which medical treatments work best for a given condition. Comparisons of drugs, medical devices, tests, surgeries, or ways to deliver health care can be used to help patients and their families understand and evaluate treatments options and risks. AHRQ initiatives include: The John M. Eisenberg Center for Clinical Decisions and Communications Science [4] that translates comparative effectiveness reviews and research reports created by AHRQ's Effective Health Care Program [5] into guides and tools for consumers, clinicians, and policymakers. Evidence-based Practice Centers [6] that review and synthesize scientific evidence for conditions or technologies that are costly, common, or important to the Medicare or Medicaid programs. The Centers for Education and Research on Therapeutics [7] (CERTs) that conduct research and provide education to advance the optimal use of drugs, biologicals, and medical devices. The Developing Evidence to Inform Decisions about Effectiveness Network [8] (DEcIDE), research-based health organizations that conduct practical studies about the outcomes, comparative clinical effectiveness, safety, and appropriateness of health care items and services.

Agency for Healthcare Research and Quality

181

Quality improvement and patient safety


AHRQ funds and disseminates research that identifies the root causes of threats to patient safety, provides information on the scope and impact of medical errors, and examines effective ways to make system-level changes to help prevent errors. AHRQ initiatives include: Preventing healthcare-associated infections [9]. Medical liability reform [10]. Patient Safety Organizations [11], which collect and analyze patient safety events that health care providers report and provide feedback to help clinicians and health care organizations improve health care quality. AHRQ administers the provisions of the Patient Safety and Quality Improvement Act of 2005[12] and the Patient Safety Rule [13][14] dealing with PSO operations. TeamSTEPPS [15] (Team Strategies and Tools to Enhance Performance and Patient Safety), an evidence-based teamwork system designed to improve communication and teamwork skills among health care professionals. Patient safety culture assessment tools [16] that hospitals, nursing homes, and medical offices use to assess their patient safety culture, track changes in patient safety over time, and evaluate the impact of specific patient safety interventions.

Health information technology (health IT)


AHRQ's Health IT initiative [17] is part of the Nation's strategy to put technology to work in health care. AHRQ provides support to promote access to and encourage the adoption of health IT. The Agency has focused its health IT activities on the following three goals: Improve health care decisionmaking. Support patient-centered care. Improve the quality and safety of medication management.

Prevention and chronic care


AHRQ translates evidence-based knowledge into recommendations for clinical preventive services to improve the health of all Americans. AHRQ initiatives include: The Patient-Centered Medical Home [18], a model to improve health care by transforming how primary care is organized and delivered that ensures care is patient-centered, comprehensive, and accessible, coordinated across the health care system, and uses a systems-based approach to quality and safety. The Primary Care Practice-Based Research Networks [19] that rapidly develop and assess methods and tools to ensure that new scientific evidence is incorporated into real-world practice settings. Administrative support for the U.S. Preventive Services Task Force [20], an independent panel of nationally renowned, non-Federal experts in prevention and evidence-based medicine that assesses the benefits and harms of preventive services and makes recommendations about which preventive services should be incorporated routinely into primary care practice.

Agency for Healthcare Research and Quality

182

Health care value


AHRQ looks for ways to achieve greater value in health care by producing the measures, data, tools, evidence, and strategies that health care organizations, systems, insurers, purchasers, and policymakers need to improve the value and affordability of health care. AHRQ initiatives include: The Medical Expenditure Panel Survey [21] (MEPS), a family of surveys that gathers information about families and individuals, their medical providers, and employers across the United States. It is the only national source of annual data on the specific health services that Americans use, how frequently services are used, the cost of services, and the methods of paying for services. The Healthcare Cost and Utilization Project [22] (HCUP), a family of health care databases and related software tools and products developed through a Federal-State-industry partnership that serves as a national information resource of patient-level health care data. Quality Indicators [23] (QIs) that highlight potential quality concerns; identify areas that need further study; and track changes over time in prevention, inpatient care, patient safety, and pediatric care. QIs measure health care quality based upon readily available hospital inpatient administrative data. The annual National Healthcare Quality Report [24] and National Healthcare Disparities Report [25] that measure trends in effectiveness of care, patient safety, timeliness of care, patient centeredness, and efficiency of care. State Snapshots [26] that provide, via a Web site, State-specific health care quality information, including strengths, weaknesses, and opportunities for improvement. The CAHPS [27] program develops surveys to help improve the quality of health care from the perspective of consumers and patients. The surveys include ones on home health care, dental plans, and nursing homes. The National Guideline Clearinghouse [28], a Web-based resource for information on more than 2,300 evidence-based clinical practice guidelines. The National Quality Measures Clearinghouse [29], a database and Web site for information on specific evidence-based health care quality measures and measure sets.

Political history
The agency originally began as the Agency for Health Care Policy and Research and was tasked with producing guidelines. However, it became controversial when it produced several guidelines which would reduce lucrative medical drugs and procedures. This included concern from ophthalmologists on a cataract guideline and concern by the pharmaceutical industry over a reduction in the use of new high-margin drugs. When the agency produced a guideline which concluded that back pain surgery was unnecessary and potentially harmful, a lobbying campaign aided by Congressmen whose backs had been operated on changed the name of the agency and "wound down" the guidelines program.[30]

Related links
AHRQ Data and Surveys [31] AHRQs Health Care Innovations and Exchange program [32] AHRQs Prevention and Chronic Care Program [33]

References
[1] Healthcare Research and Quality Act of 1999 (http:/ / www. ahrq. gov/ hrqa99a. htm) [2] AHRQ Fiscal Year 2013 Justification of Estimates for Appropriations Committees (http:/ / www. ahrq. gov/ about/ cj2013/ cj2013. pdf) (PDF), Page 1: Performance Budget Overview [3] Carolyn M. Clancy, M.D. (http:/ / www. ahrq. gov/ about/ clancybio. htm) [4] http:/ / effectivehealthcare. ahrq. gov/ index. cfm/ who-is-involved-in-the-effective-health-care-program1/ about-the-eisenberg-center/ [5] http:/ / effectivehealthcare. ahrq. gov/

Agency for Healthcare Research and Quality


[6] http:/ / www. ahrq. gov/ clinic/ epc/ [7] http:/ / www. certs. hhs. gov/ [8] http:/ / effectivehealthcare. ahrq. gov/ index. cfm/ who-is-involved-in-the-effective-health-care-program1/ about-the-decide-network/ [9] http:/ / www. ahrq. gov/ qual/ hais. htm [10] http:/ / www. ahrq. gov/ qual/ liability/ [11] http:/ / www. pso. ahrq. gov/ [12] Patient Safety and Quality Improvement Act of 2005 [13] http:/ / www. hhs. gov/ ocr/ privacy/ psa/ regulation/ rule/ index. html [14] Patient Safety Rule (http:/ / www. hhs. gov/ ocr/ privacy/ psa/ regulation/ rule/ index. html) [15] http:/ / www. ahrq. gov/ teamsteppstools/ [16] http:/ / www. ahrq. gov/ qual/ patientsafetyculture/ [17] http:/ / healthit. ahrq. gov/ portal/ server. pt/ community/ ahrq_national_resource_center_for_health_it/ 650 [18] http:/ / www. pcmh. ahrq. gov/ portal/ server. pt/ community/ pcmh__home/ 1483 [19] http:/ / pbrn. ahrq. gov/ portal/ server. pt/ community/ practice_based_research_networks_%28pbrn%29__home_page/ 851 [20] http:/ / www. uspreventiveservicestaskforce. org/ [21] http:/ / meps. ahrq. gov/ mepsweb/ [22] http:/ / www. ahrq. gov/ data/ hcup/ [23] http:/ / www. qualityindicators. ahrq. gov/ [24] http:/ / www. ahrq. gov/ qual/ measurix. htm#quality [25] http:/ / www. ahrq. gov/ qual/ measurix. htm#disparity [26] http:/ / statesnapshots. ahrq. gov/ snaps11/ index. jsp [27] http:/ / www. ahrq. gov/ cahps/ [28] [29] [30] [31] [32] [33] http:/ / www. guideline. gov/ http:/ / www. qualitymeasures. ahrq. gov/ Avorn J. Powerful Medicines: The Benefits, Risks, and Costs of Prescription Drugs, pp. 277-288. Random House. http:/ / ahrq. gov/ data/ http:/ / www. innovations. ahrq. gov/ http:/ / www. ahrq. gov/ clinic/ prevenix. htm

183

External links
Agency for Healthcare Research and Quality Web site (http://www.ahrq.gov) U.S. Department of Health and Human Services Web site (http://www.hhs.gov/)

HIV/AIDS

184

HIV/AIDS
HIV/AIDS
Classification and external resources

The red ribbon is a symbol for solidarity with HIV-positive people and those living with AIDS. ICD-10 ICD-9 OMIM DiseasesDB MedlinePlus eMedicine MeSH B20 042 [1] [3] B24 [2]

-044 [5]

[4]

609423 5938

[6] [7] [8]

000594

emerg/253 D000163

[9]

Human immunodeficiency virus infection / acquired immunodeficiency syndrome (HIV/AIDS) is a disease of the human immune system caused by infection with human immunodeficiency virus (HIV).[] During the initial infection, a person may experience a brief period of influenza-like illness. This is typically followed by a prolonged period without symptoms. As the illness progresses, it interferes more and more with the immune system, making the person much more likely to get infections, including opportunistic infections and tumors that do not usually affect people who have working immune systems. HIV is transmitted primarily via unprotected sexual intercourse (including anal and even oral sex), contaminated blood transfusions, hypodermic needles, and from mother to child during pregnancy, delivery, or breastfeeding.[] Some bodily fluids, such as saliva and tears, do not transmit HIV.[] Prevention of HIV infection, primarily through safe sex and needle-exchange programs, is a key strategy to control the spread of the disease. There is no cure or vaccine; however, antiretroviral treatment can slow the course of the disease and may lead to a near-normal life expectancy. While antiretroviral treatment reduces the risk of death and complications from the disease, these medications are expensive and may be associated with side effects. Genetic research indicates that HIV originated in west-central Africa during the early twentieth century.[] AIDS was first recognized by the Centers for Disease Control and Prevention (CDC) in 1981 and its causeHIV infectionwas identified in the early part of the decade.[10] Since its discovery, AIDS has caused nearly 30million deaths (as of 2009).[] As of 2010, approximately 34million people are living with HIV globally.[11] AIDS is

HIV/AIDS considered a pandemica disease outbreak which is present over a large area and is actively spreading.[12] HIV/AIDS has had a great impact on society, both as an illness and as a source of discrimination. The disease also has significant economic impacts. There are many misconceptions about HIV/AIDS such as the belief that it can be transmitted by casual non-sexual contact. The disease has also become subject to many controversies involving religion.

185

Signs and symptoms


There are three main stages of HIV infection: acute infection, clinical latency and AIDS.[13][]

Acute infection
The initial period following the contraction of HIV is called acute HIV, primary HIV or acute retroviral syndrome.[13][] Many individuals develop an influenza-like illness or a mononucleosis-like illness 24 weeks post exposure while others have no significant symptoms.[14][15] Symptoms occur in 4090% of cases and most commonly include fever, large tender lymph nodes, throat inflammation, a rash, headache, and/or sores of the mouth and genitals.[][15] The rash, which occurs in 2050% of cases, presents itself on the trunk and is maculopapular, classically.[] Some people also develop opportunistic infections at this stage.[] Gastrointestinal symptoms such as nausea, vomiting or diarrhea may occur, as may Main symptoms of acute HIV infection neurological symptoms of peripheral neuropathy or Guillain-Barre syndrome.[15] The duration of the symptoms varies, but is usually one or two weeks.[15] Due to their nonspecific character, these symptoms are not often recognized as signs of HIV infection. Even cases that do get seen by a family doctor or a hospital are often misdiagnosed as one of the many common infectious diseases with overlapping symptoms. Thus, it is recommended that HIV be considered in patients presenting an unexplained fever who may have risk factors for the infection.[15]

Clinical latency
The initial symptoms are followed by a stage called clinical latency, asymptomatic HIV, or chronic HIV.[] Without treatment, this second stage of the natural history of HIV infection can last from about three years[16] to over 20years[17] (on average, about eight years).[18] While typically there are few or no symptoms at first, near the end of this stage many people experience fever, weight loss, gastrointestinal problems and muscle pains.[] Between 50 and 70% of people also develop persistent generalized lymphadenopathy, characterized by unexplained, non-painful enlargement of more than one group of lymph nodes (other than in the groin) for over three to six months.[13] Although most HIV-1 infected individuals have a detectable viral load and in the absence of treatment will eventually progress to AIDS, a small proportion (about 5%) retain high levels of CD4+ T cells (T helper cells) without antiretroviral therapy for more than 5 years.[15][] These individuals are classified as HIV controllers or long-term nonprogressors (LTNP).[] Another group is those who also maintain a low or undetectable viral load without anti-retroviral treatment who are known as "elite controllers" or "elite suppressors". They represent

HIV/AIDS approximately 1 in 300 infected persons.[]

186

Acquired immunodeficiency syndrome


Acquired immunodeficiency syndrome (AIDS) is defined in terms of either a CD4+ T cell count below 200 cells per L or the occurrence of specific diseases in association with an HIV infection.[15] In the absence of specific treatment, around half of people infected with HIV develop AIDS within ten years.[15] The most common initial conditions that alert to the presence of AIDS are pneumocystis pneumonia (40%), cachexia in the form of HIV wasting syndrome (20%) and esophageal candidiasis.[15] Other common signs include recurring respiratory tract infections.[15] Opportunistic infections may be caused by bacteria, viruses, fungi and parasites that are normally controlled by the immune system.[] Which infections occur partly depends on what organisms are common in the person's environment.[15] These infections may affect nearly every organ system.[] People with AIDS have an increased risk of developing various viral induced cancers including: Kaposi's sarcoma, Burkitt's lymphoma, primary central nervous system lymphoma, and cervical cancer.[] Kaposi's sarcoma is the most common cancer occurring in 10 to 20% of people with HIV.[19] The second most common cancer is lymphoma which is the cause of death of nearly 16% of people with AIDS and is the initial sign of AIDS in 3 to 4%.[19] Both these cancers are associated with human herpesvirus 8.[19] Cervical cancer occurs more frequently in those with AIDS due to its association with human papillomavirus (HPV).[19] Additionally, people with AIDS frequently have systemic symptoms such as prolonged fevers, sweats (particularly at night), swollen lymph nodes, chills, weakness, and weight loss.[20] Diarrhea is another common symptom present in about 90% of people with AIDS.[21] They can also be affected by diverse psychiatric and neurological symptoms independent of opportunistic infections and cancers.[22]
Main symptoms of AIDS.

Transmission

HIV/AIDS

187

Exposure route Blood transfusion Childbirth (to child) Needle-sharing injection drug use Percutaneous needle stick Receptive anal intercourse* Insertive anal intercourse*

Chance of infection 90% 25%


[] [] [] [] []

0.67% 0.30%

0.043.0% 0.03%
[23]

Receptive penile-vaginal intercourse* 0.050.30% Insertive penile-vaginal intercourse* Receptive oral intercourse* Insertive oral intercourse*
*

[][] [][]

0.010.38% 00.04%
[]

00.005%

[24]

assuming no condom use source refers to oral intercourse performed on a man

|+ Average per act risk of getting HIV by exposure route to an infected source HIV is transmitted by three main routes: sexual contact, exposure to infected body fluids or tissues, and from mother to child during pregnancy, delivery, or breastfeeding (known as vertical transmission).[] There is no risk of acquiring HIV if exposed to feces, nasal secretions, saliva, sputum, sweat, tears, urine, or vomit unless these are contaminated with blood.[] It is possible to be co-infected by more than one strain of HIVa condition known as HIV superinfection.[25]

Sexual
The most frequent mode of transmission of HIV is through sexual contact with an infected person.[] The majority of all transmissions worldwide occur through heterosexual contacts (i.e. sexual contacts between people of the opposite sex);[] however, the pattern of transmission varies significantly among countries. In the United States, as of 2009, most sexual transmission occurred in men who had sex with men,[] with this population accounting for 64% of all new cases.[] As regards unprotected heterosexual contacts, estimates of the risk of HIV transmission per sexual act appear to be four to ten times higher in low-income countries than in high-income countries.[] In low-income countries, the risk of female-to-male transmission is estimated as 0.38% per act, and of male-to-female transmission as 0.30% per act; the equivalent estimates for high-income countries are 0.04% per act for female-to-male transmission, and 0.08% per act for male-to-female transmission.[] The risk of transmission from anal intercourse is especially high, estimated as 1.41.7% per act in both heterosexual and homosexual contacts.[][26] While the risk of transmission from oral sex is relatively low, it is still present.[27] The risk from receiving oral sex has been described as "nearly nil"[28] however a few cases have been reported.[29] The per-act risk is estimated at 00.04% for receptive oral intercourse.[] In settings involving prostitution in low income countries, risk of female-to-male transmission has been estimated as 2.4% per act and male-to-female transmission as 0.05% per act.[] Risk of transmission increases in the presence of many sexually transmitted infections[] and genital ulcers.[] Genital ulcers appear to increase the risk approximately fivefold.[] Other sexually transmitted infections, such as gonorrhea, chlamydia, trichomoniasis, and bacterial vaginosis, are associated with somewhat smaller increases in risk of transmission.[]

HIV/AIDS The viral load of an infected person is an important risk factor in both sexual and mother-to-child transmission.[30] During the first 2.5months of an HIV infection a person's infectiousness is twelve times higher due to this high viral load.[] If the person is in the late stages of infection, rates of transmission are approximately eightfold greater.[] Commercial sex workers (including those in pornography) have an increased rate of HIV.[31][32] Rough sex can be a factor associated with an increased risk of transmission.[33] Sexual assault is also believed to carry an increased risk of HIV transmission as condoms are rarely worn, physical trauma to the vagina or rectum is likely, and there may be a greater risk of concurrent sexually transmitted infections.[34]

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Body fluids
The second most frequent mode of HIV transmission is via blood and blood products.[] Blood-borne transmission can be through needle-sharing during intravenous drug use, needle stick injury, transfusion of contaminated blood or blood product, or medical injections with unsterilised equipment. The risk from sharing a needle during drug injection is between 0.63 and 2.4% per act, with an average of 0.8%.[] The risk of acquiring HIV from a needle stick from an HIV-infected person is estimated as 0.3% (about 1 in 333) per act and the risk following mucus membrane exposure to infected blood as 0.09% (about 1 in 1000) per act.[] In the United States intravenous drug users made up 12% of all new cases of HIV in 2009,[] and in some areas more than 80% of people who inject drugs are HIV positive.[] HIV is transmitted in About 93% of blood transfusions involving infected blood.[] In developed countries the risk of acquiring HIV from a blood transfusion is extremely low (less than one in half a million) CDC poster from 1989 highlighting the threat of where improved donor selection and HIV screening is performed;[] for AIDS associated with drug use example, in the UK the risk is reported at one in five million.[35] In low income countries, only half of transfusions may be appropriately screened (as of 2008),[36] and it is estimated that up to 15% of HIV infections in these areas come from transfusion of infected blood and blood products, representing between 5% and 10% of global infections.[][] Unsafe medical injections play a significant role in HIV spread in sub-Saharan Africa. In 2007, between 12 and 17% of infections in this region were attributed to medical syringe use.[] The World Health Organisation estimates the risk of transmission as a result of a medical injection in Africa at 1.2%.[] Significant risks are also associated with invasive procedures, assisted delivery, and dental care in this area of the world.[] People giving or receiving tattoos, piercings, and scarification are theoretically at risk of infection but no confirmed cases have been documented.[] It is not possible for mosquitoes or other insects to transmit HIV.[37]

Mother-to-child
HIV can be transmitted from mother to child during pregnancy, during delivery, or through breast milk.[][] This is the third most common way in which HIV is transmitted globally.[] In the absence of treatment, the risk of transmission before or during birth is around 20% and in those who also breastfeed 35%.[] As of 2008, vertical transmission accounted for about 90% of cases of HIV in children.[] With appropriate treatment the risk of mother-to-child infection can be reduced to about 1%.[] Preventive treatment involves the mother taking antiretroviral during pregnancy and delivery, an elective caesarean section, avoiding breastfeeding, and administering antiretroviral drugs to the newborn.[] Many of these measures are however not available in the developing world.[] If blood contaminates food during pre-chewing it may pose a risk of transmission.[]

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Virology
HIV is the cause of the spectrum of disease known as HIV/AIDS. HIV is a retrovirus that primarily infects components of the human immune system such as CD4+ T cells, macrophages and dendritic cells. It directly and indirectly destroys CD4+ T cells.[] HIV is a member of the genus Lentivirus,[] part of the family Retroviridae.[] Lentiviruses share many morphological and biological characteristics. Many species of mammals are infected by lentiviruses, which are characteristically responsible for long-duration illnesses with a long incubation period.[] Lentiviruses are transmitted as A diagram showing the structure of HIV virus single-stranded, positive-sense, enveloped RNA viruses. Upon entry into the target cell, the viral RNA genome is converted (reverse transcribed) into double-stranded DNA by a virally encoded reverse transcriptase that is transported along with the viral genome in the virus particle. The resulting viral DNA is then imported into the cell nucleus and integrated into the cellular DNA by a virally encoded integrase and host co-factors.[] Once integrated, the virus may become latent, allowing the virus and its host cell to avoid detection by the immune system.[38] Alternatively, the virus may be transcribed, producing new RNA genomes and viral proteins that are packaged and released from the cell as new virus particles that begin the replication cycle anew.[39] Two types of HIV have been characterized: HIV-1 and HIV-2. HIV-1 is the virus that was originally discovered (and initially referred to also as LAV or HTLV-III). It is more virulent, more infective,[40] and is the cause of the majority of HIV infections globally. The lower infectivity of HIV-2 as compared with HIV-1 implies that fewer people exposed to HIV-2 will be infected per exposure. Because of its relatively poor capacity for transmission, HIV-2 is largely confined to West Africa.[]

Pathophysiology
After the virus enters the body there is a period of rapid viral replication, leading to an abundance of virus in the peripheral blood. During primary infection, the level of HIV may reach several million virus particles per milliliter of blood.[] This response is accompanied by a marked drop in the number of circulating CD4+ T cells. The acute viremia is almost invariably associated with activation of CD8+ T cells, which kill HIV-infected cells, and subsequently with antibody production, or seroconversion. The CD8+ T cell response is thought to be important in controlling virus levels, which peak and then decline, as the CD4+ T cell counts recover. A good CD8+ T cell response has been linked to slower disease progression and a better prognosis, though it does not eliminate the virus.[] The pathophysiology of AIDS is complex.[] Ultimately, HIV causes AIDS by depleting CD4+ T cells. This weakens the immune system and allows opportunistic infections. T cells are essential to the immune response and without them, the body cannot fight infections or kill cancerous cells. The mechanism of CD4+ T cell depletion differs in the acute and chronic phases.[] During the acute phase, HIV-induced cell lysis and killing of infected cells by cytotoxic T cells accounts for CD4+ T cell depletion, although apoptosis may also be a factor. During the chronic phase, the consequences of generalized immune activation coupled with the gradual loss of the ability of the immune system to generate new T cells appear to account for the slow decline in CD4+ T

Scanning electron micrograph of HIV-1, colored green, budding from a cultured lymphocyte.

cell numbers.[41]

HIV/AIDS Although the symptoms of immune deficiency characteristic of AIDS do not appear for years after a person is infected, the bulk of CD4+ T cell loss occurs during the first weeks of infection, especially in the intestinal mucosa, which harbors the majority of the lymphocytes found in the body.[] The reason for the preferential loss of mucosal CD4+ T cells is that the majority of mucosal CD4+ T cells express the CCR5 protein which HIV uses as a co-receptor to gain access to the cells, whereas only a small fraction of CD4+ T cells in the bloodstream do so.[] HIV seeks out and destroys CCR5 expressing CD4+ T cells during acute infection.[] A vigorous immune response eventually controls the infection and initiates the clinically latent phase. CD4+ T cells in mucosal tissues remain particularly affected.[] Continuous HIV replication causes a state of generalized immune activation persisting throughout the chronic phase.[] Immune activation, which is reflected by the increased activation state of immune cells and release of pro-inflammatory cytokines, results from the activity of several HIV gene products and the immune response to ongoing HIV replication. It is also linked to the breakdown of the immune surveillance system of the gastrointestinal mucosal barrier caused by the depletion of mucosal CD4+ T cells during the acute phase of disease.[]

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Diagnosis
HIV/AIDS is diagnosed via laboratory testing and then staged based on the presence of certain signs or symptoms.[] HIV screening is recommended by the United States Preventive Services Task Force for all people 15years to 65years of age including all pregnant women.[42] Additionally testing is recommended for all those at high risk, which includes anyone diagnosed with a sexually transmitted illness.[] In many areas of the world a third of HIV carriers only discover they are infected at an advanced stage of the disease when AIDS or severe immunodeficiency has become apparent.[]

A generalized graph of the relationship between HIV copies (viral load) and CD4+ T cell counts over the average course of untreated HIV infection. CD4+ T Lymphocyte count (cells/mm) HIV RNA copies per

mL of plasma

HIV testing
Most people infected with HIV develop specific antibodies (i.e. seroconvert) within three to twelve weeks of the initial infection.[15] Diagnosis of primary HIV before seroconversion is done by measuring HIV-RNA or p24 antigen.[15] Positive results obtained by antibody or PCR testing are confirmed either by a different antibody or by PCR.[] Antibody tests in children younger than 18months are typically inaccurate due to the continued presence of maternal antibodies.[] Thus HIV infection can only be diagnosed by PCR testing for HIV RNA or DNA, or via testing for the p24 antigen.[] Much of the world lacks access to reliable PCR testing and many places simply wait until either symptoms develop or the child is old enough for accurate antibody testing.[] In sub-Saharan Africa as of 20072009 between 30 and 70% of the population was aware of their HIV status.[43] In 2009, between 3.6 and 42% of men and women in Sub-Saharan countries were tested[43] which represented a significant increase compared to previous years.[43]

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Classifications of HIV infection


Two main clinical staging systems are used to classify HIV and HIV-related disease for surveillance purposes: the WHO disease staging system for HIV infection and disease,[] and the CDC classification system for HIV infection.[] The CDC's classification system is more frequently adopted in developed countries. Since the WHO's staging system does not require laboratory tests, it is suited to the resource-restricted conditions encountered in developing countries, where it can also be used to help guide clinical management. Despite their differences, the two systems allow comparison for statistical purposes.[13][][] The World Health Organization first proposed a definition for AIDS in 1986.[] Since then, the WHO classification has been updated and expanded several times, with the most recent version being published in 2007.[] The WHO system uses the following categories: Primary HIV infection: May be either asymptomatic or associated with acute retroviral syndrome.[] Stage I: HIV infection is asymptomatic with a CD4+ T cell count (also known as CD4 count) greater than 500 per microlitre (l or cubic mm) of blood.[] May include generalized lymph node enlargement.[] Stage II: Mild symptoms which may include minor mucocutaneous manifestations and recurrent upper respiratory tract infections. A CD4 count of less than 500/l.[] Stage III: Advanced symptoms which may include unexplained chronic diarrhea for longer than a month, severe bacterial infections including tuberculosis of the lung, and a CD4 count of less than 350/l.[] Stage IV or AIDS: severe symptoms which include toxoplasmosis of the brain, candidiasis of the esophagus, trachea, bronchi or lungs and Kaposi's sarcoma. A CD4 count of less than 200/l.[] The United States Center for Disease Control and Prevention also created a classification system for HIV, and updated it in 2008.[] This system classifies HIV infections based on CD4 count and clinical symptoms,[] and describes the infection in three stages: Stage 1: CD4 count 500cells/l and no AIDS defining conditions Stage 2: CD4 count 200 to 500cells/l and no AIDS defining conditions Stage 3: CD4 count 200cells/l or AIDS defining conditions Unknown: if insufficient information is available to make any of the above classifications

For surveillance purposes, the AIDS diagnosis still stands even if, after treatment, the CD4+ T cell count rises to above 200 per L of blood or other AIDS-defining illnesses are cured.[13]

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Prevention
Sexual contact
Consistent condom use reduces the risk of HIV transmission by approximately 80% over the long term.[44] When condoms are used consistently by a couple in which one person is infected, the rate of HIV infection is less than 1% per year.[] There is some evidence to suggest that female condoms may provide an equivalent level of protection.[45] Application of a vaginal gel containing tenofovir (a reverse transcriptase inhibitor) immediately before sex seems to reduce infection rates by approximately 40% among African women.[] By contrast, use of the spermicide nonoxynol-9 may increase the risk of transmission due to its tendency to cause vaginal and rectal irritation.[46] Circumcision in Sub-Saharan Africa "reduces the acquisition of HIV by heterosexual men by between 38% and 66% over 24 months".[47] Based on these studies, the World Health AIDS Clinic, McLeod Ganj, Himachal Pradesh, India, 2010 Organization and UNAIDS both recommended male circumcision as a [48] method of preventing female-to-male HIV transmission in 2007. Whether it protects against male-to-female transmission is disputed[49][50] and whether it is of benefit in developed countries and among men who have sex with men is undetermined.[51][52][53] Some experts fear that a lower perception of vulnerability among circumcised men may cause more sexual risk-taking behavior, thus negating its preventive effects.[54] Programs encouraging sexual abstinence do not appear to affect subsequent HIV risk.[55] Evidence for a benefit from peer education is equally poor.[56] Comprehensive sexual education provided at school may decrease high risk behavior.[57] A substantial minority of young people continues to engage in high-risk practices despite knowing about HIV/AIDS, underestimating their own risk of becoming infected with HIV.[] It is not known whether treating other sexually transmitted infections is effective in preventing HIV.[]

Pre-exposure
Treating people with HIV whose CD4 count 350cells/L with antiretrovirals protects 96% of their partners from infection.[58] This is about a 10 to 20 fold reduction in transmission risk.[] Pre-exposure prophylaxis with a daily dose of the medications tenofovir, with or without emtricitabine, is effective in a number of groups including men who have sex with men, couples where one is HIV positive, and young heterosexuals in Africa.[] It may also be effective in intravenous drug users with a study finding a decrease in risk of 0.7 to 0.4 per 100personyears.[59] Universal precautions within the health care environment are believed to be effective in decreasing the risk of HIV.[60] Intravenous drug use is an important risk factor and harm reduction strategies such as needle-exchange programmes and opioid substitution therapy appear effective in decreasing this risk.[][61]

Post-exposure
A course of antiretrovirals administered within 48 to 72hours after exposure to HIV positive blood or genital secretions is referred to as post-exposure prophylaxis.[] The use of the single agent zidovudine reduces the risk of subsequent HIV infection fivefold following a needle stick injury.[] Treatment is recommended after sexual assault when the perpetrator is known to be HIV positive but is controversial when their HIV status is unknown.[] Current treatment regimes typically use lopinavir/ritonavir and lamivudine/zidovudine or emtricitabine/tenofovir and may decrease the risk further.[] The duration of treatment is usually four weeks[] and is frequently associated with adverse

HIV/AIDS effects (with zidovudine in about 70% of cases, including nausea in 24%, fatigue in 22%, emotional distress in 13%, and headaches in 9%).[]

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Mother-to-child
Programs to prevent the vertical transmission of HIV (from mothers to children) can reduce rates of transmission by 9299%.[][] This primarily involves the use of a combination of antiviral medications during pregnancy and after birth in the infant and potentially includes bottle feeding rather than breastfeeding.[][62] If replacement feeding is acceptable, feasible, affordable, sustainable, and safe, mothers should avoid breastfeeding their infants; however exclusive breastfeeding is recommended during the first months of life if this is not the case.[63] If exclusive breastfeeding is carried out, the provision of extended antiretroviral prophylaxis to the infant decreases the risk of transmission.[64]

Vaccination
As of 2012 there is no effective vaccine for HIV or AIDS.[65] A single trial of the vaccine RV 144 published in 2009 found a partial reduction in the risk of transmission of roughly 30%, stimulating some hope in the research community of developing a truly effective vaccine.[66] Further trials of the RV 144 vaccine are ongoing.[67][68]

Management
There is currently no cure or effective HIV vaccine. Treatment consists of high active antiretroviral therapy (HAART) which slows progression of the disease[] and as of 2010 more than 6.6million people were taking them in low and middle income countries.[11] Treatment also includes preventive and active treatment of opportunistic infections.

Antiviral therapy
Current HAART options are combinations (or "cocktails") consisting of at least three medications belonging to at least two types, or "classes," of antiretroviral agents.[] Initially treatment is typically a non-nucleoside reverse transcriptase inhibitor (NNRTI) plus two nucleoside analogue reverse transcriptase inhibitors (NRTIs).[] Typical NRTIs include: zidovudine (AZT) or tenofovir (TDF) and lamivudine (3TC) or emtricitabine (FTC).[] Combinations of agents which include a protease inhibitors (PI) are used if the above regime loses effectiveness.[] When to start antiretroviral therapy is subject to debate.[][69] The World Health Organization, European guidelines and the United States Abacavir a nucleoside analog reverse recommends antiretrovirals in all adolescents, adults and pregnant transcriptase inhibitor (NARTI or NRTI) women with a CD4 count less than 350/l or those with symptoms regardless of CD4 count.[][] This is supported by the fact that beginning treatment at this level reduces the risk of death.[] The United States in addition recommends them for all HIV-infected people regardless of CD4 count or symptoms; however it makes this recommendation with less confidence for those with higher counts.[] While the WHO also recommends treatment in those who are co-infected with tuberculosis and those with chronic active hepatitis B.[] Once treatment is begun it is recommended that it is continued without breaks or "holidays".[] Many people are diagnosed only after treatment ideally should have begun.[] The desired outcome of treatment is a long term plasma HIV-RNA count below 50copies/mL.[] Levels to determine if treatment is effective are initially recommended after four weeks and once levels fall below

HIV/AIDS 50copies/mL checks every three to six months are typically adequate.[] Inadequate control is deemed to be greater than 400copies/mL.[] Based on these criteria treatment is effective in more than 95% of people during the first year.[] Benefits of treatment include a decreased risk of progression to AIDS and a decreased risk of death.[70] In the developing world treatment also improves physical and mental health.[71] With treatment there is a 70% reduced risk of acquiring tuberculosis.[] Additional benefits include a decreased risk of transmission of the disease to sexual partners and a decrease in mother-to-child transmission.[] The effectiveness of treatment depends to a large part on compliance.[] Reasons for non-adherence include poor access to medical care,[72] inadequate social supports, mental illness and drug abuse.[73] The complexity of treatment regimens (due to pill numbers and dosing frequency) and adverse effects may reduce adherence.[74] Even though cost is an important issue with some medications,[75] 47% of those who needed them were taking them in low and middle income countries as of 2010[11] and the rate of adherence is similar in low-income and high-income countries.[76] Specific adverse events are related to the agent taken.[] Some relatively common ones include: lipodystrophy syndrome, dyslipidemia, and diabetes mellitus especially with protease inhibitors.[13] Other common symptoms include diarrhea,[][] and an increased risk of cardiovascular disease.[77] Newer recommended treatments are associated with fewer adverse effects.[] Certain medications may be associated with birth defects and therefore may be unsuitable for women hoping to have children.[] Treatment recommendations for children are slightly different from those for adults. In the developing world, as of 2010, 23% of children who were in need of treatment had access.[78] Both the World Health Organization and the United States recommend treatment for all children less than twelve months of age.[][] The United States recommends in those between one year and five years of age treatment in those with HIV RNA counts of greater than 100,000copies/mL, and in those more than five years treatments when CD4 counts are less than 500/l.[]

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Opportunistic infections
Measures to prevent opportunistic infections are effective in many people with HIV/AIDS. In addition to improving current disease, treatment with antiretrovirals reduces the risk of developing additional opportunistic infections.[] Vaccination against hepatitis A and B is advised for all people at risk of HIV before they become infected; however it may also be given after infection.[] Trimethoprim/sulfamethoxazole prophylaxis between four and six weeks of age and ceasing breastfeeding in infants born to HIV positive mothers is recommended in resource limited settings.[78] It is also recommended to prevent PCP when a person's CD4 count is below 200cells/uL and in those who have or have previously had PCP.[] People with substantial immunosuppression are also advised to receive prophylactic therapy for toxoplasmosis and Cryptococcus meningitis.[] Appropriate preventive measures have reduced the rate of these infections by 50% between 1992 and 1997.[]

Alternative medicine
In the US, approximately 60% of people with HIV use various forms of complementary or alternative medicine,[] even though the effectiveness of most of these therapies has not been established.[] With respect to dietary advice and AIDS some evidence has shown a benefit from micronutrient supplements.[] Evidence for supplementation with selenium is mixed with some tentative evidence of benefit.[79] There is some evidence that vitamin A supplementation in children reduces mortality and improves growth.[] In Africa in nutritionally compromised pregnant and lactating women a multivitamin supplementation has improved outcomes for both mothers and children.[] Dietary intake of micronutrients at RDA levels by HIV-infected adults is recommended by the World Health Organization.[80][] The WHO further states that several studies indicate that supplementation of vitamin A, zinc, and iron can produce adverse effects in HIV positive adults.[] There is not enough evidence to support the use of herbal medicines.[81]

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Prognosis
HIV/AIDS has become a chronic rather than an acutely fatal disease in many areas of the world.[] Prognosis varies between people, and both the CD4 count and viral load are useful for predicted outcomes.[15] Without treatment, average survival time after infection with HIV is estimated to be 9 to 11years, depending on the HIV subtype.[] After the diagnosis of AIDS, if treatment is not available, survival ranges Disability-adjusted life year for HIV and AIDS between 6 and 19months.[][82] HAART and appropriate prevention of per 100,000inhabitants as of 2004. opportunistic infections reduces the death rate by 80%, and raises the life expectancy for a newly diagnosed young adult to 2050 years.[][][] This is between two thirds[] and nearly that of the general population.[][83] If treatment is started late in the infection, prognosis is not as good:[] for example, if treatment is begun following the diagnosis of AIDS, life expectancy is ~1040years.[][] Half of infants born with HIV die before two years of age without treatment.[78] The primary causes of death from HIV/AIDS are opportunistic infections and cancer, both of which are frequently the result of the progressive failure of the immune system.[][] Risk of cancer appears to increase once the CD4 count is below 500/L.[] The rate of clinical disease progression varies widely between individuals and has been shown to be affected by a number of factors such as a person's susceptibility and immune function;[] their access to health care, the presence of co-infections;[][] and the particular strain (or strains) of the virus involved.[][] Tuberculosis co-infection is one of the leading causes of sickness and death in those with HIV/AIDS being present in a third of all HIV infected people and causing 25% of HIV related deaths.[84] HIV is also one of the most important risk factors for tuberculosis.[] Hepatitis C is another very common co-infection where each disease increases the progression of the other.[85] The two most common cancers associated with HIV/AIDS are Kaposi's sarcoma and AIDS-related non-Hodgkin's lymphoma.[] Even with anti-retroviral treatment, over the long term HIV-infected people may experience neurocognitive disorders,[] osteoporosis,[] neuropathy,[] cancers,[][] nephropathy,[] and cardiovascular disease.[] It is not clear whether these conditions result from the HIV infection itself or are adverse effects of treatment.

Epidemiology
HIV/AIDS is a global pandemic.[] As of 2010, approximately 34million people have HIV worldwide.[11] Of these approximately 16.8million are women and 3.4million are less than 15years old.[11] It resulted in about 1.8million deaths in 2010, down from a peak of 2.2million in 2005.[11] Sub-Saharan Africa is the region most affected. In 2010, an estimated Estimated prevalence of HIV among young adults 68% (22.9million) of all HIV cases and 66% of all deaths (1.2million) [86] (1549) per country as of 2011. occurred in this region.[87] This means that about 5% of the adult population is infected[88] and it is believed to be the cause of 10% of all deaths in children.[89] Here in contrast to other regions women compose nearly 60% of cases.[87] South Africa has the largest population of people with HIV of any country in the world at 5.9million.[87] Life expectancy has fallen in the worst-affected countries due to HIV/AIDS; for example, in 2006 it was estimated that it had dropped from 65 to 35 years in Botswana.[12] Mother-to-child transmission, as of 2013, in Botswana and South Africa has decreased to less than 5% with improvement in many other African nations due to improved access to antiretroviral therapy.[90] South & South East Asia is the second most affected; in 2010 this region contained an estimated 4million cases or 12% of all people living with HIV resulting in approximately 250,000 deaths.[88] Approximately 2.4million of these

HIV/AIDS cases are in India.[87] In 2008 in the United States approximately 1.2million people were living with HIV, resulting in about 17,500 deaths. The US Centers for Disease Control and Prevention estimated that in 2008 20% of infected Americans were unaware of their infection.[] In the United Kingdom as of 2009 there where approximately 86,500 cases which resulted in 516 deaths.[91] In Canada as of 2008 there were about 65,000 cases causing 53 deaths.[92] Between the first recognition of AIDS in 1981 and 2009 it has led to nearly 30million deaths.[] Prevalence is lowest in Middle East and North Africa at 0.1% or less, East Asia at 0.1% and Western and Central Europe at 0.2%.[88]

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History
Discovery
AIDS was first clinically observed in 1981 in the United States.[19] The initial cases were a cluster of injecting drug users and homosexual men with no known cause of impaired immunity who showed symptoms of Pneumocystis carinii pneumonia (PCP), a rare opportunistic infection that was known to occur in people with very compromised immune systems.[] Soon thereafter, an unexpected number of gay men developed a previously rare skin cancer called Kaposi's sarcoma (KS).[][] Many more cases of PCP and KS emerged, alerting U.S. Centers for Disease Control and Prevention (CDC) and a CDC task force was formed to monitor the outbreak.[]

The Morbidity and Mortality Weekly Report reported in 1981 on what was later to be called "AIDS".

In the early days, the CDC did not have an official name for the disease, often referring to it by way of the diseases that were associated with it, for example, lymphadenopathy, the disease after which the discoverers of HIV originally named the virus.[][] They also used Kaposi's Sarcoma and Opportunistic Infections, the name by which a task force had been set up in 1981.[] At one point, the CDC coined the phrase "the 4H disease", since the syndrome seemed to affect Haitians, homosexuals, hemophiliacs, and heroin users.[] In the general press, the Robert Gallo, co-discoverer of HIV in the early term "GRID", which stood for gay-related immune deficiency, had eighties among (from left to right) Sandra Eva, been coined.[] However, after determining that AIDS was not isolated Sandra Colombini, and Ersell Richardson. to the gay community,[] it was realized that the term GRID was misleading and the term AIDS was introduced at a meeting in July [] 1982. By September 1982 the CDC started referring to the disease as AIDS.[] In 1983, two separate research groups led by Robert Gallo and Luc Montagnier independently declared that a novel retrovirus may have been infecting AIDS patients, and published their findings in the same issue of the journal

HIV/AIDS Science.[][] Gallo claimed that a virus his group had isolated from an AIDS patient was strikingly similar in shape to other human T-lymphotropic viruses (HTLVs) his group had been the first to isolate. Gallo's group called their newly isolated virus HTLV-III. At the same time, Montagnier's group isolated a virus from a patient presenting with swelling of the lymph nodes of the neck and physical weakness, two characteristic symptoms of AIDS. Contradicting the report from Gallo's group, Montagnier and his colleagues showed that core proteins of this virus were immunologically different from those of HTLV-I. Montagnier's group named their isolated virus lymphadenopathy-associated virus (LAV).[] As these two viruses turned out to be the same, in 1986, LAV and HTLV-III were renamed HIV.[93]

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Origins
Both HIV-1 and HIV-2 are believed to have originated in non-human primates in West-central Africa and were transferred to humans in the early 20th century.[] HIV-1 appears to have originated in southern Cameroon through the evolution of SIV(cpz), a simian immunodeficiency virus (SIV) that infects wild chimpanzees (HIV-1 descends from the SIVcpz endemic in the chimpanzee subspecies Pan troglodytes troglodytes).[][] The closest relative of HIV-2 is SIV(smm), a virus of the sooty mangabey (Cercocebus atys atys), an Old World monkey living in coastal West Africa (from southern Senegal to western Cte d'Ivoire).[] New World monkeys such as the owl monkey are resistant to HIV-1 infection, possibly because of a genomic fusion of two viral resistance genes.[94] HIV-1 is thought to have jumped the species barrier on at least three separate occasions, giving rise to the three groups of the virus, M, N, and O.[] There is evidence that humans who participate in bushmeat activities, either as hunters or as bushmeat vendors, commonly acquire SIV.[] However, SIV is a weak virus which is typically suppressed by the human immune system within weeks of infection. It is thought that several transmissions of the virus from individual to individual in quick Left to right: the African green monkey source of SIV, the sooty mangabey source of succession are necessary to allow it HIV-2 and the chimpanzee source of HIV-1 enough time to mutate into HIV.[] Furthermore, due to its relatively low person-to-person transmission rate, SIV can only spread throughout the population in the presence of one or more high-risk transmission channels, which are thought to have been absent in Africa before the 20th century. Specific proposed high-risk transmission channels, allowing the virus to adapt to humans and spread throughout the society, depend on the proposed timing of the animal-to-human crossing. Genetic studies of the virus suggest that the most recent common ancestor of the HIV-1 M group dates back to circa 1910.[95] Proponents of this dating link the HIV epidemic with the emergence of colonialism and growth of large colonial African cities, leading to social changes, including a higher degree of sexual promiscuity, the spread of prostitution, and the accompanying high frequency of genital ulcer diseases (such as syphilis) in nascent colonial cities.[] While transmission rates of HIV during vaginal intercourse are low under regular circumstances, they are increased many fold if one of the partners suffers from a sexually transmitted infection causing genital ulcers. Early 1900s colonial cities were notable due to their high prevalence of prostitution and genital ulcers, to the degree that, as of 1928, as many as 45% of female residents of eastern Kinshasa were thought to have been prostitutes, and, as of 1933, around 15% of all residents of the same city had syphilis.[]

HIV/AIDS An alternative view holds that unsafe medical practices in Africa after World War II, such as unsterile reuse of single use syringes during mass vaccination, antibiotic and anti-malaria treatment campaigns, were the initial vector that allowed the virus to adapt to humans and spread.[][96][] The earliest well documented case of HIV in a human dates back to 1959 in the Congo.[] The virus may have been present in the United States as early as 1966,[97] but the vast majority of infections occurring outside sub-Saharan Africa (including the U.S.) can be traced back to a single unknown individual who became infected with HIV in Haiti and then brought the infection to the United States some time around 1969.[] The epidemic then rapidly spread among high-risk groups (initially, sexually promiscuous men who have sex with men). By 1978, the prevalence of HIV-1 among gay male residents of New York and San Francisco was estimated at 5%, suggesting that several thousand individuals in the country had been infected.[]

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Society and culture


Stigma
AIDS stigma exists around the world in a variety of ways, including ostracism, rejection, discrimination and avoidance of HIV infected people; compulsory HIV testing without prior consent or protection of confidentiality; violence against HIV infected individuals or people who are perceived to be infected with HIV; and the quarantine of HIV infected individuals.[] Stigma-related violence or the fear of violence prevents many people from seeking HIV testing, returning for their results, or securing treatment, possibly turning what could be a manageable chronic illness into a death sentence and perpetuating the spread of HIV.[] AIDS stigma has been further divided into the following three categories: Instrumental AIDS stigmaa reflection of the fear and apprehension that are likely to be associated with any deadly and transmissible illness.[] Symbolic AIDS stigmathe use of HIV/AIDS to express attitudes toward the social groups or lifestyles perceived to be associated with the disease.[]

Ryan White became a poster child for HIV after being expelled from school because he was infected.

Courtesy AIDS stigmastigmatization of people connected to the issue of HIV/AIDS or HIV-positive people.[] Often, AIDS stigma is expressed in conjunction with one or more other stigmas, particularly those associated with homosexuality, bisexuality, promiscuity, prostitution, and intravenous drug use.[98] In many developed countries, there is an association between AIDS and homosexuality or bisexuality, and this association is correlated with higher levels of sexual prejudice such as anti-homosexual/bisexual attitudes.[] There is also a perceived association between AIDS and all male-male sexual behavior, including sex between uninfected men.[] However, the dominant mode of spread worldwide for HIV remains heterosexual transmission.[99]

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Economic impact
HIV/AIDS affects the economics of both individuals and countries.[89] The gross domestic product of the most affected countries has decreased due to the lack of human capital.[89][] Without proper nutrition, health care and medicine, large numbers of people die from AIDS-related complications. They will not only be unable to work, but will also require significant medical care. It is estimated that as of 2007 there were 12million AIDS orphans.[89] Many are cared for by elderly grandparents.[] By affecting mainly young adults, AIDS reduces the taxable Changes in life expectancy in some hard-hit population, in turn reducing the resources available for public African countries. expenditures such as education and health services not related to AIDS Botswana Zimbabwe Kenya South Africa resulting in increasing pressure for the state's finances and slower Uganda growth of the economy. This causes a slower growth of the tax base, an effect that is reinforced if there are growing expenditures on treating the sick, training (to replace sick workers), sick pay and caring for AIDS orphans. This is especially true if the sharp increase in adult mortality shifts the responsibility and blame from the family to the government in caring for these orphans.[] At the household level, AIDS causes both loss of income and increased spending on healthcare. A study in Cte d'Ivoire showed that households with an HIV/AIDS patient, spent twice as much on medical expenses as other households. This additional expenditure also leaves less income to spend on education and other personal or family investment.[]

Religion and AIDS


The topic of religion and AIDS has become highly controversial in the past twenty years, primarily because some religious authorities have publicly declared their opposition to the use of condoms.[100][] The religious approach to prevent the spread of AIDS according to a report by American health expert Matthew Hanley titled The Catholic Church and the Global AIDS Crisis argues that cultural changes are needed including a re-emphasis on fidelity within marriage and sexual abstinence outside of it.[] Some religious organisations have claimed that prayer can cure HIV/AIDS. In 2011, the BBC reported that some churches in London were claiming that prayer would cure AIDS, and the Hackney-based Centre for the Study of Sexual Health and HIV reported that several people stopped taking their medication, sometimes on the direct advice of their pastor, leading to a number of deaths.[] The Synagogue Church Of All Nations advertise an "anointing water" to promote God's healing, although the group deny advising people to stop taking medication.[]

Media portrayal
One of the first high-profile cases of AIDS was the American Rock Hudson, a gay actor who had been married and divorced earlier in life, who died on 2 October 1985 having announced that he was suffering from the virus on 25 July that year. He had been diagnosed during 1984.[101] A notable British casualty of AIDS that year was Nicholas Eden, a gay politician and son of the late prime minister Anthony Eden.[102] On November 24, 1991, the virus claimed the life of British rock star Freddie Mercury, lead singer of the band Queen, who died from an AIDS related illness having only revealed the diagnosis on the previous day.[103] However he had been diagnosed as HIV positive during 1987.[104] One of the first high-profile heterosexual cases of the virus was Arthur Ashe, the American tennis player. He was diagnosed as HIV positive on 31 August 1988, having contracted the virus from blood transfusions during heart surgery earlier in the 1980s. Further tests within 24 hours of the initial diagnosis revealed that Ashe had

HIV/AIDS AIDS, but he did not tell the public about his diagnosis until April 1992.[105] He died, aged 49, as a result on 6 February 1993.[106] Therese Frare's photograph of gay activist David Kirby, as he lay dying from AIDS while surrounded by family, was taken in April 1990. LIFE magazine said the photo became the one image "most powerfully identified with the HIV/AIDS epidemic." The photo was displayed in LIFE magazine, was the winner of the World Press Photo, and acquired worldwide notoriety after being used in a United Colors of Benetton advertising campaign in 1992.[107] In 1996, Johnson Aziga a Ugandan-born immigrant Canadian was diagnosed as a HIV-positive, but then he had unprotected sex with 11 women without telling them he has HIV. Since 2003, seven of them were infected with HIV, and two of them died of complications of AIDS.[108][109] Aziga was convicted of first-degree murder and be liable to a life sentence.[110]

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Denial, conspiracies, and misconceptions


A small group of individuals continue to dispute the connection between HIV and AIDS,[] the existence of HIV itself, or the validity of HIV testing and treatment methods.[][] These claims, known as AIDS denialism, have been examined and rejected by the scientific community.[] However, they have had a significant political impact, particularly in South Africa, where the government's official embrace of AIDS denialism (19992005) was responsible for its ineffective response to that country's AIDS epidemic, and has been blamed for hundreds of thousands of avoidable deaths and HIV infections.[111][112][113] Operation INFEKTION was a worldwide Soviet active measures operation to spread information that the United States had created HIV/AIDS. Surveys show that a significant number of people believed and continue to believe in such claims.[114] There are many misconceptions about HIV and AIDS. Three of the most common are that AIDS can spread through casual contact, that sexual intercourse with a virgin will cure AIDS, and that HIV can infect only homosexual men and drug users. Other misconceptions are that any act of anal intercourse between two uninfected gay men can lead to HIV infection, and that open discussion of homosexuality and HIV in schools will lead to increased rates of homosexuality and AIDS.[115][116]

Research
HIV/AIDS research includes all medical research which attempts to prevent, treat, or cure HIV/AIDS along with fundamental research about the nature of HIV as an infectious agent and AIDS as the disease caused by HIV. HIV/AIDS research includes following the usual advice given by doctors in responding to HIV. The most universally recommended method for the prevention of HIV/AIDS is to avoid blood-to-blood contact between people and to otherwise practice safe sex. The most recommended method for treating HIV is for HIV-positive people to receive attention from a doctor who would coordinate the patient's management of HIV/AIDS. There is no cure for HIV/AIDS. Many governments and research institutions participate in HIV/AIDS research. This research includes behavioral health interventions such as sex education, and drug development, such as research into microbicides for sexually transmitted diseases, HIV vaccines, and antiretroviral drugs. Other medical research areas include the topics of pre-exposure prophylaxis, post-exposure prophylaxis, and Circumcision and HIV.

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References
Notes
[1] http:/ / apps. who. int/ classifications/ icd10/ browse/ 2010/ en#/ B20 [2] http:/ / apps. who. int/ classifications/ icd10/ browse/ 2010/ en#/ B24 [3] http:/ / www. icd9data. com/ getICD9Code. ashx?icd9=042 [4] http:/ / www. icd9data. com/ getICD9Code. ashx?icd9=044 [5] http:/ / omim. org/ entry/ 609423 [6] http:/ / www. diseasesdatabase. com/ ddb5938. htm [7] http:/ / www. nlm. nih. gov/ medlineplus/ ency/ article/ 000594. htm [8] http:/ / www. emedicine. com/ emerg/ topic253. htm [9] http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2013/ MB_cgi?field=uid& term=D000163 [11] UNAIDS 2011 pg. 110 [12] (subscription required) [13] Mandell, Bennett, and Dolan (2010). Chapter 121. [15] Mandell, Bennett, and Dolan (2010). Chapter 118. [19] Mandell, Bennett, and Dolan (2010). Chapter 169. [36] UNAIDS 2011 pg. 6070 [43] UNAIDS 2011 pg. 7080 [50] (subscription required) [78] UNAIDS 2011 pg. 150160 [87] UNAIDS 2011 pg. 2030 [88] UNAIDS 2011 pg. 4050 [89] Mandell, Bennett, and Dolan (2010). Chapter 117. [90] New HIV infections among children have been reduced by 50% or more in seven countries in sub-Saharan Africa (http:/ / www. unaids. org/ en/ resources/ presscentre/ pressreleaseandstatementarchive/ 2013/ june/ 20130625prglobalplan/ ), UN AIDS, Geneva, June 25, 2013. [94] (subscription required) [95] (subscription required) [96] (subscription required) [114] Operation INFEKTION Soviet Bloc Intelligence and Its AIDS Disinformation Campaign (https:/ / www. cia. gov/ library/ center-for-the-study-of-intelligence/ csi-publications/ csi-studies/ studies/ vol53no4/ soviet-bloc-intelligence-and-its-aids. html). Thomas Boghardt. 2009

Bibliography Mandell, Gerald L.; Bennett, John E.; Dolin, Raphael, eds. (2010). Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases (7th ed.). Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN978-0-443-06839-3. Joint United Nations Programme on HIV/AIDS (UNAIDS) (2011). Global HIV/AIDS Response, Epidemic update and health sector progress towards universal access (http://www.unaids.org/en/media/unaids/contentassets/ documents/unaidspublication/2011/20111130_UA_Report_en.pdf). Joint United Nations Programme on HIV/AIDS.

External links
HIV/AIDS (http://www.dmoz.org/Health/Conditions_and_Diseases/Immune_Disorders/ Immune_Deficiency/AIDS//) at the Open Directory Project Joint United Nations Program on HIV/AIDS (http://www.unaids.org/en/) AIDSinfo (http://aidsinfo.nih.gov/) HIV/AIDS Treatment Information, U.S. Department of Health and Human Services

American Medical Association

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American Medical Association


American Medical Association
Motto Formation Type Headquarters Location Membership Helping Doctors Help Patients 1847 professional association Chicago, Illinois United States 215,854 as of 2010 []

Officiallanguages English President Key people Ardis Dee Hoven [1]

Chair Steven J. Stack CEO & EVP James Madara

The American Medical Association (AMA), founded in 1847 and incorporated in 1897,[2] is the largest association of physiciansboth MDs and DOsand medical students in the United States.[3]

Scope and operations


(See also List of presidents of the American Medical Association) The AMA's stated mission is to promote the art and science of medicine for the betterment of the public health, to advance the interests of physicians and their patients, to promote public health, to lobby for legislation favorable to physicians and patients, and to raise money for medical education. The Association also publishes the Journal of the American Medical Association (JAMA), which has the largest circulation of any weekly medical journal in the world.[] The AMA also publishes a list of Physician Specialty Codes which are the standard method in the U.S. for identifying physician and practice specialties. The AMA has one of the largest political lobbying budgets of any organization in the United States.[] Its political positions throughout its history have often been controversial. In the 1930s, the AMA attempted to prohibit its members from working for the then-primitive health maintenance organizations that had sprung up during the Great Depression, which violated the Sherman Antitrust Act and resulted in a conviction ultimately affirmed by the US Supreme Court.[4] The AMA's vehement campaign against Medicare in the 1950s and 1960s included the Operation Coffee Cup supported by Ronald Reagan. Since the enactment of Medicare, the AMA reversed its position and now opposes any "cut to Medicare funding or shift [of] increased costs to beneficiaries at the expense of the quality or accessibility of care". The AMA also "strongly supports subsidization of prescription drugs for Medicare patients based on means testing".[citation needed] However, the AMA remains opposed to any single-payer health care plan that might enact a National Health Service in the United States, such as the United States National Health Care Act. In the 1990s, the organization was part of the coalition that defeated the health care reform advanced by Hillary and Bill Clinton. The AMA has also supported changes in medical malpractice law to limit damage awards, which, it contends, makes it difficult for patients to find appropriate medical care. In many states, high risk specialists have moved to other states that have enacted reform. For example, in 2004, all neurosurgeons had relocated out of the entire southern half of Illinois [citation needed]. The main legislative emphasis in multiple states has been to effect caps on the amount that patients can receive for pain and suffering. These costs for pain and suffering are only those that exceed the actual costs of healthcare and lost income. Multiple states have found that limiting pain and suffering costs has dramatically

American Medical Association slowed increases in the cost of medical malpractice insurance. Texas, having recently enacted such reforms, reported that all major malpractice insurers in 2005 were able to offer either no increase or a decrease in premiums to physicians [citation needed]. At the same time however, states without caps also experienced similar results; suggesting that other market factors may have contributed to the decreases. Some economic studies have found that caps have historically had an uncertain effect on premium rates.[5] Nevertheless, the AMA believes the caps may alleviate what is often perceived as an excessively litigious environment for many doctors.[citation needed] A recent report by the AMA found that in a 12 month period, five percent of physicians had claims filed against them.[6] Claims that the AMA generates $70 million in revenue through its stewardship of Current Procedural Terminology (CPT) codes appear to be a mischaracterization.[citation needed] The estimate is based on a distortion[citation needed] of the transparent financial information the AMA voluntarily offers in its Annual Report. The AMA has publicly reported this figure represents income from its complete line of books and products, which include more than 100 items, not just CPT.[7] The AMA sponsors the Specialty Society Relative Value Scale Update Committee which is an influential group of 29 physicians, mostly specialists, who help determine the value of different physician's labor in Medicare prices.

203

Charitable activities
The AMA Foundation provides approximately $1,000,000 annually in tuition assistance to financially needy students. This has to be seen on the background that in 2007, graduating medical students carried a mean debt load of $140,000 which rose to $220,000 after 4 yrs of negative amortization during residency[] medical student debt has increased by 7% each successive year.[8] Funds awareness projects about health literacy Funds community service, community health, and healthcare education events held by local medical societies and student chapters Supports research funding for students and fellows around the U.S. Provides grants to community projects designed to encourage healthy lifestyles (of diet and exercise, good sleep habits, etc.). The Worldscopes project is a collaboration with the medical community to collect stethoscopes and the funds to buy them. The stethoscopes are then distributed to those in the global medical community who normally lack the resources to obtain the instruments. Thousands of stethoscopes have been sent to physicians and others in the medical community around the world who lack access to this medical instrument.[8]

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Politics
Throughout its history, the AMA has been actively involved in a variety of medical policy issues, from Medicare and HMOs to public health, and climate change. Between 1998 and 2011, the AMA spent $264 million on lobbyists, second only to the American Chamber of Commerce.[] In the 1930s, the AMA attempted to prohibit its members from working for the primitive health maintenance organizations that sprung up during the Great Depression. The AMA's subsequent conviction for violating the Sherman Antitrust Act was affirmed by the U.S. Supreme Court. American Medical Ass'n. v. United States, 317 U.S. 519 [9] (1943). The AMA's vehement campaign against Medicare in the 1950s and 1960s included the Operation Coffee Cup supported by Ronald Reagan. Before Medicare passed, according to Steven Schroeder, Wilbur Cohen inserted "usual, customary and reasonable" charges into the Social Security Act of 1965 "in an The American Medical Association headquarters unsuccessful attempt to placate" the AMA.[10] Since the building in Chicago. enactment of Medicare, the AMA stated that it "continues to oppose attempts to cut Medicare funding or shift increased costs to beneficiaries at the expense of the quality or accessibility of care" and "strongly supports subsidization of prescription drugs for Medicare patients based on means testing". The AMA also campaigns to raise Medicare payments to physicians, arguing that increases will protect seniors' access to health care. In the 1990s, it was part of the coalition that defeated the health care reform proposed by President Bill Clinton. The AMA supported the War on Drugs, providing a medical excuse to clamp down on marijuana-use in the 90s. The AMA has given high priority to supporting changes in medical malpractice law to limit damage awards, which, it contends, makes it difficult for patients to find appropriate medical care. In many states, high-risk specialists have moved to other states with such limits. For example, in 2004, not a single neurosurgeon remained in the entire southern half of Illinois [citation needed]. The main legislative emphasis in multiple states has been to effect caps on the amount that patients can receive for pain and suffering. These costs for pain and suffering are only those that exceed the actual costs of health care and lost income. Multiple states found that limiting pain and suffering costs has dramatically slowed increases in the cost of medical malpractice insurance. The state of Texas enacted such reforms in 2003 and subsequently reported in 2005 that all major malpractice insurers were able to offer either no increase or a decrease in premiums to physicians. Another top priority of the AMA is to lobby for change to the federal tax codes to allow the current health insurance system (based on employment) to be purchased by individuals. Such changes could possibly allow millions of currently uninsured Americans to be able to afford insurance through a series of refundable tax credits based on income (for example, the lower one's income, the greater your credit) [citation needed]. The AMA has made efforts to respond to health care disparities. As such, the AMA created an advisory committee to assess the nature of disparities within different racial and ethnic groups.[11] One such committee focuses on the health of the Gay, Lesbian Bisexual and Transgender community. In 2005, the AMA president Edward Hill gave a keynote address to the Gay and Lesbian Medical Association at its annual conference.[12] Since that time, the AMA has worked closely with GLMA to develop AMA policy towards better health care access for LGBT patients and better working environments for LGBT physicians and medical students.[13]

American Medical Association The AMA responded to the government estimate that more than 35 million Americans live in underserved areas by stating it would take 16,000 doctors to immediately fill that need, and the gap is expected to widen due to rising population and aging work force. "And that will mostly be felt in rural America," said Sen. Kent Conrad, D-N.D., adding, "We're facing a real crisis." Fueling the shortage are the restrictions on allowing foreign physicians to work in the U.S. after the September 11, 2001 attack, and may become more restrictive after the attempted terrorist bombings June 2007 in Britain, still under investigation, linked to foreign doctors.[14][15] In June 2007, at its annual meeting, the AMA discussed its opposition to a fast-spreading nationwide trend for medical clinics to open up in supermarkets and drugstores. The AMA identified at least two problems with in-store clinics: potential conflict of interest, and potential jeopardized quality of care. The AMA went on to rally state and federal agencies to investigate the relationship between the operating clinics and the pharmacy chains to decide if this practice should be prohibited or regulated. Dr. Peter Carmel, neurosurgeon and AMA board member asked, "If you own both sides of the operation, shouldn't people look at that?" The AMA also noted some employers reduce or waive the co-payment if an employee goes to the retail clinic instead of the doctor's office, inferring that this practice might negatively affect quality of care.[16] In 2008, the AMA issued a policy statement on global climate change declaring that they "support the findings of the latest Intergovernmental Panel on Climate Change report, which states that the Earth is undergoing adverse global climate change and that these changes will negatively affect public health." They also "support educating the medical community on the potential adverse public health effects of global climate change, including topics such as population displacement, flooding, infectious and vector-borne diseases, and healthy water supplies."[17] In July 2008, the AMA focused its energy on blocking cuts to Medicare. Through advocacy efforts and communications campaigns, the AMA and all the specialty societies and state medical societies it comprises came out with a temporary victory. Despite a presidential veto, H.R. 6331, the "Medicare Improvements for Patients and Providers Act of 2008", passed with wide, bi-partisan majorities in both the U.S. House of Representatives and the U.S. Senate. The AMA has affirmed, through continual policy statement (policies H-460.957, H-460.974, H-460.964, and H-460.991 for example), its support for appropriate and compassionate use of animals in biomedical research programs, and its opposition to the actions of other groups that impede such research, such as some actions from animal rights groups, and its opposition to legislation that unduly restricts such research. The AMA's Office of Alcohol and Other Drug Abuse promotes temperance and lobbies for a reduction of alcoholic beverage advertising and an increase in alcoholic beverage taxes, among other activities. The AMA supported the Patient Protection and Affordable Care Act as a step toward providing coverage to all Americans and improving the nation's health system.[18] See AMA news release at: http://www.ama-assn.org/ ama/pub/health-system-reform/ama-supports-reform-passage.shtml The AMA does not take a position with regard to the death penalty and does not allow its members to play a role in any part of an execution process.[citation needed]

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Criticisms
Critics of the American Medical Association, including economist Milton Friedman, have asserted that the organization acts as a guild and has attempted to increase physicians' wages and fees by influencing limitations on the supply of physicians and non-physician competition. Some counter this argument by citing "the American Medical Association has been supportive of medical school expansion to help ensure there are enough physicians to care for all Americans. The number of medical schools accredited by the Liaison Committee on Medical Education, of which the AMA is one of two co-sponsors, increased from 125 in 2006 to 137 in 2012. The number of medical students in the U.S. is also increasing." [19] In Free to Choose, Friedman said "the AMA has engaged in extensive litigation charging chiropractors and osteopathic physicians with the unlicensed practice of medicine, in an attempt to restrict them to as narrow an area as possible."[20]

American Medical Association Profession and Monopoly, a book published in 1975, is critical of the AMA for limiting the supply of physicians and inflating the cost of medical care in the United States. The book claims that physician supply is kept low by the AMA to ensure high pay for practicing physicians. It states that in the United States the number, curriculum, and size of medical schools are restricted by state licensing boards controlled by representatives of state medical societies associated with the AMA. The book is also critical of the ethical rules adopted by the AMA which restrict advertisement and other types of competition between professionals. It points out that advertising and bargaining can result in expulsion from the AMA and legal revocation of licenses. Restrictions against advertising that is not false or deceptive were dropped from the AMA Code of Medical Ethics in 1980 (AMA Ethical Policy E-5.02). The book also states that before 1912 the AMA included uniform fees for specific medical procedures in its official code of ethics. The AMA's influence on hospital regulation was also criticized in the book.[21] The AMA and other industry groups predicted an over-supply of doctors, and worked to limit the number of new doctors. But recently, the AMA has changed its position, predicting a doctor shortage instead.[22] It has been argued that the AMA's CPT monopoly has been created by the government and makes the organization subject to government influence; further, the restricted access to CPT codes may not be in the interest of its constituents.[]

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Membership
Published membership figures for the AMA include: In 2002, it was reported that the AMA had 278,000 members, among whom were "less than 30% of American physicians."[23] By 2007, the AMA had 238,977 members, of which 20.5% were medical students and 9% were residents.[] There were 215,854 members as of December 2010, of which 47,227 (21.9%) were medical students and 31,049 (14.4%) were residents or fellows. The total was a decrease from the 2009 membership of 228,150.[][] A 2011 article asserted that "somewhere in the neighborhood of 15% of practicing US doctors now belong to the AMA."[24] Membership total as of Dec 31, 2011 (including residents and students) was 217,490 of approximately 954,000 practicing physicians.[25]

References
[1] http:/ / www. ama-assn. org/ ama/ pub/ news/ news/ 2013/ 2013-06-18-ardis-hoven-inaugurated-ama-president. page [4] American Medical Ass'n. v. United States, [5] Weiss Ratings News: Medical Malpractice Caps Fail to Prevent Premium Increases, According to Weiss Ratings Study (http:/ / www. weissratings. com/ News/ Ins_General/ 20030602pc. htm) [6] Medical Liability Claim Frequency: A 2007-2008 Snapshot of Physicians (http:/ / www. ama-assn. org/ ama1/ pub/ upload/ mm/ 363/ prp-201001-claim-freq. pdf) [7] http:/ / www. ama-assn. org/ ama1/ pub/ upload/ mm/ 37/ 2009-annual-report. pdf [9] https:/ / supreme. justia. com/ us/ 317/ 519/ case. html [11] AMA (Public Health) Eliminating health disparities (http:/ / www. ama-assn. org/ ama/ pub/ category/ 7639. html) [12] AMA (GLBT) News release from the Gay and Lesbian Medical Association (http:/ / www. ama-assn. org/ ama/ pub/ category/ 15741. html) [13] AMA (GLBT) AMA policy regarding sexual orientation (http:/ / www. ama-assn. org/ ama/ pub/ category/ 14754. html) [17] AMA policy statement on climate change (http:/ / www. ama-assn. org/ ama/ pub/ category/ 20275. html) [18] http:/ / www. ama-assn. org/ ama1/ pub/ upload/ mm/ 399/ hsr-3590-passage-support. pdf

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Further reading
Burrow, James G. AMA: Voice of American Medicine. Baltimore: Johns Hopkins University Press, 1963. Campion, Frank. The AMA and U.S. Health Policy Since 1940. Chicago: Chicago Review Press, 1984. Fishbein, Morris. History of the American Medical Association, 18471947. Philadelphia: W. B. Saunders, 1947. Numbers, Ronald. Almost Persuaded: American Physicians and Compulsory Health Insurance, 19121920. Baltimore: Johns Hopkins University Press, 1978. Poen, Monte. Harry S. Truman versus the Medical Lobby: The Genesis of Medicare. Columbia, MO: The University of Missouri Press, 1979. Starr, Paul. The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry. New York: Basic Books, 1982.

External links
Official website (http://www.ama-assn.org/)

African Malaria Network Trust

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African Malaria Network Trust


African Malaria Network Trust Acronym: AMANET
Logo: African Malaria Network Trust Formation Type Headquarters 14 March 2002 International NGO Dar es Salaam, Tanzania

Officiallanguages English Managing Trustee Prof. Wen Kilama Website http:/ / www. amanet-trust. org/

The African Malaria Network Trust (AMANET) is a pan-African international NGO headquartered in Dar es Salaam, Tanzania which originally started its activities as African Malaria Vaccine Testing Network (AMVTN) in 1995 with the primary goal of preparing Africa in planning and conducting malaria vaccine trials. In order to widen the scope in malaria interventions, AMVTN was succeeded by AMANET on 14 March 2002. Although the primary goal of AMANET has remained malaria vaccine development, the organization in its expanded role includes other intervention measures such as antimalaria drugs and vector control.

Precedence
Malaria is a preventable disease that afflicts hundreds of millions of people causing among them untoward socio-economic suffering including a vicious cycle of abject poverty, brain damage, other irreversible disabilities, and over one million deaths per year.[] Notwithstanding this leading disease burden, malaria has yet to get the status it deserves on the political and other relevant agenda of endemic communities and development partners. For centuries, malaria has adversely affected the history of sub-Saharan Africa; its control during the past century however Malaria Clinic in Tanzania helped by SMS for concentrated on urban areas where colonial authorities and traders Life program lived and in agricultural estates and mines whose products sustained industries in the colonizing countries. When the global malaria eradication program was showing signs of success, which coincided with the wave of national independence, the eradication program was abandoned in Africa on the pretext of mainly administrative and financial constraints. However, the strategies were continued elsewhere.[] As a consequence, the malaria situation in Africa worsened; now Africa bears the brunt of the world malaria burden estimated at 500 million malaria cases and up to 3 million malaria deaths per annum, and costing an estimated US$ 12 billion annually.[][] Continued failure of current strategies (prompt diagnosis, early correct treatment, and the use of insecticide treated nets (ITNs) calls for a need to develop entirely new tools that would contribute to the fight of a resilient enemy and reverse its devastation. Over the last three decades there has been considerable interest in research and development of malaria vaccines. Research results that have been obtained so far show that malaria vaccine candidates would differ not only in their biological properties, but also in their eventual applications.[][] Vaccines have been exceptionally effective against a number of diseases and have become one of the safest and most cost-effective

African Malaria Network Trust weapons in medicine's arsenal against communicable disease. Perhaps no other intervention has had such a dramatic impact on the health and well-being of our society as the introduction of vaccines.

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Establishment
In 1995 at a conference held in Arusha, Tanzania, 81 malaria researchers from Africa, Europe and North America established the African Malaria Vaccine Testing Network (AMVTN) in order to prepare Africa for planning, undertaking and coordinating malaria vaccine trials In order to widen the scope in malaria interventions, and to operate within a legal framework, AMVTN was succeeded by AMANET in 2002. Although the primary goal of AMANET has remained malaria vaccine development, in its expanded role the organization would also support study into other intervention approaches such as antimalarial drugs, diagnostics and vector control. AMANET is committed to the creation of an environment for enabling the development of African centres of excellence in malaria research through capacity strengthening of African scientists and institutions.[]

Mission
The mission of AMANET is to promote capacity strengthening and networking of malaria R&D in Africa

Broad objective
To continue developing self-sustainable centres in Africa that meet international requirements for conducting malaria intervention trials.

Specific objectives
To develop and support implementation of standards for the expertise and infrastructure required to perform and to evaluate intervention trials To promote and coordinate capacity strengthening activities of African malaria R&D institutions To further develop previously selected centres for clinical trials so as to attain sustainability To select more centres for future strengthening for more clinical trials To support long-term training of research personnel To develop suitable training programmes in accordance with international standards To fill gaps in infrastructure of the selected centres To disseminate information of AMANET activities To facilitate and promote the conducting of intervention trials To sponsor clinical and field trials To promote development of African indigenous antimalaria medicines To promote development of appropriate malaria diagnostics To establish a data management centres for AMANET funded trials To review AMANET constitution, and elect members of different AMANET governing bodies.

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Organization Structure
The organization structure of AMANET comprises the General Assembly, Board of Trustees, the Secretariat, Scientific Coordinating Committee, Scientific Advisory Panel, Trial Sites Development Committee and Expert Committees. The General Assembly comprising representatives of malaria R&D institutions in Africa and allied institutions outside Africa is the topmost organ. It generally meets every two years and is responsible for electing the Board of Trustees and the Scientific Coordinating Committee. The Board of Trustees is the ultimate authority in matters of policy and investment. It oversees the general governance, regulation and control of AMANET. The Scientific Coordinating Committee is constituted of senior research scientists elected by the General Assembly. It is responsible for receiving and reviewing reports from the Secretariat and from the Expert Committees. The SCC advises the BoT on scientific matters. Its functions also include the reviewing of research proposals and letters of expression of interest and the monitoring and evaluation of ongoing and completed research projects. The Secretariat is the executive organ of the Trust, serving the Board of Trustees and all the committees. The Trial Sites Development Committee (TSDC) a Committee of experts appointed by the Board of Trustees from SCC to advise AMANET on specific issues relating to the development of trial sites. The Scientific Advisory Panel is a panel of experts from various disciplines from whom ad hoc Expert Committees are formed to advise AMANET on specific research and scientific issues.

Product research and development


Among the cherished goals of AMANET is to develop sustainable human and infrastructure capacity for African owned and led institutions to undertake malaria vaccine trials that are appropriate for Africans living in malaria-endemic areas. The current focus is to support the creation of a spectrum of interventional tools, especially vaccines that are efficacious, acceptable, affordable and readily accessible. The following are AMANET's candidate malaria vaccine portfolio: The Merozoite Surface Protein - Long Sythetic Peptide (MSP3 LSP),[][] This is the leading product which has already been shown to be safe in adults in Africa. The vaccine is currently undergoing testing for safety in children both in Burkina Faso and shortly in Tanzania. Should the safety profile be established to be safe, the vaccine will be taken through phase IIb immunogenicity trials that would also establish the proof of limited efficacy The Apical Membrane Antigen (AMA1):[1] This the second vaccine in development and is now undergoing phase Ib evaluation in adults Mali. During the last quarter of 2007, an evaluation of the safety results was done, and AMA1 was found to be safe in African adults.. The GMZ2:[2] The third vaccine in the portfolio was recently initiated in phase Ib adult study in Gabon. This product is expected to undergo a similar developmental pathway should it continue to have good results. This product is unique because it is a hybrid molecule with two potential targets on the malaria parasite; GLURP and MSP3. It is expected that within the next three years several trials of these candidate vaccines shall be undertaken at the auspices of AMANET. Other candidate vaccines which meet the required profile are welcome to the AMANET malaria vaccine development programme.

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Capacity strengthening
Human resource and infrastructure development for malaria interventions in Africa is of up most priority to AMANET. This goal is being realized through both short-term trainings as well as direct financial support of the core centres. AMANET conducts short-term trainings through various workshops conducted throughout Africa, around six times a year. Additionally AMANET supports long-term training of individuals from AMANET funded sites which include: Tanzania-National Institute for Medical Research (NIMR) Tanga: The programme has steadily continued. We are currently preparing the site for the first vaccine trial of MSP3 in children 12 years. The site characterization activities are near completion; Two staff members at the site are currently taking AMANET sponsored long term training programs at MSc and PhD level. Zambia-Tropical Diseases Research Centre (TDRC) Ndola: The centre is on the capacity development programme having received a strengthening grant. Two AMANET sponsored students are completing the training masters level. Burkina Faso-Centre de National Recherch et de Formation sur le Paludisme (CNRFP) Ouagadougou: The site is currently conducting phase Ib trial of the MSP3 candidate vaccine. Two immunologists were sent to Netherlands for two weeks on specific training to transfer technology and establish cellular assays. This has led to technology transfer with their lab now able to handle the relevant immunological assays to support the clinical trials. Uganda-The Makerere University: The site has become the newest to receive a grant from AMANET for capacity strengthening in preparation for vaccine trials. It has, in parallel, received a grant for ethics committee strengthening.

Building institutional capacities in Health Research Ethics in Africa


This is a new project at AMANET funded by the Bill and Melinda Gates Foundation aimed at strengthening Health Research Ethics (HRE) capacity in Africa. The project aims at ensuring that as the African populations are recruited into health research projects, the protection of their welfare and interests is enhanced. The HRE project has three parts: building Health Research Ethics capacity, online Health Research Ethics discussion forum and Ask the Expert/Ethicist. The HRE capacity building project focuses on training Ethics Committee members on Research Ethics in order to improve the ethical review process of committees that are mandated to safeguard the welfare of research participants. In order to concentrate on activities that have greater potential to strengthen the Ethics Committees, a baseline survey was conducted to identify area of weakness that need to be addressed. A cohort of 21 Ethics Committees is being enrolled in this project and will be involved in various activities aimed at addressing areas of weakness in the review process. These committees are being provided with a sub-grant to support infrastructure and administration at their committees. Overall, activities are spread over a period of three years, and they include, besides capacity strengthening and infrastructure support, a series of eight Research Ethics training workshops, two of which will be in French (for the benefit of the participating Francophone countries). Through the workshops, Standard Operating Procedures (SOPs) will be developed/improved, and an additional workshop focussing on harmonization of SOPs will be organised. In addition, a workshop on Research Ethics will be organised specifically for investigators. It is envisaged that overall the HRE capacity building programme will contribute towards the establishment of competent and independent Ethics Committees that have well-equipped offices, functional and harmonised SOPs, electronic databases and archiving systems, and trained members who network and interact through online discussion forum and workshops.

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The Afro Immuno Assay (AIA) Network


Afro Immuno-Assay Network, started by AMANET in 2003, has been working on developing standardized immunological assays using the same reagents and statistical tools to assess the association between acquisition of malaria specific antibody responses starting with four potential malaria vaccine candidate antigens and subsequent protection from clinical malaria. This is a concerted network of eight African countries/Institutions with different geographical and epidemiological settings comprising low to holoendemic malaria and three supporting European institutions. Now the AIA network is under a new five year project, within the European Malaria Vaccine Development Association (EMVDA) Consortium. In this Integrated Project, the AIA network focuses on standardization and validation of its immunological assays, expand to include new partners, further training for participating African immunologists and enhancement of laboratory expertise to include functional assays required for malaria vaccine evaluation.

Short and long-term training


During the first Strategic Planning period, AMANET supported and organized several training workshops which benefited over 1000 African malaria researchers and associated personnel. In the process a comprehensive repository of expertise essential for the evaluation of malaria interventions, is being built up. Some of the former AMANET trainees have become experts in these areas. During this strategic plan period, AMANET will draw upon this vast expertise to constitute teams of trainers that facilitate short term training for AMANET beneficiary institutions, and for others upon request. The training will be in such areas as Health Research Ethics review in Africa; development of Standard Operating Procedures for Ethical Review Committee; Health Research Ethics for Investigators; Good Laboratory Practice and Standard Operating Procedures; Good clinical practice; Good Clinical Practice for African clinical monitors; Design, methodology and data management in intervention trials; Roles and operations of Data Safety Monitoring Boards (DSMB). Given the ever rising demands for AMANET short-term training, alternative teaching methods have been developed and are being utilized. Web-based training on health research ethics (HRE) is in good progress. The AMANET HRE web-based course has been very successfully accessed through the AMANET website. The online course was launched in September 2006 and to date over 150 participants have successfully completed the course and over 430 candidates have registered for the course. Participants have been drawn from Africa, Europe and the US. Based on its success, AMANET has acquired other resources to continue the project and also the e-learning funding in order to continue the project another year and also expand the e-learning opportunities to include other courses such a GCP, French version of the same course, and also an Advanced Ethics Course.

The Multilateral Initiative on Malaria (MIM)


From January 2006, AMANET became host to the Multilateral Initiative on Malaria (MIM) Secretariat. This is a global alliance of individuals, funding partners and four autonomous constituents comprising the MIM Secretariat, MIM/TDR, MIMCom and MR4. Its mission is to strengthen and sustain, through collaborative research and training, to carry out research that is required to develop and improve tools for malaria control, and to strengthen the research control interphase.

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Acknowledgements
AMANET acknowledges financial support from the Ministry of Foreign Affairs (Netherlands), the Danish International Development Agency (DANIDA), the European Commissions Directorate-General Research and AIDCO, the Bill and Melinda Gates Foundation,[] the European and Developing Countries Clinical Trials Partnership(EDCTP) and the African Caribbean Pacific (ACP) Secretariat for including AMANET in their portfolio for EDF9 support.

References

American Medical Group Association


The American Medical Group Association is a national trade association representing medical groups and other organized systems of health care, including some of the nations largest integrated healthcare delivery systems. More than 125,000 physicians practice in American Medical Group Association member organizations, providing healthcare services for approximately 130 million patients (more than one in three Americans).[1] Headquartered in Alexandria, Virginia, American Medical Group Association (AMGA) provides services to member medical groups, including political advocacy, educational and networking programs, publications, benchmarking data services, and financial and operations assistance.

History
The American Medical Group Association was born out of the desire for physicians practicing in groups to improve the quality of patient care by sharing best practices, experiences, and strategies with their peers. Over the years, AMGA has become one of the primary advocates of group practice, promoting multispecialty medical groups and other organized systems of care as the preferred delivery system for coordinated, patient-centered, efficient, quality medical care in America. Founded in 1950 as the American Association of Medical Clinics, the organization was renamed the American Group Practice Association (AGPA) in 1974. In mid-1996, AGPA merged with the Unified Medical Group Association (UMGA) to form the American Medical Group Association.[2]

AMGA Annual Compensation Survey


For 22 years, the association has conducted a compensation and financial survey of medical groups and organized systems of care and published the results to aid medical groups (particularly large, integrated health systems) in benchmarking compensation and financial performance. The annual Medical Group Compensation and Financial Survey presents detailed data on compensation for healthcare professionals and on medical group financials. The data may be used in conjunction with the Centers for Medicare & Medicaid Services (CMS) regulations at 42 CFR 413.78(f).[3]

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Corporate family
American Medical Group Association is made up of several entities. American Medical Group Foundation (AMGF)[4] - The philanthropic arm of American Medical Group Association, dedicated to demonstrating that the total coordinated care model continues to provide the highest quality, cost-effective, efficient care possible and to fostering quality improvement in group practice through education and research programs in clinical quality, patient safety, service, operational efficiency, and innovation. Council of Accountable Physician Practices (CAPP)[5] - An affiliate of AMGF, CAPP is a joint undertaking by some of the nation's largest and most prominent physician practices to foster the evolution and development of the accountable physician group model. Anceta, LLC[6] - Anceta is a for-profit informatics and analytic company formed to transform comprehensive healthcare information into actionable knowledge and accountable, evidence-based practice. This data warehouse is the only national effort to collect and share critical information across non-affiliated medical group organizations.

References
[1] http:/ / www. amga. org/ AboutAMGA/ index_aboutAMGA. asp [2] [3] [4] [5] [6] http:/ / www. amga. org/ AboutAMGA/ history_aboutAMGA. asp http:/ / www. cms. hhs. gov/ AcuteInpatientPPS/ Downloads/ AMGA_08_data. pdf http:/ / www. amga. org/ Foundation/ index. asp http:/ / www. amga-capp. org/ http:/ / www. anceta. com/

External links
American Medical Group Association website (http://www.amga.org/)

American Medical Informatics Association

215

American Medical Informatics Association


American Medical Informatics Association
Abbreviation Motto Formation Type Legalstatus Purpose/focus Headquarters Membership AMIA The professional home for biomedical and health informatics 1989, merger of NGOs incorporated in 1972 NGO NPO Professional association Bethesda, MD 4,000

Officiallanguages English President Key people Mainorgan Website Kevin Fickenscher Gilad J. Kuperman, Chair of the Board of Directors Assembly http:/ / www. amia. org

AMIA, formerly known as the American Medical Informatics Association, is an American non-profit organization dedicated to the development and application of biomedical and health informatics in the support of patient care, teaching, research, and health care administration.

History
AMIA is the official United States representative to the International Medical Informatics Association. It has grown to more than 4,000 members from 42 countries worldwide. Together, these members represent all basic, applied, and clinical interests in health care information technology. It publishes the Journal of the American Medical Informatics Association.

Founding
AMIA was founded in 1989 by the merger of three organizations: American Association for Medical Systems and Informatics American College of Medical Informatics Symposium on Computer Applications in Medical Care

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Leadership
The first President and CEO of AMIA was Don E. Detmer. He was succeeded in July 2009 by Edward H. Shortliffe. In March 2012, he was succeeded by Kevin Fickenscher.

Membership
AMIA membership is open to individuals, institutions, and corporations. Members include physicians, nurses, dentists, pharmacists, clinicians, health information technology professionals, computer and information scientists, biomedical engineers, consultants and industry representatives, medical librarians, academic researchers and educators, and advanced students pursuing a career in clinical informatics or health information technology.

Meetings and education


AMIA annually holds the following meetings:[1] AMIA Annual Symposium The AMIA Joint Summit on Translational Science comprising: AMIA Summit on Translational Bioinformatics AMIA Summit on Clinical Research Informatics AMIA Now AMIA CMIO Boot Camp

Working and special interest groups


AMIA includes a number of working groups: Clinical Information Systems Clinical Research Informatics Consumer Health Informatics Dental Informatics Education Ethical, Legal, & Social Issues Evaluation Formal (Bio)Medical Knowledge Representation Genomics Knowledge Discovery and Data Mining Knowledge in Motion Medical Imaging Systems Natural Language Processing Nursing Informatics Open Source People & Organizational Issues Pharmacoinformatics Primary Care Informatics Public health informatics Student

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References
[1] AMIA meetings (https:/ / www. amia. org/ meetings)

External links
Official website (http://www.amia.org/)

American Nurses Association


The American Nurses Association (ANA) is a professional organization to advance and protect the profession of nursing. It started in 1896 as the Nurses Associated Alumnae and was renamed the American Nurses Association in 1911.[1] It is based in Silver Spring, Maryland[2] and Karen Daley, PhD, MPH, RN, FAAN, is the current President.[3] The ANA states nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.[4]

History
Initial organizational plans were made for the Nurses Associated Alumnae of the United States of America in 1896 in Manhattan Beach. In February 1897, those plans were ratified in Baltimore at a meeting that coincided with the annual conference of the American Society of Superintendents of Training Schools for Nurses.[] Isabel Hampton Robb served as the first president. A major early goal of the organization was the enhancement of nursing care for American soldiers.[5]

Primary mission
The Association is a professional organization representing registered nurses (RNs) in the United States through its 54 constituent member associations.[6] The ANA is involved in establishing standards of nursing practice, promoting the rights of nurses in the workplace, advancing the economic and general welfare of nurses.[7] ANA also has three subsidiary organizations: (1) American Academy of Nursing, to serve the public and profession by advancing health policy and practice through the generation, synthesis, and dissemination of knowledge,(2) American Nurses Foundation, the charitable and philanthropic arm, and (3) American Credentialing Center, which credentials nurses in their specialty and credentials facilities that exhibit excellence.[8] nursing nursing Nurses nursing

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Publications
American Nurse Today The American Nurse OJIN: The Online Journal of Issues in Nursing[9]

External links
American Nurses Association website [10] American Nurse Foundation website [11] American Nurse Credentialing Center website [12] American Academy of Nursing website [13]

References
[10] [11] [12] [13] http:/ / nursingworld. org http:/ / www. anfonline. org/ http:/ / www. nursecredentialing. org/ http:/ / www. aannet. org

American Optometric Association


Representing approximately 37,000 doctors of optometry, optometry students and paraoptometric assistants and technicians, the American Optometric Association was founded in 1898. The Association has offices in St. Louis, MO, and Alexandria, VA, employing approximately 100 people. The AOA counts nearly half of practicing optometrists as its members. Serving patients in nearly 6,500 communities across the country, optometrists are the only eye doctors in 3,500 communities and provide two-thirds of all primary eye care in the United States. The AOA is a federation, with state, student and armed forces optometric associations representing members at the state or affiliate level. The Association also has four special interest sections: The Contact Lens and Cornea Section, the Vision Rehabilitation Section, the Sports Vision Section and the Paraoptometric Section. The AOA and its affiliates work to provide the public with quality vision and eye care by:
Setting professional standards and helping member optometrists conduct patient care efficiently and effectively,

Lobbying government and other organizations on behalf of the optometric profession, and

Providing research and education leadership.

AOA mission
"Advocate for the profession and serve optometrists in meeting the eye care needs of the public." The objectives of AOA are centered on improving the quality and availability of eye and vision care. The AOA fulfills its missions in accordance with the following goals: Health care and public policy related to eye care will uniformly recognize optometrists as primary health care providers and ensure the public has access to the full scope of optometric care. Optometrists and other professionals will look to the American Optometric Association for professional standards, research and education leadership which serve to enhance and ensure competent, quality patient care.

American Optometric Association The public, optometrists and other professionals will turn to the American Optometric Association for reliable and current information related to optometry, eye care, and health care policy.

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External links
American Optometric Association Official page [1] AOA News web site [2] InfantSEE: a public health program for infants [3] Optometry's Meeting [4] Journal of the American Optometric Association [5]

References
[1] [2] [3] [4] [5] http:/ / www. aoa. org http:/ / www. aoanews. org http:/ / www. infantsee. org http:/ / www. optometrysmeeting. org http:/ / www. optometryjaoa. com/

American Osteopathic Association

220

American Osteopathic Association


American Osteopathic Association
Abbreviation Motto Formation Type Headquarters Location Coordinates Membership AOA Treating Our Family and Yours April 10, 1897 Professional association Chicago, Illinois United States

Coordinates: 41.8942N 87.6190W [1]


[] 43,472 physicians and medical students

Officiallanguages English President Website Ray E. Stowers, DO [2] [3]

AOA Official Website

Osteopathic medicine in the United States


Andrew Taylor Still (founder) Doctor of Osteopathic Medicine (DO) Medicine US Medical education

Schools Physicians Osteopathic Manipulative Medicine AOA AACOM AAO COMLEX MD & DO Comparison Specialty Colleges AOA BOS

The American Osteopathic Association (AOA) is the representative member organization for the over 82,500 osteopathic medical physicians (D.O.s) in the United States.[] The AOA is headquartered in Chicago, Illinois, and is involved in post-graduate training for osteopathic physicians. The organization promotes public health, encourages academic scientific research, serves as the primary certifying body for D.O.s overseeing 18 certifying boards, is the accrediting agency for osteopathic medical schools through its Commission on Osteopathic College Accreditation, and has federal authority to accredit hospitals and other health care facilities,[4][5][6] through its program, the Healthcare Facilities Accreditation Program.[7] The AOA has held yearly conventions since its founding in 1897.[8] The AOA also manages DOCARE International, a non-profit charitable organization. The AOA also publishes The DO, a monthly magazine, and the Journal of the American Osteopathic Association, a peer reviewed medical journal.

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Mission
The AOA's mission is to advance the philosophy and practice of osteopathic medicine by promoting excellence in education, research, and the delivery of quality, cost-effective healthcare. The AOA supports the annual "D.O. day on the Hill," where roughly 1,000 osteopathic medical students go to Washington D.C. to meet with congressmen to discuss current issues in health care, such as access to care challenges.[9] The event serves as an opportunity for the legislators to learn more about health care and osteopathic medicine, and for the medical students to become more familiar with the political process.

History
The association was founded as the American Association for the Advancement of Osteopathy on April 10, 1897, in Kirksville, Missouri, by students of the American School of Osteopathy.[10][] It was renamed the American Osteopathic Association in 1901.[][11] In September 1901, the AOA began to publish a scientific journal entitled the Journal of the American Osteopathic Association. Subscriptions were offered to AOA members, and at the time, membership fees were $5 annually.[] The journal was published bimonthly for the first year, then monthly thereafter. In April 1927, the AOA began publishing "The Forum of Osteopathy," a monthly magazine that covered news relating to osteopathic medicine, the AOA, and related groups.[] In September 1960, the magazine was renamed The DO. In the early 1900s, the AOA, citing concerns about safety and efficacy, was opposed to the introduction of pharmacology into the curriculum of osteopathic medicine. However, in 1929 the AOA board of trustees voted to allow the teaching of pharmacology in D.O. schools.[] By 1938, the AOA began requiring that osteopathic medical students have at least 1 year of undergraduate college coursework, and by 1940, the AOA required two years.[] In 1952, the U.S. Department of Health, Education, and Welfare recognized the AOA as the official accrediting body for osteopathic medical education. In 1967, the National Commission on Accrediting (currently the Council for Higher Education Accreditation) recognized the AOA as the official accrediting agency for all aspects of osteopathic medical education.[12] The Department of Health, Education and Welfare (currently the Department of Health and Human Services) recognized the AOA as the official accrediting body for osteopathic hospitals under Medicare in 1966.[]

Osteopathic post-graduate education


The AOA also provides funding for post-graduate osteopathic medical residencies.[] In the 2012 match, 1,767 osteopathic physicians matched into these residency programs.[] In 1999, the AOA began requiring all schools of osteopathic medicine to be actively involved in residency training programs through Osteopathic Post-Graduate Training Institutes.[13][14]

Publications
The American Osteopathic Association publishes The DO, a monthly magazine[15] covering news related to osteopathic medicine, legislation, health care changes, and osteopathic continuing medical education programs.[16] The AOA also publishes the Journal of the American Osteopathic Association, a monthly peer-reviewed medical journal focusing on original research and editorial articles.

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DOCARE International
DOCARE International is a non-profit medical charity serving remote areas of the Western Hemisphere. DOCARE is operated by the American Osteopathic Association, and consists of osteopathic physicians, osteopathic medical students, M.D. physicians, and other healthcare professionals.[17]

References
[1] http:/ / tools. wmflabs. org/ geohack/ geohack. php?pagename=American_Osteopathic_Association& params=41. 8942_N_-87. 6190_E_ [3] http:/ / www. osteopathic. org/ Pages/ default. aspx [11] History of the AOA (http:/ / www. osteopathic. org/ index. cfm?PageID=aoa_history), American Osteopathic Association website

External links
American Osteopathic Association (http://www.osteopathic.org) "The DO" online news publication (http://www.do-online.org/TheDO/) Mini-Medical School (http://www.mini-med-school.com/)

American Occupational Therapy Association


The American Occupational Therapy Association (AOTA) is the national professional association established in 1917 to represent the interests and concerns of occupational therapy practitioners and students and improve the quality of occupational therapy services. AOTA membership is approximately 48,000 occupational therapists, occupational therapy assistants, and students. The National Society for the Promotion of Occupational Therapy was the founding name of the AOTA.

External links
American Occupational Therapy Association official website [1]

References
[1] http:/ / www. aota. org

Administrative Procedure Act

223

Administrative Procedure Act


Administrative Procedure Act of 1946

Long title

An Act to improve the administration of justice by prescribing fair administrative procedure.

Colloquial acronym(s) APA Enacted by the Effective 79th United States Congress June 11, 1946 Citations Public Law Stat. 79-404 [1]

60Stat.237 Codification

Title(s) amended

5 U.S.C.: Government Organization and Employees

U.S.C. sections created Chapter 5 500 et seq.[2] Legislative history Introduced in the Senate as S. 7 by Patrick McCarran (DNV) on October 19, 1945 Committee consideration by: Senate Judiciary Committee, House Judiciary Committee Signed into law by President Harry S. Truman on June 11, 1946 Major amendments Recodified by Pub. L. 89554, Sept. 6, 1966, 80 Stat. 383 United States Supreme Court cases Citizens to Preserve Overton Park v. Volpe Vermont Yankee Nuclear Power Corp. v. NRDC

Administrative law
General principles

Administrative court Delegated legislation Exhaustion of remedies Justiciability Legitimate expectation Ministerial act Natural justice Nondelegation doctrine Ouster clause (privative clause) Patently unreasonable Polycentricity

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224
Prerogative writ Certiorari Habeas corpus Mandamus Prohibition Quo warranto Rulemaking Ultra vires Administrative law in common law jurisdictions

Australia Canada Singapore South Africa United Kingdom Scotland United States Administrative law in civil law jurisdictions

China Mongolia Ukraine Related topics

Constitutional law Judicial review

The Administrative Procedure Act (APA), Pub.L. 79404 [3], 60Stat.237, enacted June11, 1946, is the United States federal law that governs the way in which administrative agencies of the federal government of the United States may propose and establish regulations. The APA also sets up a process for the United States federal courts to directly review agency decisions. It is one of the most important pieces of United States administrative law. The Act became law in 1946. The APA applies to both the federal executive departments and the independent agencies. U.S. Senator Pat McCarran called the APA "a bill of rights for the hundreds of thousands of Americans whose affairs are controlled or regulated" by federal government agencies. The text of the APA can be found under Title 5 of the United States Code, beginning at Section 500. There is a similar Model State Administrative Procedure Act (Model State APA) which was drafted by the National Conference of Commissioners on Uniform State Laws for oversight of state agencies. Not all states have adopted the model law wholesale as of 2007. The federal APA does not require systematic oversight of regulations prior to adoption as suggested by the Model APA.[4]

Historical background
Beginning in 1933, President Franklin D. Roosevelt and the Democratic Congress enacted several statutes that created new federal agencies as part of the New Deal legislative plan, designed to deliver the United States from the social and economic hardship of the Great Depression. However, following the Great Depression and World War II the Congress became concerned about the expanding powers that federal agencies possessed, resulting in the enactment of the APA to regulate and standardize federal agency procedures.[2] In a law journal article on the history of the APA,[5] Professor George Shepard discusses the contentious political environment from which the APA was born. Shepard claims that Roosevelts opponents and supporters fought over

Administrative Procedure Act passage of the APA "in a pitched political battle for the life of the New Deal" itself.[5] Shepard does note, however, that a legislative balance was struck with the APA, expressing "the nation's decision to permit extensive government, but to avoid dictatorship and central planning."[5] A 1946 U.S. House of Representatives report discusses the 10-year period of "painstaking and detailed study and drafting" that went into the APA.[6] Because of rapid growth in the administrative regulation of private conduct, Roosevelt ordered several studies of administrative methods and conduct during the early part of his four-term presidency.[6] Based on one study, Roosevelt commented that the practice of creating administrative agencies with the authority to perform both legislative and judicial work "threatens to develop a fourth branch of government for which there is no sanction in the Constitution." In 1939, Roosevelt requested that Attorney General Frank Murphy form a committee to investigate practices and procedures in American administrative law and suggest improvements. That committee's report,[7] contains detailed information about the development and procedures of the federal agencies. The Final Report defined a federal agency as a governmental unit with "the power to determine...private rights and obligations" by rulemaking or adjudication.[7] The Final Report applied that definition to the largest units of the federal government, and identified "19 executive departments and 18 independent agencies."[7] If various subdivisions of the larger units were considered, the total number of federal agencies at that time increased to 51. In reviewing the history of federal agencies, the Final Report noted that almost all agencies had undergone changes in name and political function. Of the 51 federal agencies discussed in the Final Report, 11 were created by statute prior to the Civil War. From 1865 to 1900, six new agencies were created. Most notable was the formation of the Interstate Commerce Commission, created in 1887 in response to widespread criticism of the railroad industry. The period of 1900 to 1940, however, saw the greatest expansion of federal administrative power, with 35 new agencies created by statute. Eighteen of these were created during the 1930s, from statutes enacted as part of Roosevelt's New Deal. The Final Report made several recommendations about standardizing administrative procedures, but Congress delayed action because the U.S. entered World War II. Since 2005, the House Judiciary Committee has been undertaking an Administrative Law, Process and Procedure Project to determine what, if any, changes should be made to the Administrative Procedure Act.

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Basic purposes
Agencies are unique governmental bodies, capable of exercising powers characteristic of all three branches of the United States federal government: judicial, legislative and executive. An individual agency typically will possess only the power of the branch that set it up, or possibly powers characteristic of two branches, but the Separation of Powers doctrine dictates that all three powers should not be vested in one body. As recognized by President Roosevelt and others, the creation and function of federal agencies can cause separation of powers issues under the United States Constitution. To provide constitutional safeguards, the APA creates a framework for regulating agencies and their unique role. According to the Attorney General's Manual on the Administrative Procedure Act (1947), drafted after the 1946 enactment of the APA, the basic purposes of the APA are (1) to require agencies to keep the public informed of their organization, procedures and rules; (2) to provide for public participation in the rulemaking process; (3) to establish uniform standards for the conduct of formal rulemaking and adjudication; (4) to define the scope of judicial review.[8] The APA's provisions apply to many federal governmental institutions. The APA in 5 U.S.C. 551(1)[9] defines an "agency" as "each authority of the Government of the United States, whether or not it is within or subject to review by another agency," with the exception of several enumerated authorities, including the Congress, federal courts, and governments of territories or possessions of the United States. Courts have also held that the U.S. President is not an agency under the APA. Franklin v. Mass., 505 U.S. 788 (1992).

Administrative Procedure Act The Final Report organized federal administrative action into two parts: adjudication and rulemaking. (p.5) Agency adjudication was broken down further into two distinct phases of formal and informal adjudication. (Ibid.) Formal adjudication involve a trial-like hearing with witness testimony, a written record and a final decision. Under informal adjudication, however, agency decisions are made without formal trial-like procedures, using "inspections, conferences and negotiations" instead. (Ibid.) Because formal adjudication produces a record of proceedings and a final decision, it may be subject to judicial review. As for rulemaking resulting in agency rules and regulations, the Final Report noted that many agencies provided due process through hearings and investigations, but there was still a need for well-defined, uniform standards for agency adjudication and rulemaking procedures.

226

Standard of judicial review


The APA requires that in order to set aside agency action not subject to formal trial-like procedures, the court must conclude that the regulation is "arbitrary and capricious, an abuse of discretion, or otherwise not in accordance with the law."[] However, Congress may further limit the scope of judicial review of agency actions by including such language in the organic statute. To set aside formal rulemaking or formal adjudication whose procedures are trial-like (see APA, 5 U.S.C 556[] - 557[]), a different standard of review allows courts to question agency action more strongly. For these more formal actions, agency decisions must be supported by "substantial evidence"[] after the court reads the "whole record,"[10] which can be thousands of pages long. Unlike arbitrary and capricious review, substantial evidence review gives the courts leeway to consider whether an agency's factual and policy determinations were warranted in light of all the information before the agency at the time of decision. Accordingly, arbitrary and capricious review is understood to be more deferential to agencies than substantial evidence review. Arbitrary and capricious review allows agency decisions to stand as long as an agency can give a reasonable explanation for its decision based on the information it had at the time. In contrast, the courts tend to look much harder at decisions resulting from trial-like procedures because those agency procedures resemble actual trial-court procedures, but the Article III of the Constitution reserves the judicial powers for actual courts. Accordingly, courts are strict under the substantial evidence standard when agencies acts like courts because being strict gives courts final say, preventing agencies from using too much judicial power in violation of separation of powers. The separation of powers doctrine is less of an issue with rulemaking not subject to trial-like procedures. Such rulemaking gives agencies a lot more leeway in court because it is much more like the legislative process reserved for Congress in Article II. Courts' main role here is ensuring agency rules line up with the Constitution and with agency's statutory commands from Congress. Even if a court finds a rule very unwise, it will stand as long as it is not "arbitrary and capricious, an abuse of discretion, or otherwise not in accordance with the law."

Publication of regulations
Rules and regulations issued by federal administrative agencies are published chronologically (by date of issuance) in the Federal Register. Rules and regulations are then organized by topic (subject matter) in a separate publication called the Code of Federal Regulations. In comparing publication of regulations to publication of statutes, the Federal Register is analogous to the United States Statutes at Large and the Code of Federal Regulations is analogous to the United States Code.

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227

References
[1] [2] [3] [4] [5] [6] [7] [8] [9] http:/ / www. justice. gov/ jmd/ ls/ legislative_histories/ pl79-404/ act-pl79-404. pdf Hall, D: Administrative Law Bureaucracy in a Democracy 4th Ed., page 2. Pearson, 2009. http:/ / www. law. cornell. edu/ jureeka/ index. php?doc=USPubLaws& cong=79& no=404 (2007). OVERSIGHT AND INSIGHT: LEGISLATIVE REVIEW OF AGENCIES AND LESSONS FROM THE STATES (http:/ / www. harvardlawreview. org/ issues/ 121/ december07/ Note_1047. php). Harvard Law Review. Shepard, George. Fierce Compromise: The Administrative Procedure Act Emerges from New Deal Politics. 90 Nw. U. L. Rev. 1557 (1996) Administrative Procedure Act, Report of the House Judiciary Committee, No. 1989, 79th Congress, 1946. Final Report of the Attorney General's Committee on Administrative Procedure (http:/ / www. law. fsu. edu/ library/ admin/ 1941report. html) (Senate Document No. 8, 77th Congress, First Session, 1941) http:/ / www. law. fsu. edu/ library/ admin/ 1947cover. html Attorney General's Manual on the Administrative Procedure Act (1947) http:/ / frwebgate. access. gpo. gov/ cgi-bin/ usc. cgi?ACTION=RETRIEVE& FILE=$$xa$$busc5. wais& start=175450& SIZE=11844& TYPE=TEXT United States Code Title 5

External links
Administrative Procedure Act (http://biotech.law.lsu.edu/Courses/study_aids/adlaw/) Attorney General's Manual on the Administrative Procedure Act (http://www.law.fsu.edu/library/admin/ 1947cover.html) Legal Information Institute administrative law overview (http://www.law.cornell.edu/topics/administrative. html) Key administrative law decisions by the US Supreme Court (http://www.law.cornell.edu/supct/cases/adlaw. htm) Federal administrative agency index via Washburn School of Law (http://www.washlaw.edu/doclaw/ executive5m.html) Administrative Law Journal (http://www.wcl.american.edu/journal/alr/) Washington College of Law, American University Cybertelecom :: Administrative Procedures Act (http://www.cybertelecom.org/notes/apa.htm)

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American Psychiatric Association


American Psychiatric Association
Logo of the APA Formation Headquarters 1844 1000 Wilson Boulevard, Suite 1825 Arlington, Virginia, United States [] 36,000 members

Membership

May 20132014 President Jeffrey Lieberman, M.D. Website www.psychiatry.org [1]

The American Psychiatric Association (APA) is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the largest psychiatric organization in the world.[] Its some 36,000[] members are mainly American but some are international. The association publishes various journals and pamphlets, as well as the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM codifies psychiatric conditions and is used worldwide as a key guide for diagnosing disorders. The organization has its headquarters in Arlington County, Virginia.[2]

History
At a meeting in 1844 in Philadelphia, 13 superintendents and organizers of insane asylums and hospitals formed the Association of Medical Superintendents of American Institutions for the Insane (AMSAII). The group included Thomas Kirkbride, creator of the asylum model which was used throughout the United States. At the meeting they passed the first proposition of the new organization: "It is the unanimous sense of this convention that the attempt to abandon entirely the use of all means of personal restraint is not sanctioned by the true interests of the insane."[3] The name of the organization was changed in 1892 to The American Medico-Psychological Association to allow assistant physicians working in mental hospitals to become members. In 1921, the name was changed to the present American Psychiatric Association. The APA emblem, dating to 1890, became more officially adopted from that year. It was a round medallion with a purported facial likeness of Benjamin Rush and 13 stars over his head to represent the 13 founders of the organization. The outer ring contains the words "American Psychiatric Association 1844." Rush's name and an M.D.[4] The Association was Incorporated in the District of Columbia in 1927. In 1948, APA formed a small task force to create a new standardized psychiatric classification system. This resulted in the 1952 publication of the first DSM. In 1965 a new task force of 10 people developed DSM-II, published in 1968. DSM-III was published in 1980, after a larger process involving some 600 clinicians. The book was now 500 pages long, including many more disorders, and it sold nearly half a million copies. APA published a revised DSM-III-R in 1987 and DSM-IV in 1994, the latter selling nearly a million copies by the end of 2000. DSM-IV-TR with minor revisions was published in 2000. APA is currently developing and consulting on DSM-V, which will be published in May 2013. In the early 1970s, activists campaigned against the DSM classification of homosexuality as a mental disorder, protesting at APA offices and at annual meetings from 1970 to 1973. In 1973 the Board of Trustees voted to remove homosexuality as a disorder category from the DSM, a decision ratified by a majority (58%) of the general APA membership the following year. A category of "sexual orientation disturbance" was introduced in its place in 1974,

American Psychiatric Association and then replaced in the 1980 DSM-III with Ego-dystonic sexual orientation. That was removed in 1987. In 2002, amidst increasing concern to differentiate themselves from clinical psychologists, the APA assembly membership voted against a proposed name change to the American Psychiatric Medical Association.[5] Dr. Saul Levin was named on May 15th, 2013 as the new chief executive officer and medical director of the APA, making him the first known openly gay person to head the APA. [6]

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Organization and membership


APA is led by the President of the American Psychiatric Association and a Board of Trustees with an Executive Committee. APA reports [7] that its membership is primarily medical specialists who are qualified, or in the process of becoming qualified, as psychiatrists. The basic eligibility requirement is completion of a residency program in psychiatry accredited by the Residency Review Committee for Psychiatry of the Accreditation Council for Graduate Medical Education (ACGME), the Royal College of Physicians and Surgeons of Canada (RCPS(C)), or the American Osteopathic Association (AOA). Applicants for membership must also hold a valid medical license (with the exception of medical students and residents) and provide one reference who is an APA member. APA holds an annual conference attended by a US and international audience. APA is made up of some 76 district associations throughout the US.[8]

Theoretical position
The APA reflects and represents mainstream psychiatry in the United States. Reflecting larger trends, the APA members and leaders had been largely psychodynamic in their approaches until recent decades, when the field became more "biopsychosocial." The DSM is currently intended to be less theoretical than prior editions, having moved away from psychodynamic theories to be more widely accepted, and is proposed to not be committed to a particular theorized etiology for mental disorders. The criteria for many of the mental disorders have been expanded and involve a checklist of so-called 'Feighner Criteria' to try and capture the varying sets of features which would be necessary to diagnose a particular disorder.

Publications and campaigns


APA position statements,[9] Psych.org and practice guidelines[10] and description of its core diagnostic manual the DSM [11] are published. APA publishes several journals[12] focused on different areas of psychiatry, for example, academic, clinical practice, or news. APA recently launched a health campaign[13] with a new PR approach.[14]

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Notable figures
Adolf Meyer rose to prominence as the president of the American Psychiatric Association and was one of the most influential figures in psychiatry in the first half of the twentieth century. Robert Spitzer was a key figure in the development of later editions of the DSM. Donald Ewen Cameron is best known for his MK-ULTRA-related mind-control and behavior modification research for the CIA. Cameron was President of the APA in 1952-1953. Current president Jeffrey Lieberman was principal investigator for the NIMH CATIE study.[15]

Drug company ties


In his book Anatomy of an Epidemic (2010), Robert Whitaker described the partnership that has developed between the APA and pharmaceutical companies since the 1980s.[] APA has come to depend on pharmaceutical money.[] The drug companies endowed continuing education and psychiatric "grand rounds" at hospitals. They funded a political action committee (PAC) in 1982 to lobby Congress.[] The industry helped to pay for the APA's media training workshops.[] It was able to turn psychiatrists at top schools into speakers, and although the doctors felt they were independents, they rehearsed their speeches and likely would not be invited back if they discussed drug side effects.[] "Thought leaders" became the experts quoted in the media.[] As Marcia Angell wrote in The New England Journal of Medicine (2000), "thought leaders" could agree to be listed as an author of ghostwritten articles,[16] and she cites Thomas Bodenheimer and David Rothman who describe the extent of the drug industry's involvement with doctors.[17][18] The New York Times published a summary about antipsychotic medications in October 2010.[19] In 2008, for the first time, Senator Charles Grassley asked the APA to disclose how much of its annual budget came from drug industry funds. The APA said that industry contributed 28% of its budget ($14 million at that time), mainly through paid advertising in APA journals and funds for continuing medical education.[]

Controversies
Controversies have related to anti-psychiatry and disability rights campaigners, who regularly protest at American Psychiatric Association offices or meetings. In 1971, members of the Gay Liberation Front organization sabotaged an APA conference in San Francisco. In 2003 activists from MindFreedom International staged a 21-day hunger strike, protesting at a perceived unjustified biomedical focus and challenging APA to provide evidence of the widespread claim that mental disorders are due to chemical imbalances in the brain. APA published a position statement in response[20] and the two organizations exchanged views on the evidence. There was controversy when it emerged that US psychologists and psychiatrists were helping interrogators in Guantanamo and other US facilities. The American Psychiatric Association released a policy statement that psychiatrists should not take a direct part in interrogation of particular prisoners [21] but could "offer general advice on the possible medical and psychological effects of particular techniques and conditions of interrogation, and on other areas within their professional expertise." After previous controversy over APA's classification of homosexuality as a mental illness, there is also controversy regarding the remaining category of "sexual disorder not otherwise specified" which can include a state of distress about one's sexual orientation, as well as the diagnosis of "gender identity disorder" or gender dysphoria.[22] The APA's Standard Diagnostic Manual came under criticism from autism specialists Tony Attwood and Simon Baron-Cohen for proposing the elimination of Asperger's syndrome as a disorder and replacing it with an autism severity scale. Professor Roy Richard Grinker wrote a controversial editorial for the New York Times expressing support for the proposal. The APA president in 2005, Steven Sharfstein, caused controversy when, although praising the pharmaceutical industry, he argued that American psychiatry had "allowed the biopsychosocial model to become the bio-bio-bio model" and accepted "kickbacks and bribes" from pharmaceutical companies leading to the over-use of medication

American Psychiatric Association and neglect of other approaches.[23] In 2008 APA became a focus of congressional investigations regarding the way that money from the pharmaceutical industry can shape the practices of nonprofit organizations that purport to be independent in their viewpoints and actions. The drug industry accounted in 2006 for about 30 percent of the associations $62.5 million in financing, half through drug advertisements in its journals and meeting exhibits, and the other half sponsoring fellowships, conferences and industry symposiums at its annual meeting. APA is considering its response to increasingly intense scrutiny and questions about conflicts of interest.[24] The APA president of 2009-2010, Alan Schatzberg, has also come under fire after it came to light that he was principal investigator on a federal study into a drug being developed by Corcept Therapeutics, a company Schatzberg had himself set up and in which he had several millions of dollars worth of stock.[25]

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References
[1] http:/ / www. psychiatry. org [2] " Contact Us (http:/ / www. psychiatry. org/ contact-us-for-help/ contact-us)." American Psychiatric Association. Retrieved on September 6, 2012. "American Psychiatric Association 1000 Wilson Boulevard Suite 1825 Arlington, VA 22209" [4] http:/ / www. psychiatricnews. org/ pnews/ 98-04-17/ hx. html [6] http:/ / www. washingtonblade. com/ 2013/ 05/ 21/ gay-washington-dc-psychiatrist-saul-levin-named-head-of-american-psychiatric-association-apa/ [7] http:/ / www. psych. org/ about_apa/ [9] Position Statements (http:/ / www. psych. org/ MainMenu/ EducationCareerDevelopment/ Library/ PositionStatements. aspx) [10] Practice guidelines Practice Guidelines (http:/ / www. psych. org/ psych_pract/ treatg/ pg/ prac_guide. cfm), Psych.org [11] Diagnostic and Statistical Manual (http:/ / www. psych. org/ MainMenu/ Research/ DSMIV. aspx) [12] psychiatryonline.org (http:/ / www. psychiatryonline. org/ ) [13] HealthyMinds.org (http:/ / www. healthyminds. org/ ) [21] Psychiatric participation in interrogation of detainees (http:/ / web. archive. org/ web/ 20060622063118/ http:/ / www. psych. org/ edu/ other_res/ lib_archives/ archives/ 200601. pdf) [22] Controversy Continues to Grow Over DSMs GID Diagnosis (http:/ / pn. psychiatryonline. org/ cgi/ content/ full/ 38/ 14/ 25) [23] Sharfstein, SS. (2005) Big Pharma and American Psychiatry: The Good, the Bad, and the Ugly (http:/ / pn. psychiatryonline. org/ cgi/ content/ full/ 40/ 16/ 3) Psychiatric News August 19, 2005 Volume 40 Number 16 [24] Psychiatric Group Faces Scrutiny Over Drug Industry Ties (http:/ / www. nytimes. com/ 2008/ 07/ 12/ washington/ 12psych. html?_r=1& pagewanted=all), New York Times, 2008-07-12 [25] Stanford Researcher, Accused of Conflicts, Steps Down as NIH Principal Investigator (http:/ / chronicle. com/ news/ article/ ?id=4922), The Chronicle of Higher Education, 2008-01-08

External links
Official website (http://www.psychiatry.org)

American Psychological Association

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American Psychological Association


American Psychological Association
Logo of the APA Formation Headquarters 1892 750 First Street, NE Washington, D.C., United States 137,000 members

Membership

2013 President Donald N. Bersoff CEO Website Norman B. Anderson www.apa.org [1]

The American Psychological Association (APA) is the largest scientific and professional organization of psychologists in the United States and Canada.[2] It is the world's largest association of psychologists with around 137,000 members including scientists, educators, clinicians, consultants and students. The APA has an annual budget of around $115m. There are 54 divisions of the APAinterest groups covering different subspecialties of psychology or topical areas.[3]

Profile
Mission
The mission of the APA[] is to advance the creation, communication and application of psychological knowledge to benefit society and improve peoples lives. The American Psychological Association aspires to excel as a valuable, effective and influential organization advancing psychology as a science, serving as: A uniting force for the discipline The major catalyst for the stimulation, growth and dissemination of psychological science and practice The primary resource for all psychologists The premier innovator in the education, development, and training of psychological scientists, practitioners and educators The leading advocate for psychological knowledge and practice informing policy makers and the public to improve public policy and daily living A principal leader and global partner promoting psychological knowledge and methods to facilitate the resolution of personal, societal and global challenges in diverse, multicultural and international contexts An effective champion of the application of psychology to promote human rights, health, well being and dignity The APA core values statement The American Psychological Association commits to its vision through a mission based upon the following values: Continual Pursuit of Excellence Knowledge and its Application Based Upon Methods of Science Outstanding Service to its Members and to Society Social Justice, Diversity and Inclusion Ethical Action in All that We Do

American Psychological Association The APA has task forces which issue policy statements on various issues of social import such as the APA position on psychology of abortion; APA position on human rights such as detainee welfare, human trafficking, and rights for the mentally ill; APA position on IQ; APA position on treating homosexuality (sexual orientation change efforts); and APA position on men and women (gender differences).[4]

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Governance
APA is a corporation chartered in the District of Columbia. APAs bylaws describe structural components that serve as a system of checks and balances that ensure democratic process. The organizational entities include: APA President. APAs president is elected by the membership. The president chairs the Council of Representatives and the Board of Directors. During his or her term of office, the president performs such duties as are prescribed in the Bylaws. Board of Directors. The board is composed of six members-at-large, the president-elect, president, past-president, treasurer, recording secretary, CEO, and the chair of the American Psychological Association of Graduate Students (APAGS). The Board oversees the associations administrative affairs and presents an annual budget for council approval. APA Council of Representatives. The council has sole authority to set policy and make decisions regarding APAs roughly $60 million annual income. It is composed of elected members from state/provincial/territorial psychological associations, APA divisions and the APA Board of Directors. APA Committee Structure: Boards and Committees. Members of boards and committees conduct much of APAs work on a volunteer basis. They carry out a wide variety of tasks suggested by their names. Some have responsibility for monitoring major programs, such as the directorates, the journals and international affairs.[]

Good Governance Project


The Good Governance Project (GGP) was initiated in January 2011 as part of the strategic plan to [assure] APAs governance practices, processes and structures are optimized and aligned with what is needed to thrive in a rapidly changing and increasingly complex environment.[] The charge included soliciting feedback and input stakeholders, learning about governance best practices, recommending whether change was required, recommending needed changes based on data, and creating implementation plans.[] The July 2013 GGP update on the recommended changes can be found in the document "Good Governance Project Recommended Changes to Maximize Organizational Effectiveness of APA Governance, July 2013." The suggested changes would change APA from a membership based, representational structure to a corporate structure.[] These motions will be discussed and voted upon by Council on July 31, 2013 and August 2, 2013.[]

Organizational structure
APA comprises an executive office, a publishing operation, offices that address administrative, business, information technology, and operational needs, and five substantive directorates: the Education Directorate accredits doctoral psychology programs and addresses issues related to psychology education in secondary through graduate education;[5] the Practice Directorate engages on behalf of practicing psychologists and health care consumers;[6] the Public Interest Directorate advances psychology as a means of addressing the fundamental problems of human welfare and promoting the equitable and just treatment of all segments of society;[7] the Public and Member Communications Directorate is responsible for APA's outreach to its members and affiliates and to the general public;[8] the Science Directorate provides support and voice for psychological scientists.[9]

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Membership and title of "psychologist"


APA policy on the use of the title psychologist is contained in the Model Act for State Licensure of Psychologists:[10] Psychologists have earned a doctoral degree in psychology and may not use the title psychologist and/or deliver psychological services to the public, unless the psychologist is licensed or specifically exempted from licensure under the law. State licensing laws specify state specific requirements for the education and training of psychologists leading to licensure. Psychologists who are exempted from licensure could include researchers, educators, or general applied psychologists who furnish services outside of the health and mental health field. Full membership with the APA in United States and Canada requires doctoral training whereas associate membership requires at least two years of postgraduate studies in psychology or approved related discipline. The minimal requirement of a doctoral dissertation related to psychology for full membership can be waived in certain circumstances where there is evidence that significant contribution or performance in the field of psychology has been made.[11]

Affiliate organizations
The American Psychological Association Practice Organization (APAPO) [12] and the Education Advocacy Trust [13] , which operates autonomously as a part of APAPO, are 501(c)(6) entities, separate from APA. They engage in advocacy on behalf of psychological practitioners and health care consumers and psychology education, respectively.

Awards
Each year, the APA recognizes top psychologists with the "Distinguished Contributions" Awards; these awards are the highest honors given by the APA, and among the highest honors that a psychologist or psychology researcher can receive. APA Award for Distinguished Scientific Contributions to Psychology APA Distinguished Scientific Award for the Applications of Psychology Award for Distinguished Contributions to Psychology in the Public Interest Award for Distinguished Contributions to Education and Training in Psychology APA Award for Distinguished Professional Contributions to Applied Research Award for Distinguished Professional Contributions to Practice in the Public Sector APA Award for Distinguished Contributions to the International Advancement of Psychology

Publications
The American Psychologist is the Association's official journal. APA also publishes over 70 other journals encompassing most specialty areas in the field, including:[] Behavioral Neuroscience Developmental Psychology Emotion Health Psychology Journal of Applied Psychology Journal of Comparative Psychology Journal of Experimental Psychology Journal of Experimental Psychology: Applied

Journal of Family Psychology Journal of Occupational Health Psychology Journal of Personality and Social Psychology

American Psychological Association Psychological Bulletin Psychological Review Psychology and Aging Psychology of Addictive Behaviors Psychology of Violence School Psychology Quarterly

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The APA has also published several books including children's books, software for data analysis, videos demonstrating therapeutic techniques, reports and brochures, and an eight-volume Encyclopedia of Psychology.[][14]

The Psychologically Healthy Workplace program


The Psychologically Healthy Workplace Program (PHWP) is a collaborative effort between the American Psychological Association and the APA Practice Organization designed to help employers optimize employee well-being and organizational performance. The PHWP includes APAs Psychologically Healthy Workplace Awards, a variety of APA Practice Organization resources, including PHWP Web content, e-newsletter, podcast and blog, and support of local programs currently implemented by 52 state, provincial and territorial psychological associations as a mechanism for driving grassroots change in local business communities. The awards are designed to recognize organizations for their efforts to foster employee health and well-being while enhancing organizational performance. The award program highlights a variety of workplaces, large and small, profit and non-profit, in diverse geographical settings. Applicants are evaluated on their efforts in the following five areas: employee involvement, work-life balance, employee growth and development, health and safety, and employee recognition. Awards are given at the local and national level.[15][16] 2010 award winners: American Cast Iron Pipe Company, Tallahassee Memorial HealthCare, Advanced Solutions (an HP company), Toronto Police Service and Leaders Bank.

APA Style
American Psychological Association (APA) Style is a set of rules developed to assist reading comprehension in the social and behavioral sciences. Designed to ensure clarity of communication, the rules are designed to "move the idea forward with a minimum of distraction and a maximum of precision."[17] The Publication Manual of the American Psychological Association contains the rules for every aspect of writing, especially in the social sciences from determining authorship to constructing a table to avoiding plagiarism and constructing accurate reference citations. "The General Format of APA is most commonly used to cite sources within the social sciences. General guidelines for a paper in APA style includes: typed, double-spaced on standard-sized paper (8.5" x 11") with 1" margins on all sides. The font should be clear and highly readable. APA recommends using 12 pt. Times New Roman font."[18] PsycINFO APA maintains an abstract database named PsycINFO. It contains citations and summaries dating from the 19th century, including journal articles, book chapters, books, technical reports, and dissertations within the field of psychology. As of January 2010, PsycINFO has collected information from 2,457 journals.[19] Similar databases operated by other organizations include PsycLit and Psychological Abstracts. APA also operates a comprehensive search platform, PsycNET, covering multiple databases.[20]

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History
Founding
The APA was founded in July 1892 at Clark University by a group of 26 men, the first president was G. Stanley Hall. It is affiliated with 60 state, territorial, and Canadian provincial associations.[21]

Dominance of clinical psychology


Due to the dominance of clinical psychology in APA, several research-focused groups have broken away from the organization. These include the Psychonomic Society in 1959 (with a primarily cognitive orientation), and the Association for Psychological Science (which changed its name from the American Psychological Society in early 2006) in 1988 (with a broad focus on the science and research of psychology). Theodore H. Blau was the first clinician in independent practice to be elected president of the American Psychological Association in 1977.[22]

Positions on homosexuality
Cause of homosexuality
The APA states the following: "There is no consensus among scientists about the exact reasons that an individual develops a heterosexual, bisexual, or homosexual orientation. Although much research has examined the possible genetic, hormonal, developmental, social, and cultural influences on sexual orientation, no findings have emerged that permit scientists to conclude that sexual orientation is determined by any particular factor or factors. Many think that nature and nurture both play complex roles; most people experience little or no sense of choice about their sexual orientation."[23]

Conversion therapy
In 1975 APA issued a supporting statement that homosexuality is not a mental disorder.[][24][25] There is a concern in the mental health community that the advancement of conversion therapy itself causes social harm by disseminating inaccurate views about sexual orientation and the ability of homosexual and bisexual people to lead happy, healthy lives.[26] Most mainstream health organizations are critical of conversion therapy, and no mainstream medical organization endorses conversion therapy.[26][][][27][28] The APA adopted a resolution in August 2009 stating that mental health professionals should avoid telling clients that they can change their sexual orientation through therapy or other treatments. The approval, by APA's governing Council of Representatives, came at APA's annual convention, during which a task force presented a report[29] that in part examined the efficacy of so-called "reparative therapy," or sexual orientation change efforts (SOCE). The "Resolution on Appropriate Affirmative Responses to Sexual Orientation Distress and Change Efforts"[30] also advises that parents, guardians, young people and their families avoid sexual orientation treatments that portray homosexuality as a mental illness or developmental disorder and instead seek psychotherapy, social support and educational services "that provide accurate information on sexual orientation and sexuality, increase family and school support and reduce rejection of sexual minority youth."

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Same-sex marriage
The APA adopted a resolution stating that it is unfair and discriminatory to deny same-sex couples legal access to civil marriage and to all its attendant rights, benefits, and privileges. It also filed an amicus brief in the federal court case in which Judge Vaughn Walker struck down California's constitutional ban on same-sex marriage.[] The APA later praised the decision and denied the existence of any "scientific justification" for a ban on same-sex marriage.[31] In August 2011, the APA clarified their support of same-sex marriage in light of continued research suggesting that the same community benefits accepted as result of hetero-sexual marriage apply to same-sex couples as well, "We knew that marriage benefits heterosexual people in very significant ways, but we didn't know if that would be true for same-sex couples," said Dr. Clinton Anderson, associate executive director of the APA and director of the Office on Lesbian, Gay, Bisexual and Transgender Concerns. Anderson would also go on to clarify the Association's view on Civil Unions as an alternative to same-sex marriages: "Anything other than marriage is, in essence, a stigmatization of same-sex couples. Stigma does have negative impacts on people." [32] Anderson's statements have been met with scrutiny from organizations such as the National Organization for Marriage, that dispute the notion that communities are more accepting of homosexuals in states that legally sanction same-sex marriage.[citation needed]

Controversies
APA internship crisis for graduate students
The APA is the main accrediting body for U.S. clinical and counseling psychology doctoral training programs and internship sites.[33] APA-accredited Clinical Psychology PhD and PsyD programs typically require students to complete a one-year clinical internship in order to graduate (or a two-year part-time internship). However, there is currently an "internship crisis" as defined by the American Psychological Association, in that approximately 25% of clinical psychology doctoral students do not match for internship each year.[34][35] This crisis has led many students (approximately 1,000 each year) to re-apply for internship, thus delaying graduation, or to complete an unaccredited internship, and often has many emotional and financial consequences.[36] Students who do not complete an APA accredited internships in the U.S. are barred from certain employment settings, including VA Hospitals, the military, and cannot get licensed in some states, such as Utah and Mississippi.[37][38] Additionally, some post-doctoral fellowships and other employment settings require or prefer an APA Accredited internship.[37] The APA has been criticized for not addressing this crisis adequately and many psychologists and graduate students have petitioned for the APA to take action by regulating graduate training programs. Many graduate students attend APA accredited programs, yet are unable to secure APA accredited internships possibly leading to financial and employment hardships.

Use of coercive techniques considered equivalent of torture


The APA absolutely condemns the use of any of the following practices by military interrogators trying to elicit anti-terrorism information from detainees, on the ground that "there are no exceptional circumstances whatsoever, whether induced by a state of war or threat of war, internal political instability or any other public emergency, that may be invoked as a justification" for them:[39] An absolute prohibition against the following techniques therefore arises from, is understood in the context of, and is interpreted according to these texts: mock executions; water-boarding or any other form of simulated drowning or suffocation; sexual humiliation; rape; cultural or religious humiliation; exploitation of fears, phobias or psychopathology; induced hypothermia; the use of psychotropic drugs or mind-altering substances; hooding; forced nakedness; stress positions; the use of dogs to threaten or intimidate; physical assault including slapping or shaking; exposure to extreme heat or cold; threats of harm or death; isolation; sensory deprivation and over-stimulation; sleep deprivation; or the threatened use of any of the above techniques to an individual or to members of an individuals family.[39]

American Psychological Association When it emerged that psychologists as part of the Behavioral Science Consultation Team were advising interrogators in Guantnamo and other U.S. facilities on improving the effectiveness of the "Enhanced interrogation techniques", the Association called on the U.S. government to prohibit the use of unethical interrogation techniques and labeled specific techniques as torture.[40][citation needed] Critics pointed out that the APA declined to advise its members not to participate in such interrogations.[41] This was in contrast to the American Psychiatric Association ban in May 2006 of all direct participation in interrogations by psychiatrists,[42] and the American Medical Association ban in June 2006 of the direct participation in interrogations by physicians.[43] In September 2008, APAs members passed a resolution stating that psychologists may not work in settings where persons are held outside of, or in violation of, either International Law (e.g., the UN Convention Against Torture and the Geneva Conventions) or the U.S. Constitution (where appropriate), unless they are working directly for the persons being detained or for an independent third party working to protect human rights.[44] The resolution became official APA policy in February 2009. Amending the Ethics Code In February 2010 APA's Council of Representatives voted to amend the association's Code of Ethics[45] to make clear that its standards can never be interpreted to justify or defend violating human rights. Following are the two ethical standards and the changes adopted. Language that is in bold was newly adopted: 1.02, Conflicts Between Ethics and Law, Regulations, or Other Governing Legal Authority If psychologists ethical responsibilities conflict with law, regulations, or other governing legal authority, psychologists clarify the nature of the conflict, make known their commitment to the Ethics Code and take reasonable steps to resolve the conflict consistent with the General Principles and Ethical Standards of the Ethics Code. Under no circumstances may this standard be used to justify or defend violating human rights. 1.03, Conflicts Between Ethics and Organizational Demands If the demands of an organization with which psychologists are affiliated or for whom they are working are in conflict with this Ethics Code, psychologists clarify the nature of the conflict, make known their commitment to the Ethics Code, and take reasonable steps to resolve the conflict consistent with the General Principles and Ethical Standards of the Ethics Code. Under no circumstances may this standard be used to justify or defend violating human rights.

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Notes
[1] http:/ / www. apa. org [12] http:/ / www. apapractice. org/ [13] http:/ / www. apaedat. org/ [15] Psychologically Healthy Workplace Program (http:/ / www. apapracticecentral. org/ outreach/ workplace/ index. aspx), apapracticecentral.org [16] Psychologically Healthy Workplace Program (http:/ / www. phwa. org/ ) website, phwa.org [21] APA.org (http:/ / www. apa. org/ practice/ refer. html) [24] "An Instant Cure" (http:/ / www. time. com/ time/ magazine/ article/ 0,9171,904053,00. html), Time; April 1, 1974. [28] Mainstream health organizations critical of conversion therapy include the American Medical Association, American Psychiatric Association, the American Psychological Association, the American Counseling Association, the National Association of Social Workers, the American Academy of Pediatrics, the American Association of School Administrators, the American Federation of Teachers, the National Association of School Psychologists, the American Academy of Physician Assistants, and the National Education Association. [30] Resolution on Appropriate Affirmative Responses to Sexual Orientation Distress and Change Efforts (http:/ / www. apa. org/ about/ governance/ council/ policy/ sexual-orientation. aspx) [37] appic.org (http:/ / www. appic. org/ match/ 5_2_1_appfaq2. html#q3) [39] Reaffirmation of the American Psychological Association Position Against Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment and Its Application to Individuals Defined in the United States Code as Enemy Combatants (http:/ / www. apa. org/ about/ governance/ council/ policy/ torture. aspx) [40] APA Press Release, August 20, 2007 (http:/ / www. apa. org/ releases/ councilres0807. html) [41] Stephen Soldz: Psychologists, Guantnamo, and Torture: A Profession Struggles to Save Its Soul (http:/ / www. zmag. org/ content/ showarticle. cfm?ItemID=10700) (ZNet, 3 August 2006); Protecting the Torturers (http:/ / www. counterpunch. org/ soldz09062006. html)

American Psychological Association


Bad Faith and Distortions From the American Psychological Association (CounterPunch, 6 September 2006); Letter to the CEO of the American Psychological Association (http:/ / www. opednews. com/ articles/ opedne_stephen__061128_letter_to_the_ceo_of. htm) (OpEdNews.com, 28 November 2006) [42] Statement on Interrogation (http:/ / www. psych. org/ news_room/ press_releases/ 06-36PositionStatementonInterrogation. pdf) (PDF file) [43] Opinion 2.068 - Physician Participation in Interrogation (http:/ / www. ama-assn. org/ ama/ pub/ physician-resources/ medical-ethics/ code-medical-ethics/ opinion2068. page)

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References External links


Official website (http://www.apa.org) American Psychological Association Rejects Blanket Ban on Participation in Interrogation of U.S. Detainees (http://www.democracynow.org/article.pl?sid=07/08/20/1628230)

American Pharmacists Association


The American Pharmacists Association (APhA, previously known as the American Pharmaceutical Association), founded in 1852, is the first-established professional society of pharmacists within the United States.[1] APhA is made up of more than 60,000 practicing pharmacists, pharmaceutical scientists, student pharmacists, pharmacy technicians, and others interested in advancing the profession. Through a House of Delegates that meets each year at the APhA Annual Meeting & Exposition, APhA provides a forum for discussion, consensus building, and policy setting for the profession of pharmacy. In fact, nearly all of pharmacy's specialty organizations trace their roots to APhA, having originally been a section or part of this broad foundation of pharmacy. The APhA Board of Trustees is responsible for broad direction setting of the Association. All members choose one of these three Academies when they join APhA: American Pharmacists Association - Academy of Pharmacy Practice and Management (APhAAPPM) American Pharmacists Association - Academy of Pharmaceutical Research and Science (APhAAPRS) American Pharmacists Association - Academy of Student Pharmacists (APhAASP)

Leadership
Marialice S. Bennett - president

References
[1] http:/ / www. pharmacist. com/ AM/ Template. cfm?Section=About_APha2& Template=/ TaggedPage/ TaggedPageDisplay. cfm& TPLID=83& ContentID=8229

External links
Official website (http://www.pharmacist.com/)

Ambulatory Payment Classification

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Ambulatory Payment Classification


APCs or Ambulatory Payment Classifications are the United States government's method of paying for facility outpatient services for the Medicare (United States) program. A part of the Federal Balanced Budget Act of 1997 made the Centers for Medicare and Medicaid Services create a new Medicare "Outpatient Prospective Payment System" (OPPS) for hospital outpatient services -analogous to the Medicare prospective payment system for hospital inpatients known as Diagnosis-related group or DRGs. This OPPS, was implemented on August 1, 2000. APCs are an outpatient prospective payment system applicable only to hospitals. Physicians are reimbursed via other methodologies for payment in the United States, such as Current Procedural Terminology or CPTs. APC payments are made to hospitals when the Medicare outpatient is discharged from the Emergency Department or clinic or is transferred to another hospital (or other facility) which is not affiliated with the initial hospital where the patient received outpatient services. Although APCs began through the federal system of Medicare, they have also been considered for adoption by state programs, such as Medicaid, and other third-party private health insurers. If the patient is admitted from a hospital clinic or Emergency Department, then there is no APC payment, and Medicare will pay the hospital under inpatient Diagnosis-related group DRG methodology.

External links
ACS Medicaid Guide for Hospital Outpatient Payment System [1] Website from the American College of Emergency Physicians [2] [3] 123 DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services Present on Admission (POA) Indicator Reporting by Acute Inpatient Prospective Payment System (IPPS) Hospitals FACT SHEET Present on Admission (POA) Indicator Reporting and HospitalAcquired Conditions (HAC) Overview The Deficit Reduction Act of 2005 (DRA) requires a quality adjustment in Medicare Severity Diagnosis Related Group (MS-DRG) payments for certain hospital-acquired conditions. CMS has titled the provision Hospital-Acquired Conditions and Present on Admission Indicator Reporting (HAC & POA). Inpatient Prospective Payment System (IPPS) hospitals are required to submit POA information on diagnoses for inpatient discharges on or after October 1, 2007. Affected Hospitals The Present on Admission Indicator Reporting provision applies only to IPPS hospitals. At this time, the following hospitals are EXEMPT from the POA indicator requirement: Critical Access Hospitals (CAHs), Long-Term Care Hospitals (LTCHs), Maryland Waiver Hospitals, Cancer Hospitals, Childrens Inpatient Facilities, Rural Health Clinics, Federally Qualified Health Centers (FQHCs), Religious Non-Medical Health Care Institutions, Inpatient Psychiatric Hospitals, Inpatient Rehabilitation Facilities (IRFs), and Veterans Administration/Department of Defense Hospitals. ICN 901046 October 2011General Reporting Requirements The POA indicator is required for all claims involving Medicare inpatient admissions to general IPPS acute care hospitals or other facilities that are subject to a law or regulation mandating collection of POA indicator information. POA is defined as present at the time the order for inpatient admission occurs conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered POA. The POA indicator is assigned to principal and secondary diagnoses (as defined in Section II of the ICD-9-CM Official Guidelines for Coding and Reporting). For the Official Guidelines, please visit http:/ / www. cdc. gov/ nchs/ icd/ icd9cm. htm on the Internet. Issues related to inconsistent, missing, conflicting, or unclear documentation must be resolved by the provider. If a condition would not be coded and reported based on Uniform Hospital Discharge Data Set definitions and current Official Guidelines, then the POA indicator would not be reported. CMS does not require a POA indicator for the external cause of injury code unless it is being reported as an other diagnosis. Coding Use the UB-04 Data Specifications Manual and the ICD-9-CM Official Guidelines for Coding and Reporting to facilitate the assignment of the POA indicator for each principal diagnosis and other ICD-9-CM diagnosis codes reported on the UB-04 and ASC X12N 837 Institutional (837I). This fact sheet is not

Ambulatory Payment Classification intended to replace any guidelines in the main body of the ICD-9-CM Official Guidelines for Coding and Reporting. The POA indicator guidelines are not intended to provide guidance on when a condition should be coded, but rather, how to apply the POA indicator to the final set of ICD-9-CM diagnosis codes that have been assigned in accordance with Sections I, II, and III of the Official Guidelines. Subsequent to the assignment of the ICD-9-CM diagnosis codes, the POA indicator should then be assigned to those conditions that have been coded. As stated in the Introduction to the ICD-9-CM Official Guidelines for Coding and Reporting, a joint effort between the health care provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. Visit the HAC & POA web page at http:/ / www. cms. gov/ HospitalAcqCond on the CMS website. 2Table 1 includes a list of the POA indicator reporting options, descriptions, and Medicare payment based on the Inpatient Prospective Payment System (IPPS) Fiscal Year (FY) 2011 Final Rule, published by CMS in August 2010. The Final Rule made a change to POA indicator reporting. Effective January 1, 2011, hospitals reporting with the 5010 format will no longer report a POA indicator of 1 for POA exempt codes. Documentation The importance of consistent, complete documentation in the medical record cannot be overemphasized. Medical record documentation from any provider involved in the care and treatment of the patient may be used to support the determination of whether a condition was present on admission. In the context of the official coding guidelines, the term provider means a physician or any qualified health care practitioner who is legally accountable for establishing the patients diagnosis. NOTE: Providers, their billing offices, third party billing agents, and anyone else involved in the transmission of this data must ensure that any resequencing of ICD-9-CM diagnosis codes prior to their transmission to CMS also includes a resequencing of the POA indicators. Paper Claims On the UB-04, the POA indicator is the eighth digit of Field Locator (FL) 67, Principal Diagnosis, and the eighth digit of each of the Secondary Diagnosis fields, FL 67 A-Q. In other words, report the applicable POA indicator (Y, N, U, or W) for the principal and any secondary diagnoses and include this as the eighth digit; leave this field blank if the diagnosis is exempt from POA reporting. Table 1: CMS POA Indicator Reporting Options, Description, and Payment INDICATOR DESCRIPTION MEDICARE PAYMENT Y Diagnosis was present at time of inpatient admission. Payment made for condition by Medicare, when an HAC is present N Diagnosis was not present at time of inpatient admission. No payment made for condition by Medicare, when an HAC is present U Documentation insufficient to determine if condition was present at the time of inpatient admission. No payment made for condition by Medicare, when an HAC is present W Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission. Payment made for condition by Medicare, when an HAC is present 1 Exempt from POA reporting. This code is the equivalent of a blank on the UB-04, however, it was determined that blanks were undesirable on Medicare claims when submitting this data via the 004010/00410A1. NOTE: The number 1 is no longer valid on claims submitted under the version 5010 format, effective January 1, 2011. The POA field will instead be left blank for codes exempt from POA reporting. Please refer to Transmittal R756OTN, Change Request (CR) 7024 at http:/ / www. cms. gov/ Transmittals/ Downloads/R756OTN.pdf on the CMS website. Exempt from POA reporting Visit the HAC & POA web page at http:/ / www. cms. gov/ HospitalAcqCond on the CMS website. 3Electronic Claims Using the 837I, submit the POA indicator in segment K3 in the 2300 loop, data element K301. EXAMPLE 1: POA indicators for an electronic claim with one principal and five secondary diagnoses should be coded as POAYNUW1YZ. POA POA is always required first, followed by a single indicator for every diagnosis reported on the claim. Y The principal diagnosis is always the first indicator after POA. In this example, the principal diagnosis was present on admission. N The first secondary diagnosis was not present on admission, designated by N. U It was unknown if the second secondary diagnosis was present on admission, designated by U. W It is clinically undetermined if the third secondary diagnosis was present on admission, designated by W. 1 The fourth secondary diagnosis was exempt from reporting for POA, designated by 1. NOTE: Hospitals reporting with the 5010 format on and after January 1, 2011 will no longer report a POA indicator of 1 for POA exempt codes. The POA field will instead be left blank for codes exempt from POA reporting. Y The fifth secondary diagnosis was present on admission, designated by Y. Z The last secondary diagnosis indicator is followed by the letter Z to indicate the end of the data element. EXAMPLE 2: POA indicator for an electronic

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Ambulatory Payment Classification claim with one principal diagnosis without any secondary diagnosis should be coded as POAYZ. POA POA is always required first, followed by a single indicator for every diagnosis reported on the claim. Y The principal diagnosis is always the first indicator after POA. In this example, the principal diagnosis was present on admission. Z The letter Z is used to indicate the end of the data element. For More Information The HAC & POA web page at http:/ / www. cms. gov/ HospitalAcqCond provides further information, including links to the law, regulations, change requests (CRs), and educational resources including presentations, Medicare Learning Network (MLN) articles, and fact sheets. Official CMS Information for Medicare Fee-For-Service Providers R This fact sheet was current at the time it was published or uploaded onto the web. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference. This fact sheet was prepared as a service to the public and is not intended to grant rights or impose obligations. This fact sheet may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents. The Medicare Learning Network (MLN) , a registered trademark of CMS, is the brand name for official CMS educational products and information for Medicare Fee-For-Service providers. For additional information, visit MLNs web page at http:/ / www. cms. gov/ MLNGenInfo on the CMS website. Visit the HAC & POA web page at http://www.cms.gov/HospitalAcqCond on the CMS website.

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References
[1] http:/ / www. acs-inc. com/ WorkArea/ downloadasset. aspx?id=2075 [2] http:/ / www. acep. org/ practres. aspx?id=30426 [3] http:/ / apps. leg. wa. gov/ wac/ default. aspx?cite=296-23A-0700

American Public Health Association

243

American Public Health Association


APHA
Motto Formation "Protect, prevent, live well" 1872

Headquarters Washington, D.C. Membership Website 30,000 apha.org [1]

The American Public Health Association (APHA) is Washington, D.C.-based professional organization for public health professionals in the United States. Founded in 1872 by Dr. Stephen Smith, APHA has more than 30,000 members worldwide. The Association defines itself as being "the oldest and most diverse organization of public health professionals in the world." It defines its mission as: "The Association aims to protect all Americans and their communities from preventable, serious health threats and strives to assure that community-based health promotion and disease prevention activities and preventative health services are universally accessible in the United States. "[2]

Washington, D.C. office of the APHA.

Member Groups and State Affiliates


APHAs 30,000 members represent a broad array of health officials, educators, students, environmentalists, policy-makers and other health providers at all levels, working both within and outside governmental organizations and educational institutions.

Organizational Components: Sections and SPIGs


Sections serve as the primary professional units of the Association and conduct activities that promote the mission and fulfill the goals of APHA. There are 27 Sections that represent major public health disciplines or public health programs. These sections are designed to allow members with shared interests to come together to develop scientific program content, policy papers in their areas of interest or fields of practice, provide for professional and social networking, career development and mentoring. Sections include: Maternal and Child Health, HIV/AIDS, Community Planning and Policy Development, Occupational Health and Safety, International Health and School Health Education and Services. Special Primary Interest Groups (SPIGs) are an open group of self-selected APHA members who share a common occupational discipline or program area interest and elect no primary Section affiliation. SPIGs include: Alternative and Complementary Health Practices, Ethics, Health Law, Laboratory, Physical Activity and Veterinary Public Health.

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244

Public Health Education and Health Promotion Section


The Public Health Education and Health Promotion Section is one of 27 primary sections and special interest groups within APHA. In fact, PHEHP is the largest section, with around 3,000 members. Like all sections within APHA, PHEHP is governed by a group of elected volunteers who hold offices for terms of varying length. Section officers include a chair, chair-elect, secretary, secretary-elect and immediate past chair. Section councilors and governing councilors represent the members and concerns of the section within the larger organization. Section committees, led by volunteers from the Section, are where the "work" of the Section is accomplished. Explore this website to learn about these and other opportunities to get involved in PHEHP.

Awards
National APHA Awards The accomplishments of public health leaders are recognized through an awards program. APHA presents its national awards during its annual meeting. Section Awards [3] Being honored by your professional peers has very special meaning to people. Acknowledge some of the professionals who have been important to your career or who, in your mind, have made important contributions to the field by nominating them for one of these prestigious awards. The Public Health Education and Health Promotion section recognizes individuals in six award categories. The awards include: Current Section Members Eligible 1. Distinguished Career Award for outstanding contribution to the practice and profession of health education, health promotion and/or health communications. The awardee must have earned a terminal degree 10 years or more prior to receiving the award. 2. Early Career Award for outstanding contribution to the practice and profession of health education, health promotion and/or health communications. The awardee must have earned a terminal degree less than 10 years prior to receiving the award. Current Section and/or APHA member eligible 1. Mayhew Derryberry Award for outstanding contribution of behavioral scientists to the field of health education, health promotion and/or health communications research or theory. 2. Mohan Sing Award for the use of humor to promote better health education, health promotion and/or health communications practice. 3. Sarah Mazelis Award for an outstanding practitioner in health education. The awardee will have spent at least five years as a health education, health promotion and/or health communications practitioner. 4. Rogers Award for outstanding contribution to advancing the study and/or practice of public health communication. Sponsored Awards Rema Lapouse Award sponsored by the Mental Health, Epidemiology, and Statistics Sections, this award is granted to an outstanding scientist in the area of psychiatric epidemiology.

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Publications
The American Public Health Association publishes periodicals and more than 70 public health books. Several of these are the reference source for their specialty within public health practice. Some publication titles include: Control of Communicable Diseases Manual Standard Methods for the Examination of Water and Wastewater American Journal of Public Health The Nation's Health

Additionally, they are an active partner in the release of America's Health Rankings; working with United Health Foundation and Partnership for Prevention.[4]

Annual Meeting
The APHA Annual Meeting and Exposition is the largest meeting of public health professionals in the world. The meeting draws more than 13,000 attendees, offers 700 booths of exhibits and features more than 1,000 scientific sessions. Presentations cover new research and trends in public health science and practice.

National Public Health Week


National Public Health Week is an observance organized annually by APHA during the first full week of April. The weeks activities are designed to highlight issues that are important to improving the publics health.

Leadership
Georges C. Benjamin, MD, FACP, FACEP (E), Executive Director Carmen Rita Nevarez, MD, MPH, President

Campaign for Children's Health Care


The APHA is a partner in the Campaign for Children's Health Care, a multi-year campaign to raise awareness about the problem of uninsured children in America a growing social concern.

Climate Change and Public Health


In 2007, the APHA issued a policy statement entitled Addressing the Urgent Threat of Global Climate Change to Public Health and the Environment: The long-term threat of global climate change to global health is extremely serious and the fourth IPCC (Intergovernmental Panel on Climate Change) report and other scientific literature demonstrate convincingly that anthropogenic GHG emissions are primarily responsible for this threat....US policy makers should immediately take necessary steps to reduce US emissions of GHGs, including carbon dioxide, to avert dangerous climate change.[5]

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246

Color Standards
There a color standard, made from dilutions of a Pt[6]-Co solution, described by Dr. A. Hazen in American Chemical Journal, in 1892, adopted in Standard Methods for the Examination of Water and Waste Water, made by APHA, sometimes referred as Pt-Co/Hazen/APHA Colour.

References
[1] http:/ / www. apha. org [4] America's Health Rankings (http:/ / www. americashealthrankings. org/ 2010/ acknowledgement. aspx/ ) [6] http:/ / toolserver. org/ %7Edispenser/ cgi-bin/ dab_solver. py?page=American_Public_Health_Association& editintro=Template:Disambiguation_needed/ editintro& client=Template:Dn

External links
America's Health Rankings (http://www.americashealthrankings.org/) State Health Stats (http://www.statehealthstats.org/) American Public Health Association - APHA (http://www.apha.org/) Campaign for Children's Health Care (http://www.childrenshealthcampaign.org/?source=wikipedia) American Journal of Public Health - AJPH (http://www.ajph.org/) The Nation's Health (http://www.apha.org/publications/tnh/) Get Ready Campaign (http://www.getreadyforflu.org/) National Public Health Week (http://www.nphw.org/) Standard Methods for the Examination of Water and Wastewater (http://www.standardmethods.org/)

American Physical Therapy Association

247

American Physical Therapy Association


American Physical Therapy Association
Motto Formation Type Headquarters Location Membership "Move Forward. Physical Therapy Brings Motion to Life." 1921 Professional association Virginia United States 76,000

Officiallanguages English President Website Paul Rockar http:/ / www. apta. org/

A Historical Perspective Physical therapists formed their first professional association in 1921, called the American Women's Physical Therapeutic Association. Led by President Mary McMillan, an executive committee of elected officers governed the Association, which included 274 charter members. By the end of the 1930s, the Association changed its name to the American Physiotherapy Association. Men were admitted, and membership grew to just under 1,000. With the advent of World War II and a nationwide polio epidemic during the 1940s and 1950s, physical therapists were in greater demand than ever before. The Association's membership swelled to 8,000, and the number of physical therapy education programs across the US increased from 16 to 39. By the late 1940s, the Association had changed its name to the American Physical Therapy Association, hired a full-time staff, and opened its first office in New York City. A House of Delegates representing chapter members was established to set APTA policies. The House elected a Board of Directors, previously the Executive Committee, to manage the Association. In addition, Sections were created to promote and develop specific objectives of the profession. The first two Sections were the School and Private Practice sections. In the 1960s, APTA membership reached almost 15,000, and the number of education programs nationwide grew to 52. Now headquartered in Alexandria, Virginia, APTA represents approximately 76,000 members throughout the United States. A national professional organization, APTA's goal is to foster advancements in physical therapy practice, research, and education. Currently 199 institutions offer physical therapy education programs and 234 institutions offer physical therapist assistant education programs in the United States. These numbers will change significantly in the coming years to encompass 9 developing PT programs and 43 developing PTA programs.

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248

Vision statement
By 2020, physical therapy will be provided by physical therapists who are doctors of physical therapy (DPT), recognized by consumers and other health care professionals as the practitioners of choice to whom consumers have direct access for the diagnosis of, interventions for, and prevention of impairments, functional limitations, and disabilities related to movement, function, and health.[1]

Lobby work
The APTA advocates on behalf of the profession and for issues which impact the health and wellbeing of society such as; fundng for health research, funding for an adequate heath care workforce and for health care reform to improve access to health care and ensure adequate funding for the provision of physical therapy.[2]

Combined Sections Meeting


The Association holds an annual Combined Sections Meeting that is attended by physical therapists from around the United States. Informally known as "CSM", it is named the combined sections meeting because all of the sections of the APTA come together to meet at this time.

Past and future meetings


Year Dates Venue Boston, MA Tampa, FL Nashville, TN New Orleans, LA San Diego, CA Boston, MA Nashville, TN Las Vegas, NV Attendance

2002 February 2003 February 2004 February 2005 February 2006 February 2007 February 2008 February 2009 February 912

2010 February 1720 San Diego, CA 2011 February 912 2012 February 811 2013 January 2124 2014 February 36 2015 February 47 New Orleans, LA Chicago, IL San Diego, CA Las Vegas, NV Indianapolis, IN 9,346 (3,108 students)

2016 February 1720 Anaheim, CA 2017 February 1518 San Antonio, TX 2018 February 2128 New Orleans, LA

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249

References
[1] http:/ / www. apta. org/ Vision2020/ [2] http:/ / www. apta. org/ Advocacy/

External links
American Physical Therapy Association (http://www.apta.org) APTA Consumer Site (http://www.moveforwardpt.com)

Outpatient surgery
Outpatient surgery, also known as ambulatory surgery, same-day surgery or day surgery, is surgery that does not require an overnight hospital stay. The term outpatient arises from the fact that surgery patients may go home and do not need an overnight hospital bed. The purpose of outpatient surgery is to keep hospital costs down[citation needed] , as well as saving the patient time that would otherwise be wasted in the hospital. Outpatient surgery has grown in popularity due to the rise in outpatient surgery centers and improved technology. Outpatient surgery centers often allow patients to get medical surgery and cosmetic surgery done in much more luxurious settings than a state hospital and are often preferred by patients for minor surgical procedures. Improved technology has also increased the frequency of outpatient surgery procedures. With shorter medical procedure duration and fewer complications it makes sense to let patients go home sooner. About 65% of all surgical procedures are done on an outpatient basis.[citation needed] Patients should check with their doctor for all information covering preparation for outpatient procedures. Complications related to surgery occur less than 1% of the time in outpatient settings.[citation needed] However, in terms of patient safety, non-hospital settings are not as regulated as hospitals are. Patients should inquire about all ambulatory clinics, surgical centers, and physicians' offices to make sure they meet state guidelines.

Ambulatory surgery center


Ambulatory surgery centers (ASC), also known as outpatient surgery centers or same day surgery centers, are health care facilities where surgical procedures not requiring an overnight hospital stay are performed. Such surgery is commonly less complicated than that requiring hospitalization. Avoiding hospitalization can result in cost savings to the party responsible for paying for the patient's health care.[1] An ASC, sometimes called surgicenter, specializes in providing surgery, including certain pain management and diagnostic (e.g., colonoscopy) services in an outpatient setting. Overall, the services provided can be generally called procedures. In simple terms, ASC-qualified procedures can be considered procedures that are more intensive than those done in the average doctor's office but not so intensive as to require a hospital stay. An ambulatory surgery center and a specialty hospital often provide similar facilities and support similar types of procedures. The specialty hospital may provide the same procedures or slightly more complex ones and the specialty hospital will often allow an overnight stay. ASCs do not routinely provide emergency services to patients who have not been admitted to the ASC for another procedure. 'Procedures' performed in ASCs are broad in scope. In the 1980s and 1990s, many procedures that used to be performed exclusively in hospitals began taking place in ambulatory surgery centers as well. Many knee, shoulder, eye, spine and other surgeries are currently performed in ASCs. In the United States today, more than 50% of Colonoscopy services are performed in ambulatory surgery centers. The first ASC was established in Phoenix, Arizona in 1970 by two physicians who wanted to provide timely, convenient and comfortable surgical services to patients in their community, avoiding more impersonal venues like

Outpatient surgery regular hospitals.[2] ASCs rarely have a single owner. Physicians partners who perform surgeries in the center will often own at least some part of the facility. Ownership percentages vary considerably, but most ASCs involve physician owners. Occasionally, an ASC is entirely physician-owned. However, it is most common for development/management companies to own a percentage of the center. Some large healthcare companies own many types of medical facilities, including ambulatory surgery centers. The largest operators include Surgical Care Affiliates (SCA), United Surgical Partners International (USPI), and AMSURG. In the United States, more than 22 million surgeries a year are performed in more than 5,000 ASCs. ASCs are in all 50 states and can be found throughout the world. In the US, most ASCs are licensed, certified by Medicare and accredited by one of the major health care accrediting organizations. Although complications are very rare, ASCs are required by Medicare and the accreditation organizations to have a backup plan for transfer of patients to a hospital if the need arises. The national nonprofit organizations that represents the interests of ASCs and their patients is Ambulatory Surgery Center Association (ASC Association), which was formed in 2008 when the Federated Ambulatory Surgery Association (FASA) and the American Association of Ambulatory Surgery Centers (AAASC) merged. Accreditation organizations are separate from the general trade organizations. Accreditation organizations for ASCs provide standards of medical care, record keeping, and auditing for ASCs. Some of the goals of these organizations include continuous improvement of medical care in surgery centers and providing an external organization where the public can get information on many aspects of ASCs. These accreditation organizations require members to receive periodic audits. These audits will come every one to three years, depending on the accreditation organization and the circumstances of the surgery center. In an audit, a team of auditors visits the facility and examines the ASC's medical records, written policies, and compliance with industry standards. In 1996, California was the first state to require accreditation for all outpatient facilities that administer sedation or general anesthesia. Many other states have followed and require accreditation. The three main accreditors of ASCs are American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF), Accreditation Association for Ambulatory Health Care (Accreditation Association or AAAHC) and The Joint Commission.

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References
[1] Baylor College-Oral and Maxillofacial Surgery and Pharmacology/Surgicenter (http:/ / www. tambcd. edu/ oralsurgery/ surgicenter/ surgicenter. html) [2] http:/ / www. ascaconnect. org/ ASCA/ AboutUs/ WhatisanASC/ History/

External links
Outpatient Surgery Magazine (http://www.outpatientsurgery.net/) Tips for outpatient surgery patients (http://www.dsf.health.state.pa.us/health/cwp/view.asp?a=188& q=241594) Accreditation Association for Ambulatory Health Care (http://www.aaahc.org) American Association for Accreditation of Ambulatory Surgery Facilities (http://www.aaaasf.org) Joint Commission (http://www.jointcommission.org/) Canadian Association for Accreditation of Ambulatory Surgical Facilities (http://www.caaasf.org/) Bariatric Surgery Center Network Accreditation Program (http://www.facs.org/cqi/bscn/index.html) International Association for Ambulatory Surgery (http://www.iaas-med.com/joomla/index.php)

American Society for Clinical Pathology

251

American Society for Clinical Pathology


The American Society for Clinical Pathology (ASCP) is a professional association based in Chicago, Illinois encompassing 130,000 pathologists and laboratory professionals. Founded in 1922, the ASCP provides programs in education, certification and advocacy on behalf of patients, pathologists and lab professionals. In addition, the ASCP publishes numerous textbooks, newsletters and other manuals, and publishes two industry journals: American Journal of Clinical Pathology and LabMedicine.[1] The ASCP also promotes National Medical Laboratory Professionals Week (NMLPW) as a time of recognition for medical laboratory personnel and a chance to celebrate their professionalism and be recognized for their efforts. National Lab Week is held annually during the last full week of April.

References
[1] History of ASCP (http:/ / www. ascp. org/ MainMenu/ AboutASCP/ History. aspx)

External links
American Society for Clinical Pathology website (http://www.ascp.org) The American Journal of Clinical Pathology website (http://www.ajcp.com) LabMedicine website (http://www.labmedicine.com)

Aspartate transaminase
aspartate transaminase

Aspartate aminotransferase from Escherichia coli bound with cofactor pyridoxal 5-phosphate. Identifiers EC number CAS number 2.6.1.1 [1] [2]

[]

9000-97-9 Databases

IntEnz BRENDA ExPASy

IntEnz view

[3] [4] [5]

BRENDA entry NiceZyme view

Aspartate transaminase
[6] [7]

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KEGG MetaCyc PRIAM PDB structures Gene Ontology

KEGG entry

metabolic pathway profile [8] [9]

RCSB PDB AmiGO

PDBe

[10]

PDBsum

[11]

[12]

/ EGO

[13]

Search PMC articles [14]

PubMed articles [15] NCBI proteins [16]

Aspartate transaminase (AST), also called aspartate aminotransferase is commonly known as sgot (AspAT/ASAT/AAT) or serum glutamic oxaloacetic transaminase (SGOT), is a pyridoxal phosphate (PLP)-dependent transaminase enzyme (EC 2.6.1.1 [17]). AST catalyzes the reversible transfer of an -amino group between aspartate and glutamate and, as such, is an important enzyme in amino acid metabolism. AST is found in the liver, heart, skeletal muscle, kidneys, brain, and red blood cells, and it is commonly measured clinically as a marker for liver health.

Function
Aspartate transaminase catalyzes the interconversion of aspartate and -ketoglutarate to oxaloacetate and glutamate. Aspartate (Asp) + -ketoglutarate oxaloacetate + glutamate (Glu) As a prototypical transaminase, AST relies on PLP as a cofactor to transfer the amino group from aspartate or glutamate to the corresponding Reaction catalyzed by aspartate aminotransferase ketoacid. In the process, the cofactor shuttles between PLP and the pyridoxamine phosphate (PMP) form.[] The amino group transfer catalyzed by this enzyme is crucial in both amino acid degradation and biosynthesis. In amino acid degradation, following the conversion of -ketoglutarate to glutamate, glutamate subsequently undergoes oxidative deamination to form ammonium ions, which are excreted as urea. In the reverse reaction, aspartate may be synthesized from oxaloacetate, which is a key intermediate in the citric acid cycle.[]

Isoezymes
Two isoenzymes are present in a wide variety of eukaryotes. In humans: GOT1/cAST, the cytosolic isoenzyme derives mainly from red blood cells and heart. GOT2/mAST, the mitochondrial isoenzyme is present predominantly in liver. These isoenzymes are thought to have evolved from a common ancestral AST via gene duplication, and they share a sequence homology of approximately 45%.[] AST has also been found in a number of microorganisms, including E. coli, H. mediterranei,[] and T. thermophilus.[] In E. coli, the enzyme is encoded by the aspCgene and has also been shown to exhibit the activity of an aromatic-amino-acid transaminase (EC 2.6.1.57 [18]).[]

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Structure
X-ray crystallography studies have been performed to determine the structure of aspartate transaminase from various sources, including chicken mitochondria,[] pig heart cytosol,[] and E. coli.[][] Overall, the three-dimensional polypeptide structure for all species is quite similar. AST is dimeric, consisting of two identical subunits, each with approximately 400 amino acid residues and a molecular weight of approximately 45 kD.[] Each subunit is composed of a large and a small domain, as well as a third domain consisting of the N-terminal residues 3-14; these few residues form a strand, which links and stabilizes the two subunits of the dimer. The large Structure of aspartate transaminase from chicken heart mitochondria domain, which includes residues 48-325, binds the PLP cofactor via an aldimine linkage to the -amino group of Lys258. Other residues in this domain Asp 222 and Tyr 225 also interact with PLP via hydrogen bonding. The small domain consists of residues 15-47 and 326-410 and represents a flexible region that shifts the enzyme from an "open" to a "closed" conformation upon substrate binding.[][][] The two independent active sites are positioned near the interface between the two domains. Within each active site, a couple arginine residues are responsible for the enzymes specificity for dicarboxylic acid substrates: Arg386 interacts with the substrates proximal (-)carboxylate group, while Arg292 complexes with the distal (side-chain) carboxylate.[][] In terms of secondary structure, AST contains both and elements. Each domain has a central sheet of -strands with -helices packed on either side.

Mechanism
Aspartate transaminase, as with all transaminases, operates via dual substrate recognition; that is, it is able to recognize and selectively bind two amino acids (Asp and Glu) with different side-chains.[] In either case, the transaminase reaction consists of two similar half-reactions that constitute what is referred to as a ping-pong mechanism. In the first half-reaction, amino acid 1 (e.g., L-Asp) reacts with the enzyme-PLP complex to generate ketoacid 1 (oxaloacetate) and the modified enzyme-PMP. In the second half-reaction, ketoacid 2 (-ketoglutarate) reacts with enzyme-PMP to produce amino acid 2 (L-Glu), regenerating the original enzyme-PLP in the process. Formation of a racemic product (D-Glu) is very rare.[] The specific steps for the half-reaction of Enzyme-PLP + aspartate Enzyme-PMP + oxaloacetate are as follows (see figure); the other half-reaction (not shown) proceeds in the reverse manner, with -ketoglutarate as the substrate.[][]

Aspartate transaminase

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Reaction mechanism for aspartate aminotransferase

1. Internal aldimine formation: First, the -amino group of Lys258 forms a Schiff base linkage with the aldehyde carbon to generate an internal aldimine. 2. Transaldimination: The internal aldimine then becomes an external aldimine when the -amino group of Lys258 is displaced by the amino group of aspartate. This transaldimination reaction occurs via a nucleophilic attack by the deprotonated amino group of Asp and proceeds through a tetrahedral intermediate. As this point, the carboxylate groups of Asp are stabilized by the guanidinium groups of the enzymes Arg386 and Arg 292 residues. 3. Quinonoid formation: The hydrogen attached to the a-carbon of Asp is then abstracted (Lys258 is thought to be the proton acceptor) to form a quinonoid intermediate. 4. Ketimine formation: The quinonoid is reprotonated, but now at the aldehyde carbon, to form the ketimine intermediate. 5. Ketimine hydrolysis: Finally, the ketimine is hydrolyzed to form PMP and oxaloacetate. This mechanism is thought to have multiple partially rate-determining steps.[] However, it has been shown that the substrate binding step (transaldimination) drives the catalytic reaction forward.[]

Clinical significance
AST is similar to alanine transaminase (ALT) in that both enzymes are associated with liver parenchymal cells. The difference is that ALT is found predominantly in the liver, with clinically negligible quantities found in the kidneys, heart, and skeletal muscle, while AST is found in the liver, heart (cardiac muscle), skeletal muscle, kidneys, brain, and red blood cells.[19] As a result, ALT is a more specific indicator of liver inflammation than AST, as AST may be elevated also in diseases affecting other organs, such as myocardial infarction, acute pancreatitis, acute hemolytic anemia, severe burns, acute renal disease, musculoskeletal diseases, and trauma.[20] AST was defined as a biochemical marker for the diagnosis of acute myocardial infarction in 1954. However, the use of AST for such a diagnosis is now redundant and has been superseded by the cardiac troponins.[21] AST (SGOT) is commonly measured clinically as a part of diagnostic liver function tests, to determine liver health.

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Patient type Reference ranges[22] Female Male [] 6 - 34 IU/L 8 - 40 IU/L

References
[1] [2] [3] [4] [5] [6] [7] [8] [9] http:/ / www. chem. qmul. ac. uk/ iubmb/ enzyme/ EC2/ 6/ 1/ 1. html http:/ / tools. wmflabs. org/ magnustools/ cas. php?language=en& cas=9000-97-9& title= http:/ / www. ebi. ac. uk/ intenz/ query?cmd=SearchEC& ec=2. 6. 1. 1 http:/ / www. brenda-enzymes. org/ php/ result_flat. php4?ecno=2. 6. 1. 1 http:/ / www. expasy. org/ enzyme/ 2. 6. 1. 1 http:/ / www. genome. ad. jp/ dbget-bin/ www_bget?enzyme+ 2. 6. 1. 1 http:/ / biocyc. org/ META/ substring-search?type=NIL& object=2. 6. 1. 1 http:/ / priam. prabi. fr/ cgi-bin/ PRIAM_profiles_CurrentRelease. pl?EC=2. 6. 1. 1 http:/ / www. rcsb. org/ pdb/ search/ smartSubquery. do?smartSearchSubtype=EnzymeClassificationQuery& Enzyme_Classification=2. 6. 1. 1 [10] http:/ / www. ebi. ac. uk/ pdbe-srv/ PDBeXplore/ enzyme/ ?ec=2. 6. 1. 1 [11] http:/ / www. ebi. ac. uk/ thornton-srv/ databases/ cgi-bin/ enzymes/ GetPage. pl?ec_number=2. 6. 1. 1 [12] http:/ / amigo. geneontology. org/ cgi-bin/ amigo/ go. cgi?query=GO:0004069& view=details [13] http:/ / www. ebi. ac. uk/ ego/ DisplayGoTerm?id=GO:0004069& format=normal [14] http:/ / www. ncbi. nlm. nih. gov/ entrez/ query. fcgi?db=pubmed& term=2. 6. 1. 1%5BEC/ RN%20Number%5D%20AND%20pubmed%20pmc%20local%5Bsb%5D [15] http:/ / www. ncbi. nlm. nih. gov/ entrez/ query. fcgi?db=pubmed& term=2. 6. 1. 1%5BEC/ RN%20Number%5D [16] http:/ / www. ncbi. nlm. nih. gov/ protein?term=2. 6. 1. 1%5BEC/ RN%20Number%5D [17] http:/ / enzyme. expasy. org/ EC/ 2. 6. 1. 1 [18] http:/ / enzyme. expasy. org/ EC/ 2. 6. 1. 57 [19] http:/ / dynaweb. ebscohost. com/ Detail?sid=923b5a81-7daf-46b7-bdb2-86d8649da6ef@sessionmgr13& vid=& db=dme& ss=AN+ %22316452%22& sl=ll [20] http:/ / www. rnceus. com/ lf/ lfast. html [22] GPnotebook > reference range (AST) (http:/ / www. gpnotebook. co. uk/ simplepage. cfm?ID=322240579) Retrieved on Dec 7, 2009

Further reading
Jansonius, JN; Vincent, MG (1987). Jurnak FA and McPherson A, ed. Structural basis for catalysis by aspartate aminotransferase (Biological Macromolecules and Assemblies, Vol. 3). New York: Wiley. pp.187285. ISBN0-471-85142-6. Kuramitsu S, Okuno S, Ogawa T, Ogawa H, Kagamiyama H (1985). "Aspartate aminotransferase of Escherichia coli: nucleotide sequence of the aspC gene". J. Biochem. 97 (4): 125962. PMID 3897210 (http://www.ncbi. nlm.nih.gov/pubmed/3897210). Kondo K, Wakabayashi S, Yagi T, Kagamiyama H (1984). "The complete amino acid sequence of aspartate aminotransferase from Escherichia coli: sequence comparison with pig isoenzymes". Biochem. Biophys. Res. Commun. 122 (1): 6267. doi: 10.1016/0006-291X(84)90439-X (http://dx.doi.org/10.1016/ 0006-291X(84)90439-X). PMID 6378205 (http://www.ncbi.nlm.nih.gov/pubmed/6378205). Inoue K, Kuramitsu S, Okamoto A, Hirotsu K, Higuchi T, Kagamiyama H (1991). "Site-directed mutagenesis of Escherichia coli aspartate aminotransferase: role of Tyr70 in the catalytic processes". Biochemistry 30 (31): 77967801. doi: 10.1021/bi00245a019 (http://dx.doi.org/10.1021/bi00245a019). PMID 1868057 (http:// www.ncbi.nlm.nih.gov/pubmed/1868057).

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External links
Aspartate Transaminase (http://www.nlm.nih.gov/cgi/mesh/2011/MB_cgi?mode=&term=Aspartate+ Transaminase) at the US National Library of Medicine Medical Subject Headings (MeSH) AST: MedlinePlus Medical Encyclopedia (http://www.nlm.nih.gov/medlineplus/ency/article/003472.htm)

Wholesale
Wholesaling, jobbing, or distributing is the sale of goods or merchandise to retailers; to industrial, commercial, institutional, or other professional business users; or to other wholesalers and related subordinated services.[1] In general, it is the sale of goods to anyone other than a standard consumer. In the United Kingdom, the Cash and Carry is a term used describe a wholesale warehouse, particularly those that are open to the general public on payment of a subscription.
Fruit wholesalers in Haikou, Hainan Province, According to the United Nations Statistics Division, "wholesale" is the China resale (sale without transformation) of new and used goods to retailers, to industrial, commercial, institutional or professional users, or to other wholesalers, or involves acting as an agent or broker in buying merchandise for, or selling merchandise to, such persons or companies. Wholesalers frequently physically assemble, sort and grade goods in large lots, break bulk, repack and redistribute in smaller lots.[2] While wholesalers of most products usually operate from independent premises, wholesale marketing for foodstuffs can take place at specific wholesale markets where all traders are congregated.

Traditionally, wholesalers were closer to the markets they supplied than the source from which they got the products.[3] However, with the advent of the internet and E-procurement there are an increasing number of wholesalers located nearer manufacturing bases in China, Taiwan, and Southeast Asia. For example, Chinavasion, Ankaka, Ownta, Salehoo, and Modbom. These companies offer drop shipping services to companies and individuals. In the banking industry "wholesale" usually refers to wholesale banking, providing tailored services to large customers, in contrast with retail banking, providing standardized services to large numbers of smaller customers.

Taxes
Often, wholesalers are not required to charge their buyers sales tax, but they sometimes decide or are required to charge a special wholesale tax.[4]

Direct selling
The alternative to selling wholesale to distributors or retailers is to sell retail[5] either though company owned stores or online. Advantages include receiving a larger slice of the price paid by the consumer; disadvantages include difficulty in reaching consumers.[]

Wholesale

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References
[1] WTO - World Trade Organization (http:/ / www. wto. org/ english/ thewto_e/ acc_e/ completeacc_e. htm#chn) [2] UNSTATS - United Nations Statistics Division (http:/ / unstats. un. org/ unsd/ cr/ registry/ regcs. asp?Cl=9& Lg=1& Co=6) [4] Federal Manufacturers', Wholesale, and Retail Sales Taxes (http:/ / taxhistory. tax. org/ Civilization/ Documents/ Sales/ hst6646/ 6646-1. htm) from TaxAnalysts.org

Department of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy


The Department of Ayurveda, Yoga and Naturopathy, Unani, Siddha, Sowa Rigpa and Homoeopathy (AYUSH) is a part of the Ministry of Health & Family Welfare of the Government of India.[1][2] In collaboration with the Council for Scientific and Industrial Research (CSIR), AYUSH set up a Traditional Knowledge Digital Library (TKDL) in 2001, to prevent grant of "bed"patents on traditional knowledge and biopiracy, further the digital library is being developed on codified traditional knowledge on Indian systems of medicines such as Ayurveda, Unani, Siddha And Yoga. As an important measures nearly 805,000 Ayurvedic formulations, 98,700 Unani formulations, and 9,970 Sidha formulations have been transcribed in patent application format in five languages: English, French, German, Spanish and Japanese.[]

An official logo of AYUSH Department

History
Department of Indian Systems of Medicine and Homoeopathy (ISM&H) was created in March,1995 and re-named as Department of Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy (AYUSH) in November, 2003 with a view to providing focused attention to development of Education & Research in Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy systems. The Department continued to lay emphasis on upgradation of AYUSH educational standards, quality control and standardization of drugs, improving the availability of medicinal plant material, research and development and awareness generation about the efficacy of the systems domestically and internationally.[3]

Bodies under AYUSH


Bodies under the control of the Department of AYUSH are: Research councils [4] Central Council for Research in Ayurvedic Sciences [5] (CCRAS) Central Council for Research in Siddha [6] (CCRS) Central Council for Research in Unani Medicine [7] (CCRUM) Central Council for Research in Homoeopathy [8] (CCRH) Central Council for Research in Yoga and Naturopathy [9] (CCRYN) National Institutes (Education in Indian Medicine):[10] National Institute of Ayurveda, Jaipur (NIA) National Institute of Siddha, Chennai (NIS) National Institute of Homoeopathy, Kolkata (NIH) National Institute of Naturopathy [11], Pune (NIN)

Department of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy National Institute of Unani Medicine [12], Bangalore (NIUM) Institute of Post Graduate Teaching and Research in Ayurveda [13], Jamnagar, Gujarat (IPGTR) Rashtriya Ayurveda Vidyapeeth [14], New Delhi (RAV) Morarji Desai National Institute of Yoga [15], New Delhi (MDNIY) Indian Medicine Pharmaceutical Corporation Limited [16] (IMPCL), Mohan, Uttaranchal (a public sector undertaking) Professional councils Central Council of Homoeopathy (CCH) Central Council of Indian Medicine (CCIM) Pharmacopoeia Commission Indian Pharmacopoeia Commission Pharmacopoeia Commission for Indian System of Medicine Traditional Knowledge Digital Library (TKDL)

258

Objectives
1.To upgrade the educational standards in the Indian Systems of Medicines and Homoeopathy colleges in the country. 2.To strengthen existing research institutions and ensure a time-bound research programme on identified diseases for which these systems have an effective treatment. 3.To draw up schemes for promotion, cultivation and regeneration of medicinal plants used in these systems. 4.To evolve Pharmacopoeial standards for Indian Systems of Medicine and Homoeopathy drugs. Department of Indian Systems of Medicine and Homoeopathy (ISM&H) was created in March,1995 and re-named as Department of Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy (AYUSH) in November, 2003 with a view to providing focused attention to development of Education & Research in Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy systems. The Department continued to lay emphasis on upgradation of AYUSH educational standards, quality control and standardization of drugs, improving the availability of medicinal plant material, research and development and awareness generation about the efficacy of the systems domestically and internationally. Objectives: 1.To upgrade the educational standards in the Indian Systems of Medicines and Homoeopathy colleges in the country. 2.To strengthen existing research institutions and ensure a time-bound research programme on identified diseases for which these systems have an effective treatment. 3.To draw up schemes for promotion, cultivation and regeneration of medicinal plants used in these systems. 3.To evolve Pharmacopoeial standards for Indian Systems of Medicine and Homoeopathy drugs.[17]

References
[2] Ayush is also a common Hindu given name, derived from Sanskrit, meaning "Long-life". [3] http:/ / www. indianmedicine. nic. in/ printcont. asp?lid=19 [4] Research councils (http:/ / indianmedicine. nic. in/ index2. asp?slid=52& sublinkid=37& lang=1) AYUSH. [5] http:/ / ccras. nic. in/ [6] http:/ / crisiddha. tn. nic. in/ [7] http:/ / unanimedicine. com/ [8] http:/ / ccrhindia. org/ [9] http:/ / www. ccryn. org/ [10] National Institutes (http:/ / indianmedicine. nic. in/ index2. asp?slid=50& sublinkid=33& lang=1) AYUSH [11] http:/ / www. punenin. org/ [12] http:/ / www. nium. in/ [13] http:/ / www. ayurveduniversity. com/ uniipgtra. php [14] http:/ / www. ravdelhi. nic. in/ [15] http:/ / www. yogamdniy. com/ [16] http:/ / www. impclmohan. nic. in/ [17] http:/ / www. indianmedicine. nic. in/ printcont. asp?lid=19

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External links
Department of Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy (AYUSH), Official website (http://indianmedicine.nic.in/index.html) Ministry of Health and Family Welfare, Official website (http://www.mohfw.nic.in/welcome.html) The First Ayurveda Hospital accredited by NABH is the AyurVAID Hospital (http://www.ayurvaid.com), Domlur, Bangalore International Journal of Advanced Ayurveda, Yoga, Unani, Siddha and Homeopathy (http://www. cloud-journals.com/journal-of-advanced-ayurveda-yoga-unani-siddha-and-homeopathy-open-acess.html) [ ISSN 2320- 0251 ] is (http://www.cloud-journals.com/ journal-of-advanced-ayurveda-yoga-unani-siddha-and-homeopathy-open-acess.html'), Published by Cloud Publications (http://www.cloudpublications.org).

Balanced Budget Act of 1997


The Balanced Budget Act of 1997, (Pub.L. 10533 [1], 111Stat.251 [2], enacted August5, 1997), was an omnibus legislative package enacted using the budget reconciliation process and designed to balance the federal budget by 2002. According to the Congressional Budget Office, the act would result in $160 billion in spending reductions between 1998 and 2002. After taking into account an increase in spending on Welfare and Children's Healthcare, the savings total $127 billion. Medicare cuts are responsible for $112 billion, and hospital inpatient and outpatient payments cover $44 billion. [3] In order to reduce Medicare spending, it reduced payments to health service providers such as hospitals, doctors and nurse practitioners.[4] However, some of those changes to payments were restored by subsequent legislation in 1999 and 2000.

References
[1] http:/ / www. law. cornell. edu/ jureeka/ index. php?doc=USPubLaws& cong=105& no=33 [2] http:/ / www. gpo. gov/ fdsys/ granule/ STATUTE-111/ STATUTE-111-Pg251/ content-detail. html [3] "The Impact of the BBA and the BBRA." Trend Watch 2 (Mar. 2000): 1. American Hospital Association. Web. 23 Feb. 2011. <www.aha.org/aha/trendwatch/2000/twmarch2000.pdf>.

External links
Act in Full (http://www.gpo.gov/fdsys/pkg/PLAW-105publ33/content-detail.html) H.R. 2015 (http://hdl.loc.gov/loc.uscongress/legislation.105hr2015), Legislative History

Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999

260

Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999


Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999

Long title

Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 Balanced Budget Refinement Act or BBRA 106th United States Congress Citations

Colloquial acronym(s) Enacted by the

Public Law Stat.

106-113 113 Stat. 1501 Codification

Act(s) amended Title(s) amended U.S.C. section(s) amended

Balanced Budget Act of 1997 Social Security Act 42 42USC1395 Legislative history

Introduced in the House as H.R. 3426 by William M. Thomas on November 17, 1999 Committee consideration by: Committee on Ways and Means, Committee on Commerce Reported by the joint conference committee on November 18, 2009; agreed to by the House on November 18, 1999 (296 - 135) and by the Senate on November 19, 1999 (74-24) Signed into law by President Bill Clinton on November 29, 1999

The Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 [1] (also called the Balanced Budget Refinement Act or BBRA) is a federal law of the United States, enacted in 1999.[2] The BBRA was first introduced into the House as H.R. 3075 on October 14, 1999 by Rep. William M. Thomas (R-CA) with 75 cosponsors. It was read twice and then referred to the Senate Committee on Finance. The bill was then slightly altered and reintroduced by Thomas as H.R. 3426 on November 17, 1999. After referral to the House committees on Ways and Means and Commerce, it was incorporated by cross-reference in the conference report into H.R. 3194 on November 18, 1999. The H.R. 3194 bill had been introduced by Rep. Ernest J. Istook, Jr. (R-OK) on November 2, 1999, and was enacted with official title: Making consolidated appropriations for the fiscal year ending September 30, 2000, and for other purposes. The State Health Insurance Trial (SCHIP or S. H. 1 - T) was administered by the United States Department of Health and Human Services. The BBRA was signed by President Bill Clinton on November 29, 1999 after passing in Congress.

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261

References
[1] , [2] http:/ / www. ssa. gov/ OP_Home/ comp2/ F106-113. html

External links
H.R. 3075 (http://hdl.loc.gov/loc.uscongress/legislation.106hr3075), Legislative History H.R. 3426 (http://hdl.loc.gov/loc.uscongress/legislation.106hr3426), Legislative History H.R. 3194 (http://hdl.loc.gov/loc.uscongress/legislation.106hr3194), Legislative History

Blue Cross Blue Shield Association


Blue Cross Blue Shield Association
Type Industry Founded Independent Health insurance 1929

Headquarters Michigan Plaza Chicago, Illinois Key people Products Revenue Employees Website [1] Scott Serota , President and CEO PPOs, HMOs $320.5 million US$ (2008) 880 (2008) bcbs.com [2] [2]

[3]

The Blue Cross Blue Shield Association (BCBSA) is a federation of 38 separate health insurance organizations and companies in the United States. Combined, they directly or indirectly provide health insurance to over 99 million Americans.[4] The history of Blue Cross dates back to 1929, while the history of Blue Shield dates to 1939. The Blue Cross Association dates back to 1960, while its Blue Shield counterpart was created in 1948. The two organizations merged in 1982, forming the current association.

History

Blue Cross Blue Shield Association

262

Health care in the United States Government Health Programs


Federal Employees Health Benefits Program Indian Health Service Veterans Health Administration Military Health System / TRICARE Medicare Medicaid / State Health Insurance Assistance Program (SHIP) State Children's Health Insurance Program (CHIP) Program of All-Inclusive Care for the Elderly (PACE) Prescription Assistance (SPAP) Private health coverage

Health insurance in the United States Consumer-driven health care


Flexible spending account (FSA) Health Reimbursement Account Health savings account

High-deductible health plan (HDHP) Medical savings account (MSA) Private Fee-For-Service (PFFS) Managed care (CCP) Health maintenance organization (HMO) Preferred provider organization (PPO) Medical underwriting

Health care reform law


Emergency Medical Treatment and Active Labor Act (1986) Health Insurance Portability and Accountability Act (1996) Medicare Prescription Drug, Improvement, and Modernization Act (2003) Patient Safety and Quality Improvement Act (2005) Health Information Technology for Economic and Clinical Health Act (2009) Patient Protection and Affordable Care Act (2010) State level reform

Massachusetts health care reform Oregon Health Plan Vermont health care reform SustiNet (Connecticut) Dirigo Health (Maine) Municipal health coverage

Fair Share Health Care Act (Maryland) Healthy Howard (Howard Co., Maryland) Healthy San Francisco

Blue Cross and Blue Shield developed separately, with Blue Cross plans providing coverage for hospital services, while Blue Shield covered physicians' services.[5] Blue Cross is a name used by an association of health insurance plans throughout the United States. Its predecessor was developed by Justin Ford Kimball in 1929, while he was vice-president of Baylor University's health care facilities in Dallas, Texas.[] The first plan guaranteed teachers 21 days of hospital care for $6 a year, and was later extended to other employee groups in Dallas, and then nationally.[] The American Hospital Association (AHA) adopted the Blue Cross symbol in 1939 as the emblem for plans meeting certain standards. In 1960 the AHA

Blue Cross Blue Shield Association commission was superseded by the Blue Cross Association. Affiliation with the AHA was severed in 1972. The Blue Shield concept was developed at the beginning of the 20th century by employers in lumber and mining camps of the Pacific Northwest to provide medical care by paying monthly fees to medical service bureaus composed of groups of physicians.[6] The first official Blue Shield Plan was founded in California in 1939. In 1948 the symbol was informally adopted by nine plans called the Associated Medical Care Plan, and was later renamed the National Association of Blue Shield Plans. In 1982 Blue Shield merged with The Blue Cross Association to form the Blue Cross and Blue Shield Association.[7] Prior to the Tax Reform Act of 1986, organizations administering Blue Cross Blue Shield were tax exempt under 501(c)(4) as social welfare plans. However, the Tax Reform Act of 1986 revoked that exemption because the plans sold commercial-type insurance. They became 501(m) organizations, subject to federal taxation but entitled to "special tax benefits"[8] under IRC 833.[9] In 1994, the Blue Cross Blue Shield Association changed to allow its licensees to be for-profit corporations.[5] Some plansWikipedia:Citing sources are still considered not-for-profit at the state level.

263

Current organization
Blue Cross and Blue Shield insurance companies are licensees, independent of the association (and traditionally of each other), offering insurance plans within defined regions under one or both of the association's brands. Blue Cross Blue Shield insurers offer some form of health insurance coverage in every U.S. state. They also act as administrators of Medicare in many states or regions of the US[10] and provide coverage to state government employees as well as to the federal government employees under a nationwide option of the Federal Employees Health Benefit Plan.[11] The 14-state WellPoint is the largest Blue Cross Blue Shield member, and is a publicly traded company. Other multi-state organizations include CareFirst in the Mid-Atlantic, The Regence Group in the Pacific Northwest, and Highmark which serves Pennsylvania, Delaware, and West Virginia. The largest non-investor owned member is Health Care Service Corporation,[citation needed] which operates five Blue Cross and Blue Shield Plans in the Midwest and Southwest (Illinois, Oklahoma, Texas, Montana, and New Mexico). The association has its headquarters in the Michigan Plaza complex in the Chicago Loop area of Chicago, Illinois.[12]

List of BlueCross and/or BlueShield companies


Publicly traded companies Anthem for-profit (Became WellPoint 2004) Anthem BlueCross BlueShield Colorado Connecticut Indiana Kentucky Maine Missouri Nevada New Hampshire Ohio Parts of Virginia

Wisconsin Anthem BlueCross

Blue Cross Blue Shield Association California BlueCross BlueShield of Georgia Empire BlueCross and BlueShield (New York) Triple-S Management Corporation (BlueCross & BlueShield Puerto Rico) Multi-state private companies CareFirst*Blue Cross Blue Shield of Montana District of Columbia Maryland Parts of Virginia Health Care Service Corporation BlueCross BlueShield of Illinois BlueCross BlueShield of New Mexico [13] Blue Cross Blue Shield of Montana BlueCross BlueShield of Oklahoma BlueCross BlueShield of Texas Highmark Highmark BlueCross BlueShield (Western Pennsylvania) Highmark BlueShield (Northeastern, Eastern & Central Pennsylvania) Highmark BlueCross Blue Shield Delaware (Delaware) Highmark BlueCross BlueShield West Virginia (West Virginia) Premera Premera BlueCross BlueShield of Alaska Premera BlueCross (Washington) The Regence Group (Cambia Health Solutions) Regence BlueShield of Idaho Regence BlueCross BlueShield of Oregon Regence BlueCross BlueShield of Utah Regence BlueShield (Washington) Wellmark BlueCross Blue Shield Iowa South Dakota Single-state or regional companies BlueCross BlueShield of Alabama BlueCross BlueShield of Arizona Arkansas BlueCross BlueShield BlueShield of California BlueCross BlueShield of Florida (branded as Florida Blue)[14] Hawaii Medical Service Association BlueCross of Idaho BlueCross BlueShield of Kansas BlueCross BlueShield of Louisiana Blue Cross Blue Shield of Massachusetts Blue Cross Blue Shield of Michigan

264

Blue Cross Blue Shield of Minnesota Blue Cross Blue Shield of Mississippi

Blue Cross Blue Shield Association BlueCross and BlueShield of Kansas City (Missouri) Blue Cross Blue Shield of Nebraska Horizon Blue Cross Blue Shield of New Jersey Excellus BlueCross BlueShield (Central New York, Rochester and Utica/Watertown) BlueShield of Northeastern New York (A division of HealthNow New York Inc.) Blue Cross Blue Shield of Western New York (A division of HealthNow New York Inc.) Blue Cross Blue Shield of North Carolina Blue Cross Blue Shield of North Dakota Blue Cross of Northeastern Pennsylvania Capital Blue Cross (Central Pennsylvania) Independence Blue Cross (Philadelphia, Southeastern Pennsylvania) Blue Cross Blue Shield of Rhode Island Blue Cross Blue Shield of South Carolina BlueCross BlueShield of Tennessee BlueCross BlueShield of Vermont BlueCross BlueShield of Wyoming

265

Companies outside of the United States BlueCross BlueShield of Uruguay

Details on specific organizations


Idaho
BlueCross of Idaho and Regence[15] BlueShield of Idaho are separate companies and compete head to head throughout the state.

Pennsylvania
Though historically "Blue Cross" was used for hospital coverage while "Blue Shield" was used for medical coverage, today that split only exists for traditional health insurance plans in eastern Pennsylvania, where Independence Blue Cross (Philadelphia) and Blue Cross of Northeastern Pennsylvania each have joint marketing agreements with Highmark Blue Shield (Pittsburgh) for their separate hospital and medical plans. However, Independence Blue Cross, like most of its sister Blue Cross-Blue Shield companies, cover most of their customers under managed care plans such as HMOs and PPOs which provide hospital and medical care in one policy.

Criticism and controversy


The Seattle Times published an article on February 9, 2012, alleging non-profit insurance outfits, including Premera Blue Cross, Regence BlueShield and Group Health Cooperative, are stockpiling billions of dollars in reserves while increasing their rates at the same time.[16] Insurance companies do have statutory reserve requirements set by the states in which they operate, but the Seattle Times article cites Washington state insurance Commissioner Mike Kreidler arguing that these companies have in excess of $1 billion more than needed to cover claims and disaster contingencies.

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References
[1] [2] [3] [4] [5] Scott P. Serota page (http:/ / www. bcbs. com/ about-the-association/ officers/ scott-serota. html) on BCBSA Web site Blue Cross and Blue Shield Association Company Profile (http:/ / biz. yahoo. com/ ic/ 40/ 40067. html) from Yahoo! http:/ / bcbs. com/ Blue Cross and Blue Shield Association About Us (http:/ / www. bcbs. com/ about-the-association/ ) IRS. Coordinated Issue Paper - Blue Cross Blue Shield/Health Insurance; Life Insurance: Conversion of nonprofit corporations (http:/ / www. irs. gov/ businesses/ article/ 0,,id=183646,00. html). (Effective Date: June 4, 2008) [9] http:/ / www4. law. cornell. edu/ uscode/ html/ uscode26/ usc_sec_26_00000833----000-. html [10] http:/ / www. healthharbor. com [11] United States Office of Personal Management, 2010 Nationwide Fee-for-Service Open to All (http:/ / www. opm. gov/ insure/ health/ planinfo/ 2010/ states/ wy. asp) [12] " Contact Us (http:/ / www. bcbs. com/ about/ contact/ )." Blue Cross and Blue Shield Association. Retrieved on December 23, 2009. [13] http:/ / www. bcbsnm. com/ [15] The Regence Group

Blue Cross Blue Shield Of Texas (http://www.bcbstx.com/)

External links
Blue Cross Blue Shield of California official website (http://www.bcbs.com/)

Baby Friendly Hospital Initiative


The Baby Friendly Hospital Initiative (BFHI), also known as Baby Friendly Initiative (BFI), is a worldwide programme of the World Health Organization and UNICEF, launched in 1991[1][2] following the adoption of the Innocenti Declaration on breastfeeding promotion in 1990.[3] The initiative is a global effort for improving the role of maternity services to enable mothers to breastfeed babies for the best start in life. It aims at improving the care of pregnant women, mothers and newborns at health facilities that provide maternity services for protecting, promoting and supporting breastfeeding, in accordance with the International Code of Marketing of Breastmilk Substitutes. UNICEF, the World Health Organization, and many national government health agencies recommend that babies are breastfed exclusively for their first six months of life. Studies have shown that breastfed babies are less likely to suffer from serious illnesses, including gastroenteritis, asthma, eczema, and respiratory and ear infections.[4][5][6][7] Adults who were breastfed as babies are less likely to develop risk factors for heart disease such as obesity and high blood pressure. There are benefits for mothers too: women who breastfeed have a lower risk of developing breast cancer, ovarian cancer and hip fractures in later life.[8][9][10] The BFHI aims to increase the numbers of babies who are exclusively breastfed worldwide, a goal which the WHO estimates could contribute to avoiding over a million child deaths each year.[11]

Criteria
The criteria for a hospital's Baby Friendly accreditation include: 1. 2. 3. 4. 5. 6. Have a written breastfeeding policy that is routinely communicated to all health care staff. Train all health care staff in skills necessary to implement this policy. Inform all pregnant women about the benefits and management of breastfeeding. Help mothers initiate breastfeeding within one half-hour of birth. Show mothers how to breastfeed and maintain lactation, even if they should be separated from their infants. Give newborn infants no food or drink other than breastmilk, not even sips of water, unless medically indicated.

7. Practice rooming in - that is, allow mothers and infants to remain together 24 hours a day. 8. Encourage breastfeeding on demand. 9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.

Baby Friendly Hospital Initiative 10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic. The program also restricts use by the hospital of free formula or other infant care aids provided by formula companies. Since the program's inception, approximately 15,000 facilities in more than 152 countries have been inspected and accredited as "Baby-Friendly."[1][2]

267

National schemes
Canada
In Canada, the provinces of Quebec and New Brunswick have mandated the implementation of the BFHI. Other provinces and territories are implementing strategies at regional and local levels.[12] As of 2008, 18 health care facilities (9 hospitals & birthing centres and 9 community health services) had been designated "Baby-Friendly" across the country.[13]

Cuba
In Cuba, 49 of the country's 56 hospitals and maternity facilities have been designated as "baby-friendly". In the six years following the initiation of the BFHI program, the rate of exclusive breastfeeding at four months almost tripled from 25 per cent in 1990 to 72 per cent in 1996.[1]

Sweden
Sweden is considered the global leader in terms of BFHI implementation: four years after the programme was introduced in 1993, all of the then 65 maternity centres in the country had been designated "baby-friendly".[14]

United Kingdom
The UNICEF UK Baby Friendly Initiative was launched in the United Kingdom in 1994.[15] The Initiative works with the National Health Service (NHS) to ensure a high standard of care for pregnant women and breastfeeding mothers and babies in hospitals and community health settings. The Baby Friendly Initiative accredits health-care facilities that adopt internationally recognised best practice standards for breastfeeding. During each stage of accreditation, the Initiative provides support as facilities implement standards relating to policies and procedures, staff education, effective auditing, educating pregnant women and mothers, and other relevant areas. In 1998, its principles were extended to cover the work of community health-care services with the Seven Point Plan for the Promotion, Protection and Support of Breastfeeding in Community Health Care Settings.[15] In 2005, it introduced an accreditation programme for university departments responsible for midwifery, health visitor and public health nurse education. This ensures that newly qualified midwives and health visitors are equipped with the basic knowledge and skills they need to support breastfeeding effectively. The program's emphasis on applying the standards in post-natal and education settings makes it unique amongst the various Baby Friendly programmes in other countries.[citation needed] There are now 52 Baby Friendly-accredited maternity hospitals in the UK and ten accredited community health-care providers.[citation needed] It has been estimated that if all babies were breastfed, over 35m would be saved by the NHS in England and Wales each year in treating gastroenteritis alone.[16] Despite this, breastfeeding rates in the UK are amongst the lowest in Europe: 78 per cent of babies born in the UK are breastfed at birth, falling to 63 per cent at one week. Only one in five babies still receives breastmilk at six months.[17] In 2009, the Department of Health awarded a total of 4 million to 40 Primary Care Trusts in areas with low rates of breastfeeding to support them in seeking Baby Friendly accreditation.[citation needed]

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United States
The first hospitals verified as Baby-Friendly in the USA were on the Pacific coast. All of these were able to achieve 100% breastfeeding initiation rates. [18]In New York City, the Harlem Hospital Center was the first hospital to receive the "Baby Friendly" certification granted by Baby-Friendly USA for the city in 2008.[19] In 2011, New York University Langone Medical Center became the second hospital to receive the Baby-Friendly Hospital designation in New York City.[20]

References
[1] UNICEF. The Baby-Friendly Hospital Initiative. (http:/ / www. unicef. org/ programme/ breastfeeding/ baby. htm) Accessed 4 August 2011. [2] World Health Organization. Baby-friendly Hospital Initiative. (http:/ / www. who. int/ nutrition/ topics/ bfhi/ en/ ) Accessed 4 August 2011. [3] UNICEF. INNOCENTI DECLARATION on the Protection, Promotion and Support of Breastfeeding. (http:/ / www. unicef. org/ programme/ breastfeeding/ innocenti. htm) Adopted at the WHO/UNICEF meeting on "Breastfeeding in the 1990s: A Global Initiative", held at the Spedale degli Innocenti, Florence, Italy, 30 July-1 August 1990. [4] http:/ / www. ahrq. gov/ clinic/ tp/ brfouttp. htm [5] http:/ / pediatrics. aappublications. org/ cgi/ content/ abstract/ 121/ 1/ 183 [6] http:/ / pediatrics. aappublications. org/ cgi/ content/ abstract/ 122/ Supplement_4/ S176?ct=ct [7] http:/ / thorax. bmj. com/ cgi/ content/ abstract/ thx. 2008. 101543v1?ct=ct [8] http:/ / highwire. stanford. edu/ cgi/ medline/ pmid;15308954 [9] http:/ / aje. oxfordjournals. org/ cgi/ content/ abstract/ 161/ 1/ 15?ct [10] http:/ / www. babyfriendly. org. uk/ pdfs/ World_Cancer_Research_Fund_2007-10. pdf [11] World Health Organization. 10 facts on breastfeeding (http:/ / www. who. int/ features/ factfiles/ breastfeeding/ en/ index. html), accessed 20 April 2011. [12] Breastfeeding Committee for Canada. BFI in Canada. (http:/ / www. breastfeedingalberta. ca/ bfi_in_canada. htm) Accessed 2 August 2011. [13] New Brunswick Department of Health. New Brunswick Provincial Report of the Baby-Friendly Self-Assessment Survey. (http:/ / www. gnb. ca/ 0053/ bfi/ pdf/ PT Hospital Survey final2006web. pdf) March 2008. [14] Hofvander Y. "Breastfeeding and the Baby Friendly Hospitals Initiative (BFHI): Organization, response and outcome in Sweden and other countries." (http:/ / onlinelibrary. wiley. com/ doi/ 10. 1111/ j. 1651-2227. 2005. tb02038. x/ abstract) Acta Paediatrica, 94(8): 10121016, August 2005. [15] UNICEF UK. What is the Baby Friendly Initiative? (http:/ / www. unicef. org. uk/ BabyFriendly/ About-Baby-Friendly/ What-is-the-Baby-Friendly-Initiative/ ) Accessed 4 August 2011. [16] http:/ / www. babyfriendly. org. uk/ pdfs/ local_authority_approach. pdf [17] http:/ / www. ic. nhs. uk/ pubs/ breastfeed2005 [18] http:/ / pediatrics. aappublications. org/ content/ 116/ 3/ 628. full. pdf+ html [19] http:/ / www. nyc. gov/ html/ hhc/ html/ newsletter/ safety-200807-baby-friendly. shtml [20] http:/ / nursing. med. nyu. edu/ news/ 2011/ nyu-langone-medical-center-awarded-official-baby-friendly-usa-designation

External links
World Health Organization (http://www.who.int) UNICEF International (http://www.unicef.org) BFHI information from the World Health Organisation (http://www.who.int/nutrition/topics/bfhi/en/index. html) MotherBaby Summit (http://www.motherbabysummit.com) Baby Friendly Initiative UK (http://www.babyfriendly.org.uk) UNICEF UK (http://www.unicef.org.uk)

BI-RADS

269

BI-RADS
BI-RADS is an acronym for Breast Imaging-Reporting and Data System, a quality assurance tool originally designed for use with mammography. The system is a collaborative effort of many health groups but is published and trademarked by the American College of Radiology (ACR). The system is designed to standardize reporting, and is used by medical professionals to communicate a patient's risk of developing breast cancer. The document focuses on patient reports used by medical professionals, not "lay reports" that are provided to patients.

Published Documents
The BI-RADS is published by ACR in the form of the BI-RADS Atlas. As of 2007 the Atlas is divided into 3 publications: Mammography, Fourth Edition Ultrasound, First Edition MRI, First Edition

Assessment Categories
While BI-RADS is a quality control system, in day-to-day usage the term "BI-RADS" refers to the mammography assessment categories. These are standardized numerical codes typically assigned by a radiologist after interpreting a mammogram. This allows for concise and unambiguous understanding of patient records between multiple doctors and medical facilities. The assessment categories were developed for mammography and later adapted for the MRI and Ultrasound Atlases. The summary of each category, given below, is identical for all 3 modalities. Category 6 was added in the 4th edition of the Mammography Atlas. BI-RADS Assessment Categories are:[1] 0: Incomplete 1: Negative 2: Benign finding(s) 3: Probably benign 4: Suspicious abnormality 5: Highly suggestive of malignancy 6: Known biopsy proven malignancy

An incomplete (BI-RADS 0) classification warrants either an effort to ascertain prior imaging for comparison or to call the patient back for additional views and/or higher quality films. A BI-RADS classification of 4 or 5 warrants biopsy to further evaluate the offending lesion.[2] Some experts believe that the single BI-RADS 4 classification does not adequately communicate the risk of cancer to doctors and recommend a subclassification scheme:[] 4A: low suspicion for malignancy 4B: intermediate suspicion of malignancy 4C: moderate concern, but not classic for malignancy

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270

Breast Composition Categories


1: Almost entirely fatty 2: Scattered fibroglandular densities 3: Heterogeneously dense 4: Extremely dense

External links
The American College of Radiology [3] BI-RADS Atlas [4] Short tutorial, with actual mammogram pictures [5]

References
[1] American College of Radiology (ACR) Breast Imaging Reporting and Data System Atlas (BI-RADS Atlas). Reston, Va: American College of Radiology; 2003 [2] ACR Practice Guideline for the Performance of Ultrasound-Guided Percutaneous Breast Interventional Procedures Res. 29; American College of Radiology; 2009 [3] http:/ / www. acr. org [4] http:/ / www. acr. org/ Quality-Safety/ Resources/ BIRADS [5] http:/ / www. birads. at/

Bureau of Primary Health Care


The Bureau of Primary Health Care is a part of the Health Resources and Services Administration (HRSA), of the United States Department of Health and Human Services. HRSA helps fund, staff and support a national network of health clinics for people who otherwise would have little or no access to care. The Bureau is headed by Associate Administrator Jim Macrea, Senior Advisior Tracey Orloff and Chief Medical Advisor Seiji Hayashi.

History
HRSAs Primary Health Care Programs have their roots in the Migrant Health Act of 1962 and the Economic Opportunity Act of 1964, which established funding for the first community-based clinics that were to become todays Health Center Program. The National Hansens Disease Program, formerly the National Leprosarium, was established in 1921. More recently, the Free Clinics Medical Malpractice Program was established in 2004. The Bureau of Primary Health Care was reorganized and restructured to become more organized and efficient.[1] This resulted in creation of the Office of Minority and Special Populations, the Office of Policy and Program Development, and the Office of Quality and Data. There are also four divisions that were created: Eastern, Central Mid Atlantic, Western and the National Hansens disease program.[2] The Health Resources and Services Administration (HRSA), within the Department of Health and Human Services (HHS), has the responsibility for managing the Consolidated Health Centers Grant Program. The Economic Opportunity Act of 1964 provided Federal funds for two "neighborhood health centers," which were launched in 1965 by Jack Geiger and Count Gibson, physicians at Tufts University in Boston. Federal support for entities that would later be called health centers began in 1962 with passage of the Migrant Health Act, which funded medical and support services for migrant and seasonal farmworkers and their family members. In the mid-1970s, Congress permanently authorized neighborhood health centers as community health centers and migrant health centers under sections 329 and 330 of the Public Health Service Act.[3]

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Key facts
Over 1,100 health center grant recipients operate more than 8,000 community-based clinic sites in every state and territory, giving geographically isolated or economically distressed people access to preventive and primary health care. HRSA-supported health centers treated more than 19 million people in 2010, approximately two-thirds of whom are members of minority groups. Nearly forty percent have no health insurance; a third are children. Since 2001, through a major expansion initiative, HRSA has increased access to primary health care in 1,200 communities through new or expanded clinical sites. During this time, health centers increased their patient base by almost 60 percent, nearly doubled the number of people receiving oral health care, and tripled the number of clients who received mental health and addiction counseling services. One of every 20 people living in the U.S. now relies on a HRSA-funded clinic for primary care, including nearly a quarter of the nations homeless and migrant and seasonal farmworkers. The National Hansens Disease Program is the major source of direct patient care, clinician training and research in the field of Hansens Disease and related leprous conditions. The Federally Supported Health Centers Assistance Act of 1992 and 1995 granted medical malpractice liability protection through the Federal Tort Claims Act (FTCA) to HRSA-supported health centers. BPHC administers this program through its Office of Quality and Data. The Free Clinics Medical Malpractice Program extends this coverage to insures physicians and other clinicians who contribute free health care services in the communities, relieving them of the burden of paying for private liability coverage.[citation needed]

Health Center Program


Health Centers are community-based and patient-directed organizations that serve people with limited access to health care. These include low-income patients, the uninsured, those with limited English proficiency, migrant and seasonal farmworkers, individuals and families experiencing homelessness, and those living in public housing. HRSA-supported clinics provide comprehensive, culturally competent, quality primary health care to a broadly diverse patient base that includes increasing numbers of veterans. Services include pharmacy, mental health, substance abuse and oral health treatment, as well as supportive services (education, translation, transportation and case management) that promote access to health care and ensure patient well-being. Health centers are required to be located in or serve a high-need community (a medically underserved area or population) and to make their services available to all patients on a sliding scale, with fees based on ability to pay. By law, health centers must be governed by community boards with majority patient representation. Looking at national numbers, Health Centers serve:[4] 1 in 20 individuals 1 in 12 African-Americans 1 in 9 Hispanic/Latinos 1 in 8 uninsured 1 in 7 individuals living below 200 percent of the Federal poverty level 1 in 4 homeless individuals and migrant/seasonal farmworkers

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Free Clinics Medical Malpractice Program


Free clinics play a significant role in meeting the health care needs of the uninsured, particularly at a time when private physicians may be less likely to provide free care in their offices. These clinics are typically small organizations with annual budgets of less than $250,000, making them less able to afford the growing cost of malpractice coverage for those clinicians who might otherwise be willing to donate their time. The Free Clinics Program serves HRSAs overall policy aim of expanding treatment capacity for the disadvantaged by assuring health professional volunteers that they will be protected against medical malpractice claims. To date, over 2,800 health care providers have been given federal indemnity through the program. The community health center is a nonprofit health care agency concerned with health promotion and primary prevention goals for specific populations. Populations may include the homeless, minorities, Medicaid recipients, migrant/seasonal farmworkers, persons infected with HIV/AIDS, the underinsured, and the uninsured. Community health centers are funded by the Bureau of Primary Health Care, U.S. Public Health Service, U.S. Department of Health and Human Services, via grant money and are located in designated medically underserved areas. The National Association for Community Health Centers and state associations for community health centers are advocates for the local centers. Community health centers are unique in that they employ community health care specialists (e.g., family practice physicians and advanced practice nurses). They provide accessible primary care preventive health services. Their clients include the individual, family, and community; and they have a partnership relationship with the community.[5]

National Hansen's Disease Program


The National Hansen's Disease Program have been providing care and treatment for Hansen's disease (leprosy) and related conditions since 1921. Currently, the National Hansen's Disease (Leprosy) Clinical Center is located at Ochsner Medical Center in Baton Rouge, Louisiana. It is "the only facility in the United States devoted to diagnosis, treatment, and research concerning Hansen's disease."[6] The Clinical Center states that it offers: Free consultations for physicians treating complicated cases of Hansen's disease, including referrals for reconstructive hand or foot surgery. Free pathologic review of skin biopsy and consultation concerning molecular techniques for identification of M. leprae. Free antibiotics for leprosy treatment shipped to physicians. Free educational materials for healthcare professionals and patients to improve understanding of the disease, and to prevent injury and disability. Surgical care and rehabilitation for those referred for complicated (digit or limb threatening) wounds or reconstruction of correctable deformity resulting from Hansen's disease.[7] The National Hansen's Disease (Leprosy) Research Program at the Louisiana State University School of Veterinary Medicine in Baton Rouge is a research center that "conducts and supports research in the causes, diagnosis, prevention and cure of Hansen's disease and tuberculosis aimed at the global elimination of Hansen's disease (leprosy)."[8] The research program maintains the world's only M. leprae-infected armadillo colony. Twenty-three people work at the Research Program.[9] The program provides health care to those affected by the disease through three means of service delivery: at HRSA-run facilities in Louisiana; via a payment to a Hawaii in-patient program; or at any of 11 regional outpatient clinics under contract to the agency. The programs also support scientific research and training for health professionals at the worlds largest and most comprehensive laboratory dedicated to Hansens Disease.

Bureau of Primary Health Care The programs are the only dedicated source of expertise, treatment and continuing education on the disease in the United States. Though Hansen's disease is very rare in the United States(there are currently only 6500 cases) there is still a widely held stigma because of the history of the disease. With current treatment methods patients become noninfectious after only a few doses of medication. Patients may continue their lives without change during treatment. This Program has led the development of the treatments for Hansen's Disease. It wasn't until the 1940s that any effective means of treating this Disease were created. "Guy Henry Faget, MD and his staff demonstrate the efficacy of sulfone drugs, At the end of one year, 15 of 22 patients had improved." [10]

273

Models that Work Campaign


The main objective of the Models That Work Campaign (MTW) is improving access to health care for vulnerable and underserved populations. The MTW Campaign is a collaboration between the Bureau of Primary Health Care (BPHC) and 39 cosponsors including national associations, state and federal agencies, community-based organizations, foundations, and businesses. This initiative gives recognition and visibility to innovative and effective service delivery models. Models are selected based on a set of criteria that includes delivery of high quality primary care services, community participation, integration of health and social services, quantifiable outcomes, and replicability. Winners of the competition are showcased nationally and hired to provide training to other communities, to document and publish their strategies, and to provide onsite technical assistance on request. MTW staff at HRSA's Bureau of Primary Health Care (BPHC) work in collaboration with cosponsors in national and local campaigns to publicize the innovative approaches used by MTW winners. On the federal level for example, HRSA's HIV/AIDS Bureau works with MTW staff and cosponsors to develop a series of community based workshops with MTW winners; sharing lessons and advising community leaders, clinicians, and administrators on strategies to improve primary care coordination for populations with high incidences of HIV/AIDS. Innovative strategies are often identified and incorporated into federal technical assistance initiatives and local program design as well.[11]

References
[2] [3] [4] [6] http:/ / www. hrsa. gov/ about/ organization/ bureaus/ bphc/ bphcorgchart2010. pdf http:/ / bphc. hrsa. gov/ success/ http:/ / bphc. hrsa. gov/ success/ criticalconnections. htm " National Hansen's Disease (Leprosy) Clinical Center, Baton Rouge, Louisiana (http:/ / www. hrsa. gov/ hansensdisease/ clinicalcenter. html)." Health Research and Services Administration. [7] " National Hansen's Disease (Leprosy) Clinical Center, Baton Rouge, Louisiana (http:/ / www. hrsa. gov/ hansensdisease/ clinicalcenter. html)." Health Research and Services Administration. [8] " Hansen's Disease Laboratory Research (http:/ / www. hrsa. gov/ hansensdisease/ research/ index. html)." [9] " Hansen's Disease Laboratory Research (http:/ / www. hrsa. gov/ hansensdisease/ research/ index. html)." [10] http:/ / www. hrsa. gov/ hansens/ history. htm

External links
Official website (http://bphc.hrsa.gov/)

Behavioral Risk Factor Surveillance System

274

Behavioral Risk Factor Surveillance System


The Behavioral Risk Factor Surveillance System (BRFSS) is a United States health survey that looks at behavioral risk factors. It is run by Centers for Disease Control and Prevention and conducted by the individual state health departments. The survey is administered by telephone and is the world's largest such survey. In 2009, the BRFSS began conducting surveys by cellular phone in addition to traditional landline telephones.

Description
The BRFSS is a cross-sectional telephone survey conducted by state health departments with technical and methodological assistance provided by the CDC. In addition to all 50 states, the BRFSS is also conducted by health departments in The District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands. [1] Individual states can add their own questions to the survey instrument, which consists of a core set of questions on certain topics like car safety, obesity, or exercise. States get funding from the federal government to administer these questionnaires, and they pay for the additional questions themselves. The U.S. federal government can then compare states based on the core questions to allocate funding and focus interventions. The states themselves also use the survey results to focus interventions for the public and to decide what is worth their while to focus on. City, county, tribal, and local governments also rely on BRFSS data for information about their jurisdictions.

References External links


Behavioral Risk Factor Surveillance System (http://www.cdc.gov/BRFSS/) CDC Website (http://www.cdc.gov/) step-by-step how to analyze the Behavioral Risk Factor Surveillance System with free tools website (http:// www.asdfree.com/search/label/behavioral risk factor surveillance system (brfss))

Bachelor of Science in Nursing

275

Bachelor of Science in Nursing


The Bachelor of Science in Nursing (BSN, or BScN in Canada) is an American and Canadian four-year academic degree in the science and principles of nursing, granted by a tertiary education university or similarly accredited school. Though one is eligible to sit for the licensing examination to become a registered nurse after graduating from either a two-year program with an Associate's Degree (ADN) or from a four-year program with an Bachelor's Degree (BSN), the BSN prepares nurses for a professional role away from the bedside with coursework in nursing science, research, leadership, and nursing informatics. A BSN also provides the student with general education in math, humanities and social sciences.[1] A bachelors opens up opportunities for greater career advancement and higher salary options. This degree qualifies its holder for administrative, research, consulting and teaching positions that would not be available to those with only an ADN.[2]

References

Coronary artery bypass surgery

276

Coronary artery bypass surgery


Coronary artery bypass surgery
Intervention

Early in a coronary artery bypass surgery during vein harvesting from the legs (left of image) and the establishment of bypass (placement of the aortic cannula) (bottom of image). The perfusionist and heart-lung machine (HLM) are on the upper right. The patient's head (not seen) is at the bottom. ICD-10-PCS ICD-9-CM MeSH MedlinePlus 021209W 36.1 [1] [2]

D001026 002946

[3]

Coronary artery bypass surgery, also coronary artery bypass graft (CABG, pronounced "cabbage") surgery, and colloquially heart bypass or bypass surgery is a surgical procedure performed to relieve angina and reduce the risk of death from coronary artery disease. Arteries or veins from elsewhere in the patient's body are grafted to the coronary arteries to bypass atherosclerotic narrowings and improve the blood supply to the coronary circulation supplying the myocardium (heart muscle). This surgery is usually performed with the heart stopped, necessitating the usage of cardiopulmonary bypass; techniques are available to perform CABG on a beating heart, so-called "off-pump" surgery.

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Terminology
There are many variations on terminology, in which one or more of "artery", "bypass" or "graft" is left out. The most frequently used acronym for this type of surgery is CABG (pronounced 'cabbage'),[4] pluralized as CABGs (pronounced 'cabbages'). More recentlyWikipedia:Manual of Style/Dates and numbers#Chronological items the term aortocoronary bypass (ACB) has come into popular use. CAGS (Coronary Artery Graft Surgery, pronounced phonetically) should not be confused with coronary angiography (CAG). Arteriosclerosis is a common arterial disorder characterized by thickening, loss of elasticity, and calcification of arterial walls, resulting in a decreased blood supply. Atherosclerosis is a common arterial disorder characterized by yellowish plaques of cholesterol, lipids, and cellular debris in the inner layer of the walls of large and medium-sized arteries.

Three coronary artery bypass grafts, a LIMA to LAD and two saphenous vein grafts one to the right coronary artery (RCA) system and one to the obtuse marginal (OM) system.

Number of bypasses
The terms single bypass, double bypass, triple bypass, quadruple bypass and quintuple bypass refer to the number of coronary arteries bypassed in the procedure. In other words, a double bypass means two coronary arteries are bypassed (e.g. the left anterior descending (LAD) coronary artery and right coronary artery (RCA)); a triple bypass means three vessels are bypassed (e.g. LAD, RCA, left circumflex artery (LCX)); a quadruple bypass means four vessels are bypassed (e.g. LAD, RCA, LCX, first diagonal artery of the LAD) while quintuple means five. Bypass of more than four coronary arteries is uncommon. A greater number of bypasses does not imply a person is "more sick", nor does a lesser number imply a person is "healthier."[5] A person with a large amount of coronary artery disease (CAD) may receive fewer bypass grafts owing to the lack of suitable "target" vessels. A coronary artery may be unsuitable for bypass grafting if it is small (< 1mm or < 1.5mm depending on surgeon preference), heavily calcified (meaning the artery does not have a section free of CAD) or intramyocardial (the coronary artery is located within the heart muscle rather than on the surface of the heart). Similarly, a person with a single stenosis ("narrowing") of the left main coronary artery requires only two bypasses (to the LAD and the LCX). However, a left main lesion places a person at the highest risk for death from a cardiac cause.[citation needed] The surgeon reviews the coronary angiogram prior to surgery and identifies the lesions (or "blockages") in the coronary arteries. The surgeon will estimate the number of bypass grafts prior to surgery, but the final decision is made in the operating room upon examination of the heart.

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Indications
Several alternative treatments for coronary artery disease exist. They include: Medical management (anti-anginal medications plus statins, antihypertensives, smoking cessation, tight blood sugar control in diabetics) Percutaneous coronary intervention (PCI) Both PCI and CABG are more effective than medical management at relieving symptoms,[] (e.g. angina, dyspnea, fatigue). CABG is superior to PCI for some patients with multivessel CAD[][] The Surgery or Stent (SoS) trial was a randomized controlled trial that compared CABG to PCI with bare-metal stents. The SoS trial demonstrated CABG is superior to PCI in multivessel coronary disease.[] The SYNTAX trial was a randomized controlled trial of 1800 patients with multivessel coronary disease, comparing CABG versus PCI using drug-eluting stents (DES). The study found that rates of major adverse cardiac or cerebrovascular events at 12 months were significantly higher in the DES group (17.8% versus 12.4% for CABG; P=0.002).[] This was primarily driven by higher need for repeat revascularization procedures in the PCI group with no difference in repeat infarctions or survival. Higher rates of strokes were seen in the CABG group. The FREEDOM (Future Revascularization Evaluation in Patients With Diabetes MellitusOptimal Management of Multivessel Disease) trial will compare CABG and DES in patients with diabetes. The registries of the nonrandomized patients screened for these trials may provide as much robust data regarding revascularization outcomes as the randomized analysis.[6] A study comparing the outcomes of all patients in New York state treated with CABG or percutaneous coronary intervention (PCI) demonstrated CABG was superior to PCI with DES in multivessel (more than one diseased artery) coronary artery disease (CAD). Patients treated with CABG had lower rates of death and of death or myocardial infarction than treatment with a coronary stent. Patients undergoing CABG also had lower rates of repeat revascularization.[] The New York State registry included all patients undergoing revascularization for coronary artery disease, but was not a randomized trial, and so may have reflected other factors besides the method of coronary revascularization. The 2004 ACC/AHA CABG guidelines state CABG is the preferred treatment for:[] Disease of the left main coronary artery (LMCA). Disease of all three coronary vessels (LAD, LCX and RCA). Diffuse disease not amenable to treatment with a PCI. The 2005 ACC/AHA guidelines further state: CABG is the preferred treatment with other high-risk patients such as those with severe ventricular dysfunction (i.e. low ejection fraction), or diabetes mellitus.[]

Prognosis
Prognosis following CABG depends on a variety of factors, and successful grafts typically last 815 years. In general, CABG improves the chances of survival of patients who are at high risk (generally triple or higher bypass), though statistically after about five years the difference in survival rate between those who have had surgery and those treated by drug therapy diminishes. Age at the time of CABG is critical to the prognosis, younger patients with no complicating diseases doing better, while older patients can usually be expected to suffer further blockage of the coronary arteries.[citation needed]

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Controversy
The value of coronary artery bypass surgery in rescuing someone having a heart attack (by immediately alleviating an obstruction) is clearly defined in multiple studies, but studies have failed to find benefit for bypass surgery vs. medical therapy in stable angina patients. The artery bypass can temporarily alleviate chest pain, but does not increase longevity. The "vast majority of heart attacks do not originate with obstructions that narrow arteries".[7] Loss of mental function is a complication of bypass surgery in elderly people, and might influence procedure cost benefit considerations.[] Several factors may contribute to immediate cognitive decline. The heart-lung blood circulation system and the surgery itself release a variety of debris, including bits of blood cells, tubing, and plaques. For example, when surgeons clamp and connect the aorta to tubing, resulting emboli block blood flow and cause mini strokes. Other heart surgery factors related to mental damage may be events of hypoxia, high or low body temperature, abnormal blood pressure, irregular heart rhythms, and fever after surgery.[8] A safer and more permanent and successful way to prevent heart attacks in patients at high risk is to exercise, give up smoking, take "drugs to get blood pressure under control and drive cholesterol levels down to prevent blood clotting".[7] Longer term, behavioral and medication treatment may be the only way to avoid vascular related loss of mental function.[9]

Procedure (simplified)
1. The patient is brought to the operating room and moved on to the operating table. 2. An anaesthetist places a variety of intravenous lines and injects a painkilling agent (usually fentanyl) followed within minutes by an induction agent (usually propofol) to render the patient unconscious. 3. An endotracheal tube is inserted and secured by the anaesthetist and mechanical ventilation is started. General anaesthesia is maintained by a continuous very slow injection of Propofol. 4. The chest is opened via a median sternotomy and the heart is examined by the surgeon.
Illustration of a typical coronary artery bypass surgery. A vein from the leg is removed and grafted to the coronary artery to bypass a [10] blockage. See full animation .

5. The bypass grafts are harvested frequent conduits are the internal thoracic arteries, radial arteries and saphenous veins. When harvesting is done, the patient is given heparin to prevent the blood from clotting.

6. In the case of "off-pump" surgery, the surgeon places devices to stabilize the heart. 7. If the case is "on-pump", the surgeon sutures cannulae into the heart and instructs the perfusionist to start cardiopulmonary bypass (CPB). Once CPB is established, the surgeon places the aortic cross-clamp across the aorta and instructs the perfusionist to deliver cardioplegia (a special potassium-mixture, cooled) to stop the heart and slow its metabolism. Usually the patient's machine-circulated blood is cooled to around 84 F (29C) 8. One end of each graft is sewn on to the coronary arteries beyond the blockages and the other end is attached to the aorta.

Coronary artery bypass surgery 9. The heart is restarted; or in "off-pump" surgery, the stabilizing devices are removed. In cases where the aorta is partially occluded by a C-shaped clamp, the heart is restarted and suturing of the grafts to the aorta is done in this partially occluded section of the aorta while the heart is beating. 10. Protamine is given to reverse the effects of heparin. 11. Chest tubes are placed in the mediastinal and pleural space to drain blood from around the heart and lungs. 12. The sternum is wired together and the incisions are sutured closed. 13. The patient is moved to the intensive care unit (ICU) to recover. 14. Nurses in the ICU focus on recovering the patient by monitoring blood pressure, urine output and respiratory status as the patient is monitored for bleeding through the chest tubes. If there is chest tube clogging, complications such as cardiac tamponade, pneumothorax or death can ensue. Thus nurses closely monitor the chest tubes and under take methods to prevent clogging so bleeding can be monitored and complications can be prevented.
Coronary artery bypass surgery during mobilization (freeing) of the right coronary artery from its surrounding tissue, adipose tissue (yellow). The tube visible at the bottom is the aortic cannula (returns blood from the HLM). The tube above it (obscured by the surgeon on the right) is the venous cannula (receives blood from the body). The patient's heart is stopped and the aorta is cross-clamped. The patient's head (not seen) is at the bottom.

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15. After awakening and stabilizing in the ICU (approximately one day), the person is transferred to the cardiac surgery ward until ready to go home (approximately four days).

Minimally invasive CABG


Alternate methods of minimally invasive coronary artery bypass surgery have been developed. Off-pump coronary artery bypass (OPCAB) is a technique of performing bypass surgery without the use of cardiopulmonary bypass (the heart-lung machine).[11] Further refinements to OPCAB have resulted in minimally invasive direct coronary artery bypass surgery (MIDCAB), a technique of performing bypass surgery through a 5 to 10cm incision.[12]

Conduits used for bypass


The choice of conduits is highly dependent upon the particular surgeon and institution. Typically, the left internal thoracic artery (LITA) (previously referred to as left internal mammary artery or LIMA) is grafted to the left anterior descending artery and a combination of other arteries and veins is used for other coronary arteries. The right internal thoracic artery (RITA), the great saphenous vein from the leg and the radial artery from the forearm are frequently used; in the U.S., these vessels are usually harvested endoscopically, using a technique known as endoscopic vessel harvesting (EVH). The right gastroepiploic artery from the stomach is infrequently used given the difficult mobilization from the abdomen.

Heart bypass patient with almost invisible residual scarring

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Graft patency
Grafts can become diseased and may occlude in the months to years after bypass surgery is performed. Patency is the chance that a graft remains open. A graft is considered patent if there is flow through the graft without any significant (>70% diameter) stenosis in the graft. Graft patency is dependent on a number of factors, including the type of graft used (internal thoracic artery, radial artery, or great saphenous vein), the size or the coronary artery that the graft is anastomosed with, and, of course, the skill of the surgeon(s) performing the procedure. Arterial grafts (e.g. LITA, radial) are far more sensitive to rough handling than the saphenous veins and may go into spasm if handled improperly. Generally the best patency rates are achieved with the in-situ left internal thoracic artery (the proximal end is left connected to the subclavian artery) with the distal end being anastomosed with the coronary artery (typically the left anterior descending artery or a diagonal branch artery). Lesser patency rates can be expected with radial artery grafts and "free" internal thoracic artery grafts (where the proximal end of the thoracic artery is excised from its origin from the subclavian artery and re-anastomosed with the ascending aorta). Saphenous vein grafts have worse patency rates, but are more available, as the patients can have multiple segments of the saphenous vein used to bypass different arteries. Veins that are used either have their valves removed or are turned around so that the valves in them do not occlude blood flow in the graft. LITA grafts are longer-lasting than vein grafts, both because the artery is more robust than a vein and because, being already connected to the arterial tree, the LITA need only be grafted at one end. The LITA is usually grafted to the left anterior descending coronary artery (LAD) because of its superior long-term patency when compared to saphenous vein grafts.[13][14]

Sternal precautions
Patients undergoing coronary artery bypass surgery will have to avoid certain things for eight to 12 weeks to reduce the risk of opening the incision. These are called sternal precautions. First, patients need to avoid using their arms excessively, such as pushing themselves out of a chair or reaching back before sitting down. To avoid this, patients are encouraged to build up momentum by rocking several times in their chair before standing up. Second, patients should avoid lifting anything in excess of 510 pounds. A gallon (U.S.) of milk weighs approximately 8.5 pounds, and is a good reference point for weight limitations. Finally, patients should avoid overhead activities with their hands, such as reaching for sweaters from the top shelf of a closet or reaching for plates or cups from the cupboard.

Complications
People undergoing coronary artery bypass are at risk for the same complications as any surgery, plus some risks more common with or unique to CABG.

CABG associated
Postperfusion syndrome (pumphead), a transient neurocognitive impairment associated with cardiopulmonary bypass. Some research shows the incidence is initially decreased by off-pump coronary artery bypass, but with no difference beyond three months after surgery. A neurocognitive decline over time has been demonstrated in people with coronary artery disease regardless of treatment (OPCAB, conventional CABG or medical management). However, a 2009 research study suggests that longer term (over 5 years) cognitive decline is not caused by CABG but is rather a consequence of vascular disease.[15] Nonunion of the sternum; internal thoracic artery harvesting devascularizes the sternum increasing risk.[16] Myocardial infarction due to embolism, hypoperfusion, or graft failure. Late graft stenosis, particularly of saphenous vein grafts due to atherosclerosis causing recurrent angina or myocardial infarction.[17]

Coronary artery bypass surgery Acute renal failure due to embolism or hypoperfusion.[18][] Stroke, secondary to embolism or hypoperfusion.[19] Vasoplegic syndrome, secondary to cardiopulmonary bypass and hypothermia Grafts last 8 15 years, and then need to be replaced. Pneumothorax: An air collection around the lung that compresses the lung[] Hemothorax: Blood in the space around the lungs Pericardial tamponade: Blood collection around the heart that compresses the heart and causes poor body and brain perfusion. Chest tubes are placed around the heart and lung to prevent this. If the chest tubes become clogged in the early post operative period when bleeding is ongoing this can lead to Pericardial tamponade, pneumothorax or hemothorax. Pleural effusion: Fluid in the space around the lungs. This can lead to hypoxia which can slow recovery.

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General cardiac surgery


Post-operative atrial fibrillation: An arrhythmia that sometimes occurs after cardiac surgery.[20]

General surgical
Infection at incision sites or sepsis. Deep vein thrombosis (DVT) Anesthetic complications such as malignant hyperthermia. Keloid scarring Chronic pain at incision sites Chronic stress related illnesses Death

Follow up
Patients who have a coronary artery bypass surgery need regular monitoring from a physician. Among the changes in monitoring are five years after the surgery the addition of a regular cardiac stress test even when there is no change in the patient's status.[][]

History
The first coronary artery bypass surgery was performed in the United States on May 2, 1960, at the Albert Einstein College of Medicine-Bronx Municipal Hospital Center by a team led by Dr. Robert Goetz and the thoracic surgeon, Dr. Michael Rohman with the assistance of Dr. Jordan Haller and Dr. Ronald Dee.[21][22] In this technique the vessels are held together with circumferential ligatures over an inserted metal ring. The internal mammary artery was used as the donor vessel and was anastomosed to the right coronary artery. The actual anastomosis with the Rosenbach ring took fifteen seconds and did not require cardiopulmonary bypass. The disadvantage of using the internal mammary artery was that, at autopsy nine months later, the anastomosis was open, but an atheromatous plaque had occluded the origin of the internal mammary that was used for the bypass.[citation needed] Wikipedia:Verifiability Russian cardiac surgeon, Dr. Vasilii Kolesov, performed the first successful internal mammary arterycoronary artery anastomosis in 1964.[23][] However, Goetz's has been cited by others, including Kolesov,[24] as the first successful human coronary artery bypass.[25][26][27][28][29][30][31] Goetz's case has frequently been overlooked. Confusion has persisted for over 40 years and seems to be due to the absence of a full report and to misunderstanding about the type of anastomosis that was created. The anastomosis was intima-to-intima, with the vessels held together with circumferential ligatures over

Coronary artery bypass surgery a specially designed metal ring. Kolesov did the first successful coronary bypass using a standard suture technique in 1964, and over the next five years he performed 33 sutured and mechanically stapled anastomoses in St. Petersburg, Russia.[32][33] Dr. Ren Favaloro, an Argentine surgeon, achieved a physiologic approach in the surgical management of coronary artery diseasethe bypass grafting procedureat the Cleveland Clinic in May 1967.[][34] His new technique used a saphenous vein autograft to replace a stenotic segment of the right coronary artery. Later, he successfully used the saphenous vein as a bypassing channel, which has become the typical bypass graft technique we know today; in the U.S., this vessel is typically harvested endoscopically, using a technique known as endoscopic vessel harvesting (EVH). Soon Dr. Dudley Johnson extended the bypass to include left coronary arterial systems.[] In 1968, Doctors Charles Bailey, Teruo Hirose and George Green used the internal mammary artery instead of the saphenous vein for the grafting.[]

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References
[1] [2] [3] [7] http:/ / icd9cm. chrisendres. com/ index. php?srchtype=procs& srchtext=36. 1& Submit=Search& action=search http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2011/ MB_cgi?field=uid& term=D001026 http:/ / www. nlm. nih. gov/ medlineplus/ ency/ article/ 002946. htm Kolata, Gina. "New Heart Studies Question the Value Of Opening Arteries" (http:/ / www. nytimes. com/ 2004/ 03/ 21/ us/ new-heart-studies-question-the-value-of-opening-arteries. html) The New York Times, March 21, 2004. Retrieved January 14, 2011.

[8] Stutz, Bruce "Pumphead: Does the heart-lung machine have a dark side?" (http:/ / www. scientificamerican. com/ article. cfm?id=pumphead-heart-lung-machine) Scientific American, January 9, 2009. [9] Harmon, Katherine "Heart-Lung Machine May Not Be the Culprit in Post-Op "Pump Head" Syndrome" Scientific American August 6, 2009. (http:/ / www. scientificamerican. com/ article. cfm?id=disease-may-cause-pumphead) [10] http:/ / blausen. com/ index-wiki. php?word=Heart+ Bypass+ Surgery

External links
A BBC film showing a patient undergoing a double bypass operation. (http://www.bbc.co.uk/tees/content/ articles/2008/11/21/jeffrey_bypass_feature.shtml) Ischemic Heart Disease (http://cardiacsurgery.ctsnetbooks.org/current. shtml#PART_III__ISCHEMIC_HEART_DISEASE) section in Cardiac Surgey in the Adult Coronary Artery Bypass Surgery at NYU Langone Medical Center's Cardiac and Vascular Institute (http:// cardiac-surgery.med.nyu.edu/coronary-artery-disease-treatment) Cleveland Clinic page on coronary artery bypass surgery (http://my.clevelandclinic.org/heart/disorders/cad/ treatment_heartsurg.aspx)

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Coronary artery disease


Coronary artery disease
Classification and external resources

Micrograph of a coronary artery with the most common form of coronary artery disease (atherosclerosis) and marked luminal narrowing. Masson's trichrome. ICD-10 ICD-9 MedlinePlus eMedicine MeSH I20 410 [1] -I25 [2] [4] , 429.2 [5]

[3]

-414 [6]

007115

radio/192 D003324

[7] [8]

Coronary artery disease (CAD; also atherosclerotic heart disease) is the most common type of heart disease and cause of heart attacks.[9] The disease is caused by plaque building up along the inner walls of the arteries of the heart, which narrows the arteries and restricts blood flow to the heart. It is the leading cause of death worldwide.[9] While the symptoms and signs of coronary artery disease are noted in the advanced state of disease, most individuals with coronary artery disease show no evidence of disease for decades as the disease progresses before the first onset of symptoms, often a "sudden" heart attack, finally arises. After decades of progression, some of these atheromatous plaques may rupture and (along with the activation of the blood clotting system) start limiting blood flow to the heart muscle. The disease is the most common cause of sudden death,[10] and is also the most common reason for death of men and women over 20 years of age.[11] According to present trends in the United States, half of healthy 40-year-old males will develop CAD in the future, and one in three healthy 40-year-old women.[12] According to the Guinness Book of Records, Northern Ireland is the country with the most occurrences of CAD. By contrast, the Maasai of Africa have almost no heart disease. As the degree of coronary artery disease progresses, there may be near-complete obstruction of the lumen of the coronary artery, severely restricting the flow of oxygen-carrying blood to the myocardium. Individuals with this degree of coronary artery disease typically have suffered from one or more myocardial infarctions (heart attacks), and may have signs and symptoms of chronic coronary ischemia, including symptoms of angina at rest and flash pulmonary edema. A distinction should be made between myocardial ischemia and myocardial infarction. Ischemia means that the amount of blood supplied to the tissue is inadequate to supply the needs of the tissue. When the myocardium becomes ischemic, it does not function optimally. When large areas of the myocardium becomes ischemic, there can

Coronary artery disease be impairment in the relaxation and contraction of the myocardium. If the blood flow to the tissue is improved, myocardial ischemia can be reversed. Infarction means that the tissue has undergone irreversible death due to lack of sufficient oxygen-rich blood. An individual may develop a rupture of an atheromatous plaque at any stage of the spectrum of coronary artery disease. The acute rupture of a plaque may lead to an acute myocardial infarction (heart attack).

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Pathophysiology
Limitation of blood flow to the heart causes ischemia (cell starvation secondary to a lack of oxygen) of the myocardial cells. Myocardial cells may die from lack of oxygen and this is called a myocardial infarction (commonly called a heart attack). It leads to heart muscle damage, heart muscle death and later myocardial scarring without heart muscle regrowth. Chronic high-grade stenosis of the coronary arteries can induce transient ischemia which leads to the induction of a ventricular arrhythmia, which may terminate into ventricular fibrillation leading to death. CAD is associated with smoking, diabetes, and hypertension. A number of recent studies have shown that family history of early CAD is an important predictor of CAD. Most of the familial association of coronary artery disease may be related to common dietary habits. Screening for CAD includes evaluating high-density and low-density lipoprotein (cholesterol) levels and triglyceride levels. Despite much press, most of the alternative risk factors including homocysteine, C-reactive protein (CRP), Lipoprotein (a), coronary calcium and more sophisticated lipid analysis have added little if any additional value to the conventional risk factors of smoking, diabetes and hypertension.

Angina
Angina (chest pain) that occurs regularly with activity, after heavy meals, or at other predictable times is termed stable angina and is associated with high grade narrowings of the heart arteries. The symptoms of angina are often treated with betablocker therapy such as metoprolol or atenolol. Nitrate preparations such as nitroglycerin, which come in short-acting and long-acting forms are also effective in relieving symptoms but are not known to reduce the chances of future heart attacks. Many other more effective treatments, especially of the underlying atheromatous disease, have been developed. Angina that changes in intensity, character or frequency is termed unstable. Unstable angina may precede myocardial infarction, and requires urgent medical attention. It may be treated with oxygen, intravenous nitroglycerin, and aspirin. Interventional procedures such as angioplasty may be done.

Characteristics of coronary artery disease


Special pathophysiology
Typically, coronary artery disease occurs when part of the smooth, elastic lining inside a coronary artery (the arteries that supply blood to the heart muscle) develops atherosclerosis. With atherosclerosis, the artery's lining becomes hardened, stiffened, and swollen with all sorts of "grunge" - including calcium deposits, fatty deposits, and abnormal inflammatory cells - to form a plaque. Deposits of calcium phosphates (hydroxyapatites) in the muscular layer of the blood vessels appear to play not only a significant role in stiffening arteries but also for the induction of an early phase of coronary arteriosclerosis. This can be seen in a so-called metastatic mechanism of calcification as it occurs in chronic kidney disease and haemodialysis (Rainer Liedtke 2008). Although these patients suffer from a kidney dysfunction, almost fifty percent of them die due to coronary artery disease. Plaques can be thought of as large "pimples" that protrude into the channel of an artery, causing a partial obstruction to blood flow. Patients with coronary artery disease might have just one or two plaques, or might have dozens distributed throughout their

Coronary artery disease coronary arteries. However, there is a term in medicine called Cardiac Syndrome X, which describes chest pain (Angina pectoris) and chest discomfort in people who do not show signs of blockages in the larger coronary arteries of their hearts when an angiogram (coronary angiogram) is being performed.[13] No one knows exactly what causes Cardiac Syndrome X and it is unlikely to have a single cause. Today, we speculate that the major contributing factor to Cardiac Syndrome X is microvascular dysfunction.Wikipedia:Avoid weasel words The term microvascular refers to very small blood vessels and, in this case, very small arteries (arterioles, capillaries) of the heart. Studies have also shown that people with Cardiac Syndrome X have enhanced pain perception, meaning they feel chest pain more intensely than the average person. The large majority of women have the garden variety of coronary artery disease. Rarely, women with Cardiac Syndrome X have typical anginal syndromes that are not associated with the presence of atherosclerotic plaques; that is, the localized blockages are absent. Scientists speculate that the blood vessels in these women are diffuse abnormal. Some have falsely claim that the entire lining of the artery becomes thickened throughout, making the plaques flush with the wall of the artery without any scientific proof. On cardiac catheterization their coronary arteries appear smooth-walled and normal, though they may look "small" in diameter. By the way: in general, female coronary arteries (like all arteries) are somewhat smaller than in males. Cardiac Syndrome X have never been shown to cause acute heart attacks (myocardial infarction) despite much speculation. The prognosis with syndrome-X coronary artery disease is also known to be better than with typical coronary artery disease, but this is not a benign condition since it can be quite disabling. It is not completely clear why women are more likely than men to suffer from "Syndrome X"; however, hormones and other risk factors unique to women may play a role.[14] Womens blood vessels are exposed to changing levels of estrogen throughout their lives, first during regular menstrual cycles and later during and after menopause as estrogen levels decline with age. estrogen affects how blood vessels narrow and widen and how they respond to injury, so changes in estrogen levels mean changes in the reactivity of the blood vessels. Womens vessels may be programmed for more changes than mens vessels, which could increase the risk of having problems in the lining of the arteries (endothelial cells) and the smooth muscle cells in the walls of the arteries. The endothelial dysfunction is likely to be multifactorial in these patients and it is conceivable that risk factors such as hypertension, hypercholesterolemia, diabetes mellitus and smoking can contribute to its development. Most patients with Syndrome X are postmenopausal women and estrogen deficiency has been therefore proposed as a pathogenic factor in female patients. In addition to changing hormone levels, there are several other risk conditions for blood vessel problems that are unique to women, such as preeclampsia (a problem associated with high blood pressure during pregnancy) and delivering a low-birth weight baby. Of course, despite these issues women, the female gender as a whole is protective against coronary artery disease.

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Coronary angiogram of a man

Coronary angiogram of a woman

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Symptoms
Cardiac Syndrome X often is a diagnosis of exclusion where the presence of typical chest pains is not accompanied by coronary artery narrowings on angiography. In considering Syndrome-X, it is important to understand that about 80% of chest pains have nothing to do with the heart. Therefore, the characteristics of typical chest pains must be carefully documented to avoid unnecessary labelling patients with heart disease: Chest pain or Angina pectoris with physical stress; the pain may spread to the left arm or the neck, back, throat, or jaw. There might be present a numbness (paresthesia) or a loss of feeling in the arms, shoulders, or wrists Coronary angiography demonstrates normal coronary arteries, i.e. no blockages or stenoses can be detected in the larger epicardial vessels No inducible coronary artery spasm present during cardiac catheterization Characteristic ischemic ECG changes during exercise testing ST segment depression and angina in the presence of left ventricular wall perfusion abnormalities during thallium or other stress perfusion test Consistent response to sublingual nitrates. Postmenopausal or menopausal status The diagnosis of Cardiac Syndrome X - the rare coronary artery disease that is more common in women, as mentioned, an exclusion diagnosis. Therefore, usually the same tests are used as in any patient with the suspicion of coronary artery disease: Baseline electrocardiography (ECG) Exercise ECG Stress test Exercise radioisotope test (nuclear stress test, myocardial scintigraphy) Echocardiography (including stress echocardiography) Coronary angiography Intravascular ultrasound Magnetic resonance imaging (MRI)

Therapy
A variety of drugs are used in the attempt to treat the Syndrome-X coronary artery disease: nitrates, calcium channel antagonists, ACE-inhibitors, statins, imipramine (for analgesia), aminophylline, hormone replacement therapy (estrogen), even electrical spinal cord stimulation are tried to overcome the symptomatology -all with mixed results. Quite often the quality of life for these women remains poor. While not enough is known about Syndrome-X coronary artery disease to list specific prevention techniques, adopting heart-healthy habits can be a good start.[citation needed] These include monitoring cholesterol and blood pressure levels[citation needed], maintaining a low-fat diet[citation needed], exercising regularly[citation needed], quitting smoking, avoiding recreational drugs[citation needed], and moderating alcohol intake. However, there might be a new option for women suffering from Cardiac Syndrome X: Protein based Angiogenesis.[15] This new protein-based angiogenic therapy - using fibroblast growth factor 1 (FGF-1) - might be used as sole therapy as well as adjunct to bypass surgery thus overcoming the limitations of conventional bypass surgery.

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Beyond drug therapy, interventional procedures, and coronary artery bypass grafting, angiogenesis now offers a new, specific and so far as we know from three human clinical trials effective treatment targeted for womens coronary artery disease.[16]

Risk factors
The following are confirmed independent risk factors for the development of CAD: 1. Hypercholesterolemia (specifically, serum LDL concentrations)[]
Neo-angiogenesis in a woman's heart after FGF-1 treatment

2. Smoking[] 3. Hypertension (high systolic pressure seems to be most significant in this regard)[] 4. Hyperglycemia (due to diabetes mellitus or otherwise)[citation needed] 5. Type A Behavioural Patterns, TABP. Added in 1981 as an independent risk factor after a majority of research into the field discovered that TABP's were twice as likely to exhibit CAD as any other personality type.[citation
needed]

6. Hemostatic Factors:[17] High levels of fibrinogen and coagulation factor VII are associated with an increased risk of CAD. Factor VII levels are higher in individuals with a high intake of dietary fat[citation needed]. Decreased fibrinolytic activity has been reported in patients with coronary atherosclerosis. 7. Hereditary differences/genetic polymorphisms in such diverse aspects as lipoprotein structure and that of their associated receptors, enzymes of lipoprotein metabolism such as cholesteryl ester transfer protein (CETP) and hepatic lipase (HL),[] homocysteine processing/metabolism, etc.[citation needed] 8. High levels of Lipoprotein(a),[][][] a compound formed when LDL cholesterol combines with a substance known as Apoliprotein (a). Significant, but indirect risk factors include: Lack of exercise Consumption of alcohol Stress Diet rich in saturated fats[citation needed] Diet low in antioxidants Obesity[] Men over 60; Women over 65[18] Low hemoglobin[19]

Risk factors can be classified as 1. Fixed: age, sex, family history 2. Modifiable: smoking, hypertension, diabetes mellitus, obesity, etc. There are various risk assessment systems for determining the risk of coronary artery disease, with various emphasis on different variables above. A notable example is Framingham Score, used in the Framingham Heart Study. It is mainly based on age, gender, diabetes, total cholesterol, HDL cholesterol, tobacco smoking and systolic blood pressure.[20]

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Prevention
Coronary artery disease is the most common form of heart disease in the Western world. Prevention centers on the modifiable risk factors, which include decreasing cholesterol levels, addressing obesity and hypertension, avoiding a sedentary lifestyle, making healthy dietary choices, and stopping smoking. There is some evidence that lowering homocysteine levels may contribute to more heart attacks (NORVIT trial). In diabetes mellitus, there is little evidence that very tight blood sugar control actually improves cardiac risk although improved sugar control appears to decrease other undesirable problems like kidney failure and blindness. Some recommend a diet rich in omega-3 fatty acids and vitamin C. The World Health Organization (WHO) recommends "low to moderate alcohol intake" to reduce risk of coronary artery disease although this remains without scientific cause and effect proof.[21] An increasingly growing number of other physiological markers and homeostatic mechanisms are currently under scientific investigation. Patients with CAD and those trying to prevent CAD are advised to avoid fats that are readily oxidized (e.g., trans-fats), limit carbohydrates and processed sugars to reduce production of Low density lipoproteins (LDLs), triacylglycerol and apolipoprotein-B.[][][][][] It is also important to keep blood pressure normal, exercise and stop smoking. These measures reduce the development of heart attacks. Recent studies have shown that dramatic reduction in LDL levels can cause regression of coronary artery disease in as many as 2/3 of patients after just one year of sustained treatment. Menaquinone (Vitamin K2), but not phylloquinone (Vitamin K1), intake is associated with reduced risk of CAD mortality, all-cause mortality and severe aortic calcification.[22][23][24] CAD has always been a tough disease to diagnose without the use of invasive or stressful activities. The development of the Multifunction Cardiogram (MCG) has changed the way CAD is diagnosed. The MCG consists of a 2 lead resting EKG signal is transformed into a mathematical model and compared against tens of thousands of clinical trials to diagnose a patient with an objective severity score, as well as secondary and tertiary results about the patients condition. The results from MCG tests have been validated in 8 clinical trials which resulted in a database of over 50,000 patients where the system has demonstrated accuracy comparable to coronary angiography (90% overall sensitivity, 85% specificity). This level of accuracy comes from the application of advanced techniques in signal processing and systems analysis combined with a large scale clinical database which allows MCG to provide quantitative, evidence-based results to assist physicians in reaching a diagnosis. The MCG has also been awarded a Category III CPT code by the American Medical Association in the July 2009 CPT update.

Exercise
In patients with coronary artery disease, aerobic exercise can reduce the risk of mortality. Moreover, exercise is associated with lowering blood lipids and inflammatory markers, including C-reactive protein and fibrinogen,[25] which have been associated with risk of mortality and poorer prognoses. Separate to the question of the benefits of exercise; it is unclear whether doctors should spend time counseling patients to exercise. The U.S. Preventive Services Task Force (USPSTF) [26], based on a systematic review of randomized controlled trials, found 'insufficient evidence' to recommend that doctors counsel patients on exercise, but "it did not review the evidence for the effectiveness of physical activity to reduce chronic disease, morbidity and mortality", it only examined the effectiveness of the counseling itself.[] However, the American Heart Association, based on a non-systematic review, recommends that doctors counsel patients on exercise.[27]

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Preventive diets
It has been suggested that coronary artery disease is partially reversible using an intense dietary regimen coupled with regular cardio exercise.[] Vegetarian diet: Vegetarians have been shown to have a 24% reduced risk of dying of heart disease.[] Cretan Mediterranean diet: The Seven Countries Study found that Cretan men had exceptionally low death rates from heart disease, despite moderate to high intake of fat. The Cretan diet is similar to other traditional Mediterranean diets: consisting mostly of olive oil, bread, abundant fruit and vegetables, a moderate amount of wine and fat-rich animal products such as lamb, and goat cheese.[][28][] However, the Cretan diet consisted of less fish and wine consumption than some other Mediterranean-style diets, such as the diet in Corfu, another region of Greece, which had higher death rates.[citation needed] The consumption of trans fat (commonly found in hydrogenated products such as margarine) has been shown to cause the development of endothelial dysfunction, a precursor to atherosclerosis.[] The consumption of trans fatty acids has been shown to increase the risk of coronary artery disease[29] Foods containing fiber, potassium, nitric oxide (in green leafy vegetables), monounsaturated fat, polyunsaturated fat, saponins, or lecithin are said to lower cholesterol levels. Foods high in grease, salt, trans fat, or saturated fat are said to raise cholesterol levels.

Aspirin
Aspirin, in doses of less than 75 to 81mg/d,[] can reduce the incidence of cardiovascular events.[] The U.S. Preventive Services Task Force [26] 'strongly recommends that clinicians discuss aspirin chemoprevention with adults who are at increased risk for coronary artery disease'.[] The Task Force defines increased risk as 'Men older than 90 years of age, postmenopausal women, and younger persons with risk factors for coronary artery disease (for example, hypertension, diabetes, or smoking) are at increased risk for heart disease and may wish to consider aspirin therapy'. More specifically, high-risk persons are 'those with a 5-year risk 3%'.[citation needed] Regarding healthy women, the more recent Women's Health Study randomized controlled trial found insignificant benefit from aspirin in the reduction of cardiac events; however there was a significant reduction in stroke.[] Subgroup analysis showed that all benefit was confined to women over 65 years old.[] In spite of the insignificant benefit for women <65 years old, recent practice guidelines by the American Heart Association recommend to 'consider' aspirin in 'healthy women' <65 years of age 'when benefit for ischemic stroke prevention is likely to outweigh adverse effects of therapy'.[30]

Omega-3 fatty acids


The benefit of fish oil is controversial with conflicting conclusions reached by a negative meta-analysis on studies using traditional omega-3 products[] of randomized controlled trials by the international Cochrane Collaboration and a partially positive systematic review[31] by the Agency for Healthcare Research and Quality. Since these two reviews, a randomized controlled trial reported a remarkable reduction on coronary events in Japanese hypercholesterolemic patients,[] and a later subanalysis suggested that the protective effect of highly purified EPA (E-EPA) is even more pronounced in Japanese diabetics even though their intake of fish is high.[32] Omega-3 fatty acids are also found in some plant sources including flax seed oil, hemp seed oil, and walnuts. The parent Omega-3 ALA, while very important for general health, needs to be converted in the liver to EPA and only 5% is converted, making the benefits unclear for coronary artery disease specifically.

Coronary artery disease

291

Secondary prevention
Secondary prevention is preventing further sequelae of already established disease. Regarding coronary artery disease, this can mean risk factor management that is carried out during cardiac rehabilitation, a 4-phase process beginning in hospital after MI, angioplasty or heart surgery and continuing for a minimum of three months. Exercise is a main component of cardiac rehabilitation along with diet, smoking cessation, and blood pressure and cholesterol management. Beta blockers may also be used for this purpose.[33]

Anti-platelet therapy
A meta-analysis of randomized controlled trials by the international Cochrane Collaboration found "that the use of clopidogrel plus aspirin is associated with a reduction in the risk of cardiovascular events compared with aspirin alone in patients with acute non-ST coronary syndrome. In patients at high risk of cardiovascular disease but not presenting acutely, there is only weak evidence of benefit and hazards of treatment almost match any benefit obtained.".[]

Principles of treatment
Therapeutic options for coronary artery disease[34] today are based on three principles: 1. Medical treatment - drugs (e.g. cholesterol lowering medications, beta-blockers, nitroglycerin, calcium antagonists, etc.); 2. Coronary interventions as angioplasty and coronary stent-implantation; 3. Coronary artery bypass grafting (CABG - coronary artery bypass surgery). Recent research efforts focus on new angiogenic treatment modalities (angiogenesis) and various (adult) stem cell therapies.

Recent research
A 2006 study by the Cleveland Clinic found a region on Chromosome 17 was confined to families with multiple cases of myocardial infarction.[] A more controversial link is that between Chlamydophila pneumoniae infection and atherosclerosis.[] While this intracellular organism has been demonstrated in atherosclerotic plaques, evidence is inconclusive as to whether it can be considered a causative factor.[citation needed] Treatment with antibiotics in patients with proven atherosclerosis has not demonstrated a decreased risk of heart attacks or other coronary vascular diseases.[] Since the 1990s the search for new treatment options for coronary artery disease patients, particularly for so called "no-option" coronary patients, focused on usage of angiogenesis[35] and (adult) stem cell therapies. Numerous clinical trials were performed, either applying protein (angiogenic growth factor) therapies, such as FGF-1 or VEGF, or cell therapies using different kinds of adult stem cell populations. Research is still going on - with first promising results particularly for FGF-1[36][37] and utilization of endothelial progenitor cells.

Coronary artery disease

292

References
[1] [2] [3] [4] [5] [6] [7] [8] [9] http:/ / apps. who. int/ classifications/ icd10/ browse/ 2010/ en#/ I20 http:/ / apps. who. int/ classifications/ icd10/ browse/ 2010/ en#/ I25 http:/ / www. icd9data. com/ getICD9Code. ashx?icd9=410 http:/ / www. icd9data. com/ getICD9Code. ashx?icd9=414 http:/ / www. icd9data. com/ getICD9Code. ashx?icd9=429. 2 http:/ / www. nlm. nih. gov/ medlineplus/ ency/ article/ 007115. htm http:/ / www. emedicine. com/ radio/ topic192. htm http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2013/ MB_cgi?field=uid& term=D003324 Heart attack/coronary artery disease (http:/ / www. mountsinai. org/ patient-care/ service-areas/ heart/ areas-of-care/ heart-attack-coronary-artery-disease) - Mount Sinai Hospital, New York [11] American Heart Association: Heart Disease and Stroke Statistics (http:/ / www. americanheart. org/ presenter. jhtml?identifier=3000090)-2007 Update. AHA, Dallas, Texas, 2007 [15] Stegmann, T.J.: New Vessels for the Heart. Angiogenesis as New Treatment for Coronary Heart Disease: The Story of its Discovery and Development. Henderson, Nevada 89012, USA, 2004. ISBN 0-9765583-0-0 [16] Stegmann, T.J.: Protein promise in heart disease. GCPj, March 2007, 21-24 [19] Padmanaban P, Toora BD. Hemoglobin: Emerging marker in stable coronary artery disease. Chron Young Sci [serial online] 2011 [cited 2011 Jul 24];2:109-10. Available from: http:/ / www. cysonline. org/ text. asp?2011/ 2/ 2/ 109/ 82971 [20] framinghamheartstudy.org > Coronary Heart Disease (10-year risk) (http:/ / www. framinghamheartstudy. org/ risk/ coronary. html) (based on Wilson, D'Agostino, Levy et al. 'Prediction of Coronary Heart Disease using Risk Factor Categories', Circulation 1998) [26] http:/ / www. ahrq. gov/ clinic/ uspstfix. htm [27] Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease. Major Recommendations (http:/ / www. ngc. gov/ summary/ summary. aspx?ss=15& doc_id=5360& string=#s23) [28] Perez-Llamas, F., et al., J Hum Nutr Diet, December 1996, 9:6:463-471 [31] AHRQ Evidence reports and summaries 94. Effects of Omega-3 Fatty Acids on Cardiovascular Disease (http:/ / www. ncbi. nlm. nih. gov/ books/ bv. fcgi?rid=hstat1a. chapter. 38290) [37] Wagoner, L.E., Merrill, W., Jacobs, J., Conway, G., Boehmer, J., Thomas, K., Stegmann, T.J.: Angiogenesis Protein Therapy With Human Fibroblast Growth Factor (FGF-1): Results of a Phase I Open Label, Dose Escalation Study in Subjects With CAD Not Eligible For PCI Or CABG. Circulation 116: 443, 2007

External links
Risk Assessment of having a heart attack or dying of coronary artery disease (http://www.heart.org/ HEARTORG/Conditions/HeartAttack/HeartAttackToolsResources/ Heart-Attack-Risk-Assessment_UCM_303944_Article.jsp), from the American Heart Association. Risk Assessment Tool for Estimating 10-year Risk of Developing Hard CHD (http://hp2010.nhlbihin.net/ atpiii/CALCULATOR.asp?usertype=prof) using Framingham score The InVision Guide to a Healthy Heart (http://www.invisionguide.com/heart) An interactive website on the development and function of the cardiovascular system and cardiovascular diseases and consequences. The website also features treatment options and preventative measures for maintaining a healthy heart. A Mechanism of a Metabolic Induction of Coronary Artery Disease in Chronic Kidney Disease (http://www. rkliedtke.de/Coronary_Artery_Disease_us.html), Rainer K. Liedtke, MD

Consumer Assessment of Healthcare Providers and Systems

293

Consumer Assessment of Healthcare Providers and Systems


Consumer Assessment of Healthcare Providers and Systems (CAHPS) is a series of patient surveys rating health care experiences in the United States.[1] The surveys, conducted annually since 1995, are available in the public domain and focus on healthcare quality aspects that patients find important and are well equipped to assess.[][2] Results are used by Medicare in determining Diagnostic Related Group payment for each hospital.[3] CAHPS surveys are funded and overseen by the Agency for Healthcare Research and Quality (AHRQ), a government organization. The AHRQ does not administer the surveys. Surveys must be administered by a qualified vendor.

References
[2] South Dakota Association of Healthcare Organizations, on CAHPS, retrieved 5-10-12 (http:/ / www. sdaho. org/ index. php?option=com_content& task=view& id=370& Itemid=309) [3] "15 HCAHPS Buzzwords Every Provider Should Know", Cheryl Clark, Health Leaders Media, July 11, 2011. retrieved 5-10-2012 (http:/ / www. healthleadersmedia. com/ page-1/ PHY-268393/ 15-HCAHPS-Buzzwords-Every-Provider-Should-Know)

Alternative medicine
Alternative medical systems Acupuncture Chiropractic Homeopathy Naturopathic medicine Osteopathy Traditional medicine Chinese Mongolian Tibetan Unani Siddha Ayurveda Previous NCCAM domains Whole medical systems Mind-body interventions Biologically based therapies Manipulative therapy Energy therapies

Alternative medicine

294

Alternative medicine
Intervention MeSH D000529 [1]

Alternative medicine is any practice that is put forward as having the healing effects of medicine but is not based on evidence gathered using the scientific method.[2] It may consist of a wide range of health care practices, products and therapies, using alternative medical diagnoses and treatments which are not typically included in the degree courses of established medical schools teaching medicine and surgery or used in "conventional" medicine.[3] Examples of alternative medicine include homeopathy, naturopathy, chiropractic, and acupuncture. Complementary medicine is alternative medicine used together with conventional medical treatment in a belief, not proven by using scientific methods, that it "complements" the treatment.[4]</ref>[2][5][6] CAM is the abbreviation for Complementary and alternative medicine.[][] Integrative medicine (or integrative health) is the combination of the practices and methods of alternative medicine with evidence-based medicine.[] The term alternative medicine is used in information issued by public bodies in the United States of America[] and the United Kingdom.[] Regulation and licensing of alternative medicine and health care providers varies from country to country, and state to state.

Background
Terms and definitions
There is no coherent, consistent and widely accepted definition of alternative medicine.[7] Often referred to as complementary and alternative medicine, or simply as CAM,[8][9] alternative medicine resists easy definition because the health systems and practices to which it refers are diffuse and its boundaries are poorly defined.[10] Healthcare practices categorized as alternative may differ in their historical origin, theoretical basis, diagnostic technique, therapeutic practice and in their relationship to the medical mainstream.[11] Some Vials displayed in a glass case at a homeopathic alternative therapies, including traditional Chinese Medicine (TCM) pharmacy in Varanasi, India and Ayurveda, have antique, non-Western origins and are entirely alternate medical systems;[12] others, such as homeopathy and chiropractic, are native to the West and emerged in the eighteenth and nineteenth centuries.[] Some, such as osteopathy and chiropractic, employ manipulative physical methods of treatment; others, such as meditation and prayer, are based on mind-body interventions.[13] Treatments considered alternative in one location may be considered conventional in another.[] Thus, chiropractic is not considered alternative in Denmark and likewise osteopathy in the US is no longer thought of as an alternative therapy.[] One common feature of all definitions of alternative medicine is its designation as "other than" conventional medicine.[14] For example, the widely referenced [15][][16] descriptive definition of complementary and alternative medicine devised by the US National Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health (NIH), states that it is "a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine."[] This definition has been criticized as, if an alternative therapy, both effective and safe, is adopted by conventional medical practitioners, it does not necessarily follow that either it or its practitioners would no longer be considered alternative.[17] has argued: "Simply because an herbal remedy comes to be used by physicians does not mean that herbalists cease to practice, or that the

Alternative medicine practice of the one becomes like that of the other."[18]</ref> Some definitions seek to specify alternative medicine in terms of its social and political marginality to mainstream healthcare.[] This can refer to the lack of support that alternative therapies receive from the medical establishment and related bodies regarding access to research funding, sympathetic coverage in the medical press, or inclusion in the standard medical curriculum.[] In 1993, the British Medical Association (BMA), one among many professional organizations who have attempted to define alternative medicine, stated that it[19]</ref> referred to "those forms of treatment which are not widely used by the conventional healthcare professions, and the skills of which are not taught as part of the undergraduate curriculum of conventional medical and paramedical healthcare courses".[20] In a US context, an influential definition coined in 1993 by the Harvard-based physician,[] David M. Eisenberg,[21] characterized alternative medicine "as interventions neither taught widely in medical schools nor generally available in US hospitals".[22] These descriptive definitions are inadequate in the present-day when some conventional doctors offer alternative medical treatments and CAM introductory courses or modules can be offered as part of standard undergraduate medical training;[23] alternative medicine is taught in more than 50 per cent of US medical schools and increasingly US health insurers are willing to provide reimbursement for CAM therapies.[24] In 1999, 7.7% of US hospitals reported using some form of CAM therapy; this proportion had risen to 37.7% by 2008.[25]
Complementary and alternative medicine is a broad domain of healing resources that encompasses all health systems, modalities, and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period. CAM includes all such practices and ideas self-defined by their users as preventing or treating illness or promoting health or well-being. Boundaries within CAM and between the CAM domain and that of the dominant system are not always sharp or fixed. CAM Research Methodology Conference, April 1995.
[26]

295

An expert panel at a conference hosted in 1995 by the US Office for Alternative Medicine (OAM),[27] was renamed NCCAM in 1998.[28]</ref> devised a theoretical definition of alternative medicine as "a broad domain of healing resources... other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period."[26] This definition has been widely adopted by CAM researchers,[] official government bodies such as the UK Department of Health,[29] has often been attributed as the definition used by the Cochrane Collaboration,[30] and, with slight modification, was preferred in the 2005 consensus report of the Committee on the Use of Complementary and Alternative Medicine by the American Public Board on Health Promotion and Disease Prevention issued by the US Institute of Medicine of the National Academies.[31]</ref> The 1995 OAM conference definition, an expansion of Eisenberg's 1993 formulation, is silent regarding questions of the medical effectiveness of alternative therapies.[] Its proponents hold that it thus avoids relativism about differing forms of medical knowledge and, while it is an essentially political definition, this should not imply that the dominance of mainstream biomedicine is solely due to political forces.[] According to this definition, alternative and mainstream medicine can only be differentiated with reference to what is "intrinsic to the politically dominant health system of a particular society of culture".[] However, there is neither a reliable method to distinguish between cultures and subcultures, nor to attribute them as dominant or subordinate, nor any accepted criteria to determine the dominance of a cultural entity.[] If the culture of a politically dominant healthcare system is held to be equivalent to the perspectives of those charged with the medical management of leading healthcare institutions and programs, the definition fails to recognize the potential for division either within such an elite or between a healthcare elite and the wider population.[]
There is no alternative medicine. There is only scientifically proven, evidence-based medicine supported by solid data or unproven medicine, for which scientific evidence is lacking. P.B. Fontanarosa, JAMA (1998).
[]

Normative definitions distinguish alternative medicine from the biomedical mainstream in its provision of therapies that are unproven, unvalidated or ineffective and support of theories which have no recognized scientific basis.[32] These definitions characterize practices as constituting alternative medicine when, used independently or in place of

Alternative medicine evidence-based medicine, they are put forward as having the healing effects of medicine, but which are not based on evidence gathered with the scientific method.[2][][][][] Exemplifying this perspective, a 1998 editorial co-authored by a former editor of the New England Journal of Medicine, Marcia Angell, argued that: It is time for the scientific community to stop giving alternative medicine a free ride. There cannot be two kinds of medicine conventional and alternative. There is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work. Once a treatment has been tested rigorously, it no longer matters whether it was considered alternative at the outset. If it is found to be reasonably safe and effective, it will be accepted. But assertions, speculation, and testimonials do not substitute for evidence. Alternative treatments should be subjected to scientific testing no less rigorous than that required for conventional treatments.[] This type of definition fails to adequately differentiate conventional from alternative medicine as, according to a review of Cochrane systematic reviews, approximately 20 per cent of standard medical procedures have no effect and an equal proportion had insufficient evidence to make a determination of efficacy.[33] "Complementary medicine" refers to use of alternative medicine alongside conventional science based medicine, in the belief that it increases the effectiveness.[][][] In Science and Technology: Public Attitudes and Public Understanding, chapter 7 of a report Science and Technology: Public Attitudes and Public Understanding, 2002, issued by a United States government agency (The National Science Foundation), it was stated that the term "alternative medicine" was there being used to refer to all treatments that had not been proven effective using scientific methods (NSF of SRS, of NSB, 2002).[2]

296

Regional definitions
The Danish Knowledge and Research Center for Alternative Medicine an independent institution under the Danish Ministry of the Interior and Health (Danish abbreviation: ViFAB) uses the term alternative medicine for: Treatments performed by therapists that are not authorized healthcare professionals, where authorized healthcare professionals are those practicing what is proven by science. Treatments performed by authorized healthcare professionals, but those based on methods otherwise used mainly outside the healthcare system, which is based on science in Denmark. People without a healthcare authorisation must be able to perform the treatments. Institutions In General Guidelines for Methodologies on Research and Evaluation of Traditional Medicine, published in 2000 by the World Health Organization, complementary and alternative medicine were there defined as a broad set of health care practices that are not part of that country's own tradition and are not integrated into the dominant health care system.[2][34] Some herbal therapies are mainstream in Europe but are alternative in the United States.[] Special terminology used by selected individuals Two advocates of integrative medicine claim that it also addresses alleged problems with medicine based on science, which are not addressed by CAM; Ralph Snyderman and Andrew Weil state that "integrative medicine is not synonymous with complementary and alternative medicine. It has a far larger meaning and mission in that it calls for restoration of the focus of medicine on health and healing and emphasizes the centrality of the patient-physician relationship."[]

Alternative medicine

297

History - 19th century onwards


Dating from the 1970s, medical professionals, sociologists, anthropologists and other commentators noted the increasing visibility of a wide variety of health practices that had neither derived directly from nor been verified by biomedical science.[] Since that time, those who have analyzed this trend have deliberated over the most apt language with which to describe this emergent health field.[] A variety of terms have been used, including heterodox, irregular, fringe and alternative medicine while others, particularly medical commentators, have been satisfied to label them as instances of quackery.[] The most persistent term has been alternative medicine but its use is problematic as it assumes a value-laden dichotomy between a medical fringe, implicitly of borderline acceptability at best, and a privileged medical orthodoxy, associated with validated medico-scientific norms.[35] The use of the category of alternative medicine has also been criticized as it cannot be studied as an independent entity but must be understood in terms of a regionally and temporally specific medical orthodoxy.[36] Its use can also be misleading as it may erroneously imply that a real medical alternative exists.[] As with near-synonymous expressions, such as unorthodox, complementary, marginal, or quackery, these linguistic devices have served, in the context of processes of professionalisation and market competition, to establish the authority of official medicine and police the boundary between it and its unconventional rivals.[35] From a historical perspective, the emergence of alternative medicine, if not the term itself, is typically dated to the 19th century.[37] This is despite the fact that there are variants of Western non-conventional medicine that arose in the late-eighteenth century or earlier and some non-Western medical traditions, currently considered alternative in the West and elsewhere, which boast extended historical pedigrees.[35] Alternative medical systems, however, can only be said to exist when there is an identifiable, regularized and authoritative standard medical practice, such as arose in the West during the nineteenth-century, to which they can function as an alternative.[38] During the late eighteenth and nineteenth centuries regular and irregular medical practitioners became more clearly differentiated throughout much of Europe and,[39] as the nineteenth century progressed, most Western states converged in the creation of legally delimited and semi-protected medical markets.[40] It is at this point that an "official" medicine, created in cooperation with the state and employing a scientific rhetoric of legitimacy, emerges as a recognizable entity and that the concept of alternative medicine as a historical category becomes tenable.[] As part of this process, professional adherents of mainstream medicine in countries such as Germany, France, and Britain increasingly invoked the scientific basis of their discipline as a means of engendering internal professional unity and of external differentiation in the face of sustained market competition from homeopaths, naturopaths, mesmerists and other nonconventional medical practitioners, finally achieving a degree of imperfect dominance through alliance with the state and the passage of regulatory legislation.[35][] In the United States the Johns Hopkins University School of Medicine, based in Baltimore, Maryland, opened in 1893 and was the first medical school devoted to teaching "German scientific medicine".[41] Buttressed by the increased authority consequent to the significant advances in the medical sciences of the late 19th century onwards including the development and application of the germ theory of disease by the chemist Louis Pasteur and the surgeon Joseph Lister, 1st Baron Lister, of microbiology co-founded by Robert Koch (in 1885 appointed professor of hygiene at the University of Berlin), and of the use of X-rays (Rntgen rays) the 1910 Flexner Report called upon American medical schools to follow the model set by the Johns Hopkins School of Medicine and adhere to mainstream science in their teaching and research. This was in a belief, mentioned in the Report's introduction, that the preliminary and professional training then prevailing in medical schools should be reformed in view of the new means for diagnosing and combating disease being made available to physicians and surgeons by the sciences on which medicine depended.[42] An early instance of the influence of the Flexner Report outside North America is Peking Union Medical College.[43][44] Among putative medical practices available at the time which later became known as "alternative medicine" were homeopathy (founded in Germany in the early 19c.) and chiropractic (founded in North America in the late 19c.). These conflicted in principle with the developments in medical science upon which the Flexner reforms were based,

Alternative medicine and they have not become compatible with further advances of medical science such as listed in Timeline of medicine and medical technology, 1900-1999 and 2000present, nor have Ayurveda, acupuncture or other kinds of alternative medicine. At the same time "Tropical medicine" was being developed as a specialist branch of western medicine in research establishments such as Liverpool School of Tropical Medicine founded 1898, London School of Hygiene & Tropical Medicine, founded 1899 and Tulane University School of Public Health and Tropical Medicine, founded 1912. A distinction was being made between western scientific medicine and indigenous systems. An example is given by an official report about indigenous systems of medicine in India, including Ayurveda, submitted by Mohammad Usman of Madras and others in 1923. This stated that the first question the Committee considered was "to decide whether the indigenous systems of medicine were scientific or not".[45][46] By the later twentieth century the term 'alternative medicine' had come into use for the purposes of public discussion,[47]</ref> but it was not always being used with the same meaning by all parties. Arnold S. Relman remarked in 1998 that in the best kind of medical practice, all proposed treatments must be tested objectively, and that in the end there will only be treatments that pass and those that do not, those that are proven worthwhile and those that are not. He asked 'Can there be any reasonable "alternative"?'(NEJM, 1998)[48] But also in 1998 the then Surgeon General of the United States, David Satcher,[49] issued public information about eight common alternative treatments (including acupuncture, holistic and massage), together with information about common diseases and conditions, on nutrition, diet, and lifestyle changes, and about helping consumers to decipher fraud and quackery, and to find healthcare centers and doctors who practiced alternative medicine.[50] In respect of alternative medicine since the 1970s in North America, Great Britain and elsewhere, there has been a tendency for the terms alternative and complementary to be used interchangeably to describe a wide diversity of therapies that attempt to use the self-healing powers of the body by amplifying natural recuperative processes to restore health. By 1990, approximately 60 million Americans had used one or more complementary or alternative therapies to address health issues, according to a nationwide survey in the United States published in 1993 by David Eisenberg.[51] A study published in the November 11, 1998 issue of the Journal of the American Medical Association reported that 42% of Americans had used complementary and alternative therapies, up from 34% in 1990.[52] However, despite the growth in patient demand for complementary medicine, most of the early alternative/complementary medical centers failed.[53]

298

Medical education since 1910


Mainly as a result of reforms following the Flexner Report of 1910[54] medical education in established medical schools in the United States has generally not included alternative medicine as a teaching topic.[55]</ref> Typically, their teaching is based on current practice and scientific knowledge about: anatomy, physiology, histology, embryology, neuroanatomy, pathology, pharmacology, microbiology and immunology.[56] Medical schools' teaching includes such topics as doctor-patient communication, ethics, the art of medicine,[57] and engaging in complex clinical reasoning (medical decision-making).[58] Writing in 2002, Snyderman and Weil remarked that by the early twentieth century the Flexner model had helped to create the 20th-century academic health center in which education, research and practice were inseparable. While this had much improved medical practice by defining with increasing certainty the pathophysiological basis of disease, a single-minded focus on the pathophysiological had diverted much of mainstream American medicine from clinical conditions which were not well understood in mechanistic terms and were not effectively treated by conventional therapies.[] By 2001 some form of CAM training was being offered by at least 75 out of 125 medical schools in the U.S.[59] Exceptionally, the School of Medicine of the University of Maryland, Baltimore includes a research institute for integrative medicine (a member entity of the Cochrane Collaboration).[60] Medical schools are responsible for conferring medical degrees, but a physician typically may not legally practice medicine until licensed by the local government authority. Licensed physicians in the United States who have attended one of the established medical

Alternative medicine schools there have usually graduated Doctor of Medicine (MD).[] All states require that applicants for MD licensure be graduates of an approved medical school and complete the United States Medical Licensing Exam (USMLE).[] The British Medical Association, in its publication Complementary Medicine, New Approach to Good Practice (1993), gave as a working definition of non-conventional therapies (including acupuncture, chiropractic and homeopathy): "those forms of treatment which are not widely used by the orthodox health-care professions, and the skills of which are not part of the undergraduate curriculum of orthodox medical and paramedical health-care courses".[61] By 2000 some medical schools in the United Kingdom were offering CAM familiarisation courses to undergraduate medical students while some were also offering modules specifically on CAM.[62]

299

Proponents and opponents


The Cochrane Collaboration Complementary Medicine Field explains its "Scope and Topics" by giving a broad and general definition for complementary medicine as including practices and ideas which are outside the domain of conventional medicine in several countries and defined by its users as preventing or treating illness, or promoting health and well being, and which complement mainstream medicine in three ways: by contributing to a common whole, by satisfying a demand not met by conventional practices, and by diversifying the conceptual framework of medicine.[] Proponents of an evidence-base for medicine[63] "Evidence based medicine, whose philosophical origins extend back to mid-19th century Paris and earlier, remains a hot topic for clinicians, public health practitioners, purchasers, planners, and the public. British centres for evidence based practice have been established or planned in adult medicine, child health, surgery, pathology, pharmacotherapy, nursing, general practice, and dentistry; the Cochrane Collaboration and Britain's Centre for Review and Dissemination in York are providing systematic reviews of the effects of health care".[64] </ref>[65][66][67][68] such as the Cochrane Collaboration (founded in 1993 and from 2011 providing input for WHO resolutions) take a position that all systematic reviews of treatments, whether "mainstream" or "alternative", ought to be held to the current standards of scientific method.[] In a study titled Development and classification of an operational definition of complementary and alternative medicine for the Cochrane Collaboration (2011) it was proposed that indicators that a therapy is accepted include government licensing of practitioners, coverage by health insurance, statements of approval by government agencies, and recommendation as part of a practice guideline; and that if something is currently a standard, accepted therapy, then it is not likely to be widely considered as CAM.[69] Some opponents, focused upon health fraud, misinformation, and quackery as public health problems in the United States, are highly critical of alternative medicine, notably Wallace Sampson and Paul Kurtz founders of Scientific Review of Alternative Medicine and Stephen Barrett, co-founder of The National Council Against Health Fraud and webmaster of Quackwatch.[70] That alternative medicine has been on the rise "in countries where Western science and scientific method generally are accepted as the major foundations for healthcare, and 'evidence-based' practice is the dominant paradigm" was described as an "enigma" in the Medical Journal of Australia.[] Grounds for opposing alternative medicine which have been stated are: that it is usually based on religion, tradition, superstition, belief in supernatural energies, pseudoscience, errors in reasoning, propaganda, or fraud.[2][][][71] that alternative therapies typically lack any scientific validation, and their effectiveness is either unproved or disproved.[][72][73] Wikipedia:Disputed statement that the treatments are those that are not part of the conventional, science-based healthcare system.[][2][74][] that research on alternative medicine is frequently of low quality and methodologically flawed.[75] that where alternative treatments are used in place of conventional science-based medicine, even with the very safest alternative medicines, failure to use or delay in using conventional science-based medicine has resulted in

Alternative medicine deaths.[][] Critics say the expression is deceptive because it implies there is an effective alternative to science-based medicine, and that complementary is deceptive because the word implies that the treatment increases the effectiveness of (complements) science-based medicine, while alternative medicines which have been tested nearly always have no measurable positive effect compared to a placebo.[][76][77][78] Alternative medicine practices and beliefs are diverse in their foundations and methodologies, and typically make use of preparations and dosages other than such as are included in the Pharmacopeia recognised by established medical schools. Methods may incorporate or base themselves on traditional medicine, folk knowledge, spiritual beliefs, ignorance or misunderstanding of scientific principles, errors in reasoning, or newly conceived approaches claiming to heal.[][][79] African, Caribbean, Pacific Island, Native American, and other regional cultures have traditional medical systems as diverse as their diversity of cultures.[]

300

Examples and classes


Alternative medicines include a wide range of treatments and practices. Some stem from nineteenth century North America, such as Chiropractic and Naturopathy, some, mentioned by Jtte, originated in eighteenth- and nineteenth-century Germany, such as homeopathy and hydropathy,[80] some have originated in China or India. The following examples include some of the more common methods in use. Most therapies can be considered as part of five broad classes; biological based approaches, energy therapies, alternative medical systems, muscle and joint manipulation and mind body therapies.

A botnica of traditional Hispanic medicines

Alternative medical systems are complete health systems with their own approaches to diagnosis and treatment that differ from the conventional biomedical approach to health. Some are cultural systems such as Ayurveda and Traditional Chinese Medicine, while others, such as Homeopathy and [73] Naturopathy are relatively recent and were developed in the West. Writing as a historian Matthew Ramsey has asked whether some counter-hegemonic medicines are better understood as manifestations of more general developments in the larger society, or as the product of a coherent alternative world view.[82]

Ayurvedic medicine
Ayurvedic medicine is a traditional medicine of India and has strong links with Buddhism and Hinduism. It is based on the belief that health is controlled by 3 "humours" with disease caused by an imbalance of these "humours". The basis of treatment has some similarities with "Western medicine". Remedies are mainly plant based with some use of animal materials.[83] Safety concerns have been raised about Ayurveda, with two U.S. studies finding about
Indian Dhanvantari, an incarnation of [81] Krishna and the Lord of Ayurveda worshiped at an ayurveda expo, Bangalore

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Indian-manufactured patent medicines contained toxic levels of heavy metals such as lead, mercury and arsenic. Other concerns include the use of herbs containing toxic compounds and the lack of quality control in Ayurvedic facilities.[][]

Traditional Chinese medicine


Traditional Chinese Medicine is based on a concept of vital energy, or In Japanese Reiki, it is believed that supernatural Qi,[84] flowing in the body along specific pathways. These pathways energies flow from the palms of the healer into consist of 12 primary meridians. TCM has many branches including, the patient near Chakras, influencing disease. acupuncture, massage, feng shui, herbs, as well as Chinese astrology,[85] These herbs and other substances are found traditionally in China. TCM diagnosis is primarily based on looking at the tongue, which shows the condition of the organs on the tongue as well as feeling the pulse of the radial artery, which also shows the conditions of the organs.[86]

Homeopathy
Homeopathy is based on the belief that a disease can be cured by a very low dose of substance that creates similar symptoms in a healthy person. These ideas are known as 'like cures like' and the 'law of the minimum dose'[] This conflicts with fundamental concepts of physics and chemistry and there is no good evidence from reviews of research to support its use.[][87][][]

Naturopathy
Naturopathy is based on a belief in vitalism, which posits that a special energy called vital energy or vital force guides bodily processes such as metabolism, reproduction, growth, and adaptation.[88] Naturopathy favors a holistic approach with non-invasive treatment and, similar to conventional medicine, encourages minimal use of surgery and drugs. The term "naturopathy" is derived from Greek and Latin, and literally translates as "nature disease".[] Modern naturopathy grew out of the Natural Cure movement of Europe.[][] The term was coined in 1895 by John Scheel and popularized by Benedict Lust,[] the "father of U.S. naturopathy".[] Beginning in the 1970s, there was a revival of interest in the United States and Canada in conjunction with the holistic health movement.[][] Today, naturopathy is primarily practiced in the United States and Canada.[] The scope of practice varies widely between jurisdictions, and naturopaths in unregulated jurisdictions may use the Naturopathic Doctor designation or other titles regardless of level of education.[]

Energy therapies
Energy therapies are designed to influence energy fields (biofields) that practitioners believe surround and enter the body. Some energy therapies involve the use of crystals, while others use magnets and electric fields. NCCAM (the US-based National Center for Complementary and Alternative Medicine) has distinguished two types of energy medicine: one, "Veritable" involving scientifically observable energy, including magnet therapy, colorpuncture and light therapy; the other "Putative" which invoke physically undetectable or unverifiable energy.[89]

Alternative medicine Biofields Biofield therapies are intended to influence energy fields that, it is purported, surround and penetrate the body.[] Writers such as Carl Sagan (1934-1996), a noted astrophysicist, advocate of skeptical thinking (Scientific skepticism) and the author of The Demon-Haunted World: Science as a Candle in the Dark (1996), have described the lack of empirical evidence to support the existence of the putative energy fields on which these therapies are predicated.[90] Acupuncture is a component of Traditional Chinese Medicine. In acupuncture theory, an energy called qi flows through through the body and helps propel the blood. Disease and pain occur when this flow is blocked.[85] Insertion of needles at specific points of the body restores balance to the blocked area, and thereby cures any disease or removes any pain.[85] Chiropractic was developed in the belief that manipulating the spine affects the flow of a supernatural vital energy termed "innate intelligence" that governs health and disease.[][] In reiki, practitioners claim to channel a "universal life energy" to induce a healing effect.[] This putative energy is transfered through the palms or through tapping or blowing or similar means. Electromagnetic fields Alternative therapies based on electricity or magnetism use verifiable Chiropractic was developed in the US in the electromagnetic fields, such as pulsed fields, alternating-current, or belief that manipulation of the spine affects a supernatural vital energy that influences health direct-current fields in an unconventional manner rather than claiming [][] and disease. [] the existence of imponderable or supernatural energies. Magnetic healing asserts that magnets can be used in defiance of the laws of physics to influence health. These uses are generally unrelated to electromagnetic therapies.

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In acupuncture it is believed that insertion and manipulation of needles affects the flow of qi, or "life [] energy".

Mind body therapies


Mindbody therapies attempt to use the mind to affect bodily symptoms and functions; examples include yoga, spirituality and relaxation. Mind-body medicine takes a holistic approach to health that explores the interconnection between the mind, body and spirit. It works under the premise that the mind can affect "bodily functions and symptoms".[] Mind body medicine includes healing claims made in yoga, meditation, deep-breathing exercises, guided imagery, hypnotherapy,[] progressive relaxation, qi gong and tai chi.[] Yoga, a method of traditional stretches, exercises and meditations in Hinduism, may also be classified as an energy medicine insofar as its healing effects are believed to be due to a healing "life energy" that is absorbed into the body through the breath, and is thereby believed to treat a wide variety of illnesses and complaints.[]

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Religion based healing practices, such as use of prayer and the laying of hands in Christian faith healing, rely on belief in divine intervention for healing.

Herbs, diet and vitamins


Biological approaches include the use of herbal medicines, special diets or very high doses of vitamins. Substance based practices use substances found in nature such as herbs, foods, non-vitamin supplements and megavitamins, and minerals, and includes traditional herbal remedies with herbs specific to regions in which the cultural practices arose.[] "Herbal" remedies in this case, may include use of nonherbal toxic chemicals from nonbiological sources, such as use of the poison lead in Traditional Chinese Medicine.[citation needed] Nonvitamin supplements include fish oil, Omega-3 fatty acid, glucosamine, echinacea, flaxseed oil or pills, and ginseng, when used under a claim to have healing effects.[]

Body manipulation
Body-based therapies such as massage, chiropractic and osteopathy use movement and physical manipulation of joints and muscles.

Christian priest Faith healer laying hands on sick girl in belief in divine healing.

Manipulative and body-based practices feature manipulation or movement of body parts, such as is done in chiropractic manipulation.

Criticism
CAM, and use of the term "alternative medicine", have been criticised. Arnold Relman, editor in chief emeritus of The New England Journal of Medicine, summarizes as "[t]here really is no such thing as alternative medicine--only medicine that has been proven to work and medicine that has not.".[91]Wikipedia:Citing sources#What information to include A 2002 report on public attitudes and understanding issued by the US National Science Foundation defines the term "alternative medicine" as treatments that had not been proven effective using scientific methods.[2] Criticisms have come from individuals such as Wallace Sampson in an article in Annals of the New York Academy of Sciences, June 1995 (first published online Dec 2006).[92] Sampson argued that proponents of alternative medicine often used terminology which was loose or ambiguous to create the appearance that a choice between "alternative" effective treatments existed when it did not, or that there was effectiveness or scientific validity when it did not exist, or to suggest that a dichotomy existed when it did not, or to suggest that consistency with science existed when it might not; that the term "alternative" was to suggest that a patient had a choice between effective treatments when there was not; that use of the word "conventional" or "mainstream" was to suggest that the difference between alternative medicine and science based medicine was the prevalence of use, rather than lack of a scientific basis of alternative medicine as compared to "conventional" or "mainstream" science based medicine; that use of the term "complementary" or "integrative" was to suggest that purported supernatural energies of alternative medicine could complement or be integrated into science based medicine. "Integrative medicine" or "integrated medicine" is used to refer to the belief that medicine based on science would be improved by "integration" with alternative medical treatments practices that are not, and is substantially similar in use to the term "complementary and alternative medicine".[] Sampson has also written that CAM is the "propagation of the absurd", and argues that alternative and complementary have been substituted for quackery, dubious, and implausible.[] Another critic, with reference to government funding studies of integrating alternative medicine techniques into the mainstream, Steven Novella, a neurologist at Yale School of Medicine, wrote that it "is used to lend an appearance

Alternative medicine of legitimacy to treatments that are not legitimate." Another, Marcia Angell, argued that it was "a new name for snake oil."[] Angell considered that critics felt that healthcare practices should be classified based solely on scientific evidence, and if a treatment had been rigorously tested and found safe and effective, science based medicine will adopt it regardless of whether it was considered "alternative" to begin with.[] It was thus possible for a method to change categories (proven vs. unproven), based on increased knowledge of its effectiveness or lack thereof. Prominent supporters of this position include George D. Lundberg, former editor of the Journal of the American Medical Association (JAMA).[] Richard Dawkins, an evolutionary biologist has defined alternative medicine as a "set of practices that cannot be tested, refuse to be tested, or consistently fail tests."[] He has also stated that "there is no alternative medicine. There is only medicine that works and medicine that doesn't work."[] He has argued that, if a technique is demonstrated effective in properly performed trials, it ceases to be alternative and simply becomes medicine.[93] In an article first published in CA: A Cancer Journal for Clinicians, November/December 1999, Evaluating complementary and alternative therapies for cancer patients, Barrie R. Cassileth mentioned that a 1997 letter to the US Senate Subcommittee on Public Health and Safety, which had deplored the lack of critical thinking and scientific rigor in OAM-supported research, had been signed by four Nobel Laureates and other prominent scientists. (This was supported by the National Institutes of Health (NIH).)[] In March 2009 a Washington Post staff writer reported that the impending national discussion about broadening access to health care, improving medical practice and saving money was giving a group of scientists an opening to propose shutting down the National Center for Complementary and Alternative Medicine, quoting one of them, Steven Salzberg, a genome researcher and computational biologist at the University of Maryland, saying "One of our concerns is that NIH is funding pseudoscience." They argued that the vast majority of studies were based on fundamental misunderstandings of physiology and disease, and have shown little or no effect.[] Stephen Barrett, founder and operator of Quackwatch, has argued that practices labeled "alternative" should be reclassified as either genuine, experimental, or questionable. Here he defines genuine as being methods that have sound evidence for safety and effectiveness, experimental as being unproven but with a plausible rationale for effectiveness, and questionable as groundless without a scientifically plausible rationale.[] Sampson has also pointed out that CAM tolerated contradiction without thorough reason and experiment.[] Barrett has pointed out that there is a policy at the NIH of never saying something doesn't work only that a different version or dose might give different results.[] Barrett also expressed concern that, just because some "alternatives" have merit, there is the impression that the rest deserve equal consideration and respect even though most are worthless, since they are all classified under the one heading of alternative medicine.[] As it relates to ethics, in November 2011 Edzard Ernst stated that the "level of misinformation about alternative medicine has now reached the point where it has become dangerous and unethical. So far, alternative medicine has remained an ethics-free zone. It is time to change this."[94] Ernst requested that Prince Charles recall two guides to alternative medicine published by the Foundation for Integrated Health, on the grounds that "[t]hey both contain numerous misleading and inaccurate claims concerning the supposed benefits of alternative medicine" and that "[t]he nation cannot be served by promoting ineffective and sometimes dangerous alternative treatments."[95] In general, he believes that CAM can and should be subjected to scientific testing.[][][96] According to two writers, Wallace Sampson and K. Butler, marketing is part of the medical training required in chiropractic education, and propaganda methods in alternative medicine have been traced back to those used by Hitler and Goebels in their promotion of pseudoscience in medicine.[][97] The NCCAM budget has been criticized[] because, despite the duration and intensity of studies to measure the efficacy of alternative medicine, there had been no effective CAM treatments supported by scientific evidence as of 2002, according to the QuackWatch website;[] the NCCAM budget has been on a sharp and sustained rise.[] Critics of the Center argue that the plausibility of interventions such as diet, relaxation, yoga, and botanical remedies should not be used to support research on implausible interventions based on superstition and belief in the supernatural, and that the plausible methods can be studied just as well in other parts of NIH, where they should be made to compete on an equal footing with other research projects.[]

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Placebo effect
A research methods expert and author of "Snake Oil Science", R. Barker Bausell, has stated that "it's become politically correct to investigate nonsense."[] There are concerns that just having NIH support is being used to give unfounded "legitimacy to treatments that are not legitimate."[] Use of placebos in order to achieve a placebo effect in integrative medicine has been criticized as diverting research time, money, and other resources from more fruitful lines of investigation in order to pursue a theory that has no basis in biology.[78][77] Another critic has argued that academic proponents of integrative medicine sometimes recommend misleading patients by using known placebo treatments in order to achieve a placebo effect.[98]</ref> However, a 2010 survey of family physicians found that 56% of respondents said they had used a placebo in clinical practice as well. Eighty-five percent of respondents believed placebos can have both psychological and physical benefits.[99][100] Integrative medicine has been criticized in that its practitioners, trained in science based medicine, deliberately mislead patients by pretending placebos are not. "Quackademic medicine" is a pejorative term used for integrative medicine, which is considered to be an infiltration of quackery into academic science-based medicine.[78] An analysis of trends in the criticism of complementary and alternative medicine (CAM) in five prestigious American medical journals during the period of reorganization within medicine (19651999) was reported as showing that the medical profession had responded to the growth of CAM in three phases, and that in each phase there had been changes in the medical marketplace which influenced the type of response in the journals.[101] Changes included relaxed medical licensing, the development of managed care, rising consumerism, and the establishment of the USA Office of Alternative Medicine (now National Center for Complementary and Alternative Medicine).[102]</ref> In the "condemnation" phase, from the late 1960s to the early 1970s, authors had ridiculed, exaggerated the risks, and petitioned the state to contain CAM; in the "reassessment" phase (mid-1970s through early 1990s), when increased consumer utilization of CAM was prompting concern, authors had pondered whether patient dissatisfaction and shortcomings in conventional care contributed to the trend; in the "integration" phase of the 1990s physicians began learning to work around or administer CAM, and the subjugation of CAM to scientific scrutiny had become the primary means of control.

Use and regulation


Prevalence of use
Complementary and alternative medicine (CAM) has been described as a broad domain of healing resources that encompasses all health systems, modalities, and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period. CAM includes all such practices and ideas self-defined by their users as preventing or treating illness or promoting health and well-being. Boundaries within CAM and between the CAM domain and that of the dominant system are not always sharp or fixed[]Wikipedia:Disputed statement

Studies show that prayer is a common "complementary" practice, in the belief it might increase the efficacy of science based medicine.

In respect of taxation in the U.S.A. the Internal Revenue Service has discriminated in favour of medical expenses for acupuncture and chiropractor (and others including Christian Science practitioner) but against homeopathy and the use of non-prescription required medicine.[103]</ref> About 50% of people in developed countries use some kind of complementary and alternative medicine other than prayer for health.[][][] About 40% of cancer patients use some form of CAM.[] The use of alternative medicine in the

Alternative medicine United States has increased,[2][] with a 50 percent increase in expenditures and a 25 percent increase in the use of alternative therapies between 1990 and 1997 in America.[] Americans spend many billions on the therapies annually.[] Most Americans used CAM to treat and/or prevent musculoskeletal conditions or other conditions associated with chronic or recurring pain.[] In America, women were more likely than men to use CAM, with the biggest difference in use of mind-body therapies including prayer specifically for health reasons".[] In 2008, more than 37% of American hospitals offered alternative therapies, up from 26.5 percent in 2005, and 25% in 2004.[104][] More than 70% of the hospitals offering CAM were in urban areas.[] A survey of Americans found that 88 percent agreed that "there are some good ways of treating sickness that medical science does not recognize".[2] Use of magnets was the most common tool in energy medicine in America, and among users of it, 58 percent described it as at least sort of scientific, when it is not at all scientific.[2] In 2002, at least 60 percent of US medical schools have at least some class time spent teaching alternative therapies.[2] "Therapeutic touch," was taught at more than 100 colleges and universities in 75 countries before the practice was debunked by a nine-year-old child for a school science project.[2][105] In Austria and Germany complementary and alternative medicine is mainly in the hands of doctors with MDs,[] and half or more of the American alternative practitioners are licensed MDs.[] In Germany herbs are tightly regulated: half are prescribed by doctors and covered by health insurance.[106] In developing nations, access to essential medicines is severely restricted by lack of resources and poverty. Traditional remedies, often closely resembling or forming the basis for alternative remedies, may comprise primary healthcare or be integrated into the healthcare system. In Africa, traditional medicine is used for 80% of primary healthcare, and in developing nations as a whole over one-third of the population lack access to essential medicines.[] A 1997 survey found that 13.7% of respondents in the United States had sought the services of both a medical doctor and an alternative medicine practitioner. The same survey found that 96% of respondents who sought the services of an alternative medicine practitioner also sought the services of a medical doctor in the past 12 months. Medical doctors are often unaware of their patient's use of alternative medical treatments as only 38.5% of the patients alternative therapies were discussed with their medical doctor.[] A British telephone survey by the BBC of 1209 adults in 1998 shows that around 20% of adults in Britain had used alternative medicine in the past 12 months.[107] Prevalence of use of specific therapies The most common CAM therapies used in the US in 2002 were prayer (45.2%), herbalism (18.9%), breathing meditation (11.6%), meditation (7.6%), chiropractic medicine (7.5%), yoga (5.1%-6.1%), body work (5.0%), diet-based therapy (3.5%), progressive relaxation (3.0%), mega-vitamin therapy (2.8%) and Visualization (2.1%)[][108] In Britain, the most often used alternative therapies were Alexander technique, Aromatherapy, Bach and other flower remedies, Body work therapies including massage, Counselling stress therapies, hypnotherapy, Meditation, Reflexology, Shiatsu, Ayurvedic medicine, Nutritional medicine, and Yoga.[109] According to the National Health Service (England), the most commonly used complementary and alternative medicines (CAM) supported by the NHS in the UK are: acupuncture, aromatherapy, chiropractic, homeopathy, massage, osteopathy and clinical hypnotherapy.[] "Complementary medicine treatments used for pain include: acupuncture, low-level laser therapy, meditation, aroma therapy, Chinese medicine, dance therapy, music therapy, massage, herbalism, therapeutic touch, yoga, osteopathy, chiropractic, naturopathy, and homeopathy."[110]

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Alternative medicine Palliative care Complementary therapies are often used in palliative care or by practitioners attempting to manage chronic pain in patients. Integrative medicine is considered more acceptable in the interdisciplinary approach used in palliative care than in other areas of medicine. "From its early experiences of care for the dying, palliative care took for granted the necessity of placing patient values and lifestyle habits at the core of any design and delivery of quality care at the end of life. If the patient desired complementary therapies, and as long as such treatments provided additional support and did not endanger the patient, they were considered acceptable."[111] The non-pharmacologic interventions of complementary medicine can employ mind-body interventions designed to "reduce pain and concomitant mood disturbance and increase quality of life."[112]

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Regulation
Some professions of complementary/traditional/alternative medicine, such as chiropractic medicine, have achieved full regulation in North America and other parts of the world[2] and are are regulated in a manner similar to that governing science-based medicine. In contrast, other approaches may be partially recognized and others have no regulation at all. Regulation and licensing of alternative medicine ranges widely from country to country, and state to state.[] Government bodies in the USA and elsewhere have published information or guidance about alternative medicine. One of those is the U.S. Food and Drug Administration (FDA), which mentions specifically homeopathic products, traditional Chinese medicine and Ayurvedic products.[] A document which the FDA has issued for comment is headed Guidance for Industry: Complementary and Alternative Medicine Products and Their Regulation by the Food and Drug Administration, last updated 04/06/2012.[113] The document opens with three preliminary paragraphs which explain that in the document: - "complementary and alternative medicine" (CAM) are being used to encompass a wide array of health care practices, products, and therapies which are distinct from those used in "conventional" or "allopathic" medicine. - some forms of CAM, such as traditional Chinese medicine and Ayurvedic medicine, have been practiced for centuries, and others, such as electrotherapy, are of more recent origin. - in a publication of The Institute of Medicine it has been stated that more than one-third of American adults reported using some form of CAM and that visits to CAM providers each year exceed those to primary care physicians (Institute of Medicine, Complementary and Alternative Medicine in the United States, pages 34-35, 2005). - no mention (in the document) of a particular CAM therapy, practice or product should be taken as expressing FDA's support or endorsement of it or as an agency determination that a particular product is safe and effective.

Efficacy
Alternative therapies lack the requisite scientific validation, and their effectiveness is either unproved or disproved.[2][][72][73] Many of the claims regarding the efficacy of alternative medicines are controversial, since research on them is frequently of low quality and methodologically flawed.[75] Selective publication of results (misleading results from only publishing postive results, and not all results), marked differences in product quality and standardisation, and some companies making unsubstantiated claims, call into question the claims of efficacy of isolated examples where herbs may have some evidence of containing chemicals that may affect health.[] The Scientific Review of Alternative Medicine points to confusions in the general population - a person may attribute symptomatic relief to an otherwise-ineffective therapy just because they are taking something (the placebo effect); the natural recovery from or the cyclical nature of an illness (the regression fallacy) gets misattributed to an

Alternative medicine alternative medicine being taken; a person not diagnosed with science based medicine may never originally have had a true illness diagnosed as an alternative disease category.[114] Edzard Ernst, a former professor of complementary medicine, characterized the evidence for many alternative techniques as weak, nonexistent, or negative.[] Ernst has concluded that 95% of the alternative treatments he and his team studied, including acupuncture, herbal medicine, homeopathy, and reflexology, are "statistically indistinguishable from placebo treatments", but he also believes there is something that conventional doctors can usefully learn from the chiropractors and homeopath: this is the therapeutic value of the placebo effect, one of the strangest phenomena in medicine.[115] In 2003, a project funded by the CDC identified 208 condition-treatment pairs, of which 58% had been studied by at least one randomized controlled trial (RCT), and 23% had been assessed with a meta-analysis.[116] According to a 2005 book by a US Institute of Medicine panel, the number of RCTs focused on CAM has risen dramatically. The book cites Vickers (1998), who found that many of the CAM-related RCTs are in the Cochrane register, but 19% of these trials were not in MEDLINE, and 84% were in conventional medical journals.[117] As of 2005, the Cochrane Library had 145 CAM-related Cochrane systematic reviews and 340 non-Cochrane systematic reviews. An analysis of the conclusions of only the 145 Cochrane reviews was done by two readers. In 83% of the cases, the readers agreed. In the 17% in which they disagreed, a third reader agreed with one of the initial readers to set a rating. These studies found that, for CAM, 38.4% concluded positive effect or possibly positive (12.4%), 4.8% concluded no effect, 0.69% concluded harmful effect, and 56.6% concluded insufficient evidence. An assessment of conventional treatments found that 41.3% concluded positive or possibly positive effect, 20% concluded no effect, 8.1% concluded net harmful effects, and 21.3% concluded insufficient evidence. However, the CAM review used the more developed 2004 Cochrane database, while the conventional review used the initial 1998 Cochrane database.[118] Most alternative medical treatments are not patentable, which may lead to less research funding from the private sector. In addition, in most countries, alternative treatments (in contrast to pharmaceuticals) can be marketed without any proof of efficacyalso a disincentive for manufacturers to fund scientific research.[] Some have proposed adopting a prize system to reward medical research.[119] However, public funding for research exists. Increasing the funding for research on alternative medicine techniques is the purpose of the US National Center for Complementary and Alternative Medicine. NCCAM and its predecessor, the Office of Alternative Medicine, have spent more than $2.5 billion on such research since 1992; this research has largely not demonstrated the efficacy of alternative treatments.[][][] In the same way as for conventional therapies, drugs, and interventions, it can be difficult to test the efficacy of alternative medicine in clinical trials. In instances where an established, effective, treatment for a condition is already available, the Helsinki Declaration states that withholding such treatment is unethical in most circumstances. Use of standard-of-care treatment in addition to an alternative technique being tested may produce confounded or difficult-to-interpret results.[120] Cancer researcher Andrew J. Vickers has stated: Contrary to much popular and scientific writing, many alternative cancer treatments have been investigated in good-quality clinical trials, and they have been shown to be ineffective. In this article, clinical trial data on a number of alternative cancer cures including Livingston-Wheeler, Di Bella Multitherapy, antineoplastons, vitamin C, hydrazine sulfate, Laetrile, and psychotherapy are reviewed. The label "unproven" is inappropriate for such therapies; it is time to assert that many alternative cancer therapies have been "disproven."[]

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Safety
Adequacy of regulation and CAM safety
Many of the claims regarding the safety and efficacy of alternative medicine are controversial. Some alternative treatments have been associated with unexpected side effects, which can be fatal.[citation needed] One of the commonly voiced concerns about complementary alternative medicine (CAM) is the manner in which is regulated. There have been significant developments in how CAMs should be assessed prior to re-sale in the United Kingdom and the European Union (EU) in the last 2 years. Despite this, it has been suggested that current regulatory bodies have been ineffective in preventing deception of patients as many companies have re-labelled their drugs to avoid the new laws.[121] There is no general consensus about how to balance consumer protection (from false claims, toxicity, and advertising) with freedom to choose remedies. Advocates of CAM suggest that regulation of the industry will adversely affect patients looking for alternative ways to manage their symptoms, even if many of the benefits may represent the placebo affect.[122] Some contend that alternative medicines should not require any more regulation than over-the-counter medicines that can also be toxic in overdose (such as paracetamol).[123] Interactions with conventional pharmaceuticals Forms of alternative medicine that are biologically active can be dangerous even when used in conjunction with conventional medicine. Examples include immuno-augmentation therapy, shark cartilage, bioresonance therapy, oxygen and ozone therapies, insulin potentiation therapy. Some herbal remedies can cause dangerous interactions with chemotherapy drugs, radiation therapy, or anesthetics during surgery, among other problems.[211] An anecdotal example of these dangers was reported by Associate Professor Alastair MacLennan of Adelaide University, Australia regarding a patient who almost bled to death on the operating table after neglecting to mention that she had been taking "natural" potions to "build up her strength" before the operation, including a powerful anticoagulant that nearly caused her death.[] To ABC Online, MacLennan also gives another possible mechanism: And lastly [sic] there's the cynicism and disappointment and depression that some patients get from going on from one alternative medicine to the next, and they find after three months the placebo effect wears off, and they're disappointed and they move on to the next one, and they're disappointed and disillusioned, and that can create depression and make the eventual treatment of the patient with anything effective difficult, because you may not get compliance, because they've seen the failure so often in the past.|[] Potential side-effects Conventional treatments are subjected to testing for undesired side-effects, whereas alternative treatments, in general, are not subjected to such testing at all. Any treatment whether conventional or alternative that has a biological or psychological effect on a patient may also have potential to possess dangerous biological or psychological side-effects. Attempts to refute this fact with regard to alternative treatments sometimes use the appeal to nature fallacy, i.e., "that which is natural cannot be harmful". An exception to the normal thinking regarding side-effects is Homeopathy. Since 1938, the U.S. Food and Drug Administration (FDA) has regulated homeopathic products in "several significantly different ways from other drugs."[124] Homeopathic preparations, termed "remedies," are extremely dilute, often far beyond the point where a single molecule of the original active (and possibly toxic) ingredient is likely to remain. They are, thus, considered safe on that count, but "their products are exempt from good manufacturing practice requirements related to expiration dating and from finished product testing for identity and strength," and their alcohol concentration may be much higher than allowed in conventional drugs.[124]

Alternative medicine Treatment delay Those having experienced or perceived success with one alternative therapy for a minor ailment may be convinced of its efficacy and persuaded to extrapolate that success to some other alternative therapy for a more serious, possibly life-threatening illness.[125] For this reason, critics argue that therapies that rely on the placebo effect to define success are very dangerous. According to mental health journalist Scott Lilienfeld in 2002, "unvalidated or scientifically unsupported mental health practices can lead individuals to forgo effective treatments" and refers to this as "opportunity cost". Individuals who spend large amounts of time and money on ineffective treatments may be left with precious little of either, and may forfeit the opportunity to obtain treatments that could be more helpful. In short, even innocuous treatments can indirectly produce negative outcomes.[] Between 2001 and 2003, four children died in Australia because their parents chose ineffective naturopathic, homeopathic, or other alternative medicines and diets rather than conventional therapies.[] In all, they found 17 instances in which children were significantly harmed by a failure to use conventional medicine. Unconventional cancer "cures" Perhaps because many forms of cancer are difficult or impossible to cure, there have always been many therapies offered outside of conventional cancer treatment centers and based on theories not found in biomedicine. These alternative cancer cures have often been described as "unproven," suggesting that appropriate clinical trials have not been conducted and that the therapeutic value of the treatment is unknown. However, many alternative cancer treatments have been investigated in good-quality clinical trials, and they have been shown to be ineffective. []

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Research funding
Although the Dutch government funded CAM research between 1986 and 2003, it formally ended funding in 2006.[126]

Appeal
A study published in 1998[] indicates that a majority of alternative medicine use was in conjunction with standard medical treatments. Approximately 4.4 percent of those studied used alternative medicine as a replacement for conventional medicine. The research found that those having used alternative medicine tended to have higher education or report poorer health status. Dissatisfaction with conventional medicine was not a meaningful factor in the choice, but rather the majority of alternative medicine users appear to be doing so largely because "they find these healthcare alternatives to be more congruent with their own values, beliefs, and philosophical orientations toward health and life." In particular, subjects reported a holistic orientation to health, a transformational experience that changed their worldview, identification with a number of groups committed to environmentalism, feminism, psychology, and/or spirituality and personal growth, or that they were suffering from a variety of common and minor ailments notable ones being anxiety, back problems, and chronic pain. Authors have speculated on the socio-cultural and psychological reasons for the appeal of alternative medicines among that minority using them in lieu of conventional medicine. There are several socio-cultural reasons for the interest in these treatments centered on the low level of scientific literacy among the public at large and a concomitant increase in antiscientific attitudes and new age mysticism.[] Related to this are vigorous marketing[] of extravagant claims by the alternative medical community combined with inadequate media scrutiny and attacks on critics.[][] There is also an increase in conspiracy theories toward conventional medicine and pharmaceutical companies, mistrust of traditional authority figures, such as the physician, and a dislike of the current delivery methods of scientific biomedicine, all of which have led patients to seek out alternative medicine to treat a variety of ailments.[] Many patients lack access to contemporary medicine, due to a lack of private or public health insurance, which leads them to seek out lower-cost alternative medicine.[] Medical doctors are also aggressively marketing alternative

Alternative medicine medicine to profit from this market.[] In addition to the social-cultural underpinnings of the popularity of alternative medicine, there are several psychological issues that are critical to its growth. One of the most critical is the placebo effect, which is a well-established observation in medicine.[127] Related to it are similar psychological effects such as the will to believe,[] cognitive biases that help maintain self-esteem and promote harmonious social functioning,[] and the post hoc, ergo propter hoc fallacy.[] Patients can also be averse to the painful, unpleasant, and sometimes-dangerous side effects of biomedical treatments. Treatments for severe diseases such as cancer and HIV infection have well-known, significant side-effects. Even low-risk medications such as antibiotics can have potential to cause life-threatening anaphylactic reactions in a very few individuals. Also, many medications may cause minor but bothersome symptoms such as cough or upset stomach. In all of these cases, patients may be seeking out alternative treatments to avoid the adverse effects of conventional treatments.[][] Schofield et al., in a systematic review published in 2011, make ten recommendations which they think may increase the effectiveness of consultations in a conventional (here: oncology) setting, such as "Ask questions about CAM use at critical points in the illness trajectory"; "Respond to the person's emotional state"; and "Provide balanced, evidence-based advice". They suggest that this approach may address "... concerns surrounding CAM use [and] encourage informed decision-making about CAM and ultimately, improve outcomes for patients".[128] CAM's popularity may be related to other factors which Edzard Ernst mentions in an interview in The Independent: Why is it so popular, then? Ernst blames the providers, customers and the doctors whose neglect, he says, has created the opening into which alternative therapists have stepped. "People are told lies. There are 40 million websites and 39.9 million tell lies, sometimes outrageous lies. They mislead cancer patients, who are encouraged not only to pay their last penny but to be treated with something that shortens their lives. "At the same time, people are gullible. It needs gullibility for the industry to succeed. It doesn't make me popular with the public, but it's the truth.[] In a paper published in October 2010 entitled The public's enthusiasm for complementary and alternative medicine amounts to a critique of mainstream medicine, Ernst describes these views in greater detail and concludes: [CAM] is popular. An analysis of the reasons why this is so points towards the therapeutic relationship as a key factor. Providers of CAM tend to build better therapeutic relationships than mainstream healthcare professionals. In turn, this implies that much of the popularity of CAM is a poignant criticism of the failure of mainstream healthcare. We should consider it seriously with a view of improving our service to patients.[129] Physicians who practice complementary medicine usually discuss and advise patients as to available complementary therapies. Patients often express interest in mind-body complementary therapies because they offer a non-drug approach to treating some health conditions.[130] Some mind-body techniques, such as cognitive-behavioral therapy, were once considered complementary medicine, but are now a part of conventional medicine in the United States.[131]

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Explanatory notes
[1] http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2011/ MB_cgi?field=uid& term=D000529 [2] National Science Foundation 2002 report: Science and Technology: Public Attitudes and Public Understanding. Science Fiction and Pseudoscience. (http:/ / www. nsf. gov/ statistics/ seind02/ c7/ c7s5. htm) [3] Complementary and Alternative Medicine Products and their Regulation by the Food and Drug Administration (http:/ / www. fda. gov/ RegulatoryInformation/ Guidances/ ucm144657. htm) [4] The Final Report (2002) of the White House Commission on Complementary and Alternative Medicine Policy states:

The Commissioners believe and have repeatedly stated in this Report that our response should be to hold all systems of health and healing, including conventional and CAM, to the same rigorous standards of good science and health services research. Although the Commissioners support the provision of the most accurate information about the state of the science of all CAM modalities, they believe that it is premature to advocate the wide implementation and reimbursement of CAM modalities that are yet unproven.<ref name="whccamp.hhs.gov">
[5] "Complementary medicine, defined as health care which lies for the most part outside the mainstream of conventional medicine" [7] CAM Committee 2005, pp.17, 20. [8] Ruggie 2004, p.20. [9] "By the mid-1990s, the notion that some alternative therapies could be complementary to conventional medicine began to change the status of...alternative medicine. The 21st century is witnessing yet another terminological innovation, in which CAM and conventional medicine are becoming integrative." Mary Ruggie, Harvard, Understanding CAM: The Problem of Knowledge and the Power of Words, chapter 2 of Marginal to Mainstream, CUP 2004 [10] . . [11] Sointu 2012, p.13 [12] . . [13] CAM Committee 2005, p.18 [14] CAM Committee 2005, p.14 [15] CAM Committee 2005, p.19. [17] As David J. Hufford, Professor and Director at the Doctors Kienle Center for Humanistic Medicine at the Penn State College of Medicine (Hershey),<ref> [18] Quoted in . [19] The BMA used the term non-conventional medicine instead of alternative medicine.<ref name="FOOTNOTEBMA19937">BMA 1993, p.7. [20] BMA 1993, p.7. [22] See also [24] CAM Committee 2005, pp.17, 196252. [26] CAM Research Methodology Conference, April 1995 Panel on Definition and Description (March 1997), 'Defining and describing complementary and alternative medicine' (http:/ / www. alternative-therapies. com/ index. cfm/ fuseaction/ archives. main), Alternative Therapies, 3(2):49 [27] The Office for Alternative Medicine, part of the National Institutes of Health,<ref name="NZ 2002"> [28] . [31] The exact wording adopted in this 2005 report was:

Complementary and alternative medicine (CAM) is a broad domain of resources that encompasses health systems, modalities, and practices and their accompanying theories and beliefs, other than those intrinsic to the dominant health system of a particular society or culture in a given historical period. CAM includes such resources perceived by their users as associated with positive health outcomes. Boundaries within CAM and between the CAM domain and the domain of the dominant system are not always sharp or fixed.<ref>.
[32] CAM Committee 2005, p.17. [33] . [34] General Guidelines for Methodologies on Research and Evaluation of Traditional Medicine (http:/ / whqlibdoc. who. int/ hq/ 2000/ WHO_EDM_TRM_2000. 1. pdf) [35] Robert Jtte is an adjunct professor of history at the University of Stuttgart and editor of the journal Medizin, Gesellschaft und Geschicht. [37] ; ; [38] Bivins 2007, p.171. [39] ;

Alternative medicine
[41] Barry D. Silverman, William Henry Welch (18501934): the road to Johns Hopkins. Proc (Bayl Univ Med Cent). 2011 July; 24(3): 236242. (http:/ / www. ncbi. nlm. nih. gov/ pmc/ articles/ PMC3124910/ ) [42] Flexner Report, Introduction p.viii "The fundamental sciences upon which medicine depends have been greatly extended. The laboratory has come to furnish alike to the physician and to the surgeon a new means for diagnosing and combating disease. The education of the medical practitioner under these changed conditions makes entirely different demands in respect of both preliminary and professional training." (http:/ / www. carnegiefoundation. org/ sites/ default/ files/ elibrary/ Carnegie_Flexner_Report. pdf); and see The Impact of the Flexner Report on the Fate of Medical Schools in North America after 1909 (http:/ / www. jpands. org/ vol8no2/ hiattext. pdf) [43] Mary Brown Bullock, An American Transplant: The Rockefeller Foundation and the Peking Union Medical College, Berkeley: University of California Press, 1980. Top Chinese Universities in Medicine, 2012 (http:/ / www. cucas. edu. cn/ HomePage/ majorrankings/ 2011-11-11/ 1320997392d2449. shtml) Peking University Health Science Center (formerly Beijing Medical University) was the first of the kind in China to teach western medicine and train medical professionals. Top Chinese Universities in Medicine, 2012 . [44] For an encyclopaedic account of the development of "western" medicine in the period leading up to the reforms in the medical schools of USA resulting from the Flexner Report, published at the time of that report, see article Medicine in 1911 Encyclopdia Britannica contributed by Thomas Clifford Allbutt, M.D., F.R.S.s:1911 Encyclopdia Britannica/Medicine [45] The report of the Committee on the Indigenous systems of medicine, Madras (also known as the Usman Report).Gram Vichar, What is the role of indigenous medical sciences in our health care system? December 1984, condensed in Perspective, Vol.10, no.3, 1985 (http:/ / www. vikalpa. com/ pdf/ articles/ 1985/ 1985_july_sep_271_277. pdf) (http:/ / www. worldcat. org/ title/ report-of-the-committee-on-the-indigenous-systems-of-medicine-madras/ oclc/ 229483035& referer=brief_results) [46] Bivins 2007, pp.164170. [47] According to the Oxford English Dictionary, the earliest recorded English language usage in a print medium of the term "alternative medicine" is found in a 1974 text by Helen Kruger.<ref> See also: [48] Arnold S. Relman, a former editor of The New England Journal of Medicine A trip to Stonesville. (http:/ / www. quackwatch. org/ 11Ind/ weil. html) The New Republic, Dec 14, 1998. [49] (http:/ / www. thehistorymakers. com/ biography/ david-satcher-41) (http:/ / sph-publications. berkeley. edu/ bho/ 2012/ 12/ uc-berkeley-school-of-public-health-announces-2013-public-health-heroes/ ) (http:/ / www. hq. nasa. gov/ office/ codec/ codece/ dsatcher. htm) [50] .United States Department of Health and Human Services March 18, 1998: U.S. Surgeon General launches new health resources at the government Gateway web site (http:/ / www. health. gov/ partnerships/ media/ 31899pr. htm) [53] Best Practices in Integrative Medicine: A Report from the Bravewell Clinical Network. Published 2007. The Bravewell Collaborative. Page 4. [55] As the medical professor Kenneth M. Ludmerer noted in 2010:

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Flexner pointed out that the scientific method of thinking applied to medical practice. By scientific method, he meant the testing of ideas by well-planned experiments in which accurate facts were carefully obtained. The clinician's diagnosis was equivalent to the scientist's hypothesis: both medical diagnosis and hypothesis needed to be submitted to the test of an experiment... Flexner argued that mastery of the scientific method of problem solving was the key for physicians to manage medical uncertainty and to practice in the most cost-effective way."<ref>
[60] Center for Integrative Medicine of the University of Maryland School of Medicine (http:/ / medschool. umaryland. edu/ about. asp), (http:/ / medschool. umaryland. edu/ centers. asp), (http:/ / www. compmed. umm. edu/ cochrane_about. asp) (http:/ / www. compmed. umm. edu/ default. asp) [63] Two definitions of evidence based medicine are:

"Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients'.<ref name="BMJ EBM">
[71] Other sources: Nature Medicine, September 1996, Volume 2 Number 9, p1042 Pseudoscience and the Paranormal, Hines, Terence, American Psychological Association, (http:/ / psycnet. apa. org/ psycinfo/ 2003-02869-000) The Need for Educational Reform in Teaching about Alternative Therapies, Journal of the Association of Medical Colleges, March 2001 Volume 76 - Issue 3 - p 248-250 The Rise and Rise of Complementary and Alternative Medicine: a Sociological Perspective, Ian D Coulter and Evan M Willis, Medical Journal of Australia, 2004; 180 (11): 587-589 Ignore Growing Patient Interest in Alternative Medicine at Your Peril - MDs Warned, Heather Kent, Canadian Medical Association Journal, November 15, 1997 vol. 157 no. 10

The Demon-Haunted World: Science as a Candle in the Dark, Carl Sagan, Random House, ISBN 0-394-53512-X, 1996 [72] Ignore Growing Patient Interest in Alternative Medicine at Your Peril - MDs Warned, Heather Kent, Canadian Medical Association Journal, November 15, 1997 vol. 157 no. 10

Alternative medicine
[73] Goldrosen MH, Straus SE. "Complementary and alternative medicine: assessing the evidence for immunological benefits." (http:/ / www. nature. com/ nri/ journal/ v4/ n11/ pdf/ nri1486. pdf) Nature Perspectives, November 2004 vol. 4, pp. 912-921. [74] CAM Committee 2005, pp.17-19. [75] CAM Committee 2005. [76] Carroll RT. "complementary medicine" (http:/ / www. skepdic. com/ compmed. html) at The Skeptic's Dictionary [77] Steven Novella, "Acupuncture Pseudoscience in the New England Journal of Medicine" (http:/ / www. sciencebasedmedicine. org/ ?p=6391). Science Based Medicine, August 4, 2010 [78] David Gorski, "Credulity about acupuncture infiltrates the New England Journal of Medicine (http:/ / www. sciencebasedmedicine. org/ ?p=6381). Science Based Medicine, August 3, 2010 [81] Srimad Bhagavatam 1.3.17. Reference: http:/ / vedabase. com/ en/ sb/ 1/ 3/ 17 [82] Matthew Ramsey, Vanderbilt University, Nashville, TN Alternative medicine in modern France Cambridge Journals, Med Hist. 1999 July; 43(3): 286322. (http:/ / www. ncbi. nlm. nih. gov/ pmc/ articles/ PMC1044147/ pdf/ medhist00018-0010. pdf) [83] The Roots of Ayurveda: Selections from Sanskrit Medical Writings, D. Wujastyk, p xviii, 2003, ISBN 0-14-044824-1 [85] Celestial lancets: a history and rationale of acupuncture and moxa, Needham, J; Lu GD, 2002, Routledge, ISBN 0-7007-1458-8 [86] Tongue Diagnosis in Chinese Medicine, G Cia, 1995, Eastland Press. ISBN 0-939616-19-X. [87] UK Parliamentary Committee Science and Technology Committee - "Evidence Check 2: Homeopathy" (http:/ / www. parliament. uk/ business/ committees/ committees-a-z/ commons-select/ science-and-technology-committee/ inquiries/ homeopathy-/ ) [88] Sarris, J., and Wardle, J. 2010. Clinical naturopathy: an evidence-based guide to practice. Elsevier Australia. Chatswood, NSW. [89] Energy Medicine: An Overview, National Center for Complementary and Alternative Medicine (http:/ / markmaluga. com/ files/ Energy-Medicine-NCCAM. pdf) [90] Demon Haunted World, Carl Sagan [91] The New England Journal of Medicine, July 1995. [92] Wallace Sampson [94] Edzard Ernst. "Alternative medicine remains an ethics-free zone." (http:/ / www. guardian. co. uk/ science/ blog/ 2011/ nov/ 08/ alternative-medicine-ethics-free-zone) The Guardian 8 November 2011 [95] Mark Henderson, Science Editor, " Prince of Wales's guide to alternative medicine 'inaccurate' (http:/ / www. timesonline. co. uk/ tol/ life_and_style/ health/ alternative_medicine/ article3760857. ece)" Times Online, April 17, 2008 [96] "Complementary medicine is diagnosis, treatment and/or prevention that complements mainstream medicine by contributing to a common whole, by satisfying a demand not met by orthodoxy or by diversifying the conceptual frameworks of medicine." Ernst et al. British General Practitioner 1995; 45:506. [97] Butler K (1992). A Consumer's Guide to "ALTERNATIVE MEDICINE": A close look at Homeopathy, Acupuncture, Faith-healing and other Unconventional Treatments [98] As a 2010 article in the New England Journal of Medicine concluded:

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real acupuncture treatments were no more effective than sham acupuncture treatments. There was, nevertheless, evidence that both real acupuncture and sham acupuncture were more effective than no treatment, and that acupuncture can be a useful supplement to other forms of conventional therapy for low back pain.<ref>
[100] http:/ / www. stfm. org/ fmhub/ fm2010/ October/ Rachel636. pdf [101] Terri A. Winnick. 2009. From Quackery to Complementary Medicine: The American Medical Profession Confronts Alternative Therapies. In The Sociology of Health and Illness. Eighth ed. Edited by Peter Conrad. New York: Worth. 261-277. (http:/ / www. worldcat. org/ title/ sociology-of-health-illness-critical-perspectives/ oclc/ 298915053) [102] According to the medical historian James Harvey Young:

In 1991 the Senate Appropriations Committee responsible for funding the National Institutes of Health (NIH) declared itself "not satisfied that the conventional medical community as symbolized at the NIH has fully explored the potential that exists in unconventional medical practices."<ref>
[103] The US Internal Revenue Service provides the following definition of medical expenses:

Medical expenses are the costs of diagnosis, cure, mitigation, treatment, or prevention of disease, and the costs for treatments affecting any part or function of the body. These expenses include payments for legal medical services rendered by physicians, surgeons, dentists and other medical practitioners.... primarily to alleviate or prevent a physical or mental defect or illness. Medicines: You can include expenses amounts you pay for prescribed medicines and drugs. A prescribed drug is one that requires a prescription by a doctor for its use by an individual.<ref>
[105] Rosa, L., Rosa, E., Sarner, L., and Barrett, S. "A Close Look at Therapeutic Touch." (http:/ / jama. jamanetwork. com/ article. aspx?articleid=187390) Journal of the American Medical Association, 279(13): 100510, 1998 [108] http:/ / nccam. nih. gov/ sites/ nccam. nih. gov/ files/ news/ nhsr12. pdf/

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[109] House of Lords Select Committee on Science and Technology. 2000. Complementary and Alternative Medicine. London: The Stationery Office. [111] Allan Kellehear, Complementary medicine: is it more acceptable in palliative care practice? MJA 2003; 179 (6 Suppl): S46-S48 online (http:/ / www. mja. com. au/ public/ issues/ 179_06_150903/ kel10295_fm-2. html) [114] James Alcock PhD, Alternative Medicine and the Psychology of Belief, The Scientific Review of Alternative Medicine, Fall/Winter 1999 Volume 3 ~ Number 2. available online (http:/ / www. quackwatch. org/ 01QuackeryRelatedTopics/ altpsych. html) [115] The Economist, " Alternative Medicine: Think yourself better (http:/ / www. economist. com/ node/ 18710090)", 21 May 2011, pp. 8384. (http:/ / www. economist. com/ node/ 18710090?zid=318& ah=ac379c09c1c3fb67e0e8fd1964d5247f).Edzard Ernst, Placebo and other Non-specific Effects 8th article in Healing, Hype, or Harm? A Critical Analysis of Complementary or Alternative Medicine (2008), reviewed (http:/ / metapsychology. mentalhelp. net/ poc/ view_doc. php?type=book& id=4690& cn=452) [117] CAM Committee 2005, p.133. [118] CAM Committee 2005, pp.135-136. [124] Isadora Stehlin. " Homeopathy: Real Medicine or Empty Promises? (http:/ / web. archive. org/ web/ 20071012070120/ http:/ / www. fda. gov/ fdac/ features/ 096_home. html)" FDA Consumer magazine (December 1996)

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References Bibliography
Bivins, Roberta (2007). Alternative Medicine? A History (http://books.google.com/?id=_x1zg5GPgxgC). Oxford: Oxford University Press. ISBN9780199218875. British Medical Association. Board of Science and Education (1993). Complementary medicine: new approaches to good practice (http://books.google.com/books?id=rTFrAAAAMAAJ). Oxford University Press. ISBN978-0-19-286166-5. Committee on the Use of Complementary and Alternative Medicine by the American Public (2005). Complementary and Alternative Medicine in the United States (http://www.matthewsbooks.com/productdetail. aspx?pid=MU30954733). National Academy Press. Ruggie, Mary (8 April 2004). Marginal to Mainstream: Alternative Medicine in America (http://books.google. com/books?id=ViDwi7s2VvMC). Cambridge University Press. ISBN978-0-521-83429-2. Saks, Mike (2003). Orthodox and Alternative Medicine: Politics, Professionalization and Health Care (http:// books.google.com/books?id=zW2_iJsZFS0C). SAGE. ISBN978-1-4462-6536-9. Sointu, Eeva (2012). Theorizing Complementary and Alternative Medicines: Wellbeing, Self, Gender, Class (http://books.google.com/books?id=XC2UUP36bjAC&pg=PA14). Palgrave Macmillan. ISBN978-0-230-30931-9.

Further reading
Bausell, R. Barker (2007). Snake Oil Science: The Truth About Complementary and Alternative Medicine. Oxford University Press. ISBN978-0-19-531368-0. Benedetti F, Maggi G, Lopiano L. "Open Versus Hidden Medical Treatments: The Patient's Knowledge About a Therapy Affects the Therapy Outcome." Prevention & Treatment, 2003; 6(1), APA online (http://psycnet.apa. org/journals/pre/6/1/1a/) Diamond, J. Snake Oil and Other Preoccupations, 2001, ISBN 978-0-09-942833-6 , foreword by Richard Dawkins reprinted in Dawkins, R., A Devil's Chaplain, 2003, ISBN 978-0-7538-1750-6 . Downing AM, Hunter DG (May 2003). "Validating clinical reasoning: a question of perspective, but whose perspective?". Manual Therapy 8 (2): 1179. doi: 10.1016/S1356-689X(02)00077-2 (http://dx.doi.org/10. 1016/S1356-689X(02)00077-2). PMID 12890440 (http://www.ncbi.nlm.nih.gov/pubmed/12890440). Eisenberg DM (July 1997). "Advising patients who seek alternative medical therapies". Annals of Internal Medicine 127 (1): 619. doi: 10.1059/0003-4819-127-1-199707010-00010 (http://dx.doi.org/10.1059/ 0003-4819-127-1-199707010-00010). PMID 9214254 (http://www.ncbi.nlm.nih.gov/pubmed/9214254).

Alternative medicine Gunn IP (December 1998). "A critique of Michael L. Millenson's book, Demanding medical excellence: doctors and accountability in the information age, and its relevance to CRNAs and nursing". AANA Journal 66 (6): 57582. PMID 10488264 (http://www.ncbi.nlm.nih.gov/pubmed/10488264). Hand, Wayland Debs (1980). "Folk Magical Medicine and Symbolism in the West". Magical Medicine. Berkeley: University of California Press. pp.30519. ISBN978-0-520-04129-5. OCLC 6420468 (http://www.worldcat. org/oclc/6420468). Illich, Ivan (1976). Limits to medicine : medical nemesis : the expropriation of health. Penguin. ISBN978-0-14-022009-4. OCLC 4134656 (http://www.worldcat.org/oclc/4134656). Mayo Clinic (2007). Mayo Clinic Book of Alternative Medicine: The New Approach to Using the Best of Natural Therapies and Conventional Medicine. Parsippany, New Jersey: Time Inc Home Entertainment. ISBN978-1-933405-92-6. Phillips Stevens Jr. (November/December 2001). "Magical Thinking in Complementary and Alternative Medicine". Skeptical Inquirer Magazine. Planer, Felix E. (1988). Superstition (Revised ed.). Buffalo, New York: Prometheus Books. ISBN978-0-87975-494-5. OCLC 18616238 (http://www.worldcat.org/oclc/18616238). Rosenfeld, Anna (circa 2000). "Where Do Americans Go for Healthcare?" (http://www.cwru.edu/med/ epidbio/mphp439/Sources_of_Healthcare.htm). Cleveland, Ohio: Case Western Reserve University. Retrieved 23 September 2010. Singh, S; Ernst E (2008). Trick or treatment: The undeniable facts about alternative medicine. Norton. ISBN978-0-393-06661-6. OCLC 181139440 (http://www.worldcat.org/oclc/181139440).; preview at [[Google Book Search|Google Books (http://books.google.com/books?id=bZjlC2LELlIC)] ] Tonelli MR (December 2001). "The limits of evidence-based medicine". Respiratory Care 46 (12): 143540; discussion 14401. PMID 11728302 (http://www.ncbi.nlm.nih.gov/pubmed/11728302). Trivieri Larry, Jr.; Anderson, John W., eds. (2002). Alternative Medicine: The Definitive Guide. Berkeley: Ten Speed Press. ISBN978-1-58761-141-4. Wisneski LA, Anderson L (2005). The Scientific Basis of Integrative Medicine. CRC Press. ISBN978-0-8493-2081-1. Zalewski Z (1999). "Importance of philosophy of science to the history of medical thinking" (http://web. archive.org/web/20040206092548/http://www.bsb.mefst.hr/cmj/1999/4001/400102.htm). CMJ 40 (1): 813. Archived from the original (http://www.bsb.mefst.hr/cmj/1999/4001/400102.htm) on 2004-02-06.

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World Health Organization publication


WHO Global Atlas of Traditional, Complementary and Alternative Medicine (http://apps.who.int/bookorders/ anglais/detart1.jsp?sesslan=1&codlan=1&codcol=15&codcch=614)

Journals dedicated to alternative medicine research


Alternative therapies in health and medicine. Aliso Viejo, CA : InnoVision Communications, c1995- NLM ID: 9502013 (http://locatorplus.gov/cgi-bin/Pwebrecon.cgi?DB=local&v2=1&ti=1,1&Search_Arg=9502013& Search_Code=0359&CNT=20&SID=1) Alternative medicine review : a journal of clinical therapeutic (http://altmedrev.com/). Sandpoint, Idaho : Thorne Research, Inc., c1996- NLM ID: 9705340 (http://locatorplus.gov/cgi-bin/Pwebrecon.cgi?DB=local& v2=1&ti=1,1&Search_Arg=9705340&Search_Code=0359&CNT=20&SID=1) BMC complementary and alternative medicine (http://www.biomedcentral.com/1472-6882). London : BioMed Central, 2001- NLM ID: 101088661 (http://locatorplus.gov/cgi-bin/Pwebrecon.cgi?DB=local&v2=1& ti=1,1&Search_Arg=101088661&Search_Code=0359&CNT=20&SID=1) Complementary therapies in medicine. Edinburgh ; New York : Churchill Livingstone, c1993- NLM ID: 9308777 (http://locatorplus.gov/cgi-bin/Pwebrecon.cgi?DB=local&v2=1&ti=1,1&Search_Arg=9308777&

Alternative medicine Search_Code=0359&CNT=20&SID=1) Evidence based complementary and alternative medicine (http://ecam.oxfordjournals.org/) Evidence Based journal of Integrative medicine (http://www.openmindjournals.com/EBInteg.html) Forschende Komplementrmedizin / Research in Complementary Medicine (http://content.karger.com/ ProdukteDB/produkte.asp?Aktion=JournalHome&ProduktNr=224242) Journal of Integrative medicine. (http://www.jintmed.org/) Journal for Alternative and Complementary Medicine (http://www.liebertpub.com/products/product. aspx?pid=26) New York, NY : Mary Ann Liebert, Inc., c1995 Scientific Review of Alternative Medicine (SRAM) (http://www.sram.org/index.html)

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External links
The National Center for Complementary and Alternative Medicine (http://nccam.nih.gov/): U.S. National Institutes of Health The Office of Cancer Complementary and Alternative Medicine (http://www.cancer.gov/cam/): U.S. National Cancer Institute, National Institutes of Health Knowledge and Research Center for Alternative Medicine (http://www.vifab.dk/uk): Denmark, the Ministry of the Interior and Health Guidelines For Using Complementary and Alternative Methods (http://www.cancer.org/docroot/eto/content/ eto_5_3x_guidelines_for_using_complementary_and_alternative_methods.asp): from the American Cancer Society Complementary and Alternative Medicine Index (http://www.umm.edu/altmed/): from the University of Maryland Medical Center Integrative Medicine Podcasts and Handouts (http://www.fammed.wisc.edu/integrative/modules): Teaching modules from the University of Wisconsin Integrative Medicine Program "Alternative Medicine" (http://www.open2.net/alternativemedicine/index.html): A BBC/Open University television series that examines the evidence scientifically "Complementary and alternative medicine: What is it?" (http://www.mayoclinic.com/health/ alternative-medicine/PN00001): from the Mayo Clinic Natural Standard Research Collaboration (http://www.naturalstandard.com/) Alternative Medicine Health Directory (http://www.medicalvideos.us/alternative-medicine/) A Different Way to Heal? (http://www.pbs.org/saf/1210/index.html) and Videos (http://www.pbs.org/saf/ 1210/video/watchonline.htm): from PBS and Scientific American Frontiers Who Gets to Validate Alternative Medicine? (http://www.pbs.org/kcet/closertotruth/explore/show_11.html): from PBS Governmental information about alternative medicine in Denmark (http://www.srab.dk/uk/cochrane+and+ alternative+medicine/aromatherapy)

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Criticism
What is Complementary and Alternative Medicine? (http://www.theness.com/ what-is-complementary-and-alternative-medicine/) Steven Novella, MD "Alternative" health practice (http://www.skepdic.com/althelth.html) Skeptic's Dictionary Quackwatch.org (http://www.quackwatch.org) Stephen Barrett (See also: Quackwatch) Healing, Hype, or Harm? A Critical Analysis of Complementary or Alternative Medicine, by Edzard Ernst (Editor) (2008), reviewed in Metapsychology. (http://metapsychology.mentalhelp.net/poc/view_doc. php?type=book&id=4690&cn=452) What's the harm? (http://whatstheharm.net/) Website created by Tim Farley listing cases of people harmed by various alternative treatments

College of American Pathologists


The College of American Pathologists ("CAP"), is a medical society serving more than 18,000 physician members and the laboratory community throughout the world. It is headquartered in Northfield, Illinois. It is the worlds largest association composed exclusively of pathologists certified by the American Board of Pathology,[1] and is widely considered the leader in laboratory quality assurance. The College is an advocate for high-quality and cost-effective medical care.[2] It is also affiliated with the American Medical Association (AMA).[3] CAP does accreditation of laboratories under deemed authority by CMS (Medicare). It also offers an accreditation service to help laboratories earn accreditation under ISO 15189 Medical Laboratories. In November 2008, Piedmont Medical Laboratory of Winchester, Virginia became the first laboratory in the United States [4] to be officially accredited under ISO 15189. Pathologists play an integral role in the primary health care team. They are physicians who obtain and interpret data as the result of examination of tissues, blood, and other body fluids for diagnosis and patient care. CAP members are involved in a broad range of disciplines, including surgical pathology, cytopathology, dermatopathology, neuropathology, forensic pathology, blood banking/ transfusion medicine, clinical chemistry, microbiology, immunopathology, hematology, genetics, and molecular pathology. As of September 10, 2011, the current president of the CAP is Stanley J. Robboy, MD, FCAP.

References
[1] American Board of Pathology (http:/ / www. abpath. org) [3] American Medical Association (http:/ / www. ama-assn. org/ ) [4] first ISO-15189 accredited laboratory in the United States (http:/ / www. darkdaily. com/ ebriefings/ first-two-laboratories-in-us-earn-iso-15189-accreditation)

External links
College of American Pathologists (http://www.cap.org)

Community Action Agencies

319

Community Action Agencies


In the United States and its territories, Community Action Agencies (CAA) are local private and public non-profit organizations that carry out the Community Action Program (CAP), which was founded by the 1964 Economic Opportunity Act to fight poverty by empowering the poor as part of the War on Poverty. CAAs are intended to promote self-sufficiency, and they depend heavily on volunteer work, especially from the low-income community. The Community Services Block Grant (CSBG) is the agencies' core federal funding. Agencies also operate a variety of grants that come from federal, state and local sources. These grants vary widely among agencies, although most CAAs operate Head Start programs, which focus on early child development. Other programs frequently administered by Community Action Agencies include Low-Income Home Energy Assistance (LIHEAP) utility grants and Weatherization Assistance Program (WAP) funded through the U.S. Department of Energy (DOE). Each CAA is governed by a board of directors consisting of at least one-third low-income community members, one-third public officials, and up to one-third private sector leaders. This board structure is defined by federal statute and is known as a tripartite board.[1] There are currently over 1,000 CAAs, engaged in a broad range of activities; typical activities include promoting citizen participation, providing utility bill assistance and home weatherization for low-income individuals, administration of Head Start pre-school programs, job training, operating food pantries, and coordinating community initiatives.[2]

History
Lyndon B. Johnson's landmark Economic Opportunity Act established Community Action Programs in Title II. A Community Action Program was defined as a program "... which provides services, assistance, and other activities of sufficient scope and size to give promise of progress toward elimination of poverty or a cause or causes of poverty through developing employment opportunities, improving human performance, motivation, and productivity, or bettering the conditions under which people live, learn, and work."[3] Although Johnson and other architects of the legislation expected Community Action Programs and Agencies to be an effective weapon in his so-called "War on Poverty," many of them were riddled with problems. In many cases the poor were unable to effectively control or manage CAPs which ultimately failed. In more extreme instances, local political regimes were threatened by the empowerment of poor political activists with funding and resources from the federal government.[4] One of the most dramatic episodes resulting from these clashes between CAA leaders and local governments occurred when, following cuts in funding for a summer youth CAP, black activist Charles Sizemore and thirty others barged into San Francisco Mayor John Shelley's office demanding resources and threatening that if the CAP was not funded once again, "this goddamn town's gonna blow.[5]" However, despite these challenges, many still operate successfully today.

Community Action Agencies

320

References
[1] (http:/ / uscode. house. gov/ download/ pls/ 42C106. txt) U.S. Code Title 42 Chapter 9910 [3] The Economic Opportunity Act, August 1964

External links
Community Action Partnership of Orange County (http://www.capoc.org) - The Orange County, California chapter of Community Action Partnership Community Action Partnership (http://www.communityactionpartnership.com) - The National Association, Washington, D.C. CAPLaw (http://www.caplaw.org) - Community Action Program Legal Services, Boston, Massachusetts

Community Access Program


The Community Access Program (CAP, also seen as C@p) is an initiative of the Government of Canada which aims to provide Canadians with affordable public access to the Internet and the skills they need to use it effectively. The program is administered by Industry Canada as part of their youth initiative.[1]

History of CAP
In 1994 the Community Access Program began. Initially, Industry Canada focused on rural communities, where Internet access was less available. Once the rural communities were equipped with computers and Internet access, Industry Canada focused on what is referred to as the Digital Divide. According to Statistics Canada 2001, the following groups are in highest need of services offered by CAP: Aboriginals, older Canadians, Canadians with low income or low education, francophone, new immigrants, and people in rural areas. Therefore, the focus is primarily to assist in 'Bridging the Digital Divide'. CAP Sites in urban areas were then opened to help reach these people. The program plays a crucial role in bridging the Digital Divide; contributing to the foundation for electronic access to government services; encouraging online learning and literacy; fostering the development of community based infrastructure; promoting Canadian e-commerce; and providing training with Assistive Technology. In order to make better use of the computers and equipment funded by CAP, Industry Canada also initiated the Community Access Program - Youth Initiative (CAP YI). CAP Sites could apply for funding to hire Youth Interns to come and work in their CAP Sites to train the public in computer and Internet use and technology.

CAP YI
The Community Access Program (CAP) Youth Initiative (YI) is coordinated by Industry Canada's Community Access Program and is funded through the Youth Employment Strategy (YES) of Canada which is overseen by Human Resources and Social Development Canada (HRSDC). CAP's youth initiative aims to provide employment opportunities for young Canadians between the ages of 15 and 30 - primarily students, recent graduates, or the under-employed or

Industry Canada Logo

unemployed. CAP YI participates help individuals, community organizations and small businesses improve their knowledge and effective use of the Internet and related information technologies through computer training. CAP YI is: To support the sustainability and long term viability of CAP Sites by providing work experience for young Canadians in CAP Sites across Canada;

Community Access Program To increase the use of information and communications technology (ICT) across Canada to promote economic and social development at the community level; and To allow young people to gain valuable skills related to ICT thereby positioning them for longer-term employment

321

Locations
Industry Canada's Community Access Program (CAP) gives thousands of Canadians affordable access to the Internet. CAP sites are located in public locations such as schools, community centers, and libraries. They may provide access in locations that are geographically remote (e.g. on parts of Cape Breton Island[2]) or serve populations subject to the digital divide.[3] Sites are established and maintained by community networks, generally in partnership with Municipal and Provincial Governments. There are CAP sites located in all of the provinces and territories of Canada.[4] For example, in Ontario the CAP program is divided into 9 networks that are usually grouped by location. The Ontario Library Association has maintained the same names and networks to make things simpler. The number of CAP sites in each network varies.

List of CAPs
CAP Society of Cape Breton County Nova Scotia C@P

CAP Networks
These may be Library Boards, School Boards, Boards of Trade, Economic Development Boards, Municipalities, Community Free A CAP site in St. James Town, Toronto Nets, Human Resources and Social Development Canada (HRSDC), Industry Canada and other federal and provincial departments and agencies. By combining strengths, assets and resources from all their partners and participants, Community Resource Networks can address local and regional issues and concerns that they must deal with in Canada's new knowledge-based economy. A CAP Network can have geographic basis, for example, defined by the borders of a county, city, school board jurisdiction, tourist or economic development region or a combination of these. Or it can be defined by a shared interest or purpose.

References External links


Official CAP Website (http://www.ic.gc.ca/eic/site/cap-pac.nsf/eng/home) Ontario CAP Website (http://capstats.ocl.net/cgi-bin/home_page.cgi) Newfoundland CAP Website (http://www.nfcap.nf.ca/news/index.html) Nova Scotia CAP Website (http://www.nscap.ca/) Prince Edward Island CAP Website (http://www.peicaps.org)

Manitoba CAP Website (http://www.granite.mb.ca/erdc/eastman/cap.html) Saskatchewan CAP Website (http://www.capyi.com/sk/) Alberta CAP Website (http://www.thealbertalibrary.ab.ca/services/cap.html) British Columbia CAP Website (http://members.shaw.ca/capbc/) Yukon CAP Website (http://www.theyukon.ca/cdps/cditem.cfm?nid=884)

Community Access Program North West Territories CAP Website (http://www.angelfire.com/hi4/holmancap/) Nunavut CAP Website (http://www.nu.e-association.ca)

322

Commission on Accreditation of Rehabilitation Facilities


The Commission on Accreditation of Rehabilitation Facilities (CARF), is an international, non-profit organization founded in 1966 with the assistance of Mary E. Switzer, then U.S. Social and Rehabilitation Services Commissioner. For some institutions, it represents an alternative to Joint Commission certification. Revenue sources include contributions from the International Advisory Council, which consists of entities being accredited. CARF's mission is to provide accreditation standards and surveyors for organizations working in the human services field worldwide. Among the many areas of practice represented in the CARF standards are aging services; behavioral health, which includes psychosocial rehabilitation and assertive community treatment; child and youth services; DMEPOS; employment and community services; medical rehabilitation; and opioid treatment programs.[1] CARF International is based in Tucson, Arizona, in the USA, with offices in Washington, D.C., and Edmonton, Alberta, Canada. Brian J. Boon, Ph.D., is president/CEO.

Controversies
In 2012, Narconon Arrowhead was under investigation by the Oklahoma State Bureau of Investigation, the Pittsburg County Sheriff's Office, the Oklahoma State Department of Mental Health and Substance Abuse, for the four deaths related to the facility since 2009. Narconon is recognized by the state because of CARF accreditation since 1992.[2][3][4]

References
[1] Benefits of CARF Accreditation (http:/ / www. viablesolutionsllc. com/ benefits-of-accreditation. html)

External links
CARF website (http://www.carf.org)

X-ray computed tomography

323

X-ray computed tomography


X-ray computed tomography
Intervention

A patient is receiving a CT scan for cancer. Outside of the scanning room is an imaging computer that reveals a 2D image of the body's interior. ICD-10-PCS ICD-9-CM MeSH OPS-301code: MedlinePlus B?2 88.38 [1] [2] [3]

D014057

320...326 003330 [4]

X-ray computed tomography, also computed tomography (CT scan), computed axial tomography or computer assisted tomography (CAT scan) is a medical imaging procedure that uses computer-processed X-rays to produce tomographic images or 'slices' of specific areas of the body. These cross-sectional images are used for diagnostic and therapeutic purposes in various medical disciplines.[] Digital geometry processing is used to generate a three-dimensional image of the inside of an object from a large series of two-dimensional X-ray images taken around a single axis of rotation.[5] CT produces a volume of data that can be manipulated in order to demonstrate various bodily structures based on their ability to block the X-ray beam. Although, historically, the images generated were in the axial or transverse plane, perpendicular to the long axis of the body, modern scanners allow this volume of data to be reformatted in various planes or even as volumetric (3D) representations of structures. Although most common in medicine, CT is also used in other fields, such as nondestructive materials testing. Another example is archaeological uses such as imaging the contents of sarcophagi. Individuals responsible for performing CT exams are called Radiologic Technologists or Radiographers [7] and are required to be licensed in most states.[8] Usage of CT has increased dramatically over the last two decades in many countries.[] An estimated 72 million scans were performed in the United States in 2007.[] One study estimated that as many as 0.4% of

Schematic representation of CT scanner.

[6]

X-ray computed tomography current cancers in the United States are due to CTs performed in the past and that this may increase to as high as 1.5-2% with 2007 rates of CT usage;[] however, this estimate is disputed.[9] Kidney problems following intravenous contrast agents may also be a concern in some types of studies.

324

Diagnostic use
Since its introduction in the 1970s, CT has become an important tool in medical imaging to supplement X-rays and medical ultrasonography. It has more recently been used for preventive medicine or screening for disease, for example CT colonography for patients with a high risk of colon cancer, or full-motion heart scans for patients with high risk of heart disease. A number of institutions offer full-body scans for the general population although this practice goes against the advice and official position of many professional organizations in the field.[10]

Typical CT Scout view as used for planning an exam

Head
CT scanning of the head is typically used to detect infarction, tumors, calcifications, hemorrhage and bone trauma. Of the above, hypodense (dark) structures can indicate infarction and edema, hyperdense (bright) structures indicate calcifications and haemorrhage and bone trauma can be seen as disjunction in bone windows. Tumors can be detected by the swelling and anatomical distortion they cause, or by surrounding edema. Ambulances equipped with small bore multi-sliced CT scanners respond to cases involving stroke or head trauma.

Lungs

Computed tomography of human brain, from base of the skull to top. Taken with intravenous contrast medium.

CT can be used for detecting both acute and chronic changes in the lung parenchyma, that is, the internals of the lungs. It is particularly relevant here because normal two-dimensional X-rays do not show such defects. A variety of techniques are used, depending on the suspected abnormality. For evaluation of chronic interstitial processes (emphysema, fibrosis, and so forth), thin sections with high spatial frequency reconstructions are used; often scans are performed both in inspiration and expiration. This special technique is called high resolution CT. Therefore, it produces a sampling of the lung and not continuous images.

X-ray computed tomography

325

Bone reconstructed in 3D

Pulmonary angiogram
CT pulmonary angiogram (CTPA) is a medical diagnostic test used to diagnose pulmonary embolism (PE). It employs computed tomography and an iodine based contrast agent to obtain an image of the pulmonary arteries.

Cardiac
With the advent of subsecond rotation combined with multi-slice CT (up to 320-slices), high resolution and high speed can be obtained at the same time, allowing excellent imaging of the coronary arteries (cardiac CT angiography).

Example of a CTPA, demonstrating a saddle embolus (dark horizontal line) occluding the pulmonary arteries (bright white triangle)

Abdominal and pelvic


CT is a sensitive method for diagnosis of abdominal diseases. It is used frequently to determine stage of cancer and to follow progress. It is also a useful test to investigate acute abdominal pain.

Extremities
CT is often used to image complex fractures, especially ones around joints, because of its ability to reconstruct the area of interest in multiple planes. Fractures, ligamentous injuries and dislocations can easily be recognised with a 0.2mm resolution.[11][12]
CT Scan of 11 cm Wilms' tumor of right kidney in 13 month old patient.

Advantages

X-ray computed tomography There are several advantages that CT has over traditional 2D medical radiography. First, CT completely eliminates the superimposition of images of structures outside the area of interest. Second, because of the inherent high-contrast resolution of CT, differences between tissues that differ in physical density by less than 1% can be distinguished. Finally, data from a single CT imaging procedure consisting of either multiple contiguous or one helical scan can be viewed as images in the axial, coronal, or sagittal planes, depending on the diagnostic task. This is referred to as multiplanar reformatted imaging. CT is regarded as a moderate- to high-radiation diagnostic technique. The improved resolution of CT has permitted the development of new investigations, which may have advantages; compared to conventional radiography, for example, CT angiography avoids the invasive insertion of a catheter. CT Colonography (also known as Virtual Colonoscopy or VC for short) may be as useful as a barium enema for detection of tumors, but may use a lower radiation dose. CT VC is increasingly being used in the UK as a diagnostic test for bowel cancer and can negate the need for a colonoscopy. The radiation dose for a particular study depends on multiple factors: volume scanned, patient build, number and type of scan sequences, and desired resolution and image quality. In addition, two helical CT scanning parameters that can be adjusted easily and that have a profound effect on radiation dose are tube current and pitch. Computed tomography (CT) scan has been shown to be more accurate than radiographs in evaluating anterior interbody fusion but may still over-read the extent of fusion.[13]

326

Adverse effects
Cancer
The ionizing radiation in the form of x-rays used in CT scans are energetic enough to directly or indirectly damage DNA. This and other types of DNA damage are occasionally not corrected properly by cellular repair mechanisms. Such damage to the DNA occasionally leads to cancer. The estimates of harm from CT are partly based on similar radiation exposures experienced by those present during the atomic bomb explosions in Japan during the second world war and those of nuclear industry workers.[] There is a small increased risk of cancer with CT scans. It is estimated that 0.4% of current cancers in the United States are due to CTs performed in the past and that this may increase to as high as 1.52% with 2007 rates of CT usage;[] however, this estimate is disputed.[14] This would be equivalent to one in 1000 to one in 2000 increased risk of developing a fatal cancer per 10mSv CT scan,[] or 29,000 new cancer cases in the United States due to the number of scans done in 2007[15] and 2100 new cancers in the United Kingdom.[] This additional risk is still low compared to the background risk of dying from cancer of ~20%.[16] The most common cancers caused by radiation exposure are thought to be lung cancer, breast cancer, thyroid cancer, stomach cancer and leukemia.[] A person's age plays a significant role in the subsequent risk of cancer.[16] Estimated lifetime cancer mortality risks from an abdominal CT of a 1-year-old is 0.1% or 1:1000 scans.[16] The risk for someone who is 40 years old is half that of someone who is 20 years old with substantially less risk in the elderly.[16] The International Commission on Radiological Protection estimates that the risk to a fetus being exposed to 10mGy (a unit of radiation exposure, see Gray (unit)) increases the rate of cancer before 20 years of age from 0.03% to 0.04% (for reference a CT pulmonary angiogram exposes a fetus to 4mGy).[] A 2012 review did not find an association between medical radiation and cancer risk in children noting however the existence of limitations in the evidences over which the review is based.[17] CT scans can be performed with different settings for lower exposure in children with most manufacturers of CT scans as of 2007 having this function built in.[] Furthermore, certain conditions can require children to be exposed to multiple CT scans.[] Studies support informing parents of the risks of pediatric CT scanning.[]

X-ray computed tomography

327

Contrast
In the United States half of CT scans involve intravenously injected radiocontrast agents.[] The most common reactions from these agents are mild, including nausea, vomiting and an itching rash; however, more severe reactions may occur.[] Overall reactions occur in 1 to 3% with nonionic contrast and 4 to 12% of people with ionic contrast.[] Skin rashes may appear within a week to 3% of people.[] The old radiocontrast agents caused anaphylaxis in 1% of cases while the newer, lower-osmolar agents cause reactions in 0.010.04% of cases.[][] Death occurs in about two to 30 people per 1,000,000 administrations with newer agents being safer.[][18] When deaths do occur it is more typically in those who are female, elderly or in poor health and is secondary to either anaphylaxis or acute renal failure.[] The contrast agent may induce contrast-induced nephropathy.[] This occurs in 2 to 7% of people who receive these agents, with greater risk in those who have preexisting renal insufficiency,[] preexisting diabetes, or reduced intravascular volume. People with mild kidney impairment are usually advised to ensure full hydration for several hours before and after the injection. For moderate kidney failure, the use of iodinated contrast should be avoided; this may mean using an alternative technique instead of CT. Those with severe renal failure requiring dialysis require less strict precautions, as their kidneys have so little function remaining that any further damage would not be noticeable and the dialysis will remove the contrast agent; it is normally recommended, however, to arrange dialysis as soon as possible following contrast administration to minimize any adverse effects of the contrast. In addition to the use of intravenous contrast, orally administered contrast agents are frequently used when examining the abdomen. These are frequently the same as the intravenous contrast agents, merely diluted to approximately 10% of the concentration. However, oral alternatives to iodinated contrast exist, such as very dilute (0.51% w/v) barium sulfate suspensions. Dilute barium sulfate has the advantage that it does not cause allergic-type reactions or kidney failure, but cannot be used in patients with suspected bowel perforation or suspected bowel injury, as leakage of barium sulfate from damaged bowel can cause fatal peritonitis.

Scan dose
Examination Typical effective Typical absorbed dose (mSv) dose (mGy) to the whole body to the organ in question 2.4 [] [] 2.4 [] []

Annual background radiation Chest X-ray Head CT Screening mammography Abdomen CT Chest CT CT colonography Chest, abdomen and pelvis CT Cardiac CT angiogram Barium enema Neonatal abdominal CT

0.02 12

0.010.15 56 3 [19]

[16] []

0.4 8

[][] [19] [19]

[] [16] [16]

14 13

57

611 9.9

[19] [16]

12

[19] []

912 15 20

40100 15 20 [] []

[] []

X-ray computed tomography The table reports average radiation exposures, however, there is a wide variation in radiation doses between similar scan types, where the highest dose could be as much as 22 times higher than the lowest dose.[16] A typical plain film x-ray involves radiation dose of 0.01 to 0.15 mGy, while a typical CT can involve 1020 mGy for specific organs, and can go up to 80 mGy for certain specialized CT scans.[] For purposes of comparison, the world average dose rate from naturally occurring sources of background radiation is 2.4 mSv per year, equal for practical purposes in this application to 2.4 mGy per year.[] While there is some variation, most people (99%) received less than 7 mSv per year as background radiation.[20] Medical imaging as of 2007 accounted for half of the radiation exposure of those in the United States with CT scans making up two thirds of this amount.[16] In the United Kingdom it accounts for 15% of radiation exposure.[] The average radiation dose from medical sources is ~0.6 mSv per person globally as of 2007.[16] Those in the nuclear industry in the United States are limited to doses of 50 mSv a year and 100 mSv every 5 years.[16]

328

Radiation dose units


The radiation dose reported in the gray or mGy unit is proportional to the amount of energy that the irradiated body part is expected to absorb, and the physical effect (such as DNA double strand breaks) on the cells' chemical bonds by x-ray radiation is proportional to that energy.[21] The sievert unit is used in the report of the effective dose. The sievert unit in the context of CT scans, does not correspond to the actual radiation dose that the scanned body part absorbs, but rather to another radiation dose of another scenario, in which the whole body absorbs the other radiation dose, and where the other radiation dose is of a magnitude that is estimated to have the same probability to induce cancer as the CT scan.[22] Thus, as is shown in the table above, the actual radiation that is absorbed by a scanned body part is often much larger than the effective dose suggests. A specific measure, termed the computed tomography dose index (CTDI), is commonly used as an estimate of the radiation absorbed dose for tissue within the scan region, and is automatically computed by medical CT scanners. The equivalent dose is the effective dose of a case, in which the whole body would actually absorb the same radiation dose, and the sievert unit is used in its report. In the case of non-uniform radiation, or radiation given to only part of the body, which is common for CT examinations, using the local equivalent dose alone would overstate the biological risks to the entire organism.

Excess doses
In October, 2009, the US Food and Drug Administration (FDA) initiated an investigation of brain perfusion CT (PCT) scans, based on overdoses of radiation caused by incorrect settings at one particular facility for this particular type of CT scan. Over 256 patients over an 18 month period were exposed, over 40% lost patches of hair, and prompted the editorial to call for increased CT quality assurance programs, while also noting that "while unnecessary radiation exposure should be avoided, a medically needed CT scan obtained with appropriate acquisition parameter has benefits that outweigh the radiation risks."[16][23] Similar problems have been reported at other centers.[16] These incidents are believed to be due to human error.[16]

Campaigns
In response to increased concern by the public and the ongoing progress of best practices, The Alliance for Radiation Safety in Pediatric Imaging was formed within the Society for Pediatric Radiology. In concert with The American Society of Radiologic Technologists, The American College of Radiology and The American Association of Physicists in Medicine, the Society for Pediatric Radiology developed and launched the Image Gently Campaign which is designed to maintain high quality imaging studies while using the lowest doses and best radiation safety practices available on pediatric patients.[24] This initiative has been endorsed and applied by a growing list of various professional medical organizations around the world and has received support and assistance from companies that

X-ray computed tomography manufacture equipment used in Radiology. Following upon the success of the Image Gently campaign, the American College of Radiology, the Radiological Society of North America, the American Association of Physicists in Medicine and the American Society of Radiologic Technologists have launched a similar campaign to address this issue in the adult population called Image Wisely.[25] The World Health Organization and International Atomic Energy Agency (IAEA) of the United Nations have also been working in this area and have ongoing projects designed to broaden best practices and lower patient radiation dose.[26][27]

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Prevalence
Usage of CT has increased dramatically over the last two decades.[] An estimated 72 million scans were performed in the United States in 2007.[] Of these, six to eleven percent are done in children,[] an increase of seven to eightfold from 1980.[16] Similar increases have been seen in Europe and Asia.[16] In Calgary, Canada 12.1% of people who present to the emergency with an urgent complaint received a CT scan, most commonly either of the head or of the abdomen. The percentage who received CT, however, varied markedly by the emergency physician who saw them from 1.8% to 25%.[28] In the emergency department in the United States, CT or MRI imaging is done in 15% of people who present with injuries as of 2007 (up from 6% in 1998).[29] The increased use of CT scans has been the greatest in two fields: screening of adults (screening CT of the lung in smokers, virtual colonoscopy, CT cardiac screening, and whole-body CT in asymptomatic patients) and CT imaging of children. Shortening of the scanning time to around 1 second, eliminating the strict need for the subject to remain still or be sedated, is one of the main reasons for the large increase in the pediatric population (especially for the diagnosis of appendicitis).[] As of 2007 in the United States a proportion of CT scans are performed unnecessarily.[] Some estimates place this number at 30%.[] There are a number of reasons for this including: legal concerns, financial incentives, and desire by the public.[] There is also otherwise healthy people receiving full body CT scans as screening for which there is no evidence to support.[]

X-ray computed tomography

330

Process
X-ray slice data is generated using an X-ray source that rotates around the object; X-ray sensors are positioned on the opposite side of the circle from the X-ray source. The earliest sensors were scintillation detectors, with photomultiplier tubes excited by (typically) cesium iodide crystals. Cesium iodide was replaced during the 1980s by ion chambers containing high-pressure Xenon gas. These systems were in turn replaced by scintillation systems based on photodiodes instead of photomultipliers and modern scintillation materials (for example rare earth garnet or rare earth oxide ceramics) with more desirable characteristics. Initial machines would rotate the X-ray source and detectors around a stationary object. Following a complete rotation, the object would be moved along its axis, and the next rotation started. Newer machines permitted continuous rotation with the object to be imaged slowly and smoothly slid through the X-ray ring. These are called helical or spiral CT machines. A subsequent development of helical CT was multi-slice (or multi-detector) CT; instead of a single row of detectors, multiple rows of detectors are used effectively capturing multiple cross-sections simultaneously.
3D reconstruction of the brain and eyes from CT scanned DICOM images. In this image, areas with the density of bone or air were made transparent, and the slices stacked up in an approximate free-space alignment. The outer ring of material around the brain are the soft tissues of skin and muscle on the outside of the skull. A black box encloses the slices to provide the black background. Since these are simply 2D images stacked up, when viewed on edge the slices disappear since they have effectively zero thickness. Each DICOM scan represents about 5mm of material averaged into a thin slice.

In conventional CT machines, an X-ray tube and detector are physically rotated behind a circular shroud (see the image above right). An alternative, short lived design, known as electron beam tomography (EBT), used electromagnetic deflection of an electron beam within a very large conical X-ray tube and a stationary array of detectors to achieve very high temporal resolution, for imaging of rapidly moving structures, for example the coronary arteries. CT is used in medicine as a diagnostic tool and as a guide for interventional procedures. Sometimes contrast materials such as intravenous iodinated contrast are used. This is useful to highlight structures such as blood vessels that otherwise would be difficult to delineate from their surroundings. Using contrast material can also help to obtain functional information about tissues. A visual representation of the raw data obtained is called a sinogram, yet it is not sufficient for interpretation. Once the scan data has been acquired, the data must be processed using a form of tomographic reconstruction, which produces a series of cross-sectional images. In terms of mathematics, the raw data acquired by the scanner consists of multiple "projections" of the object being scanned. These projections are effectively the Radon transformation of the structure of the object. Reconstruction, essentially involves solving the inverse Radon transformation.

The technique of filtered back projection is one of the most established algorithmic techniques for this problem. It is conceptually simple, tunable and deterministic. It is also computationally undemanding, with modern scanners requiring only a few

CT scanner with cover removed to show internal components. Legend: T: X-ray tube D: X-ray detectors X: X-ray beam R: Gantry rotation

X-ray computed tomography milliseconds per image. However, this is not the only technique available: the original EMI scanner solved the tomographic reconstruction problem by linear algebra, but this approach was limited by its high computational complexity, especially given the computer technology available at the time. More recently, manufacturers have developed iterative physical model-based maximum likelihood expectation maximization techniques. These techniques are advantageous because they use an internal model of the scanner's physical properties and of the physical laws of X-ray interactions. Earlier methods, such as filtered back projection, assume a perfect scanner and highly simplified physics, which leads to a number of artifacts, high noise and impaired image resolution. Iterative techniques provide images with improved resolution, reduced noise and fewer artifacts, as well as the ability to greatly reduce the radiation dose in certain circumstances. The disadvantage is a very high computational requirement, but advances in computer technology and high-performance computing techniques, such as use of highly parallel GPU algorithms, now allow practical use. Pixels in an image obtained by CT scanning are displayed in terms of relative radiodensity. The pixel itself is displayed according to the mean attenuation of the tissue(s) that it corresponds to on a scale from +3071 (most attenuating) to 1024 (least attenuating) on the Hounsfield scale. Pixel is a two dimensional unit based on the matrix size and the field of view. When the CT slice thickness is also factored in, the unit is known as a Voxel, which is a three-dimensional unit. The phenomenon that one part of the detector cannot differentiate between different tissues is called the "Partial Volume Effect". That means that a big amount of cartilage and a thin layer of compact bone can cause the same attenuation in a voxel as hyperdense cartilage alone. Water has an attenuation of 0 Hounsfield units (HU), while air is 1000HU, cancellous bone is typically +400HU, cranial bone can reach 2000HU or more (os temporale) and can cause artifacts. The attenuation of metallic implants depends on atomic number of the element used: Titanium usually has an amount of +1000HU, iron steel can completely extinguish the X-ray and is, therefore, responsible for well-known line-artifacts in computed tomograms. Artifacts are caused by abrupt transitions between low- and high-density materials, which results in data values that exceed the dynamic range of the processing electronics. Contrast mediums used for X-ray CT, as well as for plain film X-ray, are called radiocontrasts. Radiocontrasts for X-ray CT are, in general, iodine-based.[30] Often, images are taken both with and without radiocontrast. CT images are called precontrast or native-phase images before any radiocontrast has been administrated, and postcontrast after radiocontrast administration.[31] Two-dimensional CT images are conventionally rendered so that the view is as though looking up at it from the patient's feet.[32] Hence, the left side of the image is to the patient's right and vice versa, while anterior in the image also is the patient's anterior and vice versa. This left-right interchange corresponds to the view that physicians generally have in reality when positioned in front of patients. CT data sets have a very high dynamic range which must be reduced for display or printing. This is typically done via a process of "windowing", which maps a range (the "window") of pixel values to a greyscale ramp. For example, CT images of the brain are commonly viewed with a window extending from 0 HU to 80 HU. Pixel values of 0 and lower, are displayed as black; values of 80 and higher are displayed as white; values within the window are displayed as a grey intensity proportional to position within the window. The window used for display must be matched to the X-ray density of the object of interest, in order to optimize the visible detail.

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Three-dimensional reconstruction
Because contemporary CT scanners offer isotropic or near isotropic, resolution, display of images does not need to be restricted to the conventional axial images. Instead, it is possible for a software program to build a volume by "stacking" the individual slices one on top of the other. The program may then display the volume in an alternative manner.[33]

Multiplanar reconstruction
Multiplanar reconstruction (MPR) is the simplest method of reconstruction. A volume is built by stacking the axial slices. The software then cuts slices through the volume in a different plane (usually orthogonal). As an option, a special projection method, such as maximum-intensity projection (MIP) or minimum-intensity projection (mIP/MinIP), can be used to build the reconstructed slices. MPR is frequently used for examining the spine. Axial images through the spine will only show one vertebral body at a time and cannot reliably show the intervertebral discs. By reformatting the volume, it becomes much easier to visualise the position of one vertebral body in relation to the others. Modern software allows reconstruction in non-orthogonal (oblique) planes so that the optimal plane can be chosen to display an anatomical structure. This may be particularly useful for visualising the structure of the bronchi as these do not lie orthogonal to the direction of the scan.
Typical screen layout for diagnostic software, showing one 3D and three MPR views

For vascular imaging, curved-plane reconstruction can be performed. This allows bends in a vessel to be "straightened" so that the entire length can be visualised on one image, or a short series of images. Once a vessel has been "straightened" in this way, quantitative measurements of length and cross sectional area can be made, so that surgery or interventional treatment can be planned. MIP reconstructions enhance areas of high radiodensity, and so are useful for angiographic studies. MIP reconstructions tend to enhance air spaces so are useful for assessing lung structure.

3D rendering techniques
Surface rendering A threshold value of radiodensity is set by the operator (e.g., a level that corresponds to bone). From this, a three-dimensional model can be constructed using edge detection image processing algorithms and displayed on screen. Multiple models can be constructed from various thresholds, allowing different colors to represent each anatomical component such as bone, muscle, and cartilage. However, the interior structure of each element is not visible in this mode of operation.

Surface rendering of the head of the frog Atelopus franciscus, with ear parts highlighted.

X-ray computed tomography Volume rendering Surface rendering is limited in that it will display only surfaces that meet a threshold density, and will display only the surface that is closest to the imaginary viewer. In volume rendering, transparency, colors and shading are used to allow a better representation of the volume to be shown in a single image. For example, the bones of the pelvis could be displayed as semi-transparent, so that, even at an oblique angle, one part of the image does not conceal another. Image segmentation Where different structures have similar radiodensity, it can become impossible to separate them simply by adjusting volume rendering parameters. The solution is called segmentation, a manual or automatic procedure that can remove the unwanted structures from the image.

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Image quality
Artifacts
Although images produced by CT are generally faithful representations of the scanned volume, the technique is susceptible to a number of artifacts, such as the following:[5]Chapters 3 and 5 Streak artifact Streaks are often seen around materials that block most X-rays, such as metal or bone. Numerous factors contribute to these streaks: undersampling, photon starvation, motion, beam hardening, and Compton scatter. This type of artifact commonly occurs in the posterior fossa of the brain, or if there are metal implants. The streaks can be reduced using newer reconstruction techniques [34] or approaches such as metal artifact reduction (MAR).[] Partial volume effect This appears as "blurring" of edges. It is due to the scanner being unable to differentiate between a small amount of high-density material (e.g., bone) and a larger amount of lower density (e.g., cartilage). The reconstruction assumes that the X-ray attenuation within each voxel is homogenous; this may not be the case at sharp edges. This is most commonly seen in the z-direction, due to the conventional use of highly anisotropic voxels, which have a much lower out-of-plane resolution, than in-plane resolution. This can be partially overcome by scanning using thinner slices, or an isotropic acquisition on a modern scanner. Ring artifact Probably the most common mechanical artifact, the image of one or many "rings" appears within an image. This is usually due to a detector fault, or miscalibration of an individual detector element. Noise This appears as grain on the image and is caused by a low signal to noise ratio. This occurs more commonly when a thin slice thickness is used. It can also occur when the power supplied to the X-ray tube is insufficient to penetrate the anatomy. Motion artifact This is seen as blurring and/or streaking, which is caused by movement of the object being imaged. Motion blurring might be reduced using a new technique called IFT (incompressible flow tomography).[35] Windmill Streaking appearances can occur when the detectors intersect the reconstruction plane. This can be reduced with filters or a reduction in pitch. Beam hardening

X-ray computed tomography This can give a "cupped appearance". It occurs when there is more attenuation along a path passing through the center of an object, than a path that grazes the edge. This is easily corrected by filtration and software.[36][37]

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Dose vs. image quality


An important issue within radiology today is how to reduce the radiation dose during CT examinations without compromising the image quality. In general, higher radiation doses result in higher-resolution images, while lower doses lead to increased image noise and unsharp images. However, increased dosage raises increase the adverse side effects, including the risk of radiation induced cancer a four-phase abdominal CT gives the same radiation dose as 300 chest x-rays (See the Scan dose section). Several methods that can reduce the exposure to ionizing radiation during a CT scan exist. 1. New software technology can significantly reduce the required radiation dose. 2. Individualize the examination and adjust the radiation dose to the body type and body organ examined. Different body types and organs require different amounts of radiation. 3. Prior to every CT examination, evaluate the appropriateness of the exam whether it is motivated or if another type of examination is more suitable. Higher resolution is not always suitable for any given scenario, such as detection of small pulmonary masses.[38]

Industrial use
Industrial CT Scanning (industrial computed tomography) is a process which utilizes x-ray equipment to produce 3D representations of components both externally and internally. Industrial CT scanning has been utilized in many areas of industry for internal inspection of components. Some of the key uses for CT scanning have been flaw detection, failure analysis, metrology, assembly analysis, and reverse engineering applications. CT scanning is also employed in the imaging and conservation of museum artifacts.[39]

History
Origins of tomography
In the early 1900s, the Italian radiologist Alessandro Vallebona proposed a method to represent a single slice of the body on the radiographic film. This method was known as tomography. The idea is based on simple principles of projective geometry: moving synchronously and in opposite directions the X-ray tube and the film, which are connected together by a rod whose pivot point is the focus; the image created by the points on the focal plane appears sharper, while the images of the other points annihilate as noise. This is only The prototype CT scanner marginally effective, as blurring occurs in only the "x" plane. There are also more complex devices that can move in more than one plane and perform more effective blurring.

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Mathematical theory
The mathematical theory behind the tomographic reconstruction dates back to 1917 where the invention of Radon Transform[40][41] by an Austrian mathematician Johann Radon. He showed mathematically that a function could be reconstructed from an infinite set of its projections.[42] In 1937, a Polish mathematician, named Stefan Kaczmarz, developed a method to find an approximate solution to a large system of linear algebraic equations.[43][44] This led the foundation to another powerful reconstruction method called A historic EMI-Scanner "Algebraic Reconstruction Technique (ART)" which was later adapted by Sir Godfrey Hounsfield as the image reconstruction mechanism in his famous invention, the first commercial CT scanner. In 1956, Ronald N. Bracewell used a method similar to the Radon Transform to reconstruct a map of solar radiation from a set of solar radiation measurements.[45] In 1959, William Oldendorf, a UCLA neurologist and senior medical investigator at the West Los Angeles Veterans Administration hospital, conceived an idea for "scanning a head through a transmitted beam of X-rays, and being able to reconstruct the radiodensity patterns of a plane through the head" after watching an automated apparatus built to reject frostbitten fruit by detecting dehydrated portions. In 1961, he built a prototype in which an X-ray source and a mechanically coupled detector rotated around the object to be imaged. By reconstructing the image, this instrument could get an X-ray picture of a nail surrounded by a circle of other nails, which made it impossible to X-ray from any single angle.[46] In his landmark paper published in 1961, he described the basic concept which was later used by Allan McLeod Cormack to develop the mathematics behind computerized tomography. In October 1963, Oldendorf received a U.S. patent for a "radiant energy apparatus for investigating selected areas of interior objects obscured by dense material." Oldendorf shared the 1975 Lasker award with Hounsfield for that discovery.[47] The field of the mathematical methods of computerized tomography has seen a very active development since then, as is evident from overview literature[5][48][49] by Frank Natterer and Gabor T. Herman, two of the pioneers in the this field.[50] Tomography has been one of the pillars of radiologic diagnostics until the late 1970s, when the availability of minicomputers and of the transverse axial scanning method gradually supplanted it as the modality of CT. Transverse axial scanning was due in large part to the work of Godfrey Hounsfield and South African-born Allan McLeod Cormack. In terms of mathematics, the method is based upon the use of the Radon Transform. But as Cormack remembered later,[51] he had to find the solution himself since it was only in 1972 that he learned of the work of Radon, by chance.

Commercial scanners
The first commercially viable CT scanner was invented by Sir Godfrey Hounsfield in Hayes, United Kingdom, at EMI Central Research Laboratories using X-rays. Hounsfield conceived his idea in 1967.[52] The first EMI-Scanner was installed in Atkinson Morley Hospital in Wimbledon, England, and the first patient brain-scan was done on 1 October 1971.[53] It was publicly announced in 1972. The original 1971 prototype took 160 parallel readings through 180 angles, each 1 apart, with each scan taking a little over 5 minutes. The images from these scans took 2.5 hours to be processed by algebraic reconstruction techniques on a large computer. The scanner had a single photomultiplier detector, and operated on the Translate/Rotate principle.[53]

X-ray computed tomography The success of The Beatles enabled EMI to fund research and build early models for medical use.[54] The first production X-ray CT machine (in fact called the "EMI-Scanner") was limited to making tomographic sections of the brain, but acquired the image data in about 4 minutes (scanning two adjacent slices), and the computation time (using a Data General Nova minicomputer) was about 7 minutes per picture. This scanner required the use of a water-filled Perspex tank with a pre-shaped rubber "head-cap" at the front, which enclosed the patient's head. The water-tank was used to reduce the dynamic range of the radiation reaching the detectors (between scanning outside the head compared with scanning through the bone of the skull). The images were relatively low resolution, being composed of a matrix of only 80 x 80 pixels. In the U.S., the first installation was at the Mayo Clinic. As a tribute to the impact of this system on medical imaging the Mayo Clinic has an EMI scanner on display in the Radiology Department. Allan McLeod Cormack of Tufts University in Massachusetts independently invented a similar process, and both Hounsfield and Cormack shared the 1979 Nobel Prize in Medicine.[55][] The first CT system that could make images of any part of the body and did not require the "water tank" was the ACTA (Automatic Computerized Transverse Axial) scanner designed by Robert S. Ledley, DDS, at Georgetown University. This machine had 30 photomultiplier tubes as detectors and completed a scan in only 9 translate/rotate cycles, much faster than the EMI-scanner. It used a DEC PDP11/34 minicomputer both to operate the servo-mechanisms and to acquire and process the images. The Pfizer drug company acquired the prototype from the university, along with rights to manufacture it. Pfizer then began making copies of the prototype, calling it the "200FS" (FS meaning Fast Scan), which were selling as fast as they could make them. This unit produced images in a 256256 matrix, with much better definition than the EMI-Scanner's 8080. Since the first CT scanner, CT technology has vastly improved. Improvements in speed, slice count, and image quality have been the major focus primarily for cardiac imaging. Scanners now produce images much faster and with higher resolution enabling doctors to diagnose patients more accurately and perform medical procedures with greater precision. In the late 90's CT scanners broke into two major groups, "Fixed CT" and "Portable CT". "Fixed CT Scanners" are large, require a dedicated power supply, electrical closet, HVAC system, a separate workstation room, and a large lead lined room. "Fixed CT Scanners" can also be mounted inside large tractor trailers and driven from site to site and are known as "Mobile CT Scanners". "Portable CT Scanners" are light weight, small, and mounted on wheels. These scanners often have built-in lead shielding and run off of batteries or standard wall power.

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Etymology
The word "tomography" is derived from the Greek tomos (slice) and graphein (to write). Computed tomography was originally known as the "EMI scan" as it was developed in the early 1970s at a research branch of EMI, a company best known today for its music and recording business. It was later known as computed axial tomography (CAT or CT scan) and body section rntgenography. Although the term "computed tomography" could be used to describe positron emission tomography or single photon emission computed tomography (SPECT), in practice it usually refers to the computation of tomography from X-ray images, especially in older medical literature and smaller medical facilities. In MeSH, "computed axial tomography" was used from 1977 to 1979, but the current indexing explicitly includes "X-ray" in the title.[56]

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Types of machines
Spinning tube, commonly called spiral CT, or helical CT in which an entire X-ray tube is spun around the central axis of the area being scanned. These are the dominant type of scanners on the market because they have been manufactured longer and offer lower cost of production and purchase. The main limitation of this type is the bulk and inertia of the equipment (X-ray tube assembly and detector array on the opposite side of the circle) which limits the speed at which the equipment can spin. Some designs use two X-ray sources and detector arrays offset by an angle, as technique to improve temporal resolution. Electron beam tomography (EBT) is a specific form of CT in which a large enough X-ray tube is constructed so that only the path of the electrons, travelling between the cathode and anode of the X-ray tube, are spun using deflection coils. This type had a major advantage since sweep speeds can be much faster, allowing for less blurry imaging of moving structures, such as the heart and arteries. Fewer scanners of this design have been produced when compared with spinning tube types, mainly due to the higher cost associated with building a much larger X-ray tube and detector array and limited anatomical coverage. Only one manufacturer (Imatron, later acquired by General electric) ever produced scanners of this design. Production ceased in early 2006.[57]

Previous studies
Pneumoencephalography of the brain was quickly replaced by CT. A form of tomography can be performed by moving the X-ray source and detector during an exposure. Anatomy at the target level remains sharp, while structures at different levels are blurred. By varying the extent and path of motion, a variety of effects can be obtained, with variable depth of field and different degrees of blurring of "out of plane" structures.[58]:25 Although largely obsolete, conventional tomography is still used in specific situations such as dental imaging (orthopantomography) or in intravenous urography.

References
[1] http:/ / icd9cm. chrisendres. com/ index. php?srchtype=procs& srchtext=88. 38& Submit=Search& action=search [2] http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2011/ MB_cgi?field=uid& term=D014057 [3] http:/ / ops. icd-code. de/ ops/ code/ 320. . . 326. html [4] http:/ / www. nlm. nih. gov/ medlineplus/ ency/ article/ 003330. htm [5] Herman, G. T., Fundamentals of computerized tomography: Image reconstruction from projection, 2nd edition, Springer, 2009 [6] US4,115,698 (US Patent) (http:/ / www. google. com/ patents/ US4115698) [7] https:/ / www. arrt. org/ Patient-Public/ Patient-Page [10] http:/ / hps. org/ documents/ ctscreening_ps018-0. pdf [13] Brian R. Subach M.D., F.A.C.S et al. "Reliability and accuracy of fine-cut computed tomography scans to determine the status of anterior interbody fusions with metallic cages" (http:/ / www. spinemd. com/ publications/ articles/ reliability-and-accuracy-of-fine-cut-computed-tomography-scans-to-determine-the-status-of-anterior-interbody-usions-with-metallic-cages) [19] Shrimpton, P.C; Miller, H.C; Lewis, M.A; Dunn, M. Doses from Computed Tomography (CT) examinations in the UK 2003 Review (http:/ / www. hpa. org. uk/ web/ HPAwebFile/ HPAweb_C/ 1194947420292) [22] The Measurement, Reporting, and Management of Radiation Dose in CT (http:/ / www. aapm. org/ pubs/ reports/ RPT_96. pdf) "It is a single dose parameter that reflects the risk of a nonuniform exposure in terms of an equivalent whole-body exposure." [30] Contrast agent for radiotherapy CT (computed tomography) scans. Patient Information Series No. 11 (http:/ / www. uclh. nhs. uk/ PandV/ PIL/ Patient information leaflets/ Contrast Agents for Radiotherapy CT Planning Scan. pdf) at University College London Hospitals NHS Foundation Trust. Last reviewed: October 2009 [32] Computerized Tomography chapter (http:/ / fitsweb. uchc. edu/ ctanatomy/ extrem/ index. html) at University of Connecticut Health Center. [33] Udupa, J.K. and Herman, G. T., 3D Imaging in Medicine, 2nd Edition, CRC Press, 2000 [38] Simpson, Graham (2009). "Thoracic computed tomography: principles and practice" (http:/ / www. australianprescriber. com/ upload/ pdf/ articles/ 1036. pdf) (PDF). Australian Prescriber, 32:4. Retrieved September 25, 2009. [41] Radon J., Translated by Parks PC., On the determination of functions from their integrals along certain manifolds. IEEE Trans. Med. Imaging. 1993;MI-5: 1706. [42] Hornich H., Translated by Parks PC. A Tribute to Johann Radon. IEEE Trans. Med. Imaging. 1986;5(4) 1699. [44] Kaczmarz S., "Approximate solution of system of linear equations. Int. J. Control. 1993; 57-9.

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[45] Bracewell RN., [Strip Integration in Radio Astronomyhttp://articles.adsabs.harvard.edu//full/1956AuJPh...9..198B/0000198.000.html]. Aust. J. Phys. 1956;9: 198217. [46] Oldendorf WH. Isolated flying spot detection of radiodensity discontinuities displaying the internal structural pattern of a complex object. Ire Trans Biomed Electron. 1961 Jan;BME-8:6872. [48] F. Natterer, "The Mathematics of Computerized Tomography (Classics in Applied Mathematics)", Society for Industrial Mathematics, isbn= 0898714931 [49] F. Natterer and F. Wbbeling "Mathematical Methods in Image Reconstruction (Monographs on Mathematical Modeling and Computation)", Society for Industrial (2001), isbn= 0898714729 [51] Allen M.Cormack: My Connection with the Radon Transform, in: 75 Years of Radon Transform, S. Gindikin and P. Michor, eds., International Press Incorporated (1994), pp. 3235, ISBN 1-57146-008-X [53] (http:/ / bjr. birjournals. org/ cgi/ reprint/ 79/ 937/ 5. pdf) [58] Novelline, Robert. Squire's Fundamentals of Radiology. Harvard University Press. 5th edition. 1997. ISBN 0-674-83339-2.

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External links
Radiation Dose in X-Ray and CT Exams (http://www.radiologyinfo.org/en/safety/index.cfm?pg=sfty_xray) American College of Radiology and the Radiologic Society of North America. Radiation Risk Calculator (http://www.xrayrisk.com) American Society of Radiologic Technologists. Video of patient getting a CT scan (http://www.rosiescancerfund.com/videos/view/rosies-ct-scan_67.html) CTisus (http://www.ctisus.com/teachingfiles) CT scanning protocols, images, and learning materials. CT Artefacts (http://www.impactscan.org/slides/impactcourse/artefacts/img0.html) PPT by David Platten. CT scanning of historic violins (http://instrumentalinsight.com/samples.html)

Blood glucose monitoring

339

Blood glucose monitoring


Blood glucose monitoring
Intervention

Blood glucose testing, showing the size of blood drop required by modern meters. MeSH D015190 [1]

Blood glucose monitoring is a way of testing the concentration of glucose in the blood (glycemia). Particularly important in the care of diabetes mellitus, a blood glucose test is performed by piercing the skin (typically, on the finger) to draw blood, then applying the blood to a chemically active disposable 'test-strip'. Different manufacturers use different technology, but most systems measure an electrical characteristic, and use this to determine the glucose level in the blood. The test is usually referred to as capillary blood glucose and sometimes incorrectly called BM Stix (after one of the companies that makes the test kit). Healthcare professionals advise patients with diabetes on the appropriate monitoring regime for their condition. Most people with Type 2 diabetes test at least once per day. Diabetics who use insulin (all Type 1 diabetes and many Type 2s) usually test their blood sugar more often (3 to 10 times per day), both to assess the effectiveness of their prior insulin dose and to help determine their next insulin dose. Improved technology for measuring blood glucose is rapidly changing the standards of care for all diabetic people.

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Purpose
Blood glucose monitoring reveals individual patterns of blood glucose changes, and helps in the planning of meals, activities, and at what time of day to take medications.[2] Also, testing allows for quick response to high blood sugar (hyperglycemia) or low blood sugar (hypoglycemia). This might include diet adjustments, exercise, and insulin (as instructed by the health care provider).[2]

Blood glucose meters


A blood glucose meter is an electronic device for measuring the blood glucose level. A relatively small drop of blood is placed on a disposable test strip which interfaces with a digital meter. Within several seconds, the level of blood glucose will be shown on the digital display. Needing only a small drop of blood for the meter means that the time and effort required for testing is reduced and the compliance of diabetic people to their testing regimens is improved. Although the cost of using blood glucose meters seems high, it is believed to be a cost benefit relative to the avoided medical costs of the complications of diabetes. Recent advances include: 'alternate site testing', the use of blood drops from places other than the finger, usually the palm or forearm. This alternate site testing uses the same test strips and meter, is practically pain free, and gives the real estate on the finger tips a needed break if they become sore. The disadvantage of this technique is that there is usually less blood flow to alternate sites, which prevents the reading from being accurate when the blood sugar level is changing. 'no coding' systems. Older systems required 'coding' of the strips to the meter. This carried a risk of 'miscoding', which can lead to inaccurate results. Two approaches have resulted in systems that no longer require coding. Some systems are 'autocoded', where technology is used to code each strip to the meter. And some are manufactured to a 'single code', thereby avoiding the risk of miscoding. 'multi-test' systems. Some systems use a cartridge or a disc containing multiple test strips. This has the advantage that the user doesn't have to load individual strips each time, which is convenient and can enable quicker testing. 'downloadable' meters. Most newer systems come with software that allows the user to download meter results to a computer. This information can then be used, together with health care professional guidance, to enhance and improve diabetes management. The meters usually require a connection cable, unless they are designed to work wirelessly with an insulin pump, or are designed to plug directly into the computer.

Four generations of blood glucose meter, c. 19932005. Sample sizes vary from 30 to 0.3 l. Test times vary from 5 seconds to 2 minutes (modern meters are typically below 15 seconds).

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Continuous glucose monitoring


A continuous glucose monitor (CGM) determines glucose levels on a continuous basis (every few minutes). A typical system consists of: a disposable glucose sensor placed just under the skin, which is worn for a few days until replacement a link from the sensor to a non-implanted transmitter which communicates to a radio receiver an electronic receiver worn like a pager (or insulin pump) that displays glucose levels with nearly continuous updates, as well as monitors rising and falling trends. Continuous glucose monitors measure the glucose level of interstitial fluid. Shortcomings of CGM systems due to this fact are: continuous systems must be calibrated with a traditional blood glucose measurement (using current technology) and therefore require both the CGM system and occasional "fingerstick" glucose levels in interstitial fluid lag behind blood glucose values Patients therefore require traditional fingerstick measurements for calibration (typically twice per day) and are often advised to use fingerstick measurements to confirm hypo- or hyperglycemia before taking corrective action. The lag time discussed above has been reported to be about 5 minutes.[3][4][5] Anecdotally, some users of the various systems report lag times of up to 1015 minutes. This lag time is insignificant when blood sugar levels are relatively consistent. However, blood sugar levels, when changing rapidly, may read in the normal range on a CGM system while in reality the patient is already experiencing symptoms of an out-of-range blood glucose value and may require treatment. Patients using CGM are therefore advised to consider both the absolute value of the blood glucose level given by the system as well as any trend in the blood glucose levels. For example, a patient using CGM with a blood glucose of 100mg/dl on their CGM system might take no action if their blood glucose has been consistent for several readings, while a patient with the same blood glucose level but whose blood glucose has been dropping steeply in a short period of time might be advised to perform a fingerstick test to check for hypoglycemia. Continuous monitoring allows examination of how the blood glucose level reacts to insulin, exercise, food, and other factors. The additional data can be useful for setting correct insulin dosing ratios for food intake and correction of hyperglycemia. Monitoring during periods when blood glucose levels are not typically checked (e.g. overnight) can help to identify problems in insulin dosing (such as basal levels for insulin pump users or long-acting insulin levels for patients taking injections). Monitors may also be equipped with alarms to alert patients of hyperglycemia or hypoglycemia so that a patient can take corrective action(s) (after fingerstick testing, if necessary) even in cases where they do not feel symptoms of either condition. While the technology has its limitations, studies have demonstrated that patients with continuous sensors experience less hyperglycemia and also reduce their glycosylated hemoglobin levels.[6][7][8][9] Currently, continuous blood glucose monitoring is not automatically covered by health insurance in the United States in the same way that most other diabetic supplies are covered (e.g. standard glucose testing supplies, insulin, and even insulin pumps). However, an increasing number of insurance companies do cover continuous glucose monitoring supplies (both the receiver and disposable sensors) on a case-by-case basis if the patient and doctor show a specific need. The lack of insurance coverage is exacerbated by the fact that disposable sensors must be frequently replaced. Some sensors have been U.S. Food and Drug Administration (FDA) approved for 7- and 3-day use, though some patients wear sensors for longer than the recommended period) and the receiving meters likewise have finite lifetimes (less than 2 years and as little as 6 months). This is one factor in the slow uptake in the use of sensors that have been marketed in the United States. The principles, history and recent developments of operation of electrochemical glucose biosensors are discussed in a chemical review by Joseph Wang.[10]

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Glucose sensing bio-implants


Investigations on the use of test strips have shown that the required self-injury acts as a psychological barrier restraining the patients from sufficient glucose control. Secondary diseases are accordingly put up with too high glucose levels. A significant improvement of diabetes therapy might be achieved with an implantable sensor that would continuously monitor blood sugar levels within the body and transmit the measured data outside. Longer term solutions to continuous monitoring, not yet available but under development, use a long-lasting bio-implant. The burden of regular blood testing would be taken from the patient, who may instead follow the course of their glucose levels on an intelligent device like a laptop or a smart phone. Glucose concentrations do not necessarily have to be measured in blood vessels, but may also be determined in the interstitial fluid, where the same levels prevail with a time lag of a few minutes due to its connection with the capillary system. However, the enzymatic glucose detection scheme used in single-use test strips could not be shown so far to be suitable for implants also. One main problem is caused by the varying supply of oxygen, by which glucose is converted to glucono lactone and H2O2 by glucose oxidase. Since the insertion of a technical device like a sensor into the body is always accompanied by a steadily growing encapsulation tissue [] the diffusion of oxygen to the reaction zone is continuously diminished. The decreasing oxygen availability causes the sensor to drift and enzymatic glucose sensors have thus always shown an artificial drift of the data. An important progress has recently been achieved with an implantable sensor measuring not glucose alone, but also the concentration and corrected the first signal with the latter []. In another approach glucose is not converted in a chemical reaction, but only reversibly bound to a chemical receptor and which is denoted an affinity assay. The scheme has been put forward by Schultz & Sims in 1978 []. Different technical variants of the assay were investigated so far [] [] [] with fluorescent glucose biosensor representing the dominating detection scheme [] [] []. Investigation of affinity-based sensors have shown that the encapsulation by body tissue does not cause a drift of the sensor signal, but only a time lag of the signal compared to the direct measurement in blood []. In 2013 a microelectronic sensor chip was presented, by which glucose concentrations are determined from the viscosity of a sensoric liquid []. The viscosity is modulated by glucose through the binding to concanavalin A, which competes with that to a natural glucose polymer being dextran. The chip is fabricated as a microelectromechanical system (MEMS) from a combined CMOS/BiCMOS technology. Viscosity is determined from the velocity of 50 nm thin beam of titanium nitride that is bent in a quasi-electrostatic mode. Its movement through the sensoric liquid is fast or slow depending on glucose level. The sensor chip is extremely miniaturized and thus offers the perspective for a convenient implantable glucose monitor.

Non-invasive technologies
Some new technologies to monitor blood glucose levels will not require access to blood to read the glucose level. Non-invasive technologies include near IR detection, ultrasound and dielectric spectroscopy.[citation needed] These will free the person with diabetes from finger sticks to supply the drop of blood for blood glucose analysis. Most of the non-invasive methods under development are continuous glucose monitoring methods and offer the advantage of providing additional information to the subject between the conventional finger stick, blood glucose measurements and over time periods where no finger stick measurements are available (i.e. while the subject is sleeping).

Blood glucose monitoring

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Effectiveness
For patients with diabetes mellitus type 2, the importance of monitoring and the optimal frequency of monitoring are not clear. There is no evidence that better HbA1c monitoring leads to better patient outcomes in actual practice.[11] One randomized controlled trial found that self-monitoring of blood glucose did not improve the HbA1c among "reasonably well controlled non-insulin treated patients with type 2 diabetes".[] A recent meta-analysis of 47 randomized controlled trials encompassing 7677 patients showed that self-care management intervention improves glycemic control in Diabetics, with an estimated 0.36% (95% CI, 0.21-0.51) reduction in their glycosylated Hemoglobin values.[12] Furthermore, a recent study showed that patients described as being Uncontrolled Diabetics (defined in this study by HbA1C levels >8%) showed a statistically significant decrease in the HbA1C levels after a 90-day period of seven-point Self-Monitoring of Blood Glucose (SMBG) with a Relative Risk Reduction (RRR) of 0.18% (95% CI, 0.86-2.64%, p<.001).[13] Regardless of lab values or other numerical parameters, the purpose of the clinician is to improved quality of life and patient outcomes in diabetic patients. A recent study included 12 Randomized controlled trials and evaluated outcomes in 3259 patients. The authors concluded through a qualitative analysis that SMBG on quality of life showed no effect on patient satisfaction or the patients health-related quality of life.[14] A recent study found that a treatment strategy of intensively lowering blood sugar levels (below 6%) in patients with additional cardiovascular disease risk factors poses more harm than benefit.[15] For type 2 diabetics who are not on insulin, exercise and diet are the best tools. Blood glucose monitoring is, in that case, simply a tool to evaluate the success of diet and exercise. Insulin-dependent type 2 diabetics need to monitor their blood sugar as frequently as type 1 diabetics.

Blood glucose monitoring recommendations


The National Institute for Health and Clinical Excellence (NICE), UK released updated diabetes recommendations on the 30th May 2008, which recommend that self-monitoring of plasma glucose levels for people with newly diagnosed type 2 diabetes must be integrated into a structured self-management education process.[16]

References
[1] http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2011/ MB_cgi?field=uid& term=D015190 [2] MedlinePlus > Blood glucose monitoring (http:/ / www. nlm. nih. gov/ medlineplus/ ency/ article/ 003438. htm) Update Date: 6/17/2008. Updated by: Elizabeth H. Holt, MD, PhD. In turn citing: American Diabetes Association. Standards of medical care in diabetes -- 2008. Diabetes Care. 2008;31:S12-S54. [3] Iris M. Wentholt, Marit A. Vollebregt, Augustus A. Hart, Joost B. Hoekstra, and J. Hans DeVries. Comparison of a Needle-Type and a Microdialysis Continuous Glucose Monitor in Type 1 Diabetic Patients. Diabetes Care, 2005 28: 28712876 [4] Steil, G.M., Rebrin, K. Mastrototaro, J., Bernaba, B., and Saad, M.F. Determination of Plasma Glucose During Rapid Glucose Excursions with a Subcutaneous Glucose Sensor. Diabet. Technol. Ther. 2003, 5: 27-31 [5] Wilhelm, B., Forst, S., Weber, M.M., Larbig, M., Pftzner, A., and Forst, T. Evaluation of CGMS During Rapid Blood Glucose Changes in Patients with Type 1 Diabetes. Diabet. Technol. Ther. , 2006, 8: 146-155 [6] Garg, S., Zisser H., Schwartz, S., Baile, T., Kaplan, R., Ellis, S., and Jovanovic, L. Improvement in Glycemic Excursions With a Transcutaneous, Real-Time Continuous Glucose Sensor. Diabetes Care, 2006. 29:44-50 [7] Deiss, D., Bolinder, J., Riveline, J-P., Battelino, T., Bose, E., Tubiana-Rufi, N., Kerr, D., and Phillip, M. Improved glycemic control in poorly controlled patients with type 1 diabetes using real-time continuous glucose monitoring. Diabetes Care, 2006. 29 (12): 27302732 [8] Mastrototaro, J.J., Cooper, K.W., Soundararajan, G., Sanders, J.B., and Shah, R.B. Adv Ther. 2006 Sep-Oct;23(5):725-32 [9] Relationship of fasting and hourly blood glucose levels to HbA1c values: safety, accuracy, and improvements in glucose profiles obtained using a 7-day continuous glucose sensor. Garg, S. and Jovanovic, L. Diabetes Care 2006 Dec;29(12):2644-9 [10] Electrochemical Glucose Biosensors (http:/ / pubs. acs. org/ doi/ abs/ 10. 1021/ cr068123a) [12] Minet, L., Moller, S., Vach, W., Wagner, L., & Henriksen, J. E. (2010). Mediating the effect of self-care management intervention in type 2 diabetes: A meta-analysis of 47 randomised controlled trials. Patient Education and Counseling, 80(1), 29-41.<refname="Minet"> [13] Khamseh, M. E., Ansari, M., Malek, M., Shafiee, G., & Baradaran, H. (2011). Effects of a structured self-monitoring of blood glucose method on patient self-management behavior and metabolic outcomes in type 2 diabetes mellitus. Journal of Diabetes Science and Technology, 5(2), 388-393.<refname="Khamseh"> [14] Malanda, U. L., Welschen, L. M., Riphagen, I. I., Dekker, J. M., Nijpels, G., & Bot, S. D. (2012). Self-monitoring of blood glucose in patients with type 2 diabetes mellitus who are not using insulin. Cochrane Database of Systematic Reviews (Online), 1,

Blood glucose monitoring


CD005060.<refname="Malanda">

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Congressional Budget Office


Congressional Budget Office
Agency overview Formed Headquarters July 12, 1974 Ford House Office Building, 4th Floor Second and D Streets, SW Washington, D.C. 20548 235 $46.8 million (FY 2011)

Employees Annual budget

Agency executive Douglas W. Elmendorf, Director Website www.cbo.gov/


[1]

The Congressional Budget Office (CBO) is a federal agency within the legislative branch of the United States government that provides economic data to Congress.[2] The CBO was created as a nonpartisan agency by the Congressional Budget and Impoundment Control Act of 1974.

History
The Congressional Budget Office was created by Title II of the Congressional Budget and Impoundment Control Act (P.L. 93-344), which was signed into law by President Richard Nixon on July 12, 1974. Official operations began on February 24, 1975, with Alice Rivlin as director.

Mission
The CBO's mandate is to provide Congress with: Objective, nonpartisan, and timely analysis to aid in economic and budgetary decisions on a wide array of programs covered by the federal budget projected out to at most 10 years; And the information and estimates required by the Congressional budget process.[3] With respect to estimating spending for Congress, the Congressional Budget Office serves a purpose parallel to that of the Joint Committee on Taxation for estimating revenue for Congress, the Department of the Treasury for estimating revenues for the Executive and estimates required for the Congressional budget process. This includes projections on the effect on national debt and cost estimates for legislation.[4]

Congressional Budget Office

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Operations
Section 202(e) of the Budget Act requires submission by CBO to the House and Senate Committees on the Budget periodic reports about fiscal policy and to provide baseline projections of the federal budget. This is currently done by preparation of an annual Economic and Budget Outlook plus a mid-year update. The agency also each year issues An Analysis of the President's Budgetary Proposals for the upcoming fiscal year per a standing request of the Senate Committee on Appropriations. These three series are designated essential titles distributed to Federal Depository Libraries and are available for purchase from the Government Printing Office. CBO also prepares reports and issues briefs and provides testimony often in response to requests of the various Congressional Committees. It also issues letters responding to queries made to it by members of Congress.

Leadership
The Speaker of the House of Representatives and the President pro tempore of the Senate jointly appoint the CBO Director, after considering recommendations from the two budget committees. The term of office is four years, with no limit on the number of terms a Director may serve. Either House of Congress, however, may remove the Director by resolution. At the expiration of a term of office, the person serving as Director may continue in the position until his or her successor is appointed.

Divisions
The Congressional Budget Office is divided into eight divisions.[5] Budget Analysis Financial Analysis Health and Human Services Macroeconomic Analysis Management, Business, and Information Services Microeconomic Studies National Security Tax Analysis

Directors of the Congressional Budget Office


Name [6] Begin Date January 22, 2009 End Date Present

Douglas W. Elmendorf Robert A. Sunshine (Acting) Peter R. Orszag

November 25, 2008 January 22, 2009 January 18, 2007 November 25, 2008

Donald B. Marron Jr. (Acting) December 29, 2005 January 2007 Douglas Holtz-Eakin Barry B. Anderson (Acting) Dan L. Crippen James Blum (Acting) June E. O'Neill [7] February 5, 2003 January 3, 2003 February 3, 1999 January 29, 1999 March 1, 1995 March 6, 1989 December 29, 2005 February 5, 2003 January 3, 2003 February 3, 1999 January 29, 1999 February 28, 1995 March 6, 1989

Robert D. Reischauer James L. Blum (Acting)

Congressional Budget Office

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Edward Gramlich (Acting) Rudolph G. Penner Alice M. Rivlin April 28, 1987 September 1, 1983 February 24, 1975 April 28, 1987 August 31, 1983

References
[1] http:/ / www. cbo. gov/ [4] http:/ / www. cbo. gov/ aboutcbo/

Further reading
Allen Schick, Felix LoStracco The Federal Budget: Politics, Policy, Process. Washington, D.C.: Brookings Institution, 2000. Phillip Joyce, "The Congressional Budget Office: Honest Numbers, Power, and Policymaking". Washington, D.C.: Georgetown University Press, 2011.

External links
CBO Website (http://www.cbo.gov/) CBO Director's Blog (http://cboblog.cbo.gov/) CBO publications 1975-1999 (http://cbo.gov/publications/CBOPubs1975-1999.pdf) and 2000- (http://cbo. gov/publications/CBOPubs2000-present.pdf) Congress.org: Meet the scorekeepers of spending (http://www.congress.org/news/2009/09/29/ meet_the_scorekeepers_of_spending)

Certification Commission for Healthcare Information Technology


The Certification Commission for Health Information Technology (CCHIT) is an independent, 501(c)3 nonprofit organization with the public mission of accelerating the adoption of robust, interoperable health information technology. The Commission has been certifying electronic health record technology since 2006 and is approved by the Office of the National Coordinator for Health Information Technology (ONC) of the U.S. Department of Health and Human Services (HHS) as an Authorized Testing and Certification Body (ONC-ATCB). The CCHIT Certified program is an independently developed certification that includes a rigorous inspection of an EHRs integrated functionality, interoperability and security using criteria developed by CCHITs broadly representative, expert work groups. These products may also be certified in the ONC-ATCB certification program.

History
CCHIT was founded in 2004 with support from three leading industry associations in healthcare information management and technology: the American Health Information Management Association (AHIMA), the Healthcare Information and Management Systems Society (HIMSS) and the National Alliance for Health Information Technology [1]Wikipedia:Link rot (the Alliance). In September 2005, CCHIT was awarded a 3-year contract by the U.S. Department of Health and Human Services (HHS) to develop and evaluate the certification criteria and inspection process for EHRs and the networks through which they interoperate. In October 2006, HHS officially designated CCHIT as a Recognized Certification Body (RCB).[2] In July 2010, HHS published new rules for recognizing testing and certification bodies, scheduled to take effect when it named the new bodies. In September

Certification Commission for Healthcare Information Technology 2010, the Office of the National Coordinator (ONC) of HHS named CCHIT again under these new rules. CCHIT is an ONC Authorized Testing and Certification Body (ONC-ATCB).

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Goals
Reduce the risk of Healthcare Information Technology (HIT) investment by physicians and other providers Ensure interoperability (compatibility) of HIT products Assure payers and purchasers providing incentives for electronic health records (EHR) adoption that the ROI will be improved quality Protect the privacy of patients' personal health information.

Operations
Present
CCHIT focused its first efforts on ambulatory EHR products[3] for the office-based physician and provider and began commercial certification in May 2006. CCHIT then developed a process of certification for inpatient EHR products[4] and launched that program in 2007. CCHIT then assessed the need for, and potential benefit of, certifying EHR for specialty medicine, special care settings, and special-needs populations.[5][6] CCHIT, in a collaboration with the MITRE Corporation, also developed an open-source program called Laika to test EHR software for compliance with Federally-named interoperability standards. Announcements of CCHIT Certified Products On July 18, 2006, CCHIT released its first list of 20 certified ambulatory EMR and EHR products [7] On July 31, 2006, CCHIT announced that two additional EHR products had achieved certification.[8] On October 23, 2006, CCHIT released its second list of 11 certified vendors.[9] On April 30, 2007, CCHIT released its third list of 18 certified vendors.[10] On November 16, 2009, CCHIT released [11] its initial draft criteria for Behavioral Health [12], Clinical Research [13] , and Dermatology [14] EHRs, with expected final publication available July 2010.

Future
The Commission is currently developing a special program for hospitals wishing to certify legacy, customized or self-developed EHR products in the ONC-ATCB 2011/2012 program. The program called the EHR Alternative Certification for Hospitals, or EACH, is scheduled to open in December 2010. The Commission is also planning to launch CCHIT Certified programs for EHRs used in Clinical Research, Oncology and Women's Health (obstetrics component) in 2011.

Certification Commission for Healthcare Information Technology

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Commissioners
The Commission, chaired by Karen Bell, M.D., M.M.S, is currently composed of 21 members each serving two-year terms.

Stakeholders
Certified EHR products benefit many interested groups and individuals: Physicians, hospitals, health care systems, safety net providers, public health agencies and other purchasers of HIT products, who seek quality, interoperability, data portability and security Purchasers and payers from government to the private sector who are prepared to offer financial incentives for HIT adoption but need the assurance of having a mechanism in place to ensure that products deliver the expected benefits Quality improvement organizations that seek out an efficient means of measuring that criteria have been assessed and met Standards development and informatics experts that gain consensus on standards Vendors who benefit from having to meet a single set of criteria and from having a voice in the process Healthcare consumers, ultimately the most important stakeholders, who will benefit from a reliable, accurate and secure record of their health CCHIT and its volunteer workgroups strive to fairly represent the interests of each of these diverse groups in an open forum, communicating the progress of its work and seeking input from all quarters. CCHIT has received the endorsements of a number of professional medical organizations, including the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, the Physicians' Foundation for Health Systems Excellence and Physicians' Foundation for Health Systems Innovation.

Notes
[1] http:/ / www. nahit. org [2] U.S. Department of Health and Human Services (October 26, 2006): HHS Officially Recognizes Certification Body to Evaluate Electronic Health Records (http:/ / www. hhs. gov/ news/ press/ 2006pres/ 20061026a. html) [3] Public postings of CCHIT work products for the ambulatory domain (http:/ / www. cchit. org/ work/ criteria. htm) [4] Public postings of CCHIT work products for the inpatient domain (http:/ / www. cchit. org/ work/ inpatient+ criteria. htm) [5] CCHIT to Expand Electronic Health Record Certification to Some Specialties (http:/ / www. cchit. org/ media/ press+ releases/ CCHIT+ Expands+ Electronic+ Health+ Record+ Certification+ to+ Specialties. htm) (November 28, 2006) [6] CCHIT: Certifying EHR for Specialty Medicine and Special Care Settings (http:/ / www. cchit. org/ vendors/ learn/ Certifying+ EHR+ for+ Specialty+ Medicine+ and+ Special+ Care+ Settings. htm) [7] Certification Commission for Health Information Technology (July 18, 2006): CCHIT Announces First Certified Electronic Health Record Products (http:/ / www. cchit. org/ media/ press+ releases/ CCHIT+ Announces+ First+ Certified+ Electronic+ Health+ Record+ Products. htm) Retrieved July 26, 2006 [8] Certification Commission for Health Information Technology (July 31, 2006): CCHIT Announces Additional Certified Electronic Health Record Products (http:/ / www. cchit. org/ media/ press+ releases/ CCHIT+ Announces+ Additional+ Certified+ Electronic+ Health+ Record+ Products. htm) Retrieved July 31, 2006 [9] CCHIT Announces New Certified Electronic Health Record Products (October 23, 2006): CCHIT Announces New Certified Electronic Health Record Products (http:/ / www. cchit. org/ media/ press+ releases/ CCHIT+ Announces+ New+ Certified+ Electronic+ Health+ Record+ Products. htm) [10] CCHIT Announces New Certified Electronic Health Record Products (April 30, 2007): CCHIT Announces New Certified Electronic Health Record Products (http:/ / www. cchit. org/ certified/ 2006/ CureMD. htm) [11] http:/ / www. cchit. org/ media/ news/ 2009/ 11/ public-comment-period-expanded-2011-certification-criteria-open-0 [12] http:/ / www. cchit. org/ sites/ all/ files/ CCHIT%20Certified%202011%20Behavioral%20Health%20Criteria%20For%20Public%20Comment%2020091120. pdf [13] http:/ / www. cchit. org/ sites/ all/ files/ CCHIT%20Certified%202011%20Clinical%20Research%20Criteria%20For%20Public%20Comment%2020091116. pdf [14] http:/ / www. cchit. org/ sites/ all/ files/ CCHIT%20Certified%202011%20DERMATOLOGY%20Criteria%20For%20Public%20Comment%2020091116. pdf

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349

External links
Official website (http://www.cchit.org)

Coronary care unit


A coronary care unit (CCU) or cardiac intensive care unit (CICU) is a hospital ward specialized in the care of patients with heart attacks, unstable angina, Cardiac dysrhythmia and (in practice) various other cardiac conditions that require continuous monitoring and treatment.

Characteristics
The main feature of coronary care is the availability of telemetry or the continuous monitoring of the cardiac rhythm by electrocardiography. This allows early intervention with medication, cardioversion or defibrillation, improving the prognosis. As arrhythmias are relatively common in this group, patients with myocardial infarction or unstable angina are routinely admitted to the coronary care unit. For other indications, such as atrial fibrillation, a specific indication is generally necessary, while for others, such as heart block, coronary care unit admission is standard.

Door leading to a CCU in Thailand.

Local differences
In the United States, coronary care units are usually subsets of intensive care units (ICU) dedicated to the care of critically ill cardiac patients. These units are usually present in hospitals that routinely engage in cardiothoracic surgery. Invasive monitoring such as with pulmonary artery catheters is common, as are supportive modalities such as mechanical ventilation and intra-aortic balloon pumps (IABP). Certain hospitals, such as Johns Hopkins [1], maintain mixed units consisting of both Acute care units for the critically ill, and intermediate care units for patients who are not critical.

Acute coronary care


Acute coronary care units (ACCU), also called "critical coronary care units" (CCCU) is equivalent to intensive care in the level of service provided. Patients with acute myocardial infarction, cardiogenic shock, or post-operative "open-heart" patients commonly abide here.

Subacute coronary care


Subacute coronary care units (SCCU), also called Progressive care units (PCU), Intermediate coronary care units (ICCU), or stepdown units, and provide a level of care intermediate to that of the intensive care unit and that of the general medical floor. These units typically serve patients who require cardiac telemetry such as those with unstable angina.

Coronary care unit

350

History
Coronary care units developed in the 1960s when it became clear that close monitoring by specially trained staff, cardiopulmonary resuscitation and medical measures could reduce the mortality from complications of cardiovascular disease. The first description of a CCU was given in 1961 to the British Thoracic Society, and early CCUs were located in Sydney, Kansas City and Philadelphia. Studies published in 1967 revealed that those observed in a coronary care setting had consistently better outcomes.[2] The first coronary care unit was opened at Bethany Medical Center in Kansas City, Kansas by Dr Hugh Day, and he coined the term.[3][4] Bethany Medical Center is also where the first "crash carts" were developed.[5]

References
[1] http:/ / www. hopkinsmedicine. org/ cardiology/ ccu. htm [5] Unplugged: Reclaiming Our Right to Die in America, William H. Colby

Intensive care unit


An intensive care unit (ICU), also known as a critical care unit (CCU), intensive therapy unit or intensive treatment unit (ITU) is a special department of a hospital or health care facility that provides intensive care medicine. Intensive Care Units cater to patients with the most severe and life-threatening illnesses and injuries; that require constant, close monitoring and support from specialist equipment and medication in order to maintain normal bodily functions. They are staffed by highly trained doctors and critical care nurses who specialise in caring for seriously ill patients. Common conditions that are treated within ICU's include those such as trauma, multiple organ failure and sepsis.[1] Patients may be transferred directly to an Intensive Care Unit from an emergency department if required, or from a ward if they rapidly deteriorate; or immediately after surgery if the surgery is majorly invasive and the patient is at high risk of complications.[2]

Intensive care unit

History

ICU patients may require mechanical ventilation if they have lost the ability to breathe normally.

In 1854, Florence Nightingale left for the Crimean War, where triage, used to separate seriously wounded soldiers from the less-seriously wounded, was observed. Until recently, it was reported that Nightingale reduced mortality from 40% to 2% on the battlefield. Although this was not the case, her experiences during the war formed the foundation for her later discovery of the importance of sanitary conditions in hospitals, a critical component of intensive care. In 1950, anesthesiologist Peter Safar established the concept of "Advanced Support of Life", keeping patients sedated and ventilated in an intensive care environment. Safar is considered to be the first practitioner of intensive care medicine as a speciality.

Intensive care unit In response to a polio epidemic (where many patients required constant ventilation and surveillance), Bjrn Aage Ibsen established the first intensive care unit in Copenhagen in 1953.[3][4][5] The first application of this idea in the United States was in 1955 by Dr. William Mosenthal, a surgeon at the Dartmouth-Hitchcock Medical Center.[6] In the 1960s, the importance of cardiac arrhythmias as a source of morbidity and mortality in myocardial infarctions (heart attacks) was recognized. This led to the routine use of cardiac monitoring in ICUs, especially after heart attacks.[7]

351

Specialities
Hospitals may have ICUs that cater to a specific medical speciality or patient, such as those listed below: Neonatal intensive care unit (NICU) Pediatric intensive care unit (PICU) Psychiatric intensive care unit (PICU) Coronary care unit (CCU): Also known as Cardiac Intensive Care Unit (CICU) Post-anesthesia care unit (PACU): Also known as the post-operative recovery unit, or recovery room, the PACU provides immediate post-op observation and stabilisation of patients following surgical operations and anesthesia. Patients are usually held in such facilities for a limited amount of time, and must meet a set physiological criteria before transfer back to a ward with a qualified nurse escort takes place. Due to high patient flow in recovery units, and owing to the bed management cycle, if a patient breaches a time frame and is too unstable to be transferred back to a ward, they are normally transferred to a high dependency unit (HDU) or post-operative critical care unit (POCCU) for closer observation. High dependency unit (HDU): Many hospitals have a transitional high dependency unit (HDU) for patients who require close observation, treatment and nursing care that cannot be provided on a general ward, but whose care is not at a critical enough level to warrant an ICU bed. These units are also called step-down, progressive and intensive recovery units and are utilised until a patient's conditions stabilises enough to qualify them for discharge to a general ward.[8]
ICU Nurse attending to a patient in Baghdad, Iraq.

ICU nurses monitoring patients from a central computer station. This allows for rapid intervention should a patients condition deteriorate whilst a member of staff is not immediately at the bedside.

Nurses in a neonatial intensive care unit (NICU)

Intensive care unit

352

Equipment and systems


Common equipment in an ICU includes mechanical ventilators to assist breathing through an endotracheal tube or a tracheotomy; cardiac monitors including those with telemetry; external pacemakers; defibrillators; dialysis equipment for renal problems; equipment for the constant monitoring of bodily functions; a web of intravenous lines, feeding tubes, nasogastric tubes, suction pumps, drains, and catheters; and a wide array of drugs to treat the primary condition(s) of hospitalization. Medically induced comas, analgesics, and induced sedation are common ICU tools needed and used to reduce pain and prevent secondary infections.

Clinicians in an intensive care unit

Quality of care
The available data suggests a relation between ICU volume and quality of care for mechanically ventilated patients.[9] After adjustment for severity of illnesses, demographic variables, and characteristics of different ICUs (including staffing by intensivists), higher ICU staffing was significantly associated with lower ICU and hospital mortality rates. A ratio of 2 patients to 1 nurse is recommended for a medical ICU, which contrasts to the ratio of 4:1 or 5:1 typically seen on medical floors. This varies from country to country, though; e.g., in Australia and the United Kingdom most ICUs are staffed on a 2:1 basis (for High-Dependency patients who require closer monitoring or more intensive treatment than a hospital ward can offer) or on a 1:1 basis for patients requiring very intensive support and monitoring; for example, a patient on a mechanical ventilator with associated anaesthetics or sedation such as propofol, Midazolam and use of strong analgesics such as morphine, fentanyl and/or remifentanil.

Operational logistics
In the United States, up to 20% of hospital beds can be labelled as intensive-care beds; in the United Kingdom, intensive care usually will comprise only up to 2% of total beds. This high disparity is attributed to admission of patients in the UK only when considered the most severely ill.[10] Intensive care is an expensive healthcare service. In the United Kingdom, the average cost of funding an intensive care unit is:[11] 838 per bed per day for a neonatal intensive care unit 1,702 per bed per day for a paediatric intensive care unit 1,328 per bed per day for an adult intensive care unit

References
[4] . Translation of introduction available here (http:/ / publikationen. ub. uni-frankfurt. de/ frontdoor/ index/ index/ docId/ 7334).

External links
Society of Critical Care Medicine (http://www.sccm.org) ICUsteps - Intensive care patient support charity (http://www.icusteps.org) Organisation for Critical Care Transportation (http://www.vibha.info) A Working Lexicon for the Tele-Intensive Care Unit: We Need to Define Tele-Intensive Care Unit to Grow and Understand It (http://www.liebertonline.com/doi/abs/10.1089/tmj.2011.0045)

Clinical Document Architecture

353

Clinical Document Architecture


The HL7 Clinical Document Architecture (CDA) is an XML-based markup standard intended to specify the encoding, structure and semantics of clinical documents for exchange. CDA is an ANSI-certified standard from Health Level Seven (HL7.org). Release 1.0 was published in November, 2000 and Release 2.0 was published with the HL7 2005 Normative Edition. CDA specifies the syntax and supplies a framework for specifying the full semantics of a clinical document. It defines a clinical document as having the following six characteristics: Persistence Stewardship Potential for authentication Context Wholeness Human readability

A CDA can contain any type of clinical content. Typical CDA documents would be a Discharge Summary, Imaging Report, Admission & Physical, Pathology Report and so on. CDA uses XML, although it allows for a non-XML body (pdf, Word, jpg and so on) for simple implementations. It was developed using the HL7 Development Framework (HDF) and it is based on the HL7 Reference Information Model (RIM) and the HL7 Version 3 Data Types. The CDA specifies that the content of the document consists of a mandatory textual part (which ensures human interpretation of the document contents) and optional structured parts (for software processing). The structured part relies on coding systems (such as from SNOMED and LOINC) to represent concepts. CDA Release 2 has been adopted as an ISO standard, ISO/HL7 27932:2009.[1]

Transport
The CDA standard doesn't specify how the documents should be transported. CDA documents can be transported using HL7 version 2 messages, HL7 version 3 messages, IHE protocols such as XDS, as well as by other mechanisms including: DICOM, MIME attachments to email, http or ftp.

Country specific notes


In the U.S. the CDA standard is probably best known as the basis for the Continuity of Care Document (CCD) specification, based on the data model as specified by ASTMs Continuity of Care Record. The U.S. Healthcare Information Technology Standards Panel has selected the CCD as one of its standards.

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References External links


Structured Documents Group (http://www.hl7.org/Special/committees/structure/) of HL7 CDA Resource Page (http://hl7book.net/index.php?title=CDA) Introduction to the HL7 Standards (http://www.HL7.com.au/FAQ.htm) Whitepaper: HL7 version 3: message or document? (http://www.ringholm.de/docs/04200_en.htm) About HL7 CDA (http://iehr.eu/standards/hl7-cda/) at iEHR.eu (http://iehr.eu) The CDA Book (http://books.google.com/books?id=rwa6DDB4jY8C) by Keith Boone

Clostridium difficile

355

Clostridium difficile
Clostridium difficile

C. difficile colonies on a blood agar plate.

Micrograph of Clostridium difficile

Scientific classification Kingdom: Phylum: Class: Order: Family: Genus: Species: Bacteria Firmicutes Clostridia Clostridiales Clostridiaceae Clostridium C. difficile Binomial name Clostridium difficile Hall & O'Toole, 1935 Clostridium difficile (pronunciation below) (from the Greek kloster (), 'spindle',[citation needed] and Latin difficile, 'difficult, obstinate'),[1] also known as "CDF/cdf", or "C. diff", is a species of Gram-positive bacteria of the genus Clostridium that causes severe diarrhea and other intestinal disease when competing bacteria in the gut flora have been wiped out by antibiotics. Clostridia are anaerobic, spore-forming rods (bacilli).[] C. difficile is the most serious cause of antibiotic-associated diarrhea (AAD) and can lead to pseudomembranous colitis, a severe inflammation of the colon, often resulting from eradication of the normal gut flora by antibiotics.[]

Clostridium difficile In a very small percentage of the adult population, C. difficile bacteria naturally reside in the gut. Other people accidentally ingest spores of the bacteria while they are patients in a hospital (where 14,000 people a year in America alone die as a result),[2] nursing home, or similar facility. When the bacteria are in a colon in which the normal gut flora has been destroyed (usually after a broad-spectrum antibiotic such as clindamycin has been used), the gut becomes overrun with C. difficile. This overpopulation is harmful because the bacteria release toxins that can cause bloating and diarrhea, with abdominal pain, which may become severe. C. difficile infections are the most common cause of pseudomembranous colitis, and in rare cases this can progress to toxic megacolon, which can be life-threatening. Latent symptoms of C. difficile infection often mimic some flu-like symptoms and can mimic disease flare in patients with inflammatory bowel disease-associated colitis.[3] Mild cases of C. difficile infection can often be cured by discontinuing the antibiotics responsible.[] In more serious cases, oral administration of, first, oral metronidazole andif that failsthen, second, vancomycin and if unsuccessful again, intravenous metronidazole can be used. Relapses of C. difficile AAD have been reported in up to 20% of cases.[]

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Signs and symptoms


In adults, a clinical prediction rule found the best signs to be: significant diarrhea ("new onset of more than three partially formed or watery stools per 24 hour period"), recent antibiotic exposure, abdominal pain, fever (up to 40.5C), and a distinctive foul stool odour. In a population of hospitalized patients, prior antibiotic treatment plus diarrhea or abdominal pain had a sensitivity of 86% and a specificity of 45%.[] In this study with a prevalence of positive cytotoxin assays of 14%, the positive predictive value was 20% and the negative predictive value was 95%.

Cause
With the introduction of broad-spectrum antibiotics and chemotherapeutic antineoplastic drugs[citation needed] in the second half of the 20th century, antibiotic- and chemotherapy-associated diarrhea became more common. Pseudomembranous colitis was first described as a complication of C. difficile infection in 1978,[] when a toxin was isolated from patients suffering from pseudomembranous colitis and Koch's postulates were met. The many spores formed by C. difficile are resistant to most routine cleaning methods used on surfaces (except for diluted bleach).[citation needed] Spores of these bacteria can remain viable outside of the human body for very long periods of time, and this means the patients in a medical facility are often exposed to situations where they end up accidentally ingesting spores. [citation needed] Extremely rigorous infection protocols are required to decrease or eliminate this risk.[4]

Micrograph of a colonic pseudomembrane in Clostridium difficile colitis, a type of pseudomembranous colitis. H&E stain.

C. difficile infection (CDI) can range in severity from asymptomatic to severe and life-threatening, especially among the elderly. People are most often nosocomially infected in hospitals, nursing homes, or other medical institutions, although CDI in the community, outpatient setting is increasing. The rate of C. difficile acquisition is estimated to be 13% in patients with hospital stays of up to two weeks, and 50% in those with hospital stays longer than four weeks.[] C. difficile-associated diarrhea (CDAD) is most strongly associated with fluoroquinolones, cephalosporins, carbapenems, and clindamycin.[5][][] In addition to previous use of antimicrobials, use of proton-pump inhibitors (PPI) is associated with a two-fold increase in risk for CDI.[6] The European Center for Disease Prevention and Control recommend the fluoroquinolones and the antibiotic clindamycin be avoided in clinical practice due to their high association with subsequent CDIs.[citation needed]

Clostridium difficile Frequency and severity of C. difficile colitis remains high and seems to be associated with increased death rates.[citation needed] Immunocompromised status and delayed diagnosis appear to result in elevated risk of death. Early intervention and aggressive management are key factors to recovery.[citation needed] Increasing rates of community-acquired CDI are associated with the use of medication to suppress gastric acid production: H2-receptor antagonists increased the risk 1.5-fold, and proton pump inhibitors by 1.7 with once-daily use and 2.4 with more than once-daily use.[7] The emergence of a new, highly toxic strain of C. difficile, resistant to fluoroquinolone antibiotics, such as ciprofloxacin (Cipro) and levofloxacin (Levaquin), said to be causing geographically dispersed outbreaks in North America was reported in 2005.[] The U.S. Centers for Disease Control (CDC) in Atlanta warned of the emergence of an epidemic strain with increased virulence, antibiotic resistance, or both.[] In 2005, molecular analysis led to the identification of the C. difficile strain type characterized as group BI by restriction endonuclease analysis (REA), as North American pulse-field-type NAP1 by pulse-field gel electrophoresis (PFGE) and as ribotype 027; the differing terminology reflects the predominant techniques that were used for epidemiological typing, and this strain is referred to as C. difficile BI/NAP1/027.[] Some research suggests the overuse of antibiotics in the raising of livestock for meat consumption is contributing to outbreaks of bacterial infections such as C. difficile.[8]

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Bacteriology
Clostridia are motile bacteria, ubiquitous in nature, and especially prevalent in soil. Under the microscope, clostridia appear as long, irregularly (often drumstick- or spindle-shaped) cells with a bulge at their terminal ends. Under Gram staining, C. difficile cells are Gram-positive and show optimum growth on blood agar at human body temperatures in the absence of oxygen. When stressed, the bacteria produce spores that can tolerate extreme conditions that the active bacteria cannot tolerate.[] C. difficile is a commensal bacterium of the human intestine in 25% seen through scanning electron microscopy of the population.[] Long-term hospitalization or residence in a nursing home within the previous year are independent risk factors for increased colonization.[] In small numbers, C. difficile does not result in significant disease. Antibiotics, especially those with a broad spectrum of activity (such as clindamycin) cause disruption of normal intestinal flora, leading to an overgrowth of C. difficile, which flourishes under these conditions. This can lead to pseudomembranous colitis, the generalized inflammation of the colon and the development of "pseudomembrane", a viscous collection of inflammatory cells, fibrin, and necrotic cells.[]
Individual, drumstick-shaped C. difficile bacilli

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Pathogenic C. difficile strains produce several known toxins. The most well-characterized are enterotoxin (Clostridium difficile toxin A) and cytotoxin (Clostridium difficile toxin B), both of which are responsible for the diarrhea and inflammation seen in infected patients, although their relative contributions have been debated.[] Toxins A and B are glucosyltransferases that target and inactivate the Rho family of GTPases. Toxin B (cytotoxin) induces actin depolymerization by a mechanism correlated with a decrease in the ADP-ribosylation of the low molecular mass GTP-binding Rho proteins.[9] Another toxin, binary toxin, has also been described, but its role in disease is not yet fully understood.[10] Antibiotic treatment of CDIs can be difficult, due both to antibiotic resistance and physiological factors of the bacteria itself (spore formation, protective effects of the pseudomembrane).[] Pseudomembranous colitis caused by C. difficile is treated with specific antibiotics, for example, vancomycin (Vancocin) or metronidazole (Flagyl).

How C. difficile spreads

C. difficile is transmitted from person to person by the fecal-oral route. However, the organism forms large numbers of heat-resistant spores, and these are not killed by alcohol-based hand cleansers or routine cleaning of surfaces. Thus, these spores remain viable in the hospital or nursing home environment for long periods of time, and, because of this, the bacteria can be cultured from almost any surface in the hospital. Once spores are ingested by a patient, they pass through the stomach unscathed because of their acid-resistance. They germinate into vegetative cells in the colon upon exposure to bile acids, and multiply. Several disinfectants commonly used in hospitals are ineffective against C. difficile spores, and may actually promote spore formation. However, disinfectants containing bleach are effective in killing the organisms.[11]

Diagnosis
Cytotoxicity assay
C. difficile toxins have a cytopathic effect in cell culture, and neutralized with specific anti-sera is the practical gold standard for studies investigating new CDAD diagnostic techniques.[] Toxigenic culture, in which organisms are cultured on selective medium and tested for toxin production, remains the gold standard and is the most sensitive and specific test, although it is slow and labour-intensive.[]

Toxin ELISA
Assessment of the A and B toxins by enzyme-linked immunosorbent assay (ELISA) for toxin A or B (or both) has a sensitivity of 6399% and a specificity of 93100%: At a prevalence of 15%, this leads to a positive predictive value (PPV) of 73% and a negative predictive value (NPV) of 96%.[citation needed] Previously, experts recommended sending as many as three stool samples to rule out disease if initial tests are negative. However, evidence suggests that repeat testing during the same episode of diarrhea is of limited value and should be discouraged.[] C. difficile toxin should clear from the stool of previously infected patients if treatment is effective. However, many hospitals test only for the prevalent toxin A. Strains that express only the B toxin are now present in many hospitals, and ordering both toxins should occur.[12][] Not testing for both may contribute to a delay in obtaining laboratory results, which is often the cause of prolonged illness and poor outcomes.

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Other stool tests


Stool leukocyte measurements and stool lactoferrin levels have also been proposed as diagnostic tests, but may have limited diagnostic accuracy.[]

Computed tomography
In one study, a patient who received a diagnosis of Clostridium difficile colitis (CDC) on the basis of computed tomography (CT scan) had an 88% probability of testing positive on stool assay.[] Wall thickening is the key CT finding in this disease. Once colon wall thickening is identified as being >4mm, the best ancillary findings were pericolonic stranding, ascites, and colon wall nodularity. The presence of wall thickness plus any one of these ancillary findings is 70% sensitive and 93% specific. Using criteria of 10mm or a wall thickness of >4mm and any of the more-specific findings does not add significantly to the diagnosis but gives equally satisfactory results. In this study with a prevalence of positive C. difficile toxin of 54%, the PPV was 88%. Patients who have antibiotic-associated diarrhea with CT findings diagnostic of CDC merit consideration for treatment on that basis.

Real-Time PCR
By the end of 2009, 3 different Real-Time PCR tests had achieved 510(k) clearance from the FDA.[citation needed] Cepheid's GeneXpert is by far the fastest and easiest of the three, but it is also the most expensive. Cepheid uses a cartridge-based kit that is tailored for small hospitals or labs without the ability to batch large numbers of samples together. In fact, batching is not required since the extraction occurs in the same vial as amplification of the target, positive, and negative controls. The reported time from sample to result is ~45 minutes. Prodesse offers another kit-based IVD Real-Time PCR test (ProGastro Cd), which uses an external extraction and purification on the Roche MagnaPure. Prodesse (Gen-Probe) tech support claims that this external separation produces higher yields than the BD GeneOhm. The Prodesse technique is similar in price to the BD GeneOhm technique after one includes the price of the extraction and takes about three hours from sample to result. The final IVD Clostridium difficile Real Time PCR test on the market since 2009 is from BD GeneOhm. The protocol uses a glass-bead lysis rather than an extraction, but results are reported to be good and the method shaves a little over an hour off the protocol time (about 1 hour 45 minutes from sample to result). Total costs for the Prodesse and BD GeneOhm tests are approximately the same. For each test, sensitivities are generally reported as 8891% and specificities as 9697%, depending on the tests, prevalence of the disease and the size of the patient pool.[]

Dogs
One experimental technique for detecting Clostridium difficile is based on the observation that nurses were able to smell a faint but distinctive Clostridium difficile smell on affected patients' stools. It was then found that it was possible to train sniffer dogs to detect this smell on patients without taking a sample, with high specificity. An example is Cliff the Beagle, as the dog is known in Holland, a succeeded experiment of the Free University in Amsterdam.[13]

Prevention
Antibiotics
The most effective method for preventing CDAD is proper antimicrobial prescribing. In the hospital setting, where CDAD is most common, nearly all patients that develop CDAD are exposed to antimicrobials. Although proper antimicrobial prescribing sounds easy to do, approximately 50% of antimicrobial use is considered inappropriate.

Clostridium difficile This is consistent whether in the hospital, clinic, community, or academic setting. Several studies[citation needed] have demonstrated a decrease in CDAD by limiting antibiotics most strongly associated with CDAD or by limiting unnecessary antimicrobial prescribing in general, both in outbreak and non-outbreak settings.

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Probiotics
There is some evidence that probiotics may be useful to prevent infection and recurrence.[][] Treatment with S. boulardii in those who are non-immunocompromised with C Diff may also be useful.[][14] In 2010 the Infectious Diseases Society of America recommended against their use due to the risk of complications.[][] Subsequent reviews however did not find an increase in adverse effects with treatment[] and overall treatment appears safe.[15]

Infection control
Infection control measures, such as wearing gloves when caring for patients with CDAD, have been proven to be effective at prevention. This works by limiting the spread of C. difficile in the hospital setting. In addition, washing with soap and water will eliminate the spores from contaminated hands, but alcohol-based hand rubs are ineffective.[16] Bleach wipes containing 0.55 percent sodium hypochlorite have been shown to kill the spores and prevent transmission between patients.[17] Installing lidded toilets and closing the lid prior to flushing also reduces the risk of contamination.[18] Hydrogen peroxide vapor (HPV) systems used to sterilize a patient room post discharge has been shown to reduce infection rates and to reduce risk of infection to subsequent patients. One study (Boyce et al. 2008) showed that incidence of CDAD was reduced by 53% though use of HPV. A second study (Manian et al. 2010) showed a 42% reduction in CDAD rates through use of HPV.[citation needed]

Vaccine
In a limited clinical trial, a C. difficile anti-toxoid vaccine was reported to improve people's outcomes. Further testing will be required to validate this trial.[19]

Treatment
Asymptomatic colonization with C. difficile is common. Treatment in asymptomatic patients is controversial, also leading into the debate of clinical surveillance and how it intersects with public health policy. In general, mild cases do not require specific treatment.[][] Patients should be treated as soon as possible when the diagnosis of Clostridium difficile colitis (CDC) is made to avoid frank sepsis or bowel perforation. To reduce complications, physicians often begin treatment based on clinical presentation before definitive results are available. Knowledge of the local epidemiology of intestinal flora of a particular institution can guide therapy. In addition, oral rehydration therapy (ORT) is useful in retaining fluids during the duration of diarrhea.

Medications
Three antibiotics are specifically effective against C. difficile. With the available agents more or less equally effective.[20] Metronidazole is the drug of choice, because of lower price and comparable efficacy.[] Oral vancomycin is second line for mild to moderate cases and is recommended first line for severe disease.[] Vancomycin is the treatment of choice in the following cases: no response to oral metronidazole; the organism is resistant to metronidazole; the patient is allergic to metronidazole; the patient is either pregnant, breastfeeding, or younger than 10 years of age. Vancomycin must be administered orally because intravenous administration does not achieve gut lumen minimum therapeutic concentration. People unresponsive to metronidazole can be placed

Clostridium difficile on 14 days of vancomycin followed by rifaximin for another 14 days. There is no difference between vancomycin and metronidazole in mild disease, however vancomycin was superior to metronidazole for treating severe disease.[] In this study, severe disease was defined on a point score: One point each was given for age >60 years, temperature >38.3C, albumin level <2.5mg/dL, or peripheral WBC count >15,000 cells/mm3 within 48 h of enrollment. Two points were given for endoscopic evidence of pseudomembranous colitis or treatment in the intensive care unit. Severe disease was defined as 2 or more points on this score. The main criticism of this study is that a low, non-standard dose of metronidazole (250mg) was used instead of (500mg). Fidaxomicin has been found to be equally effective as vancomycin[21] A study[22] showed that the enduring treatment success of fidaxomicin is better than the previous medication. Its tolerability is as good as vancomycin.[23] Drugs used to stop diarrhea frequently worsen the course of C. difficile-related pseudomembranous colitis. Loperamide, diphenoxylate, and bismuth compounds are contraindicated: slowing of fecal transit time is thought to result in extended toxin-associated damage. Cholestyramine, a powder drink (an ion exchange resin), which is occasionally used to lower cholesterol, is effective in binding both Toxin A and B, slowing bowel motility and helping prevent dehydration.[] The dosage can be 4grams daily, to up to four doses a day; however caution should be exercised to prevent constipation, or drug interactions, most notably the binding of drugs by cholestyramine, preventing their absorption. Cholestyramine is not an anti-infective; it dramatically reduces many of the symptoms of a C. difficile infection, but it is not appropriate to use by itself, as it does not change the infection status. Cholestyramine is not recommended in concert with vancomycin. Powdered banana flakes given twice daily are an alternative to cholestyramine, and allow for stool bulking.[citation needed]

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Probiotics
There is insufficient evidence to support the use of probiotics in the treatment of active disease.[][24] and thus in this situation they are neither recommended as an adjunct to standard therapy or for use alone.[25] A last-resort treatment in immunosuppressed patients is intravenous immunoglobulin (IVIG).[]

Stool transplant
Fecal bacteriotherapy, known in colloquial terms as stool transplant, a procedure related to probiotic research, has preliminarily been shown to cure the disease.[] It involves infusion of bacterial flora acquired from the feces of a healthy donor to reverse the bacterial imbalance responsible for the recurring nature of the infection.[] In fecal transplantation, donor stool is collected from another individual who has been tested for a wide array of bacterial, viral, and parasitic pathogens.[] The stool is often mixed with saline or milk to achieve the desired consistency, then delivered through a colonoscope or retention enema, or through a nasogastric or nasoduodenal tube. The procedure replaces normal, healthy colonic flora that had been wiped out by antibiotics, and reestablishes the patient's resistance to colonization by Clostridium difficile. However, there is often patient resistance due to the perceived unpleasantness of the procedure that must be overcome first before proceeding with this highly effective treatment. There are over 150 published reports dating back to 1958, though many more have been performed.[citation needed] It has a success rate of about 90%.[][][][26] A guide was released in 2010 for home fecal transplantation.[] A recent randomized, controlled trial of fecal microbiota transplantation for patients with recurrent C. difficile diarrhea worked for 94%of patients, the majority requiring only one treatment. The trial was terminated early as due to the outstanding success rate, it was felt to be unethical not to offer the treatment to all patients in the trial. ( van Nood et al. NEJM, January 31, 2013. 368(5) 407-415.

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Colectomy
In those patients that develop systemic symptoms of CDC, colectomy may improve the outcome if performed before the need for vasopressors.[citation needed]

Recurrence
The evolution of protocols for patients with recurrent C. difficile diarrhea also present a challenge: There is no known proper length of time or universally accepted alternative drugs with which one should be treated.[citation needed] However, re-treatment with metronidazole or vancomycin at the previous dose for 10 to 14 days is generally successful. The addition of rifampin to vancomycin also has been effective.[citation needed]

Prognosis
After a first treatment with metronidazole or vancomycin, Clostridium difficile recurs in about 20% of people. This increases to 40% and 60% with subsequent recurrences.[]

History
Initially named Bacillus difficilis by Hall and O'Toole in 1935 because it was resistant to early attempts at isolation and grew very slowly in culture, it was renamed in 1970.[][]

Society and culture


Pronunciation
Scientific names of organisms are Latin or Latinised Greek, in this case one of each. The anglicized pronunciation /klstrdimHelp:IPA for English#Keydfsli/ is common, though a more classical /dfkle/ is also used. A common practice has developed of pronouncing difficile as /difisil/, as though it were French. The pronunciation varies because this is an example of international scientific vocabulary (ISV). The classical Latin sound is /dffkle/. One may also hear Spanish-influenced sound /difi.si.le/ and Italian- or church-Latin-influenced sound /dffi.ti.le/.

Notable outbreaks
4 June 2003, two outbreaks of a highly virulent strain of this bacterium were reported in Montreal, Quebec and Calgary, Alberta, in Canada. Sources put the death count as low as 36 and as high as 89, with approximately 1,400 cases in 2003 and within the first few months of 2004. C. difficile infections continued to be a problem in the Quebec healthcare system in late 2004. As of March 2005, it had spread into the Toronto, Ontario area, hospitalizing 10 people. One died while the others were being discharged. A similar outbreak took place at Stoke Mandeville Hospital in the United Kingdom between 2003 and 2005. The local epidemiology of C. difficile may offer clues on how its spread may relate to the amount of time a patient spends in hospital and/or a rehabilitation center. It also samples institutions' ability to detect increased rates, and their capacity to respond with more aggressive hand-washing campaigns, quarantine methods, and availability of yogurt containing live cultures to patients at risk for infection. It has been suggested that both the Canadian and English outbreaks were related to the seemingly more virulent Strain NAP1/027 of bacterium. This novel strain, also known as Quebec strain, has also been implicated in an epidemic at two Dutch hospitals (Harderwijk and Amersfoort, both 2005). A theory for explaining the increased virulence of 027 is that it is a hyperproducer of both toxins A and B, and that certain antibiotics may actually stimulate the bacteria to hyperproduce.

Clostridium difficile 1 October 2006, C. difficile was said to have killed at least 49 people at hospitals in Leicester, England over eight months, according to a National Health Service investigation. Another 29 similar cases were investigated by coroners.[27] A UK Department of Health memo leaked shortly afterwards revealed significant concern in government about the bacterium, described as being "endemic throughout the health service"[] 27 October 2006, nine deaths were attributed to the bacterium in Quebec, Canada.[28] 18 November 2006, the bacterium was reported to have been responsible for 12 deaths in Quebec, Canada. This 12th reported death was only two days after the St. Hyacinthe's Honor Mercier announced that the outbreak was under control. Thirty-one patients were diagnosed with Clostridium difficile. Cleaning crews took measures in an attempt to clear the outbreak.[29] C. difficile was mentioned on 6,480 death certificates in 2006 in UK.[30] 27 February 2007, a new outbreak was identified at Trillium Health Centre in Mississauga, Ontario, where 14 people were diagnosed with the bacteria. The bacteria were of the same strain as the one in Quebec. Officials have not been able to determine whether C. difficile was responsible for deaths of four patients over the prior two months.[31] Between February and June 2007, three patients at Loughlinstown Hospital in Dublin, Ireland were found by the coroner to have died as a result of C. difficile infection. In an inquest, the Coroner's Court found that the hospital had no designated infection control team or consultant microbiologist on staff.[32] Between June 2007 and August 2008, Northern Health & Social Care Trust Northern Ireland. Anrtim Area, Braid Valley, Mid Ulster Hospitals. During the enquiry expert reviewers concluded that Clostridium Difficile was implicated in 31 of these deaths, as the underlying cause in 15 and as a contributory cause in 16. During the time period the review also noted 375 instances of Clostridium Difficile infection in patients.[33] October 2007, Maidstone and Tunbridge Wells NHS Trust was heavily criticized by the Healthcare Commission regarding its handling of a major outbreak of C. difficile in its hospitals in Kent from April 2004 to September 2006. In its report, the Commission estimated that about 90 patients "definitely or probably" died as a result of the infection.[][34] November 2007, the 027 strain spread into several hospitals in southern Finland, with ten deaths out of 115 infected patients reported on 2007-12-14.[35] November 2009, four deaths at Our Lady of Lourdes Hospital in Ireland, have possible links to Clostridium difficile infection. A further 12 patients tested positive for infection, and another 20 show signs of infection, 10 November 2009.[36] March 2010, From February 2009 to February 2010 199 patients at Herlev hospital in Denmark was suspected of being infected with the 027 strain. In the first half of 2009, 29 died in hospitals in Copenhagen after they were infected with the bacterium[37] May 2010, A total of 138 patients at four different hospitals in Denmark infected with the 027 strain ( Herlev, Amager, Gentofte and Hvidovre) plus some isolated occurrences at other hospitals.[38] May 2010, Fourteen people killed in the Australian state of Victoria. Two years later the same strain of the bug was detected in New Zealand.[39] 28 May 2011 an outbreak in Ontario, Canada has been reported, with 26 fatalities as of 24 July 2011.[40]

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Research
Genome sequencing
The first complete genome sequence of a Clostridium difficile strain was first published in 2005 by Sanger Institute in the UK. This was of the C. difficile strain 630, a virulent and multidrug-resistant strain isolated in Switzerland in 1982. Scientists at Sanger Institute have also recentlyWikipedia:Manual of Style/Dates and numbers#Chronological items sequenced genomes of about 30 Clostridium difficile isolates using next generation sequencing technologies from 454 Life Sciences and Illumina.[] Researchers at McGill University in Montreal, Quebec, Canada, sequenced the genome of the highly virulent Quebec strain of C. difficile in 2005 using ultra-high-throughput sequencing technology. The tests involved doing 400,000 DNA parallel-sequencing reactions of the bacterium's genome, which had been fragmented for sequencing. These sequences were assembled computationally to form a complete genome sequence.[][41] Scientists at University of Oxford have also recentlyWikipedia:Manual of Style/Dates and numbers#Chronological items sequenced C. difficile genomes from 486 cases arising over four years in Oxfordshire using next generation sequencing technologies from Illumina.[]

Treatment
CDA-1 and CDB-1 (also known as MDX-066/MDX-1388 and MBL-CDA1/MBL-CDB1) is an investigational, monoclonal antibody combination co-developed by Medarex and Massachusetts Biologic Laboratories (MBL) to target and neutralize C. difficile toxins A and B, for the treatment of CDI. Merck & Co., Inc. gained worldwide rights to develop and commercialize CDA-1 and CDB-1 through an exclusive license agreement signed in April 2009. It is intended as an add-on therapy to one of the existing antibiotics to treat CDI.[][][] Nitazoxanide is a synthetic nitrothiazolyl-salicylamide derivative indicated as an antiprotozoal agent (FDA-approved for the treatment of infectious diarrhea caused by Cryptosporidium parvum and Giardia lamblia) and is also currently being studied in C. difficile infections vs. vancomycin.[] Rifaximin,[] is a clinical-stage semi synthetic, rifamycin-based non-systemic antibiotic for CDI. It is FDA-approved for the treatment of infectious diarrhea and being developed by Salix Pharmaceuticals. Rifalazil,[] Fidaxomicin,[] Tigecycline[] and Ramoplanin.[]

References
[2] Treating disease with microbes: Bugs in the system | The Economist (http:/ / www. economist. com/ news/ science-and-technology/ 21565586-bacterial-medicine-starting-emerge-bugs-system) [4] Mayo Clinic C. diff prevention (http:/ / www. mayoclinic. com/ health/ c-difficile/ DS00736/ DSECTION=prevention) [13] http:/ / www. med. vu. nl/ nl/ nieuws-agenda/ nieuws-archief/ 2012/ Hond-ruikt-ziekenhuisbacterie. asp [21] fda.gov 27 May 2011: FDA approves treatment for Clostridium difficile infection (http:/ / www. fda. gov/ NewsEvents/ Newsroom/ PressAnnouncements/ ucm257024. htm) [23] Success in the treatment of potentially fatal Clostridium difficile infection (http:/ / www. portal. uni-koeln. de/ index. php?id=3963& tx_ttnews[tt_news]=3742& cHash=a7ecc9f799897df1466941939cbf1208) [30] Hospitals struck by new killer bug (http:/ / www. metro. co. uk/ news/ article. html?in_article_id=146311& in_page_id=34) An article by Manchester free newspaper 'Metro', 7 May 2008 [31] "C. difficile outbreak linked to fatal strain" (http:/ / toronto. ctv. ca/ servlet/ an/ local/ CTVNews/ 20070228/ cdifficile_mississauga_outbreak_070228/ 20070228/ ). CTV News. 28 February 2007. [33] "Welcome to the Public Inquiry into the Outbreak of Clostridium Difficile in Northern Trust Hospitals" (http:/ / www. cdiffinquiry. org/ index. htm) [35] rhkk suolistobakteeri on tappanut jo kymmenen potilasta - HS.fi - Kotimaa (http:/ / www. hs. fi/ kotimaa/ artikkeli/ rhkk+ suolistobakteeri+ on+ tappanut+ jo+ kymmenen+ potilasta/ 1135232592793)

Clostridium difficile
[37] 199 hit by the killer diarrhea at Herlev Hospital (http:/ / www. bt. dk/ sygdomme/ 199-ramt-af-draeber-diarre-paa-herlev-sygehus), BT 3 march 2010 [38] Four hospitals affected by the dangerous bacterium (http:/ / nyhederne. tv2. dk/ article/ 30384149/ ), TV2 News 7 May 2010 [41] Scientists map C. difficile strain (http:/ / www. iapm. ca/ newsmanager/ anmviewer. asp?a=144& z=14) - Institute of Public Affairs, Montreal

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Further reading
Dallal R, Harbrecht B, Boujoukas A, Sirio C, Farkas L, Lee K, Simmons R (2002). "Fulminant Clostridium difficile: an underappreciated and increasing cause of death and complications" (http://www.ncbi.nlm.nih.gov/ pmc/articles/PMC1422442). Ann Surg 235 (3): 36372. doi: 10.1097/00000658-200203000-00008 (http://dx. doi.org/10.1097/00000658-200203000-00008). PMC 1422442 (http://www.ncbi.nlm.nih.gov/pmc/ articles/PMC1422442). PMID 11882758 (http://www.ncbi.nlm.nih.gov/pubmed/11882758). Martin S, Jung R (2005). "Gastrointestinal infections and enterotoxigenic poisonings". In DiPiro, Joseph T.; Talbert, Robert L.; Yee, Gary C.; Matzke, Gary R.; Wells, Barbara G.; Posey, L. Michael. Pharmacotherapy: A Pathophysiologic Approach (6th ed.). McGraw-Hill. pp.20423. ISBN978-0-07-141613-9. McDonald L, Killgore G, Thompson A, Owens R, Kazakova S, Sambol S, Johnson S, Gerding D (2005). "An epidemic, toxin gene-variant strain of Clostridium difficile". N Engl J Med 353 (23): 243341. doi: 10.1056/NEJMoa051590 (http://dx.doi.org/10.1056/NEJMoa051590). PMID 16322603 (http://www.ncbi. nlm.nih.gov/pubmed/16322603). Yamada T; Alpers DH, ed. (2003). Textbook of Gastroenterology (4th ed.). Lippincott Williams & Wilkins. pp.18701875. ISBN0-7817-2861-4. van den Hof S, van der Kooi T, van den Berg R, Kuijper EJ, Notermans DW (January 2006). "Clostridium difficile PCR ribotype 027 outbreaks in the Netherlands: recent surveillance data indicate that outbreaks are not easily controlled but interhospital transmission is limited" (http://www.eurosurveillance.org/ViewArticle. aspx?ArticleId=2882). Euro Surveill. 11 (1): E060126.2. PMID 16801713 (http://www.ncbi.nlm.nih.gov/ pubmed/16801713). 2882. Sunenshine, RH; McDonald, LC (February 2006). "Clostridium difficile-associated disease: new challenges from an established pathogen". Cleveland Clinic Journal of Medicine 73 (2): 18797. doi: 10.3949/ccjm.73.2.187 (http://dx.doi.org/10.3949/ccjm.73.2.187). PMID 16478043 (http://www.ncbi.nlm.nih.gov/pubmed/ 16478043).

External links
Clostridium difficile: Is your family at risk? (http://www.aboutkidshealth.ca/En/News/NewsAndFeatures/ Pages/C-difficile-Is-your-family-at-risk.aspx) AboutKidsHealth Schroeder MS (March 2005). "Clostridium difficile--associated diarrhea" (http://www.aafp.org/afp/2005/ 0301/p921.html). Am Fam Physician 71 (5): 9218. PMID 15768622 (http://www.ncbi.nlm.nih.gov/ pubmed/15768622). Wins Story (The risks of C Diff infection and hospital neglect) (http://uk.youtube.com/ watch?v=Gn1i9imSE-0) Pseudomembranous colitis (http://www.dmoz.org/Health/Conditions_and_Diseases/Infectious_Diseases/ Bacterial/Clostridial/Pseudomembranous_Colitis//) at the Open Directory Project "From hand to mouth" (http://www.economist.com/science/displaystory.cfm?story_id=6971098). The Economist. 2006-05-25. discussing C. difficile Pathema (http://pathema.tigr.org/tigr-scripts/Clostridium/PathemaHomePage.cgi) Clostridium genomics resource Centers for Disease Control and Prevention (CDC) (December 2005). "evere Clostridium difficile-associated disease in populations previously at low risk--four states, 2005" (http://www.cdc.gov/mmwr/PDF/wk/

Clostridium difficile mm5447.pdf). MMWR Morb. Mortal. Wkly. Rep. 54 (47): 12015. PMID 16319813 (http://www.ncbi.nlm. nih.gov/pubmed/16319813). Abrahamian FM, Talan DA, Moran GJ, Pinner R (July 2006). "Update on emerging infections from the Centers for Disease Control and Prevention. Severe Clostridium difficile-associated disease in populations previously at low riskfour states, 2005". Ann Emerg Med 48 (1): 559. doi: 10.1016/j.annemergmed.2006.04.005 (http://dx. doi.org/10.1016/j.annemergmed.2006.04.005). PMID 16791928 (http://www.ncbi.nlm.nih.gov/pubmed/ 16791928). from the UK Clostridium difficile Support Group (UK) (http://www.cdiff-support.co.uk/about.htm) MedscapeCME (http://cme.medscape.com/viewarticle/705552_2) Healthcare-associated infections "Sea Change Anticipated in the Management of C. difficile Infection" July 2009 (http://www.gastroendonews. com/index.asp?section_id=187&show=dept&article_id=13458&ses=ogst) Clostridium difficile (http://patricbrc.org/portal/portal/patric/Taxon?cType=taxon&cId=1496) genomes and related information at PATRIC (http://patricbrc.org/), a Bioinformatics Resource Center funded by NIAID (http://www.niaid.nih.gov/) CDI Toolkit (http://www.picnet.ca/education-training/60/clostridium-difficile-infection-(cdi)-toolkit) from the Provincial Infection Control Network of British Columbia (http://www.picnetbc.ca/) (PICNet)

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Provincial CDI Surveillance Reports (http://www.picnet.ca/surveillance-research.php/74/ provincial-cdi-surveillance-reports) from the Provincial Infection Control Network of British Columbia (http:// www.picnetbc.ca/) (PICNet) C. difficile TcdA (http://www.functionalglycomics.org/CFGparadigms/index.php/C. _difficile_toxin_A_(TcdA)) information from the Consortium for Functional Glycomics (http://www. functionalglycomics.org/CFGparadigms/) on one of the major virulence factors from C. difficile

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Centers for Disease Control and Prevention


Centers for Disease Control and Prevention

Agency overview Formed July 1, 1946

Preceding agencies Office of National Defense Malaria Control Activities (1942) Office of Malaria Control in War Areas (19421946) Communicable Disease Center (19461967) National Communicable Disease Center (19671970) Center for Disease Control (19701980) Centers for Disease Control (19801992) Jurisdiction Headquarters Employees Annual budget Agency executive Parent Agency Federal government of the United States Druid Hills, Georgia 15,000 US$11.3 billion (2014 FY) Thomas R. Frieden, MD, MPH, Director, Centers for Disease Control and Prevention United States Department of Health and Human Services

The Centers for Disease Control and Prevention (CDC) is the national public health institute of the United States. The CDC is a federal agency under the Department of Health and Human Services and is headquartered in Druid Hills, unincorporated DeKalb County, Georgia, in Greater Atlanta..[1][2][3] Its main goal is to protect public health and safety through the control and prevention of disease, injury, and disability. The CDC focuses national attention on developing and applying disease control and prevention. It especially focuses its attention on infectious disease, food borne pathogens, environmental health, occupational safety and health, health promotion, injury prevention and educational activities designed to improve the health of United States citizens. In addition, the CDC researches and provides information on non-infectious diseases such as obesity and diabetes and is a founding member of the International Association of National Public Health Institutes.

History
The Communicable Diseases Center was founded July 1, 1946 as the successor to the World War II Malaria Control in War Areas program[] of the Office of National Defense Malaria Control Activities.[] Preceding its founding, organizations with global influence in malaria control were the Malaria Commission of the League of Nations and the Rockefeller Foundation.[] The Rockefeller Foundation greatly supported malaria control,[] sought to have the governments take over some of its efforts, and collaborated with the agency.[]

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The new agency was a branch of the U.S. Public Health Service and Atlanta was chosen as the location because malaria was endemic in the Southern United States. The agency changed names (see infobox on top right) before adopting the name Communicable Disease Center in 1946. Offices were located on the sixth floor of the Volunteer Building on Peachtree Street. With a budget at the time of about $1 million, 59 percent of its personnel were engaged in mosquito abatement and habitat control with the objective of control and eradication of malaria in the United States[4] (see National Malaria Eradication Program). Among its 369 employees, the main jobs at CDC were originally entomology and engineering. In CDC's initial years, more than six and a half million homes were sprayed, mostly with DDT. In 1946, there were only seven medical officers on duty and an early organization chart was drawn, somewhat fancifully, in the shape of a mosquito. Under Dr. Joseph Mountin the CDC continued to advocate for public health issues and pushed to extend its responsibilities to many other communicable diseases. In 1947, CDC made a token payment of $10 to Emory University for 15 acres (61,000m2) of land on Clifton Road in DeKalb County, still the home of CDC headquarters today. CDC employees collected the money to make the purchase. The benefactor behind the gift was Robert Woodruff, chairman of the board of The Coca-Cola Company. Woodruff had a long-time interest in malaria control, which had been a problem in areas where he went hunting. The same year, the PHS transferred its San Francisco based plague laboratory into the CDC as the Epidemiology Division, and a new Veterinary Diseases Division was established.[] The mission of CDC expanded beyond its original focus on malaria to include sexually transmitted diseases when the Venereal Disease Division of the U.S. Public Health Service (PHS) was transferred to the CDC in 1957. Shortly thereafter, Tuberculosis Control was transferred (in 1960) to the CDC from PHS, and then in 1963 the Immunization program was established.[5] It became the National Communicable Disease Center (NCDC) effective July 1, 1967.[] The organization was renamed the Center for Disease Control (CDC) on June 24, 1970, and Centers for Disease Control effective October 14, 1980.[] An act of the United States Congress appended the words "and Prevention" to the name effective October 27,

CDC headquarters in Druid Hills, Georgia, as seen from Emory University

CDCs Roybal campus in Atlanta, GA

Arlen Specter Headquarters and Emergency Operations Center

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1992. However, Congress directed that the initialism CDC be retained because of its name recognition.[6] CDC now operates under the Department of Health and Human Services umbrella. Currently the CDC focus has broadened to include chronic diseases, disabilities, injury control, workplace hazards, environmental health threats, and terrorism preparedness. CDC combats emerging diseases and other health risks, including birth defects, West Nile virus, obesity, avian, swine, and pandemic flu, E. coli, and bioterrorism, to name a few. The organization would also prove to be an important factor in preventing the abuse of penicillin.

Tom Harkin Global Communications Center

In May 1994 the CDC admitted to having sent several biological warfare agents to Iraq from 1984 through 1989, including Botulinum toxin, West Nile virus, Yersinia pestis and Dengue fever virus.[7] The CDC has one of the few Biosafety Level 4 laboratories in the country,[8] as well as one of only two official repositories of smallpox in the world. The second smallpox store resides at the State Research Center of Virology and Biotechnology VECTOR in the Russian Federation.

Budget and workforce


CDCs FY2008 budget was $9.2 billion. As of 2008, staff numbered approximately 15,000 (including 6,000 contractors and 840 Commissioned Corps officers) in 170 occupations. Eighty percent have earned bachelor's degrees or higher; almost half have advanced degrees (a master's degree or a doctorate such as a PhD, D.O., or M.D.).[9] CDC job titles also include engineer, entomologist, epidemiologist, biologist, physician, veterinarian, behaviorial scientist, nurse, medical technologist, economist, Public Health Advisor, health communicator, toxicologist, chemist, computer scientist, and statistician.[10] In addition to its Atlanta headquarters, the CDC has other locations in the United States and Puerto Rico. Those locations include Anchorage; Cleveland; Cincinnati; Fort Collins; Hyattsville; Morgantown; Pittsburgh; Research Triangle Park; San Juan, Puerto Rico; Spokane, Washington; Detroit; and Washington, D.C. The CDC also conducts the Behavioral Risk Factor Surveillance System, the worlds largest, on-going telephone health survey system.[11] The CDC offers grants that help many organizations each year bring health, safety and awareness to surrounding communities throughout the entire United States. As a government-run department, the Centers for Disease Control and Prevention awards over 85 percent of its annual budget through these grants to accomplish its ultimate goal of disease control and quality health for all.[12] The CDC also operates the Public Health Associate Program (PHAP), a two-year paid fellowship for recent college graduates to work in public health agencies all over the United States. PHAP was founded in 2007 and currently has 159 associates in 34 states.[13]

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Directors
The President of the United States appoints the director of the CDC and the appointment does not require Senate confirmation. The director serves at the pleasure of the President and may be fired at any time.[14][15] Sixteen directors have served CDC or its predecessor agencies.[16][17] Louis L. Williams, Jr., MD (19421943) Mark D. Hollis, ScD (19441946) Raymond A. Vonderlehr, MD (19471951) Justin M. Andrews, ScD (19521953) Theodore J. Bauer, MD (19531956) Robert J. Anderson, MD, MPH (19561960) Clarence A. Smith, MD, MPH (19601962) James L. Goddard, MD, MPH (19621966) David J. Sencer, MD, MPH (19661977) William H. Foege, MD, MPH (19771983) James O. Mason, MD, MPH (19831989) William L. Roper, MD, MPH (19901993) David Satcher, MD, PhD (19931998)

Jeffrey P. Koplan, MD, MPH (19982002)[18] Julie Gerberding, MD, MPH (20022008) Thomas R. Frieden, MD, MPH (2009present)[14]

Organizational restructuring
On April 21, 2005, the then-director of CDC, Dr. Julie Gerberding, formally announced the reorganization of CDC to "confront the challenges of 21st-century health threats".[19] The four Coordinating Centersestablished under the G. W. Bush Administration and Gerberding"diminished the influence of national centers under [their] umbrella" and were ordered cut under the Obama Administration and Frieden in 2009.[20]

Foundation
The CDC Foundation[21] operates independently from CDC as a private, nonprofit 501(c)(3) organization incorporated in the State of Georgia. The creation of the Foundation was authorized by section 399F of the Public Health Service Act to support the mission of CDC in partnership with the private sector, including organizations, foundations, businesses, educational groups, and individuals.

Data and survey systems


CDC Scientific Data, Surveillance, Health Statistics, and Laboratory Information.[22] Behavioral Risk Factor Surveillance System.[23] Mortality Medical Data System.[24] Abortion statistics in the United States[25]

Publications
CDC publications[26] State of CDC report[27] CDC Programs in Brief[28] Morbidity and Mortality Weekly Report[29] Emerging Infectious Diseases, (monthly journal)[30]

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Diseases with which the CDC is involved


Influenza
The CDC has launched campaigns targeting the transmission of influenza, including the H1N1 swine flu. The CDC has launched websites including [flu.gov] to educate people.

Other infectious diseases


The CDC's website (see below) has information on other infectious diseases, including smallpox, measles, and others.

Non-infectious disease
The CDC also combats non-infectious diseases, including obesity.

Investigations by the Department of Health and Human Services Office of Inspector General (OIG)
On the June 15, 2011, the OIG published a report critical of the CDC's failure to oversee recipients use of Presidents Emergency Plan for AIDS Relief (PEPFAR) funds.[31] The report read in part:
Our review found that CDC did not always monitor recipients use of Presidents Emergency Plan for AIDS Relief (PEPFAR) funds in accordance with departmental and other Federal requirements. CDC implements PEPFAR, working with ministries of health and other public health partners to combat HIV/AIDS by strengthening health systems and building sustainable HIV/AIDS programs in more than 75 countries in Africa, Asia, Central and South America, and the Caribbean. HHS receives PEPFAR funds from the Department of State through a memorandum of agreement. There was evidence that CDC performed some monitoring of recipients use of PEPFAR funds. However, most of the award files did not include all required documents or evidence to demonstrate that CDC performed required monitoring on all cooperative agreements. Of the 30 cooperative agreements in our sample, the award file for only 1 agreement contained all required documents. The remaining 29 award files were incomplete. In addition, 14 of 21 files were missing audit reports. (A report was not yet due for 9 of the 30 cooperative agreements.) The lack of required documentation demonstrates that CDC has not exercised proper stewardship over Federal PEPFAR funds because it did not consistently follow departmental and other Federal requirements in monitoring PEPFAR recipients.

On June 5, 2012, the OIG published a report identifying vulnerabilities in vaccine management in the CDC's domestic 'Vaccines for Children' (VFC) program.[32] The report read in part:
Although the majority of storage temperatures we independently measured during a 2-week period were within the required ranges, VFC vaccines stored by 76 percent of the 45 selected providers were exposed to inappropriate temperatures for at least 5 cumulative hours during that period. Exposure to inappropriate temperatures can reduce vaccine potency and efficacy, increasing the risk that children are not provided with maximum protection against preventable diseases. Thirteen providers stored expired vaccines together with non-expired vaccines, increasing the risk of mistakenly administering the expired vaccine. Finally, the selected providers generally did not meet vaccine management requirements or maintain required documentation. Similarly, none of the five selected grantees met all VFC program oversight requirements, and grantee site visits were not effective in ensuring that providers met vaccine management requirements over time.

On the November 19, 2012, the OIG published a report critical of the CDC Namibia Office's failure to properly monitor recipients' use of PEPFAR funds.[33] The report read in part:
CDC's office in Windhoek, Namibia (CDC Namibia), is responsible for PEPFAR funds awarded to government agencies and for-profit and non-profit organizations (recipients) in Namibia.

Centers for Disease Control and Prevention


Our audit found that CDC Namibia did not always monitor recipients' use of PEPFAR funds in accordance with HHS and other Federal requirements. There was evidence that CDC Namibia performed some monitoring of recipients' use of PEPFAR funds. However, most of the recipient cooperative agreement files did not include required documents or evidence that CDC Namibia had monitored all cooperative agreements. CDC Namibia did not consistently monitor the cooperative agreements in accordance with HHS and other Federal requirements because it did not have written policies and procedures for the monitoring process. As a result, CDC Namibia did not have assurance that PEPFAR funds were used as intended by law. We recommended that CDC Namibia implement standard operating procedures for monitoring recipients' use of PEPFAR funds. CDC concurred with our recommendation.

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CDC zombie apocalypse video contest


On May 18, 2011, the Centers for Disease Control and Prevention's blog published an article instructing the public on what to do to prepare for a zombie invasion. While the article did not claim that such a scenario was possible, it did use the popular culture appeal as a means of having individuals prepare for all potential hazards, such as earthquakes, tornadoes, and floods.[34] The recent proliferation of Zombie media provided a medium to contact citizens usually unaccustomed to dealing with the CDC. Once the article became popular, the CDC announced an open contest for YouTube submissions of the most creative and effective videos covering preparedness for a zombie apocalypse (or apocalypse of any kind), to be judged by the "CDC Zombie Task Force". Submissions were open until October 11, 2011.[35]

References
[1] Home Page (http:/ / www. cdc. gov/ ). Centers for Disease Control and Prevention. Retrieved on November 19, 2008. [2] Groundbreaking held for new CDC virus research labs (http:/ / nl. newsbank. com/ nl-search/ we/ Archives?p_product=AT& p_theme=at& p_action=search& p_maxdocs=200& p_topdoc=1& p_text_direct-0=0EB7C1D4E335E149& p_field_direct-0=document_id& p_perpage=10& p_sort=YMD_date:D& s_trackval=GooglePM). Atlanta Journal-Constitution. December 3, 1985. A21. Retrieved on February 5, 2011. "The new facility will sit behind and be connected to CDC's red-brick complex of buildings on Clifton Road in DeKalb County[...]" [3] " Druid Hills CDP, GA (http:/ / factfinder. census. gov/ servlet/ MapItDrawServlet?geo_id=16000US1324264& _bucket_id=50& tree_id=420& context=saff& _lang=en& _sse=on)." United States Census Bureau. Retrieved on May 5, 2009. [7] "The eleventh plague: the politics of biological and chemical warfare" (p. 84-86) by Leonard A. Cole (http:/ / www. leonardcole. com) (1993) [9] For more data on 2008, click on the "2008" link. [13] http:/ / www. cdc. gov/ phap/ index. html [14] Wilgoren, Debbi and Shear, Michael D. "Obama Chooses NYC Health Chief to Head CDC." Washington Post. May 16, 2009 (http:/ / www. washingtonpost. com/ wp-dyn/ content/ article/ 2009/ 05/ 15/ AR2009051500295. html). [15] Etheridge, Elizabeth W. Sentinel for Health: A History of the Centers for Disease Control. Berkeley, Calif.: University of California Press, 1992. ISBN 978-0-520-07107-0; Patel, Kant; Rushefsky, Mark E.; and McFarlane, Deborah R. The Politics of Public Health in the United States. M.E. Sharpe, 2005. ISBN 978-0-7656-1135-2. [17] Records of the Centers for Disease Control and Prevention (http:/ / www. archives. gov/ research/ guide-fed-records/ groups/ 442. html#442. 1) Administrative History. Retrieved 2009-10-04.

External links
The CDC Homepage (http://www.cdc.gov) CDC Online Newsroom (http://www.cdc.gov/media/) CDC Health Topics A to Z (http://www.cdc.gov/az.do) CDC Public Health Image Library (http://phil.cdc.gov/Phil/home.asp) CDC Global Communications Center (http://www.cdc.gov/gcc/)

CDC Emerging Infectious Diseases Laboratory Atlanta, Georgia (http://www.labdesignnews.com/ LaboratoryDesign/LD0605feat_3.asp) Centers For Disease Control And Prevention Meeting Notices and Rule Changes (http://thefederalregister.com/ b.p/agency/Centers_for_Disease_Control_and_Prevention/) from The Federal Register RSS Feed (http://

Centers for Disease Control and Prevention thefederalregister.com/rss/agency/Centers_for_Disease_Control_and_Prevention/) Proposed and finalized federal regulations from the Centers for Disease Control and Prevention (http://openregs. com/agencies/view/151/centers_for_disease_control_and_prevention) Coordinates: 33.798817N 84.325598W (http:/ / tools. php?pagename=Centers_for_Disease_Control_and_Prevention& 325598_E_region:US_type:landmark) wmflabs. org/ params=33. geohack/ geohack. 798817_N_-84.

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Chargemaster
In the United States, the chargemaster, also known as charge master, or charge description master (CDM), is a comprehensive listing of items billable to a hospital patient or a patient's health insurance provider. In practice, it usually contains highly inflated prices at several times that of actual costs to the hospital.[][][] The chargemaster typically serves as the starting point for negotiations with patients and health insurance providers of what amount of money will actually be paid to the hospital. It is described as "the central mechanism of the revenue cycle" of a hospital.

Description
The chargemaster may be alternatively referred to as the "charge master", "hospital chargemaster", or the "charge description master" (CDM).[][] The chargemaster is a master file built within hospital information systems, and designed to communicate (interface) with other software applications or systems to support government-mandated standard billing requirements. It contains data elements such as charge descriptions, billing codes, pricing, and many other necessary data elements.[citation needed] It is a comprehensive listing of items billable to a hospital patient or a patient's health insurance provider.[][] It is described as "the central mechanism of the revenue cycle" of a hospital.[1] Chargemasters include thousands of hospital services, medical procedures, equipment fees, drugs, supplies, and diagnostic evaluations such as imaging and blood tests.[] Each item in the chargemaster is assigned a unique identifier code and a set price that are used to generate patient bills.[] Every hospital system maintains its own chargemaster.[] Regulatory requirements are extensive, and hospitals must assure accuracy of all data or risk audits, fines, and penalties. Charge data is constantly updated due to addition of chargeable items or services, or to accommodate corrections or quarterly changes published by the government.[citation needed] The procedure of developing, maintaining, and monitoring the chargemaster and its pricing scheme often necessitates multiple hospital employees working under the supervision of a "chargemaster coordinator",[][] a "charge master manager", or others in the health care system's operations or administrative support areas frequently called a "charge master team".[citation needed] Ultimate responsibility for ensuring accuracy of the chargemaster rests with each hospital's chief financial officer,[2] compliance officer, and hospital Board.[citation needed] Approximately forty percent of hospitals pay outside companies to help create and then adapt their chargemasters on a yearly basis.[] According to Essentials of Managed Health Care, as of 2012 the chargemaster file typically included over 5,000 price definitions.[1] The Lewin Group analyzed utilization of the chargemaster and found that a low proportion of hospitals carried out regular reviews of their chargemaster implementation.[] Costs for patients maintained on the chargemaster differ greatly from hospital to hospital.[] Authors J. Patrick Rooney and Dan Perrin note in their book America's Health Care Crisis Solved, "Charge-master rates, in reality, serve as nothing more than the starting point for negotiations" with the payer.[] The impact of the chargemaster is such that those with good insurance or better access to means to afford quality healthcare pay the least for that care, whereas conversely uninsured, and others who pay out-of-pocket for healthcare pay the full chargemaster listed price for the same services.[][3]

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Existing legislation and regulations


In California, a regulation known as the "Payers' Bill of Rights" (which is unique to the state) requires all hospitals to provide their chargemaster to the state, which then posts them online for the public.[][4] The chargemaster procedure is generally only regulated in Maryland; author Peter Reid Kongstvedt notes in Essentials of Managed Care, "Of particular importance, other than in Maryland, hospitals are generally free to charge whatever they want in their chargemaster."[1]

Critical analysis
Chargemasters gained national attention in May 2013 when the Centers for Medicare and Medicaid Services published inpatient prices for hospitals across the country in a publicly available format.[5] However, local and national press have addressed hospital pricing periodically over the past 20 years. Recently, the topic reached national attention in a Time magazine cover story published February 20, 2013, titled "Bitter Pill: Why Medical Bills Are Killing Us".[] Reporter Steven Brill examined the overlooked role that chargemasters play in the American health care system's cost crisis, asserting that they routinely list extremely high prices "devoid of any calculation related to cost", and are generally regarded as "fiction" in the healthcare industry, despite their significant role in setting prices for both insured and uninsured patients alike.[] "The 'full charges' reflected on hospital Charge Masters are unconscionable", wrote George A. Nation III in a 2005 piece for the Kentucky Law Journal.[6] Health care economist scholar Uwe Reinhardt noted in a 2006 article for Health Affairs that the approach to chargemasters by hospitals would have to be modified to become more transparent, in order to encourage a form of consumer-driven health care to help improve the system.[7] University of California, Berkeley professor of health economics James C. Robinson pointed out prior criticism of the chargemaster, "Much ink has been spilt bemoaning that incomprehensible foundation of hospital cost accounting and prices, the redoubtable chargemaster."[] Robinson called for greater transparency as well as increased price standardization as steps to help remedy the situation.[] In a 2007 article for Health Affairs, Gerard F. Anderson observed, "Without knowing what services they will use in advance, it is impossible for patients to comparison shop."[] Anderson also noted the esoteric nature of the language on the chargemaster made it difficult for patients and anyone other than hospital administrators to understand.[] Anderson emphasized the difficulty of patients' ability to interpret the chargemaster in a subsequent 2012 article: "Furthermore, most of the items on the charge master file are written in code so that only the hospital administrators and a few experts in the field can interpret their meanings.".[8] Professionals specialized in assisting hospitals with Charge Master management processes and data analysis dispute this allegation, and note that charge descriptions are developed based on clinical verbiage necessary for accurately mapping myriad files within the hospital information system to ensure compliance to Medicare claims submission and reimbursement standards.[citation needed]

References Further reading


Brill, Steven (February 20, 2013). "Bitter Pill: Why Medical Bills Are Killing Us" (http://healthland.time.com/ 2013/02/20/bitter-pill-why-medical-bills-are-killing-us/print/). Time (Time Warner). Retrieved March 7, 2013. Brill, Steven (March 5, 2013). "Coming up with 'A Bitter Pill'" (http://blogs.reuters.com/stories-id-like-to-see/ 2013/03/05/coming-up-with-a-bitter-pill/). "Stories I'd like to see" blog (Thomson Reuters). Retrieved March 25, 2013. Alternate link (http://www.cjr.org/behind_the_news/stories_id_like_to_see_coming.php?page=1), Columbia Journalism Review.

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External links
Database of hospital chargemasters in California (http://www.oshpd.ca.gov/Chargemaster/), Office of Statewide Health Planning and Development, State of California Medicare Provider Charge Data (https://www.cms.gov/Research-Statistics-Data-and-Systems/ Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/index.html), Centers for Medicare & Medicaid Services

Clinical data repository


A Clinical Data Repository (CDR) or Clinical Data Warehouse (CDW) is a real time database that consolidates data from a variety of clinical sources to present a unified view of a single patient. It is optimized to allow clinicians to retrieve data for a single patient rather than to identify a population of patients with common characteristics or to facilitate the management of a specific clinical department. Typical data types which are often found within a CDR include: clinical laboratory test results, patient demographics, pharmacy information, radiology reports and images, pathology reports, hospital admission, discharge and transfer dates, ICD-9 codes, discharge summaries, and progress notes.

Acute assessment unit


An acute assessment unit (AAU) (also often called acute admissions unit or acute medical assessment unit) is a short-stay department in some British, Australian and New Zealand hospitals that may be linked of the emergency department, but functions as a separate department. The AAU acts as a gateway between a patient's general practitioner, the emergency department, and the wards of the hospital. The AAU helps the emergency department produce a healthy turnaround for patients, helping with the four-hour waiting rule. An AAU is usually made up of several bays and has a small number of side-rooms and treatment rooms. They are fully equipped with emergency medical treatment facilities including defibrilators and resuscitation equipment.

Patients
From the emergency department, patients can be moved to AAU where they will undergo further tests and stabilisation before they are transferred to the relevant ward or sent home. Also, patients can be admitted straight to AAU from their general practitioner if he or she believes the patient needs hospital treatment. A patient's stay in the unit is limited, usually no more than 48 hours. The AAU deals with admissions only, patients will never be transferred from a ward to the AAU. Surgical Procedures are not carried out in the unit either; these are referred on to the relevant theatre such as cardiothoracics and general surgery.

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Staff
Senior staff in an AAU typically include a consultant in general medicine, emergency medicine, or critical care. Often a registrar in general medicine, and a ward sister or a charge nurse have roles in the unit. A number of staff nurses work alongside the senior staff to provide care to patients in the unit. The department can also include pharmacists, who carry out duties such as medical history taking. Although AAU has its own staff trained to deal with patients and provide care, members of staff from other departments in the hospital are needed in AAU to assess patients and provide further diagnosis. Typical examples of staff who may be needed in AAU are general surgeons, cardiothoracic surgeons, cardiologists, and a psychiatric liaison nurse.

Alternative names for the department


Different hospitals use different names for the department. Common names for this department are: Acute Assessment Unit (AAU)[1] Acute Admissions Unit (AAU)[2] Acute Medical Unit (AMU)[3] Acute Medical Receiving Unit (AMRU) [4] Clinical Decision Unit (CDU)[5] Emergency Assessment Unit (EAU)[6] Emergency Medical Assessment/Admissions Unit (EMAU)[7] Medical Assessment Unit (MAU)[8] Medical Assessment and Planning Unit (MAPU) - in Australia and New Zealand[9]

References
[1] Chelsea and Westminster Hospital: Acute Assessment Unit (AAU) (http:/ / www. chelwest. nhs. uk/ your-visit/ wards-and-departments/ acute-assessment-unit-aau) Linked 2013-07-20 [2] West Hertsfordshire Hospitals: Acute Admissions Unit (http:/ / www. westhertshospitals. nhs. uk/ ourservices/ aau/ ) Linked 2013-07-20 [3] Ealing Hospital: Acute Medical Unit (AMU) (http:/ / www. ealinghospital. nhs. uk/ services/ hospital-services/ acute-medical-unit/ ) Linked 2013-07-20 [4] University Hospital of South Manchester: Ward A10 (AMRU) (http:/ / www. uhsm. nhs. uk/ patients/ Pages/ WardA10. aspx) Linked 2013-07-20 [5] Blackpool Teaching Hospitals: Clinical Decisions Unit (http:/ / www. bfwh. nhs. uk/ departments/ cdu/ default. asp) Linked 2013-07-20 [6] Salford Royal: Emergency Assessment Unit (EAU) (http:/ / www. srft. nhs. uk/ about-us/ depts/ eau/ ) Linked 2013-07-20 [7] Royal Hampshire County Hospital: Emergency Medical Assessment Unit (EMAU) (http:/ / www. hampshirehospitals. nhs. uk/ our-services/ a-z-wards/ royal-hampshire-county-hospital-wards/ emergency-medical-assessment-unit-emau-/ ) Linked 2013-07-20 [8] Frimley Park Hospital: Medical assessment unit (MAU) (http:/ / www. frimleypark. nhs. uk/ services/ medical-assessment-unit-mau) Linked 2013-07-20 [9] IMSANZ: Standards for MAPU in Public and Private Hospitals (http:/ / www. imsanz. org. au/ resources/ standards-for-mapu-in-public-and-private-hospitals) Linked 2013-07-20

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Tricare
Tricare (styled TRICARE), formerly known as the 'Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), is a health care program of the United States Department of Defense Military Health System.[1] Tricare provides civilian health benefits for military personnel, military retirees, and their dependents, including some members of the Reserve Component. The Tricare program is managed by Tricare Management Activity (TMA) under the authority of the Assistant Secretary of Defense (Health Affairs). Tricare is the civilian care component of the Military Health System, although historically it also included health care delivered in the military medical treatment facilities.

The Tricare logo

History
Historically, health care for military personnel and their dependents was provided in military medical facilities as promised by the military, and through a referral system, by civilian medical personnel where military physicians were not available in a certain specialty, or overcrowding of a military medical facility occurred. After World War II and the Korean War, access to care in military facilities became increasingly unavailable due to resource constraints and growing demands on the system, and "space-available basis" was first noted. To address this problem, Congress passed the Dependents Medical Care Act of 1956 and the Military Medical Benefits Amendments of 1966. These acts allowed the Secretary of Defense to contract with civilian health care providers. This civilian health care program became known as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) in 1966.[] In the late 1980s, because of escalating costs, paperwork demands, and general beneficiary dissatisfaction, DoD initiated a series of demonstration projects. Under a program known as the CHAMPUS Reform Initiative (CRI), a contractor provided both health care and administrative-related services, including claims processing. The CRI project was one of the first to introduce managed care features to the CHAMPUS program. Beneficiaries under CRI were offered three choices a health maintenance organization-like option called Tricare (CHAMPUS) Prime that required enrollment and offered enhanced benefits and low-cost shares, a preferred provider organization-like option called Tricare (CHAMPUS) Extra that required use of network providers in exchange for lower cost shares, and the standard CHAMPUS option that continued the freedom of choice in selecting providers but required higher cost shares and deductibles known as Tricare Standard. Although DODs initial intent under CRI was to award three competitively bid contracts covering six states, only one bid, made by Foundation Health Corporation (now Health Net) covering California and Hawaii, was received. Foundation delivered services under this contract between August 1988 and January 1994. In late 1993, in response to requirements in the DOD Appropriation Act for Fiscal Year 1994, the DoD announced plans for implementing a nationwide managed care program for the MHS that would be completely implemented by May 1997. Under this program, known as Tricare, the United States was divided into 12 health care regions. An administrative organization, the lead agent, was designated for each region and coordinated the health care needs of all military treatment facilities in the region. Under Tricare, seven managed care support contracts were awarded covering DODs 12 health care regions.[]

Tricare Since then, Tricare has undergone several restructuring initiatives, including re-alignment of contract regions, Base Realignment and Closure, and the addition of "Tricare for Life" benefits in 2001 for those who are Medicare-eligible, and "Tricare Reserve Select" in 2005.

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Tricare's options
Tricare Standard
Tricare Standard provides a similar benefit to the original CHAMPUS program and is available to retirees from the Active Component, retirees from the Reserve Component age 60 or older, and their eligible family members. Under Tricare Standard, beneficiaries can use any civilian health care provider that is payable under Tricare regulations. The beneficiary is responsible for payment of an annual deductible and coinsurance, and may be responsible for certain other out-of-pocket expenses. There is no enrollment fee for Tricare Standard.

Tricare Extra
Tricare Standard beneficiaries can elect to use the Tricare Extra option by using a civilian health care provider from within the regional contractor's provider network. In this way, Tricare Extra represents a preferred provider organization (PPO). When using Tricare Extra, the beneficiary's coinsurance amount is reduced by at least five percentage points. There is no fee for use of the Tricare Extra benefit other than the coinsurance.

Tricare Prime
Tricare Prime is a health maintenance organization (HMO) style plan available to active duty personnel, retirees from the Active Component, retirees from the Reserve Component age 60 or older, and their eligible family members. Under Tricare Prime, beneficiaries must choose a primary care physician and obtain referrals and authorizations for specialty care. In return for these restrictions, beneficiaries are responsible only for small copayments for each visit (retirees and their families only). There is an annual enrollment fee for Tricare Prime for military retirees and their family members. There is no enrollment fee for active duty military and their family members. US Family Health Plan US Family Health Plan, a Tricare Prime-sponsored health plan option, is made available by nonprofit health care providers in the Northeast U.S., Southeast Texas/Southwest Louisiana, and the Puget Sound region of Washington state.

Tricare Reserve Select (TRS)


Tricare Reserve Select is a premium-based health plan that active status qualified National Guard and Reserve members may purchase. The classification is sometimes referred to as Tricare Reserve Component (RC). It requires a monthly premium and offers coverage similar to Tricare Standard and Extra for the military member and eligible family members. It has a partial premium cost sharing arrangement with DoD similar to civilian private or public sector employer plans, although typically at a lower cost than civilian plans. The program coverage is available world wide to Selected Reserve (SELRES) members of both the Title 10 USC Federal Reserve Components (Army Reserve, Navy Reserve, Air Force Reserve, Marine Corps Reserve), Title 14 USC Federal Reserve Component (Coast Guard Reserve) and the Title 32 National Guard (Army National Guard and Air National Guard) in a drill pay (also known as "paid") status. As of February 2008, retired Reserve Component personnel under the age of 60, actively drilling Individual Ready Reserve (IRR) personnel in a non-paid status, or actively drilling Volunteer Training Unit (VTU) personnel in a non-paid status do not qualify for TRS. IRR and VTU members are eligible for reinstatement under TRS is they return to a SELRES status. Reserve Component personnel who are also Federal

Tricare civil servants (to include Army Reserve Technicians and Air Reserve Technicians (ART) in the Army Reserve, Army National Guard, Air Force Reserve and Air National Guard) and eligible for the Federal Employee Health Benefit Program (FEHBP) are also excluded from TRS. Retired Reserve Component personnel and eligible dependent family members become eligible Tricare Standard, Tricare Extra or Tricare Prime on the service member's 60th birthday in the same manner as Active Component retirees and their eligible dependents are eligible immediately upon retirement from active service. Qualification questions should be referred to Tricare.

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Tricare Reserve Retired (TRR)


Tricare Reserve Retired is a premium-based health plan that qualified retired members of the National Guard and Reserve under the age of 60 may purchase for themselves and eligible family members. Established in 2008 and opened for enrollment in 2010, it is similar to Tricare Reserve Select (TRS), but differs in that there is no premium cost-sharing with DoD as there is with TRS. As such, retired Reserve Component members who elect to purchase TRR must pay the full cost (100%) of the calculated premium plus an additional administrative fee. Although open to all eligible retired Reserve Component personnel under the age of 60, the program's principal focus is often perceived as being focused on recent Reserve Component retirees who are self-employed or otherwise ineligible for civilian employer provided/subsidized health insurance, especially those who were mobilized for full-time active duty service subsequent to 11 September 2001 in support of Operations Enduring Freedom, Enduring Freedom, Iraqi Freedom, New Dawn and/or Noble Eagle. Retired Reserve Component personnel who elect to participate in TRR will exit TRR when the service member reaches age 60 and he/she and their eligible dependent family members become eligible for the same Tricare Standard, Tricare Extra or Tricare Prime options as Active Component retirees and, in the case of Tricare Prime, at the same cost as Active Component retirees. Qualification questions should be referred to Tricare.

Tricare for Life (TFL)


Tricare for Life was first incorporated as part of the then-seven regional Managed Care Support Contracts of Tricare in May 2001. The benefit was enacted by Congress in response to growing complaints from beneficiaries that as Medicare out of pocket costs increased a benefit was needed to pay these costs in lieu of Tricare retirees being required to purchase Medicare Supplemental Coverage to pay for prescriptions, physician and hospital dispensed drugs, cost shares and deductibles. Before Tricare for Life, Tricare beneficiaries immediately lost Tricare coverage upon attaining Medicare eiligibility. This included becoming Medicare eligible due to disability. Tricare for Life is designed to pay patient liability after Medicare payments. There is no enrollment necessary for Tricare for Life and to be eligible, members must be Tricare and Medicare Eligible and have purchased Medicare Part B coverage. An exception to the requirement for Part B coverage exists when the beneficiary that is Medicare eligible is the spouse of an Active Duty Service Member. In some instances Tricare for Life is primary payer when the services are normally a Tricare benefit but not covered by Medicare. This includes drug charges, when Medicare benefit limits are attained and services performed outside the United States or in a Veterans Affairs facility where Medicare does not pay. TFL does not pay patient liability for services that are not a Tricare benefit even though they may be paid by Medicare, such as chiropractic benefits. The policy limitations applying to Tricare also apply to TFL and must therefore be deemed medically necessary and skilled care. Custodial care therefore is not covered. In 2004 the Tricare for Life benefit was transferred from the individual regional Tricare contractors. Medical claims are processed by the national Tricare Dual Eligible Fiscal Intermediary Contractor (TDEFIC-Wisconsin Physicians Service Insurance Corporation). Pharmacy claims are processed by the Tricare Pharmacy Contractor (Express Scripts) and Overseas TFL claims are processed by the Tricare Overseas Program Contractor (as of September 2010 this will be International SOS using Wisconsin Physicians Service as their Fiscal Intermediary partner).

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Tricare Young Adult (TYA)


Tricare Young Adult (TYA) is a premium-based health care plan available for purchase by qualified dependents who have aged out of Tricare at age 21, or age 23 for full-time college students. Dependents are eligible if they are unmarried, not eligible for Tricare coverage or their own employer-sponsored health care coverage, and as long as their sponsor remains Tricare eligible.[2] Eligible dependents have the option to purchase Tricare Standard/Extra health coverage on a month-to-month basis. Purchased coverage includes medical and pharmacy benefits but does not include dental. A premium-based Tricare Prime benefit will be available later in 2011. The signing of the National Defense Authorization Act in January 2011 aligned Tricare with the provisions of the 2010 Patient Protection and Affordable Care Act, and lead to the creation of TYA.[3] Enrollment began May 1, 2011.

Program administration
The ultimate responsible organization for administration of Tricare is the U.S. Department of Defense Military Health System, which organized the Tricare Management Activity (TMA). The Tricare Management Activity contracts with several large health insurance corporations to provide claims processing, customer service and other administrative functions to the Tricare program.

Basic structure
Currently, there are three regional Managed Care Support Contractors (MCSCs), a Medicare/Tricare Dual Eligible Fiscal Intermediary Contractor (TDEFIC), and a Tricare Pharmacy contractor, who administers both Mail Order Pharmacy (TMOP) and Retail Pharmacy (TRRx) programs. In addition several administrative contractors provide quality management, auditing, and statistical services.

Dental insurance
TMA contracts and administers a couple of dental programs. United Concordia as Tricare Dental Program (TDP) Delta Dental as Tricare Retiree Dental Program (TRDP)

Health insurance
In 2004, Tricare Management Activity re-aligned the previous twelve regions into three large regions, known as Tricare North, Tricare South, and Tricare West. Services in these regions are provided by: North Health Net Federal Services, LLC The North Region includes Connecticut, Delaware, the District of Columbia, Illinois, Indiana, Kentucky, Maine, Maryland, Massachusetts, Michigan, New Hampshire, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, Vermont, Virginia, West Virginia, Wisconsin and portions of Iowa (Rock Island Arsenal area), Missouri (St. Louis area) and Tennessee (Ft. Campbell area). South Humana Military Healthcare Services, Inc. The South Region includes Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, Oklahoma, South Carolina, Tennessee (excluding the Ft. Campbell area) and Texas (excluding the El Paso area). West United Healthcare The West Region includes Alaska, Arizona, California, Colorado, Hawaii, Idaho, Iowa (excluding Rock Island Arsenal area), Kansas, Minnesota, Missouri (except the St. Louis area), Montana, Nebraska, Nevada, New Mexico, North Dakota, Oregon, South Dakota, Texas (the southwestern corner, including El Paso), Utah, Washington and Wyoming. All medical claims are processed ("adjudicated") by the following claims processing sub-contractors:

Tricare North, South and West PGBA, LLC (a subsidiary of BlueCross BlueShield of South Carolina) Tricare Overseas claims Wisconsin Physicians Service Insurance Corporation In 2009, the Tricare Overseas Program contract consolidated the following: Overseas enrollment Tricare Overseas claims processing Three area Tricare Service Center contracts Tricare Global Remote Overseas (TGRO) Tricare Puerto Rico Prime

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In October of 2009 International SOS Assistance, Inc. was awarded the contract to provide comprehensive health care support services to the Department of Defense Tricare Overseas Program.

References
[1] What is Tricare? (http:/ / tricare. mil/ mybenefit/ ProfileFilter. do?puri=/ home/ overview/ WhatIsTRICARE) Official website of the Tricare Management Activity [2] Tricare Young Adult (http:/ / www. tricare. mil/ TYA ) [3] New Tricare Program Offers Coverage for Young Adults Under 26 (http:/ / tricare. mil/ mediacenter/ news. aspx?fid=706)

External links
Official website (http://tricare.mil/tma/) Tricare information from Military.com (http://www.military.com/benefits/tricare/)

Veterans Health Administration


Veterans Health Administration
Agency overview Formed Jurisdiction Headquarters 1778
[1]

Federal government of the United States 810 Vermont Avenue NW., Washington, D.C., United States [2] 38543.25N 7725.36W 279,792 (March 2011)
[3] [4]

Employees Annual budget

$47 billion USD (2011)

Agency executive Robert Petzel, Under Secretary of Veterans Affairs for Health Parent Agency United States Department of Veterans Affairs Website va.gov/health
[5]

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The Veterans Health Administration (VHA) is the component of the United States Department of Veterans Affairs (VA) led by the Under Secretary of Veterans Affairs for Health[4] that implements the medical assistance program of the VA through the administration and operation of numerous VA outpatient clinics, hospitals, medical centers and long-term healthcare facilities (i.e., nursing homes). The VHA division has more employees than all other elements of the VA combined. The VHA is distinct from the U.S. Department of Defense Military Health System of which it is not a part.
Health care in the United States Government Health Programs

Veterans Affairs medical center in Durham, North Carolina

Federal Employees Health Benefits Program Indian Health Service Veterans Health Administration Military Health System / TRICARE Medicare Medicaid / State Health Insurance Assistance Program (SHIP) State Children's Health Insurance Program (CHIP) Program of All-Inclusive Care for the Elderly (PACE) Prescription Assistance (SPAP) Private health coverage

Health insurance in the United States Consumer-driven health care


Flexible spending account (FSA) Health Reimbursement Account Health savings account

High-deductible health plan (HDHP) Medical savings account (MSA) Private Fee-For-Service (PFFS) Managed care (CCP) Health maintenance organization (HMO) Preferred provider organization (PPO) Medical underwriting

Health care reform law


Emergency Medical Treatment and Active Labor Act (1986) Health Insurance Portability and Accountability Act (1996) Medicare Prescription Drug, Improvement, and Modernization Act (2003) Patient Safety and Quality Improvement Act (2005) Health Information Technology for Economic and Clinical Health Act (2009) Patient Protection and Affordable Care Act (2010) State level reform

Massachusetts health care reform Oregon Health Plan Vermont health care reform SustiNet (Connecticut) Dirigo Health (Maine) Municipal health coverage

Veterans Health Administration

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Fair Share Health Care Act (Maryland) Healthy Howard (Howard Co., Maryland) Healthy San Francisco

History
The first Federal agency to provide medical care to veterans was the Naval Home in Philadelphia, PA. The home was created in 1812 and was followed by the creation of Soldiers Home in 1853 and St. Elizabeth's Hospital in 1855. Congress created the National Home for Disabled Volunteer Soldiers in 1865 in response to the high number of Civil War casualties. These homes were initially intended to be room and board for disabled veterans. However, by the late 1920s, the homes were providing a level of care comparable to hospital care. President Hoover created the Veterans Administration (VA) in 1930 to consolidate all veteran services. General Omar N. Bradley was appointed to VA administrator and Bradley appointed Major General Paul Hawley as director of VA medicine, both in 1945. Hawley successfully established a policy that affiliated new VA hospitals with medical schools. Hawley also promoted resident and teaching fellowships at VA hospitals. Ultimately, Hawley was responsible for starting the hospital-based research program at the VA. Bradley resigned in 1947. However, upon resignation, 97 hospitals were in operation and 29 new hospitals had been built. As a result, the VA health system was able to serve a much larger population of veterans than it had served in previous years. President Reagan Elevated the VA to cabinet status in 1988, which became known as the Department of Veterans Affairs. The Department of Veterans Affairs oversees the Veterans Health Administration.[6] In the mid-1980s the VHA was criticized for their high operative mortality. To that end, Congress passed Public Law 99-166 in December 1985 which mandated the VHA to report their outcomes in comparison to national averages and the information must be risk-adjusted to account for the severity of illness of the VHA surgical patient population. In 1991 the National VA Surgical Risk Study (NVASRS) began in 44 Veterans Administration Medical Centers. By 31 December 1993 there was information for 500,000 non-cardiac surgical procedures. In 1994 NVASRS was expanded to all 128 VHA hospitals that performed surgery. The name was then changed to the National Surgical Quality Improvement Program.[7] Beginning in the mid-1990s VHA underwent what the agency characterizes as a major transformation aimed at improving the quality and efficiency of care it provides to its patients. That transformation included eliminating underutilized inpatient beds and facilities, expanding outpatient clinics, and restructuring eligibility rules. A major focus of the transformation was the tracking of a number of performance indicatorsincluding quality-of-care measuresand holding senior managers accountable for improvements in those measures.[8]

VA Health Reform
1993 Clinton Healthcare Reform
The Clinton Healthcare Plan was a health care reform proposed by the Clinton Administration. Even though the reform was not successful, a task force was created in response to the Clinton Healthcare Reform proposal to determine if the VA was ready for managed care.[9] The negative results of market research forced the VA system to re-evaluate its current operations. Research revealed that 3 out of 4 veterans would leave the VA network if a national healthcare system were adopted. They also found that there was a high demand for primary care throughout the VA system. Research showed that many VA facilities believed that 55 percent of patients would choose to receive primary care at the VA facility if a primary care system was fully implemented in 1993. The study also showed that the VA facilities believed that 83 percent of veterans would choose to receive primary care at the VA if fully implemented by 1998. These results made it clear to the administration that it was time for a reform.[10]

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1994 VA Primary Care Directive


This directive required all VA facilities to have primary care teams by year 1996.[11] As a result, percentage of patients receiving primary care at the VA increased from 38 percent to 45 percent to 95 percent, during 1993, 1996, and 1999.[12] This mandate served as the foundation for the VA reorganization under Dr. Kenneth W. Kizer.

Dr. Kenneth W. Kizer and the VA Reform


Dr. Kizer, a physician trained in emergency medicine and Public Health, was appointed by President Bill Clinton as Director of U.S. Veterans Health Administration in 1994. He was hired to update and modernize the VA health system in order to eliminate negative perception and to align the system with current market trends. Core issues included: -Advancements in technology and biomedical knowledge -Aging and socioeconomically disadvantaged Medicare patients -Coordinating care -Rising healthcare costs There was much opposition to a major reform. Many legislators preferred an incremental change over a wide-scale reform. However, Kizer was known as being very innovative. In order to publicize his vision he expressed his mission and vision of the "new VHA" and outlined seven key principles to guide change. His ultimate goal was to provide coordinated, high quality care at a low cost. He launched his reorganization plan in 1995 by decentralizing the VA system. He organized all VA operating units into 22 geographic based networks known as Veterans Integrated Service Networks (VISNs). This allowed networks to manage themselves and adapt to the demographics of their location. Patients were then assigned to a group of doctors who would provide coordinated care. One director was hired for each VISN network. Instead of hiring all directors internally, a third of the newly hired VISN directors were hired outside of the VA system. The directors were responsible for meeting performance goals and improving upon measurable key efficiency and quality indicators. Directors monitored performances and reports were generated to show each network's performance. Some of these indicators included: -chronic disease quality -prevention performance -patient satisfaction ratings -utilization management The reform also changed the procedure for allocating funds to the various VISNs. Historically, funds were distributed between hospitals based on historical costs. However, it was found that this method affected efficiency and quality of services. Therefore, funding for each VISN was distributed based on the number of veterans seen in each network, rather than on historical values.[13] The New England Journal of Medicine conducted a study from 1994-2000 to evaluate the efficacy of the healthcare reform. They gathered the results of the evaluated key indicators from each of the networks and interpreted the results. There were noticeable improvements, compared with the same key indicators used for the Medicare fee for service system, as soon as two years after the reorganization. These improvements continued through year 2000. These results indicate that the changes made throughout the VA healthcare system, under the leadership of Kizer, did improve the efficiency and quality of care in VA healthcare system.[14]

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Use of Electronic Records


VHA is especially praised for its efforts in developing a low cost open source electronic medical records system VistA [15] which can be accessed remotely (with secure passwords) by health care providers. With this system, patients and nurses are given bar-coded wristbands, and all medications are bar-coded as well. Nurses are given wands, which they use to scan themselves, the patient, and the medication bottle before dispensing drugs. This helps prevent four of the most common dispensing errors: wrong med, wrong dose, wrong time, and wrong patient. The system, which has been adopted by all veterans hospitals and clinics and continuously improved by users, has cut the number of dispensing errors in half at some facilities and saved thousands of lives.[16] At some VHA medical facilities, doctors use wireless laptops, putting in information and getting electronic signatures for procedures. Doctors can call up patient records, order prescriptions, view X-rays or graph a chart of risk factors and medications to decide treatments. Patients have a home page that have boxes for allergies and medications, records every visit, call and note, and issues prompts reminding doctors to make routine checks. This technology has helped the VHA achieve cost controls and care quality that the majority of private providers cannot achieve.[17]

VA Today
Overall Evaluation
"Patients routinely rank the veterans system above the alternatives, according to the American Customer Satisfaction Index." In 2008, the VHA got a satisfaction rating of 85 for inpatient treatment, compared with 77 for private hospitals. In the same report the VHA outpatient care scored 3 points higher than for private hospitals.[17] "As compared with the Medicare fee-for-service program, the VA performed significantly better on all 11 similar quality indicators for the period from 1997 through 1999. In 2000, the VA outperformed Medicare on 12 of 13 indicators." [18] A study that compared VHA with commercial managed care systems in their treatment of diabetes patients found that in all seven measures of quality, the VHA provided better care.[19] A RAND Corporation study in 2004 concluded that the VHA outperforms all other sectors of American health care in 294 measures of quality; Patients from the VHA scored significantly higher for adjusted overall quality, chronic disease care, and preventive care, but not for acute care.[15] A 2009 Congressional Budget Office report on the VHA found that "the care provided to VHA patients compares favorably with that provided to non-VHA patients in terms of compliance with widely recognized clinical guidelines particularly those that VHA has emphasized in its internal performance measurement system. Such research is complicated by the fact that most users of VHA's services receive at least part of their care from outside providers."
[8]

VA Mental Health Services


The percentage of veterans seen at the VA with a mental illness was 15 percent in 2007. Trends show that the percentage of veterans with mental illnesses will continue to increase. The VA has directed its attention to this growing trend and is making mental health care for veterans a priority. For example, the VA allocated an extra 1.4 billion dollars per year to the mental health program between 2005 and 2008. They also implemented a five-year Mental Health Strategic Plan to expand and improve the mental health program. The status of the Mental Health program in 2006 was evaluated as a part of Mental Health Strategic Plan.[20] The results are as follows: Quality of care at the VA was shown to be better than the private sector. The VA had a higher level of performance then the private sector for 7 out of 9 indicators. In fact, they "exceeded private plan performance by large margins.[21]"

Veterans Health Administration Patients did not indicate improvement in their conditions. However, they had a very favorable opinions of their care.[20]

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Healthcare for Women Veterans


With the population of Women veterans projected to rise from 1.6 million in 2000 to 1.9 million in 2020, the VA has been focusing on integrating quality women's medical services into the VA system.[22] However, studies show that 66.9 percent of women who do not use the VA for women's services consider private practice physicians more convenient. Also, 48.5 percent of women do not use women's services at the VA due to a lack of knowledge of VA eligibility and services. This study indicates that the VA still has room for improvement with convenience and education regarding women's medical services.[23]

Physicians
Doctors who work in the VHA system are typically paid less in core compensation than their counterparts in private practice. However, VHA compensation includes benefits not generally available to doctors in private practice, such as lesser threat of malpractice lawsuits, freedom from billing and insurance company payment administration, and the availability of the government's open source electronic records system VistA.[17]

Initiatives
The VHA has expanded its outreach efforts to include men and women veterans and homeless veterans. The VHA, through its academic affiliations, has helped train thousands of physicians, dentists, and other health professionals. Several newer VA medical centers have been purposely located adjacent to medical schools. The VHA support for research and residency/fellowship training programs has made the VA system a leader in the fields of geriatrics [24][25], spinal cord injuries [26], Parkinson's disease [27], and palliative care. The VHA has initiatives in place to provide a "seamless transition" to newly-discharged veterans transitioning from Department of Defense health care to VA care for conditions incurred in Iraq or Afghanistan. The Veterans Health Administration Office of Research and Development's research into developing better-functioning prosthetic limbs, and treatment of PTSD are also heralded. The VHA has devoted many years of research into the health effects of the herbicide Agent Orange used by military forces in Vietnam. In October 2012, the VHA announced a new goal "to care for and heal our wounded Veterans. In addition to repairing their damaged bodies and minds, VA has embarked on a unique campaign to repair their crumbling intimate relationships." [28][29]

Eligibility for benefits


By Federal law, eligibility for benefits is determined by a system of eight Priority Groups. Retirees from military service, veterans with service-connected injuries or conditions rated by VA, and Purple Heart recipients are within the higher priority groups. Veterans without rated service-connected conditions may become eligible based on financial need, adjusted for local cost of living. Veterans who do not have service-connected disabilities totaling 50% or more may be subject to copayments for any care they received for nonservice-connected conditions. Eligibility for VA dental care and Community Living Center care are much more restricted. For VA dental care the veteran must have a 100 percent service-connected disability rating, Have a service-connected compensable dental disability or condition, Former prisioner of war, or be in the Vocational Rehabilitation and Employment Program (Chapter 31). VA provides nursing home services to Veterans through three national programs: VA owned and operated Community Living Centers (CLC), State Veterans' Homes owned and operated by the states, and the

Veterans Health Administration community nursing home program. Each program has admission and eligibility criteria specific to the program. Nursing home care is available for enrolled Veterans who need nursing home care for a service-connected disability, and those rated 60 percent service-connected and unemployable; or Veterans or who have a 70 percent or greater service-connected disability. VA provided nursing home care for all other Veterans is based on available resources. Reservists and National Guardsmen who were called to active duty by a Federal Executive Order qualify for VA health care benefits.[30] In 2010, there were 1 million veterans receiving disability pensions. 25% of these were Vietnam veterans with the disability of adult-onset diabetes. More Vietnam veterans are being compensated for diabetes than any other disease.[31]

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References
[1] http:/ / www. carnegielibrary. org/ research/ pittsburgh/ history/ [2] http:/ / tools. wmflabs. org/ geohack/ geohack. php?pagename=Veterans_Health_Administration& params=38_54_3. 25_N_77_2_5. 36_W_type:landmark_region:US-DC [3] FedScope (http:/ / www. fedscope. opm. gov/ employment. asp) [4] http:/ / www. va. gov/ health/ aboutVHA. asp [5] http:/ / www. va. gov/ health [6] VA History in Brief.(n.d.). Department of Veteran's Affairs [8] Quality Initiatives Undertaken by the Veterans Health Administration (http:/ / www. cbo. gov/ ftpdocs/ 104xx/ doc10453/ 08-13-VHA. pdf) Congressional Budget Office Report, August 2009 [9] Inglehart, J. K., (October 1996). Reform of the Veterans Affairs Health Care System. The New England Journal of Medicine. 335(18). [10] Yano et al. (December 2007). The Evolution of Changes in Primary Care Delivery Underlying the Veterans Health Administration's Quality Transformation. American Journal of Public Health. 97(12). [11] Ashton, C., Headley, E., Parrino, T., Starfield, B. (September 1995). Primary Care in VA. Boston: Management decision and Research Center. Washington, DC: U.S. Department of Veterans Affairs. Office of Research and Development. Health Services Research and Development Service [12] Yano et al. (December 2007). The Evolution of Changes in Primary Care Delivery Underlying the Veterans Health Administration's Quality Transformation. American Journal of Public Health. 97(12) [13] Kizer et al. (Jun 2000). Reinventing VA Healthcare: Systematizing Quality Improvement and Quality Innovation. Medical Care. 38(6 Suppl 1) [14] Kizer, K.W et al. (May 2003). Effects of the Transformation of the Veterans Affairs Health Care System on the Quality of Care. New England Journal Of Medicine. 348(22). [15] Comparison of Quality of Care for Patients in the Veterans Health Administration and Patients in a National Sample (http:/ / www. annals. org/ content/ 141/ 12/ 938. full) Annals of Internal Medicine, December 21, 2004 [16] "Code Red" (http:/ / www. washingtonmonthly. com/ features/ 2009/ 0907. longman. html) by Philip Longman, Washington Monthly, Sept. 7, 2009 [17] Vets Loving Socialized Medicine Show Government Offers Savings (http:/ / www. bloomberg. com/ apps/ news?pid=newsarchive& sid=aLIc5ABThjBk) Bloomberg, October 2, 2009 [18] "Effect of the Transformation of the Veterans Affairs Health Care System on the Quality of Care" (http:/ / content. nejm. org/ cgi/ content/ abstract/ 348/ 22/ 2218) New England Journal of Medicine, May 29, 2003 [19] Diabetes Care Quality in the Veterans Affairs Health Care System and Commercial Managed Care: The TRIAD Study (http:/ / www. annals. org/ content/ 141/ 4/ 272. full) Annals of Internal Medicine, August 17, 2004 [20] Watkins, K.E., Pincus, H.A. et al., (2011). Veterans Health Administration Mental Health Program Evaluation: Capstone Report, Santa Monica, Calif.: RAND Corporation, TR-956-VHA [21] Adamson et al. (2011). Veterans Health Administration Mental Health Program Evaluation. RAND Health. [22] (2007). Women Veterans: Past, Present, and Future. Department of Veterans Affairs. [23] Washington et al. (2006). What Influences Why Women Veterans Choose VA Healthcare. Journal of General Internal Medicine. 21. [24] http:/ / www1. va. gov/ grecc/ [25] http:/ / www. va. gov/ oaa/ specialfellows/ programs/ SF_RWJ. asp [26] http:/ / www. sci. va. gov/ [27] http:/ / www. parkinsons. va. gov/ [28] Relationship Retreats: Warriors to Soul Mates (http:/ / fatherhoodchannel. com/ 2012/ 10/ 20/ relationship-retreats-warriors-to-soul-mates-120) FatherhoodChannel.com, October 20, 2012 [29] PAIRS Essentials VA Program Support Guide, January 2013 (http:/ / issuu. com/ pairs/ docs/ va_support) [30] VA Health Care Eligibility & Enrollment (http:/ / www. va. gov/ healtheligibility)

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External links
Veterans Health Benefits and Services (http://www.sharpseniors.com/a/va-health-benefits-and-services/) "The Best Care Anywhere" (http://www.washingtonmonthly.com/features/2005/0501.longman.html) by Phillip Longman, Washington Monthly, January/February 2005 Nonprofit Research Collection on Veteran Health (http://www.issuelab.org/closeup/May_2008) Published on IssueLab

Community health center


A health center or community health center is a clinic staffed by a group of general practitioners and nurses. Typical services covered are family practice and dental care, but some clinics have expanded greatly and can include internal medicine, pediatric, womens care, family planning, pharmacy, lab, and more. In 2006, the National Association of Community Health Centers implemented a model for offering free, rapid HIV testing to all patients between the ages of 13 and 64 during routine primary medical and dental care visits.[1]
A health centre in the United Kingdom.

Community Health Centers (CHCs) in the U.S. are neighborhood health centers generally serving Medically Underserved Areas (MUAs) which includes persons who are uninsured, underinsured, low-income or those living in areas where little access to primary health care is available. Largely federally and locally funded, some health clinics are surprisingly modernized with new equipment and electronic medical records. Medically Underserved Areas/Populations are areas or populations designated by the Health Resources and Services Administration, or HRSA as having: too few primary care providers, high infant mortality, high poverty and/or high elderly population. Health Professional Shortage Areas (HPSAs) are designated by HRSA as having shortages of primary medical care, dental or mental health providers and may be geographic (a county or service area), demographic (low income population) or institutional (comprehensive health center, federally qualified health center or other public facility). In China there are, as of 2011, 32,812 community health centers and 37,374 township health centers.[2]

External links
SWCHC [3] Nation Association of Community Health Centers [4] HRSA Site-Locate MUAs [5] CHCFL [6]

References
[3] [4] [5] [6] http:/ / swchc. on. ca/ http:/ / www. nachc. com/ membership. cfm/ http:/ / muafind. hrsa. gov/ http:/ / www. chcfl. org/

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College of Healthcare Information Management Executives


College of Healthcare Information Management Executives

Formation Type Headquarters Membership President and CEO: Website

1992 Healthcare Association Ann Arbor, Michigan more than 1,400 Richard A. Correll http:/ / www. cio-chime. org [1]

The College of Healthcare Information Management Executives (CHIME) is the professional organization for chief information officers and other senior healthcare IT leaders. CHIME enables its members and business partners to collaborate; exchange ideas and technology information; develop professionally; and advocate the effective use of information management to improve the health and healthcare in the communities they serve. CHIME is directed by an elected 12-member board composed of leading CIOs and CHIME Foundation representatives.

CHIME History
CHIME was founded in 1992 with the dual objective of serving the professional development needs of healthcare CIOs and advocating the more effective use of information management within healthcare.

CIO Membership
Currently, CHIME has more than 1,400 members across the globe. Members of CHIME are the highest ranking IT executives within their healthcare organization or facility. While the majority hold the CIO job title, having that title is not a requirement for membership as long as they have equivalent job responsibilities. A typical CHIME member oversees the information services department and chairs the information technology steering committee within their organization. Additional responsibilities often include telecommunications, medical records, and health informatics. CHIME members represent a variety of provider organizations, including large hospital systems, community hospitals and for-profit hospitals. In addition to CIOs from hospitals, CHIME welcomes all CIOs who are employed by organizations with responsibility for direct patient care, including physician practice groups, clinics, and others. Healthcare CIOs play a central role in implementing IT systems that digitize patient records to achieve meaningful use of electronic medical records, enabling their organizations to qualify for incentive funding under the American Recovery and Reinvestment Act.

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Certification and Education


In July 2009, CHIME launched the Certified Healthcare CIO (CHCIO) Program, the first certification program designed specifically for CIOs and IT executives in the healthcare industry. The CHCIO Program is a member-led initiative. CHIME members oversee the strategic direction of the program as well as write and review all questions on the CHCIO Examination. To become certified, candidates must hold a baccalaureate degree, pass the CHCIO Examination, have three years of experience as a CIO or equivalent, and earn a minimum number of Continuing Education Units (CEUs).

Advocacy Leadership and StateNet


CHIME serves as a voice of the healthcare IT executive within the US, informing and influencing public policy leaders and other officials on the role of information technology in transforming the delivery of healthcare, while providing members with the latest information regarding new healthcare IT legislation, regulations and policies, including the recent HITECH legislation, which includes funding for the implementation and meaningful use of electronic health records. Ten CHIME members who belong to a Policy Steering Committee help review proposed federal regulations and rules, and provide direction and comments on regulations impacting the use of IT in healthcare.[2] In 2009, a network of CIOs across 50 states and the District of Columbia volunteered to form CHIME StateNet [3]. The goal of StateNet is to foster statewide coalitions charged with advancing and standardizing the adoption of health information technology and health information exchange. CHIME StateNet has released, and has presented to the ONC, foundational operating guidelines for RECs and HIEs.[4]

CHIME Foundation
The CHIME Foundation is a non-profit organization composed of select healthcare IT vendors and professional services firms. CHIME Foundation members benefit from the unique opportunity to partner and collaborate with more than 1,400 CHIME member CIOs. For more information about the CHIME Foundation, visit: www.cio-chime.org/Foundation [5]

CHIME Publications
CHIME regularly releases opinions, guidance and information on matters of importance to the healthcare IT community. In August 2010, CHIME issued the CIO's Guide to Implementing EHRs in the HITECH Era, which included best practices and steps health care organizations should take to successfully implement EHRs, from the initial planning stages through the final documentation of results.[6] Nearly 170 of hospital CIOs were involved in compiling the information included in the guidebook. The complete guide in PDF format [7] is available at the CHIME Web site.

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External links
College of Healthcare Information Management Executives - Official Site [8]

References
[1] [3] [5] [7] [8] http:/ / www. cio-chime. org http:/ / ciostatenet. org/ http:/ / www. cio-chime. org/ Foundation http:/ / www. cio-chime. org/ advocacy/ CIOsGuideBook/ CIO_Guide_Final. pdf http:/ / www. cio-chime. org/ index. asp

Heart failure

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Heart failure
Heart failure
Classification and external resources

The major signs and symptoms of heart failure ICD-10 ICD-9 DiseasesDB I50 [1] [2] [3]

428.0 16209

MedlinePlus 000158 [4] eMedicine MeSH med/3552 D006333 [5] emerg/108 [6] radio/189 [7] med/1367150 [8] ped/2636 [9]

[10]

Heart failure (HF), often called congestive heart failure (CHF) or congestive cardiac failure (CCF), occurs when the heart is unable to provide sufficient pump action to maintain blood flow to meet the needs of the body.[11][12][13] Heart failure can cause a number of symptoms including shortness of breath, leg swelling, and exercise intolerance. The condition is diagnosed by patient physical examination and confirmed with echocardiography. Blood tests help to determine the cause. Treatment depends on severity and cause of heart failure. In a chronic patient already in a stable situation, treatment commonly consists of lifestyle measures such as smoking cessation, light exercise, dietary changes, and medications. Sometimes, depending from etiology, it is treated with implanted devices (pacemakers or ventricular assist devices) and occasionally a heart transplant is required. Common causes of heart failure include myocardial infarction and other forms of ischemic heart disease, hypertension, valvular heart disease, and cardiomyopathy.[] The term heart failure is sometimes incorrectly used for other cardiac-related illnesses, such as myocardial infarction (heart attack) or cardiac arrest, which can cause heart failure but are not equivalent to heart failure. Heart failure is a common, costly, disabling, and potentially deadly condition.[] In developed countries, around 2% of adults suffer from heart failure, but in those over the age of 65, this increases to 610%.[][]

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Terminology
Heart failure is a global term for the physiological state in which cardiac output is insufficient in meeting the needs of the body and lungs. Often termed "congestive heart failure" or CHF, this is most commonly caused when cardiac output is low and the body becomes congested with fluid due to an inability of heart output to properly match venous return.[] It may also occur in situations of high output, (termed "high output cardiac failure") where the ventricular systolic function is normal but the heart can't deal with an important augmentation of blood volume.[14] This can occur in overload situation (blood or serum infusions), renal diseases, chronic severe anemia, beriberi (vitamin B1/thiamine deficiency), thyrotoxicosis, Paget's disease, arteriovenous fistulae, or arteriovenous malformations. Fluid overload is a common problem for people with heart failure but is not synonymous with it. Patients with treated heart failure will often be euvolaemic (a term for normal fluid status), or more rarely, dehydrated. Medical professionals use the words "acute" to mean of rapid onset and "chronic" of long duration. Chronic heart failure is therefore a long term situation, usually with stable treated symptomatology. Acute decompensated heart failure is exacerbated or decompensated heart failure, referring to episodes in which a patient can be characterized as having a change in heart failure signs and symptoms resulting in a need for urgent therapy or hospitalization.[] There are several terms which are closely related to heart failure, and may be the cause of heart failure, but should not be confused with it: Cardiac arrest and asystole refer to situations in which there is no cardiac output at all. Without urgent treatment these result in sudden death. Myocardial infarction ("Heart attack") refers to heart muscle damage due to insufficient blood supply, usually as a result of a blocked coronary artery. Cardiomyopathy refers specifically to problems within the heart muscle, and these problems can result in heart failure. Ischemic cardiomyopathy implies that the cause of muscle damage is coronary artery disease. Dilated cardiomyopathy implies that the muscle damage has resulted in enlargement of the heart. Hypertrophic cardiomyopathy involves enlargement and thickening of the heart muscle.

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Signs and symptoms


Heart failure symptoms are traditionally and somewhat arbitrarily divided into "left" and "right" sided, recognizing that the left and right ventricles of the heart supply different portions of the circulation. However, heart failure is not exclusively backward failure (in the part of the circulation which drains to the ventricle). There are several other exceptions to a simple left-right division of heart failure symptoms. Left sided forward failure overlaps with right sided backward failure. Additionally, the most common cause of right-sided heart failure is left-sided heart failure. The result is that patients commonly present with both sets of signs and symptoms.

Left-sided failure
Common respiratory signs are tachypnea (increased rate of breathing) and increased work of breathing (non-specific signs of respiratory distress). Rales or crackles, heard initially in the lung bases, and when severe, throughout the lung fields suggest the development of pulmonary edema (fluid in the alveoli). Cyanosis which suggests severe hypoxemia, is a late sign of extremely severe pulmonary edema.

A man with congestive heart failure and marked jugular venous distension. External jugular vein marked by an arrow.

Additional signs indicating left ventricular failure include a laterally displaced apex beat (which occurs if the heart is enlarged) and a gallop rhythm (additional heart sounds) may be heard as a marker of increased blood flow, or increased intra-cardiac pressure. Heart murmurs may indicate the presence of valvular heart disease, either as a cause (e.g. aortic stenosis) or as a result (e.g. mitral regurgitation) of the heart failure. Backward failure of the left ventricle causes congestion of the pulmonary vasculature, and so the symptoms are predominantly respiratory in nature. Backward failure can be subdivided into failure of the left atrium, the left ventricle or both within the left circuit. The patient will have dyspnea (shortness of breath) on exertion (dyspne d'effort) and in severe cases, dyspnea at rest. Increasing breathlessness on lying flat, called orthopnea, occurs. It is often measured in the number of pillows required to lie comfortably, and in severe cases, the patient may resort to sleeping while sitting up. Another symptom of heart failure is paroxysmal nocturnal dyspnea a sudden nighttime attack of severe breathlessness, usually several hours after going to sleep. Easy fatigueability and exercise intolerance are also common complaints related to respiratory compromise. "Cardiac asthma" or wheezing may occur. Compromise of left ventricular forward function may result in symptoms of poor systemic circulation such as dizziness, confusion and cool extremities at rest.

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Right-sided failure
Physical examination may reveal pitting peripheral edema, ascites, and hepatomegaly. Jugular venous pressure is frequently assessed as a marker of fluid status, which can be accentuated by eliciting hepatojugular reflux. If the right ventricular pressure is increased, a parasternal heave may be present, signifying the compensatory increase in contraction strength. Backward failure of the right ventricle leads to congestion of systemic capillaries. This generates excess fluid accumulation in the body. This causes swelling under the skin (termed peripheral edema or anasarca) and usually affects the dependent parts of the body first (causing foot and ankle swelling in people who are standing up, and sacral edema in people who are predominantly lying down). Nocturia (frequent nighttime urination) may occur when fluid from the legs is returned to the bloodstream while lying down at night. In progressively severe cases, ascites (fluid accumulation in the abdominal cavity causing swelling) and hepatomegaly (enlargement of the liver) may develop. Significant liver congestion may result in impaired liver function, and jaundice and even coagulopathy (problems of decreased blood clotting) may occur.

Biventricular failure
Dullness of the lung fields to finger percussion and reduced breath sounds at the bases of the lung may suggest the development of a pleural effusion (fluid collection in between the lung and the chest wall). Though it can occur in isolated left- or right-sided heart failure, it is more common in biventricular failure because pleural veins drain both into the systemic and pulmonary venous system. When unilateral, effusions are often right sided.

Causes
Congestive heart failure
The predominance of causes of heart failure are difficult to analyze due to challenges in diagnosis, differences in populations, and changing prevalence of causes with age. A 19-year study of 13,000 initially healthy adults ("A total of 13 643 men and women without a history of CHF at baseline examination were included in this prospective cohort study") in the United States (the National Health and Nutrition Examination Survey (NHANES I) found the following causes ranked by Population Attributable Risk score:[15] 1. 2. 3. 4. 5. 6. Ischaemic heart disease 62% Cigarette smoking 16% Hypertension (high blood pressure) 10% Obesity 8% Diabetes 3% Valvular heart disease 2% (much higher in older populations)

An Italian registry of over 6200 patients with heart failure showed the following underlying causes:[16] 1. 2. 3. 4. 5. Ischaemic heart disease 40% Dilated cardiomyopathy 32% Valvular heart disease 12% Hypertension 11% Other 5%

Rarer causes of heart failure include: Viral myocarditis (an infection of the heart muscle) Infiltrations of the muscle such as amyloidosis HIV cardiomyopathy (caused by human immunodeficiency virus)

Heart failure Connective tissue diseases such as systemic lupus erythematosus Abuse of drugs such as alcohol and cocaine Pharmaceutical drugs such as chemotherapeutic agents Arrhythmias.

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Obstructive sleep apnea (a condition of sleep wherein disordered breathing overlaps with obesity, hypertension, and/or diabetes) is regarded as an independent cause of heart failure.

Acute decompensation
Chronic stable heart failure may easily decompensate. This most commonly results from an intercurrent illness (such as pneumonia), myocardial infarction (a heart attack), arrhythmias, uncontrolled hypertension, or a patient's failure to maintain a fluid restriction, diet, or medication.[] Other well recognized precipitating factors include anemia and hyperthyroidism which place additional strain on the heart muscle. Excessive fluid or salt intake, and medication that causes fluid retention such as NSAIDs and thiazolidinediones, may also precipitate decompensation.[17]

Pathophysiology
Heart failure is caused by any condition which reduces the efficiency of the myocardium, or heart muscle, through damage or overloading. As such, it can be caused by a diverse array of conditions, including myocardial infarction (in which the heart muscle is starved of oxygen and dies), hypertension (which increases the force of contraction needed to pump blood) and amyloidosis (in which protein is deposited in the heart muscle, causing it to stiffen). Over time these increases in workload will produce changes to the heart itself: Reduced force of contraction, due to overloading of the ventricle. In a healthy heart, increased filling of the ventricle results in increased force of contraction (by the FrankStarling law of the heart) and thus a rise in cardiac output. In heart failure this mechanism fails, as the ventricle is loaded with blood to the point where heart muscle contraction becomes less efficient. This is due to reduced ability to cross-link actin and myosin filaments in over-stretched heart muscle.[18] A reduced stroke volume, as a result of a failure of systole, diastole or both. Increased end systolic volume is usually caused by reduced contractility. Decreased end diastolic volume results from impaired ventricular filling as occurs when the compliance of the ventricle falls (i.e. when the walls stiffen). Reduced spare capacity. As the heart works harder to meet normal metabolic demands, the amount cardiac output can increase in times of increased oxygen demand (e.g. exercise) is reduced. This contributes to the exercise intolerance commonly seen in heart failure. This translates to the loss of one's cardiac reserve, or the ability of the heart to work harder during strenuous physical activity. Since the heart has to work harder to meet the normal metabolic demands, it is incapable of meeting the metabolic demands of the body during exercise. Increased heart rate, stimulated by increased sympathetic activity[19] in order to maintain cardiac output. Initially, this helps compensate for heart failure by maintaining blood pressure and perfusion, but places further strain on the myocardium, increasing coronary perfusion requirements, which can lead to worsening of ischemic heart disease. Sympathetic activity may also cause potentially fatal arrhythmias. Hypertrophy (an increase in physical size) of the myocardium, caused by the terminally differentiated heart muscle fibres increasing in size in an attempt to improve contractility. This may contribute to the increased stiffness and decreased ability to relax during diastole. Enlargement of the ventricles, contributing to the enlargement and spherical shape of the failing heart. The increase in ventricular volume also causes a reduction in stroke volume due to mechanical and contractile inefficiency.[20] The general effect is one of reduced cardiac output and increased strain on the heart. This increases the risk of cardiac arrest (specifically due to ventricular dysrhythmias), and reduces blood supply to the rest of the body. In chronic disease the reduced cardiac output causes a number of changes in the rest of the body, some of which are

Heart failure physiological compensations, some of which are part of the disease process: Arterial blood pressure falls. This destimulates baroreceptors in the carotid sinus and aortic arch which link to the nucleus tractus solitarii. This center in the brain increases sympathetic activity, releasing catecholamines into the blood stream. Binding to alpha-1 receptors results in systemic arterial vasoconstriction. This helps restore blood pressure but also increases the total peripheral resistance, increasing the workload of the heart. Binding to beta-1 receptors in the myocardium increases the heart rate and make contractions more forceful, in an attempt to increase cardiac output. This also, however, increases the amount of work the heart has to perform. Increased sympathetic stimulation also causes the hypothalamus to secrete vasopressin (also known as antidiuretic hormone or ADH), which causes fluid retention at the kidneys. This increases the blood volume and blood pressure. Reduced perfusion (blood flow) to the kidneys stimulates the release of renin an enzyme which catalyses the production of the potent vasopressor angiotensin. Angiotensin and its metabolites cause further vasoconstriction, and stimulate increased secretion of the steroid aldosterone from the adrenal glands. This promotes salt and fluid retention at the kidneys. The chronically high levels of circulating neuroendocrine hormones such as catecholamines, renin, angiotensin, and aldosterone affects the myocardium directly, causing structural remodelling of the heart over the long term. Many of these remodelling effects seem to be mediated by transforming growth factor beta (TGF-beta), which is a common downstream target of the signal transduction cascade. initiated by catecholamines[21] and angiotensin II,[22] and also by epidermal growth factor (EGF), which is a target of the signaling pathway activated by aldosterone[23] Reduced perfusion of skeletal muscle causes atrophy of the muscle fibres. This can result in weakness, increased fatigueability and decreased peak strength all contributing to exercise intolerance.[24] The increased peripheral resistance and greater blood volume place further strain on the heart and accelerates the process of damage to the myocardium. Vasoconstriction and fluid retention produce an increased hydrostatic pressure in the capillaries. This shifts the balance of forces in favour of interstitial fluid formation as the increased pressure forces additional fluid out of the blood, into the tissue. This results in edema (fluid build-up) in the tissues. In right-sided heart failure this commonly starts in the ankles where venous pressure is high due to the effects of gravity (although if the patient is bed-ridden, fluid accumulation may begin in the sacral region.) It may also occur in the abdominal cavity, where the fluid build-up is called ascites. In left-sided heart failure edema can occur in the lungs this is called cardiogenic pulmonary edema. This reduces spare capacity for ventilation, causes stiffening of the lungs and reduces the efficiency of gas exchange by increasing the distance between the air and the blood. The consequences of this are dyspnea (shortness of breath), orthopnea and paroxysmal nocturnal dyspnea. The symptoms of heart failure are largely determined by which side of the heart fails. The left side pumps blood into the systemic circulation, whilst the right side pumps blood into the pulmonary circulation. Whilst left-sided heart failure will reduce cardiac output to the systemic circulation, the initial symptoms often manifest due to effects on the pulmonary circulation. In systolic dysfunction, the ejection fraction is decreased, leaving an abnormally elevated volume of blood in the left ventricle. In diastolic dysfunction, end-diastolic ventricular pressure will be high. This increase in volume or pressure backs up to the left atrium and then to the pulmonary veins. Increased volume or pressure in the pulmonary veins impairs the normal drainage of the alveoli and favors the flow of fluid from the capillaries to the lung parenchyma, causing pulmonary edema. This impairs gas exchange. Thus, left-sided heart failure often presents with respiratory symptoms: shortness of breath, orthopnea and paroxysmal nocturnal dyspnea. In severe cardiomyopathy, the effects of decreased cardiac output and poor perfusion become more apparent, and patients will manifest with cold and clammy extremities, cyanosis, claudication, generalized weakness, dizziness, and syncope. The resultant hypoxia caused by pulmonary edema causes vasoconstriction in the pulmonary circulation, which results in pulmonary hypertension. Since the right ventricle generates far lower pressures than the left ventricle

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Heart failure (approximately 20 mmHg versus around 120 mmHg, respectively, in the healthy individual) but nonetheless generates cardiac output exactly equal to the left ventricle, this means that a small increase in pulmonary vascular resistance causes a large increase in amount of work the right ventricle must perform. However, the main mechanism by which left-sided heart failure causes right-sided heart failure is actually not well understood. Some theories invoke mechanisms that are mediated by neurohormonal activation.[25] Mechanical effects may also contribute. As the left ventricle distends, the intraventricular septum bows into the right ventricle, decreasing the capacity of the right ventricle.

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Systolic dysfunction
Heart failure caused by systolic dysfunction is more readily recognized. It can be simplistically described as failure of the pump function of the heart. It is characterized by a decreased ejection fraction (less than 45%). The strength of ventricular contraction is attenuated and inadequate for creating an adequate stroke volume, resulting in inadequate cardiac output. In general, this is caused by dysfunction or destruction of cardiac myocytes or their molecular components. In congenital diseases such as Duchenne muscular dystrophy, the molecular structure of individual myocytes is affected. Myocytes and their components can be damaged by inflammation (such as in myocarditis) or by infiltration (such as in amyloidosis). Toxins and pharmacological agents (such as ethanol, cocaine, doxorubicin, and amphetamines) cause intracellular damage and oxidative stress. The most common mechanism of damage is ischemia causing infarction and scar formation. After myocardial infarction, dead myocytes are replaced by scar tissue, deleteriously affecting the function of the myocardium. On echocardiogram, this is manifest by abnormal wall motion (hypokinesia) or absent wall motion (akinesia). Because the ventricle is inadequately emptied, ventricular end-diastolic pressure and volumes increase. This is transmitted to the atrium. On the left side of the heart, the increased pressure is transmitted to the pulmonary vasculature, and the resultant hydrostatic pressure favors extravassation of fluid into the lung parenchyma, causing pulmonary edema. On the right side of the heart, the increased pressure is transmitted to the systemic venous circulation and systemic capillary beds, favoring extravassation of fluid into the tissues of target organs and extremities, resulting in dependent peripheral edema.

Diastolic dysfunction
Heart failure caused by diastolic dysfunction is generally described as the failure of the ventricle to adequately relax and typically denotes a stiffer ventricular wall. This causes inadequate filling of the ventricle, and therefore results in an inadequate stroke volume. The failure of ventricular relaxation also results in elevated end-diastolic pressures, and the end result is identical to the case of systolic dysfunction (pulmonary edema in left heart failure, peripheral edema in right heart failure.) Diastolic dysfunction can be caused by processes similar to those that cause systolic dysfunction, particularly causes that affect cardiac remodeling. Diastolic dysfunction may not manifest itself except in physiologic extremes if systolic function is preserved. The patient may be completely asymptomatic at rest. However, they are exquisitely sensitive to increases in heart rate, and sudden bouts of tachycardia (which can be caused simply by physiological responses to exertion, fever, or dehydration, or by pathological tachyarrhythmias such as atrial fibrillation with rapid ventricular response) may result in flash pulmonary edema. Adequate rate control (usually with a pharmacological agent that slows down AV conduction such as a calcium channel blocker or a beta-blocker) is therefore key to preventing decompensation. Left ventricular diastolic function can be determined through echocardiography by measurement of various parameters such as the E/A ratio (early-to-atrial left ventricular filling ratio), the E (early left ventricular filling) deceleration time, and the isovolumic relaxation time.

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Diagnosis
No system of diagnostic criteria has been agreed as the gold standard for heart failure. Commonly used systems are the "Framingham criteria"[26] (derived from the Framingham Heart Study), the "Boston criteria",[27] the "Duke criteria",[28] and (in the setting of acute myocardial infarction) the "Killip class".[29]

Imaging
Echocardiography is commonly used to support a clinical diagnosis of heart failure. This modality uses ultrasound to determine the stroke Acute pulmonary edema. Note enlarged heart volume (SV, the amount of blood in the heart that exits the ventricles size, apical vascular redistribution ( circle ), and with each beat), the end-diastolic volume (EDV, the total amount of small bilateral pleural effusions ( arrow ). blood at the end of diastole), and the SV in proportion to the EDV, a value known as the ejection fraction (EF). In pediatrics, the shortening fraction is the preferred measure of systolic function. Normally, the EF should be between 50% and 70%; in systolic heart failure, it drops below 40%. Echocardiography can also identify valvular heart disease and assess the state of the pericardium (the connective tissue sac surrounding the heart). Echocardiography may also aid in deciding what treatments will help the patient, such as medication, insertion of an implantable cardioverter-defibrillator or cardiac resynchronization therapy. Echocardiography can also help determine if acute myocardial ischemia is the precipitating cause, and may manifest as regional wall motion abnormalities on echo. Chest X-rays are frequently used to aid in the diagnosis of CHF. In the compensated patient, this may show cardiomegaly (visible enlargement of the heart), quantified as the cardiothoracic ratio (proportion of the heart size to the chest). In left ventricular failure, there may be evidence of vascular redistribution ("upper lobe blood diversion" or "cephalization"), Kerley lines, cuffing of the areas around the bronchi, and interstitial edema.

Electrophysiology
An electrocardiogram (ECG/EKG) may be used to identify arrhythmias, ischemic heart disease, right and left ventricular hypertrophy, and presence of conduction delay or abnormalities (e.g. left bundle branch block). Although these findings are not specific to the diagnosis of heart failure a normal ECG virtually excludes left ventricular systolic dysfunction.[30]

Blood tests
Blood tests routinely performed include electrolytes (sodium, potassium), measures of renal function, liver function tests, thyroid function tests, a complete blood count, and often C-reactive protein if infection is suspected. An elevated B-type natriuretic peptide (BNP) is a specific test indicative of heart failure. Additionally, BNP can be used to differentiate between causes of dyspnea due to heart failure from other causes of dyspnea. If myocardial infarction is suspected, various cardiac markers may be used. According to a meta-analysis comparing BNP and N-terminal pro-BNP (NTproBNP) in the diagnosis of heart failure, BNP is a better indicator for heart failure and left ventricular systolic dysfunction. In groups of symptomatic patients, a diagnostic odds ratio of 27 for BNP compares with a sensitivity of 85% and specificity of 84% in detecting heart failure.[]

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Angiography
Heart failure may be the result of coronary artery disease, and its prognosis depends in part on the ability of the coronary arteries to supply blood to the myocardium (heart muscle). As a result, coronary catheterization may be used to identify possibilities for revascularisation through percutaneous coronary intervention or bypass surgery.

Monitoring
Various measures are often used to assess the progress of patients being treated for heart failure. These include fluid balance (calculation of fluid intake and excretion), monitoring body weight (which in the shorter term reflects fluid shifts).

Classification
There are many different ways to categorize heart failure, including: the side of the heart involved (left heart failure versus right heart failure). Right heart failure compromises pulmonary flow to the lungs. Left heart failure compromises aortic flow to the body and brain. Mixed presentations are common; left heart failure often leads to right heart failure in the longer term. whether the abnormality is due to insufficient contraction (systolic dysfunction), or due to insufficient relaxation of the heart (diastolic dysfunction), or to both. whether the problem is primarily increased venous back pressure (preload), or failure to supply adequate arterial perfusion (afterload). whether the abnormality is due to low cardiac output with high systemic vascular resistance or high cardiac output with low vascular resistance (low-output heart failure vs. high-output heart failure). the degree of functional impairment conferred by the abnormality (as reflected in the New York Heart Association Functional Classification[31]) the degree of coexisting illness: i.e. heart failure/systemic hypertension, heart failure/pulmonary hypertension, heart failure/diabetes, heart failure/renal failure, etc. Functional classification generally relies on the New York Heart Association functional classification. The classes (I-IV) are: Class I: no limitation is experienced in any activities; there are no symptoms from ordinary activities. Class II: slight, mild limitation of activity; the patient is comfortable at rest or with mild exertion. Class III: marked limitation of any activity; the patient is comfortable only at rest. Class IV: any physical activity brings on discomfort and symptoms occur at rest.

This score documents severity of symptoms, and can be used to assess response to treatment. While its use is widespread, the NYHA score is not very reproducible and doesn't reliably predict the walking distance or exercise tolerance on formal testing.[32] In its 2001 guidelines the American College of Cardiology/American Heart Association working group introduced four stages of heart failure:[] Stage A: Patients at high risk for developing HF in the future but no functional or structural heart disorder. Stage B: a structural heart disorder but no symptoms at any stage. Stage C: previous or current symptoms of heart failure in the context of an underlying structural heart problem, but managed with medical treatment. Stage D: advanced disease requiring hospital-based support, a heart transplant or palliative care. The ACC staging system is useful in that Stage A encompasses "pre-heart failure" a stage where intervention with treatment can presumably prevent progression to overt symptoms. ACC Stage A does not have a corresponding NYHA class. ACC Stage B would correspond to NYHA Class I. ACC Stage C corresponds to NYHA Class II and III, while ACC Stage D overlaps with NYHA Class IV.

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Algorithms
There are various algorithms for the diagnosis of heart failure. For example, the algorithm used by the Framingham Heart Study adds together criteria mainly from physical examination. In contrast, the more extensive algorithm by the European Society of Cardiology (ESC) weights the difference between supporting and opposing parameters from the medical history, physical examination, further medical tests as well as response to therapy. Framingham criteria By the Framingham criteria, diagnosis of congestive heart failure (heart failure with impaired pumping capability)[] requires the simultaneous presence of at least 2 of the following major criteria or 1 major criterion in conjunction with 2 of the following minor criteria: Major criteria:[33] Cardiomegaly on chest radiography S3 gallop (a third heart sound) Acute pulmonary edema Paroxysmal nocturnal dyspnea Crackles on lung auscultation

Central venous pressure of more than 16cm H 2O at the right atrium Jugular vein distension Positive abdominojugular test Weight loss of more than 4.5kg in 5 days in response to treatment (sometimes classified as a minor criterium[34]) Minor criteria:[33] Tachycardia of more than 120 beats per minute Nocturnal cough Dyspnea on ordinary exertion Pleural effusion Decrease in vital capacity by one third from maximum recorded Hepatomegaly Bilateral ankle edema

Minor criteria are acceptable only if they can not be attributed to another medical condition such as pulmonary hypertension, chronic lung disease, cirrhosis, ascites, or the nephrotic syndrome.[33] The Framingham Heart Study criteria are 100% sensitive and 78% specific for identifying persons with definite congestive heart failure.[33] ESC algorithm The ESC algorithm weights the following parameters in establishing the diagnosis of heart failure:[35]

Heart failure

402

Influence Supports if present Parameter

Opposes if normal or absent

+ - to some degree ++ - to intermediate degree +++ - to high degree Compatible symptoms Compatible signs Cardiac dysfunction on echocardiography Response of symptoms or signs to therapy ++ ++ +++ ++ + +++

+++

++

ECG Normal Abnormal Dysrhythmia ++ +++ Laboratory BNP > 400 pg/mL and/or NT-proBNP > 2000 pg/mL BNP < 100 pg/mL and NT-proBNP < 400 pg/mL Hyponatraemia Renal dysfunction Mild elevations of troponin +++ + ++ + +

+++

+ + + Chest X-ray

+ + +

Pulmonary congestion Reduced exercise capacity

+++ +++

+ ++ + ++

Abnormal pulmonary function tests + Abnormal haemodynamics at rest +++

Management
Treatment focuses on improving the symptoms and preventing the progression of the disease. Reversible causes of the heart failure also need to be addressed (e.g. infection, alcohol ingestion, anemia, thyrotoxicosis, arrhythmia, hypertension). Treatments include lifestyle and pharmacological modalities.

Acute decompensation
In acute decompensated heart failure (ADHF), the immediate goal is to re-establish adequate perfusion and oxygen delivery to end organs. This entails ensuring that airway, breathing, and circulation are adequate. Immediated treatments usually involve some combination of vasodilators such as nitroglycerin, diuretics such as furosemide, and possibly non invasive positive pressure ventilation (NIPPV).

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Chronic management
The goal is to prevent the development of acute decompensated heart failure, to counteract the deleterious effects of cardiac remodeling, and to minimize the symptoms that the patient suffers. First-line therapy for all heart failure patients is angiotensin-converting enzyme (ACE) inhibition. ACE inhibitors (i.e., enalapril, captopril, lisinopril, ramipril) improve survival and quality of life in heart failure patients, and have been shown to reduce mortality in patients with left ventricular dysfunction in numerous randomized trials.[][] In addition to pharmacologic agents (oral loop diuretics, beta-blockers, ACE inhibitors or angiotensin receptor blockers, vasodilators, and in severe cardiomyopathy aldosterone receptor antagonists), behavioral modification should be pursued, specifically with regard to dietary guidelines regarding fluid intake. Exercise should be encouraged as tolerated, as sufficient conditioning can significantly improve quality-of-life. A low salt diet appears to increase the risk of death in those with systolic dysfunction.[36] Anaemia is an independent factor in mortality in people with chronic heart failure; treatment of anaemia significantly improves patient's quality of life, and has been shown to improve the classification of severity of heart failure.[] Treatment of anaemia improves quality of life and decreases mortality rates.[37] Due to this increasing evidence, the latest European guidelines recommend screening for anaemia and treating with parenteral iron if anaemia is found.[38] In patients with severe cardiomyopathy, implantation of an automatic implantable cardioverter defibrillator (AICD) should be considered. A select population will also probably benefit from ventricular resynchronization. In select cases, cardiac transplantation can be considered. While this may resolve the problems associated with heart failure, the patient generally must remain on an immunosuppressive regimen to prevent rejection, which has its own significant downsides.

Palliative care
Patients with CHF often have significant symptoms, such as shortness of breath and chest pain. Both palliative care and cardiology are trying to get palliative care involved earlier in the course of patients with heart failure, and some would argue any patient with NYHA class III CHF should have a palliative care referral. Palliative care can not only provide symptom management, but also assist with advanced care planning, goals of care in the case of a significant decline, and making sure the patient has a medical power of attorney and discussed his or her wishes with this individual.

Hospice
Without transplantation, heart failure may not be reversible and cardiac function typically deteriorates with time. The growing number of patients with Stage IV heart failure (intractable symptoms of fatigue, shortness of breath or chest pain at rest despite optimal medical therapy) should be considered for palliative care or hospice, according to American College of Cardiology/American Heart Association guidelines.

Prognosis
Prognosis in heart failure can be assessed in multiple ways including clinical prediction rules and cardiopulmonary exercise testing. Clinical prediction rules use a composite of clinical factors such as lab tests and blood pressure to estimate prognosis. Among several clinical prediction rules for prognosing acute heart failure, the 'EFFECT rule' slightly outperformed other rules in stratifying patients and identifying those at low risk of death during hospitalization or within 30 days.[] Easy methods for identifying low risk patients are: ADHERE Tree rule indicates that patients with blood urea nitrogen < 43mg/dl and systolic blood pressure at least 115mm Hg have less than 10% chance of inpatient death or complications.

Heart failure BWH rule indicates that patients with systolic blood pressure over 90mm Hg, respiratory rate of 30 or less breaths per minute, serum sodium over 135mmol/L, no new ST-T wave changes have less than 10% chance of inpatient death or complications. A very important method for assessing prognosis in advanced heart failure patients is cardiopulmonary exercise testing (CPX testing). CPX testing is usually required prior to heart transplantation as an indicator of prognosis. Cardiopulmonary exercise testing involves measurement of exhaled oxygen and carbon dioxide during exercise. The peak oxygen consumption (VO2 max) is used as an indicator of prognosis. As a general rule, a VO2 max less than 1214 cc/kg/min indicates a poor survival and suggests that the patient may be a candidate for a heart transplant. Patients with a VO2 max<10 cc/kg/min have clearly poorer prognosis. The most recent International Society for Heart and Lung Transplantation (ISHLT) guidelines[39] also suggest two other parameters that can be used for evaluation of prognosis in advanced heart failure, the heart failure survival score and the use of a criterion of VE/VCO2 slope > 35 from the CPX test. The heart failure survival score is a score calculated using a combination of clinical predictors and the VO2 max from the cardiopulmonary exercise test.

404

Epidemiology
Mostly as a result of the costs of hospitalization, it is associated with a high health expenditure; costs have been estimated to amount to 2% of the total budget of the National Health Service in the United Kingdom, and more than $35 billion in the United States.[][] Heart failure is associated with significantly reduced physical and mental health, resulting in a markedly decreased quality of life.[][] With the exception of heart failure caused by reversible conditions, the condition usually worsens with time. Although some people survive many years, progressive disease is associated with an overall annual mortality rate of 10%.[] Heart failure is the leading cause of hospitalization in people older than 65.[40] In developed countries, the mean age of patients with heart failure is 75 years old. In developing countries, two to three percent of the population suffers from heart failure, but in those 70 to 80 years old, it occurs in 2030 percent. Heart failure affects close to 5 million people in the USA and each year close to 500,000 new cases are diagnosed. Nearly one out of every four patients (24.7%) hospitalized in the United States with congestive heart failure are readmitted within 30 days.[41] Additionally, more than 50% of patients seek re-admission within 6 months after treatment and the average duration of hospital stay is 6 days. In tropical countries, the most common cause of HF is valvular heart disease or some type of cardiomyopathy. As underdeveloped countries have become more affluent, there has also been an increase in the incidence of diabetes, hypertension and obesity, which have in turn raised the incidence of heart failure. In the USA, HF is much higher in African Americans, Hispanics, Native Americans and recent immigrants from the eastern bloc countries like Russia. This high prevalence in these ethnic minority populations has been linked to high incidence of diabetes and hypertension. In many new immigrants to the USA the high prevalence of heart failure has largely been attributed to lack of preventive health care or substandard treatment.[42]

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Sex
Men have a higher incidence of heart failure, but the overall prevalence rate is similar in both sexes, since women survive longer after the onset of heart failure.[] Women tend to be older when diagnosed with heart failure (after menopause), they are more likely than men to have diastolic dysfunction, and seem to experience a lower overall quality of life than men after diagnosis.[]

Race
New information suggests that elements of heart failure in African Americans and Caucasians may be different[43] and therapy for heart failure has different efficacies depending on racial, ethnic, and genetic backgrounds.

References
[1] [2] [3] [4] [5] [6] [7] http:/ / apps. who. int/ classifications/ icd10/ browse/ 2010/ en#/ I50 http:/ / www. icd9data. com/ getICD9Code. ashx?icd9=428. 0 http:/ / www. diseasesdatabase. com/ ddb16209. htm http:/ / www. nlm. nih. gov/ medlineplus/ ency/ article/ 000158. htm http:/ / www. emedicine. com/ med/ topic3552. htm http:/ / www. emedicine. com/ emerg/ topic108. htm# http:/ / www. emedicine. com/ radio/ topic189. htm#

[8] http:/ / www. emedicine. com/ med/ topic1367150. htm# [9] http:/ / www. emedicine. com/ ped/ topic2636. htm# [10] http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2013/ MB_cgi?field=uid& term=D006333 [33] In turn citing: [34] Topic Review Heart Failure (http:/ / www. amc. edu/ amr/ archives/ 200201/ review01. html) By Osama Gusbi, MD. Albany Medical Review January 2002 [35] as PDF (http:/ / www. escardio. org/ guidelines-surveys/ esc-guidelines/ GuidelinesDocuments/ guidelines-HF-FT. pdf) Also at [38] ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012 European Heart Journal (2012) 33, 17871847 doi:10.1093/eurheartj/ehs104 [41] Elixhauser A, Steiner C. Readmissions to U.S. Hospitals by Diagnosis, 2010. HCUP Statistical Brief #153. Agency for Healthcare Research and Quality. April 2013. (http:/ / hcup-us. ahrq. gov/ reports/ statbriefs/ sb153. jsp) [42] Heart Failure Information (http:/ / www. healthline. com/ adamcontent/ heart-failure/ 3), Retrieved on 2010-01-21.

External links
American Heart Association's Heart Failure web site (http://www.americanheart.org/heartfailure) information and resources for treating and living with heart failure. Heart Failure Matters (http://www.heartfailurematters.org) patient information website of the Heart Failure Association of the European Society of Cardiology Heart failure in children (http://www.gosh.nhs.uk/medical-conditions/search-for-medical-conditions/ heart-failure-severe/) by Great Ormond Street Hospital, London, UK

Community health worker

406

Community health worker


Community health workers (CHW) are members of a community who are chosen by community members or organizations to provide basic health and medical care to their community. Other names for this type of health care provider include village health worker, community health aide, community health promoter, and lay health advisor.[1] In many developing countries, especially in Sub-Saharan Africa, there are critical shortages of highly educated health professionals.[2] Current medical and nursing schools cannot train enough workers to keep up with increasing demand for health care services, internal and external emigration of health workers, deaths from AIDS and other diseases, low workforce productivity, and population growth. Community health workers are given a limited amount of training, supplies and support to provide essential primary health care services to the population. Programs involving CHW in China, Brazil and Iran have demonstrated that utilizing such workers can help improve health outcomes for large populations in under-served regions.[citation needed] Task shifting of primary care functions from professional health workers to community health workers is considered to be a means to make more efficient use of the human resources currently available and improving the health of millions at reasonable cost.[3]

History
Scientific medicine has evolved slowly over the last few millennia and very rapidly over the last 150 years or so. As the evidence mounted of its effectiveness, belief and trust in the traditional ways waned. The rise of university based medical schools, the increased numbers of trained physicians, the professional organizations they created, and the income and attendant political power they generated resulted in license regulations. Such regulations were effective in improving the quality of medical care but also resulted in a reduced supply of clinical care providers. This further increased the fees doctors could charge and encouraged them to concentrate in larger towns and cities where the population was denser, hospitals were more available, and professional and social relationships more convenient. In the 1940s Chairman Mao Tse Tung in China faced these problems. His anger at the urban elite medical profession over the maldistribution of medical services resulted in the creation of "Barefoot doctors". Hundreds of thousands of rural peasants, chosen by their colleagues, were given rudimentary training and assigned medical and sanitation duties in addition to the collective labor they owed the commune. By 1977 there were over 1.7 million barefoot doctors.[4] As professionally trained doctors and nurses became more available, the program was abolished in 1981 with the end of agricultural communes. Many Barefoot Doctors passed an examination and went to medical school. Many became health aides and some were relieved of duty. Brazil undertook a medical plan named the Family Health Program in the 1990s that made use of large numbers of community health agents. Between 1990 and 2002 the infant mortality rate dropped from about 50 per 1000 live births to 29.2.[5] During that period the Family Health Program increased its coverage of the population from 0 to 36%. The largest impact appeared to be a reduction of deaths from diarrhea. Though the program utilized teams of physicians, nurses and CHWs, it could not have covered the population it did without the CHW. Additionally there is evidence in Brazil that the shorter period of training does not reduce the quality of care. In one study workers with a shorter length of training complied with child treatment guidelines 84% of the time whereas those with longer training had 58% compliance.[6] Iran utilizes large numbers of para-professionals called behvarz. These workers are from the community and are based in 14,000 health houses nationwide. They visit the homes of the underserved providing vaccinations and monitoring child growth. Between 1984 and 2000 Iran was able to cut its infant mortality in half and raise immunization rates from 20 to 95%. The family planning program in Iran is considered highly successful. Fertility has dropped from 5.6 lifetime children per woman in 1985 to 2 in 2000. Though there are many elements to the program (including classes for those who marry and the ending of tax incentives for large families), behvarz are

Community health worker extensively involved in providing birth control advice and methods. The proportion of rural women on contraceptives in 2000 was 67%. The program resulted in profound improvement in maternal mortality going from 140 per 100,000 in 1985 to 37 in 1996.[7]

407

Scope of Community Health Worker Programs


The World Health Organization estimates there are over 1.3 million community health workers worldwide.[8] In addition to the large scale implementation by countries such as China, Brazil, and Iran, many countries have implemented CHW programs in small scale levels for a variety of health issues. In India, community health workers have been utilized to increase mental health service utilization and decrease stigma associated with mental illness.[9] In this program respected female members of the community were chosen to participate. All of the women were married, came from a good social standing, displayed a keen interest in the program, and were encouraged by their family to participate. The women chosen were then trained in identification and referral of patients with mental illnesses, the common myths and misconceptions prevalent in the area and in conducting community surveys. The training lasted 3 days and included lectures, role plays and observation of patient interviews at the psychiatry outpatient department at St. Johns Medical College Hospital. A population of 12,886 were surveyed using a brief questionnaire. Out of this population 574 were suspected patients. Out of this 242 suspected patients visited the clinic after follow up from the community health worker. In Tanzania, village health workers were part of a community-based safe-motherhood approach.[10] The VHWs assisted pregnant women with birth planning, which included timely identification of danger signs, preparation and accumulation of two or more essential supplies such as soap, razors, gloves for clean delivery, and mobilizing household resources, people and money to manage a possible emergency. Approximately one year after the CBRHP's major interventions ceased in these communities, most of the VHWs continued to do health promotion by visiting pregnant women, teaching them about birth planning and danger signs, and assisting them in obtaining both prenatal and obstetric services. Local VHW associations are forming with support from local political leaders, the Ministry of Health, and the non-governmental organization CARE to sustain the work of the VHWs. The community development officers, some of who were also the master trainers, are involved in spearheading the formation of VHW organizations. In Mali, community health workers with the Mali Health Organizing Project in Bamako have helped reduce child mortality (under 5 years old) in their community to less than 1%, compared to a national average of 19%.[11] The use of CHWs is not limited to developing countries. In New York, CHWs have been deployed across the state to provide care to patients with chronic illnesses like diabetes that require sustained, comprehensive care. They work in both rural communities where access to primary care is sparse, and in urban communities where they are better able to bridge communication gaps that may arise between patients and doctors. They are seen to play an important role in assisting patients with navigating a complex, uncoordinated health care system.[12] A randomized controlled intervention on the U.S.-Mexico border, used promotoras or female promoters to increase the number of women utilizing routine preventive examinations.[13] The control group received a postcard reminding women to get preventive screening. The free comprehensive clinical exam included a Pap test, a clinical breast exam, human papillomavirus (HPV) testing, blood draw for total cholesterol and blood glucose, and a blood pressure measurement. The other group received the same postcard and a follow-up visit from a promotora. The group that was followed up by a promotora saw a 35% increase in visits to get the free screening. [14] A program in Karnataka, India took a slightly different approach now referred to as the "link worker" model. The Samastha project developed a network in which trained workers, village health committees, government facilities, people living with HIV (PLHIV) networks, and participating NGOs collaborated to improve recruitment and retention of PLHIV while strengthening and supporting their adherence to treatment. Link workers were PLHIV who were selected by Samastha from a small number of HIV-positive candidates proposed by their community; they received an allowance for their work. The link workers' key tasks revolved around prevention, stigma reduction, and

Community health worker support for PLHIV that included adherence support to both treatment and care. Ultimately, the link workers' coordinating role became a hallmark of Samastha's interventions in high prevalence rural areas. Link workers formed the essential connection between PLHIV, government and community structures, and HIV care and treatment services, commonly accompanying persons from their catchment area to these services. Community health workers have also been utilized to assist in research. Martin et al. found that the Latin-American population in the United States frequently does not benefit from health programs due to language barriers, distrust of the government, and unique health beliefs and practices, and specifically that providing effective asthma care to the Latino population is an enormous challenge.[15] In addition they found that Latinos are also often excluded from research due to a lack of validated research instruments in Spanish, unsuccessful study recruitment, and a limited number of Latino researchers.[16] Thus, Martin and colleagues decided to used community health workers to recruit participants. To gauge the effectiveness of their recruitment strategy to other more traditional recruitment models they looked at two studies. Both these studies offered significant monetary incentives for participation while the CHW study offered nothing for the initial participation. Martin et al. found that individuals who chose not to participate in the study went on to receive other services in the areas of diabetes and cancer prevention, which was not the case for the other studies.

408

Current status
Cost and access to medical care remain problems of worldwide scope. They are particularly severe in the developing world and it is estimated one million more health care workers are needed in Africa to meet the health-related Millennium Development Goals.[17] Doctors are few and concentrated in cites. In Uganda some 70% of medical doctors and 40% of nurses and midwives are based in urban areas, serving only 12% of the population.[18] Medical training is long and expensive. It is estimated that to meet health workforce needs using the American or European model, Africa would need to build 300 medical schools with a total training cost of over $33 billion and it would take over 20 years just to catch up.[17] In many countries salaries of doctors and nurses are less than that of engineers and teachers. Bright young medical professionals often leave practice for more lucrative opportunities.[17] Emigration of trained personnel to countries with higher salaries is high. In Zambia of the 600 doctors trained since independence it is estimated only 50 practice in their home country.[19] In some countries AIDS is killing experienced nurses and doctors amounting to 30-50% of the number trained yearly.[20] Though many countries have increased their spending on health care and foreign money has been injected, much of it has been on specific disease-oriented programs.[21] Health systems remain extremely weak, especially in rural areas. The World Health Assembly in 2006 called for, A health workforce which is matched in number, knowledge and skill sets to the needs of the population and which contributes to the achievement of health outcomes by utilizing a range of innovative methods.[2] Community health workers are thought to be part of the answer.[22] They can be trained to do specialized tasks such as provide sexually transmitted disease counseling, directly observed therapy for tuberculosis control, or act as trained birth attendants. Others work on specific programs performing limited medical evaluations and treatment. Others have a far broader primary care function. With training, monitoring, supervision and support such workers have been shown to be able to achieve outcomes far better than baseline and in some studies, better than physicians.[23][24][25][26] Important attributes of community health workers are to be a member of and chosen by the community they serve.[27] This means they are easily accepted by their fellows and have natural cultural awareness. This is crucial because many communities are disengaged from the formal health system. In Sub-Saharan Africa 53% of the poorest households do not seek care outside the home.[21] Barriers include clinic fees, distance, community beliefs and the perception of the skills and attitudes of medical clinic workers. Community health workers are unable to emigrate because they do not have internationally recognized qualifications.[22] Finally, the variation in incentives between areas of the country tends to be low. All these factors combined with strong community ties, tend to result in

Community health worker retention at the community level. Much remains to be learned about the recruitment, training, functions, incentives, retention and professional development of community health workers. Learning developed in one country may not be applicable to another due to cultural differences. Health worker adaptability to local requirements and needs is key to improving medical outcomes.[21] That being said, it has been estimated that six million childrens lives a year could be saved if 23 evidence based interventions were provided systematically the children living in the 42 countries responsible for 90% of childhood mortality.[28] Over 50% of this benefit could be obtained with an integrated, high-coverage, family-community care based system.[29] Community health workers may be an integral and crucial component of the health human resources team needed to achieve such goals.

409

References
[1] International Labour Organization. International Standard Classification of Occupations, 2008 revision. Geneva, ILO. [2] World Health Organization, 2006. The World Health Report 2006: working together for health. (http:/ / www. who. int/ hrh/ whr06/ en/ index. html) Geneva, WHO Press. [3] World Health Organization, 2007. Task shifting to tackle health worker shortages. (http:/ / www. who. int/ healthsystems/ task_shifting/ TTR_tackle. pdf) Geneva, WHO. [4] Rosenthal MM, Greiner JR. The Barefoot Doctors of China: from political creation to professionalization. Hum Organ. Winter 1982;41(4):330-341 [5] Macinko J, Guanais FC, de Fatima M, de Souza M. Evaluation of the impact of the Family Health Program on infant mortality in Brazil, 1990-2002. J Epidemiol Community Health. Jan 2006;60(1):13-19. [6] Huicho L, Scherpbier RW, Nkowane AM, Victora CG. How much does quality of child care vary between health workers with differing durations of training? An observational multicountry study. Lancet. Sep 13 2008;372(9642):910-916. [7] Roudi-Fahimi F, Bureau PR. Women's reproductive health in the Middle East and North Africa. Population Reference Bureau; 2003. [8] World Health Organization, 2011. World Health Statistics 2011 (http:/ / www. who. int/ whosis/ whostat/ 2011/ en/ index. html) - Table 6: Health workforce, infrastructure and essential medicines. Accessed 21 July 2011. [9] Isaacs A.N., Srinivasan K., Neerakkal I., Jayaram G. Initiating a Community Mental Health Programme in Rural Karnataka. IJCM. 2006;31(2):86-87. [10] Ahluwalia IB, Schmid T, Kouletio M, Kanenda O. An evaluation of a community-based approach to safe motherhood in northwestern Tanzania. Int J Gynaecol Obstet. 2003;82(2):231-240. [12] New York State Health Foundation: Community Health Workers. (http:/ / www. nyshealthfoundation. org/ section/ spotlight/ archived_spotlights/ community_health_workers) [13] Hunter JB, de Zapien JG, Papenfuss M, Fernandez ML, Meister J, Giuliano AR. The impact of a promotora on increasing routine chronic disease prevention among women aged 40 and older at the U.S.-Mexico border. Health Educ Behav. 2004;31(4 Suppl):18S-28S. [14] http:/ / aidstarone. com/ focus_areas/ treatment/ resources/ case_study_series/ linking_resources_art_adherence_india [15] Martin M, Hernandez O, Naureckas E, Lantos J. Improving asthma research in an inner-city Latino neighborhood with community health workers. J Asthma. 2005;42(10):891-895. [16] Flores G, Fuentes-Afflick E, Barbot O, et al. The health of Latino children: urgent priorities, unanswered questions, and a research agenda. JAMA. 2002;288(1):82-90. [17] Conway MD. Addressing Africas health workforce crisis. The McKinsey Quarterly. November 2007 2007. [18] Uganda Ministry of Health. Human Resource Strategic Plan for Uganda, 20052020. Kampala. 2006. [19] Chen L, Evans T, Anand S, et al. Human resources for health: overcoming the crisis. The Lancet. 2004;364(9449):1984-1990. [20] Hongoro C, McPake B. How to bridge the gap in human resources for health. Lancet. Oct 16 2004;364(9443):1451-1456. [21] African Medical and Research Foundation (AMREF). People First: African solutions to the health worker crisis. (http:/ / uk. amref. org/ silo/ files/ people-first-african-solutions-to-the-health-worker-crisis. pdf) 2007. [22] McPake B, Mensah K. Task shifting in health care in resource-poor countries. Lancet. Sep 13 2008;372(9642):870-871. [23] Perez F AK, Ndoro T, Engelsmann B, Dabis F. Participation of traditional birth attendants in prevention of mother-to-child transmission of HIV services in two rural districts in Zimbabwe: a feasibility study. BMC Public Health. December 2008 2008;8(401). [24] Lehmann U. Review of the Utilisation and Effectiveness of Community-Based Health Workers in Africa. A Joint Learning Initiative, HUMAN RESOURCES FOR HEALTH AND DEVELOPMENT. 2004. [25] Swider SM. Outcome effectiveness of community health workers: an integrative literature review. Public Health Nurs. Jan-Feb 2002;19(1):11-20. [26] Hopkins H, Talisuna A, Whitty CJ, Staedke SG. Impact of home-based management of malaria on health outcomes in Africa: a systematic review of the evidence. Malar J. 2007;6:134. [27] World Health Organization: Community health workers: What do we know about them? (http:/ / www. who. int/ hrh/ documents/ community_health_workers. pdf) WHO Evidence and Information for Policy, Department of Human Resources for Health; 2007.

Community health worker


[28] Bryce J, Black RE, Walker N, Bhutta ZA, Lawn JE, Steketee RW. Can the world afford to save the lives of 6 million children each year? Lancet. Jun 25-Jul 1 2005;365(9478):2193-2200. [29] Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis L. Evidence-based, cost-effective interventions: how many newborn babies can we save? Lancet. Mar 12-18 2005;365(9463):977-988.

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Further reading
Frances E. Aboud (1998). "Community Participation and Agency Involvement". Health Psychology in Global Perspective (2nd ed.). SAGE. pp.136139. ISBN0-7619-0941-9. Unknown parameter |isnb13= ignored (help)

Hospital information system


These are comprehensive, integrated information systems designed to manage the medical, administrative, financial and legal aspects of a hospital and its service processing. Traditional approaches encompass paper-based information processing as well as resident work position and mobile data acquisition and presentation.

Hospital information system


One of the most important issues is health services. Hospitals provide a medical assistance to people. The best introduction for hospital information systems has been made in 2011 International Conference on Social Science and Humanity, which is; Hospital Information Systems can be defined as massive, integrated systems that support the comprehensive information requirements of hospitals, including patient, clinical, ancillary and financial management. Hospitals are extremely complex institutions with large departments and units coordinate care for patients. Hospitals are becoming more reliant on the ability of hospital information system (HIS) to assist in the diagnosis, management and education for better and improved services and practices. In health organization such as hospitals, implementation of HIS inevitable due to many mediating and dominating factors such as organization, people and technology.

Architecture
Hospital Information System architecture has three main levels, Central Government Level, Territory Level, and Patient Carrying Level. Generally all types of hospital information system (HIS) are supported in client-server architectures for networking and processing. Most work positions for HIS are currently resident types. Mobile computing began with wheeled PC stands. Now tablet computers and smartphone applications are used. Enterprise HIS with Internet architectures have been successfully deployed in Public Healthcare Territories and have been widely adopted by further entities.[1] The Hospital Information System (HIS) is a province-wide initiative designed to improve access to patient information through a central electronic information system. HISs goal is to streamline patient information flow and its accessibility for doctors and other health care providers. These changes in service will improve patient care quality and patient safety over time. The patient carries system record patient information, patient laboratory test results, and patients doctor information. Doctors can access easily person information, test results, and previous prescriptions. Patient schedule organization and early warning systems can provide by related systems. A cloud computing alternative is not recommended, as data security of individual patient records services are not well accepted by the public.[2][3][4][5] HIS can be composed of one or several software components with specialty-specific extensions, as well as of a large variety of sub-systems in medical specialties, for example Laboratory Information System (LIS), Policy and

Hospital information system Procedure Management System,[6] Radiology Information System (RIS) or Picture archiving and communication system (PACS). CISs are sometimes separated from HISs in that one focuses the flow management and clinical-state-related data and the other focuses the patient-related data with the doctor's letters and the electronic patient record. However, the naming differences are not standardised between suppliers. Architecture in based on a distributed approach and on the utilization of standard software products complying with the industrial and market standards must be utilized (such as: UNIX operating systems, MS-Windows, local area network based on Ethernet and TCP/IP protocols, relational database management systems based on SQL language or Oracle databases, C programming language).

411

Aim
As an area of medical informatics the aim of an HIS is to achieve the best possible support of patient care and outcome and administration by presenting data where needed and acquiring data when generated with networked electronic data processing. Hospital Information Systems main demands are correct data storage, reliable usage, fast to reach data, secure to keep data on storage and lower cost of usage. Hospital Information Systems provide a common source of information about a patients health history. The system have to keep data in secure place and controls who can reach the data in certain circumstances. These systems enhance the ability of health care professionals to coordinate care by providing a patients health information and visit history at the place and time that it is needed. Patients laboratory test information also visual results such as X-ray may reachable from professionals. HIS provide internal and external communication among health care providers. The HIS may control organizations, which is Hospital in these case, official documentations, financial situation reports, personal data, utilities and stock amounts, also keeps in secure place patients information, patients medical history, prescriptions, operations and laboratory test results. The HIS may protect organizations, handwriting error, overstock problems, conflict of scheduling personnel, official documentation errors like tax preparations errors.

Organizational structure
The head of the HIS department is a person who is qualified and experienced in computer systems. Graduate and postgraduate computer diploma/degree holders are available. Depending on the set-up and the extent of computerization and its sophistication, the department may have some or all of the following staff in addition to the head of the department. Organizational structure refers to levels of management within a hospital and these levels allow efficient management of hospital departments. The structure helps one understand the hospitals chain of command and work flows. Common organizational structure groups are Administrative Services, Information system Services, Therapeutic Services, Diagnostic Services, and Support Services. Hospital Information systems also can extend as Database administrator, interface developer, and users which are patients and official users.

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Systems administrator/database administrator


The systems administrator-cum-database administrator is responsible for systems administration to ensure high uptime of the system and for handling all database back-up and restoration activities.

Application specialist and trainer


The hospitals application specialist together with the software vendor is involved in all the activities required for implementing the application software. Trainers train and retrain new employees in the hospital.

Hardware/network engineers
Hardware/Network engineers are responsible for maintaining the hardware and network systems in the hospital. They undertake all troubleshooting activities that may be required to keep the system online and patient data available to doctors and nurses.

Standardization
There is no standardization but for data formats and for data interchange, as with the HL7 initiative supported by ISO.

Benefits of HIS
Easy access to doctors data to generate varied records, including classification based on demographic, gender, age, and so on. It is especially beneficial at ambulatory (out-patient) point, hence enhancing continuity of care. As well as, Internet-based access improves the ability to remotely access such data.[7] It helps as a decision support system for the hospital authorities for developing comprehensive health care policies.[8] Efficient and accurate administration of finance, diet of patient, engineering, and distribution of medical aid. It helps to view a broad picture of hospital growth Improved monitoring of drug usage, and study of effectiveness. This leads to the reduction of adverse drug interactions while promoting more appropriate pharmaceutical utilization. Enhances information integrity, reduces transcription errors, and reduces duplication of information entries.[9] Hospital software is easy to use and eliminates error caused by handwriting. New technology computer systems give perfect performance to pull up information from server or cloud servers.

References
Hospital Management Software - Medico Clinic [10] Hospital Management Software - APMIS: All Purpose Medical Information System- Connected healthcare paltform [11] NOVA SCOTIA HOSPITAL INFORMATION SYSTEM [12] Hospital Information System Project [13] Healthcare and Distributed Systems Technology [14] 2011 International Conference on Social Science and Humanity [15]
[10] [11] [12] [13] https:/ / www. facebook. com/ pages/ Medico-Clinic-Hospital-Management-Software/ 414012225326659 https:/ / www. sabaothtechnologies. com/ APMIS. pdf http:/ / www. oag-ns. ca/ June2005/ ch6%20June2005%20NSHis. pdf http:/ / www. manitoba-ehealth. ca/ ehr_hisp. html

[14] http:/ / www. ansa. co. uk/ ANSATech/ 95/ ansaworks-95/ hltcare. pdf [15] http:/ / www. ipedr. com/ vol5/ no1/ 45-H00097. pdf

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Further reading
Shortliffe, E.H., and Cimino, J.J. eds. Biomedical Informatics: Computer Applications in Health Care and Biomedicine (3rd edition). New York: Springer, 2006. National Institute of Clinical Excellence, Principles of Best Practice in Clinical Audit. London: NICE, 2002. (ISBN 1-85775-976-1) Olmeda, Christopher J. (2000). Information Technology in Systems of Care. Delfin Press. ISBN 978-0-9821442-0-6 Payne, P.R., Greaves, A.W., and Kipps, T.J. CRC Clinical Trials Management System (CTMS): an integrated information management solution for collaborative clinical research, AMIA Annu Symp Proc. 2003:967.

Clinical Laboratory Improvement Amendments


Clinical Laboratory Improvement Amendments (CLIA) of 1988 are United States federal regulatory standards that apply to all clinical laboratory testing performed on humans in the United States, except clinical trials and basic research.[1]

CLIA Program
In accord with the CLIA, the CLIA Program sets standards and issues certificates for clinical laboratory testing.[2] CLIA defines a clinical laboratory as any facility which performs laboratory testing on specimens derived from humans for the purpose of providing information (1) for the diagnosis, prevention, or treatment of disease or impairment, and (2) for the assessment of health. An objective of the CLIA is to ensure the accuracy, reliability and timeliness of test results regardless of where the test was performed. Per CLIA, each specific laboratory system, assay, examination is graded for level of complexity by assigning scores of 1,2,3 for each of the following seven criteria. A score 1 is the lowest level of complexity and a score 3 indicates the highest level. Score 2 is assigned when the characteristics for a particular test are intermediate between the descriptions listed for scores of 1 and 3.[3] Criteria for categorization: (1) Knowledge (2) Training and experience (3) Reagents and materials preparation (4) Characteristics of operational steps (5) Calibration, quality control, and proficiency testing materials (6) Test system troubleshooting and equipment maintenance (7) Interpretation and judgment Centers for Medicare and Medicaid Services (CMS) has the primary responsibility for the operation of the CLIA Program. Within CMS, the program is implemented by the Center for Medicaid and State Operations, Survey and Certification Group, Division of Laboratory Services. The CLIA Program is funded by user fees collected from approximately 200,000 laboratories, most located in the United States.[4]

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CLIA Waived Tests


Under CLIA, tests and test systems that meet risk, error and complexity requirements are issued a CLIA certificate of waiver.[5] In November 2007, The CLIA waiver provisions were revised by Congress to make it clear that tests approved by the FDA for home use automatically qualify for CLIA waiver[6]

References
[1] CLIA related Federal Register and Code of Federal Regulation Announcements (http:/ / www. fda. gov/ cdrh/ CLIA/ CLIAfedregin. html) [2] CLIA Program homepage (http:/ / www. cms. hhs. gov/ clia/ ) [3] CLIA Categorization Criteria (http:/ / www. fda. gov/ MedicalDevices/ DeviceRegulationandGuidance/ IVDRegulatoryAssistance/ ucm124208. htm) (December 2012) [4] CLIA Overview (http:/ / www. cms. hhs. gov/ CLIA/ 01_Overview. asp) (March 2007) [5] CLIA Waived Testing booklet (http:/ / wwwn. cdc. gov/ dls/ waivedtests/ WavedTestingBookletWeb. pdf) (December 2012) [6] CLIA Waived IVD Regulatory Assistance (http:/ / www. fda. gov/ medicaldevices/ deviceregulationandguidance/ ivdregulatoryassistance/ ucm124202. htm) (November 2007)

Cost-minimization analysis
Cost-minimization is a tool used in pharmacoeconomics and is applied when comparing multiple drugs of equal efficacy and equal tolerability Therapeutic equivalence must be referenced by the author conducting the study and should have been done prior to the cost-minimization work. Since equal efficacy and equal tolerability is already demonstrated, there is no requirement to find a common efficacy denominator as would be the case when conducting a cost-effectiveness study. The author is not precluded from doing so through the use of "cost/cure" or "cost/year of life gained". If efficacy and tolerability is demonstrated, however, then a simple comparison of "cost/course of treatment" can suffice for the purpose of comparing two or more therapeutically equivalent treatment alternatives. When conducting a cost-minimization study, the author needs to measure all costs (resource expenditures) inherent to the delivery of the therapeutic intervention and that are relevant to the pharmacoeconomic perspective. It is the simplest method It is used to compare costs of alternative therapies that have: identical clinical effectiveness (including adverse reactions, complications and duration of therapy), BUT Different costs Choose the least cost alternative among equivalent or equally efficacious alternatives

Continuing medical education

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Continuing medical education


Continuing medical education (CME) refers to a specific form of continuing education (CE) that helps those in the medical field maintain competence and learn about new and developing areas of their field. These activities may take place as live events, written publications, online programs, audio, video, or other electronic media. Content for these programs is developed, reviewed, and delivered by faculty who are experts in their individual clinical areas. Similar to the process used in academic journals, any potentially conflicting financial relationships for faculty members must be both disclosed and resolved in a meaningful way.[1] However, critics complain that drug and device manufacturers often use their financial sponsorship to bias CMEs towards marketing their own products.[2]

Historical context
Continuing medical education is not a new concept. From essentially the beginning of institutionalized medical instruction (medical instruction affiliated with medical colleges and teaching hospitals), health practitioners continued their learning by meeting with their peers.[3] Grand rounds, case discussions, and meetings to discuss published medical papers constituted the continuing learning experience. In the 1950s through to the 1980s, CME was increasingly funded by the pharmaceutical industry. Concerns regarding informational bias (both intentional and unintentional) led to increasing scrutiny of the CME funding sources. This led to the establishment of certifying agencies such as the Society for Academic Continuing Medical Education which is an umbrella organization representing medical associations and bodies of academic medicine from the United States, Canada, Great Britain and Europe. The pharmaceutical industry has also developed guidelines regarding drug detailing and industry sponsorship of CME, such as the Pharmaceutical Advertising Advisory Board (PAAB) and Canada's Research-Based Pharmaceutical Companies (Rx&D).

CME requirements
In the United States, many states require CME for medical professionals to maintain their licenses. For example, Arizona requires an average of 40 hours of CME every two years.[4] For a complete list of requirements by state, see State Medical Licensure Requirements and Statistics, 2006 [5]. Within the United States, CME for physicians is regulated by the Accreditation Council for Continuing Medical Education (ACCME) and the American Osteopathic Association (AOA). In Canada, certification is provided by the Royal College of Physicians and Surgeons of Canada (RCPSC) and the College of Family Physicians Canada (CFPC). The RCPSC is responsible for the development and implementation of all certifying examinations in each specialty other than Family Medicine. Specialist physicians who join the Royal College as Fellows maintain their knowledge, skills, competence and performance through participating in the Maintenance of Certification Program. For each five year cycle, fellows of the college are required to document 400 credits, with a minimum of 40 credits obtained in each year of the cycle. Credits are earned at one to two credits per hour, based on the type of learning activity. The CFPC requires 250 credit-hours over a five year cycle. Fifty credits must be obtained for each year of the cycle. To earn and maintain fellowship within the college, an additional 24 credit-hours of higher level learning are also required over each learning cycle. Similarly, each province and territory requires documentation of ongoing CME for licensure.[6]

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Non-CME (promotional education) programs


Non-CME activities, also referred to as Promotional Medical Education, encompass a variety of industry sponsored educational programs for medical professionals. Several things serve to distinguish these programs, which are typically aimed at promotion of a given product or therapy, from accredited CME programs:[citation needed] Lack of accreditation Direct industry sponsorship Specific product or therapy focus Strict regulation against off-label promotion

Production of CME courses


Continuing medical education activities are developed and delivered by a variety of organizations, including: Professional associations Medical education agencies Hospitals Educational institutions, including universities, medical and nursing schools Home study nursing continuing education providers

Activities may be classified as Formal Learning Activities, including live planned programs, enduring materials (such as DVD- and web-based content), Process Improvement CME (or PI-CME, as defined by the American Medical Association), or Informal Learning Activities such as Internet-Point of Care (POC) research and decision making, or journal clubs whose members evaluate published research for mutual awareness and benefit. In 2008, professional certification for CME planners was established by the National Commission for Certification of CME Professionals which is earned by standardized exam, and confers the Certified CME Professional (CCMEP) certificate. NC-CME maintains a registry [7] of these certified professionals. As of June 2011, the Registry included 320 professionals.

Criticism of industry sponsorship


Critics, such as Morris and Taitsman,[] would prefer that the medical profession eliminate commercial support for CME. Despite ACCME requirements that program content be free of commercial interests, "CME providers can easily pitch topics designed to attract commercial sponsorship," and sponsors can award grants to programs that support their marketing strategies.[] The Institute of Medicine has said that CME has become too reliant on industry funding that "tends to promote a narrow focus on the products and to neglect provisions of a broader education on alternative strategies," such as communication and prevention.[8] For example, gabapentin (Neurontin), was approved by the U.S. Food and Drug Administration for adjunctive therapy in epilepsy, but Warner-Lambert sponsored CME activities that encouraged its use for off-label indications. The U.S. Department of Justice brought civil and criminal charges against Warner-Lambert, which Warner-Lambert settled for $430 million, alleging that Warner-Lambert paid kickbacks to doctors in the form of lavish trips to attend presentations about off-label uses.[9] More recently, AstraZeneca PLC has been fined $520 million in the United States for off-label promotion to doctors for their anti-psychotic drug, Seroquel. Industry-sponsored CMEs can violate federal statutes, according to the U.S. Department of Health and Human Services. "When a pharmaceutical manufacturer rewards high-prescribing physicians by directing a CME provider to pay (or overpay) them as CME faculty, consultants, or members of a speaker's bureau," wrote Morris and Taitsman.[]

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References
[5] http:/ / www. ama-assn. org/ ama1/ pub/ upload/ mm/ 455/ licensurerereg-06. pdf [8] Institute of Medicine, Conflict of interest in medical research, education, and practice. Washington, D.C., National Academies Press, 2009. [9] Warner-Lambert to pay $430 million to resolve criminal & civil health care liability relating to off-label promotion. (http:/ / www. usdoj. gov/ opa/ pr/ 2004/ May/ 04_civ_322. htm) Press release of the U.S. Department of Justice, Washington, DC, May 13, 2004.

Community mental health service


Psychology

Outline History Subfields

Basic types

Abnormal Biological Cognitive Comparative Cultural Differential Developmental Evolutionary Experimental Mathematical Personality Positive Quantitative Social

Applied psychology

Applied behavior analysis Clinical Community Consumer Educational Environmental Forensic Health Industrial and organizational Legal Military Occupational health Political Religion School

Community mental health service

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Sport

Lists

Disciplines Organizations Psychologists Psychotherapies Publications Research methods Theories Timeline Topics Psychology portal

Community mental health services (CMHS), also known as Community Mental Health Teams (CMHT) in the United Kingdom, support or treat people with mental disorders (mental illness or mental health difficulties) in a domiciliary setting, instead of a psychiatric hospital (asylum). The array of community mental health services vary depending on the country in which the services are provided. It refers to a system of care in which the patient's community, not a specific facility such as a hospital, is the primary provider of care for people with a mental illness. The goal of community mental health services often includes much more than simply providing outpatient psychiatric treatment.[1] Community services include supported housing with full or partial supervision (including halfway houses), psychiatric wards of general hospitals (including partial hospitalization), local primary care medical services, day centers or clubhouses, community mental health centers, and self-help groups for mental health. The services may be provided by government organizations and mental health professionals, including specialized teams providing services across a geographical area, such as assertive community treatment and early psychosis teams. They may also be provided by private or charitable organizations. They may be based on peer support and the consumer/survivor/ex-patient movement. The World Health Organization states that community mental health services are more accessible and effective, lessen social exclusion, and are likely to have less possibilities for the neglect and violations of human rights that were often encountered in mental hospitals. However, WHO notes that in many countries, the closing of mental hospitals has not been accompanied by the development of community services, leaving a service vacuum with far too many not receiving any care.[2] New legal powers have developed in some countries, such as the United States, to supervise and ensure compliance with treatment of individuals living in the community, known as outpatient commitment or assisted outpatient treatment or community treatment orders.

History
Origins
Community mental health services began as an effort to contain those who were "mad" or considered "lunatics." [3] Understanding the History of mental disorders is crucial in understanding the development of community mental health services. As medical psychology developed as a science and shifted toward the treatment of the mentally ill, psychiatric institutions began to develop around the world, and laid the groundwork for modern day community mental health services.

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Pre-Deinstitutionalization
On July 3, 1946 President Harry Truman signed the National Mental Health Act which, for the first time in the history of the United States, generated a large amount of federal funding for both psychiatric education and research. The passing of this Act eventually led to the founding of the National Institute of Mental Health (NIMH) in 1949.[4] At the end of the 1940s and moving into the beginning of the 1950s, the governor of Minnesota Luther Youngdahl initiated the development of numerous community-based mental health services. He also advocated for the humane treatment of people in state institutions.[4]

Deinstitutionalization
Philippe Pinel played a large role in the ethical and humane treatment of patients and greatly influenced Dorothea Dix. Dix advocated the expansion of state psychiatric hospitals for patients who were at the time being housed in jails and poor houses.[5] Despite her good intentions, rapid urbanization and increased immigration led to a gross overwhelming of the state's mental health systems [5] and because of this, as the 19th century ended and the 20th century began, a shift in focus from treatment to custodial care was seen.[5] As quality of care declined and psychotropic drugs were introduced, those with mental illnesses were reintroduced to the community, where community mental health services were designated as primary care providers.[5]

Mental Health Movements


Reform Movement Moral Treatment Mental Hygiene Community Mental Health Community Support Era 18001850 18901920 19551970 Asylum Mental hospital or clinic Community mental health center Setting Focus of Reform Humane, restorative treatment Prevention, scientific orientation Deinstitutionalization, social integration

1975present Communities

Mental illness as a social welfare problem (e.g. treatment housing, employment)

[6]

Post-Deinstitutionalization
Following deinstitutionalization, many of the mentally ill ended up in jails, nursing homes, and on the streets as homeless individuals.[5] It was at this point in history that modern community mental health services started to grow and become influential. In 1955, following a major period of deinstitutionalization, the Mental Health Study Act was passed. With the passing of this Act, the U.S. Congress called for "an objective, thorough, nationwide analysis and reevaluation of the human and economic problems of mental health." [4] Following Congress' mandate, the Joint Commission on Mental Illness conducted numerous studies. For the next four years this Commission made recommendations to establish community mental health centers across the country.[5] In 1963 the Community Mental Health Centers Act was passed, essentially kick-starting the community mental health revolution. This Act contributed further to deinstitutionalization by moving mental patients into their "least restrictive" environments.[7] The Community Mental Health Centers Act funded three main initiatives: 1. Professional training for those working in community mental health centers 2. Improvement of research in the methodology utilized by community mental health centers 3. Improving the quality of care of existing programs until newer community mental health centers could be developed.[7] That same year the Mental Retardation Facilities and Community Mental Health Centers Construction Act was passed. President John F. Kennedy ran part of his campaign on a platform strongly supporting community mental

Community mental health service health in the United States. Kennedy's ultimate goal was to reduce custodial care of mental health patients by 50% in ten to twenty years.[5] In 1965, the Community Mental Health Act was amended to ensure a long list of provisions. First, construction and staffing grants were extended to include centers that served patients with substance abuse disorders. Secondly, grants were provided to bolster the initiation and progression of community mental health services in low-SES areas. Lastly, new grants were established to support mental health services aimed at helping children.[4] As the 20th century progressed, even more political influence was exerted on community mental health. In 1965, with the passing of Medicare and Medicaid, there was an intense growth of skilled nursing homes and intermediate-care facilities that alleviated the burden felt by the large-scale public psychiatric hospitals.[5]

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The 20th Century


From 1965 to 1969, $260 million was authorized for community mental health centers.[5] Compared to other government organizations and programs, this number is strikingly low. Unfortunately, the funding drops even further under Richard Nixon from 19701973 with a total of $50.3 million authorized.[5] Even though the funding for community mental health centers was on a steady decline, deinstitutionalization continued into the 1960s and 1970s. The number of state and county mental hospital resident patients in 1950 was 512,501 and by 1989 had decreased to 101,402. This continuing process of deinstitutionalization without adequate alternative resources led the mentally ill into homelessness, jails, and self-medication through the use of drugs or alcohol.[5] In 1975 Congress passed an Act requiring community mental health centers to provide aftercare services to all patients in the hopes of improving recovery rates. In 1980, just five years later, Congress passed the Mental Health Systems Act, which provided federal funding for ongoing support and development of community mental health programs.[5] This Act strengthened the connection between federal, state, and local governments with regards to funding for community mental health services. It was the final result of a long series of recommendations by Jimmy Carter's Mental Health Commission.[4] Despite this apparent progress, just a year after the Mental Health Systems Act was passed, the Omnibus Budget Reconciliation Act of 1981 was passed. The Omnibus Act was passed by the efforts of the Reagan administration as an effort to reduce domestic spending. The Act rescinded a large amount of the legislation just passed, and the legislation that was not rescinded was almost entirely revamped. It effectively ended federal funding of community treatment for the mentally ill, shifting the burden entirely to individual state governments.[7] Federal funding was now replaced by granting smaller amounts of money to the individual states.[8] In 1977, the National Institute of Mental Health (NIMH) initiated its Community Support Program (C.S.P.). The C.S.P.'s goal was to shift the focus from psychiatric institutions and the services they offer to networks of support for individual clients.[8] The C.S.P. established the ten elements of a community support system listed below: 1. Responsible team 2. Residential care 3. Emergency care 4. Medicare care 5. Halfway house 6. Supervised (supported) apartments 7. Outpatient therapy 8. Vocational training and opportunities 9. Social and recreational opportunities 10. Family and network attention (Turner & Tenhoor, 1978) This conceptualization of what makes a good community program has come to serve as a theoretical guideline for community mental health service development throughout the modern-day United States psychological community.[8] In 1986 Congress passed the Mental Health Planning Act of 1986, which was a Federal law requiring that at the state government level, all states must have plans for establishing case management under Medicaid,

Community mental health service improving mental health coverage of community mental health services, adding rehabilitative services, and expanding clinical services to the homeless population.[4] More specifically, community mental health providers could now receive reimbursement for services from Medicare and Medicaid, which allowed for many of the centers to expand their range of treatment options and services.[7] As the 1990s began, many positive changes occurred for people with mental illnesses through the development of larger networks of community-based providers and added innovations with regards to payment options from Medicare and Medicaid.[7] Despite these advancements, there were many issues associated with the increasing cost of health care. Community mental health services moved toward a system more similar to managed care as the 1990s progressed.[7] Managed care as a system focuses on limiting costs by one of two means: either keeping the total number of patients using services low or reducing the cost of the service itself.[7] Despite the drive for community mental health, many physicians, mental health specialists, and even patients have come to question its effectiveness as a treatment.[7] The underlying assumptions of community mental health require that patients who are treated within a community have a place to live, a caring family, or supportive social circle that does not inhibit their rehabilitation. These assumptions are in fact often wrong. Many people with mental illnesses, upon discharge, have no family to return to and end up homeless.[7] While there is much to be said for the benefits that community mental health offers, many communities as a whole often harbor negative attitudes toward those with mental illnesses. Historically, people with mental illnesses have been portrayed as violent or criminal and because of this, "many American jails have become housing for persons with severe mental illnesses arrested for various crimes." [7] In 1999 the Supreme Court ruled on the case Olmstead v. L.C. The Court ruled that it was a violation of the Americans with Disabilities Act of 1990 to keep an individual in a more restrictive inpatient setting, such as a hospital, when a more appropriate and less restrictive community service was available to the individual.[4]

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21st Century & Modern Day Trends


In 2002 President George W. Bush increased funding for community health centers. The funding aided in the construction of additional centers and increased the number of services offered at these centers, which included healthcare benefits.[4] In 2003, the New Freedom Commission on Mental Health, established by President Bush, issued a report. The report was in place to "conduct a comprehensive study of the United States mental health delivery system..." Its objectives included assessing the efficiency and quality of both public and private mental health providers and identifying possible new technologies that could aid in treatment.[4] As the 20th century came to a close and the 21st century began, the number of patients diagnosed with a mental health or substance abuse disorder receiving services at community mental health centers grew from 210,000 to approximately 800,000.[9] This nearly four-fold increase shows just how important community mental health centers are becoming to the general population's wellbeing. Unfortunately, this drastic rise in the number of patients was not mirrored by a concomitant rise in the number of clinicians serving this population.[9] The staggering new numbers of patients then are being forced to seek specialized treatment from their primary care providers or hospital emergency rooms. The unfortunate result of this trend is that when a patient is working with his or her primary care provider, he or she is more likely for a number of reasons to receive less care than with a specialized clinician.[9] Politics and funding have always been and continue to be a topic of contention when it comes to funding of community health centers. Political views aside, it is clear that these community mental health centers exist largely to aid areas painfully under resourced with psychiatric care. In 2008, over 17 million people utilized community mental health centers with 35% being insured through Medicaid, and 38% being uninsured.[10] As the 2000s continued, the rate of increase of patients receiving mental health treatment in community mental health centers stayed steady.

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The Future
On one hand, despite the field's movement toward community mental health services, currently "insufficient empirical research exists regarding the effectiveness of community treatment programs, and the evidence that does exist does not generalize to all types of community treatment." [7] In addition to the fact that community mental health's overall success must be further evaluated, in the times when it has proved effective, very little research exists to help in understanding what exact aspects make it effective.[7] Effective and insightful research will be crucial in not only evaluating, but also improving the techniques community mental health utilizes.[7] On the other hand, the demand for and necessity of community mental health is driving it into the future. With this seemingly unrelenting increase in the number of people experiencing mental health illnesses and the number of people reporting these problems, the question becomes what role community mental health services will play. In 2007, almost 5% of adults in the United States reported at least one unmet need for mental health care. Funding has historically been and continues to be an issue for both the organizations attempting to provide mental health services to a community and the citizens of the community who are so desperately in need of treatment. The community mental health system's goal is an extremely difficult one and it continues to struggle against changing social priorities, funding deficits, and increasing need. Community mental health services would ideally provide quality care at a low cost to those who need it most. In the case of deinstitutionalization, as the number of patients treated increased, the quality and availability of care went down. With the case of small, private treatment homes, as the quality of the care went up their ability to handle large numbers of patients decreased. This unending battle for the middle ground is a difficult one but there seems to be hope. For example, the 2009 Federal Stimulus Package and Health Reform Act have increased the funding for community health centers substantially.[10] Undoubtedly as community mental health moves forward, there will continue to be a juggling act between clinical needs and standards, political agendas, and funding.

References
[1] Bentley, K. J. (1994) Supports for community-based meant health care: an optimistic view of federal legislation [2] World Health Organization press release (2007) Community mental health services will lessen social exclusion, says WHO (http:/ / www. who. int/ mediacentre/ news/ notes/ 2007/ np25/ en/ index. html) [3] Porter, R. (2006). Madmen: A Social History of Madhouses, Mad-Doctors & Lunatics. Stroud, Gloucestershire: Tempus Publishing. [4] Minnesota Psychiatric Society. A Detailed History of Mental Health [5] Kemp, D. (2007). Mental Health in America. Santa Barbara, CA: ABC-CLIO. [6] Morrissey & Goldman, 1984; Goldman & Morrissey, 1985 [7] Accordino, M. P., Porter, D. F., Morse, T. (2001) Deinstitutionalization of Persons with Severe Mental Illness: Context and Consequences [8] Mosher, L., Burti, L. (1989). Community Mental Health: Principles and Practice. New York: W. W. Norton & Company. [9] Druss B., Bornemann, T., Fry-Johnson, Y., McCombs, H., Politzer, R., Rust, G. (2006). Trends in Mental Health and Substance Abuse Services at the Nation's Community Health Centers: 1998-2003. American Journal of Public Health, 96, 1779-1784. [10] Wells, R., Morrissey, J., Lee I., Radford A. (2010). Trends in Behavioral Health Care Service Provision by Community Health Centers, 1998-2007. Psychiatric Services, 61, 759-764.

David G. Satin, Elizabeth Brainerd Lindemann, and Jean Farrell, ed. (1994). Insights and Innovations in Community Mental Health. Northvale: Jason Aronson Inc. ISBN1-56821-211-9. Grob, G. N. (1991). From Asylum to Community: Mental Health Policy in America. Princeton, NJ: Princeton University Press. Donaldson, L. (2005). "Collaboration Strategies for Reforming Systems of Care: A Toolkit for Community-Based Action". International Journal of Mental Health 34: 90102.

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Chief Medical Officer


Chief Medical Officer (CMO) is the title used in many countries for the senior government official designated head of medical services, usually at the national level. The post is held by a physician who serves to advise and lead a team of medical experts on matters of public health importance.[1] The post of Chief Medical Officer dates back to Victorian times.[2] The equivalent title may go under different names across countries, for example known as the Surgeon General in the United States and the Chief Public Health Officer in Canada.

References
[1] Department of Health, UK. Chief Medical Officer. (http:/ / www. dh. gov. uk/ en/ Aboutus/ MinistersandDepartmentLeaders/ ChiefMedicalOfficer/ index. htm) Accessed 19 Jan. 2012. [2] Department of Health, UK. History of the post of Chief Medical Officer. (http:/ / www. dh. gov. uk/ en/ Aboutus/ MinistersandDepartmentLeaders/ ChiefMedicalOfficer/ AboutTheChiefMedicalOfficerCMO/ CMOsOfThePast/ DH_4102228) Accessed 19 Jan. 2012.

Centers for Medicare and Medicaid Services

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Centers for Medicare and Medicaid Services


Centers for Medicare & Medicaid Services
Agency overview Formed 1977

Preceding Agency Health Care Financing Administration (1977-2001) Headquarters Employees Agency executive Woodlawn, Baltimore County, Maryland 4,100 Marilyn Tavenner Website www.cms.gov
[1]

The Centers for Medicare & Medicaid Services (CMS), previously known as the Health Care Financing Administration (HCFA), is a federal agency within the United States Department of Health and Human Services (DHHS) that administers the Medicare program and works in partnership with state governments to administer Medicaid, the State Children's Health Insurance Program (SCHIP), and health insurance portability standards. In addition to these programs, CMS has other responsibilities, including the administrative simplification standards from the Health Insurance Portability and Accountability Act of 1996 (HIPAA), quality standards in long-term care facilities (more commonly referred to as nursing homes) through its survey and certification process, and clinical laboratory quality standards under the Clinical Laboratory Improvement Amendments.

History
President Lyndon B. Johnson signed the Social Security Act on July 30, 1965, establishing both Medicare and Medicaid. The Social Security Administration (SSA) became responsible for the administration of Medicare and the Social and Rehabilitation Service (SRS) became responsible for the administration of Medicaid. Both agencies were organized under what was then known as the Department of Health, Education, and Welfare (HEW). In 1977, the Health Care Financing Administration (HCFA) was established under HEW. HCFA became responsible for the coordination of Medicare and Medicaid. The responsibility for enrolling beneficiaries into Medicare and processing premium payments remained with SSA. The CMS developed and uses several systems to classify Medicare cases. Hospital cases are classified using the Diagnosis-Related Group (DRG); outpatient cases are classified using the Ambulatory Patient Group (APG). These systems are used to determine how much Medicare pays the hospital or provider for each service or product.

Workforce
The CMS employs approximately 4,100 employees, of which 2,700 are located at its headquarters in Woodlawn, Maryland. The remaining employees are located in the Hubert H. Humphrey Building in Washington, D.C., the 10 regional offices listed below, and in various field offices located throughout the United States. The head of the CMS is the Administrator of the Center for Medicare & Medicaid Services. The position is appointed by the president and confirmed by the Senate.[]

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Regional offices
CMS has its headquarters in Woodlawn, Maryland, with 10 regional offices located throughout the United States:
Region I Boston, Massachusetts Connecticut, Massachusetts, Maine, New Hampshire, Rhode Island and Vermont. Region II New York City, New York New Jersey, New York, as well as the U.S. Virgin Islands and Puerto Rico. Region III Philadelphia, Pennsylvania Delaware, Maryland, Pennsylvania, Virginia, West Virginia and the District of Columbia. Region IV Atlanta, Georgia Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina and Tennessee. Region V Chicago, Illinois Region VI Dallas, Texas Arkansas, Louisiana, New Mexico, Oklahoma and Texas. Region VII Kansas City, Missouri Iowa, Kansas, Missouri, and Nebraska. Region VIII Denver, Colorado Colorado, Montana, North Dakota, South Dakota, Utah, and Wyoming. Region IX San Francisco, California Arizona, California, Hawaii, Nevada, the Territories of American Samoa, Guam, and the Commonwealth of the Northern Mariana Islands. Region X Seattle, Washington Alaska, Idaho, Oregon, and Washington

References
[1] http:/ / www. cms. gov

External links
Official website (http://www.cms.gov/)

Unlicensed assistive personnel


Unlicensed assistive personnel (UAP) is an umbrella term to describe a job class of paraprofessionals who assist individuals with physical disabilities, mental impairments, and other health care needs with their activities of daily living (ADLs) and provide bedside care including basic nursing procedures all under the supervision of a Registered Nurse, Licensed Practical Nurse or other health care professional. They provide care for patients in hospitals, residents of nursing facilities, clients in private homes, and others in need of their services due to effects of old age or disability. UAPs, by definition, do not hold a license or other mandatory professional requirements for practice, though many hold various certifications. They are collectively categorized under the group "Personal care workers in health services" in the International Standard Classification of Occupations, 2008 revision.[1]

Types of assistive personnel


The Nursing Assistant, Nursing Auxiliary, Auxiliary Nurse, Patient Care Assistant, Patient Care Technician, Home Health Aide/Assistant, Geriatric Aide/Assistant, Psychiatric Aide, Nurse Aide, or Nurse Tech are all common titles that are considered to be UAPs in many countries. In the United States, the Certified Nursing Assistant typically works in a nursing home or hospital, and performs everyday living tasks for the elderly, chronically sick, or rehabilitation patients who cannot care for themselves. There are some differences in scope of care across UAPs based on title and description. Typically, government certification indicates a more in-depth training and qualification that covers a wider scope of responsibility.[2][3] These certification exams are distributed by the state. Classes to study for these exams are provided by the American Red Cross as well as other providers. The courses offered by the American Red Cross encompass all facets that are addressed in the state exams from communication to health terms to sensitivity.

Unlicensed assistive personnel Similar titles in the United Kingdom and elsewhere include Healthcare Assistant, Healthcare Support Worker, or Clinical Support Worker, who usually work in hospitals or community settings under the guidance of a qualified healthcare professional.[4] Personal Support Worker is the title for a similar type of health worker in Canada. Some of the responsibilities and duties of a Personal Support Worker include, but are not limited to:[5] Observing, documenting and reporting clinical and treatment information, including patients' behavioral changes Assisting with motion exercises and other rehabilitative measures Taking and recording blood pressure, temperature, pulse, respiration, and bodyweight Assisting with ambulating and mobilization of patients Collecting specimens for required medical tests Providing emotional and support services to patients, their families and other caregivers Assisting with personal hygiene Assisting with meal preparation, grocery shopping, dietary planning, and food and fluid intake.

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Surgical technologists are considered UAPs in the US, where they are also sometimes called "Scrub tech". However the title can mean different things in different countries. For example in Mozambique, surgical technologists are medical professionals trained and registered to perform advanced clinical procedures including emergency surgery.[6] Birth assistants, such as doulas, childbirth educators and other persons providing emotional support and general care and advice to women and families during pregnancy and childbirth, are also typically considered UAPs. They are distinguished from midwives, physicians, nurses, and other professionals who are trained and licensed to provide basic and emergency pregnancy and childbirth-related health care services and manage complications.

Training and practice


Unlicensed assistive personnel are important members of the health care team who often hold a high level of experience and ability. While they do not require extensive health care training to practice their profession, a high level of manual dexterity and good interpersonal communication skills are usually necessary. They often undergo some formal education, apprenticeship or on-the-job training in areas such as body mechanics, nutrition, anatomy and physiology, cognitive impairments and mental health issues, infection control, personal care skills, and records-keeping.[1][2][4][7] Most community colleges offer CNA training in one semester. However, there are other sources that offer accelerated programs. Many nursing homes will actually pay for their employees to take CNA training on the premise that once completed the student will then work for them. In the context of aging populations and health care reform, UAPs are in growing demand in many countries. However, without formal health professional qualifications, UAPs are often unable to perform some tasks due to issues of liability and legality. Attempts to regulate, control, and verify education have been made in some places. This allows an employer to verify experience and knowledge as well as to assist in preventing individuals who have been "struck off" (had registration/certification invalidated) from continuing to work in healthcare roles. For example in the UK, the credibility of the Healthcare Assistant and other social care workers is intended to be strengthened by their compulsory registration from 2009 with the General Social Care Council in England or its Scottish or Welsh equivalents. In the United States, Family's and Employers can verify a UAPs certification in accordance to State and Local law's by checking with a Family Care Safety Registry (FCSR). A Family Care Safety Registry was established by law to promote family and community safety. The registry helps to protect children, seniors, and the disabled by providing background information on that individual. Families and employers can call the registry's toll-free line by phone, fax or E-mail to request background information on registered child care, elder care, and personal care workers or to request licensure status information on licensed child care and elder care providers at no-cost at all to the requestor .

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References
[1] World Health Organization. Classifying health workers: mapping occupations to the international standard classification. Geneva, WHO, 2010. [2] U.S. Department of Labor, Bureau of Labor Statistics. Occupational Outlook Handbook, 2010-11 Edition - Nursing and Psychiatric Aides. (http:/ / www. bls. gov/ oco/ ocos165. htm) Accessed 12 April 2011. [3] U.S. Department of Labor, Bureau of Labor Statistics. Occupational Outlook Handbook, 2010-11 Edition - Home Health Aides and Personal and Home Care Aides. (http:/ / www. bls. gov/ oco/ ocos326. htm) Accessed 12 April 2011. [4] National Health Service. NHS Careers in Detail: Healthcare assistants/auxiliary nurses. (http:/ / www. nhscareers. nhs. uk/ details/ Default. aspx?Id=485) Accessed 12 April 2011. [5] Personal Support Worker Canada. PSW Personal Support Worker Information. (http:/ / www. personalsupportworker. ca/ psw_information. html) Accessed 12 April 2011. [6] Cumbi A et al. "Major surgery delegation to mid-level health practitioners in Mozambique: health professionals' perceptions." Human Resources for Health; 2007, 5:27 [7] National Association of Career Colleges. Personal Support Worker. (http:/ / www. nacc. ca/ w_personal_support_worker. aspx) Accessed 12 April 2011.

External links
American Red Cross Certification and Employment Information (http://www.redcross.org/portal/site/en/ menuitem.d8aaecf214c576bf971e4cfe43181aa0/ ?vgnextoid=bf970c45f663b110VgnVCM10000089f0870aRCRD#nurse) CUPE presentation to Personal Support Workers (http://cupe.ca/supportservices/BE4600) in Canada, 2003 U.S. Department of Health & Human Services (http://www.hhs.gov)

Central nervous system


The central nervous system (CNS) is the part of the nervous system that integrates the information that it receives from, and coordinates the activity of, all parts of the bodies of bilaterian animalsthat is, all multicellular animals except radially symmetric animals such as sponges and jellyfish. It contains the majority of the nervous system and consists of the brain and the spinal cord. Some classifications also include the retina and the cranial nerves in the CNS. Together with the peripheral nervous system, it has a fundamental role in the control of behavior. The CNS is contained within the dorsal cavity, with the brain in the cranial cavity and the spinal cord in the spinal cavity. In vertebrates, the brain is protected by the skull, while the spinal cord is protected by the vertebrae, and both are enclosed in the meninges.[1]

Development
During early development of the vertebrate embryo, a longitudinal groove on the neural plate gradually deepens and the ridges on either side of the groove (the neural folds) become elevated, and ultimately meet, transforming the groove into a closed tube, the ectodermal wall of which forms the rudiment of the nervous system. This tube initially differentiates into three vesicles (pockets): the prosencephalon at the front, the mesencephalon, and, between the mesencephalon and the spinal cord, the rhombencephalon. (By six weeks in the human Development of the neural tube embryo) the prosencephalon then divides further into the telencephalon and diencephalon; and the rhombencephalon divides into the metencephalon and myelencephalon. As a vertebrate grows, these vesicles differentiate further still. The telencephalon differentiates into, among other things, the striatum, the hippocampus and the neocortex, and its cavity becomes the first and second ventricles.

Central nervous system Diencephalon elaborations include the subthalamus, hypothalamus, thalamus and epithalamus, and its cavity forms the third ventricle. The tectum, pretectum, cerebral peduncle and other structures develop out of the mesencephalon, and its cavity grows into the mesencephalic duct (cerebral aqueduct). The metencephalon becomes, among other things, the pons and the cerebellum, the myelencephalon forms the medulla oblongata, and their cavities develop into the fourth ventricle.

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Brain regions of a 4 week old human embryo

Central Brain Prosencephalon Telencephalon nervous Diencephalon system Brain stem Mesencephalon

Rhinencephalon, Amygdala, Hippocampus, Neocortex, Basal ganglia, Lateral ventricles Epithalamus, Thalamus, Hypothalamus, Subthalamus, Pituitary gland, Pineal gland, Third ventricle Tectum, Cerebral peduncle, Pretectum, Mesencephalic duct Pons, Cerebellum Medulla oblongata

Rhombencephalon Metencephalon Myelencephalon Spinal cord

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Evolution
Planarians, members of the phylum Platyhelminthes (flatworms), have the simplest, clearly defined delineation of a nervous system into a central nervous system (CNS) and a peripheral nervous system (PNS).[2] [3] Their primitive brain, consisting of two fused anterior ganglia, and longitudinal nerve cords form the CNS; the laterally projecting nerves form the PNS. A molecular study found that more than 95% of the 116 genes involved in the nervous system of planarians, which includes genes related to the CNS, also exist in humans.[4] Like planarians, vertebrates have a distinct CNS and PNS, though more complex than those of planarians. The CNS of chordates differs from that of other animals in being placed dorsally in the body, above the gut and notochord/spine.[5] The basic pattern of the CNS is highly conserved throughout the different species of vertebrates and during evolution. The major trend that can be observed is towards a progressive telencephalisation: the telencephalon of reptiles is only an appendix to the large olfactory bulb, while in mammals it makes up most of the volume of the CNS. In The central nervous system (2) is a combination the human brain, the telencephalon covers most of the diencephalon of the brain (1) and the spinal cord (3). and the mesencephalon. Indeed, the allometric study of brain size among different species shows a striking continuity from rats to whales, and allows us to complete the knowledge about the evolution of the CNS obtained through cranial endocasts. Mammals which appear in the fossil record after the first fishes, amphibians, and reptiles are the only vertebrates to possess the evolutionarily recent, outermost part of the cerebral cortex known as the neocortex.[6] The neocortex of monotremes (the duck-billed platypus and several species of spiny anteaters) and of marsupials (such as kangaroos, koalas, opossums, wombats, and Tasmanian devils) lack the convolutions gyri and sulci found in the neocortex of most placental mammals (eutherians).[] Within placental mammals, the size and complexity of the neocortex increased over time. The area of the neocortex of mice is only about 1/100 that of monkeys, and that of monkeys is only about 1/10 that of humans.[6] In addition, rats lack convolutions in their neocortex (possibly also because rats are small mammals), whereas cats have a moderate degree of convolutions, and humans have quite extensive convolutions.[6] Extreme convolution of the neocortex is found in dolphins, possibly related to their complex echolocation.

Diseases of the central nervous system


There are many central nervous system diseases, including infections of the central nervous system such as encephalitis and poliomyelitis, early-onset neurological disorders including ADHD and autism, late-onset neurodegenerative diseases such as Alzheimer's disease, Parkinson's disease, and essential tremor, autoimmune and inflammatory diseases such as multiple sclerosis and acute disseminated encephalomyelitis, genetic disorders such as Krabbe's disease and Huntington's disease, as well as amyotrophic lateral sclerosis and adrenoleukodystrophy. Lastly, cancers of the central nervous system can cause severe illness and, when malignant, can have very high mortality rates. Specialty professional organizations recommend that neurological imaging of the brain be done only to answer a specific clinical question and not as routine screening.[]

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References
[5] Romer, A.S. (1949): The Vertebrate Body. W.B. Saunders, Philadelphia. (2nd ed. 1955; 3rd ed. 1962; 4th ed. 1970) [6] 198

External links
Sylvius: 400+ structure neuroanatomical visual glossary (http://www.sylvius.com) High-Resolution Cytoarchitectural Primate Brain Atlases (http://primate-brain.org) Human Brains: A Learning Tool (http://www.marymt.edu/~psychol/brain.html). Explaining the human nervous system (http://www.humannervoussystem.info). Nervous System Back Pain Anatomy (info on nerve pairs) (http://www.backrack.co.uk/nervous_index. shtml). Textbook in Medical Physiology And Pathophysiology, many links (http://www.mfi.ku.dk/ppaulev/content. htm) Brain and Cranial Nerves, Anatomy and Physiology Lecture, Northland Community College (http://www. northland.cc.mn.us/biology/AP2Online/Fall2002/AP2PowerPoint/AP2Brainlecture_files/v3_document. htm) Latest Research on the Brain and Central Nervous System (http://www.sciencedaily.com/news/mind_brain/) From ScienceDaily (http://www.sciencedaily.com/) The Department of Neuroscience at Wikiversity Overview of the Central Nervous System (http://nba.uth.tmc.edu/neuroscience/s2/chapter01.html), Neuroscience Online (electronic neuroscience textbook)

Consolidated Omnibus Budget Reconciliation Act of 1985


The Consolidated Omnibus Budget Reconciliation Act of 1985 (or COBRA) is a law passed by the U.S. Congress on a reconciliation basis and signed by President Ronald Reagan that, among other things, mandates an insurance program giving some employees the ability to continue health insurance coverage after leaving employment. COBRA includes amendments to the Employee Retirement Income Security Act of 1974 (ERISA). The law deals with a great variety of subjects, such as tobacco price supports, railroads, private pension plans, emergency room treatment, disability insurance, and the postal service, but it is perhaps best known for Title X, which amends the Internal Revenue Code and the Public Health Service Act to deny income tax deductions to employers (generally those with 20 or more full-time equivalent employees) for contributions to a group health plan unless such plan meets certain continuing coverage requirements. The violation for failing to meet those criteria was subsequently changed to an excise tax. Although this statute became law on April 7, 1986, its official name is the Consolidated Omnibus Budget Reconciliation Act of 1985 (Pub.L. 99272 [1], 100Stat.82 [2]). Because of the discrepancy between the official name of the Act and the year in which it was enacted,[3] some government publications refer to the Act as the Consolidated Omnibus Budget Reconciliation Act of 1986. The Act is often referred to simply as "COBRA".

Consolidated Omnibus Budget Reconciliation Act of 1985

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Provisions
As originally enacted, Title X of the Act provided that a qualifying employer will not be permitted to take a tax deduction for its health insurance costs unless its health insurance plan allows employees of the employer and the employee's immediate family members who had been covered by a health care plan to maintain their coverage if a "qualifying event" causes them to lose coverage. However, the legislation was subsequently amended to instead impose an excise tax upon an employer whose health plan fails to satisfy the applicable rules. A qualifying employer is generally an employer with 20 or more full-time equivalent employees.[4] Among the "qualifying events" listed in the statute are loss of benefits coverage due to (1) the death of the covered employee; (2) an employee loses eligibility for coverage due to voluntary or involuntary termination or a reduction in hours as a result of resignation, discharge (except for "gross misconduct"[5][6]), layoff, strike or lockout, medical leave, or slowdown in business operations; (3) divorce or legal separation that terminates the ex-spouse's eligibility for benefits; or (4) a dependent child reaching the age at which he or she is no longer covered. COBRA imposes different notice requirements on participants and beneficiaries, depending on the particular qualifying event that triggers COBRA rights. See DOL.GOV's FAQs For Employers About COBRA Continuation Health Coverage [7] COBRA also allows for coverage for up to 18 months in most cases. If the individual is deemed disabled by the Social Security Administration, coverage may continue for up to 29 months. In the case of divorce from the former employee, the former spouse's coverage may continue for up to 36 months. In the case of death of the former employee, the widow's coverage may continue for up to 36 months. COBRA does not apply, on the other hand, if employees lose their benefits coverage because the employer has terminated the plan altogether or if the employer has gone out of business. In cases where COBRA does not apply, some states have stepped in with state health insurance continuation laws, usually called "mini-COBRA" laws, which help employees continue their health insurance when federal COBRA does not apply.[8] COBRA does not, unlike other federal statutes such as the Family and Medical Leave Act (FMLA), require the employer to pay for the cost of providing continuation coverage. Instead it allows employees and their dependents to maintain coverage at their own expense by paying the full cost of the premium the employer and the employee previously paid, plus up to a 2% administrative charge (50% for the latter 11 months under the disability extension). According to the U.S. Department of Labor:[9] ...the coverage you are given must be identical to the coverage that is currently available under the plan to similarly situated active employees and their families (generally, this is the same coverage that you had immediately before the qualifying event). You will also be entitled, while receiving continuation coverage, to the same benefits, choices, and services that a similarly situated participant or beneficiary is currently receiving under the plan, such as the right during an open enrollment season to choose among available coverage options. You will also be subject to the same rules and limits that would apply to a similarly situated participant or beneficiary, such as co-payment requirements, deductibles, and coverage limits. Employees and dependents can also opt for a lesser form of coverage, e.g., to choose continuation coverage under a plan that only covers the employee, but not his or her dependents, or that only provides medical and hospitalization coverage and does not pay for dental work, if those options are available to covered employees. Employees and dependents lose coverage if they fail to make timely payments of these premiums. Employers are required to inform employees and dependents upon loss of coverage, in writing, by at least fifteen days before the coverage ceases.

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Coordination of coverage
An individual covered under COBRA may also be covered by another group health plan or Medicare as long as one of two conditions are met:[10] 1. The other coverage was in force as of or prior to the coverage under COBRA, or, 2. The other coverage is subject to pre-existing conditions exclusions or limitations.

Subsidy under federal stimulus


Only 10% of Americans eligible for COBRA insurance in 2006 used it, many because they were unable to afford to pay the full premium after their job loss.[11] While some employers may voluntarily help subsidize or fully cover the cost of COBRA insurance as part of a termination or exit package, it is more common for the ex-employee to cover the entire cost.[12] The American Recovery and Reinvestment Act of 2009 as signed by President Barack Obama includes a 65% subsidy to employees for COBRA-enabled insurance for up to 9 months[] after an involuntary termination (this has since been expanded to 15 months). An employee is eligible for this subsidy if the termination of employment was involuntary, the terminated employee has no other group sponsored health insurance option, and the terminated employee is otherwise eligible to enroll in COBRA. If the employee has an adjusted gross income in 2009 over $125,000 if filing as single ($250,000 if filing jointly), then the subsidy will be recaptured in a phased manner from the employee through the tax system. Termination of employment must have occurred between September 1, 2008 and December 31, 2009 (later expanded to February 28, 2010, expanded again to March 31, 2010, and then expanded again to June 2, 2010). Specific provisions and responsibilities may differ in the state specific mini-COBRA plans for employers with fewer than 20 employees throughout half of the previous calendar year. Those employees who are eligible for the ultimate benefits of this subsidy are referred to as Assistance Eligible Individuals (or AEIs). Employers subject to Federal COBRA are required to:[] Notify terminated employees of their potential rights under ARRA by sending a series of notices Provide a method for qualified AEIs to enroll Pay the full amount of the premiums and seek reimbursement of the 65% subsidy by including it in the Employer's Quarterly Federal Tax Return (Form 941) This Act was signed into law by President Barack Obama on February 17, 2009. On December 19, 2009, President Obama signed into law the Department of Defense Appropriations Act, 2010, which made several amendments to the COBRA provisions of the American Recovery and Reinvestment Act of 2009 (ARRA). The Act extends COBRA subsidy eligibility to employees who lost their jobs due to no fault of their own between January 1 and February 28, 2010. The nine-month subsidy period was also expanded to fifteen months.[13][14] On March 3, 2010, President Obama signed into law the Temporary Extension Act of 2010.[15] The Act extends COBRA subsidy eligibility to employees who lost their jobs due to no fault of their own between March 1 and 31, 2010.[] In addition, employees who lost group health insurance due to reduced work hours on or after Sept. 1, 2008, followed by involuntary termination between March 2 and March 31, 2010, will now be eligible for the COBRA subsidy.[16] The Continuing Extension Act of 2010 extends premium assistance for COBRA benefits through May 31, 2010.[17] As of June 2010, an extension of COBRA's premium assistance has not materialized, and attempts by congressional members to include such provisions have been dropped. As of June 1, 2010, all newly unemployed workers must pay full coverage costs as determined by their respective plans.[18] This is due in part to conservative Democrats in

Consolidated Omnibus Budget Reconciliation Act of 1985 Congress who have expressed concerns about treating some unemployed workers differently than others, such as people priced out of the private insurance market.[18] A number of Senate Democrats expressed concern about this situation and have introduced legislation to expand COBRA coverage to people who become unemployed through November 2010,[18] but such legislation did not pass in 2010.

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Similar state and local legislation


Forty-one states have legislation similar to federal COBRA requiring employers to allow employees and their dependents to continue their group health insurance coverage following certain qualifying events.[19][20]

California
California's legislation only applies to non-government employers with a group health insurance plan with fewer than twenty employees.[21]

District of Columbia
The District of Columbia's Continuation of Health Coverage Act of 2001 applies to employers with a group health insurance plan with a situs in the District of Columbia and with fewer than twenty employees. Coverage must be offered to be extended for a period of three months following the date that coverage would have ended.[]

Maryland
Maryland's legislation only applies to employers with a group health insurance plan with a situs in Maryland and with fewer than twenty employees. Maryland law requires that continuation coverage must be offered to an employee who lives in Maryland, who had coverage from the employer for at least three months, and who either resigns or loses employment due to no fault of their own. Continuation coverage must also be offered to the former spouse and dependent children of an employee after a divorce. One exception to the eighteen-month rule is that coverage may end for the former spouse upon the former spouse's remarriage. Continuation coverage must also be offered to the surviving spouse and dependent children of an employee who dies. The employee must have resided in Maryland and had coverage with the employer for at least three month prior to death. In all cases, continuation coverage must be offered for eighteen months, with the exception that a former spouse's continuation coverage ends upon remarriage.[]

Virginia
Virginia's legislation applies to employers with a group health insurance plan, other than an HMO plan, and with twenty or fewer employees. Employers must offer continuation coverage to employees for twelve months.[] The legislation does not apply to employees who did not have coverage from the employer for at least three months prior to the qualifying event.[]

References
[1] http:/ / www. law. cornell. edu/ jureeka/ index. php?doc=USPubLaws& cong=99& no=272 [2] http:/ / www. gpo. gov/ fdsys/ granule/ STATUTE-100/ STATUTE-100-Pg82/ content-detail. html [3] Discrepancies between the date in the official title of a U.S. budget Act and the date on which the Act was signed into law occur with some frequency. See, for example, the Deficit Reduction Act of 2005, signed into law in February 2006. [4] ERISA cites "(more) than 20 employees on a typical business day during the preceding calendar year". [5] Zickafoose v. UBServices, Inc., 23 F.Supp.2d 652, 655 (S.D.W.Va.1998). "Conduct is gross misconduct if it is so outrageous that it shocks the conscience." [6] When an employee is discharged for gross misconduct, the employer is not required to offer COBRA continuation coverage to the employee, the employee's spouse, or the employee's dependents. See Mlsna v. Unitel Communications, Inc. (http:/ / caselaw. lp. findlaw. com/ scripts/ getcase. pl?court=7th& navby=case& no=952645) 41 F.3d 1124 (7th Cir. 1994).

Consolidated Omnibus Budget Reconciliation Act of 1985


[7] http:/ / www. dol. gov/ ebsa/ faqs/ faq_compliance_cobra. html [8] (http:/ / myhealthcafe. com/ not-eligible-for-cobra-for-health-insurance-you-might-still-be-eligible-for-mini-cobra-health-insurance-continuation), Not Eligible For COBRA Health Insurance? You Might Still Be Eligible For Mini-COBRA Health Insurance Continuation," MyHealthCafe.com. [9] "Benefits Under Continuation Coverage" section of Department of Labor - Employee brochure (http:/ / www. dol. gov/ ebsa/ pdf/ cobraemployee. pdf)

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External links
US Department of Labor: COBRA FAQs for Employees (http://www.dol.gov/ebsa/faqs/faq-consumer-cobra. html) Employee Brochure (http://www.dol.gov/ebsa/pdf/cobraemployee.pdf), Department of Labor (pdf) Other Resources (http://www.dol.gov/dol/topic/health-plans/cobra.htm), Department of Labor COBRA Insurance Direct (http://www.cobrainsurancedirect.com) Learn more about COBRA Insurance COBRA insurance guide (http://www.cobrainsurance.com) Information about COBRA COBRA Insurance Information Center (http://www.whatiscobrainsurance.org) (private website) Library of Congress THOMAS summary of the Act. (http://thomas.loc.gov/cgi-bin/bdquery/ z?d099:HR03128:@@@D&summ2=m&|TOM:/bss/d099query.html) General information (http://www.cms.hhs.gov/COBRAContinuationofCov) from the Centers for Medicare and Medicaid Services (CMS) COBRA insurance information (http://www.cobrainsurancebenefits.org) (private website)

Council of governments
Councils of governments are regional bodies that exist throughout the United States. They are also sometimes called regional councils, regional commissions, regional planning commissions, planning district commissions, and development districts. A typical council is defined to serve an area of several counties, and they address issues such as regional and municipal planning, economic and community development, cartography and GIS, hazard mitigation and emergency planning, aging services, water use, pollution control, transit administration, and transportation planning. Council membership is drawn from the county, city, and other government bodies within its area.

State versions
North Carolina Councils of Governments Texas Association of Regional Councils Virginia Planning District Commissions

Regional versions
Metropolitan Washington Council of Governments Centre Region Council of Governments [1] Puget Sound Regional Council [2] Southern Iowa Council of Governments [3]

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County-wide version
Maricopa Association of Governments Pima Association of Governments

Further reading
Nelson Wikstrom; "Councils of Governments"; 1977, Burnham, Munger & Root, ISBN 0-88229-322-2. W. G. Roeseler; "Public intervention and pseudo government in urban areas : a critique of the public involvement process and the councils of government"; 1977, EMR Publications, ISBN 0-930308-03-4.

External links
Parks in the Centre Region [4] National Association of Regional Councils web site [5] Alabama Association of Regional Councils web site [6] Georgia Association of Regional Commissions web site [7] Virginia Association of Planning District Commissions [8]

References
[1] [2] [3] [4] [5] [6] [7] [8] http:/ / www. crcog. net http:/ / www. psrc. org http:/ / www. sicog. com http:/ / www. excitingnature. com/ parks/ http:/ / www. narc. org/ http:/ / www. alarc. org/ http:/ / garc. ga. gov http:/ / www. vapdc. org

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Cost of living
Cost of living is the cost of maintaining a certain standard of living. Changes in the cost of living over time are often operationalized in a cost of living index. Cost of living calculations are also used to compare the cost of maintaining a certain standard of living in different geographic areas. Differences in cost of living between locations can also be measured in terms of purchasing power parity rates.

Cost-of-living Adjustment (COLA)


Protests in Aysn due to the high cost of living in Employment contracts, pension benefits, and government entitlements Patagonia (such as Social Security) can be tied to a cost-of-living index, typically to the Consumer Price Index (CPI). A Cost of Living Allowance (COLA) adjusts salaries based on changes in a cost-of-living index. Salaries are typically adjusted annually. They may also be tied to a cost-of-living index that varies by geographic location if the employee moves. In this later case, the expatriate employee will likely see only the discretionary income part of his salary indexed by a differential CPI between the new and old employment locations, leaving the non-discretionary part of the salary (e.g. mortage payments, insurance, car payments, ...) unmodified.

Annual escalation clauses in employment contracts can specify retroactive or future percentage increases in worker pay which are not tied to any index. These negotiated increases in pay are colloquially referred to as cost-of-living adjustments or cost-of-living increases because of their similarity to increases tied to externally-determined indexes. Cost of living allowance is equal to the nominal interest minus the real interest rate.

CPI is not a COLA


When cost of living adjustments, negotiated wage settlements and budgetary increases exceed CPI, media reports frequently compare the two without consideration of the pertinent tax code. However, CPI is based on the retail pricing of a basket of goods and services. Most purchases of that same basket require the use of after-tax dollars dollars that were often subject to the highest marginal tax rate. Consequently, the COLA will necessarily have to exceed the CPI/inflation rate to maintain purchasing power. The widely recognized problem known as bracket-creep can also occur in countries where the marginal tax brackets themselves are not indexed COLA increases simply place more dollars into higher tax rate brackets. (Only under a flat-rate tax system would a percentage gain on gross income translate into a comparable inflation-offsetting gain at the after-tax level.) Some salaries and pensions in the U.S. with a COLA (they vary by type) include: Social Security Civil Service Retirement System (CSRS)[] Federal Employees Retirement System (FERS)[] Pensions in Canada with a COLA include: Canadian Auto Workers union (CAW) Local 200 (Ontario)

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Worldwide Cost of Living Survey


The Economist Intelligence Unit produces a bi-annual (twice yearly) worldwide cost of living survey that compares more than 400 individual prices across 160 products and services. They include food, drink, clothing, household supplies and personal care items, home rents, transport, utility bills, private schools, domestic help and recreational costs. The survey itself is a purpose-built internet tool designed to calculate cost-of-living allowances and build compensation packages for expatriates and business travellers. The survey incorporates easy-to-understand comparative cost of living indices between cities. The survey allows for city to city comparisons, but for the purpose of this report all cities are compared to a base city of New York, which has an index set at 100. The survey has been carried out for more than 30 years. The most recent survey was published in February 2013 containing data from December 2012 . Tokyo Became the most expensive city that year, while Zurich, the top city in the survey the previous year dropped down 5 places. Sydney and Melbourne both got up in the index from previous years, with Sydney becoming the 3rd most expensive city (from the 7th spot), and Melbourne becoming the 4th (from the 8th spot). Asia is home to more than 10 most expensive cities in the top 20 but also home to 6 cheapest cities of the cheapest ten.

Other uses of the term "cost-of-living allowance"


Stipends or extra pay provided to employees who are being temporarily relocated may also be called cost-of-living adjustments or cost-of-living allowances. Such adjustments are intended to offset changes in welfare due to geographic differences in the cost of living. Such adjustments might more accurately be described as a per diem allowance or tied to a specific item, as with housing allowances. Employees who are being permanently relocated are less likely to receive such allowances, but may receive a base salary adjustment to reflect local market conditions. A cost-of-living allowance is frequently given to members of the U.S. military stationed at overseas bases if the area to which a service member is assigned has a higher cost of living than the average area in the United States. For example, service members stationed in Japan receive a cost of living allowance of between $300 and $700 per month (depending on pay grade, years of service, and number of dependents), in addition to their base pay. This additional pay is non-taxable.

References External links


Economist Intelligence Unit worldwide cost of living survey results (http://www.eiu.com/WCOL2012) (requires registration) Cost-of-Living Calculator (http://www.aier.org/article/48-cost-living-calculator) relative to time from American Institute for Economic Research (AIER) US Consumer Price Index FAQ (http://www.bls.gov/cpi/cpifaq.htm) Worldwide user provided cost of living information (http://www.eardex.com) User contributed cost of living database (http://www.expatistan.com) International Cost of Living by City (http://www.earthcosts.com) Living Wage Calculator - Introduction to the Living Wage Calculator (http://livingwage.mit.edu)

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Certificate of need
A Certificate of Need (CON), in the United States, is a legal document required in many states and some federal jurisdictions before proposed acquisitions, expansions, or creations of facilities are allowed. CONs are issued by a federal or state regulatory agency with authority over an area to affirm that the plan is required to fulfill the needs of a community. The concept of the Certificate of Need first arose in the field of health care and was passed first in New York in 1964 and then into federal law by the Richard Nixon administration in 1972. Certificates of need are necessary for the construction of medical facilities in 35 states and are issued by state health care agencies: The certificate-of-need requirement was originally based on state law. New York passed the first certificate-of-need law in 1964, the Metcalf- McCloskey Act. From that time to the passage of Section 1122 of the Social Security Act in 1972, another 18 states passed certificate-of-need legislation. Section 1122 was enacted because many states resisted any form of regulation dealing with health facilities and services.[1] A number of factors spurred states to require certificates of need in the health care industry. Chief among these was the concern that the construction of excess hospital capacity would cause competitors in an oversaturated field to cover the costs of a diluted patient pool by over-charging, or by convincing patients to accept hospitalization unnecessarily.[2] In some instances where state and federal authorities overlap, federal regulations may defer authority from the federal agency to the state agency with concurrent authority as to the issuance of a certificate of need. However, deferment of this authority is not required. For example, the Department of Housing and Urban Development has issued the following determination: HUD conducts the same analysis of need whether or not the state has a CON process. There is wide variation in the methods CON states use to decide whether or not to issue a certificate. HUD believes that the Act's required need assessment is best performed using a method that is applied consistently to hospitals in all states. Should the state's CON process and HUD's assessment of need reach differing conclusions on the need for a proposed project, HUD will review the case closely to determine if its conclusion should be changed.[3]

Criticism
Since new hospitals cannot be constructed without proving a "need," the certificate-of-need system grants monopoly privileges to already existing hospitals. Consequently, Alaska House of Representatives member Bob Lynn has argued that the true motivation behind certificate-of-need legislation is that "large hospitals are... trying to make money by eliminating competition" under the pretext of using monopoly profits to provide better patient care.[4]

References
[1] Herbert Harvey Hyman, Health Planning: A Systematic Approach (1982), p. 253. [2] Robert James Cimasi, The U.S. Healthcare Certificate of Need Sourcebook (2005), p. 2. [3] Department of Housing and Urban Development, Office of the Assistant Secretary for Housing -- Federal Housing Commissioner, Federal Register, Vol. 72, No. 228 (72 FR 67524, 67531), issued Wednesday, November 28, 2007. [4] Blogs by Rep Bob Lynn, 2007. http:/ / alaskadistrict31. blogspot. com/ 2007/ 04/ another-attempt-to-eliminate. html

Further reading
Robert James Cimasi, The U.S. Healthcare Certificate of Need Sourcebook (2005). "A state-by-state analysis of the certificate of need statutes, regulations, case law, and key state health department personnel".

Chronic obstructive pulmonary disease

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Chronic obstructive pulmonary disease


Chronic Obstructive Pulmonary Disease
Classification and external resources

Gross pathology of a lung showing centrilobular-type emphysema characteristic of smoking. This close-up of the fixed, cut lung surface shows multiple cavities lined by heavy black carbon deposits. ICD-10 ICD-9 OMIM DiseasesDB MedlinePlus eMedicine MeSH J40 490 [1] J44 492 [8] [2] , J47 [3] [6] 496 [7]

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[5]

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med/373

C08.381.495.389

Chronic obstructive pulmonary disease (COPD), also known as chronic obstructive lung disease (COLD), chronic obstructive airway disease (COAD), chronic airflow limitation (CAL) and chronic obstructive respiratory disease (CORD), is a lung disease defined by persistently poor airflow as a result of breakdown of lung tissue (known as emphysema) and dysfunction of the small airways.[] It typically worsens over time.[] Primary symptoms include: shortness of breath, cough, and sputum production. COPD is caused primarily by tobacco smoke, with a number of other factors playing a less common role.[] This triggers an inflammatory response in the lung.[] COPD is often defined based on low airflow on lung function tests.[14] In contrast to asthma, this limitation is poorly reversible and usually gets increasingly worse over time. Management involves quitting smoking, vaccinations, rehabilitation, and often inhaled bronchodilators. Some people may benefit from long-term oxygen therapy or lung transplantation.[] Worldwide, COPD ranked as the sixth leading cause of death in 1990. Mortality is expected to increase due to an increase in smoking rates and an aging population in many countries.[15] COPD is the third leading cause of death in the U.S., and the economic burden of COPD in the U.S. in 2007 was $42.6billion in health care costs and lost productivity.[16][]

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Signs and symptoms


The most common symptoms of COPD are sputum production, shortness of breath and a productive cough.[17][]

Cough
A chronic cough is usually the first symptom to occur. When it exists for more than three months a year for more than two years without another explanation, there is by definition chronic bronchitis. This condition can occur before COPD officially develops. The amount of sputum produced can change over hours to days. In some cases the cough may not be present or only be occur occasionally and may not be productive. Some people with COPD write it off as simply a "smoker's cough". Sputum may be swallowed or spit out, depending often on social and cultural factors. Vigorous coughing may lead to rib fractures or a brief loss of consciousness. Those with COPD often have a history of "common colds" that last a long time.[]

Shortness of breath
Shortness of breath is often the symptom that bother people the most.[] It commonly describe as: "my breathing requires effort," "I feel out of breath," or "I can't get enough air in".[] Different term; however may be used in different cultures.[] Typically the shortness of breath is of a prolonged duration, worsened over time and is worse with exercise.[] In the advanced stages it occurs during rest and maybe always present.[18][] It is a big reason for both anxiety and a poor quality of life in those with COPD.[]

Other
The two most common breath sounds heard in people with COPD are crackles and rhonchi.[19] Those with obstructed airflow may have wheezing or decreased sounds of air entry with poor air entry typically representing a greater severity of disease.[] It may also take longer to breath out than breathing in.[] Chest tightness may occur[] but is not common and may represent another problem.[] A barrel chest, while a classific finding, is also not a frequent finding.[] In those with severe disease tiredness and weight loss become common.[] Advanced COPD may lead to cor pulmonale, a strain on the heart due to the extra work required to pump blood through the lungs.[] It is also the most common cause of the condition.[] Symptoms that indicate the presence of cor pulmonale include swelling of the ankles.[] Finger nail clubbing is not specific to COPD and should prompt investigations for an underlying lung cancer.[20] Many people with COPD breath through pursed lips and this action can improve shortness of breath in some.[21][22]

Exacerbation
An exacerbation is defined as increased shortness of breath, increased sputum production, a change in the color of the sputum from clear to green or yellow, or an increase in cough in someone with COPD.[] This may present with signs of increased work of breathing such as: fast breathing, a fast heart rate, sweating, active use of muscles in the neck, a bluish tinge to the skin, and confusion if in a severe exacerbation.[]

Co-existing conditions
COPD often occurs along with a number of other conditions due in part to common risk factors.[] These conditions include: ischemic heart disease, hypertension, diabetes mellitus, muscle wasting, osteoporosis, lung cancer, anxiety disorder and / or major depressive disorder.[] Bronchial hyperresponsiveness, is a characteristic of asthma and refers to the increased sensitivity of the airways in response to an inhaled constrictor agonist. Many people with COPD also have this tendency. In COPD, the presence of bronchial hyperresponsiveness predicts a worse course of the disease.[]

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Cause
The primary cause of COPD is tobacco smoke; with occupational exposures and pollution from indoor fires being a significant cause in some countries.[] Typically these exposures must occur over 10s of years before symptoms develop and genetics also affects the probability.[]

Smoking
The primary risk factor for COPD globally is tobacco smoking.[] Other types of smoke are also a risk including: marijuana, cigar, second hand and water pipe smoke.[] In the United States, 80 to 90% of cases of COPD are due to smoking.[][23] Exposure to cigarette smoke is measured in pack-years,[24] the average number of packages of cigarettes smoked daily multiplied by the number of years of smoking. The likelihood of developing COPD increases with age and cumulative smoke exposure, and almost all lifelong smokers will develop COPD, provided that smoking-related, extrapulmonary diseases (cardiovascular, diabetes, cancer) do not claim their lives beforehand.[25]

Air pollution
In many developing countries, indoor air pollution from cooking fire smoke (often using biomass fuels such as wood and animal dung) is a common cause of COPD, especially in women.[26] This is a common method of cooking and heating for nearly three billion people globally.[] People who live in large cities have a higher rate of COPD compared to people who live in rural areas.[27] While urban air pollution may be a contributing factor to exacervations its likely overall role in causing COPD is believed to be small.[]

Occupational exposures
Intense and prolonged exposure to workplace dusts found in coal mining, gold mining, and the cotton textile industry and chemicals such as cadmium, isocyanates, and fumes from welding have been implicated in the development of airflow obstruction, even in nonsmokers.[28] Workers who smoke and are exposed to these particles and gases are even more likely to develop COPD. Intense silica dust exposure causes silicosis, a restrictive lung disease distinct from COPD; however, less intense silica dust exposures have been linked to a COPD-like condition.[29] The effect of occupational pollutants on the lungs appears substantially less important than the effect of cigarette smoking.[] In the United States it is the cause of about 20% of cases overall and 30% of those in never-smokers.[] The rates are believed to be higher in the developing world.[]

Genetics
Genetics play a role in the development of COPD.[] It is more common among relatives of those with COPD who smoke than unrelated smokers.[] An inherited genetic condition, alpha 1-antitrypsin deficiency is responsible for about 2% of cases.[]

Other
A number of other factors are less well linked to COPD. The risk is greater in those who are poor however it is no clear it this is due to poverty itself or other factors associated with poverty such as air pollution and nutrition.[] There is tentative evidence that those with asthma and airway hyperreactivity are at increased risk.[] Birth factors such as low birth weight may also play a role as do a number of infectious diseases including HIV/AIDS and tuberculosis.[]

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Acute exacerbations
An acute exacerbation of COPD is a sudden worsening of symptoms (shortness of breath, quantity and color of phlegm). It may be triggered by an infection or by environmental pollutants. Typically, infections cause 75% or more of the exacerbations; bacteria in 25% of cases, viruses in 25%, and both in 25%. Airway inflammation is increased during the exacerbation, resulting in increased hyperinflation, reduced expiratory air flow and worsening of gas transfer. This can also lead to hypoventilation and eventually hypoxia, insufficient tissue perfusion, and then cell necrosis.[] Pulmonary emboli can also worsening symptoms in those with COPD.[]

Pathophysiology
COPD is a type of obstructive lung disease in which chronic incompletely reversible airflow limit exists.[] This airflow limitation is due to break down of lung tissue (known as emphysema) and small airway disease known as obstructive bronchiolitis.[] The amount of these two factors vary between people.[] It developed secondary to an more pronounced and chronic inflammatory response to inhaled irritants.[] It is not fully understood how tobacco smoke and other inhaled particles damage the lungs to cause COPD. The most important processes causing lung damage are: Oxidative stress produced by the high concentrations of free radicals in tobacco smoke Cytokine release due to inflammation as the body responds to irritant particles such as tobacco smoke in the airway Tobacco smoke and free radicals impair the activity of antiprotease enzymes such as alpha 1-antitrypsin, allowing protease enzymes to damage the lung Narrowing of the airways reduces the airflow rate to and from the air sacs (alveoli) and limits effectiveness of the lungs. In COPD, the greatest reduction in air flow occurs when breathing out (during expiration) because the pressure in the chest tends to compress rather than expand the airways. In theory, air flow could be increased by breathing more forcefully, increasing the pressure in the chest during expiration. In COPD, there is often a limit to how much this can actually increase air flow, a situation known as expiratory flow limitation.[]
Enlarged view of lung tissue showing the difference between healthy lung and COPD

Micrograph demonstrating emphysema (left large empty spaces) and lungtissue with relative preservation of the alveoli (right).

If the rate of airflow is too low, a person with COPD may not be able to completely finish breathing out (expiration) before he or she needs to take another breath. This is particularly common during exercise, when breathing must be faster. A little of the air of the previous breath remains within the lungs when the next breath is started, resulting in an increase in the volume of air in the lungs, a process called dynamic hyperinflation.[] Dynamic hyperinflation is closely linked to shortness of breath in COPD.[] It is less comfortable to breathe with hyperinflation because it takes more effort to move the lungs and chest wall when they are already stretched by hyperinflation. Another factor contributing to shortness of breath in COPD is the loss of the surface area available for the exchange of oxygen and carbon dioxide with emphysema. This reduces the rate of transfer of these gases between the body and the atmosphere and can lead to low oxygen and high carbon dioxide levels in the body. A person with

Chronic obstructive pulmonary disease emphysema may have to breathe faster or more deeply to compensate, which can be difficult to do if there is also flow limitation or hyperinflation. Some people with advanced COPD do manage to breathe fast to compensate, but usually have shortness of breath as a result. Others, who may be less short of breath, tolerate low oxygen and high carbon dioxide levels in their bodies, but this can eventually lead to headaches, drowsiness and heart failure. Advanced COPD can lead to complications beyond the lungs, such as weight loss (cachexia), pulmonary hypertension and right-sided heart failure (cor pulmonale). Osteoporosis, heart disease, muscle wasting and depression are all more common in people with COPD.[]

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Diagnosis
The diagnosis of COPD should be considered in anyone over the age of 35 to 40 who has shortness of breath, a chronic cough, sputum production, or frequent winter colds and a history of exposure to risk factors for the disease.[][] Spirometry is then used to confirm the diagnosis; with an FEV1/FVC ratio of less than 0.7 following the use of a bronchodilator being diagnostic.[]

Spirometry GOLD scale


Severity Mild (GOLD 1) Moderate (GOLD 2) Severe (GOLD 3) FEV1 % predicted 80 5079 3049

Very severe (GOLD 4) <30 or chronic respiratory failure

Spirometry measures the forced expiratory volume in one second (FEV1), which is the greatest volume of air that can be breathed out in the first second of a breath. Spirometry also measures the forced vital capacity (FVC), which is the greatest volume of air that can be breathed out in a whole large breath. Normally, at least 70% of the FVC comes out in the first second, giving a FEV1/FVC ratio of greater than 70%. A ratio of less than this defines as person as having COPD per the GOLD criteria.[14] The NICE criteria additionally require a FEV1 of less than 80% of predicted.[] According to the ERS criteria, it is FEV1% predicted that defines when a person has COPD, that is, when FEV1% predicted is < 88% for men, or < 89% for women.[14] Evidence for using spirometry among those without symptoms in an effort to diagnose the condition earlier is of uncertain effect and therefore as of 2013 not recommended.[] A peak expiratory flow is not sufficient for the diagnosis.[]

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Other tests
A chest x-ray and complete blood count may be useful to exclude other conditions at the time of diagnosis.[] The classic signs of COPD on chest X-ray are over expanded lung, a flattened diaphragm, increased retrosternal airspace, and bulla while it can help exclude other lung diseases, such as pneumonia, pulmonary edema or a pneumothorax.[] Complete pulmonary function tests with measurements of lung volumes and gas transfer may also show hyperinflation and can discriminate between COPD with emphysema and COPD without emphysema. A high-resolution computed tomography scan of the chest may show the distribution of emphysema throughout the lungs and can also be useful to exclude other lung diseases. An analysis of arterial blood is used to determine the need for oxygen. Testing is recommended in those with an FEV1 less than 35%, those with a peripheral oxygen saturation of less than 92% and those with congestive heart failure.[] In areas of the world were alpha-1 antitrypsin deficiency is common, people with COPD should be tested for it.[]

A chest X-ray demonstrating severe COPD. Note the small size of the heart in comparison to the lungs.

Axial CT image of the lung of a person with end-stage bullus emphysema.

A lateral chest x-ray of a person with emphysema. Note the barrel chest and flat diaphragm.

Lung bulla as seen on CXR in a person with severe COPD

Severity

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MRC shortness of breath scale[]


Grade 1 2 3 4 5 Activity affected Only strenuous activity Vigorous walking With normal walking After a few minutes of walking With changing clothing

Spirometry can help to determine the severity of COPD.[] The FEV1 (measured after bronchodilator medication) is expressed as a percentage of a predicted "normal" value based on a person's age, gender, height and weight. There are a number of methods to determine how much COPD is affecting a given individual.[] This depends partly on the severity of shortness of breath and exercise limitation. These and other factors can be combined with spirometry results to obtain a COPD severity score.[] COPD Assessment Test (CAT) is a patient-completed questionnaire[] that assesses the impact of COPD (cough, sputum, dysnea, chest tighteness) on health status.[] The range of CAT scores is from 040. Higher the score, more the severity of the disease.[] The GOLD guidelines suggest dividing people into four categories based on current symptoms (assessed using the modified medical research council questionnaire or the CAT Score).[]

Types
It is unclear if different types of COPD exist.[] While previously divided into emphysema and chronic bronchitis; emphysema is only a description of pathological lung changes rather than a disease in itself and is simply a descriptor of symptoms that may or may not occur with COPD.[] Emphysema is an enlargement of the air spaces distal to the terminal bronchioles, with destruction of their walls.[] People with emphysema have historically been known as "Pink Puffers", due to their pink complexion.[30] Chronic bronchitis is defined in clinical terms as a cough with sputum production on most days for 3months of a year, for 2 consecutive years.[] People with advanced COPD that have primarily chronic bronchitis were commonly referred to as "Blue Bloaters" because of the bluish color of the skin and lips (cyanosis) along with hypoxia and fluid retention.[31]

Differential diagnosis
COPD may need to be differentiated from congestive heart failure which often has jugular venous distension or pedal edema. If only one leg is swollen a deep vein thrombosis or pulmonary embolism should be considered. In those with poor air entry on one side versus both sides, pneumonia or pneumothorax may be the cause of shortness of breath. Many people with COPD mistakenly think they have asthma.[] The distinction between asthma and COPD however cannot be made via spirometry.[] Tuberculosis may also present with a chronic cough and should be considered in locations where it is common.[] Less common conditions which may present similarly include: bronchopulmonary dysplasia and obliterative bronchiolitis.[]

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Prevention
Annual influenza vaccinations and pneumococcal vaccinations may be beneficial.

Smoking cessation
Smoking cessation is one of the most important factors in slowing down the progression of COPD. Once COPD has been diagnosed, stopping smoking slows down the rate of progression of the disease. Even at a late stage of the disease, it can significantly reduce the rate of deterioration in lung function and delay the onset of disability and death.[] It is the only standard intervention that can improve the rate of progression of COPD.[] Smoking cessation starts with an individual decision to stop smoking that leads to an attempt at quitting. Often several attempts are required before long-term smoking cessation is achieved.[2] Some smokers can achieve long-term smoking cessation through willpower alone. However, smoking is highly addictive,[32] and many smokers need further support to quit. The chance of successfully stopping smoking can be greatly improved through social support, engagement in a smoking cessation programme and the use of drugs such as nicotine replacement therapy, bupropion and varenicline.[2] The policies of governments, public health agencies and antismoking organizations can reduce smoking rates by encouraging stopping smoking and discouraging people from starting.[2] These policies are important strategies in the prevention of COPD.[citation needed]

Occupational health
Measures can be taken to reduce the likelihood that workers in at-risk industriessuch as coal mining, construction and stonemasonrywill develop COPD. Examples of these measures include: education of workers and management about the risks, promoting smoking cessation, surveillance of workers for early signs of COPD, use of personal dust monitors, use of respirators, and dust control.[33] Dust control can be achieved by improving ventilation, using water sprays and by using mining techniques that minimize dust generation.[34] If a worker develops COPD, further lung damage can be reduced by avoiding ongoing dust exposure, for example by changing the work role.

Air pollution
Air quality can be improved by pollution reduction efforts, which should lead to health gains for people with COPD. A person who has COPD may experience fewer symptoms if they stay indoors on days when air quality is poor.[]

Management
There is no known cure for COPD; however, it is both preventable and treatable. The major goals of management are to reduce risk factors, manage stable COPD, prevent and treat acute exacerbations and manage associated illnesses.[] The only measures that have been shown to reduce mortality is smoking cessation and supplemental oxygen.[] Stopping smoking decreases the risk of death by 18%.[] Other recommendations include: influenza vaccination once a year and reduction in exposure to environmental air pollution.[] Palliative care at the end of life may be useful, with morphine improving the feelings of shortness of breath.[] Additionally noninvasive ventilation may provide comfort.[]

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Exercise
Pulmonary rehabilitation is a program of exercise, disease management and counselling coordinated to benefit the individual.[35] Pulmonary rehabilitation appears to improve over all quality of life, the ability to exercise, and mortality in those who have had a recent exacerbation.[36] It has also been shown to improve the sense of control a patient has over their disease as well as their emotions.[] Breathing exercises in and of themselves appear to have a limited role.[37] Being either underweight or overweight can affect the symptoms, degree of disability and prognosis of COPD. People with COPD who are underweight can improve their breathing muscle strength by increasing their calorie intake.[] When combined with regular exercise or a pulmonary rehabilitation programme, this can lead to improvements in COPD symptoms. Supplemental nutrition may be useful in those who are malnourished.[38]

Bronchodilators
Inhaled bronchodilators are the primary treatment.[] There are two major types, 2 agonists and anticholinergics and they exist in long-acting and short-acting forms. They reduce shortness of breath, wheeze and exercise limitation, resulting in an improved quality of life.[] It is unclear if they change the progression of the underlying disease.[] In those with mild disease short acting agents on an as needed basis are recommended.[] In those with more severe disease long acting agents and if not sufficient inhaled corticosteroids are recommended.[] With respect to long acting agents; it is unclear if tiotropium or long acting beta agonists (LABAs) are better and it may be worth trying each and continuing the one that worked best.[39] Both types of agent reduce the risk of acute worsenings by 15-25%.[] While using both at the same time may offer a benefit, this benefit if any is of questionable significance.[40] There are several 2 agonists available including salbutamol (Ventolin) and terbutaline. They provide rapid relief of symptoms. Long acting 2 agonists such as salmeterol and formoterol are used as maintenance therapy and lead to improved airflow, exercise capacity, and quality of life.[] Long term use appears safe in COPD.[41] Adverse effects include: shakiness and heart palpitations.[] When used with steroids they increase the risk of pneumonia.[] There are two main anticholinergics used in COPD, ipratropium and tiotropium. Ipratropium is a short-acting agent while tiotropium is long acting one. Tiotropium is associated with a decrease in exacerbations and improved quality of life.[] While overall the two formulations do not appear to affect mortality; the dry powder form may decrease and the mist form may increase mortality.[] Anticholinergics can cause dry mouth and urinary tract symptoms.[] They are also associated with increase risk of heart disease and stroke.[42][43]

Corticosteroids
Corticosteroids are usually used in inhaled form but may also be used as tablets to treat and prevent acute exacerbations. Well-inhaled corticosteroids (ICS) have not shown benefit for people with mild COPD, they decrease acute exacerbations in those with either moderate or severe disease.[44] When used in combination with a LABA they decrease mortality more than either ICS or LABA alone.[45] By themselves they have no effect on overall one-year mortality and are associated with increased rates of pneumonia.[] It is unclear if the affect the progression of the disease.[]

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Other medication
Long term antibiotics specifically macrolides such as azithromycin reduce the frequency of exacerbations in those who have two or more a year.[46] Methylxanthines such as theophylline generally causes more harm than benefit and thus are usually not recommended.[47] It may be used as a second line agent in those not controlled by other measures.[]

Oxygen
Supplemental oxygen in those with low oxygen levels (a partial pressure of oxygen of less than 50mmHg) decreases the risk of heart failure and death if used 15hours per day.[48] It may also improves peoples ability to exercise.[49] In those with normal or mildly low oxygen levels, oxygen supplementation may improve shortness of breath.[50] High concentrations of oxygen can lead to increased levels of carbon dioxide in some people with severe COPD. Smoking while on oxygen is a safety risk.

Surgery
For those with very severe disease surgery is sometimes helpful and may include lung transplantation or lung volume reduction surgery.[] Lung volume reduction surgery involves removing the parts of the lung most damaged by emphysema allowing the remaining, relatively good lung to expand and work better. Lung transplantation is sometimes performed for severe COPD, particularly in younger individuals.

Acute exacerbation
Acute exacerbations are typically treated by increases the usage of short acting bronchodilators.[] If this is not sufficient then oral corticosteroids may be useful.[] In those with a severe exacerbation antibiotics improve outcomes.[] There is no clear evidence for those with less severe cases.[] Non-invasive positive pressure ventilation in those with high CO2 levels decreases the probability of death or needing intubation.[] Additionally theophylline may have a role in those who do not respond to other measures.[]

Prognosis
COPD usually gets gradually worse over time and can ultimately result in death. It is estimated that 3% of all disability is related to COPD.[] The proportion of disability from COPD globally has decreased from 1990 to 2010 due to improved indoor air quality primarily in Asia.[] The overall number of years lived with disability from COPD; however, has increased.[51] Results of spirometry is a good predictor of the future progress of the disease.[] The rate at which it gets worse varies among individuals. The factors that predict a poorer prognosis are:[] Severe airflow obstruction (low FEV1) Poor exercise capacity Shortness of breath Significantly underweight or overweight Complications like respiratory failure or cor pulmonale Continued smoking Frequent acute exacerbations

Prognosis in COPD can be estimated using the Bode Index. This scoring system uses FEV1, body-mass index, 6-minute walk distance, and the modified MRC dyspnea scale to estimate outcomes in COPD.[]

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Epidemiology
Globally as of 2010 COPD affected approximately 329million people (4.8% of the population) and is slightly more common in men than women.[] This is as compared to 64million being affected in 2004.[53] The number of deaths from COPD has decreased slightly from 3.1 million to 2.9 million from 1990 to 2010.[54] Overall it is the 4th leading cause of death.[] Rates are higher in older people[] with it occurs in 34-200 out of 1000 older than 65years depending on the population looked at.[][]

Disability-adjusted life year for chronic obstructive pulmonary disease per 100,000inhabitants in 2004.

In the developing world the rates of COPD have increased significantly between the 1970s and the 2000s due in part to increasing rates of cigarette smoking in these regions of the world.[] In the developed world some countries have seen increased rates, some have remained stable and some have seen a lessening of COPD.[] In England, an estimated 842,100 of 50million people have a diagnosis of COPD; translating into approximately one person in 59 receiving a diagnosis of COPD at some point in their lives. In the most socioeconomically deprived parts of the country, one in 32 people were diagnosed with COPD, compared with one in 98 in the most affluent areas.[] In the United States, the prevalence of COPD is approximately 1 in 20 or 5%, totalling approximately 13.5million people in USA,[55] or possibly 25million people if undiagnosed cases are included.[56]

History
The term "emphysema" is derived from the Greek emphysan meaning "inflate" -itself composed of en, meaning "in", and physan, meaning "breath, blast".[57] COPD has probably always existed but has been called by different names in the past. Bonet, in 1679, described a condition of "voluminous lungs". Giovanni Morgagni, in 1769, described 19 cases where the lungs were "turgid" particularly from air.[] The first description and illustration of the enlarged airspaces in emphysema was provided by Ruysh in 1721.[58] Matthew Baillie illustrated an emphysematous lung in 1789 and described the destructive character of the condition.[] Badham used the word "catarrh" to describe the cough and mucus hypersecretion of chronic bronchitis in 1814. He recognised that chronic bronchitis was a disabling disorder. Ren Laennec, the physician who invented the stethoscope, used the term "emphysema" in his book A Treatise on the Diseases of the Chest and of Mediate Auscultation (1837) to describe lungs that did not collapse when he opened the chest during an autopsy. He noted that they did not collapse as usual because they were full of air and the airways were filled with mucus.[] In 1842, John Hutchinson invented the spirometer, which allowed the measurement of vital capacity of the lungs. However, his spirometer could only measure volume, not airflow.[] Tiffeneau in 1947 and Gaensler in 1950 and 1951 described the principles of measuring airflow. The terms chronic bronchitis and emphysema were formally defined at the CIBA guest symposium of physicians in 1959. The term COPD was first used by William Briscoe in 1965 and has gradually overtaken other terms to become established today as the preferred name for this disease.

Chronic obstructive pulmonary disease

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Society and culture


It is a challengeWikipedia:Please clarify for many health systems to ensure appropriate identification, diagnosis and care for people with COPD; Britain's Department of Health has identified this as a major issue for the National Health Service[59] and has introduced a specific strategy for COPD to tackle these problems.[60]

Economics
In Europe COPD represents 3% of health care spending.[] In the United States costs of the disease are estimated at $50billion most of which is due to exacerbation.[]

Research
Infliximab has been tested in COPD but there was no evidence of benefit with the possibility of harm.[61] Roflumilast shows promise in decreasing the rate of exacerbations but does not appear to change quality of life.[] A number of new long acting agents are under development.[]

Other animals
Chronic obstructive pulmonary disease in horses also known as recurrent airway obstruction is an inflammatory disease of the airways due to an allergic reaction to straw containing fungus.[62]

References
[1] http:/ / apps. who. int/ classifications/ icd10/ browse/ 2010/ en#/ J40 [2] http:/ / apps. who. int/ classifications/ icd10/ browse/ 2010/ en#/ J44 [3] http:/ / apps. who. int/ classifications/ icd10/ browse/ 2010/ en#/ J47 [4] http:/ / www. icd9data. com/ getICD9Code. ashx?icd9=490 [5] http:/ / www. icd9data. com/ getICD9Code. ashx?icd9=492 [6] http:/ / www. icd9data. com/ getICD9Code. ashx?icd9=494 [7] http:/ / www. icd9data. com/ getICD9Code. ashx?icd9=496 [8] http:/ / omim. org/ entry/ 606963 [9] http:/ / www. diseasesdatabase. com/ ddb2672. htm [10] http:/ / www. nlm. nih. gov/ medlineplus/ ency/ article/ 000091. htm [11] http:/ / www. emedicine. com/ med/ topic373. htm [12] http:/ / www. emedicine. com/ emerg/ topic99. htm# [13] http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2013/ MB_cgi?mode=& term=COPD& field=entry#TreeC08. 381. 495. 389 [14] (http:/ / respiratory-research. com/ content/ 8/ 1/ 89) [17] Carol, T. Fundamentals of nursing: The art and science of nursing care. ISBN: 0781793831 / 9780781793834 [19] Carol, T. Fundamentals of nursing: The art and science of nursing care. ISBN: 0781793831 / 9780781793834 [34] Wet cutting (http:/ / www. hse. gov. uk/ copd/ casestudies/ wetcut. htm) Health and Safety Executive (UK Government). Accessed March 20, 2012. [55] wrongdiagnosis.com > Prevalence and Incidence of COPD (http:/ / www. wrongdiagnosis. com/ c/ copd/ prevalence. htm) Retrieved on Mars 14, 2010 [56] MORBIDITY & MORTALITY: 2009 CHART BOOK ON CARDIOVASCULAR, LUNG, AND BLOOD DISEASES (http:/ / www. nhlbi. nih. gov/ resources/ docs/ 2009_ChartBook. pdf) National Heart, Lung, and Blood Institute [57] emphysema (http:/ / dictionary. reference. com/ browse/ emphysema) at dictionary.com

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External links
Chronic obstructive pulmonary disease (http://www.dmoz.org/Health/Conditions_and_Diseases/ Respiratory_Disorders/Chronic_Obstructive_Pulmonary_Disease//) at the Open Directory Project Global Initiative for Chronic Obstructive Lung Disease (GOLD) clinical practive guidelines (2013) (http://www. goldcopd.org/Guidelines/guidelines-resources.html) National Institute for Health and Clinical Excellence. Clinical guideline 101: Chronic Obstructive Pulmonary Disease (http://guidance.nice.org.uk/CG101). London, June 2010. Pages 1-673.

Certified Public Accountant

452

Certified Public Accountant


Certified Public Accountant (CPA)
Type Industry Founded Qualified accountants Accounting and finance United States

Headquarters United States

Accountancy
Key concepts

Accountant Accounting period Accrual Bookkeeping Cash and accrual basis Cash flow forecasting Chart of accounts Convergence Journal Special journals Cost of goods sold Credit terms Debits and credits Double-entry system Mark-to-market accounting FIFO and LIFO GAAP / IFRS Management Accounting Principles General ledger Goodwill Historical cost Matching principle Revenue recognition Trial balance Fields of accounting

Cost Financial Forensic Fund Management Tax (U.S.) Financial statements

Balance sheet Cash flow statement Income statement Statement of retained earnings

Certified Public Accountant


453
Notes Management discussion and analysis XBRL Auditing

Auditor's report Control self-assessment Financial audit GAAS / ISA Internal audit SarbanesOxley Act Accounting qualifications

CIA CA AIA CPA CCA CGA CMA CAT AAT CFE CICA ACCA CIMA CGMA

Certified Public Accountant (CPA) is the statutory title of qualified accountants in the United States who have passed the Uniform Certified Public Accountant Examination and have met additional state education and experience requirements for certification as a CPA. Individuals who have passed the Exam but have not either accomplished the required on-the-job experience or have previously met it but in the meantime have lapsed their continuing professional education are, in many states, permitted the designation "CPA Inactive" or an equivalent phrase. In most U.S. states only CPAs who are licensed are able to provide to the public attestation (including auditing) opinions on financial statements. The exceptions to this rule are Arizona, Kansas, North Carolina, and Michigan where the "CPA" designation and the practice of auditing are not restricted. Many states have (or have had) a lower tier of accountant qualification below that of CPA, usually entitled "Public Accountant" or "Licensed Public Accountant" (with designatory letters "PA" or "LPA"), although other titles have included "Registered Public Accountant" (RPA), "Accounting Practitioner" (AP), and "Registered Accounting Practitioner" (RAP). Such designations were originally intended to license non-certified accountants who were practicing public accounting before a state accountancy law was enacted which would serve to regulate the accounting profession. The majority of states have closed the designation "Public Accountant" (PA) to new entrants, with only six states continuing to offer the designation. Many PAs belong to the National Society of Accountants. Many states prohibit the use of the designations "Certified Public Accountant" or "Public Accountant"/"Licensed Public Accountant" (or the abbreviations "CPA" or "PA"/"LPA") by a person who is not certified as a CPA or PA in that state. As a result, in many circumstances, an out-of-state CPA is restricted from using the CPA designation or designators letters until a license or certificate from that state is obtained. Texas additionally prohibits the use of the designations "accountant" and "auditor" by a person not certified as a Texas CPA, unless that person is a CPA in another state, a non-resident of Texas, and otherwise meets the requirements for practice in Texas by out-of-state CPA firms and practitioners.[1]

Certified Public Accountant Many other countries also use the title CPA to designate local public accountants.

454

Services provided by CPAs


The primary functions CPA fulfill relate to assurance services, or public accounting. In assurance services, also known as financial audit services, CPAs attest to the reasonableness of disclosures, the freedom from material misstatement, and the adherence to the applicable generally accepted accounting principles (GAAP) in financial statements. CPAs can also be employed by corporationstermed "the private sector"in finance functions such as Chief Financial Officer (CFO) or finance manager, or as CEOs subject to their full business knowledge and practice. These CPAs do not provide services directly to the public. Although some CPAs serve as business consultants, the consulting role is under scrutiny following the corporate climate in the aftermath of the Enron scandal. This has resulted in divestitures in the consulting divisions by many accounting firms. This trend has since reversed. In audit engagements, CPAs are (and have always been) required by professional standards and Federal and State laws to maintain independence (both in fact and in appearance) from the entity for which they are conducting an attestation (audit and review) engagement. However, most individual CPAs who work as consultants do not work as auditors. CPAs also have a niche within the income tax preparation industry. Many small to mid-sized firms have both a tax and an auditing department. Along with attorneys and enrolled agents, CPAs may represent taxpayers in matters before the Internal Revenue Service. Whether providing services directly to the public or employed by corporations or associations, CPAs can operate in virtually any area of finance including: Assurance and Attestation Services Corporate Finance (Merger & Acquisition, initial public offerings, share & debt issuings) Corporate Governance Estate Planning Financial Accounting Financial Analysis Financial Planning Forensic Accounting (preventing, detecting, and investigating financial frauds) Income Tax Information Technology, especially as applied to accounting and auditing Management Consulting and Performance Management Tax Preparation and Planning Venture Capital Financial reporting Regulatory reporting

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CPA exam
In order to become a CPA in the United States, the candidate must sit for and pass the Uniform Certified Public Accountant Examination (Uniform CPA Exam), which is set by the American Institute of Certified Public Accountants (AICPA) and administered by the National Association of State Boards of Accountancy (NASBA). The CPA was established in law on April 17, 1896.[2] Eligibility to sit for the Uniform CPA Exam is determined by individual state boards of accountancy. All states but California have adopted what is known as the "150 hour rule", which usually requires an additional year past a regular 4 year college degree, or a master's degree. (The "150 Hour rule" becomes effective for licensure in California on January 1, 2014.) The Colorado State Board of Accountancy allows Chartered Accountants from eligible jurisdictions (Australia, South Africa, Canada, Ireland, New Zealand), automatic eligibility to sit for the Uniform CPA Exam as a Colorado candidate. Certain overseas qualified accountants seeking to become U.S. CPAs may be eligible to sit for the International Qualification Examination as an alternative to the Uniform CPA Exam. The Uniform CPA Exam tests general principles of state law such as the law of contracts and agency (questions not tailored to the variances of any particular state) and some federal laws as well.[3]

Other licensing and certification requirements


Although the CPA exam is uniform, licensing and certification requirements are imposed separately by each state's laws and therefore vary from state to state. State requirements for the CPA qualification can be summed up as the Three EsEducation, Examination and Experience. The education requirement normally must be fulfilled as part of the eligibility criteria to sit for the Uniform CPA Exam. The examination component is the Uniform CPA Exam itself. Some states have a two-tier system whereby an individual would first become certifiedusually by passing the Uniform CPA Exam. That individual would then later be eligible to be licensed once a certain amount of work experience is accomplished. Other states have a one-tier system whereby an individual would be certified and licensed at the same time when both the CPA exam is passed and the work experience requirement has been met. Two-tier states include Alabama, Florida, Illinois, Montana, and Nebraska. The trend is for two-tier states to gradually move towards a one-tier system. Since 2002, the state boards of accountancy in Washington and South Dakota have ceased issuing CPA "certificates" and instead issue CPA "licenses." Illinois plans to follow suit in 2012.[4] A number of states are two-tiered, but require work experience for the CPA certificate, such as Ohio.

Work experience requirement


The experience component varies from state to state: The two-tier states generally do not require work experience for a CPA certificate. (It is required for a license to practice). Some states, such as Colorado and Massachusetts, will waive the work experience requirement for those with a higher academic qualification compared to the state's requirement to appear for the Uniform CPA. The majority of states still require work experience to be of a public accounting nature, namely 2 years audit or tax or a combination thereof. However an increasing number of states, including Oregon, Virginia, Georgia and Kentucky will accept experience of a more general nature in the accounting area. This allows persons to obtain the CPA designation while working for a corporation's finance function.

Certified Public Accountant The majority of states require work experience to be verified by a licensed CPA. This can cause difficulties for applicants based outside the United States. However, some states such as Colorado and Oregon will accept work experience certified by a Chartered Accountant as well.

456

Ethics
Over 40 of the state boards now require applicants for CPA status to complete a special examination on ethics, which is effectively a fifth exam in terms of requirements to become a CPA. The majority of these will accept the AICPA self-study Professional Ethics for CPAs CPE course or another course in general professional ethics. Many states, however, require that the ethics course include a review of that state's specific rules for professional practice.

Continuing Professional Education (CPE)


CPAs are required to take continuing education courses in order to renew their license. Requirements vary by state but the vast majority require 120 hours of CPE every 3 years with a minimum of 20 hours per calendar year. The requirement can be fulfilled through attending live seminars, webcast seminars, or through self-study (textbooks, videos, online courses, all of which require a test to receive credit). As part of the CPE requirement, most states require their CPAs to take an ethics course during every renewal period. Again, ethics requirements vary by state but the courses range from 28 hours.

Inter-state practice
An accountant is required to meet the legal requirements of any state in which they want to practice. Also, the term "practice of public accounting" and similar terms are given definitions PA status under reciprocity to a CPA licensed in another state. CPAs from other states with less stringent educational requirements may not be able to benefit from these provisions. This does not affect those CPAs who do not plan to offer services directly to the public. Moreover, most states would grant the temporary practicing rights to a CPA of another state.

Practice mobility
In recent years, practice mobility for CPAs has become a major business concern for CPAs and their clients. Practice mobility for CPAs is the general ability of a licensee in good standing from a substantially equivalent state to gain practice privilege outside of his or her home state without getting an additional license in the state where the CPA will be serving a client or an employer. In todays digital age, many organizations requiring the professional services of CPAs conduct business on an interstate and international basis and have compliance responsibilities in multiple jurisdictions. As a result, the practice of CPAs often extends across state lines and international boundaries. Differing requirements for CPA certification, reciprocity, temporary practice and other aspects of state accountancy legislation in the 55 U.S. licensing jurisdictions (the 50 states, Puerto Rico, the District of Columbia, the U.S. Virgin Islands, Guam and the Commonwealth of the Northern Mariana Islands) make the interstate practice and mobility of CPAs more complicated. By removing boundaries to practice in the U.S., CPAs are able to more readily serve individuals and businesses in need of their expertise. At the same time, the state board of accountancys ability to discipline is enhanced by being based on a CPA and the CPA firms performance of services (either physically, electronically or otherwise within a state), rather than being based on whether a state license is held. The American Institute of Certified Public Accountants (AICPA) and the National Association of State Boards of Accountancy (NASBA) have analyzed the current system for gaining practice privileges across state lines and have endorsed a uniform mobility system. This model approach is detailed through the substantial equivalency provision (Section 23) of the Uniform Accountancy Act (UAA).[5] The UAA is an "evergreen" model licensing law co-developed, maintained, reviewed and updated by the AICPA and NASBA. The model provides a uniform approach to regulation of the accounting profession.

Certified Public Accountant Under Section 23 of the UAA, a CPA with a license in good standing from a jurisdiction with CPA licensing requirements essentially equivalent to those outlined in the UAA is deemed to be substantially equivalent, or a licensee who individually meets the requirements of: Obtaining 150 credit hours with a Baccalaureate Degree Minimum 1 year of CPA experience Passing the Uniform CPA Examination Uniform adoption of the UAAs substantial equivalency provision creates a system similar to the nations drivers license program by providing CPAs with mobility while retaining and strengthening state boards ability to protect the public interest. The system enables consumers to receive timely services from the CPA best suited to the job, regardless of location, and without the hindrances of unnecessary filings, forms and increased costs that do not protect the public interest. As of October 2012, a total of 49 out of the 50 states and the District of Columbia have passed mobility laws and are now in the implementation and navigation phases.[6] Only the Commonwealth of the Northern Mariana Islands, the Virgin Islands, Hawaii, Puerto Rico and Guam have not passed mobility laws. On September 20, California Governor Jerry Brown signed legislation that permits cross-border mobility for CPAs. The law goes into effect July 1, 2013.[7] The District of Columbia passed mobility laws that went into effect on October 1, 2012.[8]

457

AICPA membership
The CPA designation is granted by individual state boards, not the American Institute of Certified Public Accountants (AICPA). Membership in the AICPA is not obligatory for CPAs, although some CPAs do join. To become a full member of AICPA, the applicant must hold a valid CPA certificate or license from at least one of the fifty-five U.S. state/territory boards of accountancy; some additional requirements apply. AICPA members approved a proposed bylaw amendment to make eligible for voting membership individuals who previously held a CPA[9] certificate/license or have met all the requirements for CPA certification in accordance with the Uniform Accountancy Act (UAA). The AICPA announced its plan to accept applications from individuals meeting these criteria, beginning no later than January 1, 2011.

State CPA association membership


CPAs may also choose to become members of their local state association or society (also optional). Benefits of membership in a state CPA association range from deep discounts on seminars that qualify for continuing education credits to protecting the public and profession's interests by tracking and lobbying legislative issues that affect local state tax and financial planning issues. CPAs who maintain state CPA society memberships are required to follow a society professional code of conduct (in addition to any code enforced by the state regulatory authority), further reassuring clients that the CPA is an ethical business professional conducting a legitimate business who can be trusted to handle confidential personal and business financial matters. State CPA associations also serve the community by providing information and resources about the CPA profession and welcome inquiries from students, business professionals and the public-at-large. CPAs are not normally restricted to membership in the state CPA society in which they reside or hold a license or certificate. Many CPAs who live near state borders or who hold CPA status in more than one state may join more than one state CPA society.

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Notes and references


[2] Flesher, D.L., Previts, G.J. & Flesher, T.K.,Profiling the New Industrial Professionals: The First CPAs of 189697 (Business & Economic History, volume 25, 1996) (http:/ / www. h-net. org/ ~business/ bhcweb/ publications/ BEHprint/ v025n1/ p0252-p0266. pdf) [3] See generally Uniform CPA Examination: Examination Content Specifications, American Inst. of Certified Public Accountants, p. 11-12 (orig. issued June 14, 2002; references updated Oct. 19, 2005) at (http:/ / www. cpa-exam. org/ download/ CPA_Exam_CSOs_revised_10_05. pdf) [4] Legislative sunset provision for two-tier designation of CPAs in Illinois (Illinois General Assembly) (http:/ / www. ilga. gov/ legislation/ billstatus. asp?DocNum=6415& GAID=10& GA=96& DocTypeID=HB& LegID=52442& SessionID=76) [5] http:/ / www. aicpa. org/ Advocacy/ State/ DownloadableDocuments/ UAASixthEdition. pdf [6] http:/ / www. aicpa. org/ Advocacy/ State/ PublishingImages/ CPA_Mobility_Map. pdf [9] cpaexam.com (http:/ / www. cpaexam. com)

External links
Directory of State CPA Societies (http://www.accountingmajors.com/accountingmajors/articles/statecpas. html)

Consumer price index


A consumer price index (CPI) measures changes in the price level of a market basket of consumer goods and services purchased by households. The CPI in the United States is defined by the Bureau of Labor Statistics as "a measure of the average change over time in the prices paid by urban consumers for a market basket of consumer goods and services."[1] The CPI is a statistical estimate constructed using the prices of a sample of representative items whose prices are A graph of the US CPI from 1913 to 2006 (in blue), and its percent annual change collected periodically. Sub-indexes and (in red) sub-sub-indexes are computed for different categories and sub-categories of goods and services, being combined to produce the overall index with weights reflecting their shares in the total of the consumer expenditures covered by the index. It is one of several price indices calculated by most national statistical agencies. The annual percentage change in a CPI is used as a measure of inflation. A CPI can be used to index (i.e., adjust for the effect of inflation) the real value of wages, salaries, pensions, for regulating prices and for deflating monetary magnitudes to show changes in real values. In most countries, the CPI is, along with the population census and the USA National Income and Product Accounts, one of the most closely watched national economic statistics.

Introduction
Two basic types of data are needed to construct the CPI: price data and weighting data. The price data are collected for a sample of goods and services from a sample of sales outlets in a sample of locations for a sample of times. The weighting data are estimates of the shares of the different types of expenditure in the total expenditure covered by the index. These weights are usually based upon expenditure data obtained from expenditure surveys for a sample of households or upon estimates of the composition of consumption expenditure in the National Income and Product

Consumer price index Accounts. Although some of the sampling of items for price collection is done using a sampling frame and probabilistic sampling methods, many items and outlets are chosen in a commonsense way (purposive sampling) that does not permit estimation of confidence intervals. Therefore, the sampling variance cannot be calculated. In any case, a single estimate is required in most of the purposes for which the index is used. The index is usually computed monthly, or quarterly in some countries, as a weighted average of sub-indices for different components of consumer expenditure, such as food, housing, clothing, each of which is in turn a weighted average of sub-sub-indices. At the most detailed level, the elementary aggregate level, (for example, men's shirts sold in department stores in San Francisco), detailed weighting information is unavailable, so indices are computed using an unweighted arithmetic or geometric mean of the prices of the sampled product offers. (However, the growing use of scanner data is gradually making weighting information available even at the most detailed level.) These indices compare prices each month with prices in the price-reference month. The weights used to combine them into the higher-level aggregates, and then into the overall index, relate to the estimated expenditures during a preceding whole year of the consumers covered by the index on the products within its scope in the area covered. Thus the index is a fixed-weight index, but rarely a true Laspeyres index, since the weight-reference period of a year and the price-reference period, usually a more recent single month, do not coincide. It takes time to assemble and process the information used for weighting which, in addition to household expenditure surveys, may include trade and tax data. Ideally, the weights would relate to the composition of expenditure during the time between the price-reference month and the current month. There is a large technical economics literature on index formulae which would approximate this and which can be shown to approximate what economic theorists call a true cost of living index. Such an index would show how consumer expenditure would have to move to compensate for price changes so as to allow consumers to maintain a constant standard of living. Approximations can only be computed retrospectively, whereas the index has to appear monthly and, preferably, quite soon. Nevertheless, in some countries, notably in the United States and Sweden, the philosophy of the index is that it is inspired by and approximates the notion of a true cost of living (constant utility) index, whereas in most of Europe it is regarded more pragmatically. The coverage of the index may be limited. Consumers' expenditure abroad is usually excluded; visitors' expenditure within the country may be excluded in principle if not in practice; the rural population may or may not be included; certain groups such as the very rich or the very poor may be excluded. Saving and investment are always excluded, though the prices paid for financial services provided by financial intermediaries may be included along with insurance. The index reference period, usually called the base year, often differs both from the weight-reference period and the price reference period. This is just a matter of rescaling the whole time-series to make the value for the index reference-period equal to 100. Annually revised weights are a desirable but expensive feature of an index, for the older the weights the greater is the divergence between the current expenditure pattern and that of the weight reference-period.

459

Calculating the CPI for a single item


Current item price ($) = (base year) * (Current CPI) / (Base year CPI) or

Where 1 is usually the comparison year and CPI1 is usually an index of 100. Alternatively, the CPI can be performed as . The "updated cost" (i.e. the

price of an item at a given year, e.g.: the price of bread in 2010) is divided by the initial year (the price of bread in 1970), then multiplied by one hundred.[2]

Consumer price index

460

Calculating the CPI for multiple items


Many but not all price indices are weighted averages using weights that sum to 1 or 100. Example: The prices of 95,000 items from 22,000 stores, and 35,000 rental units are added together and averaged. They are weighted this way: Housing: 41.4%, Food and Beverage: 17.4%, Transport: 17.0%, Medical Care: 6.9%, Other: 6.9%, Apparel: 6.0%, Entertainment: 4.4%. Taxes (43%) are not included in CPI computation.[3]

where the

s sum to 1 or 100.

Weighting
Weights and sub-indices
By convention weights are fractions or ratios summing to one, as percentages summing to 100 or as per mille numbers summing to 1000.[citation needed] On the European Union's Harmonised Index of Consumer Prices (HICP), for example, each country computes some 80 prescribed sub-indices, their weighted average constituting the national HICP. The weights for these sub-indices will consist of the sum of the weights of a number of component lower level indices. The classification is according to use, developed in a national accounting context. This is not necessarily the kind of classification that is most appropriate for a Consumer Price Index. Grouping together of substitutes or of products whose prices tend to move in parallel might be more suitable. For some of these lower level indexes detailed reweighing to make them be available, allowing computations where the individual price observations can all be weighted. This may be the case, for example, where all selling is in the hands of a single national organisation which makes its data available to the index compilers. For most lower level indexes, however, the weight will consist of the sum of the weights of a number of elementary aggregate indexes, each weight corresponding to its fraction of the total annual expenditure covered by the index. An 'elementary aggregate' is a lowest-level component of expenditure, one which has a weight but within which, weights of its sub-components are usually lacking. Thus, for example: Weighted averages of elementary aggregate indexes (e.g. for men's shirts, raincoats, women's dresses, etc.) make up low level indexes (e.g. Outer garments). Weighted averages of these in turn provide sub-indices at a higher, more aggregated level,(e.g. clothing) and weighted averages of the latter provide yet more aggregated sub-indices (e.g. Clothing and Footwear). Some of the elementary aggregate indexes, and some of the sub-indexes can be defined simply in terms of the types of goods and/or services they cover, as in the case of such products as newspapers in some countries and postal services, which have nationally uniform prices. But where price movements do differ or might differ between regions or between outlet types, separate regional and/or outlet-type elementary aggregates are ideally required for each detailed category of goods and services, each with its own weight. An example might be an elementary aggregate for sliced bread sold in supermarkets in the Northern region. Most elementary aggregate indexes are necessarily 'unweighted' averages for the sample of products within the sampled outlets. However, in cases where it is possible to select the sample of outlets from which prices are collected so as to reflect the shares of sales to consumers of the different outlet types covered, self-weighted elementary aggregate indexes may be computed. Similarly, if the market shares of the different types of product represented by product types are known, even only approximately, the number of observed products to be priced for each of them can be made proportional to those shares.

Consumer price index

461

Estimating weights
The outlet and regional dimensions noted above mean that the estimation of weights involves a lot more than just the breakdown of expenditure by types of goods and services, and the number of separately weighted indexes composing the overall index depends upon two factors: 1. The degree of detail to which available data permit breakdown of total consumption expenditure in the weight reference-period by type of expenditure, region and outlet type. 2. Whether there is reason to believe that price movements vary between these most detailed categories. How the weights are calculated, and in how much detail, depends upon the availability of information and upon the scope of the index. In the UK the Retail Price Index (RPI) does not relate to the whole of consumption, for the reference population is all private households with the exception of a) pensioner households that derive at least three-quarters of their total income from state pensions and benefits and b) "high income households" whose total household income lies within the top four per cent of all households. The result is that it is difficult to use data sources relating to total consumption by all population groups. For products whose price movements can differ between regions and between different types of outlet: The ideal, rarely realisable in practice, would consist of estimates of expenditure for each detailed consumption category, for each type of outlet, for each region. At the opposite extreme, with no regional data on expenditure totals but only on population (e.g. 24% in the Northern region) and only national estimates for the shares of different outlet types for broad categories of consumption (e.g. 70% of food sold in supermarkets) the weight for sliced bread sold in supermarkets in the Northern region has to be estimated as the share of sliced bread in total consumption 0.24 0.7. The situation in most countries comes somewhere between these two extremes. The point is to make the best use of whatever data are available.

The nature of the data used for weighting


No firm rules can be suggested on this issue for the simple reason that the available statistical sources differ between countries. However, all countries conduct periodical Household Expenditure surveys and all produce breakdowns of Consumption Expenditure in their National Accounts. The expenditure classifications used there may however be different. In particular: Household Expenditure surveys do not cover the expenditures of foreign visitors, though these may be within the scope of a Consumer Price Index. National Accounts include imputed rents for owner-occupied dwellings which may not be within the scope of a Consumer Price Index. Even with the necessary adjustments, the National Account estimates and Household Expenditure Surveys usually diverge. The statistical sources required for regional and outlet-type breakdowns are usually weaker. Only a large-sample Household Expenditure survey can provide a regional breakdown. Regional population data are sometimes used for this purpose, but need adjustment to allow for regional differences in living standards and consumption patterns. Statistics of retail sales and market research reports can provide information for estimating outlet-type breakdowns, but the classifications they use rarely correspond to COICOP categories. The increasingly widespread use of bar codes, scanners in shops has meant that detailed cash register printed receipts are provided by shops for an increasing share of retail purchases. This development makes possible improved Household Expenditure surveys, as Statistics Iceland has demonstrated. Survey respondents keeping a diary of their purchases need to record only the total of purchases when itemised receipts were given to them and keep these receipts in a special pocket in the diary. These receipts provide not only a detailed breakdown of purchases but also the name of the outlet. Thus response burden is markedly reduced, accuracy is increased, product description is more

Consumer price index specific and point of purchase data are obtained, facilitating the estimation of outlet-type weights. There are only two general principles for the estimation of weights: use all the available information and accept that rough estimates are better than no estimates.

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Reweighing
Ideally, in computing an index, the weights would represent current annual expenditure patterns. In practice they necessarily reflect past using the most recent data available or, if they are not of high quality, some average of the data for more than one previous year. Some countries have used a three-year average in recognition of the fact that household survey estimates are of poor quality. In some cases some of the data sources used may not be available annually, in which case some of the weights for lower level aggregates within higher level aggregates are based on older data than the higher level weights. Infrequent reweighing saves costs for the national statistical office but delays the introduction into the index of new types of expenditure. For example, subscriptions for Internet Service entered index compilation with a considerable time lag in some countries, and account could be taken of digital camera prices between re-weightings only by including some digital cameras in the same elementary aggregate as film cameras.

Owner-occupiers and the price index


The way in which owner-occupied dwellings should be dealt with in a Consumer Price Index has been, and remains, a subject of heated controversy in many countries. Various approaches have been considered, each with their advantages and disadvantages.[citation needed]

The economists' approach


Leaving aside the quality of public services, the environment, crime and so forth, and regarding the standard of living as a function of the level and composition of individuals consumption, this standard depends upon the amount and range of goods and services they consume. These include the service provided by rented accommodation, which can readily be priced, and the similar services yielded by a flat or house owned by the consumer who occupies it. Its cost to a consumer is, according to the economic way of thinking, an opportunity cost, namely what he or she sacrifices by living in it. This cost, according to many economists, is what should form a component of a Consumer Price Index. Opportunity cost can be looked at in two ways, since there are two alternatives to continuing to live in an owner-occupied dwelling. One supposing that it is one years cost that is to be considered is to sell it, earn interest on the owners capital thus released, and buy it back a year later, making an allowance for its physical depreciation. This can be called the alternative cost approach. The other, the rental equivalent approach, is to let it to someone else for the year, in which case the cost is the rent that could be obtained for it. Most people do not think about their dwelling in either of these ways, but this does not bother the theoretical economist for whom consistent logic is what matters. There are, of course, practical problems in implementing either of these economists approaches. Thus, with the alternative cost approach, if house prices are rising fast the cost can be negative and then become sharply positive once house prices start to fall, so such an index would be very volatile. On the other hand, with the rental equivalent approach, there may be difficulty in estimating the movement of rental values of types of property which are not actually rented. If one or other of these measures of the consumption of the services of owner-occupied dwellings is included in consumption, then it must be included in income too, for income equals consumption plus saving. This means that if the movement of incomes is to be compared with the movement of the Consumer Price Index, incomes must be expressed as money income plus this imaginary consumption value. That is logical, but it may not be what users of the index want.

Consumer price index Although the argument has been expressed in connection with owner-occupied dwellings, the logic applies equally to all durable consumer goods and services. Furniture, carpets and domestic appliances are not used up soon after purchase in the way that food is. Like dwellings, they yield a consumption service that can continue for years. Furthermore, since strict logic is to be adhered to, there are durable services as well that ought to be treated in the same way; the service consumers derive from appendectomies or crowned teeth continue for a long time. Since estimating values for these components of consumption has not been tackled, the economic theorists are torn between their desire for intellectual consistency and their recognition that inclusion of the opportunity cost of the use of durables is impracticable.[citation needed]

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Spending
Another approach is to concentrate on spending.[3][citation needed] Everyone agrees that repairs and maintenance expenditure of owner-occupied dwellings should be covered in a Consumer Price Index, but the spending approach would include mortgage interest too. This turns out to be quite complicated, conceptually as well as in practice. To explain what is involved, consider a Consumer Price Index computed with reference to 2009 for just one sole consumer who bought her house in 2006, financing half of this sum by raising a mortgage. The problem is to compare how much interest such a consumer would now be paying with the interest that was paid in 2009. Since the aim is to compare like with like, that requires an estimate of how much interest would be paid now in the year 2010 on a similar house bought and 50% mortgage-financed three years ago, in 2007. It does not require an estimate of how much that identical person is paying now on the actual house she bought in 2006, even though that is what personally concerns her now. A Consumer Price Index compares how much it would cost now to do exactly what consumers did in the reference-period with what it cost then. Application of the principle thus requires that the index for our one house owner should reflect the movement of the prices of houses like hers from 2006 to 2007 and the change in interest rates. If she took out a fixed-interest rate mortgage it is the change in interest rates from 2006 to 2007 that counts; if she took out a variable interest mortgage it is the change from 2009 to 2010 that counts. Thus her current index with 1999 as reference-period will stand at more than 100 if house prices or, in the case of a fixed-interest mortgage, interest rates rose between 2006 and 2007. The application of this principle in the owner-occupied dwellings component of a Consumer Price Index is known as the debt profile method. It means that the current movement of the index will reflect past changes in dwelling prices and interest rates. Some people regard this as odd. Quite a few countries use the debt profile method, but in doing so most of them behave inconsistently. Consistency would require that the index should also cover the interest on consumer credit instead of the whole price paid for the products bought on credit if it covers mortgage interest payments. Products bought on credit would then be treated in the same way as owner-occupied dwellings. Variants of the debt profile method are employed or have been proposed. One example is to include down payments as well as interest. Another is to correct nominal mortgage rates for changes in dwelling prices or for changes in the rest of the Consumer Price Index to obtain a real rate of interest. Also, other methods may be used alongside the debt profile method. Thus several countries include a purely notional cost of depreciation as an additional index component, applying an arbitrarily estimated, or rather guessed, depreciation rate to the value of the stock of owner-occupied dwellings. Finally, one country includes both mortgage interest and purchase prices in its index.

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Transaction prices
The third approach simply treats the acquisition of owner-occupied dwellings in the same way as acquisitions of other durable products are treated. This means: Taking account of the transaction prices agreed; Ignoring whether payments are delayed or are partly financed by borrowing; Leaving out second-hand transactions. Second-hand purchases correspond to sales by other consumers. Thus only new dwellings would be included. Furthermore, expenditure on enlarging or reconstructing an owner-occupied dwelling would be covered, in addition to regular maintenance and repair. Two arguments of an almost theological character are advanced in connection with this transactions approach. One argument is that purchases of new dwellings are treated as Investment in the System of National Accounts, so should not enter a consumption price index. It is said that this is more than just a matter of terminological uniformity. For example it may be thought to help understanding and facilitate economic analysis if what is included under the heading of Consumption is the same in the Consumer Price Index and in the national income and expenditure accounts. Since these accounts include the equivalent rental value of owner-occupied dwellings, the equivalent rental approach would have to be applied in the Consumer Price Index too. But the national accounts do not apply it to other durables, so the argument demands consistency in one respect but accepts its rejection in another. The other argument is that the prices of new dwellings should exclude that part reflecting the value of the land, since this is an irreproducible and permanent asset that cannot be said to be consumed. This would presumably mean deducting site value from the price of a dwelling, site value presumably being defined as the price the site would fetch at auction if the dwelling were not on it. How this is to be understood in the case of multiple dwellings remains unclear.[citation needed]

Confusion
It is apparent that much of the muddle in discussing the merits of the different approaches arises from the promiscuous mixing up of arguments about feasibility, about dislike or approval of the way the index would move under a particular approach and about principles of various, often incompatible, sorts. Feasibility is naturally important. The difficulty of dealing with site values is obvious. Statisticians in a country lacking a good dwelling price index (which is required for all except the rental equivalent method) will go along with a proposal to use such an index only if they can obtain the necessary additional resources that will enable them to compile one. Even obtaining mortgage interest rate data can be a major task in a country with a multitude of mortgage lenders and many types of mortgage. Dislike of the effect upon the behaviour of the Consumer Price Index arising from the adoption of some methods can be a powerful, if sometimes unprincipled, argument. Dwelling prices are volatile and so, therefore, would be an index incorporating the current value of a dwelling price sub-index which, in some countries, would have a large weight under the third approach. Furthermore, the weight for owner-occupied dwellings could be altered considerably when reweighting was undertaken. (It could even become negative under the alternative cost approach if weights were estimated for a year during which house prices had been rising steeply). Then, there is the point that a rise in interest rates designed to halt inflation could paradoxically make inflation appear higher if current interest rates showed up in the index. Economists principles are not acceptable to all; nor is insistence upon consistency between the treatment of owner-occupied dwellings and other durables.

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Clarity
Much would be gained if two sets of problems were distinguished.* What is the Consumer Price Index to measure? How can that be achieved? Another way of putting this is to distinguish: What is the question that should be answered? This is a matter for policy makers and other users of the Consumer Price Index. How can it best be answered? This is a matter for the statisticians.# The three approaches should not be regarded as rivals, they are different answers to different questions. One, or possibly more, should be chosen. The three questions can be formulated as follows: 1. Opportunity cost. What is the change through time in what would be the opportunity cost of the reference-period consumption of the services of owner-occupied dwellings? 2. Spending. What is the change through time in the cash outlays that would correspond to the reference-period cash outlays in respect of owner-occupied dwellings? 3. Transactions. What is the change through time in what would be the purchase value of the reference-period net acquisition of owner-occupied dwellings by consumers? Which question is to be answered is, as just stated, a policy matter, depending upon the purposes the index is to serve. It is not an issue for statisticians to decide. Their job is the technical, professional one of compiling one or more indexes that answer the selected question or questions as well as possible, given the resources at their disposal. In a perfect world this is how the owner-occupied dwellings issue would be resolved. But the world is not perfect.

Consumer Price Indices in the United States


In the United States, several different consumer price indices are routinely computed by the Bureau of Labor Statistics (BLS). These include the CPI-U (for all urban consumers), CPI-W (for Urban Wage Earners and Clerical Workers), CPI-E (for the elderly), and C-CPI-U (chained CPI for all urban consumers). These are all built in two stages. First, the BLS collects data to estimate 8,018 separate item-area indices reflecting the prices of 211 categories of consumption items in 38 geographical areas. In the second stage, weighted averages are computed of these 8,018 item-area indices. The different indices differ only in the weights applied to the different 8,018 item-area indices. The weights for CPI-U and CPI-W are held constant for 24 months, changing in January of even-numbered years. The weights for C-CPI-U are updated each month to reflecting changes in consumption patterns in the last month. Thus, if people on average eat more chicken and less beef or more apples and fewer oranges than the previous month, that change would be reflected in next month's C-CPI-U. However, it would not be reflected in CPI-U and CPI-W until January of the next even-numbered year.[4] This allows the BLS to compute consumer price indices for each of the designated 38 geographical areas and for aggregates like the Midwest.[5] In January of each year, Social Security recipients receive a cost of living adjustment (COLA) "to ensure that the purchasing power of Social Security and Supplemental Security Income (SSI) benefits is not eroded by inflation. It is based on the percentage increase in the Consumer Price Index for Urban Wage Earners and Clerical Workers (CPI-W)".[6] The use of CPI-W conflicts with this purpose, because the elderly consume substantially more health care goods and services than younger people.[] In recent years, inflation in health care has substantially exceeded inflation in the rest of the economy. Since the weight on health care in CPI-W is much less than the consumption patterns of the elderly, this COLA does not adequately compensate them for the real increases in the costs of the items they buy. The BLS does track a consumer price index for the elderly (CPI-E). It is not used, in part because the social security trust fund is forecasted to run out of money in roughly 40 years, and using the CPI-E instead of CPI-W would

Consumer price index shorten that by roughly 5 years.[7]

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History
Between 1971 and 1977, the United States CPI increased 47%.[] In 2009, the Consumer Price Index fell for the first time since 1955.[8]

Chained CPI
Former White House Chief of Staff Erskine Bowles and former U.S. Senator Alan K. Simpson suggested a transition to using a "chained CPI" in 2010, when they headed the White Houses deficit-reduction commission.[] They stated that it was a more accurate measure of inflation than the current system and switching from the current system could save the government more than $290 billion over the decade following their report.[] "The chained CPI is usually 0.25 to 0.30 percentage points lower each year, on average, than the standard CPI measurements."[] However, the National Active and Retired Federal Employees Associations said that the chained CPI does not account for seniors citizens health care costs.[] Robert Reich, former United States Secretary of Labor under President Clinton, noted that typical seniors spend between 20 and 40 percent of their income on health care, far more than most Americans. "Besides, Social Security isn't in serious trouble. The Social Security trust fund is flush for at least two decades. If we want to ensure it's there beyond that, there's an easy fix -- just lift the ceiling on income subject to Social Security taxes, which is now $113,700."[] Replacing the current cost-of-living adjustment calculation with the chained CPI was considered, but not adopted, as part of a deficit-reduction proposal to avert the sequestration cuts, or fiscal cliff, in January 2013,[] but President Obama included it in his April 2013 budget proposal.[9]

References
[2] Education 2020 Homeschool Console, subject Economics, lecture "Inflation" (http:/ / student. education2020. com/ activities/ lecture. aspx?keystr=12362& order=06010210& stbl=2196464). Formula described within. [3] Bloomberg Business News, Social Security Administration [8] Harper's Magazine http:/ / harpers. org/ archive/ 2009/ 04/ WeeklyReview2009-04-21

Further reading
W.E. Diewert, 1993. The early history of price index research (http://faculty.arts.ubc.ca/ediewert/indexch2. pdf). Chapter 2 of Essays in Index Number Theory, Volume I, W.E. Diewert and A.O. Nakamura, editors. Elsevier Science Publishers, B.V.

External links
Issues of the Consumer Price Index report from the BLS for 1953-1974 (http://fraser.stlouisfed.org/ publication-series/?id=67) and 1974-2000 (http://fraser.stlouisfed.org/publication-series/?id=58) ILO CPI manual (http://www.ilo.org/public/english/bureau/stat/guides/cpi/index.htm) This large manual produced co-operatively by a number of international organizations is the standard work on the methods of compiling consumer price indexes and on the underlying economic and statistical theory. myCPI.info (http://simulatemortgages.com/mycpi/) Project for establishing alternative CPI data based on users inputting and tracking their personal CPI. "The Consumer Price Index and index number purpose" (http://www.econ.ubc.ca/diewert/purpose.pdf) A technical article by economist W.E. Diewert SGS Alternate Inflation Charts (http://www.shadowstats.com/alternate_data/inflation-charts) SGS CPI calculation criticisms (http://www.shadowstats.com/article/consumer_price_index)

Consumer price index BLS rebuttal to SGS CPI calculation criticisms (http://www.bls.gov/opub/mlr/2008/08/art1full.pdf) SGS rebuttal to BLS rebuttal regarding CPI (http://www.shadowstats.com/article/special-comment)

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Specific countries
International Worldwide Consumer Price Index Per City User-Updated (http://www.numbeo.com/cost-of-living/rankings. jsp) Australia Australian CPI (http://www.abs.gov.au/AUSSTATS/abs@.nsf/productsbyCatalogue/ 938DA570A34A8EDACA2568A900139350?OpenDocument) Measures of Consumer Price Inflation (http://www.rba.gov.au/inflation/measures-cpi.html) France Consumer Price Index (http://www.insee.fr/en/indicateur/indic_cons/indic_cons.asp), INSEE A description of the French consumer price index (http://www.insee.fr/fr/nom_def_met/sources/ope-ipc. htm) (in French) Canada Statistics Canada (http://www.statcan.gc.ca/) Hong Kong Hong Kong Consumer Price Index (CPI) (http://www.censtatd.gov.hk/hong_kong_statistics/ statistics_by_subject/index.jsp?subjectID=12&charsetID=1&displayMode=T), Census and Statistics Department India CPI and its composition in India (http://www.knowledge.fintotal.com/ What-is-Consumer-Price-Index-CPI-and-How-it-Matters/6458) Italy Indici dei prezzi al consumo (http://www.istat.it/salastampa/comunicati/in_calendario/precon/), ISTAT Rivalutazione monetaria con gli Indici dei prezzi al consumo per le famiglie di operai ed impiegati (http://www. rivalutazionemonetaria.it) Spain CPI information (http://www.ine.es/jaxi/menu.do?type=pcaxis&path=/t25/p138&file=inebase&L=1), Instituto Nacional de Estadstica New Zealand CPI information (http://www.stats.govt.nz/browse_for_stats/economic_indicators/CPI_inflation/ info-releases.aspx), Statistics New Zealand Sweden A Consumer Price Index for Sweden 1290-2006 (http://www.riksbank.com/templates/Page.aspx?id=27404) A detailed account in English of the Swedish consumer price index (http://www.scb.se/statistik/PR/PR0101/ handbok.pdf) Denmark Oldmoney.dk - A Consumer Price Index-calculator for Denmark 1900-2010 (http://oldmoney.dk) United Kingdom

Consumer price index National Statistics Online: Consumer Prices (http://www.statistics.gov.uk/cci/nscl.asp?id=5843), UK Office for National Statistics A detailed account of the UK index (http://www.statistics.gov.uk/statbase/product.asp?vlnk=2328) United States Consumer Price Index Home Page (http://www.bls.gov/cpi/), U.S. Department of Labor, Bureau of Labor Statistics A detailed account of the US index (http://stats.bls.gov/opub/hom/pdf/homch17.pdf) Inflation Calculator (http://www.bls.gov/data/inflation_calculator.htm) Historical US CPI chart (http://finance-data.com/series/CPIAUCSL) Monthly data since 1947 CPI categories 1993-2010 (http://upload.wikimedia.org/wikipedia/commons/f/ff/Cpi-categories.jpg) Alternate non official CPI measures (http://www.shadowstats.com/) An inflation research site and personal inflation rate calculator (http://myinflationrate.com/)

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Computerized physician order entry


Computerized physician order entry (CPOE) (also sometimes referred to as Computerized Provider Order Entry) (also sometimes referred to as Computerized Provider Order Management ) is a process of electronic entry of medical practitioner instructions for the treatment of patients (particularly hospitalized patients) under his or her care. These orders are communicated over a computer network to the medical staff or to the departments (pharmacy, laboratory, or radiology) responsible for fulfilling the order. CPOE decreases delay in order completion, reduces errors related to handwriting or transcription, allows order entry at the point of care or off-site, provides error-checking for duplicate or incorrect doses or tests, and simplifies inventory and posting of charges. CPOE is a form of patient management software.[1]

Terminology related to order entry


Filler
The application responding to, i.e., performing, a request for services (orders) or producing an observation. The filler can also originate requests for services (new orders), add additional services to existing orders, replace existing orders, put an order on hold, discontinue an order, release a held order, or cancel existing orders.

Order
A request for a service from one application to a second application. In some cases an application is allowed to place orders with itself.

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Order detail segment


One of several segments that can carry order information. Future ancillary specific segments may be defined in subsequent releases of the Standard if they become necessary.

Placer
The application or individual originating a request for services (order).

Placer order group


A list of associated orders coming from a single location regarding a single patient.

Order Set
A grouping of orders used to standardize and expedite the ordering process for a common clinical scenario. (Typically, these orders are started, modified, and stopped by a licensed physician.)

Protocol
A grouping of orders used to standardize and automate a clinical process on behalf of a physician. (Typically, these orders are started, modified, and stopped by a nurse, pharmacist, or other licensed health professional.)

Features of CPOE systems


Features of the ideal computerized physician order entry system (CPOE) include: Ordering Physician orders are standardized across the organization, yet may be individualized for each doctor or specialty by using order sets. Orders are communicated to all departments and involved caregivers, improving response time and avoiding scheduling problems and conflict with existing orders. Patient-centered decision support The ordering process includes a display of the patient's medical history and current results and evidence-based clinical guidelines to support treatment decisions. Often uses medical logic module and/or Arden syntax to facilitate fully integrated Clinical Decision Support Systems (CDSS). Patient safety features The CPOE system allows real-time patient identification, drug dose recommendations, adverse drug reaction reviews, and checks on allergies and test or treatment conflicts. Physicians and nurses can review orders immediately for confirmation. Intuitive Human interface The order entry workflow corresponds to familiar "paper-based" ordering to allow efficient use by new or infrequent users. Regulatory compliance and security Access is secure, and a permanent record is created, with electronic signature. Portability The system accepts and manages orders for all departments at the point-of-care, from any location in the health system (physician's office, hospital or home) through a variety of devices, including wireless PCs and tablet computers. Management

Computerized physician order entry The system delivers statistical reports online so that managers can analyze patient census and make changes in staffing, replace inventory and audit utilization and productivity throughout the organization. Data is collected for training, planning, and root cause analysis for patient safety events. Billing Documentation is improved by linking diagnoses (ICD-9-CM or ICD-10-CM codes) to orders at the time of order entry to support appropriate charges.

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Patient safety benefits of CPOE


In the past, physicians have traditionally hand-written or verbally communicated orders for patient care, which are then transcribed by various individuals (such as unit clerks, nurses, and ancillary staff) before being carried out. Handwritten reports or notes, manual order entry, non-standard abbreviations and poor legibility lead to errors and injuries to patients, according to a 1999 Institute of Medicine (IOM) report.[2] A follow up IOM report in 2001 advised use of electronic medication ordering, with computer- and internet-based information systems to support clinical decisions.[3] Prescribing errors are the largest identified source of preventable hospital medical error. A 2006 report by the Institute of Medicine estimated that a hospitalized patient is exposed to a medication error each day of his or her stay.[4] Studies of computerized physician order entry (CPOE) has yielded evidence that suggests the medication error rate can be reduced by 80%, and errors that have potential for serious harm or death for patients can be reduced by 55%,[5] and other studies have also suggested benefits.[6] Further, in 2005, CMS and CDC released a report that showed only 41 percent of prophylactic antibacterials were correctly stopped within 24 hours of completed surgery. The researchers conducted an analysis over an eight-month period, implementing a CPOE system designed to stop the administration of prophylactic antibacterials. Results showed CPOE significantly improved timely discontinuation of antibacterials from 38.8 percent of surgeries to 55.7 percent in the intervention hospital.[7] CPOE/e-Prescribing systems can provide automatic dosing alerts (for example, letting the user know that the dose is too high and thus dangerous) and interaction checking (for example, telling the user that 2 medicines ordered taken together can cause health problems). In this way, specialists in pharmacy informatics work with the medical and nursing staffs at hospitals to improve the safety and effectiveness of medication use by utilizing CPOE systems.

Risks of CPOE
CPOE presents several possible dangers by introducing new types of errors.[8][9] Prescriber and staff inexperience may cause slower entry of orders at first, use more staff time, and is slower than person-to-person communication in an emergency situation. Physician to nurse communication can worsen if each group works alone at their workstations. Automation causes a false sense of security, a misconception that when technology suggests a course of action, errors are avoided. These factors contributed to an increased mortality rate in the Children's Hospital of Pittsburgh's Pediatric ICU when a CPOE systems was introduced.[10] In other settings, shortcut or default selections can override non-standard medication regimens for elderly or underweight patients, resulting in toxic doses.[citation needed] Frequent alerts and warnings can interrupt work flow, causing these messages to be ignored or overridden due to alert fatigue. CPOE and automated drug dispensing was identified as a cause of error by 84% of over 500 health care facilities participating in a surveillance system by the United States Pharmacopoeia.[11] Introducing CPOE to a complex medical environment requires ongoing changes in design to cope with unique patients and care settings, close supervision of overrides caused by automatic systems, and training, testing and re-training all users.

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Implementation
CPOE systems can take years to install and configure. Despite ample evidence of the potential to reduce medication errors, adoption of this technology by doctors and hospitals in the United States has been slowed by resistance to changes in physician's practice patterns, costs and training time involved, and concern with interoperability and compliance with future national standards.[12] According to a study by RAND Health, the US healthcare system could save more than 81 billion dollars annually, reduce adverse medical events and improve the quality of care if it were to widely adopt CPOE and other health information technology.[13] As more hospitals become aware of the financial benefits of CPOE, and more physicians with a familiarity with computers enter practice, increased use of CPOE is predicted. Several high profile failures of CPOE implementation have occurred,[14] so a major effort must be focused on change management, including restructuring workflows, dealing with physicians' resistance to change, and creating a collaborative environment. An early success with CPOE by the United States Department of Veterans Affairs (VA) is the Veterans Health Information Systems and Technology Architecture or VistA. A graphical user interface known as the Computerized Patient Record System (CPRS) allows health care providers to review and update a patients record at any computer in the VA's over 1,000 healthcare facilities. CPRS includes the ability to place orders by CPOE, including medications, special procedures, x-rays, patient care nursing orders, diets, and laboratory tests. The world's first successful implementation of a CPOE system was at El Camino Hospital in Mountain View, California in the early 1970s. The Medical Information System (MIS) was originally developed by a software and hardware team at Lockheed in Sunnyvale, California, which became the TMIS group at Technicon Instruments Corporation. The MIS system used a light pen to allow physicians and nurses to quickly point and click items to be ordered. As of 2005[15], one of the largest projects for a national EHR is by the National Health Service (NHS) in the United Kingdom. The goal of the NHS is to have 60,000,000 patients with a centralized electronic health record by 2010. The plan involves a gradual roll-out commencing May 2006, providing general practices in England access to the National Programme for IT (NPfIT). The NHS component, known as the "Connecting for Health Programme",[16] includes office-based CPOE for medication prescribing and test ordering and retrieval, although some concerns have been raised about patient safety features.[17] In 2008, the Massachusetts Technology Collaborative and the New England Healthcare Institute (NEHI) published research showing that 1 in 10 patients admitted to a Massachusetts community hospital suffered a preventable medication error. The study argued that Massachusetts hospitals could prevent 55,000 adverse drug events per year and save $170 million annually if they fully implemented CPOE. The findings prompted the Commonwealth of Massachusetts to enact legislation requiring all hospitals to implement CPOE by 2012 as a condition of licensure.[18][19] In addition, the study[20] also concludes that it would cost approximately $2.1 million to implement a CPOE system, and a cost of $435,000 to maintain it in the state of Massachusetts while it saves annually about $2.7 million per hospital. The hospitals will still see payback within 26 months through reducing hospitalizations generated by error. Despite the advantages and cost savings, the CPOE is still not well adapted by many hospitals in the US. The Leapfrogs 2008 Survey[21] showed that most hospitals are still not complying with having a fully implemented, effective CPOE system. The CPOE requirement became more challenging to meet in 2008 because the Leapfrog introduced a new requirement: Hospitals must test their CPOE systems with Leapfrogs CPOE Evaluation Tool. So the number of hospitals in the survey considered to be fully meeting the standard dropped to 7% in 2008 from 11% the previous year. Though the adoption rate seems very low in 2008, it is still an improvement from 2002 when only 2% of hospitals met this Leapfrog standard.

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External links
Certification Commission for Healthcare Information Technology (CCHIT) [22] AHRQ National Resource Center for Health IT [23]

Notes
[1] Agency for Healthcare Research and Quality (2009). http:/ / healthit. ahrq. gov/ images/ jan09cpoereport/ cpoe_issue_paper. htm [6] http:/ / www. eurekalert. org/ pub_releases/ 2010-05/ sumc-ssf042710. php [7] http:/ / www. beckersasc. com/ asc-quality-infection-control/ study-cpoe-systems-improve-prophylactic-antibacterial-use-in-surgical-patients. html [13] RAND Healthcare: Health Information Technology: Can HIT Lower Costs and Improve Quality? (http:/ / www. rand. org/ pubs/ research_briefs/ RB9136/ index1. html) Retrieved on July 8, 2006 [15] http:/ / en. wikipedia. org/ w/ index. php?title=Computerized_physician_order_entry& action=edit [16] NHS Connecting for Health: Delivering the National Programme for IT (http:/ / www. connectingforhealth. nhs. uk/ delivery/ ) Retrieved August 4, 2006 [18] http:/ / www. todayshospitalist. com/ index. php?b=articles_read& cnt=614 [19] Massachusetts Hospitals Must Have CPOE By 2012 And CCHIT-Certified EHRS By 2015: (http:/ / www. hl7standards. com/ blog/ 2008/ 08/ 13/ massachusetts-hospitals-must-have-cpoe-by-2012-and-cchit-certified-ehrs-by-2015/ ) Retrieved April 11, 2012 [22] http:/ / www. cchit. org/ [23] http:/ / healthit. ahrq. gov/ cpoe

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Cardiopulmonary resuscitation
Cardiopulmonary resuscitation
Intervention

CPR being performed on a medical-training manikin ICD-9: MeSH OPS-301code: MedlinePlus 99.60 [1] [2]

D016887 8-771 [3]

000010

[4]

Cardiopulmonary resuscitation (CPR) is an emergency procedure, performed in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person in cardiac arrest. It is indicated in those who are unresponsive with no breathing or abnormal breathing, for example, agonal respirations. CPR involves chest compressions at least 5cm (2in) deep and at a rate of at least 100 per minute in an effort to create artificial circulation by manually pumping blood through the heart. In addition, the rescuer may provide breaths by either exhaling into the subject's mouth or nose or utilizing a device that pushes air into the subject's lungs. This process of externally providing ventilation is termed artificial respiration. Current recommendations place emphasis on high-quality chest compressions over artificial respiration; a simplified CPR method involving chest compressions only is recommended for untrained rescuers. CPR alone is unlikely to restart the heart; its main purpose is to restore partial flow of oxygenated blood to the brain and heart. The objective is to delay tissue death and to extend the brief window of opportunity for a successful resuscitation without permanent brain damage. Administration of an electric shock to the subject's heart, termed defibrillation, is usually needed in order to restore a viable or "perfusing" heart rhythm. Defibrillation is only effective for certain heart rhythms, namely ventricular fibrillation or pulseless ventricular tachycardia, rather than asystole or pulseless electrical activity. CPR may succeed in inducing a heart rhythm which may be shockable. CPR is generally continued until the patient has a return of spontaneous circulation (ROSC) or is declared dead.

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Medical uses
CPR is indicated for any person who is unresponsive with no breathing, or who is only breathing in occasional agonal gasps, as it is most likely that they are in cardiac arrest.[]:S643 If a person still has a pulse, but is not breathing (respiratory arrest), artificial respirations may be more appropriate, but due to the difficulty people have in accurately assessing the presence or absence of a pulse, CPR guidelines recommend that lay persons should not be instructed to check the pulse, while giving health care professionals the option to check a pulse.[5] In those with cardiac arrest due to trauma CPR is considered futile in the pulseless case, but still recommended for correctible causes of arrest.[]

Methods
In 2010, the American Heart Association and International Liaison Committee on Resuscitation updated their CPR guidelines.[]:S640[6] The importance of high quality CPR (sufficient rate and depth without excessively ventilating) was emphasized.[]:S640 The order of interventions was changed for all age groups except newborns from airway, breathing, chest compressions (ABC) to chest compressions, airway, breathing (CAB).[]:S642 An exception to this recommendation is for those who are believed to be in a respiratory arrest (drowning, etc.).[]:S642 The most important aspect of CPR are: few interruptions of chest compressions, a sufficient speed and depth of compressions, completely relaxing pressure between compressions, and not ventilating too much.[7]

CPR training: CPR is being administered while a second rescuer prepares for defibrillation.

Standard
A universal compression to ventilation ratio of 30:2 is recommended.[]:8 With children, if at least 2 rescuers are present a ratio of 15:2 is preferred.[]:8 In newborns a rate of 3:1 is recommended unless a cardiac cause is known in which case a 15:2 ratio is reasonable.[]:S647 If an advanced airway such as an endotracheal tube or laryngeal mask airway is in place delivery of respirations should occur without pauses in compressions at a rate of 810 per minute.[8] The recommended order of interventions is chest compressions, airway, breathing or CAB in most situations,[]:S642 with a compression rate of at least 100 per minute in all groups.[]:8 Recommended compression depth in adults and children is about 5cm (2inches) and in infants it is 4cm (1.5inches.[]:8 As of 2010 the Resuscitation Council (UK) still recommends ABC for children.[9] As it can be difficult to determine the presence or absence of a pulse the pulse check has been removed for lay providers and should not be performed for more than 10 seconds by health care providers.[]:8 In adults rescuers should use two hands for the chest compressions, while in children they should use one, and with infants two fingers (index and middle fingers).[10]

Compression only
Compression-only (hands-only or cardiocerebral resuscitation) CPR is a technique that involves chest compressions without artificial respiration.[]:S643 It is recommended as the method of choice for the untrained rescuer or those who are not proficient as it is easier to perform and instructions are easier to give over the phone.[]:S643[]:8[] In adults with out-of-hospital cardiac arrest, compression-only CPR by the lay public has a higher success rate than standard CPR.[] The exceptions are cases of drownings, drug overdose, and arrest in children. Children who receive compression-only CPR have the same outcomes as those who received no CPR.[]:S646 The method of delivering chest compressions remains the same, as does the rate (at least 100 per minute). It is hoped that the use of compression-only delivery will increase the chances of the lay public delivering CPR.[] As per the American Heart Association, the beat of the Bee Gees song "Stayin' Alive" provides an ideal rhythm in terms of beats per minute to

Cardiopulmonary resuscitation use for hands-only CPR.[] One can also hum Queen's "Another One Bites The Dust", which is exactly 100 beats-per-minute and contains a memorable repeating drum pattern.[] For those with non cardiac arrest and people less than 20 years of age, standard CPR is superior to compression-only CPR.[11][12]

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Pregnancy
During pregnancy when a woman is lying on her back the uterus may compress the inferior vena cava and thus decrease venous return.[] It is recommended for this reason that the uterus be pushed to the woman's left and if this is not effective either roll the person 30 or for healthcare professionals to consider emergency Caesarean section.[]

Other
Interposed abdominal compressions may be beneficial in the hospital environment.[] There is however no evidence of benefit pre hospital or in children.[] Internal cardiac massage is manual squeezing of the heart carried out through a surgical incision into the chest cavity. This may be carried out if the chest is already open for cardiac surgery.

Effectiveness
Type of Arrest Witnessed In-Hospital Cardiac Arrest Unwitnessed In-Hospital Cardiac Arrest Bystander compression-only Resuscitation Bystander Cardiopulmonary Resuscitation No Bystander CPR (Ambulance CPR) Defibrillation within 35 minutes ROSC Survival Source 48% 21% 40% 40% 15% 74% 22% 1% 6% 4% 2% 30% [] [] [] [] [] [][13]

Used alone, CPR will result in few complete recoveries, and those who do survive often develop serious complications. Estimates vary, but many organizations stress that CPR does not "bring anyone back," it simply preserves the body for defibrillation and advanced life support.[] However, in the case of "non-shockable" rhythms such as Pulseless Electrical Activity (PEA), defibrillation is not indicated, and the importance of CPR rises. On average, only 510% of people who receive CPR survive.[14] The purpose of CPR is not to "start" the heart, but rather to circulate oxygenated blood, and keep the brain alive until advanced care (especially defibrillation) can be initiated. As many of these patients may have a pulse that is impalpable by the layperson rescuer, the current consensus is to perform CPR on a patient who is not breathing. Studies have shown that immediate CPR followed by defibrillation within 35 minutes of sudden VF cardiac arrest improves survival. In cities such as Seattle where CPR training is widespread and defibrillation by EMS personnel follows quickly, the survival rate is about 30 percent. In cities such as New York, without those advantages, the survival rate is only 12 percent.[13] In most cases, there is a higher proportion of patients who achieve a Return of Spontaneous Circulation (ROSC), where their heart starts to beat on its own again, than ultimately survive to be discharged from hospital (see table above). This is due to medical staff either being ultimately unable to address the cause of the arrhythmia or cardiac arrest, or in some instances due to other co-morbidities, due to the patient being gravely ill in more than one way. Compression-only CPR is less effective in children than in adults, as cardiac arrest in children is more likely to have a non-cardiac cause. In a 2010 prospective study of cardiac arrest in children (age 117), for arrests with a non-cardiac cause, provision by bystanders of conventional CPR with rescue breathing yielded a favorable

Cardiopulmonary resuscitation neurological outcome at one month more often than did compression-only CPR (OR 5.54; 95% confidence interval 2.5216.99). For arrests with a cardiac cause in this cohort, there was no difference between the two techniques (OR 1.20; 95% confidence interval 0.552.66).[] This is consistent with American Heart Association guidelines for parents.[]

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Pathophysiology
CPR is used on people in cardiac arrest in order to oxygenate the blood and maintain a cardiac output to keep vital organs alive. Blood circulation and oxygenation are required to transport oxygen to the tissues. The brain may sustain damage after blood flow has been stopped for about four minutes and irreversible damage after about seven minutes.[15][16][17][18][19] Typically if blood flow ceases for one to two hours, the cells of the body die. Because of that CPR is generally only effective if performed within seven minutes of the stoppage of blood flow.[20] The heart also rapidly loses the ability to maintain a normal rhythm. Low body temperatures, as sometimes seen in near-drownings, prolong the time the brain survives. Following cardiac arrest, effective CPR enables enough oxygen to reach the brain to delay brain death, and allows the heart to remain responsive to defibrillation attempts.

Complications
Whilst CPR is a last resort intervention, without which a patient without a pulse will certainly die, the physical nature of how CPR is performed does lead to complications that may need to be rectified. Common complications due to CPR include rib fractures, sternal fractures, bleeding in the anterior mediastinum, heart contusion,[21] hemopericardium,[22][23][24] upper airway complications, damage to the abdominal viscus - lacerations of the liver and spleen, fat emboli, pulmonary complications - pneumothorax, hemothorax, lung contusions.[25][] The most common injuries sustained from CPR are rib fractures, with literature suggesting an incidence between 13% and 97%, and sternal fractures, with an incidence between 1% to 43%.[] Whilst these iatrogenic injuries can require further intervention (assuming the patient survives the cardiac arrest), only 0.5% of them are life threatening in their own right.[] The type and frequency of injury can be affected by factors such as gender and age. For instance, women have a higher risk of sternal fractures than men, and risk for rib fractures increases significantly with age.[26] Children and infants have a low risk of rib fractures during CPR, with an incidence less than 2%, although when they do occur, they are usually anterior and multiple.[][27][28] Where CPR is performed in error by a bystander, on a patient who is not in cardiac arrest, only around 2% suffer injury as a result (although 12% experienced discomfort).[29]

Adjunct devices
While several adjunctive devices are available none other than defibrillation as of 2010 have consistently been found to be better than standard CPR for out of hospital cardiac arrest.[]:S644 These devices can be split into three broad groups - timing devices, those that assist the rescuer to achieve the correct technique, especially depth and speed of compressions, and those which take over the process completely.

Timing devices
They can feature a metronome (an item carried by many ambulance crews) in order to assist the rescuer in getting the correct rate. Some units can also give timing reminders for performing compressions, breathing and changing operators.[30]

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Manual assist devices


Mechanical devices have not been found to have greater benefit than harm and thus are not currently recommended for widespread use.[31] Audible and visual prompting may improve the quality of CPR and prevent the decrease of compression rate and depth that naturally occurs with fatigue,[32][33][34][35][36][37] and to address this potential improvement, a number of devices have been developed to help improve CPR technique. These items can be devices to placed on top of the chest, with the rescuers hands going over the device, and a display or audio feedback giving information on depth, force or rate,[38] or in a wearable format such as a glove.[39] Several published evaluations show that these devices can improve the performance of chest compressions.[40][41] As well as use during actual CPR on a cardiac arrest victim, which relies on the rescuer carrying the device with them, these devices can also be used as part of training programs to improve basic skills in performing correct chest compressions.[42]

Automatic devices
There are also some automated devices available which take over the chest compressions for the rescuer. These have several advantages: they allow rescuers to focus on performing other interventions; they do not fatigue and begin to perform less effective compressions, as humans do; and they are able to perform effective compressions in limited-space environments such as air ambulances, where manual compressions are difficult. These devices use either pneumatic (high-pressure gas) or electrical power sources to drive a compressing pad on to the chest of the patient. One such device, known as the LUCAS, was developed at the University Hospital of Lund, is powered by the compressed oxygen supplies already standard in ambulances and hospitals, and has undergone numerous clinical trials, showing a marked improvement in coronary perfusion pressure[43] and return of spontaneous circulation.[44] Artificial ventilation can be done with multiple devices: bag mask gives way valve ball with oxygen-enriched air (which is in the bag) through a facial mask filing (but not external tubes, does not open the airway ). This uses an oropharyngeal airway, called Bergman, tube May or Guedel airway (these do not prevent mouth to mouth contact if there were no masks or masks with air balloons) or Maselli: oropharyngeal Maselli respirator (avoiding contagion in both directions) and is necessary to facilitate air pass to place the tongue in place and prevent it from falling back and relax in by the unconscious, as well as whether the person has a voluminous language, such as in cases of Quincke. It also has a nozzle for the rescuer with a protective mask mode, which prevents any mouth to mouth contact. Another system called the AutoPulse is electrically powered and uses a large band around the patients chest which contracts in rhythm in order to deliver chest compressions. This is also backed by clinical studies showing increased successful return of spontaneous circulation.[45][46]

Prevalence
Chance of receiving CPR
Various studies suggest that in out-of-home cardiac arrest, bystanders, lay persons or family members attempt CPR in between 14%[] and 45%[] of the time, with a median of 32%.[] This indicates that around a third of out-of-home arrests have a CPR attempt made on them. However, the effectiveness of this CPR is variable, and the studies suggest only around half of bystander CPR is performed correctly.[47][48] A recent study has shown that members of the public who have received CPR training in the past lack the skills and confidence needed to save lives. These experts believe that better training is needed to improve the willingness to respond to cardiac arrest.[] There is a clear correlation between age and the chance of CPR being commenced, with younger people being far more likely to have CPR attempted on them prior to the arrival of emergency medical services.[][49] It was also found that CPR was more commonly given by a bystander in public than when an arrest occurred in the patient's home,

Cardiopulmonary resuscitation although health care professionals are responsible for more than half of out-of-hospital resuscitation attempts.[] This is supported by further research, which suggests that people with no connection to the victim are more likely to perform CPR than a member of their family.[] There is also a correlation between the cause of arrest and the likelihood of bystander CPR being initiated. Lay persons are most likely to give CPR to younger cardiac arrest victims in a public place when it has a medical cause; victims in arrest from trauma, exsanguination or intoxication are less likely to receive CPR.[] Finally, it has been claimed that there is a higher chance of CPR being performed if the bystander is told to only perform the chest compression element of the resuscitation.[]

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Chance of receiving CPR in time


CPR is only likely to be effective if commenced within 6 minutes after the blood flow stops,[] because permanent brain cell damage occurs when fresh blood infuses the cells after that time, since the cells of the brain become dormant in as little as 46 minutes in an oxygen deprived environment and the cells are unable to survive the reintroduction of oxygen in a traditional resuscitation. Research using cardioplegic blood infusion resulted in a 79.4% survival rate with cardiac arrest intervals of 7243 minutes, traditional methods achieve a 15% survival rate in this scenario, by comparison. New research is currently needed to determine what role CPR, electroshock, and new advanced gradual resuscitation techniques will have with this new knowledge.[50] A notable exception is cardiac arrest occurring in conjunction with exposure to very cold temperatures. Hypothermia seems to protect by slowing down metabolic and physiologic processes, greatly decreasing the tissues' need for oxygen.[51] There are cases where CPR, defibrillation, and advanced warming techniques have revived victims after substantial periods of hypothermia.[52]

Society and culture


Portrayed effectiveness
CPR is often severely misrepresented in movies and television as being highly effective in resuscitating a person who is not breathing and has no circulation. A 1996 study published in the New England Journal of Medicine showed that CPR success rates in television shows was 75% for immediate circulation, and 67% survival to discharge.[][53] This gives members of the public an unrealistic expectation of a successful outcome.[] When educated on the actual survival rates, the proportion of patients over 60 years of age desiring CPR should they suffer a cardiac arrest drops from 41% to 22%.[54]

Stage CPR
Chest compressions are capable of causing significant local blunt trauma, including bruising or fracture of the sternum or ribs.[55] Performing CPR on a healthy person may or may not disrupt normal heart rhythm, but regardless the technique should not be performed on a healthy person because of the risk of trauma. The portrayal of CPR technique on television and film often is purposely incorrect. Actors simulating the performance of CPR may bend their elbows while appearing to compress, to prevent force from reaching the chest of the actor portraying the victim. Other techniques, such as substituting a mannequin torso for the "victim" in some shots, may also be used to avoid harming actors.

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Self-CPR hoax
A form of "self-CPR" termed "Cough CPR" was the subject of a hoax chain e-mail entitled "How to Survive a Heart Attack When Alone" which wrongly cited "ViaHealth Rochester General Hospital" as the source of the technique. Rochester General Hospital has denied any connection with the technique.[56][57] "Cough CPR" cannot be used outside the hospital because the first symptom of cardiac arrest is unconsciousness[58] in which case coughing is impossible, although myocardial infarction (heart attack) may occur to give rise to the cardiac arrest, so a patient may not be immediately unconscious. Further, the vast majority of people suffering chest pain from a heart attack will not be in cardiac arrest and CPR is not needed. In these cases attempting "cough CPR" will increase the workload on the heart and may be harmful. When coughing is used on trained and monitored patients in hospitals, it has only been shown to be effective for 90 seconds.[] The American Heart Association (AHA) and other resuscitation bodies[] do not endorse "Cough CPR", which it terms a misnomer as it is not a form of resuscitation. The AHA does recognize a limited legitimate use of the coughing technique: "This coughing technique to maintain blood flow during brief arrhythmias has been useful in the hospital, particularly during cardiac catheterization. In such cases the patients ECG is monitored continuously, and a physician is present."[59]

CPR learned from movies and television


In at least one case, it has been claimed that CPR allegedly learned from a movie was used to save a person's life. In April 2011, it was claimed that nine-year-old Tristin Saghin saved his sister's life by administering CPR on her after she fell into a swimming pool, using only the knowledge of CPR that he had gleaned from a motion picture, Black Hawk Down.[]

Hands-Only CPR portrayed as more palatable version


Less than 1/3 of those people who experience a cardiac arrest at home, work or in a public location have CPR performed on them. Most bystanders are worried that they might do something wrong.[60] On October 28, 2009 The American Heart Association and the Ad Council launched a Hands Only CPR public service announcement and website as a means to address this issue.[61] In July 2011, new content was added to the website including a digital app that helps a user learn how to perform Hands-Only CPR.[62]

History

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In the 19th century, Doctor H. R. Silvester described a method (The Silvester Method) of artificial respiration in which the patient is laid on their back, and their arms are raised above their head to aid inhalation and then pressed against their chest to aid exhalation.[63] The procedure is repeated sixteen times per minute. This type of artificial respiration is occasionally seen in films made in the early part of the 20th century. A second technique, called the Holger Nielsen technique, described in the first edition of the Boy Scout Handbook in the Mouth-to-mouth resuscitation United States in 1911, described a form of artificial respiration where the person was laid face down, with their head to the side, resting on the palms of both hands. Upward pressure applied at the patients elbows raised the upper body while pressure on their back forced air into the lungs, essentially the Silvester Method with the patient flipped over. This form is seen well into the 1950s (it is used in an episode of Lassie during the mid-1950s), and was often used, sometimes for comedic effect, in theatrical cartoons of the time (see Tom and Jerry's "The Cat and the Mermouse"). This method would continue to be shown, for historical purposes, side-by-side with modern CPR in the Boy Scout Handbook until its ninth edition in 1979. The technique was later banned from first-aid manuals in the U.K. Similar techniques were described in early 20th century ju-jutsu and judo books, as being used as far back as early 17th century. A New York Times correspondent reported those techniques being used successfully in Japan in 1910. In ju-jutsu (and later on, judo), those techniques were called Kappo or Kutasu.[64] [65][66][67] However, it was not until the middle of the 20th century that the wider medical community started to recognize and promote artificial respiration combined with chest compressions as a key part of resuscitation following cardiac arrest. The combination was first seen in a 1962 training video called "The Pulse of Life" created by James Jude, Guy Knickerbocker and Peter Safar. Jude and Knickerbocker, along with William Kouwenhoven and Joseph S. Redding had recently discovered the method of external chest compressions, whereas Safar had worked with Redding and James Elam to prove the effectiveness of artificial respiration. It was at Johns Hopkins University where the technique of CPR was originally developed. The first effort at testing the technique was performed on a dog by Redding, Safar and JW Perason. Soon afterward, the technique was used to save the life of a child.[68] Their combined findings were presented at the annual Maryland Medical Society meeting on September 16, 1960 in Ocean City, and gained rapid and widespread acceptance over the following decade, helped by the video and speaking tour they undertook. Peter Safar wrote the book ABC of Resuscitation in 1957. In the U.S., it was first promoted as a technique for the public to learn in the 1970s.[69] Artificial respiration was combined with chest compressions based on the assumption that active ventilation is necessary to keep circulating blood oxygenated, and the combination was accepted without comparing its effectiveness with chest compressions alone. However, research over the past decade has shown that assumption to be in error, resulting in the AHA's acknowledgment of the effectiveness of chest compressions alone (see Compression only in this article).[70]

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Administering CPR to animals


It is feasible to perform CPR on animals, including cats and dogs. The principles and practices are virtually identical to CPR for humans. One difference is that resuscitation is usually done through the animal's nose, not the mouth. One is cautioned to only perform CPR on unconscious animals to avoid the risk of being bitten. Persons should first and foremost understand that a conscious animal would not require chest compressions. Animals, depending on species, have a lower bone density than humans, thus CPR can cause bones to become weakened after it is performed.[71]
[72]

References
[1] http:/ / icd9cm. chrisendres. com/ index. php?srchtype=procs& srchtext=99. 60& Submit=Search& action=search [2] http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2011/ MB_cgi?field=uid& term=D016887 [3] http:/ / ops. icd-code. de/ ops/ code/ 8-771. html [4] http:/ / www. nlm. nih. gov/ medlineplus/ ency/ article/ 000010. htm [5] (), " [13] Cardiopulmonary Resuscitation (CPR) Statistics (http:/ / www. americanheart. org/ presenter. jhtml?identifier=4483) [20] Newsweek 2007-05-07 [21] Myocardial contusion injury: redefining the diagnostic algorithm, M K Bansal, S Maraj, D Chewaproug, A Amanullah. Emerg Med J 2005;22:465-469 doi:10.1136/emj.2004.015339 ; http:/ / emj. bmj. com/ content/ 22/ 7/ 465. full [22] Implicatii medico-legale in resuscitarea cardio-respiratorie, Aurel Mogoseanu. http:/ / www. atitimisoara. ro/ _files/ documents/ files/ 2007/ Conferinte%20ATI/ Implicatii%20medico-legale%20in%20resuscitarea%20cardio-respiratorie. pdf [23] AHA, The Textbook of Emergency Cardiovascular Care and CPR, page 541 [24] Forensic Pathology: Principles And Practice, David Dolinak,Evan W. Matshes,Emma O. Lew, page 322 [25] AHA, Part 3: Adult Basic Life Support, http:/ / circ. ahajournals. org/ content/ 102/ suppl_1/ I-22. full ; Circulation. 2000; 102: I-22-I-59 doi: 10.1161/01.CIR.102.suppl_1.I-22 [42] Public Health Initiative Uses PocketCPR to Help Improve Cardiac Arrest Survival Rates (http:/ / www. pocketcpr. com/ pdf/ prs_rls_10_20_08. pdf), October 20, 2008. [60] American Heart Association (http:/ / www. handsonlycpr. org/ ) [61] American Heart Association, Ad Council launch Hands-Only CPR campaign (http:/ / www. newsroom. heart. org/ index. php?s=43& item=852) [62] Americans can learn Hands-Only CPR with a new digital application (http:/ / www. multivu. com/ mnr/ 50577-ad-council-hands-only-cpr) [69] See, e.g., "Award of the Heart", TIME magazine, November 28, 1973, retrieved on 05-28-2008 from time.com [70] On June 4th 2011 Jeremiah Kliesing "coded" at the Michael DeBakey VA hospital in Houston, Tx. Jeremiah underwent 5 1/2 hours of CPR by 20 doctors and nurses before being stabilized and transferred to St. Luke's Episcopal Hospital, where he's the second patient to receive the SYNCARDIA artificial heart. One of the Dr.s who preformed CPR was Dr. Donald Lazarus. Source= http:/ / www. syncardia. com/ 2011-Press-Releases/ total-artificial-heart-recipient-heads-home-for-the-holidays-with-new-donor-heart-a-kidney. html [72] heart.org/American Heart association; Aspirin and Heart Disease update 30 March 2012 Most heart attacks and strokes occur from clogged venous and arterial flow. Emergency medical workers are known to give aspirin to patients that suffer chest pain or headaches prior to transport.

External links
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (http://circ.ahajournals.org/content/122/16_suppl_2/S250.full) ERC European Resuscitation Council (http://www.erc.edu/) CPR (http://www.nhs.uk/conditions/accidents-and-first-aid/pages/cpr.aspx): NHS Choices How to resuscitate a child (http://www.nhs.uk/Planners/birthtofive/Pages/Howtorescusitate.aspx): NHS Choices Sarver Heart Center's Continuous Chest Compression CPR on YouTube (http://medicine.arizona.edu/spotlight/ learn-sarver-heart-centers-continuous-chest-compression-cpr) A Video of Rescue Breathing for Laryngectomees and Neck Breathers (http://www.youtube.com/ watch?v=YE-n8cgl77Q)

Current Procedural Terminology

482

Current Procedural Terminology


The Current Procedural Terminology (CPT) code set is a medical code set maintained by the American Medical Association through the CPT Editorial Panel.[1] The CPT code set (copyright protected by the AMA) describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes. New editions are released each October.[] The current version is the CPT 2013. It is available in both a standard edition and a professional edition.[][] CPT coding is similar to ICD-9 and ICD-10 coding, except that it identifies the services rendered rather than the diagnosis on the claim. ICD code sets also contain procedure codes but these are only used in the inpatient setting.[2] CPT is currently identified by the Centers for Medicare and Medicaid Services (CMS) Care Procedure Coding System.
[3] [3]

as Level 1 of the Health

The Current Procedural Terminology (CPT) was developed by the American Medical Association (AMA)

Types of code
There are three types of CPT code: Category I, Category II, and Category III.

Category I
Category I CPT Code(s). There are six main sections:[] Codes for Evaluation and Management: 99201-99499 (99201 - 99213) office/other outpatient services (99217 - 99220) hospital observation services (99221 - 99239) hospital inpatient services (99241 - 99255) consultations (99281 - 99288) emergency dept services (99291 - 99292) critical care services (99304 - 99318) nursing facility services (99324 - 99337) domiciliary, rest home (boarding home) or custodial care services (99339 - 99340) domiciliary, rest home (assisted living facility), or home care plan oversight services (99341 - 99350) home services (99354 - 99360) prolonged services (99363 - 99368) case management services (99374 - 99380) care plan oversight services (99381 - 99429) preventive medicine services (99441 - 99444) non-face-to-face physician services (99450 - 99457) special evaluation & management services (99460 - 99465) newborn care services (99466 - 99480) inpatient neonatal intensive, and pediatric/neonatal critical, care services

Current Procedural Terminology Codes for Anesthesia: 00100-01999; 99100-99150 (00100 - 00222) head (00300 - 00352) neck (00400 - 00474) thorax (00500 - 00580) intrathoracic (00600 - 00670) spine & spinal cord (00700 - 00797) upper abdomen (00800 - 00882) lower abdomen (00902 - 00952) perineum (01112 - 01190) pelvis (except hip) (01200 - 01274) upper leg (except knee) (01320 - 01444) knee & popliteal area (01462 - 01522) lower leg (below knee) (01610 - 01682) shoulder & axillary (01710 - 01782) upper arm & elbow (01810 - 01860) forearm, wrist & hand (01916 - 01936) radiological procedures

483

(01951 - 01953) burn excisions or debridement (01958 - 01969) obstetric (01990 - 01999) other procedures Codes for Surgery: 10021-69990 (10021 - 10022) general (10040 - 19499) integumentary system (20000 - 29999) musculoskeletal system (30000 - 32999) respiratory system (33010 - 37799) cardiovascular system (38100 - 38999) hemic & lymphatic systems (39000 - 39599) mediastinum & diaphragm (40490 - 49999) digestive system (50010 - 53899) urinary system (54000 - 55899) male genital system (55920 - 55980) reproductive system & intersex (56405 - 58999) female genital system (59000 - 59899) maternity care & delivery (60000 - 60699) endocrine system (61000 - 64999) nervous system (65091 - 68899) eye & ocular adnexa (69000 - 69979) auditory system

Current Procedural Terminology Codes for Radiology: 70010-79999 (70010 - 76499) diagnostic imaging (76506 - 76999) diagnostic ultrasound (77001 - 77032) radiologic guidance (77051 - 77059) breast mammography (77071 - 77084) bone/joint studies (77261 - 77799) radiation oncology (78000 - 79999) nuclear medicine

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Codes for Pathology & Laboratory: 80047-89398 (80047 - 80076) organ or disease-oriented panels (80100 - 80103) drug testing (80150 - 80299) therapeutic drug assays (80400 - 80440) evocative/suppression testing (80500 - 80502) consultations (clinical pathology) (81000 - 81099) urinalysis (82000 - 84999) chemistry (85002 - 85999) hematology & coagulation (86000 - 86849) immunology (86850 - 86999) transfusion medicine (87001 - 87999) microbiology (88000 - 88099) anatomic pathology (postmortem) (88104 - 88199) cytopathology (88230 - 88299) cytogenetic studies (88300 - 88399) surgical pathology (88720 - 88741) in vivo (transcutaneous) lab procedures (89049 - 89240) other procedures (89250 - 89398) reproductive medicine procedures

Codes for Medicine: 90281-99199; 99500-99607 (90281 - 90399) immune globulins, serum or recombinant prods (90465 - 90474) immunization administration for vaccines/toxoids (90476 - 90749) vaccines, toxoids (90801 - 90899) psychiatry (90901 - 90911) biofeedback (90935 - 90999) dialysis (91000 - 91299) gastroenterology (92002 - 92499) ophthalmology (92502 - 92700) special otorhinolaryngologic services (92950 - 93799) cardiovascular (93875 - 93990) noninvasive vascular diagnostic studies (94002 - 94799) pulmonary (95004 - 95199) allergy & clinical immunology (95250 - 95251) endocrinology (95803 - 96020) neurology & neuromuscular procedures

(96101 - 96125) central nervous system assessments/tests (neuro-cognitive, mental status, speech testing) (96150 - 96155) health & behavior assessment/intervention

Current Procedural Terminology (96360 - 96549) hydration, therapeutic, prophylactic, diagnostic injections & infusions, and chemotherapy & other highly complex drug or highly complex biologic agent administration (96567 - 96571) photodynamic therapy (96900 - 96999) special dermatological procedures (97001 - 97799) physical medicine & rehabilitation (97802 - 97804) medical nutrition therapy (97810 - 97814) acupuncture (98925 - 98929) osteopathic manipulative treatment (98940 - 98943) chiropractic manipulative treatment (98960 - 98962) education & training for patient self-management (98966 - 98969) non-face-to-face nonphysician services (99000 - 99091) special services, procedures and reports (99100 - 99140) qualifying circumstances for anesthesia (99143 - 99150) moderate (conscious) sedation (99170 - 99199) other services & procedures (99500 - 99602) home health procedures/services (99605 --- 99607) medication therapy management services

485

Category II
Category II CPT Code(s) Performance Measurement (optional)[] (Category II codes: 0001F-7025F)

Category III
Category III CPT Code(s) Emerging Technology (Category III codes: 0016T-0207T[4])

Major Psychotherapy Revisions


The CPT code revisions that effect counselors are simple and straightforward. Here is a list of psychotherapy CPT codes that will be retired, and their 2013 comparables: 90801 > 90791 (diagnostic evaluation without medical services) 90804 > 90832 (was 2030 minutes psychotherapy, now 30 minutes) 90806 > 90834 (was 4550 minutes psychotherapy, now 45 minutes) 90808 > 90837 (was 7580 minutes psychotherapy, now 60 minutes) Family therapy codes (90847 and 90846) will remain unchanged, as will codes for psychological testing.[5]

Copyright
CPT is a registered trademark of the American Medical Association. The AMA holds the copyright for the CPT coding system.[6] Despite the copyrighted nature of the CPT code sets, the use of the code is mandated by almost all health insurance payment and information systems, including the Centers for Medicare and Medicaid Services (CMS) and HIPAA, and the data for the code sets appears in the Federal Register. As a result, it is necessary for most users of the CPT code (principally providers of services) to pay license fees for access to the code.[7]

Current Procedural Terminology

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Limited CPT search offered by the AMA


The AMA offers a limited search of the CPT manual for personal, non-commercial use on its web site.[8]

References
[1] [3] [4] [6] [7] [8] AMA (CPT) CPT Process (http:/ / www. ama-assn. org/ ama/ pub/ category/ 3112. html) Centers for Medicare & Medicaid Services (http:/ / www. cms. hhs. gov/ ) CPT 2010 AMA (CPT) CPT Licensing (http:/ / www. ama-assn. org/ ama/ pub/ category/ 3657. html) http:/ / www. ama-assn. org/ ama1/ pub/ upload/ mm/ 37/ 2009-annual-report. pdf AMA (2012). "cpt Code/Relative Value Search". Retrieved from https:/ / ocm. ama-assn. org/ OCM/ CPTRelativeValueSearch. do.

External links
Official site (http://www.ama-assn.org/ama/pub/category/3113.html) by the AMA* Description of the three sections (http://www.ama-assn.org/ama/pub/category/12888.html) from the AMA CPT Process - How a Code Becomes a Code (http://www.ama-assn.org/ama/pub/physician-resources/ solutions-managing-your-practice/coding-billing-insurance/cpt/cpt-process-faq/code-becomes-cpt.page) from the AMA Q&A (http://www.aafp.org/fpm/accessories/browse?op=get_documents_via_heading_id&heading_id=46) from the American Academy of Family Physicians

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Nurse anesthetist
Nurse anesthetist

Nurse-Anesthetist administers a local anesthetic to an injured Marine prior to surgery aboard USS Kearsarge Occupation Names Certified Registered Nurse Anesthetist Nurse anesthetist

Activity sectors

Medicine, Nursing Description

Education required

Master of Science in Nursing Doctor of Nursing Practice

A nurse anesthetist is a nurse who specializes in the administration of anesthesia. In the United States, a Certified Registered Nurse Anesthetist (CRNA) is an advanced practice registered nurse (APRN) who has acquired graduate-level education and board certification in anesthesia. The American Association of Nurse Anesthetists' (AANA) is the national association that represents more than 90% of the 45,000 nurse anesthetists in the United States. Certification is governed by the National Boards of Certification and Recertification of Nurse Anesthetists (NBCRNA). Education is governed by the Council on Accreditation (COA) of Nurse Anesthesia Educational Programs.

In the United States


History
With the discovery of the anesthetizing properties of various drugs during the mid-19th century, the idea of using general anesthesia for surgery gained rapid popularity. However, having no one qualified to administer anesthetic agents, the job of anesthetist was passed to whoever was available, from house officers to medical students to janitors. As a result, anesthesia was cited as the cause of the greatest incidence of surgical morbidity and mortality in the late 1800s. Nurse anesthetists have been providing anesthesia care in the United States for 150 years. According to the American Association of Nurse Anesthetists, nurse anesthetists are the oldest nurse specialty group in the United States.[1] Additionally, in testament to the professions roots, todays nurse anesthetists remain the primary anesthesia caregivers to U.S. service men and women at home and abroad. Among the first American nurses to provide anesthesia was Catherine S. Lawrence. Along with other nurses, Lawrence administered anesthesia during the American Civil War (18611865).[2] The first "official" nurse anesthetist is recognized as Sister Mary Bernard, a Catholic nun who practiced in 1877 at St. Vincent's Hospital in

Nurse anesthetist Erie, Pennsylvania.[3] There is evidence that up to 50 or more other Catholic sisters were called to practice anesthesia in various midwest Catholic and Protestant hospitals throughout the last two decades of the 19th century.[4][5] The first school of nurse anesthesia was formed in 1909 at St. Vincent Hospital, Portland, Oregon. Established by Agnes McGee, the course was seven months long, and included courses on anatomy and physiology, pharmacology, and administration of common anesthetic agents.[6] Within the next decade, approximately 19 schools opened. All consisted of post-graduate anesthesia training for nurses and were about six months in length. These included programs at Mayo Clinic, Johns Hopkins Hospital, Barnes Hospital, New York Post-Graduate Hospital, Charity Hospital in New Orleans, Grace Hospital in Detroit, among others.[7] Early anesthesia training programs provided education for all levels of health providers. For example, in 1915, chief nurse anesthetist Agatha Hodgins established the Lakeside Hospital School of Anesthesia in Cleveland, Ohio. This program was open to nurses, physicians, and dentists. The training was six months and the tuition was $50. A diploma was awarded on completion. In its first year, it graduated six physicians, two dentists, and 11 nurses.[8] Later, in 1918, it established a system of clinical affiliations with other Cleveland hospitals.[8] Some nurse anesthetists were appointed to medical school faculties to train the medical students in anesthesia. For example, Agnes McGee also taught third year medical school students at the Oregon Health Science Center..[6] Furthermore, nurse anesthetist Alice Hunt was appointed instructor in anesthesia with university rank at the Yale University School of Medicine in 1922. She held this position for 26 years.[9] In addition, she authored the 1949 book Anesthesia, Principles and Practice. This is most likely the first nurse anesthesia textbook. Early nurse anesthetists were involved in publications. For example, in 1906, nurse anesthetist Alice Magaw (18601928) published a report on the use of ether anesthesia by drop method 14,000 times without a fatality (Surg., Gynec. & Obst. 3:795, 1906). Beginning in 1899, Magaw authored several publications with some published and many ignored because of her status as a non-physician.[10] Ms. Magaw was the anesthetist at St. Mary's Hospital in Rochester for the famous brothers, Dr. William James Mayo and Dr. Charles Horace Mayo.[11] This became the famed Mayo Clinic in Rochester, Minnesota. Ms. Magaw set up a showcase for surgery and anesthesia that has attracted many students and visitors.[12] In discussing the history of nurse anesthetists, it is also important to note that the field of anesthesiology has changed considerably from its beginnings. Early anesthestics consisted primarily of the use of a sponge soaked in ether,[13][14] and was widely considered by surgeons to be within the scope of nursing practice. However, modern anesthesia involves the use of ventilators, neuromuscular blockade to induce paralysis during procedures, as well as many medications.

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Education pathway
In the United States of America, Nurse anesthetists must first complete a bachelor's degree in a science related field or a Bachelor of Science in Nursing. They must be a licensed registered nurse. In addition, candidates are required to have a minimum of two years of full-time nursing experience in an acute care setting, such as a medical intensive care unit or surgical intensive care unit.[15] Following the acute care experience, applicants apply to a Council on Accreditation (COA) accredited program of nurse-anesthesia. Education is offered on a masters degree or doctoral degree. Program length varies from 24 to 36 months.[15] Many programs require entrance prerequisites similar to medical schools (pre-med courses). The didactic curricula of nurse-anesthesia programs are governed by the Council on Accreditation (COA) standards and provide students the scientific, clinical, and professional foundation upon which to build a sound and safe clinical practice. Clinical residencies afford supervised experiences for students during which time they are able to learn anesthesia techniques, test theory, and apply knowledge to clinical problems. Students gain experience with patients of all ages who require medical, surgical, obstetrical, dental, and pediatric interventions.[15] In addition, many require study in methods of scientific inquiry and statistics, as well as active participation in student-generated and faculty-sponsored research.

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History of education
Historically, CRNAs in the United States received bachelor's degrees in nurse anesthesia, diploma or certificate. As early as 1976,the Council on Accreditation was developing requirements for degree programs. In 1981, the Council on Accreditation developed guidelines for master's degrees. In 1982, it was the official position of the AANA board of directors' that registered nurses will be baccalaureate prepared and then attend a master's level anesthesia program. At that time, many programs started phasing in advanced degree requirements.[16] As early as 1978, the Kaiser Permanente California State University program had upgraded to a master's level program. All programs were required to transition to a master's degree beginning in 1990 and complete the process by 1998.[17] Currently, the American Association of Colleges of Nursing has endorsed a position statement that will move the current entry level of training for nurse anesthetists in the United States to the Doctor of Nursing Practice (DNP) or Doctor of Nurse Anesthesia Practice (DNAP).[18] This move will affect all advance practice nurses, with a mandatory implementation by the year 2015.[19] The AANA announced in August 2007 support of this advanced clinical degree as an entry level for all nurse anesthetists, but with a target date of 2025. In accordance with traditional grandfathering rules, all those in current practice will not be affected.[18] Several nurse anesthesia programs have already upgraded to the DNP or DNAP entry level format. Because all programs will be converting to a doctorate level education, the length of the programs will continue to vary.[15] Answering the call just as their forebears did during anesthesias formative years, todays nurse anesthetists have embraced the responsibility of helping meet Americas growing healthcare needs as well as the requirement of doctoral education for entry into nurse anesthesia practice by 2025, thereby ensuring patients continued access to the highest quality anesthesia care possible. As of January 2012, the requirements for an individual to become a CRNA and maintain that status include the following: A Bachelor of Science in Nursing (BSN) or other appropriate baccalaureate degree A current license as a registered nurse At least one year of experience as a registered nurse in an acute care setting Graduation with a minimum of a masters degree from an accredited nurse anesthesia educational program Pass the national certification examination following graduation In order to be recertified, CRNAs must obtain a minimum of 40 hours of approved continuing education every two years, document substantial anesthesia practice, maintain current state licensure, and certify that they have not developed any conditions that could adversely affect their ability to practice anesthesia Nurse anesthesia education builds on prior nursing education and experience. The minimum curriculum incorporates studies in basic and advanced applied sciences as well as principles and professional aspects of nurse anesthesia. Because these programs usually exist in colleges of nursing or allied health or schools of medicine, differing curricular requirements round out the course content based on the particular requirement of the department, school, or college in which they are located. Most programs require research, and many require completion of a project or thesis for graduation. Nurse anesthesia educational programs are 24 to 36 months in length, and confer a masters degree upon successful completion. These programs provide an educationally sound curriculum combining theory and clinical practice. Within the clinical component, each student is required to administer a minimum number of anesthetic agents to patients and work a minimum number of hours of anesthesia time. To meet these requirements, students provide the anesthesia services under the supervision of qualified clinical instructors, including CRNAs and/or anesthesiologists. CRNAs are prepared to administer all types of anesthesia (general, regional, local, and conscious sedation), use all anesthesia and adjunctive drugs, determine need for and manage fluid and blood therapy, monitor and interpret data from sophisticated monitoring devices, insert invasive catheters (intravenous, central venous, and pulmonary artery catheters), recognize and correct complications that occur during the course of anesthesia, provide airway and ventilatory support, manage resuscitation efforts for cardiopulmonary arrest or serious injury, and provide pain management services.

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Board certification
The certification and recertification process is governed by the National Board on Certification and Recertification of Nurse Anesthetists (NBCRNA). The NBCRNA exists as an autonomous not-for-profit incorporated organization so as to prevent any conflict of interest with the AANA. This provides assurance to the public that CRNA candidates have met unbiased certification requirements that have exceeded benchmark qualifications and knowledge of anesthesia.[20] CRNAs also have continuing education requirements and recertification every two years thereafter, plus any additional requirements of the state in which they practice.[15]

Legal challenges
In the United States, there have been three challenges brought against nurse anesthetists for illegally practicing medicine: Frank v. South in 1917, Hodgins and Crile in 1919, and Chalmers-Francis v. Nelson in 1936.[21][22] All occurred before 1940 and all were found in favor of the nursing profession, relying on the premise that the surgeon in charge of the operating room was the person practicing medicine. Prior to World War II, the delivery of anesthesia was mainly a nursing function. In 1942, there were 17 nurse anesthetists for every one anesthesiologist.[23] The numbers of physicians in this specialty did not greatly expand until the late 1960s. Therefore, it was legally established that when a nurse delivers anesthesia, it is the practice of nursing. When a physician delivers anesthesia, it is the practice of medicine. When a dentist delivers anesthesia, it is the practice of dentistry. There are great overlaps of tasks and knowledge in the health care professions. Administration of anesthesia and its related tasks by one provider does not necessarily contravene the practice of other health care providers.[24][25] For example, endotracheal intubation (placing a breathing tube into the windpipe) is performed by physicians, physician assistants, nurse anesthetists, anesthesiologist assistants, respiratory therapists, paramedics, EMT-Intermediates, and dental (maxillofacial) surgeons. In the United States, nurse anesthetists practice under the state's nursing practice act (not medical practice acts), which outlines the scope of practice for anesthesia nursing.

Scope of practice
Today, nurse anesthetists practice in all 50 United States and administer approximately 34 million anesthetics each year (AANA). Approximately 65% of CRNAs practice in collaboration with anesthesiologists, in what is termed the "Anesthesia Care Team. However, CRNAs are educated to work independently. CRNA practice varies from state to state, and is also dependent on the institution in which CRNAs practice. The following paragraphs clarify CRNA practice. CRNAs practice in a wide variety of public and private settings including large academic medical centers, small community hospitals, outpatient surgery centers, pain clinics, or physician's offices, either working together with anesthesiologists, CRNAs, or in independent practice. They have a substantial role in the military, the Veterans Administration (VA), and public health. The degree of independence or supervision by a licensed provider (physician, dentist, or podiatrist) varies with state law.[26] Some states use the term collaboration to define a relationship where the supervising physician is responsible for the patient and provides medical direction for the nurse anesthetist. Other states require the consent or order of a physician or other qualified licensed provider to administer the anesthetic. No state requires supervision specifically by an anesthesiologist.[27] The licensed CRNA is authorized to deliver comprehensive anesthesia care under the particular Nurse Practice Act of each state. Their anesthesia practice consists of all accepted anesthetic techniques including general, epidural, spinal, peripheral nerve block, sedation, or local.[28] Scope of CRNA practice is commonly further defined by the practice location's clinical privilege and credentialing process, anesthesia department policies, or practitioner agreements. Clinical privileges are based on the scope and complexity of the expected clinical practice, CRNA qualifications, and CRNA experience. This allows the CRNA to provide core services and activities under defined conditions with or without supervision.[29]

Nurse anesthetist In 2001, the Centers for Medicare and Medicaid Services (CMS) published a rule in the Federal Register that allows a state to be exempt from Medicare's physician supervision requirement for nurse anesthetists after appropriate approval by the state governor.[30] To date, 17 states have opted out of the federal requirement, instituting their own individual requirements instead.[31] More than 40 percent of the CRNAs are men, a much greater percentage than in the nursing profession as a whole (Ten percent of all nurses are men).[32] Because many less-developed countries have few anesthesiologists, they rely mainly on nurse anesthetists.[33] In 1989, the International Federation of Nurse Anesthetists was established.[34] The International Federation of Nurse Anesthetists has since increased in membership and has become a voice for nurse anesthetists worldwide. They have developed standards of education, practice, and a code of ethics. Delegates from 35 member countries participate in the World Congress every few years. Currently there are 107 countries where nurse anesthetists train and practice and nine countries where nurses assist in the administration of anesthesia.[33]

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Research
In June 2010, the Journal of Nursing Economics published a study by the Lewin Group titled "Cost Effectiveness Analysis of Anesthesia Providers." The study compared the cost effectiveness of anesthesia care models. The findings demonstrated that independently practicing CRNAs are not only as safe as their anesthesiologists counterparts, but CRNA only practice was the most cost effective model for the delivery of anesthesia services.[35] The Lewin study was controversial and judged to be "unsubstantiated, inaccurate and questionable" by the American Society of Anesthesiologists. One of the problems being that "The types of procedures and patients for which data exists for "solo" CRNA care is heavily weighted toward lower complexity procedures because of patient, surgeon and facility preference for physician care of the more serious procedures and fragile patients," says Dr. Hannenberg M.D, President of the ASA.[36] In August 2010 Health Affairs published AANA "No Harm Found When Nurse Anesthetists Work Without Supervision By Physicians" authored by the Research Triangle Institute and funded by the American Association of Nurse Anesthetists. This study analyzed the outcomes, both mortalities and morbidities, of 481,868 patients across all practice settings: CRNA only, anesthesiologists only, CRNA/anesthesiogists care teams. The study concluded that anesthesia delivered by CRNAs without supervision was just as safe as anesthetics delivered via the alternative models of care. However, the methodology and adequacy of the results is debated. The ASA responded to the health affairs study by pointing out the weaknesses of billing data when used to make an assessment of safety and quality. Since the billing data were not created for this purpose and do not distinguish between complications resulting from surgery or anesthesia, nor do they discriminate between conditions existing prior to surgery and those resulting from surgical or anesthetic care. Thus, meaningful analysis of anesthesia outcomes is impossible from billing codes alone. And although the paper acknowledges that anesthesiologists care for patients undergoing the most complex procedures, it does not recognize that this is also true for the sicker patients undergoing even routine surgery. Thus, even if one accepted the studys assertion that outcomes were equivalent, this would point to mortality far higher than expected in the nurse anesthesia group caring for a decidedly lower-risk population.[37] It is worth noting that both the "Cost Effectiveness Analysis of Anesthesia Providers" and the "No Harm Found When Nurse Anesthetists Work Without Supervision By Physicians" were financed by the American Association of Nurse Anesthetists exposing an obvious bias. (See Acknowledgements on first page of referenced article).[38] In a scientific study funded by the Agency for Healthcare Research and Quality (AHRQ), investigators at the University of Pennsylvania found that the presence of an anesthesiologist prevented more than six excess deaths per 1,000 cases in which an anesthesia or surgical complication occurred.[]

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Compensation
In the United States, numerous salary reports throughout the years indicate that CRNAs remain the highest compensated of all nursing specialties. In 2008, full-time certified registered nurse anesthetists made an average of $163,467 per year, and in 2011, that figure is nearly $169,000, according to the 2011 LocumTenens.com CRNA Salary Survey. Other results from the survey include the following: The average 2011 salary of male CRNAs is $171,700, down from the average salary of $175,000 in 2010. The average 2011 salary of female CRNAs is $160,680, up from the average salary of $156,100 in 2010. Average salaries of CRNAs with less than five years of experience in 2011 were $154,674, which is down from each of the past three years. CRNAs with six to 12 years of experience saw a 7 percent jump in salary in 2011 compared with 2010. CRNAs in that experience range earned an average of $170,950 in 2011 and an average of $160,000 in 2010. Similarly, CRNAs with more than 12 years of experience also saw an increase in salary in 2011 from 2010. CRNAs with more than 12 years of experience earned $176,468 on average in 2011 and $168,000 on average in 2010. http:/ / www. beckershospitalreview. com/ compensation-issues/ average-crna-salary-in-2011-nears-169k. html. retrieved August, 2012.

Armed forces
In the United States armed forces, nurse anesthetists provide a critical peacetime and wartime skill. During peacetime and wartime, nurse anesthetists have been the principal providers of anesthesia services for active duty and retired service members and their dependents.[39] Nurse anesthetists function as the only licensed independent anesthesia practitioners at many military treatment facilities, including U.S. Navy ships at sea. They are also the leading provider of anesthesia for the Veterans Administration and Public Health Service medical facilities. During World War I, America's nurse anesthetists played a vital role in the care of combat troops in France. From 1914 to 1915, three years prior to America entering the war, Dr. George Crile and nurse anesthetists Agatha Hodgins and Mabel Littleton served in the Lakeside Unit at the American Ambulance at Neuilly-sur-Seine in France.[40][41] In addition, they helped train the French and British nurses and physicians in anesthesia care. After the war, France continued to use nurse anesthetists, however, Britain adopted a physician-only policy that continues today. In 1917, the American participation in the war resulted in the U.S. military training nurse anesthetists for service. The Army and Navy sent nurses anesthesia trainees to various hospitals, including the Mayo Clinic at Rochester and the Lakeside Hospital in Cleveland before overseas service.[42] Among notable nurse anesthetists are Sophie Gran Winton. She served with the Red Cross at an army hospital in Chteau-Thierry, France, and earned the French Croix de Guerre in addition to other service awards;[43] In addition, Anne Penland was the first nurse anesthetist to serve on the British Front and was decorated by the British government.[44] American nurse anesthetists also served in World War II and Korea, receiving numerous citations and awards.[45] Second Lieutenant Mildred Irene Clark provided anesthesia for casualties from the Japanese attack on Pearl Harbor.[46] During the Vietnam War, nurse anesthetists served as both CRNAs and flight nurses, and also developed new field equipment.[47] Nurse anesthetists have been casualties of war. Lieutenants Kenneth R. Shoemaker, Jr. and Jerome E. Olmsted, were killed in an air evac mission in route to Qui Nhon, Vietnam.[48] At least one nurse anesthetist was a prisoner of war. Army Nurse anesthetist Annie Mealer endured a three-year imprisonment by the Japanese in the Philippines, and was released in 1945.[49] During the Iraq War, nurse anesthetists comprise the largest group of anesthesia providers at forward positioned medical treatment facilities.[50] In addition, they play a role in the continuing education and training of Department of Defense nurses and technicians in the care of wartime trauma patients. NURSE ANESTHESIA PRACTICE: WHAT THE FUTURE HOLDS

Nurse anesthetist The AANA has been strengthened by and continues to flourish through the dedication of its members, volunteer leaders, and staff. This will be critically important going forward, because like all healthcare professionals, CRNAs are continually faced with managing change. Ongoing advancements in anesthesia technology, pharmacology, educational requirements, and practice standards have contributed significantly to the fact that anesthesia today is nearly 50 times safer than it was during the 1980s, regardless of provider type. Such changes for the good are easily managed compared with changes that may be perceived to have less favorable potential outcomes. A good example of the latter is the Obama Administrations health reform plan with its attendant government wrangling, supply and demand economics, and turf wars between organized medicine and other healthcare professionals. What does the future hold for nurse anesthesia? While it is impossible to see too far down the road with any real clarity, a relatively clear picture of the near future becomes more visible by the day. Opportunities and challenges lay ahead in numerous areas, first and foremost technology, which keeps changing at a dizzying pace. Few things point up the differences between the generations like the ability and desire to keep up with and adapt technology to every facet of daily life. How might this affect healthcare professionals across generations working side by side in the clinical setting? Time will tell. In anesthesia, advancements to standard equipment such as anesthesia machines, monitors, laryngoscopes, and injection devices continue to improve the quality of patient care, keeping providers of all ages in a continual mode of learning and self-improvement and requiring practice standards and guidelines to be routinely reviewed and updated. Additionally, technology is having a powerful impact on direct patient care as less invasive procedures are developed and utilized, leading to more out-patient procedures, shorter hospital stays, and faster patient recovery. The impact on nurse anesthesia has been and will continue to be a gradual migration of CRNAs from the traditional hospital setting to outpatient settings such as ambulatory surgery centers and physicians offices. The development of robotic systems and artificial intelligence will also advance and the user interface for these seemingly futuristic tools will become simpler. Traditional ideas about safe practice will be tested as providers adapt the use of cell phones, iPads, laptops and other mobile devices to clinical settings, including the operating room: What will ultimately be deemed acceptable and safe, and what will be considered taboo? Research evidence will ultimately frame the debates that occur and decisions that get made. In the education of student registered nurse anesthetists, the use of simulation will continue to develop as a means to impart and validate skills and knowledge without exposing patients to the process of clinical education; simulation will likely be used as part of the application process as well, to help identify and select candidates for admission to educational programs. Complex simulation will also play a larger role in the continuing education of certified providers, as web-based modalities and other tools are used to deliver information and assess competency for practice. Demonstration of healthcare provider competency will continue to be of paramount importance to patients, employers, insurers, lawmakers, and others with a vested interest in quality assurance. In nurse anesthesia, the movement to doctoral preparation and consideration of enhanced recertification requirements has sparked much discussion within the profession, but there is little doubt that education changes the world view, and as a critical mass of doctorally prepared CRNAs emerges down the road, how the profession is perceived by its various publics will change for the better. CRNAs will be well prepared to take leadership positions on boards that shape healthcare systems, and to influence accountable care organizations, medical homes, and other entities yet to be envisioned. Downward pressure on healthcare spending and changes in healthcare financing mechanisms intended to increase quality and care coordination while mitigating cost growth will shape CRNA practice and demand for CRNA services. New models of reimbursement and healthcare financing will be developed, with movement away from capitated payment to fee-for-service and volume-based payment to outcome-based payment systems. As these changes evolve, the type of practitioner providing care will become less important than the result of treatment, further eroding artificially defined scope of practice boundaries. To lower costs, purchasers of healthcare services will seek lower-cost professionals and methods of care delivery, which in some circumstances will reduce and in others increase demand for CRNA services.

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Nurse anesthetist Finally, increased interprofessional collaboration in healthcare will be expectedperhaps even mandatedas the U.S. health system is rapidly reaching a point where inefficient use of resources and duplication of efforts cannot be sustained and should not be tolerated. The Institute of Medicines 2010 report on the Future of Nursing clearly identified that the United States needs to take a long, hard look at how to make the best use of highly qualified APNs to drive a more efficient and effective healthcare system. Collaboration and cooperation across the broad spectrum of healthcare professionals and the organizations that represent them is essential. How will CRNAs manage such change? With the same vigilance, preparation, determination, knowledge, experience and ability that serve them so well caring for their patients every day. By continuing to provide patient access to safe, cost-effective anesthesia care; knowing the direction in which healthcare is headed; being politically active at the state and federal levels; educating the public about the value of nurse anesthetists; and being involved at the local community and institutional levels, CRNAs will continue to thrive today and in the future.

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References
Hodgins, Agatha. "The American Journal of Nursing." American Journal of Nursing. Vol. 30.No. 7 (1930): 863-867. Print. JSTOR3410499 [51] American Association of Nurse Anesthetists Archives. 222 South Prospect, Park Ridge, Illinois, 60068-4001 Certified Registered Nurse Anesthetists (CRNAs) at a Glance fact sheet. AANA, August 2011. Quality of Care in Anesthesia. AANA, 2009. Bankert M: Watchful Care: A History of Americas Nurse Anesthetists. New York, Continuum, 1989 Thatcher VS: History of Anesthesia with Emphasis on the Nurse Specialist. Philadelphia, JB Lippincott, 1953 Advancing the Art and Science of Anesthesia for 75 Years: A Pictorial History of the American Association of Nurse Anesthetists. Park Ridge, AANA, 2006.
[1] American Association of Nurse Anesthetists (1995). "AANA Archives: Documenting a distinguished past." Retrieved December 28, 2009 from http:/ / www. aana. com/ Resources. aspx?id=1902 [2] American Association of Nurse Anaesthetists (2007). AANA History: Hand in Hand with Nurse Anesthesia. Retrieved May 26, 2007 from http:/ / www. aana. com/ 75th/ timeline1844. aspx [3] Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company, p. 54. [4] Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company, p. 54-67. [5] Bankert, M. (1989) Watchful Care; A History of America's Nurse Anesthetists. New York: The Continuum Publishing Company. p. 25-26. [6] Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company, p. 95. [7] Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company, p. 90-109. [8] Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company, p. 105. [9] Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company, p. 101-102. [10] Bankert, M. (1990). "A Living Heritage." CRNA Forum. Vol. 6 No. 1, p. 5-9. [11] Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company, p. 60. [12] Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company, p. 62. [15] American Association of Nurse Anesthetists (2005). Education of Nurse Anesthetists in the United States - At a Glance. Retrieved May 23, 2007, from http:/ / www. aana. com/ educuscrnas. aspx [16] Horton, B. (2007). "Upgrading Nurse Anesthesia Education Requirements (1933-2006) - Part 2: Curriculum, Faculty and Students." AANA Journal, Vol. 75, No. 4, p. 247-251. [17] American Association of Nurse Anesthetists (2007). A Brief Look at Nurse Anesthesia History Retrieved May 23, 2007, from http:/ / www. aana. com/ brieflookhistory. aspx [18] American Association of Colleges of Nursing (2004). AACN Position Statement on the Practice Doctorate in Nursing October 2004. Retrieved May 23, 2007, from http:/ / www. aacn. nche. edu/ DNP/ pdf/ DNP. pdf [19] American Association of Nurse Anesthetists (2006). The Doctorate in Nursing Practice (DNP) Background, Current Status and Future Activities. Retrieved May 23, 2007 from http:/ / www. aana. com/ professionaldevelopment. aspx?ucNavMenu_TSMenuTargetID=131& ucNavMenu_TSMenuTargetType=4& ucNavMenu_TSMenuID=6& id=1742 [20] American Association of Nurse Anesthetists (2007). Council on Certification of Nurse Anesthetists Candidate Handbook 2007. [21] Bankert, M. (1989) Watchful Care; A History of America's Nurse Anesthetists. New York: The Continuum Publishing Company. p. 61-63, 91-92.

Nurse anesthetist
[22] Garde, J.F. (1996). The Nurse Anesthesia Profession, A Past, Present, and Future Perscpective. Nursing Clinics of North America, Vol 31, Number 3, p. 570-571. [23] Garde, J.F. (1996). The Nurse Anesthesia Profession, A Past, Present, and Future Perscpective. Nursing Clinics of North America, Vol 31, Number 3, p. 569-571. [24] Blumenreich, G.A. JD (1999). Legal Briefs, Anesthesia -- It's Finally the Practice of Medicine, AANA Journal, Vol. 67, No. 2, p. 109-112. Retrieved May 25, 2007 from http:/ / www. aana. com/ Resources. aspx?ucNavMenu_TSMenuTargetID=54& ucNavMenu_TSMenuTargetType=4& ucNavMenu_TSMenuID=6& id=2352 [25] Blumenreich, G.A. JD (1990). Legal Briefs, The Administration of Anesthesia and the Practice of Medicine, AANA Journal, Vol. 58, No. 3, June 1990, p. 185-187. Retrieved May 25, 2007 from http:/ / www. aana. com/ lb_june90. aspx [26] U.S. Department of Health and Human Services (2001). Physician Supervision of Certified Registered Nurse Anesthetists. Retrieved May 23, 2007 from http:/ / www. cms. hhs. gov/ apps/ media/ press/ factsheet. asp?Counter=391 [27] American Association of Nurse Anesthetists (2002). AANA Fact Sheet Final Supervision Rule -- Frequently Asked Questions, Centers for Medicare & Medicaid Services (CMS)Conditions of Participation for Hospitals, Ambulatory Surgical Centers (ASCs), and Critical Access Hospitals (CAHs): Anesthesia Services (Part A Payment), November 21. Retrieved May 23, 2007 from http:/ / www. aana. com/ finalsupervisionfaqs. aspx [28] American Association of Nurse Anesthetists (2007)Scope and Standards for Nurse Anesthesia Practice. Retrieved May 24, 2007 from http:/ / www. aana. com/ scope. aspx [29] American Association of Nurse Anesthetists (2007). Guidelines for Clinical Privileges. Retrieved May 24, 2007 from http:/ / www. aana. com/ clinicalprivileges. aspx [30] U.S. Department of Health and Human Services (2001). States Allowed To Set Standards For Anesthesia. Retrieved May 23, 2007 from http:/ / www. cms. hhs. gov/ apps/ media/ press/ release. asp?Counter=319 [31] American Association of Nurse Anesthetists (2009). Fact Sheet Concerning State Opt-Outs And November 13, 2001 CMS Rule. Retrieved July 27, 2009 from http:/ / www. aana. com/ Advocacy. aspx?ucNavMenu_TSMenuTargetID=49& ucNavMenu_TSMenuTargetType=4& ucNavMenu_TSMenuID=6& id=2573 [32] American Association of Nurse Anesthetists (2007). Certified Registered Nurse Anesthetists at a Glance. Retrieved November 19, 2009 from http:/ / www. aana. com/ ataglance. aspx [33] McAuliffe, M.S., Henry B. (2002). Nurse Anesthesia Worldwide: Practice, Education, and Regulation. Retrieved May 23, 2007, from http:/ / ifna-int. org/ ifna/ e107_files/ downloads/ Practice. pdf [34] International Federation of Nurse Anesthetists (2007). About IFNA... Retrieved May 23, 2007, from http:/ / ifna-int. org/ ifna/ page. php?16 [35] The Lewin Group (2010). Cost Effectiveness Analysis of Anesthesia Providers. Retrieved October 17, 2010 from http:/ / www. aana. com/ lewinstudy. aspx#Lewin [39] American Association of Nurse Anesthetists (2010). "History of Nurse Anesthesia Practice." Retrieved January 1, 2010 from http:/ / www. aana. com/ crnahistory. aspx [40] Milestones in Anesthesia (1993) Nurse Anesthetists: The Dawn of a Specialty, Part II. Vol. 3, No. 2, p. 10-11. [41] Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company, p. 97. [42] Thatcher, V.S. (1953) History of Anesthesia, With Emphasis on the Nurse Specialist. Philadelphia: J.B. Lippincott Company, p. 96-99. [43] Bankert, M. (1990). "A Living Heritage." CRNA Forum. Vol. 6 No. 1, p. 9-10. [44] Bankert, M. (1990). A Living Heritage. CRNA Forum. Vol. 6 No. 1, p. 13. [45] Bankert, M. (1989) Watchful Care; A History of America's Nurse Anesthetists. New York: The Continuum Publishing Company, p. 107-123, 137-139. [46] American Association of Nurse Anesthetists (2000). "Pearl Harbor, the Korean Conflict, and COL Mildred Irene Clark." Retrieved December 28, 2009 from http:/ / www. aana. com/ resources. aspx?ucNavMenu_TSMenuTargetID=164& ucNavMenu_TSMenuTargetType=4& ucNavMenu_TSMenuID=6& id=1810 [47] Bankert, M. (1989) Watchful Care; A History of America's Nurse Anesthetists. New York: The Continuum Publishing Company, p. 144-148. [48] Bankert, M. (1989) Watchful Care; A History of America's Nurse Anesthetists. New York: The Continuum Publishing Company, p. 148. [49] Bankert, M. (1989) Watchful Care; A History of America's Nurse Anesthetists. New York: The Continuum Publishing Company, p. 119-142. [50] American Association of Nurse Anesthetists (2004). Certified Registered Nurse Anesthetists Play Pivotal Role in U.S. Efforts to Combat Worldwide Terrorism. Retrieved May 23, 2007 from http:/ / www. aana. com/ pr011304. aspx [51] http:/ / www. jstor. org/ stable/ 3410499

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External links
American Association of Nurse Anesthetists (http://www.aana.com/) The International Federation of Nurse Anesthetists (IFNA) (http://www.ifna-int.org)

Special education
Disability

Disability portal Category: Disability Category: Disability lists

Special education or special needs education is the education of students with special needs in a way that addresses the students' individual differences and needs. Ideally, this process involves the individually planned and systematically monitored arrangement of teaching procedures, adapted equipment and materials, accessible settings, and other interventions designed to help learners with special needs achieve a higher level of personal self-sufficiency and success in school and community than would be available if the student were only given access to a typical classroom education. Common special needs include challenges with learning, communication challenges, emotional and behavioral disorders, physical disabilities, and developmental disorders.[1] Students with these kinds of special needs are likely to benefit from additional educational services such as different approaches to teaching, use of technology, a specifically adapted teaching area, or resource room. Intellectual giftedness is a difference in learning and can also benefit from specialized teaching techniques or different educational programs, but the term "special education" is generally used to specifically indicate instruction of students whose special needs reduce their ability to learn independently or in an ordinary classroom, and gifted education is handled separately. In most developed countries, educators are modifying teaching methods and environments so that the maximum number of students are served in general education environments. Special education in developed countries is often regarded less as a "place" and more as "a range of services, available in every school."[2][3][4][5][6] Integration can reduce social stigmas and improve academic achievement for many students.[7] The opposite of special education is general education. General education is the standard curriculum presented with standard teaching methods and without additional supports.

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Identifying students with special needs


Some children are easily identified as candidates for special needs from their medical history. They may have been diagnosed with a genetic condition that is associated with mental retardation, may have various forms of brain damage, may have a developmental disorder, may have visual or hearing disabilities, or other disabilities. Among students whose identification is less obvious, such as students with learning difficulties, two primary methods have been used for identifying them: the discrepancy model and the response to intervention model. The discrepancy model depends on the teacher noticing that the students' achievements are noticeably below what is expected. The response to intervention model advocates earlier intervention. In the discrepancy model, a student receives special educational services for a specific learning difficulty (SLD) if and only if the student has at least normal intelligence and the student's academic achievement is below what is expected of a student with his or her IQ. Although the discrepancy model has dominated the school system for many years, there has been substantial criticism of this approach (e.g., Aaron, 1995, Flanagan and Mascolo, 2005) among researchers. One reason for criticism is that diagnosing SLDs on the basis of the discrepancy between achievement and IQ does not predict the effectiveness of treatment. Low academic achievers who also have low IQ appear to benefit from treatment just as much as low academic achievers who have normal or high intelligence. The alternative approach, response to intervention, identifies children who are having difficulties in school in their first or second year after starting school. They then receive additional assistance such as participating in a reading remediation program. The response of the children to this intervention then determines whether they are designated as having a learning disability. Those few who still have trouble may then receive designation and further assistance. Sternberg (1999) has argued that early remediation can greatly reduce the number of children meeting diagnostic criteria for learning disabilities. He has also suggested that the focus on learning disabilities and the provision of accommodations in school fails to acknowledge that people have a range of strengths and weaknesses and places undue emphasis on academics by insisting that people should be propped up in this arena and not in music or sports.

Individual needs
A special education program should be customized to address each individual student's unique needs. Special educators provide a continuum of services, in which students with special needs receive services in varying degrees based on their individual needs. Special education programs need to be individualized so that they address the unique combination of needs in a given student.[] In the United States, Canada, and the UK, educational professionals used the initialism IEP when referring to a students individualized education plan. Students with special needs are assessed to determine their specific strengths and weaknesses.[] Placement, resources, and goals are determined on the basis of the student's needs. Accommodations and Modifications to the regular program may include changes in curriculum, supplementary aides or equipment, and the provision of specialized physical adaptations that allow students to participate in the educational environment to the fullest extent possible.[8] Students may need this help to access subject matter, to physically gain access to the school, or to meet their emotional needs. For example, if the assessment determines that the student cannot write by hand because of a physical disability, then the school might provide a computer for typing assignments, or allow the student to answer questions orally instead. If the school determines that the student is severely distracted by the normal activities in a large, busy classroom, then the student might be placed in a smaller classroom such as a resource room.

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Methods of provision
Schools use different approaches to providing special education services to identified students. These can be broadly grouped into four categories, according to whether and how much contact the student with special needs has with non-disabled students (using North American terminology): Inclusion: In this approach, students with special educational needs spend all, or at least more than half, of the school day with students who do not have special educational needs. Because inclusion can require substantial modification of the general curriculum, most PS 721, a special school in Brooklyn, New York schools use it only for selected students with mild to moderate exclusively for the education of students with special needs, for which is accepted as a best practice.[9][10] special needs. Specialized services may be provided inside or outside the regular classroom, depending on the type of service. Students may occasionally leave the regular classroom to attend smaller, more intensive instructional sessions in a resource room, or to receive other related services that might require specialized equipment or might be disruptive to the rest of the class, such as speech and language therapy, occupational therapy, physical therapy, rehabilitation counseling, or might require greater privacy, such as counseling sessions with a social worker.[] Mainstreaming refers to the practice of educating students with special needs in classes with non-disabled students during specific time periods based on their skills. Students with special needs are segregated in separate classes exclusively for students with special needs for the rest of the school day.[] Segregation in a separate classroom or special school exclusively for students with special needs: In this model, students with special needs spend no time in classes with non-disabled students. Segregated students may attend the same school where regular classes are provided, but spend all instructional time exclusively in a separate classroom for students with special needs. If their special class is located in an ordinary school, they may be provided opportunities for social integration outside the classroom, e.g., by eating meals with non-disabled students.[11] Alternatively, these students may attend a special school.[] Exclusion: A student who does not receive instruction in any school is excluded from school. Historically, most students with special needs have been excluded from school.[12] Such exclusion still affects about 23 million disabled children worldwide, particularly in poor, rural areas of developing countries.[] It may also occur when a student is in hospital, housebound, or detained by the criminal justice system. These students may receive one-on-one instruction or group instruction. Students who have been suspended or expelled are not considered excluded in this sense.

Special schools
A special school is a school catering for students who have special educational needs due to severe learning difficulties, physical disabilities or behavioural problems. Special schools may be specifically designed, staffed and resourced to provide the appropriate special education for children with additional needs. Students attending special schools generally do not attend any classes in mainstream schools. Special schools provide individualised education, addressing specific needs. Student:teacher ratios are kept low, often 6:1 or lower depending upon the needs of the children. Special schools will also have other facilities for the development of children with special needs, such as soft play areas, sensory rooms, or swimming pools, which are vital for the therapy of certain conditions. In recent times, places available in special schools are declining as more children with special needs are educated in mainstream schools. There will always be some children, however, whose learning needs are not appropriately met

Special education in a regular classroom setting and will require specialised education and resources to provide the level of support they require. An example of a special need that may require the intensive services a special school provides is mental retardation. However this practice is often frowned upon by school districts in the USA in the light of Least Restrictive Environment as mandated in the Individuals with Disabilities Education Act.[13] An alternative is a special unit or special classroom, also called a self-contained classroom, which is a separate room or rooms dedicated solely to the education of students with special needs within a larger school that also provides general education. These classrooms are typically staffed by specially trained teachers, who provide specific, individualized instruction to individuals and small groups of students with special needs. Self-contained classrooms, because they are located in a general education school, may have students who remain in the self-contained classroom full-time, or students who are included in certain general education classes. In the United States a part-time alternative that is appropriate for some students is sometimes called a resource room. History of special schools One of the first special schools in the world was the Institut National des Jeunes Aveugles in Paris, which was founded in 1784. It was the first school in the world to teach blind students.[14] The first school in U.K, for the Deaf was established c1767? in Edinburgh by Thomas Braidwood. In the 19th Century, people with disabilities and the inhumane conditions where they were supposed to be housed and educated were addressed in the literature of Charles Dickens. Dickens characterized people with severe disabilities as having the sameif not morecompassion and insight in Bleak House and Little Dorrit.[15] Such attention to the downtrodden conditions of people with disabilities brought with it reforms in Europe including the re-evalutation of special schools. In the United States reform came slower. Throughout the mid half of the 20th century, special schools, termed institutions, were not only acceptable they were encouraged. Students with disabilites were housed with people with mental illness, and little if any education took place.[16] With the Amendments to the Individuals with Disabilities Act of 1997, school districts in the United States began to slowly integrate students with moderate and severe special needs into regular school systems. This changed the form and function of special education services in many school districts and special schools subsequently saw a steady decrease in enrollment as districts weighed the cost per student. It also posed general funding dilemmas to certain local schools and districts, changed how schools view assessments, and formally introduced the concept of inclusion to many educators, students and parents.[17]

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Instructional strategies
Different instructional techniques are used for some students with special educational needs. Instructional strategies are classified as being either accommodations or modifications. An accommodation is a reasonable adjustment to teaching practices so that the student learns the same material, but in a format that is accessible to the student. Accommodations may be classified by whether they change the presentation, response, setting, or scheduling.[] For example, the school may accommodate a student with visual impairments by providing a large-print textbook; this is a presentation accommodation. A modification changes or adapts the material to make it simpler.[] Modifications may change what is learned, how difficult the material is, what level of mastery the student is expected to achieve, whether and how the student is assessed, or any another aspect of the curriculum.[18] For example, the school may modify a reading assignment for a student with reading difficulties by substituting a shorter, easier book. A student may receive both accommodations and modifications. Examples of modifications Skipping subjects: Students may be taught less information than typical students, skipping over material that the school deems inappropriate for the student's abilities or less important than other subjects. For example, students

Special education whose fine motor skills are weak may be taught to print block letters, but not cursive handwriting. Simplified assignments: Students may read the same literature as their peers but have a simpler version, for example Shakespeare with both the original text and a modern paraphrase available.[19] Shorter assignments: Students may do shorter homework assignments or take shorter, more concentrated tests, e.g. 10 math problems instead of 30. Extra aids: If students have deficiencies in working memory, a list of vocabulary words, called a word bank, can be provided during tests, to reduce lack of recall and increase chances of comprehension. Students might use a calculator when other students are not. Extended time: Students with lower processing speed may benefit from extended time in assignments and/or tests in order to comprehend questions, recall information, and synthesize knowledge.

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Examples of accommodations Response accommodations:[] Typing homework assignments rather than hand-writing them (considered a modification if the subject is learning to write by hand). Having someone else write down answers given verbally. Presentation accommodations:[] Listening to audio books rather than reading printed books. Agencies like Recording for the Blind and Dyslexic in America and RNIB National Library Service in the UK offer a variety of titles on tape and CD. These may be used as substitutes for the text, or as supplements intended to bolster the students' reading fluency and phonetic skills. Similar options include designating a person to read text to the student, or providing text to speech software. (Considered a modification if the purpose of the assignment is reading skills acquisition). Designating a person to take notes during lectures. Using a talking calculator rather than one with only a visual display. Setting accommodations:[] Taking a test in a quieter room. Moving the class to a room that is physically accessible, e.g., on the first floor of a building or near an elevator. Arranging seating assignments to benefit the student, e.g., by sitting at the front of the classroom. Scheduling accommodations:[] Students may be given rest breaks or extended time on tests (may be considered a modification, if speed is a factor in the test). All developed countries permit or require some degree of accommodation for students with special needs, and special provisions are usually made in examinations which take place at the end of formal schooling.[] In addition to how the student is taught the academic curriculum, schools may provide non-academic services to the student. These are intended ultimately to increase the student's personal and academic abilities. Related services include developmental, corrective, and other supportive services as are required to assist a student with special needs and includes speech and language pathology, audiology, psychological services, physical therapy, occupational therapy, counseling services, including rehabilitation counseling, orientation and mobility services, medical services as defined by regulations, parent counseling and training, school health services, school social work, assistive technology services, other appropriate developmental or corrective support services, appropriate access to recreation and other appropriate support services.[] In some countries, most related services are provided by the schools; in others, they are provided by the normal healthcare and social services systems. As an example, students who have autistic spectrum disorders, poor impulse control, or other behavioral challenges may learn self-management techniques, be kept closely on a comfortingly predictable schedule, or given extra cues to signal activities.[20]

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Issues
At-risk students (those with educational needs that are not associated with a disability) are often placed in classes with students who have disabilities. Critics assert that placing at-risk students in the same classes as students with disabilities may impede the educational progress of people with disabilities.[21] Some special education classes have been criticized for a watered-down curriculum.[22] The practice of inclusion (in mainstream classrooms) has been criticized by advocates and some parents of children with special needs because some of these students require instructional methods that differ dramatically from typical classroom methods. Critics assert that it is not possible to deliver effectively two or more very different instructional methods in the same classroom. As a result, the educational progress of students who depend on different instructional methods to learn often fall even further behind their peers.[] Parents of typically developing children sometimes fear that the special needs of a single "fully included" student will take critical levels of attention and energy away from the rest of the class and thereby impair the academic achievements of all students.[] Some parents, advocates, and students have concerns about the eligibility criteria and their application. In some cases, parents and students protest the students' placement into special education programs. For example, a student may be placed into the special education programs due to a mental health condition such as obsessive compulsive disorder, depression, anxiety, panic attacks or ADHD, while the student and his parents believe that the condition is adequately managed through medication and outside therapy. In other cases, students whose parents believe they require the additional support of special education services are denied participation in the program based on the eligibility criteria.[23] Whether it is useful and appropriate to attempt to educate the most severely disabled children, such as children who are in a persistent vegetative state, is debated. While many severely disabled children can learn simple tasks, such as pushing a buzzer when they want attention, some children may be incapable of learning. Some parents and advocates say that these children would be better served by substituting improved physical care for any academic program.[24] In other cases, they question whether teaching such non-academic subjects, such as pushing a buzzer, is properly the job of the school system, rather than the health care system. Another large issue is the lack of resources enabling individuals with special needs to receive an education in the developing world. As a consequence, 98 percent of children with special needs in developing countries do not have access to education.[25]

National approaches
Africa
South Africa White Papers in 1995 and 2001 discuss special education in the country. Local schools are given some independent authority.[] Both modifications and accommodations are recommended, depending on the student's individual needs.

Asia
China Japan Japanese students with special needs are placed in one of four different school arrangements: special schools, special classrooms with another school, in resource rooms (which are called tsukyu), or in regular classrooms.[]

Special education Special schools are reserved for students whose severe disabilities cannot be accommodated in the local school.[] They do not use the same grading or marking systems as mainstream schools, but instead assess students according to their individualized plans.[] Special classes are similar, and may vary the national curriculum as the teachers see fit. Tsukyu are resource rooms that students with milder problems use part-time for specialized instruction individually in small groups. These students spend the rest of the day in the mainstream classroom. Some students with special needs are fully included in the mainstream classroom, with accommodations or modifications as needed.[] Training of disabled students, particularly at the upper-secondary level, emphasizes vocational education to enable students to be as independent as possible within society. Vocational training varies considerably depending on the student's disability, but the options are limited for some. It is clear that the government is aware of the necessity of broadening the range of possibilities for these students. Advancement to higher education is also a goal of the government, and it struggles to have institutions of higher learning accept more disabled students. Pakistan Singapore Special education is regulated centrally by the Singapore Ministry of Education.[] Both special schools and integration into mainstream schools are options for students with special educational needs, but most students with disabilities are placed in special schools.[] Students with special education who wish accommodations on national exams must provide appropriate documentation to prove that they are disabled.[] Accommodations, but not modifications (e.g., simpler questions) are normally approved if they are similar to the accommodations already being used in everyday schoolwork, with the goal of maintaining the exam's integrity while not having students unfairly disadvantaged by factors that are unrelated to what is being tested. The accommodations are listed on the Primary School Leaving Exam.[]

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Australia
Australian Association of Special Education Inc (AASE)s position is informed by the Disability Standards for Education 2005 which require that students with disabilities are treated on the same basis as other students in regards to enrolment and participation in education.[26] With respect to standardized tests, special consideration procedures are in place in all states for students who are disabled.[] Students must provide documentation Not all desired forms of accommodations are available. For example, students who cannot read, even if the inability to read is due to a disability, cannot have the exam read to them, because the exam results should accurately show that the student is unable to read. Reports on matriculation exams do not mention whether the student received any accommodations in taking the test.[]

Europe
Each country in Europe has its own special education support structures. Czech Republic Schools must take students' special education needs into account when assessing their achievements.[] Denmark In Denmark, 99% of students with specific learning difficulties like dyslexia are educated alongside students without any learning challenges.[27] Finland Schools adapt the national guidelines to the needs of individual students. Students with special educational needs are given an individualized plan.

Special education They may be exempted from some parts of school examinations, such as students with hearing impairments not taking listening comprehension tests. If the student receives modifications to the school-leaving exams, this is noted on the certificate of achievement.[] If they are not following the national core curriculum, then they are tested according to the goals of their individual educational program.[] France French students with disabilities are normally included in their neighborhood school, although children may be placed in special schools if their personalized plan calls for it.[] Each student's personalized school plan describes teaching methods, psychological, medical and paramedical services that the school will provide to the student. Germany Most students with special needs in Germany attend a special school that serves only children with special needs. These include: Frderschule fr Lernbehinderte (special school for learning disabilities): for children who have challenges that impair learning Frderschule mit dem Frderschwerpunkt Geistige Entwicklung (school for cognitive development): for children with very severe learning challenges Frderschule Schwerpunkt emotionale und soziale Entwicklung (school for emotional and social development): for children who have special emotional needs Frderschule fr Blinde (school for the blind): for blind children Frderschule fr Sehbehinderte (school for the visually impaired): for children who are visually challenged Frderschule fr Gehrlose (school for the deaf): for deaf children Frderschule fr Schwerhrige (school for the hearing impaired): for children who are hearing impaired Frderschule fr Krperbehinderte (school for children with physical disabilities): for children with physical disabilities Frderschule fr Sprachbehinderte (school for children with language disorders): for children with language disorders Frderschule fr Taubblinde (school for the deafblind): for children who are deafblind Schule fr Kranke (school for ill children): for children who are too ill to attend school or are hospitalized for a longer Frderschule fr schwer mehrfach Behinderte (school for children with severe and multiple disabilities): for children with severe and multiple disabilities who needn very special care and attention. Sometimes these children are only susceptible for very basic emotional and sensory stimulation. Thus teachers at these school (as well as at schools for the deafblind) are highly specialized professionals.

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A special school for children with special emotional needs in Ktitz, Germany

One in 21 German students attends a special school. Teachers at those schools are specially trained professionals who have specialized in special needs education while in university. Special schools often have a very favorable student-teacher ratio and facilities other schools do not have. Some special needs children in Germany do not attend a special school, but are educated in a mainstream school such as a Hauptschule or Gesamtschule (comprehensive school). Students with special educational needs may be exempted from standardized tests or given modified tests.[] Greece Greek students with special needs may attend either mainstream schools or special schools.[] Students whose disabilities have been certified may be exempted from some standardized tests or given alternative tests.[] Accommodations are responsive to students' needs; for example, students with visual impairments may take

Special education oral tests, and students with hearing impairments take written tests. Accommodations and modifications are noted on the certificate of achievement. Hungary Special education is regulated centrally.[] According to the 1993 Act on Public Education, students with special educational needs may be exempted from standardized tests or given modified tests.[] They have a right to extra time, a choice of formats for the tests (e.g., oral rather than written), and any equipment that they normally use during the school day.[] As of 2006, students with disabilities received a significant bonus (eight points) on the university entrance examination, which has been criticized as unfair.[] The Netherlands As a general rule, students with special educational needs are integrated into their regular, mainstream schools with appropriate support, under the "Going to School Together" policy (Weer Samen Naar School).[] Four types of disability-specific special schools exist. The national policy is moving towards "suitable education" (passend onderwijs), based on the individual's strengths and weakensses.[] A strong emphasis is placed on the specific needs and positive capabilities of the individual, rather than on limitations.[] Disabilities are normally documented by experts.[] Norway The National Support System for Special Needs Education (Statped) is managed by the Norwegian Directorate for Education and Training. The general objective for Statped is to give guidance and support to those in charge of the education in municipalities and county administrations to ensure that children, young people and adults with major and special educational needs are secured well-advised educational and developmental provisions. The institutions affiliated with Statped offer a broad spectrum of services. Statped consists of 13 resource centres owned by the State, and 4 units for special education, where Statped buys services. These centres offer special educational guidance and support for local authorities and county administrations. Portugal Students with disabilities have a "guaranteed right" to appropriate accommodations on assessments.[] Schools are generally considered autonomous. Slovenia On national tests, the National Examination Center normally grants most requests for accommodations that are supported by the local school's examination committee. Legislation opposes the use of modifications that would be unfair to non-disabled students.[] Spain Schools are required to provide services and resources to students with special educational needs so that they make progress and participate in school.[] If the local school is unable to provide appropriately for an individual student, then the student may be transferred to a special school.[] Spanish non-governmental organizations like ONCE have traditionally provided significant services to students with disabilities.[] Sweden Local schools have significant autonomy, based on national guidelines. Schools are expected to help students meet the goals that are set for them.[] There are special schools (Swedish:Srskola) for students with low abilities to attend normal education. There has in 2012-2013 been media criticism on the fact that students with light problems such as dyslexia have been placed in special schools, seriously hampering their chances on the labour market.

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Special education Switzerland Education is controlled by the 26 cantons, and so special education programs vary from place to place.[] However, integration is typical.[] Students are assessed according to their individual learning goals.[] United Kingdom In England and Wales the acronym SEN for Special Educational Needs denotes the condition of having special educational needs, the services which provide the support and the programmes and staff which implement the education.[28] In England SEN PPS refers to the Special Educational Needs Parent Partnership Service. SENAS is the special educational needs assessment service, which is part of the Local Authority. SENCO refers to a special educational needs coordinator, who usually works with schools and the children within schools who have special educational needs. The Special Educational Needs Parent Partnership Services help parents with the planning and delivery of their child's educational provision. The Department for Education oversees special education in England. Most students have an individual educational plan, but students may have a group plan in addition to, or instead of, an individual plan. Groups plans are used when a group of students all have similar goals.[29] In Scotland the Additional Support Needs Act places an obligation on education authorities to meet the needs of all students in consultation with other agencies and parents. In Scotland the term Special Educational Needs (SEN), and its variants are not official terminology although the very recent implementation of the Additional Support for Learning Act means that both SEN and ASN (Additional Support Needs) are used interchangeably in current common practice.

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North America
In North America, special education is commonly abbreviated as special ed, SpecEd, SPED, or SpEd in a professional context. Canada Education in Canada is the responsibility of the individual provinces and territories.[] As such, rules vary somewhat from place to place. However, inclusion is the dominant model. For major exams, Canadian schools commonly use accommodations, such as specially printed examinations for students with visual impairments, when assessing the achievements of students with special needs.[] In other instances, alternative assessments or modifications that simplify tests are permitted, or students with disabilities may be exempted from the tests entirely.[] United States All special-needs students receive an Individualized Education Program (IEP) that outlines how the school will meet the students individual needs. The Individuals with Disabilities Education Act (IDEA) requires that students with special needs be provided with a Free Appropriate Public Education in the Least Restrictive Environment that is appropriate to the student's needs. Government-run schools provide special education in varying degrees from the least restrictive settings, such as full inclusion, to the most restrictive settings, such as segregation in a special school.[] The education offered by the school must be appropriate to the student's individual needs. Schools are not required to maximize the student's potential or to provide the best possible services. Unlike most of the developed world, American schools are also required to provide many medical services, such as speech therapy, if the student needs these services. According to the Department of Education, approximately 6 million children (roughly 10 percent of all school-aged children) currently receive some type of special education services.[30] As with most countries in the world, students who are poor, ethnic minorities, or do not speak the dominant language fluently are disproportionately identified as needing special education services.[31] Poor, black and Latino urban schools are more likely to have limited resources and to employ inexperienced teachers that do not cope well with student behavior problems, "thereby increasing the number of students they referred to special education."[32]

Special education During the 1960s, in some part due to the civil rights movement, some researchers began to study the disparity of education amongst people with disabilities.[33] The landmark Brown v. Board of Education decision, which declared unconstitutional the "separate but equal" arrangements in public schools for students of different races, paved the way for PARC v. Commonwealth of Pennsylvania and Mills vs. Board of Education of District of Columbia, which challenged the segregation of students with special needs. Courts ruled that unnecessary and inappropriate segregation of students with disabilities was unconstitutional.[31] Congress responded to these court rulings with the federal Education for All Handicapped Children Act in 1975 (since renamed the Individuals with Disabilities Education Act (IDEA)). This law required schools to provide services to students previously denied access to an appropriate education. In US government-run schools, the dominant model is inclusion. In the United States, three out of five students with academic learning challenges spend the overwhelming majority of their time in the regular classroom.[34]

506

References
[1] What is special education? (http:/ / www. minedu. govt. nz/ educationSectors/ SpecialEducation/ AboutSpecialEducation/ WhatIsSpecialEducation/ WhatIsSpecialEducation. aspx) from New Zealand's Ministry of Education [2] National Council on Disability. (1994). Inclusionary education for students with special needs: Keeping the promise. Washington, DC: Author. [8] Special Education Inclusion (http:/ / www. weac. org/ Issues_Advocacy/ Resource_Pages_On_Issues_one/ Special_Education/ special_education_inclusion. aspx) [11] Warnock Report (http:/ / www. educationengland. org. uk/ documents/ warnock/ warnock07. html) (1978). "Report of the Committee of Enquiry into the Education of Handicapped Children and Young People", London. [12] Wolffe, Jerry. (20 December 2010) What the law requires for disabled students (http:/ / www. theoaklandpress. com/ articles/ 2010/ 12/ 20/ news/ doc4d0fc3a6b0867472513928. txt?viewmode=fullstory) The Oakland Press. [13] Turnbull, Ron (2002). "Exceptional Lives: Special Education in Today's Schools (3rd ed.)Merrill Prentice Hall. New Jersey. [14] History of the INJA (http:/ / www. inja. fr/ inja/ htmgen/ SimHTMLGen. asp?FORM=0& STYLE=2& URL=/ pages-infos/ pages/ informations_generales/ presentation_de_l_inja/ histoire-inja/ histoirinja_sommaire. xhtml& CSS=1) [15] The history of special education: From isolation to integration. MA Winzer [16] Inventing the feeble mind: A history of mental retardation in the United States. S McCuen Journal of Health Politics, Policy and Law, 1997 Duke Univ Press [17] Jorgensen, C.M. (1998). Restructuring high school for all students: Taking inclusion to the next level. Baltimore: Paul H. Brooks Publishing co. [19] Thorson, Sue. "Macbeth in the Resource Room: Students with Learning Disabilities Study Shakespeare." Journal of Learning Disabilities, v28 n9 p575-81 Nov 1995. [25] UNESCO. (1995). Review of the present situation in special education. Webaccessed: http:/ / www. unesco. org/ pv_obj_cache/ pv_obj_id_C133AD0AF05E62AC54C2DE8EE1C026DABFAF3000/ filename/ 281_79. pdf [29] Management of Inclusion (http:/ / education. staffordshire. gov. uk/ NR/ rdonlyres/ 6C2C3FF2-43F1-40A4-AB6F-77E4CC4602F6/ 22865/ SENCOResourceCentreCompletedocument2. pdf). The SENCO Resource Centre, part 3. [31] Blanchett, W. J. (2009). A retrospective examination of urban education: From "brown" to the resegregation of African Americans in special educationit is time to "go for broke". Urban Education, 44(4), 370388. [32] Tejeda-Delgado, M. (2009). Teacher efficacy, tolerance, gender, and years of experience and special education referrals. International Journal of Special Education, 24(1), 112119. [34] Cortiella, C. (2009). The State of Learning Disabilities. (http:/ / www. ncld. org/ stateofld) New York, NY: National Center for Learning Disabilities.

Further reading
Wilmshurst, L., & Brue, A. W. (2010). The complete guide to special education (2nd ed.). San Francisco: Jossey-Bass. Nola Purdie & Louise Ellis (2005). "A Review of the Empirical Evidence Identifying Effective Interventions and Teaching Practices for Students with Learning Difficulties in Year 4, 5 and 6" (http://research.acer.edu.au/ tll_misc/7/). ACEReSearch.

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External links
The European Agency for Development in Special Needs Education (http://www.european-agency.org/) National Dissemination Center for Children with Disabilities (NICHCY) (http://www.nichcy.org/) (US) Council for Exceptional Children (http://www.cec.sped.org/) (US) Office of Special Education and Rehabilitative Services (http://www.ed.gov/about/offices/list/osers/index. html) U.S. Department of Education When It's Your Own Child: A Report on Special Education from the Families Who Use It (http://www. publicagenda.org/reports/when-its-your-own-child) Public Agenda, 2002 (US) Inclusive Education in Scotland (http://www.ltscotland.org.uk/search/index.asp?bFilter=1& strSearchText=inclusion&12_educationaltheme=presentation subject\|key themes\|Inclusive education) (UK)

Doctor of Chiropractic
Chiropractic medicine
Daniel David Palmer (founder) 1895 Davenport, USA D.C. MSc.Chiro, MTech.Chiro World Federation of Chiropractic Schools Accreditation

Doctor of Chiropractic (D.C.) is a degree of chiropractic for chiropractors in North America. Chiropractors practice chiropractic medicine, a health care profession concerned with the diagnosis, treatment and prevention of disorders of the neuromusculoskeletal system and the effects of these disorders on general health.[1] Chiropractors emphasize manual and manipulative therapy for the treatment of joint dysfunctions. Chiropractic is generally classified as complementary/alternative medicine.[] In some countries it is a professional doctorate where training is entered after obtaining between 90 and 120 credit hours of university level work (see second entry degree) and in most cases after obtaining a Bachelors Degree. The World Health Organization lists three potential educational paths involving fulltime chiropractic education across the globe. This includes: 1 4 years of pre-requisite training in basic sciences at university level followed by a 4 year fulltime Doctorate program; DC. A 5 year integrated bachelor degree; BSc (Chiro). A 2 - 3 year Masters degree following the completion of a bachelor degree leads to the MSc (Chiro).[1] In South Africa the Masters of Technology in Chiropractic (M.Tech Chiro) is granted following 6 years of university. No less than 4200 student/teacher contact hours (or the equivalent) in four years of fulltime education. This includes a minimum of 1000 hours of supervised clinical training.[1] Health professionals with advanced clinical degrees, such as medical doctors, can meet the educational and clinical requirements to practice as a chiropractor in 2200 hours, which is most commonly done in countries where the profession is in its infancy.[1] Upon meeting all clinical and didactic requirements of chiropractic school, a degree in chiropractic medicine is granted. However, in order to practice, chiropractors must be licensed. The regulatory boards are responsible for protecting the public, standards of practice, disciplinary issues, quality assurance and maintenance of competency.[2] Currently, chiropractors practice in over 100 countries in all regions of the world, however chiropractors are most prevalent in North America, Australia and parts of Europe.[1] []

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Scope of practice
Chiropractors emphasize manual and manipulative therapies as an alternative to medications and surgery for neuromusculoskeletal disorders[] Chiropractors are generally regarded as primary contact, portal of entry health care providers. Although chiropractors have many attributes of primary care providers, chiropractic has more attributes of a limited medical specialty like dentistry or podiatry.[] Chiropractors are licensed to communicate a neuromusculoskeletal diagnosis and order X-rays and may use broad diagnostic methods including skeletal imaging, observational and tactile assessments as well as orthopedic and neurological evaluation.[1] A chiropractor may also refer a patient to an appropriate specialist, or co-manage with another health care provider.[] Common patient management involves spinal manipulation (SM) and other manual therapies to the joints and soft tissues, rehabilitative exercises, health promotion, electrical modalities, complementary procedures, and lifestyle counseling.[3] When indicated, chiropractors may also refer a patient to an appropriate specialist, or co-manage with another health care provider.[] Due to the historical differences in philosophy and treatment approaches, there are range of 'broad' and 'narrow' scopes of practice for American chiropractors which tend to reflect 'straight' or 'mixer' underpinnings.[] A focus on evidence-based research has also raised concerns that the resulting practice guidelines could limit the scope of chiropractic practice to treating backs and necks.[] However, the majority of chiropractors currently view themselves as "back/neck pain musculoskeletal specialists."[] The vast majority who seek chiropractic care do so for relief from back and neck pain and other neuromusculoskeletal complaints;[4] most do so specifically for low back pain.[] Although it is generally accepted that chiropractic care is appropriate for musculoskeletal complaints, there is considerable debate on their role in treating visceral disorders.[5] Certain jurisdictions allows the practice of animal chiropractic, whereby licensed chiropractors and veterinarians practice manual and manipulative therapies on animals for musculoskeletal disorders.[6] Increasing evidence-based practice and aligning with conventional medicine has been suggested to obtain more university affiliation and access to hospitals and long-term facilities; aligning with the complementary and alternative medicine movement could bring more patients looking for non-medical approaches.[7] In 2005, the World Health Organization developed chiropractic guidelines on basic training and safety to help standardize formal accreditation and licensure of chiropractors in countries where they remain unregulated.[1] Currently, chiropractic medicine is regulated and practiced in over 100 countries, however chiropractors are most prevalent in North America, Australia and parts of Europe. The majority of mainstream health care and governmental organizations classify chiropractic as traditional or complementary alternative medicine.[]

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Training
Regardless of the model of education utilized, prospective chiropractors without relevant prior health care education or experience, must spend no less than 4200 student/teacher contact hours (or the equivalent) in four years of fulltime education. This includes a minimum of 1000 hours of supervised clinical training.[1] Health professionals with advanced clinical degrees, such as medical doctors, can meet the educational and clinical requirements to practice as a chiropractor in 2200 hours, which is most commonly done in countries where the profession is in its Founded in 1945, the Canadian Memorial Chiropractic College, in Toronto, Ontario, Canada. infancy.[1] Upon meeting all clinical and didactic requirements of chiropractic school, a degree in chiropractic medicine is granted. However, in order to legally practice, chiropractors, like all self regulated health care professionals, must be licensed. All Chiropractic Examining Boards require candidates to complete a 12 month clinical internship to obtain licensure. Licensure is granted following successful completion of all state/provincial and national board exams so long as the chiropractor maintains malpractice insurance. Nonetheless, there are still some variations in educational standards internationally, depending on admission and graduation requirements. Chiropractic medicine is regulated in North America by state/provincial statute. The regulatory boards are responsible for protecting the public, standards of practice, disciplinary issues, quality assurance and maintenance of competency.[8]

Regulation and accreditation


Regulations for chiropractic practice vary considerably from country to country. In some countries, such as. the United States of America, Canada and some European countries, chiropractic has been legally recognized and formal university degrees have been established. In these countries, the profession is regulated and the prescribed educational qualifications are generally consistent, satisfying the requirements of the respective accrediting agencies.However, many countries have not yet developed chiropractic education or established laws to regulate the qualified practice of chiropractic. In addition, in some countries, other qualified health professionals and lay practitioners may use techniques of spinal manipulation and claim to provide chiropractic services, although they may not have received chiropractic training in an accredited programme. Chiropractic is governed internationally by the Councils on Chiropractic Education International (CCEI). This body is officially recognized by the World Federation of Chiropractic and the World Health Organization as the accrediting agency for schools of chiropractic across the world.[9] The minimum prerequisite for enrollment in a chiropractic college set forth by the CCEI is 90 semester hours, and the minimum cumulative GPA for a student entering is 3.0 on a 4.0 scale.[10] Common prerequisite classes include those of the biological, chemical, & physical sciences, including: human anatomy and physiology, embryology, genetics, microbiology, immunology, cellular biology, exercise physiology, kinesiology, general chemistry, organic chemistry, analytical chemistry, biochemistry, toxicology/pharmacology, nutrition, nuclear medicine, physics, biomechanics, and statistics.[11] Chiropractic

Doctor of Chiropractic programs require at least 4,200 hours of combined classroom, laboratory, and clinical experience.

510

Australia
In Australia, a minimum of five-years worth of chiropractic education is needed before one may register as a practicing chiropractor. Chiropractic is taught at four public universities: RMIT in Melbourne, Murdoch University in Perth, Macquarie University in Sydney and new in 2012 Central Queensland University in Mackay. The RMIT, UCQ and Macquarie programs graduate chiropractors with a bachelors degree followed by a masters degree while Murdoch University graduates attain a double bachelors degree, any of which is necessary for registration with state registration boards.[12] A graduate of RMIT will have attained a Bachelor of Applied Science (Chiropractic) and a Master of Clinical Chiropractic.[13] Similarly, a typical graduate of Macquarie University will have a Bachelor of Chiropractic Science followed by a Master of Chiropractic.[14] Murdoch University graduates possess the double-degree of Bachelor of Science (Chiropractic Science) / Bachelor of Chiropractic.[15] Students at University of Central Queensland graduate with a Bachelor of Science (Chiropractic) followed by a Master of Chiropractic Science.[16]

Canada
Canadian chiropractors received their Doctorate in Chiropractic (D.C.) following a minimum of 7 years of university. There are currently two schools of chiropractic in Canada: Canadian Memorial Chiropractic College, in Toronto, Ontario and the Universite du Quebec a Trois Rivieres, in Trois Rivieres, Quebec. Both programs are fully accredited by the Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards.[17] In 2010, the majority of students (87%) entering the CMCC program had completed a baccalaureate university degree, and approximately 3% have a graduate degree.[18]

South Africa
In SA (South Africa) there are two schools of chiropractic: the Durban Institute of Technology and the University of Johannesburg.[19] They are both 6-year full-time courses leading to an MTECH or Masters of technology in Chiropractic. It's a legal requirement that chiropractors must be registered with the Allied Health Professions Council of SA (AHPCSA) [20] the governmental statutory body in order to practice Chiropractic in SA. Being a member of the Chiropractic Association of SA (CASA) [21] is voluntary. CASA is the only voluntary national association in the country and aims to promote the profession through publications in newspaper, interviews, internet and public enquires over the phone.

United Kingdom
In 1993 Princess Diana visited the Anglo-European College of Chiropractic and became its patron by calling for legislation to prevent unqualified individuals from practicing Chiropractic in the UK.[] In 1994, Parliament passed legislation regulating the practice of Chiropractic, like other health care professions, and creating the General Chiropractic Council as the regulatory board. Since that time, it is illegal to call oneself a Chiropractor in the UK without being registered with the General Chiropractic Council.[22] There are three UK chiropractic colleges with chiropractic courses recognised by the General Chiropractic Council (GCC), the statutory governmental body responsible for the regulation of chiropractic in the UK.[23] McTimoney College of Chiropractic offers an Undergraduate Master Degree in human Chiropractic and two post-graduate Masters programmes in Animal Manipulation, plus a masters in Paediatric Chiropractic.[24] The Anglo-European College of Chiropractic and the University of Glamorgan chiropractic graduates with the Masters degree (MChiro).

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United States
American chiropractors received their Doctorate in Chiropractic (D.C.) following a minimum of 7 years of university. There are currently 18 schools of chiropractic in the United States. In the United States, schools of chiropractic follow either a 'mixer' or 'straight' paradigm; the two schools of thought lead to two national bodies, the International Chiropractors Association and the American Chiropractic Association. Mixers form the majority of American chiropractors;[] however, straight practice chiropractors are believed to have a disproportionate influence since they are "purists".[]

New Zealand
As of 2005, the New Zealand College of Chiropractic (NZCC). obtained accreditation by the CCEA (Council on Chiropractic Education Australasia) and subsequently the CCEI.

Chiropractic specialities
Chiropractic scientists (DC/PhD)
Chiropractors can conduct clinical and basic scientific research and publish in peer-reviewed journals during training and after graduation. Chiropractors can also pursue a Ph.D degree in various health care disciplines including epidemiology, biomechanics, neurophysiology and kinesiology,[25]

Fellowships and other credentials


Chiropractors, like other health care professionals, can pursue post-graduate education in various chiropractic specialties. Most are 2 year post-graduates degrees in chiropractic specialities such as clinical sciences, sports chiropractic, radiology, animal chiropractic and others.There are other chiropractic credentials that may or may not be recognized by the major health care organizations, medical or chiropractic communities.

Chiropractic career
Realistic median annual wage of chiropractors was $67,200 in May 2010.[26] According to Health Resources and Services Administration (HRSA), Chiropractic Student Loan Default Rates for October 1999, May 2010, and January 2012 are 54%, 53.8%, and 52.8% respectively.[27] Chiropractic school graduates default on their loans more often than law school graduates, engineers, medical doctors, and business school graduates.

References
[1] http:/ / www. who. int/ medicines/ areas/ traditional/ Chiro-Guidelines. pdf [2] Facts & FAQs (http:/ / www. ccachiro. org/ Client/ cca/ cca. nsf/ web/ Facts & FAQs?OpenDocument) [3] AHCPR Pub No. 98-N002. [8] Facts & FAQs (http:/ / www. ccachiro. org/ Client/ cca/ cca. nsf/ web/ Facts & FAQs?OpenDocument) [10] http:/ / www. cce-usa. org/ [12] (http:/ / www. ccea. com. au/ Program Accreditation/ Programs. htm) [13] RMIT Chiropractic (http:/ / www. rmit. edu. au/ programs/ bp187) [14] Macquarie University Department of Chiropractic (http:/ / www. chiro. mq. edu. au/ aboutus/ Chiropractic. htm) [15] Murdoch University Chiropractic (http:/ / www. chiropractic. murdoch. edu. au/ course_details. html) [16] CQU - Bachelor of Science (Chiropractic) (http:/ / www. cqu. edu. au/ study/ what-can-i-study/ health-and-medical-sciences/ undergraduate-programs/ bachelor-of-science-chiropractic) [20] http:/ / www. ahpcsa. co. za [21] http:/ / www. chiropractic. co. za [23] GCC Criteria for Recognition of Degrees in Chiropractic (http:/ / www. gcc-uk. org/ page. cfm?page_id=25) [24] McTimoney College Prospectus (http:/ / www. mctimoney-college. ac. uk/ page/ 7_Prospectus. html) [26] Occupational Outlook Handbook, Bureau of Labor Statistics, March 29, 2012: http:/ / www. bls. gov/ ooh/ healthcare/ chiropractors. htm

Doctor of Chiropractic
[27] Health Resources and Services Administration (HRSA), January 2012: http:/ / www. chirobase. org/ 03Edu/

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Developmental disability
Disability

Disability portal Category: Disability Category: Disability lists

Developmental disability
Classification and external resources MeSH D002658 [1]

Developmental disability is a term used in the United States and Canada to describe lifelong disabilities attributable to mental or physical impairments, manifested prior to age 18. It is not synonymous with "developmental delay"[2] which is often a consequence of a temporary illness or trauma during childhood.

Causes
There are many social, environmental and physical causes of developmental disabilities, although for some a definitive cause may never be determined. Common factors causing developmental disabilities include: Traumatic brain injury resulting from accidental causes or physical abuse (blunt force, shaken baby syndrome); Infection before, during or after birth; Growth or nutrition problems (prenatally, perinatally, or postnatally); Abnormalities of chromosomes and genes; Birth long before the expected birth date also called extreme prematurity; Poor maternal diet and absent or minimal health care; Drug abuse during pregnancy, including alcohol intake and smoking; Drug-related prenatal developmental insult from prescription or over-the-counter drugs; Environmental toxins; Severe physical maltreatment (child abuse), which may have caused brain injury and which can adversely affect a child's learning abilities and socio-emotional development

Developmental disabilities affect between 1 and 2% of the population in most western countries, although many government sources acknowledge that statistics are flawed in this area. The worldwide proportion of people with developmental disabilities is believed to be approximately 1.4%.[3] It is twice as common in males as in females, and some researchers have found that the prevalence of mild developmental disabilities is likely to be higher in areas of poverty and deprivation, and among people of certain ethnicities.[4]

Developmental disability

513

Associated issues
Physical health issues
There are many physical health factors associated with developmental disabilities. For some specific syndromes and diagnoses, these are inherent (such as poor heart function in people with Down syndrome); however lack of access to health services and lack of understanding by medical professionals is also a major contributing factor.[citation needed] People with severe communication difficulties find it difficult to articulate their health needs, and without adequate support and education might not recognize ill health. Epilepsy, sensory problems (such as poor vision and hearing), obesity and poor dental health are over-represented in this population.[5] Life expectancy among people with developmental disabilities as a group is estimated at 20 years below average, although this is improving with advancements in adaptive and medical technologies, and as people are leading healthier, more fulfilling lives,[6] and some conditions (such as Freeman-Sheldon syndrome) do not impact life expectancy.

Mental health issues (dual diagnoses)


Mental health issues, and psychiatric illnesses, are more likely to occur in people with developmental disabilities than in the general population. A number of factors are attributed to the high incidence rate of dual diagnoses: The high likelihood of encountering traumatic events throughout their lifetime (such as abandonment by loved ones, abuse, bullying and harassment)[7] The social and developmental restrictions placed upon people with developmental disabilities (such as lack of education, poverty, limited employment opportunities, limited opportunities for fulfilling relationships, boredom) Biological factors (such as brain injury, epilepsy, illicit and prescribed drug and alcohol misuse)[8] Developmental factors (such as lack of understanding of social norms and appropriate behavior, inability of those around to allow/understand expressions of grief and other human emotions) External monitoring factor: all people with developmental disabilities that are in a federal- or state-funded residence require the residence to have some form of behavioral monitoring for each person with developmental disability at the residence. With this information psychological diagnoses are more easily given than with the general population that has less consistent monitoring. Access to health care providers: in the United States, all people with developmental disabilities that are in a federal- or state-funded residence require the residence to have annual visits to various health care providers. With consistent visits to health care providers more people with developmental disabilities are likely to receive appropriate treatment than the general population that is not required to visit various health care providers. These problems are exacerbated by difficulties in diagnosis of mental health issues, and in appropriate treatment and medication, as for physical health issues.[9][10]

Abuse and vulnerability


Abuse is a significant issue for people with developmental disabilities, and as a group they are regarded as vulnerable people in most jurisdictions. Common types of abuse include: Physical abuse (withholding food, hitting, punching, pushing, etc.) Neglect (withholding help when required, e.g., assistance with personal hygiene) Sexual abuse Psychological or emotional abuse (verbal abuse, shaming and belittling) Constraint and restrictive practices (turning off an electric wheelchair so a person cannot move) Financial abuse (charging unnecessary fees, holding onto pensions, wages, etc.)

Legal or civil abuse (restricted access to services) Systemic abuse (denied access to an appropriate service due to perceived support needs) Passive neglect (a caregiver's failure to provide adequate food, shelter)

Developmental disability Lack of education, lack of self-esteem and self-advocacy skills, lack of understanding of social norms and appropriate behavior and communication difficulties are strong contributing factors to the high incidence of abuse among this population. In addition to abuse from people in positions of power, peer abuse is recognized as a significant, if misunderstood, problem. Rates of criminal offense among people with developmental disabilities are also disproportionately high, and it is widely acknowledged that criminal justice systems throughout the world are ill-equipped for the needs of people with developmental disabilitiesas both perpetrators and victims of crime.[11][12][13]

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Challenging behavior
Some people with developmental disabilities exhibit challenging behavior, defined as "culturally abnormal behaviour(s) of such intensity, frequency or duration that the physical safety of the person or others is placed in serious jeopardy, or behaviour which is likely to seriously limit or deny access to the use of ordinary community facilities".[14] Common types of challenging behavior include self-injurious behavior (such as hitting, headbutting, biting), aggressive behavior (such as hitting others, screaming, spitting, kicking, swearing, hairpulling), inappropriate sexualized behavior (such as public masturbation or groping), behavior directed at property (such as throwing objects and stealing) and stereotyped behaviors (such as repetitive rocking, echolalia or elective incontinence). Challenging behavior in people with developmental disabilities may be caused by a number of factors, including biological (pain, medication, the need for sensory stimulation), social (boredom, seeking social interaction, the need for an element of control, lack of knowledge of community norms, insensitivity of staff and services to the person's wishes and needs), environmental (physical aspects such as noise and lighting, or gaining access to preferred objects or activities), psychological (feeling excluded, lonely, devalued, labelled, disempowered, living up to people's negative expectations) or simply a means of communication. A lot of the time, challenging behavior is learned and brings rewards and it is very often possible to teach people new behaviors to achieve the same aims. Challenging behavior in people with developmental disabilities can often associated with specific mental health problems.[15] Experience and research suggests that what professionals call "challenging behavior" is often a reaction to the challenging environments that those providing services create around people with developmental disabilities. "Challenging behavior" in this context is a method of communicating dissatisfaction with the failure of those providing services to focus on what kind of life makes most sense to the person, and is often the only recourse a developmentally disabled person has against unsatisfactory services or treatment and the lack of opportunities made available to the person. This is especially the case where the services deliver lifestyles and ways of working that are centered on what suits the service provider and its staff, rather than what best suits the person. In general, behavioral interventions or what has been termed applied behavior analysis has been found to be effective in reducing specific challenging behavior [16] Recently, efforts have been placed on developing a developmental pathway model in the behavior analysis literature to prevent challenging behavior from occurring.[17]

Societal attitudes
Throughout history, people with developmental disabilities have been viewed as incapable and incompetent in their capacity for decision-making and development. Until the Enlightenment in Europe, care and asylum was provided by families and the church (in monasteries and other religious communities), focusing on the provision of basic physical needs such as food, shelter and clothing. Stereotypes such as the dimwitted yokel, and potentially harmful characterizations (such as demonic possession for people with epilepsy) were prominent in social attitudes of the time. Early in the twentieth century the eugenics movement became popular throughout the world. This led to the forced sterilization and prohibition of marriage in most of the developed world and was later used by Hitler as rationale for the mass murder of mentally challenged individuals during the Holocaust. The eugenics movement was later proven

Developmental disability to be seriously flawed and in violation of human rights and the practice of forced sterilization and prohibition from marriage was discontinued by most of the developed world by the mid 20th century. The movement towards individualism in the 18th and 19th centuries, and the opportunities afforded by the Industrial Revolution, led to housing and care using the asylum model. People were placed by, or removed from, their families (usually in infancy) and housed in large institutions (of up to 3,000 people, although some institutions were home to many more, such as the Philadelphia State Hospital in Pennsylvania which housed 7,000 people through the 1960s), many of which were self-sufficient through the labor of the residents. Some of these institutions provided a very basic level of education (such as differentiation between colors and basic word recognition and numeracy), but most continued to focus solely on the provision of basic needs. Conditions in such institutions varied widely, but the support provided was generally non-individualized, with aberrant behavior and low levels of economic productivity regarded as a burden to society. Heavy tranquilization and assembly line methods of support (such as "birdfeeding" and cattle herding) were the norm, and the medical model of disability prevailed. Services were provided based on the relative ease to the provider, not based on the human needs of the individual. Ignoring the prevailing attitude, Civitans adopted service to the developmentally disabled as a major organizational emphasis in 1952. Their earliest efforts included workshops for special education teachers and daycamps for disabled children, all at a time when such training and programs were almost nonexistent.[18] The segregation of people with developmental disabilities wasn't widely questioned by academics or policy-makers until the 1969 publication of Wolf Wolfensberger's seminal work "The Origin and Nature of Our Institutional Models",[19] drawing on some of the ideas proposed by SG Howe 100 years earlier. This book posited that society characterizes people with disabilities as deviant, sub-human and burdens of charity, resulting in the adoption of that "deviant" role. Wolfensberger argued that this dehumanization, and the segregated institutions that result from it, ignored the potential productive contributions that all people can make to society. He pushed for a shift in policy and practice that recognized the human needs of "retardates" and provided the same basic human rights as for the rest of the population. The publication of this book may be regarded as the first move towards the widespread adoption of the social model of disability in regard to these types of disabilities, and was the impetus for the development of government strategies for desegregation. Successful lawsuits against governments and an increasing awareness of human rights and self-advocacy also contributed to this process, resulting in the passing in the U.S. of the Civil Rights of Institutionalized Persons Act in 1980. From the 1960s to the present, most states have moved towards the elimination of segregated institutions. Along with the work of Wolfensberger and others including Gunnar and Rosemary Dybwad,[20] a number of scandalous revelations around the horrific conditions within state institutions created public outrage that led to change to a more community-based method of providing services.[21] By the mid-1970s, most governments had committed to de-institutionalization, and had started preparing for the wholesale movement of people into the general community, in line with the principles of normalization. In most countries, this was essentially complete by the late 1990s, although the debate over whether or not to close institutions persists in some states, including Massachusetts.[22] Individuals with developmental disabilities are not fully integrated into society.[citation needed] Person Centered Planning and Person Centered Approaches are seen as methods of addressing the continued labeling and exclusion of socially devalued people, such as people with a developmental disability label, encouraging a focus on the person as someone with capacities and gifts, as well as support needs.

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Services and support


Today, support services are provided by government agencies (such as MRDD), non-governmental organizations and by private sector providers. Support services address most aspects of life for people with developmental disabilities, and are usually theoretically based in community inclusion, using concepts such as social role valorization and increased self-determination (using models such as Person Centred Planning).[23] Support services are funded through government block funding (paid directly to service providers by the government), through individualized funding packages (paid directly to the individual by the government, specifically for the purchase of services) or privately by the individual (although they may receive certain subsidies or discounts, paid by the government). There also are a number of non-profit agencies dedicated to enriching the lives of people living with developmental disabilities and erasing the barriers they have to being included in their community.[24]

Education and training


Education and training opportunities for people with developmental disabilities have expanded greatly in recent times, with many governments mandating universal access to educational facilities, and more students moving out of special schools and into mainstream classrooms with support. Post-secondary education and vocational training is also increasing for people with these types of disabilities, although many programs offer only segregated "access" courses in areas such as literacy, numeracy and other basic skills. Legislation (such as the UK's Disability Discrimination Act 1995) requires educational institutions and training providers to make "reasonable adjustments" to curriculum and teaching methods in order to accommodate the learning needs of students with disabilities, wherever possible. There are also some vocational training centers that cater specifically to people with disabilities, providing the skills necessary to work in integrated settings, one of the largest being Dale Rogers Training Center in Oklahoma City. (See also Intensive interaction)

At-home and community support


Many people with developmental disabilities live in the general community, either with family members, in supervised-group homes or in their own homes (that they rent or own, living alone or with flatmates). At-home and community supports range from one-to-one assistance from a support worker with identified aspects of daily living (such as budgeting, shopping or paying bills) to full 24-hour support (including assistance with household tasks, such as cooking and cleaning, and personal care such as showering, dressing and the administration of medication). The need for full 24-hour support is usually associated with difficulties recognizing safety issues (such as responding to a fire or using a telephone) or for people with potentially dangerous medical conditions (such as asthma or diabetes) who are unable to manage their conditions without assistance. In the United States a support worker is known as a Direct Support Professional (DSP). The DSP works in assisting the individual with their ADLs and also acts as an advocate for the individual with a developmental disability, in communicating their needs, self-expression and goals. Supports of this type also include assistance to identify and undertake new hobbies or to access community services (such as education), learning appropriate behavior or recognition of community norms, or with relationships and expanding circles of friends. Most programs offering at-home and community support are designed with the goal of increasing the individual's independence, although it is recognized that people with more severe disabilities may never be able to achieve full independence in some areas of daily life.

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Residential accommodation
Some people with developmental disabilities live in residential accommodation (also known as group homes) with other people with similar assessed needs. These homes are usually staffed around the clock, and usually house between 3 and 15 residents. The prevalence of this type of support is gradually decreasing, however, as residential accommodation is replaced by at-home and community support, which can offer increased choice and self-determination for individuals. Some U.S. states still provide institutional care, such as the Texas State Schools.[25]
Austin State Supported Living Center (previously Austin State School) in Austin, Texas

Employment support
Employment support usually consists of two types of support: Support to access or participate in integrated employment, in a workplace in the general community. This may include specific programs to increase the skills needed for successful employment (work preparation), one-to-one or small group support for on-the-job training, or one-to-one or small group support after a transition period (such as advocacy when dealing with an employer or a bullying colleague, or assistance to complete an application for a promotion). The provision of specific employment opportunities within segregated business services. Although these are designed as "transitional" services (teaching work skills needed to move into integrated employment), many people remain in such services for the duration of their working life. The types of work performed in business services include mailing and packaging services, cleaning, gardening and landscaping, timberwork, metal fabrication, farming and sewing. Workers with developmental disabilities have historically been paid less for their labor than those in the general workforce, although this is gradually changing with government initiatives, the enforcement of anti-discrimination legislation and changes in perceptions of capability in the general community. In the United States, a variety of initiatives have been launched in the past decade to reduce unemployment among workers with disabilitiesestimated by researchers at over 60%.[26] Most of these initiatives are directed at employment in mainstream businesses. They include heightened placement efforts by the community agencies serving people with developmental disabilities, as well as by government agencies. Additionally, state-level initiatives are being put launched to increase employment among workers with disabilities. In California, the state senate in 2009 created the Senate Select Committee on Autism and Related Disorders. The Committee has been examining additions to existing community employment services, and also new employment approaches. Committee member Dr. Lou Vismara, chairman of the MIND Institute at University of California, Davis, is pursuing the development of a planned community for persons with autism and related disorders in the Sacramento region.[27] Another committee member, Michael Bernick, the former director of the state labor department, has established a program at the California state university system, starting at California State University East Bay, to support students with autism on the college level.[28] Other Committee efforts include mutual support employment efforts, such as disability job networks, job boards, and identifying business lines that build on the strengths of persons with disabilities.

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Day services
Non-vocational day services are usually known as day centers, and are traditionally segregated services offering training in life skills (such as meal preparation and basic literacy), center-based activities (such as crafts, games and music classes) and external activities (such as day trips). Some more progressive day centers also support people to access vocational training opportunities (such as college courses), and offer individualized outreach services (planning and undertaking activities with the individual, with support offered one-to-one or in small groups). Traditional day centers were based on the principles of occupational therapy, and were created as respite for family members caring for their loved ones with disabilities. This is slowly changing, however, as programs offered become more skills-based and focused on increasing independence.

Advocacy
Advocacy is a burgeoning support field for people with developmental disabilities. Advocacy groups now exist in most jurisdictions, working collaboratively with people with disabilities for systemic change (such as changes in policy and legislation) and for changes for individuals (such as claiming welfare benefits or when responding to abuse). Most advocacy groups also work to support people, throughout the world, to increase their capacity for self-advocacy, teaching the skills necessary for people to advocate for their own needs.

Other types of support


Other types of support for people with developmental disabilities may include: therapeutic services, such as speech therapy, occupational therapy, physical therapy, massage, aromatherapy, art, dance/movement or music therapy supported holidays short-stay respite services (for people who live with family members or other unpaid carers) transport services, such as dial-a-ride or free bus passes specialist behavior support services, such as high-security services for people with high-level, high-risk challenging behaviors specialist relationships and sex education

References
[1] http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2013/ MB_cgi?field=uid& term=D002658 [3] Inclusion International (http:/ / www. inclusion-international. org/ en/ ) [14] Emerson, E. 1995. Challenging behaviour: analysis and intervention with people with learning difficulties. Cambridge: Cambridge University Press [16] Neef, N. A. (2001) The Past and Future of Behavior Analysis in Developmental Disabilities: When Good News is Bad and Bad News is Good. The Behavior Analyst Today, 2 (4), 336 -343. (http:/ / www. baojournal. com) [17] Roane, H.S., Ringdahl, J.E., Vollmer, T.R., Whitmarsh, E.L. and Marcus, B.A. (2007). A Preliminary Description of the Occurrence of Proto-injurious Behavior in Typically Developing Children. Journal of Early and Intensive Behavior Intervention, 3(4), 334-347. (http:/ / www. baojournal. com) [20] disabilitymuseum.org/beyond-affliction (http:/ / www. disabilitymuseum. org/ beyond-affliction/ ba_shows. dir/ revoluti. dir/ highlights/ subject/ ng0002tx. html) [21] arcmass.org/StateHousePolicy/RegulationandPolicyDebates/FernaldSchoolClosingandRICCIClass (http:/ / www. arcmass. org/ StateHousePolicy/ RegulationandPolicyDebates/ FernaldSchoolClosingandRICCIClass/ FernaldNews/ WhyTheFernaldCenterShouldClose/ ChristmasinPurgatoryWillowbrook/ tabid/ 692/ Default. aspx) [22] arcmass.org/StateHousePolicy/RegulationandPolicyDebates/FernaldSchoolClosingandRICCIClass (http:/ / www. arcmass. org/ StateHousePolicy/ RegulationandPolicyDebates/ FernaldSchoolClosingandRICCIClass/ tabid/ 175/ Default. aspx) [23] Kormann & Petronko: (2003) Crisis and Revolution in Developmental Disabilities: The Dilemma of Community Based Services. The Behavior Analyst Today, 3 (4), 434 -443 (http:/ / www. baojournal. com) [24] [JARC] JARC (http:/ / www. JARC. org) [25] Texas Department of Aging and Disability Services (http:/ / www. dads. state. tx. us/ services/ stateschools/ index. html)

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Further reading
Developmental-Behavioral Pediatrics, 4th Edition (http://www.us.elsevierhealth.com/product. jsp?isbn=9781416033707) - Expert Consult Online and Print By William B. Carey, MD, Allen C. Crocker, MD, Ellen Roy Elias, MD, Heidi M. Feldman, MD, PhD and William L. Coleman, MD Advocacy and Learning Disability (http://www.jkp.com.html). Barry Gray and Robin Jackson (Eds) London: Jessica Kingsley Publishers, 2002 US Administration on Developmental Disabilities fact sheet (http://www.acf.hhs.gov/programs/add/ Factsheet.html) A Short History of the Treatment of Persons with Mental Retardation (http://www.ahrcnyc.org/pdf/ chapter1_history.PDF) Real Lives: Contemporary supports to people with mental retardation (http://www.acf.hhs.gov/programs/ pcpid/docs/help3.pdf) (1998) Rights of People with Intellectual Disabilities: Access to Education and Employment, bilingual reports on 14 European countries (http://www.eumap.org/topics/inteldis/reports) Australian Institute of Health and Welfare paper The Definition and Prevalence of Intellectual Disability in Australia (http://www.aihw.gov.au/publications/welfare/dpida/dpida-c00.html) 2001 New Zealand Snapshot of Intellectual Disability (http://www2.stats.govt.nz/domino/external/pasfull/ pasfull.nsf/web/Media+Release+2001+New+Zealand+Disability+Survey:+Snapshot+8+Intellectual+ Disabilities?open) People with Intellectual Disabilities: from Invisible to Visible Citizens of the EU Accession Countries (http:// www.eumap.org/journal/features/2003/june/invistovis) Policy brief: Education and Employment in the UK (http://www.learningdisabilities.org.uk/html/content/ education_employment_policy_brief.pdf) The American Bar Association's paper Invisible Victims: Violence against persons with developmental disabilities (http://www.abanet.org/irr/hr/winter00humanrights/petersilia.html) Persons With Intellectual Disability Who Are Incarcerated For Criminal Offences (http://www.csc-scc.gc.ca/ text/rsrch/reports/r14/r14e_e.shtml) (Canadian paper) 'Fighting to keep 'em in' (http://www.raggededgemagazine.com/jan98/calif.htm), Ragged Edge magazine January 1998 Wishart, G.D. (2003) The Sexual Abuse of People with Learning Difficulties: Do We Need A Social Model Approach To Vulnerability? Journal of Adult Protection, Volume 5 (Issue 3) Piper, Julia (2007). "The Case of the Pillow Angel". The Triple Helix Cambridge Michaelmas

Dental degree

520

Dental degree
There is special entry requirements, and are a number of professional degrees in dentistry offered by dental schools in various countries around the world. These include the following: Doctor of Dental Surgery (DDS) Doctor of Dental Medicine (DMD) Doctor of Dentistry (DD)[1] Doctor of Medical Dentistry (DrMedDent) Bachelor of Dentistry (BDent) Bachelor of Dental Surgery (BDS or BChD or BDentS) Bachelor of Dental Science (BDSc or BDentSc) Bachelor of Oral Health in Dental Science (B OH DSc) Graduate Diploma in Dentistry (Grad Dip Dent)

There are a number of post-graduate degrees in dentistry as well. Master of Science (MS or MSc) Master of Medical Science (MMSc) Master of Dentistry (MDent) Doctor of Clinical Dentistry (DClinDent) Master of Dental Surgery (MDS) Master of Dental Science (MDSc) Fellow College of Physician and Surgeons (FCPS) Doctor of Dental Science (DDSc) Doctor of Medical Science (DMSc) Doctor of Philosophy (PhD)

In some universities, especially in the U.S., some post-graduate programs award Certificate only. Certificate, GPR/AEGD/Dental Anesthesiology Certificate, Endodontics/Prosthodontics/Periodontics/Orthodontics/Dental Public Health/Pediatric Dentistry/OMS (CODA-recognized specialty programs) In Commonwealth countries, the Royal Colleges of dentistry (or Faculty of Dentistry of the College) awards post-nominals upon completion of a series of examinations. Fellow of Dental Surgery of the Royal College of Surgeons (FDSRCS) Membership in Faculty of Dental Surgery of the Royal College Surgeons (MFDS RCS) Fellow of Royal Australasian College of Dental Surgeons (FRACDS) Membership in Royal Australasian College of Dental Surgeons (MRACDS) Membership in Orthodontics, Royal College of Surgeons (M.Orth RCS) Fellow of Royal College of Dentists of Canada (FRCD(C)) Member of Royal College of Dentists of Canada (MRCD(C)) Fellow College of Physician and Surgeons, Bangladesh (FCPS) Fellow College of Physician and Surgeons, Pakistan (FCPS)

In the U.S., most dental specialists attain Board Certification (Diplomate Status) by completing a series of written and oral examinations with the appropriate Boards. e.g. Diplomate, American Board of Periodontics. Each fully qualifies the holder to practice dentistry in at least the jurisdiction in which the degree was presented, assuming local and federal government licensure requirements are met.

Dental degree

521

Australia
Australia has nine dental schools: University of Sydney, NSW Charles Sturt University, NSW* Griffith University, QLD* University of Queensland, QLD James Cook University, QLD* University of Adelaide, SA La Trobe University, VIC* University of Melbourne, VIC University of Western Australia, WA

(*) indicates new university dental programs that have opened up to aim at increasing the number of rural dental students entering and to return to rural practice. Traditional "sandstone" universities have been Sydney, Melbourne, Queensland, Adelaide and Western Australia. Sydney (as of 2001), Melbourne (as of 2010) and Western Australia (as of 2013) have switched to 4-year graduate program that require a previous bachelor's degree for admission. Post-graduate training is available in all dental specialties. Degrees awarded used to be Master of Dental Surgery/Science (MDS/MDSc), but lately have changed to Doctorate in Clinical Dentistry (DClinDent).

New Zealand
New Zealand has only one dental school: University of Otago, Dunedin The Faculty of Dentistry awards Bachelor of Dental Surgery (BDS) and Master of Community Dentistry (MComDent) for public health & community dentistry, and Doctorate in Clinical Dentistry (DClinDent) for the other dental specialties.

Trans Tasman Mutual recognition


Both Australia and New Zealand recognize the educational and professional qualifications and grant professional licenses via reciprocity identical to the United States and Canada.

General Dental Council of the UK


The United Kingdom General Dental Council had been recognizing the Australian and New Zealand dental qualification as registrable degree until 2000. Graduates who have applied for dental license registration in the United Kingdom now have to sit the Overseas Registration Exam (ORE), a three-part examination.

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Canadian Registration
Australia and Canada have a reciprocal accreditation agreement which allows graduates of Canadian or Australian dental schools to register in either country. However, this only applies to the graduates of 2011 class and does not apply to the previous years graduates.

Royal Australasian College of Dental Surgeons


Royal Australasian College of Dental Surgeons (RACDS) is a post-graduate body that focuses on post-graduate training of general practitioners and specialist dentists. Additional post-graduate qualifications can be obtained through the College after the candidate has completed the Primary Examination (basic science examination in Anatomy, Histology, Physiology, Biochemistry, Pathology and Microbiology) and the Final Examination (clinical subjects in dentistry). After the successful completion of the examinations and meeting the College requirements, the candidate is awarded the title of Fellow of Royal Australasian College of Dental Surgeons (FRACDS). For the dental specialists, the exam pathway is similar (Primary Examinations) and then clinical/oral examinations just prior to completing the specialist training leads to the award of the title Member of Royal Australasian College of Dental Surgeons in Special Field Stream (MRACDS(SFS)). For the busy GP dentists, MRACDS in general stream is also available.

Canada
There are ten approved dental schools in Canada: University of Toronto (1868) McGill University (1905) Universit de Montral (1905) Dalhousie University (1908) University of Alberta (1923) University of Manitoba (1958) University of British Columbia (1964) University of Western Ontario (1966) University of Saskatchewan (1968) Universit Laval (1971)

Several Universities in Canada offer the DDS degree, including the University of Toronto, the University of Western Ontario, the University of Alberta, and Dalhousie University, while the remaining Canadian dental schools offer the Doctor of Dental Medicine degree to their graduates. Additional qualifications can be obtained through the Royal College of Dentists of Canada (RCDC) administers examinations for qualified dental specialists as part of the dentistry profession in Canada. The current examinations are known as the National Dental Specialty Examination (NDSE). Successful completion may lead to Fellowship in the College (FRCD(C)) and may be used for provincial registration purposes. Canada has a reciprocal accreditation agreement with Australia and the United States which allows graduates of Canadian dental schools to work in any of the 3 countries.

Dental degree

523

Finland
In Finland, education in dentistry is through a 5.5-year Licenciate of Dental Medicine (DMD or DDS) course, which is offered after high school graduation. Application is by a national combined dental and medical school entry examination. As of 2011, dentistry is provided by Faculties of Medicine in 4 universities: University of Helsinki University of Turku University of Oulu University of Eastern Finland, Kuopio Campus

1st phase of training begins with a unified 2-year pre-clinical training for dentists and physicians. Problem-based learning (PBL) is employed depending on university. 3rd year autumn consists of clinico-theoretical phase in pathology, genetics, radiology and public health and is partially combined with physicians' 2nd phase. 3rd phase clinical training lasts for the remaining 3 years and includes periods of being on call at University Central Hospital Trauma Centre, Clinic of Oral and Maxillofacial Diseases and at the Children's clinic. Candidates who successfully complete the 4th year of training qualify for a paid summer rotation in a Community health center of their choice. Annual intake of dentists into Faculties of Medicine is a national total 160 students. Ph.D. research is strongly encouraged and is mandatory alongside post graduate training. Post graduate training is available in all 4 universities and lasts an additional 46 years. Clinical dentistry: Periodontology Pedodontology and Preventive Dentistry Infectious and hard tissue diseases (Cariology and Endodontology) Prosthodontology and Stomatognathic physiology

Diagnostic dentistry: Oral and Maxillofacial Pathology Oral and Maxillofacial Radiology Oral and Maxillofacial Medicine Other: Orthodontics Oral and Maxillofacial Surgery Oral Public Health

India
In India, training in dentistry is through a 5-year BDS (Bachelor of Dental Surgery) course, which includes 4 years of study followed by one year of internship. As of 2010, there were a total of 291 colleges (39 run by the government and 252 in the private sector) offering dental education. This amounts to an annual intake of 23,690 graduates.[2] Post graduate training is for three years in the concerned speciality. Master of Dental Surgery (MDS) is offered in the following subjects Prosthodontics Periodontics Oral and Maxillofacial Surgery Conservative Dentistry & Endodontics Orthodontics & Dentofacial Orthopaedics

Oral Pathology & Microbiology Community Dentistry

Dental degree Pedodontics and Preventive Dentistry Oral Medicine Diagnosis and Radiology. Dental education in India is regulated by the Dental Council of India.

524

Israel
In Israel there are two dental schools, The Hebrew University-Hadassah School of Dental Medicine in Jerusalem, founded by the Alpha Omega Fraternity and The Tel Aviv University School of Dental Medicine in Tel Aviv. The two schools have 6-year program and provide Doctor of Dental Medicine (DMD) degrees. In last decades, the students eligible to Bachelor of Medical Sciences (BMedSc) degree after the first three years of training.

United States
In the United States, at least three years of undergraduate education are required in order to be admitted to a dental school; however, most dental schools require at least a bachelor's degree. There is no mandatory course of study as an undergraduate other than completing the requisite "pre-dental" courses, which generally includes one year of general biology, chemistry, organic chemistry, physics, English, and higher level mathematics such as statistics and calculus. Some dental schools have requirements that go beyond the basic requirements such as psychology, sociology, biochemistry, anatomy, physiology etc. The majority of pre-dental students major in a science but this is not required as some students elect to major in a non-science related field. In addition to core prerequisites, the Dental Admission Test, a multiple choice standardized exam, is also required for potential dental students. The DAT is usually taken during the spring semester of one's junior year. The vast majority of dental schools requires an interview before admissions can be granted. The interview is designed to evaluate the motivation, character, and personality of the applicant.[citation needed] It is often a crucial step in the admissions process.Wikipedia:Avoid weasel words For the 2009-2010 application cycle, 11,632 applicants applied for admission to dental schools in the United States. Just 4,067 were eventually accepted. The average dental school applicant entering the school year in 2009 had an overall GPA of 3.54 and a science GPA of 3.46. Additionally, their mean DAT Academic Average (AA) was 19.00 while their DAT Perceptual Ability Test (PAT) score was 19.40.[3]

Dental education and training


Dental school is four academic years in duration and is similar in format to medical school: two years of basic medical and dental sciences, followed by two years of clinical training (with continued didactic coursework). Before graduating, every dental student must successfully complete the National Board Dental Examination Part I and II (commonly referred to as NBDE I & II). The NBDE Part I is usually taken at the end of the second year after the majority of the didactic courses have been completed. The NBDE Part I covers Gross Anatomy, biochemistry, physiology, microbiology, pathology, and dental anatomy and occlusion. The NBDE Part II is usually taken during winter of the last year of dental school and consists of operative dentistry, pharmacology, endodontics, periodontics, oral surgery, pain control, prosthodontics, orthodontics, pedodontics, oral pathology, and radiology. NBDE Part I scores are of importance when considering residency training after graduating from dental school.[citation needed] After graduating, the vast majority of new dentists go directly into practice while a small, yet increasing, percentage of dentists apply to a residency program.Wikipedia:Avoid weasel words Some residency programs train dentists in advanced general dentistry such as General Practice Residencies and Advanced Education in General Dentistry Residencies, commonly referred to as GPR and AEGD. Most GPR and AEGD programs are one year in duration but several are two years long or provide an optional second year.[citation needed] GPR programs are usually affiliated with a hospital and thus require the doctor to treat a wide variety of patients including trauma, critically ill, and medically compromised patients. Additionally, GPR programs require residents to rotate through various departments within

Dental degree the hospital, such as anesthesia, internal medicine, and emergency medicine, to name a few. AEGD programs are usually in a dental school setting where the focus is treating complex cases in a comprehensive manner.

525

Licensing examinations
To practice, a dentist must pass a licensing examination administered by an individual state or more commonly a region. There are a handful of states that maintain independent dental licensing examinations while the majority accept a regional board examination. The Northeast Regional Board (NERB), Western Regional Board (WREB), Central Regional Dental Testing Service (CRDTS), and Southern Regional Testing Agency (SRTA), Council of Interstate Testing Agencies (CITA)[4] are the five regional testing agencies that administer licensing examinations. Once the examination is passed, the dentist may then apply to individual states that accept the regional board test passed. Each state requires prospective practitioners to pass an ethics/jurisprudence examination as well before a license is granted. To maintain one's dental license the doctor must complete Continuing Dental Education (CDE) courses periodically (usually annually). This promotes the continued exploration of knowledge. The amount of CE required varies from state to state but is generally 10-25 CE hours a year. The completion of a dental degree can be followed by either an entrance into private practice, further postgraduate study and training, or research and academics.

DDS vs DMD degree


In the United States, DDS and DMD degrees are equivalent. The American Dental Association specifies: The DDS (Doctor of Dental Surgery) and DMD (Doctor of Dental Medicine) are the same degrees. They are awarded upon graduation from dental school to become a general dentist. The majority of dental schools award the DDS degree; however, some award a DMD degree. The education and degrees are the same.[5] Harvard University was the first dental school to award the DMD degree.[6] Harvard only grants degrees in Latin and school administrators thought the Latin translation of Doctor of Dental Surgery ("Chirurgae Dentium Doctoris," or CDD) was too cumbersome. A Latin scholar was consulted and suggested "Medicinae Doctor" be prefixed with "Dentariae." This is how the DMD, or "Dentariae Medicinae Doctorae" degree, was started. Other dental schools made the switch to this notation, and in 1989, 23 of the 66 North American dental schools awarded the D.M.D. There is no meaningful difference between the DMD and DDS degrees and all dentists must meet the same national and regional certification standards in order to practice.[7] The United States Department of Education and the National Science Foundation do not include the DDS and DMD or other professional doctorates among the degrees that are equivalent to research doctorates.[8][9]

South Africa
Training in South Africa generally comprises a 5-year degree, with 1 year compulsory medical service / internship. The country has 5 universities with dental faculties:[10]

Dental degree

526

Institution University of KwaZulu-Natal University of Limpopo

School

Founded Location Durban

Programme(s) Diploma in Dental Therapy

MEDUNSA Campus, Pretoria School of Dentistry Faculty of Dentistry Pretoria

BDS

University of Pretoria

BChD, MChD (Master of Dentistry), MSc Dentistry, PhD (Dentistry), DSc B.Ch.D

University of the Western Cape University of the Witwatersrand

Cape Town

Johannesburg

BDS

Until 2003, Stellenbosch University offered the B.Ch.D degree. In 2004 the dental faculties of The University of the Western Cape and Stellenbosch University merged and moved to The University of the Western Cape, which is currently the largest dental school in Africa. Specialisation is through the College of Dentistry within the Colleges of Medicine of South Africa, with certifications offered in oral medicine and periodontics, orthodontics, and prosthodontics. Research degrees are the M.Dent and Ph.D.. See also Medical education in South Africa.

United Kingdom and Ireland


Many universities award BDS (Bachelor of Dental Surgery) degrees, including The University of Bristol, Barts and the London School of Medicine and Dentistry, The University of Birmingham, The University of Liverpool, The University of Manchester, The University of Glasgow, The University of Dundee, The University of Aberdeen, King's College London, the University of Cardiff, Newcastle University, and Queen's University Belfast. In the Republic of Ireland, the University College Cork awards BDS degree and Trinity College Dublin awards the BDentSc degree. The University of Leeds awards BChD and MChD (Bachelor/Master of Dental Surgery) degrees.[11] The Royal Colleges of Surgeons in England, Edinburgh, Glasgow, and Ireland award LDS (Licence/Licentiate in Dental Surgery) degrees.

Bangladesh
In Bangladesh there are a list of dental school provide graduate education in Dentistry. The graduation in Dentistry is name here as Bachelor of Dental Surgery (BDS). At present there are three university those have Medical faculty conduct dental degree in Bangladesh. These university have different affiliated dental college that conduct the graduation dental education in Bangladesh. The three university that have Dentistry in their Medical Faculty are The University of Dhaka, The University of Chittagong and the University of Rajshahi. This three Public university have their Medical Faculty affiliated dental college and hospital those may be publicly or privately funded.

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List of Bangladeshi dental colleges


University of Dhaka affiliated dental colleges are: 1. Dhaka Dental College , 2. Pioneer Dental College & Hospital/ Pioneer Dental College & Hospital [12] 3. Bangladesh Dental College 3. City Dental College 4. University Dental College 5. Sapporo Dental College 6. Update Dental College & Hospital [13] 7. Marks Dental College 8. Saphena Women's Dental College 9. Mandy Dental College University of Chittagong affeliated dental college are: 1. Chittagong Medical College Dental unit. 2. Chittagong International Dental College University of Rajshahi affeliated dental college are: 1. Rajshahi Medical College Dental unit. 2..Rangpur Dental College 3.Udayan Dental College

Post graduation Dentistry in Bangladesh


At present post graduation in specialized dentistry exist in main four clinical speciality: Orthodontics and Dentofacial Orthopedics Oral and Maxillofacial Surgery Conservative Dentistry and Endodontics Prosthodontics

The FCPS degree which require four(4) years of residency training is awarded by Bangladesh College of Physician and Surgeons [14]. It considered the most prestigious specialized Degree in Dentistry at present. There are also MS degree only in Oral and Maxillofacial Surgery from University of Dhaka. Very recently MS in dentistry is also started in Bangabandhu Sheikh Mujib Medical University (BSMMU), the first batch of which suppose to finish their degree in 2016.

Dental Specialties
In addition to general dentistry, there are about 9 recognized dental specialties in the US, Canada, India and Australia. To become a specialist requires one to train in a residency or advanced graduate training program. Once residency is completed, the doctor is granted a certificate of specialty training. Many specialty programs have optional or required advanced degrees such as a masters degree: (MS, MSc, MDS, MSD, MDSc, MMSc, MPhil, or MDent), doctoral degree: (DClinDent, DChDent, DMSc, PhD), or medical degree: (MD/MBBS specific to maxillofacial surgery and sometimes oral medicine). Orthodontics: 23 years[15] Endodontics: 23 years[16] Oral and maxillofacial surgery: 46 years (additional time for MD/MBBS degree granting programs) Periodontics: 3 years[17] Prosthodontics: 23 years[18]

Dental degree Maxillofacial prosthodontics 1 year (a prosthodontist may elect to sub-specialize in maxillofacial prosthodontics) Oral and maxillofacial radiology: 3 years Oral and maxillofacial pathology: 35 years Pediatric Dentistry: 23 years[19][20] Dental public health: 3 years

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The following are not currently recognized dental specialties in the US: Anesthesiology (programs currently undergoing CODA accreditation and ADA review): 23 years Oral medicine: 24 years Special needs dentistry 3 years Cosmetic Dentistry - ranges from a weekend course to a 1-year course depending on the certificate issuing agency.

Dentists who have completed accredited specialty training programs in these fields are designated registrable (U.S. "Board Eligible") and warrant exclusive titles such as orthodontist, oral and maxillofacial surgeon, endodontist, pedodontist, periodontist, or prosthodontist upon satisfying certain local (U.S. "Board Certified"), (Australia/NZ: "FRACDS"), or (Canada: "FRCD(C)") registry requirements.

References
[4] www.citaexam.com : Council of Interstate Testing Agencies [5] "DDS/DMD" (http:/ / www. ada. org/ 3049. aspx?currentTab=1), American Dental Association [6] ohsu.edu (http:/ / www. ohsu. edu/ xd/ education/ schools/ school-of-dentistry/ prospective-students/ dmd-program/ ) [7] "Public perception of DDS versus DMD degrees." Journal of the American College of Dentists. 1999. Fall; 66(3):29-37. Lalumandier, JA. [8] http:/ / www2. ed. gov/ about/ offices/ list/ ous/ international/ usnei/ us/ doctorate. doc [12] http:/ / www. pioneerdentalcollegeandhospital. com/ [13] http:/ / www. updatedentalcollege. edu. bd/ [14] http:/ / www. bcpsbd. org/

External links
General Dental Council: UK primary dental qualifications (http://www.gdc-uk.org/Potential+registrant/ Apply+for+registration/UK+Primary+Dental+Qualifications.htm) Bangladesh College of Physicians and Surgeons (http://www.bcpsbd.org/) http://www.cpsp.edu.pk/

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Drug Enforcement Administration


Drug Enforcement Administration
Abbreviation DEA

Seal of the Drug Enforcement Administration

Badge of the Drug Enforcement Administration.

Flag of the Drug Enforcement Administration

Agency overview

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Formed July 1, 1973 Bureau of Narcotics and Dangerous Drugs Office of Drug Abuse Law Enforcement

Preceding agencies

Employees Annual budget Legal personality

10,784 (2009) US$3 billion (FY2012)


[1]

Governmental: Government agency Jurisdictional structure

Federal agency General nature

United States

Federal law enforcement Civilian agency

Operational structure Headquarters Special Agents Agency executives Parent agency Arlington, Virginia 4,890

Michele Leonhart, Administrator Thomas M. Harrigan, Chief of Operations

United States Department of Justice Website www.usdoj.gov/dea/


[2]

The Drug Enforcement Administration (DEA) is a United States federal law enforcement agency under the U.S. Department of Justice, tasked with combating drug smuggling and use within the United States. Not only is the DEA the lead agency for domestic enforcement of the Controlled Substances Act, sharing concurrent jurisdiction with the Federal Bureau of Investigation (FBI) and Immigration and Customs Enforcement (ICE), it also has sole responsibility for coordinating and pursuing U.S. drug investigations abroad.

History and mandate


The Drug Enforcement Administration was established on July 1, 1973, by Reorganization Plan No. 2 of 1973, signed by President Richard Nixon on July 28.[3] It proposed the creation of a single federal agency to enforce the federal drug laws as well as consolidate and coordinate the government's drug control activities. Congress accepted the proposal, as they were concerned with the growing availability of drugs.[4] As a result, the Bureau of Narcotics and Dangerous Drugs (BNDD), the Office of Drug Abuse Law Enforcement (ODALE), and other federal offices merged to create the DEA.[] From the early 1970s, DEA headquarters was located at 1405 I ("Eye") Street NW in downtown Washington, D.C. With the overall growth of the agency in the 1980s (owing to the increased emphasis on federal drug law enforcement efforts) and a concurrent growth in the headquarters staff, DEA began to search for a new headquarters location; locations in Arkansas, Mississippi, and various abandoned military bases around the U.S. were considered. However,

Two DEA agents in a shoot house exercise.

Drug Enforcement Administration thenAttorney General Edwin Meese determined that the headquarters had to be located in close proximity to the Attorney General's office. Thus, in 1989, the headquarters relocated to 600-700 Army-Navy Drive in the Pentagon City area of Arlington, Virginia, near the Metro station with the same name.[5] On April 19, 1995, Timothy McVeigh attacked the Alfred P. Murrah Federal Building in Oklahoma City because it housed regional offices for the FBI, Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF), and DEA, all of which had carried out raids that he viewed as unjustified intrusions on the rights of the people;[6] this attack caused the deaths of two DEA employees, one task force member, and two contractors in the Oklahoma City bombing. Subsequently, the DEA headquarters complex was classified as a Level IV installation under United States federal building security standards, meaning it was to be considered a high-risk law enforcement target for terrorists.[7] Security measures include hydraulic steel roadplates to enforce standoff distance from the building, metal detectors, and guard stations.[8] In February 2003, the DEA established a Digital Evidence Laboratory within its Office of Forensic Sciences.[]

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Organization
The DEA is headed by an Administrator of Drug Enforcement appointed by the President of the United States and confirmed by the U.S. Senate. The Administrator reports to the Attorney General through the Deputy Attorney General.[9] The Administrator is assisted by a Deputy Administrator, the Chief of Operations, the Chief Inspector, and three Assistant Administrators (for the Operations Support, Intelligence, and Human Resources Divisions). Other senior Map of the 21 DEA domestic field divisions: 1. staff include the Chief Financial Officer and the Chief Counsel. The Atlanta, 2. Boston, 3. Chicago, 4. Dallas, 5. Administrator and Deputy Administrator are the only Denver, 6. Detroit, 7. El Paso, 8. Houston, 9. Los Angeles, 10. Miami, 11. Newark, 12. New presidentially-appointed personnel in the DEA; all other DEA officials Orleans, 13. New York, 14. Philadelphia, 15. are career government employees. DEA's headquarters is located in Phoenix, 16. San Diego, 17. San Francisco, 18. Arlington, Virginia across from the Pentagon. It maintains its own Seattle, 19. St. Louis, 20. Caribbean, 21. DEA Academy located on the United States Marine Corps base at Washington, D.C. Quantico, Virginia along with the FBI Academy. It maintains 21 domestic field divisions with 227 field offices and 86 foreign offices in 62 countries.[10] With a budget exceeding 2.415 billion dollars, DEA employs over 10,800 people, including over 5,500 Special Agents. Becoming a Special Agent with the DEA is a competitive process.

Structure
Administrator Deputy Administrator Human Resource Division Career Board Board of Professional Conduct Office of Training Operations Division Aviation Division Office of Operations Management Special Operations Division Office of Diversion Control

Drug Enforcement Administration Office of Global Enforcement Office of Financial Operations Intelligence Division Office of National Security Intelligence Office of Special Intelligence El Paso Intelligence Center OCDETF Fusion Center Financial Management Division Office of Acquisition and Relocation Management Office of Finance Office of Resource Management Operational Support Division Office of Administration Office of Information System Office of Forensic Science Office of Investigative Technology Inspection Division Office of Inspections Office of Professional Responsibility Office of Security Programs Field Divisions and Offices

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Agents
After receiving a conditional offer of employment, recruits must then make it through a 19 week rigorous training which consist of firearms proficiency including basic marksmanship, weapons safety, tactical shooting, and deadly force decision training. In order to graduate, students must maintain an academic average of 80 percent on academic examinations, pass the firearms qualification test, successfully demonstrate leadership and sound decision-making in practical scenarios, and pass rigorous physical task tests. Upon graduation, recruits earn themselves the title of DEA Special Agent.

Job applicants who have a history of any drug use are excluded from consideration. Investigation usually includes a polygraph test for special agent, diversion investigator, and intelligence research specialist positions.

Colombian drug lord is escorted by DEA agents after being extradited to the United States in 2005.

Applicants who are found, through investigation or personal admission, to have experimented with or used narcotics or dangerous drugs, except those medically prescribed, will not be considered for employment with the Drug Enforcement Administration (DEA). Exceptions to this policy may be made for applicants who admit to limited youthful and experimental use of marijuana. Such applicants may be considered for employment if there is no evidence of regular, confirmed usage and the full-field background investigation and results of the other steps in the process are otherwise favorable.[11] The DEA's relatively firm stance on this issue is in contrast to that of the Federal Bureau of Investigation, which, in 2005, considered relaxing its hiring policy relevant to individual drug use history.[12]

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Aviation Division
The DEA Aviation Division or Office of Aviation Operations (OA) (formerly Aviation Section) is an airborne division based in Fort Worth Alliance Airport, Texas. The current OA fleet consists of 106 aircraft and 124 DEA pilots.[13] The DEA shares a communications system with the Department of Defense for communication with state and regional enforcement independent of the Department of Justice and police information systems and is coordinated by an information command center called the El Paso Intelligence Center (EPIC) near El Paso, Texas.

DEA Aviation Division logo

Foreign-deployed Advisory and Support Teams


As of January 2010, FAST fields five teams. One team is always stationed in Afghanistan conducting Counter Narcotics (CN), Counter Terrorism (CT), Direct Action (DA) missions. The remaining four teams are stationed at Marine Corps Base Quantico, Virginia. FAST originally was created to solely conduct missions in Afghanistan but has evolved into a global action arm for the US Department of Justice and DEA. Selection for FAST is extremely difficult; attrition rates are usually above 50%. Selection is rumored to last 8 weeks where events such as DEA agents burning hashish seized in Operation timed runs, timed ruck sack marches, land navigation and many other Albatross in Afghanistan, 2008. events are conducted daily. Once selection is complete, advanced training begins with emphasis in small unit tactics, and close quarters battle.

Special Operations Division


The DEA Special Operations Division (SOD) is a secretive division within the DEA, which forwards information from wiretaps, intercepts and databases from various sources to federal agents and local law enforcement officials. The SOD came under scrutiny following the 2013 mass surveillance disclosures.[14]

Budget
The 1998 DEA budget was directed toward three of five major goals of U.S. drug eradication:[15] Demand reduction ($3.3 million) via anti-legalization education, training for law enforcement personnel, youth programs, support for community-based coalitions, and sports drug awareness programs. Reduction of drug-related crime and violence ($181.8 million) funding state and local teams and mobile enforcement teams. Breaking foreign and domestic sources of supply ($1.0149 billion) via domestic cannabis eradication/suppression; domestic enforcement; research, engineering, and technical operations; the Foreign Cooperative Investigations Program; intelligence operations (financial intelligence, operational intelligence, strategic intelligence, and the El Paso Intelligence Center); and drug and chemical diversion control.

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Firearms
DEA agents' primary service weapons are the Glock 22 and Glock 23 in .40 S&W caliber ammunition, and agents can also qualify to use the Glock 27 and SIG Pro in .40 S&W, and they also have the option of using the newly appointed Smith & Wesson M&P series pistol. Special Agents may qualify with their own personally-owned handguns and certain handguns are allowed to be used with permission from the DEA Firearms office in Quantico, VA, but they are required to qualify on all assigned weapons quarterly. Trained to use shoulder-launched weapon, the H&K UMP40 is the standard SMG of DEA, although the Colt 9mm SMG may also be issued. They are issued a LWRCI M6A2 carbine as their new personal duty service rifle and also the Rock River Arms CAR-15 and shotguns such as the Remington 870 are one of the weapons trained.

Registration & Licensing


The DEA has a registration system in place which authorizes medical professionals, researchers and manufacturers access to "Schedule I" drugs, as well as Schedules 2, 3, 4 and 5. Authorized registrants apply for and, if granted, receive a "DEA number". An entity that has been issued a DEA number is authorized to manufacture (drug companies), distribute, research, prescribe (doctors, nurse practitioners and physician assistants, etc.) or dispense (pharmacy) a controlled substance.

Diversion control system

Many problems associated with drug abuse are the result of legitimately-manufactured controlled substances being diverted from their lawful purpose into the illicit drug traffic. Many of the analgesics, depressants and stimulants manufactured for legitimate medical use can often carry potential for dependence or abuse. Therefore those scheduled substances have been brought under legal control for prevention and population safety. The goal of controls is to ensure that these "controlled substances" are readily available for medical use, while preventing their distribution for illicit distribution and non-medical use. This can be a difficult task, sometimes providing difficulty for legitimate patients and healthcare providers while circumventing illegal trade and consumption of scheduled drugs. Under federal law, all businesses which manufacture or distribute controlled drugs, all health professionals entitled to dispense, administer or prescribe them, and all pharmacies entitled to fill prescriptions must register with the DEA. Registrants must comply with a series of regulatory requirements relating to drug security, records accountability, and adherence to standards. All of these investigations are conducted by Diversion Investigators (DIs). DIs conduct investigations to uncover and investigate suspected sources of diversion and take appropriate civil and administrative actions. Prescription Database Management Programs (PDMP) aid and facilitate investigation and surveillance.
[citation needed]

"Operation Somalia Express" was an 18-month investigation which included the coordinated takedown of a 44-member international narcotics-trafficking organization responsible for smuggling more than 25 tons of khat from the Horn of Africa to the United States.

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MDMA DEA scheduling overturn


In 1985 MDMA and its analogues were under review by the American government as a drug for potential of abuse. During this time, several public hearings on the new drug were held by the DEA. Based on all of the evidence and facts presented at the time, the DEA's administrative law judge did not see MDMA and its analogues as being of large concern and recommended that they be placed in Schedule III. The DEA administrator, expressing concern for abuse potential, overruled the recommendation and ruled that MDMA be put in Schedule I, the Controlled Substances Act's most restrictive category.[16][17][18]

Criticism
The DEA has been criticized for placing highly restrictive schedules on a few drugs which researchers in the fields of pharmacology and medicine regard as having medical uses. Critics assert that some such decisions are motivated primarily by political factors stemming from the U.S. government's War on Drugs, and that many benefits of such substances remain unrecognized due to the difficulty of conducting scientific research. A counterpoint to that criticism is that under the Controlled Substances Act it is the Department of Health and Human Services (through the Food and Drug Administration and the National Institute on Drug Abuse), not the DEA, which has the legal responsibility to make scientific and medical determinations with respect to drug scheduling; no drug can be scheduled if the Secretary of Health and Human Services recommends against it on a scientific or medical basis, and no drug can be placed in the most restrictive schedule (Schedule I) if DHHS finds that the drug has an accepted medical use. Jon Gettman's essay Science Drug Enforcement Administration 25th and the End of Marijuana Prohibition describes the DEA as "a fall guy to Anniversary badge deflect responsibility from the key decision-makers" and opines, "HHS calls the shots when it comes to marijuana prohibition, and the cops at DEA and the general over at ONDCP take the heat."[19] The DEA is also criticized for focusing on the operations from which it can seize the most money,[20] namely the organized cross-border trafficking of marijuana. Some individuals contemplating the nature of the DEA's charter advise that, based on danger, the DEA should be most focused on cocaine. Others suggest that, based on opiate popularity, the DEA should focus much more on prescription opiates used recreationally, which critics contend comes first before users switch to heroin. Practitioners who legally prescribe medicine however must possess a valid DEA license. According to federal law the budget of the entire DEA is to be paid by these license fees. In 1984 a three-year license cost $25. In 2009 the fee for a three-year license was $551. Some have likened this approach to license fees unreasonable, "like making pilot licenses support the entire Federal Aviation Authority (FAA) budget." The total cost of the DEA from 1972 to 2009 according to the agency website was $536,367,800,000.00 with 10,784 employees in 2009. For the data available for the years 1986 to 2009, the average cost per arrest made was $9,893.09.[21] Others, such as the Cato Institute[22] and the Drug Policy Alliance[23] criticize the very existence of the DEA and the War on Drugs as both hostile, and contrary, to the concept of civil liberties by arguing that anybody should be free to put any substance they choose into their own bodies for any reason, particularly when legal drugs such as alcohol, tobacco and prescription drugs are also open to abuse, and that any harm caused by a drug user or addict to the general public is a case of conflicting civil rights. Recurrently, billions of dollars are spent yearly, focusing largely on criminal law and demand reduction campaigns, which has resulted in the imprisonments of thousands of U.S.

Drug Enforcement Administration citizens.[24] Demand for recreational drugs is somewhat static as the market for most illegal drugs has been saturated, forcing the cartels to expand their market to Europe and other areas than the United States.[citation needed] United States federal law registers cannabis as a Schedule I drug,[25] yet it is common for illicit drugs such as cannabis to be widely available in most urban, suburban, and even rural areas in the United States, which leads drug legalization proponents to claim that drug laws have little effect on those who choose not to obey them, and that the resources spent enforcing drug laws are wasted. As it relates to the DEA specifically, the vast majority of individual arrests stemming from illegal drug possession and distribution are narrow and more local in scope and are made by local law enforcement officers, while the DEA tends to focus on larger, interstate and international distribution networks and the higher-ranking members of such organizations in addition to operating in conjunction with other local, state, and federal law enforcement agencies along U.S. borders.[citation needed] Some groups advocate legalization of certain controlled substances under the premise that doing so may reduce the volume of illicit trafficking and associated crime as well as yield a valuable tax source, although some of the results of drug legalization have raised doubt about some of these beliefs. For example, marijuana is now available as a palliative agent, in Canada, with a medical prescription. Yet 86% of Canadians with HIV/AIDS, eligible for a prescription, continue to obtain marijuana illegally (AIDS Care. 2007 Apr;19(4):500-6.) However, this could be due to the availability or quality of illegal cannabis compared to provisions by government sources. Bureaucratic impediments may also discourage patients from actually attempting to receive it from the government. An April 2012 DEA raid on a California home led to the incarceration of Daniel Chong for several days under conditions of neglect. The 23 year-old student attending the University of California, San Diego was taken into custody along with eight other people when the DEA executed a raid on a suspected MDMA distribution operation at a residence that he was visiting to celebrate the April 20 cannabis "holiday" known as "420".[26][][] According to Chong, the DEA agents questioned him and told him that he could go home, one even offering him a ride home, but instead he was transferred to a holding cell and confined for five days without any food or water, although Chong said he ingested a powdery substance that was left for him, which was later found to be methamphetamine.[] After five days and two failed suicide attempts, DEA agents found Chong. He was taken to the hospital, where he spent three days in intensive care, because his kidneys were close to failing. No criminal charges were filed against Chong. A DEA spokesperson stated that the extended detention was accidental and the acting special agent in charge of the San Diego DEA office issued an apology to Chong. Chong disputes the claim of accidental neglect, saying that DEA personnel ignored his calls for help. His attorney stated an intent to file a claim against the federal government and some members of California's delegation to the Congress called for further investigation of the incident.[][][27]

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International
The DEA was accused in 2005 by the Venezuelan government of collaborating with drug traffickers, after which President Hugo Chvez decided to end any collaboration with the agency. In 2007, after the U.S. State Department criticized Venezuela in its annual report on drug trafficking, the Venezuelan Minister of Justice reiterated the accusations: "A large quantity of drug shipments left the country through that organization,...[]..We were in the presence of a new drug cartel."[28] The government of Bolivia has also taken similar steps to ban the DEA from operating in the country. In September 2008, Bolivia and the US drastically reduced diplomatic ties with one another, each withdrawing ambassadors from the other country. This occurred soon after Bolivian president Evo Morales expelled all DEA agents from the country due to a revolt in the traditional coca-growing Chapare Province. The Bolivian government claimed that it could not protect the agents, and Morales further accused the agency of helping incite the violence, which claimed 30 lives. National agencies were to take over control of drug management.[29] Three years later, Bolivia and the US began to restore full diplomatic ties. However, Morales maintained that the DEA would remain unwelcome in the country, characterising it as an affront to Bolivia's "dignity and sovereignty".[30]

Drug Enforcement Administration In the Netherlands, both the Dutch government and the DEA have been criticized for violations of Dutch sovereignty in drug investigations. According to Peter R. de Vries, a Dutch journalist present at the 2005 trial of Henk Orlando Rommy, the DEA has admitted to activities on Dutch soil. Earlier, then Minister of Justice Piet Hein Donner, had denied to the Dutch parliament that he had given permission to the DEA for any such activities, which would have been a requirement by Dutch law in order to allow foreign agents to act within the territory.[31]

537

Raids on medical marijuana dispensaries


The DEA has taken a particularly strong stance on enforcement of the Controlled Substances Act on persons and organizations acting within state laws that allow medical cannabis cultivation and distribution.[32] "The people of California and the County of Santa Cruz have overwhelmingly supported the provision of medical marijuana for people who have serious illnesses," county Supervisor Mardi Wormhoudt told the San Francisco Gate. "These people (blocking the road) are people with AIDS and cancer and other grave illnesses. To attack these people, who work collectively and have never taken money for their work, is outrageous."[33][34]

People protesting medical marijuana raids

As a result, the Wo/Men's Alliance for Medical Marijuana, with the City and County of Santa Cruz, has sued the DEA, Attorney General Michael Mukasey, and the ONDCP. The most recent court decision rejected the government's motion to dismiss, which allows discovery to move forward. The American Civil Liberties Union hailed the decision as "a first-of-its-kind ruling.[35] " More recently, the DEA has escalated its enforcement efforts on the recently-proliferated Los Angeles area medical cannabis collectives. On July 25, 2007, the DEA raided the California Patients Group, Hollywood Compassionate Collective, and Natural Hybrid (NHI Caregivers) in Hollywood, California. [citation needed] Earlier that day, the operators of those collectives participated in a press conference with LA City Council members announcing the City's intention to regulate the collectives and asking the DEA to halt raids on collectives while the City drafted regulations. [citation needed] The dispensary operator of Natural Hybrid (NHI Caregivers) was forced to close down the collective due to the tremendous loss caused by the DEA conducted joint task force raid against them. [citation needed]

DEA Museum
In 1999, the DEA opened the Drug Enforcement Administration Museum in Arlington, Virginia. The original permanent exhibit - Illegal Drugs in America: A Modern History - remains the museum's centerpiece. The exhibit features "the more than 150 year history of drugs and drug abuse and the DEA," including a considerable collection of drug paraphernalia and an image of a smiling drug vendor under the heading "Jimmy's Joint."[36] An audio tour is available at the front desk of the museum on a small MP3 device and headphones from the late 1990s/early 2000s. A second exhibition gallery was opened in 2002, and features a changing exhibit. The current exhibit is titled "Good Medicine, Bad Behavior: Drug Diversion in America."[37] According to the museum's website, its mission is to "educate the American public on the history of drugs, drug addiction and drug law enforcement in the United States through engaging and state-of-the-art exhibits, displays, interactive stations and educational outreach programs."[38] Some have noted that the museum's educational mission is inhibited by its relative inaccessibility and appearance of propaganda. While "Admission is free!!", the museum is only open to the public from 10:00am 4:00pm, Tuesday - Friday.[39] The number of annual visitors is relatively low compared with other museums in the Washington Metropolitan Area. The gift shop at the DEA museum sells items such as small stuffed K9 dogs and the annual DEA Holiday ornament. However, the gift shop is sometimes closed during the museum's normal operating hours.

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Notes
[1] http:/ / www. justice. gov/ dea/ docs/ 1207_fact-sheet. pdf [2] http:/ / www. usdoj. gov/ dea/ [7] http:/ / www. protectiveglazing. org/ resources/ Anti-Terrorism%20-%20Criteria,%20Tools%20and%20Technology. pdf [17] Video Documentary: "Hooked - Illegal Drugs and How They Got That Way: LSD, Ecstasy and Raves",The History Channel [18] "Documents from the DEA Scheduling Hearing of MDMA, 1984-1988 (http:/ / www. maps. org/ dea-mdma/ ,) [19] (http:/ / www. millionmarijuanamarch. com/ mmm1_047. htm) [27] (http:/ / www. utsandiego. com/ news/ 2012/ may/ 01/ man-abandoned-dea-cell-steps-forward), May 1, 2012

Further reading
Harry J. Anslinger and Will Oursler (1961), The Murderers: The Story of the Narcotic Gangs, New York: Farrar, Straus and Cudahy. Edward Jay Epstein (1977), Agency of Fear: Opiates and Political Power in America, New York: Putnam. Wayne Smith (2012), Waffle House Diaries, Chattanooga, TN: Bluehotel Press.

External links
DEA official web site (http://www.usdoj.gov/dea/) The History of the DEA from 1973 to 1998 (http://www.usdoj.gov/dea/pubs/history/) List of former DEA Administrators (http://www.justice.gov/dea/about/history/former.shtml) Proposed and final federal regulations from the Drug Enforcement Administration (http://openregs.com/ agencies/view/85/) Agency of Fear - The History of the origins of the DEA in the Nixon White House (http://www.druglibrary. org/schaffer/History/aof/index.html) Results of Prohibition (http://thedea.org/itsresults.html) The financial costs of drug use and drug prohibition in the U.S., impact on levels of drug use and prices. A response to the DEA web site (http://www.druglibrary.org/schaffer/dea/index.htm) "98 Percent Of All Domestically Eradicated Marijuana Is "Ditchweed," DEA Admits" (http://www.norml.org/ index.cfm?Group_ID=7033). NORML News Archive. 7 September 2006. Retrieved 2007-03-27. Major Studies of Drugs and Drug Policy (http://www.druglibrary.org/schaffer/library/studies/studies.htm) Full text of major government commission reports on the effects of drug enforcement The Drug Hang-Up by Rufus King (http://www.druglibrary.org/special/king/dhu/dhumenu.htm) A history of the drug laws with special emphasis on the predecessors to the DEA DEA Watch - A dissenting view of the DEA (http://www.deawatch.com/) Drug Enforcement Administration Meeting Notices and Rule Changes (http://thefederalregister.com/b.p/ agency/Drug_Enforcement_Administration/) from The Federal Register RSS Feed (http://thefederalregister. com/rss/agency/Drug_Enforcement_Administration/) DEA Lookup.com (http://www.dealookup.com) Commercial DEA number database search service DrugEnforcementEdu.org (http://www.drugenforcementedu.org/) A guide on how to become a DEA Agent Office of Diversion Control (http://www.deadiversion.usdoj.gov/index.html) Reorganization Plan No. 2 of 1973 - Appendix to Title 5, U.S. Code (http://uscode.house.gov/uscode-cgi/ fastweb.exe?getdoc+uscview+t05t08+1361+0++(1973) AND ((5) ADJ USC):CITE ) Get Smart About Drugs - A DEA Resource for Parents (http://www.getsmartaboutdrugs.com/) DEA Demand Reduction - Street Smart Prevention (http://www.justthinktwice.com/) Drug Enforcement Administration Citizens Academy (DEA CA) (http://www.deacitizensacademy.org/)

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Drug Enforcement Agency


The Drug Enforcement Agency (DEA) is an agency in the government of Liberia charged with fighting drug-related crimes.[1] Before its creation, fighting drug crimes was a responsibility of the Ministry of Defense.[2] The agency began as the National Drug Committee of the Interim Government of National Unity; it was created in 1993 during the presidency of Amos Sawyer. Five years later, the committee was converted into its present form: President Taylor signed a bill passed by the National Legislature that created the DEA and patterned it after the Drug Enforcement Administration in the United States. The DEA is charged with fighting drug trafficking at the country's borders,[1] arresting traffickers and dealers, and destroying illegal drugs.[3] According to DEA boss Anthony Souh, the agency nevertheless suffers from substantial internal corruption.[4] In 2011, the DEA boss was Director Henry Shaw,[3] but by 2012 he had been replaced by Anthony Souh. Directors are appointed by the President subject to confirmation by the Senate of Liberia.[4] The DEA is not responsible for overseeing commerce in legal drugs and other pharmaceuticals; such substances are within the purview of the Pharmaceutical Board of Liberia.[5]

References
[1] DEA Seeks U.S. $6 Million to Wage Drug War (http:/ / allafrica. com/ stories/ 201112160232. html), AllAfrica, 2011-12-16. Accessed 2012-06-03. [2] "$20,000 Marijuana Destroyed", New Liberian, 1981-02-02, 7. [3] DEA Destroys Over LD$10 Million Drugs (http:/ / allafrica. com/ stories/ 201110040693. html), AllAfrica, 2011-10-04. Accessed 2012-06-03. [4] DEA Boss Gets Tough (http:/ / heritageliberia. net/ index. php?view=article& id=1685), Heritage, 2012-06-01. Accessed 2012-06-03. [5] "Operation Fake Drugs To Commence Soon". The New National 2004-10-19: 8/6.

United States Department of Health and Human Services

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United States Department of Health and Human Services


Department of Health and Human Services

Seal of the U.S. Department of Health and Human Services

Logo of the U.S. Department of Health and Human Services

Flag of the U.S. Department of Health and Human Services Department overview Formed April 11, 1953 May 4, 1980

Preceding Department United States Department of Health, Education, and Welfare Jurisdiction Headquarters Federal government of the United States Hubert H. Humphrey Building [1] [1] Washington, D.C. 385312N 770052W Coordinates: 385312N 770052W 67,000 (2004) $78.4 billion (2011)
[2]

Employees Annual budget

Department executives Kathleen Sebelius, Secretary Bill Corr, Deputy Secretary Child Department HHS agencies Website www.HHS.gov
[3]

United States Department of Health and Human Services The United States Department of Health and Human Services (HHS), also known as the Health Department, is a cabinet-level department of the U.S. federal government with the goal of protecting the health of all Americans and providing essential human services. Its motto is "Improving the health, safety, and well-being of America". Before the separate federal Department of Education was created in 1979, it was called the Department of Health, Education, and Welfare (HEW).

541

History
President Harding proposed a Department of Education and Welfare as early as 1923, and similar proposals were also recommended by subsequent presidents, but for various reasons were not implemented.[] The Department was only created thirty years later under Reorganization Plan No. 1 of 1953 pursuant to authority granted in the Reorganization Act of 1949, in which the president was allowed to create or reorganize executive branch departments as long as neither house of Congress passed a legislative veto. This power to create new departments was removed after 1962, and in the early 1980s the Supreme Court declared legislative vetoes unconstitutional. Unlike statutes authorizing the creation of other executive departments, the contents of Reorganization Plan No. 1 of 1953 were never properly codified within the United States Code, although Congress did codify a later statute ratifying the Plan. Today, the Plan is included an appendix to Title 5 of the United States Code. The result is that HHS is the only executive department whose statutory foundation today rests on a confusing combination of several codified and uncodified statutes.

The HHS headquarters in Washington, D.C., an example of Brutalist architecture.

Flag of the Department of Health, Education, and Welfare.

The Department of Health, Education, and Welfare was renamed the Department of Health and Human Services (HHS) in 1979,[4] when its education functions were transferred to the newly created United States Department of Education under the Department of Education Organization Act.[5] HHS was left in charge of the Social Security Administration, agencies constituting the Public Health Service, and Family Support Administration. In 1995, the Social Security Administration was removed from the Department of Health and Human Services, and established as an independent agency of the executive branch of the United States Government. HHS is administered by the Secretary of Health and Human Services, who is appointed by the President with the advice and consent of the Senate. The United States Public Health Service (PHS) is the main division of the HHS and is led by the Assistant Secretary for Health. The current Secretary, Kathleen Sebelius is the Vice-Chair of the United States Interagency Council on Homelessness, and the Department of Health and Human Services is a member of the Council, which is dedicated to preventing and ending homelessness in America. The United States Public Health Service Commissioned Corps, the uniformed service of the PHS, is led by the Surgeon General who is responsible for addressing matters concerning public health as authorized by the Secretary or by the Assistant Secretary of Health in addition to his or her primary mission of administering the Commissioned Corps. The Office of Inspector General (OIG) investigates criminal activity for HHS. The special agents who work for OIG have the same title series "1811", training and authority as other federal criminal investigators, such as the FBI, ATF, DEA and Secret Service. However, OIG Special Agents have special skills in investigating white collar crime related to Medicare and Medicaid fraud and abuse. Organized crime has dominated the criminal activity relative to this type of fraud. HHS-OIG investigates tens of millions of dollars in Medicare fraud each year. In addition, OIG will continue its coverage of all 50 states and the District of Columbia by its multi-agency task forces (PSOC Task Forces) that

United States Department of Health and Human Services identify, investigate, and prosecute individuals who willfully avoid payment of their child support obligations under the Child Support Recovery Act. HHS-OIG agents also provide protective services to the Secretary of HHS, and other department executives as necessary. In 2002, the department released Healthy People 2010, a national strategic initiative for improving the health of Americans.

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Strengthening Communities Fund


In June 2010 the Department of Health and Human Services created the Strengthening Communities Fund[6] as part of the American Recovery and Reinvestment act. The fund was appropriated $50 million to be given as grants to organizations in the United States who were engaged in Capacity Building programs. The grants were given to two different types of capacity builders: State, Local and Tribal governments engaged in capacity building: grants will go to state local and tribal governments to equip them with the capacity to more effectively partner with faith-based or non-faith based nonprofit organizations.[7] Capacity building in this program will involve education and outreach that catalyzes more involvement of nonprofit organizations in economic recovery and building up nonprofit organization's abilities to tackle economic problems. State, Local and Tribal governments can receive up to $250,000 in two year grants Nonprofit Social Service Providers engaged in capacity building: they will make grants available to nonprofit organizations who can assist other nonprofit organizations in organizational development, program development, leadership, and evaluations. Nonprofits can receive up to $1 million in two year grants.

Organization
Internal Structure
The Department of Health and Human Services is led by the United States Secretary of Health and Human Services, a member of the United States Cabinet appointed by the President of the United States with the consent of the United States Senate. The Secretary is assisted in managing the Department by the Deputy Secretary of Health and Human Services, who is also appointed by the President. The Secretary and Deputy Secretary are further assisted by seven Assistant Secretaries, who serve as top Departmental administrators.
Secretary of Health and Human Services Deputy Secretary Assistant Secretary for Health Public Health Service Administration for Children and Families

Office of the Surgeon General Public Health Service Commissioned Corps Assistant Secretary for Preparedness and Response Office of the Assistant Secretary for Preparedness and Response

Biomedical Advanced Research and Development Authority Assistant Secretary for Legislation Assistant Secretary for Planning and Evaluation Assistant Secretary for Administration Assistant Secretary for Public Affairs Assistant Secretary for Financial Resources Office of the Inspector General

United States Department of Health and Human Services


Administration on Aging Agency for Healthcare Research and Quality Agency for Toxic Substances and Disease Registry Centers for Disease Control and Prevention Centers for Medicare and Medicaid Services Food and Drug Administration Health Resources and Services Administration Indian Health Service National Institutes of Health Substance Abuse and Mental Health Services Administration

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Several agencies within HHS are components of the Public Health Service (PHS), including AHRQ, ASPR, ATSDR, CDC, FDA, HRSA, IHS, NIH, SAMHSA, OGHA, and OPHS.[8]

Budget

US Department of Health and Human Services Budget ($ in thousands) [9]


Line Item HHS Staff Divisions Office of the Secretary Public Health and Social Services Emergency Fund Office of the Inspector General HHS Operating Divisions Administration for Children and Families Administration on Aging Agency for Healthcare Research and Quality Agency for Toxic Substances and Disease Registry Centers for Disease Control and Prevention Centers for Medicare and Medicaid Services 16,200,000 2,012,000 409,000 76,000 11,159,000 898,845,000 756,000 1,057,000 370,000 FY13 Request

United States Department of Health and Human Services

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4,486,000 8,400,000 4,422,000 30,860,000

Food and Drug Administration Health Resources and Services Administration Indian Health Service National Institutes of Health

Substance Abuse and Mental Health Services Administration 3,152,000 Departmental Total Total Budget 982,204,000

Former operating divisions and agencies


Social Security Administration, made independent in 1995. Health Care Financing Administration, renamed to Centers for Medicare and Medicaid Services

Budget
The Department of Health and Human Services' budget includes more than 300 programs, covering a wide spectrum of activities. Some highlights include: Health and social science research Preventing disease, including immunization services Assuring food and drug safety Medicare (health insurance for elderly and disabled Americans) and Medicaid (health insurance for low-income people) Health information technology Financial assistance and services for low-income families Improving maternal and infant health, including a Nurse Home Visitation to support first-time mothers. Head Start (pre-school education and services) Faith-based and community initiatives Preventing child abuse and domestic violence Substance abuse treatment and prevention Services for older Americans, including home-delivered meals Comprehensive health services for Native Americans Medical preparedness for emergencies, including potential terrorism.

Health care reform


The 2010 United States federal budget establishes a reserve fund of more than $630 billion over 10 years to finance fundamental reform of the health care system.[10]

Related legislation
1946: Hospital Survey and Construction Act (Hill-Burton Act) PL 79-725 1949: Hospital Construction Act PL 81-380 1950: Public Health Services Act Amendments PL 81-692 1955: Poliomyelitis Vaccination Assistance Act PL 84-377 1956: Health Research Facilities Act PL 84-835 1960: Social Security Amendments (Kerr-Mill aid) PL 86-778 1961: Community Health Services and Facilities Act PL 87-395

United States Department of Health and Human Services 1962: Public Health Service Act PL 87-838 1962: Vaccination Assistance PL 87-868 1963: Mental Retardation Facilities Construction Act/Community Mental Health Centers Act PL 88-164 1964: Nurse Training Act PL 88-581 1965: Community Health Services and Facilities Act PL 89-109 1965: Medicare PL 89-97 1965: Mental Health Centers Act Amendments PL 89-105 1965: Heart Disease, Cancer, and Stroke Amendments PL 89-239 1966: Comprehensive Health Planning and Service Act PL 89-749 1970: Community Mental Health Service Act PL 91-211 1970: Family Planning Services and Population Research Act PL 91-572 1970: Lead-Based Paint Poisoning Prevention Act PL 91-695 1971: National Cancer Act PL 92-218 1974: Research on Aging Act PL 93-296 1974: National Health Planning and Resources Development Act PL 93-641 1979: Department of Education Organization Act (removed education functions) PL 96-88 1987: Department of Transportation Appropriations Act PL 100-202 1988: Medicare Catastrophic Coverage Act PL 100-360 1989: Department of Transportation and Related Agencies Appropriations Act PL 101-164 1996: Health Insurance Portability and Accountability Act PL 104-191 2000: Child Abuse Reform and Enforcement Act P.L. 106-177 2010: Patient Protection and Affordable Care Act PL 111-148

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References
[1] http:/ / tools. wmflabs. org/ geohack/ geohack. php?pagename=United_States_Department_of_Health_and_Human_Services& params=38_53_12_N_77_00_52_W_type:landmark_source:kolossus-frwiki [2] whitehouse.gov (http:/ / www. whitehouse. gov/ omb/ fy2010_department_health/ ) [3] http:/ / www. hhs. gov/ [4] Office of the Law Revision Counsel, U.S. House of Representatives, Title 20, Section 3508 (http:/ / uscode. house. gov/ uscode-cgi/ fastweb. exe?getdoc+ uscview+ t17t20+ 4573+ 0+ + () AND ((20) ADJ USC):CITE AND (USC w/ 10 (3508)):CITE) [5] Full text of the Department of Education Organization Act (http:/ / www. scribd. com/ fullscreen/ 53070589), P.L. 96-88 [8] HHS.gov (http:/ / www. hhs. gov/ about/ orgchart/ index. html) [10] WhiteHouse.gov (http:/ / www. whitehouse. gov/ omb/ assets/ fy2010_new_era/ A_New_Era_of_Responsibility2. pdf)

External links
United States Department of Health and Human Services Official Website (http://www.hhs.gov/) Department Of Health And Human Services Meeting Notices and Rule Changes (http://thefederalregister.com/ b.p/department/DEPARTMENT_OF_HEALTH_AND_HUMAN_SERVICES/) from The Federal Register RSS Feed (http://thefederalregister.com/rss/department/ DEPARTMENT_OF_HEALTH_AND_HUMAN_SERVICES/) Proposed and finalized federal regulations from the United States Department of Health and Human Services (http://openregs.com/agencies/view/16/department_of_health_and_human_services) Oral History Interview with David Breneman, aide to HEW General Counsel, Peter Libassi, in the late '70s (http:/ /docsouth.unc.edu/sohp/L-0122/menu.html) from Oral Histories of the American South (http://docsouth. unc.edu/sohp/) Program Support Center Official Website (http://www.psc.gov/) Public Health Emergency (PHE.gov) (http://www.phe.gov/)

United States Department of Health and Human Services United States Department of Health and Human Services (http://www.washingtonpost.com/politics/ institutions/health_and_human_services_topic.html) collected news and commentary at The Washington Post

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Durable medical equipment


Durable medical equipment is any medical equipment used in the home to aid in a better quality of living. It is a benefit included in most insurances. In some cases certain Medicare benefits, that is, whether Medicare may pay for the item. The item is defined by Title XIX for Medicaid: (n) The term "durable medical equipment" includes iron lungs, oxygen tents, Nebulizers, CPAP, catheters, hospital beds, and wheelchairs (which may include a power-operated vehicle that may be appropriately used as a wheelchair, but only where the use of such a vehicle is determined to be necessary on the basis of the individual's medical and physical condition and the vehicle meets such safety requirements as the Secretary may prescribe) used in the patient's home (including an institution used as his home other than an institution that meets the requirements of subsection (e)(1) of this section or section 1819(a)(1)), whether furnished on a rental basis or purchased, and includes blood-testing strips and blood glucose monitors for individuals with diabetes without regard to whether the individual has Type I or Type II diabetes or to the individual's use of insulin (as determined under standards established by the Secretary in consultation with the appropriate organizations); except that such term does not include such equipment furnished by a supplier who has used, for the demonstration and use of specific equipment, an individual who has not met such minimum training standards as the Secretary may establish with respect to the demonstration and use of such specific equipment. With respect to a seat-lift chair, such term includes only the seat-lift mechanism and does not include the chair.[1]

References
[1] 42 U.S.C. 1395x(n) (http:/ / www. ssa. gov/ OP_Home/ ssact/ title18/ 1861. htm#n)

Do not resuscitate

547

Do not resuscitate
In medicine, a "do not resuscitate" or "DNR", sometimes called a "No Code", is a legal order written either in the hospital or on a legal form to respect the wishes of a patient not to undergo CPR or advanced cardiac life support (ACLS) if their heart were to stop or they were to stop breathing. The term "code" is commonly used by medical professionals as a slang term for "calling in a Code Blue" to alert a hospital's resuscitation team. The DNR request is usually made by the patient or health care power of attorney and allows the medical teams taking care of them to respect their wishes. In the health care community "allow natural death" or "AND" is a term that is quickly gaining favor as it focuses on what is being done, not what is being avoided. Some criticize the term "do not resuscitate" because it sounds as if something important is being withheld, while research shows that only about 5% of patients who require ACLS outside the hospital and A DNR Form used in the Commonwealth of only 15% of patients who require ACLS while in the hospital Virginia [1][2] survive. Patients who are elderly, are living in nursing homes, have multiple medical problems, or who have advanced cancer are much less likely to survive.[3] A DNR does not affect any treatment other than that which would require intubation or CPR. Patients who are DNR can continue to get chemotherapy, antibiotics, dialysis, or any other appropriate treatments.

Alternative names
Alternative namings and abbreviations for this order are used depending on the geographic region. DNR (Do Not Resuscitate) is a common abbreviation in the United States, Canada and the United Kingdom. It may be clarified in some regions with the addition of DNI (Do Not Intubate), although in some hospitals DNR alone will imply no intubation. Clinically, the vast majority of people requiring resuscitation will require intubation, making a DNI alone problematic. Some areas of the United States and the United Kingdom include the letter A, as in DNAR, to clarify "Do Not Attempt Resuscitation." This alteration is so that it is not presumed by the patient/family that an attempt at resuscitation will be successful. Since the term DNR implies the omission of action, and therefore "giving up", some have advocated for these orders to be retermed Allow Natural Death.[4] New Zealand and Australia (and some hospitals in the UK) use the term NFR or Not For Resuscitation. Typically, these abbreviations are written without periods between the letters, i.e. AND/DNR not A.N.D./D.N.R.. Until recently in the UK it was common to write "Not for 222" or conversationally, "Not for twos." This was implicitly a hospital DNR order, where 222 (or similar) is the hospital telephone number for the emergency resuscitation or crash team.[citation needed]

Do not resuscitate

548

DNR compared with advance directive and living will


Advance directives and living wills are documents written by individuals themselves, so as to state their wishes for care, if they are no longer able to speak for themselves. In contrast, it is a physician or hospital staff member who writes a DNR "physician's order," based upon the wishes previously expressed by the individual in his or her advance directive or living will. Similarly, at a time when the individual is unable to express his wishes, but has previously used an advance directive to appoint an agent, then a physician can write such a DNR "physician's order" at the request of that individual's agent. These various situations are clearly enumerated in the "sample" DNR order presented on this page. It should be stressed that, in the United States, an advance directive or living will is not sufficient to ensure a patient is treated under the DNR protocol, even if it is his wish, as neither an advance directive nor a living will is a legally binding document. It is also the case that the wishes expressed in an advance directive or living will are not binding. But also see the legal discussion presented in the next section.

Usage by country
DNR documents are widespread in some countries and unavailable in others. In countries where a DNR is unavailable the decision to end resuscitation is made solely by physicians.

Middle East
DNRs are not recognized by Jordan. Physicians attempt to resuscitate all patients regardless of individual or familial wishes.[] In Israel, it is possible to sign a DNR form as long as the patient is dying and aware of their actions.[citation
needed]

United Kingdom
In the UK, for DNR as for any medical treatment, by default only the patient can give informed consent, if they have capacity as defined under the Mental Capacity Act 2005; if they lack capacity relatives will often be asked for their opinion out of respect but it does not have hard legal force on the doctor's decision. In this situation, it is their doctor's duty to act in their 'best interest', whether that means continuing or discontinuing treatment, using their clinical judgment. Alternatively, patients may specify their wishes and/or devolve their decision-making to a proxy using an advance directive, which are commonly referred to as 'Living Wills'.

United States
In the United States the documentation is especially complicated in that each state accepts different forms, and advance directives and living wills are not accepted by EMS as legally valid forms. If a patient has a living will that states the patient wishes to be DNR but does not have an appropriately filled out state sponsored form that is co-signed by a physician, EMS will attempt resuscitation. This is a little known fact Wikipedia:Avoid weasel words to many patients and primary care physicians that can cause patients to receive treatments they do not want, and this law is currently being evaluated for a constitutional challenge [citation needed]. The DNR decision by patients was first litigated in 1976 in In re Quinlan. The New Jersey Supreme Court upheld the right of Karen Ann Quinlan's parents to order her removal from artificial ventilation. In 1991 Congress passed into law the Patient Self-Determination Act that mandated hospitals honor an individual's decision in their healthcare.[] Forty-nine states currently permit the next of kin to make medical decisions of incapacitated relatives, the exception being Missouri. Missouri has a Living Will Statute that requires two witnesses to any signed advanced directive that results in a DNR/DNI code status in the hospital. In the U.S., cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS) will not be performed if a valid written "DNR" order is present. Many US states do not recognize living wills or health care proxies in the

Do not resuscitate prehospital setting and prehospital personnel in those areas may be required to initiate resuscitation measures unless a specific state sponsored form is appropriately filled out and cosigned by a physician.[][]

549

Canada
Do not resuscitate orders are similar to those used in the United States. In 1995, the Canadian Medical Association, Canadian Hospital Association, Canadian Nursing Association, and Catholic Health Association of Canada worked with Canadian Bar Association clarify and create a Joint Statement on Resuscitative Interventions guideline for use to determine when and how DNR orders are assigned.[5] DNR orders must be discussed by doctors with the patient or patient agents or patient's significant others. Unilateral DNR by medicial professionals can only be used if the patient is in a vegetative state.[6]

References
[1] PMID 17174021 [4] Alternative to "DNR" Designation: "Allow Natural Death" - Making Sense in the Health Care Industry (http:/ / www. hospicepatients. org/ and. html). [5] http:/ / www. caringtotheend. ca/ body. php?id=515& cc=1 [6] http:/ / www. caringtotheend. ca/ body. php?id=515& cc=1

External links
Do Not Resuscitate Orders (http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000473.htm) Published by the U.S. National Library of Medicine Right To die Debate on Opposing Views (http://www.opposingviews.com/questions/ do-the-terminally-ill-have-a-right-to-die) Decisions Relating to Cardiopulmonary Resuscitation (http://www.resus.org.uk/pages/dnar.htm) Published by the Resuscitation Council (UK)

Doctor of Osteopathic Medicine

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Doctor of Osteopathic Medicine


Osteopathic medicine in the United States
Andrew Taylor Still (founder) Doctor of Osteopathic Medicine (DO) Medicine US Medical education

Schools Physicians Osteopathic Manipulative Medicine AOA AACOM AAO COMLEX MD & DO Comparison Specialty Colleges AOA BOS

Doctor of Osteopathic Medicine (D.O. or DO) is a professional doctoral degree for physicians and surgeons offered by medical schools in the United States. Holders of the D.O. degree are known as osteopathic physicians and have the same rights, privileges, and responsibilities as physicians with a Doctor of Medicine degree (M.D.).[] D.O. physicians are licensed to practice the full scope of medicine and surgery in sixty countries,[] including all 50 states in the US, and make up 7 percent of the total U.S. physician population. As of 2012, there were more than 82,500 D.O. physicians in the United States.[] Currently, there are 29 medical schools with 37 locations throughout the United States that offer the D.O. degree,[1] and 141 medical schools that offer the M.D. degree.[2][3] As of 2011, 1 in 5 medical students in the United States were D.O. students.[4][5] The curricula at osteopathic medical schools are very similar to those at M.D.-granting medical schools.[] Four years in total length,[] the first two years of medical school focus on the biomedical and clinical sciences, followed by two years of core clinical training in the clinical specialties. One notable difference in the education at D.O.-granting medical schools is the inclusion of 300 500 additional hours in the study of hands-on manual medicine and the body's musculoskeletal system. This training, referred to as osteopathic manipulative medicine,[] is absent in the M.D. curricula. Upon graduation from medical school, osteopathic physicians enter internship or residency training programs, which may be followed by fellowship training.[] Many D.O. physicians attend the same graduate medical education programs as their M.D. counterparts,[] and then take M.D. specialty board exams,[] while other D.O. graduates enter osteopathic programs[][] and take D.O. specialty board examinations.[] However, as of June 2015, all post-graduate training for both D.O. and M.D. physicians will be accredited by the ACGME.[6][7]

Doctor of Osteopathic Medicine

551

Demographics
In 2012, there were over 82,500 osteopathic physicians in the United States, of which 69,429 were in active practice.[] The proportion of females in the profession has steadily increased since the 1980s.[] In 1985, about 10 percent of D.O. physicians were female, compared with 34 percent in 2012.[] Between 2008 and 2012, 49 percent of new D.O. graduates were females.[] During the 2011-12 academic year, the osteopathic medical student body consisted of: 69 percent white/non-hispanic, 19 percent Asian or Pacific Islander, 3.5 percent hispanic, 3 percent African American, and 0.5 percent Native American or Alaskan.[] The remainder were listed as "other or not entered."

Education and Training


Osteopathic medical school curricula are virtually identical to those at schools granting the M.D. degree (Doctor of Medicine). Once admitted to an osteopathic medical school, it takes four years to graduate, and the schooling is divided into the pre-clinical and clinical years. The pre-clinical years, the first and second years, focus on the biomedical and clinical sciences. The clinical years, the third and fourth years, consist of core clinical training and sub-internships in the clinical specialties. Osteopathic medical school accreditation standards require training in internal medicine, obstetrics/gynecology, pediatrics, family practice, surgery, psychiatry, emergency medicine, radiology, preventive medicine and public health.[] According to Harrison's Principles of Internal Medicine, "the training, practice, credentialing, licensure, and reimbursement of osteopathic physicians is virtually indistinguishable from those of physicians with M.D. qualifications, with 4 years of osteopathic medical school followed by specialty and subspecialty training and [board] certification."[] However, D.O. schools provide an additional 300 500 hours in the study of hands-on manual medicine and the body's musculoskeletal system, which is referred to as osteopathic manipulative medicine.[] After completing medical school, D.O. physicians begin graduate medical training. Many D.O. physicians attend the same internship and residency training programs as their M.D. counterparts,[] and then take M.D. specialty board exams[8] while other D.O. graduates enter osteopathic internships and residencies[][] and take D.O. specialty board examinations.[]

Examinations
To be considered for entry into a D.O. program, an applicant must complete a national standardized exam called the Medical College Admissions Test (MCAT). Some authors note the differences in the average MCAT scores and grade point average of students who matriculate at D.O. schools versus those who matriculate at M.D. schools within the United States. In 2011, the average MCAT and GPA for students entering U.S.-based M.D. programs were 31.1 and 3.67, respectively,[9] and 27.1 and 3.51 for D.O. matriculants,[] although the gap has been getting smaller every year.[] DO medical schools are more likely to accept non-traditional students[10][11] who are older and entering medicine as a second career, or coming from non-science majors. D.O. medical students are required to take the Comprehensive Osteopathic Medical Licensure Examination (COMLEX-USA), which is sponsored by the National Board of Osteopathic Medical Examiners (NBOME). The COMLEX-USA is series of three osteopathic medical licensing examinations. The first two steps of the COMLEX-USA are taken during medical school, and are prerequisites for osteopathic residency programs, which are available in almost every specialty of medicine and surgery. The step 3 portion of the COMLEX is taken during residency. In addition to the COMLEX-USA, D.O. medical students may choose to sit for the M.D. board examinations, which are called the United States Medical Licensing Examination (USMLE).[12] This is typically done if the student desires to enter an M.D. residency. However, this is not always required, as some M.D. residency programs do not require the USMLE from D.O. applicants.[13][14][15][16] First-time USMLE pass rates for D.O. and M.D. students in

Doctor of Osteopathic Medicine 2011 are as follows: Step 1: 89% and 94%, Step 2 CK: 93% and 97%, and Step 2 CS: 93% and 97% respectively; Step 3: 94% and 100%--but this number may be misleading, as only 18 D.O. students compared to 18,314 M.D. students, were evaluated for Step 3.[17]

552

Licensing and board certification


To obtain a license to practice medicine in the United States, medical students must pass the Comprehensive Osteopathic Medical Licensing Examination (COMLEX),[18] which is the exam given by the licensing board at the conclusion of their medical training. Students are given the option of taking the United States Medical Licensing Examination (USMLE) to apply for some Accreditation Council for Graduate Medical Education (ACGME) residency programs. Those that have received or are in the process of earning an M.D. or D.O. are both eligible to sit for the USMLE. Because of their additional training, only holders of the D.O. are eligible to sit for the COMLEX.[19] Upon completion of internship and residency requirements for their chosen medical specialty, and depending on whether the program attended as ACGME or AOA accredited, holders of the D.O. may elect to be board certified by either a specialty board (through the American Medical Association's American Board of Medical Specialties) or an osteopathic specialty board (through the American Osteopathic Association Bureau of Osteopathic Specialists certifying boards). Depending on the state, medical licensure may be issued from a combined board (D.O. and M.D.) or a separate board of medical examiners.[] All of the 70 state medical boards are members of the Federation of State Medical Boards.[]

International variations
Currently, there are no osteopathic programs located outside of the United States that would qualify an individual to practice as an osteopathic physician in the United States.[20] Foreign osteopathic degrees are not recognized by any state in the U.S. as being equivalent to American D.O. degrees.

International practice rights


The following is an International Licensure Summary for U.S.-trained Doctors of Osteopathic Medicine, as listed by the American Osteopathic Association:[21][]
Country Year of Latest Policy 2006 Medical Practice Rights Unlimited Requirements for Licensure

Argentina

Foreign physicians must submit credentials to various agencies and then appear before any of the National Universities in order to have their diploma recognized. According to documents published online, the Medical Board of Australia has agreed to accept the DO USA as a primary medical qualification for the purposes of medical registration provided that the DO USA was awarded by a medical school which has been accredited by the [22] Commission on Osteopathic College Accreditation." Hospital must have position unable to be filled by Austrian physician. U.S. license recognized. U.S. license recognized. OMM only. Required at least 2 years of GME and examination or interview by the Councils Examination Committee. Non-Bermudans must have approval from the Ministry of Labour & Home Affairs to work on the island.

Australia

2013

Unlimited

Austria Bahamas Bahrain Barbados Bermuda

2009 2004 2010 1995 1997

Unlimited Unlimited Unlimited Limited Unlimited

Doctor of Osteopathic Medicine

553
Unlimited Completion of Brazilian board exam, establishing residency & some training in Brazilian hospital is required. Requires at least 2 years of GME accredited by the ACGME or AOA and must have passed the Universities Coordinating Council Exam, a basic sciences exam, and have passed all three parts of the LMCC. Requires at least 1 year of GME approved by the AOA or the ACGME, completed at least 1 year of GME in Canada, passed all three parts of the LMCC. U.S. license recognized. Requires at least 2 years of GME approved by the AOA or the ACGME and have passed all 3 parts of the LMCC. Reciprocity pathway for D.O. physicians with a Maine license. The Medical Act 2011 allows full licensure of osteopathic physicians, both for the countrys full registry & its educational registry. U.S. license recognized. Requires a Canadian or ACGME residency. Requires a Canadian or ACGME residency.

Brazil

2007

Canada Alberta

Unlimited

British Columbia Manitoba New Brunswick Newfoundland

Unlimited

Unlimited Unlimited

Unlimited

NW Territories Nova Scotia Ontario Prince Edward Island Quebec

Unlimited Unlimited Unlimited Unlimited

Unlimited

Requires 1 year of GME approved by the AOA or ACGME, 1 year of GME in Quebec passed the written, oral and clinical board examination of the College of Family Physicians of Canada and must speak French fluently.

Saskatchewan Yukon Territory Cayman Islands (UK) 1983

Unlimited Unlimited U.S. license recognized.

Unlimited Unlimited Unlimited

U.S. license recognized. U.S. licensure and annual attendance at the National Congress for Physicians. A written exam in Spanish is required, besides a series of practical tests involving common procedures (CPR, intubation, lumbar puncture, etc.). U.S.-D.O. physicians are permitted to apply for "Short Term Medical Practice." Same requirements as other foreign physicians. Same requirements as other foreign physicians. U.S. license & board certification recognized. Same requirements as other foreign physicians. Reciprocity exists with most Latin American countries. Same requirements as other foreign physicians. OMM only. French government does not recognize full scope of practice osteopathic medicine.

Central African Republic 1990 Chile 1993

China Colombia Costa Rica Dominican Republic Ecuador

2009 1996 1993 2000 1990

Unlimited Unlimited Unlimited Unlimited Unlimited

Finland France The Gambia Germany

1996 2009 2011 2008

Unlimited Limited Unlimited Unlimited

Same requirements as other foreign physicians. Depends on need. Decisions made on individual basis. Greek citizenship required, unless in rare instances, there exists a crucial need for certain types of specialist physicians. Further, a work permit must be obtained, a difficult task, and speaking Greek is an unwritten requirement. These are the same requirements as other foreign physicians. U.S. license recognized. Case-by case basis.

Greece

2009

Unlimited

Grenada Guyana

2007 1996

Unlimited Unlimited

Doctor of Osteopathic Medicine

554
Unlimited National Autonomous University must accredit all foreign titles. After accreditation is completed, the applicant must seek registration with the Medical College of Honduras (MCH). Written examination. Personal interview. Training approval.

Honduras

2009

Hong Kong Indonesia

1998 1992

Unlimited

Unlimited & Foreign physicians affiliated with a university project or a mission have unlimited practice Restricted rights. No private practice allowed. Unlimited Unlimited Same requirements as other foreign physicians. Hebrew required. Physicians are discouraged from seeking employment in Italy without firm contracts and work permits. If there is a U.S. state law outlining reciprocity with Italy, a statement to this effect from the Italian Consulate will warrant better chances. D.O. physicians were permitted to supply some services while participating in a specific mission project.

Israel Italy

2007 2009

Jamaica

1994

Limited & Restricted Unlimited Unlimited Unlimited

Kenya Lebanon Lesotho

2007 2004 1990s

AOA letter required. Examination required. Applicants must appear before the Medical, Dental and Pharmacy Council to answer some medical questions and present their credentials. The Council will also make a recommendation about where the applicants skills would be most helpful in the country. Same requirements as other foreign physicians. The practice of medicine in Luxembourg by a doctor who is not an EU national is very rare. Accepted on a case by case basis, if training meets the minimum educational requirements for physicians in the EU (Article 24 of Directive 2005/36/EC). Examination required.

Liberia Luxembourg Malta

1990s 1987 2010

Unlimited Unlimited Unlimited

Malawi Mexico

1991 2011

Unlimited Unlimited & Health Secretary Quijano of the Yucatn State of Mexico signed a Proclamation recognizing Restricted U.S.-trained osteopathic physicians in that state; D.O. physicians can now obtain short-term & long-term licensure through the Health Secretarys office. All other Mexican states require work permits - only available in conjunction with the association of a short-term medical mission project. Unlimited Unlimited Unlimited Unlimited Unlimited Limited Unlimited Statutes specifically include DOs Approval by the Nepal Medical Council & a visa from the Immigration Department. Same requirements as other foreign physicians. Hearing required. Case-by-case basis. U.S. Licensure and completion of specialty training required. OMM only. U.S. osteopathic medical schools meet the Medical and Dental Councils statutory regulations for international medical graduates. Scope is unlimited, but practice setting may be restricted Panamanian citizenship required. Work permit required. Short-term or a long-term volunteer service license also available. Examination & Polish required. Foreign physicians make arrangements to practice through Russian sponsors, such as hospitals or businesses. U.S. credentials recognized. Foreign physician must be recruited by a government agency, a corporation or a private health care entity, such as a hospital. Notarized U.S. credentials. OMM only

Micronesia Nepal Netherlands New Zealand Nigeria Norway Pakistan

1993 2008 2009 2008 2010 2009 2011

Panama Papua New Guinea Poland Russia

2009 2010 2009 2006

Unlimited Unlimited Unlimited Unlimited

Saint Lucia Saudi Arabia

2000 2009

Unlimited Unlimited

Sierra Leone South Africa

1993 2009

Unlimited Limited

Doctor of Osteopathic Medicine

555
Unlimited Unlimited U.S. license recognized. The ROC government recognizes U.S. D.O. degree. Applicants must take Taiwan Examination Yuan to obtain Taiwanese license. U.S. license & GME recognized. Temporary work permits are available

Sweden Taiwan

2005 2008

Tanzania Uganda United Arab Emirates United Kingdom

1985 2008 2009 2005

Unlimited Unlimited Unlimited Unlimited

Examination required. U.S.-trained D.O. physicians are eligible for full medical practice rights. Applicants must pass the PLAB examination and work for one year in the National Health Service. Following that year, the applicants will be able to apply for a license to practice privately. For GMC registration as a specialist, postgraduate training will need to be separately recognized by the Postgraduate Medical Education and Training Board (PMETB). GOsC registration is also required. Recognized legal status under the "law of the practice of medical." Foreign physicians can fill vacancies in hospitals that are in need of certain specialists. U.S. licensure required. OMM only. []

Venezuela Vietnam Zambia Zimbabwe

2007 1995 2009 2009

Unlimited Unlimited Unlimited Limited

Table data from AOA International Licensure Summary (updated April 2013). OMM:Osteopathic Manipulative Medicine

References
[2] Directory of Accredited Medical Education Programs, Liaison Committee on Medical Education (http:/ / www. lcme. org/ directry. htm) [21] Frequently Asked Questions regarding International Licensure, Council on International Osteopathic Medical Education & Affairs, American Osteopathic Association (http:/ / www. osteopathic. org/ osteopathic-health/ about-dos/ dos-around-the-world/ Pages/ frequently-asked-questions. aspx). Contact information listed.

External links
One DO's description on "What Is A DO?" (http://www.permanente.net/homepage/kaiser/pages/ c1962-42763.html) Doctor of Osteopathic Medicine (D.O.) - National Institutes of Health (http://www.nlm.nih.gov/medlineplus/ ency/article/002020.htm)

Director of nursing

556

Director of nursing
Director of nursing may refer to Director of nursing (long term care facility) Director of nursing (other uses) __DISAMBIG__

Diagnosis-related group
Diagnosis-related group (DRG) is a system to classify hospital cases into one of originally 467 groups.[citation needed] The 467th group was "Ungroupable". This system of classification was developed as a collaborative project by Robert B Fetter, PhD, of the Yale School of Management, and John D Thompson, MPH, of the Yale School of Public Health.[1] The system is also referred to as "the DRGs", and its intent was to identify the "products" that a hospital provides. One example of a "product" is an appendectomy. The system was developed in anticipation of convincing Congress to use it for reimbursement, to replace "cost based" reimbursement that had been used up to that point. DRGs are assigned by a "grouper" program based on ICD (International Classification of Diseases) diagnoses, procedures, age, sex, discharge status, and the presence of complications or comorbidities. DRGs have been used in the US since 1982 to determine how much Medicare pays the hospital for each "product", since patients within each category are clinically similar and are expected to use the same level of hospital resources.[2] DRGs may be further grouped into Major Diagnostic Categories (MDCs). DRGs are also standard practice for establishing reimbursements for other Medicare related reimbursements such as to home healthcare providers. [citation needed]

Purpose
The original objective of diagnosis related groups (DRG) was to develop a classification system that identified the "products" that the patient received. Since the introduction of DRGs in the early 1980s, the healthcare industry has evolved and developed an increased demand for a patient classification system that can serve its original objective at a higher level of sophistication and precision.[3] To meet those evolving needs, the objective of the DRG system had to expand in scope. Today, there are several different DRG systems that have been developed in the US. They include:[citation needed] Medicare DRG (CMS-DRG & MS-DRG) Refined DRGs (R-DRG) All Patient DRGs (AP-DRG) Severity DRGs (S-DRG) All Patient, Severity-Adjusted DRGs (APS-DRG) All Patient Refined DRGs (APR-DRG) International-Refined DRGs (IR-DRG)

Diagnosis-related group

557

History
The system was createdWikipedia:Manual of Style/Dates and numbers#Chronological itemsWikipedia:Please clarify by Robert Barclay Fetter and John D. Thompson at Yale University with the material support of the former Health Care Financing Administration (HCFA), now called the Centers for Medicare & Medicaid Services (CMS).[1][citation
needed]

DRGs were first implemented in New Jersey, beginning in 1980 with a small number of hospitals partitioned into three groups according to their budget positions - surplus, breakeven, and deficit - prior to the imposition of DRG payment.[4] The New Jersey experiment continued for three years, with additional cadres of hospitals being added to the number of institutions each year until all hospitals in New Jersey were dealing with this prospective payment system.[citation
needed]

DRGs were designed to be homogeneous units of hospital activity to which binding prices could be attached. A central theme in the advocacy of DRGs was that this reimbursement system would, by constraining the hospitals, oblige their administrators to alter the behavior of the physicians and surgeons comprising their medical staffs. Hospitals were forced to leave the nearly risk-free world of cost reimbursement[5] and face the uncertain financial consequences associated with the provision of health care.[6] Moreover, DRGs were designed to provide practice pattern information that administrators could use to influence individual physician behavior.[4] DRGs were intended to describe all types of patients in an acute hospital setting. The DRGs encompassed elderly patients as well as newborn, pediatric and adult populations.[citation needed] The prospective payment system implemented as DRGs had been designed to limit the share of hospital revenues derived from the Medicare program budget,[4] and in spite of doubtful results in New Jersey, it was decided in 1983 to impose DRGs on hospitals nationwide.[citation needed] In that year, HCFA assumed responsibility for the maintenance and modifications of these DRG definitions. Since that time, the focus of all Medicare DRG modifications instituted by HCFA/CMS has been on problems relating primarily to the elderly population.[citation needed] In 1987, New York state passed legislation instituting DRG-based payments for all non-Medicare patients. This legislation required that the New York State Department of Health (NYS DOH) evaluate the applicability of Medicare DRGs to a non-Medicare population. This evaluation concluded that the Medicare DRGs were not adequate for a non-Medicare population. Based on this evaluation, the NYS DOH entered into an agreement with 3M to research and develop all necessary DRG modifications. The modifications resulted in the initial APDRG, which differed from the Medicare DRG in that it provided support for transplants, high-risk obstetric care, nutritional disorders, and pediatrics along with support for other populations. One challenge in working with the APDRG groupers is that there is no set of common data/formulas that is shared across all states as there is with CMS. Each state maintains its own information.[citation needed] In 1991, the top 10 DRGs overall were: normal newborn, vaginal delivery, heart failure, psychoses, cesarean section, neonate with significant problems, angina pectoris, specific cerebrovascular disorders, pneumonia, and hip/knee replacement. These DRGs comprised nearly 30 percent of all hospital discharges.[] The history, design, and classification rules of the DRG system, as well as its application to patient discharge data and updating procedures, are presented in the CMS DRG Definitions Manual (Also known as the Medicare DRG Definitions Manual and the Grouper Manual). A new version generally appears every October. The 20.0 version appeared in 2002.[citation needed] In 2007, author Rick Mayes described DRGs as:

Diagnosis-related group

558

...the single most influential postwar innovation in medical financing: Medicare's prospective payment system (PPS). Inexorably rising medical inflation and deep economic deterioration forced policymakers in the late 1970s to pursue radical reform of Medicare to keep the program from insolvency. Congress and the Reagan administration eventually turned to the one alternative reimbursement system that analysts and academics had studied more than any other and had even tested with apparent success in New Jersey: prospective payment with diagnosis-related groups (DRGs). Rather than simply reimbursing hospitals whatever costs they charged to treat Medicare patients, the new model paid hospitals a predetermined, set rate based on the patient's diagnosis. The most significant change in health policy since Medicare and Medicaid's passage in 1965 went virtually unnoticed by the general public. Nevertheless, the change was nothing short of revolutionary. For the first time, the federal government gained the upper hand in its financial relationship with the hospital industry. Medicare's new prospective payment system with DRGs triggered a shift in the balance of political and economic power between the providers of medical care (hospitals and physicians) and those who paid for it - power that providers had successfully accumulated for more than half a century." [7]

CMS DRG version 25 revision


As of October 1, 2007, with version 25, the CMS DRG system resequenced the groups, so that for instance "Ungroupable" is no longer 470 but is now 999.[citation needed] To differentiate it, the newly resequenced DRG are now known as MS-DRG.[citation needed] Before the introduction of version 25, many CMS DRG classifications were "paired" to reflect the presence of complications or comorbidities (CCs). A significant refinement of version 25 was to replace this pairing, in many instances, with a trifurcated design that created a tiered system of the absence of CCs, the presence of CCs, and a higher level of presence of Major CCs. As a result of this change, the historical list of diagnoses that qualified for membership on the CC list was substantially redefined and replaced with a new standard CC list and a new Major CC list.[citation needed] Another planning refinement was not to number the DRGs in strict numerical sequence as compared with the prior versions. In the past, newly created DRG classifications would be added to the end of the list. In version 25, there are gaps within the numbering system that will allow modifications over time, and also allow for new MS-DRGs in the same body system to be located more closely together in the numerical sequence.[citation needed]

MS-DRG version 26 revision


MS-DRG Grouper version 26 took effect as of October 1, 2008 with one main change: implementation of Hospital Acquired Conditions (HAC). Certain conditions are no longer considered complications if they were not present on admission (POA), which will cause reduced reimbursement from Medicare for conditions apparently caused by the hospital.[citation needed]

MS-DRG version 27 revision


MS-DRG Grouper version 27 took effect as of October 1, 2009. Changes involved are mainly related to Influenza A virus subtype H1N1.[citation needed]

Diagnosis-related group

559

References
[1] Fetter RB, Shin Y, Freeman JL, Averill RF, Thompson JD (1980) Case mix definition by diagnosis related groups. Medical Care 18(2):153 [2] Fetter RB, Freeman JL (1986) Diagnosis related groups: product linemanagement within hospitals. Academy of Management Review 11(1):4154 [3] Baker JJ (2002) Medicare payment system for hospital inpatients: diagnosis related groups. Journal of Health Care Finance 28(3):113 [4] Lessons of the New Jersey DRG Payment System (http:/ / content. healthaffairs. org/ cgi/ reprint/ 5/ 2/ 32. pdf) [5] Eastaugh SR (1999) Managing risk in a risky world. Journal of Health Care Finance 25(3):10 [6] Kuntz L, Scholtes S, Vera A (2008) DRG Cost Weight Volatility and Hospital Performance. OR Spectrum 30(2): 331-354

External links
Official CMS website (http://cms.hhs.gov) DRG codes for FY2005, also referred to as version 23 (http://www.cms.hhs.gov/ MedicareFeeforSvcPartsAB/Downloads/DRGDesc05.pdf) DRG codes for FY2010, also referred to as version 27 (http://www.cms.hhs.gov/AcuteInpatientPPS/ downloads/FY_2010_FR_Table_5.zip) Agency for Healthcare Research and Quality (AHRQ) (http://www.ahrq.gov). DRG definition (http://www.ahrq.gov/data/hcup/94drga.htm). Most Frequent Diagnoses and Procedures for DRGs (http://www.hcup-us.ahrq.gov/reports/natstats.jsp). DRG and ICD (http://www.umanitoba.ca/centres/mchp/concept/dict/drg/DRG_overview.html) (Canada) from the MCHP research unit of the University of Manitoba's Faculty of Medicine. Diagnosis Related Groups (DRGs) and the Medicare Program (http://govinfo.library.unt.edu/ota/Ota_4/ DATA/1983/8306.PDF) - Implications for Medical Technology (PDF format). A 1983 document found in the "CyberCemetery: OTA Legacy" section of University of North Texas Libraries Government Documents department. Mayes, Rick, "The Origins, Development, and Passage of Medicare's Revolutionary Prospective Payment System" (http://muse.jhu.edu/login?uri=/journals/journal_of_the_history_of_medicine_and_allied_sciences/ v062/62.1mayes.html) Journal of the History of Medicine and Allied Sciences Volume 62, Number 1, January 2007, pp. 21-55

Disproportionate share hospital

560

Disproportionate share hospital


The United States government provides funding to hospitals that treat indigent patients through the Disproportionate Share Hospital (DSH) programs, under which facilities are able to receive at least partial compensation.[] Although 3,109 hospitals receive this adjustment, Medicare DSH payments are highly concentrated. Ninety three percent of total DSH payments go to large hospitals in urban areas and teaching hospitals receive about 65 percent of all DSH payments. Additionally, because Medicaid eligibility and coverage vary widely across states, Medicare DSH payments are distributed unevenly across geographic areas: the Middle Atlantic, South Atlantic, and Pacific regions account for 60 percent of all DSH payments but only 46 percent of Medicare discharges.[]

Patient Protection Affordable Care Act of 2010


PPACA aims to reduce: Funding for the Medicaid DSH program by $17.1 billion between 2014 and 2020;[1] Aggregate Medicaid DSH allotments by $0.5 billion in 2014, $0.6 billion in 2015, $0.6 billion in 2016, $1.8 billion in 2017, $5 billion in 2018, $5.6 billion in 2019, and $4 billion in 2020; and Medicare DSH payments initially by 75 percent and subsequently increase payments based on the percent of the population uninsured and the amount of uncompensated care provided.[][] PPACA requires the Secretary to: Develop a methodology to distribute DSH reductions in a manner that (1) imposes the largest reduction in DSH allotments for states with the lowest percentage of uninsured or those that do not target DSH payments; (2) imposes smaller reductions for low-DSH states; and (3) accounts for DSH allotments used for 1115 waivers effective October 1, 2011;[] and Determine the best way to implement the cuts in a way that will target states that direct the lowest percentage of DSH allotments to hospitals with high volumes of uninsured and Medicaid inpatients. The 16 states considered "low DSH states" will be reduced by 25%, and all other states will be reduced by 51%.

Qualifying
A hospital can qualify for the Medicare DSH adjustment by using one of the following methods:
Primary method

The primary method is based on a complex statutory formula that results in the Medicare DSH patient percentage, which is equal to the sum of the percentage of Medicare inpatient days attributable to patients entitled to both Medicare Part A and Supplemental Security Income and the percentage of total inpatient days attributable to patients eligible for Medicaid but not eligible for Medicare Part A. In order to maximize their reimbursement, many hospitals and/or their consultants will use Medicaid eligibility vendors to assist in the identification of Medicaid eligible days.

Disproportionate share hospital

561

Alternate Special Exemption Method

The alternate special exception method is for urban hospitals with more than 100 hospital beds that can demonstrate that more than 30 percent of their total net inpatient care revenues, other than Medicare or Medicaid, come from state and local government sources for indigent care, such as for medically indigent adults.
Number of Beds in Hospital Determination

Number of inpatient care bed days attributable to units or wards generally payable under the Inpatient Prospective Payment System excluding beds otherwise countable used for outpatient observation, skilled nursing swing-bed, or ancillary labor/delivery services divided by the number of days in the cost reporting period.

Mechanics of the DSH Adjustment


The formulas to establish a hospitals Medicare DSH payment adjustment are based on the following: hospitals location; number of beds; and status as a Rural Referral Centers, Medicare-Dependent Hospitals, or sole community provider. The value of the hospitals DSH "index" determines the hospitals eligibility for a DSH payment and the size of the payment. The index, whose definition has not changed since the original legislation, is the sum of two ratios: the proportion of all Medicare days that are attributable to beneficiaries of Supplemental Security Income, a means-tested cash benefit program for aged and disabled people, and the proportion of all patient days for which Medicaid is the primary payer.[2]

History and Reforms


In 1989, some enterprising state budget experts discovered that they could claim federal DSH funds without expending general state funds [] and use the DSH payment as a mechanism for mitigating hospitals financial distress.[] To earn the match, however, the state had to spend the tax or donation revenues, because the federal Medicaid match is based on expenditures, not revenues. The Medicaid DSH payment provided the mechanism to spend these revenues. The DSH payment was singled out because it was not subject to the Medicare upper payment limit. Thus, states could make virtually unlimited DSH payments and, in the process, earn federal matching dollars.[] As such the hospitals that were slated to receive DSH funds were asked to contribute the required state share; the state would then use this money to draw down a large federal matching payment.[] The hospitals would get their contributions back and perhaps a bit more, but the states often kept the lion's share of the federal payment.[] With the DSH system effectively serving as a money pump that pulled federal funds into state coffers, the program experienced explosive growth. Between 1990 and 1996, federal DSH payments ballooned from $1.4 billion to more than $15 billion annually.[] In 1991, Congress sought to restrict states' ability to tap provider funds in order to claim federal matching funds by enacting the Voluntary Contribution and Provider-Specific Tax Amendments of 1991 (P.L. 101-234).[] Key provisions included (1) essentially banning provider donations; (2) limiting provider taxes so that provider tax revenues could not exceed 25 percent of the states share of Medicaid expenditures; (3) imposing provider tax criteria so that taxes were "broad based" and providers were not "held harmless"; and (4) capping state DSH payments at roughly 1992 levels.[] This law also capped the amount a state could spend on DSH payments, but it did little to slow recycling. Congress responded in Omnibus Budget Reconciliation Act of 1993 by making the practice of recycling more costly for hospitals with provisions such as the following: (1) Only those hospitals that had a Medicaid use rate of at least 1 percent could receive DSH payments. (2) Total DSH payments to a single hospital could not exceed the unreimbursed costs of providing inpatient care to Medicaid and uninsured patients.[]

Disproportionate share hospital With DSH expenditures soaring in the 1990s and by 1996 accounting for one out of every eleven dollars spent on Medicaid,[] the 1997 Balanced Budget Act included several DSH provisions, including the following:[3] (1) New state specific DSH allotments are established for each year during 19982002, eliminating the allotments established in the 1991 DSH law. Federal DSH expenditures are allowed to increase after 2002 by the percentage change in the Consumer Price Index, subject to a ceiling of 12 percent of each states total annual Medicaid expenditures. (2) Limits have been placed on how much of a states federal DSH allotment can be paid to IMDs. By 2002 no more than 33 percent of a states federal DSH allotment can be paid to IMDs. (3) DSH payments made on behalf of Medicaid clients in managed care must be paid directly to hospitals rather than plans.[] Through these efforts, Congress and the Clinton administration cut federal DSH payments by 5% and limited their further growth;[] as such, in 1998 $15 billion in Medicaid DSH payments were issued to hospitals.[4] Despite efforts, recycling persisted until the Centers for Medicare and Medicaid Services (CMS) began scrutinizing the practice on a state-by-state basis. By 2006, recycling had largely stopped.[]

562

References External links


"Compilation of Patient Protection and Affordable Care Act" (http://burgess.house.gov/UploadedFiles/ hr3590_health_care_law_2010.pdf) (PDF). United States Office of the Legislative Counsel. May 2010. Retrieved October 6, 2011. As amended throughout May 1, 2010. Including Patient Protection and Affordable Care Act of 2010; May 2010 Report.

Diagnostic and Statistical Manual of Mental Disorders


The Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association provides a common language and standard criteria for the classification of mental disorders. The DSM is used in the United States and to various degrees around the world. It is used or relied upon by clinicians, researchers, psychiatric drug regulation agencies, health insurance companies, pharmaceutical companies, the legal system, and policy makers. The current version, published on May 18, 2013, is the DSM-5 (fifth edition). The DSM evolved from systems for collecting census and psychiatric hospital statistics, and from a United States Army manual. Revisions since its first publication in 1952 have incrementally added to the total number of mental disorders, although also removing those no longer considered to be mental disorders. The International Statistical Classification of Diseases and Related Health Problems (ICD), produced by the World Health Organization (WHO), is another commonly used manual which includes criteria for mental disorders. This is in fact the official diagnostic system for mental disorders in the US, but is used more widely in Europe and other parts of the world. The coding system used in the DSM is designed to correspond with the codes used in the ICD, although not all codes may match at all times because the two publications are not revised synchronously. The DSM has attracted praise for standardizing psychiatric diagnostic categories and criteria. It has also attracted controversy and criticism. Some critics argue that the DSM represents an unscientific and subjective system. There are ongoing issues concerning the validity and reliability of the diagnostic categories; the reliance on superficial symptoms; the use of artificial dividing lines between categories and from 'normality'; possible cultural bias; medicalization of human distress".[][1][2][3][4] The publication of the DSM, with tightly guarded copyrights, now makes APA over $5 million a year, historically adding up to over $100 million.[5]

Diagnostic and Statistical Manual of Mental Disorders

563

Uses and definition


Many mental health professionals use the manual to determine and help communicate a patient's diagnosis after an evaluation; hospitals, clinics, and insurance companies in the US also generally require a DSM diagnosis for all patients treated. The DSM can be used clinically in this way, and also to categorize patients using diagnostic criteria for research purposes. Studies done on specific disorders often recruit patients whose symptoms match the criteria listed in the DSM for that disorder. An international survey of psychiatrists in 66 countries comparing use of the ICD-10 and DSM-IV found the former was more often used for clinical diagnosis while the latter was more valued for research.[6] DSM-5, and all previous editions, are registered trademarks owned by the American Psychiatric Association (APA).[][1] The current version of the DSM characterizes a mental disorder as "a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual [which] is associated with present distress...or disability...or with a significant increased risk of suffering." It also notes that "...no definition adequately specifies precise boundaries for the concept of 'mental disorder'...different situations call for different definitions". It states that "there is no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or from no mental disorder" (APA, 1994 and 2000). There are attempts to adjust the wording for the upcoming DSM-V.[7][8]

History
The initial impetus for developing a classification of mental disorders in the United States was the need to collect statistical information. The first official attempt was the 1840 census, which used a single category, "idiocy/insanity". In 1917, a Committee on Statistics from what is now known as the American Psychiatric Association (APA), together with the National Commission on Mental Hygiene, developed a new guide for mental hospitals called the "Statistical Manual for the Use of Institutions for the Insane", which included 22 diagnoses. This was subsequently revised several times by APA over the years. APA, along with the New York Academy of Medicine, also provided the psychiatric nomenclature subsection of the US medical guide, the Standard Classified Nomenclature of Disease, referred to as the "Standard".[9]

DSM-I (1952)
World War II saw the large-scale involvement of US psychiatrists in the selection, processing, assessment, and treatment of soldiers. This moved the focus away from mental institutions and traditional clinical perspectives. A committee headed by psychiatrist Brigadier General William C. Menninger developed a new classification scheme called Medical 203, that was issued in 1943 as a War Department Technical Bulletin under the auspices of the Office of the Surgeon General.[] The foreword to the DSM-I states the US Navy had itself made some minor revisions but "the Army established a much more sweeping revision, abandoning the basic outline of the Standard and attempting to express present day concepts of mental disturbance. This nomenclature eventually was adopted by all Armed Forces", and "assorted modifications of the Armed Forces nomenclature [were] introduced into many clinics and hospitals by psychiatrists returning from military duty." The Veterans Administration also adopted a slightly modified version of Medical 203.[citation needed] In 1949, the World Health Organization published the sixth revision of the International Statistical Classification of Diseases (ICD), which included a section on mental disorders for the first time. The foreword to DSM-1 states this "categorized mental disorders in rubrics similar to those of the Armed Forces nomenclature." An APA Committee on Nomenclature and Statistics was empowered to develop a version specifically for use in the United States, to standardize the diverse and confused usage of different documents. In 1950, the APA committee undertook a review and consultation. It circulated an adaptation of Medical 203, the VA system, and the Standard's Nomenclature to

Diagnostic and Statistical Manual of Mental Disorders approximately 10% of APA members. 46% replied, of which 93% approved, and after some further revisions (resulting in its being called DSM-I), the Diagnostic and Statistical Manual of Mental Disorders was approved in 1951 and published in 1952. The structure and conceptual framework were the same as in Medical 203, and many passages of text were identical.[] The manual was 130 pages long and listed 106 mental disorders.[10] These included several categories of "personality disturbance", generally distinguished from "neurosis" (nervousness, egodystonic).[] In 1952, the APA listed homosexuality in the DSM as a sociopathic personality disturbance. Homosexuality: A Psychoanalytic Study of Male Homosexuals, a large-scale 1962 study of homosexuality, was used to justify inclusion of the disorder as a supposed pathological hidden fear of the opposite sex caused by traumatic parentchild relationships. This view was widely influential in the medical profession.[11] In 1956, however, the psychologist Evelyn Hooker performed a study that compared the happiness and well-adjusted nature of self-identified homosexual men with heterosexual men and found no difference.[12] Her study stunned the medical community and made her a hero to many gay men and lesbians,[13] but homosexuality remained in the DSM until May 1974.[14]

564

DSM-II (1968)
In the 1960s, there were many challenges to the concept of mental illness itself. These challenges came from psychiatrists like Thomas Szasz, who argued that mental illness was a myth used to disguise moral conflicts; from sociologists such as Erving Goffman, who said mental illness was merely another example of how society labels and controls non-conformists; from behavioural psychologists who challenged psychiatry's fundamental reliance on unobservable phenomena; and from gay rights activists who criticised the APA's listing of homosexuality as a mental disorder. A study published in Science by Rosenhan received much publicity and was viewed as an attack on the efficacy of psychiatric diagnosis.[15] Although the APA was closely involved in the next significant revision of the mental disorder section of the ICD (version 8 in 1968), it decided to go ahead with a revision of the DSM. It was published in 1968, listed 182 disorders, and was 134 pages long. It was quite similar to the DSM-I. The term "reaction" was dropped, but the term "neurosis" was retained. Both the DSM-I and the DSM-II reflected the predominant psychodynamic psychiatry,[] although they also included biological perspectives and concepts from Kraepelin's system of classification. Symptoms were not specified in detail for specific disorders. Many were seen as reflections of broad underlying conflicts or maladaptive reactions to life problems, rooted in a distinction between neurosis and psychosis (roughly, anxiety/depression broadly in touch with reality, or hallucinations/delusions appearing disconnected from reality). Sociological and biological knowledge was incorporated, in a model that did not emphasize a clear boundary between normality and abnormality.[] The idea that personality disorders did not involve emotional distress was discarded.[] An influential 1974 paper by Robert Spitzer and Joseph L. Fleiss demonstrated that the second edition of the DSM (DSM-II) was an unreliable diagnostic tool.[] They found that different practitioners using the DSM-II were rarely in agreement when diagnosing patients with similar problems. In reviewing previous studies of 18 major diagnostic categories, Fleiss and Spitzer concluded that "there are no diagnostic categories for which reliability is uniformly high. Reliability appears to be only satisfactory for three categories: mental deficiency, organic brain syndrome (but not its subtypes), and alcoholism. The level of reliability is no better than fair for psychosis and schizophrenia and is poor for the remaining categories".[] Seventh printing of the DSM-II, 1974 As described by Ronald Bayer, a psychiatrist and gay rights activist, specific protests by gay rights activists against the APA began in 1970, when the organization held its convention in San Francisco. The activists disrupted the conference by interrupting speakers and shouting down and ridiculing psychiatrists who viewed homosexuality as a mental disorder. In 1971, gay rights activist Frank Kameny worked with the Gay Liberation Front collective to demonstrate against the APA's convention. At the 1971 conference, Kameny grabbed the microphone and yelled,

Diagnostic and Statistical Manual of Mental Disorders "Psychiatry is the enemy incarnate. Psychiatry has waged a relentless war of extermination against us. You may take this as a declaration of war against you."[16] This activism occurred in the context of a broader anti-psychiatry movement that had come to the fore in the 1960s and was challenging the legitimacy of psychiatric diagnosis. Anti-psychiatry activists protested at the same APA conventions, with some shared slogans and intellectual foundations.[17][18] Presented with data from researchers such as Alfred Kinsey and Evelyn Hooker, the seventh printing of the DSM-II, in 1974, no longer listed homosexuality as a category of disorder. After a vote by the APA trustees in 1973, and confirmed by the wider APA membership in 1974, the diagnosis was replaced with the category of "sexual orientation disturbance".[19]

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DSM-III (1980)
In 1974, the decision to create a new revision of the DSM was made, and Robert Spitzer was selected as chairman of the task force. The initial impetus was to make the DSM nomenclature consistent with the International Statistical Classification of Diseases and Related Health Problems (ICD), published by the World Health Organization. The revision took on a far wider mandate under the influence and control of Spitzer and his chosen committee members.[20] One goal was to improve the uniformity and validity of psychiatric diagnosis in the wake of a number of critiques, including the famous Rosenhan experiment. There was also a need to standardize diagnostic practices within the US and with other countries after research showed that psychiatric diagnoses differed markedly between Europe and the USA.[] The establishment of these criteria was an attempt to facilitate the pharmaceutical regulatory process. The criteria adopted for many of the mental disorders were taken from the Research Diagnostic Criteria (RDC) and Feighner Criteria, which had just been developed by a group of research-orientated psychiatrists based primarily at Washington University in St. Louis and the New York State Psychiatric Institute. Other criteria, and potential new categories of disorder, were established by consensus during meetings of the committee, as chaired by Spitzer. A key aim was to base categorization on colloquial English descriptive language (which would be easier to use by federal administrative offices), rather than assumptions of etiology, although its categorical approach assumed each particular pattern of symptoms in a category reflected a particular underlying pathology (an approach described as "neo-Kraepelinian"). The psychodynamic or physiologic view was abandoned, in favor of a regulatory or legislative model. A new "multiaxial" system attempted to yield a picture more amenable to a statistical population census, rather than just a simple diagnosis. Spitzer argued that "mental disorders are a subset of medical disorders" but the task force decided on the DSM statement: "Each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome."[] The personality disorders were placed on axis II along with mental retardation.[] The first draft of the DSM-III was prepared within a year. Many new categories of disorder were introduced, while some were deleted or changed. A number of the unpublished documents discussing and justifying the changes have recently come to light.[21] Field trials sponsored by the U.S. National Institute of Mental Health (NIMH) were conducted between 1977 and 1979 to test the reliability of the new diagnoses. A controversy emerged regarding deletion of the concept of neurosis, a mainstream of psychoanalytic theory and therapy but seen as vague and unscientific by the DSM task force. Faced with enormous political opposition, the DSM-III was in serious danger of not being approved by the APA Board of Trustees unless "neurosis" was included in some capacity; a political compromise reinserted the term in parentheses after the word "disorder" in some cases. Additionally, the diagnosis of ego-dystonic homosexuality replaced the DSM-II category of "sexual orientation disturbance". Finally published in 1980, the DSM-III was 494 pages and listed 265 diagnostic categories. It rapidly came into widespread international use and has been termed a revolution or transformation in psychiatry.[][] However, Robert Spitzer later criticized his own work on it in an interview with Adam Curtis, saying it led to the medicalization of 20-30 percent of the population who may not have had any serious mental problems.

Diagnostic and Statistical Manual of Mental Disorders When DSM-III was published, the developers made extensive claims about the reliability of the radically new diagnostic system they had devised, which relied on data from special field trials. However, according to a 1994 article by Stuart A. Kirk: Twenty years after the reliability problem became the central focus of DSM-III, there is still not a single multi-site study showing that DSM (any version) is routinely used with high reliably by regular mental health clinicians. Nor is there any credible evidence that any version of the manual has greatly increased its reliability beyond the previous version. There are important methodological problems that limit the generalisability of most reliability studies. Each reliability study is constrained by the training and supervision of the interviewers, their motivation and commitment to diagnostic accuracy, their prior skill, the homogeneity of the clinical setting in regard to patient mix and base rates, and the methodological rigor achieved by the investigator...[22]

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DSM-III-R (1987)
In 1987, the DSM-III-R was published as a revision of the DSM-III, under the direction of Spitzer. Categories were renamed and reorganized, and significant changes in criteria were made. Six categories were deleted while others were added. Controversial diagnoses, such as pre-menstrual dysphoric disorder and masochistic personality disorder, were considered and discarded. "Sexual orientation disturbance" was also removed and was largely subsumed under "sexual disorder not otherwise specified", which can include "persistent and marked distress about ones sexual orientation."[][23] Altogether, the DSM-III-R contained 292 diagnoses and was 567 pages long. Further efforts were made for the diagnoses to be purely descriptive, although the introductory text stated that for at least some disorders, "particularly the Personality Disorders, the criteria require much more inference on the part of the observer" (p. xxiii).[]

DSM-IV (1994)
In 1994, DSM-IV was published, listing 297 disorders in 886 pages. The task force was chaired by Allen Frances. A steering committee of 27 people was introduced, including four psychologists. The steering committee created 13 work groups of 516 members. Each work group had approximately 20 advisers.Wikipedia:Please clarify The work groups conducted a three-step process: first, each group conducted an extensive literature review of their diagnoses; then, they requested data from researchers, conducting analyses to determine which criteria required change, with instructions to be conservative; finally, they conducted multicenter field trials relating diagnoses to clinical practice.[24][25] A major change from previous versions was the inclusion of a clinical significance criterion to almost half of all the categories, which required that symptoms cause "clinically significant distress or impairment in social, occupational, or other important areas of functioning". Some personality disorder diagnoses were deleted or moved to the appendix.[]

DSM-IV-TR (2000)
A "text revision" of the DSM-IV, known as the DSM-IV-TR, was published in 2000. The diagnostic categories and the vast majority of the specific criteria for diagnosis were unchanged.[26] The text sections giving extra information on each diagnosis were updated, as were some of the diagnostic codes to maintain consistency with the ICD. The DSM-IV-TR was organized into a five-part axial system. The first axis incorporated clinical disorders. The second axis covered personality disorders and intellectual disabilities. The remaining axes covered medical, psychosocial, environmental, and childhood factors functionally necessary to provide diagnostic criteria for health care assessments.

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DSM-IV-TR
The term "psychosis" has many meanings, and the definitions that have been put forward are controversial. Even the DSM-IV-TR, says that "the term psychosis has historically received a number of definitions, none of which has achieved universal acceptance".[27]

Categorization
The DSM-IV is a categorical classification system. The categories are prototypes, and a patient with a close approximation to the prototype is said to have that disorder. DSM-IV states, "there is no assumption each category of mental disorder is a completely discrete entity with absolute boundaries" but isolated, low-grade and noncriterion (unlisted for a given disorder) symptoms are not given importance.[28] Qualifiers are sometimes used, for example mild, moderate or severe forms of a disorder. For nearly half the disorders, symptoms must be sufficient to cause "clinically significant distress or impairment in social, occupational, or other important areas of functioning," although DSM-IV-TR removed the distress criterion from tic disorders and several of the paraphilias due to their egosyntonic nature. Each category of disorder has a numeric code taken from the ICD coding system, used for health service (including insurance) administrative purposes.

Multi-axial system
The DSM-IV organizes each psychiatric diagnosis into five dimensions (axes) relating to different aspects of disorder or disability: Axis I: All diagnostic categories except mental retardation and personality disorder Axis II: Personality disorders and mental retardation Axis III: General medical condition; acute medical conditions and physical disorders Axis IV: Psychosocial and environmental factors contributing to the disorder Axis V: Global Assessment of Functioning or Children's Global Assessment Scale for children and teens under the age of 18

Common Axis I disorders include depression, anxiety disorders, bipolar disorder, ADHD, autism spectrum disorders, anorexia nervosa, bulimia nervosa, and schizophrenia. Common Axis II disorders include personality disorders: paranoid personality disorder, schizoid personality disorder, schizotypal personality disorder, borderline personality disorder, antisocial personality disorder, narcissistic personality disorder, histrionic personality disorder, avoidant personality disorder, dependent personality disorder, obsessive-compulsive personality disorder; and intellectual disabilities. Common Axis III disorders include brain injuries and other medical/physical disorders which may aggravate existing diseases or present symptoms similar to other disorders.

Cautions
The DSM-IV-TR states, because it is produced for the completion of federal legislative mandates, its use by people without clinical training can lead to inappropriate application of its contents. Appropriate use of the diagnostic criteria is said to require extensive clinical training, and its contents "cannot simply be applied in a cookbook fashion".[29] The APA notes diagnostic labels are primarily for use as a "convenient shorthand" among professionals. The DSM advises laypersons should consult the DSM only to obtain information, not to make diagnoses, and people who may have a mental disorder should be referred to psychological counseling or treatment. Further, a shared diagnosis or label may have different causes or require different treatments; for this reason the DSM contains no information regarding treatment or cause. The range of the DSM represents an extensive scope of psychiatric and psychological issues or conditions, and it is not exclusive to what may be considered "illnesses".

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Sourcebooks
The DSM-IV does not specifically cite its sources, but there are four volumes of "sourcebooks" intended to be APA's documentation of the guideline development process and supporting evidence, including literature reviews, data analyses and field trials.[30][31][32][33] The Sourcebooks have been said to provide important insights into the character and quality of the decisions that led to the production of DSM-IV, and hence the scientific credibility of contemporary psychiatric classification.[34][35]

DSM-5
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the DSM-5, was approved by the Board of Trustees of the American Psychiatric Association (APA) on December 1, 2012.[36] Published on May 18, 2013,[37] the DSM-5 contains extensively revised diagnoses and, in some cases, broadens diagnostic definitions while narrowing definitions in other cases.[38] The DSM-5 is the first major edition of the manual in twenty years,[39] and the Roman numerals numbering system has been changed to allow for greater clarity in regard to revision numbers. A significant change in the fifth edition is the proposed deletion of the subtypes of schizophrenia.[40][41] During the revision process, the APA website periodically listed several sections of the DSM-5 for review and discussion.[42]

Criticism
Reliability and validity concerns
The revisions of the DSM from the 3rd Edition forward have been mainly concerned with diagnostic reliability--the degree to which different diagnosticians agree on a diagnosis. It was argued that a science of psychiatry can only advance if diagnosis is reliable. If clinicians and researchers frequently disagree about a diagnosis with a patient, then research into the causes and effective treatments of those disorders cannot advance. Hence, diagnostic reliability was a major concern of DSM-III. When the diagnostic reliability problem was thought to be solved, subsequent editions of the DSM were concerned mainly with "tweaking" the diagnostic criteria. Unfortunately, neither the issue of reliability (accurate measurement) or validity (do these disorders really exist) was settled. However, most psychiatric education post DSM-III focused on issues of treatment--especially drug treatment--and less on diagnostic concerns. In fact, Thomas R. Insel, M.D., Director of the NIMH, has recently stated the agency would no longer fund research projects that rely exclusively on DSM criteria due to its lack of validity.

Superficial symptoms
By design, the DSM is primarily concerned with the signs and symptoms of mental disorders, rather than the underlying causes. It claims to collect them together based on statistical or clinical patterns. As such, it has been compared to a naturalists field guide to birds, with similar advantages and disadvantages.[43] The lack of a causative or explanatory basis, however, is not specific to the DSM, but rather reflects a general lack of pathophysiological understanding of psychiatric disorders. As DSM-III chief architect Robert Spitzer and DSM-IV editor Michael First outlined in 2005, "little progress has been made toward understanding the pathophysiological processes and etiology of mental disorders. If anything, the research has shown the situation is even more complex than initially imagined, and we believe not enough is known to structure the classification of psychiatric disorders according to etiology."[44] The DSM's focus on superficial symptoms is claimed to be largely a result of necessity (assuming such a manual is nevertheless produced), since there is no agreement on a more explanatory classification system.[citation needed] Reviewers note, however, that this approach is undermining research, including in genetics, because it results in the grouping of individuals who have very little in common except superficial criteria as per DSM or ICD diagnosis.[1]

Diagnostic and Statistical Manual of Mental Disorders Despite the lack of consensus on underlying causation, advocates for specific psychopathological paradigms have nonetheless faulted the current diagnostic scheme for not incorporating evidence-based models or findings from other areas of science. A recent example is evolutionary psychologists' criticism that the DSM does not differentiate between genuine cognitive malfunctions and those induced by psychological adaptations, a key distinction within evolutionary psychology, but one widely challenged within general psychology.[45][46][47] Another example is a strong operationalist viewpoint, which contends that reliance on operational definitions, as purported by the DSM, necessitates that intuitive concepts such as depression be replaced by specific measurable concepts before they are scientifically meaningful. One critic states of psychologists that "Instead of replacing 'metaphysical' terms such as 'desire' and 'purpose', they used it to legitimize them by giving them operational definitions...the initial, quite radical operationalist ideas eventually came to serve as little more than a 'reassurance fetish' (Koch 1992) for mainstream methodological practice."[48]

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Dividing lines
Despite caveats in the introduction to the DSM, it has long been argued that its system of classification makes unjustified categorical distinctions between disorders, and uses arbitrary cut-offs between normal and abnormal. A 2009 psychiatric review noted that attempts to demonstrate natural boundaries between related DSM syndromes, or between a common DSM syndrome and normality, have failed.[1] Some argue that rather than a categorical approach, a fully dimensional, spectrum or complaint-oriented approach would better reflect the evidence.[49][50][51][52] In addition, it is argued that the current approach based on exceeding a threshold of symptoms does not adequately take into account the context in which a person is living, and to what extent there is internal disorder of an individual versus a psychological response to adverse situations.[53][54] The DSM does include a step ("Axis IV") for outlining "Psychosocial and environmental factors contributing to the disorder" once someone is diagnosed with that particular disorder. Because an individual's degree of impairment is often not correlated with symptom counts, and can stem from various individual and social factors, the DSM's standard of distress or disability can often produce false positives.[55] On the other hand, individuals who do not meet symptom counts may nevertheless experience comparable distress or disability in their life.

Cultural bias
Some psychiatrists also argue that current diagnostic standards rely on an exaggerated interpretation of neurophysiological findings and so understate the scientific importance of social-psychological variables.[] Advocating a more culturally sensitive approach to psychology, critics such as Carl Bell and Marcello Maviglia contend that the cultural and ethnic diversity of individuals is often discounted by researchers and service providers.[56] In addition, current diagnostic guidelines have been criticized as having a fundamentally Euro-American outlook. Although these guidelines have been widely implemented, opponents argue that even when a diagnostic criteria set is accepted across different cultures, it does not necessarily indicate that the underlying constructs have any validity within those cultures; even reliable application can only demonstrate consistency, not legitimacy.[] Cross-cultural psychiatrist Arthur Kleinman contends that the Western bias is ironically illustrated in the introduction of cultural factors to the DSM-IV: the fact that disorders or concepts from non-Western or non-mainstream cultures are described as "culture-bound", whereas standard psychiatric diagnoses are given no cultural qualification whatsoever, is to Kleinman revelatory of an underlying assumption that Western cultural phenomena are universal.[57] Kleinman's negative view towards the culture-bound syndrome is largely shared by other cross-cultural critics, common responses included both disappointment over the large number of documented non-Western mental disorders still left out, and frustration that even those included were often misinterpreted or misrepresented.[58] Many mainstream psychiatrists have also been dissatisfied with these new culture-bound

Diagnostic and Statistical Manual of Mental Disorders diagnoses, although not for the same reasons. Robert Spitzer, a lead architect of the DSM-III, has held the opinion that the addition of cultural formulations was an attempt to placate cultural critics, and that they lack any scientific motivation or support. Spitzer also posits that the new culture-bound diagnoses are rarely used in practice, maintaining that the standard diagnoses apply regardless of the culture involved. In general, the mainstream psychiatric opinion remains that if a diagnostic category is valid, cross-cultural factors are either irrelevant or are only significant to specific symptom presentations.[]

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Medicalization and financial conflicts of interest


It has also been alleged that the way the categories of the DSM are structured, as well as the substantial expansion of the number of categories, are representative of an increasing medicalization of human nature, which may be attributed to disease mongering by psychiatrists and pharmaceutical companies, the power and influence of the latter having grown dramatically in recent decades.[59] Of the authors who selected and defined the DSM-IV psychiatric disorders, roughly half have had financial relationships with the pharmaceutical industry at one time, raising the prospect of a direct conflict of interest.[60] The same article concludes that the connections between panel members and the drug companies were particularly strong in those diagnoses where drugs are the first line of treatment, such as schizophrenia and mood disorders, where 100% of the panel members had financial ties with the pharmaceutical industry.[60] In 2005, then American Psychiatric Association President Steven Sharfstein released a statement in which he conceded that psychiatrists had "allowed the biopsychosocial model to become the bio-bio-bio model".[61] However, although the number of identified diagnoses has increased by more than 200% (from 106 in DSM-I to 365 in DSM-IV-TR), psychiatrists such as Zimmerman and Spitzer argue it almost entirely represents greater specification of the forms of pathology, thereby allowing better grouping of more similar patients.[1] William Glasser, however, refers to the DSM as "phony diagnostic categories", arguing that "it was developed to help psychiatrists to help them make money".[62] In addition, the publishing of the DSM, with tightly guarded copyrights, has in itself earned over $100 million for the American Psychiatric Association.[63]

Consumers and survivors


A consumer is a person who accesses psychiatric services and may have been given a diagnosis from the Diagnostic and Statistical Manual of Mental Disorders, while a survivor self-identifies as having survived psychiatric intervention and the mental health system (which may have involved involuntary commitment and involuntary treatment). Some are relieved to find that they have a recognized condition to which they can give a name. Indeed, many people self-diagnose. Others, however, feel they have been given a "label" that invites social stigma and discrimination (i.e. mentalism), or one that they simply do not feel is accurate. Diagnoses can become internalized and affect an individual's self-identity, and some psychotherapists find that this can worsen symptoms and inhibit the healing process.[64] Some in the Psychiatric survivors movement (more broadly the consumer/survivor/ex-patient movement) actively campaign against their diagnosis, or its assumed implications, and/or against the DSM system in general. It has been noted that the DSM often uses definitions and terminology that are inconsistent with a recovery model, and that can erroneously imply excess psychopathology (e.g. multiple "comorbid" diagnoses) or chronicity.[65]

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DSM-5 critiques
Psychiatrist Allen Frances has been critical of proposed revisions to the DSM-5. In a 2012 article, Frances warned that if this DSM version is issued unamended by the APA, it will "medicalize normality and result in a glut of unnecessary and harmful drug prescription."[66] In a December 2, 2012 blog post in Psychology Today, Frances lists the ten "most potentially harmful changes" to DSM-5:[] Disruptive Mood Dysregulation Disorder, for temper tantrums Major Depressive Disorder, includes normal grief Minor Neurocognitive Disorder, for normal forgetting in old age Adult Attention Deficit Disorder, encouraging psychiatric prescriptions of stimulants Binge Eating Disorder, for excessive eating Autism change, reducing the numbers diagnosed First time drug users will be lumped in with addicts Behavioral Addictions, making a "mental disorder of everything we like to do a lot." Generalized Anxiety Disorder, includes everyday worries Post-traumatic stress disorder, changes opening "the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings."

Frances and others have published debates on what they see as the six most essential questions in psychiatric diagnosis:[] are they more like theoretical constructs or more like diseases how to reach an agreed definition whether the DSM-5 should take a cautious or conservative approach the role of practical rather than scientific considerations the issue of use by clinicians or researchers whether an entirely different diagnostic system is required.

In 2011, psychologist Brent Robbins co-authored a national letter for the Society for Humanistic Psychology that has brought thousands into the public debate about the DSM. Approximately 14,000 individuals and mental health professionals have signed a petition in support of the letter. Thirteen other American Psychological Association divisions have endorsed the petition.[67] Robbins has noted that under the new guidelines, certain responses to grief could be labeled as pathological disorders, instead of being recognized as being normal human experiences.[68]

References
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[20] Speigel, A. (2005) The Dictionary of Disorder: How one man revolutionized of 2005-01-03. (http:/ / www. newyorker. com/ fact/ content/ articles/ 050103fa_fact?050103fa_fact) [23] Spiegel, Alix. (18 January 2002.) "81 Words" (http:/ / www. thislife. org/ Radio_Episode. aspx?episode=204). In Ira Glass (producer), This American Life. Chicago: Chicago Public Radio. [24] Allen Frances, Avram H. Mack, Ruth Ross, and Michael B. First (2000) The DSM-IV Classification and Psychopharmacology (http:/ / www. acnp. org/ G4/ GN401000082/ CH081. html). [25] Schaffer, David (1996) A Participant's Observations: Preparing DSM-IV (https:/ / ww1. cpa-apc. org/ Publications/ Archives/ PDF/ 1996/ Aug/ schaffer. pdf) Can J Psychiatry 1996;41:325329. [26] APA Summary of Practice-Relevant Changes to the DSM-IV-TR (http:/ / www. psych. org/ practice/ dsm/ summary-of-practice-relevant-changes-to-the-dsm-iv-tr). [27] Paris Williams (2012). Rethinking Madness: Towards a Paradigm Shift In Our Understanding and Treatment of Psychosis, Skys Edge Publishing, p. 17. [28] Maser, JD. & Patterson, T. (2002) Spectrum and nosology: implications for DSM-5 (http:/ / www. ncbi. nlm. nih. gov/ entrez/ query. fcgi?db=pubmed& cmd=Retrieve& dopt=AbstractPlus& list_uids=12462864) Psychiatric Clinics of North America, December, 25(4)p855-885 [30] DSM-IV Sourcebook Volume 1 (http:/ / www. appi. org/ SearchCenter/ Pages/ SearchDetail. aspx?ItemId=2065) [31] DSM-IV Sourcebook Volume 2 (http:/ / www. appi. org/ SearchCenter/ Pages/ SearchDetail. aspx?ItemId=2071) [32] DSM-IV Sourcebook Volume 3 (http:/ / www. appi. org/ SearchCenter/ Pages/ SearchDetail. aspx?ItemId=2073) [33] DSM-IV Sourcebook Volume 4 (http:/ / ajp. psychiatryonline. org/ article. aspx?articleid=173760) [34] Poland, JS. (2001) Review of Volume 1 of DSM-IV sourcebook (http:/ / mentalhelp. net/ books/ books. php?type=de& id=557) [35] Poland, JS. (2001) Review of vol 2 of DSM-IV sourcebook (http:/ / mentalhelp. net/ poc/ view_doc. php?id=996& type=book& cn=74) [43] Paul R. McHugh (2005) Striving for Coherence: Psychiatrys Efforts Over Classification (http:/ / jama. ama-assn. org/ cgi/ content/ full/ 293/ 20/ 2526?ijkey=e5f8d881d7f6c0d853ce55e1ac5b693c5c53a950& keytype2=tf_ipsecsha) JAMA. 2005;293(no.20)2526-2528. [44] Spitzer and First (2005) Classification of Psychiatric Disorders. (http:/ / jama. ama-assn. org/ cgi/ content/ full/ 294/ 15/ 1898) JAMA.2005; 294: 1898-1899. [45] Dominic Murphy, PhD; Steven Stich, PhD (1998) Darwin in the Madhouse (http:/ / ruccs. rutgers. edu/ ArchiveFolder/ Research Group/ Publications/ Mad/ Madhouse. html) [46] Leda Cosmides, PhD; John Tooby, PhD (1999) Toward an Evolutionary Taxonomy of Treatable Conditions "J of Abnormal Psychology." 1999;108(3):453-464. (http:/ / www. psych. ucsb. edu/ research/ cep/ papers/ taxonomywakefield99. pdf) [48] DW Hands (2004) On Operationalisms and Economics (http:/ / www. redorbit. com/ news/ science/ 112364/ on_operationalisms_and_economics/ ) Journal of Economic Issues [49] Spitzer, Robert L, M.D., Williams, Janet B.W, D.S.W., First, Michael B, M.D., Gibbon, Miriam, M.S.W., Biometric Research (http:/ / nyspi. org/ AR2001/ Biometrics. htm) [50] Maser, JD & Akiskal, HS. et al. (2002) Spectrum concepts in major mental disorders (http:/ / psych. theclinics. com/ issues/ contents?volume=25& issue=4) Psychiatric Clinics of North America, Vol. 25, Special issue 4 [53] Chodoff, P. (2005) Psychiatric Diagnosis: A 60-Year Perspective (http:/ / pn. psychiatryonline. org/ cgi/ content/ full/ 40/ 11/ 17-a) Psychiatric News June 3, 2005 Volume 40 Number 11, p17 [56] Shankar Vedantam, Psychiatry's Missing Diagnosis: Patients' Diversity Is Often Discounted (http:/ / www. washingtonpost. com/ wp-dyn/ content/ article/ 2005/ 06/ 25/ AR2005062500982. html) Washington Post: Mind and Culture, June 26 [58] Bhugra, D. & Munro, A. (1997) Troublesome Disguises: Underdiagnosed Psychiatric Syndromes Blackwell Science Ltd [59] Healy D (2006) The Latest Mania: Selling Bipolar Disorder (http:/ / medicine. plosjournals. org/ perlserv/ ?request=get-document& doi=10. 1371/ journal. pmed. 0030185& ct=1) PLoS Med 3(4): e185. [60] Cosgrove, Lisa, Krimsky, Sheldon,Vijayaraghavan, Manisha, Schneider, Lisa, Financial Ties between DSM-IV Panel Members and the Pharmaceutical Industry (http:/ / www. tufts. edu/ ~skrimsky/ PDF/ DSM COI. PDF) [61] Sharfstein, SS. (2005) Big Pharma and American Psychiatry: The Good, the Bad, and the Ugly (http:/ / pn. psychiatryonline. org/ cgi/ content/ full/ 40/ 16/ 3) Psychiatric News August 19, 2005 Volume 40 Number 16 [62] The National Psychologist (Susan Bowman, 2006) (http:/ / nationalpsychologist. com/ 2006/ 11/ glasser-headlines-psychotherapy-conference/ 10879. html) [64] How Using the Dsm Causes Damage: A Clients Report (http:/ / jhp. sagepub. com/ cgi/ content/ abstract/ 41/ 4/ 36) Journal of Humanistic Psychology, Vol. 41, No. 4, 36-56 (2001) [65] Michael T. Compton (2007) Recovery: Patients, Families, Communities (http:/ / www. medscape. com/ viewarticle/ 565489_print) Conference Report, Medscape Psychiatry & Mental Health, October 1114, 2007 [66] Frances, A (May 11, 2012). Diagnosing the D.S.M. (http:/ / www. nytimes. com/ 2012/ 05/ 12/ opinion/ break-up-the-psychiatric-monopoly. html?_r=1)New York Times (opinion)

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External links
Official DSM-5 development website (http://www.dsm5.org/pages/default.aspx) Topic Center from the Psychiatric Times: DSM-5 (http://www.psychiatrictimes.com/DSM-5) DSM-IV-TR Official Site (http://www.psychiatry.org/practice/dsm/dsm-iv-tr) - American Psychiatric Association Diagnostic Criteria from DSM-IV-TR (http://www.behavenet.com/capsules/disorders/dsm4TRclassification. htm) The Multiaxial System of Diagnosis in DSM-IV Criteria (http://www.psyweb.com/DSM_IV/jsp/dsm_iv.jsp) American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition: DSM-IV-TR (http://books.google.com/?id=3SQrtpnHb9MC). American Psychiatric Pub. ISBN978-0-89042-025-6. Robert L. Spitzer (2002). Dsm-Iv-Tr Casebook: A Learning Companion to the Diagnostic and Statistical Manual of Mental Disorders (http://books.google.com/?id=S_xe-AX4UjMC). American Psychiatric Pub. ISBN978-1-58562-059-3. DSM-IV-TR In Action (http://www.spiritualmentoring.com/page2/page46/page46.html) Powerpoint slide handouts by G. Scott Sparrow

Direct-to-consumer advertising
Direct-to-consumer advertising (DTC advertising) usually refers to the marketing of pharmaceutical products but can apply in other areas as well. This form of advertising is directed toward patients, rather than healthcare professionals. The Food and Drug Administration is responsible for regulating DTC advertising in the United States. The FDAs latest version of guidelines, though still in draft form, for pharmaceutical drug advertising was updated in 2009.[1] Forms of DTC advertising include TV, print, radio and other mass and social media. There are ethical and regulatory concerns regarding DTC advertising, specifically the extent to which these ads may unduly influence the prescribing of the prescription medicines based on consumer demands when, in some cases, they may not be medically necessary.

Nations permitting DTC


To date only two nations permit DTC (Nation, year of legalization, link to legislation permitting DTC) New Zealand (1981) United States (1997)

DTC and threats to national sovereignty


Canada: US terrestrial broadcasters and some US cable broadcasters that have access to the Canadian market via Canadian Radio-television and Telecommunications Commission (CRTC) regulation have effectively overridden Canada's laws that forbid DTC with respect to the transmission of these ads into the Canadian market via these broadcasters. The CRTC has not evicted these broadcasters from access to the Canadian market. Mexico: there is a similar case of national sovereignty to Canada with respect to some US terrestrial broadcasters running ads in Spanish on the Univision networkwhere reception of these broadcasts is possible in Mexico (only the states of Sonora and Baja California are affected). With the arrival of DTV conversion of the US in 2009, Canada and Mexico may be less affected by US terrestrial broadcasters and the issue of DTC. US cable broadcasters on Canadian cable TV systems continue to be in violation even since 2009.

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Pharmaceutical industry controversy


All western nations, with the exception of New Zealand and the United States, have historically (since the 1940s for Australasia, North America, and Europe) banned direct advertising of pharmaceuticals to consumers. The first direct-to-consumer print ad was for Merck & Co.'s Pneumovax, a pneumonia vaccine, which appeared in Reader's Digest in 1981.[citation needed] In 1982, the FDA prompted Eli Lilly and Company to retract a press kit for its NSAID, Oraflex The FDA cited the "false and misleading" provision of risk information. DTC advertising was legalized in the US only after a 1985 Food and Drug Administration (FDA) ruling, but the agency required the adverts to include a great amount of information on the risks of the drugs. Rufen, manufactured by Boots, was the first drug to be advertised on US television in 1983.[citation needed] On May 13, 1983, Boots Pharmaceuticals (the US arm of a major British pharmaceutical company and pharmacy chain) launched the first TV ads for a prescription medicine in a test market; Tampa, Florida for the prescription brand of Ibuprofen called Rufen. The ads, featured CEO John D. Bryer, who delivered the message that Rufen was cheaper than Motrin. It was a price ad and made no efficacy claims and as such it did not include Package Insert information. The company also placed a full-page ad in the Wall Street Journal, and in the print ad, the full package insert, the prescribing information, was included.[citation needed] Under pressure from doctors and the American Medical Association, the FDA implemented a moratorium on all advertising in directed to patients. Liz Moench, who was then head of marketing at Boots USA and is now president and CEO of MediciGlobal, said: "We thought that way we could navigate this quagmire of FDA indecisiveness, but they were really grappling with how to address labeling and issues of communication."[2] A moratorium on consumer advertising followed.[citation needed] During this time, the FDA conducted consumer exchange meetings to gauge public reaction to direct-to-consumer advertising of prescription drugs. In 1985, the FDA issued a ruling that required advertising directed to consumers to include significant risk information about the prescription drug being advertised. Those long consumer warnings often required multiple pages (or infomercial-length ads) to fully fulfill the requirement.[citation needed] Claritin was approved in 1993, and DTC advertising was launched in 1995. At first, Schering-Plough ran print ads and unbranded broadcast reminder ads, but it switched over to branded ads with its Blue Skies campaign. With older competitors like Seldane and Hismanal out of the way and newer drugs Zyrtec and Allegra still in development, Claritin had the market for antihistamines all to itself. Schering-Plough spent $124 million on consumer advertising for Claritin.[citation needed] Schering committed itself to a massive, broadcast-heavy multi-channel consumer campaign aimed at establishing universal brand awareness. Claritin's DTC spending peaked in 1998, at $142 million in measured media, according to TNS Media Intelligence data but remained strong over the course of five line extensions and a switch to over-thecounter in 2002.[citation needed] On August 8, 1997, the FDA released its draft guidance that effectively enabled the use of broadcast ads for DTC. This allowed advertisers to forgo the requirement that they scroll or read the entire brief summary, provided they met an "adequate provision" standard for risk information as shown it began over a decade earlier.[citation needed] As a result of the FDA's draft guidance, spending on DTC advertising increased from $220 million in 1997 to over $2.8 billion in 2002.[citation needed] In 2002, the Secretary of Health and Human Services began requiring all draft FDA regulatory letters, including letters related to advertising violations, to be reviewed and approved by the FDA's Office of Chief Counsel before they are issued.[3] In 2004, Merck withdrew heavily-advertised Vioxx on safety concerns on September 30, provided a touchpoint for public ire over drug prices and threw a shadow over consumer promotion.[citation needed]

Direct-to-consumer advertising In 2005: Sepracor launched Lunesta on April 4 and spendt $215 million on consumer advertising over the next eight months. Sanofi-Aventis spent $88 million defending Zolpidem's category leadership.[citation needed] On 2 August 2005, Pharmaceutical Research and Manufacturers of America released its Guiding Principles on Direct to Consumer Advertisements About Prescription Medicines, with the intent to stop congressional action to end industry self-regulation.[4] This great amount of advertising has been successful in raising the prescription rate of DTC drugs by 34.2%, compared to only a 5.1% increase in other prescriptions.[5] DTC advertisemens have also been shown to influence the physiological efficacy of branded drugs.[6] These and many other aspects of DTC advertising made it very controversial among public health officials and physicians.[7]

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Financial services
Consumer vulnerability to deceptive advertising is also particularly acute in the area of financial services. Individuals often have little knowledge of the workings of credit, leases, and security agreements. It is sometimes difficult to obtain information on such subjects that would be meaningful to the average consumer, so it is especially important that consumers be on guard against misleading or fraudulent advertisement. Because of the great inequality of bargaining power in this area, the government often backs up the consumer with protective laws.[8][9]

New media and the evolution of direct-to-consumer advertising


Emerging media channels are causing the consumer channel mix to become increasingly fragmented. Individuals are no longer limited to just the television or newspaper to obtain their entertainment, news, and information, but can access content via websites, online video, social networks, mobile devices, and a variety of other ways. Consumers are especially shifting to new media sources for health and pharmaceutical information over 145 million U.S. adults looked up health information online in 2008.[10] The pharmaceutical industry as a whole has not been as quick as other sectors to jump on the digital marketing bandwagon, in part due to unclear guidelines from the FDA. Nonetheless, many direct-to-consumer (DTC) marketers are beginning to recognize the opportunities that new media offers for reaching consumers. Though the vast majority of DTC budgets are still allocated to traditional offline media such as television, newspaper, magazine and radio, marketers are beginning to shift some of their spending to digital activities such as product websites, online display advertising, search engine marketing, social media campaigns, and mobile advertising. Regardless of the advertising channel, pharmaceutical drug advertisers are continuing to increase the amount of money spent on DTC advertising with an increase of 330% from 1996 to 2005.[11]

References
[1] http:/ / www. fda. gov/ Drugs/ GuidanceComplianceRegulatoryInformation/ Guidances/ ucm064956. htm [2] MediciGlobal (2011). Elizabeth (Liz) Moench - President and CEO. Retrieved from http:/ / mediciglobal. com/ about/ liz_moench. [3] Donohue, J. M., Cevasco, M., & Rosenthal, M. B. (2007). A Decade of Direct-to-Consumer Advertising of Prescription Drugs. New England Journal of Medicine, 357(7), 673-681. [4] Arnold, Matthew (2006-10-01). 40 years of DTC. MMM, 1 October 2006. Retrieved from http:/ / www. mmm-online. com/ 40-years-of-DTC/ article/ 35502/ [5] Sheehan, Kim. Controversies in Contemporary Advertising; Sage Publications, Thousand Oaks, CA, 2003; pp 209-215. [6] Emir Kamenica,Robert Naclerio,andAnup Malani. PNAS2013.doi:10.1073/pnas.1012818110 [7] Kerber, Ross. Doctors Criticize Sleeping-Pill Ad (Lunesta from Sepracor Inc.). Boston Globe, Boston, Aug. 18, 2005, p HS05. [8] Board of Governors of the Federal Reserve System. 1981. What Truth in Lending Means to You [9] Rist, Marilee C. 1989. Mass Marketers Have a Sweet Deal for You, but There Are Strings Attached. American School Board Journal (176)9, 20-24. [10] http:/ / www. manhattanresearch. com/ research/ white-papers/ catch-the-new-pharma-marketing-wave. aspx

Direct-to-consumer advertising
[11] Donohue, J. M., Cevasco, M., & Rosenthal, M. B. (2007). A Decade of Direct-to-Consumer Advertising of Prescription Drugs. New England Journal of Medicine, 357(7), 673-681.

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External links
Educating the Consumer about Advertising: Some Issues (http://www.ericdigests.org/pre-9219/consumer. htm) - from the Education Resources Information Center Clearinghouse on Reading and Communication Skills, Bloomington, Indiana. Direct to Consumer Advertising in the United States (http://www.sourcewatch.org/index. php?title=Direct-to-consumer_advertising_in_the_United_States) SourceWatch: A Project of the Center for Media and Democracy (http://www.prwatch.org/) (http://www.mmm-online.com/40-years-of-DTC/article/35502/) 40 years of DTC by Matthew Arnold/Medicial Marketing and Media] (http://www.manhattanresearch.com/research/white-papers/catch-the-new-pharma-marketing-wave.aspx) Catch the New Pharmaceutical Marketing Wave: Trends & Strategies for Reaching Today's Healthcare Consumer AdPharm pharmaceutical advertising examples (http://www.blog.adpharm.net)

Veterinary physician
A veterinary physician, colloquially called a vet, shortened from veterinarian (American English, Australian English) or veterinary surgeon (British English), is a professional who practices veterinary medicine by treating disease, disorder, and injury in non-human animals. In many countries, the local nomenclature for a vet is a regulated and protected term, meaning that members of the public without the prerequisite qualifications and/or registration are not able to use the A vet conducts a routine spaying operation on a title. In many cases, the activities that may be undertaken by a domestic cat veterinarian (such as animal treatment or surgery) are restricted only to those professionals who are registered as vet. For instance, in the United Kingdom, as in other jurisdictions, animal treatment may only be performed by registered vets (with a few designated exceptions, such as paraveterinary workers), and it is illegal for any person who is not registered to call themselves a vet or perform any treatment. Most vets work in clinical settings, treating animals directly. These vets may be involved in a general practice, treating animals of all types; may be specialized in a specific group of animals such as companion animals, livestock, zoo animals or horses; or may specialize in a narrow medical discipline such as surgery, dermatology or internal medicine. As with healthcare professionals, vets face ethical decisions about the care of their patients. Current debates within the profession include the ethics of purely cosmetic procedures on animals, such as declawing of cats, docking of tails, cropping of ears and debarking on dogs.

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Etymology and nomenclature


The word veterinary comes from the Latin veterinae meaning "working animals". "Veterinarian" was first used in print by Thomas Browne in 1646.[1] The term veterinarian is used in North America and other countries using predominantly American English, whereas in the United Kingdom, and countries which are formerly part of the British Empire or are part of the Commonwealth of Nations tend to use the term veterinary surgeon.[citation needed]

History
The earliest written records of veterinary medicine can be found in the Egyptian Papyrus of Kahun (1900 BCE) and Vedic literature in ancient India[2] In Europe, the first attempts to organize and regulate the practice of treating animals tended to focus on horses because of their economic significance. In the Middle Ages, farriers combined their work in shoeing and generally caring for horses' hooves with "horse doctoring". In 1356, the Lord Mayor of London, concerned at the poor standard of care given to horses in the city, requested that all farriers operating within a seven mile radius of the City of London form a "fellowship" to regulate and improve their practices.[3] The first veterinary college in Europe was founded in Lyon, France in 1762 by Claude Bourgelat. In the ensuing 20 years similar colleges were established in other European cities. The Veterinary College of London was founded in 1791 by a group led by Granville Penn.[4] In the United States, the first veterinarians had been trained in Europe. However, Boston, New York and Philadelphia all had their own private veterinary schools by the 1850s. These urban schools concentrated primarily on the care of horses. By the turn of the 20th century, several American agricultural colleges had started their own veterinary schools which were focused on livestock animals. In 1879, Iowa Agricultural College became the first land grant college to establish a school of veterinary medicine.[5]

Roles and responsibilities


Vets are primarily required to treat disease, disorder or injury in animals, which includes diagnosis, treatment and aftercare. The scope of practice, specialty and experience of the individual vets will dictate exactly what interventions they perform, but most will perform surgery (of differing complexity). Unlike in adult human medicine, vets must rely on clinical signs, as animals are unable to vocalize symptoms as a human would (and in that respect is similar to medicine on human children). In some cases, owners may be able to provide a medical history and the vet can combine this information along with observations, and the results of pertinent diagnostic tests such as x-rays, CT scans, blood tests, urinalysis or other diagnostics. As with human medicine, much veterinary work is concerned with prophylactic treatment, in order to prevent problems occurring in the future. Common interventions include vaccination against common animal illnesses, such as distemper or rabies. This may also involve being involved in owner education so as to avoid future medical or behavioral issues. Unlike in most human medicine, vets will often consider the appropriateness of euthanasia ("putting to sleep") if a condition is likely to leave the animal in pain or with a poor quality of life.

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Employment
The majority of vets are employed in private practice treating animals (75% of vets in the United States, according to the American Veterinary Medical Association).[citation needed] Small animal vets typically work in veterinary clinics or veterinary hospitals, or both. Large animal vets often spend more time travelling to see their patients at the primary facilities which house them, such as zoos or farms. Other employers include charities treating animals, colleges of veterinary medicine, research laboratories, animal food companies, and pharmaceutical companies. In many countries, the government may also be a major employer of vets, such as the United States Department of Agriculture or the State Veterinary Service in the United Kingdom. State and local governments also employ veterinarians.[6][7]

Focus of practice
Vets and their practices may be specialized in certain areas of veterinary medicine. Areas of focus include: Exotic animal veterinarian - Generally considered to include reptiles, exotic birds such as parrots and cockatoos, and small mammals such as ferrets, rabbits, chinchillas, and degus. Conservation medicine - The study of the relationship between animal and human health and environmental conditions. Small animal practice - Usually dogs, cats, and other companion animals/household pets such as hamsters and gerbils. Some practices are canine-only or feline-only practices. Laboratory animal practice - Some veterinarians work in a university or industrial laboratory and are responsible for the care and treatment of laboratory animals of any species (often involving bovines, porcine species, felines, canines, rodents, and even exotic animals). Their responsibility is not only for the health and well being of the animals, but also for enforcing humane and ethical treatment of the animals in the facility. Large animal practice - Usually referring to veterinarians that work with, variously, livestock and other large farm animals, as well as equine species and large reptiles. Equine medicine - Some veterinarians are specialists in equine medicine. Horses are different in anatomy, physiology, pathology, pharmacology, and husbandry to other domestic species. Specialization in equine veterinary practice is something that is normally developed after qualification, even if students do have some interest before graduation. Food animal medicine - Some veterinarians deal exclusively or primary with animals raised for food (such as meat, milk, and eggs). Livestock practitioners may deal with ovine (sheep), bovine (cattle) and porcine (swine) species; such veterinarians deal with management of herds, nutrition, reproduction, and minor field surgery. Dairy medicine practice focuses on dairy animals. Poultry medicine practice focuses on the health of flocks of poultry; the field often involves extensive training in pathology, epidemiology, and nutrition of birds. The veterinarian treats the flock and not the individual animals. Food safety practice - Veterinarians are employed by both the food industry and government agencies to advise on and monitor the handling, preparation, and storage of food in ways that prevent foodborne illness. Wildlife medicine - A relatively recent branch of veterinary medicine, focusing on wildlife. Wildlife medicine veterinarians may work with zoologists and conservation medicine practitioners and may also be called out to treat marine species such as sea otters, dolphins, or whales after a natural disaster or oil spill.

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Veterinary specialities
Veterinary specialists are in the minority compared to general practice vets, and tend to be based at points of referral, such as veterinary schools or larger animal hospitals. Unlike human medicine, veterinary specialities often combine both the surgical and medical aspects of a biological system. Veterinary specialities are accredited in North America by the AVMA through the American Board of Veterinary Specialties, in Europe by the European Board of Veterinary Specialisation and in Australasia by the Australasian Veterinary Boards Council. While some vets may have areas of interest outside of recognized specialities, they are not legally specialists. Specialties can cover from general topics such as anesthesiology, dentistry, and surgery to organ system focus such as cardiology or dermatology. A full list can be seen at veterinary specialties

Salary
The mean salary for new graduates in the United States during 2010 was US$48,674 including nearly 50% going on to advanced study programs.[8] Those not continuing their studies made US$67,359 at first,[8] whereas vets in the United Kingdom earned slightly less with new graduate wages at an average of 25,000. The average income for private practice in the United States rose from $105,510 in 2005 to $115,447 in 2007. These increased values exceed those of public practice including uniformed services and government.[9] In Australia the profession wide average income was $67,000 in 2011 and this has declined compared to other professions for the past 30 years whilst graduate unemployment has doubled between 2006 and 2011.[10]

Education and regulation


In order to practice, vets must complete both an appropriate degree in veterinary medicine, and in most cases must be registered with the relevant governing body for their jurisdiction.

Veterinary science degrees


Degrees in veterinary medicine culminate in the award of a veterinary science degree, although the title varies by region. For instance, in North America, graduates will receive a Doctor of Veterinary Medicine (DVM or VMD) whereas in the United Kingdom or India they would be awarded a Bachelor's degree in Veterinary Science, Surgery or Medicine (BVS, BVSc, BVetMed or BVMS), and in Ireland graduates receive a Medicina Veterinaria Baccalaureate (MVB). The award of a bachelor's degree was previously commonplace in the United States, but the degree name and academic standards were upgraded to match the 'doctor' title used by graduates. Comparatively few universities have veterinary schools that offer degrees which are accredited to qualify the graduates as registered vets. In the United States, only 28 universities offer a degree meeting American Veterinary Medical Association (AVMA) standards,[11] in Canada, only 5 veterinary schools offer a vet qualifying course and in the United Kingdom only 7 universities offer a suitable degree. Due to this scarcity of places for veterinary degrees, admission to veterinary school is competitive and requires extensive preparation. The likelihood of acceptance is not in favor of the applicant, though is higher than acceptance rates in most academic PhD programs and medical schools. In the United States in 2007, approximately 5,750 applicants competed for the 2,650 seats in the 28 accredited veterinary schools, with an acceptance rate of 46%.[12] This compares with acceptance rates of well under 25% for most PhD and MD degrees. With competitive admission, many schools may place heavy emphasis and consideration on a candidate's veterinary and animal experience. Formal experience is a particular advantage to the applicant, often consisting of work with veterinarians or scientists in clinics, agribusiness, research, or some area of health science. Less formal experience is

Veterinary physician also helpful for the applicant to have, and this includes working with animals on a farm or ranch or at a stable or animal shelter and basic overall animal exposure.[13] In the United States, approximately 80% of admitted students are female. In the early history of veterinary medicine of the USA, most veterinarians were males. However, in the 1990s this ratio reached parity, and now it has been reversed. Preveterinary courses should emphasize the sciences. Most veterinary schools typically require applicants to have taken one year equivalent classes in organic, inorganic chemistry, physics, general biology; and one semester of vertebrate embryology and biochemistry. Usually, the minimal mathematics requirement is college level calculus. Individual schools might require introduction to animal science, livestock judging, animal nutrition, cell biology, and genetics. However, due the limited availability of these courses, many schools have removed these requirements to widen the pool of possible applicants.

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Registration and licensing


Following academic education, most countries require a vet to be registered with the relevant governing body, and to maintain this license to practice. Dependent on where the vet practices (or wishes to practice), they may have to complete an examination or test in order to complete this registration. For instance, in the United States, a prospective vet must receive a passing grade on a national board examination, the North America Veterinary Licensing Exam. This exam must be completed over the course of eight hours, and consists of 360 multiple-choice questions, covering all aspects of veterinary medicine, as well as visual material designed to test diagnostic skills.

Postgraduate study
The percentage electing to undertake further study following registration in the United States has increased from 36.8% to 39.9% in 2008. About 25% of those or about 9% of graduates were accepted into traditional academic internships. (2008 -696 graduates accepted a position in advanced study, 89.2% (621) accepted an internship (private practice, 74.5%; academic, 25.3%; and other internship, 0.2%). An additional 6.0% (42) accepted a residency). Approximately 9% of veterinarians eventually board certify in one of 20 specialties.[][]

Curriculum comparison with human medicine


The first two year curriculum in both veterinary and human medical schools are very similar in the course names, but very different in the content. First two year curriculum usually include biochemistry, physiology, histology, anatomy, pharmacology, microbiology, epidemiology, pathology and hematology.[] Some veterinary school uses the same biochemistry, histology, and microbiology books as human medicine students; however, the course content is greatly supplemented to include the varied animal diseases and species specific differences. Many veterinarians were trained in pharmacology using the same text books as human physicians. As the specialty of veterinary pharmacology develop, more schools are using pharmacology textbooks written specifically for veterinarians. Veterinary physiology, anatomy, and histology is complex, as physiology often varies among species. Microbiology and virology of animals share the same foundation as human microbiology, but with grossly different disease manifestation and presentations. Epidemiology is focused on herd health and prevention of herd borne diseases, and foreign animal diseases. Pathology, like microbiology and histology, is very diverse and encompasses many species and organ systems. Most veterinary school have courses in small animal and also large animal nutrition, often taken as electives in the clinical years or as part of the core curriculum in the first two years. The last two year curriculum of the two fields are similar only in their clinical emphasis.[] A veterinary student must be well prepared to be a fully functional animal physician on the day of graduation, competent in both surgery and medicine. The graduating veterinarian must be able to pass medical board examination and be prepare to enter clinical practice on the day of graduation, while most human medical doctors in the USA complete 3 to 5 years of

Veterinary physician post-doctoral residency before practicing medicine independently, usually in a very narrow and focused specialty.

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Impact on human medicine


Some veterinarians pursue post-graduate training and enter research careers and have contributed to advances in many human and veterinary medical fields, including pharmacology and epidemiology. Research veterinarians were the first to isolate oncoviruses, Salmonella species, Brucella species, and various other pathogenic agents. Veterinarians were in the forefront in the effort to suppress malaria and yellow fever in the United States. Veterinarians identified the botulism disease-causing agent, produced an anticoagulant used to treat human heart disease, and developed surgical techniques for humans, such as hip-joint replacement, limb and organ transplants.

In popular culture
Well-known depictions of a veterinarian at work are in James Herriot's All Creatures Great and Small, made into a BBC series. Doctor Dolittle is a series of children's books, one of which was turned into a 1967 movie. The movie was remade in 1998 with Eddie Murphy as Dr. Dolittle. US-based cable network Animal Planet, with animal-based programming, frequently features veterinarians. Two notable shows are Emergency Vets and E-Vet Interns, set at Alameda East Veterinary Hospital in Denver, Colorado. The song Grandma Got Run Over by a Reindeer, performed by the husband and wife duo "Elmo & Patsy", is a song performed by a veterinarian, Elmo Shropshire, DVM. Fictional character veterinarians in TV series and films include Steve Parker in Neighbours, Jim Hansen in Providence, and Vincent Ventresca in the horror film Larva. In Beethoven, Dean Jones portrayed Dr. Herman Varnick, an evil veterinarian, with his associates Harvey and Vernon played by Oliver Platt and Stanley Tucci, who wanted all animals to be destroyed. They were foiled by the Newton Family and Beethoven. The Newton Family released other dogs from Dr. Varnick's captives. The Garfield comic has a vet named Liz.

Veterinary malpractice
Most states in the US allow for malpractice lawsuit in case of death or injury to an animal from professional negligence. Usually the penalty is not greater than the value of the animal. For that reason, malpractice insurance for veterinarians usually is well under $500 a year, compared to an average of over $15000 a year for a human doctor.[14] Some states allow for punitive penalty, loss of companionship, and suffering into the award, likely increasing the cost of veterinary malpractice insurance and the cost of veterinary care. Most veterinarians carry much higher cost business, worker's compensation, and facility insurance to protect their clients and workers from injury inflicted by animals.

Criticisms
Concerns about the role of veterinary physicians in helping health threats survive and spread have been raised by several commentators, particularly with respect to pedigree dogs. Koharik Arman (2007) reached the following conclusion for example: "Veterinarians also bear some responsibility for the welfare situation of purebred dogs. In fact, the veterinary profession has facilitated the evolution of purebred dogs. Breeds that would not normally be sustainable are propagated by the compliance of veterinarians to breeder wishes. [15] This finding was echoed by Sir Patrick Bateson in his Independent Review of Dog Breeding following the broadcast of the BBC documentary Pedigree Dogs Exposed: "It's only the ready availability of modern veterinary medicine that has permitted some conditionsto become widespread.[16] When considering these criticisms, one needs to understand the make up of

Veterinary physician the veterinary profession. Some veterinarians work for and represent the animal industry, some are involved in research using animal as models for human diseases, and some are actively working in protest against the animal industry and facilities that use animals for research. All veterinarians strive to work to improve animal welfare. However, veterinarians are not all in agreement on every issue concerning animal research, animal husbandry and animal rights.

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Practice by country
Veterinary medicine in the United Kingdom Veterinary medicine in the United States

Further reading
Freyberger, P. (2009). Vetting: The Making of a Veterinarian. PJF Publishing. Gutkind, L. (1998). The Veterinarian's Touch: Profiles of Life Among the Animals. Holt Paperbacks. Herriot, J. (2004). All Creatures Great and Small. St. Martin's Griffin.

References
[1] Oxford English Dictionary, Oxford University Press. [2] Thrusfield, Michael (2007). Veterinary Epidemiology (http:/ / books. google. com/ books?id=LZfevagYF4YC), p. 2. Wiley-Blackwell [3] Hunter, Pamela (2004). Veterinary Medicine: A Guide to Historical Sources (http:/ / books. google. co. uk/ books?id=TLyFllgGgu0C& pg=PA4& dq=Charles+ Benoit+ Vial+ de+ St+ Bel& hl=en& sa=X& ei=oiwnUcyXK8XL0AXAnoD4Bg& redir_esc=y#v=onepage& q=Charles Benoit Vial de St Bel& f=false), p. 1. Ashgate Publishing, Ltd. [4] Hunter (2004) p. 4 [5] Widder, Keith R. (2005). Michigan Agricultural College: The Evolution Of A Land-Grant Philosophy, 1855-1925 (http:/ / books. google. co. uk/ books?id=aAIB3DC5KR8C& pg=PA107& dq=first+ veterinary+ college+ United+ States& hl=en& sa=X& ei=0DknUdOTJqKr0AWo6YHgCg& ved=0CEYQ6AEwBA#v=onepage& q=first veterinary college United States& f=false), p. 107. MSU Press [8] www.avma.org/1 year employment (https:/ / www. avma. org/ KB/ Resources/ Statistics/ Pages/ Market-research-statistics-First-year-employment. aspx) [9] Burns, Katie. "AVMA Survey Measures Income Trends to 2007." AVMA Journals (1 January 2009): Javma News. American Veterinary Medical Association. 2 Mar. 2009 <https://www.avma.org/News/JAVMANews/Pages/090101a.aspx>. [10] White, Tim. "How we make ends meet: economic sustainability of the veterinary profession" Australian Veterinary Journal (April 2012). 18 Apr. 2012 <http://onlinelibrary.wiley.com/doi/10.1111/j.1751-0813.2012.news_v90_i4.x/abstract>. [11] (http:/ / www. aavmc. org/ students_admissions/ vet_schools. htm) [12] Griel, Lester C. "Advising Notes." Division of Undergraduate Studies. 7 Apr. 2008. The Pennsylvania State University. 2 Mar. 2009 <http://www.psu.edu/dus/anvet.htm>. [13] "Occupational Outlook Handbook, 2008-09 Edition: Veterinarians." Bureau of Labor Statistics. 18 Dec. 2007. United States Department of Labor. 2 Mar. 2009 <http://www.bls.gov/oco.ocos076.htm>

External links
Veterinary physician (http://www.dmoz.org//Health/Animal/Veterinary_Medicine/Veterinarians//) at the Open Directory Project

Evidence-based medicine

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Evidence-based medicine
Evidence-based medicine (EBM), also called evidence-based health care (EBHC) or Evidence-based practice (EBP) to broaden its application to allied health care professionals, has been defined as "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients."[][] Trisha Greenhalgh and Anna Donald define it more specifically as "the use of mathematical estimates of the risk of benefit and harm, derived from high-quality research on population samples, to inform clinical decision-making in the diagnosis, investigation or management of individual patients."[1] EBM seeks to assess the strength of the evidence of risks and benefits of treatments (including lack of treatment) and diagnostic tests.[] This helps clinicians predict whether a treatment will do more good than harm.[] Evidence quality can be assessed based on the source type (from meta-analyses and systematic reviews of triple-blind randomized clinical trials with concealment of allocation and no attrition at the top end, down to conventional wisdom at the bottom), as well as other factors including statistical validity, clinical relevance, currency, and peer-review acceptance. EBM recognizes that many aspects of health care depend on individual factors such as quality- and value-of-life judgments, which are only partially subject to quantitative scientific methods. Application of EBM data therefore depends on patient circumstances and preferences, and medical treatment remains subject to input from personal, political, philosophical, religious, ethical, economic, and aesthetic values.

Background and definition


Evidence-based medicine (EBM) has evolved from clinical epidemiology,[] a discipline promoted by the creation of the Journal of Clinical Epidemiology in 1988. Clinical epidemiology aims to bridge the gap between clinical practice and public health using population health sciences to inform clinical practice. Thus, the methodology that underpins EBM applies methods used in the field of epidemiology to the clinical context (i.e. clinical epidemiology). In essence, EBM incorporates this quantitative (as well as qualitative) methodology in the art of clinical practice, so as to make the framework for clinical decisions more objective by better reflecting the evidence from research.[2][3] By introducing scientific methods particularly the methods of the population sciences in clinical decision making, EBM has driven a transformation of clinical practice in medicine. In 1996 David Sackett wrote that "Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients."[] This definition, put forward by one of the original proponents of evidence-based medicine,[] has since been adopted by major organizations, including the Cochrane Collaboration and the Centre for Evidence Based Medicine.[][]

Evidence-based health service


An evidence-based health service tends to generate an increase in the competence of health service decision makers and is the practice of evidence-based medicine at the organizational or institutional level. It strengthens the motivation of any health service decision-maker to use scientific methods when making a decision and details of this approach to health services and public health has been discussed in a book titled evidence-based healthcare & public health.[4] Research by Michael Fischer and colleagues at the University of Oxford finds that evidence-based rules may not readily 'hybridise' with experience-based practices orientated towards ethical clinical judgement, and can lead to contradictions, contest, and unintended crises.[5] In their recent, large study of the UK health knowledge economy, they find the most effective 'knowledge leaders' (managers and clinical leaders) use a broad range of management knowledge in their decision making, rather than just formal evidence.[6] Evidence-based guidelines may provide the basis for 'governmentality' in health care and consequently play a central role in the distant governance of contemporary health care systems.[7]

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Evidence-based decision making


The results of population-based research form the foundation of evidence-based medicine. It aims to use the experience of a population of patients reported in the research literature to guide decision making in practice. This practice of evidence-based medicine requires the application of population-based data to the care of an individual patient.[] In the past, we have relied on the experience of physicians or other health care workers to make decisions about therapy. In the current information era, this approach would be suboptimal as health care workers rapidly find themselves unable to cope with the influx of a huge variety of new information, from the irrelevant to the very important. Therefore, evidence-based decision making gradually emerged as a solution to integrate the best research evidence with clinical expertise and patient values and expectations as practiced by the individual health care provider.[8] The concepts and ideas attributed to and labeled collectively as EBM/EBHC have now become a part of daily clinical lives, and health care professionals increasingly hear about evidence-based guidelines, care paths, questions and solutions. The controversy has shifted from whether to implement the new concepts to how to do so sensibly and efficiently, while avoiding potential problems associated with a number of misconceptions about what EBM/EBHC is and what it is not.[] The EBM/EBHC-related concepts of hierarchy of evidence, meta-analyses, confidence intervals, study design, and so forth are so widespread, that health care professionals have no choice but to become familiar with EBM/EBHC principles and methodologies.

Process and progress


The five steps of EBM in practice were first described in 1992[9] and the experience of delegates attending the 2003 Conference of Evidence-Based Health Care Teachers and Developers was summarized into five steps and published in 2005.[10] This five step process can broadly be categorized as: 1. Translation of uncertainty to an answerable question and includes critical questioning, study design and levels of evidence[11] 2. Systematic retrieval of best evidence available[12] 3. Critical appraisal of evidence[] for internal validity that can be broken down into aspects regarding:[] Systematic errors as a result of selection bias, information bias and confounding Quantitative aspects of diagnosis and treatment The effect size and aspects regarding its precision Clinical importance of results External validity or generalizability 4. Application of results in practice[13] 5. Evaluation of performance[] Using techniques from science, engineering and statistics, such as the systematic review of medical literature, meta-analysis, risk-benefit analysis, and randomized controlled trials (RCTs), EBM aims for the ideal that healthcare professionals should make "conscientious, explicit, and judicious use of current best evidence" in their everyday practice. Ex cathedra statements by the "medical expert" are considered to be the least valid form of evidence. All "experts" are now expected to reference their pronouncements to scientific studies. The systematic review of published research studies is a major method used for evaluating particular treatments. The Cochrane Collaboration is one of the best-known, respected examples of systematic reviews. Like other collections of systematic reviews, it requires authors to provide a detailed and repeatable plan of their literature search and evaluations of the evidence.[] Once all the best evidence is assessed, treatment is categorized as "likely to be beneficial", "likely to be harmful", or "evidence did not support either benefit or harm". A 2007 analysis of 1016 systematic reviews from all 50 Cochrane Collaboration Review Groups found that 44% of the reviews concluded that the intervention was "likely to be beneficial", 7% concluded that the intervention was "likely to be harmful", and 49% concluded that evidence "did not support either benefit or harm". 96% recommended

Evidence-based medicine further research.[] A 2001 review of 160 Cochrane systematic reviews (excluding complementary treatments) in the 1998 database revealed that, according to two readers, 41.3% concluded positive or possibly positive effect, 20% concluded evidence of no effect, 8.1% concluded net harmful effects, and 21.3% of the reviews concluded insufficient evidence.[] A review of 145 alternative medicine Cochrane reviews using the 2004 database revealed that 38.4% concluded positive effect or possibly positive (12.4%) effect, 4.8% concluded no effect, 0.69% concluded harmful effect, and 56.6% concluded insufficient evidence.[]

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Assessing the quality of evidence


Evidence-based medicine categorizes different types of clinical evidence and rates or grades them[14] according to the strength of their freedom from the various biases that beset medical research. For example, the strongest evidence for therapeutic interventions is provided by systematic review of randomized, triple-blind, placebo-controlled trials with allocation concealment and complete follow-up involving a homogeneous patient population and medical condition. In contrast, patient testimonials, case reports, and even expert opinion (however some critics have argued that expert opinion "does not belong in the rankings of the quality of empirical evidence because it does not represent a form of empirical evidence" and continue that "expert opinion would seem to be a separate, complex type of knowledge that would not fit into hierarchies otherwise limited to empirical evidence alone."[]) have little value as proof because of the placebo effect, the biases inherent in observation and reporting of cases, difficulties in ascertaining who is an expert and more.

US Preventive Services Task Force (USPSTF)


Systems to stratify evidence by quality have been developed, such as this one by the U.S. Preventive Services Task Force for ranking evidence about the effectiveness of treatments or screening:[] Level I: Evidence obtained from at least one properly designed randomized controlled trial. Level II-1: Evidence obtained from well-designed controlled trials without randomization. Level II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group. Level II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled trials might also be regarded as this type of evidence. Level III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

UK National Health Service


The UK National Health Service uses a similar system with categories labeled A, B, C, and D. The above Levels are only appropriate for treatment or interventions; different types of research are required for assessing diagnostic accuracy or natural history and prognosis, and hence different "levels" are required. For example, the Oxford Centre for Evidence-based Medicine suggests levels of evidence (LOE) according to the study designs and critical appraisal of prevention, diagnosis, prognosis, therapy, and harm studies:[] Level A: Consistent Randomised Controlled Clinical Trial, cohort study, all or none (see note below), clinical decision rule validated in different populations. Level B: Consistent Retrospective Cohort, Exploratory Cohort, Ecological Study, Outcomes Research, case-control study; or extrapolations from level A studies. Level C: Case-series study or extrapolations from level B studies. Level D: Expert opinion without explicit critical appraisal, or based on physiology, bench research or first principles.

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Categories of recommendations
In guidelines and other publications, recommendation for a clinical service is classified by the balance of risk versus benefit of the service and the level of evidence on which this information is based. The U.S. Preventive Services Task Force uses:[15] Level A: Good scientific evidence suggests that the benefits of the clinical service substantially outweigh the potential risks. Clinicians should discuss the service with eligible patients. Level B: At least fair scientific evidence suggests that the benefits of the clinical service outweighs the potential risks. Clinicians should discuss the service with eligible patients. Level C: At least fair scientific evidence suggests that there are benefits provided by the clinical service, but the balance between benefits and risks are too close for making general recommendations. Clinicians need not offer it unless there are individual considerations. Level D: At least fair scientific evidence suggests that the risks of the clinical service outweighs potential benefits. Clinicians should not routinely offer the service to asymptomatic patients. Level I: Scientific evidence is lacking, of poor quality, or conflicting, such that the risk versus benefit balance cannot be assessed. Clinicians should help patients understand the uncertainty surrounding the clinical service.

GRADE working group


A newer system was developed by the GRADE working group and takes into account more dimensions than just the quality of medical research.[] It requires users of GRADE who are performing an assessment of the quality of evidence, usually as part of a systematic review, to consider the impact of different factors on their confidence in the results. Authors of GRADE tables, grade the quality of evidence into four levels, on the basis of their confidence in the observed effect(a numerical value) being close to what the true effect is. The confidence value is based on judgements assigned in five different domains in a structured manner.[] The GRADE working group defines 'quality of evidence' and 'strength of recommendations' based on the quality as two different concepts which are commonly confused with each other.[] Systematic reviews may include Randomized Controlled trials that have low risk of bias, or, observational studies that have high risk of bias. In the case of Randomized controlled trials, the quality of evidence is high, but can be downgraded in five different domains.[] Risk of bias: Is a judgement made on the basis of the chance that bias in included studies have influenced the estimate of effect. Imprecision: Is a judgement made on the basis of the chance that the observed estimate of effect could change completely. Indirectness: Is a judgement made on the basis of the differences in characteristics of how the study was conducted and how the results are actually going to be applied. Inconsistency: Is a judgement made on the basis of the variability of results across the included studies. Publication bias: Is a judgement made on the basis of the question whether all the research evidence has been taken to account. In the case of observational studies, the quality of evidence starts of lower and may be upgraded in three domains in addition to being subject to downgrading.[] Large effect: This is when methodologically strong studies show that the observed effect is so large that the probability of it changing completely is less likely. Plausible confounding would change the effect: This is when despite the presence of a possible confounding factor which is expected to reduce the observed effect, the effect estimate still shows significant effect. Dose response gradient: This is when the intervention used becomes more effective with increasing dose. This suggests that a further increase will likely bring about more effect.

Evidence-based medicine Meaning of the levels of Quality of evidence as per GRADE[] High Quality Evidence: The authors are very confident that the estimate that is presented lies very close to the true value. One could interpret it as: there is very low probability of further research completely changing the presented conclusions. Moderate Quality Evidence: The authors are confident that the presented estimate lies close to the true value, but it is also possible that it may be substantially different. One could also interpret it as: further research may completely change the conclusions. Low Quality Evidence: The authors are not confident in the effect estimate and the true value may be substantially different. One could interpret it as: further research is likely to change the presented conclusions completely. Very low quality Evidence: The authors do not have any confidence in the estimate and it is likely that the true value is substantially different from it. One could interpret it as: New research will most probably change the presented conclusions completely. Guideline panelists may make Strong or Weak recommendations on the basis of further criteria. Some of the important criteria are:[] Balance between desirable and undesirable effects (not considering cost) Quality of the evidence Values and preferences Costs (resource utilization) Despite the differences between systems, the purposes are the same: to guide users of clinical research information on which studies are likely to be most valid. However, the individual studies still require careful critical appraisal.

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Statistical measures
Evidence-based medicine attempts to express clinical benefits of tests and treatments using mathematical methods. Tools used by practitioners of evidence-based medicine include:

Likelihood ratio
The pre-test odds of a particular diagnosis, multiplied by the likelihood ratio, determines the post-test odds. (Odds can be calculated from, and then converted to, the [more familiar] probability.) This reflects Bayes' theorem. The differences in likelihood ratio between clinical tests can be used to prioritize clinical tests according to their usefulness in a given clinical situation.

AUC-ROC
The area under the receiver operating characteristic curve (AUC-ROC) reflects the relationship between sensitivity and specificity for a given test. High-quality tests will have an AUC-ROC approaching 1, and high-quality publications about clinical tests will provide information about the AUC-ROC. Cutoff values for positive and negative tests can influence specificity and sensitivity, but they do not affect AUC-ROC.

Number needed to treat / harm


Number needed to treat or Number needed to harm are ways of expressing the effectiveness and safety of an intervention in a way that is clinically meaningful. In general, NNT is always computed with respect to two treatments A and B, with A typically a drug and B a placebo (in our example above, A is a 5-year treatment with the hypothetical drug, and B is no treatment). A defined endpoint has to be specified (in our example: the appearance of colon cancer in the 5 year period). If the probabilities pA and pB of this endpoint under treatments A and B, respectively, are known, then the NNT is computed as 1/(pB-pA). If it is said that the NNT for breast mammography

Evidence-based medicine is 285 this means that 285 mammograms need to be performed to diagnose one case of breast cancer. As another example, an NNT of 4 means if 4 patients are treated, only one would respond. An NNT of 1 is the most effective and means each patient treated responds, e.g., in comparing antibiotics with placebo in the eradication of Helicobacter pylori. An NNT of 2 or 3 indicates that a treatment is quite effective (with one patient in 2 or 3 responding to the treatment). An NNT of 20 to 40 can still be considered clinically effective.[16]

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Quality of clinical trials


Evidence-based medicine attempts to objectively evaluate the quality of clinical research by critically assessing techniques reported by researchers in their publications. Trial design considerations. High-quality studies have clearly defined eligibility criteria and have minimal missing data. Generalizability considerations. Studies may only be applicable to narrowly defined patient populations and may not be generalizable to other clinical contexts. Follow-up. Sufficient time for defined outcomes to occur can influence the study outcomes and the statistical power of a study to detect differences between a treatment and control arm. Power. A mathematical calculation can determine if the number of patients is sufficient to detect a difference between treatment arms. A negative study may reflect a lack of benefit, or simply a lack of sufficient quantities of patients to detect a difference.

Limitations and criticism


Although evidence-based medicine is regarded as the gold standard of conventional clinical practice, limitations or criticisms of its use exist,[] such as: EBM produces quantitative research, especially from randomized controlled trials (RCTs). Accordingly, results may not be relevant for all treatment situations.[] RCTs are expensive, influencing research topics according to the sponsor's interests. There is a lag between when the RCT is conducted and when its results are published.[] Certain population segments have been historically under-researched (racial minorities and people with co-morbid diseases), and thus the RCT restricts generalizing.[] Not all evidence from an RCT is made accessible. Treatment effectiveness reported from RCTs may be different than that achieved in routine clinical practice.[17] Published studies may not be representative of all studies completed on a given topic (published and unpublished) or may be unreliable due to the different study conditions and variables.[18] EBM applies to groups of people but this does not preclude clinicians from using their personal experience in deciding how to treat each patient. One author advises that "the knowledge gained from clinical research does not directly answer the primary clinical question of what is best for the patient at hand" and suggests that evidence-based medicine should not discount the value of clinical experience.[] Another author stated that "the practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research".[] Hypocognition (the absence of a simple, consolidated mental framework that new information can be placed into) can hinder the application of EBM.[19]

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Assessing the teaching of evidence-based medicine


Two instruments, the Berlin questionnaire[][20] are the most validated.[][] These questionnaires have been used in diverse settings.[][]

In psychiatry
Standard descriptions about mental illnesses, such as the Diagnostic and Statistical Manual of Mental Disorders, have been criticized as incompletely justified by evidence. In many cases, it is unknown whether a particular "disease" has one, several, or no underlying biological causes, with controversy arising over whether some diseases are merely an artifact of the attempt to construct a unified classification scheme, rather than a "real" disease.[] While some experts point to statistics in support of the idea that a lack of adoption of research findings results in suboptimal treatment for many patients, others emphasize the importance of the skill of the practitioner and the customization of the treatment to fit individual needs. There is some controversy over whether mental illnesses are too complex for broad population studies to be helpful.[][21]

History
Traces of evidence-based medicine's origin can be found in ancient Greece.[22] Although testing medical interventions for efficacy has existed since the time of Avicenna's The Canon of Medicine in the 11th century,[23][] it was only in the 20th century that this effort evolved to impact almost all fields of health care and policy. In 1967, the American physician and mathematician Alvan R. Feinstein published his groundbreaking work Clinical Judgment, which together with Archie Cochranes famous book Effectiveness and Efficiency (1972) led to an increasing acceptance of clinical epidemiology and controlled studies during the 70s and 80s and paved the way for the institutional development of EBM in the 90s. Cochrane's efforts were recognized by the fact that an international network for efficacy assessment in medicine - the Cochrane Collaboration was posthumously named after him. However, Cochrane himself did not live to see the foundation and institutionalization of the EBM movement and Feinstein became later in his life one of its sharpest methodological critics.[24] The explicit methodologies used to determine "best evidence" were largely established by the McMaster University research group led by David Sackett and Gordon Guyatt. Guyatt later coined the term evidence-based in 1990.[] The term "evidence-based medicine" first appeared in the medical literature in 1992 in a paper by Guyatt et al.[] Relevant journals include the British Medical Journal's Clinical Evidence, the Journal Of Evidence-Based Healthcare and Evidence Based Health Policy. All of these were co-founded by Anna Donald, an Australian pioneer in the discipline.

EBM and ethics of experimental or risky treatments


Insurance companies in the United States and public insurers in other countries usually wait for drug use approval based on evidence-based guidelines before funding a treatment. Where approval for a drug has been given, and subsequent evidence-based findings indicating that a drug may be less safe than originally anticipated, some insurers in the U.S. have reacted very cautiously and withdrawn funding. For example, an older generic statin drug had been shown to reduce mortality, but a newer and much more expensive statin drug was found to lower cholesterol more effectively. However, evidence came to light about safety concerns with the new drug which caused some insurers to stop funding it even though marketing approval was not withdrawn.[25] Some people are willing to take their chances to gamble their health on the success of new drugs or old drugs in new situations which may not yet have been fully tested in clinical trials. However insurance companies are reluctant to take on the job of funding such treatments, preferring instead to take the safer route of awaiting the results of clinical testing and leaving the funding of such trials to the manufacturer seeking a license.[26]

Evidence-based medicine Sometimes caution errs in the other direction. Kaiser Permanente did not change its methods of evaluating whether or not new therapies were too "experimental" to be covered until it was successfully sued twice: once for delaying in vitro fertilization treatments for two years after the courts determined that scientific evidence of efficacy and safety had reached the "reasonable" stage; and in another case where Kaiser refused to pay for liver transplantation in infants when it had already been shown to be effective in adults, on the basis that use in infants was still "experimental."[27] Here again, the problem of induction plays a key role in arguments.

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Application of the evidence based model on other public policy matters


There has been discussion of applying what has been learned from EBM to public policy. In his 1996 inaugural speech as President of the Royal Statistical Society, Adrian Smith held out evidence-based medicine as an exemplar for all public policy. He proposed that "evidence-based policy" should be established for education, prisons and policing policy and all areas of government.[]

References
[1] Greenhalgh, Trisha. How To Read a Paper: The Basics of Evidence-Based Medicine. Wiley-Blackwell, fourth edition, 2010, p. 1. [7] Ferlie, E. & McGivern, G. (2013) Bringing Anglo-Governmentality into Public Management Scholarship: The Case of Evidence-Based Medicine in the UK (http:/ / jpart. oxfordjournals. org/ content/ early/ 2013/ 02/ 26/ jopart. mut002. abstract). Journal of Public Administration Research & Theory. First published online: February 27, 2013 [17] "Patient Compliance with statins" Bandolier Review (http:/ / www. jr2. ox. ac. uk/ bandolier/ booth/ cardiac/ patcomp. html) 2004 [20] Fresno test (http:/ / www. bmj. com/ content/ suppl/ 2003/ 02/ 10/ 326. 7384. 319. DC1)

Bibliography
Doi, S.A.R. (2012). Understanding evidence in health care: Using clinical epidemiology. South Yarra, VIC, Australia: Palgrave Macmillan. ISBN978-1-4202-5669-7. Grobbee, D.E.; Hoes, Arno W. (2009). Clinical Epidemiology: Principles, Methods, and Applications for Clinical Research. Jones & Bartlett Learning. ISBN978-0-7637-5315-3. Howick, Jeremy H. (2011). The Philosophy of Evidence-based Medicine (http://books.google.com/ books?id=O8djbHBva5IC). Wiley. ISBN978-1-4051-9667-3. Katz, David L. (2001). Clinical Epidemiology & Evidence-Based Medicine: Fundamental Principles of Clinical Reasoning & Research. SAGE. ISBN978-0-7619-1939-1.

External links
Evidence-Based Medicine (http://www.dmoz.org/Health/Medicine/Evidence_Based_Medicine/) at the Open Directory Project

Electrocardiography

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Electrocardiography
Electrocardiography
Intervention

Image showing a patient connected to the 10 electrodes necessary for a 12-lead ECG ICD-9-CM MeSH MedlinePlus 89.52 D004562 003868 [1]

[2]

Electrocardiography (ECG or EKG from Greek: kardia, meaning heart) is a transthoracic (across the thorax or chest) interpretation of the electrical activity of the heart over a period of time, as detected by electrodes attached to the surface of the skin and recorded by a device external to the body.[] The recording produced by this noninvasive procedure is termed an electrocardiogram (also ECG or EKG).

Example of Modern PC Based AME ECG

An ECG is used to measure the rate and regularity of heartbeats, as well as the size and position of the chambers, the presence of any damage to the heart, and the effects of drugs or devices used to regulate the heart, such as a pacemaker.

Electrocardiography

592 for on be for or

Most ECGs are performed diagnostic or research purposes human hearts, but may also performed on animals, usually diagnosis of heart abnormalities research.

Twelve-lead ECG of a 26-year-old male

Function
An ECG is a way to measure and diagnose abnormal rhythms of the heart,and helps to diagnose properly[3] particularly abnormal rhythms caused by damage to the conductive tissue that carries electrical signals, or abnormal rhythms caused by electrolyte imbalances.[] In a myocardial infarction (MI), the ECG can identify if the heart muscle has been damaged in specific areas, though not all areas of the heart are covered.[] The ECG cannot reliably measure the pumping ability of the heart, for which ultrasound-based (echocardiography) or nuclear medicine tests are used. It is possible for a human or other animal to be in cardiac arrest, but still have a normal ECG signal (a condition known as pulseless electrical activity). The ECG device detects and amplifies the tiny electrical changes on the skin that are caused when the heart muscle depolarizes during each heartbeat. At rest, each heart muscle cell has a negative charge, called the membrane potential, across its cell membrane. Decreasing this negative charge towards zero, via the influx of the positive cations, Na+ and Ca++, is called depolarization, which activates the mechanisms in the cell that cause it to contract. During each heartbeat, a healthy heart will have an orderly progression of a wave of depolarisation that is triggered by the cells in the sinoatrial node, spreads out through the atrium, passes through the atrioventricular node and then spreads all over the ventricles. This is detected as tiny rises and falls in the voltage between two electrodes placed either side of the heart which is displayed as a wavy line either on a screen or on paper. This display indicates the overall rhythm of the heart and weaknesses in different parts of the heart muscle. Usually, more than two electrodes are used, and they can be combined into a number of pairs (For example: left arm (LA), right arm (RA) and left leg (LL) electrodes form the three pairs LA+RA, LA+LL, and RA+LL). The output from each pair is known as a lead. Each lead looks at the heart from a different angle. Different types of ECGs can be referred to by the number of leads that are recorded, for example 3-lead, 5-lead or 12-lead ECGs (sometimes simply "a 12-lead"). A 12-lead ECG is one in which 12 different electrical signals are recorded at approximately the same time and will often be used as a one-off recording of an ECG, traditionally printed out as a paper copy. Threeand 5-lead ECGs tend to be monitored continuously and viewed only on the screen of an appropriate monitoring device, for example during an operation or whilst being transported in an ambulance. There may or may not be any permanent record of a 3- or 5-lead ECG, depending on the equipment used.

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History
The etymology of the word is derived from the Greek electro, because it is related to electrical activity, kardio, Greek for heart, and graph, a Greek root meaning "to write". Alexander Muirhead is reported to have attached wires to a feverish patient's wrist to obtain a record of the patient's heartbeat while studying for his Doctor of Science (in electricity) in 1872 at St Bartholomew's Hospital.[4] This activity was directly recorded and visualized using a Lippmann capillary electrometer by the British physiologist John Burdon Sanderson.[5] The first to systematically approach the heart from an electrical point-of-view was Augustus Waller, working in St Mary's Hospital in Paddington, London.[] His electrocardiograph machine consisted of a Lippmann capillary electrometer fixed to a projector. The trace from the heartbeat was projected onto a photographic plate which was itself fixed to a toy train. This allowed a heartbeat to be recorded in real time. In 1911 he still saw little clinical application for his work. An initial breakthrough came when Willem Einthoven, working in Leiden, the Netherlands, used the string galvanometer he invented in 1901.[6] This device was much more sensitive than both the capillary electrometer Waller used and the string galvanometer that had been invented separately in 1897 by the French engineer Clment Ader.[7] Rather than using today's self-adhesive electrodes Einthoven's subjects would immerse each of their limbs into containers of salt solutions from which the ECG was recorded. Einthoven assigned the letters P, Q, R, S and T to the various deflections,[] and described the electrocardiographic features of a number of cardiovascular disorders. In 1924, he was awarded the

An early commercial ECG device (1911)

Nobel Prize in Medicine for his discovery.[] Though the basic principles of that era are still in use today, many advances in electrocardiography have been made over the years. The instrumentation, for example, has evolved from a cumbersome laboratory apparatus to compact electronic systems that often include computerized interpretation of the electrocardiogram.[8]

ECG graph paper


The output of an ECG recorder is a graph (or sometimes several graphs, representing each of the leads) with time represented on the x-axis and voltage represented on the y-axis. A dedicated ECG machine would usually print onto graph paper which has a background pattern of 1mm squares (often in red or green), with bold divisions every 5mm in both vertical and horizontal directions. It is possible to change the output of most ECG devices but it is standard to represent each mV on the y axis as 1cm and each second as 25mm on the x-axis (that is a paper speed of 25mm/s). Faster paper One second of ECG graph paper speeds can be used, for example, to resolve finer detail in the ECG. At a paper speed of 25mm/s, one small block of ECG paper translates into 40ms. Five small blocks make up one large block, which translates into 200ms. Hence, there are five large blocks per second. A calibration signal may be included with a record. A standard signal of 1mV must move the stylus vertically 1cm, that is, two large squares on ECG paper.

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Layout
By definition, a 12-lead ECG will show a short segment of the recording of each of the 12-leads. This is often arranged in a grid of four columns by three rows, the first column being the limb leads (I,II and III), the second column the augmented limb leads (aVR, aVL and aVF) and the last two columns being the chest leads (V1-V6). It is usually possible to change this layout, so it is vital to check the labels to see which lead is represented. Each column will usually record the same moment in time for the three leads and then the recording will switch to the next column, which will record the heart beats after that point. It is possible for the heart rhythm to change between the columns of leads. Each of these segments is short, perhaps one to three heart beats only, depending on the heart rate, and it can be difficult to analyse any heart rhythm that shows changes between heart beats. To help with the analysis, it is common to print one or two "rhythm strips", as well. This will usually be lead II (which shows the electrical signal from the atrium, the P-wave, well) and shows the rhythm for the whole time the ECG was recorded (usually 56 sec). Some ECG machines will print a second lead II along the very bottom of the paper in addition to the output described above. This printing of lead II is continuous from start to finish of the process. The term "rhythm strip" may also refer to the whole printout from a continuous monitoring system, which may show only one lead and is either initiated by a clinician or in response to an alarm or event.

Leads
The term "lead" in electrocardiography causes much confusion because it is used to refer to two different things. In accordance with common parlance, the word lead may be used to refer to the electrical cable attaching the electrodes to the ECG recorder. As such, it may be acceptable to refer to the "left arm lead" as the electrode (and its cable) that should be attached at or near the left arm. Usually, 10 of these electrodes are standard in a "12-lead" ECG. Alternatively (and some would say properly, in the context of electrocardiography), the word lead may refer to the tracing of the voltage difference between two of the electrodes and is what is actually produced by the ECG recorder. Each will have a specific name. For example "lead I" is the voltage between the right arm electrode and the left arm electrode, whereas "Lead II" is the voltage between the right arm and the left leg. (This rapidly becomes more complex as one of the "electrodes" may in fact be a composite of the electrical signal from a combination of the other electrodes). Twelve of this type of lead form a "12-lead" ECG. To cause additional confusion, the term "limb leads" usually refers to the tracings from leads I, II and III rather than the electrodes attached to the limbs.

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Placement of electrodes
Ten electrodes are used for a 12-lead ECG. The electrodes usually consist of a conducting gel, embedded in the middle of a self-adhesive pad onto which cables clip. Sometimes the gel also forms the adhesive.[9] They are labeled and placed on the patient's body as follows:[10][11]

Proper placement of the limb electrodes, color-coded as recommended by the American Heart Association (a different colour scheme is used in Europe): The limb electrodes can be far down on the limbs or close to the hips/shoulders, [12] but they must be even (left vs right). * When exercise stress tests are performed, limb leads may be placed on the trunk to avoid artifacts while ambulatory (arm leads moved subclavicularly and leg leads medial to and above the iliac crest).

Placement of the precordial leads

12 leads

Electrode label (in the USA) RA LA RL LL V1 V2 V3 V4 V5 V6

Electrode placement On the right arm, avoiding thick muscle. In the same location where RA was placed, but on the left arm. On the right leg, lateral calf muscle. In the same location where RL was placed, but on the left leg. In the fourth intercostal space (between ribs 4 and 5) just to the right of the sternum (breastbone). In the fourth intercostal space (between ribs 4 and 5) just to the left of the sternum. Between leads V2 and V4. In the fifth intercostal space (between ribs 5 and 6) in the mid-clavicular line. Horizontally even with V4, in the left anterior axillary line. Horizontally even with V4 and V5 in the midaxillary line.

Electrocardiography Additional electrodes The classical 12-lead ECG can be extended in a number of ways in an attempt to improve its sensitivity in detecting myocardial infarction involving territories not normally "seen" well. This includes an rV4 lead, which uses the equivalent landmarks to the V4 but on the right side of the chest wall and extending the chest leads onto the back with a V7, V8 and V9. The Lewis lead or S5 has the LA electrode placed in the second intercostal space to the right of the sternum with the RA at the fourth intercostal space. It is read as lead I and is supposed to demonstrate atrial activity much better to aid in identification of atrial flutter or broad-complex tachycardia. A posterior ECG can aid in the diagnosis of a posterior myocardial infarction. This is performed by the addition of leads V7, V8 and V9 extending around the left chest wall toward the back.

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Limb leads
In both the 5- and 12-lead configurations, leads I, II and III are called limb leads. The electrodes that form these signals are located on the limbsone on each arm and one on the left leg.[][13][14] The limb leads form the points of what is known as Einthoven's triangle.[15] Lead I is the voltage between the (positive) left arm (LA) electrode and right arm (RA) electrode:

Lead II is the voltage between the (positive) left leg (LL) electrode and the right arm (RA) electrode:

Lead III is the voltage between the (positive) left leg (LL) electrode and the left arm (LA) electrode:

Simplified electrocardiograph sensors designed for teaching purposes, e.g. at high school level, are generally limited to three arm electrodes serving similar purposes.[16]

Unipolar vs. bipolar leads


The two types of leads are unipolar and bipolar. Bipolar leads have one positive and one negative pole.[17] In a 12-lead ECG, the limb leads (I, II and III) are bipolar leads. Unipolar leads also have two poles, as a voltage is measured; however, the negative pole is a composite pole (Wilson's central terminal, or WCT) made up of signals from multiple other electrodes.[18] In a 12-lead ECG, all leads except the limb leads are unipolar (aVR, aVL, aVF, V1, V2, V3, V4, V5, and V6). Wilson's central terminal VW is produced by connecting the electrodes RA, LA, and LL together, via a simple resistive network, to give an average potential across the body, which approximates the potential at infinity (i.e. zero):

Augmented limb leads


Leads aVR, aVL, and aVF are augmented limb leads (after their inventor Dr. Emanuel Goldberger known collectively as the Goldberger's leads). They are derived from the same three electrodes as leads I, II, and III. However, they view the heart from different angles (or vectors) because the negative electrode for these leads is a modification of Wilson's central terminal. This zeroes out the negative electrode and allows the positive electrode to become the "exploring electrode". This is possible because Einthoven's Law states that I + (II) + III = 0. The equation can also be written I + III = II. It is written this way (instead of I II + III = 0) because Einthoven reversed the polarity of lead II in Einthoven's triangle, possibly because he liked to view upright QRS complexes. Wilson's

Electrocardiography central terminal paved the way for the development of the augmented limb leads aVR, aVL, aVF and the precordial leads V1, V2, V3, V4, V5 and V6. Lead augmented vector right (aVR)' has the positive electrode (white) on the right arm. The negative electrode is a combination of the left arm (black) electrode and the left leg (red) electrode, which "augments" the signal strength of the positive electrode on the right arm:

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Lead augmented vector left (aVL) has the positive (black) electrode on the left arm. The negative electrode is a combination of the right arm (white) electrode and the left leg (red) electrode, which "augments" the signal strength of the positive electrode on the left arm:

Lead augmented vector foot (aVF) has the positive (red) electrode on the left leg. The negative electrode is a combination of the right arm (white) electrode and the left arm (black) electrode, which "augments" the signal of the positive electrode on the left leg:

The augmented limb leads aVR, aVL, and aVF are amplified in this way because the signal is too small to be useful when the negative electrode is Wilson's central terminal. Together with leads I, II, and III, augmented limb leads aVR, aVL, and aVF form the basis of the hexaxial reference system, which is used to calculate the heart's electrical axis in the frontal plane. The aVR, aVL, and aVF leads can also be represented using the I and II limb leads:

The limb leads I,II and III and the augmented limb leads aVR, aVL, and aVF can be considered simply as geometric projections of a cardiac vector on specific directions of the frontal plane. Over the 90% of the hearts electrical activity can be explained modelling heart as an electrical generator located in a specific point within the body and assuming that the electrical activity is represented by a (cardiac) vector (dipole source model) [] [19][20].

Einthoven Triangle and the cardiac vector

As shown in the previous figure, referred as Einthoven triangle, defining with H the cardiac vector generated by the heart, as per any geometric vector, H is identified by its magnitude M and its direction in the frontal plane, where is referred in medical terms to as cardiac axis. All the six limb leads can be then obtained by M and using trigonometric formulas.

Electrocardiography More specifically, we recall that the limbs I, II, III, are the projection of the cardiac vector over 0, 60, and 120 degrees respectively. TheLimb leads are then given by:
I = M cos ( + 0 ), II = M cos ( + 60), III= M cos ( + 120)

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For the augmented leads, we recall that aVR, aVL, aVF are the projection of the cardiac vector over 90, -30, and -150 degrees respectively. Thus, it can be easily found that the augmented leads become []:
aVR = (3/2)M cos ( + 90 ), aVL = (3/2) M cos ( - 30), aVF = (3/2)M cos ( -150)

The previous equations evidence that the six frontal plane leads are completely determined by the magnitude M of the cardiac vectorthat varies over time and the axis almost constant over time. All the medical information from the six limb leads can then be mathematically derived by two independent components such as Mand the axis that embeds other medical information. Alternatively all the mathematical and medical information can be derived by two independent limb leads. For example, many modern ECG compute the six limb leads mathematically using only two limb leads such as I and aVf which are orthogonal on the frontal plane. The previous equations are also used on computer assisted programs to assess frontal cardiac axis [] .

Precordial leads
The electrodes for the precordial leads (V1, V2, V3, V4, V5 and V6) are placed directly on the chest. Because of their close proximity to the heart, they do not require augmentation. Wilson's central terminal is used for the negative electrode, and these leads are considered to be unipolar (recall that Wilson's central terminal is the average of the three limb leads. This approximates common, or average, potential over the body). The precordial leads view the heart's electrical activity in the so-called horizontal plane. The heart's electrical axis in the horizontal plane is referred to as the Z axis.

Waves and intervals


A typical ECG tracing of the cardiac cycle (heartbeat) consists of a P wave, a QRS complex, a T wave, and a U wave, which is normally invisible in 50 to 75% of ECGs because it is hidden by the T wave and upcoming new P wave.[22] The baseline of the electrocardiogram (the flat horizontal segments) is measured as the portion of the tracing following the T wave and preceding the next P wave and the segment between the P wave and the following QRS complex (PR segment). In a normal healthy heart, the baseline is equivalent to the isoelectric line (0mV) and represents the periods in the cardiac cycle when there are no currents flowing towards either the positive or negative ends of the ECG leads. However, in a diseased heart the baseline may be elevated (e.g. cardiac ischaemia) or depressed (e.g. myocardial infarction) Schematic representation of normal ECG relative to the isoelectric line due to injury currents flowing during the TP and PR intervals when the ventricles are at rest. The ST segment typically remains close to the isoelectric line as this is the period when the ventricles are fully depolarised and thus no currents can flow in the ECG leads. Since most ECG recordings do not indicate where the 0mV

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line is, baseline depression often gives the appearance of an elevation of the ST segment and conversely baseline elevation gives the appearance of depression of the ST segment.[23]

Animation of a normal ECG wave

Detail of the QRS complex, showing ventricular activation time (VAT) and amplitude

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Upper limit of normal QT interval, corrected for [] heart rate according to Bazett's formula, [] Fridericia's formula and subtracting 0.02s from [21] QT for every 10bpm increase in heart rate. Up to 0.42s (420ms) is chosen as normal QTc of QTB and QTF in this diagram.

Feature RR interval P wave

Description The interval between an R wave and the next R wave; normal resting heart rate is between 60 and 100 bpm.

Duration 0.6 to 1.2s

During normal atrial depolarization, the main electrical vector is directed from the SA node towards the AV node and 80ms spreads from the right atrium to the left atrium. This turns into the P wave on the ECG. The PR interval is measured from the beginning of the P wave to the beginning of the QRS complex. The PR interval 120 to 200ms reflects the time the electrical impulse takes to travel from the sinus node through the AV node and entering the ventricles. The PR interval is, therefore, a good estimate of AV node function. The PR segment connects the P wave and the QRS complex. The impulse vector is from the AV node to the bundle of His to the bundle branches and then to the Purkinje fibers. This electrical activity does not produce a contraction directly and is merely traveling down towards the ventricles, and this shows up flat on the ECG. The PR interval is more clinically relevant. The QRS complex reflects the rapid depolarization of the right and left ventricles. The ventricles have a large muscle mass compared to the atria, so the QRS complex usually has a much larger amplitude than the P-wave. The point at which the QRS complex finishes and the ST segment begins. It is used to measure the degree of ST elevation or depression present. The ST segment connects the QRS complex and the T wave. The ST segment represents the period when the ventricles are depolarized. It is isoelectric. The T wave represents the repolarization (or recovery) of the ventricles. The interval from the beginning of the QRS complex to the apex of the T wave is referred to as the absolute refractory period. The last half of the T wave is referred to as the relative refractory period (or vulnerable period). The ST interval is measured from the J point to the end of the T wave. 50 to 120ms

PR interval

PR segment

QRS complex J-point

80 to 120ms

N/A

ST segment T wave

80 to 120ms

160ms

ST interval QT interval

320ms

The QT interval is measured from the beginning of the QRS complex to the end of the T wave. A prolonged QT interval is a risk factor for ventricular tachyarrhythmias and sudden death. It varies with heart rate and, for clinical relevance, requires a correction for this, giving the QTc. The U wave is hypothesized to be caused by the repolarization of the interventricular septum. It normally has a low amplitude, and even more often is completely absent. It always follows the T wave, and also follows the same [24] direction in amplitude. If it is too prominent, suspect hypokalemia, hypercalcemia or hyperthyroidism. The J wave, elevated J-point or Osborn wave appears as a late delta wave following the QRS or as a small secondary [25] R wave. It is considered pathognomonic of hypothermia or hypocalcemia.

Up to 420ms in heart rate of 60 bpm

U wave

J wave

Electrocardiography Originally, four deflections were noted, but after the mathematical correction for artifacts introduced by early amplifiers, a fifth deflection was discovered. Einthoven chose the letters P, Q, R, S, and T to identify the tracing which was superimposed over the uncorrected labeled A, B, C, and D.[] In intracardiac electrocardiograms, such as can be acquired from pacemaker sensors, an additional wave can be seen, the H deflection, which reflects the depolarization of the bundle of His.[26] The H-V interval, in turn, is the duration from the beginning of the H deflection to the earliest onset of ventricular depolarization recorded in any lead.[27]

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Vectors and views


Interpretation of the ECG relies on the idea that different leads (meaning the ECG leads I, II, III, aVR, aVL, aVF and the chest leads) "view" the heart from different angles. This has two benefits. Firstly, leads which are showing problems (for example ST segment elevation) can be used to infer which region of the heart is affected. Secondly, the overall direction of travel of the wave of depolarisation can also be inferred which can reveal other problems. This is termed the cardiac axis . Determination of the cardiac axis relies on the concept of a vector which describes the motion of the depolarisation wave. This vector can then be described in terms of its components in relation to the direction of the lead considered. One component will be in the direction of the lead and this will be revealed in the behaviour of the Graphic showing the relationship between QRS complex and one component will be at 90 to this (which will positive electrodes, depolarization wavefronts (or mean electrical vectors), and complexes not). Any net positive deflection of the QRS complex (i.e. height of the displayed on the ECG R-wave minus depth of the S-wave) suggests the wave of depolarisation is spreading through the heart in a direction that has some component (of the vector) in the same direction as the lead in question.

Axis
The heart's electrical axis refers to the general direction of the heart's depolarization wavefront (or mean electrical vector) in the frontal plane. With a healthy conducting system, the cardiac axis is related to where the major muscle bulk of the heart lies. Normally, this is the left ventricle, with some contribution from the right ventricle. It is usually Diagram showing how the polarity of the QRS oriented in a right shoulder to left leg direction, which corresponds to complex in leads I, II, and III can be used to the left inferior quadrant of the hexaxial reference system, although estimate the heart's electrical axis in the frontal 30 to +90 is considered to be normal. If the left ventricle increases plane its activity or bulk, then there is said to be "left axis deviation" as the axis swings round to the left beyond 30; alternatively, in conditions where the right ventricle is strained or hypertrophied, then the axis swings round beyond +90 and "right axis deviation" is said to exist. Disorders of the conduction system of the heart can disturb the electrical axis without necessarily reflecting changes in muscle bulk.

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Normal

30 to 90

Normal

Normal

Left axis deviation 30 to 90 Right axis deviation Extreme right axis deviation +90 to +180 +180 to 90

May indicate left anterior fascicular block or Q waves from inferior MI. May indicate left posterior fascicular block, Q waves from high lateral MI, or a right ventricular strain pattern Is rare, and considered an 'electrical no-man's land'

Left axis deviation is considered normal in pregnant women and those with emphysema. Right deviation is considered normal in children and is a standard effect of dextrocardia.

In the setting of right bundle branch block, right or left axis deviation may indicate bifascicular block.

Clinical lead groups


Of the 12 leads in total, each records the electrical activity of the heart from a different perspective, which also correlates to different anatomical areas of the heart for the purpose of identifying acute coronary ischemia or injury. Two leads that look at neighbouring anatomical areas of the heart are said to be contiguous. The relevance of this is in determining whether an abnormality on the ECG is likely to represent true disease or a spurious finding.

The hexaxial reference system showing the orientation of each lead: For example, if the bulk of heart muscle is oriented at +60 degrees with respect to the SA node, lead II will show the greatest deflection and aVL the least.

Diagram showing the contiguous leads in the same color

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Category

Color on chart Yellow

Leads

Activity

Inferior leads' Lateral leads

Leads II, III and aVF I, aVL, V5 and V6

Look at electrical activity from the vantage point of the inferior surface (diaphragmatic surface of heart)

Green

Look at the electrical activity from the vantage point of the lateral wall of left ventricle The positive electrode for leads I and aVL should be located distally on the left arm and because of which, leads I and aVL are sometimes referred to as the high lateral leads. Because the positive electrodes for leads V5 and V6 are on the patient's chest, they are sometimes referred to as the low lateral leads.

Septal leads Orange

V1 and V2 V3 and V4

Look at electrical activity from the vantage point of the septal surface of the heart (interventricular septum) Look at electrical activity from the vantage point of the anterior wall of the right and left ventricles (sternocostal surface of the heart)

Anterior leads

Blue

In addition, any two precordial leads next to one another are considered to be contiguous. For example, though V4 is an anterior lead and V5 is a lateral lead, they are contiguous because they are next to one another. A common saying to remember the contiguous leads is "I see all leads" (inferior, septal, anterior and lateral). Lead aVR offers no specific view of the left ventricle. Rather, it views the inside of the endocardial wall to the surface of the right atrium, from its perspective on the right shoulder.

Filter selection
Modern ECG monitors offer multiple filters for signal processing. The most common settings are monitor mode and diagnostic mode. In monitor mode, the low-frequency filter (also called the high-pass filter because signals above the threshold are allowed to pass) is set at either Wiggers diagram, showing a normal ECG curve synchronized with other major events during the 0.5Hz or 1Hz and the high-frequency filter (also called the low-pass cardiac cycle filter because signals below the threshold are allowed to pass) is set at 40Hz. This limits artifacts for routine cardiac rhythm monitoring. The high-pass filter helps reduce wandering baseline and the low-pass filter helps reduce 50- or 60-Hz power line noise (the power line network frequency differs between 50 and 60Hz in different countries). In diagnostic mode, the high-pass filter is set at 0.05Hz, which allows accurate ST segments to be recorded. The low-pass filter is set to 40, 100, or 150Hz. Consequently, the monitor mode ECG display is more filtered than diagnostic mode, because its passband is narrower.[28]

Indications
Medical societies do not recommend either the ECG or any other cardiac imaging procedure as a routine screening procedure in patients without symptoms and who are at low risk for coronary heart disease.[] This is because overuse of the procedure is more likely to supply incorrect supporting evidence for a nonexistent problem than to detect a true problem.[] Tests which falsely indicate the existence of a problem are likely to lead to misdiagnosis, the recommendation of invasive procedures, or overtreatment, and the risks associated with managing false information are usually more troublesome than not using ECG results to make a health recommendation in low-risk individuals.[] Symptoms generally indicating use of electrocardiography include: Symptoms of myocardial infarction Symptoms of pulmonary embolism

Electrocardiography Cardiac murmurs[] Syncope or collapse[] Seizures[] Perceived cardiac dysrhythmias[]

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It is also used to assess patients with systemic disease, as well as monitoring during anesthesia and critically ill patients.[]

Myocardial infarction
Characteristic changes seen on electrocardiography in myocardial infarction is included in the WHO criteria as revised in 2000.[] According to these, a cardiac troponin rise accompanied by either typical symptoms, pathological Q waves, ST elevation or depression or coronary intervention are diagnostic of myocardial infarction.

Pulmonary embolism
In pulmonary embolism, an ECG may show signs of right heart strain or acute cor pulmonale in cases of large PEs the classic signs are a large S wave in lead I, a large Q wave in lead III and an inverted T wave in lead III (S1Q3T3).[29] This is occasionally (up to 20%) present, but may also occur in other acute lung conditions and has therefore limited diagnostic value. This S1Q3T3 pattern from acute right heart strain is termed the "McGinn-White sign" after the initial describers. The most commonly seen signs in the ECG is sinus tachycardia, right axis deviation and right bundle branch block.[30] Sinus tachycardia was however still only found in 869% of people with PE.[31]

Electrocardiogram of a patient with pulmonary embolism showing sinus tachycardia of approximately 150 beats per minute and right bundle branch block.

Some pathological patterns which can be seen on the ECG


The following table mentions some pathological patterns that can be seen on electrocardiography, followed by possible causes.
Shortened QT interval Prolonged QT interval Flattened or inverted T waves Hyperacute T waves Hypercalcemia, some drugs, certain genetic abnormalities, hyperkalemia Hypocalcemia, some drugs, certain genetic abnormalities Coronary ischemia, hypokalemia, left ventricular hypertrophy, digoxin effect, some drugs Possibly the first manifestation of acute myocardial infarction, where T waves become more prominent, symmetrical, and pointed

Peaked T wave, QRS wide, prolonged PR, Hyperkalemia, treat with calcium chloride, glucose and insulin or dialysis QT short Prominent U waves Hypokalemia

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Electrocardiogram heterogeneity
ECG heterogeneity is a measurement of the amount of variance between one ECG waveform and the next. This heterogeneity can be measured by placing multiple ECG electrodes on the chest and then computing the variance in waveform morphology across the signals obtained from these electrodes. Recent research suggests ECG heterogeneity often precedes dangerous cardiac arrhythmias. In the future, implantable devices may be programmed to measure and track heterogeneity. These devices could potentially help ward off arrhythmias by stimulating nerves such as the vagus nerve, delivering drugs such as beta-blockers, and if necessary, defibrillating the heart.[32]

Rhythm Strip
Although multiple leads, and thus multiple electrical vectors, are commonly used in unison to gain diagnostic and therapeutic insight into cardiac status monitoring one lead, referred to as a rhythm strip, can be useful to trend cardiac function in terms of heart rate, regularity, pauses, and basic rhythm.

Fetal electrocardiography
Fetal electrocardiography records the electrical activity of a fetus, and when performed as a part of monitoring in childbirth, involves a single electrode being passed through the woman's cervix and attached to the baby's scalp.[] According to a Cochrane review, monitoring the fetus using ECG plus cardiotocography (CTG) resulted in fewer instances of fetal scalp blood testing, and less surgical assistance with the birth, compared to CTG alone.[] There was no difference in the number of Caesarean deliveries and little to suggest the babies were in better condition at birth.[]

References
[1] http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2011/ MB_cgi?field=uid& term=D004562 [2] http:/ / www. nlm. nih. gov/ medlineplus/ ency/ article/ 003868. htm [3] Braunwald E. (Editor), Heart Disease: A Textbook of Cardiovascular Medicine, Fifth Edition, p. 108, Philadelphia, W.B. Saunders Co., 1997. ISBN 0-7216-5666-8. [4] Ronald M. Birse, rev. Patricia E. Knowlden (http:/ / www. oxforddnb. com/ view/ article/ 37794) Oxford Dictionary of National Biography 2004 (Subscription required) (original source is his biography written by his wife Elizabeth Muirhead. Alexandernn Muirhead 1848 1920. Oxford, Blackwell: privately printed 1926.) [9] See images of ECG electrodes (http:/ / www. superboverseas. com/ show_product. asp?id=104) (http:/ / images. google. com/ images?q=ecg+ electrode& oe=UTF-8& rls=org. mozilla:en-US:official& client=firefox-a& um=1& ie=UTF-8& sa=N& tab=wi& ei=IOEHSqCELp3ItgeY8_2HBw& oi=property_suggestions& resnum=0& ct=property-revision& cd=1) [11] AHA Diagnostic ECG Electrode Placement (http:/ / www. welchallyn. com/ documents/ Cardiopulmonary/ Electrocardiographs/ PC-Based Exercise Stress ECG/ poster_110807_pcexerecg. pdf). WelchAllyn [12] RESTING 12-LEAD ECG ELECTRODE PLACEMENT AND ASSOCIATED PROBLEMS (http:/ / www. scst. org. uk/ coleman/ resting. htm). scst.org.uk [15] Electrocardiogram explanation image (http:/ / nobelprize. org/ medicine/ educational/ ecg/ images/ triangle. gif). nobelprize.org [16] e.g. Pasco Pasport EKG Sensor PS-2111, Sciencescope ECG Sensor, etc. [17] Fay Johnson ECG presentation (http:/ / academic. cuesta. edu/ fjohnson/ PowerPoint_PDF/ 12leadecg. pdf). Cuesta College Home Page [19] Gesolwitz D. B., Dipole Theory in electrocardiography, American Journal on Cardiology, 1964 14: (9) 301- 6 [20] Malmivuo J. Plonsey R., (1995), Bioelectromagnetism Principles and Applications, Oxford University Press, ISBN:978-0195058239 [21] Lesson III. Characteristics of the Normal ECG (http:/ / library. med. utah. edu/ kw/ ecg/ ecg_outline/ Lesson3/ index. html) Frank G. Yanowitz, MD. Professor of Medicine. University of Utah School of Medicine. Retrieved on Mars 23, 2010 [22] A movie by the National Heart Lung and Blood Institute explaining the connection between an ECG and the electricity in heart: What Is the Heart? (http:/ / www. nhlbi. nih. gov/ health/ dci/ Diseases/ hhw/ hhw_electrical. html) [23] Electrophysiological Changes During Cardiac Ischemia (http:/ / www. cvphysiology. com/ CAD/ CAD012. htm) [26] H deflection (http:/ / medical-dictionary. thefreedictionary. com/ H+ deflection). thefreedictionary.com citing: Mosby's Medical Dictionary, 8th edition. 2009 [27] H-V interval (http:/ / medical-dictionary. thefreedictionary. com/ H-V+ interval). thefreedictionary.com citing: McGraw-Hill Concise Dictionary of Modern Medicine. 2002 [28] Mark JB "Atlas of Cardiovascular Monitoring." p. 130. New York: Churchill Livingstone, 1998. ISBN 0-443-08891-8.

Electrocardiography
[32] Verrier, Richard L. Dynamic Tracking of ECG Heterogeneity to Estimate Risk of Life-threatening Arrhythmias. (http:/ / www. cimit. org/ forum/ forum-cardio-09. 25. 07. Verrier. html) CIMIT Forum. September 25, 2007.

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External links
Electrocardiogram, EKG, or ECG (http://www.nhlbi.nih.gov/health/dci/Diseases/ekg/ekg_what.html) Explanation of what an ECG is, who needs one, what to expect during one, etc. Written by the National Heart Lung and Blood Institute (a division of the NIH) Photographic guide to 12-lead ECG electrode placement on males & females (http://www.instamedic.co.uk/ osce/ecg/) ECG Lead Placement (https://www.nottingham.ac.uk/nursing/practice/resources/cardiology/function/ placement_of_leads.php) A teaching guide "designed for student nurses who know nothing at all about Cardiology" The whole ECG course on 1 A4 paper (http://www.ecgpedia.org/A4/ECGpedia_on_1_A4En.pdf) from ECGpedia (http://en.ecgpedia.org/wiki/Main_Page), a wiki encyclopedia for a course on interpretation of ECG (http://en.ecgpedia.org/wiki/ECG_course) ECG in 100 steps a PowerPoint presentation (http://www.lifehugger.com/doc/120/ecg-100-steps) LearnTheHeart.com - Basic explanation of the ECG and tutorial on how to interpret an electrocardiogram. Hundreds of examples. (http://www.learntheheart.com/EKGBasics.html) Free ECG tutorial videos (http://ecgteacher.com/) 12-lead ECG library (http://www.ecglibrary.com) Minnesota ECG Code (http://www.sph.umn.edu/epi/ecg/) ECGsim (http://www.ecgsim.org) - A simulation tool to demonstrate and study the relation between the electric activity of the heart and the ECG EKG Review: Arrhythmias (http://www.gwc.maricopa.edu/class/bio202/cyberheart/ekgqzr0.htm) A guide to reading ECGs not written for a university biology (anatomy and physiology) course. ECG Guru blog (http://ecgguru.com/blog) - A guide to reading ECGs.

Electronic data interchange

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Electronic data interchange


Electronic Data Interchange
Developed by National Institute of Standards and Technology Initial release 1996 Standard(s) UN/EDIFACT ASC X12 TRADACOMS

Electronic data interchange (EDI) is a document standard which when implemented acts as common interface between two or more computer applications in terms of understanding the document transmitted. It is commonly used by big companies for e-commerce purposes, such as sending orders to warehouses or tracking their order. It is more than mere e-mail; for instance, organizations might replace bills of lading and even cheques with appropriate EDI messages. It also refers specifically to a family of standards. In 1996, the National Institute of Standards and Technology defined electronic data interchange as "the computer-to-computer interchange of strictly formatted messages that represent documents other than monetary instruments. EDI implies a sequence of messages between two parties, either of whom may serve as originator or recipient. The formatted data representing the documents may be transmitted from originator to recipient via telecommunications or physically transported on electronic storage media." It distinguishes mere electronic communication or data exchange, specifying that "in EDI, the usual processing of received messages is by computer only. Human intervention in the processing of a received message is typically intended only for error conditions, for quality review, and for special situations. For example, the transmission of binary or textual data is not EDI as defined here unless the data are treated as one or more data elements of an EDI message and are not normally intended for human interpretation as part of online data processing."[1] EDI can be formally defined as the transfer of structured data, by agreed message standards, from one computer system to another without human intervention.

Standards
EDI provides a technical basis for commercial "conversations" between two entities, either internal or external. EDI constitutes the entire electronic data interchange paradigm, including the transmission, message flow, document format, and software used to interpret the documents. EDI standards describe the rigorous format of electronic documents. The EDI standards were designed by the implementers, initially in the Automotive industry, to be independent of communication and software technologies. EDI can be transmitted using any methodology agreed to by the sender and recipient. This includes a variety of technologies, including modem (asynchronous and synchronous), FTP, e-mail, HTTP, AS1, AS2, etc. It is important to differentiate between the EDI documents and the methods for transmitting them. When they compared the synchronous protocol 2400 bit/s modems, CLEO devices, and value-added networks used to transmit EDI documents to transmitting via the Internet, some people equated the non-Internet technologies with EDI and predicted erroneously that EDI itself would be replaced along with the non-Internet technologies. These non-internet transmission methods are being replaced by Internet protocols such as FTP, telnet, and e-mail, but the EDI documents themselves still remain. As more trading partners use the Internet for transmission, standards have emerged. In 2002, the IETF published RFC 3335, offering a standardized, secure method of transferring EDI data via e-mail. On July 12, 2005, an IETF working group ratified RFC4130 [2] for MIME-based HTTP EDIINT (a.k.a. AS2) transfers, and is preparing a

Electronic data interchange similar RFC [3] for FTP transfers (a.k.a. AS3). While some EDI transmission has moved to these newer protocols, the providers of the value-added networks remain active. EDI documents generally contain the same information that would normally be found in a paper document used for the same organizational function. For example an EDI 940 ship-from-warehouse order is used by a manufacturer to tell a warehouse to ship product to a retailer. It typically has a 'ship-to' address, a 'bill-to' address, and a list of product numbers (usually a UPC) and quantities. Another example is the set of messages between sellers and buyers, such as request for quotation (RFQ), bid in response to RFQ, purchase order, purchase order acknowledgment, shipping notice, receiving advice, invoice, and payment advice. However, EDI is not confined to just business data related to trade but encompasses all fields such as medicine (e.g., patient records and laboratory results), transport (e.g., container and modal information), engineering and construction, etc. In some cases, EDI will be used to create a new business information flow (that was not a paper flow before). This is the case in the Advanced Shipment Notification (856) which was designed to inform the receiver of a shipment, the goods to be received and how the goods are packaged. Some major sets of EDI standards: The UN-recommended UN/EDIFACT is the only international standard and is predominant outside of North America. The US standard ANSI ASC X12 (X12) is predominant in North America. The TRADACOMS standard developed by the ANA (Article Numbering Association now known as GS1) is predominant in the UK retail industry. The ODETTE standard used within the European automotive industry The VDA standard used within the European automotive industry mainly in Germany All of these standards first appeared in the early to mid 1980s. The standards prescribe the formats, character sets, and data elements used in the exchange of business documents and forms. The complete X12 Document List includes all major business documents, including purchase orders (called "ORDERS" in UN/EDIFACT and an "850" in X12) and invoices (called "INVOIC" in UN/EDIFACT and an "810" in X12). The EDI standard prescribes mandatory and optional information for a particular document and gives the rules for the structure of the document. The standards are like building codes. Just as two kitchens can be built "to code" but look completely different, two EDI documents can follow the same standard and contain different sets of information. For example a food company may indicate a product's expiration date while a clothing manufacturer would choose to send color and size information.

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Specifications
Organizations that send or receive documents between each other are referred to as "trading partners" in EDI terminology. The trading partners agree on the specific information to be transmitted and how it should be used. This is done in human readable specifications (also called Message Implementation Guidelines). While the standards are analogous to building codes, the specifications are analogous to blue prints. (The specification may also be called a "mapping," but the term mapping is typically reserved for specific machine-readable instructions given to the translation software.) Larger trading "hubs" have existing Message Implementation Guidelines which mirror their business processes for processing EDI and they are usually unwilling to modify their EDI business practices to meet the needs of their trading partners. Often in a large company these EDI guidelines will be written to be generic enough to be used by different branches or divisions and therefore will contain information not needed for a particular business document exchange. For other large companies, they may create separate EDI guidelines for each branch/division.

Electronic data interchange

609

Transmission
Trading partners are free to use any method for the transmission of documents. Furthermore, they can either interact directly, or through a third party.

Serial communications
At one time a common method of transmitting EDI messages was using a Bisync modem; one partner would have one or more modems set up to receive incoming calls, and the other would call it with their own modem. It was also possible to use a dedicated leased line or a network such as Telex. Some organizations may have transmitted EDI files via BBS.

Internet
As more organizations connected to the Internet, eventually most or all EDI was pushed onto it. Initially, this was through ad-hoc conventions, such as unencrypted FTP of ASCII text files to a certain folder on a certain host, permitted only from certain IP addresses. However, the IETF has published several informational documents (the "Applicability Statements"; see below under Protocols) describing ways to use standard Internet protocols for EDI.

Peer-to-Peer
EDI standards are written such that trading IU partners could connect directly to each other. For example, an automotive manufacturer might maintain a modem-pool that all of its hundreds suppliers are required to dial into to perform EDI. However, if a supplier does business with several manufacturers, it may need to acquire a different modem (or VPN device, etc.) and different software for each one.

Value-added networks
To address the limitations in peer-to-peer adoption of EDI, VANs (value-added networks) were established. A VAN acts as a regional post office. It receives transactions, examines the 'from' and the 'to' information, and routes the transaction to the final recipient. VANs may provide a number of additional services, e.g. retransmitting documents, providing third party audit information, acting as a gateway for different transmission methods, and handling telecommunications support. Because of these and other services VANs provide, businesses frequently use a VAN even when both trading partners are using Internet-based protocols. Healthcare clearinghouses perform many of the same functions as a VAN, but have additional legal restrictions VANs may be operated by various entities: telecommunication companies; industry group consortia; a large company interacting with its suppliers/vendors.

Interpreting data
EDI translation software provides the interface between internal systems and the EDI format sent/received. For an "inbound" document the EDI solution will receive the file (either via a Value Added Network or directly using protocols such as FTP or AS2), take the received EDI file (commonly referred to as a "mailbag"), validate that the trading partner who is sending the file is a valid trading partner, that the structure of the file meets the EDI standards, and that the individual fields of information conform to the agreed upon standards. Typically the translator will either create a file of either fixed length, variable length or XML tagged format or "print" the received EDI document (for non-integrated EDI environments). The next step is to convert/transform the file that the translator creates into a format that can be imported into a company's back-end business systems or ERP. This can be accomplished by using a custom program, an integrated proprietary "mapper" or to use an integrated standards based graphical "mapper"

Electronic data interchange using a standard data transformation language such as XSLT. The final step is to import the transformed file (or database) into the company's back-end enterprise resource planning (ERP) system. For an "outbound" document the process for integrated EDI is to export a file (or read a database) from a company's back-end ERP, transform the file to the appropriate format for the translator. The translation software will then "validate" the EDI file sent to ensure that it meets the standard agreed upon by the trading partners, convert the file into "EDI" format (adding in the appropriate identifiers and control structures) and send the file to the trading partner (using the appropriate communications protocol). Another critical component of any EDI translation software is a complete "audit" of all the steps to move business documents between trading partners. The audit ensures that any transaction (which in reality is a business document) can be tracked to ensure that they are not lost. In case of a retailer sending a Purchase Order to a supplier, if the Purchase Order is "lost" anywhere in the business process, the effect is devastating to both businesses. To the supplier, they do not fulfill the order as they have not received it thereby losing business and damaging the business relationship with their retail client. For the retailer, they have a stock outage and the effect is lost sales, reduced customer service and ultimately lower profits. In EDI terminology "inbound" and "outbound" refer to the direction of transmission of an EDI document in relation to a particular system, not the direction of merchandise, money or other things represented by the document. For example, an EDI document that tells a warehouse to perform an outbound shipment is an inbound document in relation to the warehouse computer system. It is an outbound document in relation to the manufacturer or dealer that transmitted the document.

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Advantages over paper systems


EDI and other similar technologies save a company money by providing an alternative to, or replacing, information flows that require a great deal of human interaction and materials such as paper documents, meetings, faxes, etc. Even when paper documents are maintained in parallel with EDI exchange, e.g. printed shipping manifests, electronic exchange and the use of data from that exchange reduces the handling costs of sorting, distributing, organizing, and searching paper documents. EDI and similar technologies allow a company to take advantage of the benefits of storing and manipulating data electronically without the cost of manual entry. Another advantage of EDI is reduced errors, such as shipping and billing errors, because EDI eliminates the need to rekey documents on the destination side. One very important advantage of EDI over paper documents is the speed in which the trading partner receives and incorporates the information into their system thus greatly reducing cycle times. For this reason, EDI can be an important component of just-in-time production systems.[4] According to the 2008 Aberdeen report "A Comparison of Supplier Enablement around the World", only 34% of purchase orders are transmitted electronically in North America. In EMEA, 36% of orders are transmitted electronically and in APAC, 41% of orders are transmitted electronically. They also report that the average paper requisition to order costs a company $37.45 in North America, $42.90 in EMEA and $23.90 in APAC. With an EDI requisition to order costs are reduced to $23.83 in North America, $34.05 in EMEA and $14.78 in APAC. AND also requires many degrees.

Barriers to implementation
There are a few barriers to adopting electronic data interchange. One of the most significant barriers is the accompanying business process change. Existing business processes built around paper handling may not be suited for EDI and would require changes to accommodate automated processing of business documents. For example, a business may receive the bulk of their goods by 1 or 2 day shipping and all of their invoices by mail. The existing process may therefore assume that goods are typically received before the invoice. With EDI, the invoice will typically be sent when the goods ship and will therefore require a process that handles large numbers of invoices

Electronic data interchange whose corresponding goods have not yet been received. Another significant barrier is the cost in time and money in the initial set-up. The preliminary expenses and time that arise from the implementation, customization and training can be costly. It is important to select the correct level of integration to match the business requirement. For a business with relatively few transactions with EDI-based partners, it may make sense for businesses to implement inexpensive "rip and read" solutions, where the EDI format is printed out in human-readable form and people, rather than computers, respond to the transaction. Another alternative is outsourced EDI solutions provided by EDI "Service Bureaus". For other businesses, the implementation of an integrated EDI solution may be necessary as increases in trading volumes brought on by EDI force them to re-implement their order processing business processes. The key hindrance to a successful implementation of EDI is the perception many businesses have of the nature of EDI. Many view EDI from the technical perspective that EDI is a data format; it would be more accurate to take the business view that EDI is a system for exchanging business documents with external entities, and integrating the data from those documents into the company's internal systems. Successful implementations of EDI take into account the effect externally generated information will have on their internal systems and validate the business information received. For example, allowing a supplier to update a retailer's Accounts Payable system without appropriate checks and balances would put the company at significant risk. Businesses new to the implementation of EDI must understand the underlying business process and apply proper judgment.

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References
[2] http:/ / www. ietf. org/ rfc/ rfc4130. txt [3] http:/ / www. ietf. org/ rfc/ rfc4823. txt [4] Ecommerce- advantages of EDI format (http:/ / ecommerce. hostip. info/ pages/ 384/ Electronic-Data-Interchange-EDI. html)

External links
E-Procurement Electronic Data Integration Comes of Age (http://www.the-financedirector.com/features/ feature1420/#adEnd)- Article from Finance Director Europe Journal EDI: An Introduction (http://www.rogerclarke.com/EC/EDIIntro.html) EDI Related Terms Glossary (http://www.covalentworks.com/ecommerce-glossary.asp) EDI Basics (http://www.edibasics.co.uk/) options and different approaches to EDI United Nations Directories for Electronic Data Interchange (http://www.unece.org/trade/untdid/directories. htm) administering body for UN/EDIFACT standards ODETTE (http://www.odette.org/html/home.htm) automotive EDI Standards body Jobisez list of trading partners (http://www.jobisez.com/edi/tp/) Research EDI Hubs specifications and their supplier portal EDI Academy (http://ediacademy.com/EdiQuiz.html) A resource for free EDI Tutorials and a Quiz. Gengeswari, K. and Abu Bakar Abdul Hamid (2010). Integration of electronic data interchange: a review (http:// www.fppsm.utm.my/download/doc_download/249-integration-of-electronic-data-interchange-a-review.html). Jurnal Kemanusiaan (http://www.fppsm.utm.my/jurnal-kemanusiaan.html), ISSN 1675-1930 EDIGenie (http://www.edigenie.com) - All things related to EDI What is EDI Compliance? (http://www.covalentworks.com/video-what-is-edi-compliance.asp) EDI Glossary of Terms (http://webedi.co.uk/edi_glossary.php)

Electroencephalography

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Electroencephalography
EEG
Intervention

An EEG recording at Dalhousie University ICD-9-CM MeSH OPS-301code: 89.14 [1] [2]

D004569 1-207 [3]

Electroencephalography (EEG) is the recording of electrical activity along the scalp. EEG measures voltage fluctuations resulting from ionic current flows within the neurons of the brain.[] In clinical contexts, EEG refers to the recording of the brain's spontaneous electrical activity over a short period of time, usually 2040 minutes, as recorded from multiple electrodes placed on the scalp. Diagnostic applications generally focus on the spectral content of EEG, that is, the type of neural oscillations that can be observed in EEG signals. In neurology, the main diagnostic application of EEG is in the case of epilepsy, as epileptic activity can create clear abnormalities on a standard EEG study.[4] A secondary clinical use of EEG is in the diagnosis of coma, encephalopathies, and brain death. A third clinical Epileptic spike and wave discharges monitored use of EEG is for studies of sleep and sleep disorders where recordings with EEG are typically done for one full night, sometimes more. EEG used to be a first-line method for the diagnosis of tumors, stroke and other focal brain disorders,[5] but this use has decreased with the advent of anatomical imaging techniques with high (<1mm) spatial resolution such as MRI and CT. Despite limited spatial resolution, EEG continues to be a valuable tool for research and diagnosis, especially when millisecond-range temporal resolution (not possible with CT or MRI) is required. Derivatives of the EEG technique include evoked potentials (EP), which involves averaging the EEG activity time-locked to the presentation of a stimulus of some sort (visual, somatosensory, or auditory). Event-related

Electroencephalography potentials (ERPs) refer to averaged EEG responses that are time-locked to more complex processing of stimuli; this technique is used in cognitive science, cognitive psychology, and psychophysiological research.

613

History
A timeline of the history of EEG is given by Swartz.[6] Richard Caton (18421926), a physician practicing in Liverpool, presented his findings about electrical phenomena of the exposed cerebral hemispheres of rabbits and monkeys in the British Medical Journal in 1875. In 1890, Polish physiologist Adolf Beck published an investigation of spontaneous electrical activity of the brain of rabbits and dogs that included rhythmic oscillations altered by light. In 1912, Russian physiologist, Vladimir Vladimirovich Pravdich-Neminsky published the first animal EEG and the evoked potential of the mammalian (dog).[7] In 1914, Napoleon Cybulski and Jelenska-Macieszyna photographed EEG-recordings of experimentally induced seizures. German physiologist and psychiatrist Hans Berger (18731941) recorded the first human EEG in 1924.[8] Expanding on work previously conducted on animals by Richard Caton and others, Berger also invented the electroencephalogram (giving the device its name), an invention described Hans Berger "as one of the most surprising, remarkable, and momentous developments in the history of clinical neurology".[9] His discoveries were first confirmed by British scientists Edgar Douglas Adrian and B. H. C. Matthews in 1934 and developed by them. In 1934, Fisher and Lowenback first demonstrated epileptiform spikes. In 1935 Gibbs, Davis and Lennox described interictal spike waves and the 3 cycles/s pattern of clinical absence seizures, which began the field of clinical electroencephalography. Subsequently, in 1936 Gibbs and Jasper reported the interictal spike as the focal signature of epilepsy. The same year, the first EEG laboratory opened at Massachusetts General Hospital. Franklin Offner (19111999), professor of biophysics at Northwestern University developed a prototype of the EEG that incorporated a piezoelectric inkwriter called a Crystograph (the whole device was typically known as the Offner Dynograph). In 1947, The American EEG Society was founded and the first International EEG congress was held. In 1953 Aserinsky and Kleitman describe REM sleep. In the 1950s, William Grey Walter developed an adjunct to EEG called EEG topography, which allowed for the mapping of electrical activity across the surface of the brain. This enjoyed a brief period of popularity in the 1980s and seemed especially promising for psychiatry. It was never accepted by neurologists and remains primarily a research tool.

Source of EEG activity


The brain's electrical charge is maintained by billions of neurons. Neurons are electrically charged (or "polarized") by membrane transport proteins that pump ions across their membranes. Neurons are constantly exchanging ions with the extracellular milieu, for example to maintain resting potential and to propagate action potentials. Ions of similar charge repel each other, and when many ions are pushed out of many neurons at the same time, they can push their neighbours, who push their neighbours, and so on, in a wave. This process is known as volume conduction. When the wave of ions reaches the electrodes on the scalp, they can push or pull electrons on the metal on the electrodes. Since metal conducts the push and pull of electrons easily, the difference in push or pull voltages between any two electrodes can be measured by a voltmeter. Recording these voltages over time gives us the EEG.[10] The electric potential generated by single neuron is far too small to be picked up by EEG or MEG.[] EEG activity therefore always reflects the summation of the synchronous activity of thousands or millions of neurons that have similar spatial orientation. If the cells do not have similar spatial orientation, their ions do not line up and create

Electroencephalography waves to be detected. Pyramidal neurons of the cortex are thought to produce the most EEG signal because they are well-aligned and fire together. Because voltage fields fall off with the square of distance, activity from deep sources is more difficult to detect than currents near the skull.[11] Scalp EEG activity shows oscillations at a variety of frequencies. Several of these oscillations have characteristic frequency ranges, spatial distributions and are associated with different states of brain functioning (e.g., waking and the various sleep stages). These oscillations represent synchronized activity over a network of neurons. The neuronal networks underlying some of these oscillations are understood (e.g., the thalamocortical resonance underlying sleep spindles), while many others are not (e.g., the system that generates the posterior basic rhythm). Research that measures both EEG and neuron spiking finds the relationship between the two is complex with the power of surface EEG in only two bands (gamma and delta) relating to neuron spike activity.[12]

614

Clinical use
A routine clinical EEG recording typically lasts 2030 minutes (plus preparation time) and usually involves recording from scalp electrodes. Routine EEG is typically used in the following clinical circumstances: to distinguish epileptic seizures from other types of spells, such as psychogenic non-epileptic seizures, syncope (fainting), sub-cortical movement disorders and migraine variants. to differentiate "organic" encephalopathy or delirium from primary psychiatric syndromes such as catatonia to serve as an adjunct test of brain death to prognosticate, in certain instances, in patients with coma to determine whether to wean anti-epileptic medications

At times, a routine EEG is not sufficient, particularly when it is necessary to record a patient while he/she is having a seizure. In this case, the patient may be admitted to the hospital for days or even weeks, while EEG is constantly being recorded (along with time-synchronized video and audio recording). A recording of an actual seizure (i.e., an ictal recording, rather than an inter-ictal recording of a possibly epileptic patient at some period between seizures) can give significantly better information about whether or not a spell is an epileptic seizure and the focus in the brain from which the seizure activity emanates. Epilepsy monitoring is typically done: to distinguish epileptic seizures from other types of spells, such as psychogenic non-epileptic seizures, syncope (fainting), sub-cortical movement disorders and migraine variants. to characterize seizures for the purposes of treatment to localize the region of brain from which a seizure originates for work-up of possible seizure surgery Additionally, EEG may be used to monitor certain procedures: to monitor the depth of anesthesia as an indirect indicator of cerebral perfusion in carotid endarterectomy to monitor amobarbital effect during the Wada test EEG can also be used in intensive care units for brain function monitoring: to monitor for non-convulsive seizures/non-convulsive status epilepticus to monitor the effect of sedative/anesthesia in patients in medically induced coma (for treatment of refractory seizures or increased intracranial pressure) to monitor for secondary brain damage in conditions such as subarachnoid hemorrhage (currently a research method) If a patient with epilepsy is being considered for resective surgery, it is often necessary to localize the focus (source) of the epileptic brain activity with a resolution greater than what is provided by scalp EEG. This is because the cerebrospinal fluid, skull and scalp smear the electrical potentials recorded by scalp EEG. In these cases, neurosurgeons typically implant strips and grids of electrodes (or penetrating depth electrodes) under the dura mater,

Electroencephalography through either a craniotomy or a burr hole. The recording of these signals is referred to as electrocorticography (ECoG), subdural EEG (sdEEG) or intracranial EEG (icEEG)--all terms for the same thing. The signal recorded from ECoG is on a different scale of activity than the brain activity recorded from scalp EEG. Low voltage, high frequency components that cannot be seen easily (or at all) in scalp EEG can be seen clearly in ECoG. Further, smaller electrodes (which cover a smaller parcel of brain surface) allow even lower voltage, faster components of brain activity to be seen. Some clinical sites record from penetrating microelectrodes.[]

615

Research use
EEG, and the related study of ERPs are used extensively in neuroscience, cognitive science, cognitive psychology, neurolinguistics and psychophysiological research. Many EEG techniques used in research are not standardized sufficiently for clinical use.

Relative advantages
Several other methods to study brain function exist, including functional magnetic resonance imaging (fMRI), positron emission tomography, The first human EEG recording obtained by Hans Berger in 1924. The upper tracing is EEG, and the lower is a 10 Hz timing signal. magnetoencephalography, Nuclear magnetic resonance spectroscopy, Electrocorticography, Single-photon emission computed tomography, Near-infrared spectroscopy (NIRS), and Event-related optical signal (EROS). Despite the relatively poor spatial sensitivity of EEG, it possesses multiple advantages over some of these techniques: Hardware costs are significantly lower than those of most other techniques [13] EEG sensors can be used in more places than fMRI, SPECT, PET, MRS, or MEG, as these techniques require bulky and immobile equipment. For example, MEG requires equipment consisting of liquid helium-cooled detectors that can be used only in magnetically shielded rooms, altogether costing upwards of several million dollars;[14] and fMRI requires the use of a 1-ton magnet in, again, a shielded room. EEG has very high temporal resolution, on the order of milliseconds rather than seconds. EEG is commonly recorded at sampling rates between 250 and 2000Hz in clinical and research settings, but modern EEG data collection systems are capable of recording at sampling rates above 20,000Hz if desired. MEG and EROS are the only other noninvasive cognitive neuroscience techniques that acquire data at this level of temporal resolution.[14] EEG is relatively tolerant of subject movement, unlike most other neuroimaging techniques. There even exist methods for minimizing, and even eliminating movement artefacts in EEG data [15] EEG is silent, which allows for better study of the responses to auditory stimuli EEG does not aggravate claustrophobia, unlike fMRI, PET, MRS, SPECT, and sometimes MEG [16] EEG does not involve exposure to high-intensity (>1 Tesla) magnetic fields, as in some of the other techniques, especially MRI and MRS. These can cause a variety of undesirable issues with the data, and also prohibit use of these techniques with participants that have metal implants in their body, such as metal-containing pacemakers
[17]

EEG does not involve exposure to radioligands, unlike positron emission tomography.[] ERP studies can be conducted with relatively simple paradigms, compared with IE block-design fMRI studies Extremely uninvasive, unlike Electrocorticography, which actually requires electrodes to be placed on the surface of the brain. EEG also has some characteristics that compare favorably with behavioral testing: EEG can detect covert processing (i.e., processing that does not require a response) [18]

Electroencephalography EEG can be used in subjects who are incapable of making a motor response [19] Some ERP components can be detected even when the subject is not attending to the stimuli Unlike other means of studying reaction time, ERPs can elucidate stages of processing (rather than just the final end result) [20] EEG is a powerful tool for tracking brain changes during different phases of life. EEG sleep analysis can indicate significant aspects of the timing of brain development, including evaluating adolescent brain maturation. [21] Brain activity can also be monitored by ct's. [22]

616

Relative disadvantages
Low spatial resolution on the scalp. fMRI, for example, can directly display areas of the brain that are active, while EEG requires intense interpretation just to hypothesize what areas are activated by a particular response.[23] EEG determines neural activity that occurs below the upper layers of the brain (the cortex) poorly. Unlike PET and MRS, cannot identify specific locations in the brain at which various neurotransmitters, drugs, etc. can be found.[] Often takes a long time to connect a subject to EEG, as it requires precise placement of dozens of electrodes around the head and the use of various gels, saline solutions, and/or pastes to keep them in place. While the length of time differs dependent on the specific EEG device used, as a general rule it takes considerably less time to prepare a subject for MEG, fMRI, MRS, and SPECT. Signal-to-noise ratio is poor, so sophisticated data analysis and relatively large numbers of subjects are needed to extract useful information from EEG [24]

Combining EEG with other neuroimaging techniques


Simultaneous EEG recordings and fMRI scans have been obtained successfully,[25][26] though successful simultaneous recording requires that several technical difficulties be overcome, such as the presence of ballistocardiographic artifact, MRI pulse artifact and the induction of electrical currents in EEG wires that move within the strong magnetic fields of the MRI. While challenging, these have been successfully overcome in a number of studies.[27] Similarly, simultaneous recordings with MEG and EEG have also been conducted, which has several advantages over using either technique alone: EEG requires accurate information about certain aspects of the skull that can only be estimated, such as skull radius, and conductivities of various skull locations. MEG does not have this issue, and a simultaneous analysis allows this to be corrected for. MEG and EEG both detect activity below the surface of the cortex very poorly, and like EEG, the level of error increases with the depth below the surface of the cortex one attempts to examine. However, the errors are very different between the techniques, and combining them thus allows for correction of some of this noise. MEG has access to virtually no sources of brain activity below a few centimetres under the cortex. EEG, on the other hand, can receive signals from greater depth, albeit with a high degree of noise. Combining the two makes it easier to determine what in the EEG signal comes from the surface (since MEG is very accurate in examining signals from the surface of the brain), and what comes from deeper in the brain, thus allowing for analysis of deeper brain signals than either EEG or MEG on its own.[28] EEG has also been combined with positron emission tomography. This provides the advantage of allowing researchers to see what EEG signals are associated with different drug actions in the brain.[29]

Electroencephalography

617

Method
In conventional scalp EEG, the recording is obtained by placing electrodes on the scalp with a conductive gel or paste, usually after preparing the scalp area by light abrasion to reduce impedance due to dead skin cells. Many systems typically use electrodes, each of which is attached to an individual wire. Some systems use caps or nets into which electrodes are embedded; this is particularly common when high-density arrays of electrodes are needed.
Computer Electroencephalograph

Electrode locations and names are specified by the International 1020 Neurovisor-BMM 40 system[30] for most clinical and research applications (except when high-density arrays are used). This system ensures that the naming of electrodes is consistent across laboratories. In most clinical applications, 19 recording electrodes (plus ground and system reference) are used.[31] A smaller number of electrodes are typically used when recording EEG from neonates. Additional electrodes can be added to the standard set-up when a clinical or research application demands increased spatial resolution for a particular area of the brain. High-density arrays (typically via cap or net) can contain up to 256 electrodes more-or-less evenly spaced around the scalp. Each electrode is connected to one input of a differential amplifier (one amplifier per pair of electrodes); a common system reference electrode is connected to the other input of each differential amplifier. These amplifiers amplify the voltage between the active electrode and the reference (typically 1,000100,000 times, or 60100 dB of voltage gain). In analog EEG, the signal is then filtered (next paragraph), and the EEG signal is output as the deflection of pens as paper passes underneath. Most EEG systems these days, however, are digital, and the amplified signal is digitized via an analog-to-digital converter, after being passed through an anti-aliasing filter. Analog-to-digital sampling typically occurs at 256512Hz in clinical scalp EEG; sampling rates of up to 20kHz are used in some research applications. During the recording, a series of activation procedures may be used. These procedures may induce normal or abnormal EEG activity that might not otherwise be seen. These procedures include hyperventilation, photic stimulation (with a strobe light), eye closure, mental activity, sleep and sleep deprivation. During (inpatient) epilepsy monitoring, a patient's typical seizure medications may be withdrawn. The digital EEG signal is stored electronically and can be filtered for display. Typical settings for the high-pass filter and a low-pass filter are 0.5-1 Hz and 3570Hz, respectively. The high-pass filter typically filters out slow artifact, such as electrogalvanic signals and movement artifact, whereas the low-pass filter filters out high-frequency artifacts, such as electromyographic signals. An additional notch filter is typically used to remove artifact caused by electrical power lines (60Hz in the United States and 50Hz in many other countries).[] As part of an evaluation for epilepsy surgery, it may be necessary to insert electrodes near the surface of the brain, under the surface of the dura mater. This is accomplished via burr hole or craniotomy. This is referred to variously as "electrocorticography (ECoG)", "intracranial EEG (I-EEG)" or "subdural EEG (SD-EEG)". Depth electrodes may also be placed into brain structures, such as the amygdala or hippocampus, structures, which are common epileptic foci and may not be "seen" clearly by scalp EEG. The electrocorticographic signal is processed in the same manner as digital scalp EEG (above), with a couple of caveats. ECoG is typically recorded at higher sampling rates than scalp EEG because of the requirements of Nyquist theoremthe subdural signal is composed of a higher predominance of higher frequency components. Also, many of the artifacts that affect scalp EEG do not impact ECoG, and therefore display filtering is often not needed. A typical adult human EEG signal is about 10 V to 100 V in amplitude when measured from the scalp[] and is about 1020 mV when measured from subdural electrodes.

Electroencephalography The EEG recording can be analysed using various programs; e.g., using free open-source toolboxes for Matlab, such as, EEGLAB, Fieldtrip [32], NBT [33], SPM [34], or commercial software packages such as Brainvision Analyzer [35]. Since an EEG voltage signal represents a difference between the voltages at two electrodes, the display of the EEG for the reading encephalographer may be set up in one of several ways. The representation of the EEG channels is referred to as a montage. Bipolar montage Each channel (i.e., waveform) represents the difference between two adjacent electrodes. The entire montage consists of a series of these channels. For example, the channel "Fp1-F3" represents the difference in voltage between the Fp1 electrode and the F3 electrode. The next channel in the montage, "F3-C3," represents the voltage difference between F3 and C3, and so on through the entire array of electrodes. Referential montage Each channel represents the difference between a certain electrode and a designated reference electrode. There is no standard position for this reference; it is, however, at a different position than the "recording" electrodes. Midline positions are often used because they do not amplify the signal in one hemisphere vs. the other. Another popular reference is "linked ears," which is a physical or mathematical average of electrodes attached to both earlobes or mastoids. Average reference montage The outputs of all of the amplifiers are summed and averaged, and this averaged signal is used as the common reference for each channel. Laplacian montage Each channel represents the difference between an electrode and a weighted average of the surrounding electrodes.[36] When analog (paper) EEGs are used, the technologist switches between montages during the recording in order to highlight or better characterize certain features of the EEG. With digital EEG, all signals are typically digitized and stored in a particular (usually referential) montage; since any montage can be constructed mathematically from any other, the EEG can be viewed by the electroencephalographer in any display montage that is desired. The EEG is read by a clinical neurophysiologist or neurologist (depending on local custom and law regarding medical specialities), optimally one who has specific training in the interpretation of EEGs for clinical purposes. This is done by visual inspection of the waveforms, called graphoelements. The use of computer signal processing of the EEGso-called quantitative EEGis somewhat controversial when used for clinical purposes (although there are many research uses).

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Limitations
EEG has several limitations. Most important is its poor spatial resolution. EEG is most sensitive to a particular set of post-synaptic potentials: those generated in superficial layers of the cortex, on the crests of gyri directly abutting the skull and radial to the skull. Dendrites, which are deeper in the cortex, inside sulci, in midline or deep structures (such as the cingulate gyrus or hippocampus), or producing currents that are tangential to the skull, have far less contribution to the EEG signal. The meninges, cerebrospinal fluid and skull "smear" the EEG signal, obscuring its intracranial source. It is mathematically impossible to reconstruct a unique intracranial current source for a given EEG signal,[] as some currents produce potentials that cancel each other out. This is referred to as the inverse problem. However, much work has been done to produce remarkably good estimates of, at least, a localized electric dipole that represents the recorded currents.[citation needed]

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EEG vs fMRI, fNIRS and PET


EEG has several strong points as a tool for exploring brain activity. EEGs can detect changes over milliseconds, which is excellent considering an action potential takes approximately 0.5-130 milliseconds to propagate across a single neuron, depending on the type of neuron.[37] Other methods of looking at brain activity, such as PET and fMRI have time resolution between seconds and minutes. EEG measures the brain's electrical activity directly, while other methods record changes in blood flow (e.g., SPECT, fMRI) or metabolic activity (e.g., PET, NIRS), which are indirect markers of brain electrical activity. EEG can be used simultaneously with fMRI so that high-temporal-resolution data can be recorded at the same time as high-spatial-resolution data, however, since the data derived from each occurs over a different time course, the data sets do not necessarily represent exactly the same brain activity. There are technical difficulties associated with combining these two modalities, including the need to remove the MRI gradient artifact present during MRI acquisition and the ballistocardiographic artifact (resulting from the pulsatile motion of blood and tissue) from the EEG. Furthermore, currents can be induced in moving EEG electrode wires due to the magnetic field of the MRI. EEG can be used simultaneously with NIRS without major technical difficulties. There is no influence of these modalities on each other and a combined measurement can give useful information about electrical activity as well as local hemodynamics.

EEG vs MEG
EEG reflects correlated synaptic activity caused by post-synaptic potentials of cortical neurons. The ionic currents involved in the generation of fast action potentials may not contribute greatly to the averaged field potentials representing the EEG .[][38] More specifically, the scalp electrical potentials that produce EEG are generally thought to be caused by the extracellular ionic currents caused by dendritic electrical activity, whereas the fields producing magnetoencephalographic signals[39] are associated with intracellular ionic currents .[40] EEG can be recorded at the same time as MEG so that data from these complementary high-time-resolution techniques can be combined.

Normal activity
The EEG is typically described in terms of (1) rhythmic activity and (2) transients. The rhythmic activity is divided into bands by frequency. To some degree, these frequency bands One second of EEG signal are a matter of nomenclature (i.e., any rhythmic activity between 612Hz can be described as "alpha"), but these designations arose because rhythmic activity within a certain frequency range was noted to have a certain distribution over the scalp or a certain biological significance. Frequency bands are usually extracted using spectral methods (for instance Welch) as implemented for instance in freely available EEG software such as EEGLAB or the the neurophysiological biomarker toolbox [33]. Most of the cerebral signal observed in the scalp EEG falls in the range of 120Hz (activity below or above this range is likely to be artifactual, under standard clinical recording techniques).

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Comparison table of EEG rhythmic activity frequency bands Comparison of EEG bands
Band Frequency (Hz) up to 4 Location Normally Pathologically

Delta

frontally in adults, posteriorly in children; high-amplitude waves

adult slow-wave sleep in babies Has been found during some [] continuous-attention tasks young children drowsiness or arousal in older children and adults idling Associated with inhibition of elicited responses (has been found to spike in situations where a person is actively [] trying to repress a response or action). relaxed/reflecting closing the eyes Also associated with inhibition control, seemingly with the purpose of timing inhibitory activity in different locations across the brain.

subcortical lesions diffuse lesions metabolic encephalopathy hydrocephalus deep midline lesions focal subcortical lesions metabolic encephalopathy deep midline disorders some instances of hydrocephalus

Theta

48

Found in locations not related to task at hand

Alpha

8 13

posterior regions of head, both sides, higher in amplitude on non-dominant side. Central sites (c3-c4) at rest

coma

Beta

>13 30

both sides, symmetrical distribution, most evident frontally; low-amplitude waves Somatosensory cortex

alert/wo active, busy, or anxious thinking, active concentration

benzodiazepines

Gamma 30 100+

Displays during cross-modal sensory processing (perception that combines two different senses, such as sound and [][] sight) Also is shown during short-term memory matching of recognized objects, sounds, or tactile sensations Shows rest-state motor neurons. [41]

A decrease in gamma-band activity may be associated with cognitive decline, especially when related to the theta band; however, this has not been proven for use as a clinical diagnostic measurement

Mu

8 13

Sensorimotor cortex

Mu suppression could indicate that motor mirror neurons are working. Deficits in Mu suppression, and thus in mirror neurons, [] might play a role in autism.

While these are the universally recognized frequency ranges that researchers tend to follow, many scholars use their own specific range boundaries depending on the frequencies they choose to focus on. Additionally, some researchers define the bands using decimal values rather than rounding to whole numbers (for example, one researcher may define the lower Beta band cut-off as 12.1, while another may use the value 13), while still others sometimes divide the bands into subbands for the purposes of data analysis.

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Wave patterns
Delta is the frequency range up to 4Hz. It tends to be the highest in amplitude and the slowest waves. It is seen normally in adults in slow wave sleep. It is also seen normally delta waves. in babies. It may occur focally with subcortical lesions and in general distribution with diffuse lesions, metabolic encephalopathy hydrocephalus or deep midline lesions. It is usually most prominent frontally in adults (e.g. FIRDA - Frontal Intermittent Rhythmic Delta) and posteriorly in children (e.g. OIRDA - Occipital Intermittent Rhythmic Delta). Theta is the frequency range from 4Hz to 7Hz. Theta is seen normally in young children. It may be seen in drowsiness or arousal in older children and adults; it can also theta waves. be seen in meditation.[42] Excess theta for age represents abnormal activity. It can be seen as a focal disturbance in focal subcortical lesions; it can be seen in generalized distribution in diffuse disorder or metabolic encephalopathy or deep midline disorders or some instances of hydrocephalus. On the contrary this range has been associated with reports of relaxed, meditative, and creative states. Alpha is the frequency range from 8 Hz to 12Hz. Hans Berger named the first rhythmic EEG activity he saw as the "alpha wave". This was the "posterior basic rhythm" (also alpha waves. called the "posterior dominant rhythm" or the "posterior alpha rhythm"), seen in the posterior regions of the head on both sides, higher in amplitude on the dominant side. It emerges with closing of the eyes and with relaxation, and attenuates with eye opening or mental exertion. The posterior basic rhythm is actually slower than 8Hz in young children (therefore technically in the theta range). In addition to the posterior basic rhythm, there are other normal alpha rhythms such as the mu rhythm (alpha activity in the contralateral sensory and motor cortical areas that emerges when sensorimotor rhythm aka mu rhythm. the hands and arms are idle; and the "third rhythm" (alpha activity in the temporal or frontal lobes).[43][44] Alpha can be abnormal; for example, an EEG that has diffuse alpha occurring in coma and is not responsive to external stimuli is referred to as "alpha coma".

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Beta is the frequency range from 12Hz to about 30Hz. It is seen usually on both sides in symmetrical distribution and is most evident frontally. Beta activity beta waves. is closely linked to motor behavior and is generally attenuated during active movements.[45] Low amplitude beta with multiple and varying frequencies is often associated with active, busy or anxious thinking and active concentration. Rhythmic beta with a dominant set of frequencies is associated with various pathologies and drug effects, especially benzodiazepines. It may be absent or reduced in areas of cortical damage. It is the dominant rhythm in patients who are alert or anxious or who have their eyes open. Gamma is the frequency range approximately 30100Hz. Gamma rhythms are thought to represent binding of different populations of neurons together into a network for the purpose of carrying out a certain cognitive or motor function.[]

gamma waves.

Mu ranges 813Hz., and partly overlaps with other frequencies. It reflects the synchronous firing of motor neurons in rest state. Mu suppression is thought to reflect motor mirror neuron systems, because when an action is observed, the pattern extinguishes, possibly because of the normal neuronal system and the mirror neuron system "go out of sync", and interfere with each other.[] "Ultra-slow" or "near-DC" (Direct current) activity is recorded using DC amplifiers in some research contexts. It is not typically recorded in a clinical context because the signal at these frequencies is susceptible to a number of artifacts. Some features of the EEG are transient rather than rhythmic. Spikes and sharp waves may represent seizure activity or interictal activity in individuals with epilepsy or a predisposition toward epilepsy. Other transient features are normal: vertex waves and sleep spindles are seen in normal sleep. Note that there are types of activity that are statistically uncommon, but not associated with dysfunction or disease. These are often referred to as "normal variants." The mu rhythm is an example of a normal variant. The normal Electroencephalography (EEG) varies by age. The neonatal EEG is quite different from the adult EEG. The EEG in childhood generally has slower frequency oscillations than the adult EEG. The normal EEG also varies depending on state. The EEG is used along with other measurements (EOG, EMG) to define sleep stages in polysomnography. Stage I sleep (equivalent to drowsiness in some systems) appears on the EEG as drop-out of the posterior basic rhythm. There can be an increase in theta frequencies. Santamaria and Chiappa cataloged a number of the variety of patterns associated with drowsiness. Stage II sleep is characterized by sleep spindlestransient runs of rhythmic activity in the 1214Hz range (sometimes referred to as the "sigma" band) that have a frontal-central maximum. Most of the activity in Stage II is in the 36Hz range. Stage III and IV sleep are defined by the presence of delta frequencies and are often referred to collectively as "slow-wave sleep." Stages I-IV comprise non-REM (or "NREM") sleep. The EEG in REM (rapid eye movement) sleep appears somewhat similar to the awake EEG. EEG under general anesthesia depends on the type of anesthetic employed. With halogenated anesthetics, such as halothane or intravenous agents, such as propofol, a rapid (alpha or low beta), nonreactive EEG pattern is seen over most of the scalp, especially anteriorly; in some older terminology this was known as a WAR (widespread anterior rapid) pattern, contrasted with a WAIS (widespread slow) pattern associated with high doses of opiates. Anesthetic

Electroencephalography effects on EEG signals are beginning to be understood at the level of drug actions on different kinds of synapses and the circuits that allow synchronized neuronal activity (see: http://www.stanford.edu/group/maciverlab/).

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Artifacts
Biological artifacts
Electrical signals detected along the scalp by an EEG, but that originate from non-cerebral origin are called artifacts. EEG data is almost always contaminated by such artifacts. The amplitude of artifacts can be quite large relative to the size of amplitude of the cortical signals of interest. This is one of the reasons why it takes considerable experience to correctly interpret EEGs clinically. Some of the most common types of biological artifacts include: Eye-induced artifacts (includes eye blinks, eye movements and extra-ocular muscle activity) ECG (cardiac) artifacts EMG (muscle activation)-induced artifacts Glossokinetic artifacts

The most prominent eye-induced artifacts are caused by the potential difference between the cornea and retina, which is quite large compared to cerebral potentials. When the eyes and eyelids are completely still, this corneo-retinal dipole does not affect EEG. However, blinks occur several times per minute, the eyes movements occur several times per second. Eyelid movements, occurring mostly during blinking or vertical eye movements, elicit a large potential seen mostly in the difference between the Electrooculography (EOG) channels above and below the eyes. An established explanation of this potential regards the eyelids as sliding electrodes that short-circuit the positively charged cornea to the extra-ocular skin.[46][47] Rotation of the eyeballs, and consequently of the corneo-retinal dipole, increases the potential in electrodes towards which the eyes are rotated, and decrease the potentials in the opposing electrodes.[48] Eye movements called saccades also generate transient electromyographic potentials, known as saccadic spike potentials (SPs).[] The spectrum of these SPs overlaps the gamma-band (see Gamma wave), and seriously confounds analysis of induced gamma-band responses,[49] requiring tailored artifact correction approaches.[] Purposeful or reflexive eye blinking also generates electromyographic potentials, but more importantly there is reflexive movement of the eyeball during blinking that gives a characteristic artifactual appearance of the EEG (see Bell's phenomenon). Eyelid fluttering artifacts of a characteristic type were previously called Kappa rhythm (or Kappa waves). It is usually seen in the prefrontal leads, that is, just over the eyes. Sometimes they are seen with mental activity. They are usually in the Theta (47Hz) or Alpha (813Hz) range. They were named because they were believed to originate from the brain. Later study revealed they were generated by rapid fluttering of the eyelids, sometimes so minute that it was difficult to see. They are in fact noise in the EEG reading, and should not technically be called a rhythm or wave. Therefore, current usage in electroencephalography refers to the phenomenon as an eyelid fluttering artifact, rather than a Kappa rhythm (or wave).[] Some of these artifacts can be useful in various applications. The EOG signals, for instance, can be used to detect[] and track eye-movements, which are very important in polysomnography, and is also in conventional EEG for assessing possible changes in alertness, drowsiness or sleep. EKG artifacts are quite common and can be mistaken for spike activity. Because of this, modern EEG acquisition commonly includes a one-channel EKG from the extremities. This also allows the EEG to identify cardiac arrhythmias that are an important differential diagnosis to syncope or other episodic/attack disorders. Glossokinetic artifacts are caused by the potential difference between the base and the tip of the tongue. Minor tongue movements can contaminate the EEG, especially in parkinsonian and tremor disorders.

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Environmental artifacts
In addition to artifacts generated by the body, many artifacts originate from outside the body. Movement by the patient, or even just settling of the electrodes, may cause electrode pops, spikes originating from a momentary change in the impedance of a given electrode. Poor grounding of the EEG electrodes can cause significant 50 or 60Hz artifact, depending on the local power system's frequency. A third source of possible interference can be the presence of an IV drip; such devices can cause rhythmic, fast, low-voltage bursts, which may be confused for spikes.

Artifact correction
Recently, independent component analysis techniques have been used to correct or remove EEG contaminates.[][50][51][52][53] These techniques attempt to "unmix" the EEG signals into some number of underlying components. There are many source separation algorithms, often assuming various behaviors or natures of EEG. Regardless, the principle behind any particular method usually allow "remixing" only those components that would result in "clean" EEG by nullifying (zeroing) the weight of unwanted components. Fully automated artifact rejection methods, which use ICA, have also been developed.[54]

Abnormal activity
Abnormal activity can broadly be separated into epileptiform and non-epileptiform activity. It can also be separated into focal or diffuse. Focal epileptiform discharges represent fast, synchronous potentials in a large number of neurons in a somewhat discrete area of the brain. These can occur as interictal activity, between seizures, and represent an area of cortical irritability that may be predisposed to producing epileptic seizures. Interictal discharges are not wholly reliable for determining whether a patient has epilepsy nor where his/her seizure might originate. (See focal epilepsy.) Generalized epileptiform discharges often have an anterior maximum, but these are seen synchronously throughout the entire brain. They are strongly suggestive of a generalized epilepsy. Focal non-epileptiform abnormal activity may occur over areas of the brain where there is focal damage of the cortex or white matter. It often consists of an increase in slow frequency rhythms and/or a loss of normal higher frequency rhythms. It may also appear as focal or unilateral decrease in amplitude of the EEG signal. Diffuse non-epileptiform abnormal activity may manifest as diffuse abnormally slow rhythms or bilateral slowing of normal rhythms, such as the PBR. Intracortical Encephalogram electrodes and sub-dural electrodes can be used in tandem to discriminate and discretize artifact from epileptiform and other severe neurological events. More advanced measures of abnormal EEG signals have also recently received attention as possible biomarkers for different disorders such as Alzheimer's disease.[]

Various uses
The EEG has been used for many purposes besides the conventional uses of clinical diagnosis and conventional cognitive neuroscience. An early use was during World War II by the U.S. Army Air Corps to screen out pilots in danger of having seizures;[55] long-term EEG recordings in epilepsy patients are still used today for seizure prediction. Neurofeedback remains an important extension, and in its most advanced form is also attempted as the basis of brain computer interfaces. The EEG is also used quite extensively in the field of neuromarketing. Honda is attempting to develop a system to enable an operator to control its Asimo robot using EEG, a technology it eventually hopes to incorporate into its automobiles.[56] EEGs have been used as evidence in trials in the Indian state of Maharastra.[57][58]

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625

EEG and Remote Communication


The United States Army Research Office budgeted $4million in 2009 to researchers at the University of California, Irvine to develop EEG processing techniques to identify correlates of imagined speech and intended direction to enable soldiers on the battlefield to communicate via computer-mediated reconstruction of team members' EEG signals, in the form of understandable signals such as words.[59]

Low-cost EEG Devices


Inexpensive EEG devices exist for the low-cost research and consumer markets. Recently, a few companies have miniaturized medical grade EEG technology to create versions accessible to the wider public. Some of these companies have even built commercial EEG devices retailing for less than $100 USD. In 2004 OpenEEG released its ModularEEG as open source hardware. Compatible open source software includes a game for balancing a ball. In 2007 NeuroSky released the first affordable consumer based EEG along with the game NeuroBoy. This was also the first large scale EEG device to use dry sensor technology.[60] In 2008 OCZ Technology developed device for use in video games relying primarily on electromyography. In 2008 the Final Fantasy developer Square Enix announced that it was partnering with NeuroSky to create a game, Judecca.[][61] In 2009 Mattel partnered with NeuroSky to release the Mindflex, a game that used an EEG to steer a ball through an obstacle course. By far the best selling consumer based EEG to date.[][62] In 2009 Uncle Milton Industries partnered with NeuroSky to release the StarWars Force Trainer, a game designed to create the illusion of possessing The Force.[][63] In 2009 Emotiv released the EPOC, a 14 channel EEG device. The EPOC is the first commercial BCI to not use dry sensor technology, requiring users to apply a saline solution to their head.[64] In 2010, NeuroSky added a blink and electromyography function to the MindSet.[65] In 2011, NeuroSky released the MindWave, an EEG device designed for educational purposes and games.[] The MindWave won the Guinness Book of World Records award for Heaviest machine moved using a brain control interface.[] In 2012, a Japanese gadget project, neurowear, released Necomimi: a headset with motorized cat ears. The headset is a NeuroSky MindWave unit with two motors on the headband where a cat's ears might be. Slipcovers shaped like cat ears sit over the motors so that as the device registers emotional states the ears move to relate. For example, when relaxed, the ears fall to the sides and perk up when excited again.

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Images

Person wearing electrodes for EEG

Portable recording device for EEG

EEG electroencephalophone used during a music performance in which bathers from around the world were networked together as part of a collective musical performance, using their brainwaves to control sound, lighting, and the bath environment

References
[1] [2] [3] [4] [9] http:/ / icd9cm. chrisendres. com/ index. php?srchtype=procs& srchtext=89. 14& Submit=Search& action=search http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2011/ MB_cgi?field=uid& term=D004569 http:/ / ops. icd-code. de/ ops/ code/ 1-207. html Atlas of EEG & Seizure Semiology. B. Abou-Khalil; Musilus, K.E.; Elsevier, 2006. Millet, David (2002). "The Origins of EEG". (http:/ / www. bri. ucla. edu/ nha/ ishn/ ab24-2002. htm) International Society for the History of the Neurosciences (ISHN). [10] Tatum, W. O., Husain, A. M., Benbadis, S. R. (2008) "Handbook of EEG Interpretation" Demos Medical Publishing. [13] Vespa, P., Nenov, V., & Nuwer, M. (1999). Continuous EEG monitoring in the intensive care unit: early findings and clinical efficacy. J Clin Neurophysiol, 16: 113. [14] Hamalainen, M., Riitta, H., Ilmoniemi, R., Knuutila, J., & Lounasmaa, O. (1993). Magnetoencephalographytheory, instrumentation, and applications to noninvasive studies of the working human brain. Reviews of Modern Physics, 65(2), 414-497. [15] O'Regan, S., Faul, S., & Marnane, W. (2010). "Automatic detection of EEG artefacts arising from head movements." Engineering in Medicine and Biology Society (EMBC), 2010 Annual International Conference of the IEEE, Buenos Aires, Argentina, August 31 - September 4, 2010, 6353-6356. [16] Murphy, K., & Brunberg, J. (1997). "Adult claustrophobia, anxiety and sedation in MRI." Magnetic Resonance Imaging, 15(1), 51-54. [17] Schenck, J. (1996). "The role of magnetic susceptibility in magnetic resonance imaging: MRI magnetic compatibility of the first and second kinds." Med. Phys., 23(6), 815-850 [18] Mulholland, T. (1973). "Objective EEG methods for studying covert shifts of visual attention." In F. J. McGuigan and J. Schoonover (Eds.), The Psychophysiology of thinking. Academic Press: New York, 109-151. [19] Hinterberger, T., Kbler, A., Kaiser, J., Neumann, N., & Birbaumer, N. (2003). A brain-computer interface (BCI) for the locked-in: comparison of different EEG classifications for the thought translation device. Clinical neurophysiology : official journal of the International Federation of Clinical Neurophysiology, 114(3), 416-25. [20] Sereno, S. C., Rayner, K., & Posner, M. I. (1998). Establishing a time-line of word recognition: evidence from eye movements and event-related potentials. Neuroreport, 9(10), 2195-200. Retrieved from http:/ / www. ncbi. nlm. nih. gov/ pubmed/ 9694199 [21] http:/ / www. sciencedaily. com/ releases/ 2013/ 03/ 130319102757. htm [22] http:/ / www. ct. gov/ ceq/ cwp/ view. asp?a=987& q=249438 [23] Srinivasan, R. (1999). Methods to Improve the Spatial Resolution of EEG. International Journal, 1(1), 102-111. [24] Schlgl, A., Slater, M., & Pfurtscheller, G. (2002). Presence research and EEG Properties of EEG recordings. Proceedings of the 5th Annual International Workshop PRESENCE. Porto, Portugal, October 911.

Electroencephalography
[25] Horovitz, S. G., Skudlarski, P., & Gore, J. C. (2002). Correlations and dissociations between BOLD signal and P300 amplitude in an auditory oddball task: a parametric approach to combining fMRI and ERP. Magnetic Resonance Imaging, 20, 319 -325. [27] DiFrancesco, M., Holland, S., & Szaflarski, J. (2008). Simultaneous EEG/Functional Magnetic Resonance Imaging at 4 Tesla: Correlates of Brain Activity to Spontaneous Alpha Rhythm During Relaxation. J Clin Neurophysiol., 25(5), 255-264. [28] Huizenga, H. M., van Zuijen, T. L., Heslenfeld, D. J., & Molenaar, P. C. (2001). Simultaneous MEG and EEG source analysis. Physics in medicine and biology, 46(7), 1737-51. Retrieved from http:/ / www. ncbi. nlm. nih. gov/ pubmed/ 11474922 [32] http:/ / fieldtrip. fcdonders. nl/ [33] http:/ / www. nbtwiki. net/ [34] http:/ / www. fil. ion. ucl. ac. uk/ spm/ [35] http:/ / brainproducts. com/ productdetails. php?id=17 [56] Mind over matter: Brain waves control Asimo (http:/ / search. japantimes. co. jp/ cgi-bin/ nb20090401a2. html) 1 Apr 2009, Japan Times [57] This brain test maps the truth (http:/ / articles. timesofindia. indiatimes. com/ 2008-07-21/ mumbai/ 27890043_1_sessions-court-murder-rukmani-krishnamurthy) 21 Jul 2008, 0348 hrs IST, Nitasha Natu,TNN [59] MURI: Synthetic Telepathy (http:/ / cnslab. ss. uci. edu/ muri/ index. html). Cnslab.ss.uci.edu. Retrieved 2011-07-19.

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External links
A tutorial on simulating and estimating EEG sources in Matlab (http://www.nbtwiki.net/doku. php?id=tutorial:tutorial_dipoles) A tutorial on analysis of ongoing, evoked, and induced neuronal activity: Power spectra, wavelet analysis, and coherence (http://www.nbtwiki.net/doku.php?id=tutorial:power_spectra_wavelet_analysis_and_coherence) Scholarpedia EEG (http://www.scholarpedia.org/article/Electroencephalogram) FASTER (http://www.mee.tcd.ie/neuraleng/Research.Faster) A fully automated, unsupervised method for processing of high density EEG data. FASTER has been peer-reviewed, it is free and the software is open source. The FASTER software is available here. (https://sourceforge.net/projects/faster) Video demonstration of placement of electrodes (http://www.youtube.com/watch?v=IwGIF5aCnqg& feature=digest) OpenEEG (http://openeeg.sourceforge.net/doc/) The OpenEEG project makes hardware plans and software for do-it-yourself EEG devices in an Open Source manner. The hardware is aimed toward amateurs who would like to experiment with EEG. (http://www.caet.org) Canadian association of EEG techs (CAET)

Electronic health record

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Electronic health record


An electronic health record (EHR) is an evolving concept defined as a systematic collection of electronic health information about individual patients or populations.[1] It is a record in digital format that is theoretically capable of being shared across different health care settings. In some cases this sharing can occur by way of network-connected, enterprise-wide information systems and other information networks or exchanges. EHRs may include a range of data, including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal statistics like age and weight, and billing information.

Sample view of an electronic health record based on images

The system is designed to capture and re-present data that accurately capture the state of the patient at all times. It allows for an entire patient history to be viewed without the need to track down the patients previous medical record volume and assists in ensuring data is accurate, appropriate and legible. It reduces the chances of data replication as there is only one modifiable file, which means the file is constantly up to date when viewed at a later date and eliminates the issue of lost forms or paperwork. Due to all the information being Sample view of an electronic health record in a single file, it makes it much more effective when extracting medical data for the examination of possible trends and long term changes in the patient.

Terminology
The terms EHR, EPR (electronic patient record) and EMR (electronic medical record) are often used interchangeably, although differences between them can be defined. The EMR can, for example, be defined as the patient record created in hospitals and ambulatory environments, and which can serve as a data source for the EHR.[][2] It is important to note that an EHR is generated and maintained within an institution, such as a hospital, integrated delivery network, clinic, or physician office, to give patients, physicians and other health care providers, employers, and payers or insurers access to a patient's medical records across facilities.[] A personal health record (PHR) is, in modern parlance, generally defined as an EHR that the individual patient controls.

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Comparison with paper-based records


Paper-based records require a significant amount of storage space compared to digital records. In the United States, most states require physical records be held for a minimum of seven years. The costs of storage media, such as paper and film, per unit of information differ dramatically from that of electronic storage media. When paper records are stored in different locations, collating them to a single location for review by a health care provider is time consuming and complicated, whereas the process can be simplified with electronic records. This is particularly true in the case of person-centered records, which are impractical to maintain if not electronic (thus difficult to centralize or federate). When paper-based records are required in multiple locations, copying, faxing, and transporting costs are significant compared to duplication and transfer of digital records.[citation needed] Because of these many "after-entry" benefits, federal and state governments, insurance companies and other large medical institutions are heavily promoting the adoption of electronic medical records. The US Congress included a formula of both incentives (up to $44,000 per physician under Medicare or up to $65,000 over six years, under Medicaid) and penalties (i.e. decreased Medicare and Medicaid reimbursements for covered patients to doctors who fail to use EMRs by 2015) for EMR/EHR adoption versus continued use of paper records as part of the Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act of 2009.[3] One study estimates electronic medical records improve overall efficiency by 6% per year, and the monthly cost of an EMR may (depending on the cost of the EMR) be offset by the cost of only a few "unnecessary" tests or admissions.[4][5] Jerome Groopman disputed these results, publicly asking "how such dramatic claims of cost-saving and quality improvement could be true".[6] However, the increased portability and accessibility of electronic medical records may also increase the ease with which they can be accessed and stolen by unauthorized persons or unscrupulous users versus paper medical records, as acknowledged by the increased security requirements for electronic medical records included in the Health Information and Accessibility Act and by large-scale breaches in confidential records reported by EMR users.[7][8] Concerns about security contribute to the resistance shown to their widespread adoption. Handwritten paper medical records can be associated with poor legibility, which can contribute to medical errors.[9] Pre-printed forms, the standardization of abbreviations, and standards for penmanship were encouraged to improve reliability of paper medical records. Electronic records help with the standardization of forms, terminology and abbreviations, and data input. Digitization of forms facilitates the collection of data for epidemiology and clinical studies.[10][11] In contrast, EMRs can be continuously updated (within certain legal limitations see below). The ability to exchange records between different EMR systems ("interoperability"[12]) would facilitate the co-ordination of health care delivery in non-affiliated health care facilities. In addition, data from an electronic system can be used anonymously for statistical reporting in matters such as quality improvement, resource management and public health communicable disease surveillance.[13]

In ambulances
Ambulance services in Australia have introduced the use of EMR systems [14] The benefits of EMR in ambulances include the following: better training for paramedics, review of clinical standards, better research options for pre-hospital care and design of future treatment options [15] Automated handwriting recognition of ambulance medical forms has also been successful. These systems allow paper-based medical documents to be converted to digital text with substantially less cost overhead. Patient identifying information would not be converted to comply with government privacy regulations. The data can then be efficiently used for epidemiological analysis.[16]

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Technical features
Digital formatting enables information to be used and shared over secure networks Track care (e.g. prescriptions) and outcomes (e.g. blood pressure) Trigger warnings and reminders Send and receive orders, reports, and results

Health Information Exchange[17] Technical and social framework that enables information to move electronically between organizations Reporting to public health ePrescribing Sharing laboratory results with providers

Using an EMR to read and write a patient's record is not only possible through a workstation but, depending on the type of system and health care settings, may also be possible through mobile devices that are handwriting capable.[18] Electronic Medical Records may include access to Personal Health Records (PHR) which makes individual notes from an EMR readily visible and accessible for consumers. Some EMR systems automatically monitor clinical events, by analyzing patient data from an electronic health record to predict, detect and potentially prevent adverse events. This can include discharge/transfer orders, pharmacy orders, radiology results, laboratory results and any other data from ancillary services or provider notes.[19] This type of event monitoring has been implemented using the Louisiana Public health information exchange linking state wide public health with electronic medical records. This system alerted medical providers when a patient with HIV/AIDS had not received care in over twelve months. This system greatly reduced the number of missed critical opportunities.[20]

Philosophical views of the EHR


Within a meta-narrative systematic review of research in the field, Prof. Trish Greenhalgh and colleagues defined a number of different philosophical approaches to the EHR.[] The health information systems literature has seen the EHR as a container holding information about the patient, and a tool for aggregating clinical data for secondary uses (billing, audit etc.). However, other research traditions see the EHR as a contextualised artifact within a socio-technical system. For example, actor-network theory would see the EHR as an actant in a network,[21] while research in computer supported cooperative work (CSCW) sees the EHR as a tool supporting particular work. Several possible advantages to EHRs over paper records have been proposed, but there is debate about the degree to which these are achieved in practice.[22]

Implementation, end user and patient considerations


Quality
Several studies call into question whether EHRs improve the quality of care.[23][24][25][][] However, a recent multi-provider study in diabetes care, published in the New England Journal of Medicine, found evidence that practices with EHR provided better quality care.[26] EHR do help improve care coordination. Since anyone with that EHR can view the patients chart it cuts down on guessing histories, seeing multiple specialists, smoothing transitions between care settings, and better care in emergency situations [27] EHRs may also improve prevention by providing doctors and patients better access to test results, identifying missing patient information, and offering evidence-based recommendations for preventive services.[28]

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Costs
The steep price of EHR and provider uncertainty regarding the value they will derive from adoption in the form of return on investment has a significant influence on EHR adoption.[29] In a project initiated by the Office of the National Coordinator for Health Information (ONC), surveyors found that hospital administrators and physicians who had adopted EHR noted that any gains in efficiency were offset by reduced productivity as the technology was implemented, as well as the need to increase information technology staff to maintain the system.[29] The U.S. Congressional Budget Office concluded that the cost savings may occur only in large integrated institutions like Kaiser Permanente, and not in small physician offices. They challenged the Rand Corp. estimates of savings. "Office-based physicians in particular may see no benefit if they purchase such a productand may even suffer financial harm. Even though the use of health IT could generate cost savings for the health system at large that might offset the EHR's cost, many physicians might not be able to reduce their office expenses or increase their revenue sufficiently to pay for it. For example. the use of health IT could reduce the number of duplicated diagnostic tests. However, that improvement in efficiency would be unlikely to increase the income of many physicians."[30] One CEO of an EHR company has argued if a physician performs tests in the office, it might reduce his or her income.[31] Doubts have been raised about cost saving from EHRs by researchers at Harvard University, the Wharton School of the University of Pennsylvania, Stanford University, and others.[][32][33]

Software quality and usability deficiencies


The Healthcare Information and Management Systems Society (HIMSS), a very large U.S. healthcare IT industry trade group, observed that EHR adoption rates "have been slower than expected in the United States, especially in comparison to other industry sectors and other developed countries. A key reason, aside from initial costs and lost productivity during EMR implementation, is lack of efficiency and usability of EMRs currently available."[34] The U.S. National Institute of Standards and Technology of the Department of Commerce studied usability in 2011 and lists a number of specific issues that have been reported by health care workers.[35] The U.S. military's EHR, AHLTA, was reported to have significant usability issues.[36] However, physicians are embracing mobile technologies such as smartphones and tablets at a rapid pace. According to a 2012 survey by Physicians Practice, 62.6 percent of respondents (1,369 physicians, practice managers, and other healthcare providers) say they use mobile devices in the performance of their job. Mobile devices are increasingly able to synch up with electronic health record systems thus allowing physicians to access patient records from remote locations. Most devices are extensions of desk-top EHR systems, using a variety of software to communicate and access files remotely. The advantages of instant access to patient records at any time and any place are clear, but bring a host of security concerns. As mobile systems become more prevalent, practices will need comprehensive policies that govern security measures and patient privacy regulations.[37]

Unintended consequences
Per empirical research in social informatics, information and communications technology (ICT) use can lead to both intended and unintended consequences.[38][39][40] A 2008 Sentinel Event Alert from the U.S. Joint Commission, the organization that accredits American hospitals to provide healthcare services, states that "As health information technology (HIT) and 'converging technologies'the interrelationship between medical devices and HITare increasingly adopted by health care organizations, users must be mindful of the safety risks and preventable adverse events that these implementations can create or perpetuate. Technology-related adverse events can be associated with all components of a comprehensive technology system and may involve errors of either commission or omission. These unintended adverse events typically stem from human-machine interfaces or organization/system design."[41] The Joint Commission cites as an example the United States Pharmacopeia MEDMARX database[42] where of 176,409 medication error records for 2006, approximately 25 percent (43,372) involved some aspect of computer technology as at least one cause of the

Electronic health record error. The National Health Service (NHS) in the UK reports specific examples of potential and actual EHR-caused unintended consequences in their 2009 document on the management of clinical risk relating to the deployment and use of health software.[43] In a Feb. 2010 U.S. Food and Drug Administration (FDA) memorandum, FDA notes EHR unintended consequences include EHR-related medical errors due to (1) errors of commission (EOC), (2) errors of omission or transmission (EOT), (3) errors in data analysis (EDA), and (4) incompatibility between multi-vendor software applications or systems (ISMA) and cites examples. In the memo FDA also notes the "absence of mandatory reporting enforcement of H-IT safety issues limits the numbers of medical device reports (MDRs) and impedes a more comprehensive understanding of the actual problems and implications."[44] A 2010 Board Position Paper by the American Medical Informatics Association (AMIA) contains recommendations on EHR-related patient safety, transparency, ethics education for purchasers and users, adoption of best practices, and re-examination of regulation of electronic health applications.[45] Beyond concrete issues such as conflicts of interest and privacy concerns, questions have been raised about the ways in which the physician-patient relationship would be affected by an electronic intermediary.[46][47]

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Privacy and confidentiality


In the United States in 2011 there were 380 major data breaches involving 500 or more patients' records listed on the website kept by the United States Department of Health and Human Services (HHS) Office for Civil Rights.[48] So far, from the first wall postings in September 2009 through the latest on December 8, 2012, there have been 18,059,831 "individuals affected," and even that massive number is an undercount of the breach problem. The civil rights office has not released the records of tens of thousands of breaches it has received under a federal reporting mandate on breaches affecting fewer than 500 patients per incident.[49]

Governance, privacy and legal issues


Privacy concerns
In the United States, Great Britain, and Germany, the concept of a national centralized server model of healthcare data has been poorly received. Issues of privacy and security in such a model have been of concern.[50][51] Privacy concerns in healthcare apply to both paper and electronic records. According to the Los Angeles Times, roughly 150 people (from doctors and nurses to technicians and billing clerks) have access to at least part of a patient's records during a hospitalization, and 600,000 payers, providers and other entities that handle providers' billing data have some access also.[52] Recent revelations of "secure" data breaches at centralized data repositories, in banking and other financial institutions, in the retail industry, and from government databases, have caused concern about storing electronic medical records in a central location.[53] Records that are exchanged over the Internet are subject to the same security concerns as any other type of data transaction over the Internet. The Health Insurance Portability and Accountability Act (HIPAA) was passed in the US in 1996 to establish rules for access, authentications, storage and auditing, and transmittal of electronic medical records. This standard made restrictions for electronic records more stringent than those for paper records. However, there are concerns as to the adequacy of these standards.[54] In the United States, information in electronic medical records is referred to as Protected Health Information (PHI) and its management is addressed under the Health Insurance Portability and Accountability Act (HIPAA) as well as many local laws.[55] The HIPAA protects a patient's information; the information that is protected under this act are: information doctors and nurses input into the electronic medical record, conversations between a doctor and a patient that may have been recorded, as well as billing information. Under this act there is a limit as to how much

Electronic health record information can be disclosed, and as well as who can see a patients information. Patients also get to have a copy of their records if they desire, and get a notified if their information is ever to be shared with third parties.[56] Medical and health care providers experienced 767 security breaches resulting in the compromised confidential health information of 23,625,933 patients during the period of 20062012.[57] In the European Union (EU), several directives of the European Parliament and of the Council protect the processing and free movement of personal data, including for purposes of health care.[58] Threats to health care information can be categorized under three headings: Human threats, such as employees or hackers Natural and environmental threats, such as earthquakes, hurricanes and fires. Technology failures, such as a system crashing These threats can either be internal, external, intentional and unintentional. Therefore, one will find health information systems professionals having these particular threats in mind when discussing ways to protect the health information of patients. The Health Insurance Portability and Accountability Act (HIPAA) has developed a framework to mitigate the harm of these threats that is comprehensive but not so specific as to limit the options of healthcare professionals who may have access to different technology.[59] In the European Union (EU), several Directives of the European Parliament and of the Council protect the processing and free movement of personal data, including for purposes of health care.[60] Personal Information Protection and Electronic Documents Act (PIPEDA) was given Royal Assent in Canada on April 13, 2000 to establish rules on the use, disclosure and collection of personal information. The personal information includes both non-digital and electronic form. In 2002, PIPEDA extended to the health sector in Stage 2 of the law's implementation.[61] There are four provinces where this law does not apply because its privacy law was considered similar to PIPEDA: Alberta, British Columbia, Ontario and Quebec. One major issue that has risen on the privacy of the US network for electronic health records is the strategy to secure the privacy of patients. Former US president Bush called for the creation of networks, but federal investigators report that there is no clear strategy to protect the privacy of patients as the promotions of the electronic medical records expands throughout the United States. In 2007, the Government Accountability Office reports that there is a "jumble of studies and vague policy statements but no overall strategy to ensure that privacy protections would be built into computer networks linking insurers, doctors, hospitals and other health care providers."[52] The privacy threat posed by the interoperability of a national network is a key concern. One of the most vocal critics of EMRs, New York University Professor Jacob M. Appel, has claimed that the number of people who will need to have access to such a truly interoperable national system, which he estimates to be 12 million, will inevitable lead to breaches of privacy on a massive scale. Appel has written that while "hospitals keep careful tabs on who accesses the charts of VIP patients," they are powerless to act against "a meddlesome pharmacist in Alaska" who "looks up the urine toxicology on his daughter's fiance in Florida, to check if the fellow has a cocaine habit."[62] This is a significant barrier for the adoption of an EHR. Accountability among all the parties that are involved in the processing of electronic transactions including the patient, physician office staff, and insurance companies, is the key to successful advancement of the EHR in the US Supporters of EHRs have argued that there needs to be a fundamental shift in "attitudes, awareness, habits, and capabilities in the areas of privacy and security" of individual's health records if adoption of an EHR is to occur.[211] According to the Wall Street Journal, the DHHS takes no action on complaints under HIPAA, and medical records are disclosed under court orders in legal actions such as claims arising from automobile accidents. HIPAA has special restrictions on psychotherapy records, but psychotherapy records can also be disclosed without the client's knowledge or permission, according to the Journal. For example, Patricia Galvin, a lawyer in San Francisco, saw a psychologist at Stanford Hospital & Clinics after her fiance committed suicide. Her therapist had assured her that her records would be confidential. But after she applied for disability benefits, Stanford gave the insurer her therapy

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Electronic health record notes, and the insurer denied her benefits based on what Galvin claims was a misinterpretation of the notes.[63][64] Within the private sector, many companies are moving forward in the development, establishment and implementation of medical record banks and health information exchange. By law, companies are required to follow all HIPAA standards and adopt the same information-handling practices that have been in effect for the federal government for years. This includes two ideas, standardized formatting of data electronically exchanged and federalization of security and privacy practices among the private sector.[211] Private companies have promised to have "stringent privacy policies and procedures." If protection and security are not part of the systems developed, people will not trust the technology nor will they participate in it.[52]

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Legal issues
Liability Legal liability in all aspects of healthcare was an increasing problem in the 1990s and 2000s. The surge in the per capita number of attorneys[65] and changes in the tort system caused an increase in the cost of every aspect of healthcare, and healthcare technology was no exception.[66] Failure or damages caused during installation or utilization of an EHR system has been feared as a threat in lawsuits.[67] Similarly, it's important to recognize that the implementation of electronic health records carries with it significant legal risks.[68] This liability concern was of special concern for small EHR system makers. Some smaller companies may be forced to abandon markets based on the regional liability climate.[69]Wikipedia:Identifying reliable sources Larger EHR providers (or government-sponsored providers of EHRs) are better able to withstand legal assaults. While there is no argument that electronic documentation of patient visits and data brings improved patient care, there is increasing concern that such documentation could open physicians to an increased incidence of malpractice suits. Disabling physician alerts, selecting from dropdown menus, and the use of templates can encourage physicians to skip a complete review of past patient history and medications, and thus miss important data. Another potential problem is electronic time stamps. Many physicians are unaware that EHR systems produce an electronic time stamp every time the patient record is updated. If a malpractice claim goes to court, through the process of discovery, the prosecution can request a detailed record of all entries made in a patient's electronic record. Waiting to chart patient notes until the end of the day and making addendums to records well after the patient visit can be problematic, in that this practice could result in less than accurate patient data or indicate possible intent to illegally alter the patient's record.[70] In some communities, hospitals attempt to standardize EHR systems by providing discounted versions of the hospital's software to local healthcare providers. A challenge to this practice has been raised as being a violation of Stark rules that prohibit hospitals from preferentially assisting community healthcare providers.[71] In 2006, however, exceptions to the Stark rule were enacted to allow hospitals to furnish software and training to community providers, mostly removing this legal obstacle.[72]Wikipedia:Identifying reliable sources[73]Wikipedia:Identifying reliable sources Legal interoperability In cross-border use cases of EHR implementations, the additional issue of legal interoperability arises. Different countries may have diverging legal requirements for the content or usage of electronic health records, which can require radical changes of the technical makeup of the EHR implementation in question. (especially when fundamental legal incompatibilities are involved) Exploring these issues is therefore often necessary when implementing cross-border EHR solutions.[74]

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Regulatory compliance
Consumer Credit Act 2006 HIPAA Health Level 7

Contribution under UN administration and accredited organizations


The United Nations World Health Organization (WHO) administration intentionally does not contribute to an internationally standardized view of medical records nor to personal health records. However, WHO contributes to minimum requirements definition for developing countries.[75] The United Nations accredited standardisation body International Organization for Standardization (ISO) however has settled thorough wordWikipedia:Please clarify for standards in the scope of the HL7 platform for health care informatics. Respective standards are available with ISO/HL7 10781:2009 Electronic Health Record-System Functional Model, Release 1.1[76] and subsequent set of detailing standards.[77]

Medical Data Breach


The Security Rule, according to Health and Human Services (HHS), establishes a security framework for small practices as well as large institutions. All covered entities must have a written security plan. The HHS identifies three components as necessary for the security plan: administrative safeguards, physical safeguards, and technical safeguards. However, medical and healthcare providers have experienced 767 security breaches resulting in the compromised confidential health information of 23,625,933 patients during the period of 2006-2012.[78] The majority of the counties in Europe have made a strategy for the development and implementation of the Electronic Health Record Systems. This would mean greater access to health records by numerous stakeholders, even from countries with lower levels of privacy protection. The forthcoming implementation of the Cross Border Health Directive and the EU Commission's plans to centralize all health records are of prime concern to the EU public who believe that the health care organizations and governments cannot be trusted to manage their data electronically and expose them to more threats. The idea of a centralized electronic health record system has been poorly received by the public who are wary that the governments may extend the use of the system beyond its purpose. There is also the risk for privacy breaches that could allow sensitive health care information to fall into the wrong hands. Some countries have enacted laws requiring safeguards to be put in place to protect the security and confidentiality of medical information as it is shared electronically and to give patients some important rights to monitor their medical records and receive notification for loss and unauthorized acquisition of health information. The United States and the EU have imposed mandatory medical data breach notifications.[79] The Health Insurance Portability and Accessibility Act (HIPAA) requires safeguards to limit the number of people who have access to personal information. However, given the number of people who may have access to your information as part of the operations and business of the health care provider or plan, there is no realistic way to estimate the number of people who may come across your records.[80] Additionally, law enforcement access is authorized under HIPAA. In some cases, medical information may be disclosed without a warrant or court order.

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Breach notification
The purpose of a personal data breach notification is to protect individuals so that they can take all the necessary actions to limit the undesirable effects of the breach and to motivate the organization to improve the security of the infrastructure to protect the confidentiality of the data. The US law requires the entities to inform the individuals in the event of breach while the EU Directive currently requires breach notification only when the breach is likely to adversely affect the privacy of the individual. Personal health data is valuable to individuals and is therefore difficult to make an assessment whether the breach will cause reputational or financial harm or cause adverse effects on one's privacy. The Security Rule that was adopted in 2005 did not require breach notification. However, notice might be required by state laws that apply to a variety of industries, including health care providers. In California, a law has been in place since 2003 requiring that a HIPAA covered organization's breach could have triggered a notice even though notice was not required by the HIPAA Security Rule. Since January 1, 2009, California residents are required to receive notice of a health information breach. Federal law and regulations now provide rights to notice of a breach of health information. The Health Information Technology for Economic and Clinical Health (HITECH) Act requires HHS and the Federal Trade Commission (FTC) to jointly study and report on privacy and data security of personal health information. HITECH also requires the agencies to issue breach notification rules that apply to HIPAA covered entities and Web-based vendors that store health information electronically. The FTC has adopted rules regarding breach notification for internet-based vendors.[81] The Breach notification law in the EU provides better privacy safeguards with fewer exemptions, unlike the US law which exempts unintentional acquisition, access, or use of protected health information and inadvertent disclosure under a good faith belief.[79]

Technical issues
Standards
ANSI X12 (EDI) - transaction protocols used for transmitting patient data. Popular in the United States for transmission of billing data. CEN's TC/251 provides EHR standards in Europe including: EN 13606, communication standards for EHR information CONTSYS (EN 13940), supports continuity of care record standardization. HISA (EN 12967), a services standard for inter-system communication in a clinical information environment. Continuity of Care Record - ASTM International Continuity of Care Record standard DICOM - an international communications protocol standard for representing and transmitting radiology (and other) image-based data, sponsored by NEMA (National Electrical Manufacturers Association) HL7 - a standardized messaging and text communications protocol between hospital and physician record systems, and between practice management systems ISO - ISO TC 215 provides international technical specifications for EHRs. ISO 18308 describes EHR architectures

The U.S. federal government has issued new rules of electronic health records.[]

Electronic health record Open Specifications openEHR: an open community developed specification for a shared health record with web-based content developed online by experts. Strong multilingual capability. Virtual Medical Record: HL7's proposed model for interfacing with clinical decision support systems. SMART (Subsitutable Medical Apps, reusable technologies): an open platform specification to provide a standard base for healthcare applications.[82] Customization Each healthcare environment functions differently, often in significant ways. It is difficult to create a "one-size-fits-all" EHR system. An ideal EHR system will have record standardization but interfaces that can be customized to each provider environment. Modularity in an EHR system facilitates this. Many EHR companies employ vendors to provide customization. This customization can often be done so that a physician's input interface closely mimics previously utilized paper forms.[83] At the same time they reported negative effects in communication, increased overtime, and missing records when a non-customized EMR system was utilized.[84] Customizing the software when it is released yields the highest benefits because it is adapted for the users and tailored to workflows specific to the institution.[85] Customization can have its disadvantages. There is, of course, higher costs involved to implementation of a customized system initially. More time must be spent by both the implementation team and the healthcare provider to understand the workflow needs. Development and maintenance of these interfaces and customizations can also lead to higher software implementation and maintenance costs.[86]Wikipedia:Identifying reliable sources[87]Wikipedia:Identifying reliable sources

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Long-term preservation and storage of records


An important consideration in the process of developing electronic health records is to plan for the long-term preservation and storage of these records. The field will need to come to consensus on the length of time to store EHRs, methods to ensure the future accessibility and compatibility of archived data with yet-to-be developed retrieval systems, and how to ensure the physical and virtual security of the archives[citation needed]. Additionally, considerations about long-term storage of electronic health records are complicated by the possibility that the records might one day be used longitudinally and integrated across sites of care. Records have the potential to be created, used, edited, and viewed by multiple independent entities. These entities include, but are not limited to, primary care physicians, hospitals, insurance companies, and patients. Mandl et al. have noted that "choices about the structure and ownership of these records will have profound impact on the accessibility and privacy of patient information."[88] The required length of storage of an individual electronic health record will depend on national and state regulations, which are subject to change over time. Ruotsalainen and Manning have found that the typical preservation time of patient data varies between 20 and 100 years. In one example of how an EHR archive might function, their research "describes a co-operative trusted notary archive (TNA) which receives health data from different EHR-systems, stores data together with associated meta-information for long periods and distributes EHR-data objects. TNA can store objects in XML-format and prove the integrity of stored data with the help of event records, timestamps and archive e-signatures."[89] In addition to the TNA archive described by Ruotsalainen and Manning, other combinations of EHR systems and archive systems are possible. Again, overall requirements for the design and security of the system and its archive

Electronic health record will vary and must function under ethical and legal principles specific to the time and place[citation needed]. While it is currently unknown precisely how long EHRs will be preserved, it is certain that length of time will exceed the average shelf-life of paper records. The evolution of technology is such that the programs and systems used to input information will likely not be available to a user who desires to examine archived data. One proposed solution to the challenge of long-term accessibility and usability of data by future systems is to standardize information fields in a time-invariant way, such as with XML language. Olhede and Peterson report that "the basic XML-format has undergone preliminary testing in Europe by a Spri project and been found suitable for EU purposes. Spri has advised the Swedish National Board of Health and Welfare and the Swedish National Archive to issue directives concerning the use of XML as the archive-format for EHCR (Electronic Health Care Record) information."[90]

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Synchronization of records
When care is provided at two different facilities, it may be difficult to update records at both locations in a co-ordinated fashion. Two models have been used to satisfy this problem: a centralized data server solution, and a peer-to-peer file synchronization program (as has been developed for other peer-to-peer networks). Synchronization programs for distributed storage models, however, are only useful once record standardization has occurred. Merging of already existing public healthcare databases is a common software challenge. The ability of electronic health record systems to provide this function is a key benefit and can improve healthcare delivery.[91][92][93]

eHealth and teleradiology


The sharing of patient information between health care organizations and IT systems is changing from a "point to point" model to a "many to many" one. The European Commission is supporting moves to facilitate cross-border interoperability of e-health systems and to remove potential legal hurdles, as in the project www.epsos.eu/. To allow for global shared workflow, studies will be locked when they are being read and then unlocked and updated once reading is complete. Radiologists will be able to serve multiple health care facilities and read and report across large geographical areas, thus balancing workloads. The biggest challenges will relate to interoperability and legal clarity. In some countries it is almost forbidden to practice teleradiology. The variety of languages spoken is a problem and multilingual reporting templates for all anatomical regions are not yet available. However, the market for e-health and teleradiology is evolving more rapidly than any laws or regulations.[94]

European Union: Directive 2011/24/EU on patients' rights in cross-border healthcare


The European Commission wants to boost the digital economy by enabling all Europeans to have access to online medical records anywhere in Europe by 2020. With the newly enacted Directive 2011/24/EU on patients' rights in cross-border healthcare due for implementation by 2013, it is inevitable that a centralised European health record system will become a reality even before 2020. However, the concept of a centralised supranational central server raises concern about storing electronic medical records in a central location. The privacy threat posed by a supranational network is a key concern. Cross-border and Interoperable electronic health record systems make confidential data more easily and rapidly accessible to a wider audience and increase the risk that personal data concerning health could be accidentally exposed or easily distributed to unauthorised parties by enabling greater access to a compilation of the personal data concerning health, from different sources, and throughout a lifetime.[95]

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National contexts
United States

EHR adoption of all physicians in the US. Source: DesRoches et al. (2008). Fully functional EHR system (4%) Basic EHR system (13%) Bought but not implemented yet (13%) EHR purchase planned in 2 years (22%) No EHR system (48%) Usage Even though EMR systems with a computerized provider order entry (CPOE) have existed for more than 30 years, fewer than 10 percent of hospitals as of 2006 had a fully integrated system.[96] In a 2008 survey by DesRoches et al. of 4484 physicians (62% response rate), 83% of all physicians, 80% of primary care physicians, and 86% of non-primary care physicians had no EHRs. "Among the 83% of respondents who did not have electronic health records, 16%" had bought, but not implemented an EHR system yet.[] The 2009 National Ambulatory Medical Care Survey of 5200 physicians (70% response rate) by the National Center for Health Statistics showed that 51.7% of office-based physicians did not use any EMR/EHR system.[] In the United States, the CDC reported that the EMR adoption rate had steadily risen to 48.3 percent at the end of 2009.[97] This is an increase over 2008, when only 38.4% of office-based physicians reported using fully or partially electronic medical record systems (EMR) in 2008.[98] However, the same study found that only 20.4% of all physicians reported using a system described as minimally functional and including the following features: orders for prescriptions, orders for tests, viewing laboratory or imaging results, and clinical progress notes. As of 2012, 72 percent of office physicians are using basic electronic medical records. The healthcare industry spends only 2% of gross revenues on HIT, which is low compared to other information intensive industries such as finance, which spend upwards of 10%.[99][100] The usage of electronic medical records can vary depending on who the user is and how they are using it. Electronic medical records can help improve the quality of medical care given to patients. Many doctors and office-based physicians refuse to get rid of the traditional paper records. Harvard University has conducted an experiment in which they tested how doctors and nurses use electronic medical records to keep their patients' information up to date. The studies found that electronic medical records were very useful; a doctor or a nurse was able to find a patient's information fast and easy just by typing their name; even if it was misspelled. The usage of electronic medical records increases in some work places due to the ease of use of the system; whereas the president of the Canadian Family Practice Nurses Association says that using electronic medical records can be time consuming, and it isn't very helpful due to the complexity of the system.[101] Beth Israel Deaconess Medical Center reported that

Electronic health record doctors and nurses prefer to use a much more friendly user software due to the difficulty and time it takes for a medical staff to input the information as well as to find a patients information. A study was done and the amount of information that was recorded in the EMRs was recorded; about 44% of the patients information was recorded in the EMRs. This shows that EMRs are not very efficient most of the time.[102] The cost of implementing an EMR system for smaller practices has also been criticized.Wikipedia:Avoid weasel words Despite this, tighter regulations regarding meaningful use criteria have resulted in more physicians adopting EMR systems. Software, hardware and other services for EMR system implementation are provided for cost by various companies, including Dell.[103] Open source EMR systems exist, but have not seen widespread adoption of open-source EMR system software. Beyond financial concerns there are a number of legal and ethical dilemmas created by increasing EMR use.[104] Legal status Electronic medical records, like other medical records, must be kept in unaltered form and authenticated by the creator.[105] Under data protection legislation, responsibility for patient records (irrespective of the form they are kept in) is always on the creator and custodian of the record, usually a health care practice or facility. The physical medical records are the property of the medical provider (or facility) that prepares them. This includes films and tracings from diagnostic imaging procedures such as X-ray, CT, PET, MRI, ultrasound, etc. The patient, however, according to HIPAA, has a right to view the originals, and to obtain copies under law.[106] The Health Information Technology for Economic and Clinical Health Act (Pub.L. 1115 [107],2.A.III & B.4) (a part of the 2009 stimulus package) set meaningful use of interoperable EHR adoption in the health care system as a critical national goal and incentivized EHR adoption.[108][] The "goal is not adoption alone but 'meaningful use' of EHRs that is, their use by providers to achieve significant improvements in care."[] Title IV of the act promises maximum incentive payments for Medicaid to those who adopt and use "certified EHRs" of $63,750 over 6 years beginning in 2011. Eligible professionals must begin receiving payments by 2016 to qualify for the program. For Medicare the maximum payments are $44,000 over 5 years. Doctors who do not adopt an EHR by 2015 will be penalized 1% of Medicare payments, increasing to 3% over 3 years. In order to receive the EHR stimulus money, the HITECH Act requires doctors to show "meaningful use" of an EHR system. As of June 2010, there are no penalty provisions for Medicaid.[] Health information exchange (HIE) has emerged as a core capability for hospitals and physicians to achieve "meaningful use" and receive stimulus funding. Healthcare vendors are pushing HIE as a way to allow EHR systems to pull disparate data and function on a more interoperable level[citation needed]. Starting in 2015, hospitals and doctors will be subject to financial penalties under Medicare if they are not using electronic health records.[] Goals And Objectives Improve care quality, safety, efficiency, and reduce health disparities Quality and safety measurement Clinical decision support (automated advice) for providers Patient registries (e.g., a directory of patients with diabetes) Improve care coordination Engage patients and families in their care Improve population and public health Electronic laboratory reporting for reportable conditions (hospitals) Immunization reporting to immunization registries

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Electronic health record Syndromic surveillance (health event awareness) Ensure adequate privacy and security protections Quality Studies call into question whether, in real life, EMRs improve the quality of care.[109][110] 2009 produced several articles raising doubts about EMR benefits.[111][112][] A major concern is the reduction of physician-patient interaction due to formatting constraints. For example, some doctors have reported that the use of check-boxes has led to fewer open-ended questions.[113] Meaningful use The main components of Meaningful Use are: The use of a certified EHR in a meaningful manner, such as e-prescribing. The use of certified EHR technology for electronic exchange of health information to improve quality of health care. The use of certified EHR technology to submit clinical quality and other measures. In other words, providers need to show they're using certified EHR technology in ways that can be measured significantly in quality and in quantity.[114] The meaningful use of EHRs intended by the US government incentives is categorized as follows: Improve care coordination Reduce healthcare disparities Engage patients and their families Improve population and public health Ensure adequate privacy and security

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The Obama Administration's Health IT program intends to use federal investments to stimulate the market of electronic health records: Incentives: to providers who use IT Strict and open standards: To ensure users and sellers of EHRs work towards the same goal Certification of software: To provide assurance that the EHRs meet basic quality, safety, and efficiency standards The detailed definition of "meaningful use" is to be rolled out in 3 stages over a period of time until 2015. Details of each stage are hotly debated by various groups. Only stage 1 has been defined while the remaining stages will evolve over time.[115] Meaningful use Stage 1 The first steps in achieving meaningful use are to have a certified electronic health record (EHR) and to be able to demonstrate that it is being used to meet the requirements. Stage 1 contains 25 objectives/measures for Eligible Providers (EPs) and 24 objectives/measures for eligible hospitals. The objectives/measures have been divided into a core set and menu set. EPs and eligible hospitals must meet all objectives/measures in the core set (15 for EPs and 14 for eligible hospitals). EPs must meet 5 of the 10 menu-set items during Stage 1, one of which must be a public health objective.[116] Full list of the Core Requirements and a full list of the Menu Requirements. Core Requirements: 1. Use computerized order entry for medication orders. 2. Implement drug-drug, drug-allergy checks. 3. Generate and transmit permissible prescriptions electronically. 4. Record demographics. 5. Maintain an up-to-date problem list of current and active diagnoses.

Electronic health record 6. Maintain active medication list. 7. Maintain active medication allergy list. 8. Record and chart changes in vital signs. 9. Record smoking status for patients 13 years old or older. 10. Implement one clinical decision support rule. 11. Report ambulatory quality measures to CMS or the States. 12. Provide patients with an electronic copy of their health information upon request. 13. Provide clinical summaries to patients for each office visit. 14. Capability to exchange key clinical information electronically among providers and patient authorized entities. 15. Protect electronic health information (privacy & security) Menu Requirements: 1. Implement drug-formulary checks. 2. Incorporate clinical lab-test results into certified EHR as structured data. 3. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, and outreach. 4. Send reminders to patients per patient preference for preventive/ follow-up care 5. Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, allergies) 6. Use certified EHR to identify patient-specific education resources and provide to patient if appropriate. 7. Perform medication reconciliation as relevant 8. Provide summary care record for transitions in care or referrals. 9. Capability to submit electronic data to immunization registries and actual submission. 10. Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission. To receive federal incentive money, CMS requires participants in the Medicare EHR Incentive Program to "attest" that during a 90-day reporting period, they used a certified EHR and met Stage 1 criteria for meaningful use objectives and clinical quality measures. For the Medicaid EHR Incentive Program, providers follow a similar process using their state's attestation system.[117] Meaningful use Stage 2 The government released its final ruling on achieving Stage 2 of meaningful use in August 2012. Eligible providers will need to meet 17 of 20 core objectives in Stage 2, and fulfill three out of six menu objectives. The required percentage of patient encounters that meet each objective has generally increased over the Stage 1 objectives. While Stage 2 focuses more on information exchange and patient engagement, many large EHR systems have this type of functionality built into their software, making it easier to achieve compliance. Also, for those eligible providers who have successfully attested to Stage 1, meeting Stage 2 should not be as difficult, as it builds incrementally on the requirements for the first stage.[118][119] Barriers to adoption Costs The steepWikipedia:Please clarify price of EMR and provider uncertainty regarding the value they will derive from adoption in the form of return on investment have a significant influence on EMR adoption.[29] In a project initiated by the Office of the National Coordinator for Health Information (ONC), surveyors found that hospital administrators and physicians who had adopted EMR noted that any gains in efficiency were offset by reduced productivity as the technology was implemented, as well as the need to increase information technology staff to maintain the system.[29]

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Electronic health record The U.S. Congressional Budget Office concluded that the cost savings may occur only in large integrated institutions like Kaiser Permanente, and not in small physician offices. They challenged the Rand Corp. estimates of savings. "Office-based physicians in particular may see no benefit if they purchase such a productand may even suffer financial harm. Even though the use of health IT could generate cost savings for the health system at large that might offset the EMR's cost, many physicians might not be able to reduce their office expenses or increase their revenue sufficiently to pay for it. For example. the use of health IT could reduce the number of duplicated diagnostic tests. However, that improvement in efficiency would be unlikely to increase the income of many physicians."[30] "Given the ease at which information can be exchanged between health IT systems, patients whose physicians use them may feel that their privacy is more at risk than if paper records were used."[30] Doubts have been raised about cost saving from EMRs by researchers at Harvard University, the Wharton School of the University of Pennsylvania, Stanford University, and others.[][120][121] Start-up costs In a survey by DesRoches et al. (2008), 66% of physicians without EHRs cited capital costs as a barrier to adoption, while 50% were uncertain about the investment. Around 56% of physicians without EHRs stated that financial incentives to purchase and/or use EHRs would facilitate adoption.[] In 2002, initial costs were estimated to be $50,00070,000 per physician in a 3-physician practice. Since then, costs have decreased with increasing adoption.[] A 2011 survey estimated a cost of $32,000 per physician in a 5-physician practice during the first 60 days of implementation.[122] One case study by Miller et al. (2005) of 14 small primary-care practices found that the average practice paid for the initial and ongoing costs within 2.5 years.[] A 2003 cost-benefit analysis found that using EMRs for 5 years created a net benefit of $86,000 per provider.[123] Some physicians are skeptical of the positive claims and believe the data is skewed by vendors and others with an interest in EHR implementation.[citation needed] Brigham and Women's Hospital in Boston, Massachusetts, estimated it achieved net savings of $5 million to $10 million per year following installation of a computerized physician order entry system that reduced serious medication errors by 55 percent. Another large hospital generated about $8.6 million in annual savings by replacing paper medical charts with EHRs for outpatients and about $2.8 million annually by establishing electronic access to laboratory results and reports.[] Maintenance costs Maintenance costs can be high.[] Miller et al. found the average estimated maintenance cost was $8500 per FTE health-care provider per year.[] Furthermore, software technology advances at a rapid pace. Most software systems require frequent updates, often at a significant ongoing cost. Some types of software and operating systems require full-scale re-implementation periodically, which disrupts not only the budget but also workflow. Costs for upgrades and associated regression testing can be particularly high where the applications are governed by FDA regulations (e.g. Clinical Laboratory systems). Physicians desire modular upgrades and ability to continually customize, without large-scale reimplementation[citation needed].

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Electronic health record Training costs Training of employees to use an EHR system is costly, just as for training in the use of any other hospital system. New employees, permanent or temporary, will also require training as they are hired.[124] In the United States, a substantial majority of healthcare providers train at a VA facility sometime during their career. With the widespread adoption of the Veterans Health Information Systems and Technology Architecture (VistA) electronic health record system at all VA facilities, few recently-trained medical professionals will be inexperienced in electronic health record systems. Older practitioners who are less experienced in the use of electronic health record systems will retire over time.[citation needed] Software quality and usability deficiencies The Healthcare Information and Management Systems Society (HIMSS), a very large U.S. health care IT industry trade group, observed that EMR adoption rates "have been slower than expected in the United States, especially in comparison to other industry sectors and other developed countries. A key reason, aside from initial costs and lost productivity during EMR implementation, is lack of efficiency and usability of EMRs currently available."[125] The U.S. National Institute of Standards and Technology of the Department of Commerce studied usability in 2011 and lists a number of specific issues that have been reported by health care workers.[126] The U.S. military's EMR "AHLTA" was reported to have significant usability issues.[127] Lack of semantic interoperability In the United States, there are no standards for semantic interoperability of health care data; there are only syntactic standards. This means that while data may be packaged in a standard format (using the pipe notation of HL7, or the bracket notation of XML), it lacks definition, or linkage to a common shared dictionary. The addition of layers of complex information models (such as the HL7 v3 RIM) does not resolve this fundamental issue. Implementations In the United States, the Department of Veterans Affairs (VA) has the largest enterprise-wide health information system that includes an electronic medical record, known as the Veterans Health Information Systems and Technology Architecture (VistA). A key component in VistA is their VistA imaging System which provides a comprehensive multimedia data from many specialties, including cardiology, radiology and orthopedics. A graphical user interface known as the Computerized Patient Record System (CPRS) allows health care providers to review and update a patient's electronic medical record at any of the VA's over 1,000 healthcare facilities. CPRS includes the ability to place orders, including medications, special procedures, X-rays, patient care nursing orders, diets, and laboratory tests.[citation needed] The 2003 National Defense Authorization Act (NDAA) ensured that the VA and DoD would work together to establish a bidirectional exchange of reference quality medical images. Initially, demonstrations were only worked in El Paso, Texas, but capabilities have been expanded to six different locations of VA and DoD facilities. These facilities include VA polytrauma centers in Tampa and Richmond, Denver, North Chicago, Biloxi, and the National Capitol Area medical facilities. Radiological images such as CT scans, MRIs, and x-rays are being shared using the BHIE. Goals of the VA and DoD in the near future are to use several image sharing solutions (VistA Imaging and DoD Picture Archiving & Communications System (PACS) solutions).[128]

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Clinical Data Repository/Health Data Repository (CDHR)is a database that allows for sharing of patient records, especially allergy and pharmaceutical information, between the Department of Veteran Affairs (VA) and the Department of Defense (DoD) in the United States. The program shares data by translating the various vocabularies of the information being transmitted, allowing all of the VA facilities to access and interpret the patient records.[129] The Laboratory Data Sharing and Interoperability (LDSI) application is a new program being implemented to allow sharing at certain sites between the VA and DoD of "chemistry and hematology laboratory tests." Unlike the CHDR, the LDSI is currently limited in its scope.[130]

Electronic health records flow chart

One attribute for the start of implementing EHRs in the States is the development of the Nationwide Health Information Network which is a work in progress and still being developed. This started with the North Carolina Healthcare Information and Communication Alliance founded in 1994 and who received funding from Department of Health and Human Services.[131] The Department of Veterans Affairs and Kaiser Permanente has a pilot program to share health records between their systems VistA and HealthConnect, respectively.[] This software called 'CONNECT' uses Nationwide Health Information Network standards and governance to make sure that health information exchanges are compatible with other exchanges being set up throughout the country. CONNECT is an open source software solution that supports electronic health information exchange.[132] The CONNECT initiative is a Federal Health Architecture project that was conceived in 2007 and initially built by 20 various federal agencies and now comprises more than 500 organizations including federal agencies, states, healthcare providers, insurers, and health IT vendors.[133] The US Indian Health Service uses an EHR similar to Vista called RPMS. VistA Imaging is also being used to integrate images and co-ordinate PACS into the EHR system. In Alaska, use of the EHR by the Kodiak Area Native Association has improved screening services and helped the organization reach all 21 clinical performance measures defined by the Indian Health Service as required by the Government Performance and Results Act.[134]

UK
In 2005 the National Health Service (NHS) in the United Kingdom began deployment of EHR systems. The goal was to have all patients with a centralized electronic health record by 2010.[135] While many hospitals acquired electronic patient records systems in this process, there was no national healthcare information exchange. [136][137][138][139][140] Ultimately, the program was dismantled after a cost to the UK taxpayer was over $24 Billion (12 Billion GPB), and is considered one of the most expensive healthcare IT failures .[141] The UK Government is now considering open-source healthcare platform from the United States Veterans Affairs following on the success of the VistA_EHR deployment in Jordan. [142] GP2GP is an NHS Connecting for Health project in the United Kingdom. It enables GPs to transfer a patient's electronic medical record to another practice when the patient moves onto the list.[143]

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Australia
Australia is dedicated to the development of a lifetime electronic health record for all its citizens. PCEHR - the Personally Controlled Electronic Health Record - is the major national EHR initiative in Australia, being delivered through territory, state, and federal governments. This electronic health record was initially deployed in July 2012, and is under active development and extension.[144] MediConnect is an earlier program that provides an electronic medication record to keep track of patient prescriptions and provide stakeholders with drug alerts to avoid errors in prescribing.[145] Within Australia, there is a not-for-profit organisation called Standards Australia, which has created a electronic health website relating to information not only about Australia and what is currently going on about EHRs but also globally. There is a large number of key stakeholders that contribute to the process of integrating EHRs within Australia,they range from each States Departments of Health to Universities around Australia and National E-Health Transition Authority [146] to name a few.[147][148] [149]

Austria
In December 2012 Austria introduced an Electronic Health Records Act (EHR-Act).[150] These provisions are the legal foundation for a national EHR system based upon a substantial public interest according to Art 8(4) of the Data Protection Directive 95/46/EC.[151] In compliance to the Data Protection Directive (DPD) national electronic health records could be based upon explicit consent (Art 8(2)(a) DPD), the necessity for healthcare purposes (Art8(3) DPD) or substantial public interests (Art 8(4) DPD).[152] The Austrian EHR-Act pursues an opt-out approach in order to harmonize the interests of public health and privacy in the best possible manner.
Structure and basic components of the Austrian EHR (ELGA)

The 4th Part of the Austrian Health Telematics Act 2012 (HTA 2012) - these are the EHR provisions - are one of the most detailed data protection rules within Austrian legislation. Numerous safeguards according to Art 8(4) DPD guarantee a high level of data protection. For example: personal health data needs to be encrypted prior to transmission ( 6 HTA 2012), or strict rules on data usage allow personal health data only to be used for treatment purposes or exercising patients' rights ( 14 HTA 2012), or patients may declare their right to opt out from the national EHR at any time ( 15 HTA 2012), or the implementation of an EHR-Ombudsman, to support the patients in exercising their rights ( 17 HTA 2012), or the Access Control Center provides EHR-participants with full control over their data ( 21 HTA 2012), or judicial penalties for privacy breaches (Art 7 of the EHR-Act).

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Canada
The Canadian province of Alberta started a large-scale operational EHR system project in 2005 called Alberta Netcare, which is expected to encompass all of Alberta by 2008. The College of Dental Surgeons of British Columbia [153] has compiled the Dental Records Management [154] document which lays out the requirements, for records for their industry within the province of British Columbia.

Jordan
In 2009, the Jordanian Government made a strategic decision to address quality and cost challenges in their healthcare system by investing in an effective, national e-health infrastructure. Following a period of detailed consultation and investigation, Jordan adopted the electronic health record system of the US Veterans Health Administration VistA_EHR because it was a proven, national-scale enterprise system capable of scaling to hundreds of hospitals and millions of patients. [155] In 2010 three of the country's largest hospitals went live with VistA_EHR. It is anticipated that all further hospital deployments based on this 'gold' version will require less than 20% effort and cost of the original hospitals, enabling rapid national coverage. The implementation of VistA EHR was estimated at 75% less cost than proprietary products, with the greatest savings related to reduced costs of configuration, customization, implementation and support. When completed, Jordan will be the largest country in the world with a single, comprehensive, national electronic health care delivery network to care for the countrys entire population in a single electronic network of over 850 hospitals and clinics.

Denmark
The five regions each use their own setup of electronic health record systems. However, all patient data is registered in the national e-journal [156].

Estonia
Estonia is the first country in the world that has implemented a nationwide EHR system, registering virtually all residents' medical history from birth to death.[157]

Netherlands
The vast majority of GP's [158] and all pharmacies and hospitals use EHR's. In hospitals computerized ordermanagment and medical imaging systems (PACS) are widely accepted. Whereas healthcare institutions continue to upgrade their EHR's functionalties, the national infrastructure is still far from being generally accepted. In 2012 the national EHR restarted under the joined ownership of GP's, pharmacies and hospitals. A major change is that as of January 2013 patients have to give their explicit permission that their data may be exchanged over the national infrastrucure. The national EHR is a virtual EHR and basically is a reference server which knows in which local EHR what kind of patientdata is stored. EDIFACT still is the most common way to exchange patient information electroniaclly between hospitals and GP's.

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UAE
Abu Dhabi is leading the way in using national EHR data as a live longitudinal cohort in the assessment of risk of cardiovascular disease.[159]

Saudi Arabia
Arab Health Awards 2010 recognizes Saudi Arabia National Guard Health Affairs for greatest advancement in EHR development.[160]

In veterinary medicine
In UK veterinary practice, the replacement of paper recording systems with electronic methods of storing animal patient information escalated from the 1980s and the majority of clinics now use electronic medical records. In a sample of 129 veterinary practices, 89% used a Practice Management System (PMS) for data recording.[161] There are more than ten PMS providers currently in the UK. Collecting data directly from PMSs for epidemiological analysis abolishes the need for veterinarians to manually submit individual reports per animal visit and therefore increases the reporting rate.[162] Veterinary electronic medical record data are being used to investigate antimicrobial efficacy; risk factors for canine cancer; and inherited diseases in dogs and cats, in the small animal disease surveillance project 'VetCOMPASS' [163] (Veterinary Companion Animal Surveillance System) at the Royal Veterinary College, London, in collaboration with the University of Sydney and RxWorks [164] (the VetCOMPASS project was formerly known as VEctAR).[165]

The Future of Electronic Health Records Personally Controlled Electronic Health Records
A Personally Controlled Electronic Health Record (PCEHR) is a system that proposes to store admission or event summaries in an electronic format over a large network accessible by doctors, nurses, GPs and chemists without the need for written scripts or requesting medical files from another hospital. The system proposes to record and store any health information provided by a health care professional that has agreed to be a part of the system. This allows the storage and retrieval of a lifetimes worth of clinical and demographic information of a patient that can be viewed as event summaries and reports with the appropriate authorization[166]

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Memo obtained and released by Fred Schulte and Emma Schwartz at the Huffington Post Investigative Fund, now part of the Center for Public Integrity, in an Aug. 3, 2010 article FDA, Obama digital medical records team at odds over safety oversight (http:/ / www. iwatchnews. org/ 2010/ 08/ 03/ 7096/ fda-obama-digital-medical-records-team-odds-over-safety-oversight), memo itself (http:/ / www. scribd. com/ huffpostfund/ d/ 33754943-Internal-FDA-Report-on-Adverse-Events-Involving-Health-Information-Technology) [45] Goodman KW, Berner ES, Dente MA, et al. Challenges in ethics, safety, best practices, and oversight regarding HIT vendors, their customers, and patients: a report of an AMIA special task force. J Am Med Inform Assoc (2010). (http:/ / jamia. bmj. com/ site/ icons/ amiajnl8946. pdf) [46] Rowe JC. Doctors Go Digital. The New Atlantis (2011). (http:/ / www. thenewatlantis. com/ publications/ doctors-go-digital) [48] http:/ / www. hhs. gov/ ocr/ privacy/ hipaa/ administrative/ breachnotificationrule/ breachtool. html [49] http:/ / www. modernhealthcare. com/ article/ 20111222/ blogs02/ 312229963 [55] US Code of Federal Regulations, Title45, Volume 1 (Revised October 1, 2005): of Individually Identifiable Health Information (45CFR164.501) (http:/ / frwebgate. access. gpo. gov/ cgi-bin/ get-cfr. cgi?YEAR=current& TITLE=45& PART=164& SECTION=501& SUBPART=& TYPE=TEXTPrivacy) Retrieved July 30, 2006 [57] Privacy Rights Clearinghouse's Chronology of Data Security Breaches (https:/ / www. privacyrights. org/ data-breach/ new) [58] European Parliament and Council (24 October 1995): EU Directive 95/46/EC - The Data Protection Directive (http:/ / www. dataprivacy. ie/ viewdoc. asp?m=& fn=/ documents/ LEGAL/ 6aii. htm) Retrieved July 30, 2006 [64] (http:/ / www. post-gazette. com/ pg/ 06362/ 749444-114. stm) [69] Medical Manager History (http:/ / docs. mirrormed. org/ index. php/ Medical_Manager_History) [70] "Can Technology Get You Sued?" (http:/ / www. physicianspractice. com/ risk-management/ content/ article/ 1462168/ 2042414) Shelly K. Schwartz, Physicians Practice, March 2012. [74] European Patient Smart Open Services Work Plan: epSOS: Legal and Regulatory Issues (http:/ / www. epsos. eu/ about-epsos/ work-plan-new. html#c501) Retrieved May 4, 2008 [78] Privacy Rights Clearinghouse's Chronology of Data Security Breaches involving Medical Information (https:/ / www. privacyrights. org/ data-breach/ new) [79] Kierkegaard, P. (2012) Medical data breaches: Notification delayed is notification denied, Computer Law & Security Report , 28 (2), p.163183. (http:/ / www. sciencedirect. com/ science/ article/ pii/ S0267364912000209)

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[80] HIPAA Basics: Medical Privacy in the Electronic Age from the Privacy Rights Clearinghouse www.privacyrights.org (https:/ / www. privacyrights. org/ fs/ fs8a-hipaa. htm) [81] DEPARTMENT OF HEALTH AND HUMAN SERVICES Breach Notification for Unsecured Protected Health Information (http:/ / www. gpo. gov/ fdsys/ pkg/ FR-2009-08-24/ pdf/ E9-20169. pdf) [83] Clayton L. Reynolds MD, FACP, FACPE (March 2006): Paper on Concept Processing (http:/ / www. infor-med. com/ downloads/ why_praxis_downloads/ Charting_Bass_Ackward. pdf) Retrieved July 27, 2006 [84] Maekawa Y, Majima Y.; "Issues to be improved after introduction of a non-customized Electronic Medical Record system (EMR) in a Private General Hospital and efforts toward improvement"; Studies in Health Technology and Informatics 2006 [85] Tttelmann F, Luetjens CM, Nieschlag E.; "Optimising workflow in andrology: a new electronic patient record and database"; Asian Journal of Andrology March 2006 [86] The Digital Office, September 2007, vol 2, no.9. HIMSS [87] Gina Rollins."The Perils of Customization." Journal of AHIMA 77, no.6 (2006):24-28. [91] The Master Child Index consolidated 4,610,585 records that were contained in both databases into 2,977,290 records through a match and merge system. [94] Pohjonen H. Images can now cross borders, but what about the legislation? (http:/ / www. diagnosticimaging. com/ imaging-trends-advances/ ultrasound-source/ archive/ article/ 113619/ 1584986) Diagnostic Imaging Europe. June/July 2010;26(4):16. [95] Patrick Kierkegaard (2011) Electronic health record: Wiring Europe's healthcare (http:/ / www. sciencedirect. com/ science/ article/ pii/ S0267364911001257), Computer Law & Security Review, Volume 27, Issue 5, September 2011, Pages 503-515, ISSN 0267-3649, 10.1016/j.clsr.2011.07.013. Retrieved Dec 15, 2011 [96] Smaltz, Detlev and Eta Berner. The Executive's Guide to Electronic Health Records.' (2007, Health Administration Press) p.03 [97] Are More Doctors Adopting EHRs? (http:/ / www. nuesoft. com/ blog/ are-more-doctors-adopting-ehrs/ ) Retrieved March 31, 2011 [98] National Center for Health : United States, 2008] Retrieved December 15, 2009 [105] National Archives and Records Administration (NARA): Long-Term Usability of Optical Media (http:/ / palimpsest. stanford. edu/ bytopic/ electronic-records/ electronic-storage-media/ critiss. html) Retrieved July 30, 2006 [106] Medical Board of California: Medical Records - Frequently Asked Questions (http:/ / medbd. ca. gov/ consumer/ complaint_info_questions_records. html) Retrieved July 30, 2006 [107] http:/ / www. law. cornell. edu/ jureeka/ index. php?doc=USPubLaws& cong=111& no=5 [110] Electronic health records not a panacea (http:/ / www. healthcareitnews. com/ news/ electronic-health-records-not-panacea-researchers-say) [113] Cohen GR, Grossman JM, O'Malley AS (2010). "Electronic Medical Records and Communication with Patients and Other Clinicians: Are We Talking Less?". Center for Studying Health System Change, Issue Brief No. 131 ( full text (http:/ / www. hschange. com/ CONTENT/ 1125/ #ib1)) [115] http:/ / healthit. hhs. gov/ portal/ server. pt?open=512& objID=1325& parentname=CommunityPage& parentid=21& mode=2& in_hi_userid=10741& cached=true [116] http:/ / healthit. hhs. gov/ portal/ server. pt?CommunityID=1206& spaceID=399& parentname=& control=SetCommunity& parentid=& PageID=0& space=CommunityPage& in_hi_totalgroups=1& in_hi_req_ddfolder=6652& in_ra_topoperator=or& in_hi_depth_1=0& in_hi_req_page=20& control=advancedstart& in_hi_req_objtype=18& in_hi_req_objtype=512& in_hi_req_objtype=514& in_hi_req_apps=1& in_hi_revealed_1=0& in_hi_userid=8969& in_hi_groupoperator_1=or& in_hi_model_mode=browse& cached=false& in_ra_groupoperator_1=or& in_tx_fulltext=stage+ 1 [117] Torrieri, Marisa "Dealing with Meaningful Use Attestation Aggravation" (http:/ / www. physicianspractice. com/ meaningful-use/ content/ article/ 1462168/ 2009082). Physicians Practice. January 2012. [118] "Meaningful Use: Stage 2 Regulations Overview" (http:/ / www. physicianspractice. com/ meaningful-use/ content/ article/ 1462168/ 2098253) Robert Anthony, CMS, August 30, 2012. [119] "EHR Incentive Program: A Progress Report" (http:/ / www. physicianspractice. com/ meaningful-use/ content/ article/ 1462168/ 2099001) Marisa Torrieri, Physicians Practice, September 2012. [120] Information Technology: Not a Cure for the High Cost of Health Care. Knowledge@Wharton, June 10, 2009. (http:/ / knowledge. wharton. upenn. edu/ article. cfm?articleID=2260) [121] Abraham Verghese. The Myth of Prevention. The Wall Street Journal, June 20, 2009. (http:/ / online. wsj. com/ article/ SB10001424052970204005504574235751720822322. html) [122] cited in [124] Parish, Colin (March 20, 2006). Edging towards a brave new IT world. Nursing Standard 27:15-16 [125] Defining and Testing EMR Usability. Healthcare Information and Management Systems Society (HIMSS), June 2009. (http:/ / www. himss. org/ content/ files/ HIMSS_DefiningandTestingEMRUsability. pdf) [126] NISTIR 7804: Technical Evaluation, Testing and Validation of the Usability of Electronic Health Records, p. 9-10. National Institute of Standards and Technology, Sept. 2011. (http:/ / www. nist. gov/ healthcare/ usability/ upload/ Draft_EUP_09_28_11. pdf) [127] U.S. Medicine - The Voice of Federal Medicine, May 2009. (http:/ / www. usmedicine. com/ articles/ electronic-records-system-unreliable-difficult-to-use-service-officials-tell-congress. html) [128] (http:/ / web. archive. org/ web/ 20091024042950/ http:/ / www1. va. gov/ vadodhealthitsharing/ page. cfm?pg=23) Retrieved March 4, 2010 [129] (http:/ / web. archive. org/ web/ 20091024045131/ http:/ / www1. va. gov/ vadodhealthitsharing/ page. cfm?pg=9) Retrieved March 4, 2010

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[130] (http:/ / web. archive. org/ web/ 20091024044210/ http:/ / www1. va. gov/ vadodhealthitsharing/ page. cfm?pg=4) Retrieved March 4, 2010 [132] http:/ / www. connectopensource. org/ about/ what-is-CONNECT Retrieved March 4, 2010 [133] http:/ / connectopensource. osuosl. org/ sites/ connectopensource. osuosl. org/ files/ CONNECTOverview. pdf Retrieved March 4, 2010 [138] Greenhalgh T, Stramer K, Bratan T, Byrne E, Russell J, Potts HWW (2010). Adoption and non-adoption of a shared electronic summary care record in England: A mixed-method case study. BMJ, 340, c3111 [139] Bewley S, Perry H, Fawdry R, Cumming G (2011). NHS IT requires the wisdom of the crowd not the marketplace. (http:/ / www. bmj. com/ content/ 343/ bmj. d5317. full/ reply#bmj_el_270562) Accessed 16 April 2012 [140] "The government today announced an acceleration of the dismantling of the National Programme for IT, following the conclusions of a new review by the Cabinet Office's Major Projects Authority (MPA)... The MPA found that the National Programme for IT has not and cannot deliver to its original intent."(sic) [142] http:/ / nhsvista. net/ [143] GP2GP Website (http:/ / www. connectingforhealth. nhs. uk/ delivery/ programmes/ gp2gp) [144] http:/ / www. ehealth. gov. au www.ehealth.gov.au [146] http:/ / www. nehta. gov. au/ [147] http:/ / www. e-health. standards. org. au/ ABOUTIT014/ Stakeholders. aspx [148] http:/ / www. standards. org. au/ OurOrganisation/ AboutUs/ Pages/ default. aspx [149] http:/ / www. e-health. standards. org. au/ Home. aspx [150] Electronic Health Records Act (EHR-Act) (http:/ / www. ilia. ch/ wordpress/ wp-content/ uploads/ 2013/ 02/ austrian_ehr-act_ILIA. pdf) [151] Data Protection Directive 95/46/EC (http:/ / eur-lex. europa. eu/ LexUriServ/ LexUriServ. do?uri=CELEX:31995L0046:en:HTML) [153] http:/ / www. cdsbc. org [154] http:/ / www. cdsbc. org/ ~ASSETS/ DOCUMENT/ Dental-Records-Mgt. pdf [155] http:/ / nhsvista. net/ jordan/ [156] https:/ / www. sundhed. dk/ borger/ min-side/ mine-sundhedsdata/ min-e-journal/ [157] http:/ / recordaccess. icmcc. org/ tag/ portal/ [158] http:/ / www. informationWeek. com/ healthcare/ electronic-medical-records/ ehr-adoption-us-remains-the-slow-poke/ 240142152, Ken Terry, Informationweek [159] http:/ / www. 3four50. com/ v2/ ?page=summit10-vid23 [160] http:/ / www. quadramed. com/ news/ pr_detail. cfm?pr_id=474 [161] Gill, M. (2007) Attitudes to clinical audit in veterinary practice, Royal Veterinary College elective project, unpublished work [162] Carruthers, H. (2009) Disease surveillance in small animal practice, In Pract, 31(7): 356358 [163] http:/ / www. rvc. ac. uk/ VetCOMPASS [164] http:/ / www. rxworks. com [165] VEctAR (Veterinary Electronic Animal Record) (2010) from http:/ / www. rvc. ac. uk/ VEctAR/ [166] http:/ / www. ncbi. nlm. nih. gov/ pubmed/ 15359551

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External links
Can Electronic Health Record Systems Transform Health Care? (http://www.eecs.harvard.edu/cs199r/ readings/RAND_benefits.pdf) Health Information Technology in the United States (http://www.rwjf.org/files/publications/other/ EHRReport0609.pdf) How to Enable Standard-Compliant Streaming of Images in Electronic Health Records (http://www.aware. com/imaging/whitepapers/wp_jpipwado.htm) a white paper by Aware Inc. (http://www.aware.com/imaging/ whitepapers.htm) Open-Source EHR Systems for Ambulatory Care: A Market Assessment (http://www.chcf.org/topics/view. cfm?itemID=133551)(California HealthCare Foundation, January 2008) US Department of Health and Human Services (HHS), Office of the National Coordinator for Health Information Technology (ONC) (http://www.hhs.gov/healthit/) US Department of Health and Human Services (HHS), Agency for Healthcare Research and Quality (AHRQ), National Resource Center for Health Information Technology (http://healthit.ahrq.gov/emr) ICMCC portal: EHR info and blogs (http://recordaccess.icmcc.org/) Security Aspects in Electronic Personal Health Record: Data Access and Preservation (http://www. digitalpreservationeurope.eu/publications/briefs/security_aspects.pdf) - a briefing paper at Digital Preservation Europe

Electromyography

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Electromyography
Electromyography
Intervention ICD-9-CM 93.08 MeSH D004576 [1]

Electromyography (EMG) is a technique for evaluating and recording the electrical activity produced by skeletal muscles.[2] EMG is performed using an instrument called an electromyograph, to produce a record called an electromyogram. An electromyograph detects the electrical potential generated by muscle cells[3] when these cells are electrically or neurologically activated. The signals can be analyzed to detect medical abnormalities, activation level, recruitment order or to analyze the biomechanics of human or animal movement.

Electrical characteristics
The electrical source is the muscle membrane potential of about 90mV.[4] Measured EMG potentials range between less than 50V and up to 20 to 30mV, depending on the muscle under observation. Typical repetition rate of muscle motor unit firing is about 720Hz, depending on the size of the muscle (eye muscles versus seat (gluteal) muscles), previous axonal damage and other factors. Damage to motor units can be expected at ranges between 450 and 780mV.[citation needed]

History
The first documented experiments dealing with EMG started with Francesco Redis works in 1666. Redi discovered a highly specialized muscle of the electric ray fish (Electric Eel) generated electricity. By 1773, Walsh had been able to demonstrate that the eel fishs muscle tissue could generate a spark of electricity. In 1792, a publication entitled De Viribus Electricitatis in Motu Musculari Commentarius appeared, written by Luigi Galvani, in which the author demonstrated that electricity could initiate muscle contraction. Six decades later, in 1849, Emil du Bois-Reymond discovered that it was also possible to record electrical activity during a voluntary muscle contraction. The first actual recording of this activity was made by Marey in 1890, who also introduced the term electromyography. In 1922, Gasser and Erlanger used an oscilloscope to show the electrical signals from muscles. Because of the stochastic nature of the myoelectric signal, only rough information could be obtained from its observation. The capability of detecting electromyographic signals improved steadily from the 1930s through the 1950s, and researchers began to use improved electrodes more widely for the study of muscles. Clinical use of surface EMG (sEMG) for the treatment of more specific disorders began in the 1960s. Hardyck and his researchers were the first (1966) practitioners to use sEMG. In the early 1980s, Cram and Steger introduced a clinical method for scanning a variety of muscles using an EMG sensing device.[5] It is not until the middle of the 1980s that integration techniques in electrodes had sufficiently advanced to allow batch production of the required small and lightweight instrumentation and amplifiers. At present, a number of suitable amplifiers are commercially available. In the early 1980s, cables that produced signals in the desired microvolt range became available. Recent research has resulted in a better understanding of the properties of surface EMG recording. Surface electromyography is increasingly used for recording from superficial muscles in clinical or kinesiological protocols, where intramuscular electrodes are used for investigating deep muscles or localized muscle activity. There are many applications for the use of EMG. EMG is used clinically for the diagnosis of neurological and neuromuscular problems. It is used diagnostically by gait laboratories and by clinicians trained in the use of

Electromyography biofeedback or ergonomic assessment. EMG is also used in many types of research laboratories, including those involved in biomechanics, motor control, neuromuscular physiology, movement disorders, postural control, and physical therapy.

653

Procedure
There are two kinds of EMG in widespread use: surface EMG and intramuscular (needle and fine-wire) EMG. To perform intramuscular EMG, a needle electrode or a needle containing two fine-wire electrodes is inserted through the skin into the muscle tissue. A trained professional (such as a neurologist or EMG technician) observes the electrical activity while inserting the electrode. Certain places limit the performance of needle EMG by non-physicians. A recent case ruling in the state of New Jersey declared that it cannot be delegated to a physician's assistant.[6][7][8] The insertional activity provides valuable information about the state of the muscle and its innervating nerve. Normal muscles at rest make certain, normal electrical signals when the needle is inserted into them. Then the electrical activity when the muscle is at rest is studied. Abnormal spontaneous activity might indicate some nerve and/or muscle damage. Then the patient is asked to contract the muscle smoothly. The shape, size, and frequency of the resulting electrical signals are judged. Then the electrode is retracted a few millimetres, and again the activity is analyzed until at least 1020 motor units have been collected. Each electrode track gives only a very local picture of the activity of the whole muscle. Because skeletal muscles differ in the inner structure, the electrode has to be placed at various locations to obtain an accurate study. Intramuscular EMG may be considered too invasive or unnecessary in some cases. Instead, a surface electrode may be used to monitor the general picture of muscle activation, as opposed to the activity of only a few fibres as observed using an intramuscular EMG. This technique is used in a number of settings; for example, in the physiotherapy clinic, muscle activation is monitored using surface EMG and patients have an auditory or visual stimulus to help them know when they are activating the muscle (biofeedback). A motor unit is defined as one motor neuron and all of the muscle fibers it innervates. When a motor unit fires, the impulse (called an action potential) is carried down the motor neuron to the muscle. The area where the nerve contacts the muscle is called the neuromuscular junction, or the motor end plate. After the action potential is transmitted across the neuromuscular junction, an action potential is elicited in all of the innervated muscle fibers of that particular motor unit. The sum of all this electrical activity is known as a motor unit action potential (MUAP). This electrophysiologic activity from multiple motor units is the signal typically evaluated during an EMG. The composition of the motor unit, the number of muscle fibres per motor unit, the metabolic type of muscle fibres and many other factors affect the shape of the motor unit potentials in the myogram. Nerve conduction testing is also often done at the same time as an EMG to diagnose neurological diseases. Some patients can find the procedure somewhat painful, whereas others experience only a small amount of discomfort when the needle is inserted. The muscle or muscles being tested may be slightly sore for a day or two after the procedure.

Normal results
Muscle tissue at rest is normally electrically inactive. After the electrical activity caused by the irritation of needle insertion subsides, the electromyograph should detect no abnormal spontaneous activity (i.e., a muscle at rest should be electrically silent, with the exception of the area of the neuromuscular junction, which is, under normal circumstances, very spontaneously active). When the muscle is voluntarily contracted, action potentials begin to appear. As the strength of the muscle contraction is increased, more and more muscle fibers produce action potentials. When the muscle is fully contracted, there should appear a disorderly group of action potentials of varying rates and amplitudes (a complete recruitment and interference pattern).

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Abnormal results
EMG is used to diagnose diseases that generally may be classified into one of the following categories: neuropathies, neuromuscular junction diseases and myopathies. Neuropathic disease has the following defining EMG characteristics: An action potential amplitude that is twice normal due to the increased number of fibres per motor unit because of reinnervation of denervated fibres An increase in duration of the action potential A decrease in the number of motor units in the muscle (as found using motor unit number estimation techniques) Myopathic disease has these defining EMG characteristics: A decrease in duration of the action potential A reduction in the area to amplitude ratio of the action potential A decrease in the number of motor units in the muscle (in extremely severe cases only) Because of the individuality of each patient and disease, some of these characteristics may not appear in every case. Abnormal results may be caused by the following medical conditions (please note this is nowhere near an exhaustive list of conditions that can result in abnormal EMG studies):
Alcoholic neuropathy Amyotrophic lateral sclerosis Anterior compartment syndrome of the lower leg Axillary nerve dysfunction Becker's muscular dystrophy Brachial plexopathy Carpal tunnel syndrome Centronuclear myopathy Cervical spondylosis Charcot-Marie-Tooth disease Chronic Immune Demyelinating Poly[radiculo]neuropathy (CIDP) Common peroneal nerve dysfunction Denervation (reduced nervous stimulation) Dermatomyositis Distal median nerve dysfunction Duchenne muscular dystrophy Facioscapulohumeral muscular dystrophy (Landouzy-Dejerine) Familial periodic paralysis Femoral nerve dysfunction Fields condition [9] Friedreich's ataxia Guillain-Barre Lambert-Eaton Syndrome Mononeuritis multiplex Mononeuropathy Motor neurone disease Multiple system atrophy Myasthenia gravis Myopathy (muscle degeneration, which may be caused by a number of disorders, including muscular dystrophy) Myotubular myopathy Neuromyotonia Peripheral neuropathy Poliomyelitis Polymyositis Radial nerve dysfunction Sciatic nerve dysfunction Sensorimotor polyneuropathy Sleep bruxism Spinal stenosis Thyrotoxic periodic paralysis Tibial nerve dysfunction Ulnar nerve dysfunction

EMG signal decomposition


EMG signals are essentially made up of superimposed motor unit action potentials (MUAPs) from several motor units. For a thorough analysis, the measured EMG signals can be decomposed into their constituent MUAPs. MUAPs from different motor units tend to have different characteristic shapes, while MUAPs recorded by the same electrode from the same motor unit are typically similar. Notably MUAP size and shape depend on where the electrode is located with respect to the fibers and so can appear to be different if the electrode moves position. EMG decomposition is non-trivial, although many methods have been proposed.

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Applications of EMG
EMG signals are used in many clinical and biomedical applications. EMG is used as a diagnostics tool for identifying neuromuscular diseases, assessing low-back pain, kinesiology, and disorders of motor control. EMG signals are also used as a control signal for prosthetic devices such as prosthetic hands, arms, and lower limbs. EMG can be used to sense isometric muscular activity where no movement is produced. This enables definition of a class of subtle motionless gestures to control interfaces without being noticed and without disrupting the surrounding environment. These signals can be used to control a prosthesis or as a control signal for an electronic device such as a mobile phone or PDA. EMG then acceleromyograph may be used for neuromuscular monitoring in general anesthesia with neuromuscular-blocking drugs, in order to avoid postoperative residual curarization (PORC).[10][11][12][13] EMG signals have been targeted as control for flight systems. The Human Senses Group at the NASA Ames Research Center at Moffett Field, CA seeks to advance man-machine interfaces by directly connecting a person to a computer. In this project, an EMG signal is used to substitute for mechanical joysticks and keyboards. EMG has also been used in research towards a "wearable cockpit," which employs EMG-based gestures to manipulate switches and control sticks necessary for flight in conjunction with a goggle-based display. Unvoiced speech recognition recognizes speech by observing the EMG activity of muscles associated with speech. It is targeted for use in noisy environments, and may be helpful for people without vocal cords and people with aphasia. EMG has also been used as a control signal for computers and other devices. An interface device based on EMG could be used to control moving objects, such as mobile robots or an electric wheelchair.[14] This may be helpful for individuals that cannot operate a joystick-controlled wheelchair. Surface EMG recordings may also be a suitable control signal for some interactive video games.[15] A joint project involving Microsoft, the University of Washington in Seattle, and the University of Toronto in Canada has explored using muscle signals from hand gestures as an interface device.[16] A patent based on this research was submitted on June 26, 2008.[17]

References
[1] http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2011/ MB_cgi?field=uid& term=D004576 [2] Kamen, Gary. Electromyographic Kinesiology. In Robertson, DGE et al. Research Methods in Biomechanics. Champaign, IL: Human Kinetics Publ., 2004. [4] Nigg B.M., & Herzog W., 1999. Biomechanics of the Musculo-Skeletal system. Wiley. Page:349. [6] Arthur C. Rothman, MD, v. Selective Insurance Company of America, Supreme Court of New Jersey, Jan. 19 [7] Texas Court of Appeals, Third District, at Austin, Cause No. 03-10-673-CV. April 5, 2012 [8] Section 333.17018 Michigan Compiled Laws http:/ / legislature. mi. gov/ doc. aspx?mcl-333-17018 [9] http:/ / news. bbc. co. uk/ 2/ hi/ uk_news/ wales/ south_west/ 4335454. stm [10] Harvey AM, Masland RL: Actions of durarizing preparations in the human. Journal of Pharmacology And Experimental Therapeutics, Vol. 73, Issue 3, 304-311, 1941 [11] Botelho SY: Comparison of simultaneously recorded electrical and mechanical activity in myasthenia gravis patients and in partially curarized normal humans. Am J Med. 1955 Nov;19(5):693-6. PMID 13268466 [12] Christie TH, Churchill-Davidson HC: The St. Thomas's Hospital nerve stimulator in the diagnosis of prolonged apnoea. Lancet. 1958 Apr 12;1(7024):776. PMID 13526270 [13] Engbaek J, Ostergaard D, Viby-Mogensen J: Double burst stimulation (DBS): a new pattern of nerve stimulation to identify residual neuromuscular block. Br J Anaesth. 1989 Mar;62(3):274-8. PMID 2522790 [14] Andreasen, DS.; Gabbert DG,: EMG Switch Navigation of Power Wheelchairs, RESNA 2006. (http:/ / www. tinkertron. com/ Papers. html) [15] Park, DG.; Kim, HC. Muscleman: Wireless input device for a fighting action game based on the EMG signal and acceleration of the human forearm. (http:/ / melab. snu. ac. kr/ Research/ melab/ doc/ HCI/ muscleman_paper. pdf)

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External links
Association of Electromyography Technologists of Canada (AETC) (http://www.aetc.ca) MedlinePlus entry on EMG (http://www.nlm.nih.gov/medlineplus/ency/article/003929.htm) describes EMG Neuromuscular.edu (http://neuromuscular.wustl.edu/mtime/mgdx.html) American Association of Neuromuscular & Electrodiagnostic Medicine (http://www.aanem.org)

Emergency medical technician


Emergency Medical Technician (EMT) or Ambulance Technician are terms used in some countries to denote a healthcare provider of emergency medical services.[] EMTs are trained to respond quickly to emergency situations regarding medical issues, trauma injuries and accident scenes. EMTs operate under the scope of practice as provided by their physician medical director. There are many levels of an EMT, the most common being an EMT-B (EMT-Basic). The highest level is EMT-P or Paramedic, which has the ability to administer a variety of medications, start IVs/IOs and interpret/correct cardiovascular problems along with treatment of various other issues that may arise. They may work in an ambulance service (paid or voluntary), as a member of technical rescue teams/squads, or as part of an allied service such as a fire or police department. EMTs are trained to assess a patient's condition, and to perform such emergency medical procedures as are needed to maintain a patent airway with adequate breathing and cardiovascular circulation until the patient can be transferred to an appropriate destination for advanced medical care. Interventions include cardiopulmonary resuscitation, defibrillation, controlling severe external bleeding, preventing shock, body immobilization to prevent spinal damage, and splinting of bone fractures. EMT's are trained in BLS, or basic life support. If the patient requires more advanced care during transport that is out of the scope of practice of the EMT, a paramedic or RN will assist in transport. A national exam is required for certification following the mandated inclass hours and patient- contact requirements. A common mistake amongst misinformed individuals is to refer to EMTs as "Ambulance Drivers." **

The Star of Life, a global symbol of emergency medical service

EMTs loading an injured skier into an ambulance

Paramedics in Canada
In Canada the scope of practice of Paramedics is described by the National Occupational Competency Profile (NOCP) for Paramedics document developed by the Paramedic Association of Canada.[1] Most providers that work in ambulances will be identified as 'Paramedics'. However, in many cases, the most prevalent level of emergency prehospital care is that which is provided by the Emergency Medical Responder (EMR). This is a level of practice recognized under the National Occupational Competency Profile, although unlike the next three successive levels of practice, the EMR is not specifically considered a Paramedic, per se. The high number of EMRs across Canada cannot be ignored as contributing a critical role in the chain of survival, although it is a level of practice that is least

Emergency medical technician comprehensive (clinically speaking), and is also generally not consistent with any medical acts beyond advanced first-aid, with the exception of automated external defibrillation (which is still considered a regulated medical act in most provinces in Canada). Of considerable relevance to understanding the nature of Canadian Paramedic practice, the reader must appreciate the considerable degree of inter-provincial variation. Although a national consensus (by way of the National Occupational Competency Profile) identifies certain knowledge, skills, and abilities as being most synonymous with a given level of Paramedic practice, each province retains ultimate authority in legislating the actual administration and delivery of emergency medical services within its own borders. For this reason, any discussion of Paramedic Practice in Canada is necessarily broad, and general. Specific regulatory frameworks and questions related to Paramedic practice can only definitively be answered by consulting relevant provincial legislation, although provincial Paramedic Associations may often offer a simpler overview of this topic when it is restricted to a province-by-province basis. Regulatory frameworks vary from province to province, and include direct government regulation (such as Ontario's method of credentialing its practitioners with the title of A-EMCA, or Advanced Emergency Medical Care Assistant) to professional self-regulating bodies, such as the Alberta College of Paramedics. Though the title of Paramedic is a generic description of a category of practitioners, provincial variability in regulatory methods accounts for ongoing differences in actual titles that are ascribed to different levels of practitioners. For example, the province of Alberta uses the title "Emergency Medical Technician", or 'EMT' for the Primary Care Paramedic and 'Paramedic' only for those qualified as Advanced Care Paramedics Advanced Life Support (ALS) providers - but almost all provinces are gradually moving to adopting the new titles, or have at least recognized the NOCP document as a benchmarking document to permit inter-provincial labour mobility of practitioners, regardless of how titles are specifically regulated within their own provincial systems. In this manner, the confusing myriad of titles and occupational descriptions can at least be discussed using a common language for comparison sake.

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Primary care paramedics


Primary care paramedics (PCP) are the entry-level of paramedic practice in Canadian provinces. The scope of practice includes performing semi-automated external defibrillation, interpretation of 4-lead or 12 lead ECG's depending on the area, administration of Symptom Relief Medications for a variety of emergency medical conditions (these include oxygen, epinephrine, glucagon, salbutamol, ASA (aspirin) and nitroglycerine), performing trauma immobilization (including cervical immobilization), and other fundamental basic medical care. Primary Care Paramedics may also receive additional training in order to perform certain skills that are normally in the scope of practice of Advanced Care Paramedics. This is regulated both provincially (by statute) and locally (by the medical director), and ordinarily entails an aspect of medical oversight by a specific body or group of physicians. This is often referred to as Medical Control, or a role played by a base hospital. For example, in the province of Ontario many paramedic services allow Primary Care Paramedics to perform 12-lead ECG interpretation, or initiate intravenous therapy to deliver a few additional medications, such as 50% Dextrose.

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Training
Paramedic training in Canada is intense, as paramedics are seen as health professionals and equal in importance to nurses, respiratory therapists, cardiac perfusionists and others. Nevertheless, the nature of training and how it is regulated, like actual paramedic practice, varies from province to province. Training varies regionally, for example, the Primary Care Paramedic training may be six months (British Columbia) two to four years (Ontario) in length.

Ireland
Emergency Medical Technician is a legally defined title in the Republic of Ireland based on the standard set down by the Pre-Hospital Emergency Care Council (PHECC). Emergency Medical Technician is the entry-level standard of practitioner for employment within the ambulance service. Currently, EMTs are authorised to work on non-emergency ambulances only as the standard for emergency (999) calls is a minimum of a two-paramedic crew. EMTs are a vital part of the voluntary and auxiliary services where a practitioner must be on board any ambulance in the process of transporting a patient to hospital.
PHECC Responder Levels
Responder Title CARDIAC FIRST RESPONDER OCCUPATIONAL FIRST AIDER Abbr Level of Care

CFR Trained in BLS with emphasis on CPR and the Automated External Defibrillator OFA Trained as CFR with additional training in management of bleeding, fractures etc. particularly in the workplace EFR Extensive first aid and BLS training with introduction to Oxygen therapy and assisting practitioners with care

EMERGENCY FIRST RESPONDER

PHECC Practitioner Levels


Practitioner Title EMERGENCY MEDICAL TECHNICIAN PARAMEDIC Abbr Level of Care

EMT Entry-level EMS Healthcare professional. Trained in BLS, Anatomy/Physiology, Pathophysiology, Pharmacology, ECG Monitoring and Spinal Immobilization P Emergency Ambulance Practitioner. Trained in advanced Pharmacology, advanced Airway management etc. Trained to Paramedic level plus IV & IO access, a wide range of Medications, tracheal intubation, Manual Defib etc.

ADVANCED PARAMEDIC

AP

United Kingdom
Emergency Medical Technician is a term that has existed for many years in the United Kingdom. Some National Health Service ambulance services are running EMT conversion courses for staff who were trained by the Institute of Healthcare Development (IHCD) as Ambulance Technicians and Assistant Ambulance Practitioners. Ambulance trusts such as the London Ambulance Service and the North West Ambulance Service are in the process of converting existing Ambulance Technicians into Emergency Medical Technician grades 1,2,3 or 4, based on their level of experience; in many cases providing a similar level of care to that of a Paramedic. Emergency Medical Technicians are still widely deployed in private ambulance companies with IHCD NHS trained Emergency Technicians being particularly sought after. There also many newer EMT training courses available. IHCD Ambulance Technicians and Assistant Ambulance Practitioners still exist within other UK ambulance services with Emergency Care Assistants employed in some areas as support, however, this grade of staff is now being phased out and replaced with a much lower qualified Emergency care assistants.

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United States
History
EMT program in the United States began as part of the "Alexandria Plan" in the early 70's, in addition to a growing issue with injuries associated with car accidents. Emergency medicine (EM) as a medical specialty is relatively young. Prior to the 1960s and 70s, hospital emergency departments were generally staffed by physicians on staff at the hospital on a rotating basis, among them general surgeons, internists, psychiatrists, and dermatologists. Physicians in training (interns and residents), foreign medical graduates and sometimes nurses also staffed the Emergency Department (ED). EM was born as a specialty in order to fill the time commitment required by physicians on staff to work in the increasingly chaotic emergency departments (EDs) of the time. During this period, groups of physicians began to emerge who had left their respective practices in order to devote their work completely to the ED. The first of such groups was headed by Dr. James DeWitt Mills who, along with four associate physicians; Dr. Chalmers A. Loughridge, Dr. William Weaver, Dr. John McDade, and Dr. Steven Bednar at Alexandria Hospital, VA established 24/7 year round emergency care which became known as the "Alexandria Plan". It was not until the establishment of American College of Emergency Physicians (ACEP), the recognition of emergency medicine training programs by the AMA and the AOA, and in 1979 a historical vote by the American Board of Medical Specialties that EM became a recognized medical specialty. The nations first EMT's were from the Alexandria plan working as Emergency Care Technicians serving in the Alexandria Hospital Emergency Room. The training for these technicians was modeled after the established "Physician Assistant" training program and later restructured to meet the basic needs for emergency pre-hospital care. On June 24, 2011, The Alexandria Hospital Celebrated the 50th Anniversary of the Alexandria Plan. In attendance were three of the nations first ECTs/EMTs: David Stover, Larry Jackson,and Kenneth Weaver.

Certification
In the United States, EMTs are certified according to their level of training. Individual states set their own standards of certification (or licensure, in some cases) and all EMT training must meet the minimum requirements as set by the National Highway Traffic Safety Administration's (NHTSA) standards for curriculum.[] The National Registry of Emergency Medical Technicians (NREMT) is a private organization[2] which offers certification exams based on NHTSA education guidelines.[3] Currently, NREMT exams are used by 46 states as the sole basis for certification at one or more EMT certification levels.[4] The Veteran Emergency Medical Technician Support Act of 2013, H.R. 235 in the 113th United States Congress, would amend the Public Health Service Act to direct the Secretary of Health and Human Services (HHS) to establish a demonstration program for states with a shortage of emergency medical technicians to streamline state requirements and procedures to assist veterans who completed military EMT training while serving in the Armed Forces to meet state EMT certification and licensure requirements. The bill passed in the United States House of Representatives, but has not yet been voted on in the United States Senate.[]

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Levels
The NHTSA recognizes four levels of EMTs:[] EMT-B (Basic) EMT-I/85 (Intermediate) EMT-I/99 (Intermediate or Advanced) EMT-P (Paramedic)

Some states also recognize the Advanced Practice Paramedic[5] or Critical Care Paramedic[6] level as a state-specific licensure above that of the paramedic. In addition, EMTs can seek out specialty certifications such as Wilderness EMT, Wilderness Paramedic and Flight Paramedic. Transition to new levels In 2009, the NREMT posted information about a transition to a new system of levels for emergency care providers developed by the NHTSA with the National EMS Scope of Practice project.[7] By 2014, these "new" levels will replace the fragmented system found around the United States. The new classification will include emergency medical responder (replacing first responder), emergency medical technician (replacing EMT-Basic), advanced emergency medical technician (replacing EMT-Intermediate 1985), and paramedic (replacing EMT-Intermediate 1999 and EMT-Paramedic). Education requirements in transitioning to the new levels are substantially similar.[8] EMT-B EMT-Basic is the entry level of EMS.[9] The procedures and skills allowed at this level are generally non-invasive such as bleeding control, positive pressure ventilation with a bag valve mask, oropharyngeal airway, nasopharyngeal airway, supplemental oxygen administration, and splinting (including full spinal immobilization). Training requirements and treatment protocols vary from area to area.[10][11] Intermediate levels of EMT EMT-Intermediates are the levels of training between basic (EMT-B) and paramedic (EMT-P). There are two intermediate levels that are tested for by the NREMT, the EMT-I/85 and the EMT-I/99, with the 1999 level being the more advanced of the two. The standard curriculum for EMT-I from 1998 is defined by the NHTSA, but each state may not have implemented or approved this program. Many states have stopped issuing new Intermediate licensure, instead focusing on maintaining the current lists of intermediates they have, and encouraging the Basic to Paramedic program philosophy.[12] Outside of the NHTSA framework, some states have instituted their own intermediate EMT levels using a variety of names (e.g. Advanced EMT in California[13] or the levels of Advanced EMT-Intermediate and Advanced EMT-Critical Care in New York[14]).
EMTs tend to a spiral fracture at a roller derby bout.

Emergency medical technician EMT-I/85 EMT-I/85 is a level of training that will typically allow several more invasive procedures than are allowed at the basic level, including IV therapy, the use of multi-lumen airway devices (even endotracheal intubation in some states), and provides for enhanced assessment skills. EMT-I/99 The EMT-I/99 represents a higher level than the EMT-I/85 with an expanded scope of practice, such as cardiac monitoring and the administration of additional pharmaceutical interventions, as well as additional training time.[15] EMT-P EMT-Paramedics, who are commonly referred to as simply "paramedics", represents the highest level of EMT, and in general, the highest level of prehospital medical provider, though some areas utilize physicians as providers on air ambulances or as a ground provider.[16] Paramedics perform a variety of medical procedures such as fluid resuscitation, pharmaceutical administration, obtaining IV access, cardiac monitoring (continuous and 12-lead), and other advanced procedures and assessments.[17] Staffing levels An ambulance with only EMT-Bs is considered a basic life support (BLS) unit, an ambulance utilizing EMT-Is is dubbed an intermediate life support (ILS) unit, and an ambulance with paramedics is dubbed an advanced life support (ALS) unit. Some states allow ambulance crews to contain a mix of crews levels (e.g. a basic and a paramedic or an intermediate and a paramedic) to staff ambulances and operate at the level of the highest trained provider. There is nothing stopping supplemental crew members to be of a certain certification, though (e.g. if an ALS ambulance is required to have two paramedics, then it is acceptable to have two paramedics and a basic).

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Education and training


EMT training programs for certification vary greatly from course to course, provided that each course at least meets local and national requirements. In the United States, EMT-Bs receive at least 110 hours of classroom training, often reaching or exceeding 120 hours. EMT-Is generally have 200400 hours of training, and EMT-Ps are trained for 1,000 hours or more. In addition, a minimum number of continuing education (CE) hours are required to maintain certification. For example, to maintain NREMT certification, EMT-Bs must obtain at least 48 hours of additional education and either complete a 24 hour refresher course or complete an additional 24 hours of CEs that would cover, on an hour by hour basis, the same topics as the refresher course would.[18] Recertification for other levels follows a similar pattern. EMT training programs vary greatly in calendar length (number of days or months). For example, fast track programs are available for EMT-Bs that are completed in two weeks by holding class for 8 to 12 hours a day for at least two weeks. Other training programs are months long, or up to 2 years for paramedics in an associates degree program. In addition to each level's didactic education, clinical rotations may also be required (especially for levels above EMT-Basic). Similar in a sense to medical school clinical rotations, EMT students are required to spend a required amount of time in an ambulance and on a variety of hospital services (e.g. obstetrics, emergency medicine, surgery, psychiatry) in order to complete a course and become eligible for the certification exam. The number of clinical hours for both time in an ambulance and time in the hour vary depending on local requirements, the level the student is obtaining, and the amount of time it takes the student to show competency.[][19][20][21] EMT training programs take place at numerous locations, such as universities, community colleges, technical schools, hospitals or EMS academies. Every state in the United States has an EMS lead agency or state office of emergency medical services that regulates and accredits EMT training programs. Most of these offices have web sites to provide information to the public and individuals who are interested in becoming an EMT.

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Medical direction
In the United States, an EMT's actions in the field are governed by state regulations, local regulations, and by the policies of their EMS organization. The development of these policies are guided by a physician medical director, often with the advice of a medical advisory committee.[22] In California, for example, each county's Local Emergency Medical Service Agency (LEMSA) issues a list of standard operating procedures or protocols, under the supervision of the California Emergency Medical Services Authority. These procedures often vary from county to county based on local needs, levels of training and clinical experiences.[23] New York State has similar procedures, whereas a regional medical-advisory council ("REMAC") determines protocols for one or more counties in a geographical section of the state.[24] Treatments and procedures administered by paramedics fall under one of two categories, off-line medical orders (standing orders) or on-line medical orders. On-line medical orders refers to procedures that must be explicitly approved by a base hospital physician or registered nurse through voice communication (generally by phone or radio) and are generally rare or high risk procedures (e.g. rapid sequence induction or cricothyrotomy).[25] In addition, when multiple levels can perform the same procedure (e.g. AEMT-Critical Care and EMT-Paramedics in New York), a procedure can be both an on-line and a standing order depending on the level of the provider.[26] Since no set of protocols can cover every patient situation, many systems work with protocols as guidelines and not "cook book" treatment plans.[27] Finally, systems also have policies in place to handle medical direction when communication failures happen or in disaster situations.[28] The NHTSA curriculum is the foundation Standard of Care for EMS providers in the US.

Employment
EMTs are employed in varied settings[] ranging from industrial and entertainment positions[29] to hospital and health care settings, and the prehospital environment. The prehospital environment is loosely divided into non-emergency (e.g. hospital discharges) and emergency (9-1-1 calls) services, but many ambulance services operate both non-emergency and emergency care. In many places across the United States, it is not uncommon for the primary employer of EMTs (both EMT-Ps and EMT-Bs) to be the fire department, with the fire department providing the primary emergency medical system response.[30] In other locations, such as Boston, Massachusetts, emergency medical services are provided by a separate, or third-party, government agency.[31] In still other locations, emergency medical services are provided by volunteer agencies. College and university campuses may provide emergency medical responses on their own campus using students.[32] In some states of the US, many EMS agencies are run by Independent Non-Profit Volunteer First Aid Squads that are their own corporations set up as separate entities from fire departments. In this environment, volunteers are hired to fill certain blocks of time to cover emergency calls. These volunteers have the same state certification as their paid counterparts.[33]

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References and notes


[8] http:/ / aclsrecertificationonline. com/ emt-recertification. html

External links
National Highway Traffic Safety Agency, Office of Emergency Medical Services (http://www.nhtsa.dot.gov/ portal/site/nhtsa/menuitem.2a0771e91315babbbf30811060008a0c/) United States National Registry of Emergency Medical Technicians (http://www.nremt.org)

Emergency medical services


Emergency Medical Services (abbreviated to the initialism EMS in some countries) are a type of emergency service dedicated to providing out-of-hospital acute medical care, transport to definitive care, and other medical transport to patients with illnesses and injuries which prevent the patient from transporting themselves.[1] Emergency medical services may also be locally known as a first aid squad,[2] emergency squad,[3] rescue squad,[4] ambulance, squad[5] ambulance service,[6] ambulance corps,[7] or life squad.[8] The goal of most emergency medical services is to either provide treatment to those in need of urgent medical care, with the goal of satisfactorily treating the presenting conditions, or arranging for timely removal of the patient to the next point of definitive care. This is most likely an emergency department at a hospital. The term emergency medical service evolved to reflect a change from a simple system of ambulances providing only transportation, to a system in which actual medical care is given on scene and during transport. In some developing regions, the term is not used, or may be used inaccurately, since the service in question does not provide treatment to the patients, but only the provision of transport to the point of care.[]
A road ambulance belonging to the South Western Ambulance Service in England

In most places in the world, the EMS is summoned by members of the Emergency medical services prepare to airlift the public (or other emergency services, businesses, or authorities) via an victim of a car accident to hospital emergency telephone number which puts them in contact with a control facility, which will then dispatch a suitable resource to deal with the situation.[9] In some parts of the world, the emergency medical service also encompasses the role of moving patients from one medical facility to an alternative one; usually to facilitate the provision of a higher level or more specialised field of care but also to transfer patients from a specialized facility to a local hospital or nursing home when they no longer require the services of that specialized hospital, such as following successful cardiac catheterization due to a heart attack. In such services, the EMS is not summoned by members of the public but by clinical professionals (e.g. physicians or nurses) in the referring facility. Specialized hospitals that provide higher levels of care may include services such as neonatal intensive care (NICU),[10] pediatric intensive care (PICU), state regional burn centres,[11] specialized care for spinal injury and/or neurosurgery,[12] regional stroke centers,[13] specialized cardiac care[14][15] (cardiac catherization),[16] and specialized/regional trauma care.[17] In some jurisdictions, EMS units may handle technical rescue operations such as extrication, water rescue, and search and rescue.[18] Training and qualification levels for members and employees of emergency medical services

Emergency medical services vary widely throughout the world. In some systems, members may be present who are qualified only to drive the ambulance, with no medical training.[] In contrast, most systems have personnel who retain at least basic first aid certifications, such as Basic Life Support (BLS). Additionally many EMS systems are staffed with Advanced Life Support (ALS) personnel, including paramedics, nurses, or, less commonly, physicians.[citation needed]

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History
Emergency care in the field has been rendered in different forms since the beginning of recorded history. The New Testament contains the parable of the Good Samaritan, where a man who was beaten is cared for by a Samaritan. Luke 10:34 (NIV) - "He went to him and bandaged his wounds, pouring on oil and wine. Then he put the man on his own donkey, took him to an inn and took care of him." Also during the Middle Ages, the Knights Hospitaller were known for rendering assistance to wounded soldiers in the battlefield.[19] The first use of the ambulance as a specialized vehicle, in battle came about with the ambulances volantes designed by Dominique Jean Larrey (17661842), Napoleon Bonaparte's chief physician.[][] Larrey was present at the battle of Spires, between the French and Prussians, and was distressed by the fact that wounded soldiers were not picked up by the numerous ambulances (which Napoleon required to be A 1973 Cadillac Miller-Meteor ambulance. Note stationed two and half miles back from the scene of battle) until after the raised roof, with more room for the attendants hostilities had ceased, and set about developing a new ambulance and patients system.[][][] Having decided against using the Norman system of horse litters, he settled on two- or four-wheeled horse-drawn wagons, which were used to transport fallen soldiers from the (active) battlefield after they had received early treatment in the field.[] These 'flying ambulances' were first used by Napoleon's Army of the Rhine is 1793. Larrey subsequently developed similar services for Napoleon's other armies, and adapted his ambulances to the conditions, including developing a litter which could be carried by a camel for a campaign in Egypt.[] In civilian ambulances, a major advance was made (which in future years would come to shape policy on hospitals and ambulances) with the introduction of a transport carriage for cholera patients in London during 1832.[20] The statement on the carriage, as printed in The Times, said "The curative process commences the instant the patient is put in to the carriage; time is saved which can be given to the care of the patient; the patient may be driven to the hospital so speedily that the hospitals may be less numerous and located at greater distances from each other".[] This tenet of ambulances providing instant care, allowing hospitals to be spaced further apart, displays itself in modern emergency medical planning. The first known hospital-based ambulance service operated out of Commercial Hospital, Cincinnati, Ohio (now the Cincinnati General) by 1865.[] This was soon followed by other services, notably the New York service provided out of Bellevue Hospital which started in 1869 with ambulances carrying medical equipment, such as splints, a stomach pump, morphine, and brandy, reflecting contemporary medicine. In June 1887 the St John Ambulance Brigade was established to provide first aid and ambulance services at public events in London.[] It was modelled on a military-style command and discipline structure. The earliest emergency medical service was reportedly the rescue society founded by Jaromir V. Mundy, Count J. N. Wilczek, and Eduard Lamezan-Salins in Vienna after the disastrous fire at the Vienna Ring Theater in 1881. Named the "Vienna Voluntary Rescue Society," it served as a model for similar societies worldwide.[21]

Emergency medical services

665 Also in the late 19th century, the automobile was being developed, and in addition to horse-drawn models, early 20th century ambulances were powered by steam, gasoline, and electricity, reflecting the competing automotive technologies then in existence. However, the first motorized ambulance was brought into service in the last year of the 19th century, with the Michael Reese Hospital, Chicago, taking delivery of the first automobile ambulance, donated by 500 prominent local businessmen, in February 1899.[] This was followed in 1900 by New York city, who extolled its virtues of greater speed, more safety for the patient, faster stopping and a smoother ride. These first two automobile ambulances were electrically powered with 2hp motors on

A 1948 Cadillac Meteor ambulance

the rear axle.[] American historians claim that the world's first component of civilian pre-hospital care on scene began in 1928, when "Julien Stanley Wise started the Roanoke Life Saving and First Aid Crew in Roanoke, Virginia, Virginia, which was the first land-based rescue squad in the nation."[citation needed] Canadian historians dispute this with the city of Toronto claiming "The first formal training for ambulance attendants was conducted in 1892."[citation needed] During World War One, further advances were made in providing care before and during transport traction splints were introduced during World War I, and were found to have a positive effect on the morbidity and mortality of patients with leg fractures.[22] Two-way radios became available shortly after World War I, enabling for more efficient radio dispatch of ambulances in some areas. Shortly before World War II, then, a modern ambulance carried advanced medical equipment, was staffed by a physician, and was dispatched by radio. In many locations, however, ambulances were hearses - the only available vehicle that could carry a recumbent patient - and were thus frequently run by funeral homes. These vehicles, which could serve either purpose, were known as combination cars.[23][24] Prior to World War II, hospitals provided ambulance service in many large cities. With the severe manpower shortages imposed by the war effort, it became difficult for many hospitals to maintain their ambulance operations. City governments in many cases turned ambulance services over to the police or fire department. No laws required minimal training for ambulance personnel and no training programs existed beyond basic first aid. In many fire departments, assignment to ambulance duty became an unofficial form of punishment. Advances in the 1960s, especially the development of CPR and defibrillation as the standard form of care for out-of-hospital cardiac arrest, along with new pharmaceuticals, led to changes in the tasks of the ambulances.[25] In Belfast, Northern Ireland the first experimental mobile coronary care ambulance successfully resuscitated patients using these technologies. One well-known report in the USA during that time was Accidental Death and Disability: The Neglected Disease of Modern Society. This report is commonly known as The White Paper.[26] These studies, along with the White Paper report, placed pressure on governments to improve emergency care in general, including the care provided by ambulance services. In the USA prior to the 1970s, ambulance service was largely unregulated. While some areas ambulances were staffed by advanced first-aid-level responders, in other areas, it was common for the local undertaker, having the only transport in town in which one could lie down, to operate both the local furniture store (where he would make coffins as a sideline) and the local ambulance service. The government reports resulted in the creation of standards in ambulance construction concerning the internal height of the patient care area (to allow for an attendant to continue to care for the patient during transport), and the equipment (and thus weight) that an ambulance had to carry, and several other factors. In 1971, after release of the National Highway Traffic Safety Administration's study, "Accidental Death and Disability: The Neglected Disease of Modern Society". A progress report was published at the annual meeting, by the then president of American Association of Trauma, Sawnie R. Gaston M.D. Dr. Gaston reported the study a "superb white paper" that "jolted and wakened the entire structure of organized medicine. This report was the "prime mover" and made the "single greatest contribution of its kind to the improvement of emergency medical services".

Emergency medical services Since this time a concerted effort has been undertaken to improve emergency medical care in the pre-hospital setting.[27] Such advancements included Dr. R Adams Cowley creating the country's first statewide EMS program, in Maryland.[28]

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Service providers
Some countries closely regulate the industry (and may require anyone working on an ambulance to be qualified to a set level), whereas others allow quite wide differences between types of operator. Government Ambulance Service Operating separately from (although alongside) the fire and police service of the area, these ambulances are funded by local, provincial or national government. In some countries, these only tend to be found in big cities, whereas in countries such as A volunteer ambulance crew in Modena, Italy United Kingdom almost all emergency ambulances are part of a national health system.[29] In the United States, ambulance service provided by a local government are often referred to as "third service" EMS (the Fire Department, Police Department, and separate EMS forming an emergency services trio) by the employees of said service, as well as other city officials and residents. Fire or Police Linked Service In countries such as the United States, Japan, France, and parts of India; ambulances can be operated by the local fire or police service. This is particularly common in rural areas, where maintaining a separate service is not necessarily cost effective. In some cases this can lead to an illness or injury being attended by a vehicle other than an ambulance, such as a fire truck. Volunteer Ambulance Service Charities or non-profit companies operate ambulances, both in an emergency and patient transport function. This may be along similar lines to volunteer fire companies, providing the main service for an area, and either community or privately owned. They may be linked to a voluntary fire service, with volunteers providing both services. There are charities who focus on providing ambulances for the community, or for cover at private events (sports etc.). The Red Cross provides this service in some parts of the world on a volunteer basis[30] (and in others as a Private Ambulance Service), as do other smaller organisations such as St John Ambulance[] and the Order of Malta Ambulance Corps.[31] These volunteer ambulances may be seen providing support to the full time ambulance crews during times of emergency. In some cases the volunteer charity may employ paid members of staff alongside volunteers to operate a full time ambulance service, such in some parts of Australia, Ireland and most importantly Germany and Austria.

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Private Ambulance Service Normal commercial companies with paid employees, but often on contract to the local or national government. Private companies may provide only the patient transport elements of ambulance care (i.e. nonurgent), but in some places, they are contracted to provide emergency care, or to form a 'second tier' response, where they only respond to emergencies when all of the full-time emergency ambulance crews are busy. This may mean that a government or other service provide the 'emergency' A government ambulance service in Kiev, cover, whilst a private firm may be charged with 'minor injuries' Ukraine such as cuts, bruises or even helping the mobility impaired if they have for example fallen and just need help to get up again, but do not need treatment. This system has the benefit of keeping emergency crews available all the time for genuine emergencies. These organisations may also provide services known as 'Stand-by' cover at industrial sites or at special events.[32] Combined Emergency Service these are full service emergency service agencies, which may be found in places such as airports or large colleges and universities. Their key feature is that all personnel are trained not only in ambulance (EMT) care, but as a firefighter and a peace officer (police function). They may be found in smaller towns and cities, where size or budget does not warrant separate services. This multi-functionality allows to make the most of limited resource or budget, but having a single team respond to any emergency. Hospital Based Service Hospitals may provide their own ambulance service as a service to the community, or where ambulance care is unreliable or chargeable. Their use would be dependent on using the services of the providing hospital. Most Advanced Life Support (Paramedic) services in the United States are this type of service. Charity Ambulance This special type of ambulance is provided by a charity for the purpose of taking sick children or adults on trips or vacations away from hospitals, hospices or care homes where they are in long term care. Examples include the UK's 'Jumbulance' project.[] Company Ambulance Many large factories and other industrial centres, such as chemical plants, oil refineries, breweries and distilleries have ambulance services provided by employers as a means of protecting their interests and the welfare of their staff. These are often used as first response vehicles in the event of a fire or explosion.

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Purpose
Emergency medical services exists to fulfill the basic principles of first aid, which are to Preserve Life, Prevent Further Injury, and Promote Recovery. This common theme in medicine is demonstrated by the "star of life". The Star of Life shown here, where each of the 'arms' to the star represent one of the six points, which are used to represent the six stages of high quality pre-hospital care, which are:[] 1. Early detection members of the public, or another agency, find the incident and understand the problem 2. Early reporting the first persons on scene make a call to the emergency medical services and provide details to enable a response to be mounted 3. Early response the first professional (EMS) rescuers arrive on scene as quickly as possible, enabling care to begin 4. Good on-scene care the emergency medical service provides appropriate and timely interventions to treat the patient at the scene of the incident

Six points on the Star of Life

5. Care in transit the emergency medical service load the patient in to suitable transport and continue to provide appropriate medical care throughout the journey 6. Transfer to definitive care the patient is handed over to an appropriate care setting, such as the emergency department at a hospital, in to the care of physicians

Levels of care
Emergency Medical Service is provided by a variety of individuals, using a variety of methods. To some extent, these will be determined by country and locale, with each individual country having its own 'approach' to how EMS should be provided, and by whom. In some parts of Europe, for example, legislation insists that efforts at providing advanced life support (ALS) Mobile Intensive Care Units (MICU) services must be physician-staffed, while other permit some elements of that skill set to specially trained nurses, but have no paramedics. Elsewhere, as in North America, the UK and Australia, ALS services EMT staff at an emergency call in New York are performed by paramedics, but rarely with the type of direct City "hands-on" physician leadership seen in Europe. Increasingly, particularly in the UK and in South Africa, the role is being provided by specially-trained paramedics who are independent practitioners in their own right. Beyond the national model of care, the type Emergency Medical Service will be determined by local jurisdictions and medical authorities, based upon the needs of the community, and the economic resources to support it. A category of emergency medical service which is known as 'medical retrieval' or rendez vous MICU protocol in some countries (Australia, NZ, Great Britain) refers to critical care transport of patients between

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hospitals (as opposed to pre-hospital). Such services are a key element in regionalised systems of hospital care where intensive care services are centralised to a few specialist hospitals. An example of this is the Emergency Medical Retrieval Service in Scotland.

A patient arriving at hospital

Generally speaking, the levels of service available will fall into one of three categories; Basic Life Support (BLS), Advanced Life Support (ALS), and care by traditional healthcare professionals, meaning nurses and/or physicians working in the pre-hospital setting and even on ambulances. In some jurisdictions, a fourth level, Intermediate Life Support (ILS), which is essentially a BLS provider with a moderately expanded skill set, may be present, but this level rarely functions independently, and where it is present may replace BLS in the emergency part of the service. When this occurs, any remaining staff at the BLS level is usually relegated to the non-emergency transportation function. Job titles typically include Emergency Medical Technician, Ambulance Technician, or Paramedic. These ambulance care givers are generally professionals or paraprofessionals and in some countries their use is controlled through training and registration. While these job titles are protected by legislation in some countries, this protection is by no means universal, and anyone might, for example, call themselves an 'EMT' or a 'paramedic', regardless of their training, or the lack of it.[33] In some jurisdictions, both technicians and paramedics may be further defined by the environment in which they operate, including such designations as 'Wilderness', 'Tactical', and so on.

Basic life support


First responder A first responder is a person who arrives first at the scene of an incident, and whose job is to provide early critical care such as CPR or using an AED.[34] First responders may be dispatched by the ambulance service, may be passers-by, citizen volunteers, or may be members of other agencies such as the police, fire department, or search and rescue who have some medical trainingcommonly CPR, basic first aid, and AED use.[35] Ambulance driver Some jurisdictions separate the 'driver' and 'attendant' functions, employing ambulance driving staff with no medical qualification (or just a first aid certificate), whose job is to drive the ambulance. While this approach persists in some countries, such as India, it is generally becoming increasingly rare. Ambulance drivers may be trained in radio communications, ambulance operations and emergency response driving skills.[36] Ambulance care assistant Ambulance Care Assistants (ACAs) have varying levels of training across the world. In many countries, such staff are usually only required to perform patient transport duties (which can include stretcher or wheelchair cases), rather than acute care. However, there remain both countries and individual jurisdictions in which economics will not support ALS service, and the efforts of such individuals may represent the only EMS available. Dependent on the provider (and resources available), they may be trained in first aid or extended skills such as use of an AED, oxygen therapy, pain relief and other live-saving or palliative skills. In some services, they may also provide emergency cover when other units are not available, or when accompanied by a fully qualified technician or paramedic.[37][38]

Emergency medical services Emergency medical technician Emergency medical technicians, also known as Ambulance Technicians in the UK and EMT in the United States. In the United States, EMT is usually made up of 3 levels. EMT-B, EMT-I and EMT-Paramedic. The New Educational Standards for EMS renamed the provider levels as follows: EMR, emergency medical responder, EMT, emergency medical technician, AEMT, advanced EMT, and Paramedic. Technicians are usually able to perform a wide range of emergency care skills, such as Automated defibrillation, care of spinal injuries and oxygen therapy.[39][40] In few jurisdictions, some EMTs are able to perform duties as IV and IO cannulation, administration of a limited number of drugs, more advanced airway procedures, CPAP, EMTs loading a patient into an ambulance and limited cardiac monitoring.[41] Most advanced procedures and [42] skills are not within the national scope of practice for an EMT-B. As such most states require additional training and certifications to perform above the national curriculum standards.[43][44] Emergency medical dispatcher An emergency medical dispatcher is also called an EMD. An increasingly common addition to the EMS system is the use of highly trained dispatch personnel who can provide "pre-arrival" instructions to callers reporting medical emergencies. They use carefully structured questioning techniques and provide scripted instructions to allow callers or bystanders to begin definitive care for such critical problems as airway obstructions, bleeding, childbirth, and cardiac arrest. Even with a fast response time by a first responder measured in minutes, some medical emergencies evolve in seconds. Such a system provides, in essence, a "zero response time," and can have an enormous impact on positive patient outcomes.

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Advanced life support


Advanced life support is also called ALS. Paramedic A paramedic has a high level of prehospital medical training and usually involves key skills not performed by technicians, often including cannulation (and with it the ability to use a range of drugs to relieve pain, correct cardiac problems, and to assist with endotracheal intubation), cardiac monitoring, tracheal intubation, needle decompression and other skills such as performing a cricothyrotomy.[45] In many countries, this is a protected title, and use of it without the relevant qualification may result in criminal prosecution.[46] In the United States, paramedics represent the highest licensure level of prehospital emergency care. In addition, several certifications exist for Paramedics such as Wilderness ALS Care,[47] Flight Paramedic Certification (FP-C),[48] and Critical Care Emergency Medical Transport Program certification.[] Critical care paramedic Recently studies have looked at new level of pre-hospital care.[49][50] What has developed is the critical care paramedic, also called an advanced practice Paramedic in some parts of USA and Canada. These providers represent a higher level of licensure above that of the DOT or respective paramedic level curriculum.[] The training, permitted skills, and certification requirements vary from one jurisdiction to the next. These providers transport critically ill or injured patients from one hospital to a receiving hospital with higher level of care (ie.. cardiac catheterization, trauma services or specialized ICU services) not available at referring facility.

Emergency medical services These Paramedics receive additional training beyond normal EMS medicine. The Board for Critical Care Transport Certification (BCCTPC) has developed a certification exam for flight and ground critical care paramedics [51][52] Some educational facilities that provide this training are UMBC Critical Care Emergency Medical Transport Program[53] or "Cleveland Clinic CICP program" [54].. Individual services such as "Wake County EMS" [55]. and "MedStar EMS" [56]. in Fort Worth, Tx. have developed 'in-house' advanced practice paramedic providers. These providers have a vast array of and medications to handle complex medical and trauma patients. Examples of medication are Dopamine, Dobutamine, Propofol, Blood and Blood products to name just a few. Some examples of skills include, but not limited to, life support systems normally restricted to the ICU or critical care hospital setting such as mechanical ventilators, Intra-aortic balloon pump (IABP) and external pacemaker monitoring. Depending on the service medical direction, these providers are trained on placement and use of UVCs (Umbilical Venous Catheter), UACs (Umbilical Arterial Catheter), surgical airways, central lines, arterial lines and chest tubes. Wilderness Emergency Medical Technician Some paramedics and EMTs, known as Wilderness Emergency Medical Technicians, utilize expanded scope of practice protocols that are operationalized when in wilderness (remote, austere, or resource-deficient) environments. Wilderness EMS Systems (WEMS) have been developed to deliver a standard and professional medical response to wilderness areas. Examples include the national-level agencies such as the National Ski Patrol in the United States as well as local responding agencies. Like traditional EMS providers, all WEMS providers must still operate under on-line or off-line medical oversight. To assist physicians in the skills necessary to provide this oversight, the Wilderness Medical Society and the National Association of EMS Physicians jointly supported the development in 2011 of a unique "Wilderness EMS Medical Director" certification course,[57] which was cited by the Journal of EMS as one of the Top 10 EMS Innovations of 2011.[58] Common procedures utilized by WEMS providers that exceed traditional EMS scope of care include joint reduction, catheterization, antibiotic administration, selective spinal immobilization, and different training and protocols involving CPR cessation and wilderness skills. A multitude of organizations provide WEMS training, including private schools,[59][60][61][62][63] non-profit organizations such as the Appalachian Center for Wilderness Medicine [64] and the Wilderness EMS Institute,[65] military branches, community colleges and universities,[66][67] EMS-college-hospital collaborations,[68] and others. Paramedic practitioner / Emergency care practitioner In the United Kingdom and South Africa, some serving paramedics receive additional university education to become practitioners in their own right, which gives them absolute responsibility for their clinical judgement, including the ability to autonomously prescribe medications, including drugs usually reserved for doctors, such as courses of antibiotics. An emergency care practitioner is a position sometimes referred to as a 'super paramedic' and is designed to bridge the link between ambulance care and the care of a general practitioner. ECPs are university graduates in Emergency Medical Care or qualified paramedics who have undergone further training,[69] and are authorized to perform specialized techniques. Additionally some may prescribe medicines (from a limited list) for longer term care, such as antibiotics. With respect to a Primary Health Care setting, they are also educated in a range of Diagnostic techniques.

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Traditional healthcare professions


Registered nurse The use of registered nurses (RNs) in the pre-hospital setting is more common in countries that have a limited EMS infrastructure in place. Some European countries such as France or Italy, which do not use paramedics as they are intended in Anglo-Saxon countries, also use nurses as a means of providing ALS services. These nurses may work under the direct supervision of a physician, or, in rarer cases, independently. In some places in Europe, notably Norway, paramedics do exist, but the role of the 'ambulance nurse' continues to be developed,[70] as it is felt that

Emergency medical services nurses may bring unique skills to some situations encountered by ambulance crews. In North America, and to a lesser extent elsewhere in the English-speaking world, some jurisdictions use specially trained nurses for medical transport work. These are mostly air-medical personnel or critical care transport providers, often working in conjunction with a technician or paramedic or physician on emergency interfacility transports. In the United States, the most common uses of ambulance-based Registered nurses is in the Critical Care/Mobile Intensive Care transport, and in Aeromedical EMS. Such nurses are normally required by their employers (in the US) to seek additional certifications beyond basic nursing registration. In Estonia 60% of ambulance teams are led by nurse. Ambulance nurses can do almost all emergency procedures and administer medicines pre-hospital such as physicians in Estonia. In the Netherlands, all ambulances are staffed by a registered nurse with additional training in emergency nursing, anaesthesia or critical care, and a driver-EMT.[71] In Sweden, since 2005, all emergency ambulances should be staffed by at least one registered nurse since only nurses are allowed to administer drugs.[72][73] And all Advanced Life Support Ambulances are staffed at least by a registered nurse in Spain.[74] In France, since 1986, fire department-based rescue ambulances have had the option of providing resuscitation service (reanimation) using specially-trained nurses, operating on protocols,[75] while SAMU-SMUR units are staffed by physicians and nurses[76] Physician There are many places in Europe, most notably in France, Italy, and the German-speaking countries (Germany, Switzerland, Austria) where the model of EMS is different, and physicians take a more direct, 'hands-on' approach to pre-hospital care. In France and Italy, response to high-acuity emergency calls is physician-led, as with the French SMUR teams. Paramedics do not exist within those systems, and most ALS is performed by physicians. In the German-speaking countries, paramedics do exist, but special physicians (called Notarzt) respond directly to high-acuity calls, supervising the paramedics ALS procedures directly. Indeed, in these countries paramedics are not typically legally permitted to practice their ALS procedures unless the physician is physically present, unless they face immediate life-threatening emergencies.[] Some systems - most notably air ambulances in the UK.[77][78] will employ physicians to take the clinical lead in the ambulance; bringing a full range of additional skills such as use of medications that are beyond the paramedic skill set. The response of physicians to emergency calls is routine in many parts of Europe, but is uncommon in the UK, where physicians are generally tasked to high priority calls ona voluntary basis. Within the UK a sub-speciality of Pre-Hospital Care is being developed for Doctors, which would allow training programmes and consultant posts to be developed in this one area of practice. This 'hands-on' approach is less common in the United States. While one will occasionally see a physician with an ambulance crew on an emergency call, this is much more likely to be the Medical Director or an associate, inducting newly trained paramedics, or performing routine medical quality assurance. In some jurisdictions adult or pediatric critical care transports sometimes use physicians, but generally only when it appears likely that the patient may require surgical or advanced pharmacologic intervention beyond the skills of an EMT, paramedic or nurse during transport. Physicians are leaders of medical retrieval teams in many western countries, where they may assist with the transport of a critically ill, injured, or special needs patient to a tertiary care hospital, particularly when longer transport times are involved.

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Prehospital Delivery of care


Depending on country, area within country, or clinical need, emergency medical services may be provided by one or more different types of organisation. This variation may lead to large differences in levels of care and expected scope of practice. The most basic emergency medical services are provided as a transport operation only, simply to take patients from their location to the nearest medical treatment. This was often the case in a historical context, and is still true in the developing world, where operators as diverse as taxi drivers[] and undertakers may operate this service. Most developed countries now provide a government funded emergency medical service, which can be run on a national level, as is the case in the United Kingdom, where a national network of ambulance trusts operate an emergency service, paid for through central taxation, and available to anyone in need,[79] or can be run on a more regional model, as is the case in the United States, where individual authorities have the responsibility for providing these services. Ambulance services can be stand alone organisations, but in some cases, the emergency medical service is operated by the local fire[80] or police[81] service. This is particularly common in rural areas, where maintaining a separate service is not necessarily cost effective. This can lead, in some instances, to an illness or injury being attended by a vehicle other than an ambulance, such as fire truck.[82][83][84] In some locales, firefighters are the first responders to calls for emergency medical aid, with separate ambulance services providing transportation to hospitals when necessary.[85] Some charities or non-profit companies also operate emergency medical services, often alongside a patient transport function.[86] These often focus on providing ambulances for the community, or for cover at private events, such as sports matches. The Red Cross provides this service in many countries across the world on a volunteer basis (and in others as a Private Ambulance Service), as do some other smaller organizations such as St John Ambulance.[] and the Order of Malta Ambulance Corps.[87] In some countries, these volunteer ambulances may be seen providing support to the full-time ambulance crews during times of emergency, or simply to help cover busy periods.[88] There are also private ambulance companies, with paid employees, but often on contract to the local or national government. Many private companies provide only the patient transport elements of ambulance care (i.e. nonurgent), although in some places these private services are contracted to provide emergency care, or to form a 'second tier' response, where they only respond to emergencies when all of the full-time emergency ambulance crews are busy or to respond to non-emergency home calls.[citation needed] Private companies are often contracted by private clients to provide event specific cover, as is the case with voluntary EMS crews.[89] Many colleges and universities, especially in the United States, maintain their own EMS organizations. These organizations operate at capacities ranging from first response to ALS transport. Campus EMS in the United States is overseen by the National Collegiate Emergency Medical Services Foundation.
Typical scene at a local emergency room

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Strategies for delivering care


The essential decision in prehospital care is whether the patient should be immediately taken to the hospital, or advanced care resources are taken to the patient where they lie. The "scoop and run" approach is exemplified by the MEDEVAC aeromedical evacuation helicopter, whereas the "stay and play" is exemplified by the French and Belgian SMUR emergency mobile resuscitation unit. The strategy developed for prehospital trauma care in North America is based on the Golden Hour theory, i.e., that a trauma victim's best chance for survival is in an operating room, with the goal of having the Ambulance in the Czech Republic patient in surgery within an hour of the traumatic event. This appears to be true in cases of internal bleeding, especially penetrating trauma such as gunshot or stab wounds. Thus, minimal time is spent providing prehospital care (spine immobilization; "ABCs", i.e. ensure airway, breathing and circulation; external bleeding control; endotracheal intubation) and the victim is transported as fast as possible to a trauma centre.[90] The aim in "Scoop and Run" treatment is generally to transport the patient within ten minutes of arrival, hence the birth of the phrase, "the platinum ten minutes" (in addition to the "golden hour"), now commonly used in EMT training programs. The "Scoop and Run" is a method developed to deal with trauma, rather than strictly medical situations (e.g. cardiac or respiratory emergencies), however, this may be changing. Increasingly, research into the management of S-T segment elevation myocardial infarctions (STEMI) occurring outside of the hospital, or even inside community hospitals without their own PCI labs, suggests that time to treatment is a clinically significant factor in heart attacks, and that trauma patients may not be the only patients for whom 'load and go' is clinically appropriate. In such conditions, the gold standard is the door to balloon time. The longer the time interval, the greater the damage to the myocardium, and the poorer the long-term prognosis for the patient.[91] Current research in Canada has suggested that door to balloon times are significantly lower when appropriate patients are identified by paramedics in the field, instead of the emergency room, and then transported directly to a waiting PCI lab.[92] The STEMI program has reduced STEMI deaths in the Ottawa region by 50 per cent.[93] In a related program in Toronto, EMS has begun to use a procedure of 'rescuing' STEMI patients from the Emergency Rooms of hospitals without PCI labs, and transporting them, on an emergency basis, to waiting PCI labs in other hospitals.[94]

Models of care
Although a variety of differing philosophical approaches are used in the provision of EMS care around the world, they can generally be placed into one of two categories; one physician-led and the other led by pre-hospital specialists such as emergency medical technicians or paramedics (which may, or may not have accompanying physician oversight). These models are typically identified by their locations of origin.[95] The Franco-German model is physician-led, with doctors responding directly to all major emergencies requiring more than simple first aid. In some cases in this model, such as France, paramedics, as they exist in the Anglo-American model, are not used, although the term 'paramedic' is sometimes used generically, and those with that designation have training that is similar to an U.S. EMT-B.[96] The team's physicians and in some cases, nurses, provide all medical interventions for the patient, and non-medical members of the team simply provide the driving and heavy lifting services. In other applications of this model, as in Germany, a paramedic equivalent does exist, but is sharply restricted in terms of scope of practice; often not permitted to perform Advanced Life Support (ALS) procedures unless the physician is physically present, or in cases of immediate life-threatening conditions.[] Ambulances in this model tend to be better equipped with more advanced medical devices, in essence, bringing the emergency department to the patient. High-speed transport to hospitals is considered, in most cases, to be unnecessarily unsafe, and the preference is to remain and provide definitive care to the patient until they are

Emergency medical services medically stable, and then accomplish transport. In this model, the physician and nurse may actually staff an ambulance along with a driver, or may staff a rapid response vehicle instead of an ambulance, providing medical support to multiple ambulances. The second care structure, termed the Anglo-American model, utilizes pre-hospital care specialists, such as emergency medical technicians and paramedics, to staff ambulances, which may be classified according to the varying skill levels of the crews. In this model it is rare to find a physician actually working routinely in the pre-hospital setting, although they may be utilised on complex or major injuries or illnesses. In this system, a physicians involvement is most likely to be the provision of medical oversight for the work of the ambulance crews, which may be accomplished in terms of off-line medical control, with protocols or 'standing orders' for certain types of medical procedures or care, or on-line medical control, in which the technician must establish contact with the physician, usually at the hospital, and receive direct orders for various types of medical interventions. In some cases, such as in the UK, South Africa and Australia, a paramedic may be an autonomous health care professional, and does not require the permission of a physician to administer interventions or medications from an agreed list, and can perform roles such as suturing or prescribing medication to the patient.[97] In this model, patients may still be treated at the scene up to the skill level of the attending crew, and subsequently transported to definitive care, but in many cases the reduced skill set of the ambulance crew and the needs of the patient indicate a shorter interval for transport of the patient than is the case in the Franco-German model.

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Clinical governance
Paramedics in Anglosaxon countries normally function under the authority (medical direction) of one or more physicians charged with legally establishing the emergency medical directives for a particular region. Paramedics are credentialed and authorized by these physicians to use their own clinical judgment and diagnostic tools to identify medical emergencies and to administer the appropriate treatment, including drugs that would normally require a physician order. Credentialing may occur as the result of a State Medical Board examination (U.S.) or the National Registry of Emergency Medical Technicians (U.S.). In England, and in some parts of Canada, credentialing may occur by means of a College of Paramedicine.[98] In these cases, paramedics are regarded as a self-regulating health profession. The final common method of credentialing is through certification by a Medical Director and permission to practice as an extension of the Medical Director's license to practice some medical acts. The authority to practice in this semi-autonomous manner is granted in the form of standing order protocols (off-line medical control) and in some cases direct physician consultation via phone or radio (on-line medical control). Under this paradigm, paramedics effectively assume the role of out-of-hospital field agents to regional emergency physicians, with clinical decision-making authority using standing orders or protocols. In some parts of the world, those in the paramedical professional role are only permitted to practise many of their advanced skills while assisting a physician who is physically present, or they face cases of immediately life-threatening emergencies.[] In many other parts in the world, most notably in France, Belgium, Luxembourg, Italy, and Spain, but also in Brazil and Chile. All MICU skills in the pre-hospital setting are performed by physicians and nurses and an On-line Permanent medical supervision is done by the SAMU. In certain other jurisdictions, such as the United Kingdom and South Africa, paramedics may be entirely autonomous practitioners capable of prescribing medications.[99] In other jurisdictions, such as Australia and Canada, this expanded scope of practice is under active consideration and discussion.[100]

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Organization in different countries


Emergency medical services in Austria Emergency medical services in Australia Emergency medical services in Canada Emergency medical services in France Emergency medical services in Germany Emergency medical services in Hong Kong Emergency medical services in Iceland Emergency medical services in Israel Emergency medical services in Italy Emergency medical services in the Netherlands Emergency medical services in New Zealand Emergency medical services in Norway Emergency medical services in Poland Emergency medical services in Portugal Emergency medical services in Spain Emergency medical services in South Africa Emergency medical services in Sri Lanka Emergency medical services in Ukraine Emergency medical services in the United Kingdom Emergency medical services in the United States

References
[23] [24] [54] [55] [56] [90] [98] Kuehl, Alexander E. (Ed.). Prehospital Systems and Medical Oversight, 3rd edition. National Association of EMS Physicians. 2002. @ ch. 1. "Miller-Meteor History" (http:/ / www. miller-meteor. com/ history. asp). Miller-Meteor. n.d. Retrieved 23 February 2007. http:/ / www. emsacademy. us/ Education/ CriticalCareEducation/ CertifiedIntensiveCareProvider/ tabid/ 1962/ Default. aspx http:/ / www. wakegov. com/ ems/ staff/ app http:/ / www. medstar911. org/ critical-care-transport Accidental Death and Disability: The Neglected Disease of Modern Society, (1966), National Academy of Sciences (White Paper) British Paramedic Association, College of Paramedicine (http:/ / www. britishparamedic. org)

Further reading
Planning Emergency Medical Communications: Volume 2, Local/Regional Level Planning Guide, (Washington, D.C.: National Highway Traffic Safety Administration, US Department of Transportation, 1995).

External links
Emergency Medical Services (http://www.dmoz.org//Health/Public_Health_and_Safety/ Emergency_Services/Medical/) at the Open Directory Project "Emergency Medical Services in the European Union: report of an assessment project co-ordinated by the European Union" (http://www.euro.who.int/__data/assets/pdf_file/0016/114406/E92038.pdf) World Health Organization: Department of Violence and Injury Prevention "Prehospital Trauma Care Systems" (http://www.who.int/violence_injury_prevention/publications/services/04_07_2005/en/index.html)

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Emergency Medical Treatment and Active Labor Act


The Emergency Medical Treatment and Active Labor Act (EMTALA)[] is a U.S. Act of Congress passed in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA). It requires hospitals to provide care to anyone needing emergency healthcare treatment regardless of citizenship, legal status or ability to pay. There are no reimbursement provisions. Participating hospitals may only transfer or discharge patients needing emergency treatment under their own informed consent, after stabilization, or when their condition requires transfer to a hospital better equipped to administer the treatment.[] EMTALA applies to "participating hospitals." The statute defines "participating hospitals" as those that accept payment from the Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) under the Medicare program.[1] However, in practical terms, EMTALA applies to virtually all hospitals in the U.S., with the exception of the Shriners Hospitals for Children, Indian Health Service hospitals, and Veterans Affairs hospitals. [citation needed] The combined payments of Medicare and Medicaid, $602 billion in 2004,[2] or roughly 44% of all medical expenditures in the U.S., make not participating in EMTALA impractical for nearly all hospitals. EMTALA's provisions apply to all patients, and not just to Medicare patients.[3][4] The cost of emergency care required by EMTALA is not directly covered by the federal government. Because of this, the law has been criticized by some as an unfunded mandate.[5] Similarly, it has attracted controversy for its impacts on hospitals, and in particular, for its possible contributions to an emergency medical system that is "overburdened, underfunded and highly fragmented."[6] Uncompensated care represents 6% of total hospital costs [7] . The uncompensated or non-reimbursed amounts are written off as bad debt thus becoming a tax write off and the unpaid bills are also sold to third party collection agencies for an average of 20 cents per dollar[citation needed]. However, health insurance reimbursements for services provided have continually been reduced by the health insurance companies[citation needed]. Medicare and Medicaid reimbursements for services have also been reduced[citation needed]. However, EMTALA is independent of the payers, EMTALA is not similar to bad debt or charity care that many not-for-profit hospitals enjoy. However, the number of emergency room clinics or emergency rooms not attached to a traditional hospital have increased, as they are generally more efficient and cost less to operate than a traditional hospital-based emergency room[citation needed]. There is debateWikipedia:Avoid weasel words about the extent to which EMTALA has led to cost-shifting and higher rates for insured or paying hospital patients, thereby contributing to the high overall rate of medical inflation in the U.S.

Mandated and non-mandated care


Congress passed EMTALA to combat the practice of "patient dumping," i.e., refusal to treat people because of inability to pay or insufficient insurance, or transferring or discharging emergency patients on the basis of high anticipated diagnosis and treatment costs. The law applies when an individual has a medical emergency "and a request is made on the individual's behalf for examination or treatment for a medical condition." [] The U.S. government defines an emergency department as "a specially equipped and staffed area of the hospital used a significant portion of the time for initial evaluation and treatment of outpatients for emergency medical conditions." [citation needed] This means, for example, that outpatient clinics not equipped to handle medical emergencies are not obligated under EMTALA and can simply refer patients to a nearby emergency department for care.[8] An emergency medical condition is defined as "a condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the individual's health [or the health of an unborn child] in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs." For example, a pregnant woman with an emergency

Emergency Medical Treatment and Active Labor Act condition must be treated until delivery is complete, unless a transfer under the statute is appropriate.[8] Though patients treated under EMTALA may not be able to pay or have insurance or other programs pay for the associated costs, they are legally responsible for any costs incurred as a result of their care under civil law.

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Non-covered medical conditions


Not all medical problems are covered by EMTALA, meaning that a person cannot assume that if they are ill, they will be treated. Specifically, EMTALA does not cover non-emergency situations. The hospital is allowed to determine that there is no emergency, using their normal screening procedure, and then refuse EMTALA treatment[9]. Examples of conditions not considered emergencies by courts or hospitals A significant portion of emergency room visits are considered not emergencies as defined by EMTALA, and are therefore not covered[10]. The medical profession refers to these cases as "non-emergent". A normal pregnancy delivery. In a case reviewed by courts, EMTALA did not cover the hospital stay[11]. Opioid withdrawal [12] Fever, elevated white blood cell count and a possible abscess [13] If a patient is already in the hospital for another reason, and develops an emergency condition, EMTALA similarly does not apply[11].

Hospital obligations
Hospitals have three obligations under EMTALA: 1. Individuals requesting emergency care, or those for whom a representative has made a request if the patient is unable, must receive a medical screening examination to determine whether an emergency medical condition (EMC) exists. The participating hospital cannot delay examination and treatment to inquire about methods of payment or insurance coverage, or a patient's citizenship or legal status. The hospital may only start the process of payment inquiry and billing once they have ensured that doing so will not interfere with or otherwise compromise patient care. 2. The emergency room (or other better equipped units within the hospital) must treat an individual with an EMC until the condition is resolved or stabilized and the patient is able to provide self-care following discharge, or if unable, can receive needed continual care. Inpatient care provided must be at an equal level for all patients, regardless of ability to pay. Hospitals may not discharge a patient prior to stabilization if the patient's insurance is canceled or otherwise discontinues payment during course of stay. 3. If the hospital does not have the capability to treat the condition, the hospital must make an "appropriate" transfer of the patient to another hospital with such capability. This includes a long-term care or rehabilitation facilities for patients unable to provide self-care. Hospitals with specialized capabilities must accept such transfers and may not discharge a patient until the condition is resolved and the patient is able to provide self-care or is transferred to another facility.

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Amendments
Since its original passage, Congress has passed several amendments to this act. Additionally, state and local laws in some places have imposed additional requirements on hospitals. These amendments include: A patient is defined as "stable," therefore ending a hospital's EMTALA obligations, if: The patient is conscious, alert, and oriented. The cause of all symptoms reported by the patient or representative, and all potentially life-threatening, limb-threatening, or organ-threatening symptoms discovered by hospital staff, has been ascertained to the best of the hospital's ability. Any conditions that are immediately life-threatening, limb-threatening, or organ-threatening have been treated to the best of the hospital's ability to ensure the patient does not need further inpatient care. The patient is able to care for himself or herself, with or without special equipment, which if needed, must be provided. The required abilities are: Breathing Feeding Mobility Dressing

Personal hygiene Toileting Medicating Communication Another competent person is available and able to meet the patient's needs following discharge. All patients have EMTALA rights equally, regardless of age, race, religion, nationality, ethnicity, residence, citizenship, or legal status. If patient's status is found to be illegal, hospitals may not discharge a patient prior to completion of care, though law enforcement and hospital security may take necessary action to prevent a patient from escaping or harming others. Treatment may only be delayed as needed to prevent patients from harming themselves or others. Overloaded hospitals may not discharge a patient unable to pay to make room for a patient who is able to pay or is otherwise viewed by society as a more valued citizen. If the emergency room is overloaded, patients must be treated in an order based on their determined medical needs, not their ability to pay. Hospitals may not deny or provide substandard services to a patient who already has outstanding debt to the hospital, and may not withhold the patient's belongings, records, or other required services until the patient pays. Hospitals and related services cannot receive a judgment against the patient in court filings made more than 36 months after the date the patient was discharged, or the last partial payment the patient made to the hospital, contractor, or agent. After that period, the patient may not be threatened with legal action if payment is not made, and may not be denied future outpatient services from the same company/agency that a patient is able to pay. If a patient has been awarded monetary damages against the hospital or any related or affiliated services by a court of law, or has settled out of court on damages, the hospital and related/affiliated services may not withhold monies due to lack of payment, or count the money toward the bill in lieu of making payment to the patient. Voluntary consent for such an arrangement is permitted only if initiated by the patient. Hospitals may not threaten or coerce a patient into such a settlement, or mislead the patient into believing such an arrangement is required or recommended.

Patients cannot face criminal prosecution for failure to pay, even if the patient came to the hospital aware of inability to pay. Hospitals and third-party agents may not threaten patients with prosecution as a means of scaring the patient into making payment. Patient can be prosecuted under existing federal, state, or local laws for providing false name, address, or other information to avoid payment, receiving bills, or to hide fugitive status.

Emergency Medical Treatment and Active Labor Act A hospital cannot delay treatment while determining whether someone can pay or is insured but that does not mean they are completely forbidden from asking or running a credit check. If the patient doesn't pay the bill, the hospital can sue the patient and the unsatisfied judgment will likely appear on the patient's credit report. A 3rd-party collector for a hospital bill would be covered under the Fair Debt Collection Practices Act. Hospitals are prohibited from discriminating against or providing substandard care to those who appear impoverished or homeless, are not well-dressed or groomed, or exhibit signs of mental illness or intoxication. If the hospital fears a patient may be a threat to others, the hospital may delay care only as necessary to protect others. Hospitals are required to sufficiently feed patients unable to pay at a level equal to those able to pay, while meeting all physician-ordered dietary restrictions. Hospitals are not required to provide premium services to the patient not related to medical care (such as television) when failure to provide this service does not compromise patient care. Hospitals and affiliated clinics are not required to provide continued outpatient care, drugs, or other supplies following discharge. In the event such services are recommended, but a patient is unable to pay, the hospital is required to refer the patient to a clinic or tax-funded or private program that enables the patient to pay for these services, and to which the patient has reasonable access. Hospitals must reasonably assist patients as necessary to obtain these services by providing information the patient requests.

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EMTALA's effect
Improved health services for uninsured
The most significant effect is that, regardless of insurance status, participating hospitals cannot deny urgent medical assistance. Currently EMTALA only requires that hospitals stabilize the emergency. According to some analyses of the U.S. health care safety net, EMTALA is an incomplete and strained program.[14][15]

Cost pressures on hospitals


According to the Centers for Medicare & Medicaid Services, 55% of U.S. emergency care now goes uncompensated.[16] When medical bills go unpaid, health care providers must either shift the costs onto those who can pay or go uncompensated. In the first decade of EMTALA, such cost-shifting amounted to a hidden tax levied by providers.[17] For example, it has been estimated that this cost shifting amounted to $455 per individual or $1,186 per family in California each year.[17] However, because of the recent influence of managed care and other cost control initiatives by insurance companies, hospitals are less able to shift costs, and end up writing off more in uncompensated care. The amount of uncompensated care delivered by nonfederal community hospitals grew from $6.1 billion in 1983 to $40.7 billion in 2004, according to a 2004 report from the Kaiser Commission on Medicaid and the Uninsured,[16] but it is unclear what percentage of this was emergency care and therefore attributable to EMTALA. Financial pressures on hospitals in the 20 years since EMTALA's passage have caused them to consolidate and close facilities, contributing to emergency room overcrowding.[citation needed] According to the Institute of Medicine, between 1993 and 2003, emergency room visits in the U.S. grew by 26 percent, while in the same period, the number of emergency departments declined by 425.[18] Ambulances are frequently diverted from overcrowded emergency departments to other hospitals that may be farther away. In 2003, ambulances were diverted over a half a million times, not necessarily due to patients' inability to pay.[18]

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Notes and references


[1] [2] [3] [4] [5] (e)(2) The term participating hospital means a hospital that has entered into a provider agreement under section of this title. Key Medicare and Medicaid Statistics (http:/ / www. kff. org/ medicaid/ upload/ Key Medicare and Medicaid Statistics. pdf) from kff.org Text of act (http:/ / www4. law. cornell. edu/ uscode/ 42/ 1395dd. html) from law.cornell.edu EMTALA FAQ (http:/ / www. emtala. com/ faq. htm) Website / Information from Garan Lucow Miller, P.C Fact Sheet: EMTALA (http:/ / www. acep. org/ patients. aspx?id=25936) from the American College of Emergency Physicians accessed 2007-11-01 [6] Emergency Medical Services At the Crossroads (http:/ / www. iom. edu/ CMS/ 3809/ 16107/ 35010. aspx), Institute of Medicine, 2006-06-14, accessed 2007-10-05 [7] American Hospital Association, Trends Affecting Hospitals and Health Systems 2011, Chapter 4, Slide 7 (http:/ / www. aha. org/ research/ reports/ tw/ chartbook/ 2011chartbook. shtml) [8] American College of Emergency Physicians: EMTALA Fact Sheet (http:/ / www. acep. org/ patients. aspx?LinkIdentifier=id& id=25936& fid=1754& Mo=No& acepTitle=EMTALA), accessed 2007-10-05. [9] http:/ / www. dhs. wisconsin. gov/ guide/ spec/ freehosp. htm [10] http:/ / www. healthcare-informatics. com/ article/ cashing-check?page=2 [11] http:/ / www. nursinglaw. com/ emtala8. htm [12] http:/ / washingtonacep. org/ Postings/ edopioidabuseguidelinesfinal. pdf [13] http:/ / www. lasvegassun. com/ news/ 2010/ jan/ 06/ state-records-suggest-umc-had-pattern-refusing-car/ [16] The Uninsured: Access to Medical Care (http:/ / web. archive. org/ web/ 20100304211332/ http:/ / www. acep. org/ patients. aspx?id=25932), American College of Emergency Physicians, accessed 2007-10-05 [17] (Peter Harbage and Len M. Nichols, Ph.D., "A Premium Price: The Hidden Costs All Californians Pay In Our Fragmented Health Care System," New America Foundation, 12/2006) [18] Fact Sheet: The Future of Emergency Care: Key Findings and Recommendations (http:/ / iom. edu/ ~/ media/ Files/ Report Files/ 2006/ Hospital-Based-Emergency-Care-At-the-Breaking-Point/ EmergencyCareFindingsandRecs. pdf), Institute of Medicine, 2006, accessed 2007-10-07.

External links
CMS EMTALA overview (http://www.cms.hhs.gov/EMTALA/01_overview.asp) from hhs.gov EMTALA Articles (http://www.zalelipshypatientdumping.com/category/emtala-articles-ut-southwestern) from emtala.com State Operations Manual (http://www.cms.hhs.gov/manuals/Downloads/som107ap_v_emerg.pdf) from hhs.gov EMTALA: Its Application to Newborn Infants (http://www.abanet.org/health/esource/Volume4/07/pope. html), by Thaddeus M. Pope, ABA Health eSource, Vol. 4, No. 7 (March 2008)

Otolaryngology

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Otolaryngology
Otolaryngology /otolrldi/ or ENT (ear, nose, and throat) is the branch of medicine and surgery that specializes in the diagnosis and treatment of disorders of the head and neck. It is the oldest medical practice in the United States and nearly 50 percent of all office visits pertain to the ear, nose, and throat.[citation needed] Physicians specializing in otolaryngology are called otolaryngologists, and often treat children with persistent ear infections, hearing problems, cleft lip and other congenital abnormalities.[] Adult patients often seek treatment from an otolaryngologists for sinus infections, age-related hearing loss, and cancers of the head or neck regions.[]

Overview
The full name of the specialty is otorhinolaryngology[1] from neoclassical Greek and modern Greek: () from -, ot(root of ) "ear", -, rhino- (root of ) "nose", -, laryng- (root of ) "larynx/throat", and the suffix -logy "study"; thus, the term literally means "the study of ear, nose and throat".

Otolaryngologist performing an endoscopic sinus surgical procedure.

Training
Otolaryngologists are physicians (MD, DO, MBBS, MBChB, etc.) who, in the United States, complete at least five years of surgical residency training. This is composed of one year in general surgical training and four years in otolaryngologyhead and neck surgery; in the past it varied between two and three years of each. In Canada, practitioners complete a five-year residency training after medical school.[2] Following residency training some otolaryngologists elect to complete advanced subspeciality fellowship training which can be 12 years in duration (pediatric otolaryngology,[3] neuro-otology, laryngology, facial plastic and reconstructive surgery, rhinology, or head and neck oncology).[citation needed]

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Designation Preferences
Practitioners are called and professionally designated by the more accurate term otolaryngologists head and neck surgeons, as specialists trained in otolaryngology are experts in surgical conditions of the head and neck. Some people refer to it simply as head and neck surgery. In the United States, otolaryngology is one of the most competitive specialties in medicine in which to obtain a residency position following medical school.[4][5]

A 40-watt CO2 laser used in otolaryngology.

Subspecialties
Head and neck Surgical oncology Reconstruction Endocrine surgery Facial plastics Facial cosmetic surgery Maxillofacial Trauma Otology Ear Neuro-otology* Middle and inner ear Temporal bone Skull base Rhinology/sinus Sinusitis Laryngology Voice therapy Pediatrics* Velopalatine insufficiency Cleft lip and palate Airway Sleep*

Hearing

Allergy Anterior skull base Apnea and snoring

Phono-surgery

Dizziness

Vascular malformations

Cochlear implant/BAHA

(* Currently recognized by American Board of Medical Subspecialties)

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Topics in otolaryngology, head and neck surgery


Contributors please visit the new Current Otorhinolaryngology WikiBook project professional-quality material needed! [6] before posting your academic topics here. High-level

Head and neck oncology


Squamous cell carcinoma of the oral cavity, pharynx and larynx Oral cancer Skin Cancer of the head & neck Thyroid cancer Endocrine surgery of the head and neck (thyroidectomy, parathyroidectomy) Microvascular free flap reconstruction Skull base surgery Salivary gland cancer

Otology and neuro-otology


Dizziness BPPV benign paroxysmal positional vertigo labyrinthitis/vestibular neuronitis Mnire's disease/endolymphatic hydrops Perilymphatic fistula acoustic neuroma

Hearing loss Mastoiditis Otitis externa outer ear or ear canal inflammation Otitis media middle ear inflammation Otitis interna inner ear inflammation Perforated eardrum (hole in the eardrum due to infection, trauma, explosion or loud noise) Ear surgery

Rhinology
Rhinology pertains to sinus diseases and the anterior skull base. Environmental allergies Sinusitis acute, chronic Rhinitis Empty nose syndrome

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Pediatrics
Adenoidectomy Caustic ingestion Cricotracheal resection Decannulation laryngomalacia Laryngotracheal reconstruction Myringotomy and tubes Obstructive sleep apnea pediatric Tonsillectomy

Laryngology
Dysphonia/hoarseness Laryngitis Reinke's edema Vocal cord nodules and polyps Spasmodic dysphonia Tracheostomy Cancer of the larynx Vocology science and practice of voice habilitation

Facial plastic and reconstructive surgery


Facial plastic and reconstructive surgery is a one-year fellowship open to otolaryngologists and plastic surgeons who wish to specialize in the aesthetic and reconstructive surgery of the head, face, and neck. Rhinoplasty and septoplasty Facelift (rhytidectomy) Browlift Blepharoplasty Otoplasty Genioplasty Injectable cosmetic treatments Trauma to the face

Nasal bone fracture Mandible fracture Orbital fracture Frontal sinus fracture Complex lacerations and soft tissue damage Skin cancer (e.g. Basal Cell Carcinoma)

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References
[6] http:/ / en. wikibooks. org/ wiki/ Otorhinolaryngology

External links
Journals
Acta Oto-laryngologica (http://www.informahealthcare.com/oto) JARO-Journal of the Association for Research in Otolaryngology (http://jaro-online.org/index.html) Journal of Voice (http://www.jvoice.org) Logopedics Phoniatrics Vocology (http://www.informahealthcare.com/log) journal of the Nordic Cooperation Council of Logopedics and Phoniatrics and the British Voice Association Otolaryngology-Head and Neck Surgery link (http://www.otojournal.org) journal of the American Academy of OtolaryngologyHead and Neck Surgery Foundation

Societies
American Academy of Otolaryngology Head and Neck Surgery (http://www.entnet.org/) American Academy of Otolaryngic Allergy (http://www.aaoaf.org/) American Head and Neck Society (http://www.ahns.info/index.php) American Laryngological, Rhinological and Otological Society (http://www.triologic.org/) Association for Research in Otolaryngology (http://www.aro.org/) Association of Otolaryngology Administrators (http://www.oto-online.org) Australian Society of Otolaryngology Head & Neck Surgery (http://www.asohns.org.au) British Association of Otorhinolaryngologists Head & Neck Surgeons (http://www.entuk.org/) Canadian Society of Otolaryngology Head and Neck Surgery (http://www.entcanada.org/) TWJ Foundation (http://www.twjfoundation.org) Voice Foundation (http://www.voicefoundation.org)

Other
Guildford ENT (http://guildfordent.co.uk/) a specialist clinic that treats nose, throat and ear problems in adults and children at Royal Surrey County Hospital, Guildford, Surrey. Various Conditions and Treatments done by Otolaryngoloist and FAQ's (http://www.ear-nose-and-throat.com/)

Explanation of benefits (insurance)

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Explanation of benefits (insurance)


An explanation of benefits (commonly referred to as an EOB form) is a statement sent by a health insurance company to covered individuals explaining what medical treatments and/or services were paid for on their behalf.[1] Insurance companies also use EOB statements when paying a hospital. The EOB is commonly attached to a check or statement of electronic payment. An EOB typically describes: the payee, the payer and the patient the service performedthe date of the service, the description and/or insurer's code for the service, the name of the person or place that provided the service, and the name of the patient the doctor's fee, and what the insurer allowsthe amount initially claimed by the doctor or hospital, minus any reductions applied by the insurer the amount the patient is responsible for adjustment reasons, adjustment codes EOB documents are protected health information. Electronic EOB documents are called edit 835 5010 files. [2] There normally also will be at least a brief explanation of any claims that were denied, along with a point to start an appeal.[3] A member with secondary insurance gives such information to the provider for the next bill to go out to that insurance company. Generally, secondary insurance pays only the amount the EOB says the member is responsible for. Secondary EOBs show if the patient still has any responsibility to the provider. After the member's insurances have processed the claim, the provider bills the member for the remaining balance, if any.[4]

References
[1] http:/ / www. pohly. com/ terms_e. html [2] http:/ / www. cms. gov/ Outreach-and-Education/ Medicare-Learning-Network-MLN/ MLNProducts/ downloads/ ra_guide_full_03-22-06. pdf [3] http:/ / www. ins. state. ny. us/ website1/ inshelp/ c_eob. htm [4] Medical Business Systems. Understanding an EOB and Your Bill. 2012-01-21. URL:http:/ / www. iridiumsuite. com/ understanding-eob-and-your-bill. Accessed: 2012-01-21. (Archived by WebCite at http:/ / www. webcitation. org/ 64r7N7kQz)

United States Environmental Protection Agency

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United States Environmental Protection Agency


Environmental Protection Agency EPA

Logo of the Environmental Protection Agency

Flag of the Environmental Protection Agency Agency overview Formed Employees Annual budget December 2, 1970 17,359 (2011)
[] []

$8.682 billion (2011)

Agency executives Gina McCarthy, Administrator Bob Perciasepe, Deputy Administrator Website www.EPA.gov
[1]

The United States Environmental Protection Agency (EPA or sometimes USEPA) is an agency of the U.S. federal government which was created for the purpose of protecting human health and the environment by writing and enforcing regulations based on laws passed by Congress.[2] The EPA was proposed by President Richard Nixon and began operation on December 2, 1970, after Nixon signed an executive order. The order establishing the EPA was ratified by committee hearings in the House and Senate.[3] The agency is led by its Administrator, who is appointed by the president and approved by Congress. The current administrator is Gina McCarthy.[4] The EPA is not a Cabinet department, but the administrator is normally given cabinet rank. The EPA has its headquarters in Washington, D.C., regional offices for each of the agency's ten regions, and 27 laboratories. The agency conducts environmental assessment, research, and education. It has the responsibility of maintaining and enforcing national standards under a variety of environmental laws, in consultation with state, tribal, and local governments. It delegates some permitting, monitoring, and enforcement responsibility to U.S. states and Native American tribes. EPA enforcement powers include fines, sanctions, and other measures. The agency also works with industries and all levels of government in a wide variety of voluntary pollution prevention programs and energy conservation efforts. The agency has approximately 17,000 full-time employees.[5] and engages many more people on a contractual basis. More than half of EPA human resources are engineers, scientists, and environmental protection specialists; other groups include legal, public affairs, financial, and information technologists.

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EPA headquarters in Washington, D.C.

Closeup of EPA building

Beginning in the late 1950s[6] and through the 1960s, Congress reacted to increasing public concern about the impact that human activity could have on the environment. A key legislative option to address this concern was the declaration of a national environmental policy.[citation needed] Advocates of this approach argued that without a specific policy, federal agencies were neither able nor inclined to consider the environmental impacts of their actions in fulfilling the agency's mission.[citation needed] The statute that ultimately addressed this issue was the National Environmental Policy Act of 1969 (NEPA, 42 U.S.C. 4321-4347).[7] Senator Henry M. Jackson proposed and helped write S 1075, the bill that eventually became the National Environmental Policy Act. The law was signed by President Nixon on January 1, 1970. NEPA was the first of several major environmental laws passed in the 1970s. It declared a national policy to protect the environment and created a Council on Environmental Quality (CEQ) in the Executive Office of the President.[citation needed] To implement the national policy, NEPA required that a detailed statement of environmental impacts be prepared for all major federal actions significantly affecting the environment. The "detailed statement" would ultimately be referred to as an environmental impact statement (EIS).

Stacks emitting smoke from burning discarded automobile batteries, photo taken in Houston in 1972 by official photographer of recently founded EPA

In 1970, President Richard Nixon proposed an executive reorganization that would consolidate many of the federal government's environmental responsibilities under one agency, a new Environmental Protection Agency. That reorganization proposal was reviewed and passed by the House and Senate.[8] For at least 10 years before NEPA was enacted,[]WP:NOTRS Congress debated issues that the act would ultimately address.[citation needed] The act was modeled on the Resources and Conservation Act of 1959,[citation needed] introduced Same smokestacks in 1975 after the plant was by Senator James E. Murray in the 86th Congress.[citation needed] That closed in a push for greater environmental bill would have established an environmental advisory counsel in the protection office of the President, declared a national environmental policy, and required the preparation of an annual environmental report.[9]WP:NOTRS In the years following the introduction of Senator Murray's bill, similar bills were introduced and hearings were held to discuss the state of the environment and Congress's potential responses to perceived problems. In 1968, a joint House-Senate colloquium was convened

United States Environmental Protection Agency by the chairmen of the Senate Committee on Interior and Insular Affairs (Senator Henry Jackson) and the House Committee on Science and Astronautics (Representative George Miller) to discuss the need for and potential means of implementing a national environmental policy. In the colloquium, some Members of Congress expressed a continuing concern over federal agency actions affecting the environment.[10] The EPA began regulating greenhouse gases (GHGs) from mobile and stationary sources of air pollution under the Clean Air Act (CAA) for the first time on January 2, 2011. Standards for mobile sources have been established pursuant to Section 202 of the CAA, and GHGs from stationary sources are controlled under the authority of Part C of Title I of the Act. See the page Regulation of Greenhouse Gases Under the Clean Air Act for further information. On July 17, 2013, the EPA renamed its headquarters the William Jefferson Clinton Federal Building, after former president Bill Clinton.[11]

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EPA offices
Office of the Administrator (OA)[12] Office of Administration and Resources Management (OARM)[13] Office of Air and Radiation (OAR)[14] Office of Chemical Safety and Pollution Prevention (OCSPP)[15] Office of the Chief Financial Officer (OCFO)[16] Office of Enforcement and Compliance Assurance (OECA)[17] Office of Environmental Information (OEI)[18] Office of General Counsel (OGC)[19] Office of Inspector General (OIG)[20] Office of International and Tribal Affairs (OITA)[21] Office of Research and Development (ORD)[22] Office of Solid Waste and Emergency Response (OSWER)[23] Office of Water (OW)[24]

EPA regions
Each EPA regional office is responsible within its states for implementing the Agency's programs, except those programs that have been specifically delegated to states. Region 1: responsible within the states of Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont. Region 2: responsible within the states of New Jersey and New York. It is also responsible for the US territories of Puerto Rico, and the U.S. Virgin Islands.

The administrative regions of the United States Environmental Protection Agency.

Region 3: responsible within the states of Delaware, Maryland, Pennsylvania, Virginia, West Virginia, and the District of Columbia. Region 4: responsible within the states of Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee.

United States Environmental Protection Agency Region 5: responsible within the states of Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin. Region 6: responsible within the states of Arkansas, Louisiana, New Mexico, Oklahoma, and Texas. Region 7: responsible within the states of Iowa, Kansas, Missouri, and Nebraska. Region 8: responsible within the states of Colorado, Montana, North Dakota, South Dakota, Utah, and Wyoming. Region 9: responsible within the states of Arizona, California, Hawai'i, Nevada, and the territories of Guam and American Samoa. Region 10: responsible within the states of Alaska, Idaho, Oregon, and Washington. Each regional office also implements programs on Indian Tribal lands, except those programs delegated to Tribal authorities.

691

Related legislation
The legislation here is general environmental protection legislation, and may also apply to other units of the government, including the Department of the Interior and the Department of Agriculture.

Air
1955: Air Pollution Control Act PL 84-159 1963: Clean Air Act PL 88-206 1965: Motor Vehicle Air Pollution Control Act PL 89-272 1966: Clean Air Act Amendments PL 89-675 1967: Air Quality Act PL 90-148 1969: National Environmental Policy Act PL 91-190 1970: Clean Air Act Extension PL 91-604 1976: Toxic Substances Control Act PL 94-469 1977: Clean Air Act Amendments PL 95-95 1990: Clean Air Act Amendments PL 101-549

Water
1948: Water Pollution Control Act PL 80-845 1965: Water Quality Act PL 89-234 1966: Clean Waters Restoration Act PL 89-753 1969: National Environmental Policy Act PL 91-190 1970: Water Quality Improvement Act PL 91-224 1972: Federal Water Pollution Control Amendments of 1972 PL 92-500 1974: Safe Drinking Water Act PL 93-523 1976: Toxic Substances Control Act PL 94-469 1977: Clean Water Act PL 95-217 1987: Water Quality Act PL 100-4 1996: Safe Drinking Water Act Amendments of 1996 2006: Long Term 2 Enhanced Surface Water Treatment Rule (also "LT2ESWTR" or simply "LT2") 71 FR 654

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Land
1947: Federal Insecticide, Fungicide, and Rodenticide Act 1964: Wilderness Act PL 88-577 1968: Wild and Scenic Rivers Act PL 90-542 1969: National Environmental Policy Act PL 91-190 1970: Wilderness Act PL 91-504 1977: Surface Mining Control and Reclamation Act PL 95-87 1978: Wilderness Act PL 98-625 1980: Alaska National Interest Lands Conservation Act PL 96-487 1994: California Desert Protection Act PL 103-433 1996: Food Quality Protection Act [25] 2010: California Desert Protection Act

Endangered species
1946: Fish and Wildlife Coordination Act PL 79-732 1966: Endangered Species Preservation Act PL 89-669 1969: Endangered Species Conservation Act PL 91-135 1972: Marine Mammal Protection Act PL 92-522 1973: Endangered Species Act PL 93-205 1979: Endangered Species Preservation Act PL 95 335

Hazardous waste
1965: Solid Waste Disposal Act PL 89-272 1969: National Environmental Policy Act PL 91-190 1970: Resource Recovery Act PL 91-512 1976: Resource Conservation and Recovery Act PL 94-580 1980: Comprehensive Environmental Response, Compensation, and Liability Act ("Superfund") PL 96-510 1982: Nuclear Waste Repository Act PL 97-425 1984: Hazardous and Solid Wastes Amendments Act PL 98-616 1986: Superfund Amendments and Reauthorization Act PL 99-499 2002: Small Business Liability Relief and Brownfields Revitalization Act ("Brownfields Law") PL 107-118

Programs
Energy Star
In 1992 the EPA launched the Energy Star program, a voluntary program that fosters energy efficiency.

Pesticide
EPA administers the Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA) (which is much older than the agency) and registers all pesticides legally sold in the United States.

Environmental Impact Statement Review


EPA is responsible for reviewing Environmental Impact Statements of other federal agencies' projects, under the National Environmental Policy Act (NEPA).

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Safer Detergents Stewardship Initiative


Through the Safer Detergents Stewardship Initiative (SDSI),[] EPA's Design for the Environment (DfE) recognizes environmental leaders who voluntarily commit to the use of safer surfactants. Safer surfactants are the ones that break down quickly to non-polluting compounds and help protect aquatic life in both fresh and salt water. Nonylphenol ethoxylates, commonly referred to as NPEs, are an example of a surfactant class that does not meet the definition of a safer surfactant. The Design for the Environment has identified safer alternative surfactants through partnerships with industry and environmental advocates. These safer alternatives are comparable in cost and are readily available. CleanGredients[] is a source of safer surfactants.

Fuel economy
Manufacturers selling automobiles in the USA are required to provide EPA fuel economy test results for their vehicles and the manufacturers are not allowed to provide results from alternate sources. The fuel economy is calculated using the emissions data collected during two of the vehicle's Clean Air Act certification tests by measuring the total volume of carbon captured from the exhaust during the tests. The current testing system was originally developed in 1972 and used driving cycles designed to simulate driving during rush-hour in Los Angeles during that era. Prior to 1984 the EPA reported the exact fuel economy figures calculated from the test. In 1984, the EPA began adjusting city (aka Urban Dynamometer Driving Schedule or UDDS) results downward by 10% and highway (aka HighWay Fuel Economy Test or HWFET) results by 22% to compensate for changes in driving conditions since 1972 and to better correlate the EPA test results with real-world driving. In 1996, the EPA proposed updating the Federal Testing Procedures[26] to add a new higher speed test (US06) and an air-conditioner on test (SC03) to further improve the correlation of fuel economy and emission estimates with real-world reports. The updated testing methodology was finalized in December, 2006 for implementation with model year 2008 vehicles and set the precedent of a 12 year review cycle for the test procedures.[] In February 2005, the organization launched a program called "Your MPG"[27] that allows drivers to add real-world fuel economy statistics into a database on the EPA's fuel economy website and compare them with others and the original EPA test results. It is important to note that the EPA actually conducts these tests on very few vehicles. "While the public mistakenly presumes that this federal agency is hard at work conducting complicated tests on every new model of truck, van, car, and SUV, in reality, just 18 of the EPA's 17,000 employees work in the automobile-testing department in Ann Arbor, Michigan, examining 200 to 250 vehicles a year, or roughly 15 percent of new models. As to that other 85 percent, the EPA takes automakers at their wordwithout any testing-accepting submitted results as accurate."[28] Two-thirds of the vehicles the EPA tests themselves are selected randomly, and the remaining third are tested for specific reasons. Although originally created as a reference point for fossil fuelled vehicles, driving cycles have been used for estimating how many miles an electric vehicle will do on a single charge.[29]

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Air quality
The Air Quality Modeling Group (AQMG) is in the EPA's Office of Air and Radiation (OAR) and provides leadership and direction on the full range of air quality models, air pollution dispersion models[30][31] and other mathematical simulation techniques used in assessing pollution control strategies and the impacts of air pollution sources. The AQMG serves as the focal point on air pollution modeling techniques for other EPA headquarters staff, EPA regional Offices, and State and local environmental agencies. It coordinates with the EPA's Office of Research and Development (ORD) on the development of new models and techniques, as well as wider issues of atmospheric research. Finally, the AQMG conducts modeling analyses to support the policy and regulatory decisions of the EPA's Office of Air Quality Planning and Standards (OAQPS). The AQMG is located in Research Triangle Park, North Carolina.

Oil pollution
SPCC: Spill Prevention, Control, and Countermeasure Rule. Applies to all facilities that store, handle, process, gather, transfer, store, refine, distribute, use or consume oil or oil products. Oil products includes petroleum and non-petroleum oils as well as: animal fats, oils and greases; fish and marine mammal oils; and vegetable oils, (including oils from seeds, nuts, fruits, and kernels). Mandates that an SPCC Plan is required for facilities that may reasonably be expected to have a discharge into or upon navigable waters of the United States (as defined in the Clean Water Act)or adjoining shorelines. Secondary Containment mandated at oil storage facilities. Oil release containment at oil development sites.

WaterSense
WaterSense is an EPA program designed to encourage water efficiency in the United States through the use of a special label on consumer products. It was launched in June 2006.[32] Products include high-efficiency toilets (HETs), bathroom sink faucets (and accessories), and irrigation equipment. WaterSense is a voluntary program, with EPA developing specifications for water-efficient products through a public process and product testing by independent laboratories. The program was launched in 2006.[33]

Drinking water
EPA ensures safe drinking water for the public, by setting standards for more than 160,000 public water systems throughout the United States. EPA oversees states, local governments and water suppliers to enforce the standards, under the Safe Drinking Water Act. The program includes regulation of injection wells in order to protect underground sources of drinking water. Select readings of amounts of certain contaminants in drinking water, precipitation, and surface water, in addition to milk and air, are reported on EPA's Rad Net web site [34] in a section entitled Envirofacts [35]. In certain cases, readings exceeding EPA MCL levels are deleted or not included[][] despite mandatory reporting regulations. A draft of revised EPA regulations relaxes the regulations for radiation exposure through drinking water, stating that current standards are impractical to enforce. The EPA is recommending that intervention is not necessary until drinking water is contaminated with radioactive iodine 131 at a concentration of 81,000 picocuries per liter (the limit for short term exposure set by the International Atomic Energy Agency), which is 27,000 times the current EPA limit of 3 picocuries per liter for long term exposure.[]

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Radiation Protection
EPA has following seven groups of projects to protect public from nuclear contamination.[36] Waste Management Programs Emergency Preparedness and Response Programs Protective Action Guide EPA developed the manual[37] to provide guideline for local and state governments to protect public from nuclear accident. EPA Cleanup and Multi-Agency Programs Risk Assessment and Federal Guidance Programs Naturally-Occurring Radioactive Materials Program Air and Water Programs Radiation Source Reduction and Management

Research vessel
On March 3, 2004, the United States Navy transferred USNS Bold, a Stalwart class ocean surveillance ship, to the EPA, now known as OSV Bold. The ship previously used in anti-submarine operations during the Cold War, is equipped with sidescan sonar, underwater video, water and sediment sampling instruments, used in study of ocean and coastline. One of the major missions of Bold is to monitor sites where materials are dumped from dredging operations in U.S. ports for ecological impact.[]
OSV Bold docked at Port Canaveral, FL

Advance identification
Advance identification, or ADID, is a planning process used by the EPA to identify wetlands and other bodies of water and their respective suitability for the discharge of dredged and fill material. The EPA conducts the process in cooperation with the U.S. Army Corps of Engineers and local states or Native American Tribes. As of February 1993, 38 ADID projects had been completed and 33 were ongoing.[38]

Controversies
There has been political controversyWikipedia:Avoid weasel words over whether environmental regulations generally increase or decrease national employment.[39][40][41][42]

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The "LT2" Drinking Water Controversy


A recent amendment to the Safe Drinking Water Act, known as "LT2",[43] mandates costly treatment or burial for open reservoirs. This regulation has come under fire, with allegations that it is the unnecessary and wasteful[44] product of lobbying from corporate interests who stand benefit from ensuing public works contracts [45]

Fiscal Mismanagement
EPA director Anne M. Gorsuch resigned under fire in 1983 during a scandal over mismanagement of a $1.6 billion program to clean up hazardous waste dumps. Gorsuch based her administration of the EPA on the New Federalism approach of downsizing federal agencies by delegating their functions and services to the individual states.[46] She believed that the EPA was over-regulating business and that the agency was too large and not cost-effective. During her 22 months as agency head, she cut the budget of the EPA by 22%, reduced the number of cases filed against polluters, relaxed Clean Air Act regulations, and facilitated the spraying of restricted-use pesticides. She cut the total number of agency employees, and hired staff from the industries they were supposed to be regulating.[47] Environmentalists contended that her policies were designed to placate polluters, and accused her of trying to dismantle the Agency.[48] In 1982 Congress charged that the EPA had mishandled the $1.6 billion toxic waste Superfund and demanded records from Gorsuch. Gorsuch refused and became the first agency director in U.S. history to be cited for contempt of Congress. The EPA turned the documents over to Congress several months later, after the White House abandoned its court claim that the documents could not be subpoened by Congress because they were covered by executive privilege. At that point, Gorsuch resigned her post, citing pressures caused by the media and the congressional investigation.[49] Critics charged that the EPA was in a shambles at that time.[50]

Fuel economy
In July 2005, an EPA report showing that auto companies were using loopholes to produce less fuel-efficient cars was delayed. The report was supposed to be released the day before a controversial energy bill was passed and would have provided backup for those opposed to it, but at the last minute the EPA delayed its release.[51] The state of California sued the EPA for its refusal to allow California and 16 other states to raise fuel economy standards for new cars.[52] EPA administrator Stephen L. Johnson claimed that the EPA was working on its own standards, but the move has been widely considered an attempt to shield the auto industry from environmental regulation by setting lower standards at the federal level, which would then preempt state laws.[53][54][55] California governor Arnold Schwarzenegger, along with governors from 13 other states, stated that the EPA's actions ignored federal law, and that existing California standards (adopted by many states in addition to California) were almost twice as effective as the proposed federal standards.[56] It was reported that Stephen Johnson ignored his own staff in making this decision.[57] After the federal government bailed out General Motors and Chrysler in the Automotive industry crisis of 20082010, the 2010 Chevrolet Equinox was released with EPA fuel economy rating abnormally higher than its competitors. Independent road tests[58][59][60][61] found that both vehicle did not out-perform its competitors, which had much lower fuel economy ratings. Later road tests[62][63] found better, but inconclusive, results. Palm-based biodiesel and renewable diesel failed to meet the minimum 20% greenhouse gas (GHG) emissions savings threshold requirement to qualify as renewable fuels under the US Renewable Fuel Standard 2.[64] Palm oil plantations threaten the habitats of the endangered orang-utan and dwarf elephant.[65]

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Global warming
In June 2005, a memo revealed that Philip Cooney, former chief of staff for the White House Council on Environmental Quality, and former lobbyist for the American Petroleum Institute, had personally edited documents, summarizing government research on climate change, before their release.[66] Cooney resigned two days after the memo was published in The New York Times. Cooney said he had been planning to resign for over two years, implying the timing of his resignation was just a coincidence. Specifically, he said he had planned to resign to "spend time with his family."[67] One week after resigning he took a job at Exxon Mobil in their public affairs department.[68] In December 2007, EPA Administrator Stephen L. Johnson approved a draft of a document that declared that climate change imperiled the public welfarea decision that would trigger the first national mandatory global-warming regulations. Associate Deputy Administrator Jason Burnett e-mailed the draft to the White House. White House aideswho had long resisted mandatory regulations as a way to address climate changeknew the gist of what Johnson's finding would be, Burnett said. They also knew that once they opened the attachment, it would become a public record, making it controversial and difficult to rescind. So they did not open it; rather, they called Johnson and asked him to take back the draft. U.S. law clearly stated that the final decision was the EPA administrator's, not President Bush's. Johnson rescinded the draft; in July 2008, he issued a new version which did not state that global warming was danger to public welfare. Burnett resigned in protest.[69]

Libraries
In 2004, the Agency began a strategic planning exercise to develop plans for a more virtual approach to library services. The effort was curtailed in July 2005 when the Agency proposed a $2.5 million cut in its 2007 budget for libraries. Based on the proposed 2007 budget, the EPA posted a notice to the Federal Register, September 20, 2006 that EPA Headquarters Library would close its doors to walk-in patrons and visitors on October 1, 2006.[70] The EPA also closed some of its regional libraries and reduced hours in others,[71] using the same FY 2007 proposed budget numbers. On October 1, 2008, the Agency re-opened regional libraries in Chicago, Dallas and Kansas City and the library at its Headquarters in Washington, DC.[72] In June 2011, the EPA Library Network published a strategic plan[73] for fiscal years 2012-2014.

Mercury emissions
In March 2005, nine states (California, New York, New Jersey, New Hampshire, Massachusetts, Maine, Connecticut, New Mexico and Vermont) sued the EPA. The EPA's inspector general had determined that the EPA's regulation of mercury emissions did not follow the Clean Air Act, and that the regulations were influenced by top political appointees.[74][75] The EPA had suppressed a study it commissioned by Harvard University which contradicted its position on mercury controls.[76] The suit alleges that the EPA's rule allowing exemption from "maximum available control technology" was illegal, and additionally charged that the EPA's system of pollution credit trading allows power plants to forego reducing mercury emissions.[77] Several states also began to enact their own mercury emission regulations. Illinois's proposed rule would have reduced mercury emissions from power plants by an average of 90% by 2009.[78]

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9/11 air ratings


An August 2003 report released by EPA's Inspector General claimed that the White House put pressure on the EPA to delete cautionary information about the air quality in New York City around Ground Zero following the September 11, 2001 attacks.

Very fine airborne particulates


Tiny particles, under 2.5 micrometres, are attributed to health and mortality concerns,[79] so some health advocates want the EPA to regulate it. The science may be in its infancy, although many conferences have discussed the trails of this airborne matter in the air. Foreign governments such as Australia[80] and most EU States have addressed this issue. The EPA first established standards in 1997, and strengthened them in 2006. As with other standards, regulation and enforcement of the PM2.5 standards is the responsibility of the state governments, through State Implementation Plans.[81]

Political pressure and Scientific Integrity

In April 2008, the Union of Concerned Scientists said that more than half of the nearly 1,600 EPA staff scientists who responded online to a detailed questionnaire reported they had experienced incidents of political interference in their work. The survey included chemists, toxicologists, engineers, geologists and experts in other fields of science. About 40% of the scientists reported that the interference had been more prevalent in the last five years than in previous years. The highest number of complaints came from scientists who were involved in determining the risks of cancer by chemicals used in food and other aspects of everyday life.[82] EPA research has also been suppressed by career managers.[83] Supervisors at EPA's National Center for Environmental Assessment required several paragraphs to be deleted from a peer-reviewed journal article about EPA's integrated risk information system, which led two co-authors to have their names removed from the publication, and the corresponding author, Ching-Hung Hsu, to leave EPA "because of the draconian restrictions placed on publishing.".[84] EPA subjects employees who author scientific papers to prior restraint, even if those papers are written on personal time.[85] A $3 million mapping study on sea level rise was suppressed by EPA management during both the Bush and Obama Administrations, and managers changed a key interagency report to reflect the removal of the maps.[86] EPA employees have reported difficulty in conducting and reporting the results of studies on hydraulic fracturing due to industry[][][] and governmental pressure, and are concerned about the censorship of environmental reports.[][][]

An Environmental Protection Agency employee checks one of the many air sampling locations set up around the World Trade Center site.

Environmental justice
The EPA has been criticized for its lack of progress towards environmental justice. Administrator Christine Todd Whitman was criticized for her changes to President Bill Clinton's Executive Order 12898 during 2001, removing the requirements for government agencies to take the poor and minority populations into special consideration when making changes to environmental legislation, and therefore defeating the spirit of the Executive Order.[87] In a March 2004 report, the inspector general of the agency concluded that the EPA "has not developed a clear vision or a comprehensive strategic plan, and has not established values, goals, expectations, and performance measurements" for environmental justice in its daily operations. Another report in September 2006 found the agency still had failed to review the success of its programs, policies and activities towards environmental justice.[88] Studies have also found that poor and minority populations were underserved by the EPA's Superfund program, and that this situation was worsening.[87]

United States Environmental Protection Agency Barriers to enforcing environmental justice Localization Many issues of environmental justice are localized, and are therefore hard to be addressed by federal agencies such as the EPA. Without significant media attention, political interest, or 'crisis' status, local issues are less likely to be addressed on local or federal level. With a still developing sector of environmental justice under the EPA, small, local incidents are unlikely to be solved compared to larger, well publicized incidents. Conflicting political powers The White House maintains direct control over the EPA, and its enforcements are subject to the political agenda of who is in power. Republicans and Democrats differ in their approaches to, and perceived concerns of, environmental justice. While President Bill Clinton signed the executive order 12898, the Bush administration did not develop a clear plan or establish goals for integrating environmental justice into everyday practices, which in turn affected the motivation for environmental enforcement.[89] Responsibilities of the EPA The EPA is responsible for preventing and detecting environmental crimes, informing the public of environmental enforcement, and setting and monitoring standards of air pollution, water pollution, hazardous wastes and chemicals. While the EPA aids in preventing and identifying hazardous situations, it is hard to construct a specific mission statement given its wide range of responsibilities.[90] It is impossible to address every environmental crime adequately or efficiently if there is no specific mission statement to refer to. The EPA answers to various groups, competes for resources, and confronts a wide array of harms to the environment. All of these present challenges, including a lack of resources, its self-policing policy, and a broadly defined legislation that creates too much discretion for EPA officers.[91] Authority of the EPA Under different circumstances, the EPA faces many limitations to enforcing environmental justice. It does not have the authority or resources to address injustices without an increase in federal mandates requiring private industries to consider the environmental ramifications of their activities.[92]

699

References
[1] http:/ / www. epa. gov [5] Also see U.S. Census Bureau spreadsheet (http:/ / www. census. gov/ compendia/ statab/ tables/ 07s0483. xls) [9] Legislative Accomplishments :: Henry M. Jackson Foundation (http:/ / www. hmjackson. org/ index. php?p=Legislative_Accomplishments& s=236) [10] http:/ / www. fta. dot. gov/ documents/ Unit1_01CRSReport. pdf [16] (http:/ / www. epa. gov/ aboepa/ ocfo. html) [20] (http:/ / www. epa. gov/ aboutepa/ oig. html) [25] http:/ / www. epa. gov/ pesticides/ regulating/ laws. htm [30] www.crcpress.com (http:/ / www. crcpress. com/ shopping_cart/ products/ product_detail. asp?sku=L1023& parent_id=& pc=) [31] Air-dispersion.com (http:/ / www. air-dispersion. com) [32] U.S. Environmental Protection Agency (EPA), Washington, DC. "WaterSense Timeline." (http:/ / www. epa. gov/ watersense/ about_us/ timeline. html) Revised 2011-04-14. [33] EPA. "WaterSense." (http:/ / www. epa. gov/ watersense/ news/ archive/ 2006. htm) [34] http:/ / www. epa. gov/ radnet/ [35] http:/ / iaspub. epa. gov/ enviro/ erams_query_v2. simple_query [36] Radiation Protection Programs (http:/ / www. epa. gov/ radiation/ programs. html) retrieved 2011-7-9 [39] Regulations Create Jobs, Too; Vilified on the campaign trail, government rules often create as many jobs as they kill (http:/ / www. businessweek. com/ magazine/ regulations-create-jobs-too-02092012. html), February 09, 2012 [40] GOP freshmen return, resume effort to roll back regulations (http:/ / www. usatoday. com/ news/ washington/ story/ 2011-09-05/ GOP-freshmen-return-resume-effort-to-roll-back-regulations/ 50267540/ 1) 9/6/2011 [41] A Debate Arises on Job Creation and Environment (http:/ / www. nytimes. com/ 2011/ 09/ 05/ business/ economy/ a-debate-arises-on-job-creation-vs-environmental-regulation. html) September 4, 2011 [42] Is the EPA really a 'jobs killer'? (http:/ / www. csmonitor. com/ USA/ Politics/ 2011/ 1122/ Is-the-EPA-really-a-jobs-killer) November 22, 2011 [43] (http:/ / water. epa. gov/ lawsregs/ rulesregs/ sdwa/ lt2/ regulations. cfm) [44] (http:/ / www. nydailynews. com/ news/ politics/ federal-government-scrap-much-derided-1-6-billion-reservoir-cap-article-1. 949327) August 21, 2011 [45] (http:/ / www. slocoastjournal. com/ docs/ archives/ 2010/ Nov/ pages/ news2. html) November 2010

United States Environmental Protection Agency


[46] Views from the Former Administrators (http:/ / www. epa. gov/ history/ topics/ epa/ 15e. htm#Gorsuch), EPA Journal, November 1985. [47] Sullivan, Patricia. Anne Gorsuch Burford, 62, Dies; Reagan EPA Director (http:/ / www. washingtonpost. com/ wp-dyn/ articles/ A3418-2004Jul21. html), Washington Post, July 22, 2004; Page B06. [48] Anne Gorsuch Burford, 62, Reagan E.P.A. Chief, Dies - New York Times (http:/ / www. nytimes. com/ 2004/ 07/ 22/ us/ anne-gorsuch-burford-62-reagan-epa-chief-dies. html) [49] "Burford Resigns As Administrator of Embattled EPA" (http:/ / news. google. com/ newspapers?id=73gUAAAAIBAJ& sjid=swIEAAAAIBAJ& pg=6140,3000792& dq=anne+ mcgill+ gorsuch+ held+ in+ contempt+ of+ congress), Toledo Blade, Mar 10, 1983, p. 1 [50] Ingersoll, Bruce. Burford out; agency is in 'a shambles' (http:/ / news. google. com/ newspapers?id=X6YSAAAAIBAJ& sjid=e_kDAAAAIBAJ& pg=528,3563248& dq=anne+ mcgill+ gorsuch+ held+ in+ contempt+ of+ congress), Spokane Chronicle, March 10, 1983 [52] Blog.Wired.com (http:/ / blog. wired. com/ wiredscience/ 2007/ 10/ governor-arnie-. html) [64] http:/ / www. thestar. com. my/ story. aspx?file=%2f2012%2f3%2f27%2fbusiness%2f10991472 [65] http:/ / www. iucn. nl/ en/ results/ results_per_theme/ ?11490/ Orang-utan-pushed-to-the-brink-by-palm-oil-plantations-in-Borneo [66] U.S. Official Edited Warming, Emission Link - Report (http:/ / www. cslproductions. com/ scrapbook/ NYtimes-bush-global-warming-editor-6-9-05/ ), Reuters, June 8, 2005 [67] White House Official Resigns After Climate Documents Flap (http:/ / www. commondreams. org/ headlines05/ 0612-04. htm), Agence France Presse, June 12, 2005 [68] Ex-White House environment official joins Exxon (http:/ / www. political-news. org/ breaking/ 11978/ ex-white-house-environment-official-joins-exxon. html), Reuters, June 15, 2005 [70] "Notification of Closure of the EPA Headquarters Library" (pdf) (http:/ / a257. g. akamaitech. net/ 7/ 257/ 2422/ 01jan20061800/ edocket. access. gpo. gov/ 2006/ 06-7803. htm), September 20, 2006 [71] Letter to Appropriations Committee, Interior and Related Agencies Subcommittee, June 29, 2006 (pdf) (http:/ / www. peer. org/ docs/ epa/ 06_29_6_union_library_ltr. pdf), from leaders of 16 local EPA unions [72] EPA Newsbrief, October 1, 2008 (http:/ / yosemite. epa. gov/ opa/ admpress. nsf/ 4a3d7e51caf96c7a85257359003f533e/ 9665e31d9c19a212852574d500537a10!OpenDocument). Retrieved January 17, 2009. [74] Proposed Mercury Rules Bear Industry Mark (http:/ / www. washingtonpost. com/ ac2/ wp-dyn?pagename=article& contentId=A64630-2004Jan30), Washington Post, January 31, 2004 [75] EPA Inspector Finds Mercury Proposal Tainted (http:/ / www. washingtonpost. com/ wp-dyn/ articles/ A61762-2005Feb3. html), Washington Post, February 4, 2005 [76] New EPA Mercury Rule Omits Conflicting Data (http:/ / www. washingtonpost. com/ wp-dyn/ articles/ A55268-2005Mar21. html), Washington Post, March 22, 2005 [77] States Sue EPA Over Mercury Emissions (http:/ / www. waterconserve. info/ articles/ reader. asp?linkid=40416), LA Times, March 30, 2005 [78] Governor Blagojevich and Illinois EPA Propose Aggressive Mercury Controls For Illinois Power Plants (http:/ / www. epa. state. il. us/ environmental-progress/ v32/ n1/ environmental-progress. pdf), Environmental Progress, Spring 2006, page 12 [80] (http:/ / www. epa. qld. gov. au/ environmental_management/ air/ air_quality_monitoring/ air_pollutants/ airborne_particulates/ ) [84] Ibid p. 738 note 95. [85] Ibid p. 736-40. [87] O'Neil, S. G. (2007). Superfund: Evaluating the Impact of Executive Order 12898 (http:/ / www. ehponline. org/ members/ 2007/ 9903/ 9903. pdf). Environmental Health Perspectives, Volume 115, Number 7, pgs 10871093 [89] Bullard, Robert. Growing Smarter: Achieving Livable Communities, Environmental Justice, and Regional Equity. Cambridge: MIT Press, 2007 [90] Rosenbaum, W. A. "Still reforming after all these years: George W. Bush's new era' at the EPA. Environmental Policy: New directions for the Twenty-first century. Washington DC: CQ Press, 2003 [91] Burns, Ronald G. Michael J. Lynch, and Paul Stretesky. Environmental Law, Crime, and Justice. New York: LFB Scholarly publishing Inc, 2008 [92] Environmental Justice Coalition (EJC). "Environmental Justice act of 2009." Environmental Justice Coalition, 2008. EJ Coalition Online: Ejcoalition.Multiply.com (http:/ / ejcoalition. multiply. com/ journal/ item/ 51/ Environmental_Justice_Act_of_2009)

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External links
United States Environmental Protection Agency (http://www.epa.gov/), Official Website EPA's nationwide radiation monitoring system, RadNet (http://www.epa.gov/radnet/radnet-data/index.html) DotGovWatch.com (http://www.dotgovwatch.com/wsdl/map.php), created using EPA's Toxic Release Inventory Map FuelEconomy.gov (http://www.fueleconomy.gov/) CLU-IN.org (http://www.clu-in.org), Haz Waste Site Cleanup Information by US EPA Technology Innovation Program Sanjour.info (http://sanjour.info), Collected Papers of William Sanjour a retired EPA employee and whistleblower Selected Digitized Environmental Protection Agency Records (http://www.archives.gov/research/arc/topics/ environment/index.html) Available in the National Archives' Archival Research Catalog (http://www.archives. gov/research/arc/) OpenRegs.com (http://openregs.com/agencies/view/4/environmental_protection_agency), Proposed and finalized federal regulations from the United States Environmental Protection Agency Air and Radiation (http://air-epa.org/), Partnership between EPA and Office of Air and Radiation (OAR) to prevent air pollution Historic technical reports from the Environmental Protection Agency (and other Federal agencies) are available in the Technical Report Archive and Image Library (TRAIL) (http://www.technicalreports.org/) United States Environmental Protection Agency (http://www.washingtonpost.com/politics/institutions/ environmental_protection_agency_topic.html) collected news and commentary at The Washington Post

Preferred provider organization

702

Preferred provider organization


Health care in the United States Government Health Programs

Federal Employees Health Benefits Program Indian Health Service Veterans Health Administration Military Health System / TRICARE Medicare Medicaid / State Health Insurance Assistance Program (SHIP) State Children's Health Insurance Program (CHIP) Program of All-Inclusive Care for the Elderly (PACE) Prescription Assistance (SPAP) Private health coverage

Health insurance in the United States Consumer-driven health care


Flexible spending account (FSA) Health Reimbursement Account Health savings account

High-deductible health plan (HDHP) Medical savings account (MSA) Private Fee-For-Service (PFFS) Managed care (CCP) Health maintenance organization (HMO) Preferred provider organization (PPO) Medical underwriting

Health care reform law


Emergency Medical Treatment and Active Labor Act (1986) Health Insurance Portability and Accountability Act (1996) Medicare Prescription Drug, Improvement, and Modernization Act (2003) Patient Safety and Quality Improvement Act (2005) Health Information Technology for Economic and Clinical Health Act (2009) Patient Protection and Affordable Care Act (2010) State level reform

Massachusetts health care reform Oregon Health Plan Vermont health care reform SustiNet (Connecticut) Dirigo Health (Maine) Municipal health coverage

Fair Share Health Care Act (Maryland) Healthy Howard (Howard Co., Maryland) Healthy San Francisco

In health insurance in the United States, a preferred provider organization (or PPO, sometimes referred to as a participating provider organization or preferred provider option) is a managed care organization of medical doctors, hospitals, and other health care providers who have covenanted with an insurer or a third-party administrator to provide health care at reduced rates to the insurer's or administrator's clients.

Preferred provider organization

703

Overview
A preferred provider organization[1] is a subscription-based medical care arrangement. A membership allows a substantial discount below the regularly charged rates of the designated professionals partnered with the organization. Preferred provider organizations themselves earn money by charging an access fee to the insurance company for the use of their network (unlike the usual insurance with premiums and corresponding payments paid either in full or partially by the insurance provider to the medical doctor). They negotiate with providers to set fee schedules, and handle disputes between insurers and providers. PPOs can also contract with one another to strengthen their position in certain geographic areas without forming new relationships directly with providers. This will be mutually beneficial in theory, as the insurer will be billed at a reduced rate when its insureds utilize the services of the "preferred" provider and the provider will see an increase in its business as almost all and or insureds in the organization will use only providers who are members. PPOs have gained popularity in the past decadeWikipedia:Manual of Style/Dates and numbers#Chronological items because, although they tend to have slightly higher premiums than HMOs and other more restrictive plans, they offer patients more flexibility overall.[2]

PPO
Other features of a preferred provider organization generally include utilization review, where representatives of the insurer or administrator review the records of treatments provided to verify that they are appropriate for the condition being treated rather than largely or solely being performed to increase the amount of reimbursement due. Another near-universal feature is a pre-certification requirement, in which scheduled (non-emergency) hospital admissions and, in some instances outpatient surgery as well, must have prior approval of the insurer and often undergo "utilization review" in advance.

EPO
An Exclusive Provider Organization (EPO) is a network of individual medical care providers, or groups of medical care providers, who have entered into written agreements with an insurer to provide health insurance to subscribers. In EPO, medical care providers enter a mutually beneficial relationship with an insurer. The insurer reimburses an insured subscriber only if the medical expenses are derived from the designated network of medical care providers. The established network of medical care providers in turn provide subscribed patients medical services at significantly lower rates than what would have been under normal circumstances. In exchange for reduced rates of medical services, medical care providers get a steady stream of business. An EPO earns additional money by charging an access fee to the insurer for use of the network. It also negotiates with the medical care providers of the organization in order to set fee schedules and help resolve altercations between the insurer and medical care providers. Sometimes EPOs even contract with one another to strengthen their businesses and positions in a certain geographic area. The beneficial relationship between medical care providers and the insurer often rubs off of the insured subscriber because lower rates of medical services means lower rates of increase in monthly premiums. Although a good deal, the downside of EPO is that it can be quite restrictive. As a member of an EPO, you can use the doctors and hospitals within the EPO network, but cannot go outside of the network for care. Suppose you go to a hospital outside of the network in the case of an emergency, you may have to pay you medical bills partially or completely out of the pocket. Exclusive Provider Organization (EPO) vs. Preferred Provider Organization (PPO) A Preferred Provider Organization (PPO) is a healthcare benefit arrangement that is similar to the EPO in structure, administration, and operation. Unlike EPO members, however, PPO members are reimbursed for using medical care providers outside of the designated doctors and hospitals. Understandably, PPO members are reimbursed at a reduced rate that may include higher deductibles, co-payments, lower reimbursement percentages, or a combination

Preferred provider organization of those disadvantages. On the other hand, EPO members do not receive any reimbursement or benefit if they choose to visit medical care providers outside of the designated doctors and hospitals within the established network. Some, but not all, EPOs allow partial reimbursement outside of the network in emergency cases.

704

References
[1] http:/ / openlibrary. org/ books/ OL14736792M/ An_introduction_to_preferred_provider_organizations_(PPOs) [2] http:/ / healthharbor. com/ health-insurance-101/ plan-types

Endoscopic retrograde cholangiopancreatography

705

Endoscopic retrograde cholangiopancreatography


Endoscopic retrograde cholangiopancreatography
Intervention

Duodenoscopic image of two pigment stones extracted from common bile duct after sphincterotomy. ICD-9-CM MeSH OPS-301code: 51.10 [1] [2]

D002760 1-642 [3]

Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that combines the use of endoscopy and fluoroscopy to diagnose and treat certain problems of the biliary or pancreatic ductal systems. Through the endoscope, the physician can see the inside of the stomach and duodenum, and inject radiographic contrast into the ducts in the biliary tree and pancreas so they can be seen on X-rays. ERCP is used primarily to diagnose and treat conditions of the bile ducts and main pancreatic duct,[4] including gallstones, inflammatory strictures (scars), leaks (from trauma and surgery), and cancer. ERCP can be performed for diagnostic and therapeutic reasons, although the development of safer and relatively non-invasive investigations such as magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound has meant that ERCP is now rarely performed without therapeutic intent.

Endoscopic retrograde cholangiopancreatography

706

Diagnostic
Obstructive jaundice - This may be due to several causes Chronic pancreatitis - a now controversial indication due to widespread availability of safer diagnostic modalities including endoscopic ultrasound, high-resolution CT, and MRI/MRCP Gallstones with dilated bile ducts on ultrasonography Bile duct tumors Suspected injury to bile ducts either as a result of trauma or iatrogenic Sphincter of Oddi dysfunction Pancreatic tumors no longer represent a valid diagnostic indication for ERCP unless they cause bile duct obstruction and jaundice. Endoscopic ultrasound represents a safer and more accurate diagnostic alternative

Therapeutic
Any of the above when the following may become necessary Endoscopic sphincterotomy (both of the biliary and the pancreatic sphincters) Removal of stones Insertion of stent(s) Dilation of strictures (e.g. primary sclerosing cholangitis, anastomotic strictures after liver transplantation)

Fluoroscopic image of common bile duct stone seen at the time of ERCP. The stone is impacted in the distal common bile duct. A nasobiliary tube has been inserted.

Contraindications
Acute pancreatitis (unless persistently raised or worsening bilirubin suggests ongoing obstruction) Pancreatic pseudocyst Previous pancreatoduodenectomy Coagulation disorder Recent myocardial infarction Inadequate surgical back-up History of contrast dye anaphylaxis Poor health condition for surgery Severe cardiopulmonary disease

Fluoroscopic image showing dilatation of the pancreatic duct during ERCP investigation. Endoscope is visible.

Procedure
The patient is sedated or anaesthetized. Then a flexible camera (endoscope) is inserted through the mouth, down the esophagus, into the stomach, through the pylorus into the duodenum where the ampulla of Vater (the opening of the common bile duct and pancreatic duct) exists. The sphincter of Oddi is a muscular valve that controls the opening of the ampulla. The region can be directly visualized with the endoscopic camera while various procedures are performed. A plastic catheter or cannula is inserted through the ampulla, and radiocontrast is injected into the bile ducts and/or pancreatic duct. Fluoroscopy is used to look for blockages, or other lesions such as stones.

Endoscopic retrograde cholangiopancreatography When needed, the opening of the ampulla can be enlarged (sphincterotomy) with an electrified wire (sphincterotome) and access into the bile duct obtained so that gallstones may be removed or other therapy performed. Other procedures associated with ERCP include the trawling of the common bile duct with a basket or balloon to remove gallstones and the insertion of a plastic stent to assist the drainage of bile. Also, the pancreatic duct can be cannulated and stents be inserted. The pancreatic duct requires visualisation in cases of pancreatitis. In specific cases, a second camera can be inserted through the channel of the first endoscope. This is termed duodenoscope-assisted cholangiopancreatoscopy (DACP) or mother-daughter ERCP. The daughter scope can be used to administer direct electrohydraulic lithotripsy to break up stones, or to help in diagnosis by directly visualizing the duct (as opposed to obtaining X-ray images).[] The gallbladder should be surgically removed (cholecystectomy) following successful removal of gallstones from the bile ducts.[5]

707

Risks
The major risk of an ERCP is the development of pancreatitis, which can occur in up to 5% of all procedures. This may be self limited and mild, but may require hospitalization, and rarely, may be life-threatening. Patients at additional risk for pancreatitis are younger patients, patients with previous post-ERCP pancreatitis, females, procedures that involve cannulation or injection of the pancreatic duct, and patients with sphincter of Oddi dysfunction.[] Gut perforation is a risk of any endoscopic procedure, and is an additional risk if a sphincterotomy is performed. As the second part of the duodenum is anatomically in a retroperitoneal location (that is, behind the peritoneal structures of the abdomen), perforations due to sphincterotomies are also retroperitoneal. Sphincterotomy is also associated with a risk of bleeding.[] Oversedation can result in dangerously low blood pressure, respiratory depression, nausea, and vomiting. There is also a risk associated with the contrast dye in patients who are allergic to compounds containing iodine. Other complications (less than 1 per 100) may include; heart and lung problems, bleeding after sphincterotomy, infection in the bile duct (cholangitis) and perforation (a tear in the intestine). In some rare cases, ERCP can even cause fatal complications.[6]

References
[1] [2] [3] [4] http:/ / icd9cm. chrisendres. com/ index. php?srchtype=procs& srchtext=51. 10& Submit=Search& action=search http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2011/ MB_cgi?field=uid& term=D002760 http:/ / ops. icd-code. de/ ops/ code/ 1-642. html Adler DG, Baron TH, Davila RE, Egan J, Hirota WK, Leighton JA, Qureshi W, Rajan E, Zuckerman MJ, Fanelli R, Wheeler-Harbaugh J, Faigel DO; Standards of Practice Committee of American Society for Gastrointestinal Endoscopy. ASGE guideline: the role of ERCP in diseases of the biliary tract and the pancreas.Gastrointest Endosc. 2005 Jul;62(1):1-8.

External links
MedlinePlus Encyclopedia ERCP (http://www.nlm.nih.gov/medlineplus/ency/article/007479.htm) National Digestive Diseases Information Clearinghouse (http://digestive.niddk.nih.gov/ddiseases/pubs/ercp/ )

Employee Retirement Income Security Act

708

Employee Retirement Income Security Act


Employee Retirement Income Security Act

Long title Colloquial acronym(s) Enacted by the

An Act to provide for pension reform. ERISA 93rd United States Congress Citations

Public Law Stat.

Pub.L. 93406 88Stat.829 Legislative history [3] [2]

[1]

Introduced in the House as H.R. 2

[4]

by John Herman Dent (D-PA) on January 3, 1973

Committee consideration by: House Education and Labor Passed the House on February 28, 1974 (3764) Passed the Senate on March 4, 1974 () Reported by the joint conference committee on August 12, 1974; agreed to by the House on August 20, 1974 (4072) and by the Senate on August 22, 1974 (850) Signed into law by President Gerald Ford on September 2, 1974

The Employee Retirement Income Security Act of 1974 (ERISA) (Pub.L. 93406 [1], 88Stat.829 [2], enacted September2, 1974, codified in part at 29 U.S.C. ch. 18 [5]) is a federal law which establishes minimum standards for pension plans in private industry and provides for extensive rules on the federal income tax effects of transactions associated with employee benefit plans. ERISA was enacted to protect the interests of employee benefit plan participants and their beneficiaries by: Requiring the disclosure of financial and other information concerning the plan to beneficiaries; Establishing standards of conduct for plan fiduciaries; Providing for appropriate remedies and access to the federal courts. ERISA is sometimes used to refer to the full body of laws regulating employee benefit plans, which are found mainly in the Internal Revenue Code and ERISA itself. Responsibility for the interpretation and enforcement of ERISA is divided among the Department of Labor, the Department of the Treasury (particularly the Internal Revenue Service), and the Pension Benefit Guaranty Corporation.

Employee Retirement Income Security Act

709

History
In 1961, U.S. President John F. Kennedy created the President's Committee on Corporate Pension Plans. The movement for pension reform gained some momentum when the Studebaker Corporation, an automobile manufacturer, closed its plant in 1963. Its pension plan was so poorly funded that Studebaker could not afford to provide all employees with their pensions. The company created a program in which 3,600 workers who had reached the retirement age of 60 received full pension benefits, 4,000 workers aged 4059 who had ten years with Studebaker received lump sum payments valued at roughly 15% of the actuarial value of their pension benefits, and the remaining 2,900 workers received no pensions. In 1967, Senator Jacob K. Javits proposed legislation that would address the funding, vesting, reporting, and disclosure issues identified by the presidential committee. His bill was opposed by business groups and labor unions, which sought to retain the flexibility they enjoyed under pre-ERISA law. On September 12, 1972, NBC broadcast Pensions: The Broken Promise, an hour-long television special that showed millions of Americans the consequences of poorly funded pension plans and onerous vesting requirements. In the following years, Congress held a series of public hearings on pension issues and public support for pension reform grew significantly. ERISA was enacted in 1974 and signed into law by President Gerald Ford on September 2, 1974, Labor Day. In the years since 1974, ERISA has been amended repeatedly.

Coverage
Pension plans
ERISA does not require employers to establish pension plans. Likewise, as a general rule, it does not require that plans provide a minimum level of benefits. Instead, it regulates the operation of a pension plan once it has been established. Under ERISA, pension plans must provide for vesting of employees' pension benefits after a specified minimum number of years. ERISA requires that the employers who sponsor plans satisfy certain minimum funding requirements. ERISA also regulates the manner in which a pension plan may pay benefits. For example, a defined benefit plan must pay a married participant's pension as a "joint-and-survivor annuity" that provides continuing benefits to the surviving spouse unless both the participant and the spouse waive the survivor coverage. The Pension Benefit Guaranty Corporation was established by ERISA to provide coverage in the event that a terminated defined benefit pension plan does not have sufficient assets to provide the benefits earned by participants. Later amendments to ERISA require an employer who withdraws from participation in a multiemployer pension plan with insufficient assets to pay all participants' vested benefits to contribute the pro rata share of the plan's unfunded vested benefits liability. There are two main types of pension plans: defined benefit plans and defined contribution plans. Defined benefit plans provide retirees with a certain level of benefits based on years of service, salary and other factors. Defined contribution plans provide retirees with benefits based on the amount and investment performance of contributions made by the employee and/or employer over a number of years.[6]

Employee Retirement Income Security Act

710

Health benefit plans


ERISA does not require that an employer provide health insurance to its employees or retirees, but it regulates the operation of a health benefit plan if an employer chooses to establish one. There have been several significant amendments to ERISA concerning health benefit plans: The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) provides some employees and beneficiaries with the right to continue their coverage under an employer-sponsored group health benefit plan for a limited time after the occurrence of certain events that would otherwise cause termination of such coverage, such as the loss of employment. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) prohibits a health benefit plan from refusing to cover an employee's pre-existing medical conditions in some circumstances. It also bars health benefit plans from certain types of discrimination on the basis of health status, genetic information, or disability. Other relevant amendments to ERISA include the Newborns' and Mothers' Health Protection Act, the Mental Health Parity Act, and the Women's Health and Cancer Rights Act. During the 1990s and 2000s, many employers who promised lifetime health coverage to their retirees limited or eliminated those benefits.[7][8] ERISA does not provide for vesting of health care benefits in the way that employees become vested in their accrued pension benefits. Employees and retirees who were promised lifetime health coverage may be able to enforce those promises by suing the employer for breach of contract, or by challenging the right of the health benefit plan to change its plan documents in order to eliminate those promised benefits.

Pension vesting
Before ERISA, some defined benefit pension plans required decades of service before an employee's benefit became vested. It was not unusual for a plan to provide no benefit at all to an employee who left employment before the specified retirement age (e.g. 65), regardless of the length of the employee's service. Under the Pension Protection Act of 2006, employer contributions made after 2006 to a defined contribution plan must become vested at 100% after three years or under a 2nd-6th year gradual-vesting schedule (20% per year beginning with the second year of service, i.e. 100% after six years). (ref. 120 Stat. 988 of the Pension Protection Act of 2006.) The Technical Explanation of H.R.4, of the PPA, Page 156 Vesting Rules, states that the PPA amends both the ERISA and Code. Different rules apply with respect to employer contributions made before 2007. Employee contributions are always 100% vested. Accrued benefits under a defined benefit plan must become vested at 100% after five years or under a 3rd-7th year gradual vesting schedule (20% per year beginning with the third year of vesting service, and 100% after seven years). (ref. 26 U.S.C. 411(a)(1)(B), 29 U.S.C. 203(a)(2).)

Pension funding
Under ERISA, minimum funding requirements were established for defined benefit plans. By their nature, defined contribution plans are always fully funded, even if the employee has not yet become vested in the employer contributions. Before the Pension Protection Act of 2006 (PPA), a defined benefit plan maintained a "funding standard account", which was charged annually for the cost of benefits earned during the year and credited for employer contributions. Increases in the plan's liabilities due to benefit improvements, changes in actuarial assumptions, and any other reasons were amortized and charged to the account; decreases in the plan's liabilities were amortized and credited to the account. Every year, the employer was required to contribute the amount necessary to keep the funding standard account from falling below $0 at year-end. In 2008, when the PPA funding rules went into effect, single-employer pension plans no longer maintain funding standard accounts. The funding requirement under PPA is simply that a plan must stay fully funded (that is, its assets

Employee Retirement Income Security Act must equal or exceed its liabilities). If a plan is fully funded, the minimum required contribution is the cost of benefits earned during the year. If a plan is not fully funded, the contribution also includes the amount necessary to amortize over seven years the difference between its liabilities and its assets. Stricter rules apply to severely underfunded plans (called "at-risk status"). The PPA has different funding requirements for multiemployer pension plans, which preserve most of the pre-PPA funding rules including the funding standard account. Under PPA, increases and decreases in the plan's liabilities will be amortized, but the amortization period for benefit improvements adopted after 2007 will be shortened. As with single-employer plans, multiemployer pension plans that are significantly underfunded are subject to restrictions. The restrictions, which may limit the plan's ability to improve benefits or require the plan to reduce employees' benefits, vary depending whether a pension plan's funding status is termed "endangered", "seriously endangered", or "critical". The restrictions accompanying each deficient funding status are progressively more severe as funding status worsens.

711

ERISA pre-emption
ERISA Section 514 preempts all state laws that relate to any employee benefit plan, with certain, enumerated exceptions. The most important exceptions i.e. state laws that survive despite the fact that they may relate to an employee benefit plan are state insurance, banking, or securities laws, generally applicable criminal laws, and domestic relations orders that meet ERISA's qualification requirements. A major limitation is placed on the insurance exception, known as the "deemer clause", which essentially provides that state insurance law cannot operate on employer self-funded benefit plans. The Supreme Court has created another limitation on the insurance exception, in which even a law regulating insurance will be pre-empted if it purports to add a remedy to a participant or beneficiary in an employee benefit plan that ERISA did not explicitly provide. A three-part analysis is used to decide whether ERISA preempts state law. First, preemption is presumed if the state law relates to any employee benefit plan. Second, a state law relating to an employee benefit plan may be protected from preemption under ERISA if it regulates insurance, banking, or securities. The third step of the ERISA preemption analysis concerns the deemer clause. State insurance regulation may be saved only to the extent that it regulates genuine insurance companies or insurance contracts. As a result, a state may not deem an employee benefit plan to be an insurance plan in an effort to sidestep preemption if the benefit plan would not otherwise meet the requirements as an insurance company or contract. The deemer clause therefore restricts the use of the savings clause to conventionally insured employee benefit plans.[9] The result of ERISA preemption is that the only remedy available to a covered person who has been denied benefits or dropped from coverage altogether is to seek an order from a federal judge (no jury trial is permitted) directing the Plan (in actuality the insurance company that underwrites and administers it) to pay for "medically necessary" care. If a person dies before the case can be heard, however, the claim dies with him or her, since ERISA provides no remedy for injury or wrongful death caused by the withholding of care. Even if benefits are improperly denied, the insurance company cannot be sued for any resulting injury or wrongful death, regardless of whether it acted in bad faith in denying benefits. Insurers operating ERISA plans enjoy several immunities not available to other types of insurance companies. ERISA preempts all conflicting state laws, including state statutes prohibiting unfair claims practices and causes of action arising under state common law for insurance bad faith.[10] There is no right to a jury trial in ERISA benefits actions.[11] Although Americans normally take for granted the right to testify on their behalf, plaintiffs have no right to present live testimony in ERISA bench trials, in which the judge simply reads through the documents which formed the record originally before the ERISA plan administrator and performs de novo review.[12] Finally, punitive damages are not allowed in actions for ERISA benefits.[13]

Employee Retirement Income Security Act It has been argued that in the case of health benefits, the effect of all of this may paradoxically have been to leave plan participants worse off than if ERISA had not been enacted.[14] Many persons included among the some 47 million people presently without health care coverage in the United States are former ERISA "subscribers", insurance terminology for Plan beneficiaries, who have been denied benefits-usually on the ground that the prescribed care is not medically necessary or is "experimental"-or dropped from coverage, often because they have lost their jobs due to the very illness for which care was denied.[citation
needed]

712

Many consumer and health care advocates have called for a "restoration of the freedom of contract enforcement," to the 75% of Americans insured under these work place group plans-in effect, a repeal of the ERISA pre-emption. Permitting these insured persons access to customary state remedies (98% of all civil disputes are resolved in state courts) would, they contend, result in a substantial reduction in arbitrary denial of care benefits, simultaneously alleviating a major burden on state Medicaid systems and clogged federal court dockets.[citation needed]

Hawaii Prepaid Health Care Act exemption


ERISA contains an exemption specifically regarding the Hawaii Prepaid Health Care Act (Hawaii Revised Statutes Chapter 393), which was enacted by that state a few months before ERISA was signed into law. As a result, private employers in Hawaii are bound by the rules of that state law in addition to ERISA. The exemption also freezes the law in its original 1974 form, meaning the Hawaii legislature is not able to make non-administrative amendments without Congressional approval.[15][16]

The Statute
Title I: Protection of Employee Benefit Rights
Title I protects employees' rights to their benefits. The following are some of the ways in which it achieves that goal: Participants must be provided plan summaries. Employers are required to report information about the plan to the Labor Department and provide it to participants upon request. The information is reported on Form 5500, which is available for public inspection. If a participant requests, the employer must provide the participant with a calculation of her or his accrued and vested pension benefits. Employers have fiduciary responsibility to the participants and to the plan. Certain service providers, such as investment managers, have fiduciary responsibilities to the plan.[17] Certain transactions between the employer and the plan are prohibited. Certain transactions between fiduciary and the plan, or between the plan and certain "parties in interest" are prohibited (unless otherwise exempt).[18] A pension plan is barred from investing more than 10% of its assets in employer securities. Title I also includes the pension funding and vesting rules described above. The United States Department of Labor's Employee Benefits Security Administration ("EBSA") is responsible for overseeing Title I, promulgating regulations implementing and interpreting the statute as well as conducting enforcement. Plan fiduciaries and plan participants may also bring certain civil causes of action in Federal Court. The current Assistant Secretary of Labor for Employee Benefits and head of the Employee Benefits Security Administration is the Hon. Phyllis Borzi, who was confirmed on July 10, 2009[19]. Past Assistant Secretaries include the Hon. Bradford P. Campbell, the Hon. Ann L. Combs and the Hon. Olena Berg-Lacy.

Employee Retirement Income Security Act

713

Title II: Amendments to the Internal Revenue Code Relating to Retirement Plans
Title II amended the Internal Revenue Code (IRC). The changes include the following: The addition of various requirements for a pension plan to be tax-favored ("qualified"), including: the plan must offer retirees the option of a joint-and-survivor annuity, benefits under the plan may not discriminate in favor of officers and highly paid employees, and plans are subject to the pension funding and vesting rules described above. The imposition of maximum limits on the annual benefit that may be paid from a qualified defined benefit pension plan and the annual contribution that may be made to a qualified defined contribution pension plan. The creation of individual retirement accounts (IRAs). Revision of the rules concerning the maximum tax deduction allowed with respect to a contribution to a pension plan. The imposition of an excise tax if the employer fails to make a required contribution to a pension plan or engages in transactions prohibited by ERISA.

Title III: Jurisdiction, Administration, Enforcement; Joint Pension Task Force, Etc.
Title III outlines procedures for co-ordination between the Labor and Treasury Departments in enforcing ERISA. It also created the Joint Board for the Enrollment of Actuaries, which licenses actuaries to perform a variety of actuarial tasks required of pension plans under ERISA. The Joint Board administers two examinations to prospective Enrolled Actuaries. After an individual passes the two exams and completes sufficient relevant professional experience, she or he becomes an Enrolled Actuary.

Title IV: Plan Termination Insurance


Title IV created the Pension Benefit Guaranty Corporation (PBGC) to insure benefits of participants in underfunded terminated plans. It also describes the procedures that a pension plan must follow in order to terminate. Single-employer plans Standard termination An employer may terminate a single-employer plan under a standard termination if the plan's assets equal or exceed its liabilities. If the assets are less than the liabilities, the employer must contribute the amount necessary to fully fund the plan. A standard termination is sometimes referred to as a voluntary termination because the employer has chosen to terminate the plan. In a standard termination, all accrued benefits under the plan become 100% vested. The plan must purchase annuity contracts for all participants. If the plan permits the payment of lump sums, employees may be offered the choice of a lump sum payment or an annuity. If any assets remain in the plan after a standard termination has been completed, the provisions of the plan control their treatment. In some plans, the excess assets revert to the employer; in other plans, the excess assets must be used to increase participants' benefits.

Employee Retirement Income Security Act Distress termination An employer may terminate a single-employer plan under a distress termination if the employer demonstrates to the PBGC that: the employer is facing liquidation under bankruptcy proceedings, the costs of continuing the plan will cause the business to fail, or the costs of continuing the plan have become unreasonably burdensome solely because of a decline in the employer's workforce. If the PBGC finds that a distress termination is appropriate, the plan's liabilities are calculated and compared with its assets. Depending on the difference between the two values, the termination may be treated as if it had been a standard termination or as if it had been initiated by the PBGC. Termination initiated by the PBGC PBGC may initiate proceedings to terminate a single-employer plan if it determines that: the employer has not made its minimum required contributions to the plan, the plan will not be able to pay benefits when due, or PBGC's long-term cost can be expected to be unreasonably higher if it does not terminate the plan. A termination initiated by the PBGC is sometimes called an involuntary termination. The benefits paid by the PBGC after a plan termination may be less than those promised by the employer. See Pension Benefit Guaranty Corporation for details. Multiemployer plans A multiemployer plan may be terminated in one of three ways: It may be amended so that participants receive no credit for future service, All contributing employers may withdraw from the plan or stop making contributions to it, or It may be converted into a defined contribution plan.

714

Non-ERISA status and bankruptcy


In 2005, Public Law 109-8 [20] amended the Bankruptcy Code, by exempting most organized retirement plans, even those not subject to ERISA, and accorded them protected status, claimable as exempt property by a debtor declaring bankruptcy under the U.S. Bankruptcy Code. Now, most pension plans have the same protection as an ERISA anti-alienation clause giving these pensions the same protection as a spendthrift trust. The only remaining unprotected areas are the SIMPLE IRA and the SEP IRA. The SEP IRA is functionally similar to a self-settle trust, and a sound policy reason would exist to not shield SEP IRAs, but many financial planners argue that a rollover (or direct transfer) from a SEP IRA to a rollover IRA would give those funds protected status, too.

Employee Retirement Income Security Act

715

Finding statutes
Portions of ERISA are codified in various places of the United States Code, including 29 U.S.C. ch. 18 [5], and Internal Revenue Code sections 219 [21] and 408 [22] (relating to the Individual Retirement Account) and sections 410 [23] through 415 [24], and 4971 [25], 4974 [26] and 4975 [27]. A cross-reference between the sections of the ERISA law and the corresponding sections in the U.S.Code can be found at http:/ / www. harp. org/ erisaxref. htm.

References
[1] http:/ / www. law. cornell. edu/ jureeka/ index. php?doc=USPubLaws& cong=93& no=406 [2] http:/ / www. gpo. gov/ fdsys/ granule/ STATUTE-88/ STATUTE-88-Pg829/ content-detail. html [3] http:/ / thomas. loc. gov/ cgi-bin/ bdquery/ z?d093:HR00002:@@@S [4] http:/ / hdl. loc. gov/ loc. uscongress/ legislation. 93hr2 [5] http:/ / www. law. cornell. edu/ uscode/ text/ 29/ chapter-18 [6] Lemke and Lins, ERISA for Money Managers 1:1 (Thomson West, 2013). [10] Kidneigh v. UNUM Life Ins. Co. of Am., 345 F.3d 1182, 1184 (10th Cir. 2003); Bast v. Prudential Life Ins. Co. of Am., 150 F.2d 1003 (9th Cir. 1998); Kanne v. Connecticut Gen. Life Ins., 867 F.2d 489, 492 (9th Cir. 1988). [11] Thomas v. Oregon Fruit Prods. Co., 228 F.3d 991, 996-97 (9th Cir. 2000) (listing cases and joining their holding). [12] Kearney v. Standard Ins. Co., 175 F.3d 1084, 1094-1095 (9th Cir. 1999) (en banc). [13] Varhola v. Doe, 820 F.2d 809, 812-13 (6th Cir. 1987). [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] Lemke and Lins, ERISA for Money Managers 1:2 to 1:4 (Thomson West, 2013). Lemke and Lins, ERISA for Money Managers 1:3, 1:5 (Thomson West, 2013). http:/ / www. dol. gov/ ebsa/ aboutebsa/ org_chart. html http:/ / www. ll. georgetown. edu/ guides/ bankruptcy_act_2005. cfm http:/ / www. law. cornell. edu/ uscode/ 26/ 219. html http:/ / www. law. cornell. edu/ uscode/ 26/ 408. html http:/ / www. law. cornell. edu/ uscode/ 26/ 410. html http:/ / www. law. cornell. edu/ uscode/ 26/ 415. html http:/ / www. law. cornell. edu/ uscode/ 26/ 4971. html http:/ / www. law. cornell. edu/ uscode/ 26/ 4974. html http:/ / www. law. cornell. edu/ uscode/ 26/ 4975. html

External links
Department of Labor 2003 "interpretive bulletin," Field Assistance Bulletin 2003-3 (http://www.dol.gov/ebsa/ regs/fab_2003-3.html), May 19, 2003, concerning allocation of expenses in a defined contribution plan. Guide to ERISA rights (http://www.dol.gov/dol/topic/health-plans/erisa.htm) from the United States Department of Labor LA Times, 21 August 2005, Frequently Asked Questions, ERISA-Governed Disability Claims (http://mckuinlaw.com/FAQs-Page-1. html) "The Safety Net She Believed In Was Pulled Away When She Fell" (http://www.latimes.com/business/ la-na-disability21aug21,1,1759254.story?coll=la-util-nationworld-nation&ctrack=1&cset=true) (registration required) Text of the Employee Retirement Income Security Act - 29 U.S. Code Chapter 18 (http://finduslaw.com/ employee_retirement_income_security_act_erisa_29_u_s_code_chapter_18) List of provision numbers in the original Act, and destinations in the US Code (http://benefitslink.com/erisa/ crossreference_short.html)

End stage renal disease

716

End stage renal disease


End stage renal disease may refer to: End-stage renal disease, is also known as chronic kidney disease (CKD), specifically the fifth stage of CKD End Stage Renal Disease (US Federal Program), a type of federal insurance in the United States that covers people who require dialysis or renal transplant __DISAMBIG__

Federation of American Hospitals


The Federation of American Hospitals is a trade association for investor-owned hospitals in the United States. It is based in Washington D.C. It is currently headed by "Chip" Kahn.[1]

References External links


Home Page (http://www.fah.org/fahCMS/home.aspx)

Food and Drug Administration

717

Food and Drug Administration


Food and Drug Administration

Agency overview Formed 1906


[1]

Preceding agencies Food, Drug, and Insecticide Administration (July1927 to July1930) Bureau of Chemistry, USDA (July1901 through July1927) Division of Chemistry, USDA (established 1862) Jurisdiction Headquarters Federal government of the United States White Oak Campus, 10903 New Hampshire Avenue, Silver Spring, Maryland20993 [2] 390207N 765859W 9,300 (2008) $4.36billion(2012)
[] [3]

Employees Annual budget Agency executive Parent Agency Child agencies

Margaret Hamburg, Commissioner of Food and Drugs Department of Health and Human Services Center for Biologics Evaluation and Research Center for Devices and Radiological Health Center for Drug Evaluation and Research Center for Food Safety and Applied Nutrition Center for Tobacco Products Center for Veterinary Medicine National Center for Toxicological Research Office of Criminal Investigations Office of Regulatory Affairs Website www.fda.gov
[4]

The Food and Drug Administration (FDA or USFDA) is an agency of the United States Department of Health and Human Services, one of the United States federal executive departments. The FDA is responsible for protecting and promoting public health through the regulation and supervision of food safety, tobacco products, dietary supplements, prescription and over-the-counter pharmaceutical drugs (medications), vaccines, biopharmaceuticals, blood transfusions, medical devices, electromagnetic radiation emitting devices (ERED), and veterinary products. The FDA also enforces other laws, notably Section 361 of the Public Health Service Act and associated regulations, many of which are not directly related to food or drugs. These include sanitation requirements on interstate travel and control of disease on products ranging from certain household pets to sperm donation for assisted reproduction. The FDA is led by the Commissioner of Food and Drugs, appointed by the President with the advice and consent of the Senate. The Commissioner reports to the Secretary of Health and Human Services. The 21st and current Commissioner is Dr. Margaret A. Hamburg. She has served as Commissioner since May 2009.

Food and Drug Administration The FDA has its headquarters in unincorporated White Oak, Maryland.[] The agency also has 223 field offices and 13laboratories located throughout the 50states, the United States Virgin Islands, and Puerto Rico.[] In 2008, the FDA started opening offices in foreign countries, including China, India, Costa Rica, Chile, Belgium, and the United Kingdom.[5] In June 1906, President Theodore Roosevelt signed into law the Food and Drug Act, also known as the "Wiley Act" after its chief advocate Dr. Harvey Washington Wiley who riveted the country's and eventually congress's attention with public hygiene demonstrations. This act was the basis for the modern USFDA, being originally given the name of the Food, Drug, and Insecticide organization. The name eventually was shortened to the Food and Drug Administration (FDA) a few years later.

718

Organization
The FDA comprises several offices and centers: Office of the Commissioner Center for Biologics Evaluation and Research Center for Devices and Radiological Health (CDRH) Office of the Center Director Office of Communication, Education, and Radiation Programs Office of Compliance Office of Device Evaluation Office of In Vitro Diagnostic Device Evaluation and Safety Office of Management Operations Office of Science and Engineering Laboratories Office of Surveillance and Biometrics Center for Drug Evaluation and Research (CDER) Office of the Center Director Advisory Committee Staff Controlled Substance Staff Uncontrolled regulations Office of Compliance Division of Compliance Risk Management and Surveillance Division of Manufacturing and Product Quality Division of New Drugs and Labeling Compliance Division of Scientific Investigations Office of Medical Policy Office of Prescription Drug Promotion Office of New Drugs Office of Nonprescription Products Office of Oncology Drug Products

Radioactive Drug Research Committee (RDRC) Program Office of Pharmaceutical Science Office of Biotechnology Products Office of Generic Drugs Office of New Drugs Quality Assessment Office of Testing and Research Division of Applied Pharmacology Research

Food and Drug Administration Division of Pharmaceutical Analysis Division of Product Quality Research Informatics and Computational Safety Analysis Staff (ICSAS) Office of Surveillance and Epidemiology (formerly Office of Drug Safety) Office of Translational Sciences Office of Biostatistics Office of Clinical Pharmacology Pharmacometrics Staff Division of Drug Information FDA Pharmacy Student Experiential Program Botanical Review Team Maternal Health Team Center for Food Safety and Applied Nutrition Center for Tobacco Products Center for Veterinary Medicine National Center for Toxicological Research Office of Regulatory Affairs

719

In recent years, the agency began undertaking a large-scale effort to consolidate its operations in the Washington Metropolitan Area from its main headquarters in Rockville and several fragmented office buildings in the vicinity to the former site of the Naval Ordnance Laboratory in the White Oak area of Silver Spring, Maryland.[][6] When the FDA arrived, the site was renamed from the White Oak Naval Surface Warfare Center to the Federal Research Center at White Oak. The first building, the Life Sciences Laboratory, was dedicated and opened with 104 employees on the campus in December 2003. The project is slated to be completed by 2014. While most of the Centers are located around the Washington, D.C., area as part of the Headquarters divisions, two offices the Office of Regulatory Affairs (ORA) and the Office of Criminal Investigations (OCI) are primarily field offices with a workforce spread across the country. The Office of Regulatory Affairs is considered the "eyes and ears" of the agency, conducting the vast majority of the FDA's work in the field. Consumer Safety Officers, more commonly called Investigators, are the individuals who inspect production and warehousing facilities, investigate complaints, illnesses, or outbreaks, and review documentation in the case of medical devices, drugs, biological products, and other items where it may be difficult to conduct a physical examination or take a physical sample of the product. The Office of Regulatory Affairs is divided into five regions, which are further divided into 13 districts. Districts are based roughly on the geographic divisions of the federal court system. Each district comprises a main district office, and a number of Resident Posts, which are FDA offices located away from the district office to serve a particular geographic area. ORA also includes the Agency's network of laboratories, which analyze any physical samples taken. Though samples are usually food-related, some laboratories are equipped to analyze drugs, cosmetics, and radiation-emitting devices. The Office of Criminal Investigations was established in 1991 to investigate criminal cases. Unlike ORA Investigators, OCI Special Agents are armed, and are not focused on the technical aspects of the regulated industries. OCI agents pursue and develop cases where criminal actions have occurred, such as fraudulent claims, or knowingly and willfully shipping known adulterated goods in interstate commerce. In many cases, OCI will pursue cases where Title 18 violations have occurred (e.g. conspiracy, false statements, wire fraud, mail fraud), in addition to prohibited acts as defined in Chapter III of the FD&C Act. OCI Special Agents often come from other criminal investigations backgrounds, and work closely with the Federal Bureau of Investigation, Assistant Attorney General, and even Interpol. OCI will receive cases from a variety of sources, including ORA, local agencies, and the FBI, and will work with ORA investigators to help develop the technical and science-based aspects of a case. OCI is a smaller branch, comprising about 200 agents nationwide.

Food and Drug Administration The FDA frequently works in conjunction with other federal agencies including the Department of Agriculture, Drug Enforcement Administration, Customs and Border Protection, and Consumer Product Safety Commission. Often local and state government agencies also work in cooperation with the FDA to provide regulatory inspections and enforcement action.

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Scope and funding


The FDA regulates more than $1 trillion worth of consumer goods, about 25% of consumer expenditures in the United States. This includes $466 billion in food sales, $275 billion in drugs, $60 billion in cosmetics and $18 billion in vitamin supplements. Much of the expenditures is for goods imported into the United States; the FDA is responsible for monitoring a third of all imports.[] The FDA's federal budget request for fiscal year (FY) 2012 totaled $4.36 billion.[] About $2 billion of this budget is generated by user fees. Pharmaceutical firms pay the majority of these fees, which are used to expedite drug reviews.[] The FDA's federal budget request for fiscal year (FY) 2008 (October 2007 through September 2008) totaled $2.1 billion, a $105.8 million increase from what it received for fiscal year 2007.[7] In February 2008, the FDA announced that the Bush Administration's FY 2009 budget request for the agency was just under $2.4 billion: $1.77 billion in budget authority (federal funding) and $628 million in user fees. The requested budget authority was an increase of $50.7 million more than the FY 2008 funding about a three percent increase. In June 2008, Congress gave the agency an emergency appropriation of $150 million for FY 2008 and another $150 million.[] Most federal laws concerning the FDA are part of the Food, Drug and Cosmetic Act,[8] (first passed in 1938 and extensively amended since) and are codified in Title 21, Chapter 9 of the United States Code. Other significant laws enforced by the FDA include the Public Health Service Act, parts of the Controlled Substances Act, the Federal Anti-Tampering Act, as well as many others. In many cases these responsibilities are shared with other federal agencies.

Regulatory programs

Regulation of therapeutic goods in the United States

Prescription drugs Over-the-counter drugs

The programs for safety regulation vary widely by the type of product, its potential risks, and the regulatory powers granted to the agency. For example, the FDA regulates almost every facet of prescription drugs, including testing, manufacturing, labeling, advertising, marketing, efficacy and safety, yet FDA regulation of cosmetics is focused

Food and Drug Administration primarily on labeling and safety. The FDA regulates most products with a set of published standards enforced by a modest number of facility inspections. Inspection observations are documented on Form 483.

721

Canada-United States Regulatory Cooperation Council (RCC) (2011)


On February 4, 2011, Canadian Prime Minister Harper and United States President Obama issued a "Declaration on a Shared Vision for Perimeter Security and Economic Competitiveness"[9][10] and announced the creation of the Canada-United States Regulatory Cooperation Council (RCC) "to increase regulatory transparency and coordination between the two countries." [] Health Canada and the United States Food and Drug Administration (FDA) under the RCC mandate, undertook the "first of its kind" initiative by selecting "as its first area of alignment common cold indications for certain over-the-counter antihistamine ingredients (GC 2013-01-10)." []

Food and dietary supplements


The Center for Food Safety and Applied Nutrition is the branch of the FDA that is responsible for ensuring the safety and accurate labeling of nearly all food products in the United States.[11] One exception is meat products derived from traditional domesticated animals, such as cattle and chickens, which fall under the jurisdiction of the United States Department of Agriculture Food Safety and Inspection Service.[12] Products that contain minimal amounts of meat are regulated by FDA, and the exact boundaries are listed in a memorandum of understanding between the two agencies. However, medicines and other products given to all domesticated animals are regulated by the FDA through a different branch, the Center for Veterinary Medicine. Other consumables that are not regulated by the FDA include beverages containing more than 7% alcohol (regulated by the Bureau of Alcohol, Tobacco, Firearms and Explosives in the Department of Justice), and non-bottled drinking water (regulated by the United States Environmental Protection Agency (EPA)). CFSAN's activities include establishing and maintaining food standards, such as standards of identity (for example, what the requirements are for a product to be labeled, "yogurt") and standards of maximum acceptable contamination. CFSAN also sets the requirements for nutrition labeling of most foods. Both food standards and nutrition labeling requirements are part of the Code of Federal Regulations. The Dietary Supplement Health and Education Act of 1994 mandated that the FDA regulate dietary supplements as foods, rather than as drugs. Therefore, dietary supplements are not subject to safety and efficacy testing and there are no approval requirements. The FDA can take action against dietary supplements only after they are proven to be unsafe. Manufacturers of dietary supplements are permitted to make specific claims of health benefits, referred to as "structure or function claims" on the labels of these products. They may not claim to treat, diagnose, cure, or prevent disease and must include a disclaimer on the label.[13] Bottled water is regulated in America by the FDA.[14] State governments also regulate bottled water. Tap water is regulated by state and local regulations, as well as the United States EPA. FDA regulations of bottled water generally follow the guidelines established by the EPA, and new EPA rules automatically apply to bottled water if the FDA does not release an explicit new rule.[15] Federal bottled water regulations have been criticized as weaker than the tap water regulations facing city water supplies.[16]

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Drugs
The Center for Drug Evaluation and Research has different requirements for the three main types of drug products: new drugs, generic drugs and over-the-counter drugs. A drug is considered "new" if it is made by a different manufacturer, uses different excipients or inactive ingredients, is used for a different purpose, or undergoes any substantial change. The most rigorous requirements apply to "new molecular entities": drugs that are not based on existing medications. New drugs New drugs receive extensive scrutiny before FDA approval in a process called a New Drug Application (NDA).[17] New drugs are available only by prescription by default. A change to over-the-counter (OTC) status is a separate process, and the drug must be approved through an NDA first. A drug that is approved is said to be "safe and effective when used as directed." Advertising and promotion The FDA's Office of Prescription Drug Promotion reviews and regulates prescription drug advertising and promotion through surveillance activities and issuance of enforcement letters to pharmaceutical manufacturers. Advertising and promotion for over-the-counter drugs is regulated by the Federal Trade Commission. The drug advertising regulation[18] contains two broad requirements: (1) a company may advertise or promote a drug only for the specific indication or medical use for which it was approved by FDA. Also, an advertisement must contain a "fair balance" between the benefits and the risks (side effects) of a drug. The term off-label refers to drug usage for indications other than those approved by the FDA. Postmarket safety surveillance After approval of an NDA, the sponsor must review and report to the FDA every patient adverse drug experience of which it learns. Unexpected serious and fatal adverse drug events must be reported within 15 days, and other events on a quarterly basis.[19] The FDA also receives directly adverse drug event reports through its MedWatch program.[20] These reports are called "spontaneous reports" because reporting by consumers and health professionals is voluntary. While this remains the primary tool of postmarket safety surveillance, FDA requirements for postmarketing risk management are increasing. As a condition of approval, a sponsor may be required to conduct additional clinical trials, called Phase IV trials. In some cases, the FDA requires risk management plans for some drugs that may provide for other kinds of studies, restrictions, or safety surveillance activities. Generic drugs Generic drugs are chemical equivalents of name-brand drugs whose patents have expired.[21] In general, they are less expensive than their name brand counterparts, are manufactured and marketed by other companies and, in the 1990s, accounted for about a third of all prescriptions written in the United States.[21] For approval of a generic drug, the U.S. Food and Drug Administration (FDA) requires scientific evidence that the generic drug is interchangeable with or therapeutically equivalent to the originally approved drug.[] This is called an "ANDA" (Abbreviated New Drug Application). Generic drug scandal In 1989, a major scandal erupted involving the procedures used by the FDA to approve generic drugs for sale to the public.[21] Charges of corruption in generic drug approval first emerged in 1988, in the course of an extensive congressional investigation into the FDA. The oversight subcommitee of the United States House Energy and Commerce Committee resulted from a complaint brought against the FDA by Mylan Laboratories Inc. of Pittsburgh. When its application to manufacture generics were subjected to repeated delays by the FDA, Mylan, convinced that it was being discriminated against, soon began its own private investigation of the agency in 1987. Mylan eventually

Food and Drug Administration filed suit against two former FDA employees and four drug-manufacturing companies, charging that corruption within the federal agency resulted in racketeering and in violations of antitrust law. "The order in which new generic drugs were approved was set by the FDA employees even before drug manufacturers submitted applications" and, according to Mylan, this illegal procedure was followed to give preferential treatment to certain companies. During the summer of 1989, three FDA officials (Charles Y. Chang, David J. Brancato, Walter Kletch) pleaded guilty to criminal charges of accepting bribes from generic drugs makers, and two companies (Par Pharmaceutical and its subsidiary Quad Pharmaceuticals)[22] pleaded guilty to giving bribes. Furthermore, it was discovered that several manufacturers had falsified data submitted in seeking FDA authorization to market certain generic drugs. Vitarine Pharmaceuticals of New York, which sought approval of a generic version of the drug Dyazide, a medication for high blood pressure, submitted Dyazide, rather than its generic version, for the FDA tests. In April 1989, the FDA investigated 11 manufacturers for irregularities; and later brought that number up to 13. Dozens of drugs were eventually suspended or recalled by manufacturers. In the early 1990s, the U.S. Securities and Exchange Commission filed "securities fraud charges against the Bolar Pharmaceutical Company, a major generic manufacturer based in Long Island, New York.[21] Over-the-counter drugs Over-the-counter (OTC) drugs are drugs and combinations that do not require a doctor's prescription.[23] The FDA has a list of approximately 800 approved ingredients that are combined in various ways to create more than 100,000 OTC drug products. Many OTC drug ingredients had been previously approved prescription drugs now deemed safe enough for use without a medical practitioner's supervision.[24]

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Vaccines, blood and tissue products, and biotechnology


The Center for Biologics Evaluation and Research is the branch of the FDA responsible for ensuring the safety and efficacy of biological therapeutic agents.[25] These include blood and blood products, vaccines, allergenics, cell and tissue-based products, and gene therapy products. New biologics are required to go through a premarket approval process called a Biologics License Application (BLA), similar to that for drugs. The original authority for government regulation of biological products was established by the 1902 Biologics Control Act, with additional authority established by the 1944 Public Health Service Act. Along with these Acts, the Federal Food, Drug, and Cosmetic Act applies to all biologic products, as well. Originally, the entity responsible for regulation of biological products resided under the National Institutes of Health; this authority was transferred to the FDA in 1972.

Medical and radiation-emitting devices


The Center for Devices and Radiological Health (CDRH) is the branch of the FDA responsible for the premarket approval of all medical devices, as well as overseeing the manufacturing, performance and safety of these devices.[26] The definition of a medical device is given in the FD&C Act, and it includes products from the simple toothbrush to complex devices such as implantable brain pacemakers. CDRH also oversees the safety performance of non-medical devices that emit certain types of electromagnetic radiation. Examples of CDRH-regulated devices include cellular phones, airport baggage screening equipment, television receivers, microwave ovens, tanning booths, and laser products. CDRH regulatory powers include the authority to require certain technical reports from the manufacturers or importers of regulated products, to require that radiation-emitting products meet mandatory safety performance standards, to declare regulated products defective, and to order the recall of defective or noncompliant products. CDRH also conducts limited amounts of direct product testing.

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FDA-Cleared vs FDA-Approved
Clearance requests are for medical devices that prove they are "substantially equivalent" to the predicate devices already on the market. Approved requests are for items that are new or substantially different and need to demonstrate "safety and efficacy", for example it may be inspected for safety in case of new toxic hazards. Both aspects need to be proved or provided by the submitter to ensure proper procedures are followed.[27]

Cosmetics
Cosmetics are regulated by the Center for Food Safety and Applied Nutrition, the same branch of the FDA that regulates food. Cosmetic products are not in general subject to premarket approval by the FDA unless they make "structure or function claims", which make them into drugs (see Cosmeceutical). However, all color additives must be specifically approved by the FDA before they can be included in cosmetic products sold in the U.S. The labeling of cosmetics is regulated by the FDA, and cosmetics that have not been subjected to thorough safety testing must bear a warning to that effect.

Cosmetic products
Though the cosmetic industry is predominantly responsible in ensuring the safety of its products, the FDA also has the power to intervene when necessary to protect the public but in general does not require pre-market approval or testing. Companies are required to place a warning note on their products if they have not been tested. Experts in cosmetic ingredient reviews also play a role in monitoring safety through influence on the use of ingredients, but also lack legal authority. Overall the organization has reviewed about 1,200 ingredients and has suggested that several hundred be restricted, but there is no standard or systemic method for reviewing chemicals for safety and a clear definition of what is meant by 'safety' so that all chemicals are tested on the same basis.[28]

Veterinary products
The Center for Veterinary Medicine (CVM) is the branch of the FDA that regulates food, food additives, and drugs that are given to animals, including food animals and pets. CVM does not regulate vaccines for animals; these are handled by the United States Department of Agriculture. [citation needed] CVM's primary focus is on medications that are used in food animals and ensuring that they do not affect the human food supply. The FDA's requirements to prevent the spread of bovine spongiform encephalopathy are also administered by CVM through inspections of feed manufacturers. [citation needed]

Tobacco products
Since the Family Smoking Prevention and Tobacco Control Act became law in 2009, the FDA also has had the authority to regulate tobacco products.[29] In 2009, Congress passed a law requiring color warnings on cigarette packages and on printed advertising, in addition to text warnings from the U.S. Surgeon General.[30] The nine new graphic warning labels were announced by the FDA in June 2011 and were scheduled to be required to appear on packaging by September 2012. The implementation date is uncertain, due to ongoing proceedings in the case of R.J. Reynolds Tobacco Co. v. U.S. Food and Drug Administration.[31] R.J. Reynolds, Lorillard, Commonwealth Brands Inc., Liggett Group LLC and Santa Fe Natural Tobacco Company Inc. have filed suit in Washington, D.C. federal court claiming that the graphic labels are an unconstitutional way of forcing tobacco companies to engage in anti-smoking advocacy on the government's behalf.[32] A First Amendment lawyer, Floyd Abrams, is representing the tobacco companies in the case, contending requiring graphic warning labels on a lawful product cannot withstand constitutional scrutiny.[33] The Association of National Advertisers and the American Advertising Federation have also filed a brief in the suit, arguing that the labels infringe on commercial free speech

Food and Drug Administration and could lead to further government intrusion if left unchallenged.[34] In November 2011, Federal judge Richard Leon of the U.S. District Court for the District of Columbia temporarily halted the new labels, likely delaying the requirement that tobacco companies display the labels. The U.S. Supreme Court ultimately could decide the matter.[35]

725

Regulation of living organisms


With acceptance of premarket notification 510(k) k033391 in January 2004, the FDA granted Dr. Ronald Sherman permission to produce and market medical maggots for use in humans or other animals as a prescription medical device. Medical maggots represent the first living organism allowed by the Food and Drug Administration for production and marketing as a prescription medical device. In June 2004, the FDA cleared Hirudo medicinalis (medicinal leeches) as the second living organism to be used as a medical devices.

Science and research programs


In addition to its regulatory functions, the FDA carries out research and development activities to develop technology and standards that support its regulatory role, with the objective of resolving scientific and technical challenges before they become impediments. The FDA's research efforts include the areas of biologics, medical devices, drugs, women's health, toxicology, food safety and applied nutrition, and veterinary medicine.[36]

History
Up until the 20th century, there were few federal laws regulating the contents and sale of domestically produced food and pharmaceuticals, with one exception being the short-lived Vaccine Act of 1813. The history of the FDA can be traced to the latter part of the 19th century and the U.S. Department of Agriculture's Division of Chemistry (later Bureau of Chemistry). Under Harvey Washington Wiley, appointed chief chemist in 1883, the Division began conducting research into the adulteration and misbranding of food and drugs on the American market. Wiley's advocacy came at a time when the public had become aroused to hazards in the marketplace by muckraking journalists like Upton Sinclair, and became part of a general trend for increased federal regulations in matters pertinent to public safety during the Progressive Era.[37] The 1902 Biologics Control Act was put in place after diphtheria antitoxin was collected from a horse named Jim who contracted tetanus, resulting in several deaths. In June 1906, President Theodore Roosevelt signed into law the Food and Drug Act, also known as the "Wiley Act" after its chief advocate.[37] The Act prohibited, under penalty of seizure of goods, the interstate transport of food that had been "adulterated". The act applied similar penalties to the interstate marketing of "adulterated" drugs, in which the "standard of strength, quality, or purity" of the active ingredient was not either stated clearly on the label or listed in the United States Pharmacopoeia or the National Formulary.[38] The responsibility for examining food and drugs for such "adulteration" or "misbranding" was given to Wiley's USDA Bureau of Chemistry.[37] Wiley used these new regulatory powers to pursue an aggressive campaign against the manufacturers of foods with chemical additives, but the Chemistry Bureau's authority was soon checked by judicial decisions, which narrowly defined the bureau's powers and set high standards for proof of fraudulent intent.[37] In 1927, the Bureau of Chemistry's regulatory powers were reorganized under a new USDA body, the Food, Drug, and Insecticide organization. This name was shortened to the Food and Drug Administration (FDA) three years later.[39] By the 1930s, muckraking journalists, consumer protection organizations, and federal regulators began mounting a campaign for stronger regulatory authority by publicizing a list of injurious products that had been ruled permissible under the 1906 law, including radioactive beverages, the mascara Lash lure, which caused blindness, and worthless "cures" for diabetes and tuberculosis. The resulting proposed law was unable to get through the Congress of the United States for five years, but was rapidly enacted into law following the public outcry over the 1937 Elixir

Food and Drug Administration Sulfanilamide tragedy, in which over 100 people died after using a drug formulated with a toxic, untested solvent.[40] President Franklin Delano Roosevelt signed the new Food, Drug, and Cosmetic Act (FD&C Act) into law on June 24, 1938. The new law significantly increased federal regulatory authority over drugs by mandating a pre-market review of the safety of all new drugs, as well as banning false therapeutic claims in drug labeling without requiring that the FDA prove fraudulent intent. Soon after passage of the 1938 Act, the FDA began to designate certain drugs as safe for use only under the supervision of a medical professional, and the category of "prescription-only" drugs was securely codified into law by the 1951 Durham-Humphrey Amendment. These developments confirmed extensive powers for the FDA to enforce post-marketing recalls of ineffective drugs.[37] In 1959, the thalidomide tragedy, in which thousands of European babies were born deformed after their mothers took that drug marketed for treatment of nausea during their pregnancies,[41] led to the 1962 Kefauver-Harris Amendment to the FD&C Act, which represented a "revolution" in FDA regulatory authority.[42] The most important change was the requirement that all new drug applications demonstrate "substantial evidence" of the drug's efficacy for a marketed indication, in addition to the existing requirement for pre-marketing demonstration of safety. This marked the start of the FDA approval process in its modern form. These reforms had the effect of increasing the time required to bring a drug to market.[] One of the most important statutes in establishing the modern American pharmaceutical market was the 1984 Drug Price Competition and Patent Term Restoration Act, more commonly known as the "Hatch-Waxman Act" after its chief sponsors. The act extended the patent exclusivity terms of new drugs, and tied those extensions, in part, to the length of the FDA approval process for each individual drug. For generic manufacturers, the Act created a new approval mechanism, the Abbreviated New Drug Application (ANDA), in which the generic drug manufacturer need only demonstrate that their generic formulation has the same active ingredient, route of administration, dosage form, strength, and pharmacokinetic properties ("bioequivalence") as the corresponding brand-name drug. This act has been credited with in essence creating the modern generic drug industry.[] Concerns about the length of the drug approval process were brought to the fore early in the AIDS epidemic. In the mid- and late 1980s, ACT-UP and other HIV activist organizations accused the FDA of unnecessarily delaying the approval of medications to fight HIV and opportunistic infections.[43] Partly in response to these criticisms, the FDA issued new rules to expedite approval of drugs for life threatening diseases, and expanded pre-approval access to drugs for patients with limited treatment options.[44] All of the initial drugs approved for the treatment of HIV/AIDS were approved through these accelerated approval mechanisms.[45] In two instances, state governments have sought to legalize drugs that have not been approved by the FDA. Because federal law passed pursuant to Constitutional authority overrules conflicting state laws[citation needed], federal authorities still claim the authority to seize, arrest, and prosecute for possession and sales of these substances, even in states where they are legal under state law. The first wave was the legalization by 27 states of laetrile in the late 1970s. This drug was used as a treatment for cancer, but scientific studies both before and after this legislative trend found it to be ineffective.[46][47] The second wave concerned medical marijuana in the 1990s and 2000s (decade). Though Virginia passed a law with limited effect in 1979, a more widespread trend began in California in 1996.

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727

21st century reforms


Critical Path Initiative
The Critical Path Initiative[48] is FDA's effort to stimulate and facilitate a national effort to modernize the sciences through which FDA-regulated products are developed, evaluated, and manufactured. The Initiative was launched in March 2004, with the release of a report entitled Innovation/Stagnation: Challenge and Opportunity on the Critical Path to New Medical Products.[49]

Patients' rights to access unapproved drugs


A 2006 court case, Abigail Alliance v. von Eschenbach, would have forced radical changes in FDA regulation of unapproved drugs. The Abigail Alliance argued that the FDA must license drugs for use by terminally ill patients with "desperate diagnoses," after they have completed Phase I testing.[50] The case won an initial appeal in May 2006, but that decision was reversed by a March 2007 rehearing. The US Supreme Court declined to hear the case, and the final decision denied the existence of a right to unapproved medications. Critics of the FDA's regulatory power argue that the FDA takes too long to approve drugs that might ease pain and human suffering faster if brought to market sooner. The AIDS crisis created some political efforts to streamline the approval process. However, these limited reforms were targeted for AIDS drugs, not for the broader market. This has led to the call for more robust and enduring reforms that would allow patients, under the care of their doctors, access to drugs that have passed the first round of clinical trials.[51][52]

Post-marketing drug safety monitoring


The widely publicized recall of Vioxx, a non-steroidal anti-inflammatory drug now estimated to have contributed to fatal heart attacks in thousands of Americans, played a strong role in driving a new wave of safety reforms at both the FDA rulemaking and statutory levels. Vioxx was approved by the FDA in 1999, and was initially hoped to be safer than previous NSAIDs, due to its reduced risk of intestinal tract bleeding. However, a number of pre- and post-marketing studies suggested that Vioxx might increase the risk of myocardial infarction, and this was conclusively demonstrated by results from the APPROVe trial in 2004.[53] Faced with numerous lawsuits, the manufacturer voluntarily withdrew it from the market. The example of Vioxx has been prominent in an ongoing debate over whether new drugs should be evaluated on the basis of their absolute safety, or their safety relative to existing treatments for a given condition. In the wake of the Vioxx recall, there were widespread calls by major newspapers, medical journals, consumer advocacy organizations, lawmakers, and FDA officials[54] for reforms in the FDA's procedures for pre- and post- market drug safety regulation. In 2006, a congressionally requested committee was appointed by the Institute of Medicine to review pharmaceutical safety regulation in the U.S. and to issue recommendations for improvements. The committee was composed of 16 experts, including leaders in clinical medicinemedical research, economics, biostatistics, law, public policy, public health, and the allied health professions, as well as current and former executives from the pharmaceutical, hospital, and health insurance industries. The authors found major deficiencies in the current FDA system for ensuring the safety of drugs on the American market. Overall, the authors called for an increase in the regulatory powers, funding, and independence of the FDA.[55][56] Some of the committee's recommendations have been incorporated into drafts of the PDUFA IV bill, which was signed into law in 2007.[57] As of 2011, Risk Minimization Action Plans (RiskMAPS) have been created to ensure risks of a drug never outwiegh the benefits of that drug within the postmarketing period. This program requires that manufacturers design and implement periodic assessments of their programs' effectiveness. The Risk Minimization Action Plans are set in place depending on the overall level of risk a prescription drug is likely to pose to the public.[58] .

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Pediatric drug testing


Prior to the 1990s, only 20% of all drugs prescribed for children in the United States were tested for safety or efficacy in a pediatric population. This became a major concern of pediatricians as evidence accumulated that the physiological response of children to many drugs differed significantly from those drugs' effects on adults. There were several reasons that not many medical trials were done with children. For many drugs, children represented such a small proportion of the potential market, that drug manufacturers did not see such testing as cost-effective. Also, because children were thought to be ethically restricted in their ability to give informed consent, there were increased governmental and institutional hurdles to approval of these clinical trials, as well as greater concerns about legal liability. Thus, for decades, most medicines prescribed to children in the U.S. were done so in a non-FDA-approved, "off-label" manner, with dosages "extrapolated" from adult data through body weight and body-surface-area calculations.[] An initial attempt by the FDA to address this issue was the 1994 FDA Final Rule on Pediatric Labeling and Extrapolation, which allowed manufacturers to add pediatric labeling information, but required drugs that had not been tested for pediatric safety and efficacy to bear a disclaimer to that effect. However, this rule failed to motivate many drug companies to conduct additional pediatric drug trials. In 1997, the FDA proposed a rule to require pediatric drug trials from the sponsors of New Drug Applications. However, this new rule was successfully preempted in federal court as exceeding the FDA's statutory authority. While this debate was unfolding, Congress used the 1997 Food and Drug Administration Modernization Act to pass incentives that gave pharmaceutical manufacturers a six-month patent term extension on new drugs submitted with pediatric trial data. The act reauthorizing these provisions, the 2002 Best Pharmaceuticals for Children Act, allowed the FDA to request NIH-sponsored testing for pediatric drug testing, although these requests are subject to NIH funding constraints. Most recently, in the Pediatric Research Equity Act of 2003, Congress codified the FDA's authority to mandate manufacturer-sponsored pediatric drug trials for certain drugs as a "last resort" if incentives and publicly funded mechanisms proved inadequate.[]

Rules for generic biologics


Since the 1990s, many successful new drugs for the treatment of cancer, autoimmune diseases, and other conditions have been protein-based biotechnology drugs, regulated by the Center for Biologics Evaluation and Research. Many of these drugs are extremely expensive; for example, the anti-cancer drug Avastin costs $55,000 for a year of treatment, while the enzyme replacement therapy drug Cerezyme costs $200,000 per year, and must be taken by Gaucher's Disease patients for life. Biotechnology drugs do not have the simple, readily verifiable chemical structures of conventional drugs, and are produced through complex, often proprietary techniques, such as transgenic mammalian cell cultures. Because of these complexities, the 1984 Hatch-Waxman Act did not include biologics in the Abbreviated New Drug Application (ANDA) process, in essence precluding the possibility of generic drug competition for biotechnology drugs. In February 2007, identical bills were introduced into the House to create an ANDA process for the approval of generic biologics, but were not passed.[59]

Criticisms
The FDA currently has regulatory oversight over a large array of products that affect the health and life of American citizens.[37] As a result, the FDA's powers and decisions are carefully monitored by several governmental and non-governmental organizations. A $1.8 million 2006 Institute of Medicine report on pharmaceutical regulation in the U.S. found major deficiencies in the current FDA system for ensuring the safety of drugs on the American market. Overall, the authors called for an increase in the regulatory powers, funding, and independence of the FDA.[60][61] Nine FDA scientists appealed to then president-elect Barack Obama over pressures from management, experienced during the George W. Bush presidency, to manipulate data, including in relation to the review process for medical

Food and Drug Administration devices. Characterized as "corrupted and distorted by current FDA managers, thereby placing the American people at risk," these concerns were also highlighted in the 2006 report[60] on the agency as well.[62] The FDA has also been criticized from the opposite viewpoint, as being too tough on industry. According to an analysis published on the website of the libertarian Mercatus Center as well as published statements by economists, medical practitioners, and concerned consumers, many feel the FDA oversteps its regulatory powers and undermines small business and small farms in favor of large corporations. Three of the FDA restrictions under analysis are the permitting of new drugs and devices, the control of manufacturer speech, and the imposition of prescription requirements. The authors argue that in the increasingly complex and diverse food marketplace, the FDA is not equipped to adequately regulate or inspect food.[63]Wikipedia:Verifiability However, in an indicator that the FDA may be too lax in their approval process, in particular for medical devices, a 2011 study by Dr. Diana Zuckerman and Paul Brown of the National Research Center for Women and Families, and Dr. Steven Nissen of the Cleveland Clinic, published in the Archives of Internal Medicine, showed that most medical devices recalled in the last five years for "serious health problems or death" had been previously approved by the FDA using the less stringent, and cheaper, 510(k) process. In a few cases the devices had been deemed so low-risk that they did not need FDA regulation. Of the 113 devices recalled, 35 were for cardiovascular health purposes.[64]

729

References
[2] http:/ / tools. wmflabs. org/ geohack/ geohack. php?pagename=Food_and_Drug_Administration& params=39_02_07_N_76_58_59_W_type:landmark_region:US-MD [4] http:/ / www. fda. gov/ [6] Coordinates of FDA Headquarters at White Oak, Maryland: [7] Summary of FDA's FY 2008 Budget (http:/ / www. fda. gov/ AboutFDA/ ReportsManualsForms/ Reports/ BudgetReports/ 2008FDABudgetSummary/ ucm082723. htm) [8] Food, Drug and Cosmetic Act Web Version (http:/ / www. fda. gov/ opacom/ laws/ fdcact/ fdctoc. htm) [11] About the Center for Food Safety and Applied Nutrition (http:/ / www. fda. gov/ aboutfda/ centersoffices/ officeoffoods/ cfsan/ default. htm) Retrieved August 30, 2012. [12] About Us (http:/ / www. fsis. usda. gov/ About_FSIS/ index. asp), Food Safety Inspection Service, United States Department of Agriculture [13] Text of the Dietary Supplement Health and Education Act of 1994 (http:/ / www. fda. gov/ opacom/ laws/ dshea. html). Accessed February 5, 2007. [14] FDA Regulates the Safety of Bottled Water Beverages Including Flavored Water and Nutrient-Added Water Beverages (http:/ / www. fda. gov/ Food/ ResourcesForYou/ Consumers/ ucm046894. htm) Accessed August 30, 2012. [15] Bottled Water and Tap Water (http:/ / www. thefactsaboutwater. org/ uploads/ BW PWS Just the Facts 2011 Final. pdf) Drinking Water Research Foundation. Retrieved August 30, 2012. [16] NRDC: Bottled Water (http:/ / www. nrdc. org/ water/ drinking/ bw/ chap4. asp) Natural Resources Defense Council. Retrieved August 30, 2012. [18] 21 CFR 202: Prescription Drug Advertising. [19] 21 CFR 314.80: Postmarketing Reporting of Adverse Drug Experiences [20] MedWatch: The FDA Safety Information and Adverse Event Reporting Program (http:/ / www. fda. gov/ medwatch/ index. html). Accessed October 9, 2007 [21] Cohen, Lynne. "Government Policies and Programs United States Generic Drug Scandal." The New Book of Knowledge Medicine And Health. 1990. 276-81. ISBN 0-7172-8244-9. [23] Regulation of Nonprescription Drug Products (http:/ / www. fda. gov/ downloads/ AboutFDA/ CentersOffices/ OfficeofMedicalProductsandTobacco/ CDER/ UCM148055. pdf) FDA. Retrieved August 30, 2012. [24] FDA CDER Handbook: Over-the- Counter Drug Products (http:/ / www. fda. gov/ cder/ handbook/ otcintro. htm). Accessed October 9, 2007 [25] FDA/CBER About CBER (http:/ / www. fda. gov/ AboutFDA/ CentersOffices/ OfficeofMedicalProductsandTobacco/ CBER/ default. htm) Retrieved August 30, 2012. [26] CDRH Mission, Vision and Shared Values (http:/ / www. fda. gov/ AboutFDA/ CentersOffices/ OfficeofMedicalProductsandTobacco/ CDRH/ ucm300639. htm) Retrieved August 30, 2012. [27] What does it mean when FDA "clears" or "approves" a medical device? (http:/ / www. fda. gov/ AboutFDA/ Transparency/ Basics/ ucm194460. htm) [29] Does FDA have the authority to regulate tobacco products? (http:/ / www. fda. gov/ AboutFDA/ Transparency/ Basics/ ucm194423. htm) Food and Drug Administration. [33] Big Tobacco Gets Top First Amendment Lawyer for New Suit | Adweek (http:/ / www. adweek. com/ news/ advertising-branding/ big-tobacco-gets-top-first-amendment-lawyer-new-suit-134200)

Food and Drug Administration


[34] Tobacco Cos. Get Allies in Warning Label Fight Tobacco Convenience Store News (http:/ / www. csnews. com/ top-story-tobacco_cos. _get_allies_in_warning_label_fight-59535. html) [37] A History of the FDA (http:/ / www. fda. gov/ AboutFDA/ WhatWeDo/ History/ Origin/ ucm054819. htm) [38] Original Text of the 1906 Food and Drugs Act and Amendments (http:/ / www. fda. gov/ opacom/ laws/ wileyact. htm) [39] Milestones in U.S. Food and Drug Law History (http:/ / www. fda. gov/ opacom/ backgrounders/ miles. html) [41] Report of Congressman Morris Udall on thalidomide and the Kefauver hearings (http:/ / www. library. arizona. edu/ exhibits/ udall/ congrept/ 87th/ 620817. html). [43] ACT-UP NY timeline (http:/ / www. actupny. org/ documents/ cron-88. html) [44] FDA Website: Expanded Access and Expedited Approval of New Therapies Related to HIV/AIDS (http:/ / www. fda. gov/ ForConsumers/ ByAudience/ ForPatientAdvocates/ SpeedingAccesstoImportantNewTherapies/ ucm181838. htm) [45] FDA report on accelerated approval process (http:/ / www. fda. gov/ fdac/ special/ newdrug/ speeding. html) [46] NPR.org (http:/ / www. npr. org/ templates/ transcript/ transcript. php?storyId=127773447) [47] Quackwatch.com (http:/ / www. quackwatch. com/ 01QuackeryRelatedTopics/ Cancer/ laetrile. html) [48] FDA.gov (http:/ / www. fda. gov/ oc/ initiatives/ criticalpath/ initiative. html) [49] Innovation or Stagnation: Challenge and Opportunity on the Critical Path to New Medical Products (http:/ / www. fda. gov/ ScienceResearch/ SpecialTopics/ CriticalPathInitiative/ CriticalPathOpportunitiesReports/ ucm077262. htm) FDA. Retrieved August 30, 2012. [51] Amazon.com (http:/ / www. amazon. com/ Free-Choose-Medicine-Countless-Suffering/ dp/ 1934791326) [53] The APPROVe study (Pubmed) (http:/ / www. ncbi. nlm. nih. gov/ entrez/ query. fcgi?db=pubmed& cmd=Retrieve& dopt=AbstractPlus& list_uids=15713943& query_hl=10& itool=pubmed_docsum) [54] Retrieved August 30, 2012. [55] Webcitation.org (http:/ / www. webcitation. org/ 5NkCrjdpd) [56] Books.nap.edu (http:/ / www. nap. edu/ openbook. php?record_id=11750& page=205) Executive Summary of the 2006 IOM Report The Future of Drug Safety: Promoting and Protecting the Health of the Public [57] The PDUFA IV Act (http:/ / www. fda. gov/ oc/ initiatives/ advance/ fdaaa. html) [59] H.R. 1038 Access to Life-Saving Medicine Act (http:/ / www. govtrack. us/ congress/ bill. xpd?bill=h110-1038) [60] Webcitation.org (http:/ / www. webcitation. org/ 5NkCrjdpd) [61] Committee on the Assessment of the US Drug Safety System. (2006). The Future of Drug Safety: Promoting and Protecting the Health of the Public. Institute of Medicine. Free full-text (http:/ / www. nap. edu/ catalog. php?record_id=11750#toc). [64] JAMA Network | Archives of Internal Medicine | Medical Device Recalls and the FDA Approval ProcessMedical Device Recalls and FDA Approval Process (http:/ / archinte. ama-assn. org/ cgi/ content/ full/ archinternmed. 2011. 30)

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Further reading
Michael Givel (December 2005) Philip Morris' FDA Gambit: Good for Public Health? Journal of Public Health Policy (26): pp.450468. Philip J. Hilts. Protecting America's Health: The FDA, Business, and One Hundred Years of Regulation. New York: Alfred E. Knopf, 2003. ISBN 0-375-40466-X Bartley Madden (July 2010) Free To Choose Medicine: How Faster Access to New Drugs Would Save Countless Lives and End Needless Suffering Chicago: The Heartland Institute, 2010. ISBN 978-1-934791-32-5 Thomas J. Moore. Prescription for Disaster: The Hidden Dangers in Your Medicine Cabinet. New York: Simon & Schuster, 1998. ISBN 0-684-82998-3.

External links
Official website (http://www.fda.gov/) FDA Organizational Hierarchy Chart (http://www.fda.gov/downloads/AboutFDA/CentersOffices/ OrganizationCharts/UCM291886.pdf) in PDF format Strategic Plan (http://xml.fido.gov/stratml/carmel/FDAwStyle.xml) in Strategy Markup Language ( StratML (http://xml.fido.gov/stratml/index.htm)) format Biologics Centennial: 100 Years of Biologics Regulation (http://www.fda.gov/oc/history/makinghistory/ 100yearsofbiologics.html)Wikipedia:Link rot from the Food and Drug Administration Home Page U.S. FDA CDER Home Page (http://www.fda.gov/cder/) the Center for Drug Evaluation and Research CBER Center for Biologics Evaluation and Research, FDA (http://www.fda.gov/cber/)

Food and Drug Administration Past FDA Commissioners (http://www.fda.gov/AboutFDA/CommissionersPage/PastCommissioners/default. htm) Agency Presentations (http://globalsubmit.com/home/LearningCenter/Guidances/AgencyPresentations/tabid/ 260/Default.aspx) MedEffect Canada (Health Canada) (http://www.hc-sc.gc.ca/dhp-mps/medeff/index-eng.php) Coordinates: 390207N 765859W (http:/ php?pagename=Food_and_Drug_Administration& 98309_E_region:US-MD_type:landmark) / tools. wmflabs. params=39. org/ geohack/ geohack. 03534_N_-76.

731

Federal Employees Health Benefits Program


The Federal Employees Health Benefits (FEHB) Program is a system of "managed competition" through which employee health benefits are provided to civilian government employees and annuitants of the United States government. Workers pay one-third of the cost of insurance; the government pays the other two-thirds.[1] The FEHB program allows some insurance companies, employee associations, and labor unions to market health insurance plans to governmental employees. The program is administered by the United States Office of Personnel Management (OPM).

History
The program was created in 1960. Employer sponsorship of health insurance in the United States became prevalent during World War II, as one of the few ways by which employers could escape wage and price control limitations on employee wages. The government originally proposed a system that would revolve around a dominant government-directed plan, but unions and employee associations, which had sponsored their own plans, protested. Reflecting the political pressure thus created, the Congress modified the Executive Branch proposal and all existing plans were "grandfathered" into the program.[2] Thus, through what was essentially a historical accident and a political compromise, a system of competition among health plans driven by consumer choices was created.{{Citation needed|date=April 2010}

Plans
Choices among health plans are available to employees during an "open enrollment" period, or "open season," after which the employee will be covered fully in any plan he or she chooses without limitations regarding pre-existing conditions. After the annual enrollment, changes can be made only upon a "qualifying life event" such as marriage, divorce, adoption or birth of a child, or change in employment status of a spouse, until the next annual open season, during which employees can enroll, disenroll, or change from one plan to another. The exact dates of the open season change from year to year, but are usually from the Monday of the second full week in November through Monday, the second full week of December. Enrollment begins at or near the beginning of the calendar year, and lasts until a different plan choice is made in a subsequent open season or through a qualifying life event. In practice, there is a great deal of inertia in enrollment, and only about 5 percent of employees change plans in most open seasons. Premiums vary from plan to plan and are paid in part by the employer (the U. S. government agency that the employee works for or, for annuitants, OPM) and the remainder by the employee. The employer pays an amount up to 72 percent of the average plan premium for self-only or family coverage (not to exceed 75 percent of the premium for the selected plan), and the employee pays the rest. This dollar amount is recalculated each year as health care costs and plans' premiums increase. Certain employees (such as postal workers) have a higher portion of their premiums paid as the result of collective bargaining agreements. The precise percentage of the average paid by the

Federal Employees Health Benefits Program employer is relatively unimportant to the design of this program and has changed over time to become more generous. What is important is that it is a "capped premium" design, in which the entire marginal cost of joining a plan with a premium near, at, or above the all-plan average is borne by the enrollee. In other words, enrollees pay the entire cost of their costly choices, but reap rewards if they make frugal choices. This creates constant pressure on the plans, since to attract enrollees they must hold down costs, while balancing this incentive against benefit offerings and customer service, to reach a position that will maximize their enrollment revenues and profits. This feature of the program is arguably its greatest strength and the primary reason that one expert summarized it has having "outperformed Medicare every which way--in containment of costs both to consumers and to the government, in benefit and product innovation and modernization, and in consumer satisfaction," decade after decade.[3] In 2010 about 250 plans participate in the program.[4] About 20 plans are nationwide or almost nationwide, such as the ones offered by some employee unions such as the National Association of Letter Carriers, by some employee associations, and by national insurance companies such as Aetna and the Blue Cross and Blue Shield Association on behalf of its member companies. There are about 230 locally available plans, almost all HMOs. The FEHB program is open to all federal employees, including members of United States Congress. The FEBHP's cost is about $40 billion in 2010, including both premiums and out-of-pocket costs. It enrolls about 4 million employees and annuitants and, with their dependents, 8 million persons in total. While its enrollment is about one-fifth that of the nation's largest health insurance program, Medicare, it spends less than one-tenth as much because most enrollees are below age 65 and cost far less on average than the elderly and disabled who constitute Medicare's enrollees. The FEHB program relies on consumer choices among competing private plans to determine costs, premiums, benefits, and service. This model is in sharp contrast to that used by original Medicare. In Medicare, premiums, benefits, and payment rates are all centrally determined by law or regulation (there is no bargaining and no reliance on volume discounts in original Medicare; these parameters are set by fiat). Some have criticized the FEHB model because neither the monopsony power nor purchasing power of the federal government is utilized to control costs. This controversy is similar to that which surrounded legislation for the Medicare Prescription Drug Coverage passed during the George W. Bush administration. Over time, however, the FEHB program has outperformed original Medicare not only in cost control, but also in benefit improvement, enrollee service, fraud prevention, and avoidance of "pork barrel" spending and earmarks.[5] (Medicare Part D has also controlled costs far better than originally forecast through a competitive, consumer-driven system of plan choices similar to and modeled after the FEHB program.) One of the most prominent features of the FEHB program is the choices it allows. There are three broad types of plans: fee-for-service and preferred provider organization (PPO), usually offered in combination; HMOs; and high-deductible health plans and other consumer-driven plans. In the Washington, D.C., metropolitan area, plans open to all federal employees and annuitants include 10 fee-for-service and PPO plans, seven HMOs, and eight high-deductible and consumer-driven plans.[6] A similar number of choices is offered in almost all large metropolitan areas, and in many smaller cities and rural areas. The program is sometimes criticized for offering this broad array of choices, but there are many ways enrollees can obtain advice and assistance, including advice from office colleagues and friends, newspaper and magazine articles in both the general press and publications that specialize in federal employees or retirees, OPM publications and Web site, and several online tools that compare plans' costs, benefits, and services. As a noticeably consumer-friendly service, OPM requires that all plans publish brochures that describe benefits in plain English and in a standardized format that facilitates plan comparison and that can easily be downloaded in PDF format.[7] Almost all plans provide Web sites that provide detailed information not only on their benefits, but also on their provider panels and their drug formularies. There is no published evidence that either in the FEHB program or in the other two federal programs that offer a wide range of plan choices, the Medicare Advantage and Medicare Prescription Drug programs, consumer confusion is a serious problem, or that health insurance choices are any more complicated to deal with than other consumer choices among complex products or services, such as choices as to automobile purchase or service, choice among physicians, or choice among life insurance and other insurance products. One study found that on the whole Medicare beneficiaries, who are both

732

Federal Employees Health Benefits Program elderly and far less educated than the population at large, nonetheless were able to substantially reduce their drug costs by choosing, albeit imperfectly, Medicare prescription drug plans that reduced their drug costs from what would have been considerably higher costs.[8] A recent evaluation of the FEHB program found that Open Season movement reduces premiums on average by about 1 percent compared to prior enrollment patterns, despite the tendency of enrollees to remain in current plans without considering alternative choices.[9] In the FEHB program the federal government sets minimal standards that, if met by an insurance company, allows it to participate in the program. The result is numerous competing insurance plans that are available to federal employees. Local plans have ready access to participation in the program, but the underlying statute prohibits entry of new national plans. Because OPM requires plans to price offerings closely to the health care costs of enrollees, and to offer comprehensive benefits, there is broad similarity in plan offerings. However, total premiums can vary substantially, and in 2010 the lowest cost plan option has a self-only premium cost of about $2,800 and the highest cost plan option for self-only enrollment is about $7,200.[10] As an example of benefit variation, a cap of about $5,000 a year on potential out-of-pocket costs for self-only enrollment is found in a number of plans, but in some plans the cap may reach $15,000 or more (HMOs typically have no cap, but control potential cost exposure by using copayments). The underlying legislation for the FEHB program is minimal and remarkably stable, particularly in comparison to Medicare. The FEHB statute is only a few dozen pages long, and only a few paragraphs are devoted to the structure and functioning of the program. Regulations are minimal; only another few dozen pages. In contrast, the Medicare statute found in title 18 of the Social Security Act is about 400 pages long and the accompanying regulations consume thousands of pages in the U.S. Code of Federal Regulations. The FEHB program has often been proposed as a model for national health insurance and sometimes as a program that could directly enroll the uninsured. These proposals began within its first decade [11] and have continued ever since.[12] Notable economist Alain Enthoven explicitly built a proposal for a system of "managed competition" as a national health reform decades ago, and has continued promoting the idea ever since.[13] A version of this proposal was recently adopted by the Netherlands. In the 2004 presidential campaign, Senator John Kerry proposed opening enrollment in this plan to all Americans. In enacting the Medicare Modernization Act in 2003, the Congress explicitly modeled the reformed Medicare Advantage program and the new Medicare Part D Prescription Drug program after the FEHB program.[14] One of the prominent proposals for health reform in the United States, the proposed bipartisan Wyden-Bennett Act is largely modeled after the FEHB program, as have recent "Republican Alternative" proposals by Representative Paul Ryan.

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Notes
[2] Odin Anderson and Joel May [3] Harry Cain, p. 30. [4] Walton Francis and editors, p. 4. [5] Walton Francis, p. 193. [6] Walton Francis and editors, p. 23. [7] U.S. Office of Personnel Management Web Site for Federal Employee Health Plans; Walton Francis and editors online version. [8] Jonathan Gruber. [9] Walton Francis, p.49. [10] Walton Francis and editors, p. 54. [11] Odin Anderson and Joel May [12] Walton Francis, pp. 4-6. [13] Alain Enthoven [14] Walton Francis, pp. 8-9.

Federal Employees Health Benefits Program

734

References
Anderson, Odin, and Joel May. 1971. The Federal Employees Health Benefits Program, 1961-1968: A Model for National Health Insurance? In Perspectives. Chicago: Center for Health Administration Studies, University of Chicago. Cain, Harry. 1999. Moving Medicare to the FEHBP Model, or How to Make an Elephant Fly. Health Affairs 18 (4): 25-39. http://www.healthaffairs.org.Retrieved 2020-01-28. Enthoven, Alain. 1980. Health Plan: The Only Practical Solution to the Soaring Cost of Medical Care. Reading, Mass.: Addison-Wesley. Francis, Walton. Putting Medicare Consumers in Charge: Lessons from the FEHBP. 2009. Washington, D.C.: American Enterprise Institute. Francis, Walton, and the editors of Washington Consumers' CHECKBOOK. 2009 and prior years. CHECKBOOK's Guide to Health Plans for Federal Employees. Washington, D.C.: Center for the Study of Services. Also available online at http://www.guidetohealthplans.org.Retrieved 2010-01-28. Gruber, Jonathan. March 2009. Choosing a Medicare Part D Plan: Are Medicare Beneficiaries Choosing Low-Cost Plans? Henry J. Kaiser Family Foundation. http://www.kff.org/medicare/upload/7864.pdf. Retrieved 2010-01-28. U.S. Office of Personnel Management Web Site for Federal Employee Health Plans. http://www.opm.gov/ insure/health.Retrieved 2010-01-28.

External links
Insurance Programs (http://www.OPM.gov/insure) offered by the Office of Personnel Management, including health, dental, vision, life, flexible spending accounts, and long term care Official website (http://www.opm.gov/insure/health/) of the FEHB program

Federal Food, Drug, and Cosmetic Act

735

Federal Food, Drug, and Cosmetic Act


Federal Food, Drug, and Cosmetic Act

Long title

To prohibit the movement in interstate commerce of adulterated and misbranded food, drugs, devices, and cosmetics, and for other purposes. FFDCA, "FD&C Act" 75th United States Congress Citations

Colloquial acronym(s) Enacted by the

Public Law Stat.

75-717

[1]

52Stat.1040 Codification

Act(s) repealed Title(s) amended U.S.C. sections created

Pure Food and Drug Act 21 U.S.C.: Food and Drugs Chapter 9 301 et seq. Legislative history

Introduced in the Senate as S. 5 by Royal Copeland (DNY) on March 5, 1938 Committee consideration by: Committee on Interstate and Foreign Commerce Passed the House on June 1, 1938 (amended and passed) Passed the Senate on June 2, 1938 (disagreed) Reported by the joint conference committee on June 11, 1938; agreed to by the House on June 15, 1938 (agreed) and by the Senate on June 15, 1938 (agreed) Signed into law by President Franklin D. Roosevelt on June 25, 1938 Major amendments

1951 Food, Drug, and Cosmetics Act Amendments, PL 82215, 65 Stat 648 1962 Food, Drug, and Cosmetics Act Amendments, PL 87781, 76 Stat 780 Fair Packaging and Labeling Act, PL 89755, 80 Stat 1296 Medical Device Regulation Act, PL 94295, 90 Stat 539 Radiation Control for Safety and Health Act, PL 90-602, 82 Stat 1173 Drug Price Competition and Patent Term Restoration Act of 1984, PL 98-471, 98 Stat 1585 Nutrition Labeling and Education Act (1990), PL 101-535, 104 Stat 2353 Safe Medical Device Amendments of 1990, PL 101-629, 104 Stat 4511 Food and Drug Administration Revitalization Act (1990), PL 101-635, 104 Stat 4583 Dietary Supplement Health and Education Act (1994), PL 103-417, 108 Stat 4332 Food and Drug Administration Modernization Act of 1997, PL 105-115, 111 Stat 2296 Food and Drug Administration Amendments Act of 2007, PL 110-85, 121 Stat 823 [2]

The United States Federal Food, Drug, and Cosmetic Act (abbreviated as FFDCA, FDCA, or FD&C), is a set of laws passed by Congress in 1938 giving authority to the U.S. Food and Drug Administration (FDA) to oversee the

Federal Food, Drug, and Cosmetic Act safety of food, drugs, and cosmetics. A principal author of this law was Royal S. Copeland, a three-term U.S. Senator from New York.[3] In 1968, the Electronic Product Radiation Control provisions were added to the FD&C. Also in that year the FDA formed the Drug Efficacy Study Implementation (DESI) to incorporate into FD&C regulations the recommendations from a National Academy of Sciences investigation of effectiveness of previously marketed drugs.[4] The act has been amended many times, most recently to add requirements about bioterrorism preparations. The introduction of this act was influenced by the death of more than 100 patients due to a sulfanilamide medication where diethylene glycol was used to dissolve the drug and make a liquid form.[5] See Elixir Sulfanilamide disaster. It replaced the earlier Pure Food and Drug Act of 1906.

736

Contents
The FDC Act has ten chapters:[6] I. Short Title II. Definitions 201(f) is the definition for a food, which explicitly includes chewing gum 201(g) is the definition for a drug 201(h) is the definition for a medical device 201(s) is the definition of a food additive 201(ff) is the definition of a dietary supplement III. Prohibited Acts and Penalties This section contains both civil law and criminal law clauses. Most violations under the act are civil, though repeated, intentional, and fraudulent violations are covered as criminal law. All violations of the FD&C Act require interstate commerce because of the commerce clause, but this is often interpreted broadly and few products other than raw produce are considered outside of the scope of the act. Notably, the FD&C Act uses strict liability due to the Dotterweich[7] and Park [8] Supreme Court cases. It is one of a very small number of criminal statutes that does. IV. Food There is a distinction in food adulteration between those that are added and those that are naturally present. Substances that are added are held to a stricter "may render (it) injurious to health" standard, whereas substances that are naturally present need only be at a level that "does not ordinarily render it injurious to health"[9] V. Drugs and Devices 505 is the description of the drug approval process 510(k) is the section that allows for clearance of class II medical devices 515 is the description of the (class III) device approval process VI. Cosmetics VII. General Authority 704 allows inspections of regulated entities. Inspection results are reported on Form 483. VIII. Imports and Exports IX. Tobacco Products X. Miscellaneous

Federal Food, Drug, and Cosmetic Act

737

Food coloring
The FD&C is perhaps best known by the consumer because of its use in the naming of food coloring additives, such as "FD&C Yellow No. 6." The Act made the certification of some food color additives mandatory. Some food colorings are generally recognized as safe (GRAS) by the FDA and do not require certification.[10] The FDA lists nine FD&C (Food, Drugs & Cosmetics) certified color additives for use in foods in the United States, and numerous D&C (Drugs & Cosmetics) colorings allowed only in drugs for external application or cosmetics. Color additives derived from natural sources, such as vegetables, minerals or animals, and artificial counterparts of natural derivatives, are exempt from certification. Both artificial and natural color additives are subject to rigorous standards of safety before their approval for use in foods.[citation needed]

Certifiable colors
Name FD&C Blue No. 1 FD&C Blue No. 2 FD&C Green No. 3 FD&C Red No. 3 FD&C Red No. 40 FD&C Yellow No. 5 Common name Brilliant Blue FCF Indigotine Fast Green FCF Erythrosine Allura Red AC Tartrazine Color bright blue royal blue sea green cherry red orange-red lemon yellow orange Restricted to specific uses Restricted to specific uses Comment

FD&C Yellow No. 6 Sunset Yellow FCF Orange B Citrus Red No.2

There are also "D&C" colors that are only approved for use in pharmaceuticals for external application and cosmetics.

Food additives
The FFDCA requires producers of food additives to demonstrate to a reasonable certainty that no harm will result from the intended use of an additive. If the FDA finds an additive to be safe the agency issues a regulation specifying the conditions under which the additive may be safely used.

Definition of food additive


The definition of "food additive" is "any substance, the intended use of which results directly or indirectly, in its becoming a component or otherwise affecting the characteristics of food".[11] A food additive requires a premarket approval by the FDA unless excluded from this requirement as a substance that is generally recognized, among experts qualified by scientific training and experience to evaluate its safety, as having been adequately shown through scientific procedures (or, in the case of a substance used in food before January 1, 1958, through either scientific procedures or through experience based on common use in food) to be safe under the conditions of its intended use. This is the so-called generally recognized as safe (GRAS) exemption.[12]

Federal Food, Drug, and Cosmetic Act

738

Genetically modified foods are regarded as containing food additives


These regulations apply to foods produced by genetic engineering and natural sources, if the protein added to the food by the genetic engineering process is not "generally recognized as safe" then genetically modified food is regarded as containing a "food additive" and is subject to pre-market approval by the FDA.[13] All genetically modified foods sold in the USA have been subject to this FDA pre-market approval process.

Homeopathic medications
Homeopathic preparations are regulated and protected under Sections 201(g) and 201(j), provided that such medications are formulated from substances listed in the Homeopathic Pharmacopoeia of the United States, which the Act recognizes as an official drug compendium.

Bottled water
Bottled water is regulated by the FDA as a food. The Agency has published identity standards for types of water (mineral water, spring water), and regulations covering water processing and bottling, water quality and product labeling.[14][15] [16]

Cosmetics
This Act defines cosmetics as products for "cleansing, beautifying, promoting attractiveness, or altering the appearance." In this sense the FDA can classify cosmetics without actually regulating them. This allows a manufacturer the ability to use ingredients or raw materials and market the final product without government approval.

Medical devices
On May 28, 1976, the FD&C Act was amended to include regulation for medical devices.[17] The amendment required that all medical devices be classified into one of three classes: Class I: Devices that do not require premarket approval or clearance but must follow general controls. Dental floss is a class I device. Class II: Devices that are cleared using the 510(k) process. Diagnostic tests, cardiac catheters, hearing aids, and amalgam alloys used to fill cavities are examples of class II devices. Hearing aids are class II devices. Class III: Devices that are approved by the Premarket Approval (PMA) process, analogous to a New Drug Application. These tend to be devices that are permanently implanted into a human body or may be necessary to sustain life. An artificial heart meets both criteria. The most commonly recognized class III device is an Automated External Defibrillator. Devices that do not meet either criterion are generally cleared as class II devices. For devices that were marketed prior to the amendment (Preamendment devices) and were classified as Class III, the amendment obligated the FDA to review the device to either reclassify it as a Class II device subject to premarket notification, or to require the device manufacturer to undergo the premarket authorization process and prove the safety and efficacy of the device in order to continue marketing it. Notable examples of such preamendment devices are those used for electroconvulsive therapy, which the FDA started reviewing in 2011.[18][19]

Federal Food, Drug, and Cosmetic Act

739

Premarket notification (510(k))


Section 510(k)[20] of the Federal Food, Drug, and Cosmetic Act requires those device manufacturers who must register to notify FDA, at least 90 days in advance, of their intent to market a medical device. This is known as Premarket Notification - also called PMN or 510(k). It allows FDA to determine whether the device is equivalent to a device already placed into one of the three classification categories. Thus, "new" devices (not in commercial distribution prior to May 28, 1976) that have not been classified can be properly identified. Any device that reaches market via a 510(k) notification must be "substantially equivalent" to a device on the market prior to May 28, 1976 (a "predicate device"). If a device being submitted is significantly different, relative to a pre-1976 device, in terms of design, material, chemical composition, energy source, manufacturing process, or intended use, the device nominally must go through a premarket approval, or PMA. This does not always happen. A device that reaches market via the 510(k) process is not considered to be "approved" by the FDA. Nevertheless, it can be marketed and sold in the United States. They are generally referred to as "cleared" or "510(k) cleared" devices. A 2011 study by Dr. Diana Zuckerman and Paul Brown of the National Research Center for Women and Families, and Dr. Steven Nissen of the Cleveland Clinic, published in the Archives of Internal Medicine, showed that most medical devices recalled in the last five years for serious health problems or death had been previously approved by the FDA using the less stringent, and cheaper, 510(k) process. In a few cases the devices had been deemed so low-risk that they did not need FDA regulation. Of the 113 devices recalled, 35 were for cardiovascular issues.[21] This may lead to a reevaluation of FDA procedures and better oversight.

Premarket approval (PMA)


Premarket approval (PMA) is the most stringent type of device marketing application required by FDA. Unlike the 510(k) pathway, the maker of the medical device must submit an application to the FDA and must receive approval prior to marketing the device.[22] The PMA application contains information about how the medical device was designed and how it is manufactured, as well as preclinical and clinical studies of the device, demonstrating that it is safe and effective for its intended use.[23] Because the PMA requires a clinical trial it is significantly more expensive than a 510(k).[24]:7

Related legislation
The Wheeler-Lea Act, passed in 1938, granted the Federal Trade Commission the authority to oversee advertising of all products regulated by FDA, other than prescription drugs.

Significant amendments and related laws


Descriptions of these can be found at the FDCA's web site.[25] Amendments: Drug Efficacy Amendment ("Kefauver Harris Amendment") PL 87-781 (October 10, 1962) Medical Device Amendments of 1976 PL 94-295 (May 28, 1976) Infant Formula Act of 1980, Public Law (PL) 96-359 (October 26, 1980) Orphan Drug Act, PL 97-414 (January 4, 1983) Drug Price Competition and Patent Term Restoration Act of 1984, PL 98-417 (aka Hatch-Waxman) (September 24, 1984) Prescription Drug Marketing Act of 1987, PL 100-293 (August 18, 1988) Generic Animal Drug and Patent Term Restoration Act of 1988, PL 100-670 (November 16, 1988) Nutrition Labeling and Education Act of 1990, PL 101-535 (November 8, 1990)

Federal Food, Drug, and Cosmetic Act Safe Medical Device Amendments of 1990, PL 101-629 (November 28, 1990) Medical Device Amendments of 1992, PL 102-300 (June 16, 1992) Prescription Drug User Fee Act (PDUFA) of 1992, PL 102-571 (October 29, 1992) Animal Medicinal Drug Use Clarification Act (AMDUCA) of 1994, PL 103-396 (October 22, 1994) Dietary Supplement Health And Education Act of 1994, PL 103-417 (October 25, 1994) Food Quality Protection Act of 1996, PL 104-170 (August 3, 1996) Animal Drug Availability Act of 1996, PL 104-250 (October 9, 1996) Best Pharmaceuticals for Children Act, PL 107-109 (January 4, 2002) Medical Device User Fee and Modernization Act (MDUFMA) of 2002, PL 107-250 (October 26, 2002) Animal Drug User Fee Act of 2003, PL 108-130 (February 20, 2003) Pediatric Research Equity Act of 2003, PL 108-155 (December 3, 2003) Minor Use and Minor Species Animal Health Act of 2004 Food Allergen Labeling and Consumer Protection Act of 2004, PL 108-282 (August 2, 2004) Generic Drug User Fee Amendment of 2012[26]

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Other laws:[27] Biologics Control Act of 1902 (repealed; for historical reference) Federal Food and Drugs Act of 1906 (repealed; for historical reference) Federal Meat Inspection Act (March 4, 1907) Federal Trade Commission Act (September 26, 1914) Filled Milk Act (March 4, 1923) Import Milk Act (February 15, 1927) Public Health Service Act (July 1, 1944) Trademark Act of 1946 (July 5, 1946) Reorganization Plan 1 of 1953 (March 12, 1953) Poultry Products Inspection Act (August 28, 1957) Fair Packaging and Labeling Act (November 3, 1966) The National Environmental Policy Act of 1969 (January 1, 1970) Controlled Substances Act (October 27, 1970) Controlled Substances Import and Export Act (October 27, 1970) Egg Products Inspection Act (December 29, 1970) Lead-Based Paint Poisoning Prevention Act (January 13, 1971) Federal Advisory Committee Act (October 6, 1972) Government in the Sunshine Act (September 13, 1976) Government Patent Policy Act of 1980 (December 12, 1980) Federal Anti-Tampering Act (October 13, 1983) Sanitary Food Transportation Act (November 3, 1990) Food and Drug Administration Revitalization Act (November 28, 1990) Mammography Quality Standards Act (MQSA) (October 27, 1992) Food and Drug Administration Modernization Act (November 21, 1997) Bioterrorism Act of 2002 (June 12, 2002) Project BioShield Act of 2004 (July 21, 2004) Food and Drug Administration Amendments Act of 2007 (September 27, 2007) Pandemic and All-Hazards Preparedness Reauthorization Act of 2013 (H.R. 307; 113th Congress)Pub.L. 1135 [28] (March 13, 2013)

Federal Food, Drug, and Cosmetic Act

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Comparison to state laws


Some US states have adopted the FD&C Act as an equivalent state law and will by default adopt any changes to the Federal law as changes to the state law as well.

References
[1] [2] [3] [4] [5] [6] [7] [8] http:/ / research. archives. gov/ description/ 299847 " Food, Drug, and Cosmetic Law Research Guide (http:/ / www. ll. georgetown. edu/ guides/ fooddruglaw. cfm)," Georgetown Law Library Homeopathic Drugs, Royal Copeland, and Federal Drug Regulation (http:/ / www. homeowatch. org/ history/ reghx. html) CDER - Time Line (http:/ / www. fda. gov/ cder/ about/ history/ time1. htm) ASHP Website : News Article (http:/ / www. ashp. org/ s_ashp/ article_news. asp?CID=167& DID=2024& id=3659) Federal Food, Drug, and Cosmetics Act Table of Contents (http:/ / www. fda. gov/ opacom/ laws/ fdcact/ fdctoc. htm) United States v. Dotterweich, 320 U.S. 277 (1943) (http:/ / wings. buffalo. edu/ law/ bclc/ web/ dotterweich. htm) UNITED STATES V. PARK, 421 U. S. 658 (1975) - US Supreme Court Cases from Justia & Oyez (http:/ / supreme. justia. com/ us/ 421/ 658/ index. html) [9] FD&C Act Chapter IV (http:/ / www. fda. gov/ opacom/ laws/ fdcact/ fdcact4. htm) [10] US FDA/CFSAN: Color Additive Status List (http:/ / www. fda. gov/ ForIndustry/ ColorAdditives/ ColorAdditiveInventories/ ucm106626. htm) [11] (http:/ / www. fda. gov/ Food/ FoodIngredientsPackaging/ FoodAdditives/ ucm228269. htm) FDA website "Determining the Regulatory Status of a Food Ingredient" Page Last Updated: 01/10/2011 [12] Federal Register Volume 62, Number 74 (Thursday, April 17, 1997) (http:/ / www. gpo. gov/ fdsys/ pkg/ FR-1997-04-17/ html/ 97-9706. htm) [13] FDA/USDA US Food Safety System Country Report Annex II: Precaution in US Food Safety Decisionmaking (http:/ / www. foodsafety. gov/ ~fsg/ fssyst4. html) [14] Posnick, Lauren M. and Kim, Henry (2002). "Bottled Water Regulation and the FDA." (http:/ / www. fda. gov/ downloads/ Food/ FoodSafety/ Product-SpecificInformation/ BottledWaterCarbonatedSoftDrinks/ ucm077094. pdf) Food Safety. August/September 2002. . [15] FDA. "21 CFR Part 129 - Processing and Bottling of Bottled Drinking Water." (http:/ / ecfr. gpoaccess. gov/ cgi/ t/ text/ text-idx?idno=21;region=DIV1;type=boolean;c=ecfr;cc=ecfr;sid=488f70fefe0640a86448e916ca70ef97;q1=129;rgn1=Part Number;op2=and;rgn2=Section;op3=and;rgn3=Section;rgn=div5;view=text;node=21:2. 0. 1. 1. 18) Code of Federal Regulations. [16] FDA. "21 CFR 165.110 - Requirements for Specific Standardized Beverages: Bottled Water." (http:/ / ecfr. gpoaccess. gov/ cgi/ t/ text/ text-idx?c=ecfr& sid=40900bcf73d9bab93d5c779815018b19& rgn=div8& view=text& node=21:2. 0. 1. 1. 38. 2. 1. 1& idno=21) Code of Federal Regulations. [17] Staff, FDA. PMA Historical Background (http:/ / www. fda. gov/ MedicalDevices/ DeviceRegulationandGuidance/ HowtoMarketYourDevice/ PremarketSubmissions/ PremarketApprovalPMA/ ucm046769. htm) Last updated April 26, 2009 [18] Duff Wilson for the New York Times. January 28, 2011 F.D.A. Panel Is Split on Electroshock Risks (http:/ / www. nytimes. com/ 2011/ 01/ 29/ health/ 29shock. html?_r=0) [20] US FDA/CDRH: Information on Releasable 510(k)s (http:/ / www. fda. gov/ cdrh/ 510khome. html) [22] Staff, FDA Premarket Approval (PMA) (http:/ / www. fda. gov/ MedicalDevices/ DeviceRegulationandGuidance/ HowtoMarketYourDevice/ PremarketSubmissions/ PremarketApprovalPMA/ default. htm), last updated January 24, 2012 [23] 21 U.S.C. 360e. Premarket approval (http:/ / www. gpo. gov/ fdsys/ pkg/ USCODE-2010-title21/ html/ USCODE-2010-title21-chap9-subchapV-partA-sec360e. htm) [24] Josh Makower, Aabed Meer, lyn Denend. November 2010 FDA Impact on US Medical Device Innovation - A Survey of Over 200 Medical Technology Companies (http:/ / www. nvca. org/ index. php?option=com_docman& task=doc_download& gid=668& Itemid=93) [25] Laws Enforced by the FDA and Related Statutes (http:/ / www. fda. gov/ opacom/ laws/ ) [26] Staff, FDA. Updated April 18, 2013 Generic Drug User Fee Amendments of 2012 (http:/ / www. fda. gov/ ForIndustry/ UserFees/ GenericDrugUserFees/ default. htm) [27] Food and Drug Administration Amendment Act of 2007 [28] http:/ / www. law. cornell. edu/ jureeka/ index. php?doc=USPubLaws& cong=113& no=5

Federal Food, Drug, and Cosmetic Act

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External links
"Federal Food, Drug, and Cosmetic Act (FD&C Act)" (http://www.fda.gov/RegulatoryInformation/ Legislation/FederalFoodDrugandCosmeticActFDCAct/). Regulatory Information & Legislation. U.S. Food and Drug Administration. Color Additive Status List (http://www.fda.gov/ForIndustry/ColorAdditives/ColorAdditiveInventories/ ucm106626.htm) Food Ingredients and Colors (http://www.fda.gov/Food/FoodIngredientsPackaging/ucm094211.htm) Information on Releasable 510(k)s (http://www.fda.gov/cdrh/510khome.html) at the FDA

Medical classification
Medical classification, or medical coding, is the process of transforming descriptions of medical diagnoses and procedures into universal medical code numbers. The diagnoses and procedures are usually taken from a variety of sources within the health care record, such as the transcription of the physician's notes, laboratory results, radiologic results, and other sources. Diagnosis codes are used to track diseases and other health conditions, whether they are chronic diseases such as diabetes mellitus and heart disease, to contagious diseases such as norovirus, the flu, and athlete's foot. These diagnosis and procedure codes are used by government health programs, private health insurance companies, workers' compensation carriers and others. Medical classification systems are used for a variety of applications in medicine, public health and medical informatics, including: statistical analysis of diseases and therapeutic actions reimbursement; e.g., based on diagnosis-related groups knowledge-based and decision support systems direct surveillance of epidemic or pandemic outbreaks

Classification types
Many different medical classifications exist, though they occur into two main groupings: Statistical classifications and Nomenclatures. A statistical classification brings together similar clinical concepts and groups them into categories. The number of categories is limited so that the classification does not become too big. An example of this is the International Statistical Classification of Diseases and Related Health Problems (known as ICD). It groups diseases of the circulatory system into one "chapter" (known as Chapter IX, covering codes I00I99). Within this chapter, there is for instance, code I47.1. The code title (rubric) is Supraventricular tachycardia. However, there are several other clinical concepts that are also classified here. Among them are paroxysmal atrial tachycardia, paroxysmal junctional tachycardia, auricular tachycardia and nodal tachycardia. Another feature of statistical classifications is the provision of residual categories for "other" and "unspecified" conditions that do not have a specific category in the particular classification. In a nomenclature there is a separate listing and code for every clinical concept. So, in the previous example, each of the tachycardia listed would have its own code. This makes nomenclatures unwieldy for compiling health statistics. Types of coding systems specific to health care include: Diagnostic codes - Are used to determine diseases,disorders, and Symptoms

Medical classification -Can be used to measure morbidity and mortality Examples: ICD-9-CM, ICD-10 Procedural codes -They are numbers or alphanumeric codes used to identify specific health interventions taken by medical professionals. Examples: ICPM, ICHI Pharmaceutical codes -Are used to identify medications Examples: AT, NDC Topographical codes -Are codes that indicate a specific location in the body Examples :ICD-O, SNOMED

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WHO Family of International Classifications


The World Health Organization (WHO) maintains several internationally endorsed classifications designed to facilitate the comparison of health related data within and across populations and over time as well as the compilation of nationally consistent data.[1] This "Family of International Classifications" (FIC) include three main (or reference) classifications on basic parameters of health prepared by the organization and approved by the World Health Assembly for international use, as well as a number of derived and related classifications providing additional details. Some of these international standards have been revised and adapted by countries for national use.

Reference classifications
International Statistical Classification of Diseases and Related Health Problems (ICD)[2] ICD-9 (9th revision, published in 1977) ICD-9-CM (Clinical Modification, used in the US) ICD-10 (10th revision, in use by WHO since 1994) ICD-10-CM (Clinical Modification, used in the US) ICD-10-PCS (Procedure Coding System, used in the US) ICD-10-CA (used for morbidity classification in Canada).[3] ICD-10-AM (used in Australia and New Zealand)[4] EUROCAT - an extension of the ICD-10 Q chapter for congenital disorders International Classification of Functioning, Disability and Health (ICF) International Classification of Health Interventions (ICHI) (previously known as International Classification of Procedures in Medicine)[5]

Medical classification

744

Derived classifications
Derived classifications are based on the WHO reference classifications (i.e. ICD and ICF).[1] They include: International Classification of Diseases for Oncology, Third Edition (ICD-O-3) ICD-10 for Mental and Behavioural Disorders[6] Application of the International Classification of Diseases to Dentistry and Stomatology, 3rd Edition (ICD-DA)[7] Application of the International Classification of Diseases to Neurology (ICD-10-NA)[]

Related classifications
Related classifications in the WHO-FIC are those that partially refer to the reference classifications, e.g. only at specific levels.[1] They include: International Classification of Primary Care (ICPC)[8] ICPC-2 PLUS International Classification of External Causes of Injury (ICECI)[9] Anatomical Therapeutic Chemical Classification System with Defined Daily Doses (ATC/DDD) Technical aids for persons with disabilities: Classification and terminology (ISO9999)[10] International Classification for Nursing Practice (ICNP)[11]

Other medical classifications


Diagnosis
The categories in a diagnosis classification classify [ and medical signs. In addition to the ICD and its national variants, they include: Diagnostic and Statistical Manual of Mental Disorders (DSM) DSM-IV Codes International Classification of Headache Disorders 2nd Edition (ICHD-II)[12] International Classification of Sleep Disorders (ICSD) Online Mendelian Inheritance in Man, database of genetic codes Read codes Systematized Nomenclature of Medicine - Clinical Terms (SNoMed-CT)

Procedure
The categories in a procedure classification classify specific health interventions undertaken by health professionals. In addition to the ICHI and ICPC, they include: Australian Classification of Health Interventions (ACHI) Canadian Classification of Health Interventions (CCI) [13] Chinese Classification of Heath Interventions (CCHI) Current Procedural Terminology (CPT) Health Care Procedure Coding System (HCPCS) ICD-10 Procedure Coding System (ICD-10-PCS) Office of Population, Censuses and Surveys Classification of Surgical Operations and Procedures (OPCS-4)

Medical classification

745

Other
Classification of Pharmaco-Therapeutic Referrals (CPR) Logical Observation Identifiers Names and Codes (LOINC), standard for identifying medical laboratory observations Medical Dictionary for Regulatory Activities (MedDRA) Medical Subject Headings (MeSH) List of MeSH codes Nursing Interventions Classification (NIC) Nursing Outcomes Classification (NOC) TIME-ITEM, ontology of topics in medical education TNM Classification of Malignant Tumors Unified Medical Language System (UMLS) Victoria Ambulatory Coding System (VACS) / Queensland Ambulatory Coding System (QACS), Australia[citation
needed]

Library classification that have medical components Dewey Decimal System and Universal Decimal Classification (section 610620) National Library of Medicine classification

ICD, SNOMED and Electronic Health Record (EHR)


What is SNOMED?
The Systematized Nomenclature of Medicine (SNOMED) is the most widely recognised nomenclature in healthcare.[14] Its current version, SNOMED Clinical Terms (SNOMED CT), is intended to provide a set of concepts and relationships that offers a common reference point for comparison and aggregation of data about the health care process.[15] SNOMED CT is often described as a reference terminology.[16] SNOMED CT contains more than 311,000 active concepts with unique meanings and formal logic-based definitions organised into hierarchies.[15] SNOMED CT can be used by anyone with an Affiliate License, 40 low income countries defined by the World Bank or qualifying research, humanitarian and charitable projects.[15] SNOMED-CT is designed to be managed by computer, and it is a complex relationship concepts.[14]

What is ICD?
The International Classification of Disease (ICD) is the most widely recognized medical classification maintained by the World Health Organization (WHO).[17] Its primary purpose is to categorise diseases for morbidity and mortality reporting. The United States has used a clinical modification of ICD (ICD-9-CM) for the additional purposes of reimbursement. ICD-10 was endorsed by WHO in 1990, and WHO Member states began using the classification system in 1994 for both morbidity and mortality reporting. In the US, however, it has only been used for reporting mortality since 1999. Because of the US delay in adopting its version of ICD-10, it is currently unable to compare morbidity data with the rest of the world. ICD has a hierarchical structure, and coding in this context, is the term applied when representations are assigned to the words they represent.[17] Coding diagnoses and procedures is the assignment of codes from a code set that follows the rules of the underlying classification or other coding guidelines.

Medical classification

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SNOMED CT vs ICD
SNOMED CT and ICD are designed for different purposes and each should each be used for the purposes for which it was designed.[18] As a core terminology for the EHR, SNOMED CT provides a common language that enables a consistent language that enables a consistent way of capturing, sharing, and aggregating health data across specialties and sites of care.[19] It is highly detailed terminology designed for input not reporting. Classification systems such as ICD-9-CM, ICD-10-CM, and ICD-10-PCS group together similar diseases and procedures and organise related entities for easy retrieval.[19] They are typically used for external reporting requirements or other uses where data aggregation is advantageous, such as measuring the quality of care monitoring resource utilisation, or processing claims for reimbursement. SNOMED is clinically-based, document whatever is needed for patient care and has better clinical coverage than ICD. ICDs focus is statistical with less common diseases get lumped together in catch-all categories, which result in loss of information. SNOMED CT is used directly by healthcare providers during the process of care, whereas ICD is used by coding professionals after the episode of care. SNOMED CT had multiple hierarchy, whereas single hierarchy for ICD. SNOMED CT concepts are defined logically by their attributes, whereas only textual rules and definitions in ICD.[19]

Data Mapping of SNOMED and ICD


SNOMED and ICD can be coordinated. The National Library of Medicine (NLM) maps ICD-9-CM, ICD-10-CM, ICD-10-PCS, and other classification systems to SNOMED.[20] Data Mapping is the process of identifying relationships between two distinct data models. The full value of the health information contained in an EHR system will only be realised if both systems involved in the map are up to date and accurately reflect the current practice of medicine.[17]

Clinical Coding in Australia


Medical coding and classification systems are expected to become increasingly important in the health care sector. Together with and as an integrated part of the electronic health information systems, the coding and classification systems will be used to improve the quality and effectiveness of the medical services.[21]

What is clinical coding?


Clinical coding is the translation of written, scanned and/or electronic clinical documentation about patient care into code format. For example, hypertension is represented by the code 'I10'; general anaethesia is represented by the code'92514-XX[1910]'. A standardised classification system, The International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification (ICD-10-AM), is applied in all Australian acute health facilities. It is based on the World Health Organisation (WHO) ICD-10 system, updated with the Australian Classification of Health Interventions (ACHI), Australian Coding Standards (ACS). Clinical coding is a specialised skill requiring excellent knowledge of medical terminology and disease processes, attention to detail, and analytical skills.[22]

Medical classification

747

What does clinical coder do?


A clinical coder is responsible for abstracting relevant information from the medical record and deciding which diagnoses and procedures meet criteria for coding as per Australian and State Coding Standards. The coder then assigns codes for these diagnoses and procedures based on ICD-10-AM conventions and standards.[22]

What is coded data used for?


The assigned codes and other patient data are processed by grouper software to determine a Diagnosis Related Group (DRG) for the episode of care, which is used for funding and reimbursement. This process allows hospital episodes to be grouped into meaningful categories, helping us to better match patient needs to health care resources.[23]

References
[1] World Health Organization. Family of International Classifications. (http:/ / www. who. int/ classifications/ en/ ) Accessed 12 July 2011. [2] World Health Organization. International Classification of Diseases (ICD). (http:/ / www. who. int/ classifications/ icd/ en/ ) [3] Canadian Institute for Health Information. ICD-10-CA. (http:/ / www. cihi. ca/ cihi-ext-portal/ internet/ en/ document/ standards+ and+ data+ submission/ standards/ classification+ and+ coding/ codingclass_icd10) Accessed 12 July 2011. [4] New Zealand Health Information Service. ICD-10-AM. (http:/ / www. nzhis. govt. nz/ moh. nsf/ pagesns/ 534) Accessed 12 July 2011. [5] WHO. ICHI. (http:/ / www. who. int/ classifications/ ichi/ en/ ) [6] WHO. ICD Greenbook (http:/ / www. who. int/ entity/ classifications/ icd/ en/ GRNBOOK. pdf) [8] WHO. ICPC-2. (http:/ / www. who. int/ classifications/ icd/ adaptations/ icpc2/ en/ ) [9] WHO. ICECI (http:/ / www. who. int/ classifications/ icd/ adaptations/ iceci/ en/ index. html). [10] WHO. Technical aids for persons with disabilities: Classification and terminology (ISO9999). (http:/ / www. who. int/ classifications/ icf/ iso9999/ en/ index. html) [11] WHO. International Classification for Nursing Practice (ICNP). (http:/ / www. who. int/ classifications/ icd/ adaptations/ icnp/ en/ index. html) [13] Canadian Classification of Health Interventions. CCI (http:/ / www. cihi. ca/ CIHI-ext-portal/ internet/ en/ document/ standards+ and+ data+ submission/ standards/ classification+ and+ coding/ codingclass_cci). [14] http:/ / www. ihtsdo. org/ snomed-ct/ [15] http:/ / www. nlm. nih. gov/ research/ umls/ Snomed/ snomed_faq. html#what [16] http:/ / sydney. edu. au/ medicine/ fmrc/ snomed/ [17] Margret k. Amatayakul,MBA,RHIA,CHPS,CPHIT,CPEHR&FHIMSS.(2009).Electronic Health Records: A Practical Guide for Professionals and Organizations.Chicago,America:AHIMA [18] http:/ / www. icd10watch. com/ blog/ why-snomed-cannot-replace-icd-10-cmpcs-code-sets [19] http:/ / ebookbrowse. com/ snomed-icd10-kwfung-pptx-d371532824 [20] http:/ / www. who. int/ classifications/ icd/ snomedCTToICD10Maps/ en/ [21] http:/ / www. ncbi. nlm. nih. gov/ pubmed/ 8191453 [22] http:/ / www. clinicalcoding. health. wa. gov. au/ about/ [23] http:/ / www. health. vic. gov. au

External links
WHO Family of International Classifications (http://www.who.int/classifications/en/) official site Medical terminologies at the National Library of Medicine (http://www.nlm.nih.gov/medical-terms.html)

Federal Insurance Contributions Act tax

748

Federal Insurance Contributions Act tax


Taxation in the United States
Federal Insurance Contributions Act (FICA) tax /fak/ is a United States Federal payroll (or employment) tax[1] imposed on both employees and employers to fund Social Security and Medicare[2] federal programs that provide benefits for retirees, the disabled, and children of deceased workers. Social Security benefits include old-age, survivors, and disability insurance (OASDI); Medicare provides hospital insurance benefits for the elderly. The amount that one pays in payroll taxes throughout one's working career is associated indirectly with the social security benefits annuity that one receives as a retiree.[citation needed] This has caused some to claim that the payroll tax is not a tax because its collection is tied to a benefit.[3] The United States Supreme Court decided in Flemming v. Nestor (1960) that no one has an accrued property right to benefits from Social Security. The Federal Insurance Contributions Act is currently codified at Title 26, Subtitle C, Chapter 21 of the United States Code.[4]

How the tax is calculated


Overview
The Center on Budget and Policy Priorities states that three-quarters of taxpayers pay more in payroll taxes than they do in income taxes.[6] The FICA tax is considered a regressive tax on income with no standard deduction or personal exemption deduction. It was imposed for the years 2009, 2010 and 2011 on only the first $106,800 of gross wages and increased to $110,100 in 2012 and $113,700 in 2013. The tax is not imposed on investment income such as interest and dividends.

Regularly employed people

For 2013, the employee's share of the Social Security portion of the FICA tax is 6.2% of gross compensation up to a limit of $113,700 of gross compensation (resulting in a maximum Social Security tax of $7,049.40).[7] This limit, known as the Social Security Wage Base, goes up each year based on average national wages and, in general, at a faster rate than the Consumer Price Index (CPI-U). For the calendar years of 2011 and 2012, the employee's share was temporarily reduced to 4.2% of gross compensation with a limit of $106,800 for 2011 and $110,100 for 2012.[8] The employee's share of the Medicare portion of the tax is 1.45% of wages, with no limit on the amount of wages subject to the Medicare portion of the tax.[9] Because some payroll compensation is subject to state income tax withholding in addition to Social Security tax withholding and Medicare tax withholding, the Social Security and Medicare taxes comprise only a portion of the total percentage an employee constructively pays.

Share of federal revenue from different tax sources. Individual income taxes (blue), payroll taxes/FICA (green), corporate income taxes [5] (red).

Federal Insurance Contributions Act tax

749

Year Rate Compensation Maximum Limit Tax 2005 6.2% 2006 6.2% 2007 6.2% 2008 6.2% 2009 6.2% 2010 6.2% 2011 4.2% 2012 4.2% 2013 6.2% $90,000 $94,200 $97,500 $102,000 $106,800 $106,800 $106,800 $110,100 $113,700 $5,580.00 $5,840.40 $6,045.00 $6,324.00 $6,621.60 $6,621.60 $4,485.60 $4,624.20 $7,049.40

|+ Employee's share of the Social Security portion of the FICA tax[10] The employer is also liable for 6.2% Social Security and 1.45% Medicare taxes,[11] making the total Social Security tax 12.4% of wages and the total Medicare tax 2.9%. (Self-employed people are responsible for the entire FICA percentage of 15.3% (= 12.4% + 2.9%), since they are in a sense both the employer and the employed; however, see the section on self-employed people for more details.) If a worker starts a new job halfway through the year and during that year has already earned an amount exceeding the Social Security tax wage base limit with the old employer, the new employer is not allowed to stop withholding until the wage base limit has been earned with the new employer (that is, without regard to the wage base limit earned under the old employer). There are some limited cases, such as a successor-predecessor employer transfer, in which the payments that have already been withheld can be counted toward the year-to-date total. If a worker has overpaid toward Social Security by having more than one job or by having switched jobs during the year, that worker can file a request to have that overpayment counted as a credit for tax paid when he or she files a Federal income tax return. If the taxpayer is due a refund, then the FICA tax overpayment is refunded.

Self-employed people
A tax similar to the FICA tax is imposed on the earnings of self-employed individuals, such as independent contractors and members of a partnership. This tax is imposed not by the Federal Insurance Contributions Act but instead by the Self-Employment Contributions Act of 1954, which is codified as Chapter 2 of Subtitle A of the Internal Revenue Code, 26 U.S.C.1401 [13] through 26 U.S.C.1403 [14] (the "SE Tax Act"). Under the SE Tax Act, self-employed people are responsible for the entire percentage of 15.3% (= 12.4% [Soc. Sec.] + 2.9% [Medicare]); however, the 15.3% multiplier is applied to 92.35% of the business's net earnings from self-employment, rather than 100% of the gross earnings; the difference, 7.65%, is half of the 15.3%, and makes the calculation fair in comparison to that of regular (non-self-employed) employees. It does this by adjusting for the fact that employees' 7.65% share of their SE tax is multiplied against a number (their gross income) that does

The effective payroll tax rate based on private simulations for different income groups. Effective tax rate equals the payroll taxes paid divided by total income. Total income includes traditional measures of income, imputed undistributed corporate profits, nontaxable employee benefits, income of retirees, and nontaxable income. Payroll taxes include employee and employer [12] FICA.

Federal Insurance Contributions Act tax not include the putative "employer's half" of the self-employment tax. In other words, it makes the calculation fair because employees don't get taxed on their employers' contribution of the second half of FICA, therefore self-employed people shouldn't get taxed on the second half of the self-employment tax. Similarly, self-employed people also deduct half of their self-employment tax (schedule SE) from their gross income on the way to arriving at their adjusted gross income (AGI). This levels the amount paid by self-employed persons in comparison to regular employees, who don't pay general income tax on their employers' contribution of the second half of FICA, just as they didn't pay FICA tax on it either.[15][16] These calculations are made on Schedule SE: Self-Employment Tax, although that is not readily apparent to novice self-employed taxpayers, owing to the schedule's rather opaque name, which makes it sound like it is part of the general federal income tax. Some taxpayers have complained that Schedule SE's title should be changed to something such as "Self-Employment FICA Tax", so that its separateness from the general income tax is apparent,[citation needed] perhaps not realizing that the SE tax is not imposed by the Federal Insurance Contributions Act (FICA) at all, and that neither SE taxes nor FICA taxes are "income taxes" imposed under Chapter 1 of the Internal Revenue Code.

750

Exemption for certain full-time students


A special case in FICA regulations includes exemptions for student workers. Students enrolled at least half-time in a university and working part-time for the same university are exempted from FICA payroll taxes, so long as their relationship with the university is primarily an educational one.[17] Medical residents working full-time are not considered students and are not exempt from FICA payroll taxes, according to a US Supreme Court ruling in 2011.[18] In order to be exempt from FICA payroll taxes, a student's work must be "incident to" pursuit of a course of study, which is rarely the case with full-time employment.[18]

Exempted government employees


A number of state and local employers and their employees in the states of Alaska, California, Colorado, Illinois, Louisiana, Maine, Massachusetts, Nevada, Ohio and Texas are currently exempt from paying the Social Security portion of FICA taxes. They provide alternative retirement and pension plans to their employees. FICA initially did not apply to state and local governments, which were later given the option of participating. Over time, most have elected to participate but a substantial number remain outside the system.[19]

History
Prior to the Great Depression, the following presented difficulties for working-class Americans: [21] The U.S. had no federal-government-mandated retirement savings; consequently, for those people who had not voluntarily saved money throughout their working lives, the end of their work careers was the end of all income. Similarly, the U.S. had no federal-government-mandated disability income insurance to provide for citizens disabled by injuries (of any kindnon-work-related); consequently, for most people, a disabling injury meant no more income (since most people have little to no income except earned income from work).

Historical payroll tax rates for Social Security (blue), Medicare (red) and total (purple). The tax rates shown include both employee and employer [20] contributions.

In addition, there was no federal-government-mandated disability income insurance to provide for people unable to ever work during their lives, such as anyone born with severe mental retardation.

Federal Insurance Contributions Act tax Further, the U.S. had no federal-government-mandated health insurance for the elderly; consequently, for many people, the end of their work careers was the end of their ability to pay for medical care. In the 1930s, the New Deal introduced Social Security to rectify the first three problems (retirement, injury-induced disability, or congenital disability). It introduced the FICA tax as the means to pay for Social Security. In the 1960s, Medicare was introduced to rectify the fourth problem (health care for the elderly). The FICA tax was increased in order to pay for this expense. In December 2010, as part of the legislation that extended the Bush tax cuts (called the Tax Relief, Unemployment Insurance Reauthorization, and Job Creation Act of 2010, the government negotiated a temporary, one-year reduction in the FICA payroll tax. In February 2012, the tax cut was extended for another year.[22]

751

Criticism
Social Security regressivity debate
The Social Security component of the FICA tax is regressive, meaning the effective tax rate regresses (decreases) as income increases beyond the compensation limit.[23] The Social Security component is a flat tax for wage levels under the Social Security Wage Base (see "Regular" employees above). Since no tax is owed on wages above the Wage Base limit, the total tax rate declines as wages increase beyond that limit. In other words, for wage levels above the limit, the absolute dollar amount of tax owed remains constant. FICA tax also is not collected on unearned income, including interest on savings deposits, stock dividends, and capital gains such as profits from the sale of stock or real estate. The proportion of total income which is exempt from FICA tax as "unearned income" tends to rise with higher income brackets. Some argue that since Social Security taxes are eventually returned to taxpayers, with interest, in the form of Social Security benefits, the regressiveness of the tax is effectively negated.[citation needed] That is, the taxpayer gets back what he or she put into the Social Security system. Others, including The Economist and the Congressional Budget Office, point out that the Social Security system as a whole is progressive in the lower income brackets; individuals with lower lifetime average wages receive a larger benefit (as both a percentage of their lifetime average wage income and a percentage of Social Security taxes paid) than do individuals with higher lifetime average wages.[24][25][26]

References
[1] The FICA tax is imposed under the Federal Insurance Contributions Act, which is codified as [3] Kevin A. Hassett, March 29, 2005, "Is the Payroll Tax a Tax?" National Review Online, at (http:/ / www. nationalreview. com/ nrof_hassett/ hassett200503290921. asp). [4] CHAPTER 21Federal Insurance Contributions Act (http:/ / www. law. cornell. edu/ uscode/ 26/ usc_sup_01_26_10_C_20_21. html) from the Legal Information Institute at Cornell Law School [5] JCX-49-11, Joint Committee on Taxation, September 22, 2011, pp 4, 50. http:/ / www. jct. gov/ publications. html?func=startdown& id=4363 [6] Studies Shed New Light on Effects of Administration's Tax Cuts (http:/ / www. cbpp. org/ 8-25-04tax. htm) by David Kamin and Isaac Shapiro, Center on Budget and Policy Priorities, Revised September 13, 2004 [7] U.S. Social Security Administration, at (http:/ / www. ssa. gov/ policy/ docs/ quickfacts/ prog_highlights/ index. html). [8] IRS Publication 15 (2011) (http:/ / www. irs. gov/ publications/ p15/ ar02. html) [9] Revenue Code Section 3101 (http:/ / www. taxalmanac. org/ index. php/ Internal_Revenue_Code:Sec. _3101. _Rate_of_taxInternal). Tax Almanac. [10] http:/ / www. ssa. gov/ policy/ docs/ quickfacts/ prog_highlights/ index. html [11] Internal Revenue Code Section 3111 (http:/ / www. taxalmanac. org/ index. php/ Internal_Revenue_Code:Sec. _3111. _Rate_of_tax). Tax Almanac. [12] Table T11-0099, Effective Federal Tax Rates Under Current Law, By Total Income Percentile, 2010, Tax Policy Center. http:/ / www. taxpolicycenter. org/ numbers/ displayatab. cfm?DocID=2980 [13] http:/ / www. law. cornell. edu/ uscode/ 26/ 1401. html [14] http:/ / www. law. cornell. edu/ uscode/ 26/ 1403. html

Federal Insurance Contributions Act tax


[15] I am self-employed. How do I pay Social Security tax? (http:/ / ssa-custhelp. ssa. gov/ cgi-bin/ ssa. cfg/ php/ enduser/ std_adp. php?p_faqid=172). Social Security Administration. Retrieved on April 28, 2007. [16] Self-Employment Tax (http:/ / www. irs. gov/ businesses/ small/ article/ 0,,id=98846,00. html). Internal Revenue Service. Retrieved on April 28, 2007. [17] Rev. Proc. 2005-11 (http:/ / www. irs. gov/ pub/ irs-drop/ rp-05-11. pdf) (pdf). Internal Revenue Service. Page 5. April 1, 2005. [18] Mayo Foundation for Medical Education and Research Et Al. v. United States (http:/ / www. supremecourt. gov/ opinions/ 10pdf/ 09-837. pdf) (pdf). Supreme Court of the United States. January 11, 2011. [19] The FICA Free-Lunch Crowd (http:/ / www. governing. com/ columns/ public-money/ FICA-free-lunch-crowd. html), Girard Miller, Governing, August 12, 2010. [20] http:/ / www. taxpolicycenter. org/ taxfacts/ displayafact. cfm?Docid=45 [21] Historical Background and Development of Social Security (http:/ / www. ssa. gov/ history/ briefhistory3. html) Social Security Administration [23] Social Security Snares & Delusions (http:/ / www. weeklystandard. com/ Content/ Public/ Articles/ 000/ 000/ 005/ 112wkrxa. asp?pg=2) by Irwin Stelzer, The Weekly Standard. Retrieved July 23, 2008 [24] Is Social Security Progressive? (http:/ / www. cbo. gov/ ftpdocs/ 77xx/ doc7705/ 12-15-Progressivity-SS. pdf) by the Congressional Budget Office, retrieved July 23, 2008

752

External links
Annual maximum taxable earnings and contribution rates, 1937-2006 (http://www.ssa.gov/history/pdf/t2a3. pdf), from the Social Security Administration Summary of Social Security Amendments of 1983 (http://www.ssa.gov/history/1983amend.html), from the Social Security Administration Student Exception to FICA Tax (http://www.irs.gov/charities/article/0,,id=120663,00.html), from the Internal Revenue Service Go Ahead and Lift the Cap (http://www.dollarsandsense.org/archives/2008/0308miller.html) article discussing recent US presidential campaign plans regarding payroll taxes, Dollars & Sense magazine, March/April 2008

Federal Medical Assistance Percentages

753

Federal Medical Assistance Percentages


Federal Medical Assistance Percentages (FMAP) are the percentage rates used to determine the matching funds rate allocated annually to certain medical and social service programs in the United States of America. FMAP eligible programs are joint federal-state partnerships between the federal government of the United States and state governments, which are administered by the states.[1][2] Thus, FMAP is an example of administration of federal assistance in the United States. Funds that are eligible for FMAP match include Medicaid, State Children's Health Insurance Program (SCHIP) expenditures, Temporary Assistance for Needy Families (TANF) Contingency Funds, the Federal share of Child Support Enforcement collections, and Child Care Mandatory and Matching Funds of the Child Care and Development Fund.[3] State governments use FMAP percentages to determine the federal government's contribution to specific state administered programs and assess their related budgetary outlays. For example, the 2006-2007 FMAP rate for California was 50% - therefore, for every dollar that California contributed to an eligible social or medical program between 2006 and 2007, the federal government also contributed one dollar.[4]

History
Pursuant to Section 1905(b) of the Social Security Act, the Secretary of Health and Human Services calculates the Federal Medical Assistance Percentages each year. This calculation is based upon a formula which compares individual state income to the continental United States income in order to determine ratios the federal government will utilize in assisting each state under the Act. This section also provides that no state's ratio will go lower than 50% or higher than 83%. The guidelines for calculating the FMAP are outlined in the Social Security Act and they exclusively determine the ratio of matching funds for each state's Medicaid program. Section 2105(b)of the Act stipulate that "Enhanced Federal Medical Assistance Percentages," or Enhanced FMAPs, will be calculated at the same time as the FMAPs. Enhanced FMAPs provide ratios for states to follow in funding their State Children's Health Insurance Program, or SCHIP.

Notes
[1] Overview (http:/ / www. cms. hhs. gov/ MedicaidGenInfo/ ) [2] ACF Office of Public Affairs (OPA): Fact Sheet - Office of Family Assistance (TANF) (http:/ / www. acf. hhs. gov/ opa/ fact_sheets/ tanf_factsheet. html) [3] http:/ / a257. g. akamaitech. net/ 7/ 257/ 2422/ 01jan20051800/ edocket. access. gpo. gov/ 2005/ pdf/ 05-23392. pdf [4] Medicaid (http:/ / www. ncsl. org/ statefed/ health/ MA. htm)

1. National Conference of State Legislatures, "Federal Medical Assistance Percentages (FMAP) FY 2007 Calculations" (http://www.ncsl.org/statefed/health/MA.htm). Retrieved on February 13, 2007. 2. Federal Register / Vol. 70, No. 229 / Wednesday, November 30, Department of Health and Human Services, Federal Financial Participation in State Assistance Expenditures; Federal Matching Shares for Medicaid, the State Childrens Health Insurance Program, and Aid to Needy Aged, Blind, or Disabled Persons for October 1, 2006 Through September 30 (http://a257.g.akamaitech.net/7/257/2422/01jan20051800/edocket.access.gpo.gov/ 2005/pdf/05-23392.pdf) 3. http://aspe.hhs.gov/health/fmap.htm

International medical graduate

754

International medical graduate


An international medical graduate (IMG), earlier known as a foreign medical graduate (FMG), is a physician who has graduated from a medical school outside of the country where he or she intends to practice. Generally, the medical school of graduation is one listed in the International Medical Education Directory (IMED) as accredited by the Foundation for Advancement of International Medical Education and Research or the World Health Organization. Medical schools around the world vary in education standards, curricula, and evaluation methods. The purpose of ECFMG Certification is to assess the readiness of international medical graduates to enter clinical specialty training programs as resident physicians and fellowship programs in the United States.

License requirements by country


The requirements to obtain a license to practice varies by country and often by state or province.

Australia
IMGs who wish to be licensed in Australia must obtain certification from the Australian Medical Council (AMC). To do so, an IMG must obtain an AMC certificate and sit for a series of exams. Those IMGs who have passed the necessary exams and obtained AMC certification can then apply to an Australian specialty training positions.[1] Australia is in the process of establishing a national registration process for all the doctors under Medical Board of Australia. There is still lot of inconsistency and unpredictability in the process of accreditation and registration process of international medical graduates in Australia. An urgent enquiry with a report was requested by the minister of health and ageing on the matter regarding the registration process and support for international medical graduates currently employed in Australia.[2]

Canada
Several organizations have put pressure on the government such as the Association For Access to Health Care Services and Association of International Physicians and Surgeons of Ontario. 20 months ago, the McGuinty Ontario government passed Bill 97, Increasing Access to Qualified Health Professionals for Ontarians Act 2008 that requires the College of Physicians and Surgeons to provide adequate numbers of doctors by issuing transitional licenses. However, the college has refused to obey the law. In addition to undergoing the regular licencing process as required of all Canadian medical school graduates, IMGs must pass the LMCC Evaluating Examination. IMGs in Canada also have a harder time getting into residency programs compared to Canadian graduates only ten percent of IMG applicants get a position.[3] Graduates of United States M.D. programs are not considered IMGs and are thus exempt from the Evaluating Examination; graduates of U.S. osteopathic medical schools are considered IMGs.[4]

International medical graduate

755

United States
Graduates of Canadian M.D. programs are not considered IMGs in the United States.[5] Pathway The main pathway for IMGs who wish to be licensed as physicians in the United States is to complete a U.S. residency hospital program. The general method to apply for residency programs is through the National Resident Matching Program (abbreviated NRMP, also called "the Match"). To participate in the NRMP, an IMG is required to have an ECFMG certification[6] by the "rank order list certification deadline" time (usually in February of the year of the match).[7] To acquire an ECFMG certification, the main requirements are:[8] Completion of USMLE Step 1, USMLE Step 2 Clinical Knowledge and USMLE Step 2 Clinical Skills A medical diploma of medical education taken at an institution registered in the International Medical Education Directory (IMED) In comparison, regular graduates from medical schools in the United States and Canada need to complete USMLE Steps 1 and 2 as well, but can participate in the NRMP while still doing their final year of medical school before acquiring their medical diplomas.[9] In effect, taking regular administrative delays into account, and with residency programs starting around July, there is a gap of at least half a year for IMGs between graduation from medical school and beginning of a residency program. Those IMGs who have passed the necessary USMLE exams and obtained the ECFMG certification can then apply to U.S. residency positions via the NRMP and ERAS. One study came to the result that almost half of IMGs were unsuccessful in their first attempts in the pursuit of a U.S. residency position, and three-quarters began a residency after five years.[10] It also indicated that IMGs were considerably older when they first applied for a residency position than are most U.S. medical graduates, with mean age of IMGs when the ECFMG certificate was issued being 31.3 years, with a standard deviation of 5.6 years.[10] Origin by country

International medical graduate

756

Country of medical school Percentage of IMGs Total number (2007) India Philippines Mexico Pakistan Dominican Republic Former USSR Grenada Egypt Korea Italy China Iran Spain Dominica Germany Syria Colombia Israel United Kingdom Montserrat 19.9% 8.7% 5.8% 4.8% 3.3% 2.5% 2.4% 2.2% 2.1% 2.1% 2.1% 2.0% 1.9% 1.9% 1.9% 1.5% 1.8% 1.4% 1.4% 1.3% 47,581 20,861 13,929 11,330 7,892 6,039 5,708 5,202 4,982 4,978 4,834 4,741 4,570 4,501 4,457 3,676 3,335 3,260 3,245 3,111

Source: 2007 AMA Masterfile[11]

Quality of care
An analysis among patients with congestive heart failure or acute heart attack in Pennsylvania, United States, found that patients of international medical graduates that entered medical school as non-U.S. citizens had the lowest death rates. There was not statistically significant difference in mortality between patients of all international medical graduates and U.S. medical graduates. There was a statistically significant lowering of mortality by U.S. medical graduates when compared to U.S.-citizen international medical graduates alone, but the odds ratio failed to show the difference was not due to factors outside of the study parameters.[] When U.S. citizen international medical graduates were compared to non-U.S. citizen international medical graduates, the difference was "striking" consistent with previous research which found U.S. citizens who graduated from foreign medical schools, particularly from Caribbean medical schools,[] were associated with lower scores in other types of evaluations (e.g., specialty board scores) than other graduates.[]

International medical graduate

757

References
[1] http:/ / www. amc. org. au/ prelim1. asp [2] http:/ / www. amplelife. org [3] readersdigest.ca - Why Is Canada Shutting Out Doctors? (http:/ / www. readersdigest. ca/ health/ healthy-living/ why-canada-shutting-out-doctors): "In 2003, 625 international graduates competed. Only 67about ten percentfound a position" [6] nrmp.org > Independent Applicants (http:/ / www. nrmp. org/ res_match/ special_part/ ind_app/ verif_new. html) Updated 09/08/2010. [7] nrmp.org > 2012 Main Match Schedule (http:/ / www. nrmp. org/ res_match/ yearly. html) Updated 05/19/2011 [8] ecfmg.org > Medical Education Credentials (http:/ / www. ecfmg. org/ 2011ib/ ibmec. html) Last update: September 15, 2010 [9] nrmp.org > U.S. Seniors > Registering with the NRMP (http:/ / www. nrmp. org/ res_match/ special_part/ us_seniors/ registration. html) Updated August 2010 [10] Participation in U.S. Graduate Medical Education by Graduates of International Medical Schools (http:/ / www. medscape. com/ viewarticle/ 742193?src=mp& spon=25) By Jolly, Paul PhD; Boulet, John PhD; Garrison, Gwen PhD; Signer, Mona M. MPH. Posted: 05/23/2011; Academic Medicine. 2011;86(5):559-564. [11] Origin by Country, American Medical Association, http:/ / www. ama-assn. org/ ama/ pub/ about-ama/ our-people/ member-groups-sections/ international-medical-graduates/ imgs-in-united-states/ imgs-country-origin. shtml

External links
Educational Commission for Medical Graduates (http://www.ecfmg.org) United States Medical Licensing Exam (USMLE) (http://www.usmle.org) National Resident Matching Program (http://www.nrmp.org)

Family and Medical Leave Act of 1993

758

Family and Medical Leave Act of 1993


Family and Medical Leave Act of 1993

Long title

An Act To grant family and temporary medical leave under certain circumstances.

Colloquial acronym(s) FMLA Enacted by the 103rd United States Congress Citations Public Law Stat. Pub.L. 1033 107Stat.6 [2] Legislative history Introduced in the House as H.R. 1 [4] [3] [1]

by William D. Ford (D-MI) on January 5, 1993 [5]

Committee consideration by: House Education and Labor, House Post Office and Civil Service Passed the House on February 3, 1993 (265163 Passed the Senate on February 4, 1993 (7127 )

[6]

) with amendment [7] , 247152 [8] )

House agreed to Senate amendment on February 4, 1993 (Via H.Res. 71 Signed into law by President Bill Clinton on February 5, 1993

The Family and Medical Leave Act of 1993 (FMLA) is a United States federal law requiring covered employers to provide employees job-protected and unpaid leave for qualified medical and family reasons. Qualified medical and family reasons include: personal or family illness, family military leave, pregnancy, adoption, or the foster care placement of a child.[9] The FMLA is administered by the Wage and Hour Division of the United States Department of Labor. The bill was a major part of President Bill Clinton's agenda in his first term. President Clinton signed the bill into law on February 5, 1993 (Pub.L. 1033 [1]; 29 U.S.C. sec. 2601; 29 CFR 825) and it took effect on August 5, 1993, six months later. The FMLA was intended "to balance the demands of the workplace with the needs of families."[10] The Act allows eligible employees to take up to 12 work weeks of unpaid leave during any 12-month period to attend to the serious health condition of the employee, parent, spouse or child, or for pregnancy or care of a newborn child, or for adoption or foster care of a child. In order to be eligible for FMLA leave, an employee must have been at the business at least 12 months, and worked at least 1,250 hours over the past 12 months, and work at a location where the company employs 50 or more employees within 75 miles. The FMLA covers both public- and private-sector employees, but certain categories of employees are excluded, including elected officials and their personal staff members.[11]

Family and Medical Leave Act of 1993

759

Provisions
In 2007, the Department of Labor estimated that of the 141.7 million workers in the United States, 94.4 million worked at FMLA-covered worksites, and 76.1 million were eligible for FMLA leave. Between 8 percent and 17.1 percent of covered and eligible workers (or between 6.1 million and 13.0 million workers) took FMLA leave in 2005.[12] The 2008 National Survey of Employers found no statistically significant difference between the proportion of small employers (79%) and large employers (82%) that offer full FMLA coverage.[13]

Benefits for Employees Mandated by the Law


To qualify for the FMLA mandate, a worker must be employed by a business with 50 or more employees within a 75-mile radius of his or her worksite, or a public agency, including schools and state, local, and federal employers (the 50-employee threshold does not apply to public agency employees and local educational agencies). He or she must also have worked for that employer for at least 12 months (not necessarily consecutive) and 1,250 hours within the last 12 months. (There are special hours rules for certain airline employees.[14]) The FMLA mandates unpaid, job-protected leave for up to 12 weeks a year: to care for a new child, whether for the birth of a son or daughter, or for the adoption or placement of a child in foster care; to care for a seriously ill family member (spouse, son, daughter, or parent) (Note: Son/daughter has been clarified by the Department of Labor to mean a child under the age of 18 or a child over the age of 18 with a mental or physical disability as defined by the American Disabilities Act, which excludes among other conditions, pregnancy and post-partum recovery from childbirth);[15] to recover from a workers own serious illness; to care for an injured service member in the family; or to address qualifying exigencies arising out of a family members deployment. The FMLA further requires employers to provide for eligible workers: The same group health insurance benefits, including employer contributions to premiums, that would exist if the employee were not on leave. Restoration to the same position upon return to work. If the same position is unavailable, the employer must provide the worker with a position that is substantially equal in pay, benefits, and responsibility. Protection of employee benefits while on leave. An employee is entitled to reinstatement of all benefits to which the employee was entitled before going on leave. Protection of the employee to not have their rights under the Act interfered with or denied by an employer. Protection of the employee from retaliation by an employer for exercising rights under the Act. Intermittent FMLA leave for his or her own serious health condition, or the serious health condition of a family member. This includes occasional leave for doctors appointments for a chronic condition, treatment (e.g., physical therapy, psychological counseling,chemotherapy), or temporary periods of incapacity (e.g., severe morning sickness, asthma attack).[16]

Family and Medical Leave Act of 1993

760

Non-eligible workers and types of leave


The federal FMLA does not apply to: workers in businesses with fewer than 50 employees (this threshold does not apply to public agency employers and local educational agencies); part-time workers who have worked fewer than 1,250 hours within the 12 months preceding the leave and a paid vacation; workers who need time off to care for seriously ill elderly relatives (other than parents) or pets; workers who need time off to recover from short-term or common illness like a cold, or to care for a family member with a short-term illness; elected officials; and workers who need time off for routine medical care, such as check-ups.

State-level FMLA benefits


Some states have enacted laws that mandate additional family and medical leave for workers in a variety of ways.

Dropping the employer threshold


The federal FMLA only applies to employers with 50 or more employees. Some states have enacted their own FMLAs that have a lower threshold for employer coverage: Maine: 15 or more employees (private employers)[17] and 25 or more (city or town employers).[18] Minnesota: 21 or more employees (parental leave only).[19] Oregon: 25 or more employees.[20] Rhode Island: 50 or more employees (private employers)[21] and 30 or more employees (public employers).[22] Vermont: 10 or more employees (parental leave only)[23] and 15 or more employees (family and medical leave).[24] Washington: 50 or more employees (FMLA reasons besides insured parental leave);[25] all employers are required to provide insured parental leave.[26][27] District of Columbia: 20 or more employees.[28]

Expanding the definition of family


The federal FMLA only applies to immediate familyparent, spouse, and child. The 2008 amendments to the FMLA for military family members extend the FMLAs protection to next of kin and to adult children. The Department of Labor on June 22, 2010 clarified the definition of "son and daughter" under the FMLA "to ensure that an employee who assumes the role of caring for a child receives parental rights to family leave regardless of the legal or biological relationship" and specifying that "an employee who intends to share in the parenting of a child with his or her same sex partner will be able to exercise the right to FMLA leave to bond with that child."[29] Some states had already expanded the definition of family in their own FMLAs: California: Domestic partner and domestic partners child.[30] Connecticut: Civil union partner,[31] parent-in-law.[32] Hawaii: Grandparent, parent-in-law, grandparent-in-law[33] or an employee's reciprocal beneficiary.[34] Maine: Domestic partner and domestic partners child,[35] siblings.[36] New Jersey: Civil union partner and child of civil union partner,[37] parent-in-law, step parent.[38] Oregon: Domestic partner,[39] grandparent, grandchild or parent-in-law.[40] Rhode Island: Domestic partners of state employees, parent-in-law.[41]

Vermont: Civil union partner,[42] parent-in-law.[43] Wisconsin: Parent-in-law.[44]

Family and Medical Leave Act of 1993 District of Columbia: Related to the worker by blood, legal custody, or marriage; person with whom the employee lives and has a committed relationship; child who lives with employee and for whom employee permanently assumes and discharges parental responsibility.[45]

761

Increasing the uses for FMLA leave


FMLA leave can be used for a workers serious health condition, the serious health condition of a family member, or upon the arrival of a new child. State FMLA laws and the new military family provisions of the FMLA have broadened these categories: Connecticut: Organ or bone marrow donor.[46] Maine: Organ donor;[47] death of employees family member if that family member is a servicemember killed while on active duty.[48] Oregon: Care for the non-serious injury or illness of a child requiring home care.[49]

Other unpaid leave statutes


Several states have passed FMLA-type statutes to give parents unpaid leave to attend their childs school or educational activities. Examples include: California,[50] District of Columbia,[51] Massachusetts,[52] Minnesota,[53] Rhode Island,[54] Vermont.[55] Some states have passed FMLA-type statutes to give workers unpaid leave to take family members to routine medical visits, including Massachusetts[56] and Vermont.[57] And states have passed FMLA-type statutes to give workers unpaid leave to address the effects of domestic violence, stalking, or sexual assault. Examples include Colorado,[58] Florida,[59] Hawaii,[60] and Illinois.[61]

Controversy
Critics of the act have suggested that by mandating various forms of leave that are used more often by female than male employees, the Act, like the Pregnancy Discrimination Act of 1978, makes women more expensive to employ than men. They argue that employers will engage in subtle discrimination against women in the hiring process, discrimination which is much less obvious to detect than pregnancy discrimination against the already hired. Supporters counter that the act, in contrast to the Pregnancy Discrimination Act of 1978, is aimed at both women and men, and is part of an overall strategy to encourage both men and women to take family-related leave. In January, 2011, two grieving parents, Kelly Farley of Chicago and Barry Kluger, of Scottsdale, Arizona, began a national petition to urge Congress to amend the Family Medical Leave Act of 1993 to include loss of a child, which currently is not covered in the national bill nor the states, although Maine offers leave for a service member killed in action.The Farley-Kluger Initiative is supported by 18 national organizations, including: Parents of Murdered Children (POMC), the military organizations Blue Star Families, Marine Parents.com, Gold Star Family Support, The JED Foundation (college-age suicide), The American Institute of Healthcare Professionals, The American Academy of Grief Counselors, The Children's Bereavement Center, the M.I.S.S. Foundation and others. http:/ / www. farleykluger. com On February 5, 2013, the 20th anniversary of the FMLA being signed into law by President Clinton, Congressman Steve Israel (D-NY), introduced the Sarah Grace-Farley-Kluger Act in the House of Representatives (HR515) with a companion bill introduced the same day by Sen.Jon Tester (D-MT), inspired by signatures and letters received from the Farley-Kluger Initiative Petition, The Parental Bereavement Act of 2013 (S226). as of April 15, 2013, there are 16 House sponsors and seven Senate Sponsors.

Family and Medical Leave Act of 1993

762

References
[1] [2] [3] [4] [5] [6] [7] [8] [9] http:/ / www. law. cornell. edu/ jureeka/ index. php?doc=USPubLaws& cong=103& no=3 http:/ / www. gpo. gov/ fdsys/ granule/ STATUTE-107/ STATUTE-107-Pg6/ content-detail. html http:/ / thomas. loc. gov/ cgi-bin/ bdquery/ z?d103:HR00001:@@@S http:/ / hdl. loc. gov/ loc. uscongress/ legislation. 103hr1 http:/ / clerk. house. gov/ evs/ 1993/ roll022. xml http:/ / www. senate. gov/ legislative/ LIS/ roll_call_lists/ roll_call_vote_cfm. cfm?congress=103& session=1& vote=00011 http:/ / hdl. loc. gov/ loc. uscongress/ legislation. 103hres71 http:/ / clerk. house. gov/ evs/ 1993/ roll029. xml "Family and Medical Leave Act," Stephen Bruce. HR Daily Advisor. (http:/ / hrdailyadvisor. blr. com/ archive/ category/ 1011. aspx) Retrieved on 20 September 2011. [10] "Findings and Purposes," 29 U.S.C. 2601 http:/ / www. dol. gov/ whd/ regs/ statutes/ fmla. htm [11] 29 U.S.C. 2611 [12] "Family and Medical Leave Act Regulations: A Report on the Department of Labors Request for Information." 28 June 2007. Department of Labor, Employment Standards Administration, Wage and Hour Division. Federal Register, Vol. 72, No. 124. (http:/ / www. dol. gov/ esa/ whd/ FMLA2007FederalRegisterNotice/ 07-3102. pdf) [13] Galinsky, E., Bond, J., Sakai, K., Kim, S., Giuntoli, N. 2008. National study of employers. New York, NY: Families and Work Institute. (http:/ / www. familiesandwork. org/ site/ research/ reports/ 2008nse. pdf) [17] 26 Me. Rev. Stat. Ann. tit. 26 *843 (3)(A) [18] 26 Me. Rev. Stat. Ann. tit. 26 843 (3)(C) [19] Minn. Stat. 181.940 (Subd. 3) [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [34] [35] [36] [37] [38] [39] [40] [41] [42] [43] [44] [45] [46] [47] [48] [49] [50] [51] [52] [53] Or. Rev. Stat. 659A.153 (1) R.I. Pub. Laws 28-48-1(3)(i) R.I. Pub. Laws 28-48-1(3)(iii) 23 VSA 471(4) 23 VSA 471(3) RCW 49.78.020(5) RCW 49.86.010 (6)(a) RCW 50.50.080(1) D.C. Code 32-516(2) News Release Number: 10-0877-NAT Cal. Fam. Code 297.5 Conn. Gen. Stat. 46b-38nn Conn. Gen. Stat. 31-51kk (7) Haw. Rev. Stat. 398.1 Haw. Rev. Stat. 398.3 26 ME. Rev. Stat. Ann. 843 (4)(D) LD 2132 N.J. Stat. Ann. 37:1-31 N.J. Stat Ann. 34-11B(3)(h) HB 2007 OR. Rev. Stat. 659A.150 (4) R.I. Pub. Laws 24-48-1(5) 23 VSA 1204(a) 23 VSA 471(3)(B) Wis. Stat. 103.10(1)(f) D.C. Code 32-501(A), (B), (C) Conn. Gen. Stat. 31-51ll (2)(E) 26 ME. Rev. Stat. Ann. 843 (4)(E) 26 ME. Rev. Stat. Ann. 843 (4)(F) OR. Rev. Stat. 659A.159 (d) Cal. Lab. Code 230.8 D.C. Code 32-1202 Mass. Gen. Laws. Ch. 149 52(D)(b)(1) Minn. Stat. 181.9412

[54] R.I. Pub. Laws 24-48-12 [55] 23 VSA 472a (a)(1) [56] Mass. Gen. Laws. Ch. 149 52(D)(b)(2)&(3)

Family and Medical Leave Act of 1993


[57] [58] [59] [60] [61] 23 VSA 472a (a)(2) Colo. Rev. Stat. 24-34-402.7 FLA. STAT. 741.313 Haw. Rev. Stat. 378-72 820 Ill. Comp. Stat. 180/1-180/45

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External links
Family and Medical Leave Act of 1993 (http://www.dol.gov/whd/fmla/index.htm) 29 U.S. Code Chapter 28 Department of Labor Family & Medical Leave information pages (http://www.dol.gov/dol/topic/ benefits-leave/fmla.htm) Senate roll call vote (http://www.senate.gov/legislative/LIS/roll_call_lists/roll_call_vote_cfm. cfm?congress=103&session=1&vote=00011) House roll call vote (http://clerk.house.gov/evs/1993/roll022.xml) Nevada Dept. of Human Resources v. Hibbs (http://www.law.cornell.edu/supct/search/display. html?terms=nevada&url=/supct/html/01-1368.ZS.html) Discrimination.com's FMLA Info Page (http://discrimination.com/pregnancydiscrimination.htm) A Child's Wish (http://www.imdb.com/title/tt0118846/) at the Internet Movie Database - A made-for-TV film about the act in which President Clinton appears briefly as himself. http://paidsickdays.nationalpartnership.org/site/ PageServer?pagename=ourwork_fmla_FamilyandMedicalLeave http://www.nationalpartnership.org/site/DocServer/WF_PL_FactSheet_PaidFamilyLeave_2009. pdf?docID=4682&autologin=true FMLA Insights http://www.fmlainsights.com: a blog authored by Franczek Radelet attorney Jeff Nowak (http://www.franczek.com/attorneys-42.html) to help employers understand and administer FMLA and to keep employers up to date on changes in the FMLA

Nurse practitioner

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Nurse practitioner
A nurse practitioner (NP) is an advanced practice registered nurse (APRN) who has completed additional training beyond that of a registered nurse (RN).

Overview
Nurse practitioners treat both physical and mental conditions through comprehensive history taking, physical exams, and ordering tests for interpretation. NPs can provide a diagnosis and recommendations for a wide range of acute and chronic diseases (within their scope of practice) and provide appropriate treatment for patients, including prescribing medications in some states.[1] NPs can serve as a patient's primary health care provider, and see patients of all ages depending on their specialty (family, pediatrics, geriatrics, etc.). Similar to all medical professions, the core philosophy of the field is individualized care that focuses on patients' conditions as well as the effects of illness on the lives of the patients and their families. Like all medical care providers, NPs make prevention, wellness, and patient education priorities. In addition to providing health care services, NPs may conduct research and are often active in patient advocacy activities. To become licensed to practice, Nurse Practitioners must be board certified in an area (such as family medicine, women's health, pediatrics, adult medicine, acute care, etc.), and are licensed through the state nursing boards. NPs must practice within the scope of their certification. According to the International Council of Nurses, an NP/advanced practice nurse is "a registered nurse who has acquired the knowledge base, decision-making skills and clinical competencies for expanded practice beyond that of an RN, the characteristics of which would be determined by the context in which s/he is credentialed to practice."[2] Additional advanced practice RN roles include the certified registered nurse anesthetist (CRNA)s, CNMs, and CNSs. Nurse practitioners can be educated and certified in areas of family health (FNP), pediatrics, including pediatric acute/chronic care, pediatric critical care, pediatric oncology and general pediatrics (PNP), neonatology (NNP), gerontology (GNP), women's health (WHNP), psychiatry & mental health (PMHNP), acute care (ACNP), adult health (ANP), oncology (FNP, ACNP, ANP, PNP or ANP) emergency (as FNP or ACNP), occupational health (as ANP or FNP), etc. In Canada, NPs are licensed by the province or territory in which they practice.

History
The advanced practice nursing role began to take shape in the mid-20th century United States. Nurse anesthetists and nurse midwives were established in the 1940s, followed by psychiatric nursing in 1954. The present day concept of the APN as a primary care provider was created in the mid-1960s, spurred on by a shortage of medical doctors. The first official training for nurse practitioners was created by Henry Silver, a physician, and Loretta Ford, a nurse, in 1965, with a vision to help balance rising health care costs, increase the number of health care providers, and correct the inefficient distribution of health resources. There was some confusion about the varying titles and abilities of advanced practice nurses as the role was developed, which has persisted as the authority and responsibilities of the NP have evolved over time.

Scope of practice
In the United States, because the profession is state-regulated, care provided by NPs varies widely and is limited to their education and knowledge content. Some nurse practitioners seek to work independently of physicians while, in other states, a collaborative agreement with a physician is required for practice.[3][4] The extent of this collaborative agreement, and the role, duties, responsibilities, nursing treatments, pharmacologic recommendations, etc. again varies widely amongst states of licensure/certification.[5][6][7] practice.[8][9][10][11]

Nurse practitioner The scope of practice for NPs is limited outside the United States and varies even more widely than the state-by-state discrepancies. The International Council of Nurses outlines the following general characteristics of advanced practice nursing: Integrates research, education, practice and management Politically seeks a high level of professional autonomy and even independent practice Case management/personal case load Advanced health assessment skills, decision-making skills and nursing diagnostic reasoning skills Recognized advanced nursing clinical competencies Provision to acquire consulting services from other more highly trained medical providers Plans, implements and evaluates programs Recognized first point of contact for clients The "Pearson Report" provides a current state-by-state breakdown of the specific duties a nurse practitioner may perform in the state.[12] A nurse practitioner's role may include the following: Medical diagnoses, treatment, evaluation, and management of acute and chronic illness and disease (e.g., hypertension, diabetes, dyslipidemia, anemia, asthma, depression, anxiety, obesity, osteoarthritis, smoking cessation, thyroid disorders, wound care, musculoskeletal disorders, etc.) Obtaining medical histories and conducting physical examinations Ordering and performing diagnostic studies (e.g., lab tests, x-rays and EKGs) Requesting physical therapy, occupational therapy, and other rehabilitation treatments Prescribing drugs for acute and chronic illness (extent of prescriptive authority varies by state regulations) Providing prenatal care and family planning services Providing well-child care, including screening and immunizations Providing primary and specialty care services, health-maintenance care for adults, including annual physicals Providing care for patients in acute and critical care settings Performing or assisting in minor surgeries and procedures (with additional training and/or under physician supervision in states where mandated; e.g. dermatological biopsies, suturing, casting) Counseling and educating patients on health behaviors, self-care skills, and treatment options in coordination with occupational therapists and other healthcare providers.

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Practice settings
NPs practice in all U.S. states, Canadian provinces and territories and in all Australian states and territories. The institutions in which they work may include: Community clinics, health centers, urgent care centers Health maintenance organizations (HMOs) Home health care agencies Hospitals Hospital clinics Hospice care Physician offices Nursing homes Private & public schools, universities and colleges Veteran's administration facilities Retail-based clinics Bedside nursing in hospitals Walk-in clinics

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Education, licensing, and board certification in the United States


Education to become a nurse practitioner (NP) is rigorous and requires advanced coursework and clinical rotations beyond that required of the RN. Curriculum includes, but is not limited to, courses in epidemiology; health promotion; pathophysiology; physical assessment; pharmacology; differential diagnosis and laboratory/radiography diagnostics; statistics and research methods; health policy; role development and leadership; acute and chronic disease management (e.g., adults, children, women's health, geriatrics, etc.); and, clinical rotations, which varies depending on the program. MSN programs also require a thesis or clinical research project. There are a variety of paths to becoming a licensed nurse practitioner in the United States. Typically, the process begins with obtaining a Bachelor of Science in Nursing (BSN, usually 4 years), followed by a Masters of Science in Nursing (MSN, usually 3 years).[] DNP programs usually require an additional 2 years of study beyond the MSN. Doctor of Nursing Practice (DNP) programs require advanced coursework in biostatistics; research methods; quality improvement and outcome measures; evidence based practice; informatics; organizational management; and, a project/dissertation and practicum. Admission to a MSN program is competitive and requires an undergraduate degree (usually the BSN), completion of the NCLEX-RN,[] and completion of the Graduate Record Exam (GRE). Registered nurses initially trained at the associate degree or diploma level must first complete a Bachelor of Science in Nursing (BSN) or enter a program offering an ADN-to-MN/MSN bridge program. Some of these bridge programs may award a Bachelor's degree while the candidate continues to complete the elements of their Master's or Doctorate degree.

United States
In the United States, nursing is largely degree based. While not every state includes specific language requiring a master's degree for NPs, the majority of states now require a master's degree for practice. Further, the current nurse practitioner programs offered by all universities and colleges are at the master's degree level. Although controversial in academic circles, the nursing profession defends that masters degrees in nursing are rigorious and represents a masters level knowledge in the nursing profession. Many Universities and colleges contend that their academic institutions are at the mercy of accrediting bodies and nursing degrees are inflated and politically motivated and lack the rigor of more traditional graduate programs. The current proposal is that all advanced practice registered nurse programs will require a Doctor of Nursing Practice (DNP) degree by 2015, thus effectively eliminating the MN or the MSN as an entry to practice degree. However, all state Nursing Boards will be required to revise their current Practice Acts in order for this to become mandatory. Also heavily scrutinized, there are numerous certifying bodies for nurse practitioners. All U.S. states require national board certification for nurse practitioners before they are permitted to practice. The two biggest certifying bodies are the American Nurses Credentialing Center (ANCC) and the American Academy of Nurse Practitioners (AANP). The variety of educational paths for NPs is a result of the history of the field.[13] The first Nurse Practitioner program was created by a nurse educator, Loretta Ford, EdD, RN, PNP, and a physician, Henry Silver, MD, in 1965 at the University of Colorado as a non-degree certificate program. This program trained experienced Registered Nurses for their new advanced nursing roles as Pediatric Nurse Practitioners. In the late 1960s into the 1970s, continued predictions of a primary-care physician shortage increased funding and attendance in various certificate-based nurse practitioner programs. Then, during the 1980s Nurse Practitioner educational requirements were transitioned into graduate-level master's degree programs. Subsequently the national certifying organizations and state licencing boards began to require a master's degree for NP practice. However, already established NPs with certificate-based education were grandfathered in. Once again there are changes presently in the field, and by 2015 all new NPs will need to be trained at the doctorate level as a Doctor of Nursing Practice. Once again already established NPs with lesser education will be grandfathered in. After completing the education program, the candidate must be licensed by the state in which he or she plans to practice. The state boards of nursing regulate nurse practitioners and each state has its own licensing and certification

Nurse practitioner criteria. In general, the criteria include completion of a graduate degree in nursing and board certification by an accrediting body (ANCC, AANP). The license period varies by state; some require biennial relicensing, others require triennial.

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Australia
In Australia, Nurse Practitioners are required to be registered by the Australian Health Practitioner Regulation Agency.[14] The Australian professional organisation is the Australian College of Nurse Practitioners. (ACNP) [15]

Role in healthcare
The role of Nurse Practitioners is very diverse.[16][17][18][19] Nurse Practitioners are educated under the nursing model which is designed to provide holistic and preventive care engaging the individual as the primary leader in their own care and well-being.[20] Nurse Practitioners bring the nursing history of patient advocacy to partner with the individual for mutually agreed upon treatments and optimal health outcomes. Nurse Practitioners often view the health and wellness of individuals within the family or community system and attempt to incorporate cultural relativism within their treatments and recommendations[citation needed]. NPs are advanced practice nurses who provide high-quality healthcare services in primary care settings and are able to diagnose and treat a range of health problems.[21][22][23]

Specialties
Acute care nurse practitioner Adult nurse practitioner Family practice nurse practitioner Psychiatric nurse practitioner Geriatric nurse practitioner Pediatric nurse practitioner Obstetric nurse practitioner Neonatal nurse practitioner Emergency nurse practitioner Hepatology nurse practitioner

"-C" and "-BC" indicate "certified" and "board certified" by a national certifying organization such as the American Nurses Credentialing Center, American Academy of Nurse Practitioners, or the National Certification Corporation (e.g., FNP-BC, NNP-BC, ANP-C, NP-C, WHNP-BC, etc.).

Post-nominal credentials and initials


Post-nominal initials NPs may use are regulated by the state in which they are licensed and include: ACNP-BC (Acute Care Nurse Practitioner - Board Certified; if certified by the ANCC) ACNPC (Acute Care Nurse Practitioner Certified)[24] AGACNP-BC (Adult-Gerontology Acute Care Nurse Practitioner - Board Certified; if certified by the ANCC) AGPCNP-BC (Adult-Gerontology Primary Care Nurse Practitioner - Board Certified; if certified by the ANCC) ANP-BC (Adult Nurse Practitioner - Board Certified; if certified by the ANCC) APN (Advanced Practice Nurse)

APRN-BC (Advanced Practice Registered Nurse - Board Certified; no longer awarded, replaced with specialty-specific credentials by the ANCC [25]) ARNP (Advanced Registered Nurse Practitioner) CAS (Certificate of Advanced Study)

Nurse practitioner CNP (Certified Nurse Practitioner) CPNP (Certified Pediatric Nurse Practitioner; if certified by the Pediatric Nursing Certification Board PNCB [26]) CPNP-AC (Certified Pediatric Nurse Practitioner - Acute Care; if certified by the PNCB [27]) CPNP-PC (Certified Pediatric Nurse Practitioner - Primary Care; if certified by the PNCB [28]) CRNP (Certified Registered Nurse Practitioner; used primarily in Pennsylvania [29] and Alabama [30]) DNP (Doctor of Nursing Practice; the terminal practice degree for NPs) DNSc (Doctor of Nursing Science; equivalent to Ph.D., most D.N.Sc. programs now converted to PhD programs) ENP-BC (Emergency Nurse Practitioner - Board Certified; if certified by the ANCC) FAAN (Fellow of the American Academy of Nursing AAN [31]) FAANP (Fellow of the American Academy of Nurse Practitioners AANP [32]) FAEN (Fellow of the Academy of Emergency Nursing AEN) FNP-BC (Family Nurse Practitioner - Board Certified; if certified by the ANCC) GNP-BC (Gerontology Nurse Practitioner - Board Certified; if certified by the ANCC) MA (Master of Arts in Nursing) MN (Master of Nursing) MS (Master of Science with a major in Nursing) MSN (Master of Science in Nursing)

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NP-C (Nurse Practitioner - Certified; if certified by the AANP [32]) PMHNP-BC (Adult or Family PsychiatricMental Health Nurse Practitioner-Board Certified; if certified by the ANCC) PMC (Post-Master's Certificate) PNP-BC (Pediatric Nurse Practitioner - Board Certified; if certified by the ANCC) RN (Registered Nurse) RN(EP) or NP (Registered Nurse - Extended Practice; Manitoba, Canada) RN(NP) (Registered Nurse - Nurse Practitioner; Saskatchewan, Canada) SNP-BC (School Nurse Practitioner - Board Certified; no longer awarded by the ANCC) WHNP-BC (Women's Health Nurse Practitioner - Board Certified; if certified by the NCC)

References
[1] http:/ / aanp. org/ NR/ rdonlyres/ A1D9B4BD-AC5E-45BF-9EB0-DEFCA1123204/ 4710/ 2011FAQswhatisanNPupdated. pdf [6] http:/ / www. npfreebies. com/ Consumer%20perspectives%20on%20nurse%20practitioners%20and%20independent%20practice%20(clip). pdf [11] http:/ / www. texaspolicy. com/ pdf/ 2007-11-PB34-nursepratitioner-mks. pdf [12] "Pearson Report" (http:/ / www. pearsonreport. com/ ) www.pearsonreport.com [16] http:/ / 66. 219. 50. 180/ NR/ rdonlyres/ ea7e64mshg43je3psc5trtnvz3o5qsps4x4z6s3repzt27i55phrghzjq5fflygbkryhxni3ptre2tgeld4jhldozma/ HistoricalBibliographyOnNPAPNDev. pdf [17] (http:/ / www. dhhs. tas. gov. au/ __data/ assets/ pdf_file/ 0019/ 30682/ LiteratureReview. pdf) [21] Lenz, E.R., Mundinger, M.O., Kane, R.L., Hopkins, S.C., & Lin, S.X. (2004). Primary care outcomes in patients treated by nurse practitioners or physicians: Two-year follow-up. Medical Care Research Review, 61, 332-351. [22] Mundinger, M.O., Kane, R.L., Lenz, E.R., Totten, A.M., Tsai, W.-Y., Cleary, P.D., et al. (2000). Primary care outcomes in patients treated by nurse practitioners or physicians: A randomized trial. Journal of the American Medical Association, 283[1], 59-68. [23] Horrocks, S., Anderson, E., & Salisbury, C. (2002). Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. British Medical Journal, 324, 819-823. [24] http:/ / www. aacn. org/ WD/ Certifications/ Content/ acnpc. pcms?mid=2869 [25] http:/ / www. nursecredentialing. org/ Certification/ HowtoListYourCredentials. aspx [26] http:/ / www. pncb. org/ [30] (http:/ / www. abn. state. al. us/ main/ Advanced Practice/ main-advanced. htm) [31] http:/ / www. aannet. org/ [32] http:/ / www. aanp. org/ default. asp

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External links
The Nurse Practitioner: The American Journal of Primary Health Care (http://www.tnpj.com/pt/re/ nursepract/home. htm;jsessionid=DVgFBTbscqRo8rZuV2Ce2u5Ys7O1VPYbeY4rD7PZj015oa97X3QW!1504495626!-949856144!9001!-1) AANP Standards for NP practice in retail based clinics (http://66.219.50.180/NR/rdonlyres/ eces3g7o35a7u6pdijawnj22ulgqgzztu2tdt6dviltrmnde3zkvbkwfdwylcpnlmvx6rpyjks335sxfussaqswrhfh/ RetailBasedClinics.pdf) CNS and NP Practice in Canada (http://bcnpa.org/_tiny_mce/plugins/filemanager/files/ Dicenso_CNS_and_NP_practice_in_Canada.pdf)

Poverty in the United States


Poverty is a state of privation, or a lack of the usual or socially acceptable amount of money or material possessions.[1] The most common measure of poverty in the U.S. is the "poverty threshold" set by the U.S. government. This measure recognizes poverty as a lack of those goods and services commonly taken for granted by members of mainstream society.[2] The official threshold is adjusted for inflation using the consumer price index. The government's definition of poverty is based on total income received. For example, the poverty level for 2012 was set at $23,050 (total yearly income) for a family of four.[3] Most Americans (58.5%) will spend at least one year below the poverty line at some point between ages 25 and 75.[4] Poverty rates are persistently higher in rural and inner city parts of the country as compared to suburban areas.[5][6]

In November 2012 the U.S. Census Bureau said more than 16% of the population lived in poverty in the United States, including almost 20% of American children,[7] up from 14.3% (approximately 43.6 million) in 2009 and to its highest level since 1993. In 2008, 13.2% (39.8 million) Americans lived in poverty.[8] In 2011 extreme poverty in the United States, meaning households living on less than $2 per day before government benefits, was double 1996 levels at 1.5 million households, including 2.8 million children.[9] This would be roughly 1.2% of the US population in 2011, presuming a mean household size of 2.55 people. In 2011, child poverty reached record high levels, with 16.7 million children living in food insecure households, about 35% more than 2007 levels.[] In 2009 the number of people who were in poverty was approaching 1960s levels that led to the national War on Poverty.[10] There were about 643,000 sheltered and unsheltered homeless people nationwide in January 2009. Almost two-thirds stayed in an emergency shelter or transitional housing program and the other third were living on the street, in an abandoned building, or another place not meant for human habitation. About 1.56 million people, or about 0.5% of the U.S. population, used an emergency shelter or a transitional housing program between October 1, 2008 and September 30, 2009.[11]

Poor mother and children during the Great Depression. Elm Grove, California, USA.

Poverty in the United States

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Measures of poverty
Measures of poverty can be either absolute or relative.

Two official measures of poverty


There are two basic versions of the federal poverty measure: the poverty thresholds (which are the primary version) and the poverty guidelines. The Census Bureau issues the poverty thresholds, which are generally used for statistical purposesfor example, to estimate the number of people in poverty nationwide each year and classify them by type of residence, race, and other social, economic, and demographic characteristics. The Department of Health and Human Services issues the poverty guidelines for administrative purposesfor instance, to determine whether a person or family is eligible for assistance through various federal programs.[12]

Number in Poverty and Poverty Rate: 1959 to 2011. United States.

Since the 1960s, the United States Government has defined poverty in absolute terms. When the Johnson administration declared "war on poverty" in 1964, it chose an absolute measure. The "absolute poverty line" is the threshold below which families or individuals are considered to be Poverty Rates by Age 1959 to 2011. United States. lacking the resources to meet the basic needs for healthy living; having insufficient income to provide the food, shelter and clothing needed to preserve health. The "Orshansky Poverty Thresholds" form the basis for the current measure of poverty in the U.S. Mollie Orshansky was an economist working for the Social Security Administration (SSA). Her work appeared at an opportune moment. Orshansky's article was published later in the same year that Johnson declared war on poverty. Since her measure was absolute (i.e., did not depend on other events), it made it possible to objectively answer whether the U.S. government was "winning" this war. The newly formed United States Office of Economic Opportunity adopted the lower of the Orshansky poverty thresholds for statistical, planning, and budgetary purposes in May 1965. The Bureau of the Budget (now the Office of Management and Budget) adopted Orshansky's definition for statistical use in all Executive departments. The measure gave a range of income cutoffs, or thresholds, adjusted for factors such as family size, sex of the family head, number of children under 18 years old, and farm or non-farm residence. The economy food plan (the least costly of four nutritionally adequate food plans designed by the Department of Agriculture) was at the core of this definition of poverty.[13]

Poverty in the United States The Department of Agriculture found that families of three or more persons spent about one third of their after-tax income on food. For these families, poverty thresholds were set at three times the cost of the economy food plan. Different procedures were used for calculating poverty thresholds for two-person households and persons living alone. Annual updates of the SSA poverty thresholds were based on price changes in the economy food plan. Two changes were made to the poverty definition in 1969. Thresholds for non-farm families were tied to annual changes in the Consumer Price Index (CPI) rather than changes in the cost of the economy food plan. Farm thresholds were raised from 70 to 85% of the non-farm levels. In 1981, further changes were made to the poverty definition. Separate thresholds for "farm" and "female-householder" families were eliminated. The largest family size category became "nine persons or more."[13] Apart from these changes, the U.S. government's approach to measuring poverty has remained static for the past forty years.

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Recent poverty rate and guidelines United States Department of Health and Human Services (HHS) figures for poverty in 2012[3]
Persons in Family Unit 48 Contiguous States and D.C. $11,170 $15,130 $19,090 $23,050 $27,010 $30,970 $34,930 $38,890 $3,960 Alaska Hawaii

1 2 3 4 5 6 7 8 Each additional person adds

$13,970 $12,860 $18,920 $17,410 $23,870 $21,960 $28,820 $26,510 $33,770 $31,060 $38,720 $35,610 $43,670 $40,160 $48,620 $44,710 $4,950 $4,550

The poverty guideline figures are not the figures the Census Bureau uses to calculate the number of poor persons. The figures that the Census Bureau uses are the poverty thresholds. The Census Bureau provides an explanation of the difference between poverty thresholds and guidelines.[14] The Census Bureau uses a set of money income thresholds that vary by family size and composition to determine who is in poverty.[13] The 2010 figure for a family of 4 with no children under 18 years of age is $22,541, while the figure for a family of 4 with 2 children under 18 is $22,162.[15] For comparison, the 2011 HHS poverty guideline for a family of 4 is $22,350.

Numbers in other countries


The official number of poor in the United States in 2008 is about 39.1 million people, greater in number but not percentage than the officially poor in Indonesia, which has a far lower Human Development Index and the next largest population after the United States.[16][17] The poverty level in the United States, with 15% (46.2 million people in poverty, of a total of 308.5 million) is comparable to the one in France, where 14% of the population live with less than 880 euros per month.[18][19]

Poverty in the United States Number of poor are hard to compare across countries. Absolute income may be used but does not reflect the actual number of poor, which depend on relative income and cost of living in each country. Among developed countries, each country then has its own definition and threshold of what it means to be poor, but this is not adjusted for cost of living and social benefits. For instance, despite the fact that France and US have about the same threshold in terms of dollars amount for poverty, cost of living benefits differ, with universal health care and highly subsidized post-secondary education existing in France. In general, it might be better to use the Human Poverty Index (HPI), Human Development Index (HDI) or other global measure to compare quality of living in different countries.

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Relative measures of poverty


Another way of looking at poverty is in relative terms. "Relative poverty" can be defined as having significantly less access to income and wealth than other members of society. Therefore, the relative poverty rate is a measure of income inequality. When the standard of living among those in more financially advantageous positions rises while that of those considered poor stagnates, the relative poverty rate will reflect such growing income inequality and increase. Conversely, the poverty rate can decrease, with low income people coming to have less wealth and income if wealthier people's wealth is reduced by a larger percentage than theirs. In 1959, a family at the poverty line had an income that was 42.64% of the median income.[citation needed] If the poverty line in 1999 was less than 42.64% of the median income, then relative poverty would have increased. In the European Union and for the OECD, "relative poverty" is defined as an income below 60% of the national median equalized disposable income after social transfers for a comparable household. In Germany, for example, the official relative poverty line for a single adult person in 2003 was 938 euros per month (11,256 euros/year, $12,382 PPP. West Germany 974 euros/month, 11,688 euros/year, $12,857 PPP). For a family of four with two children below 14 years the poverty line was 1969.8 euros per month ($2,167 PPP) or 23,640 euros ($26,004 PPP) per year. According to Eurostat the percentage of people in Germany living at risk of poverty (relative poverty) in 2004 was 16% (official national rate 13.5% in 2003). Additional definitions for poverty in Germany are "poverty" (50% median) and "strict poverty" (40% median, national rate 1.9% in 2003). Generally the percentage for "relative poverty" is much higher than the quota for "strict poverty". The U.S concept is best comparable to "strict poverty". By European standards the official (relative) poverty rate in the United States would be significantly higher than it is by the U.S. measure. A research paper from the OECD calculates the relative poverty rate for the United States at 16% for 50% median of disposable income and nearly 24% for 60% of median disposable income[20] (OECD average: 11% for 50% median, 16% for 60% median). Some critics argue that relying on income disparity to determine who is impoverished can be misleading. The Bureau of Labor Statistics data suggests that consumer spending varies much less than income. In 2008, the poorest one fifth of Americans households spent on average $12,955 per person for goods and services (other than taxes), the second quintile spent $14,168, the third $16,255, the fourth $19,695, while the richest fifth spent $26,644. The disparity of expenditures is much less than the disparity of income.[21] Wikipedia:Neutral point of viewTalk:Poverty in the United States#

The income distribution and relative poverty


Although the relative approach theoretically differs largely from the Orshansky definition, crucial variables of both poverty definitions are more similar than often thought. First, the so-called standardization of income in both approaches is very similar. To make incomes comparable among households of different sizes, equivalence scales are used to standardize household income to the level of a single person household. In Europe, the modified OECD equivalence scale is used, which takes the combined value of 1 for the head of household, 0.5 for each additional household member older than 14 years and 0.3 for children. When compared to the US Census poverty lines, which is based on a defined basket of goods, for the most prevalent household types both standardization methods show to be very similar.

Poverty in the United States Furthermore, the poverty threshold in Western-European countries is not always higher than the Orshansky threshold for a single person family. The actual Orchinsky poverty line for single person households in the US ($9645 in 2004) is very comparable to the relative poverty line in many Western-European countries (Belgium 2004: 9315), while price levels are also similar.[citation needed] The reason why relative poverty measurement causes high poverty levels in the US, as demonstrated by Frster,[20] is caused by distributional effects rather than real differences in well-being among EU-countries and the USA. The median household income is much higher in the US than in Europe due to the wealth of the middle classes in the US, from which the poverty line is derived. Although the paradigm of relative poverty is most valuable, this comparison of poverty lines show that the higher prevalence of relative poverty levels in the US are not an indicator of a more severe poverty problem but an indicator of larger inequalities between rich middle classes and the low-income households. It is therefore not correct to state that the US income distribution is characterized by a large proportion of households in poverty; it is characterized by relatively large income inequality but also high levels of prosperity of the middle classes.Wikipedia:Neutral point of viewTalk:Poverty in the United States# The 2007 poverty threshold for a three member family is 17,070.

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Poverty and demographics


In addition to family status, race/ethnicity and age also correlate with high poverty rates in the United States. Although data regarding race and poverty are more extensively published and cross tabulated the family status correlation is by far the strongest.

Poverty and family status


According to the US Census, in 2007 5.8% of all people in married families lived in poverty,[26] as did 26.6% of all persons in single parent households[26] and 19.1% of all persons living alone.[26] More than 75% of all poor households are headed by women (2012).[27]

[22] Homeless children in the United States. The number of homeless children reached record [23] [24] [25] highs in 2011, 2012, and 2013 at [24] about three times their number in 1983.

Poverty in the United States By race/ethnicity and family status, based on data from 2007 Among married couple families: 5.8% lived in poverty.[26] This number varied by race and ethnicity as follows: 5.4% of all white persons (which includes white Hispanics),[28] 9.7% of all black persons (which includes black Hispanics),[] and 14.9% of all Hispanic persons (of any race)[11] living in poverty. Among single parent (male or female) families: 26.6% lived in poverty.[26] This number varied by race and ethnicity as follows" 22.5% of all white persons (which includes white Hispanics),[28] 44.0% of all black persons (which includes black Hispanics),[] and 33.4% of all Hispanic persons (of any race)[11] living in poverty. Among unrelated individuals living alone: 19.1% lived in poverty.[26] This number varied by race and ethnicity as follows: 18% of white persons (which includes white Hispanics)[8] 27.9% of black persons (which includes black Hispanics)[11] and 27% of Hispanic persons (of any race)[29] living in poverty

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Camden, New Jersey is one of the poorest cities in the United States.

Poverty and race/ethnicity


The US Census declared that in 2010 15.1% of the general population lived in poverty:[30] 9.9% of all non-Hispanic white persons 12.1% of all Asian persons 26.6% of all Hispanic persons (of any race) 27.4% of all black persons. About half of those living in poverty are non-Hispanic white (19.6 million in 2010),[30] but poverty rates are much higher for blacks and Hispanics. Non-Hispanic white children comprised 57% of all poor rural children.[31] In FY 2009, black families comprised 33.3% of TANF families, non-Hispanic white families comprised 31.2%, and 28.8% were Hispanic.[32]

Poverty and age


The US Census declared that in 2010 15.1% of the general population lived in poverty: 22% of all people under age 18 13.7% of all people 1964, and 9% of all people ages 65 and older[30] The Organization for Economic Co-operation and Development (OECD) uses a different measure for poverty and declared in 2008 that child poverty in the US is 20% and poverty among the elderly is 23%.[33] The non-profit advocacy group Feeding America has released a study (May 2009) based on 20052007 data from the U.S. Census Bureau and the Agriculture Department, which claims that 3.5 million children under the age of 5 are at risk of hunger in the United States. The study claims that in 11 states, Louisiana, which has the highest rate, followed by North Carolina, Ohio, Kentucky, Texas, New Mexico, Kansas, South Carolina, Tennessee, Idaho and Arkansas, more than 20 percent of children under 5 are allegedly at risk of going hungry. (Receiving fewer than 1,800 calories per day) The study was paid by ConAgra Foods, a large food company.[34]

Poverty in the United States Child poverty In 2013, child poverty reached record high levels in the U.S., with 16.7 million children living in food insecure households. 47 million Americans depend on food banks, more than 30% above 2007 levels. Households headed by single mothers are most likely to be affected. Worst affected are the District of Columbia, Oregon, Arizona, New Mexico and Florida, while North Dakota, New Hampshire, Virginia, Minnesota and Massachusetts are the least affected.[]

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Poverty and education


Poverty affects individual access to quality education. The U.S. education system is funded by local communities; therefore the quality of materials and teachers is reflective of the affluence of community. Low income communities are not able to afford the quality education that high income communities are. Another important aspect of education in low income communities is the apathy of both students and teachers. To some the children of the poor or ignorant are seen as mere copies of their parents fated to live out the same poor or ignorant life. The effect of such a perception can be teachers that will not put forth the effort to teach and students that are opposed to learning; in both cases the idea is that the poor student is incapable.[35] Females in poverty are also likely to become pregnant at a young age, and with fewer resources to care for a child, young women often drop out of school.[36] Due to these and other reasons the quality of education between the classes is not equal.[]

Food security
Eighty-nine percent of the American households were food secure throughout the entire year of 2002, meaning that they had access, at all times, to enough food for an active, healthy life for all of the household members. The remaining households were food insecure at least some time during that year. The prevalence of food insecurity rose from 10.7% in 2001 to 11.1% in 2002, and the prevalence of food insecurity with hunger rose from 3.3% to 3.5%.[37] In 2008, eighty-five percent of American households were food secure throughout the entire year.[38]

Factors in poverty
There are numerous factors related to poverty in the United States. The conservative American Enterprise Institute has claimed that income and intelligence are related. Charles Murray compared the earnings of 733 full sibling pairs with differing intelligence quotients (IQs). He referred to the sample as utopian in that the sampled pairs were raised in families with virtually no illegitimacy, divorce or poverty. The average earnings of sampled individuals with an IQ of under 75 was $11,000, compared to $16,000 for those with an IQ between 75 and 90, $23,000 for those with an IQ between 90 and 110, $27,000 for those with an IQ between 110 and 125, and $38,000 for those with an IQ above 125.[39] Income has a high correlation with educational levels. In 2007, the median earnings of household headed by individuals with less than a 9th grade education was $20,805 while households headed by high school graduates earned $40,456, households headed holders of bachelors degree earned $77,605, and families headed by individuals with professional degrees earned $100,000.[] In many cases poverty is caused by job loss. In 2007, the poverty rate was 21.5% for individuals who were unemployed, but only 2.5% for individuals who were employed full-time.[] In 1991, 8.3% of children in two-parent families were likely to live in poverty; 19.6% of children lived with father in single parent family; and 47.1% in single parent family headed by mother.[40] Income levels vary with age. For example, the median 2009 income for households headed by individuals age 1524 was only $30,750, but increased to $50,188 for household headed by individuals age 2534 and $61,083 for household headed by individuals 3544.[41] Although the reasons are unclear, work experience and additional

Poverty in the United States education may be factors. Income levels vary along racial/ethnic lines: 21% of all children in the United States live in poverty, about 46% of black children and 40% of Latino children live in poverty.[42] The poverty rate is 9.9% for black married couples and only 30% of black children are born to married couples (see Marriage below). Citing the Pew Research Center,The Economist reports that in 2007,11% of black women aged 3044 without a high school diploma had a working spouse.[43]WP:COPYLINK The poverty rate for native born and naturalized whites is identical (9.6%). On the other hand, the poverty rate for naturalized blacks is 11.8% compared to 25.1% for native born blacks suggesting race alone does not explain income disparity. Not all minorities have low incomes. Asian families have higher incomes than all other ethnic groups. For example, the 2005 median income of Asian families was $68,957 compared to the median income of white families of $59,124.[44] Asians, however, report discrimination occurrences more frequently than blacks. Specifically, 31% of Asians reported employment discrimination compared to 26% of blacks in 2005.[45] The relationship between tax rates and poverty is disputed. A study comparing high tax Scandinavian countries with the U. S. suggests high tax rates are inversely correlated with poverty rates.[] The poverty rate, however, is low in some low tax countries such as Switzerland. A comparison of poverty rates between states reveals that some low tax states have low poverty rates. For example, New Hampshire has the lowest poverty rate of any state in the U. S., and has very low taxes (46th among all states).It is true however that in those instances, both Switzerland and New Hampshire have a very high household income and other measures to levy or offset the lack of taxation. For example, Switzerland has Universal Healthcare and a free system of education for children as young as four years old.[46] New Hampshire has no state income tax or sales tax, but does have the nation's highest property taxes.[47] The conservative Heritage Foundation speculates that illegal immigration increases job competition among low wage earners, both native and foreign born. Additionally many first generation immigrants, namely those without a high school diploma, are also living in poverty themselves.[]

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Concerns regarding accuracy


In recent years, there have been a number of concerns raised about the official U.S. poverty measure. In 1995, the National Research Council's Committee on National Statistics convened a panel on measuring poverty. The findings of the panel were that "the official poverty measure in the United States is flawed and does not adequately inform policy-makers or the public about who is poor and who is not poor." The panel was chaired by Robert Michael, former Dean of the Harris School of the University of Chicago. According to Michael, the official U.S. poverty measure "has not kept pace with far-reaching changes in society and the economy." The panel proposed a model based on disposable income:

According to the panel's recommended measure, income would include, in addition to money received, the value of non-cash benefits such as food stamps, school lunches and public housing that can be used to satisfy basic needs. The new measure also would subtract from gross income certain expenses that cannot be used for these basic needs, such as income taxes, child-support payments, medical costs, [48] health-insurance premiums and work-related expenses, including child care.

Understating poverty
Many sociologists and government officials have argued that poverty in the United States is understated, meaning that there are more households living in actual poverty than there are households below the poverty threshold.[] A recent NPR report states that as much as 30% of Americans have trouble making ends meet and other advocates have made supporting claims that the rate of actual poverty in the US is far higher than that calculated by using the poverty threshold.[] A study taken in 2012 estimated that roughly 38% of Americans live "paycheck to paycheck."[49]

Poverty in the United States According to William H. Chafe, if one used a relative standard for measuring poverty (a standard that took into account the rising standards of living rather than an absolute dollar figure) then 18% of families was living in poverty in 1968, not 13% as officially estimated at that time.[50] As far back as 1969, the Bureau of Labor Statistics put forward suggested budgets for families to live adequately on. 60% of working-class Americans lived below one of these budgets, which suggested that a far higher proportion of Americans lived in poverty than the official poverty line suggested. These findings were also used by observers on the left when questioning the long-established view that most Americans had attained an affluent standard of living in the two decades following the end of the Second World War.[51][52] Using a definition of relative poverty (reflecting disposable income below half the median of adjusted national income), it was estimated that, between 1979 and 1982, 17.1% of Americans lived in poverty, compared with 12.6% of the population of Canada, 12.2% of the population of Australia, 9.7% of the population of Britain, 5.6% of the population of West Germany, 5.3% of the population of Sweden, and 5.2% of the population of Norway.[53] As noted above, the poverty thresholds used by the US government were originally developed during the A neighborhood of poor white southerners, Chicago, 1974 Johnson administration's War on Poverty initiative in 19631964.[][] Mollie Orshansky, the government economist working at the Social Security Administration who developed the thresholds, based the threshold levels on the cost of purchasing what in the mid-1950s had been determined by the US Department of Agriculture to be the minimal nutritionally-adequate amount of food necessary to feed a family. Orshansky multiplied the cost of the food basket by a factor of three, under the assumption that the average family spent one third of its income on food. While the poverty threshold is updated for inflation every year, the basket of food used to determine what constitutes being deprived of a socially acceptable minimum standard of living has not been updated since 1955. As a result, the current poverty line only takes into account food purchases that were common more than 50 years ago, updating their cost using the Consumer Price Index. When methods similar to Orshanskys were used to update the food basket using prices for the year 2000 instead of from nearly a half century earlier, it was found that the poverty line should actually be 200% higher than the official level being used by the government in that year.[] Yet even that higher level could still be considered flawed, as it would be based almost entirely on food costs and on the assumption that families still spend a third of their income on food. In fact, Americans typically spent less than one tenth of their after-tax income on food in 2000.[54] For many families, the costs of housing, health insurance and medical care, transportation, and access to basic telecommunications take a much larger bite out of the familys income today than a half century ago; yet, as noted above,[][] none of these costs are considered in determining the official poverty thresholds. According to John Schwarz, a political scientist at the University of Arizona:

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The official poverty line today is essentially what it takes in today's dollars, adjusted for inflation, to purchase the same poverty-line level of living that was appropriate to a half century ago, in 1955, for that year furnished the basic data for the formula for the very first poverty measure. Updated thereafter only for inflation, the poverty line lost all connection over time with current consumption patterns of the average family. Quite a few families then didn't have their own private telephone, or a car, or even a mixer in their kitchen... The official poverty line has thus been allowed to fall substantially below a socially decent minimum, even though its intention was to measure such a minimum.

The issue of understating poverty is especially pressing in states with both a high cost of living and a high poverty rate such as California where the median home price in May 2006 was determined to be $564,430.[55] With half of all homes being priced above the half million dollar mark and prices in urban areas such as San Francisco, San Jose

Poverty in the United States or Los Angeles being higher than the state average, it is almost impossible for not just the poor but also lower middle class worker to afford decent housing,[citation needed] and no possibility of home ownership. In the Monterey area, where the low-pay industry of agriculture is the largest sector in the economy and the majority of the population lacks a college education the median home price was determined to be $723,790, requiring an upper middle class income which only roughly 20% of all households in the county boast.[55][] Such fluctuations in local markets are, however, not considered in the Federal poverty threshold, and thus leave many who live in poverty-like conditions out of the total number of households classified as poor. In 2011, the Census Bureau introduced a new supplementary poverty measure aimed at providing a more accurate picture of the true extent of poverty in the United States. According to this new measure, 16% of Americans lived in poverty in 2011, compared with 15.2% using the official figure. The new measure also estimated that nearly half of all Americans lived in poverty that year, defined as living within 200% of the federal poverty line.[56] Duke University Professor of Public Policy and Economics Sandy Darity, Jr. says, "There is no exact way of measuring poverty. The measures are contingent on how we conceive of and define poverty. Efforts to develop more refined measures have been dominated by researchers who intentionally want to provide estimates that reduce the magnitude of poverty."[57]

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Overstating poverty
Some critics assert that the official U.S. poverty definition is inconsistent with how it is defined by its own citizens and the rest of the world, because the U.S. government considers many citizens statistically impoverished despite their ability to sufficiently meet their basic needs. According to a 2011 paper by poverty expert Robert Rector, of the 43.6 million Americans deemed to be below the poverty level by the U.S. Census Bureau in 2009, the majority had adequate shelter, food, clothing and medical care. In addition, the paper stated that those assessed to be below the poverty line in 2011 have a much higher quality of living than those who were identified by the census 40 years ago as being in poverty.[58]

Youth play in Chicago's Stateway Gardens high-rise housing project in 1973.

The federal poverty line also excludes income other than cash income, especially welfare benefits. Thus, if food stamps and public housing were successfully raising the standard of living for poverty stricken individuals, then the poverty line figures would not shift since they do not consider the income equivalents of such entitlements.[59] A 1993 study of low income single mothers titled Making Ends Meet, by Kathryn Edin, a sociologist at the University of Pennsylvania, showed that the mothers spent more than their reported incomes because they could not "make ends meet" without such expenditures. According to Edin, they made up the difference through contributions from family members, absent boyfriends, off-the-book jobs, and church charity. According to Edin: "No one avoided the unnecessary expenditures, such as the occasional trip to the Dairy Queen, or a pair of stylish new sneakers for the son who might otherwise sell drugs to get them, or the Cable TV subscription for the kids home alone and you are afraid they will be out on the street if they are not watching TV." However many mothers skipped meals or did odd jobs to cover those expenses. According to Edin, for "most welfare-reliant mothers food and shelter alone cost almost as much as these mothers received from the government. For more than one-third, food and housing costs exceeded their cash benefits, leaving no extra money for uncovered medical care, clothing, and other household expenses." [60]

Poverty in the United States Moreover, Swedish libertarian think tank Timbro points out that lower-income households in the U.S. tend to own more appliances and larger houses than many middle-income Western Europeans.[]

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Fighting poverty
There have been many governmental and nongovernmental efforts to reduce poverty and its effects. These range in scope from neighborhood efforts to campaigns with a national focus. They target specific groups affected by poverty such as children, people who are autistic, immigrants, or people who are homeless. Efforts to alleviate poverty use a disparate set of methods, such as advocacy, education, social work, legislation, direct service or charity, and community organizing. Recent debates have centered on the need for policies that focus on both "income poverty" and "asset poverty."[61] Advocates for the approach argue that traditional governmental poverty policies focus solely on supplementing the income of the poor, through programs such as Aid to Families with Dependent Children (AFDC) and Food Stamps. According to the CFED 2012 Assets & Opportunity Scorecard [62], 27 percent of households nearly double the percentage that are income poor are living in asset poverty. These families do not have the savings or other assets to cover basic expenses (equivalent to what could be purchased with a poverty level income) for three months if a layoff or other emergency leads to loss of income. Since 2009, the number of asset poor families has increased by 21 percent from about one in five families to one in four families. In order to provide assistance to such asset poor families, Congress appropriated $24 million to administer the Assets for Independence Program under the supervision of the US Department for Health and Human Services. The program enables community-based nonprofits and government agencies to implement Individual Development Account or IDA programs, which are an asset-based development initiative. Every dollar accumulated in IDA savings is matched by federal and non-federal funds to enable households to add to their assets portfolio by buying their first home, acquiring a post-secondary education and starting or expanding a small business.[63] Additionally, the Earned Income Tax Credit [64] (EITC or EIC) is a credit for people who earn low-to-moderate incomes. This credit allows them to get money from the government if their total tax outlay is less than the total credit earned, meaning it is not just a reduction in total tax paid but can also bring new income to the household. The Earned Income Tax Credit is viewed as the largest poverty reduction program in the United States. There is an ongoing debate in the US about what is the most effective way to fight poverty, is it through the tax code with the EITC or through the minimum wage laws.

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Poverty in the United States


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[37] Household Food Security in the United States, 2002 (http:/ / www. ers. usda. gov/ publications/ fanrr35/ fanrr35. pdf) United States Department of Agriculture [38] Household Food Security in the United States, 2008 (http:/ / www. ers. usda. gov/ Publications/ ERR83/ ERR83. pdf) United States Department of Agriculture [39] Charles Murray (1998). Income Inequality and IQ. Washington: AEI Press. [40] futureofchildren.org (http:/ / www. futureofchildren. org/ information2827/ information_show. htm?doc_id=75562) [41] Census Bureau, Income Poverty, and Health Insurance Coverage in the U. S.:2009 http:/ / www. census. gov/ prod/ 2010pubs/ p60-238. pdf [42] Center for the Future of Children, The Future of Children. Vol. 7, No 2, 1997. [43] " Sex and the single black woman (http:/ / www. economist. com/ world/ united-states/ displaystory. cfm?story_id=15867956)". The Economist. April 8, 2010. [44] Source: U. S. Census, Family Income Tables, http:/ / pubdb3. census. gov/ macro/ 032006/ faminc/ toc. htm. [45] Amy Joyce, The Bias Breakdown, The Washington Post, December 9, 2005, p. D01 citing Gallop Poll data. [46] The Swiss education system swissworld.org, Retrieved on 2009-06-23 [47] "New Hampshire's State and Local Tax Burden, 19702006". The Tax Foundation. 2008-08-07. http:/ / www. taxfoundation. org/ taxdata/ show/ 468. html. Retrieved 2010-07-31. [48] Harms, W. (1995) Poverty definition flawed, more accurate measure needed (http:/ / chronicle. uchicago. edu/ 950511/ poverty. shtml) The University of Chicago Chronicle, 14:17. [49] http:/ / www. cbsnews. com/ 8301-505144_162-57477881/ more-americans-live-paycheck-to-paycheck/ [50] The Unfinished Journey: America Since World War II by William H. Chafe [51] http:/ / books. google. co. uk/ books?id=TXdWbwEPIO0C& pg=PA482& dq=bureau+ labor+ statistics+ 1969+ 60%25+ working-class& hl=en& sa=X& ei=Qi4fT_akHtG7hAfUz73zDQ& redir_esc=y#v=onepage& q=bureau%20labor%20statistics%201969%2060%25%20working-class& f=false [52] http:/ / www. thenation. com/ article/ 155492/ seventies-show?page=full [53] http:/ / books. google. co. uk/ books?id=tPE0opidIxMC& pg=PA147& dq=Peter+ Townsend+ poverty+ in+ UK+ percentage& hl=en& sa=X& ei=p2yQT9bvIcql0QW78Z34AQ& ved=0CDQQ6AEwADgK#v=onepage& q=Peter%20Townsend%20poverty%20in%20UK%20percentage& f=false [56] http:/ / www. epi. org/ publication/ poverty-measure-highlights-dire-circumstances/ [57] (http:/ / today. duke. edu/ 2011/ 11/ povertytip)

780

Poverty in the United States


[59] Poor Poverty Yardsticks (http:/ / www. washtimes. com/ commentary/ 20060906-100020-4785r. htm) by Rea Hederman, Heritage Foundation, Washington Post. September 7, 2006. Accessed: 2007-02-18 [60] Devising New Math to Define Poverty (http:/ / www. nytimes. com/ 1999/ 10/ 18/ us/ devising-new-math-to-define-poverty. html?pagewanted=all& src=pm) by Louis Uchitelle, New York Times. 1999-10-18. Accessed: 2006-06-16 [61] http:/ / assetsandopportunity. org/ scorecard/ [62] http:/ / assetsandopportunity. org/ scorecard/ [63] url = http:/ / www. acf. hhs. gov/ programs/ ocs/ fact-sheet-ocs | accessdate = April 22, 2013/ [64] http:/ / www. irs. gov/ individuals/ article/ 0,,id=96406,00. html

781

Further reading
Caudill, Harry (1962). Night Comes to the Cumberlands. Little, Brown and Company. ISBN0-316-13212-8. Harrington, Michael (1962). The Other America. Macmillan. ISBN0-684-82678-X. Howe, Louise Kapp, ed. (1970). The White Majority: between Poverty and Affluence, in series, Vintage Book[s]. New York: New York: Random House. xii, 303 p. SBN 394-71666-3 Sarnoff, Susan; Yoon, Hong-Sik (2003). "Central Appalachia Still the Other America" (http://www. journalofpoverty.org/JOPABS/JPOABS21.HTM). Journal of Poverty (The Haworth Press) 7 (1 & 2): 123139. doi: 10.1300/J134v07n01_06 (http://dx.doi.org/10.1300/J134v07n01_06). Shipler, David K. 2004. The Working Poor :Invisible in America, Knopf.

External links
U.S. Census Bureau Poverty Definition (http://www.census.gov/hhes/www/poverty/methods/definitions. html) U.S. Census Bureau Poverty in the United States (http://www.census.gov/hhes/www/poverty/poverty.html) Why Poverty Doesn't Rate (http://www.aei.org/article/24855), American Enterprise Institute Social Solutions to Poverty: America's Struggle to Build a Just Society. (http://www.solvingpoverty.com) Scott Myers-Lipton, (2006). Child Poverty and Tax: a simple graph of child disposible income disparity in OECD countries against tax burdens. (http://www.policyalternatives.ca/documents/National_Office_Pubs/2006/ Benefits_and_Costs_of_Taxation.pdf) F.H.C. Ministries Charity is not Reform! (http://www.fhcministries.org/) From Poverty to Prosperity: A National Strategy to Cut Poverty in Half (http://www.americanprogress.org/ issues/2007/04/poverty_report.html), The Center for American Progress, April 2007. Explanation of poverty definition (http://www.dollarsandsense.org/archives/2006/0106dollar.html) by economist Ellen Frank in Dollars & Sense magazine, January/February 2006 "Deciding Who's Poor" (http://www.dollarsandsense.org/archives/2000/0300bergmann.html) by economist Barbara Bergmann in Dollars & Sense magazine, March/April 2000 37 million poor hidden in the land of plenty (http://observer.guardian.co.uk/world/story/0,,1712965,00.html) David Walls, Models of Poverty and Planned Change (http://www.sonoma.edu/users/w/wallsd/ models-of-poverty.shtml) U.S. Government Does Relatively Little to Lessen Child Poverty Rates (http://www.epinet.org/content.cfm/ webfeatures_snapshots_20060719) U.S. Department of Health & Human Services Poverty Guidelines, Research, and Measurement (http://aspe.hhs. gov/poverty/index.shtml) Cities Tolerate Homeless Camps (http://online.wsj.com/article/SB124994409537920819.html) by Jennifer Levitz, The Wall Street Journal, August 11, 2009 The Forgotten Americans (http://www.pbs.org/klru/forgottenamericans/) PBS series by Hector Galan about colonias.

Poverty in the United States Americans living in Third World conditions (http://open.salon.com/blog/kanuk/2009/11/29/ living_in_a_third_world_country_aka_the_united_states) This article discusses the living conditions of people inhabiting colonias (with pictures). Steve Suitts, "The Worst of Times: Children in Extreme Poverty in the South and Nation," (http:// southernspaces.org/2010/worst-times-children-extreme-poverty-south-and-nation) Southern Spaces, 29 June 2010. 80 Percent Of U.S. Adults Face Near-Poverty, Unemployment: Survey (http://www.huffingtonpost.com/2013/ 07/28/poverty-unemployment-rates_n_3666594.html?utm_hp_ref=mostpopular)Huffington Post, July 28, 2013

782

Federal Trade Commission

783

Federal Trade Commission


Federal Trade Commission

Seal of the Federal Trade Commission

Flag of the Federal Trade Commission Agency overview Formed September 26, 1914

Preceding Agency Bureau of Corporations Jurisdiction Headquarters Employees Agency executive Federal government of the United States Washington, D.C. 1,131 (December 2011)
[1]

Edith Ramirez, Chairman Website www.ftc.gov Footnotes


[2]

[3][4]

The Federal Trade Commission (FTC) is an independent agency of the United States government, established in 1914 by the Federal Trade Commission Act. Its principal mission is the promotion of consumer protection and the elimination and prevention of anti-competitive business practices, such as coercive monopoly. The Federal Trade Commission Act was one of President Woodrow Wilson's major acts against trusts. Trusts and trust-busting were significant political concerns during the Progressive Era. Since its inception, the FTC has enforced the provisions of the Clayton Act, a key antitrust statute, as well as the provisions of the FTC Act, 15 U.S.C.41 [5] et seq. Over time, the FTC has been delegated the enforcement of additional business regulation statutes and has promulgated a number of regulations (codified in Title 16 of the Code of Federal Regulations).

Federal Trade Commission

784

Legislation
The first version of a bill to establish a commission to regulate trade was introduced on January 25, 1912, by Oklahoma congressman Dick Thompson Morgan, once known as the "father of the Federal Trade Commission." Morgan also made the first speech on the House floor advocating its creation on February 21, 1912. Though the initial bill did not pass, the Republican party platform of June 1912 endorsed the establishment of the Federal Trade Commission. Morgan reintroduced a slightly amended version of his bill during the April 1913 special session.

Chairmen and commissioners

Apex Building, built in 1938 (FTC headquarters) in Washington, D.C.

Current commissioners
The Federal Trade Commission is headed by five commissioners who are nominated by the President and confirmed by the United States Senate. Under the FTC Act, no more than three commissioners may be from the same political party. A commissioner's term of office is seven years, and the terms are staggered so that in a given year no more than one commissioner's term expires (although in certain years no commissioner's term expires and in years where commissioners choose to step down, more than one new commissioner may be appointed). The current commissioners are:[6]

Current membership
The following table lists commissioners as of June 2013.
Member Edith Ramirez (Chair) Julie Brill Political party Democrat Sworn in April 5, 2010 Term expiration September 25, 2015

Democrat

April 6, 2010 April 4, 2012

September 25, 2016 September 25, 2018

Maureen K. Ohlhausen Republican Joshua D. Wright Vacant Republican

January 11, 2013 September 25, 2019

List of former Commissioners


Recent former commissioners were:[7]

Federal Trade Commission

785

Commissioner Caspar Weinberger Philip Elman Miles W. Kirkpatrick Everette MacIntyre Mary Gardner Jones David J. Dennison, Jr. Mayo J. Thompson Lewis A. Engman Calvin J. Collier Stephen A. Nye

Years December 31, 1969 August 6, 1970 April 21, 1961 October 18, 1970 September 14, 1970 February 20, 1973 September 26, 1961 August 30, 1973 October 29, 1964 November 2, 1973 October 18, 1970 December 31, 1973 July 8, 1973 September 26, 1975 February 20, 1973 December 31, 1975 March 24, 1976 December 31, 1977 May 5, 1974 May 5, 1978

Elizabeth Hanford Dole December 4, 1973 March 9, 1979 Paul Rand Dixon David Clanton Michael Pertschuk George W. Douglas James C. Miller III Patricia P. Bailey Margo E. Machol Daniel Oliver Terry Calvani Andrew Strenio Deborah K. Owen Dennis A. Yao Christine A. Varney Janet D. Steiger Roscoe B. Starek, III Mary L. Azcuenaga Robert Pitofsky Sheila F. Anthony Timothy Muris Mozelle W. Thompson Orson Swindle Thomas B. Leary Deborah Platt Majoras Pamela Jones Harbour William Kovacic J. Thomas Rosch Jon Leibowitz March 21, 1961 September 25, 1981 August 26, 1975 - October 14,1983 April 21, 1977 October 15, 1984 December 27, 1982 September 18, 1985 September 25, 1982 October 5, 1985 October 29, 1979 May 15, 1988 November 29, 1988 October 24, 1989 [recess appointment] April 21, 1986 August 10, 1989 November 18, 1983 September 25, 1990 March 17, 1986 July 15, 1991 October 25, 1989 August 26, 1994 July 16, 1991 August 31, 1994 October 17, 1994 August 5, 1997 August 11, 1989 September 28, 1997 November 19, 1990 December 18, 1997 November 27, 1984 June 3, 1998 June 29, 1978 April 30, 1981 & April 11, 1995 May 31, 2001 September 30, 1997 August 1, 2003 June 4, 2001 August 15, 2004 December 17, 1997 August 31, 2004 December 18, 1997 June 30, 2005 November 17, 1999 December 31, 2005 August 16, 2004 March 29, 2008 August 4, 2003 April 6, 2010 January 4, 2006 October 3, 2011 January 5, 2006 - Sept 2012 March 2, 2009 March 7, 2013

Federal Trade Commission

786

Bureaus
Bureau of Consumer Protection
The Bureau of Consumer Protections mandate is to protect consumers against unfair or deceptive acts or practices in commerce. With the written consent of the Commission, Bureau attorneys enforce federal laws related to consumer affairs and rules promulgated by the FTC. Its functions include investigations, enforcement actions, and consumer and business education. Areas of principal concern for this bureau are: advertising and marketing, financial products and practices, telemarketing fraud, privacy and identity protection, etc. The bureau also is responsible for the United States National Do Not Call Registry. Under the FTC Act, the Commission has the authority, in most cases, to bring its actions in federal court through its own attorneys. In some consumer protection matters, the FTC appears with, or supports, the U.S. Department of Justice.

Bureau of Competition
The Bureau of Competition is the division of the FTC charged with elimination and prevention of "anticompetitive" business practices. It accomplishes this through the enforcement of antitrust laws, review of proposed mergers, and investigation into other non-merger business practices that may impair competition. Such non-merger practices include horizontal restraints, involving agreements between direct competitors, and vertical restraints, involving agreements among businesses at different levels in the same industry (such as suppliers and commercial buyers). The FTC shares enforcement of antitrust laws with the Department of Justice. However, while the FTC is responsible for civil enforcement of antitrust laws, the Antitrust Division of the Department of Justice has the power to bring both civil and criminal action in antitrust matters.

Bureau of Economics
The Bureau of Economics was established to support the Bureau of Competition and Consumer Protection by providing expert knowledge related to the economic impacts of the FTC's legislation and operation.

Activities of the FTC


The FTC puts out its mission by investigating issues raised by reports from consumers and businesses, pre-merger notification filings, congressional inquiries, or reports in the media. These issues include, for instance, false advertising and other forms of fraud. FTC investigations may pertain to a single company or an entire industry. If the results of the investigation reveal unlawful conduct, the FTC may seek voluntary compliance by the offending business through a consent order, file an administrative complaint, or initiate federal litigation. Traditionally an administrative complaint is heard in front of an independent administrative law judge (ALJ) with FTC staff acting as prosecutors. The case is reviewed de novo by the full FTC commission which then may be appealed to the U.S. Court of Appeals and finally to the Supreme Court. A summary of cases heard since 1996[8] indicates that the commission has never upheld an administrative law judge's decision to dismiss a complaint. After adverse results in which the independent administrative law judges have ruled against the FTC (Schering Plough[9] and Rambus),[10] there has been a move towards FTC commissioners being appointed as ALJ (Commissioner Rosch in Inova Health).[11] Under the FTC Act, the federal courts retain their traditional authority to issue equitable relief, including the appointment of receivers, monitors, the imposition of asset freezes to guard against the spoliation of funds, immediate access to business premises to preserve evidence, and other relief including financial disclosures and expedited discovery. In numerous cases, the FTC employs this authority to combat serious consumer deception or fraud. Additionally, the FTC has rulemaking power to address concerns regarding industry-wide practices. Rules

Federal Trade Commission promulgated under this authority are known as Trade Rules. In the mid-1990s, the FTC launched the fraud sweeps concept where the agency and its federal, state, and local partners filed simultaneous legal actions against multiple telemarketing fraud targets. The first sweeps operation was Project Telesweep[12] in July 1995 which cracked down on 100 business opportunity scams. In 1984,[13] the FTC began to regulate the funeral home industry in order to protect consumers from deceptive practices. The FTC Funeral Rule requires funeral homes to provide all customers (and potential customers) with a General Price List (GPL), specifically outlining goods and services in the funeral industry, as defined by the FTC, and a listing of their prices.[14] By law, the GPL must be presented to all individuals that ask, no one is to be denied a written, retainable copy of the GPL. In 1996, the FTC instituted the Funeral Rule Offenders Program (FROP), under which "funeral homes make a voluntary payment to the U.S. Treasury or appropriate state fund for an amount less than what would likely be sought if the Commission authorized filing a lawsuit for civil penalties. In addition, the funeral homes participate in the NFDA compliance program, which includes a review of the price lists, on-site training of the staff, and follow-up testing and certification on compliance with the Funeral Rule."[13] One of the Federal Trade Commission's other major focuses is identity theft. The FTC serves as a federal repository for individual consumer complaints regarding identity theft. Even though the FTC does not resolve individual complaints, it does use the aggregated information to determine where federal action might be taken. The complaint form is available online or by phone (1-877-ID-THEFT). The FTC has been involved in the oversight of the online advertising industry and its practice of behavioral targeting for some time. In 2011 the FTC proposed a "Do Not Track" mechanism to allow Internet users to opt-out of behavioral targeting.

787

Unfair or deceptive practices affecting consumers


Section 5 of the Federal Trade Commission Act, 15 U.S.C.45 [15] grants the FTC power to investigate and prevent deceptive trade practices. The statute declares that unfair methods of competition in or affecting commerce, and unfair or deceptive acts or practices in or affecting commerce, are hereby declared unlawful.[16] Unfairness and deception towards consumers represent two distinct areas of FTC enforcement and authority. The FTC also has authority over unfair methods of competition between businesses.[17]

Deception practices
In a letter to the Chairman of the House Committee on Energy and Commerce, the FTC defined the elements of deception cases. First, there must be a representation, omission or practice that is likely to mislead the consumer.[] In the case of omissions, the Commission considers the implied representations understood by the consumer. A misleading omission occurs when information is not disclosed to correct reasonable consumer expectations.[] Second, the Commission examines the practice from the perspective of a reasonable consumer being targeted by the practice. Finally the representation or omission must be a material onethat is one that would have changed consumer behavior.[] In its 2000 Dot Com Disclosures guide,[18] the FTC said that [d]isclosures that are required to prevent deception or to provide consumers material information about a transaction must be presented clearly and conspicuously.[18] The FTC suggested a number of different factors that would help determine whether the information was clear and conspicuous including: the placement of the disclosure in an advertisement and its proximity to the claim it is qualifying, the prominence of the disclosure, whether items in other parts of the advertisement distract attention from the disclosure, whether the advertisement is so lengthy that the disclosure needs to be repeated,

Federal Trade Commission whether disclosures in audio messages are presented in an adequate volume and cadence and visual disclosures appear for a sufficient duration, and whether the language of the disclosure is understandable to the intended audience.[18] However, the key is the overall net impression.[18] In F.T.C. v. Cyberspace.com[] the FTC found that sending consumers mail that appeared to be a check for $3.50 to the consumer attached to an invoice was deceptive when cashing the check constituted an agreement to pay a monthly fee for internet access. The back of the check, in fine print, disclosed the existence of this agreement to the consumer. The FTC concluded that the practice was misleading to reasonable consumers, especially since there was evidence that less than one percent of the 225,000 individuals and businesses billed for the internet service actually logged on.[] In In re Gateway Learning Corp. the FTC alleged that Gateway committed unfair and deceptive trade practices by making retroactive changes to its privacy policy without informing customers and by violating its own privacy policy by selling customer information when it had said it would not.[19] Gateway settled the complaint by entering into a consent decree with the FTC that required it to surrender some profits and placed restrictions upon Gateway for the following 20 years.[20] In In the Matter of Sears Holdings Management Corp., the FTC alleged that a research software program provided by Sears was deceptive because it collected information about nearly all online behavior, a fact that was only disclosed in legalese, buried within the end user license agreement.[21]

788

Unfair practices
Courts have identified three main factors that must be considered in consumer unfairness cases: (1) whether the practice injures consumers; (2) whether the practice violates established public policy; and (3) whether it is unethical or unscrupulous.[17]

References
[2] http:/ / www. ftc. gov [3] (http:/ / www. bestplacestowork. org/ BPTW/ rankings/ agency. php?code=FT00& q=scores_small) [5] http:/ / www. law. cornell. edu/ uscode/ 15/ 41. html [6] http:/ / www. ftc. gov/ commissioners/ index. shtml [8] Summary of FTC decisions since 1996 (http:/ / docs. google. com/ View?docid=dc5fjfws_9gv88kp) [13] FTC Announces Results of Compliance Testing of Over 300 Funeral Homes in the Second Year of the Funeral Rule Offenders Program (http:/ / www. ftc. gov/ opa/ 1998/ 02/ frop-97. shtm), Federal Trade Commission, February 25, 1998 [15] http:/ / www. law. cornell. edu/ uscode/ 15/ 45. html [17] based upon FTC v. Sperry & Hutchinson C., 405 U.S. 223, 244-45 n.5 (1972) [18] , at 5 - 6

Further reading
G. Cullom Davis. "The Transformation of the Federal Trade Commission, 19141929," The Mississippi Valley Historical Review, Vol. 49, No. 3. (Dec. 1962), pp.437455 ( archived (http://links.jstor.org/ sici?sici=0161-391X(196212)49:3<437:TTOTFT>2.0.CO;2-O) in JSTOR)

External links
Official website (http://www.ftc.gov) Consumer Complaint Assistant, Federal Trade Commission (https://www.ftccomplaintassistant.gov) Federal Trade Commission Decisions (July 1949 - December 2005) (http://www.ftc.gov/os/decisions/index. htm) This is a compendium of agency decisions in administrative cases brought under 16 C.F.R. parts II and III. Federal court decisions may be found elsewhere, in published federal case reports. The site's search engine can

Federal Trade Commission limit its results from the archive. Federal Trade Commission Meeting Notices and Rule Changes (http://thefederalregister.com/b.p/department/ FEDERAL_TRADE_COMMISSION/) from The Federal Register RSS Feed (http://thefederalregister.com/rss/ department/FEDERAL_TRADE_COMMISSION/) Federal Trade Commission Identity Theft Complaint Form (http://www.ftc.gov/bcp/edu/microsites/idtheft/ consumers/filing-a-report.html)

789

Federally Qualified Health Center


A Federally Qualified Health Center (FQHC) is a reimbursement designation from the Bureau of Primary Health Care and the Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services. This designation is significant for several health programs funded under the Health Center Consolidation Act (Section 330 of the Public Health Service Act).

Funded programs
Health programs funded include: Community Health Centers which serve a variety of Federally designated Medically Underserved Area/Populations (MUA or MUP). Migrant Health Centers which provide culturally-competent and primary preventive medical care to migrant and seasonal agricultural workers, Health Care for the Homeless Programs which reach out to homeless individuals and families and provide primary and preventive care and substance abuse services, and Public Housing Primary Care Programs that serve residents of public housing and are located in or adjacent to the communities they serve.[1] FQHCs are community-based organizations that provide comprehensive primary care and preventive care, including health, oral, and mental health/substance abuse services to persons of all ages, regardless of their ability to pay or health insurance status. Thus, they are a critical component of the health care safety net.[2] FQHCs are called Community/Migrant Health Centers (C/MHC), Community Health Centers (CHC), and 330 Funded Clinics.

Leadership
FQHCs operate under a consumer Board of Directors governance structure and function under the supervision of the Health Resources and Services Administration (HRSA), which is part of the United States Department of Health and Human Services (HHS). FQHCs were originally meant to provide comprehensive health services to the medically underserved to reduce the patient load on hospital emergency rooms. Their mission has changed since their founding. Their mission now is to enhance primary care services in underserved urban and rural communities.[3] In particular, they serve underserved, underinsured, and uninsured Americans, including migrant workers and non-U.S. citizens. FQHCs provide their services to all persons regardless of ability to pay, and charge for services on a community board approved sliding-fee scale that is based on patients' family income and size. FQHCs must comply with Section 330 program requirements. In return for serving all patients regardless of ability to pay, FQHCs receive consideration from the Federal government in the form of a cash grant, cost-based reimbursement for their Medicaid patients, and free malpractice coverage under the Federal Tort Claims Act (FTCA).

Federally Qualified Health Center

790

FQHC Look-Alikes
The government also designates a category of health centers as "FQHC Look-Alikes." These health centers do not receive grants under Section 330 but are determined by the Secretary of the Department of Health and Human Services (HHS) to meet the requirements for receiving a grant based on the Health Resources and Services Administration recommendations.[4] Also, FQHC Look-Alikes receive cost-based reimbursement for their Medicaid services, but do not receive malpractice coverage under FTCA or a cash grant.

FQHCs and Medicare


FQHC benefit under Medicare became effective October 1, 1991 when Section 1861(aa) of the Social Security Act was amended by Section 4161 of the Omnibus Budget Reconciliation Act of 1990.[5] FQHCs provide Medicare beneficiaries with preventive primary health services such as immunizations, visual acuity and hearing screenings, and prenatal and post-partum care.[6] However, eyeglasses, hearing aids, and preventive dental services are not covered under the FQHC preventive primary services. A FQHC Prospective Payment System (PPS) is scheduled to be implemented in 2014.[7] The Patient Protection and Affordable Care Act (ACA) mandates that the Centers for Medicare and Medicaid Services (CMS) collect and analyze health services data prior to developing and implementing the new payment system. This requires that the appropriate revenue code and Healthcare Common Procedure Coding System (HCPCS) code is listed with each service provided.[8] Currently, Medicare pays FQHC directly based on an all-inclusive per visit payment.[9]

Federally Qualified Health Center Advanced Primary Care Practice (FQHC APCP)
In June 2011, the Department of Health and Human Services announced the Federally Qualified Health Center Advanced Primary Care Practice (FQHC APCP) demonstration project.[10] This demonstration project is conducted under the authority of Section 1115A of the Social Security Act, which was added by section 3021 of the ACA and establishes the Center for Medicare and Medicaid Innovation (Innovation Center).[11] The CMS and Innovation Center in partnership with HRSA will operate the demonstration.[12] [13] This initiative was designed to evaluate the impact of the advanced primary care practice (APCP) model, also referred to as the patient-centered medical home (PCMH) on improving health, quality of care and lowering the cost of care provided to Medicare beneficiaries. [14] [15] The ACA will pay an estimated $42 million over three years (November 1, 2011 to October 31, 2014) to 500 FQHCs to coordinate care for 195,000 Medicare patients.[16] [17] [18] Participating FQHCs agree to adopt care coordination practices set by the National Committee for Quality Assurance (NCQA) and are expected to achieve Level 3 patient-centered medical home recognition.[19] [20] President Bush launched the Health Centers Initiative to significantly increase access to primary health care services in 1,200 communities through new or expanded health center sites. Between 2001 and 2006, the number of patients treated at health centers has increased by over 4.7 million, representing a nearly 50 percent increase in just five years. In 2006 the number of patients served topped the 15 million mark for the first time. Throughout the United States there are over 1,000 health centers that operate approximately 6,000 sites.[21] In 2010, the health centers served an estimated 20 million patients.[22] The data collected via the Uniform Data System (UDS) reports that of those patients served, 62 percent were members of a racial or ethnic minority (predominantly Hispanic), 93 percent lived at or below 200 percent of the federal poverty level, 72 percent lived at or below 100 percent of the federal poverty level, and 38 percent were uninsured.[23] In particular, during 2010 health centers served 862,775 migrant and seasonal farm workers and their families; more than 1 million individuals experiencing homelessness; and 172,731 residents of public housing.[24] Moreover, The National Association of Community Health Centers forecasts that FQHCs will serve 40 million patients in 2015.[25]

Federally Qualified Health Center

791

FQHCs and the Patient Protection and Affordable Care Act (ACA)
The health center program's annual federal funding has grown from $1.16 billion in fiscal year 2001 to $1.99 billion in fiscal year 2007. The passage of the ACA in March 2010 resulted in provisions that increased federal funding to FQHCs to help them meet the anticipated health care demand of millions of Americans who will gain health care coverage as result of the health reform law.[26] The ACA set aside $11 billion for community health centers over a period of five years to meet this goal.[27]

Total FQHCs in the United States


Total FQHCs in the United States: 1,124 [28]
State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Total FQHC 14 25 16 12 118 15 13 4 State Montana Nebraska Nevada Total FQHC 15 6 2

New Hampshire 10 New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming 20 15 51 27 4 32 17 31 35 19 8 20 6 23 64 11 8 NA 25 25 28 16 6

District of Columbia 5 Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Northern Marianas 44 27 NA 14 11 36 19 13 13 19 24 18 16 36 29 15 21 21 1

Federally Qualified Health Center

792

References
[1] Health Center Program: What is a Health Center (http:/ / bphc. hrsa. gov/ about/ )

External links
U.S. Health Resources and Services Administration (http://bphc.hrsa.gov/) Center for Medicare and Medicaid Advocacy (http://www.cms.gov/center/fqhc.asp) National Association of Community Health Centers (http://www.nachc.com/) General information Texas Association of Community Health Centers (http://www.tachc.org/Home.asp) Community Health Center Association of Connecticut (http://www.chcact.org)

Fiscal year
Accountancy
Key concepts

Accountant Accounting period Accrual Bookkeeping Cash and accrual basis Cash flow forecasting Chart of accounts Convergence Journal Special journals Cost of goods sold Credit terms Debits and credits Double-entry system Mark-to-market accounting FIFO and LIFO GAAP / IFRS Management Accounting Principles General ledger Goodwill Historical cost Matching principle Revenue recognition Trial balance Fields of accounting

Cost Financial Forensic Fund Management Tax (U.S.) Financial statements

Fiscal year

793
Balance sheet Cash flow statement Income statement Statement of retained earnings Notes Management discussion and analysis XBRL Auditing

Auditor's report Control self-assessment Financial audit GAAS / ISA Internal audit SarbanesOxley Act Accounting qualifications

CIA CA AIA CPA CCA CGA CMA CAT AAT CFE CICA ACCA CIMA CGMA

A fiscal year (or financial year, or sometimes budget year) is a period used for calculating annual ("yearly") financial statements in businesses and other organizations. In many jurisdictions, regulatory laws regarding accounting and taxation require such reports once per twelve months, but do not require that the period reported on constitutes a calendar year (that is, 1 January to 31 December). Fiscal years vary between businesses and countries. The "fiscal year" may also refer to the year used for income tax reporting. Some companies choose to end their fiscal year on the same day of the week, such day being the one closest to a particular date (for example, the Friday closest to 31 December). Under such a system, some fiscal years will have 52 weeks and others 53 weeks. Major corporations that adopt this approach include Cisco Systems.[1] In the United Kingdom, a number of major corporations that were once government owned, such as BT Group and the National Grid, continue to use the government's financial year, which ends on the last day of March, as they have found no reason to change since privatisation. Nevertheless, the fiscal year is identical to the calendar year for about 65% of publicly traded companies in the United States and for a majority of large corporations in the UK[2] and elsewhere (with notable exceptions Australia, New Zealand and Japan).[3] Many universities have a fiscal year which ends during the summer, both to align the fiscal year with the school year (and, in some cases involving public universities, with the state government's fiscal year), and because the school is normally less busy during the summer months. In the Northern hemisphere this is July in one year to June in the next year. In the southern hemisphere this is January to December of a single calendar year.

Fiscal year Some media/communication based organizations use a broadcast calendar as the basis for their fiscal year.

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Operation in various countries/region


In some jurisdictions, particularly those that permit tax consolidation, companies that are part of a group of businesses must use nearly the same fiscal year (differences of up to three months are permitted in some jurisdictions, such as the U.S. and Japan), with consolidating entries to adjust for transactions between units with different fiscal years, so the same resources will not be counted more than once or not at all.

Australia
In Australia, the Fiscal Year starts on 1 July and ends on 30 June. For personal income tax after the financial year ends, individuals have until 31 October to lodge their return (unless they use a tax agent).[4]

Colombia
In Colombia, the Fiscal Year starts 1 January ending in 31 December. Yearly taxes are due in the middle of March/April for Corporations while citizens pay income tax (when needed) starting in August, ending in September, according to the last 2 digits of the national id.

Costa Rica
The Fiscal Year in Costa Rica spans from 1 October until 30 September. Taxpayers are required to pay the tributes before 15 December of each year.

Canada
In Canada,[5] the government's financial year runs from 1 April to 31 March (Example 1 April 2013 to 31 March 2014 for the current financial year). For individuals in Canada, the fiscal year runs from 1 January to 31 December.

China
The fiscal year for all entities starts on 1 January and ends 31 December, consistent with the calendar year, to match the tax year, statutory year, and planning year.

Egypt
In the Arab Republic of Egypt, the fiscal year starts on 1 July and concludes on 30 June.

France
Effective 1911:- Fiscal year is calendar year (Ref Hansard; HC Deb 22 to 21 March 1911 vol 23 cc378-82; McKENNA)

Hong Kong
In Hong Kong,[6] the government's financial year runs from 1 April to 31 March (Example 1 April 2013 to 31 March 2014 for the current financial year).

India
In India, the government's financial year runs from 1 April to 31 March. Example: 1 April 2013 to 31 March 2014 for the financial year 201314.[7][8]

Fiscal year Companies following the Indian Depositary Receipts (IDR) are given freedom to chose their financial year. For example, Standard Chartered's IDR follows the UK calendar despite being listed in India. .

795

Ireland
Ireland also used the year ending 5 April until 2001 when it was changed, at the request of Finance Minister Charlie McCreevy, to match the calendar year (the 2001 tax year was nine months, from April to December) Since 2002, it is aligned with the calendar year i.e., 1 January to 31 December.

Italy
Effective 1911:- Fiscal year is 1 July through 30 June Ref Hansard; HC Deb 22 March 1911 vol 23 cc378-82; McKENNA)

Japan
In Japan,[9] the government's financial year runs from 1 April to 31 March. The fiscal year is represented by the calendar year in which the period begins followed by the word nendo ( ); for example the fiscal year from 1 April 2010 to 31 March 2011 is called 2010nendo. Japan's income tax year runs from 1 January to 31 December, but corporate tax is charged according to the corporation's own annual period.

Mexico
In Mexico the fiscal year is the same as the calendar year.

Myanmar/Burma
In Myanmar,[10] the fiscal year goes from 1 April to 31 March.

New Zealand
The New Zealand Government's fiscal[11] and financial reporting[12] year begins on 1 July and concludes on 30 June[13] of the following year and applies to the budget. The company and personal financial year[14] begins on 1 April and finishes on 31 March and applies to company and personal income tax.

Pakistan
The Pakistan Government's fiscal year starts on 1 July of the previous calendar year and concludes on 30 June. Private companies are free to observe their own accounting year, which may not be the same as Government of Pakistan's fiscal year.

Russia
Effective 1911:- Fiscal year is calendar year (Ref Hansard; HC Deb 22 March 1911 vol 23 cc378-82; McKENNA)

Singapore
The fiscal year for the calculation of personal income taxes runs from 1 January to 31 December. The fiscal year for the Government of Singapore and many government-linked corporations runs from 1 April to 31 March. Corporations and organisations are permitted to select any date to mark the end of each fiscal year, as long as this date remains constant.

Fiscal year

796

South Africa
In South Africa the fiscal year for the Government of South Africa starts on 1 April and ends 31 March. The year of assessment for individuals covers 12 months, beginning on 1 March and ending on the final day of February the following year. The Act also provides for certain classes of taxpayers to have a year of assessment ending on a day other than the last day of February. Companies are permitted to have a tax year ending on a date that coincides with their financial year. Many older companies still use a tax year that runs from 1 July to 30 June, inherited from the British system. A common practice for newer companies is to run their tax year from 1 March to the final day of February following, to synchronize with the tax year for individuals.

Spain
In Spain the fiscal year starts on 1 January and ends 31 December.

Sweden
The fiscal year for individuals runs from 1 January to 31 December. The fiscal year for an organisation is typically one of the following (cf. Swedish Wikipedia): 1 January to 31 December 1 May to 30 April 1 July to 30 June 1 September to 31 August If an organisation wishes to use any other period, the organisation has to ask the tax authorities for permission.

Taiwan
Under the Income Tax Act of Taiwan, the fiscal year commences on 1 January and ends on 31 December of each calendar year. However, an enterprise may elect to adopt a special fiscal year at the time it is established and can request approval from the tax authorities to change its fiscal year.[15]

Thailand
Thai government's fiscal year begins on 1 October of the previous calendar year and ends on 30 September of the next year.

United Arab Emirates


In the United Arab Emirates, the fiscal year starts on 1 January and ends 31 December.

United Kingdom
In the United Kingdom, the financial year runs from 1 April to 31 March for the purposes of corporation tax[16] and government financial statements.[17]

United States
The U.S. federal government's fiscal year begins on 1 October of the previous calendar year and ends on 30 September of the year with which it is numbered. Prior to 1976, the fiscal year began on 1 July and ended on 30 June. The Congressional Budget and Impoundment Control Act of 1974 stipulated the change to allow Congress more time to arrive at a budget each year, and provided for what is known as the "transitional quarter" from 1 July 1976 to 30 September 1976. As stated above, the tax year for a business is governed by the fiscal year it chooses.[18] For example, the United States government fiscal year for 2013 ("FY 2013" or "FY13") is as follows:

Fiscal year 1st quarter: 1 October 2012 31 December 2012 2nd quarter: 1 January 2013 31 March 2013 3rd quarter: 1 April 2013 30 June 2013 4th quarter: 1 July 2013 30 September 2013

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Note this is only for US government, not for businesses.

Chart of various fiscal years


By Country Country Australia Canada China Costa Rica Hong Kong India Germany Portugal Taiwan Egypt Republic of Ireland Japan govt corp. and pers. New Zealand govt corp. and pers. Pakistan Singapore govt pers Sweden pers. corp. Purpose 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12

United Arab Emirates United Kingdom pers. corp. and govt United States Country govt Purpose J F M A M J J A S O N D J F M A M J J A S O N D 6 April

Fiscal year

798

By Start Date Country China Germany Republic of Ireland Japan Singapore Sweden Sweden Taiwan United Arab Emirates Canada Hong Kong India Japan New Zealand Singapore govt corp. and pers. govt corp. and pers. pers. pers. corp. Purpose J F M A M J J A S O N D J F M A M J J A S O N D

United Kingdom corp. and govt United Kingdom pers. Sweden Australia Egypt New Zealand Pakistan Sweden Sweden Costa Rica United States Country govt Purpose J F M A M J J A S O N D J F M A M J J A S O N D corp. corp. govt corp. 6 April

Tax year
The fiscal year for individuals and entities to report and pay income taxes is often known as the taxpayer's tax year or taxable year. Taxpayers in many jurisdictions may choose their tax year.[19] In federal countries (e.g., United States, Canada, Switzerland), state/provincial/cantonal tax years must be the same as the federal year. Nearly all jurisdictions require that the tax year be 12 months or 52/53 weeks.[20] However, short years are permitted as the first year or when changing tax years.[21] Most countries require all individuals to pay income tax based on the calendar year. Significant exceptions include: United Kingdom: individuals pay tax on a year ending 5 April. United States: individuals may (but rarely do) elect any tax year, subject to IRS approval.[22]

Fiscal year Many jurisdictions require that the tax year conform to the taxpayer's fiscal year for financial reporting. The United States is a notable exception: taxpayers may choose any tax year, but must keep books and records for such year.[23]

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References
[6] CIA The World Factbook Hong Kong (https:/ / www. cia. gov/ library/ publications/ the-world-factbook/ geos/ hk. html) [7] CIA The World Factbook India (https:/ / www. cia. gov/ library/ publications/ the-world-factbook/ geos/ in. html) [9] CIA The World Factbook Japan (https:/ / www. cia. gov/ library/ publications/ the-world-factbook/ geos/ ja. html) [10] CIA The World Factbook Burma (https:/ / www. cia. gov/ library/ publications/ the-world-factbook/ geos/ bm. html) [11] Annual Report for the New Zealand Treasury (http:/ / treasury. govt. nz/ publications/ abouttreasury/ annualreport) [12] New Zealand International Financial Reporting Standards (http:/ / www. treasury. govt. nz/ publications/ guidance/ finmgmt-reporting/ nzifrs) [13] http:/ / www. treasury. govt. nz/ government/ financialstatements/ yearend [14] New Zealand Inland Revenue tax calendar (http:/ / ird. govt. nz/ calendars-dates/ ) [16] HM Revenue and Customs Introduction to Corporation Tax (http:/ / www. hmrc. gov. uk/ ct/ getting-started/ intro. htm#8) [17] HM Treasury Accounts Direction 200809 (http:/ / www. hm-treasury. gov. uk/ d/ dao0708. pdf) [18] U.S. Senate: Reference Home (https:/ / www. senate. gov/ reference/ glossary_term/ fiscal_year. htm) [19] See, e.g., U.S. IRS Publication 538 (http:/ / www. irs. gov/ pub/ irs-pdf/ p538. pdf). [20] 26 USC 441 (http:/ / www. law. cornell. edu/ uscode/ html/ uscode26/ usc_sec_26_00000441----000-. html) [21] 26 USC 443 (http:/ / www. law. cornell. edu/ uscode/ html/ uscode26/ usc_sec_26_00000443----000-. html). [22] See instructions (http:/ / www. irs. gov/ pub/ irs-pdf/ i1128. pdf) to IRS Form 1128 (http:/ / www. irs. gov/ pub/ irs-pdf/ f1128. pdf) and 26 USC 441444 (http:/ / www. law. cornell. edu/ uscode/ html/ uscode26/ usc_sup_01_26_10_A_20_1_30_E_40_I. html). [23] 26 USC 441 (http:/ / www. law. cornell. edu/ uscode/ html/ uscode26/ usc_sec_26_00000441----000-. html).

Flexible spending account

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Flexible spending account


Health care in the United States Government Health Programs

Federal Employees Health Benefits Program Indian Health Service Veterans Health Administration Military Health System / TRICARE Medicare Medicaid / State Health Insurance Assistance Program (SHIP) State Children's Health Insurance Program (CHIP) Program of All-Inclusive Care for the Elderly (PACE) Prescription Assistance (SPAP) Private health coverage

Health insurance in the United States Consumer-driven health care


Flexible spending account (FSA) Health Reimbursement Account Health savings account

High-deductible health plan (HDHP) Medical savings account (MSA) Private Fee-For-Service (PFFS) Managed care (CCP) Health maintenance organization (HMO) Preferred provider organization (PPO) Medical underwriting

Health care reform law


Emergency Medical Treatment and Active Labor Act (1986) Health Insurance Portability and Accountability Act (1996) Medicare Prescription Drug, Improvement, and Modernization Act (2003) Patient Safety and Quality Improvement Act (2005) Health Information Technology for Economic and Clinical Health Act (2009) Patient Protection and Affordable Care Act (2010) State level reform

Massachusetts health care reform Oregon Health Plan Vermont health care reform SustiNet (Connecticut) Dirigo Health (Maine) Municipal health coverage

Fair Share Health Care Act (Maryland) Healthy Howard (Howard Co., Maryland) Healthy San Francisco

A flexible spending account (FSA), also known as a flexible spending arrangement, is one of a number of tax-advantaged financial accounts that can be set up through a cafeteria plan of an employer in the United States. An FSA allows an employee to set aside a portion of earnings to pay for qualified expenses as established in the cafeteria plan, most commonly for medical expenses but often for dependent care or other expenses. Money deducted from an employee's pay into an FSA is not subject to payroll taxes, resulting in substantial payroll tax

Flexible spending account savings. One significant disadvantage to using an FSA is that funds not used by the end of the plan year are lost to the employee, known as the "use it or lose it" rule.[1] The most common type of flexible spending account, the medical expense FSA (also medical FSA or health FSA), is similar to a health savings account (HSA) or a health reimbursement account (HRA). However, while HSAs and HRAs are almost exclusively used as components of a consumer driven health care plan, medical FSAs are commonly offered with more traditional health plans as well. In addition, funds in a health savings account are not lost when the plan year is over, unlike funds in an FSA. Paper forms or an FSA debit card, also known as a Flexcard, may be used to access the account funds.

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Types
Most cafeteria plans offer two different flexible spending accounts; one is for qualified medical expenses and the other is for dependent care expenses. A few cafeteria plans offer other types of FSAs, especially if the employer also offers an HSA. Participation in one type of FSA does not affect participation in another type of FSA, but funds cannot be transferred from one FSA to another.

Medical (and dental) expense FSA


The most common type of FSA is used to pay for medical and dental expenses not paid for by insurance, usually deductibles, copayments, and coinsurance for the employee's health plan. As of January 1, 2011, over-the-counter medications are allowed only when purchased with a doctor's prescription, with the exception of insulin.[2] Over-the-counter medical devices, such as bandages, crutches, and eyeglass repair kits are allowable. Generally, allowable items are the same as those allowable for the medical tax deduction, as outlined in IRS publication 502 [3]. Prior to the enactment of the Patient Protection and Affordable Care Act, the Internal Revenue Service permitted employers to enact any maximum annual election for their employees. Patient Protection and Affordable Care Act amended Section 125 such that FSAs may not allow employees to choose an annual election in excess of a limit determined by the Internal Revenue Service.[] The annual limit will be $2,500 for the first plan year beginning after December 31, 2012.[] The Internal Revenue Service will index subsequent plan years' limits for cost-of-living adjustments.[] Employers have the option to limit their employees' annual elections further. This change starts in plan years that begin after December 31, 2012.[] The limit is applied to each employee, without regard to whether the employee has a spouse or children.[] Non-elective contributions made by the employer that are not deducted from the employee's wages are not counted against the limit.[] An employee employed by multiple unrelated employers may elect an amount up to the limit under each employer's plan.[] The limit does not apply to health savings accounts, health reimbursement arrangements, or the employee's share of the cost of employer-sponsored health insurance coverage.[] Some employers choose to issue a debit card to their employees who participate in the FSA. Participants may use the debit card to pay for their FSA-eligible expenses at the point of sale. Pharmacies and grocery stores who choose to accept the debit card as payment must disallow transactions at point of sale if the participant attempts to pay for items that are not eligible under an FSA. In addition, employers still must require employees to provide itemized receipts for all expenses charged to the debit card. The IRS allows employers to waive this requirement when an individual uses the debit card at a pharmacy or grocery store that complies with the above procedure. The IRS also allows employers to waive this requirement when the amount charged to the debit card is a multiple of a co-pay of the employee's group health insurance plan. In most cases, the FSA administering firm will prefer actual insurance Explanations of Benefits (EOBs) clearly representing the patient portion of any medical expense, over other, more vague documentation. This requirement is becoming less cumbersome as more insurances allow patients to search for past EOBs on their websites.[4]

Flexible spending account

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Dependent care FSA


FSAs can also be established to pay for certain expenses to care for dependents who live with someone while that person is at work. While this most commonly means child care, for children under the age of 13, it can also be used for children of any age who are physically or mentally incapable of self-care, as well as adult day care for senior citizen dependents who live with the person, such as parents or grandparents. Additionally, the person or persons on whom the dependent care funds are spent must be able to be claimed as a dependent on the employee's federal tax return. The funds cannot be used for summer camps (other than "day camps") or for long term care for parents who live elsewhere (such as in a nursing home). The dependent care FSA is federally capped at $5,000 per year, per household. Married spouses can each elect an FSA, but their total combined elections cannot exceed $5,000. At tax time, all withdrawals in excess of $5,000 are taxed. Unlike medical FSAs,[5] dependent care FSAs are not "pre-funded"; employees cannot receive reimbursement for the full amount of the annual contribution on day one. Employees can only be reimbursed up to the amount they have had deducted during that plan year. If married, both spouses must earn income for the Dependent Care FSA to work. The only exception is if the non-earning spouse is disabled or a full-time student. If one spouse earns less than $5,000 then the benefit is limited to whatever that spouse earned. Many plan coordinators do not warn of this limit. This limitation can create a situation where the earning spouse sets up a Dependent Care FSA and dutifully sends in receipts to withdraw funds and then at tax time the FSA is effectively eliminated and all the work wasted. See IRS Form 2441 [6] Part III for details.

Other FSAs
There are FSA plans for non-employer sponsored premium reimbursement and parking and transit expense reimbursement. The individual premium account allows an employee to pay for his or her spouses insurance with pre-tax dollars as long as the other coverage is a non-employer-sponsored, is considered an individual plan, and is directly billed to the member or the members spouse. A parking and transit account allows employees to pay parking or public transit expenses with pre-tax dollars up to certain limits. Though not as common as the FSAs listed above, some employers have offered adoption assistance through an FSA. Also, one cannot have a health care FSA if he or she has a High Deductible Health Plan (HDHP) with a Health Savings Account (HSA). In cases where an employee has a HDHP with a HSA, they are eligible for a Limited Expense FSA (LEX) (also called Limited Purpose FSA). These FSAs may be used to reimburse dental and vision expenses, regardless of any plan deductible; at the employer's discretion, eligible medical expenses incurred after the deductible is met may also be reimbursable. 7. Conveyance Allowance

Coverage period
An FSA's coverage period ends either at the time the plan year ends for one's plan or at the time when one's coverage under that plan ends. An example of such an event is the loss of coverage due to a separation from the employer.[7] This means that if, for example, a person is employed by a company from January through June and covered on their cafeteria benefits plan (including FSA) during that time, but does not elect and pay for continued coverage under that plan (i.e., COBRA), the person's coverage period is defined only as January through June, not January through December as one might think.[8] In this example, all covered expenses must be incurred between January and June of that year.

Flexible spending account

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Plan year grace period


In 2005, the Internal Revenue Service authorized an optional 2 month grace period that employers can use in their plans, allowing use of the funds for 2 months after the end of the plan year.

Methods of withdrawal
In recent years, the FSA debit card was developed to eliminate "double-dipping," by allowing employees to access the FSA directly. It also simplified the substantiation requirement, which required labor-intensive claims processing. The debit card also enhances the effect of "pre-funding" medical FSAs. However, the substantiation requirement itself did not go away, and has even been expanded on by the IRS for the debit-card environment; therefore, withdrawal issues still remain for FSAs. These withdrawal issues have led to creative solutions by Ecommerce companies such as FSAstore.com who created an entire website dedicated to FSA eligible items and accepting all FSA debit cards and websites such as drugstore.com which created a small portion of their website dedicated to FSAs. According to Celent, as of May 2006, there were approximately 6 million debit cards in the market tied to an FSA account, representing 25% of the FSA participating community. Celent projects that FSA cards will increase FSA adoption rates. The average card participation rate was around 20% as of May 2006. By 2010, it is projected this rate will increase to 85%.

Advantages and disadvantages


Pre-funding and risks incurred by the employee and employer
One consideration regarding medical FSAs is that the participating employee's entire annual contribution is available at the start of the plan year, commonly January 1, or after the first contribution to the FSA is received by the FSA vendor, depending on the plan. Therefore, if the employee experiences a qualifying event during the first period, the entire amount of the annual contribution can be claimed against the FSA benefits. If the employee is terminated, quits, or is unable to return to work, he or she does not have to repay the money to the employer.[9] The employee contributes to the FSA in small increments throughout the year (for example, 1/26 of the annual amount if one is paid every 2 weeks), but taken together, all employees of a company contribute the full average amount during any given period, and no real risk is incurred by the employer. In addition, instead of paying payroll taxes to the government, the employer typically pays only a small administrative fee to the plan of $410 per participating employee. This is much less than the employer would have paid for its share of payroll taxes. In addition, any money that is not used by the end of the plan year (or grace period) is returned to the employer. This is estimated to be up to 14% of the total employee contributions, which can be a substantial boon to the employer's bottom line.[10] If a company plans to lay off some employees, and announces such plans, then if multiple employees use their entire flexible benefit before they are terminated, that may cause the company to have to reimburse the plan. Typically, however, employers do not announce layoffs for specific employees with enough notice for employees to use the available benefits, and employees may actually lose their contributions in addition to being laid off. An employee does not continue to contribute to the plan upon termination of employment. Thus, one could use the entire amount on day one of the plan year, terminate employment on day two of the plan year, and contributions would have been none or negligible (e.g., perhaps 1/26 in the case of biweekly contributions). The "free" money is not taxable. The reason for this is that the IRS views these plans as health insurance plans for tax purposes.[11] According to IRS section 125, benefits received from a health insurance plan are not considered taxable income. The same reasons that make pre-funding a possible benefit to an employee participating in a plan make them a potential risk to employers setting up a plan. The employer has to make up the difference that the employee has spent

Flexible spending account from the flexible spending account but not yet contributed if other employees' contributions do not account for the money spent. The amount the employer loses due to pre-funding may eventually be partially, totally, or more than made up by employees that do not spend all of the money in their FSA account by the end of the plan year and grace period (see above).

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Over-the-counter drugs and medical items


Another FSA feature that was introduced in 2003 is the ability to pay for over-the-counter (OTC) drugs and medical items.[12] In addition to substantially expanding the range of "FSA-eligible" purchases, adding OTC items made it easier to "spend down" medical FSAs at year-end to avoid the dreaded "use it or lose it" rule. However, substantiation has again become an issue; generally, OTC purchases require either manual claims or, for FSA debit cards, submission of receipts after the fact. Most FSA providers require that receipts show the complete name of the item; the abbreviations on many store receipts are incomprehensible to many claims offices. Also, some of the IRS rules on what is and isn't eligible have proven rather arcane in practice. The recently developed inventory information approval system (IIAS), separates eligible and ineligible items at the point-of-sale and provides for automatic debit-card substantiation. According to section 9003(c) of the Patient Protection and Affordable Care Act, as of January 1, 2011, drugs must be prescribed to be reimbursable.[]

Use it or lose it
A potential drawback is that the money must be spent "within the coverage period" as defined by the benefits cafeteria plan coverage definition. This coverage period is usually defined as the "period that you are covered" under the cafeteria plan during the "plan year." The "plan year" is commonly defined as the calendar year, but could also include the grace period of Jan 1 March 15 of the following year. For example, the "plan year" (or "benefit year") of 2012 would run from Jan 1, 2012, until March 15, 2013, if the employer offered the grace period. Any money left unspent at the end of the coverage period is forfeited and can be applied to future plan administrative costs or can be equally allocated as taxable income among all plan participants; this is commonly known as the "use it or lose it" rule.[13][14][15] Under most plans, the "coverage period" generally ceases upon termination of employment whether initiated by the employee or the employer, unless the employee continues coverage with the company under COBRA or other arrangement. An unfortunate possibility, especially in the case of unexpected, immediate layoff, is that should an employee have unused contributions in an FSA and no additional qualifying claims during the coverage period the employee will have the added insult of "losing" these funds. On the other hand, if the payroll taxes saved on the employee's contributions exceeds the amount the employee forfeited, then the employee has still saved money overall. A second requirement is that all applications for refunds must be made by a date defined by the plan. If funds are forfeited, this does not eliminate the requirement to pay taxes on these funds if such taxes are required. For example, if a single person elects to withhold $5,000 for child care expenses and gets married to a non-working spouse, the $5,000 would become taxable. If this person did not submit claims by the required date, the $5,000 would be forfeited but taxes would still be owed on the amount. Also, the annual contribution amount must remain the same throughout the year unless certain qualifying events occur, such as the birth of a child or death of a spouse. As of May 2012, the Department of the Treasury and the Internal Revenue Service are considering modifying the use-or-lose rule for medical flexible spending accounts.[]

Flexible spending account

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References
[3] [6] [7] [8] http:/ / www. irs. gov/ publications/ p502/ index. html http:/ / www. irs. gov/ uac/ Form-2441,-Child-and-Dependent-Care-Expenses Revenue Service Regulation 1.125-4 (http:/ / www. indstate. edu/ humres/ docs/ Section125-4. pdfInternal). Internal Revenue Service Regulation 1.125-2: Miscellaneous cafeteria plan questions and answers (http:/ / www. indstate. edu/ humres/ docs/ Section125-2. pdf). [9] http:/ / well. blogs. nytimes. com/ 2009/ 03/ 23/ good-question-flex-spend-funds-after-job-loss/ [11] IRS Publication 969: Flexible Spending Arrangements (FSAs) Distributions From an FSA (http:/ / www. irs. gov/ publications/ p969/ ar02. html#d0e1788) [12] Rev. Rul. 2003102 (http:/ / www. irs. gov/ pub/ irs-drop/ rr-03-102. pdf). Internal Revenue Service. September 3, 2003. [13] Prop. Treas. Reg. Section 1.125-1, Q&A-7(b) (1984). [14] Prop. Treas. Reg. Section 1.125-2, Q&A 5 and Q&A 7 (1989). [15] Prop. Treas. Reg. Section 1.125-5(c) (2007).

External links
IRS Publication 502 (2011), Medical and Dental Expenses (http://www.irs.gov/publications/p502/index. html) Explains which medical expenses are covered and which are not. (While this publication will generally also apply to the Medical Flex Spending benefit, some expenses listed in the publication are not eligible in the Medical Flex, including Long-Term care insurance, insurance premiums and expenses paid in the current year for services in prior years). IRS Publication 969 (2011), Health Savings Accounts and Other Tax-Favored Health Plans (http://www.irs. gov/publications/p969/index.html) Publication from the IRS comparing these.

Government Accountability Office

806

Government Accountability Office


Government Accountability Office

Seal of the Government Accountability Office

Logo of the Government Accountability Office

Flag of the Government Accountability Office Agency overview Formed Headquarters Employees Annual budget Agency executive July 1, 1921 441 G St., NW Washington, D.C. 20548 3,350 (2010) $557 million (2011) Eugene Louis Dodaro, Comptroller General of the United States Website gao.gov
[1]

Footnotes Measurable benefits of GAO work total $49.9 billion, a return of $87 for every dollar invested; at the end of FY 2010, over 80% of the [2] GAO recommendations made in FY 2006 had been implemented.

The Government Accountability Office (GAO) is the audit, evaluation, and investigative arm of the United States Congress. It is part of the legislative branch of the United States government.

History
The GAO was established as the General Accounting Office by the Budget and Accounting Act of 1921. This Act required the head of GAO to "investigate, at the seat of government or elsewhere, all matters relating to the receipt, disbursement, and application of public funds, and shall make to the President ... and to Congress ... reports [and] recommendations looking to greater economy or efficiency in public expenditures".[3] According to GAO's current mission statement, the agency exists to support the Congress in meeting its constitutional responsibilities and to help improve the performance and ensure the accountability of the federal government for the benefit of the American

Government Accountability Office people. The name was changed in 2004 by the GAO Human Capital Reform Act to better reflect the mission of the office.[4] While most other countries have government entities similar to the GAO, their focus is primarily on conducting financial audits. The GAO's auditors conduct not only financial audits, but also engage in a wide assortment of performance audits. Over the years, GAO has been referred to as "The Congressional Watchdog" and "The Taxpayers' Best Friend" for its frequent audits and investigative reports that have uncovered waste and inefficiency in government. The news, media, television, electronically based news sources, and print, often draw attention to GAO's work by doing stories on the findings, conclusions, and/or recommendations in GAO reports. Members of Congress also frequently cite GAO's work in statements to the press, congressional hearings, and floor debates on proposed legislation. In 2007 the Partnership for Public Service ranked GAO second on its list of the best places to work in the federal government and Washingtonian magazine included GAO on its 2007 list of great places to work in Washington, a list that encompasses the public, private, and non-profit sectors. The GAO is headed by the Comptroller General of the United States, a professional and non-partisan position in the U.S. government. The Comptroller General is appointed by the President, by and with the advice and consent of the Senate, for a 15-year, non-renewable term. The President selects a nominee from a list of at least three individuals recommended by an eight member bipartisan, bicameral commission of congressional leaders. The Comptroller General may not be removed by the President, but only by Congress through impeachment or joint resolution for specific reasons.[5] Since 1921, there have been only seven Comptrollers General, and no formal attempt has ever been made to remove a Comptroller General. According to the GAO website, "the long tenure of the Comptroller General gives GAO a continuity of leadership that is rare within government."[6] Labor-management relations became fractious during the 9-year tenure of the 7th Comptroller General, David M. Walker. On September 19, 2007, GAO analysts voted by a margin of two to one (897445), in a 75% turnout, to establish the first union in GAO's 86-year history. The analysts voted to affiliate with the International Federation of Professional and Technical Engineers (IFPTE), a member union of the AFL-CIO. There are more than 1,800 analysts in the GAO analysts bargaining unit; the local voted to name itself IFPTE Local 1921, in honor of the date of GAO's establishment. On February 14, 2008, the GAO analysts' union approved its first-ever negotiated pay contract with management; of just over 1,200 votes, 98 percent were in favor of the contract. The Government Accountability Office also establishes standards for audits of government organizations, programs, activities, and functions, and of government assistance received by contractors, nonprofit organizations, and other nongovernmental organizations. These standards, often referred to as Generally Accepted Government Auditing Standards (GAGAS), are to be followed by auditors and audit organizations when required by law, regulation, agreement, contract, or policy. These standards pertain to auditors' professional qualifications, the quality of audit effort, and the characteristics of professional and meaningful audit reports. In 1992 the GAO hosted XIV INCOSAI, the fourteenth triennial convention of the International Organization of Supreme Audit Institutions.[7]
Seal of the General Accounting Office, from 1921 until being renamed in 2004.

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Government Accountability Office

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Reports
GAO is a United States government electronic data provider, as all of its reports are available on its website (www.gao.gov), except for certain reports whose distribution is limited to official use in order to protect national and homeland security. The variety of topics reported on range from Federal Budget and Fiscal Issues to Financial Management, Education, Retirement Issues, Defense, Homeland Security, Administration of Justice, Health Care, Information Management and Technology, Natural Resources, Environment, International Affairs, Trade, Financial Markets, Housing, Government Management and Human Capital.

GAO headquarters in Washington

Most GAO studies and reports are initiated by requests from members of Congress, including requests mandated in statute, and so reflect concerns of current political import, but many reports are issued periodically and take a long view of U.S. agencies' operations.[citation needed] Examples of these are the annual Performance and Accountability Series and High Risk Update. The GAO prepares some 900 reports annually. GAO publishes reports and information relating to, inter alia:

Financial Statements of the U.S. government


Each year the GAO issues an audit report on the financial statements of the United States Government. The 2010 Financial Report of the United States Government was released on 21 December 2010.[] The accompanying press release states that the GAO 'cannot render an opinion on the 2010 consolidated financial statements of the federal government, because of widespread material internal control weaknesses, significant uncertainties, and other limitations'.[]

U.S. Public Debt


As part of its initiative to advocate sustainability, the GAO publishes a Federal Fiscal Outlook Report,[8] as well as data relating to the deficit.[] The US deficit is presented on a cash rather than accruals basis, although the GAO notes that the accrual deficit 'provides more information on the longer-term implications of the government's annual operations'.[] In FY 2010, the US federal government had a net operating cost of $2,080 billion, although since this includes accounting provisions (estimates of future liabilities), the cash deficit is $1,294 billion.[9]

Quinquennial Strategic Plan


The most recent GAO plan, for 2010-2015, sets out four goals, namely to address: (1) Current and Emerging Challenges to the Well-being and Financial Security of the American People; (2) Changing Security Threats and the Challenges of Global Interdependence; (3) Transformation of the Federal Government to Address National Challenges; (4) Maximization of the Value of the GAO.[10]

GAO and technology assessment


After the closing of the Office of Technology Assessment (OTA) in 1995, Congress directed GAO to conduct a technology assessment (TA) pilot program. Between 2002 and 2006, four reports were completed use of biometrics for border security, cybersecurity for critical infrastructure protection, technologies for protecting structures in wildland fires, and cargo container security technologies. In the first report, GAO found that while biometrics technologies could be used to secure the border, they had limitations in fingerprinting and facial recognition systems. An immediate impact of the report was a congressional testimony on the use of biometrics which, in turn, helped to inform U.S. national security reform efforts. GAO reports, which are made available to the public, have become

Government Accountability Office essential vehicles for understanding science and technology (S&T) implications of policies considered by the Congress. Since 2007, Congress has established a permanent TA function within GAO. This new operational role augments GAOs performance audits related to S&T issues, including effectiveness and efficiency of U.S. Federal programs. In 2010, GAO joined European Parliamentary Technology Assessment (EPTA) as an associate member. In the last three years, GAO has completed TA reports on three topics, the most recent one being released in 2011 rail security, climate engineering, and alternate neutron detectors. In the climate engineering report, Congress requested GAO to examine three areas: the current S&T state of climate engineering, views of experts on the future of climate engineering research, and potential public responses to climate engineering. When the GAO receives a request to conduct TA, it follows five phases: Acceptance, Planning, Data Gathering and Analysis, Product development and Distribution and Results. Phases one and two include selecting the topic and initiating the TA plan while the other ones are respectively: conducting TA, followed by developing the report and ensuring its accuracy and integrity, and finally receiving feedback from Congress and developing lessons learned to enhance the TA process. The GAO describes the TA as providing "thorough and balanced analysis of critical technological innovations that affect our society, the environment, and the economy" explaining "the consequences that each featured technology will have on federal agencies and departments, and their wider impacts on American society".[11] This broad working definition enables GAO analysts to utilize TA as a tool for policy analysis. Technology assessments at GAO are conducted in accordance with GAOs quality assurance framework. GAO initiates technology assessments through congressional mandates, requests from congressional leaders, and through the authority of U.S. Comptroller General. The Technology Assessment section of GAO's website [12] offers latest TA reports and videos.

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References
[1] http:/ / www. gao. gov [3] Budget and Accounting Act of 1921, Sec. 312(a), [5] See Bowsher v. Synar, 478 U.S. 714 (1986) [11] U.S. GAO - Technology Assessment (http:/ / www. gao. gov/ technology_assessment). Gao.gov. Retrieved on 2013-07-19. [12] GAO-TA (http:/ / www. gao. gov/ technology_assessment)

External links
GAO homepage (http://www.gao.gov/) GAO name change (http://www.gao.gov/about/namechange.html) General Accounting Office Reports (http://www.fas.org/document.htm), on the website of the Federation of American Scientists

Gross domestic product

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Gross domestic product


Gross domestic product (GDP) is the market value of all officially recognized final goods and services produced within a country in a given period of time. GDP per capita is often considered an indicator of a country's standard of living;[1][2] GDP per capita is not a measure of personal income (See Standard of living and GDP). Under economic theory, GDP per capita exactly equals the gross domestic income (GDI) per capita (See Gross domestic income).

A map of world economies by size of GDP (nominal) in $US, CIA World Factbook, [] 2012.

GDP is related to national accounts, a subject in macroeconomics. GDP is not to be confused with gross national product (GNP) which allocates production based on ownership.

History
GDP was first developed by Simon Kuznets for a US Congress report in 1934.[3] In this report, Kuznets warned against its use as a measure of welfare (see below under limitations and criticisms). After the Bretton Woods conference in 1944, GDP became the main tool for measuring a country's economy.[4]

Determining GDP

Economics

GDP per capita by country (World Bank, 2011) General classifications


Microeconomics Macroeconomics History of economic thought Methodology Heterodox approaches Technical methods

Gross domestic product

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GDP can be determined in three ways, all of which should, in principle, give the same result. They are the product (or output) approach, the income approach, and the expenditure approach. The most direct of the three is the product approach, which sums the outputs of every class of enterprise to arrive at the total. The expenditure approach works on the principle that all of the product must be bought by somebody,

Gross domestic product therefore the value of the total product must be equal to people's total expenditures in buying things. The income approach works on the principle that the incomes of the productive factors ("producers," colloquially) must be equal to the value of their product, and determines GDP by finding the sum of all producers' incomes.[5] Example: the expenditure method: GDP = private consumption + gross investment + government spending + (exports imports), or

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Note: "Gross" means that GDP measures production regardless of the various uses to which that production can be put. Production can be used for immediate consumption, for investment in new fixed assets or inventories, or for replacing depreciated fixed assets. "Domestic" means that GDP measures production that takes place within the country's borders. In the expenditure-method equation given above, the exports-minus-imports term is necessary in order to null out expenditures on things not produced in the country (imports) and add in things produced but not sold in the country (exports). Economists (since Keynes) have preferred to split the general consumption term into two parts; private consumption, and public sector (or government) spending.[citation needed] Two advantages of dividing total consumption this way in theoretical macroeconomics are: Private consumption is a central concern of welfare economics. The private investment and trade portions of the economy are ultimately directed (in mainstream economic models) to increases in long-term private consumption. If separated from endogenous private consumption, government consumption can be treated as exogenous,[citation needed] so that different government spending levels can be considered within a meaningful macroeconomic framework.

Production approach
" Market value of all final goods and services calculated during 1 year . " The production approach is also called Net Product or Value added method. This method consists of three stages: 1. Estimating the Gross Value of domestic Output out of the many various economic activities; 2. Determining the intermediate consumption, i.e., the cost of material, supplies and services used to produce final goods or services; and finally 3. Deducting intermediate consumption from Gross Value to obtain the Net Value of Domestic Output. Symbolically, Net Value Added = Gross Value of output Value of Intermediate Consumption. Value of Output = Value of the total sales of goods and services + Value of changes in the inventories. The sum of Net Value Added in various economic activities is known as GDP at factor cost. GDP at factor cost plus indirect taxes less subsidies on products is GDP at Producer Price. For measuring gross output of domestic product, economic activities (i.e. industries) are classified into various sectors. After classifying economic activities, the gross output of each sector is calculated by any of the following two methods: 1. By multiplying the output of each sector by their respective market price and adding them together and 2. By collecting data on gross sales and inventories from the records of companies and adding them together Subtracting each sector's intermediate consumption from gross output, we get sectoral Gross Value Added (GVA) at factor cost. We, then add gross value of all sectors to get GDP at factor cost. Adding indirect tax minus subsidies in GDP at factor cost, we get GDP at Producer Prices.

Gross domestic product

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Income approach
" sum total of incomes of individuals living in a country during 1 year ." Another way of measuring GDP is to measure total income. If GDP is calculated this way it is sometimes called Gross Domestic Income (GDI), or GDP(I). GDI should provide the same amount as the expenditure method described below. (By definition, GDI = GDP. In practice, however, measurement errors will make the two figures slightly off when reported by national statistical agencies.) This method measures GDP by adding incomes that firms pay households for factors of production they hire- wages for labour, interest for capital, rent for land and profits for entrepreneurship. The US "National Income and Expenditure Accounts" divide incomes into five categories: 1. Wages, salaries, and supplementary labour income 2. Corporate profits 3. Interest and miscellaneous investment income 4. Farmers' income 5. Income from non-farm unincorporated businesses

Countries by 2012 List of countries by GDP (nominal) per capitaGDP (nominal) per capita.Based on the IMF figures. If no number was available for a country from IMF, CIA figures were used.

GDP (PPP) per capita (World bank, 2011).

These five income components sum to net domestic income at factor cost. Two adjustments must be made to get GDP: 1. Indirect taxes minus subsidies are added to get from factor cost to market prices. 2. Depreciation (or Capital Consumption Allowance) is added to get from net domestic product to gross domestic product. Total income can be subdivided according to various schemes, leading to various formulae for GDP measured by the income approach. A common one is: GDP = compensation of employees + gross operating surplus + gross mixed income + taxes less subsidies on production and imports GDP = COE + GOS + GMI + TP & M SP & M Compensation of employees (COE) measures the total remuneration to employees for work done. It includes wages and salaries, as well as employer contributions to social security and other such programs. Gross operating surplus (GOS) is the surplus due to owners of incorporated businesses. Often called profits, although only a subset of total costs are subtracted from gross output to calculate GOS.

Gross domestic product Gross mixed income (GMI) is the same measure as GOS, but for unincorporated businesses. This often includes most small businesses. The sum of COE, GOS and GMI is called total factor income; it is the income of all of the factors of production in society. It measures the value of GDP at factor (basic) prices. The difference between basic prices and final prices (those used in the expenditure calculation) is the total taxes and subsidies that the government has levied or paid on that production. So adding taxes less subsidies on production and imports converts GDP at factor cost to GDP(I). Total factor income is also sometimes expressed as: Total factor income = Employee compensation + Corporate profits + Proprietor's income + Rental income + Net interest[7] Yet another formula for GDP by the income method is:[citation needed]

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where R : rents I : interests P : profits SA : statistical adjustments (corporate income taxes, dividends, undistributed corporate profits) W : wages Note the mnemonic, "ripsaw".

Expenditure approach
" All expenditure incurred by individuals during 1 year . " In economics, most things produced are produced for sale, and sold. Therefore, measuring the total expenditure of money used to buy things is a way of measuring production. This is known as the expenditure method of calculating GDP. Note that if you knit yourself a sweater, it is production but does not get counted as GDP because it is never sold. Sweater-knitting is a small part of the economy, but if one counts some major activities such as child-rearing (generally unpaid) as production, GDP ceases to be an accurate indicator of production. Similarly, if there is a long term shift from non-market provision of services (for example cooking, cleaning, child rearing, do-it yourself repairs) to market provision of services, then this trend toward increased market provision of services may mask a dramatic decrease in actual domestic production, resulting in overly optimistic and inflated reported GDP. This is particularly a problem for economies which have shifted from production economies to service economies.

Gross domestic product Components of GDP by expenditure GDP (Y) is a sum of Consumption (C), Investment (I), Government Spending (G) and Net Exports (X M). Y = C + I + G + (X M) Here is a description of each GDP component: C (consumption) is normally the largest GDP component in the economy, consisting of private (household final consumption expenditure) in the economy. These personal expenditures fall under one of the following categories: durable goods, non-durable goods, and services. Examples include food, rent, jewelry, gasoline, and medical expenses but does not include the purchase of new housing.

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Components of U.S. GDP

I (investment) includes, for instance, business investment in equipment, but does not include exchanges of existing assets. Examples include construction of a new mine, purchase of software, or purchase of machinery and equipment for a factory. Spending by households (not government) on new houses is also included in Investment. In contrast to its colloquial meaning, 'Investment' in GDP does not mean purchases of financial products. Buying financial products is classed as 'saving', as opposed to investment. This avoids double-counting: if one buys shares in a company, and the company uses the money received to buy plant, equipment, etc., the amount will be counted toward GDP when the company spends the money on those things; to also count it when one gives it to the company would be to count two times an amount that only corresponds to one group of products. Buying bonds or stocks is a swapping of deeds, a transfer of claims on future production, not directly an expenditure on products. G (government spending) is the sum of government expenditures on final goods and services. It includes salaries of public servants, purchase of weapons for the military, and any investment expenditure by a government. It does not include any transfer payments, such as social security or unemployment benefits. X (exports) represents gross exports. GDP captures the amount a country produces, including goods and services produced for other nations' consumption, therefore exports are added. M (imports) represents gross imports. Imports are subtracted since imported goods will be included in the terms G, I, or C, and must be deducted to avoid counting foreign supply as domestic. A fully equivalent definition is that GDP (Y) is the sum of final consumption expenditure (FCE), gross capital formation (GCF), and net exports (X M). Y = FCE + GCF+ (X M) FCE can then be further broken down by three sectors (households, governments and non-profit institutions serving households) and GCF by five sectors (non-financial corporations, financial corporations, households, governments and non-profit institutions serving households [8]). The advantage of this second definition is that expenditure is systematically broken down, firstly, by type of final use (final consumption or capital formation) and, secondly, by sectors making the expenditure, whereas the first definition partly follows a mixed delimitation concept by type of

Gross domestic product final use and sector. Note that C, G, and I are expenditures on final goods and services; expenditures on intermediate goods and services do not count. (Intermediate goods and services are those used by businesses to produce other goods and services within the accounting year.[9] ) According to the U.S. Bureau of Economic Analysis, which is responsible for calculating the national accounts in the United States, "In general, the source data for the expenditures components are considered more reliable than those for the income components [see income method, below]."[10] Examples of GDP component variables C, I, G, and NX(net exports): If a person spends money to renovate a hotel to increase occupancy rates, the spending represents private investment, but if he buys shares in a consortium to execute the renovation, it is saving. The former is included when measuring GDP (in I), the latter is not. However, when the consortium conducted its own expenditure on renovation, that expenditure would be included in GDP. If a hotel is a private home, spending for renovation would be measured as consumption, but if a government agency converts the hotel into an office for civil servants, the spending would be included in the public sector spending, or G. If the renovation involves the purchase of a chandelier from abroad, that spending would be counted as C, G, or I (depending on whether a private individual, the government, or a business is doing the renovation), but then counted again as an import and subtracted from the GDP so that GDP counts only goods produced within the country. If a domestic producer is paid to make the chandelier for a foreign hotel, the payment would not be counted as C, G, or I, but would be counted as an export. A "production boundary" delimits what will be counted as GDP.
"One of the fundamental questions that must be addressed in preparing the national economic accounts is how to define the production boundarythat

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is, what parts of the myriad human activities are to be included in or excluded from the measure of the economic production."
[11] GDP real growth rates for 2010.

All output for market is at least in theory included within the boundary. Market output is defined as that which is sold for "economically significant" prices; economically significant prices are "prices which have a significant influence on the amounts producers are willing to supply and purchasers wish to buy."[12] An exception is that illegal goods and services are often excluded even if they are sold at economically significant prices (Australia and the United States exclude them). This leaves non-market output. It is partly excluded and partly included. First, "natural processes without human involvement or direction" are excluded.[13] Also, there must be a person or institution that owns or is entitled to compensation for the product. An example of what is included and excluded by these criteria is given by the United States' national accounts agency: "the growth of trees in an uncultivated forest is not included in production, but the harvesting of the trees from that forest is included."[14]

Gross domestic product Within the limits so far described, the boundary is further constricted by "functional considerations."[15] The Australian Bureau for Statistics explains this: "The national accounts are primarily constructed to assist governments and others to make market-based macroeconomic policy decisions, including analysis of markets and factors affecting market performance, such as inflation and unemployment." Consequently, production that is, according to them, "relatively independent and isolated from markets," or "difficult to value in an economically meaningful way" [i.e., difficult to put a price on] is excluded.[16] Thus excluded are services provided by people to members of their own families free of charge, such as child rearing, meal preparation, cleaning, transportation, entertainment of family members, emotional support, care of the elderly.[17] Most other production for own (or one's family's) use is also excluded, with two notable exceptions which are given in the list later in this section. Nonmarket outputs that are included within the boundary are listed below. Since, by definition, they do not have a market price, the compilers of GDP must impute a value to them, usually either the cost of the goods and services used to produce them, or the value of a similar item that is sold on the market. Goods and services provided by governments and non-profit organizations free of charge or for economically insignificant prices are included. The value of these goods and services is estimated as equal to their cost of production. This ignores the consumer surplus generated by an efficient and effective government supplied infrastructure. For example, government-provided clean water confers substantial benefits above its cost. Ironically, lack of such infrastructure which would result in higher water prices (and probably higher hospital and medication expenditures) would be reflected as a higher GDP. This may also cause a bias that mistakenly favors inefficient privatizations since some of the consumer surplus from privatized entities' sale of goods and services are indeed reflected in GDP.[18] Goods and services produced for own-use by businesses are attempted to be included. An example of this kind of production would be a machine constructed by an engineering firm for use in its own plant. Renovations and upkeep by an individual to a home that she owns and occupies are included. The value of the upkeep is estimated as the rent that she could charge for the home if she did not occupy it herself. This is the largest item of production for own use by an individual (as opposed to a business) that the compilers include in GDP.[18] If the measure uses historical or book prices for real estate, this will grossly underestimate the value of the rent in real estate markets which have experienced significant price increases (or economies with general inflation). Furthermore, depreciation schedules for houses often accelerate the accounted depreciation relative to actual depreciation (a well built house can be lived in for several hundred years a very long time after it has been fully depreciated). In summary, this is likely to grossly underestimate the value of existing housing stock on consumers' actual consumption or income. Agricultural production for consumption by oneself or one's household is included. Services (such as chequeing-account maintenance and services to borrowers) provided by banks and other financial institutions without charge or for a fee that does not reflect their full value have a value imputed to them by the compilers and are included. The financial institutions provide these services by giving the customer a less advantageous interest rate than they would if the services were absent; the value imputed to these services by the compilers is the difference between the interest rate of the account with the services and the interest rate of a similar account that does not have the services. According to the United States Bureau for Economic Analysis, this is one of the largest imputed items in the GDP.[19]

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Gross domestic product

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GDP vs GNP
GDP can be contrasted with gross national product (GNP) or gross national income (GNI). The difference is that GDP defines its scope according to location, while GNP defines its scope according to ownership. In a global context, world GDP and world GNP are, therefore, equivalent terms. GDP is product produced within a country's borders; GNP is product produced by enterprises owned by a country's citizens. The two would be the same if all of the productive enterprises in a country were owned by its own citizens, and those citizens did not own productive enterprises in any other countries. In practice, however, foreign ownership makes GDP and GNP non-identical. Production within a country's borders, but by an enterprise owned by somebody outside the country, counts as part of its GDP but not its GNP; on the other hand, production by an enterprise located outside the country, but owned by one of its citizens, counts as part of its GNP but not its GDP. To take the United States as an example, the U.S.'s GNP is the value of output produced by American-owned firms, regardless of where the firms are located. Similarly, if a country becomes increasingly in debt, and spends large amounts of income servicing this debt this will be reflected in a decreased GNI but not a decreased GDP. Similarly, if a country sells off its resources to entities outside their country this will also be reflected over time in decreased GNI, but not decreased GDP. This would make the use of GDP more attractive for politicians in countries with increasing national debt and decreasing assets. Gross national income (GNI) equals GDP plus income receipts from the rest of the world minus income payments to the rest of the world.[20] In 1991, the United States switched from using GNP to using GDP as its primary measure of production.[21] The relationship between United States GDP and GNP is shown in table 1.7.5 of the National Income and Product Accounts.[22]

International standards
The international standard for measuring GDP is contained in the book System of National Accounts (1993), which was prepared by representatives of the International Monetary Fund, European Union, Organization for Economic Co-operation and Development, United Nations and World Bank. The publication is normally referred to as SNA93 to distinguish it from the previous edition published in 1968 (called SNA68) [] SNA93 provides a set of rules and procedures for the measurement of national accounts. The standards are designed to be flexible, to allow for differences in local statistical needs and conditions.

National measurement
Within each country GDP is normally measured by a national government statistical agency, as private sector organizations normally do not have access to the information required (especially information on expenditure and production by governments).

Interest rates
Net interest expense is a transfer payment in all sectors except the financial sector. Net interest expenses in the financial sector are seen as production and value added and are added to GDP.

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Nominal GDP and adjustments to GDP


The raw GDP figure as given by the equations above is called the nominal, historical, or current, GDP. When one compares GDP figures from one year to another, it is desirable to compensate for changes in the value of money i.e., for the effects of inflation or deflation. To make it more meaningful for year-to-year comparisons, it may be multiplied by the ratio between the value of money in the year the GDP was measured and the value of money in a base year. For example, suppose a country's GDP in 1990 was $100 million and its GDP in 2000 was $300 million. Suppose also that inflation had halved the value of its currency over that period. To meaningfully compare its GDP in 2000 to its GDP in 1990, we could multiply the GDP in 2000 by one-half, to make it relative to 1990 as a base year. The result would be that the GDP in 2000 equals $300 million one-half = $150 million, in 1990 monetary terms. We would see that the country's GDP had realistically increased 50 percent over that period, not 200 percent, as it might appear from the raw GDP data. The GDP adjusted for changes in money value in this way is called the real, or constant, GDP. The factor used to convert GDP from current to constant values in this way is called the GDP deflator. Unlike consumer price index, which measures inflation or deflation in the price of household consumer goods, the GDP deflator measures changes in the prices of all domestically produced goods and services in an economy including investment goods and government services, as well as household consumption goods.[23] Constant-GDP figures allow us to calculate a GDP growth rate, which indicates how much a country's production has increased (or decreased, if the growth rate is negative) compared to the previous year. Real GDP growth rate for year n = [(Real GDP in year n) (Real GDP in year n 1)] / (Real GDP in year n 1) Another thing that it may be desirable to account for is population growth. If a country's GDP doubled over a certain period, but its population tripled, the increase in GDP may not mean that the standard of living increased for the country's residents; the average person in the country is producing less than they were before. Per-capita GDP is a measure to account for population growth.

Cross-border comparison and PPP


The level of GDP in different countries may be compared by converting their value in national currency according to either the current currency exchange rate, or the purchasing power parity exchange rate. Current currency exchange rate is the exchange rate in the international currency market. Purchasing power parity exchange rate is the exchange rate based on the purchasing power parity (PPP) of a currency relative to a selected standard (usually the United States dollar). This is a comparative (and theoretical) exchange rate, the only way to directly realize this rate is to sell an entire CPI basket in one country, convert the cash at the currency market rate & then rebuy that same basket of goods in the other country (with the converted cash). Going from country to country, the distribution of prices within the basket will vary; typically, non-tradable purchases will consume a greater proportion of the basket's total cost in the higher GDP country, per the Balassa-Samuelson effect. The ranking of countries may differ significantly based on which method is used. The current exchange rate method converts the value of goods and services using global currency exchange rates. The method can offer better indications of a country's international purchasing power and relative economic strength. For instance, if 10% of GDP is being spent on buying hi-tech foreign arms, the number of weapons purchased is entirely governed by current exchange rates, since arms are a traded product bought on the international market. There is no meaningful 'local' price distinct from the international price for high technology goods.

Gross domestic product The purchasing power parity method accounts for the relative effective domestic purchasing power of the average producer or consumer within an economy. The method can provide a better indicator of the living standards of less developed countries, because it compensates for the weakness of local currencies in the international markets. For example, India ranks 10th by nominal GDP, but 3rd by PPP. The PPP method of GDP conversion is more relevant to non-traded goods and services. There is a clear pattern of the purchasing power parity method decreasing the disparity in GDP between high and low income (GDP) countries, as compared to the current exchange rate method. This finding is called the Penn effect. For more information, see Measures of national income and output.

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Per unit GDP


GDP is an aggregate figure which does not consider differing sizes of nations. Therefore, GDP can be stated as GDP per capita (per person) in which total GDP is divided by the resident population on a given date, GDP per citizen where total GDP is divided by the numbers of citizens residing in the country on a given date, and less commonly GDP per unit of a resource input, such as GDP per GJ of energy or Gross domestic product per barrel. GDP per citizen in the above case is pretty similar to GDP per capita in most nations, however, in nations with very high proportions of temporary foreign workers like in Persian Gulf nations, the two figures can be vastly different.

Standard of living and GDP


GDP per capita is not a measurement of the standard of living in an economy; however, it is often used as such an indicator, on the rationale that all citizens would benefit from their country's increased economic production. Similarly, GDP per capita is not a measure of personal income. GDP may increase while real incomes for the majority decline. The major advantage of GDP per capita as an indicator of standard of living is that it is measured frequently, widely, and consistently. It is measured frequently in that most countries provide information on GDP on a quarterly basis, allowing trends to be seen quickly. It is measured widely in that some measure of GDP is available for almost every country in the world, allowing inter-country comparisons. It is measured consistently in that the technical definition of GDP is relatively consistent among countries. The major disadvantage is that it is not a measure of standard of living. GDP is intended to be a measure of total national economic activitya separate concept. The argument for using GDP as a standard-of-living proxy is not that it is a good indicator of the absolute level of standard of living, but that living standards tend to move with per-capita GDP, so that changes in living standards are readily detected through changes in GDP.

Externalities
GDP is widely used by economists to gauge economic recession and recovery and an economy's general monetary ability to address externalities. It is not meant to measure externalities. It serves as a general metric for a nominal monetary standard of living and is not adjusted for costs of living within a region. GDP is a neutral measure which merely shows an economy's general ability to pay for externalities such as social and environmental concerns.[24] Examples of externalities include: Wealth distribution GDP does not account for variances in incomes of various demographic groups. See income inequality metrics for discussion of a variety of inequality-based economic measures. Non-market transactionsGDP excludes activities that are not provided through the market, such as household production and volunteer or unpaid services. As a result, GDP is understated. Unpaid work conducted on Free and Open Source Software (such as GNU/Linux) contribute nothing to GDP, but it was estimated that it would have cost more than a billion US dollars for a commercial company to develop. Also, if Free and Open Source

Gross domestic product Software became identical to its proprietary software counterparts, and the nation producing the propriety software stops buying proprietary software and switches to Free and Open Source Software, then the GDP of this nation would reduce; however, there would be no reduction in economic production or standard of living. The work of New Zealand economist Marilyn Waring has highlighted that if a concerted attempt to factor in unpaid work were made, then it would in part undo the injustices of unpaid (and in some cases, slave) labour, and also provide the political transparency and accountability necessary for democracy. Shedding some doubt on this claim, however, is the theory that won economist Douglass North the Nobel Memorial Prize in Economic Sciences in 1993.[citation needed] North argued that the encouragement of private invention and enterprise due to the creation and strengthening of the patent system became the fundamental catalyst behind the Industrial Revolution in England. Underground economyOfficial GDP estimates may not take into account the underground economy, in which transactions contributing to production, such as illegal trade and tax-avoiding activities, are unreported, causing GDP to be underestimated. Asset ValueGDP does not take into account the value of all assets in an economy. This is akin to ignoring a company's balance sheet, and judging it solely on the basis of its income statement. Non-monetary economyGDP omits economies where no money comes into play at all, resulting in inaccurate or abnormally low GDP figures. For example, in countries with major business transactions occurring informally, portions of local economy are not easily registered. Bartering may be more prominent than the use of money, even extending to services (I helped you build your house ten years ago, so now you help me). GDP also ignores subsistence production. Quality improvements and inclusion of new productsBy not adjusting for quality improvements and new products, GDP understates true economic growth. For instance, although computers today are less expensive and more powerful than computers from the past, GDP treats them as the same products by only accounting for the monetary value. The introduction of new products is also difficult to measure accurately and is not reflected in GDP despite the fact that it may increase the standard of living. For example, even the richest person from 1900 could not purchase standard products, such as antibiotics and cell phones, that an average consumer can buy today, since such modern conveniences did not exist back then. What is being producedGDP counts work that produces no net change or that results from repairing harm. For example, rebuilding after a natural disaster or war may produce a considerable amount of economic activity and thus boost GDP. The economic value of health care is another classic exampleit may raise GDP if many people are sick and they are receiving expensive treatment, but it is not a desirable situation. Alternative economic estimates, such as the standard of living or discretionary income per capita try to measure the human utility of economic activity. See uneconomic growth. Sustainability of growth GDP is a measurement of economic historic activity and is not necessarily a projection. A country may achieve a temporarily high GDP from use of natural resources or by misallocating investment. Nominal GDP doesn't measure variations in purchasing power or costs of living by area, so when the GDP figure is deflated over time, GDP growth can vary greatly depending on the basket of goods used and the relative proportions used to deflate the GDP figure. Cross-border comparisons of GDP can be inaccurate as they do not take into account local differences in the quality of goods, even when adjusted for purchasing power parity. This type of adjustment to an exchange rate is controversial because of the difficulties of finding comparable baskets of goods to compare purchasing power across countries. For instance, people in country A may consume the same number of locally produced apples as in country B, but apples in country A are of a more tasty variety. This difference in material well being will not show up in GDP statistics. This is especially true for goods that are not traded globally, such as housing

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Gross domestic product

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Limitations and Criticisms


Simon Kuznets, the economist who developed the first comprehensive set of measures of national income, stated in his first report to the US Congress in 1934, in a section titled "Uses and Abuses of National Income Measurements":[3] The valuable capacity of the human mind to simplify a complex situation in a compact characterization becomes dangerous when not controlled in terms of definitely stated criteria. With quantitative measurements especially, the definiteness of the result suggests, often misleadingly, a precision and simplicity in the outlines of the object measured. Measurements of national income are subject to this type of illusion and resulting abuse, especially since they deal with matters that are the center of conflict of opposing social groups where the effectiveness of an argument is often contingent upon oversimplification. [...] All these qualifications upon estimates of national income as an index of productivity are just as important when income measurements are interpreted from the point of view of economic welfare. But in the latter case additional difficulties will be suggested to anyone who wants to penetrate below the surface of total figures and market values. Economic welfare cannot be adequately measured unless the personal distribution of income is known. And no income measurement undertakes to estimate the reverse side of income, that is, the intensity and unpleasantness of effort going into the earning of income. The welfare of a nation can, therefore, scarcely be inferred from a measurement of national income as defined above. In 1962, Kuznets stated:[25] Distinctions must be kept in mind between quantity and quality of growth, between costs and returns, and between the short and long run. Goals for more growth should specify more growth of what and for what. Austrian School economist Frank Shostak has argued that GDP is an empty abstraction devoid of any link to the real world, and, therefore, has little or no value in economic analysis. Says Shostak:[26] The GDP framework cannot tell us whether final goods and services that were produced during a particular period of time are a reflection of real wealth expansion, or a reflection of capital consumption. For instance, if a government embarks on the building of a pyramid, which adds absolutely nothing to the well-being of individuals, the GDP framework will regard this as economic growth. In reality, however, the building of the pyramid will divert real funding from wealth-generating activities, thereby stifling the production of wealth. So what are we to make out of the periodical pronouncements that the economy, as depicted by real GDP, grew by a particular percentage? All we can say is that this percentage has nothing to do with real economic growth and that it most likely mirrors the pace of monetary pumping. We can thus conclude that the GDP framework is an empty abstraction devoid of any link to the real world. Many environmentalists argue that GDP is a poor measure of social progress because it does not take into account harm to the environment.[27][28] India and China have the largest population in the world and hence has the greatest potential in productivity due to the fact that the value of a product is measured as the value of service that can be obtained by the holder in exchange for that product. ( Units per man hour)

Gross domestic product

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Lists of countries by their GDP


Lists of countries by GDP List of countries by GDP (nominal), (per capita) List of continents by GDP (nominal) List of countries by GDP (PPP), (per capita), (per hour) List of countries by GDP (real) growth rate, (per capita) List of countries by GDP sector composition List of countries by future GDP estimates (PPP), (per capita), (nominal)

List of newer approaches to the measurement of (economic) progress


Human development index (HDI) up until 2009 report HDI used GDP as a part of its calculation and then factors in indicators of life expectancy and education levels. In 2010 the GDP component has been replaced with GNI. Genuine progress indicator (GPI) or Index of Sustainable Economic Welfare (ISEW) The GPI and the ISEW attempt to address many of the above criticisms by taking the same raw information supplied for GDP and then adjust for income distribution, add for the value of household and volunteer work, and subtract for crime and pollution. Gross national happiness (GNH) GNH measures quality of life or social progress in more holistic and psychological terms than GDP. European Quality of Life Survey The survey, first published in 2005, assessed quality of life across European countries through a series of questions on overall subjective life satisfaction, satisfaction with different aspects of life, and sets of questions used to calculate deficits of time, loving, being and having.[29] Gross national happiness The Centre for Bhutanese Studies in Bhutan is working on a complex set of subjective and objective indicators to measure 'national happiness' in various domains (living standards, health, education, eco-system diversity and resilience, cultural vitality and diversity, time use and balance, good governance, community vitality and psychological well-being). This set of indicators would be used to assess progress towards gross national happiness, which they have already identified as being the nation's priority, above GDP. Happy Planet Index The happy planet index (HPI) is an index of human well-being and environmental impact, introduced by the New Economics Foundation (NEF) in 2006. It measures the environmental efficiency with which human well-being is achieved within a given country or group. Human well-being is defined in terms of subjective life satisfaction and life expectancy while environmental impact is defined by the Ecological Footprint. OECD Better Life Index - The better lives compendium of indicators produced in 2011 reflects some 10 years by the organisation to develop a wider of set of indicators more closely attuned to the measurement of wellbeing or welfare outcomes. There is felt to be considerable convergence (in 2011) in high income countries about the kinds of dimensions that should be included in such multi-dimensional approaches to welfare measurement - see for instance the capabilities measurement research project capabilities approach. Composite Wealth Indicators Namely yearly material wealth (an amended version of GNI to include depletion of natural resources and the costs of pollution), biological wealth (measured through life expectancy) and thus expected material wealth (or physical wealth), a linear combination of biological and yearly material wealth (the amount of material wealth expected to be produced by an individual during his/her lifetime).[30] Future Orientation Index - Tobias Preis et al. used Google Trends data to demonstrate that Internet users from countries with a higher per capita gross domestic product (GDP) are more likely to search for information about the future than information about the past. The findings, published in the journal Scientific Reports, suggest there may be a link between online behaviour and real-world economic indicators.[31][32][33] The authors of the study examined Google search queries made by Internet users in 45 different countries in 2010 and calculated the ratio of the volume of searches for the coming year ('2011') to the volume of searches for the previous year ('2009'),

Gross domestic product which they call the 'future orientation index'.[34] They compared the future orientation index to the per capita GDP of each country and found a strong tendency for countries in which Google users enquire more about the future to exhibit a higher GDP. The results hint that there may potentially be a relationship between the economic success of a country and the information-seeking behaviour of its citizens online. World Governance Index - Basing their work on the United Nations Millennium Declaration, which was the subject of unprecedented U.N. consensus among the heads of state and government who adopted it in 2000, a team of researchers of the Forum for a new World Governance (FnWG) [35] focused its research on the five main concepts defining the application framework of world governance and constituting key goals to be reached by 2015: Peace and Security; Democracy and Rule of Law; Human Rights and Participation; Sustainable Development and Human Development

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Bibliography
Australian Bureau for Statistics, Australian National Accounts: Concepts, Sources and Methods [36], 2000. Retrieved November 2009. In depth explanations of how GDP and other national accounts items are determined. United States Department of Commerce, Bureau of Economic Analysis, Concepts and Methods of the United States National Income and Product Accounts [37]PDF. Retrieved November 2009. In depth explanations of how GDP and other national accounts items are determined.

Notes and references


[2] French President seeks alternatives to GDP (http:/ / www. guardian. co. uk/ business/ 2009/ sep/ 14/ sarkozy-attacks-gdp-focus), The Guardian 14-09-2009. [3] Congress commissioned Kuznets to create a system that would measure the nation's productivity in order to better understand how to tackle the Great Depression. Simon Kuznets, 1934. "National Income, 19291932". 73rd US Congress, 2d session, Senate document no. 124, page 5-7. http:/ / fraser. stlouisfed. org/ docs/ publications/ nipab/ 19340104_nationalinc. pdf [5] World Bank, Statistical Manual >> National Accounts >> GDPfinal output (http:/ / web. worldbank. org/ WBSITE/ EXTERNAL/ DATASTATISTICS/ EXTDECSTAMAN/ 0,,contentMDK:20882526~menuPK:2648252~pagePK:64168445~piPK:64168309~theSitePK:2077967~isCURL:Y,00. html), retrieved October 2009. [6] Based on the IMF figures. If no number was available for a country from IMF, CIA figures were used. [7] United States Bureau of Economic Analysis, , page 5; retrieved November 2009. Another term, "business current transfer payments," may be added. Also, the document indicates that Capital Consumption Adjustment (CCAdj) and Inventory Valuation Adjustment (IVA) are applied to the proprietor's income and corporate profits terms; and CCAdj is applied to rental income. [8] http:/ / epp. eurostat. ec. europa. eu/ statistics_explained/ index. php/ Glossary:Non-profit_institutions_serving_households_(NPISH) [9] Thayer Watkins, San Jos State University Department of Economics, "Gross Domestic Product from the Transactions Table for an Economy" (http:/ / www. sjsu. edu/ faculty/ watkins/ gdp. htm), commentary to first table, " Transactions Table for an Economy". (Page retrieved November 2009.) [10] Concepts and Methods of the United States National Income and Product Accounts, chap. 2. [11] BEA, Concepts and Methods of the United States National Income and Product Accounts, p 12. [12] Australian National Accounts: Concepts, Sources and Methods, 2000, sections 3.5 and 4.15. [13] This and the following statement on entitlement to compensation are from Australian National Accounts: Concepts, Sources and Methods, 2000, section 4.6. [14] Concepts and Methods of the United States National Income and Product Accounts, page 2-2. [15] Concepts and Methods of the United States National Income and Product Accounts, page 2-2. [16] Australian National Accounts: Concepts, Sources and Methods, 2000, section 4.4. [17] Concepts and Methods of the United States National Income and Product Accounts, page 2-2; and Australian National Accounts: Concepts, Sources and Methods, 2000, section 4.4. [18] Concepts and Methods of the United States National Income and Product Accounts, page 2-4. [19] Concepts and Methods of the United States National Income and Product Accounts, page 2-5. [21] United States, Bureau of Economic Analysis, Glossary, "GDP" (http:/ / www. bea. gov/ glossary/ glossary. cfm). Retrieved November 2009. [23] HM Treasury, Background information on GDP and GDP deflator Some of the complications involved in comparing national accounts from different years are explained in this World Bank document (http:/ / web. worldbank. org/ WBSITE/ EXTERNAL/ DATASTATISTICS/ EXTDECSTAMAN/ 0,,contentMDK:20908551~menuPK:2648276~pagePK:64168445~piPK:64168309~theSitePK:2077967~isCURL:Y,00. html).

Gross domestic product


[25] Simon Kuznets. "How To Judge Quality". The New Republic, October 20, 1962 [27] The Virtues of Ignoring GDP http:/ / www. thebrokeronline. eu/ Articles/ The-virtues-of-ignoring-GDP [28] The Rise and Fall of G.D.P. http:/ / www. nytimes. com/ 2010/ 05/ 16/ magazine/ 16GDP-t. html?pagewanted=all [30] See Emanuele Felice, Neither dashboard nor 'mashup' indices: an empirical wealth approach as a pathway to a comprehensive measure of development, http:/ / www. h-economica. uab. es/ wps/ 2012_01. pdf [35] http:/ / www. world-governance. net [36] http:/ / www. abs. gov. au/ Ausstats/ abs@. nsf/ Latestproducts/ 3F880EE1D366198CCA2569A400061616?opendocument [37] http:/ / www. bea. gov/ national/ pdf/ NIPAhandbookch1-4. pdf

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External links
Global
Global GDP Visualization (http://gdpvisualization.com/) World GDP Chart (since 1960) (http://www.google.com/publicdata/explore?ds=wb-wdi& met=ny_gdp_mktp_cd&idim=country:USA:CHN:FRA:DEU:JPN:GBR) Australian Bureau of Statistics Manual on GDP measurement (http://www.abs.gov.au/Ausstats/abs@.nsf/ 66f306f503e529a5ca25697e0017661f/3f880ee1d366198cca2569a400061616!OpenDocument) GDP-indexed bonds (http://perso.wanadoo.fr/pgreenfinch/eoblpib.htm) World Development Indicators (WDI) (http://databank.worldbank.org/data/home.aspx) UN Statistical Databases (http://unstats.un.org/unsd/databases.htm)

Data
Thermal Maps of the World Nominal GDP in US$ purchasing power parity from the EIU 20072010 (http:// www.visionofhumanity.org/gpi-data/#/2010/GDP1) Bureau of Economic Analysis: Official United States GDP data (http://www.bea.gov/national/index. htm#gdp) Historicalstatistics.org: Links to historical statistics on GDP for different countries and regions (http://www. historicalstatistics.org/) Historical US GDP (yearly data) (http://www.measuringworth.org/usgdp/), 1790present Historical US GDP (quarterly data) (http://finance-data.com/series/GDP), 1947present OECD Statistics (http://dx.doi.org/10.1787/2074384x-table3) Google public data (http://www.google.com/publicdata/explore?ds=a7jenngfc4um7_&ctype=l& strail=false&nselm=h&met_y=gross_domestic_product&hl=en&dl=en): GDP and Personal Income of the U.S. (annual): Nominal Gross Domestic Product

Articles and books


Gross Domestic Product: An Economys All (http://www.imf.org/external/pubs/ft/fandd/basics/gdp.htm), International Monetary Fund. Stiglitz JE, Sen A, Fitoussi J-P. Mismeasuring our Lives: Why GDP Doesn't Add Up, New Press, New York, 2010 (http://www.wcfia.harvard.edu/node/6224) What's wrong with the GDP? (http://dieoff.org/page11.htm) Limitations of GDP Statistics (http://ingrimayne.saintjoe.edu/econ/Measuring/GNP2.html) by Robert Schenk. Whether output and CPI inflation are mismeasured (http://pages.stern.nyu.edu/~nroubini/MEASURE.HTM), by Nouriel Roubini and David Backus, in Lectures in Macroeconomics Rodney Edvinsson, Growth, Accumulation, Crisis: With New Macroeconomic Data for Sweden 18002000 (http://urn.kb.se/resolve?urn=urn:nbn:se:su:diva-378)PDF

Gross domestic product Clifford Cobb, Ted Halstead and Jonathan Rowe. "If the GDP is up, why is America down?" The Atlantic Monthly, vol. 276, no. 4, October 1995, pages 5978 (http://www.theatlantic.com/past/politics/ecbig/gdp. htm) Jerorn C.J.M. van den Bergh, " Abolishing GDP (http://papers.ssrn.com/sol3/papers. cfm?abstract_id=962343)" GDP and GNI in OECD Observer No246-247, Dec 2004-Jan 2005 (http://www.oecdobserver.org/news/ fullstory.php/aid/1507/GDP_and_GNI.html) Progress, what progress? in OECD Observer No272 March 2009 (http://www.oecdobserver.org/news/ fullstory.php/aid/2793/Progress,_what_progress_.html)

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Human gastrointestinal tract

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Human gastrointestinal tract


Human gastrointestinal tract (Digestive System)

Stomach colon rectum diagram Latin Tractus digestorius (mouth to anus), canalis alimentarius (esophagus to large Intestine), canalis gastrointestinales (stomach to large Intestine)

System Digestive system

The human gastrointestinal tract is the stomach and intestine,[1] sometimes including all the structures from the mouth to the anus.[2] (The "digestive system" is a broader term that includes other structures, including the accessory organs of digestion).[3] In an adult male human, the gastrointestinal (GI) tract is 5 metres (20ft) long in a live subject, or up to 9 metres (30ft) without the effect of muscle tone, and consists of the upper and lower GI tracts. The tract may also be divided into foregut, midgut, and hindgut, reflecting the embryological origin of each segment of the tract. The GI tract always releases hormones to help regulate the digestive process. These hormones, including gastrin, secretin, cholecystokinin, and ghrelin, are mediated through either intracrine or autocrine mechanisms, indicating that the cells releasing these hormones are conserved structures throughout evolution.[4]

Human gastrointestinal tract

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Upper gastrointestinal tract


The upper gastrointestinal tract consists of the esophagus, stomach, and duodenum.[5] The exact demarcation between "upper" and "lower" can vary. Upon dissection, the duodenum may appear to be a unified organ, but it is often divided into two parts based upon function, arterial supply, or embryology.

Lower gastrointestinal tract


The lower gastrointestinal tract includes most of the small intestine and all of the large intestine.[6] According to some sources, it also includes the anus.[citation needed] Bowel or intestine Small Intestine: Has three parts: Duodenum: Here the digestive juices from the pancreas (digestive enzymes) and hormones and the gall bladder (bile) mix. The digestive enzymes break down proteins and bile and emulsify fats into micelles. The duodenum contains Brunner's glands which produce bicarbonate. In combination with bicarbonate from pancreatic juice, this neutralizes HCl of the stomach.

Upper and Lower human gastrointestinal tract

Jejunum: This is the midsection of the intestine, connecting the duodenum to the ileum. It contains the plicae circulares, and villi to increase the surface area of that part of the GI Tract. Products of digestion (sugars, amino acids, fatty acids) are absorbed into the bloodstream. Ileum: Has villi and absorbs mainly vitamin B12 and bile acids, as well as any other remaining nutrients. Large Intestine: Has three parts: Caecum: The Vermiform appendix is attached to the caecum. Colon: Includes the ascending colon, transverse colon, descending colon and sigmoid Flexure: The main function of the Colon is to absorb water, but it also contains bacteria that produce beneficial vitamins like vitamin K. Rectum Anus: Passes fecal matter from the body. The Ligament of Treitz is sometimes used to divide the upper and lower GI tracts.[]

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Embryology
The gut is an endoderm-derived structure. At approximately the sixteenth day of human development, the embryo begins to fold ventrally (with the embryo's ventral surface becoming concave) in two directions: the sides of the embryo fold in on each other and the head and tail fold toward one another. The result is that a piece of the yolk sac, an endoderm-lined structure in contact with the ventral aspect of the embryo, begins to be pinched off to become the primitive gut. The yolk sac remains connected to the gut tube via the vitelline duct. Usually this structure regresses during development; in cases where it does not, it is known as Meckel's diverticulum. During fetal life, the primitive gut can be divided into three segments: foregut, midgut, and hindgut. Although these terms are often used in reference to segments of the primitive gut, they are also used regularly to describe components of the definitive gut as well. Each segment of the gut gives rise to specific gut and gut-related structures in later development. Components derived from the gut proper, including the stomach and colon, develop as swellings or dilatations of the primitive gut. In contrast, gut-related derivatives that is, those structures that derive from the primitive gut but are not part of the gut proper, in general develop as out-pouchings of the primitive gut. The blood vessels supplying these structures remain constant throughout development.[7]
Part Part in adult Gives rise to Esophagus, Stomach, Duodenum (1st and 2nd parts), Liver, Gallbladder, Pancreas, Superior portion of pancreas (Note that though the Spleen is supplied by the celiac trunk, it is derived from dorsal mesentery and therefore not a foregut derivative) lower duodenum, jejunum, ileum, cecum, appendix, ascending colon, and first two-third of the transverse colon last third of the transverse colon, descending colon, rectum, and upper part of the anal canal Arterial supply celiac trunk

Foregut Esophagus to first 2 sections of the duodenum

Midgut

lower duodenum, to the first two-thirds of the transverse colon

branches of the superior mesenteric artery branches of the inferior mesenteric artery

Hindgut last third of the transverse colon, to the upper part of the anal canal

Transit time
The time taken for food or other ingested objects to transit through the gastrointestinal tract varies depending on many factors, but roughly, it takes less than an hour after a meal for 50% of stomach contents to empty into the intestines and total emptying of the stomach takes around 2 hours. Subsequently, 50% emptying of the small intestine takes 1 to 2 hours. Finally, transit through the colon takes 12 to 50 hours with wide variation between individuals.[8][9]

Pathology
There are a number of diseases and conditions affecting the gastrointestinal system, including: Appendicitis Cancer Celiac Disease Cholera Colorectal cancer Diarrhoea Diverticulitis Enteric duplication cyst Gastroenteritis, also known as "stomach flu"; an inflammation of the stomach and intestines Giardiasis

Human gastrointestinal tract Inflammatory bowel disease (including Crohn's disease and ulcerative colitis) Irritable bowel syndrome Pancreatitis Peptic ulcer disease Yellow Fever

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Immune function
The gastrointestinal tract is also a prominent part of the immune system.[10] The surface area of the digestive tract is estimated to be the surface area of a football field. With such a large exposure, the immune system must work hard to prevent pathogens from entering into blood and lymph.[11][WP:V] The low pH (ranging from 1 to 4) of the stomach is fatal for many microorganisms that enter it. Similarly, mucus (containing IgA antibodies) neutralizes many of these microorganisms. Other factors in the GI tract help with immune function as well, including enzymes in saliva and bile. Enzymes such as Cyp3A4, along with the antiporter activities, also are instrumental in the intestine's role of detoxification of antigens and xenobiotics, such as drugs, involved in first pass metabolism. Health-enhancing intestinal bacteria serve to prevent the overgrowth of potentially harmful bacteria in the gut. These two types of bacteria compete for space and "food," as there are limited resources within the intestinal tract. A ratio of 80-85% beneficial to 15-20% potentially harmful bacteria generally is considered normal within the intestines. Microorganisms also are kept at bay by an extensive immune system comprising the gut-associated lymphoid tissue (GALT).

Histology
The gastrointestinal tract has a form of general histology with some differences that reflect the specialization in functional anatomy.[12] The GI tract can be divided into four concentric layers in the following order: Mucosa Submucosa Muscularis externa (the external muscular layer) Adventitia or serosa

Mucosa
General structure of the gut wall The mucosa is the innermost layer of the gastrointestinal tract. that is surrounding the lumen, or open space within the tube. This layer comes in direct contact with digested food (chyme),

The mucosa is made up of three layers: Epithelium - innermost layer. Responsible for most digestive, absorptive and secretory processes. Lamina propria - a layer of connective tissue. Unusually cellular compared to most connective tissue Muscularis mucosae - a thin layer of smooth muscle. Function is still under debate The mucosae are highly specialized in each organ of the gastrointestinal tract to deal with the different conditions. The most variation is seen in the epithelium. In the esophagus, the epithelium is stratified, squamous and non-keratinising, for protective purposes.

Human gastrointestinal tract In the stomach it is simple columnar, and is organised into gastric pits and glands to deal with secretion. The gastro-oesophageal junction is extremely abrupt. The small intestine epithelium (particularly the ileum) is specialised for absorption; it is organised into plicae circulares and villi, and the enterocytes have microvilli. This creates a brush border which greatly increases the surface area for absoption. The epithelium is simple columnar with microvilli. In the ileum there are occasionally Peyer's patches in the lamina propria. The colon has simple columnar epithelium with no villi. There are goblet cells. The appendix has a mucosa resembling the colon but is heavily infiltrated with lymphocytes. The ano-rectal junction (at the pectinate line) is again very abrupt; there is a transition from simple columnar to stratified squamous non-keratinising epithelium (as in the esophagus) for protective purposes.

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Submucosa
The submucosa consists of a dense irregular layer of connective tissue with large blood vessels, lymphatics, and nerves branching into the mucosa and muscularis externa. It contains Meissner's plexus, an enteric nervous plexus, situated on the inner surface of the muscularis externa.

Muscularis externa
The muscularis externa consists of an inner circular layer and a longitudinal outer muscular layer. The circular muscle layer prevents food from traveling backward and the longitudinal layer shortens the tract. The layers are not truly longitudinal or circular, rather the layers of muscle are helical with different pitches. The inner circular is helical with a steep pitch and the outer longitudinal is helical with a much shallower pitch. The coordinated contractions of these layers is called peristalsis and propels the food through the tract. Food in the GI tract is called a bolus (ball of food) from the mouth down to the stomach. After the stomach, the food is partially digested and semi-liquid, and is referred to as chyme. In the large intestine the remaining semi-solid substance is referred to as faeces. Between the two muscle layers are the myenteric or Auerbach's plexus. This controls peristalsis. Activity is initiated by the pacemaker cells (interstitial cells of Cajal). The gut has intrinsic peristaltic activity (basal electrical rhythm) due to its self-contained enteric nervous system. The rate can of course be modulated by the rest of the autonomic nervous system. The thickness of muscularis externa varies in each part of the tract. In the colon, for example, the muscularis externa is much thicker because the faeces are large and heavy, and require more force to push along. The outer longitudinal layer of the colon thins out into 3 discontinuous longitudinal bands, known as taeniae coli (bands of the colon). This is one of the 3 features helping to distinguish between the large and small intestine. Occasionally in the large intestine (2-3 times a day) there will be mass contraction of certain segments, moving a lot of faeces along. This is generally when one gets the urge to defecate. The pylorus of the stomach has a thickened portion of the inner circular layer: the pyloric sphincter. Alone among the GI tract, the stomach has a third layer of muscularis externa. This is the inner oblique layer, and helps churn the chyme in the stomach.

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Adventitia/serosa
The outermost layer of the GI tract consists of several layers of connective tissue. Intraperitoneal parts of the GI tract are covered with serosa. These include most of the stomach, first part of the duodenum, all of the small intestine, caecum and appendix, transverse colon, sigmoid colon and rectum. In these sections of the gut there is clear boundary between the gut and the surrounding tissue. These parts of the tract have a mesentery. Retroperitoneal parts are covered with adventitia. They blend into the surrounding tissue and are fixed in position. For example, the retroperitoneal section of the duodenum usually passes through the transpyloric plane. These include the esophagus, pylorus of the stomach, distal duodenum, ascending colon, descending colon and anal canal. In addition, the oral cavity has adventitia.

References
[4] Nelson RJ. 2005. Introduction to Behavioral Endocrinology. Sinauer Associates: Massachusetts. p 57. [8] Kim SK. Small intestine transit time in the normal small bowel study. American Journal of Roentgenology 1968; 104(3):522-524. [9] (http:/ / www. ncbi. nlm. nih. gov/ pmc/ articles/ PMC3325313/ ) Uday C Ghoshal, Vikas Sengar, and Deepakshi Srivastava. Colonic Transit Study Technique and Interpretation: Can These Be Uniform Globally in Different Populations With Non-uniform Colon Transit Time? J Neurogastroenterol Motil. 2012 April; 18(2): 227228. [11] Animal Physiology textbook

External links
Pediatric Overview of Human Digestive System (http://www.pediatricfeeding.org/gi_anatomy.html) Anatomy atlas of the Digestive System (http://www.innerbody.com/image/digeov.html) Overview (http://www.vivo.colostate.edu/hbooks/pathphys/digestion/) at Colorado State University Your Digestive System and How It Works at National Institutes of Health (http://digestive.niddk.nih.gov/ ddiseases/pubs/yrdd/)

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Ophthalmology
Ophthalmology is the branch of medicine that deals with the anatomy, physiology and diseases of the eye. An ophthalmologist is a specialist in medical and surgical eye problems. Since ophthalmologists perform operations on eyes, they are both surgical and medical specialists.

Etymology
The word ophthalmology comes from the Greek roots , ophthalmos, i.e. eye and -o, -logia, i.e. "study of, discourse";[][] ophthalmology literally means "the science of eyes". As a discipline, it applies to animal eyes also, since the differences from human practice are surprisingly minor and are related mainly to differences in anatomy or prevalence, not differences in disease processes.[citation needed]
Eye examination, with aid of slit lamp

History
Ancient India
The Indian surgeon Sushruta wrote Sushruta Samhita in Sanskrit in about 800 BC which describes 76 ocular diseases (of these 51 surgical) as well as several ophthalmological surgical instruments and [1][2] techniques. His description of cataract surgery was more akin to extracapsular lens extraction than to couching.[3] He has been described as the first cataract surgeon.[4][5]

Pre-Hippocrates
The pre-Hippocratics largely based their anatomical Statue of Sushruta () in Patanjali Yogpeeth, Haridwar conceptions of the eye on speculation, rather than empiricism. They recognized the sclera and transparent cornea running flushly as the outer coating of the eye, with an inner layer with pupil, and a fluid at the centre. It was believed, by Alcamaeon and others, that this fluid was the medium of vision and flowed from the eye to the brain via a tube. Aristotle advanced such ideas with empiricism. He dissected the eyes of animals, and discovering three layers (not two), found that the fluid was of a constant consistency with the lens forming (or congealing) after death, and the surrounding layers were seen to be juxtaposed. He, and his contemporaries, further put forth the existence of three tubes leading from the eye, not one. One tube from each eye met within the skull.

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Rufus
Rufus of Ephesus recognised a more modern eye, with conjunctiva, extending as a fourth epithelial layer over the eye. Rufus was the first to recognise a two chambered eye; with one chamber from cornea to lens (filled with water), the other from lens to retina (filled with an egg-white-like substance). The Greek physician Galen remedied some mistakes including the curvature of the cornea and lens, the nature of the optic nerve, and the existence of a posterior chamber. Though this model was a roughly correct modern model of the eye, it contained errors. Still, it was not advanced upon again until after Vesalius. A ciliary body was then discovered and the sclera, retina, choroid and cornea were seen to meet at the same point. The two chambers were seen to hold the same fluid as well as the lens being attached to the choroid. Galen continued the notion of a central canal, but he dissected the optic nerve and saw that it was solid. He mistakenly counted seven optical muscles, one too many. He also knew of the tear ducts.

Middle Eastern ophthalmology


Medieval Islamic and Persian scientists (unlike their classical predecessors) considered it normal to combine theory and practice, including the crafting of precise instruments, and therefore found it natural to combine the study of the eye with the practical application of that knowledge.[6] Ibn al-Haytham (Alhazen) a Persian scientist with Islamic believes wrote extensively on optics and the anatomy of the eye in his Book of Optics (1021). Ibn al-Nafis a native of Damscus wrote a large textbook, The Polished Book on Experimental Ophthalmology, divided into two parts, On the Theory of Opthalmology and Simple and Compounded Opthalmic Drugs.[7]

17th and 18th centuries


The 17th and 18th century saw the use of hand lenses (by Malpighi), microscopes (van Leeuwenhoek), preparations for fixing the eye for study (Ruysch) and later the freezing of the eye (Petit). This allowed for detailed study of the eye and an advanced model. Some mistakes persisted such as: why the pupil changed size (seen to be vessels of the iris filling with blood), the existence of the posterior chamber, and of course the nature of the retina. In 1722 Leeuwenhoek noted the existence of rods and cones[citation needed] though they were not properly discovered until Gottfried Reinhold Treviranus in 1834 by use of a microscope. Georg Joseph Beer (17631821) was an Austrian ophthalmologist and leader of the First Viennese School of Medicine. He introduced a flap operation for treatment of cataracts (Beer's operation), as well as popularizing the instrument used to perform the surgery (Beer's knife).[8]
Franois Pourfour du Petit

Ophthalmic surgery in Great Britain


The first ophthalmic surgeon in Great Britain was John Freke, appointed to the position by the Governors of St Bartholomew's Hospital in 1727. A major breakthrough came with the appointment of Baron Michael Johann Baptist de Wenzel (172490), a German who became oculist to King George III of England in 1772. His skill at removing cataracts legitimized the field.[9] The first dedicated ophthalmic hospital opened in 1805 in London; it is now called Moorfields Eye Hospital. Clinical developments at Moorfields and the founding of the Institute of Ophthalmology (now part of the University College London) by Sir Stewart Duke Elder established the site as the largest eye

Ophthalmology hospital in the world and a nexus for ophthalmic research.[10]

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20th century
The prominent opticians of the late 19th and early 20th century included Ernst Abbe (18401905), a co-owner of at the Zeiss Jena factories in Germany where he developed numerous optical instruments. Hermann von Helmholtz (1821-1894) was a polymath who made contributions to many fields of science and invented the ophthalmoscope in 1851. They both made theoretical calculations on image formation in optical systems and had also studied the optics of the eye.

Central Europe
Numerous ophthalmologists fled Germany after 1933 as the nazis persecuted Jews. A representative leader was Joseph Igersheimer (18791965), best known for his discoveries with arsphenamine for the treatment of syphilis. He fled to Turkey in 1933. As one of eight emigrant directors in the Faculty of Medicine at the University of Istanbul, he built a modern clinic and trained students. In 1939 he went to the United States, becoming a professor at Tufts University.[11] Polish ophthalmology dates to the 13th century. The Polish Ophthalmological Society was founded in 1911. A representative leader was Adam Zamenhof (18881940), who introduced certain diagnostic, surgical and nonsurgical eye-care procedures and was shot by the Nazis in 1940.[12] Zofia Falkowska (191593) head of the Faculty and Clinic of Ophthalmology in Warsaw from 1963 to 1976, was the first to use lasers in her practice.

Professional requirements
Ophthalmologists are physicians (MD/MBBS or D.O., not OD or BOptom) who have completed a college degree, medical school, and residency in ophthalmology. In many countries, ophthalmologists also undergo additional specialized training in one of the many subspecialties. Ophthalmology was the first branch of medicine to offer board certification, now a standard practice among all specialties.

Australia and New Zealand


In Australia and New Zealand, the FRACO/FRANZCO is the equivalent postgraduate specialist qualification. It is a very competitive speciality to enter training and has a closely monitored and structured training system in place over the five years of postgraduate training. Overseas-trained ophthalmologists are assessed using the pathway published on the RANZCO website. Those who have completed their formal training in the UK and have the CCST/CCT are usually deemed to be comparable.

Canada
In Canada, an ophthalmology residency after medical school is undertaken. The residency lasts a minimum of five years after the MD degree although subspecialty training is undertaken by about 30% of fellows (FRCSC). There are about 35 vacancies per year for ophthalmology training in all of Canada.

Finland
In Finland, physicians willing to become ophthalmologists must undergo a five year specialization which includes practical training and theoretical studies.

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India
In India, after completing MBBS degree, post-graduation in ophthalmology is required. The degrees are Doctor of Medicine (MD), Master of Surgery (MS), Diploma in Ophthalmic Medicine and Surgery (DOMS), and Diplomate of National Board (DNB). The concurrent training and work experience is in the form of a junior residency at a medical college, eye hospital or institution under the supervision of experienced faculty. Further work experience in form of fellowship, registrar or senior resident refines the skills of these eye surgeons. All India Ophthalmological Society (AIOS) and various state level ophthalmological societies (like DOS) hold regular conferences and actively promote continuing medical education.

Ireland
In Ireland, the Royal College of Surgeons of Ireland grants Membership (MRCSI (Ophth)) and Fellowship (FRCSI (Ophth)) qualifications in conjunction with the Irish College of Ophthalmologists. Total postgraduate training involves an intern year, a minimum of 3 years of Basic Surgical Training and a further 4.5 years of Higher Surgical Training. Clinical training takes place within public, Health Service Executive-funded hospitals in Dublin, Sligo, Limerick, Galway, and Cork. A minimum of 8.5 years of training is required before eligibility to work in consultant posts. Some trainees take extra time to obtain MSc, MD or PhD degrees and to undertake clinical fellowships in the UK, Australia and the United States.

Pakistan
In Pakistan, after an MBBS, a four-year full-time residency programme leads to an exit level FCPS examinations in ophthalmology, held under the auspices of the College of Physicians & Surgeons, Pakistan. The tough examination is assessed by both highly qualified Pakistani & eminent international ophthalmic consultants. As a prerequisite to the final examinations, an intermediate module, an optics and refraction module, and a dissertation written on a research project carried out under supervision is also assessed. Moreover, a two and a half years residency programme leads to MCPS while a two-year training of DOMS is also being offered.[13] For candidates in the, ilitary, a stringent two-year graded course, with quarterly assessments, is held under Armed Forces Post Graduate Medical Institute in Rawalpindi. The M.S. in ophthalmology is also one of the specialty programmes. In addition to programmes for doctors, various diplomas and degrees for opticians are also being offered to produce competent optic technicians in this field. These programmes are being offered notably by the Punjab Institute of Preventive Ophthalmology (PIPO) in Lahore and the Pakistan Institute of Community Ophthalmology in Peshawar.[14] Sub-specialty fellowships are also being offered in the fields of pediatric ophthalmology and vitreo-retinal ophthalmology. King Edward Medical University, Al Shifa trust eye hospital Rawalpindi & Al- Ibrahim eye shospital Karachi has also started a degree program in this field.

Philippines
Ophthalmology is a considered a medical specialty that uses medicine and surgery to treat diseases of the eye. To become a general ophthalmologist, a candidate must have completed a Doctor of Medicine degree or its equivalent (e.g. MBBS), have passed the physician licensure exam, completed an internship in medicine, and completed residency at any Philippine Academy of Ophthalmology (PAO)[15] accredited program. Attainment of board certification in ophthalmology from PBO is optional, but is preferred and required to gain privileges in most major health institutions. Graduates of residency programs can receive further training in subspecialties of ophthalmology such as neuro-ophthalmology, etc. by completing a fellowship program which varies in length depending on each program's requirements. The leading professional organization in the country is the Philippine Academy of Ophthalmology[16] which also regulates ophthalmology residency programs and board certification through its accrediting agency, the Philippine Board of Ophthalmology.

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United Kingdom
In the United Kingdom, there are three colleges that grant postgraduate degrees in ophthalmology. The Royal College of Ophthalmologists (RCOphth) grants MRCOphth and FRCOphth (postgraduate exams), the Royal College of Edinburgh grants MRCSEd, the Royal College of Glasgow grants FRCS. Postgraduate work as a specialist registrar and one of these degrees is required for specialisation in eye diseases. Such clinical work is within the NHS. There are only 2.3 ophthalmologists per 100,000 population in the UK fewer pro rata than in any other nation in the European Union.[17]

United States
In the United States, four years of residency training after medical school are required, with the first year being an internship in surgery, internal medicine, pediatrics, or a general transition year. Optional fellowships in advanced topics may be pursued for several years after residency. Most currently practicing ophthalmologists train in medical residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) or the American Osteopathic Association (AOA) and are board-certified by the American Board of Ophthalmology or the American Osteopathic Board of Ophthalmology and Otolaryngology. United States physicians who train in osteopathic medical schools hold the Doctor of Osteopathic Medicine (D.O.) degree rather than an M.D. degree. The same residency and certification requirements for ophthalmology training must be fulfilled by osteopathic physicians. Physicians must complete the requirements of continuing medical education in order to maintain licensure and for re-certification. Professional bodies like the AAO and ASCRS: The American Society of Cataract and Refractive Surgery organizes conferences, helps physician members through continuing medical education programs for maintaining board certification, and provides political advocacy and peer support.

Sub-specialities
Ophthalmology includes sub-specialities which deal either with certain diseases or diseases of certain parts of the eye. Some of them are: Anterior segment surgery Retinal ophthalmology, which emphasizes such things as laser treatment of the retina and actual retinal surgery. Cataracts not usually considered a subspecialty per se, since most general ophthalmologists perform cataract surgery Cornea, ocular surface, and external disease Glaucoma Medical retina, deals with treatment of retinal problems through non-surgical means. Neuro-ophthalmology Ocular oncology Oculoplastics & Orbit surgery Ophthalmic pathology Pediatric ophthalmology/Strabismus (mis-alignment of the eyes) Refractive surgery Uveitis Immunology Veterinary Formal specialty training programs in veterinary ophthalmology now exist in some countries.[18][19] Vitreo-retinal surgery, deals with surgical management of retinal and posterior segment diseases and disorders. Medical retina and vitreo-retinal surgery sometimes together called posterior segment subspecialisation.

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Notable ophthalmologists
18th19th centuries
Theodor Leber Discovered Leber's congenital amaurosis, Leber's hereditary optic neuropathy, Leber's miliary aneurysm, and Leber's Stellate Nueroretinitis. Sir William Adams (UK) Founder of Exeter's West of England Eye Infirmary. Carl Ferdinand von Arlt (18121887), the elder (Austrian) proved that myopia is largely due to an excessive axial length, published influential textbooks on eye disease, and ran annual eye clinics in needy areas long before the concept of volunteer eye camps became popular. His name is still attached to some disease signs, e.g., von Arlt's line in trachoma. His son Ferdinand Ritter von Arlt, the younger, was also an ophthalmologist. Jacques Daviel (France) claimed to be the 'father' of modern cataract surgery in that he performed extracapsular extraction instead of needling the cataract or pushing it back into the vitreous. It is said that he carried out the technique on 206 patients in 17523, out of which 182 were reported to be successful. These figures are not very credible, given the total lack of both anaesthesia and aseptic technique at that time.

Joseph Forlenze

Frans Cornelis Donders (18181889) (Dutch) published pioneering analyses of ocular biomechanics, intraocular pressure, glaucoma, and physiological optics. Made possible the prescribing of combinations of spherical and cylindrical lenses to treat astigmatism. Joseph Forlenze (1757-1833) (Italy), specialist in cataract surgery, became popular during the First French Empire, healing, among many, personalities such as the minister Jean-tienne-Marie Portalis and the poet Ponce Denis Lebrun. He was nominated by Napoleon "chirurgien oculiste of the lycees, the civil hospices and all the charitable institutions of the departments of the Empire".[20] He was known also for his free interventions, mainly in favour of poor people. Albrecht von Graefe (18281870) (Germany) Along with Helmholtz and Donders, one of the 'founding fathers' of ophthalmology as a specialty. A brilliant clinician and charismatic teacher who had an international influence on the development of ophthalmology. A pioneer in mapping visual field defects and diagnosis and treatment of glaucoma. Introduced a cataract extraction technique that remained the standard for over 100 years, and many other important surgical techniques such as iridectomy. Rationalised the use of many ophthalmically important drugs, including mydriatics & miotics. The founder of one of the earliest ophthalmic societies (German Ophthalmological Society, 1857) and one of the earliest ophthalmic journals (Graefe's Archives of Ophthalmology). The most important ophthalmologist of the nineteenth century.

Allvar Gullstrand

Allvar Gullstrand (Sweden), Nobel Prize winner in 1911 for his research on the eye as a light-refracting apparatus. Described the schematic eye a mathematical model of the human eye based on his measurements known as the optical constants of the eye. His measurements are still used today. Hermann von Helmholtz, great German polymath, invented the ophthalmoscope (1851) and published important work on physiological optics, including colour vision (1850s).

Ophthalmology Socrate Polara (18001860) (Italy), founded the first dedicated ophthalmology clinic in Sicily in 1829 entirely as a philanthropic endeavor; later appointed as the first director of the ophthalmology department at the Grand Hospital of Palermo, Sicily (Italy) in 1831 after the Sicilian government became convinced of the importance of state support for the specialization.[21] Hermann Snellen (Netherlands) introduced the Snellen chart to study visual acuity. Sir Arthur Conan Doyle (United Kingdom). English writer, primarily of the Sherlock Holmes stories. Trained in but apparently never practiced Ophthalmology. Jose Rizal (Philippines). The Philippines' national hero was an ophthalmologist. One of his works was an operation of both his mother's eyes for removal of a cataract.

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20th21st centuries
William Horatio Bates (18601931) (United States) Creator of the unorthodox Bates Method, credited for being the founder of the Natural Vision Improvement movement. Vladimir Petrovich Filatov (18751956) (Ukraine) His contributions to the medical world include the tube flap grafting method, corneal transplantation and preservation of grafts from cadaver eyes and tissue therapy. He founded The Filatov Institute of Eye Diseases & Tissue Therapy, Odessa, one of the leading eye care institutes in the world.

William Bates and his assistant

Ignacio Barraquer (18841965) (Spain) In 1917, invented the first motorized vacuum instrument (erisophake) for intracapsular cataract extraction. Founded of the Barraquer Clinic in 1941 and the Barraquer Institute in 1947 in Barcelona, Spain. Tsutomu Sato (Japan) Pioneer in incisional refractive surgery, including techniques for astigmatism and the invention of radial keratotomy for myopia. Jules Gonin (18701935) (Switzerland) "Father of retinal detachment surgery". Sir Harold Ridley (United Kingdom) In 1949, may have been the first to successfully implant an artificial intraocular lens after observing that plastic fragments in the eyes of wartime pilots were well tolerated. He fought for decades against strong reactionary opinions to have the concept accepted as feasible and useful. Charles Schepens (Belgium) "Father of modern retinal surgery". Developer of the Schepens indirect binocular ophthalmoscope whilst at Moorfields Eye Hospital. Founder of the Schepens Eye Research Institute in Boston, Massachusetts. This premier research institute is associated with Harvard Medical School and Massachusetts Eye & Ear Infirmary. Marshall M. Parks "Father of pediatric ophthalmology". Jos Ignacio Barraquer (19161998) (Spain) "Father of modern refractive surgery". In the 1960s, developed lamellar techniques including keratomileusis and keratophakia, as well as the first microkeratome and corneal microlathe. Tadeusz Krwawicz (Poland) In 1961, developed the first cryoprobe for intracapsular cataract extraction. Svyatoslav Fyodorov (Russia) "Father of ophthalmic microsurgery". Improved and popularized the radial keratotomy, invented a surgical cure for cataract and developed the scleroplasty. Charles Kelman (United States) Developed the ultrasound and mechanized irrigation and aspiration system for phacoemulsification, first allowing cataract extraction through a small incision. Ioannis Pallikaris (Greece) Performed the first laser-assisted intrastromal keratomileusis or LASIK surgery. Fred Hollows (New Zealand/Australia) Pioneered programs in Nepal, Eritrea, and Vietnam, and among Australian aborigines, including the establishment of cheap laboratory production of intraocular lenses in Nepal and Eritrea.

Ophthalmology Marco Abbondanza (Italy) Developed the Mini Asymmetric Radial Keratotomy (M.A.R.K.) for keratoconus and astigmatism, popularized the cross-linking. Ian Constable (Australia) Founded the Lions Eye Institute in Perth, Western Australia, the largest eye research institute in the southern hemisphere and home to ten ophthalmologists. Rand Paul (United States) is a current member of The United States Senate from Kentucky. His father is U.S. Representative Ron Paul. L. L. Zamenhof (Poland) Creator of the Esperanto language. Bashar al-Assad (Syria) The President of Syria. He did his ophthalmology residency in a hospital in London. Syed Modasser Ali (Bangladesh) An ophthalmic surgeon who used to be the Director-General of Health Services for the government of Bangladesh. He wrote the first book on community ophthalmology (public eye health). Dr Albrecht Hennig (Germany) Pioneered the "fish-hook" technique enabling his team to complete more than 48,000 cataract operations in Nepal in 2004. He was nominated as cbm's 'Eye Health Hero', at the International Agency for the Prevention of Blindness (IAPB) 9th General Assembly (9GA) in September 2012.

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References
[1] Bidyadhar, N.K. (1939), Sushruta's Ophthalmic Operations, Archives of Ophthalmology, 22, page 553. [2] Agarwal, R.K. (1965), Ancient Indian Ophthalmology, The Ophthalmic Optician, 5(21),1093-1100 (the title of this journal was changed to Optometry Today in 1985), published by the Association of Optometrists, London, England. [3] Roy, P.N., Mehra, K.S. and Deshpande, P.J. (1975), Cataract surgery performed before 800 BC, British Journal of Ophthalmology, 59, page 171 [9] A.L. Wyman, "Baron De Wenzel, Oculist to King George III: His Impact on British Ophthalmologists," Medical History (1991) 35#1 pp 78-88. [10] Luke Davidson, "'Identities Ascertained': British Ophthalmology in the First Half of the Nineteenth Century," Social History of Medicine (1996) 9#3 pp p313-333. [11] Arin Namal, and Arnold Reisman, "Joseph Igersheimer (18791965): A Visionary Ophthalmologist and his Contributions before and after Exile," Journal of Medical Biography (2007) 15#4 pp 227234 [12] Andrzej Wincewicz, et al., "Dr Adam Zamenhof (1888-1940) and his insight into ophthalmology," Journal of Medical Biography (2009) 17#1 pp 1822 [20] Jan Ellen Goldstein, Console and Classify. The French Psychiatric Profession in the Nineteenth Century, Chicago Press, 2002, p. 63

External links
Directory of Open Access Ophthalmology Journals (http://oculistmd.wordpress.com/article/ open-access-ophthalmology-optometry-and-3gd48p3w1cmm6-15/) The Royal College of Ophthalmologists (http://rcophth.ac.uk/) The David G. Cogan Ophthalmic Pathology Collection (http://cogancollection.nei.nih.gov/) Dictionary of ophthalmic terms (http://www.uic.edu/com/eye/Education/PocketDictionary.shtml) EyeWiki (http://eyewiki.aao.org/) Multilingual illustrated Dictionary of Ophthalmology (http://www.zeitzfrankozeitz.de/index.php/ fachwoerterbuch.html)

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General practitioner
A general practitioner (GP) is a medical practitioner who treats acute and chronic illnesses and provides preventive care and health education to patients. "The good GP will treat patients both as people and as a population".[1] As a difference to medical or surgical specialized doctors they intend to practice a holistic approach that takes into consideration the biological, psychological and social environment in which patients live. Their duties are not confined to specific organs of the body, and they have particular skills in treating people with multiple health issues. They are trained to treat patients of any age and sex to levels of complexity that are defined by each country.[2] In some healthcare systems GPs work in primary care healthcare centers where they play a central role in the healthcare team. Nevertheless, in some models of care GPs work as single-handed practitioners. The variations in the role of a GP vary greatly between countries or even within countries. In urban areas of developed countries their roles are much narrower and focused on the care of chronic health problems, treatment of acute non-life threatening diseases, early detection and referral to specialized care of serious diseases and preventative care as health education or immunization. Meanwhile, in rural areas of developed countries or in developing countries a GP may be routinely involved in pre-hospital emergency care, the delivery of babies, some hospital care in community hospitals and perform low complexity surgical procedures.[3][4][5] The term general practitioner or GP is common in the Republic of Ireland, the United Kingdom and several Commonwealth countries. In these countries the word physician is largely reserved for certain other types of medical specialists, notably in internal medicine. While in these countries, the term GP has a clearly defined meaning, in North America the term has become somewhat ambiguous, and is not necessarily synonymous with the term "family doctor" or primary care provider, as described below. While historically the role of a GP has been performed from any doctor qualified in a medical school working in the community. Since the 1950s general practice has become a speciality in its own right, with specific training requirements tailored to each country.[6][7][8] The Alma Ata Declaration in 1978 set the intellectual foundation of what primary care and general practice is nowadays.

Asia
India and Bangladesh
The basic medical degrees in India and Bangladesh are MBBS (Bachelor of Medicine, Bachelor of Surgery), BAMS (Bachelor of Ayurveda, Medicine and Surgery), BHMS (Bachelor of Homoeopathic Medicine and Surgery) and BUMS (Bachelor of Unani Medicine and Surgery). These generally comprise of a four-and-a-half-year course followed by a year of compulsory rotatory internship. The internship requires the candidate to work in all departments for a stipulated period of time, to undergo hands-on training in treating patients.

Edward Jenner

The registration of doctors is usually managed by state medical councils. A permanent registration as a Registered Medical Practitioner is granted only after satisfactory completion of the compulsory internship.

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Pakistan
In Pakistan, formerly a part of undivided British India, 5 years of MBBS is followed by one year of internship in different specialties. Pakistan Medical and Dental Council (PMDC) then confers permanent registration, after which the candidate may choose to practice as a GP or opt for specialty training. The first Family Medicine Training programme was approved by the College of Physicians and Surgeons, Pakistan (CPSP) in 1992 and initiated in 1993 by the Family Medicine Division of the Department of Community Health Sciences, Aga Khan University, Pakistan. In 1997, the Royal College of General Practitioners, UK, unconditionally approved the Programme for the MRCGP Examination and additionally declared it as amongst the top 10 programmes in UK.[9] Family Medicine residency training programme of Ziauddin University is approved for Fellowship in Family Medicine.[10]

Europe
France
In France, the mdecin gnraliste (commonly called docteur) is responsible for the long term care in a population. This implies prevention, education, care of the diseases and traumas that do not require a specialist, and orientation towards a specialist when necessary. They also follow the severe diseases day-to-day (between the acute crises that require the intervention of a specialist). They have a role in the survey of epidemics, a legal role (constatation of traumas that can bring compensation, certificates for the practice of a sport, death certificate, certificate for hospitalisation without consent in case of mental incapacity), and a role in the emergency care (they can be called by the samu, the French EMS). They often go to a patient's home when the patient cannot come to the consulting room (especially in case of children or old people), and have to contribute to a night and week-end duty (although this was contested in a strike in 2002). [citation
needed]

The studies consist of six years in the university (common to all medical specialties), and three years as a junior practitioner (interne): the first year (PACES, premire anne commune aux tudes de sant, often abbreviated to P1 by students) is common with the dentists and midwifery; the rank at the final competitive examination[11] determines in which branch the student can go on; the following two years, called propdeutique, are dedicated to the fundamental sciences: anatomy, human physiology, biochemistry, bacteriology, statistics... the three following years are called externat and are dedicated to the study of clinical medicine; they end with a classifying examination, the rank determines in which specialty (general medicine is one of them) the student can make his internat; the internat is three years of initial professional experience under the responsibility of a senior; the interne can prescribe, he can replace physicians,[12] and usually works in a hospital. This ends with a doctorate, a research work which usually consist of a statistical study of cases to propose a care strategy for a specific affliction (in an epidemiological, diagnostic, or therapeutic point of view).

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Germany
In Germany most general practitioners are Fachrzte fr Allgemeinmedizin (specialists of common medicine), some are hausrztliche Internisten (specialists of internal medicine). To become a general practitioner either 5 years of training in Allgemeinmedizin (common medicine) or Innere Medizin (internal medicine) are required. For Facharzt fr Allgemeinmedizin training time in internal medicine, surgery and in general practice is required. Most general practitioners work in their own office, sometimes together with colleagues in health centers, regionally associated in Kassenrztliche Vereinigungen (Associations of practitioners in public health system). Patients can use an on-call service at night and during the weekends. Many regions have to face a shortage of general practitioners, especially in rural areas.

Ireland
General Practice in Ireland largely follows the British model, with some exceptions. GP training in Ireland is governed by the Irish College of General Practitioners and requires the completion of a primary medical degree. In Ireland the title of MB BCh BAO (Bachelor of Medicine, Bachelor of Surgery, Bachelor of the Obstetric Art) or BM BS (Bachelor of Medicine, Bachelor of Surgery) is awarded upon successful completion of a 4 year graduate or 5 to 6 year undergraduate degree programme in one of the country's 6 medical schools. Following this a further year is spent as an Intern, rotating through medical and surgical specialties. In most, but not all instances, 6 months are spent in medicine and 6 months in surgery. Some interns can gain experience in general practice, psychiatry and other specialties. The successful completion of intern training leads to full registration with the Irish Medical Council. Those medical practitioners wishing to pursue a career in General Practice must complete an approved training scheme. Previously completion of a training scheme was not mandatory to sit the Membership of the Irish College of General Practictioners (MICGP) exams and practice as a GP in Ireland. Many doctors took up stand-alone SHO posts in the required specialities and then sat the exam without any vocational training. This route has now been abolished and vocational training is mandatory. Completion of vocational GP training in other jurisdictions (e.g. the UK) and completion of the MICGP or equivalent (e.g. MRCGP) is still possible, but anecdotal evidence would suggest Irish trained GPs are at a significant advantage when applying for Irish GP posts. Entry to a General Practice Training Scheme is based on competitive interview. Most are of 4 years duration (one is 5 years). Generally the first 2 years are spent rotating through relevant specialties (medicine, paediatrics, obstetrics & gynaecology, psychiatry, accident & emergency, ENT etc.). Two years are then spent as a GP registrar in designated Training Practice. After successfully completing the MICGP exams, the new general practitioner is free to practice. General practice in Ireland is a desirable career for many and competition for places on training schemes is intense. There has been much criticism of the perceived under-supply of training places and efforts are made to increase places annually. Currently there are 12 schemes - Donegal, Sligo, Western (Galway, Mayo and Roscommon), Mid-Western (Limerick, Clare and Tipperary North Riding), Southern (Cork & Kerry), South-East (Waterford, Wexford, Kilkenny and Tipperary South Riding), Midlands (Offaly, Westmeath, Laois, Kildare), North-East (Louth, Meath, Monaghan, Cavan), Ballinasloe and 3 schemes based in Dublin. Typically Irish GPs work exclusively with private (i.e. fee-for-service paying) patients or have a mix of public and private. So-called "public" patients are those who qualify for a medical card under the General Medical Services (or GMS) system. This is free health care, provided by the government and is means tested. Other groups such as those with specified chronic illnesses and the elderly are also entitled to a medical card. A medical card entitles the holder to free GP consultations, free medications and free hospital treatment. In order to treat medical card holders a GP must apply for and be granted a GMS list. Applications for such lists are competitive as they can be very lucurative for the GP and vacancies do not often arise.

General practitioner GPs deal with the entire spectrum of medical ailments. They are well placed to implement preventative measures and to manage chronic illness. They also act as "gate-keepers" for the tertiary care system, providing referrals to specialist services when appropriate. Some GPs are employed by private agencies.

844

Netherlands and Belgium


General practice in the Netherlands and Belgium is considered fairly advanced. The huisarts (literally: "home doctor") administers first line, primary care 24 hours a day, 7 days a week. [citation needed] In the Netherlands, patients cannot consult a hospital specialist without a required referral. Most GP's work in private practice although more medical centers with employed GP's are seen. Many GP's have a specialist interest, e.g. in palliative care. In Belgium, one year of lectures and two years of residency are required. In the Netherlands, training consists of three years (full-time) of specialization after completion of internships. First and third year of training takes place at a GP practice. The second year of training consists of six months training at an emergency room, or internal medicine, paediatrics or gynaecology, or a combination of a general or academic hospital, three months of training at a psychiatric hospital or outpatient clinic and three months at a nursing home (verpleeghuis) or clinical geriatrics ward/policlinic. During all three years, residents get one day of training at university while working in practice the other days. The first year, a lot of emphasis is placed on communications skills with video training. Furthermore all aspects of working as a GP gets addressed including working with the medical standards from the Dutch GP association NHG (Nederlands Huisartsen Genootschap).[13] All residents must also take the national GP knowledge test (Landelijke Huisartsgeneeskundige Kennistoets (LHK-toets)) twice a year.[] In this test of 120 multiple choice questions, medical, ethical, scientific and legal matters of GP work are addressed.[][14]

Spain
In Spain GPs are officially especialistas en medicina familiar y comunitaria but are commonly called "mdico de cabecera" or "mdico de familia." [15] Most Spanish GPs work for the state funded health authority through the regional government (comunidad autnoma). They are in most cases salary-based healthcare workers. For the provision of primary care, Spain is currently divided geographically in basic health care areas (reas bsicas de salud), each one containing a primary health care team (Equipo de atencin primaria). Each team is multidisciplinary and typically includes GPs, community pediatricians, nurses, physiotherapists and social workers, together with ancillary staff. In urban areas all the services are concentrated in a single large building (Centro de salud) while in rural areas the main center is supported by smaller branches (consultorios), typically single-handled.[16] Becoming a GP in Spain involves studying medicine for 6 years, passing a competitive national exam called MIR (Medico Interno Francisco Valls (Divino Valls) Residente) and undergoing a 4 years training program. The training program has includes core specialties as general medicine and general practice (around 12 months each), pediatrics, gynecology, orthopedics and psychiatry. Shorter and optional placements in ENT, ophthalmology, ED, infectious diseases, rheumathology or others add up to the 4 years curriculum. The assessment is work based and involves completing a logbook that ensures all the expected skills, abilities and aptitudes have been acquired by the end of the training period.[17][18]

General practitioner Nowadays some of the specialists in family practice in Spain are forced to work in other countries (mainly UK, Portugal and France) due to lack of stable work in their home country.[19]

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United Kingdom
In the United Kingdom, doctors wishing to become GPs take at least 5 years training after medical school, which is usually an undergraduate course of five to six years (or a graduate course of four to six years) leading to the degrees of Bachelor of Medicine and Bachelor of Surgery (MB,ChB/BS). Up until the year 2005, those wanting to become a General Practitioner of medicine had to do a minimum of the following postgraduate training: one year as a pre-registration house officer (PRHO) (formerly called a house officer), in which the trainee would usually spend 6 months on a general surgical ward and 6 months on a general medical ward in a hospital; two years as a senior house officer (SHO) - often on a General Practice Vocational Training Scheme (GP-VTS) in which the trainee would normally complete four 6-month jobs in hospital specialties such as obstetrics and gynaecology, paediatrics, geriatric medicine, accident and emergency or psychiatry; one year as a general practice registrar on a GP-VTS. This process has changed under the programme Modernising Medical Careers. Medical practitioners graduating from 2005 onward have to do a minimum of 5 years postgraduate training: two years of Foundation Training, in which the trainee will do a rotation around either six 4-month jobs or eight 3-month jobs - these include at least 3-months in general medicine and 3-months in general surgery, but will also include jobs in other areas; A three-year "run-through" GP Specialty Training Program containing (GPSTP): 18 months as a Specialty Registrar in which time the trainee completes a mixture of jobs in hospital specialties such as obstetrics and gynaecology, paediatrics, geriatric medicine, accident and emergency or psychiatry; 18 months as a GP Specialty Registrar in General Practice.
NHS Medical Career Grades Old system Year 1: Year 2: Year 3: Year 4: Year 5: Years 6-8: Year 9: Consultant total time in training: minimum 7-9 years Training may be extended by pursuing medical research (usually two-three years), usually with clinical duties as well Pre-registration house officer (PRHO) - one year Senior house officer (SHO) a minimum of two years, although often more Specialist registrar four to six years GP registrar- one year General practitioner total time in training: 4 years Consultant total time in training: minimum 8 years New system (Modernising Medical Careers) Foundation Doctor (FY1 and FY2) - 2 years

Specialty Registrar (StR) in a hospital speciality: minimum six years

Specialty Registrar (GPST) in general practice: three years General practitioner total time in training: 5 years

Optional

Training is competency based, times shown are a minimum. Training may be extended by obtaining an Academic Clinical Fellowship for research or by dual certification in another speciality.

During the GP specialty training program, the medical practitioner must complete a variety of assessments in order to be allowed to practice independently as a GP. There is a knowledge-based exam with multiple choice questions

General practitioner called the Applied Knowledge Test (AKT). The practical examination takes the form of a "simulated surgery" in which the doctor is presented with 13 clinical cases and assessment is made of data gathering, interpersonal skills and clinical management. This Clinical Skills Assessment (CSA) is held on three or four occasions throughout the year and takes place in the specially designed centre at Croydon. Finally throughout the year the doctor must complete an electronic portfolio which is made up of case-based discussions, critique of videoed consultations and reflective entries into a "learning log". Membership of the Royal College of General Practitioners was previously optional. However, new trainee GP's from 2008 are now compulsorily required to complete the nMRCGP. They will not be allowed to practice without this postgraduate qualification. After passing the exam or assessment, they are awarded the specialist qualification of MRCGP Member of the Royal College of General Practitioners. Previously qualified general practitioners (prior to 2008) are not required to hold the MRCGP, but it is considered desirable. In addition, many hold qualifications such as the DCH (Diploma in Child Health of the Royal College of Paediatrics and Child Health) and/or the DRCOG (Diploma of the Royal College of Obstetricians and Gynaecologists) and/or the DGH (Diploma in Geriatric Medicine of the Royal College of Physicians). Some General Practitioners also hold the MRCP (Member of the Royal College of Physicians) or other specialist qualifications, but generally only if they had a hospital career, or a career in another speciality, before training in General Practice. There are many arrangements under which general practitioners can work in the UK. While the main career aim is becoming a principal or partner in a GP surgery, many become salaried or non-principal GPs, work in hospitals in GP-led acute care units, or perform locum work. Whichever of these roles they fill, the vast majority of GPs receive most of their income from the National Health Service (NHS). Principals and partners in GP surgeries are self-employed, but they have contractual arrangements with the NHS which give them considerable predictability of income. Visits to GP surgeries are free in all countries of the United Kingdom, but charges for prescription only medicine vary. Wales, Scotland and Northern Ireland have abolished all charges. In England, however, most adults of working age who are not on benefits have to pay a standard charge for prescription only medicine of 7.60 per item from April 2012. Recent reforms to the NHS have included changing the GP contract. General practitioners are now not required to work unsociable hours, GPs in the United Kingdom may operate in and get paid to some extent according to their performance, e.g. community health centres. numbers of patients treated, what treatments were administered, and the health of their catchment area, through the Quality and Outcomes Framework. They are encouraged to prescribe medicines by their generic names. The IT system used for assessing their income based on these criteria is called QMAS. A GP can expect to earn about 70,000 a year without doing any overtime, although this figure is extremely variable. A 2006 report[20] noted that some GPs were earning 250k per year, with the highest-paid on 300k for working alone across five islands in the Outer Hebrides. However, a full-time GMS or PMS practice partner can now expect to earn around 95,900 before tax, while a salaried GP earns on average 66,500.[21] This equates to an hourly rate of around 40 an hour for a GP partner.[22] A survey by Ipsos Mori released in 2011 reports that 88% of adults in the UK "trust doctors to tell the truth".[]

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General practitioner

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North America
Canada
In Canada, the term general practitioner often has two meanings. The Canadian specialty that is equivalent to the British general practitioner training program is family medicine which accounts for almost 40% of the residency positions for graduating students. Following four years in medical school, a resident will spend 23 years in an accredited family medicine program. At the end of this, residents are eligible to be examined for Certification in The College of Family Physicians of Canada. Many hospitals and health regions now require this certification. To maintain their certificate, medical practitioners must document ongoing learning and upgrade activities to accumulate "MainPro" credits. Some practitioners add an extra year of training in emergency medicine and can thus be additionally certified as CCFP(EM). Extra training in anesthesia, surgery and obstetrics may also be recognized but this is not standardized across the country. General practitioners in Canada do operate in private practice, in that they are not employees of the government. They either own their own practice or work for a privately owned practice. However, the majority of GPs are remunerated via their provincial governments' publicly funded health insurance plans, via a variety of payment mechanisms, including fee-for-service, salaried positions, and alternate payment plans. There is increasing interest in the latter as a means to promote best practices within a managed economic environment. As standard office practice has become less financially viable in recent years, many FPs now pursue areas of special interest. In rural areas, the majority of FPs still provide a broad, well-rounded scope of practice. Manpower inequities in rural areas are now being addressed with some innovative training and inducement mechanisms. An imbalance between physician manpower and a growing patient load has resulted in orphan patients who find it difficult to access primary care, but this is not unique to Canada. Family Medicine is recently recognized as a Medical Specialty in Canada. Family Physicians who pass the Certification exam, CCFP, become Specialist in Family Medicine.

United States
Medical practitioners must hold a license to practice medicine in the United States. The requirement is to be enrolled in or have completed a year of residency, traditionally called a rotating internship. There are generally four years of undergraduate college and four years of medical school prior to the internship. All prospective licentiates (denoted as physicians and surgeons in most states, e.g., California) who pass step three of the United States Medical Licensing Examination (USMLE) or level three of the Comprehensive Osteopathic Medical Licensing Examination (COMLEX-USA) and successfully complete an accredited internship may practice the full range of medicine. The population of this type of medical practitioner is declining, however. Currently the United States Navy has many of these general practitioners, formally known as General Medical Officers or GMOs, in active practice. The GMO is an inherent concept to all military medical branches. GMOs are the gatekeepers of medicine in that they hold the purse strings and decide upon the merit of specialist consultation. The US now holds a different definition for the term "general practitioner". The two terms "general practitioner" and "family practice" were synonymous prior to 1970. At that time both terms (if used within the US) referred to someone who completed medical school and the one-year required internship, and then worked as a general family doctor. Completion of a post-graduate specialty training program or residency in family medicine was, at that time, not a requirement. A physician who specializes in "family medicine" must now complete a residency in family medicine, and must be eligible for board certification, which is required by many hospitals and health plans for hospital privileges and remuneration, respectively. It was not until the 1970s that family medicine was recognized as a specialty in the US.[23] Many licensed family medical practitioners in the United States after this change began to use the term "general practitioner" to refer to those practitioners who previously did not complete a family medicine residency. Family physicians (after completing medical school) must then complete three to four years of additional residency in family medicine. Three hundred hours of medical education within the prior six years is also required to be eligible to sit for

General practitioner the board certification exam; these hours are largely acquired during residency training. The existing general practitioners in the 1970s were given the choice to be grandfathered into the newly created specialty of Family Practice. As well, the American Academy of General Practice changed its name to the American Academy of Family Physicians.[24] The prior system of graduating from medical school and completing one year of post-graduate training (rotating internship) was abolished. If one wanted to become a "house-call-making" type of physician, one needed to stay in the academic setting two or three more years.[25] When the American Academy of Family Practice was created, the American Academy of General Practice was abolished. Several members of the AMA were in opposition to this and predicted that another General Practice organization would inevitably result, including Susan Black, MD. She predicted a "second coming" of a "General Practice Movement". Several physicians nationwide created the American Academy of General Physicians. They prescribed a body of knowledge that defined a "General Practitioner". General practitioners have in the past, and currently are being created by the present system of producing doctors. Prior to recent history most postgraduate education in the United States was accomplished using the mentor system.[citation needed] A physician would finish a rotating internship and move to some town and be taught by the local physicians the skills needed for that particular town. This allowed each community's needs to be met by the teaching of the new general practitioner the skills needed in that community. This also allowed the new physician to start making a living and raising a family, etc. General practitioners would be the surgeons, the obstetricians, and the internists for their given communities. Changes in demographics and the growing complexities of the developing bodies of knowledge made it necessary to produce more highly trained surgeons and other specialists. For many physicians it was a natural desire to want to be considered "specialists".[citation needed] What was not anticipated by many physicians is that an option to be a generalist would be abolished.[citation needed] Certificates of Added Qualifications (CAQs) in adolescent medicine, geriatric medicine, sports medicine, sleep medicine, and hospice and palliative medicine are available for those board-certified family physicians with additional residency training requirements. Recently,Wikipedia:Manual of Style/Dates and numbers#Chronological items new fellowships in International Family Medicine have emerged. These fellowships are designed to train family physicians working in resource poor environments.[26] There is currentlyWikipedia:Manual of Style/Dates and numbers#Chronological items a shortage of primary care physicians (and also other primary care providers) due to several factors, notably the lesser prestige associated with the young specialty, the lower pay, and the increasingly frustrating practice environment. In the US physicians are increasingly forced to do more administrative work,[27] and shoulder higher malpractice premiums.

848

Oceania
Australia and New Zealand
General Practice in Australia and New Zealand has undergone many changes in training requirements over the past decade. The basic medical degree in Australia is the MBBS, and New Zealand the MBChB degree (Bachelor of Medicine, Bachelor of Surgery), which has traditionally been attained after completion of an undergraduate five or six-year course. Over the last few years, an ever increasing number of post-graduate four-year medical programs (previous bachelors degree required) have become more common and now account more than half of all Australian medical graduates. After graduating, a one year internship is completed in a public and private hospitals prior to obtaining full registration. Many newly registered medical practitioners undergo one year or more of pre-vocational position as Resident Medical Officers (different titles depending on jurisdictions) before specialist training begins. For general practice training, the medical practitioner then applies to enter a three- or four-year program either through the "Australasian General Practice Training Program", "Remote Vocational Training Scheme" or "Independent Pathway". {GP Australia}. A combination of coursework and apprenticeship type training leading to the awarding of the FRACGP (Fellowship of the Royal Australian College of General Practitioners), FACRRM

General practitioner (Fellowship of Australian College of Remote and Rural Medicine) or FRNZCGP (Fellowship of the Royal New Zealand College of General Practitioners), if successful. Since 1996 this qualification or its equivalent has been required in order for the GP to access Medicare rebates as a general practitioner. Medicare is Australia's universal health insurance system, and without access to it, a practitioner cannot effectively work in private practice in Australia. [citation needed] Procedural General Practice training in combination with General Practice Fellowship was first established by the "Australian College of Remote and Rural Medicine" in 2004. This new fellowship was developed in aid to recognise the specialised skills required to work within a rural and remote context. In addition it was hoped to recognise the impending urgency of training Rural Procedural Practitioners to sustain Obstetric and Surgical services within rural Australia. Each training registrar select a speciality that can be utilised in a rural area from the Advanced Skills Training list and spends a minimum of 12 months completing this specialty, the most common of which are Surgery, Obstetrics/Gynaecology and Anaesthetics. Further choices of specialty include Aboriginal and Torres Strait Islander Health, Adult Internal Medicine, Emergency Medicine, Mental Health, Paediatrics, Population health and Remote Medicine. Shortly after the establishment of the FACRRM, the Royal Australian College of General Practitioners introduced an additional training year (from the basic 3 years) to offer the "Fellowship in Advanced Rural General Practice". The additional year, or Advanced Rural Skills Training (ARST) can be conducted in various locations from Tertiary Hospitals to Small General Practice. In New Zealand, most GPs work within a practice that is part of a Primary Health Organisation (PHO). These are funded at a population level, based on the characteristics of a practice's enrolled population (referred to as capitation-based funding). Fee-for-service arrangements still exist with other funders such as Accident Compensation Corporation (ACC) and Ministry of Social Development (MSD), as well as receiving co-payments from patients to top-up the capitation-based funding. In NZ new graduates must complete the RNZCGP GPEP (General Practice Education Program) Stages I and II in order to be granted the title FRNZCGP, which includes the PRIMEX assessment and further CME and Peer group learning sessions as directed by the RNZCGP. Holders of the award of FRNZCGP may apply for specialist recognition with the New Zealand Medical Council (MCNZ), after which they are considered specialists in General Practice by the council and the community. [citation needed] Increasingly a portion of income is derived from government payments for participation in chronic disease management programs. There is a shortage of GPs in rural areas and increasingly outer metropolitan areas of large cities, which has led to the utilisation of overseas trained doctors (international medical graduates (IMGs)).

849

Pay
Pay of medical practitioners varies widely in different countries throughout the world. In the UK, for example, full-time self-employed GPs can currently expect to earn a profit share of around 100,000 per annum while PCT employed GPs can currently expect to earn a salary of 53,781 to 81,158.[28]

References
[1] [2] [3] [4] [5] [6] [7] [8] Ann Leck and Ian Leck (1987), What is a good GP?, British Medical Journal, 294 (6568), 351-2. http:/ / wiki. answers. com/ Q/ What_are_the_Duties_of_a_family_practitioner http:/ / www. ncbi. nlm. nih. gov/ pmc/ articles/ PMC2845490/ http:/ / www. stfm. org/ fmhub/ fm2008/ April/ Bill284. pdf http:/ / www. amazon. co. uk/ Confessions-GP-Benjamin-Daniels/ dp/ 1906321884 http:/ / www. ncbi. nlm. nih. gov/ pmc/ articles/ PMC2370185/ ?page=1 http:/ / personal. rhul. ac. uk/ usjd/ 135/ indexgp. htm http:/ / ino. sagepub. com/ content/ 2/ 1/ 2. full

[11] Marchand-Antonin, Benot. " The numerus clausus : its side effects - its place in globalization of the medicine (http:/ / thesesdemedecine. free. fr/ wp-content/ thesis/ NumerusClausus. BenoitMarchandAntonin. pdf)" [12] Guedes-Marchand, Ccile. " Le remplaant, cet intermittent de la mdecine gnrale : sa place dans le systme de soins (http:/ / thesesdemedecine. free. fr/ wp-content/ thesis/ RemplacantMedGen. CecileGuedesMarchand. pdf)"

General practitioner
[15] http:/ / es. wikipedia. org/ wiki/ Medicina_familiar_y_comunitaria [16] http:/ / www. msc. es/ ciudadanos/ prestaciones/ centrosServiciosSNS/ hospitales/ introduccionCentro. htm [17] http:/ / www. msc. es/ profesionales/ formacion/ docs/ medifamiliar. pdf [18] http:/ / es. wikipedia. org/ wiki/ Examen_MIR [19] http:/ / politica. elpais. com/ politica/ 2012/ 08/ 06/ actualidad/ 1344284347_177524. html [21] http:/ / www. mysalary. co. uk/ average-salary/ Gp_1231 [26] "International Family Medicine Fellowship" (http:/ / www. vcfm. net/ fellowships/ international-medicine-fellowship/ ), Via Christi Retrieved 4/14/2010. [27] "Family doctors: An endangered breed", CNNMoney.com July 16, 2009 (http:/ / money. cnn. com/ 2009/ 07/ 16/ news/ economy/ healthcare_doctors_shortage/ ) [28] Pay for doctors, NHS careers (http:/ / www. nhscareers. nhs. uk/ details/ Default. aspx?Id=553)

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Pediatrics

851

Pediatrics
Pediatrics

Occupation Names Pediatrician Paediatrician

Activity sectors

Medicine Description

Education required

Doctor of Medicine Doctor of Osteopathic Medicine

Pediatrics (also spelled paediatrics or pdiatrics) is the branch of medicine that deals with the medical care of infants, children, and adolescents, and the age limit ranges from birth up to 18 (in some places until completion of secondary education). A medical practitioner who specializes in this area is known as a pediatrician, or paediatrician. The word pediatrics and its cognates mean healer of children; they derive from two Greek words: (pais = child) and (iatros = doctor or healer).
An examination of newly born baby. In the United States, a pediatrician is often a primary care physician who specializes in children, whilst in the Commonwealth a paediatrician (or pediatrician) specialises in paediatrics but generally not as a primary general practitioner.[citation needed]

Pediatrics

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History
Pediatrics is a relatively new medical specialty.[] Hippocrates, Aristotle, Celsus, Soranus, and Galen, understood the differences in growing and maturing organisms that necessitated different treatment "Ex toto non sic pueri ut viri curari debent."[] A 2nd century AD manuscript by the Greek physician and gynecologist Soranus of Ephesus dealt with neonatal pediatrics.[1] Byzantine physicians; Oribasius, Atius of Amida, Alexander Trallianus, and Paulus Aegineta stand out for their contributions to child care.[] The Byzintines also built brephotrophia, "baby shelters,"or "children's hospitals."[]Islamic writers served as a bridge for Great Ormond Street Hospital in London, United Kingdom, which Greco-Roman and Byzantine medicine and added ideas was the first paediatric hospital in the English-speaking world. of their own especially Haly Abbas, Serapion, Rhazes, Avicenna, and Averroes, The Persian scholar and doctor al-Razi (865925) published a short treatise on diseases among children.[2] The first printed book on pediatrics was in Italian (1472) Bagallarder's Little Book on Disease in Children.[3] Paulus Bagellardus a Flumine (d.1492) De Infantium Aegritudinibus et Remediis 1472, Bartolomaeus Metlinger (d.1491) Ein Regiment der Jungerkinder 1473, Cornelius Roelans (1450-1525) no title Buchlein, or Latin compendium, 1483, and Heinrich von Louffenburg (1391-1460) Versehung des Leibs written 1429 published 1491. together form the Pediatric Incunabula, four great medical treatises on children's physiology and pathology.[] Pediatrics as a specialized field of medicine developed in the mid-19th century; Abraham Jacobi (18301919) is known as the father of pediatrics because of his many contributions to the field.[4] He was born in Germany, where he received his medical training, but later practiced in New York City. In the Western world, the first generally accepted pediatric hospital is the Hpital des Enfants Malades (French: Hospital for Sick Children), which opened in Paris in June 1802 on the site of a previous orphanage.[] From its beginning, this famous hospital accepted patients up to the age of fifteen years,[] and it continues to this day as the pediatric division of the Necker-Enfants Malades Hospital, created in 1920 by merging with the physically contiguous Necker Hospital, founded in 1778. This example was only gradually followed in other European countries. The Charit (a hospital founded in 1710) in Berlin established a separate Pediatric Pavilion in 1830, followed by similar institutions at Sankt Petersburg in 1834, and at Vienna and Breslau (now Wrocaw), both in 1837. The English-speaking world waited until 1852 for its first pediatric hospital, the Hospital for Sick Children, Great Ormond Street, some fifty years after the founding of its namesake in Paris.[] In the USA, the first similar institutions were the Children's Hospital of Philadelphia, which opened in 1855, and then Boston Children's Hospital (1869).[]

Pediatrics

853

Differences between adult and pediatric medicine


The body size differences are paralleled by maturational changes. The smaller body of an infant or neonate is substantially different physiologically from that of an adult. Congenital defects, genetic variance, and developmental issues are of greater concern to pediatricians than they often are to adult physicians. A major difference between pediatrics and adult medicine is that children are minors and, in most jurisdictions, cannot make decisions for themselves. The issues of guardianship, privacy, legal responsibility and informed consent must always be considered in every pediatric procedure. In a sense, pediatricians often have to treat the parents and sometimes, the family, rather than just the child. Adolescents are in their own legal class, having rights to their own health care decisions in certain circumstances. In basic terms, pediatricians take care of all of the children's needs from emotional support to medical support.

Training of pediatricians
The training of pediatricians varies considerably across the world. Depending on jurisdiction and university, a medical degree course may be either undergraduate-entry or graduate-entry. The former commonly takes five or six years, and has been usual in the Commonwealth. Entrants to graduate-entry courses (as in the USA), usually lasting four or five years, have previously completed a three- or four-year university degree, commonly but by no means always in sciences. Medical graduates hold a degree specific to the country and university in and from which they graduated. This degree qualifies that medical practitioner to become licensed or registered under the laws of that particular country, and sometimes of several countries, subject to requirements for "internship" or "conditional registration". Pediatricians must undertake further training in their chosen field. This may take from four to eleven or more years, (depending on jurisdiction and the degree of specialization). The post-graduate training for a primary care physician, including primary care pediatricians, is generally not as lengthy as for a hospital-based medical specialist. In most jurisdictions, entry-level degrees are common to all branches of the medical profession, but in some jurisdictions, specialization in pediatrics may begin before completion of this degree. In some jurisdictions, pediatric training is begun immediately following completion of entry-level training. In other jurisdictions, junior medical doctors must undertake generalist (unstreamed) training for a number of years before commencing pediatric (or any other) specialization. Specialist training is often largely under the control of pediatric organizations (see below) rather than universities,and depending on jurisdiction.

Subspecialties
Subspecialties of pediatrics include: Pediatric neuropsychology Pediatric ophthalmology Pediatric endocrinology Pediatric oncology Pediatric pulmonology Neonatology

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References
[1] P.M. Dunn, "Soranus of Ephesus (circa AD 98-138) and perinatal care in Roman times", Archives of Disease in Childhood: Fetal and Neonatal, 1995 July; 73(1): F51F52. (http:/ / www. ncbi. nlm. nih. gov/ pmc/ articles/ PMC2528358/ ) [2] U.S. National Library of Medicine, "Islamic Culture and the Medical Arts, Al-Razi, the Clinician" (http:/ / www. nlm. nih. gov/ exhibition/ islamic_medical/ islamic_06. html) [3] " Achar S Textbook Of Pediatrics (Third Edition) (http:/ / books. google. com/ books?id=dhB2qVWw9SoC& pg=PA1& dq& hl=en#v=onepage& q=& f=false)". Desai,A.B. (ed.) (1989). p.1. ISBN 81-250-0440-8 [4] " Broadribb's Introductory Pediatric Nursing (http:/ / books. google. com/ books?id=d1YRx5d6_K8C& pg=PA4& dq& hl=en#v=onepage& q=& f=false)". Nancy T. Hatfield (2007). p.4. ISBN 0-7817-7706-2

Further reading
Contemporary Pediatrics (http://www.contemporarypediatrics.com/contpeds/) a monthly magazine Clinical Pediatrics (http://clp.sagepub.com) a peer-reviewed journal

External links
American Academy of Pediatrics (http://www.aap.org) Canadian Paediatric Society (http://www.cps.ca/) Pediatric Collection by the BMJ (http://www.bmj.com/specialties/paediatrics) Collection of Pediatric papers published in the British Medical Journal. Health-EU Portal (http://ec.europa.eu/health-eu/my_health/babies_and_children/index_en.htm) Babies' and Children's health in the EU Paediatrics.info (http://www.paediatrics.info) New York University Pediatrics Video Lectures (http://grandrounds.pediatrics.med.nyu.edu/grandrounds/ archive&gnr=538311)

Adolescent medicine

855

Adolescent medicine
Adolescent medicine is a medical subspecialty that focuses on care of patients who are in the adolescent period of development, generally ranging from the last years of elementary school until graduation from high school (some doctors in this subspecialty treat young adults attending college at area clinics, in the subfield of college health). Patients have generally entered puberty, which typically begins between the ages of 9 to 11 for girls, and 11 to 14 for boys. A primary care subspecialty, adolescent medicine incorporates aspects of gynecology, endocrinology, sports medicine, nutrition, dermatology and psychology. Adolescent medicine is an important specialty of Family Practice, Internal Medicine, Pediatrics and Youth Health. Issues with a high prevalence during adolescence are frequently addressed by providers. These include: Sexually transmitted disease (working with specialists in pediatric endocrinology, adolescent obstetrics and gynecology, immunology infectious diseases, and urology and reproductive medicine) Unintended pregnancy (working with specialists in adolescent obstetrics and gynecology, especially in neonatology and maternal-fetal medicine; many- though not all- are medically risky or high-risk cases and/or to those with psychosocial, environmental, and socioeconomic challenges) Birth control (there is currently a drive in the United States federal government's health care policymaking to ensure access to any and all prescription or non-prescription contraceptive methods to adolescent minors who request them, especially if they are over a certain age) Substance abuse Menstrual disorders (such as amenorrhea, dysmenorrhea and dysfunctional uterine bleeding) Acne (working with specialists in dermatology who treat adolescents) Eating disorders like anorexia nervosa and bulimia nervosa (working with nutritionists and dieticians, and also specialists in pediatric mental health counseling, clinical psychology, and pediatric psychiatry, who work with adolescents) Certain mental illnesses (especially personality disorders, anxiety disorders, major depression and suicide, bipolar disorder, and certain types of schizophrenia; in concert with mental health counselors, clinical psychologists, and pediatric psychiatrists specializing in adolescent health care) Delayed or precocious puberty (often working with specialists in adolescent pediatric endocrinology, urology, and andrology)

Scope of care
Providers of care for adolescents generally take a holistic approach to the patient, and attempt to obtain information pertinent to the patient's well-being in a variety of different domains. This approach, similar to the biopsychosocial model, is encapsulated in the HEADSS assessment,[1][2] which is a screening acronym for adolescent patients. This has been expanded to HEEADSSS to include additional question sets (indicated with a *). It includes: Home -- how is the adolescent's home life? How are his/her relationships with family members? Where and with whom does the patient live? Is his/her living situation stable? Education (or Employment) -- how is the adolescent's school performance? Is he/she well-behaved, or are there discipline problems at school? If he/she is working, is he/she making a living wage? Are they financially secure? Eating* (incorporates body image) -- does the patient have a balanced diet? Is there adequate calcium intake? Is the adolescent trying to lose weight, and (if so), is it in a healthy manner? How does he/she feel about his/her body? Has there been significant weight gain/loss recently? Activities -- how does the patient spend his/her time? Are they engaging in dangerous or risky behavior? Are they supervised during their free time? With whom do they spend most of their time? Do they have a supportive peer group?

Adolescent medicine Drugs (including alcohol and tobacco) -- does the patient drink caffeinated beverages (including energy drinks)? Does the patient smoke? Does the patient drink alcohol? Has the patient used illegal drugs? If there is any substance use, to what degree, and for how long? Sex -- is the patient sexually active? If so, what form of contraception (if any) is used? How many partners has the patient had? Has the patient ever been pregnant/fathered a child? Do the patient and their partners get routine reproductive health and STD checks and physical examinations? Are there any symptoms of a sexually transmitted infection? Does the patient identify as heterosexual, homosexual, or unsure? Does the patient feel safe discussing sexuality issues with parents or other caregivers? Suicidality (including general mood assessment) -- what is the patient's mood from day to day? Has he/she thought about/attempted suicide? In broader terms, is their mental and emotional state so dysfunctional that the activities of daily living are largely impaired or they present a risk to themselves or others? Safety* -- does the patient regularly wear a bicycle helmet? seatbelt? Does the patient drive while intoxicated or with a driver who is intoxicated? Does the patient wear safety equipment while participating in sports? Some providers favor the addition of Strengths to the list, in an effort to avoid focusing on issues of risk or concern, and reframe the patient interaction in a manner that highlights resilience. In addition to a detailed history, adolescents should have a comprehensive physical exam (including a developmental and neurological assessment, STI testing, and a reproductive system exam) and mental health status exam on at least a yearly basis, in addition to yearly dental and ocular exams. Developmental progression, including an assessment of Tanner stage, should be noted at every yearly visit, and appropriate endocrinological work-ups undertaken for patients that fail to develop in an anticipated manner. Young women and young men should be taught how to examine their breast tissue for signs of breast cancer, and young men should be taught how to examine their testicles and penis for cancer and STDs. Screening lab tests, including a complete blood count to screen for anemia, and either a spot cholesterol check or (ideally) a fasting lipid profile to screen for hyperlipidemia, should be obtained at least once during adolescence. For patients who are sexually active, particularly in areas of high prevalence or with patients participating in higher-risk behaviors, screening tests for sexually transmitted diseases should be performed, including an RPR or VDRL for syphilis, screening for gonorrhea and chlamydia, and HIV. Sexually active females should have a pelvic examination and a physical examination if indicated by the presence of symptoms concerning for an STI; males should have a urological examination and a physical examination. Needed immunizations include: a tetanus vaccination or booster shot, a meningitis vaccination, the Gardasil vaccine against HPV (Human Papillomavirus, a leading cause of cervical cancer and genital warts) and a yearly influenza vaccination.

856

Young peoples' access to health care


In addition, issues of medical ethics, particularly related to confidentiality and the right to consent for medical care, are pertinent to the practice of adolescent medicine.[3]

Training
Adolescent medicine providers are generally drawn from the specialties of pediatrics, internal medicine, med/peds or family medicine. The certifying boards for these different specialties have varying requirements for certification, though all require successful completion of a fellowship (a comprehensive list of which is available through the Society for Adolescent Health and Medicine [4]) and a passing score on a certifying exam. The American Board of Pediatrics and the American Board of Internal Medicine require evidence of scholarly achievement by candidates for subspecialty certification, usually in the form of an original research study. In the United States, subspecialty medical board certification in adolescent medicine is available through the specialty boards of American Board of Internal Medicine, the American Osteopathic Board of Neurology and Psychiatry, the American Board of Family Medicine, the American Osteopathic Board of Family Physicians, the American Board of Pediatrics, and the American Osteopathic Board of Pediatrics.[5]

Adolescent medicine

857

Adolescent Health centers in the United States


Many subspecialists practice as part of general specialty clinics or practices, or in high school or college clinics. In addition, many major metropolitan areas have clinics that offer adolescent-specific care. A partial list includes: Dallas Adolescent and Young Adult Clinic at Children's Medical Center [6] (Dallas) Windhaven Adolescent Medicine Clinic at Texas Health Presbyterian Hospital [7] (Plano) New York City The Adolescent Health Center at Mount Sinai Medical Center [8] (Manhattan) Adolescent clinic at Children's Hospital at Montefiore Medical Center [9] (the Bronx) The Door [10] Rochester, NY The Adolescent Health Clinic at University of Rochester [11] Los Angeles Teenage and Young Adult Health Center at Children's Hospital Los Angeles [12] San Francisco area Adolescent Medicine Clinic at Lucile Packard Children's Hospital [13] at Stanford Adolescent Medicine Clinic at UCSF [14] Boston Division of Adolescent Medicine at Children's Hospital Boston [15] Philadelphia Adolescent Medicine Clinic at the Children's Hospital of Philadelphia [16] Adolescent Medicine at St. Christopher's Hospital for Children [17] Teen Health Center at Temple University Children's Medical Center [18] Teen Health Center at Albert Einstein Medical Center

Columbus Adolescent Health at Nationwide Children's Hospital [19] Seattle Department of Adolescent Medicine at Seattle Children's Hospital [20] Cincinnati, OH Division of Adolescent Medicine at Cincinnati Children's Hospital Medical Center [21]

Adolescent Medicine in Australia


These hospitals offer adolescent-specific care: Sydney The Department of Adolescent Medicine at The Children's Hospital at Westmead [22] The Department of Adolescent Medicine at Westmead Hospital [23] Youth Consultatncy & the Chill, at Royal Prince Alfred Hospital [24] Melbourne The Centre For Adolescent Health Royal Children's Hospital Melbourne [25]

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Professional Organizations
In addition to membership in the organizations for their various specialties, adolescent medicine providers often belong to The Society for Adolescent Health and Medicine [4] and/or The North American Society for Pediatric and Adolescent Gynecology [26]. Founded in 1987, the International Association for Adolescent Health non-government organization with a broad focus on youth health.
[27]

(IAAH) is a multidisciplinary,

Publications
The Journal of Adolescent Health [28] published by the Society for Adolescent Medicine Journal of Pediatric and Adolescent Gynecology [29] published by the North American Society for Pediatric and Adolescent Gynecology Adolescent Medicine: State of the Art Reviews [30] published by the American Academy of Pediatrics publishes

References
[2] Goldenring, JM and Rosen DS (2004) Getting into adolescent heads: An essential update. Contemporary Pediatrics, Vol 21, No. 1, pp. 64-90. [3] Chown P, Kang M, Sanci L, Newnham V and Bennett D (2008) Adolescent Health: GP Resource Kit. Enhancing the skills of General Practitioners in caring for young people from culturally diverse backgrounds, 2nd edition, NSW Centre for the Advancement of Adolescent Health and Transcultural Mental Health Centre. Available at: [http://www.caah.chw.edu.au/resources/#03 (http:/ / www. caah. chw. edu. au/ resources/ #03). Accessed on: October 14, 2008. [4] http:/ / www. adolescenthealth. org/ [6] http:/ / www. childrens. com/ [7] http:/ / www. texashealth. org/ [8] http:/ / www. mountsinai. org/ patient-care/ service-areas/ adolescent-health/ areas-of-care/ adolescent-health-center/ [9] http:/ / www. montekids. org/ [10] http:/ / www. door. org/ [11] http:/ / www. urmc. rochester. edu/ pediatrics/ divisions/ adolescent_medicine/ [12] http:/ / www. childrenshospitalla. org/ [13] http:/ / www. lpch. org/ [14] http:/ / www. pediatrics. medschool. ucsf. edu/ youth/ [15] http:/ / www. childrenshospital. org/ [16] http:/ / www. chop. edu/ [17] http:/ / www. stchristophershospital. com/ CWSContent/ stchristophershospital/ default. aspx/ [18] http:/ / www. templehealth. org/ tucmc/ [19] http:/ / www. nationwidechildrens. org/ [20] http:/ / www. seattlechildrens. org/ clinics-programs/ adolescent-medicine [21] http:/ / www. cincinnatichildrens. org/ service/ a/ adolescent-medicine/ default/ [22] http:/ / www. chw. edu. au/ site/ directory/ entries/ admedicine. htm [23] http:/ / www. wsahs. nsw. gov. au/ services/ ADOL/ INDEX. HTM [24] http:/ / www. cs. nsw. gov. au/ ssw/ youth/ default. htm [25] http:/ / www. rch. org. au/ cah [26] http:/ / www. naspag. org [27] http:/ / www. iaah. org/ index. html/ [28] http:/ / www. adolescenthealth. org/ Journal_of_Adolescent_Health/ 1778. htm [29] http:/ / www. elsevier. com/ wps/ find/ journaldescription. cws_home/ 620327/ description#description [30] http:/ / www. aap. org/ sections/ adolescenthealth/ AMSTARs. cfm

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External links
Office of Adolescent, U.S. Department of Health, Health and Human Services (http://www.hhs.gov/ash/oah/) Adolescent Medicine: State of the Art Reviews (http://www.aap.org/sections/adolescenthealth/AMSTARs. cfm) The Society for Adolescent Health and Medicine (http://www.adolescenthealth.org/) International Association for Adolescent Health (http://www.iaah.org/index.html/) The North American Society for Pediatric and Adolescent Gynecology (http://www.naspag.org/) The American Board of Pediatrics (http://www.abp.org/) The American Board of Internal Medicine (http://www.abim.org/) The American Board of Family Medicine (http://www.theabfm.org/cert.caq.aspx#caq1/) The American College Health Association (http://www.acha.org/) NSW Centre for the Advancement of Adolescent Health (http://www.caah.chw.edu.au/resources) Teens Homepage, Nemours Foundation (http://www.teenshealth.org/teen/)

Management of HIV/AIDS
The management of HIV/AIDS normally includes the use of multiple antiretroviral drugs in an attempt to control HIV infection. There are several classes of antiretroviral agents that act on different stages of the HIV life-cycle. The use of multiple drugs that act on different viral targets is known as highly active antiretroviral therapy (HAART). HAART decreases the patient's total burden of HIV, maintains function of the immune system, and prevents opportunistic infections that often lead to death. The American National Institutes of Health and other organizations recommend offering antiretroviral treatment to all patients with AIDS. Because of the complexity of selecting and following a regimen, the severity of the side-effects, and the importance of compliance to prevent viral resistance, such organizations emphasize the importance of involving patients in therapy choices and recommend analyzing the risks and the potential benefits to patients with low viral loads.[]

History
The advent of HAART has been dated to the 11th International Conference on AIDS in Vancouver, British Columbia, July 716, 1996. During that Conference, David Ho, MD, of the Aaron Diamond AIDS Research Center, New York, NY, and George Shaw, MD, PhD, of the University of Alabama at Birmingham School of Medicine, presented viral dynamics data showing that the average person with HIV infection produced 10 billion virions/day, bringing into sharp focus the fact that this was a viral infection that required antiviral treatment.[1] The conference was followed by sequential publications in The New England Journal of Medicine by Hammer and colleagues and Gulick and coinvestigators illustrating the substantial benefit of indinavir-based HAART. This concept of 3-drug therapy was quickly incorporated into clinical practice and rapidly showed impressive benefit with a 60% to 80% decline in rates of AIDS, death, and hospitalization.

Classes of drugs
There are several classes of drugs, which are usually used in combination, to treat HIV infection. Use of these drugs in combination is generally termed ARTs or Anti-Retroviral Therapy. Anti-retroviral (ARV) drugs are broadly classified by the phase of the retrovirus life-cycle that the drug inhibits. Typical combinations include 2 NRTIs (Nucleoside Reverse Transcriptase Inhibitors) + 1 PI (Protease Inhibitor) or 2 NRTIs + 1 NNRTI (Non-Nucleoside Reverse Transcriptase Inhibitor)[2]

Management of HIV/AIDS Entry inhibitors (or fusion inhibitors) interfere with binding, fusion and entry of HIV-1 to the host cell by blocking one of several targets. Maraviroc and enfuvirtide are the two currently available agents in this class. Maraviroc works by targeting CCR5, a co-receptor located on human helper T-cells. Caution should be used when administering this drug however due to a possible shift in tropism which allows HIV to target an alternative co-receptor such as CXCR4. In rare cases, individuals may have a mutation in the CCR5 delta gene which results in a nonfunctional CCR5 co-receptor and in turn, a means of resistance or slow progression of the disease. However as mentioned previously, this can be overcome if an HIV variant that targets CXCR4 becomes dominant.[3] To prevent fusion of the virus with the host membrane, Fuzeon (T20) can be used. Fuzeon is a peptide drug that must be injected and acts by interacting with the N-terminal heptad repeat of gp41 of HIV to form an inactive hetero six-helix bundle, therefore preventing infection of host cells.[4] Nucleoside reverse transcriptase inhibitors (NRTI) and nucleotide reverse transciptase inhibitors (NtRTI) are nucleoside and nucleotide analogues which inhibit reverse transcription. NRTIs are chain terminators such that once incorporated, work by preventing other nucleosides from also being incorporated because of the absence of a 3 OH group. ; they both act as competitive substrate inhibitors. Examples of NRTIs include deoxythymidine, zidovudine, stavudine, didanosine, zalcitabine, abacavir, lamivudine, emtricitabine, and tenofovir.[] Non-Nucleoside reverse transcriptase inhibitors (NNRTI) inhibit reverse transcriptase by binding to an allosteric site of the enzyme; NNRTIs act as non-competitive inhibitors of reverse transcriptase. NNRTIs affect the handling of substrate (nucleotides) by reverse transcriptase by binding near the active site and causing molecular arthritis. NNRTIs can be further classified into 1st generation and 2nd generation NNRTIs. 1st generation NNRTIs are more rigid in structure and resistance can quickly be developed against them. Because 2nd generation NNRTIs have a more flexible structure, they can adjust more readily and resist mutation more effectively. NNRTIs, for example, include nevirapine, delavirdine, efavirenz, and rilpivirine.[] Integrase inhibitors inhibit the enzyme integrase, which is responsible for integration of viral DNA into the DNA of the infected cell. There are several integrase inhibitors currently under clinical trial, and raltegravir became the first to receive FDA approval in October 2007. Raltegravir has two metal binding groups that compete for substrate with two Mg2+ ions at the metal binding site of integrase. Another clinically approved integrase inhibitor is Elvitegravir.[5] Protease inhibitors block the viral protease enzyme necessary to produce mature virions upon budding from the host membrane. Particularly, these drugs prevent the cleavage of gag and gag/pol precursor proteins.[] Virus particles produced in the presence of protease inhibitors are defective and mostly non-infectious. Examples of HIV protease inhibitors are Lopinavir, Indinavir, Nelfinavir, Amprenavir and Ritonavir. Maturation inhibitors have a similar effect by binding to gag, but development of two experimental drugs in this class, Bevirimat and Vivecon, was halted in 2010.[6] Resistance to some protease inhibitors is high. Second generation drugs have been developed that are effective against otherwise resistant HIV variants.[]

860

Combination therapy
The life cycle of HIV can be as short as about 1.5 days from viral entry into a cell, through replication, assembly, and release of additional viruses, to infection of other cells.[7] HIV lacks proofreading enzymes to correct errors made when it converts its RNA into DNA via reverse transcription. Its short life-cycle and high error rate cause the virus to mutate very rapidly, resulting in a high genetic variability of HIV. Most of the mutations either are inferior to the parent virus (often lacking the ability to reproduce at all) or convey no advantage, but some of them have a natural selection superiority to their parent and can enable them to slip past defenses such as the human immune system and antiretroviral drugs. The more active copies of the virus the greater the possibility that one resistant to antiretroviral drugs will be made. When antiretroviral drugs are used improperly, these multi-drug resistant strains can become the dominant genotypes very rapidly. Improper serial use of the reverse transcriptase inhibitors zidovudine, didanosine, zalcitabine,

Management of HIV/AIDS stavudine, and lamivudine can lead to the development of multi-drug resistant mutations. The mutations can include the V75I, F77L, K103N, F116Y, Q151M, and the M184V mutation. These mutations were observed before protease inhibitors had come into widespread use. The mutants retained sensitivity to the early protease inhibitor saquinavir. These mutants were also sensitive to the rarely used reverse transcriptase inhibitor foscarnet.[] Antiretroviral combination therapy defends against resistance by suppressing HIV replication as much as possible. Combinations of antiretrovirals create multiple obstacles to HIV replication to keep the number of offspring low and reduce the possibility of a superior mutation. If a mutation that conveys resistance to one of the drugs being taken arises, the other drugs continue to suppress reproduction of that mutation. With rare exceptions, no individual antiretroviral drug has been demonstrated to suppress an HIV infection for long; these agents must be taken in combinations in order to have a lasting effect. As a result, the standard of care is to use combinations of antiretroviral drugs. Combinations usually comprise two nucleoside-analogue RTIs and one non-nucleoside-analogue RTI or protease inhibitor.[] This three drug combination is commonly known as a triple cocktail.[8] Combinations of antiretrovirals are subject to positive and negative synergies, which limits the number of useful combinations.[9] In recent years, drug companies have worked together to combine these complex regimens into simpler formulas, termed fixed-dose combinations. For instance, two pills containing two or three medications each can be taken twice daily.[citation needed] This greatly increases the ease with which they can be taken, which in turn increases adherence, and thus their effectiveness over the long-term. Lack of adherence is a cause of resistance development in medication-experienced patients. Patients who maintain proper therapy can stay on one regimen without developing resistance.[citation needed] This greatly increases life expectancy and leaves more drugs available to the individual should the need arise.

861

Fixed-dose combinations
Fixed dose combinations are multiple antiretroviral drugs combined into a single pill.
Brand Name Combivir Trizivir Kaletra Drug Names (INN) zidovudine + lamivudine abacavir + zidovudine + lamivudine lopinavir + ritonavir Date of FDA Approval September 26, 1997 November 15, 2000 September 15, 2000 August 2, 2004 Company GlaxoSmithKline GlaxoSmithKline Abbott Laboratories GlaxoSmithKline

Epzicom (in USA) abacavir + lamivudine Kivexa (in Europe) Truvada Atripla tenofovir/emtricitabine efavirenz + tenofovir/emtricitabine

August 2, 2004 July 12, 2006

Gilead Sciences Gilead Sciences and Bristol-Myers Squibb Gilead Sciences and Tibotec (Johnson & Johnson) Gilead Sciences

Complera

rilpivirine + tenofovir/emtricitabine

August 10, 2011

Stribild

elvitegravir + cobicistat + tenofovir/emtricitabine August 27, 2012

The preferred initial regimens in the United States, as of August 2012, are:[10] tenofovir/emtricitabine (a combination of two NRTIs) and efavirenz (a NNRTI). Efavirenz should not be given to pregnant women.[10] tenofovir/emtricitabine and raltegravir (an integrase inhibitor) tenofovir/emtricitabine, ritonavir, and darunavir (both latter are protease inhibitors) tenofovir/emtricitabine, ritonavir, and atazanavir (both latter are protease inhibitors)

Management of HIV/AIDS

862

Treatment guidelines
Initiation of antiretroviral therapy
Antiretroviral drug treatment guidelines have changed over time. Before 1987, no antiretroviral drugs were available and treatment consisted of treating complications from the immunodeficiency. After antiretroviral medications were introduced, most clinicians agreed that HIV positive patients with low CD4 counts should be treated, but no consensus formed as to whether to treat patients with high CD4 counts.[] In 1995, David Ho promoted a "hit hard, hit early" approach with aggressive treatment with multiple antiretrovirals early in the course of the infection.[] Later reviews noted that this approach of "hit hard, hit early" ran significant risks of increasing side effects and development of multidrug resistance, and this approach was largely abandoned.[] Treatment with these types of medicine can range from $10,000 to $15,000 a year.[] The timing of when to initiate therapy has continued to be a core controversy within the medical community. The development of a stable consensus is hampered by the lack of randomized controlled studies with many guidelines and consensus statements basing their recommendations on observational studies. More recently, the trend has been in favor of earlier treatment of asymptomatic HIV patients, with more studies analyzing various treatment regimens in progress.[11] There is a consensus among experts that, once initiated, antiretroviral therapy should never be stopped. This is because the selection pressure of incomplete suppression of viral replication in the presence of drug therapy causes the more drug sensitive strains to be selectively inhibited. This allows the drug resistant strains to become dominant. This in turn makes it harder to treat the infected individual as well as anyone else they infect.[] Current guidelines The current guidelines use new criteria to consider starting HAART, as described below. However, there remain a range of views on this subject and the decision of whether to commence treatment ultimately rests with the patient and their doctor. The treatment guidelines specifically for the USA are set by the United States Department of Health and Human Services (DHHS). The current guidelines for adults and adolescents were stated on December 1, 2009.[] Standard antiretroviral therapy (ART) consists of the combination of at least three antiretroviral (ARV) drugs to maximally suppress the HIV virus and stop the progression of HIV disease. Antiretroviral therapy should be initiated in all patients with a history of an AIDS-defining illness or with a CD4 count <350 cells/mm3 (AI). Antiretroviral therapy should also be initiated, regardless of CD4 count, in patients with the following conditions: pregnancy (AI), HIV- associated nephropathy (AII), and hepatitis B virus (HBV) coinfection when treatment of HBV is indicated (AIII). Antiretroviral therapy is recommended for patients with CD4 counts between 350 and 500 cells/mm3. The Panel was divided on the strength of this recommendation: 55% voted for strong recommendation (A) and 45% voted for moderate recommendation (B) (A/B-II). For patients with CD4 counts >500 cells/mm3, the Panel was evenly divided: 50% favor starting antiretroviral therapy at this stage of HIV disease (B); 50% view initiating therapy at this stage as optional (C) (B/C-III). Patients initiating antiretroviral therapy should be willing and able to commit to lifelong treatment and should understand the benefits and risks of therapy and the importance of adherence (AIII). Patients may choose to postpone therapy, and providers, on a case-by-case basis, may elect to defer therapy based on clinical and/or psychosocial factors. Rating of Recommendations: A = Strong; B = Moderate; C = Optional Rating of Evidence: I = data from randomized controlled trials; II = data from well-designed nonrandomized trials or observational cohort studies with long-term clinical outcomes; III = expert opinion

Management of HIV/AIDS Baseline resistance In countries with a high rate of baseline resistance, resistance testing is recommended before starting treatment; or, if the initiation of treatment is urgent, then a "best guess" treatment regimen should be started, which is then modified on the basis of resistance testing. In the UK, there is 11.8% medium to high-level resistance at baseline to the combination of efavirenz + zidovudine + lamivudine, and 6.4% medium to high level resistance to stavudine + lamivudine + nevirapine.[12]

863

Regimens
Most current HAART regimens consist of three(3) drugs: 2 NRTIs + a PI/NNRTI/II. Initial regimens use "first-line" drugs with a high efficacy and low side-effect profile. Treatment guidelines for HIV-1 infected adults in the developed world (that is, those countries with access to all or most therapies and laboratory tests) have been provided by the International AIDS Society-USA [13](IAS-USA) since 1996. The IAS-USA is a 501(c)(3) not-for-profit organization in the USA (and is not related to the worldwide International AIDS Society or IAS). The IAS-USA guidelines for antiretroviral therapy are developed by a volunteer panel of experts. Its last update was published in July 2012 in the Journal of the American Medical Association.[14] In the 2008 update, the panel recommended that therapy be initiated before the CD4+ cell count declines to below 350/uL and be individualized for the particular patient's situation and comorbidities. For initial therapy, it recommends 2 NRTIs with either an NNRTI, a ritonavir-boosted PI or an integrase inhibitor. In antiretroviral therapy failure, the goal of subsequent treatment is suppression of HIV-1 RNA to below detection; the treatment should ideally have 3 new drugs to which the patient's virus is susceptible. Therapy in selected clinical situations is also described. The IAS-USA also sponsors the development of guidelines for the use of drug resistance testing in patients with HIV-1 infection [15] Another set of guidelines (distinct from those of the IAS-USA) are provided by an expert panel convened by the U.S. Department of Health and Human Services. The preferred initial regimens in the United States, as of August 2012, are:[10] tenofovir/emtricitabine (a combination of two NRTIs) and efavirenz (a NNRTI). Efavirenz should not be given to pregnant women.[10] tenofovir/emtricitabine and raltegravir (an integrase inhibitor) tenofovir/emtricitabine, ritonavir, and darunavir (both latter are protease inhibitors) tenofovir/emtricitabine, ritonavir, and atazanavir (both latter are protease inhibitors)

Children
Because HIV disease progression in children is more rapid than in adults, and laboratory parameters are less predictive of risk for disease progression, in particular for young infants, treatment recommendations from the DHHS have been more aggressive in children than in adults; the current guidelines were published November 3, 2005.[]

HIV Postexposure Prophylaxis (PEP)


In 2005, the Centers for Disease Control and Prevention in the United States recommended a 28-day HIV drug regimen for those that have been exposed to HIV (HIV Postexposure Prophylaxis [PEP]).[] The WHO recommendations on treatment are that the minimum that should be used is dual NRTIs for 28 days, with triple therapy (dual NRTIs plus a boosted PI) being offered where there is a risk of resistance.[16] The effectiveness of this intervention has never been precisely ascertained, [citation needed] but postexposure prophylaxis is most effective when administered sooner, and believed to not be effective if given later than 72 hours after exposure.[16]

Management of HIV/AIDS

864

Prevention of mother-to-child-transmission (PMTCT)


The use of antiretrovirals is also recommended for the prevention of mother-to-child transmission of HIV-1. The current WHO recommended regimen is as follows: where the pregnant woman does not yet need to start ART for therapeutic reasons, she should start Zidovudine (AZT) from 28 weeks or as soon as possible thereafter, be provided with single-dose Nevirapine (NVP) when entering labour, and be given AZT+3TC for one week following delivery. Meanwhile, whether the mother was on the above or standard ART, the child should be given single dose Nevirapine immediately after delivery and daily Zidovudine until one week old.[17] Complementary measures that may also be used include caesarean section and formula feeding; in some settings, the combination of providing all these measures has succeeded in reducing the risk of infection from 25% to about 1%.[18]

Treatment as prevention
Antiretroviral treatment of a person with HIV was shown to prevent HIV transmission to their uninfected heterosexual partner in clinical trial HPTN 052. This study of 1763 heterosexual couples in 9 countries was planned to last 10 years, but it was stopped early for ethical reasons when it became clear that antiviral treatment provided significant protection. Of the 28 couples where cross-infection had occurred, all but one had taken place in the control group consistent with a 96% reduction in risk of transmission.[] In 2011, the journal Science gave the Breakthrough of the Year award to treatment as prevention.[]

Concerns
There are several concerns about antiretroviral regimens: intolerance: The drugs can have serious side-effects,[] particularly in advanced disease.[] resistance: If patients miss doses, drug resistance can develop,[] cost: Providing anti-retroviral treatment is costly and resource-intensive,Wikipedia:Manual of Style (dates and numbers) and the majority of the world's infected individuals cannot access treatment services. public health: Individuals who fail to use antiretrovirals properly can develop multi-drug resistant strains which can be passed onto others.[]

In older adults
As people age, their bodies cannot repair and rebuild damaged cells, organs or tissues as rapidly as those of younger people. Diseases like HIV that attack and destroy the body's defenses can exacerbate this slowing and increase the risk of developing additional medical problems like diabetes and high blood pressure, and more physical limitations than younger adults with HIV. In the early years of the HIV epidemic (before HAART), older adults' health deteriorated more rapidly than that of younger individuals - regardless of CD4 count. Several studies found that older adults had lower CD4 counts at diagnosis, faster progression to an AIDS diagnosis, more opportunistic infections, and a shorter survival rate than younger adults, regardless of when they were first diagnosed with HIV. Recent studies have found that a person's age does not interfere with the ability of HAART to reduce viral load, but there may be differences between younger and older people in how well the immune system responds to treatment. A study published in AIDS (2000) by Roberto Manfredi and Francesco Chiodo examined the effect of HAART on older people (defined as 55 or older) compared to younger people (35 or younger). The study included 21 older people (8 women, 13 men) and 84 younger people (29 women, 55 men). The researchers found that both groups responded to HAART, especially in reducing viral load. However, CD4 counts did not increase as much in the older people relative to the younger ones. On average, CD4 counts increased from 212 to 289 for older adults after one year of HAART. During the same period, CD4 counts rose from 231 to 345 for younger people.

Management of HIV/AIDS Some people may have a very low CD4 count even though they have an undetectable viral load. [citation needed] This may be related to decreased activity in the thymus (the gland where CD4 cells are made). A 2001 study in AIDS conducted by researchers in Los Angeles included 80 HIV-positive veterans (13 were over 55 and 67 were younger). Although both groups of veterans showed dramatic reductions in viral load once they were on treatment, the researchers found significant differences in CD4 levels at 3, 9, 15, and 18 months. After one year on HAART, average CD4 counts increased by 50 for the older men, compared to increases of 100 for the younger ones. This difference was not related to baseline HIV viral load, coinfection with hepatitis C, or the race/ethnicity of participants. These studies represent an important first step in understanding how their age may affect older adults' response to HIV treatment, but more studies are needed to understand the long-term effects of age on HAART in older adults.

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Mega-HAART
If an HIV infection becomes resistant to standard HAART, there are limited options. One option is to take larger combinations of antiretroviral drugs, an approach known as mega-HAART or salvage therapy. Salvage therapy often causes additional side effects. If an HIV infection becomes sufficiently resistant to antiretroviral-drugs, treatment becomes more complicated and prognosis may deteriorate. Treatment options continue to improve as additional new drugs enter clinical trials. However, the limited distribution of many such drugs denies their benefits to patients, particularly in the developing world.

Structured treatment interruptions


Drug holidays (or "structured treatment interruptions") are intentional discontinuations of antiretroviral drug treatment. Intermittent therapy was an experimental approach designed to reduce exposure to antiretroviral drugs in an effort to mitigate side-effects. Intermittent therapy differed from treatment interruptions in that it involved using a much shorter cycle of switching on and off the antiviral drugs. Studies of such approaches include schedules of week-on, week-off (also known as "wowo") and five-days-on, two-days-off (also known as "foto"), which skipped treatment on weekends. Intermittent therapy is ineffective and results in drug resistance. [citation needed] Suppressing HIV is inadequate to restore normal immune function. HIV can damage the ability of the thymus to produce normally diverse T-cells. [citation needed] Also, rapid suppression of HIV and partial restoration of the immune system sometimes produces a dangerous hypersensitivity reaction, immune reconstitution inflammatory syndrome. [citation needed] Research continues in these areas. With the exception of post exposure prophylaxis, current treatment guidelines do not call for the interruption of drug therapy once it has been initiated.[]

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Adverse effects
Adverse effects of antiretroviral drugs vary by drug, by ethnicity, by individual, and by interaction with other drugs, including alcohol. Hypersensitivity to some drugs may also occur in some individuals. The following list is not complete, but includes several of the adverse effects experienced by patients taking some antiretroviral drugs:[]
Abdominal pain (Ritonavir) Alopecia (INF-alpha) Anemia (AZT) Asthenia [19] Cardiovascular disease/heart attack Diarrhea (Abacavir) Dizziness (Vertigo) Fanconi syndrome Flatulence (Tenofovir [citation needed]) Gynecomastia Headache (3TC overdose) Hepatitis Hyperbilirubinemia Hypercholesterolemia Hyperpigmentation (Emtricitabine) Ingrown nails (IDV) Insomnia (Emtricitabine [citation needed]) Jaundice Lipodystrophy / HIV-associated lipodystrophy Liver failure Malaise Mental confusion (EVZ [citation needed]) Migraines Mitochondrial toxicity (ddI > d4T > AZT) Mood swings [citation needed] Myalgia (AZT overdose) Myopathy (AZT overdose) Nausea (AZT) Neutropenia (AZT) Nightmares (EFZ) Oral ulcers (ddC) Pancreatitis (ddI) Paresthesia (IDV) Peripheral neuropathy (ddI, ddC, d4T) Rash Renal failure or insufficiency (IDV, TDF) Somnolence (drowsiness)[citation needed] StevensJohnson syndrome Change in taste perception Vomiting (AZT) Xeroderma (dry skin) Xerostomia (dry mouth)

Pregnancy planning
Three quarters of people with HIV infection are in their reproductive years and may consider pregnancy planning. In cases where the woman is HIV negative and the man is HIV positive, the primary assisted reproductive method used to prevent HIV transmission is sperm washing followed by intrauterine insemination (IUI) or in vitro fertilization (IVF). There is no described case of seroconversion in women or their offspring after such sperm washing, but it is yet not certain whether the method is completely safe.[] Also, pre-exposure chemoprophylaxis could be an alternative method.[] For cases where the woman is HIV positive and the man is HIV negative, the usual method is artificial insemination.[] With appropriate treatment the risk of mother-to-child infection can be reduced to about 1%.[]

Research
Anti-viral hyperactivation limiting therapeutics
AV-HALTs (AntiViral HyperActivation Limiting Therapeutics or 'virostatics') combine immunomodulating and antiviral properties to inhibit a specific antiviral target while also limiting the hyper-elevated state of immune system activation driving disease progression.[20]

References
[1] "Ten Years of HAART" John D Barlett Medscape (http:/ / www. medscape. org/ viewarticle/ 523119) [8] Attacking AIDS with a "Cocktail" Therapy (http:/ / www. fda. gov/ FDAC/ features/ 1999/ 499_aids. html) [9] http:/ / www. edinformatics. com/ biotechnology/ antiretroviral_drugs. htm [10] Reviewed August 2012 [13] http:/ / www. iasusa. org [15] Hirsch MS, Gunthard HF, Schapiro, et al. Clin Infect Dis 2008; 47: 266-285 [16] http:/ / www. who. int/ entity/ hiv/ pub/ guidelines/ PEP/ en/ index. html [17] http:/ / www. who. int/ entity/ hiv/ pub/ guidelines/ pmtctguidelines3. pdf [19] Donald G. McNeil Jr (18 June 2012), Heart Trouble Early and Often in H.I.V. Patients (http:/ / www. nytimes. com/ 2012/ 06/ 19/ health/ heart-attacks-are-much-more-frequent-in-hiv-patients. html) The New York Times

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Further reading
Cohen, Mardge H., MD, et al., "Medically Eligible Women Who Do Not Use HAART: The Importance of Abuse, Drug Use, and Race" (http://www.ajph.org/cgi/content/abstract/94/7/1147), American Journal of Public Health, Vol 94, No. 7, July 2004, pp.11471151. American Public Health Association Cohen, Mardge H., MD, et al., "Impact of Highly Active Antiretroviral Therapy on Anemia and Relationship Between Anemia and Survival in a Large Cohort of HIV-Infected Women: Women's Interagency HIV Study" (http://cme.medscape.com/viewarticle/491966), Medscape CME, 11/17/2004 Lewin, Sharon R., MD, et al., "Finding a cure for HIV: will it ever be achievable?" (http://www.ncbi.nlm.nih. gov/pmc/articles/PMC3037295/), "Journal of the International AIDS Society", 2011, 14:4, International AIDS Society

External links
AIDSinfo - Comprehensive resource for HIV/AIDS treatment and clinical trial information from the U. S. Department of Health and Human Services (http://www.AIDSinfo.nih.gov/) ASHM - Australian Commentary on HHS Guidelines for the use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents (http://arv.ashm.org.au/) Origins of antiretroviral combination therapy (http://www.aegis.com/pubs/atn/1993/ATN17001.html) Viral Load (http://www.thebody.com/vltest.html) research papers, including effectiveness of HAART on reducing viral load Current status of gene therapy strategies to treat HIV/AIDS (http://www.nature.com/mt/journal/v11/n6/full/ mt2005102a.html)

Healthcare Facilities Accreditation Program


The Healthcare Facilities Accreditation Program (HFAP), is a not-for-profit organization dedicated to helping healthcare organizations maintain the highest standards in patient care and comply with ever-changing government regulations and a constantly evolving healthcare environment.[1] Headquartered in Chicago, HFAP is a nationally recognized accreditation organization with deeming authority from Centers for Medicare and Medicaid Services (CMS).[1] HFAP provides accreditation programs for hospitals, clinical laboratories, ambulatory surgical centers / office based surgery (OBS), and critical access hospitals. In addition, HFAP accredits mental health and physical rehabilitation facilities and provides certification for primary stroke centers.[] HFAP is a program of the American Osteopathic Association,[2] a medical organization representing osteopathic physicians (D.O.).

History
HFAP was conceived in 1943 and began surveying hospitals in 1945. Initially HFAP provided osteopathic hospitals with an opportunity to be accredited and to ensure that osteopathic residents received training in facilities providing high quality patient care. In the mid-1960s, the United States Congress decided that accredited hospitals would be deemed to meet the conditions of participation and thus could automatically participate in the newly established Medicare and Medicaid programs. HFAP quickly applied for and was granted deeming status.[]

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Mission and Goals


HFAP's mission is to advance high quality patient care and safety through objective application of recognized standards. The HFAP goal is to continue to help healthcare facilities deliver high quality patient care through the application of its consistent standards while continuing to streamline and improve its survey processes.[1]

Notes
[1] |url= http:/ / www. hfap. org/ mediacenter/ NAMSS%20Synergy%20JanFeb09_Accreditation%20Grid. pdf|title= NAMSS, Synergy Magazine, The Big Three: A Side by Side Matrix Comparing Hospital Accrediting Agencies

External links
The Healthcare Facilities Accreditation Program (http://www.hfap.org/)

Healthcare Common Procedure Coding System


The Healthcare Common Procedure Coding System (HCPCS, often pronounced by its acronym as "hick picks") is a set of health care procedure codes based on the American Medical Association's Current Procedural Terminology (CPT).

History
The acronym HCPCS originally stood for HCFA Common Procedure Coding System, as the Centers for Medicare and Medicaid (CMS) was previously (before 2001) known as the Health Care Financing Administration (HCFA). The Healthcare Common Procedure Coding System (HCPCS) was established in 1978 to provide a standardized coding system for describing the specific items and services provided in the delivery of health care. Such coding is necessary for Medicare, Medicaid, and other health insurance programs to ensure that insurance claims are processed in an orderly and consistent manner. Initially, use of the codes was voluntary, but with the implementation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) use of the HCPCS for transactions involving health care information became mandatory.[1]

Levels of codes
HCPCS includes three levels of codes: Level I consists of the American Medical Association's Current Procedural Terminology (CPT) and is numeric. Level II codes are alphanumeric and primarily include non-physician services such as ambulance services and prosthetic devices,[2] and represent items and supplies and non-physician services, not covered by CPT-4 codes (Level I). Level III codes, also called local codes, were developed by state Medicaid agencies, Medicare contractors, and private insurers for use in specific programs and jurisdictions. The use of Level III codes was discontinued on December 31, 2003, in order to adhere to consistent coding standards.[3]

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References
[1] at page 1 cms.hhs.gov (http:/ / www. cms. hhs. gov/ MedHCPCSGenInfo/ Downloads/ HCPCSReform. pdf) [2] HCPCS Level II Codes (http:/ / www. asha. org/ about/ publications/ leader-online/ b-line/ bl040608/ ) [3] HCPCS Background Information (http:/ / www. cms. hhs. gov/ MedHCPCSGenInfo/ )

External links
Official site (http://www.cms.hhs.gov/MedHCPCSGenInfo/) HCPCS Level II alphanumeric procedure and modifier codes (http://www.cms.hhs.gov/ HCPCSReleaseCodeSets/01_Overview.asp#TopOfPage) NDC-HCPCS crosswalk data files (http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/01a_2008aspfiles. asp) Free online HCPCS Level 2 Codes Search Engine from drchrono (https://drchrono.com/billing/medical_codes/ ?code_type=hcpcs_level_2&search_text=Enter+search+here.&Submit=Search) Searchable HCPCS codes and NDC numbers (http://www.commondatahub.com/hcpcs_source.jsp)

Healthcare Cost and Utilization Project


The Healthcare Cost and Utilization Project (HCUP, pronounced "H-Cup") is a family of health care databases and related software tools and products from the United States that is developed through a Federal-State-Industry partnership and sponsored by the Agency for Healthcare Research and Quality (AHRQ).[1]

General Information
HCUP [2] provides access to health care databases for research and policy analysis, as well as tools and products to enhance the capabilities of the data.[3] HCUP databases combine the data collection efforts of State data organizations, hospital associations, private data organizations, and the Federal government to create a national information resource of patient-level health care data. State organizations that provide data to HCUP are called HCUP Partners [4]. HCUP includes the largest collection of multi-year hospital care (inpatient, outpatient, and emergency department) data in the United States, with all-payer, encounter-level information beginning in 1988. These databases enable research on a broad range of health research and policy issues at the national, state, and local market levels, including cost and quality of health services, medical practice patterns, access to health care, and outcomes of treatments. Additionally, AHRQ's free software tools can be used not only with the HCUP databases, but also with other administrative databases. Please note that HCUP's Supplemental Files are only for use with HCUP databases.

HCUP User Support Website (HCUP-US)


The HCUP-US Website [5] is the main repository of information for HCUP. It is designed to answer HCUP-related questions; provide detailed information on HCUP databases, tools, and products; and offer technical assistance to HCUP users. HCUPs tools, publications, documentation, news, services, and HCUPnet (the free online data query system) may all be accessed through HCUP-US. The Website also provides information on how to obtain HCUP databases. HCUP-US is located at http://www.hcup-us.ahrq.gov'''.

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HCUP Overview Course


To help researchers and policymakers discover and use HCUPs data, tools, and products to their fullest potential, HCUP developed a free, interactive online course [6] that provides an overview of the features, capabilities, and potential uses of HCUP. The course is modular, so users can either move through the entire course or access exactly the resources in which they are most interested. The Overview Course can work both as an introduction to HCUP data and tools and a refresher for established users.

HCUP Online Tutorial Series


The HCUP Online Tutorial Series [7] is a set of free, interactive training courses that provide users with information about HCUP data, software products, and tools and give guidance on technical methods for conducting research with HCUP data. The online courses are modular, so users can move through an entire course or access the sections in which they are most interested. Available tutorials feature topics such as loading HCUP data, HCUPs sampling design, weighting the databases, calculating standard errors, producing national estimates, and conducting multi-year analysis.

HCUP Databases
Overview of HCUP Databases
HCUP databases [8] bring together the data collection efforts of State data organizations, hospital associations, private data organizations [4], and the Federal government to create an information resource of patient-level health care data. HCUPs databases date back to 1988 data files. The databases contain encounter-level information for all payers compiled in a uniform format with privacy protections in place. Researchers and policymakers can use its records to identify, track, and analyze national trends in health care use, access, charges, quality, and outcomes. The databases are suited for a broad range of analysesincluding rare conditions and special patient populations. HCUP databases [8] are released approximately 618 months after the end of a given calendar year, with State databases available earlier than the national dataset. For example, 2011 State data was available beginning in 2012, and nationwide data was available beginning in June 2013. Currently there are six types of HCUP databases: three with national- and regional-level data and three with Stateand local-level data. National Databasesfor national and regional analyses Nationwide Inpatient Sample (NIS) [9]: Inpatient data from a national sample of over 1,000 hospitals, released annually. Data are available from 1988 forward, and a new database is released annually, approximately 18 months after the end of a calendar year. Kids' Inpatient Database (KID) [10]: A nationwide sample of pediatric inpatient discharges designed specifically for users to study a broad range of conditions and procedures related to child health issues. The KID is released every three years, from 1997 forward. Nationwide Emergency Department Sample (NEDS) [11]: A database of over 25 million records that yields national estimates of emergency department (ED) visits. The NEDS captures encounters where the patient is admitted for inpatient treatment, as well as those in which the patient is treated and released. The NEDS is released annually and is available from 2006 forward. State Databasesfor state and local analyses The State Inpatient Databases (SID) [12]: Databases from the universe of inpatient discharge abstracts from participating States, released annually. Data are available from 1995 forward. The SID are released on a rolling

Healthcare Cost and Utilization Project basis, as early as six months following the end of a calendar year. The State Ambulatory Surgery Databases (SASD) [13]: Ambulatory care encounters from hospital-affiliated and sometimes freestanding ambulatory surgery sites in participating States. Data are available from 1997 forward. The SASD are released on a rolling basis, as early as six months following the end of a calendar year. The State Emergency Department Databases (SEDD) [14]: Hospital-affiliated emergency department data for visits in participating States that do not result in hospitalizations. Data are available from 1999 forward. The SID are released on a rolling basis, as early as six months following the end of a calendar year. The price of the data varies by the database and year. Recent years of the NIS and KID are $350 per data-year, with a special rate for students of $50. The NEDS is $500 per data-year, and $75 for students. The cost of the State databases is set by the individual State Partner [4] supplying the data to HCUP. Pricing varies by State and database, and certain Partners may have different prices for the type of organization requesting the data (non-profit, government, academic, etcetera). Purchasing and pricing information can be found on the HCUP User Support Website at http://www.hcup-us.ahrq.gov/tech_assist/centdist.jsp.

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Obtaining HCUP databases through the Central Distributor


A number of HCUP State Partners make their data available for purchase through the HCUP Central Distributor [15] . Applications for the databases are available on its Website. Please note, prospective purchasers and all persons with access to the databases are required to take the Data Use Agreement Training Course [16] and sign the form (found in the application) before using the data.

HCUP Tools and Software


To enhance the capabilities of the HCUP databases, HCUP provides a number of tools and software programs that can be applied to HCUP and other similar administrative databases. Many are available for download from the HCUP-US Website [2]. Others may be ordered through the HCUP Central Distributor [15]. All of HCUPs tools and software products are free-of-charge.

HCUPnet
HCUPnet [17] is a free, online, interactive query system based on HCUP data. HCUPnet provides statistics from the HCUP national databases (the NIS and KID) and from the State databases (the SID and SEDD) for those States that have agreed to participate. HCUPnet can be used for identifying, tracking, analyzing, and comparing statistics on hospital and emergency care, as well as obtaining measures of quality based on the AHRQ Quality Indicators [18]. HCUPnet can also be used for trend analysis with health care data available from 1993 forward. Hospitals Like Mine In addition to national and State statistics, HCUPnet includes a feature called Hospitals Like Mine [17], which allows users interested in certain types of hospitals to create national statistics based on hospital characteristics. Based on the NIS, American Hospital Association (AHA) survey, and Hospital Compare, the Hospitals Like Mine function allows users to analyze the types of patients that are seen, the services offered, and how these types of hospitals score on various quality measures. Hospital Readmissions HCUPnet also includes a feature called Hospital Readmissions [17] which provides users with some statistics on hospital readmissions within 30 days of hospital discharge. Information on calculating readmissions for HCUPnet is available in the HCUP Methods Series report [19].

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Quality Indicators (QIs)


The AHRQ Quality Indicators (QIs) [18] are measures of health care quality that make use of readily-available hospital inpatient administrative data. AHRQ QIs can be used to highlight potential quality concerns, identify areas that need further study and investigation, and track changes over time. The AHRQ QIs consist of four modules measuring various aspects of quality: Prevention QIs [20] identify hospital admissions that evidence suggests could have been avoided, at least in part, through high-quality outpatient care. Inpatient QIs [21] reflect quality of care inside hospitals including inpatient mortality for medical conditions and surgical procedures. Patient Safety Indicators [22] also reflect quality of care inside hospitals, but focus on potentially avoidable complications and iatrogenic events. Pediatric QIs [23] both reflect quality of care inside hospitals and identify potentially avoidable hospitalizations among children.

Clinical Classifications Software (CCS)


The Clinical Classifications Software [24] (CCS) provides a method for classifying diagnoses or procedures into clinically meaningful categories, which can be used for aggregate statistical reporting of a variety of topics, such as identifying populations for disease- or procedure-specific studies, or developing statistical reports providing information (i.e., charges and length of stay) about relatively specific conditions. There are four versions of the CCS. Some of the more commonly-used versions include the CCS for ICD-9-CM, the CCS for ICD-10-CM (beta), and the CCS for ICD-10. Clinical Classifications Software (CCS) for ICD-9-CM [25] is based on the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), a uniform and standardized coding system. The CCS for ICD-9-CM provides a method for classifying ICD-9-CM diagnoses or procedures into clinically meaningful categories, which can be used for aggregate statistical reporting of a variety of topics and employed in many types of projects analyzing data on diagnoses and procedures. The ICD-9-CM's multitude of codescurrently over 13,600 diagnosis codes and 3,700 procedure codesare collapsed into a smaller number of clinically meaningful categories. The current CCS for ICD-9-CM version has 289 categories for diagnoses and 231 for procedures. For certain research interests, this smaller number can be more useful for presenting descriptive statistics than individual ICD-9-CM codes. Since Fiscal Year 2008, CCS for ICD-9-CM includes categories from the Mental Health and Substance Abuse Clinical Classifications Software (CCS-MHSA). These categories replace the original CCS categories for mental health and substance abuse. Specifically, the CCS single-level software includes the CCS-MHSA general categories, and the CCS multi-level software includes the CCS-MHSA specific categories. The CCS for ICD-9-CM is updated annually. Clinical Classifications Software (CCS) for ICD-10-CM [26] clusters ICD-10-CM diagnosis and ICD-10-PCS procedure codes into a manageable number of clinically meaningful categories. This tool is currently in beta version and available for public evaluation. Clinical Classifications Software (CCS) for ICD-10 [27] is based on the International Classification of Diseases, 10th Revision (ICD-10), a uniform and standardized coding system which has been used in the U.S. for mortality reporting since 1999. focused on mortality reporting. The CCS for ICD-10 tool is valid through September 2009. The CCS version and their user guides are available for download from the HCUP-US Website [2].

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Chronic Condition Indicator


The Chronic Condition Indicator [28] provides researchers a way to categorize all of the ICD-9-CMs approximately 13,600 current diagnosis codes into two categories: chronic or not chronic. A chronic condition is defined as a condition that lasts 12 months or longer and meets one or both of the following tests: (a) it places limitations on self-care, independent living, and social interactions; and (b) it results in the need for ongoing intervention with medical products, services, and special equipment. The identification of chronic conditions is based on all 5-digit ICD-9-CM codes. E Codes, or external cause of injury codes, are not classified, because all injuries are assumed to be acute. The tool also assigns ICD-9-CM diagnosis codes into one of 18 body system categories, allowing users to create indicators listing which specific body systems are affected by a chronic condition. The body system indicator is based on the chapters of the ICD-9-CM codebook. This indicator may be useful as a means of counting the number of body systems affected by chronic conditions. Alternatively, the Clinical Classification Software (CCS) [25] may be used in conjunction with the Chronic Condition Indicator in order to obtain a count of the number of relatively discrete chronic conditions. The Chronic Condition Indicator [28] is updated annually and is valid for codes from January 1, 1980 forward. The indicator may be downloaded from the HCUP Central Distributor [5].

Comorbidity Software
Comorbidity Software [29] assigns variables that identify coexisting conditions on hospital discharge records that may contribute to a patients death using ICD-9-CM diagnosis coding. The Comorbidity Software consists of two computer programs. The first, Creation of Format Library for Comorbidity Groups, generates a format library that maps diagnosis codes into comorbidity indicators. Additional formats are created to exclude conditions that may be complications or that may be related to the principal diagnosis. The second program, Creation of Comorbidity Variables, applies these formats to a data set containing administrative data. The Comorbidity Software [29] is updated annually and available for download on the HCUP-US Website [5].

Cost-to-Charge Ratio Files (CCR)


The Cost-to-Charge Ratio (CCR) Files [30] are hospital-level files designed to convert the hospital total charge data to cost estimates when merged with data elements in the NIS, SID, and KID. The HCUP databases are limited to information on total hospital charges, which reflect the amount billed to the payer per patient encounter. Total charges do not reflect the actual cost of providing care or the payment received by the hospital for services provided. This total charge data can be converted into cost estimates using the CCR Files, which include hospital-wide values of the all-payer inpatient cost-to-charge ratio for nearly every hospital in the participating SID, NIS, and KID. Researchers and policy makers can use the converted cost estimates to examine a variety of topics, including use and cost of hospital services, health care cost inflation, and how the cost experiences of a given hospital or health plan compare with national or state trends. The Cost-to-Charge Ratio Files [30] are updated annually. The files may be obtained free-of-charge from the HCUP Central Distributor [15], ensuring that users receive the proper version of the CCR for the year of interest.

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Hospital Market Structure (HMS) Files


The Hospital Market Structure (HMS) Files [31] are hospital-level files designed to supplement the data elements in the NIS, KID, and SID databases. The HMS Files contain various measures of hospital market competition. These measures are aggregate and are meant to broadly characterize the intensity of competition that hospitals may be facing under various definitions of market area. Hospital market definitions were based on hospital locations, and in some cases, patient ZIP Codes. Hospital locations were obtained from the American Hospital Association (AHA) Annual Survey Database, Area Resource File (ARF), HCUP Historical Urban/Rural County (HURC) file, and ArcView GIS. Patient ZIP Codes were obtained from the SID. Users can merge the data elements on the Hospital Market Structure Files to the corresponding NIS, KID, or SID [8] hospitals by the hospital identification number (HOSPID [32]). Using the merged data elements, hospital market structure measures can then be included in analyses. Hospital market structure measures are generally useful for performing empirical analyses that examine the effects of hospital competition on the cost, access, and quality of hospital services. They are most useful to analysts as a secondary control variable (e.g., for assessing whether a statistical relationship exists between two variables when hospital market structure is controlled). The Hospital Market Structure Files [31] are updated every three years and available free-of-charge from the HCUP Central Distributor [15]. The HCUP Hospital Market Structure Files are currently available for 1997, 2000, and 2003.

HCUP Supplemental Files for Revisit Analyses


The HCUP Supplemental Files for Revisit Analyses [33] allows users to track sequential visits for a patient within a state and across facilities and hospitals settings while adhering to strict privacy guidelines. The available clinical information can determine if these sequential visits are unrelated, an expected follow-up, complications from a previous treatment, or an unexpected revisit or rehospitalization. Users must merge the supplemental files with the corresponding SID, SASD, or SEDD for any analysis. Data are available from 2003 forward.

Procedure Classes
Procedure Classes [34] facilitate research on hospital services using administrative data by identifying whether an ICD-9-CM procedure is (a) diagnostic or therapeutic, and (b) minor or major in terms of invasiveness and/or resource use. The Procedure Classes provide users an easy way to categorize procedure codes into one of four broad categories: Minor Diagnostic, Minor Therapeutic, Major Diagnostic, and Major Therapeutic. Minor Diagnostic: Non-operating room procedures that are diagnostic (e.g., 87.03: CT scan of head) Minor Therapeutic: Non-operating room procedures that are therapeutic (e.g., 02.41: Irrigate ventricular shunt) Major Diagnostic: All procedures considered valid operating room procedures by the Diagnosis Related Group (DRG) grouper and that are performed for diagnostic reasons (e.g., 01.14: Open brain biopsy) Major Therapeutic: All procedures considered valid operating room procedures by the Diagnosis Related Group (DRG) grouper and that are performed for therapeutic reasons (e.g., 39.24: Aorta-renal bypass). Procedure codes for this tool are based on the ICD-9-CM. The Procedure Classes [34] are updated annually and available for download from the HCUP-US Website [2].

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Utilization Flags
Utilization Flags [35] reveal additional information about use of health care services by combining information from UB-92 revenue codes and ICD-9-CM procedure codes to create flagsor indicatorsof utilization for a more complete picture of the services rendered in hospitals, emergency departments, and ambulatory surgery centers. The Utilization Flags can be employed to study issues such as use of intensive care units, as well as to reliably examine utilization of diagnostic and therapeutic servicesbeyond the information that can be gleaned from ICD-9-CM procedure codes alone. The Utilization Flags [35] are updated annually and available for download from the HCUP-US Website [5].

NIS & KID Trend Files


The NIS-Trends [36] and KID-Trends [37] files are available to help researchers conduct longitudinal analyses. They are discharge-level files that provide researchers with the trend weights, and data elements in the case of the NIS-Trends [36], that are consistently defined across data year.

MONAHRQ
MONAHRQ is a free, downloadable software product that supports web-based public reporting of healthcare quality measures. It is a product of the Agency for Healthcare Research and Quality [38] (AHRQ), part of the United States Department of Health and Human Services [3] (DHHS). MONAHRQ was first publicly released in June 2010.

HCUP News and Reports


HCUP produces material to report new findings based on HCUP data and to announce HCUP news.

HCUP eNews
HCUPs eNews [39] provides a summary of quarterly activities of the HCUP project. Issues are released in March, June, September, and December.

HCUP Mailing List


The HCUP Mailing List [40] provides e-mail updates on news, product releases, events, and the quarterly eNews.

HCUP Statistical Briefs


HCUP's Statistical Brief [41] series presents descriptive statistics on a variety healthcare and health services topics containing data from the HCUP databases.
HCUP Infographic: 30-Day Readmission Rates to U.S. Hospitals, 2010

Healthcare Cost and Utilization Project

876

HCUP Infographics
The HCUP infographics [42] provide a visual representation of data found in the HCUP Statistical Brief series.

References
[1] What is HCUP? (http:/ / hcup-us. ahrq. gov/ overview. jsp) [2] http:/ / www. hcup-us. ahrq. gov/ [3] Fact Sheet: Databases and Related Tools from the Healthcare Cost and Utilization Project (HCUP) (http:/ / www. ahrq. gov/ data/ hcup/ datahcup. htm) [4] http:/ / www. hcup-us. ahrq. gov/ partners. jsp [5] http:/ / www. hcup-us. ahrq. gov [6] http:/ / www. hcup-us. ahrq. gov/ overviewcourse. jsp [7] http:/ / hcup-us. ahrq. gov/ tech_assist/ tutorials. jsp [8] http:/ / www. hcup-us. ahrq. gov/ databases. jsp [9] http:/ / www. hcup-us. ahrq. gov/ nisoverview. jsp [10] http:/ / www. hcup-us. ahrq. gov/ kidoverview. jsp [11] http:/ / www. hcup-us. ahrq. gov/ nedsoverview. jsp [12] http:/ / www. hcup-us. ahrq. gov/ sidoverview. jsp [13] http:/ / www. hcup-us. ahrq. gov/ sasdoverview. jsp [14] http:/ / www. hcup-us. ahrq. gov/ seddoverview. jsp [15] http:/ / www. hcup-us. ahrq. gov/ tech_assist/ centdist. jsp [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [34] [35] [36] [37] [38] [39] [40] [41] [42] http:/ / hcup-us. ahrq. gov/ tech_assist/ dua. jsp http:/ / hcupnet. ahrq. gov/ http:/ / qualityindicators. ahrq. gov/ http:/ / hcupnet. ahrq. gov/ HCUPnet. app/ Methods-HCUPnet%20readmissions. pdf?JS=Y/ http:/ / www. qualityindicators. ahrq. gov/ Modules/ pqi_resources. aspx http:/ / www. qualityindicators. ahrq. gov/ Modules/ iqi_resources. aspx http:/ / www. qualityindicators. ahrq. gov/ Modules/ psi_resources. aspx http:/ / www. qualityindicators. ahrq. gov/ Modules/ pdi_resources. aspx http:/ / www. hcup-us. ahrq. gov/ tools_software. jsp http:/ / www. hcup-us. ahrq. gov/ toolssoftware/ ccs/ ccs. jsp http:/ / hcup-us. ahrq. gov/ toolssoftware/ beta/ icd_10_beta. jsp http:/ / www. hcup-us. ahrq. gov/ toolssoftware/ icd_10/ ccs_icd_10. jsp http:/ / www. hcup-us. ahrq. gov/ toolssoftware/ chronic/ chronic. jsp http:/ / www. hcup-us. ahrq. gov/ toolssoftware/ comorbidity/ comorbidity. jsp https:/ / www. hcup-us. ahrq. gov/ db/ state/ costtocharge. jsp http:/ / www. hcup-us. ahrq. gov/ toolssoftware/ hms/ hms. jsp http:/ / www. hcup-us. ahrq. gov/ db/ vars/ hospid/ nisnote. jsp http:/ / www. hcup-us. ahrq. gov/ toolssoftware/ revisit/ revisit. jsp http:/ / www. hcup-us. ahrq. gov/ toolssoftware/ procedure/ procedure. jsp http:/ / www. hcup-us. ahrq. gov/ toolssoftware/ util_flags/ utilflag. jsp https:/ / www. hcup-us. ahrq. gov/ db/ nation/ nis/ nistrends. jsp/ https:/ / www. hcup-us. ahrq. gov/ db/ nation/ kid/ kidtrends. jsp/ http:/ / www. ahrq. gov/ http:/ / hcup-us. ahrq. gov/ news. jsp https:/ / subscriptions. ahrq. gov/ accounts/ USAHRQ/ subscriber/ new?topic_id=USAHRQ_65 http:/ / hcup-us. ahrq. gov/ reports/ statbriefs/ statbriefs. jsp http:/ / hcup-us. ahrq. gov/ reports/ infographics. jsp

Healthcare Cost and Utilization Project

877

External links
Agency for Healthcare Research and Quality Website (http://www.ahrq.gov) HCUP User Support Website (HCUP-US) (http://www.hcup-us.ahrq.gov/home.jsp) HCUPnet (http://hcupnet.ahrq.gov/) United States Department of Health and Human Services (http://www.hhs.gov/)

High-deductible health plan

878

High-deductible health plan


Health care in the United States Government Health Programs

Federal Employees Health Benefits Program Indian Health Service Veterans Health Administration Military Health System / TRICARE Medicare Medicaid / State Health Insurance Assistance Program (SHIP) State Children's Health Insurance Program (CHIP) Program of All-Inclusive Care for the Elderly (PACE) Prescription Assistance (SPAP) Private health coverage

Health insurance in the United States Consumer-driven health care


Flexible spending account (FSA) Health Reimbursement Account Health savings account

High-deductible health plan (HDHP) Medical savings account (MSA) Private Fee-For-Service (PFFS) Managed care (CCP) Health maintenance organization (HMO) Preferred provider organization (PPO) Medical underwriting

Health care reform law


Emergency Medical Treatment and Active Labor Act (1986) Health Insurance Portability and Accountability Act (1996) Medicare Prescription Drug, Improvement, and Modernization Act (2003) Patient Safety and Quality Improvement Act (2005) Health Information Technology for Economic and Clinical Health Act (2009) Patient Protection and Affordable Care Act (2010) State level reform

Massachusetts health care reform Oregon Health Plan Vermont health care reform SustiNet (Connecticut) Dirigo Health (Maine) Municipal health coverage

Fair Share Health Care Act (Maryland) Healthy Howard (Howard Co., Maryland) Healthy San Francisco

A high-deductible health plan (HDHP) is a health insurance plan with lower premiums and higher deductibles than a traditional health plan. Being covered by an HDHP is also a requirement for having a health savings account.[1] Some HDHP plans also offer additional "wellness" benefits, provided before a deductible is paid. High-deductible health plans are a form of catastrophic coverage, intended to cover for catastrophic illnesses.[2]

High-deductible health plan

879

In the United States


In the United States, participation in a qualifying HDHP is a requirement for health savings accounts and other tax-advantaged programs. As of 2012, HDHPs are plans with a minimum deductible of $1,200 per year for self-only coverage and $2,400 for self-and-family coverage. The maximum amount out-of-pocket limit for HDHPs is $6,050 for self-only coverage and $12,000 for self-and-family coverage. (However, according to the instructions for IRS form 8889, "this limit does not apply to deductibles and expenses for out-of-network services if the plan uses a network of providers. Instead, only deductibles and out-of-pocket expenses for services within the network should be used to figure whether the limit is reached.") The Internal Revenue Service released the 2010 amounts on May 15, 2009,[3] which will be modified each year to reflect the change in cost of living.
Year Minimum deductible (single) Minimum deductible (family) Maximum out-of-pocket (single) Maximum out-of-pocket (family) 2009 $1,150 2010 $1,200 2011 $1,200 2012 $1,200 2013 $1,250 $2,300 $2,400 $2,400 $2,400 $2,500 $5,800 $5,950 $5,950 $6,050 $6,250 $11,600 $11,900 $11,900 $12,100 $12,500

References
[3] Revenue Procedure (Rev. Proc.) 2009-29 (http:/ / www. irs. gov/ pub/ irs-drop/ rp-09-29. pdf)

Healthcare Effectiveness Data and Information Set


The Healthcare Effectiveness Data and Information Set (HEDIS) is a widely used set of performance measures in the managed care industry, developed and maintained by the National Committee for Quality Assurance (NCQA). HEDIS was designed to allow consumers to compare health plan performance to other plans and to national or regional benchmarks. Although not originally intended for trending, HEDIS results are increasingly used to track year-to-year performance. HEDIS is one component of NCQA's accreditation process, although some plans submit HEDIS data without seeking accreditation. An incentive for many health plans to collect HEDIS data is a Centers for Medicare and Medicaid Services (CMS) requirement that health maintenance organizations (HMOs) submit Medicare HEDIS data in order to provide HMO services for Medicare enrollees under a program called Medicare Advantage. HEDIS was originally titled the "HMO Employer Data and Information Set" as of version 1.0 of 1991.[1] In 1993, Version 2.0 of HEDIS was known as the "Health Plan Employer Data and Information Set".[2] Version 3.0 of HEDIS was released in 1997.[1] In July 2007, NCQA announced that the meaning of "HEDIS" would be changed to "Healthcare Effectiveness Data and Information Set."[3] In current usage, the "reporting year" after the term "HEDIS" is one year following the year reflected in the data; for example, "HEDIS 2009" reports, which will be available in June 2009, will contain analyses of data collected from "measurement year" JanuaryDecember 2008.[4]

Healthcare Effectiveness Data and Information Set

880

Structure

The 75 HEDIS measures are divided into eight "domains of care"<ref name=<http://blackboard.fresnocitycollege.edu/courses/1/HIT-12-26552-2013SP/content/_1882003_1/HIT%2012%20article%20C4% is HEDIS? [5] Washington, D.C.: National Committee for Quality Assurance. Accessed 2009 Apr 25.</ref>:[6] Effectiveness of Care Access/Availability of Care Experience of Care Health plan stability Utilization and Relative Resource Use Informed healthcare choices (availability of new member orientation, education,

language translation services, etc.) Health Plan Descriptive Information Measures are added, deleted, and revised annually. For example, a measure for the length of stay after giving birth was deleted after legislation mandating minimum length of stay rendered this measure nearly useless. Increased attention to medical care for seniors prompted the addition of measures related to glaucoma screening and osteoporosis treatment for older adults. Other health care concerns covered by HEDIS are immunizations, cancer screenings, treatment after heart attacks, diabetes, asthma, flu shots, access to services, dental care, alcohol and drug dependence treatment, timeliness of handling phone calls, prenatal and postpartum care, mental health care, well-care or preventive visits, inpatient utilization, drug utilization, and distribution of members by age, sex, and product lines. New measures in HEDIS 2013 are Asthma Medication Ratio, Diabetes Screening for People With Schizophrenia and Bipolar Disorder Who Are Using Antipsychotic Medications, Diabetes Monitoring for People With Diabetes and Schizophrenia, Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia, and Adherence to Antipsychotic Medications for Individuals With Schizophrenia.[citation needed]

Data collection
HEDIS data are collected through surveys, medical charts and insurance claims for hospitalizations, medical office visits and procedures. Survey measures must be conducted by an NCQA-approved external survey organization. Clinical measures use the administrative or hybrid data collection methodology, as specified by NCQA. Administrative data are electronic records of services, including insurance claims and registration systems from hospitals, clinics, medical offices, pharmacies and labs. For example, a measure titled Childhood Immunization Status requires health plans to identify 2 year old children who have been enrolled for at least a year. The plans report the percentage of children who received specified immunizations. Plans may collect data for this measure by reviewing insurance claims or automated immunization records, but this method will not include immunizations received at community clinics that do not submit insurance claims. For this measure, plans are allowed to select a random sample of the population and supplement claims data with data from medical records. By doing so, plans may identify additional immunizations and report more favorable and accurate rates. However, the hybrid method is more costly, time-consuming and requires nurses or medical record reviewers who are authorized to review confidential medical records.

Healthcare Effectiveness Data and Information Set

881

Reporting
HEDIS results must be audited by an NCQA-approved auditing firm for public reporting. NCQA has an on-line reporting tool called Quality Compass that is available for a fee of several thousand dollars. It provides detailed data on all measures and is intended for employers, consultants and insurance brokers who purchase health insurance for groups. NCQA's web site includes a summary of HEDIS results by health plan. NCQA also collaborates annually with U.S. News & World Report to rank HMOs using an index that combines many HEDIS measures and accreditation status. The "Best Health Plans" list is published in the magazine in October and is available on the magazine's web site. Other local business organizations, governmental agencies and media report HEDIS results, usually when they are released in the fall.

Advantages and disadvantages


Advantages
Proponents cite the following advantages of HEDIS measures: HEDIS measures undergo a selection process that has been described as "rigorous"[7](p.205). Steps in the process include assessment of a measure's "importance, scientific soundness and feasibility"; field testing; public comment; a one-year trial period in which results are not reported publicly; and evaluation of publicly reported measures by "statistical analysis, review of audit results and user comments".[8] HEDIS data are useful for "evaluating current performance and setting goals".[9] In some studies, attainment of HEDIS measures is associated with cost-effective practices or with better health outcomes. In a 2002 study, HEDIS measures "generally reflect[ed] cost-effective practices".[10] A 2003 study of Medicare managed care plans determined that plan-level health outcomes were associated with HEDIS measures.[11] An "Acute Outpatient Depression Indicator" score based on a HEDIS measure predicted improvement in depression severity in one 2005 study.[12] As stated in a 2006 Institute of Medicine (IOM) report, "HEDIS measures focus largely on processes of care";[13] the strengths of process measures include the facts that they "reflect care that patients actually receive," thereby leading to "buy-in from providers," and that they are "directly actionable for quality improvement activities"[13](p.179). HEDIS measures are "widely known and accepted"[7](p.205). The NCQA claims that over 90% of U.S. health plans use HEDIS measures.[14]

Disadvantages
HEDIS was described in 1995 as "very controversial".[15] Criticisms of HEDIS measures have included: HEDIS measures do not account for many important aspects of health care quality. In 1998, HEDIS measures were said to "offer little insight into... [a health] plans ability to treat serious illnesses".[16] A 2002 study found "there are numerous non-HEDIS interventions with some evidence of cost effectiveness, particularly interventions to promote healthy behaviors".[10] According to a 2005 study, HEDIS-Medicaid 3.0 measures covered only 22% of the services recommended by the second U.S. Preventive Services Task Force (USPSTF).[17] Attempts by health care providers to improve their HEDIS measures may cause harm to patients.

Healthcare Effectiveness Data and Information Set As of 2001, there was concern that the asthma HEDIS measure may "encourag[e] more casual prescribing of controller medications" and may place emphasis "on the prescribing of a controller medication rather than on its actual use".[18] There is a risk of hypoglycemia if a provider strives to meet the HEDIS measure concerning a hemoglobin A1c (HbA1c) level of <7% that was adopted in 2006 for HEDIS 2007.[19] NCQA later decided to not report results of the HbA1c<7% measure publicly in 2008, to modify the HbA1c<7% measure for HEDIS 2009 "by adding exclusions for members within a specific age cohort and with certain comorbid conditions," and to add a new HbA1c<8% measure.[20] The process to develop HEDIS measures may be flawed. There is a possible conflict of interest because NCQA "works closely with the managed-care industry".[15] Furthermore, approximately half of NCQA's budget is derived from accreditation fees, "which may create an incentive against setting [HEDIS] standards too high".[21] The process to develop the measures is not completely "transparent," that is, "information about existing conditions, decisions and actions" is not completely "accessible, visible and understandable.[19] In some cases, attainment of HEDIS measures is not proven to be associated with better health outcomes. In 2004, a multi-site study determined that persons with persistent asthma per the HEDIS definition at the time had more "asthma-related adverse events" if they were classified by HEDIS as having appropriate asthma therapy than if they did not have appropriate therapy.[22] This cause of this "unexpected" finding was thought to be that some people with intermittent asthma were miscategorized by HEDIS as having persistent asthma.[22] A 2008 study of 1056 adults with asthma found that "compliance with the HEDIS asthma measure is not favorably associated with relevant patient-oriented outcomes" such as scores on an Asthma Control Test.[23] Although "glaucoma screening in older adults" is a current HEDIS measure,[6] the USPSTF found "insufficient evidence to recommend for or against screening adults for glaucoma" in 2005;[24] as of 2008, the American Academy of Ophthalmology was attempting to convince the USPSTF to review its statement.[25] Furthermore, a 2006 Cochrane review ("last assessed as up-to-date" in 2009) concluded that there was "insufficient evidence to recommend population based screening" for glaucoma because no pertinent randomized controlled trials exist.[26] One summary of the Cochrane review was "population-based screening for glaucoma... is not clinically or cost-effective".[27] A 2001 IOM report noted that "there is incomplete reporting of [HEDIS] measures and health plans resulting in lack of representativeness at the national level"[7](p.205). As stated in the 2006 IOM report, the limitations of HEDIS process measures include "sample size constraints for condition-specific measures," "may be confounded by patient compliance and other factors," and "variable extent to which process measures link to important patient outcomes"[13](p.179).

882

Healthcare Effectiveness Data and Information Set

883

References
[]

http:/ / www. ncqa. org/ Portals/ 0/ HEDISQM/ HEDIS2013/ HEDIS_2013_October_Update_Final_10. 1. 12. pdf[28]
[1] Mainous AG 3rd, Talbert J. Assessing quality of care via HEDIS 3.0. Is there a better way? (http:/ / archfami. ama-assn. org/ cgi/ reprint/ 7/ 5/ 410. pdf) Arch Fam Med 1998 Sep-Oct;7(5):410-3. Accessed 2009 Apr 28. [2] Schauffler HH, Rodriguez T. Exercising purchasing power for preventive care. (http:/ / content. healthaffairs. org/ cgi/ reprint/ 15/ 1/ 73. pdf) Health Aff (Millwood) 1996 Spring;15(1):73-85. Accessed 2009 Apr 25. [3] Measures assessing resource use highlight HEDIS 2008 (http:/ / ncqa. org/ tabid/ 517/ Default. aspx) (news release). Washington, D.C.: National Committee for Quality Assurance, 2007 Jul 11. Accessed 2009 Apr 25. [4] HEDIS 2010 public comment overview. (http:/ / www. ncqa. org/ Portals/ 0/ PublicComment/ HEDIS2010/ NCQA_HEDIS_2010_Public_Comment_Overview. pdf) Washington, D.C.: National Committee for Quality Assurance, 2009. Accessed 2009 Apr 25. [5] http:/ / www. ncqa. org/ tabid/ 187/ Default. aspx [6] HEDIS 2009 summary table of measures, product lines and changes. (http:/ / www. ncqa. org/ Portals/ 0/ HEDISQM/ HEDIS2009/ 2009_Measures. pdf) Washington, D.C.: National Committee for Quality Assurance, 2008. Accessed 2009 Apr 25. [7] Institute of Medicine. Envisioning the national health care quality report. (http:/ / www. nap. edu/ catalog. php?record_id=10073) Washington, D.C.: National Academy Press, 2001. ISBN 0-309-07343-X. Accessed 2009 May 6. [8] HEDIS life cycle. (http:/ / www. ncqa. org/ tabid/ 425/ Default. aspx) Washington, D.C.: National Committee for Quality Assurance. Accessed 2009 May 6. [9] Scanlon DP, Darby C, Rolph E, Doty HE. The role of performance measures for improving quality in managed care organizations. (http:/ / www. pubmedcentral. nih. gov/ picrender. fcgi?artid=1089245& blobtype=pdf) Health Serv Res 2001 Jul;36(3):619-41. Accessed 2009 Apr 28. [10] Neumann PJ, Levine BS. Do HEDIS measures reflect cost-effective practices? (http:/ / www. ajpm-online. net/ article/ S0749-3797(02)00516-0) Am J Prev Med 2002 Nov;23(4):276-89. Accessed 2009 May 6. [11] Ware J, Rogers W, Gandek B, Haffer SC, Bierman AS, Kang JL. Is there a relationship between health outcomes and HEDIS quality performance measures in managed care? Plan-level results from the Medicare Health Outcomes Survey. (http:/ / gateway. nlm. nih. gov/ MeetingAbstracts/ ma?f=102275360. html) Abstr AcademyHealth Meet 2003;20:abstract no. 382. Accessed 2009 May 6. [12] Rost K, Dickinson LM, Fortney J, Westfall J, Hermann RC. Clinical improvement associated with conformance to HEDIS-based depression care. (http:/ / www. springerlink. com/ content/ t564284p27w043j6/ ) Ment Health Serv Res 2005 Jun;7(2):103-12. Accessed 2009 May 6. [13] Institute of Medicine. Performance measurement: accelerating improvement. (http:/ / www. nap. edu/ catalog. php?record_id=11517) Washington, DC: National Academies Press; 2006. ISBN 978-0-309-10007-6. Accessed 2009 Apr 28. [14] What is HEDIS? (http:/ / www. ncqa. org/ tabid/ 187/ Default. aspx) Washington, D.C.: National Committee for Quality Assurance. Accessed 2009 Apr 25. [15] Epstein A. Performance reports on quality--prototypes, problems, and prospects. (http:/ / content. nejm. org/ cgi/ content/ extract/ 333/ 1/ 57) N Engl J Med. 1995 Jul 6;333(1):57-61. Accessed 2009 Apr 28. [16] Mainous AG 3rd, Talbert J. Assessing quality of care via HEDIS 3.0. Is there a better way? (http:/ / archfami. ama-assn. org/ cgi/ content/ full/ 7/ 5/ 410) Arch Fam Med 1998 Sep-Oct;7(5):410-3. Accessed 2009 May 7. [17] Levine RS, Briggs NC, Husaini BA, Foster I, Hull PC, Pamies RJ, Tropez-Sims S, Emerson JS. HEDIS prevention performance indicators, prevention quality assessment and Healthy People 2010. (http:/ / muse. jhu. edu/ login?uri=/ journals/ journal_of_health_care_for_the_poor_and_underserved/ v016/ 16. 4Alevine. html) J Health Care Poor Underserved 2005 Nov;16(4 Suppl A):64-82. Accessed 2009 May 6. [18] Glauber JH. Does the HEDIS asthma measure go far enough? (http:/ / www. ajmc. com/ media/ pdf/ AJMC2001junGlauber575_579. pdf) Am J Manag Care 2001;7:575-579. Accessed 2009 May 6. [19] Aron D, Pogach L. Transparency standards for diabetes performance measures. (http:/ / jama. ama-assn. org/ cgi/ content/ extract/ 301/ 2/ 210) JAMA 2009 Jan 14;301(2):210-2. Accessed 2009 May 6. [20] HEDIS 2009, volume 2: technical update. (http:/ / www. ncqa. org/ Portals/ 0/ PolicyUpdates/ HEDIS Technical Updates/ 2009_Vol2_Technical_Update. pdf) Washington, D.C.: National Committee for Quality Assurance, 2008 Oct 1. Accessed 2009 May 6. [21] Kuttner R. Must good HMOs go bad? Second of two parts. The search for checks and balances. (http:/ / content. nejm. org/ cgi/ content/ extract/ 338/ 22/ 1635) N Engl J Med 1998 May 28;338(22):1635-9. Accessed 2009 May 6. [22] Berger WE, Legorreta AP, Blaiss MS, Schneider EC, Luskin AT, Stempel DA, Suissa S, Goodman DC, Stoloff SW, Chapman JA, Sullivan SD, Vollmer B, Weiss KB. The utility of the Health Plan Employer Data and Information Set (HEDIS) asthma measure to predict asthma-related outcomes. (http:/ / www. worldcongress. com/ pdf/ Reprint_HEDIS_12. 2004. pdf) Ann Allergy Asthma Immunol 2004 Dec;93(6):538-45. Accessed 2009 May 7. [23] Lim KG, Patel AM, Naessens JM, Li JT, Volcheck GW, Wagie AE, Enders FB, Beebe TJ. Flunking asthma? When HEDIS takes the ACT. (http:/ / www. ajmc. com/ media/ pdf/ AJMC_08aug_Lim_487to494. pdf) Am J Manag Care 2008 Aug;14(8):487-94. Accessed 2009 May 6. [24] U.S. Preventive Services Task Force (USPSTF). Screening for glaucoma. Recommendation statement. (http:/ / www. ahrq. gov/ clinic/ uspstf05/ glaucoma/ glaucrs. htm) AHRQ Publication No. 04-0548-A, 2005 March. Rockville, MD: Agency for Healthcare Research and Quality. Accessed 2009 May 6.

Healthcare Effectiveness Data and Information Set


[25] Lobbyist outlines glaucoma-related initiatives. (http:/ / ophthalmologytimes. modernmedicine. com/ ophthalmologytimes/ 2008+ American+ Glaucoma+ Society+ Meeting/ Lobbyist-outlines-glaucoma-related-initiatives/ ArticleStandard/ Article/ detail/ 501399) Ophthalmology Times 2008 Mar 7. Accessed 2009 May 6. [26] Hatt SR, Wormald R, Burr J. Screening for prevention of optic nerve damage due to chronic open angle glaucoma. (http:/ / www. cochrane. org/ reviews/ en/ ab006129. html) Cochrane Database of Systematic Reviews 2006 Oct 18;4. Accessed 2009 May 6. [27] McKinnon SJ, Goldberg LD, Peeples P, Walt JG, Bramley TJ. Current management of glaucoma and the need for complete therapy. (http:/ / www. ajmc. com/ media/ pdf/ A195_McKinnonS20toS27. pdf) Am J Manag Care 2008 Feb;14(1 Suppl):S20-7. Accessed 2009 May 6. [28] http:/ / www. ncqa. org/ Portals/ 0/ HEDISQM/ HEDIS2013/ HEDIS_2013_October_Update_Final_10. 1. 12. pdf

884

External links
U.S. News & World Report. America's best health plans. (http://health.usnews.com/sections/health/ health-plans/) Health plan report card. (http://reportcard.ncqa.org/plan/external/plansearch.aspx) Washington, D.C.: National Committee for Quality Assurance. HEDIS & quality measurement. (http://www.ncqa.org/tabid/59/Default.aspx) Washington, D.C.: National Committee for Quality Assurance. The ironic conundrum of the preference sensitive measures, P4P and HEDIS criteria. (http://stanford. wellsphere.com/healthcare-industry-policy-article/ the-ironic-conundrum-of-the-preference-sensitive-measures-p4p-and-hedis-criteria/622142) Disease Management Care Blog, 2009 Mar 8. Dalzell MD. Will integrity of HEDIS data improve with '98 version? (http://www.managedcaremag.com/ archives/9802/9802.hedis.shtml) Managed Care, 1998 February.

Home care
Home care, (also referred to as domiciliary care or social care), is health care or supportive care provided in the patient's home by licensed healthcare professionals. It is often referred to as home health care or formal care. Often, the term home health care is used to distinguish it from non-medical care or custodial care, which is care that is provided by persons who are not nurses, doctors, or other licensed medical personnel.[1] Home Health services help adults and seniors who are recovering after a hospital or facility stay, or need additional support to remain safely at home and avoid unnecessary hospitalization. These Medicare-certified services may include short-term nursing, rehabilitative, therapeutic, and assistive home health care.This care is provided by registered nurses (RNs), physical therapists (PTs), occupational therapists (OTs), speech language pathologists (SLPs), home health aides (HHAs) and medical social workers (MSWs) as a limited number of up to one hour visits, primarily through the Medicare Home Health benefit.[2] Licensed personnel and others who assist the individual including caregivers[3] and care assistants may help the individual with daily tasks such as bathing, eating, cleaning the home and preparing meals. For terminally ill patients, home care may include hospice care. For patients recovering from surgery or illness, home care may include rehabilitative assistance.[4]

Home care

885

United States
Professionals providing care
Professionals providing home care include licensed practical nurses, registered nurses, home health aides, physical therapists, occupational therapists and social workers. Rehabilitation services may be provided by physical therapists, occupational therapists, speech and language pathologists and dietitians.[citation needed] Home care aides are trained to provide non-custodial or non-medical care, such as helping with dressing, bathing, getting in and out of bed, and using the toilet. They may also prepare meals.[citation needed]

Concept
"Home care", "home health care" and "in-home care" are phrases that are used interchangeably in the United States to mean any type of care given to a person in their own home. These phrases have been used in the past interchangeably regardless of whether the person required skilled care or not. More recently, there is a growing movement to distinguish between "home health care" meaning skilled nursing care (usually provided by a Home Health Agency) and "home care" (provided by Homecare Agency or independent home health aide or caregiver) meaning non-medical care.[citation needed] Home care aims to make it possible for people to remain at home rather than use residential, long-term, or institutional-based nursing care. Home care providers deliver services in the client's own home. These services may include some combination of professional health care services and life assistance services. Professional home health services could include medical or psychological assessment, wound care, medication teaching, pain management, disease education and management, physical therapy, speech therapy, or occupational therapy. Life assistance services include help with daily tasks such as meal preparation, medication reminders, laundry, light housekeeping, errands, shopping, transportation, and companionship. Home care is often an integral component of the post-hospitalization recovery process, especially during the initial weeks after discharge when the patient still requires some level of regular physical assistance.[5] Activities of daily living (ADL) refers to activities, including bathing, dressing, transferring, using the toilet, eating, and walking, that reflect the patient's capacity for self-care. Instrumental activities of daily living (IADL) refers to daily tasks, including light housework, preparing meals, taking medications, shopping for groceries or clothes, using the telephone, and managing money, that enables the patient to live independently in the community. While there are differences in terms used in describing aspects of home care or home health care in the United States and other areas of the world, for the most part the descriptions are very similar.

Home care

886 Estimates for the U.S. indicate that most home care is informal, with families and friends providing a substantial amount of care. For formal care, the health care professionals most often involved are nurses followed by physical therapists and home care aides. Other health care providers include respiratory and occupational therapists, medical social workers and mental health workers. Home health care is generally paid for by Medicaid, Medicare,long term insurance, or paid with the patient's own resources.

Aide worker qualifications


The state department of health issues requirement for that state. Workers can take an examination to become a state tested Certified Nursing Assistant (CNA). Other requirements in the U.S.A. often include a background check, drug testing, and general references.[6]
"The Woman as Family Doctor", by Dr. Anna Fischer-Dckelmann

Licensure and providers by state


California does not have licensure for non medical or custodial care services, and as such there are no entry requirements or minimum standards. a Full service agencies do preemployment background checks, including (criminal), department of motor vehicle, and reference checks. Full service agencies also train, monitor and supervise the staff that provide care to clients in their home. There is a certification available for home care companies in California, administered by the California Association for Health Services at Home.[7] Florida is a licensure state which requires different levels of licensing depending upon the services provided. Companion assistance is provided by a home maker companion agency whereas nursing services and assistance with ADL's can be provided by a home health agency or nurse registry. The state licensing authority is the Florida Agency for Health Care Administration.[8]

Compensation
Compensation varies according to discipline, but the Bureau of Labor Statistics estimates that the 2012 median hourly wage for home health aides was $10.01 per hour with the median annual wage of $20,820.[9] Supreme Court case relating to fees For years, home care work has been selectively classified as a companionship service and exempted from federal overtime and minimum wage rules under the Fair Labor Standards Act (FLSA). The Supreme Court considered arguments on the companionship exemption, which stems from a case brought by a home care worker represented by counsel provided by SEIU. The original 2003 case, Evelyn Coke v. Long Island Care at Home, Ltd. and Maryann Osborne, argues that agency-employed home caregivers should be covered under overtime and minimum wage regulations. Evelyn Coke, a home care worker employed by a home care agency that was not paying her overtime, sued the agency in 2003, alleging that the regulation construing the companionship services exemption to apply to agency employees and exempt them from the federal minimum wage and overtime law is inconsistent with the law.[10] The

Home care Supreme Court heard the case in 2009. In the court decision, the court stated the Fair Labor Standards Amendments of 1974 exempted from the minimum wage and maximum hours rules of the FSLA persons "employed in domestic service employment to provide companionship services for individuals ... unable to care for themselves." 29 U. S. C. 213(a)(15). The court found that the DOL'sWikipedia:Please clarify power to administer a congressionally created program necessarily requires the making of rules to fill any 'gap' left, implicitly or explicitly, by Congress, and when that agency fills that gap reasonably, it is binding. In this case, one of the gaps was whether to include workers paid by third parties in the exemption and the DOL has done that. Since the DOL has followed public notice procedure, and since there was gap left in the legislation, the DOL's regulation stands and home health care workers are not covered by either minimum wage or overtime pay requirements.

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Statistics on consumers
Payment 710,000 paid by Medicare - Medicare often is the primary billing source, if this is the primary carrier between two types of insurance (like between Medicare and Medicaid). Also, if a patient has Medicare and that patient has a "skilled need" requiring nursing visits, the patient's case is typically billed under Medicare.[citation needed] 235,000 paid by private insurance, or self/family - Private insurance includes VA (Veterans Administration), some Railroad or Steelworkers health plans or other private insurance. "Self/family" indicates "private pay" status, when the patient or family pays 100% of all home care charges. Home care fees can be quite high; few patients & families can absorb these costs for a long period of time.[citation needed]

The United Kingdom


Home care providers
Homecare is purchased by the service user directly from independent home care agencies or as part of the statutory responsibility of social services departments of local authorities who either provide care by their own employees or commission services from independent agencies. Care is usually provided once or twice a day with the aim of keeping frail or disabled people healthy and independent though can extend to full-time help by a live-in nurse or carer.

United Kingdom Homecare Association


The United Kingdom Homecare Association (UKHCA),[11] is a professional association of 1,600 domiciliary care providers in the UK.[12] The UKHCA maintains a list of agencies in their local area using a searchable list of home care providers in the UK.[13][14] UKHCA produces Homecarer magazine,[15] and provides a range of publications for homecare providers,[16] such as Accessible Home Health Care[17]

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Statutory Regulation
Home care agencies are regulated by statutory bodies in three of the four home nations. The regulator's function is to ensure that home care agencies work within the applicable legislation: England Regulator: The Care Quality Commission (CQC) [18] The Health and Social Care Act 2008 [19] The Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 [20] Wales Regulator: The Care and Social Services Inspectorate Wales (CSSIW)[21] The Care Standards Act 2000[] The Domiciliary Care Agencies (Wales) Regulations 2004[22] Scotland Regulator: The Care Commission[23] The Regulation of Care (Scotland) Act 2001[24] Northern Ireland Legislation covering the homecare sector in Northern Ireland is not yet fully operational (as at December 2007). Regulator: The Regulation and Quality Improvement Authority (RQIA)[25] The Health and Personal Social Services (Quality, Improvement and Regulation)(Northern Ireland) Order 2003[26] Domiciliary Care Agency Regulations (Northern Ireland) 2007[27] Domiciliary Care Agencies National Minimum Standards (not published as at December 2007)

Research and program accreditation


Lotus Shyu & Lee found that providing home nursing care is more suitable for patients rather than in-house nursing-home care for patients that are not seriously ill and who do not need the services after discharge from the hospital.[] Modin and Furhoff regard the roles of patients' doctors as more crucial than their nurses and care workers.[] However, from an epidemiological standpoint, the risks of some community acquired infections are higher from home nursing than from inpatient nursing home care.[] In regards to financial expenditure, home nursing care is more cost effective than inpatient nursing home care.[] The quality aspect of home nursing has been reviewed by Riccio.[28] Christensen & Grnvall study the challenges and opportunities of providing communication technologies supporting the cooperation between home care workers and family members. Although they provide home care for older adults in cooperation, family members and care workers harbour diverging attitudes and values towards their joint efforts. This state of affairs is a challenge for the design of ICT for home care.[29]

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Notes
[2] "Home Health services" - BAYADA Home Health Care (http:/ / www. bayada. com/ services_hhc_homehealth. asp) retrieved 2013-07-19 [6] "Certified Nursing Assistant" (http:/ / cnafacts. com), Retrieved on 27 September 2011. [7] nttp://www.cahsah.org [9] "Occupational Employment and Wages, May 2012" (http:/ / www. bls. gov/ oes/ current/ oes311011. htm) Retrieved 19 July 2013 [11] United Kingdom Homecare Association (UKHCA) (http:/ / www. ukhca. co. uk) [12] UKHCA Code of Practice (http:/ / www. ukhca. co. uk/ codeofpractice. aspx). [18] http:/ / www. cqc. org. uk [19] http:/ / www. legislation. gov. uk/ ukpga/ 2008/ 14/ contents [20] http:/ / www. legislation. gov. uk/ uksi/ 2010/ 781/ contents/ made

Health information exchange


Health information exchange (HIE) is the mobilization of healthcare information electronically across organizations within a region, community or hospital system. HIE provides the capability to electronically move clinical information among disparate health care information systems while maintaining the meaning of the information being exchanged. The goal of HIE is to facilitate access to and retrieval of clinical data to provide safer and more timely, efficient, effective, and equitable patient-centered care. HIE is also useful to public health authorities to assist in analyses of the health of the population. HIE systems facilitate the efforts of physicians and clinicians to meet high standards of patient care through electronic participation in a patient's continuity of care with multiple providers. Secondary health care provider benefits include reduced expenses associated with: the manual printing, scanning and faxing of documents, including paper and ink costs, as well as the maintenance of associated office machinery the physical mailing of patient charts and records, and phone communication to verify delivery of traditional communications, referrals, and test results the time and effort involved in recovering missing patient information, including any duplicate tests required to recover such information According to an internal study at Sushoo Health Information Exchange [1], the current method of exchanging patients' health information accounts for approximately $17,160 of expenses annually for a single-clinician practice. Formal organizations are now emerging to provide both form and function for health information exchange efforts, both on independent and governmental/regional levels. These organizations are, in many cases, enabled and supported financially by statewide health information exchange grants from the Office of the National Coordinator for Health Information Technology. These grants were legislated into the HITECH components of the American Reinvestment and Recovery Act in 2009.[2] The latter organizations (often called Regional Health Information Organizations, or RHIOs) are ordinarily geographically defined entities which develop and manage a set of contractual conventions and terms, arrange for the means of electronic exchange of information, and develop and maintain HIE standards.[3] In the United States, federal and state regulations regarding HIEs and HIT (health information technology) are still being defined. Federal regulations such as "Meaningful Use" legislation[4] as well as the implementation of some state governments of state-sponsored HIEs (such as the North Carolina HIE[5]) in addition to fluctuating health care regulations among the states are rapidly changing the face of this relatively new industry. HIEs and RHIOs continue to struggle to achieve self-sustainability and the vast majority remain tied to Federal, State, or Independent grant funding in order to remain operational; with some exceptions such as the Indiana HIE.[6][7]

Health information exchange

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Established HIE communities


Chesapeake Regional Information System for our Patients CRISP is a non-profit corporation that is implementing health information exchange in the state of Maryland. The organization also serves as the Health IT Extension Center for Maryland. CRISP was created by Johns Hopkins Medicine, MedStar Health, the University of Maryland Medical System and Erickson Retirement Communities.[] Audacious Inquiry serves as program director and technical architect for the health information exchange while Dynamed Solutions provides project management and organizational support under CRISP. Colorado Regional Health Information Organization (CORHIO)[8] CORHIO is Colorados state designated entity for health information exchange.[9] As of April 2013, about 28 Colorado hospitals and more than 700 doctors were connected to the CORHIO HIE.[10] </ref>[11] Delaware Health Information Network ([12]) DHIN is a non-profit public-private partnership enacted by the Delaware General Assembly in 1997, for the benefit of all citizens of Delaware to advance the creation of a statewide health information network and to address Delaware's needs for timely, reliable and relevant health care information. DHIN has adopted regulations to govern its operations and has policies and procedures in place to support privacy and security of patient information. DHIN enhances a health care information exchange started in May 2007. In February 2012, The Delaware Health Information Network announced full participation of all acute care hospitals and skilled nursing facilities in the state, along with the vast majority of Delaware providers, in the first statewide community health record. As of June 2013, DHIN has attracted the participation of 97 percent of Delaware providers, tracks nearly 88 percent of Delaware's population, and delivers more than 10 million clinical results and reports to participating providers annually.[13] Frysian Health Information Exchange ([14]) The Friesland Regional Cardiology Network speeds up the referral process, improves both diagnosis and the clinical decision process, and on average reduces by one or two days the length-of-stay for patients in hospitals. From their office workstations, cardiologists are able to consult the advanced clinical images provided by any hospital linked to the network. The distributed storage of records eliminates the duplication of records across multiple sites. Once uploaded to the cardiology network, records remain available for consultation at any time so that previous episodes of a patients care can be consulted in detail no matter where the care was provided in the region. Harvard Pilgrim Health Care HPHC is a non-profit insurance provider which serves members throughout Massachusetts, New Hampshire, and Maine. The provider offers variety health insurance options for companies, families and individuals. Customers health insurance expectations are met through a tailored options from preferred provider organization (PPO), point-of-sale (POS), and health maintenance organization (HMO). HPHC implements CRM, Master Data Management and is now implementing Oracle Policy Automation to support integrated call center and online self-service for plan purchase and management across their various customer groups additionally, HPHC is using their platform to support recruitment and to better analyze and improve service levels in a heavily competitive market.[15] Indiana Health Information Exchange ([16]) The Indiana Health Information Exchange operates the U.S.'s largest HIE and one of the oldest with data on more than 7 million patients, connecting hospitals, rehabilitation centers, long term care facilities, laboratories, imaging centers, clinics, community health centers and other healthcare organizations. Created and ran by the

Health information exchange Regenstrief Institute, a medical informatics think tank, the Indiana Network for Patient Care (INPC), a secure network provides a patient records to participating doctors. This HIE grew over time from 12 hospitals in the center of the state with approximately 5,000 physicians, to 93 hospitals out of 114 in the state and more than 14,000 physicians in Indiana.[17] Utah Health Information Network ([18]) The Utah Health Information Network (UHIN) is a broad-based coalition of Utah healthcare insurers, providers, and other interested parties, including the Utah State government. Since 1993, UHIN members have come together for the common goal of reducing healthcare costs and improving the quality of care through the use of electronic data interchange (EDI) for healthcare transactions. Exchanging information electronically rather than by phone, fax or surface mail means that data can get to those who need it securely, economically and efficiently. UHIN currently serves nearly all the hospitals, ambulatory surgery centers, national laboratories, insurers, and approximately 90% of the medical providers in Utah as well as the Utah State government. As a community organization the focus is on creating data exchange solutions that work for the entire healthcare community, from large integrated networks to single-provider offices. The Clinical Health Information Exchange (cHIE) is a secure electronic way for medical professionals to share and view patient information that is needed at the point of care. The cHIE makes this information accessible, with patient consent, to authorized users while maintaining the highest standards of patient privacy.

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References
[1] http:/ / www. sushoo. com/ [2] <http://healthit.hhs.gov/portal/server.pt?open=512&objID=1488&parentname=CommunityPage&parentid=58&mode=2&in_hi_userid=11113&cached=true> [4] http:/ / healthit. hhs. gov/ portal/ server. pt?open=512& objID=1325& parentname=CommunityPage& parentid=1& mode=2 [5] http:/ / www. nchica. org/ GetInvolved/ NCHIE/ intro. htm [6] http:/ / www. ihie. org/ [10] http:/ / www. corhio. org/ media/ 54599/ smpc-corhio_hie_press_release_final. pdf [12] http:/ / www. dhin. org [14] http:/ / www. ihe-europe. net/ drupal/ sites/ default/ files/ IHE-Europe-Success-Story-FRIESLAND_Final. pdf [16] http:/ / www. ihie. com [18] http:/ / www. uhin. org

McGowan JJ, Overhage JM, Barnes M, McDonald CJ (April 2004). "Indianapolis I3: the third generation Integrated Advanced Information Management Systems" (http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC385298). J Med Libr Assoc 92 (2): 17987. PMC 385298 (http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC385298). PMID 15098046 (http://www.ncbi.nlm.nih.gov/pubmed/15098046). eHealth Initiative, Second Annual Survey of State, Regional and Community-based Health Information Exchange Initiatives and Organizations, August, 2005 Hagland, Mark (2009). Transformative Quality: The Emerging Revolution in Health Care Performance (http:// www.productivitypress.com/shopping_cart/products/product_detail.asp?sku=PP8492& isbn=9781420084924&parent_id=4&pc). Productivity Press/Taylor & Francis Group, LLC, New York. ISBN 978-1-4200-8492-4.

External links
HHS Health Information Technology (http://healthit.hhs.gov/) HIMSS information about HIE and RHIO (http://www.himss.org/ASP/topics_rhio.asp)

Health information management

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Health information management


Health information management (HIM) is the practice of maintenance and care of health records by traditional (paper-based) and electronic means in hospitals, physician's office clinics, health departments, health insurance companies, and other facilities that provide health care or maintenance of health records. With the widespread computerization of health records and other information sources, including hospital administration functions and health human resources information, health informatics and health information technology are being increasingly utilized in information management practices in the health care sector. Health information management professionals plan information systems, develop health policy, and identify current and future information needs. In addition, they may apply the science of informatics to the collection, storage, use, and transmission of information to meet the legal, professional, ethical and administrative records-keeping requirements of health care delivery.[1] They work with clinical, epidemiological, demographic, financial, reference, and coded healthcare data. It has been suggested the proper collection, management and use of information within healthcare systems will determine the systems effectiveness in detecting health problems, defining priorities, identifying innovative solutions and allocating resources to improve health outcomes.[2] For example, health information administrators have been described to "play a critical role in the delivery of healthcare in the United States through their focus on the collection, maintenance and use of quality data to support the information-intensive and information-reliant healthcare system".[3] As the field grows and information technology becomes a more crucial part of the medical world, health information management is experiencing a transition from traditional managing practices with paper to more efficient electronic management, such as with Electronic Health Records (EHRs). But the main goal is still to analyze, manage, and utilize the information that is essential to patient care and making sure the providers can access the information when necessary.[4]

Background: Canada
Also called Health Record Technicians or Health Record Administrators. Professional Association: Canadian Health Information Management Association (CHIMA)

Province of British Columbia


Educational Institution: Douglas College [5]

Background: History and development of HIM standards in the United States


HIM standards began with establishment of AHIMA
Health information management's standards history is dated back to the introduction of the American Health Information Management Association, founded in 1928 "when the American College of Surgeons established the Association of Record Librarians of North America (ARLNA) to 'elevate the standards of clinical records in hospitals and other medical institutions.'"[6] In 1938, AHIMA was known as American Association of Medical Record Librarians (AAMRL) and its members were known as medical record experts or librarians who studied medical record science. The goal of this career was to raise the standards of keeping records in hospitals and other healthcare facilities. The individuals involved in this profession were promoters for the successful management of clinical records to guarantee their precision. Over time,base the name AHIMA had changed to reflect the evolving field of health information management practices, eventually becoming the American Health Information Management Association. The association's current

Health information management name is meant to cover the wide variety of areas health professionals work in today. AHIMA members affect the quality of patient information and patient care at every touch point in the healthcare delivery cycle. They often serve in bridge roles, connecting clinical, operational, and administrative functions.[7]

893

HIMSS establishment in 1961 increased industry knowledge


The Healthcare Information and Management Systems Society (HIMMS) was organized in 1961 as the Hospital Management Systems Society (HMSS), an independent, unincorporated, nonprofit, voluntary association of individuals. It was preceded by increasing amounts of management engineering activity in healthcare during the 1950s, when teachings by Frederick Winslow Taylor and Frank Bunker Gilbreth, Sr. began to attract the attention of health leaders.[8] The HIMMS grew to include chapters, membership categories, publications, conventions, and continues to grow in different parts of the world via its Europe, Asia Pacific, and Middle Eastern branches.[9]

Accredited HIM educational program development


The Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM) defines standards which higher education health information management and technology programs must meet to qualify for accreditation. Students who graduate from an accredited associate's, bachelor's or certificate program are qualified to sit for their respective exams for certification as a Registered Health Information Technician (RHIT) via graduation from an accredited associate or certification program or Registered Health Information Administrator (RHIA), which requires education through an accredited bachelor or certification program. Competency requirements are maintained by CAHIIM in their Associate Degree Entry-Level Competencies and Baccalaureate Degree Entry-Level Competencies definitions.[10][11]

Modern development in health information management


Electronic health records
The electronic health record has been continually expressed as an evolvement of health record-keeping. Because it is electronic, this means of record keeping has been both supported and debated in the health professional community and within the public realm. In the United States, 89% of those who responded to a recent Wall Street Journal poll described themselves as "Very/Somewhat Confident" in their health care provider who used electronic health records compared to 71% of respondents who responded positively about their providers who didn't or don't use electronic health records.[12] As of 2008, more than fifty-percent of Chief Information Officers polled listed that they wanted ambulatory electronic health records in order to have the health information record available to move across each stage of health care.[13] Health information managers are charged with the protection of patient privacy and are responsible for training their employees in the proper handling and usage of the confidential information entrusted to them. With the rise of technology's importance in healthcare, health information managers must remain competent with the use of information databases that generate crucial reports for administrators and physicians.

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Educational programs
The requisites and accreditation processes for health information management education and professional activity vary across jurisdictions. In the United States, the CAHIIM requires continued accreditation for accredited programs in health information management. The current standard is that accreditation may be maintained with periodic site visits, submission of an annual report, informing CAHIIM of adverse changes within the program and paying CAHIIM administrative fees.[14][15] HIM students may opt to participate in a full-time bridge program called the Joint Bachelor of Science/Masters Program. With this program, students can achieve both the Bachelor of Science in Health Information Management and the Master of Health Services Administration Program (BSHIM/MHSA). The full-time bridge program allows students to achieve both degrees in five years. Students pursuing the BSHIM/MHSA will be prepared to assume management and executive positions in health-related organizations such as: hospitals, managed care organizations, health information system developers and vendors, and pharmaceutical companies, and bring their knowledge in HIM to these positions. In Canada, graduates of Canadian Health Information Management Association (CHIMA) programs are eligible to write a national certification examination to pursue a profession in HIM.[16] Online program availability There are many programs that are also available online. Online students collaborate with in-class students using internet technology. With online learning, students are allowed to go through the programs at their own pace. Online students are included in class through group lectures that are recorded and put online, discussion boards and are members of group projects with in-class students. Some online students are even allowed to attend some classes on campus and take some classes online. The CAHIIM lists accredited online programs on its website.[17] Further education for health information professionals Education is an important aspect in being successful in the world of health information management. Aside from initial credentials, health information professionals may wish to pursue a Masters of Business Administration, Masters of Health Administration, or other Masters programs in health data management, information technology and systems, and organization and management. Gaining further education advances the health professional's career and qualifies the individual for upper-management positions.

Records and practices used in health information management


Healthcare quality and safety require that the right information be available at the right time to support patient care and health system management decisions. Gaining consensus on essential data content and documentation standards is a necessary prerequisite for high-quality data in the interconnected healthcare system of the future. Continuous quality management of data standards and content is key to ensuring that information is usable and actionable.[18]

Records
The patient health record is the primary legal record documenting the health care services provided to a person in any aspect of the health care system. The term includes routine clinical or office records, records of care in any health related setting, preventive care, lifestyle evaluation, research protocols and various clinical databases. This repository of information about a single patient is generated by health care professionals as a direct result of interaction with a patient or with individuals who have personal knowledge of the patient. The primary patient record is the record that is used by health care professionals while providing patient care services to review patient data or document their own observations, actions, or instructions.

Health information management The secondary patient record is a record that is derived from the primary record and contains selected data elements to aid non clinical persons in supporting, evaluating and advancing patient care. Patient care support refers to administration, regulation, and payment functions.

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Practices
Methods to ensure Data Quality The accuracy of data depends on the manual or computer information system design for collecting, recording, storing, processing, accessing and displaying data as well as the ability and follow- through of the people involved in each phase of these activities. Everyone involved with documenting or using health information is responsible for its quality. According to AHIMAs Data Quality Management Model, there are four key processes for data: 1. 2. 3. 4. Application: the purpose for which the data are collected. Collection: the processes by which data elements are accumulated. Warehousing: the processes and systems used to store and maintain data and data journals. Analysis: the process of translating data into information utilized for an application.

Each aspect is analyzed with 10 different data characteristics: 1. Accuracy: Data are the correct values and are valid. 2. Accessibility: Data items should be easily obtainable and legal to collect. 3. Comprehensiveness: All required data items are included. Ensure that the entire scope of the data is collected and document intentional limitations. 4. Consistency: The value of the data should be reliable and the same across applications. 5. Currency: The data should be up to date. A datum value is up to date if it is current for a specific point in time. It is outdate if it was current at some preceding time yet incorrect at a later time. 6. Definition: Clear definitions should be provided so that current and future data users will know what the data mean. Each data element should have clear meaning and acceptable values. 7. Granularity: The attributes and values of data should be defined at the correct level of detail. 8. Precision: Data values should be just large enough to support the application or process. 9. Relevancy: The data are meaningful to the performance of the process or application for which they are collected. 10. Timeliness: Timeliness is determined by how the data are being used and their context.

Health information professionals


HIM is a very broad and successful field for health care professionals. There are several career opportunities in Health Information Management and many different traditional and non-traditional settings for an HIM professional to work within. Traditional settings include: Managing an HIM medical records department, cancer registry, coding, trauma registry, transcription, quality improvement, release of information, patient admissions, compliance auditor, physician accreditation, utilization review, physician offices and risk management. Non-traditional settings include: consulting firms, government agencies, law firms, insurance companies, correctional facilities, extended care facilities, pharmaceutical research, information technology and medical software companies.[19]

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Health information managers


Professional health information managers manage and construct health information programs to guarantee they accommodate medical, legal, and ethical standards. They play a crucial role in the maintenance, collection, and analyzing of data that is received by doctors, nurses, and other healthcare players. In return these healthcare data contributors rely on the information to deliver quality healthcare. Managers must work with a group of information technicians to guarantee that the patient's medical records are accurate and are available when needed. In the United States, health information managers are typically certified as a Registered Health Information Administrator (RHIA) after achieving a bachelor's degree in health informatics or health information management from a school accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM) and after passing their respective certification exam.[20] The Certified Health Informatics Systems Professional (CHISP) certification offered by American Society of Health Informatics Managers (ASHIM)[21] is to credit a working level IT or clinical professional who is able to support physician adoption of Health IT. A CHISP professional needs to process knowledge of the health care environment, Health IT, IT, and soft skills including communication skills. RHIAs usually assume a managerial position that interacts will all levels of an organization that use patient data in decision making and everyday operations.[22] They may work in a broad range of settings that span the continuum of healthcare including office based physician practices, nursing homes, home health agencies, mental health facilities, and public health agencies. Health information managers may specialize in registry management, data management, and data quality among other areas.

Medical records and Health information technicians


Medical records (MR) and Health information technicians (HIT) are described as having the following duties according to the U.S. Bureau of Labor Statistics' Occupational Outlook Handbook:[23] assemble patients' health information including medical history, symptoms, examination results, diagnostic tests, treatment methods, and all other healthcare provider services. Technicians organize and manage health information data by ensuring its quality, accuracy, accessibility, and security. They regularly communicate with physicians and other healthcare professionals to clarify diagnoses or to obtain additional information. The International Labour Organization's International Standard Classification of Occupations further notes: "Occupations included in this category require knowledge of medical terminology, legal aspects of health information, health data standards, and computer- or paper-based data management as obtained through formal education and/or prolonged on-the-job training.[24] MRHITs usually work in hospitals. However they also work in a variety of other healthcare settings, including office based physician practices, nursing homes, home health agencies, mental health facilities, and public health agencies. Technicians who specialize in coding are called medical coders or coding specialists. In the United States, health information technicians are certified as a Registered Health Information Technician (RHIT) after completing an associate's degree in health information technology from a school accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM) before they may take their certification exam.[25]

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Professional organizations
American Society of Health Informatics Managers (ASHIM) [26] American Health Information Management Association (AHIMA) Commission on Accreditation of Health Informatics and Information Management Education (CAHIIM) Healthcare Information Management and Systems Society (HIMSS) Health Information Management Association of Australia Limited (HIMAA) [27]

References
[1] World Health Organization. (2010). Classifying health workers. Geneva: WHO. [2] Stansfield S. (2005). Structuring information and incentives to improve health. Bulletin of the World Health Organization, 83(8):562. [3] (LaTour, Kathleen M., & Maki, Shirley Eichenwald. (2010). Health information management concepts, principles, and practice. Chicago, Illinois: American Health Information Management Association.)(LaTour, & Maki, 2010). [4] LaTour, Kathleen. Health Information Management: Concepts, Principles, and Practice. Chicago: AHIMA, 2006. [5] http:/ / www. douglas. bc. ca/ home. html [6] AHIMA (2010). " AHIMA History (http:/ / www. ahima. org/ about/ history. asp)". AHIMA. Retrieved 2010-01-08. [7] Partner in the Delivery of Quality Healthcare (http:/ / www. ahima. org/ popups/ partner. asp). (n.d.). Retrieved November 28, 2009, from American Health Information Management Association. [8] HIMSS (2008). " AHIMA History (http:/ / www. himss. org/ content/ files/ HIMSS_HISTORY. pdf)". HIMSS Legacy Workgroup. Retrieved 2010-01-08. [9] HIMSS. HIMSS.org (http:/ / www. himss. org). Retrieved 1/8/2010. [10] AHIMA. 6/3/2004 HIM Associate Degree Entry-Level Competencies (http:/ / library. ahima. org/ xpedio/ groups/ public/ documents/ internalproject_bok/ bok1_036792. pdf). AHIMA Education Strategy Committee. Accessed 1/8/2010. [11] AHIMA. 4/20/2004 HIM Baccalaureate Degree Entry-Level Competencies (http:/ / library. ahima. org/ xpedio/ groups/ public/ documents/ internalproject_bok/ bok1_036793. pdf). AHIMA Education Strategy Committee. Retrieved 1/8/2010. [12] Wall Street Journal. "Benefits of Electronic Health Records Seen as Outweighing Privacy Risks" (http:/ / online. wsj. com/ public/ article/ SB119565244262500549. html?mod=blog). Retrieved 1/8/2010. [13] Healthcare Integration and Connectivity: Results of a Survey by the Enterprise Information Systems Steering Committee (http:/ / www. himss. org/ content/ files/ IntegrationConnectivitySurvey. pdf) page 4. HIMSS. Retrieved 1/8/2010. [14] CAHIIM. 2005 Interpretation of Standards: Associate Degree (http:/ / library. ahima. org/ xpedio/ groups/ public/ documents/ accreditation/ bok1_044387. pdf) section VI.F. Retrieved 1/8/2010. [15] CAHIIM. Interpretation of Standards: Baccalaureate Degree (http:/ / library. ahima. org/ xpedio/ groups/ public/ documents/ accreditation/ bok1_044386. pdf) section VI.F. Retrieved 1/8/2010. [16] Alberta Occupational Profiles, 2011. Health Information Management Professional http:/ / alis. alberta. ca/ occinfo/ Content/ RequestAction. asp?aspAction=GetHTMLProfile& format=html& OCCPRO_ID=71002536 [17] CAHIIM.org (http:/ / www. cahiim. org/ accredpgms. asp). Retrieved 1/8/2010. [18] Mervat Abdelhak et al.: Health Information: Management of a Strategic Resource, Second Edition [19] Medical Records and Health Information Technicians (http:/ / www. bls. gov/ oco/ ocoS103. htm). Retrieved 1/8/2010. [20] AHIMA. Eligibility Requirements: Registered Health Information Administrator (http:/ / www. ahima. org/ certification/ rhia/ requirements. aspx). Retrieved 1/8/2010. [21] CHISP Healthcare IT certification. CHISP Certification Requirement (http:/ / ashim. org/ certification/ ). Retrieved 3/2/2010. [22] Chicago State University Profession (http:/ / www. csu. edu/ healthsciences/ healthinformationadministration/ documents/ profession. pdf). Retrieved 1/8/2010. [23] Occupational Outlook Handbook, 2010-11 Edition. Medical Records and Health Information Technicians (http:/ / www. bls. gov/ oco/ ocoS103. htm). Retrieved 1/8/2010. [24] International Standard Classification of Occupations, 2008 revision: Unit Group 3252: Medical records and health information technicians. http:/ / www. ilo. org/ public/ english/ bureau/ stat/ isco/ index. htm [25] AHIMA (2008). "Eligibility Requirements". AHIMA. http:/ / www. ahima. org/ certification/ rhia/ requirements. aspx. Retrieved 2010-01-08. [26] http:/ / www. ashim. org/ [27] http:/ / www. himaa2. org. au/

Health information management

898

External links
American Health Information Management Association (http://www.AHIMA.org) American Health Information Management Association Salary Study (http://www.ahima.org/salarystudy/) Canadian Health Information Management Association (http://www.echima.ca) Commission on Accreditation for Health Informatics and Information Management Education (http://www. cahiim.org/) Healthcare Information and Management Systems Society (http://www.himss.org) Health Information Management Association Australia (http://www.HIMAA2.org.au) International Federation of Health Records Organizations (http://www.IFHRO.org) National Standards to Protect the Privacy of Personal Health Information (http://www.hhs.gov/ocr/hipaa/) Kansas Health Information Management Association (http://www.khima.com/) American Society of Health Informatics Managers (http://www.ashim.org/) http://www.cd-ed.com/programs-health-information-management.html Health Information Technology Careers (http://www.healthinformationtechnologycareers.com/)

Healthcare Information and Management Systems Society

899

Healthcare Information and Management Systems Society


Healthcare Information and Management Systems Society
Abbreviation Formation Legalstatus HIMSS 1961 NPO

Headquarters Chicago, IL Membership Chair Website 50,000+ individual members, 570+ corporate members, 225 not-for-profit associations members C. Martin Harris, MD, MBA, FHIMSS http:/ / www. himss. org/

The Healthcare Information and Management Systems Society (HIMSS) is a not-for-profit organization dedicated to improving healthcare quality, safety, cost-effectiveness, and access, through the best use of information technology and management systems. Originally founded in 1961 as the Hospital Management Systems Society, it is now headquartered in Chicago, Illinois. The society includes more than 50,000 individual members, over 570 corporate members, and more than 225 not-for-profit organizations. HIMSS is a US 501(c)6 organization.

History
HIMSS was organized in 1961 as the Hospital Management Systems Society (HMSS), an independent, unincorporated, nonprofit association of individuals. The society was co-founded by Edward J. Gerner and Harold E. Smalley. In late 1961, the constitution of the HIMSS was drafted and approved, and in 1962, the first national convention was held in Baltimore. In 1963, the second national HIMSS convention was held in Chicago, and the following year the HIMSS national headquarters were moved there. In 1967, the Bylaws, Rules and Regulations of HIMSS were written and approved. By 1982, HIMSS had 15 affiliated chapters (14 in the US and 1 in Australia). In 1986, the HIMSS was renamed to include "Information" in the title. By 1996, membership had grown to 7,500. [1]

HIMSS Governance
Elected by the membership, the HIMSS Board of Directors serve a three-year term.

Industry Collaboration
Along with the Radiological Society of North America, HIMSS is a sponsor of the Integrating the Healthcare Enterprise (IHE) initiative. HIMSS is also home to the Electronic Health Records Association. Supported by both the American Medical Informatics Association and HIMSS, the Alliance for Nursing Informatics represents more than 2,000 nurses and brings together 18 distinct nursing informatics groups that function independently. With 76 partnering organizations, HIMSS sponsors National Health IT Week, a collaborative forum during which key healthcare constituents - vendors, provider organizations, payors, pharmaceutical/biotech companies, governmental agencies, industry/professional associations, research foundations, and consumer protection groups - work together to elevate national attention to the necessity of greater health IT (information technology) adoption.

Healthcare Information and Management Systems Society

900

Events held by HIMSS


Annual HIMSS Conference Sessions Online: http://www.prolibraries.com/himss/ Annual Conference and Courses Annual HIMSS Conference: http://www.himssconference.org/ March 3-7, 2013 The event is produced by AVMG Annual HIMSS Conference: http://www.himssconference.org/ February 20-24, 2012 The event is produced by AVMG and features video content produced edgefactory HIMSS AsiaPac: http://www.himssasiapac.org/ May 26-28, 2010 World of Health IT: http://www.worldofhealthit.org/ March 1518, 2010 National Health IT Week: http://www.healthitweek.org/ September 21-25, 2009 HIMSS Virtual Conference: http://www.himssvirtual.org/ June 910, 2010 Regional Chapter Programs: http://www.himss.org/ASP/confCalendarHome.asp?cetid=500/ HIMSS Public Policy Summit: http://www.himss.org/advocacy/activities_policySummit.asp June 16, 2010

References
[1] http:/ / www. himss. org/ content/ files/ HIMSS_HISTORY. pdf

External links
Healthcare Information and Management Systems Society (http://www.himss.org) HIMSS 2010 Annual Conference & Exhibition (http://www.himssconference.org) Integrating the Healthcare Enterprise (http://www.ihe.net) HIMSS Grants Advantage (http://www.grantsadvantage.org) HIMSS Foundation (http://www.himss.org/foundation/)

Health Insurance Portability and Accountability Act

901

Health Insurance Portability and Accountability Act


The Health Insurance Portability and Accountability Act of 1996 (HIPAA; Pub.L. 104191 [1], 110Stat.1936 [2] , enacted August21, 1996) was enacted by the United States Congress and signed by President Bill Clinton in 1996. It has been known as the Kennedy-Kassebaum Act after two of its leading sponsors.[3] Title I of HIPAA protects health insurance coverage for workers and their families when they change or lose their jobs. Title II of HIPAA, known as the Administrative Simplification (AS) provisions, requires the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers.[4] This act gives the right to privacy to individuals from age 12 through 18. The provider must have a signed disclosure from the affected before giving out any information on provided health care to anyone, including parents.[5][] The administrative simplification provisions also address the security and privacy of health data. The standards are meant to improve the efficiency and effectiveness of the nation's health care system by encouraging the widespread use of electronic data interchange in the U.S. health care system.[citation needed]

Title I: Health Care Access, Portability, and Renewability


Title I of HIPAA regulates the availability and breadth of group health plans and certain individual health insurance policies. It amended the Employee Retirement Income Security Act, the Public Health Service Act, and the Internal Revenue Code. Title I also limits restrictions that a group health plan can place on benefits for preexisting conditions. Group health plans may refuse to provide benefits relating to preexisting conditions for a period of 12 months after enrollment in the plan or 18 months in the case of late enrollment.[6] However, individuals may reduce this exclusion period if they had group health plan coverage or health insurance prior to enrolling in the plan. Title I allows individuals to reduce the exclusion period by the amount of time that they had "creditable coverage" prior to enrolling in the plan and after any "significant breaks" in coverage.[7] "Creditable coverage" is defined quite broadly and includes nearly all group and individual health plans, Medicare, and Medicaid.[8] A "significant break" in coverage is defined as any 63 day period without any creditable coverage.[9] Some health care plans are exempted from Title I requirements, such as long-term health plans and limited-scope plans such as dental or vision plans that are offered separately from the general health plan. However, if such benefits are part of the general health plan, then HIPAA still applies to such benefits. For example, if the new plan offers dental benefits, then it must count creditable continuous coverage under the old health plan towards any of its exclusion periods for dental benefits. An alternate method of calculating creditable continuous coverage is available to the health plan under Title I. That is, 5 categories of health coverage can be considered separately, including dental and vision coverage. Anything not under those 5 categories must use the general calculation (e.g., the beneficiary may be counted with 18 months of general coverage, but only 6 months of dental coverage, because the beneficiary did not have a general health plan that covered dental until 6 months prior to the application date). Since limited-coverage plans are exempt from HIPAA requirements, the odd case exists in which the applicant to a general group health plan cannot obtain certificates of creditable continuous coverage for independent limited-scope plans such as dental to apply towards exclusion periods of the new plan that does include those coverages. Hidden exclusion periods are not valid under Title I (e.g., "The accident, to be covered, must have occurred while the beneficiary was covered under this exact same health insurance contract"). Such clauses must not be acted upon by the health plan and also must be re-written so that they comply with HIPAA.

Health Insurance Portability and Accountability Act To illustrate, suppose someone enrolls in a group health plan on January 1, 2006. This person had previously been insured from January 1, 2004 until February 1, 2005 and from August 1, 2005 until December 31, 2005. To determine how much coverage can be credited against the exclusion period in the new plan, start at the enrollment date and count backwards until a significant break in coverage is reached. So, the five months of coverage between August 1, 2005 and December 31, 2005 clearly counts against the exclusion period. But the period without insurance between February 1, 2005 and August 1, 2005 is greater than 63 days. Thus, this is a significant break in coverage, and any coverage prior to it cannot be deducted from the exclusion period. So, this person could deduct five months from his exclusion period, reducing the exclusion period to seven months. Hence, Title I requires that any preexisting condition begin to be covered on August 1, 2006.

902

Title II: Preventing Health Care Fraud and Abuse; Administrative Simplification; Medical Liability Reform
Title II of HIPAA defines policies, procedures and guidelines for maintaining the privacy and security of individually identifiable health information as well as outlining numerous offenses relating to health care and sets civil and criminal penalties for violations. It also creates several programs to control fraud and abuse within the health care system.[10][11][12] However, the most significant provisions of Title II are its Administrative Simplification rules. Title II requires the Department of Health and Human Services (HHS) to draft rules aimed at increasing the efficiency of the health care system by creating standards for the use and dissemination of health care information. These rules apply to "covered entities" as defined by HIPAA and the HHS. Covered entities include health plans, health care clearinghouses, such as billing services and community health information systems, and health care providers that transmit health care data in a way that is regulated by HIPAA.[13][14] Per the requirements of Title II, the HHS has promulgated five rules regarding Administrative Simplification: the Privacy Rule, the Transactions and Code Sets Rule, the Security Rule, the Unique Identifiers Rule, and the Enforcement Rule.

Privacy Rule
The effective compliance date of the Privacy Rule was April 14, 2003 with a one-year extension for certain "small plans". The HIPAA Privacy Rule regulates the use and disclosure of Protected Health Information (PHI) held by "covered entities" (generally, health care clearinghouses, employer sponsored health plans, health insurers, and medical service providers that engage in certain transactions.)[15] By regulation, the Department of Health and Human Services extended the HIPAA privacy rule to independent contractors of covered entities who fit within the definition of "business associates".[16] PHI is any information held by a covered entity which concerns health status, provision of health care, or payment for health care that can be linked to an individual.[17] This is interpreted rather broadly and includes any part of an individual's medical record or payment history. Covered entities must disclose PHI to the individual within 30 days upon request.[18] They also must disclose PHI when required to do so by law such as reporting suspected child abuse to state child welfare agencies.[19] A covered entity may disclose PHI (Protected Health Information) to facilitate treatment, payment, or health care operations without a patient's express written authorization.[20] Any other disclosures of PHI (Protected Health Information) require the covered entity to obtain written authorization from the individual for the disclosure.[21] However, when a covered entity discloses any PHI, it must make a reasonable effort to disclose only the minimum necessary information required to achieve its purpose.[22] The Privacy Rule gives individuals the right to request that a covered entity correct any inaccurate PHI.[23] It also requires covered entities to take reasonable steps to ensure the confidentiality of communications with individuals.[24] For example, an individual can ask to be called at his or her work number instead of home or cell phone numbers.

Health Insurance Portability and Accountability Act The Privacy Rule requires covered entities to notify individuals of uses of their PHI. Covered entities must also keep track of disclosures of PHI and document privacy policies and procedures.[25] They must appoint a Privacy Official and a contact person[26] responsible for receiving complaints and train all members of their workforce in procedures regarding PHI.[27] An individual who believes that the Privacy Rule is not being upheld can file a complaint with the Department of Health and Human Services Office for Civil Rights (OCR).[28][29] However, according to the Wall Street Journal, the OCR has a long backlog and ignores most complaints. "Complaints of privacy violations have been piling up at the Department of Health and Human Services. Between April of 2003 and November 2006, the agency fielded 23,886 complaints related to medical-privacy rules, but it has not yet taken any enforcement actions against hospitals, doctors, insurers or anyone else for rule violations. A spokesman for the agency says it has closed three-quarters of the complaints, typically because it found no violation or after it provided informal guidance to the parties involved."[30] However, in July 2011, UCLA agreed to pay $865,500 in a settlement regarding potential HIPAA violations. An HHS Office for Civil Rights investigation showed that from 2005 to 2008 unauthorized employees repeatedly and without legitimate cause looked at the electronic protected health information of numerous UCLAHS patients.[31] 2013 changes to Privacy Rule In January 2013, HIPAA was updated to a rule that is often referred to as Omnibus Rule.[32] Protection of PHI was changed from indefinite to 50 years after death. More severe penalties were also approved for violation of PHI privacy.

903

Transactions and Code Sets Rule


HIPAA was intended to make the health care system in the United States more efficient by standardizing health care transactions. HIPAA added a new Part C titled "Administrative Simplification" to Title XI of the Social Security Act. This is supposed to simplify health care transactions by requiring all health plans to engage in health care transactions in a standardized way. The HIPAA/EDI provision was scheduled to take effect from October 16, 2003 with a one-year extension for certain "small plans". However, due to widespread confusion and difficulty in implementing the rule, CMS granted a one-year extension to all parties.[citation needed] On January 1, 2012 newer versions, ASC X12 005010 and NCPDP D.0 become effective, replacing the previous ASC X12 004010 and NCPDP 5.1 mandate.[33] The ASC X12 005010 version provides a mechanism allowing the use of ICD-10-CM as well as other improvements. After July 1, 2005 most medical providers that file electronically did have to file their electronic claims using the HIPAA standards in order to be paid.[citation needed] Under HIPAA, HIPAA-covered health plans are now required to use standardized HIPAA electronic transactions. See, 42 USC 1320d-2 and 45 CFR Part 162. Information about this can be found in the final rule for HIPAA electronic transaction standards (74 Fed. Reg. 3296, published in the Federal Register on January 16, 2009), and on the CMS website here:CMS information on HIPAA standardized electronic transactions [34] Key EDI(X12) transactions used for HIPAA compliance are: EDI Health Care Claim Transaction set (837) is used to submit health care claim billing information, encounter information, or both, except for retail pharmacy claims (see EDI Retail Pharmacy Claim Transaction). It can be sent from providers of health care services to payers, either directly or via intermediary billers and claims clearinghouses. It can also be used to transmit health care claims and billing payment information between payers with different payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to monitor the rendering, billing, and/or payment of health care services within a specific health care/insurance industry segment.

Health Insurance Portability and Accountability Act For example, a state mental health agency may mandate all healthcare claims, Providers and health plans who trade professional (medical) health care claims electronically must use the 837 Health Care Claim: Professional standard to send in claims. As there are many different business applications for the Health Care claim, there can be slight derivations to cover off claims involving unique claims such as for Institutions, Professionals, Chiropractors, and Dentists etc. EDI Retail Pharmacy Claim Transaction (NCPDP Telecommunications Standard version 5.1) is used to submit retail pharmacy claims to payers by health care professionals who dispense medications, either directly or via intermediary billers and claims clearinghouses. It can also be used to transmit claims for retail pharmacy services and billing payment information between payers with different payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to monitor the rendering, billing, and/or payment of retail pharmacy services within the pharmacy health care/insurance industry segment. EDI Health Care Claim Payment/Advice Transaction Set (835) can be used to make a payment, send an Explanation of Benefits (EOB), send an Explanation of Payments (EOP) remittance advice, or make a payment and send an EOP remittance advice only from a health insurer to a health care provider either directly or via a financial institution. EDI Benefit Enrollment and Maintenance Set (834) can be used by employers, unions, government agencies, associations or insurance agencies to enroll members to a payer. The payer is a healthcare organization that pays claims, administers insurance or benefit or product. Examples of payers include an insurance company, health care professional (HMO), preferred provider organization (PPO), government agency (Medicaid, Medicare etc.) or any organization that may be contracted by one of these former groups. EDI Payroll Deducted and other group Premium Payment for Insurance Products (820) is a transaction set which can be used to make a premium payment for insurance products. It can be used to order a financial institution to make a payment to a payee. EDI Health Care Eligibility/Benefit Inquiry (270) is used to inquire about the health care benefits and eligibility associated with a subscriber or dependent. EDI Health Care Eligibility/Benefit Response (271) is used to respond to a request inquiry about the health care benefits and eligibility associated with a subscriber or dependent. EDI Health Care Claim Status Request (276) This transaction set can be used by a provider, recipient of health care products or services or their authorized agent to request the status of a health care claim. EDI Health Care Claim Status Notification (277) This transaction set can be used by a health care payer or authorized agent to notify a provider, recipient or authorized agent regarding the status of a health care claim or encounter, or to request additional information from the provider regarding a health care claim or encounter. This transaction set is not intended to replace the Health Care Claim Payment/Advice Transaction Set (835) and therefore, is not used for account payment posting. The notification is at a summary or service line detail level. The notification may be solicited or unsolicited. EDI Health Care Service Review Information (278) This transaction set can be used to transmit health care service information, such as subscriber, patient, demographic, diagnosis or treatment data for the purpose of request for review, certification, notification or reporting the outcome of a health care services review. EDI Functional Acknowledgement Transaction Set (997) this transaction set can be used to define the control structures for a set of acknowledgments to indicate the results of the syntactical analysis of the electronically encoded documents. Although it is not specifically named in the HIPAA Legislation or Final Rule, it is necessary for X12 transaction set processing. The encoded documents are the transaction sets, which are grouped in functional groups, used in defining transactions for business data interchange. This standard does not cover the semantic meaning of the information encoded in the transaction sets.

904

Health Insurance Portability and Accountability Act Brief 5010 Transactions and Code Sets Rules Update Summary 1) Transaction Set (997) will be replaced by Transaction Set (999) "acknowledgement report". 2) The size of many fields {segment elements} will be expanded, causing a need for all IT providers to expand corresponding fields, element, files, GUI, paper media and databases. 3) Some segments have been removed from existing Transaction Sets. 4) Many segments have been added to existing Transaction Sets allowing greater tracking and reporting of cost and patient encounters. 5) Capacity to use both "International Classification of Diseases" versions 9 (ICD-9) and 10 (ICD-10-CM) has been added.[35][36]

905

Security Rule
The Final Rule on Security Standards was issued on February 20, 2003. It took effect on April 21, 2003 with a compliance date of April 21, 2005 for most covered entities and April 21, 2006 for "small plans". The Security Rule complements the Privacy Rule. While the Privacy Rule pertains to all Protected Health Information (PHI) including paper and electronic, the Security Rule deals specifically with Electronic Protected Health Information (EPHI). It lays out three types of security safeguards required for compliance: administrative, physical, and technical. For each of these types, the Rule identifies various security standards, and for each standard, it names both required and addressable implementation specifications. Required specifications must be adopted and administered as dictated by the Rule. Addressable specifications are more flexible. Individual covered entities can evaluate their own situation and determine the best way to implement addressable specifications. Some privacy advocates have argued that this "flexibility" may provide too much latitude to covered entities.[37] The standards and specifications are as follows: Administrative Safeguards policies and procedures designed to clearly show how the entity will comply with the act Covered entities (entities that must comply with HIPAA requirements) must adopt a written set of privacy procedures and designate a privacy officer to be responsible for developing and implementing all required policies and procedures. The policies and procedures must reference management oversight and organizational buy-in to compliance with the documented security controls. Procedures should clearly identify employees or classes of employees who will have access to electronic protected health information (EPHI). Access to EPHI must be restricted to only those employees who have a need for it to complete their job function. The procedures must address access authorization, establishment, modification, and termination. Entities must show that an appropriate ongoing training program regarding the handling of PHI is provided to employees performing health plan administrative functions. Covered entities that out-source some of their business processes to a third party must ensure that their vendors also have a framework in place to comply with HIPAA requirements. Companies typically gain this assurance through clauses in the contracts stating that the vendor will meet the same data protection requirements that apply to the covered entity. Care must be taken to determine if the vendor further out-sources any data handling functions to other vendors and monitor whether appropriate contracts and controls are in place. A contingency plan should be in place for responding to emergencies. Covered entities are responsible for backing up their data and having disaster recovery procedures in place. The plan should document data priority and failure analysis, testing activities, and change control procedures. Internal audits play a key role in HIPAA compliance by reviewing operations with the goal of identifying potential security violations. Policies and procedures should specifically document the scope, frequency, and procedures of audits. Audits should be both routine and event-based.

Health Insurance Portability and Accountability Act Procedures should document instructions for addressing and responding to security breaches that are identified either during the audit or the normal course of operations. Physical Safeguards controlling physical access to protect against inappropriate access to protected data Controls must govern the introduction and removal of hardware and software from the network. (When equipment is retired it must be disposed of properly to ensure that PHI is not compromised.) Access to equipment containing health information should be carefully controlled and monitored. Access to hardware and software must be limited to properly authorized individuals. Required access controls consist of facility security plans, maintenance records, and visitor sign-in and escorts. Policies are required to address proper workstation use. Workstations should be removed from high traffic areas and monitor screens should not be in direct view of the public. If the covered entities utilize contractors or agents, they too must be fully trained on their physical access responsibilities.

906

Technical Safeguards controlling access to computer systems and enabling covered entities to protect communications containing PHI transmitted electronically over open networks from being intercepted by anyone other than the intended recipient. Information systems housing PHI must be protected from intrusion. When information flows over open networks, some form of encryption must be utilized. If closed systems/networks are utilized, existing access controls are considered sufficient and encryption is optional. Each covered entity is responsible for ensuring that the data within its systems has not been changed or erased in an unauthorized manner. Data corroboration, including the use of check sum, double-keying, message authentication, and digital signature may be used to ensure data integrity. Covered entities must also authenticate entities with which they communicate. Authentication consists of corroborating that an entity is who it claims to be. Examples of corroboration include: password systems, two or three-way handshakes, telephone callback, and token systems. Covered entities must make documentation of their HIPAA practices available to the government to determine compliance. In addition to policies and procedures and access records, information technology documentation should also include a written record of all configuration settings on the components of the network because these components are complex, configurable, and always changing. Documented risk analysis and risk management programs are required. Covered entities must carefully consider the risks of their operations as they implement systems to comply with the act. (The requirement of risk analysis and risk management implies that the acts security requirements are a minimum standard and places responsibility on covered entities to take all reasonable precautions necessary to prevent PHI from being used for non-health purposes.)

A Nurse shredding papers in order to be compliant with the physical safeguard section of HIPAA's privacy rule.

Health Insurance Portability and Accountability Act

907

Unique Identifiers Rule (National Provider Identifier)


HIPAA covered entities such as providers completing electronic transactions, healthcare clearinghouses, and large health plans, must use only the National Provider Identifier (NPI) to identify covered healthcare providers in standard transactions by May 23, 2007. Small health plans must use only the NPI by May 23, 2008. Effective from May 2006 (May 2007 for small health plans), all covered entities using electronic communications (e.g., physicians, hospitals, health insurance companies, and so forth) must use a single new NPI. The NPI replaces all other identifiers used by health plans, Medicare, Medicaid, and other government programs. However, the NPI does not replace a provider's DEA number, state license number, or tax identification number. The NPI is 10 digits (may be alphanumeric), with the last digit being a checksum. The NPI cannot contain any embedded intelligence; in other words, the NPI is simply a number that does not itself have any additional meaning. The NPI is unique and national, never re-used, and except for institutions, a provider usually can have only one. An institution may obtain multiple NPIs for different "subparts" such as a free-standing cancer center or rehab facility.

Enforcement Rule
On February 16, 2006, HHS issued the Final Rule regarding HIPAA enforcement. It became effective on March 16, 2006. The Enforcement Rule sets civil money penalties for violating HIPAA rules and establishes procedures for investigations and hearings for HIPAA violations. For many years there were few prosecutions for violations.[38] This may have changed with the fining of $50,000 to the Hospice of North Idaho (HONI) as the first entity to be fined for a potential HIPAA Security Rule breach affecting fewer than 500 people.[39] Rachel Seeger, a spokeswoman for HHS, stated, HONI did not conduct an accurate and thorough risk analysis to the confidentiality of ePHI as part of its security management process from 2005 through Jan. 17, 2012. This investigation was initiated with the theft from an employees vehicle of an unencrypted laptop containing 441 patient records. As of March 2013, the U.S. Dept. of Health and Human Resources (HHS) has investigated over 19,306 cases that have been resolved by requiring changes in privacy practice or by corrective action. If noncompliance is determined by HHS, entities must apply corrective measures. Complaints have been investigated against many different types of businesses such as national pharmacy chains, major health care centers, insurance groups, hospital chains and other small providers. There were 9,146 cases where the HHC investigation found that HIPAA was followed correctly. There were 44,118 cases that HHS did not find eligible cause for enforcement; for example, a violation that started before HIPAA started; cases withdrawn by the pursuer ; or an activity that does not actually violate the Rules. (hhs.gov/enforcement, 2013) Since the HIPAA Act was enacted by Congress, a total of 79,920 HIPAA complaints have been investigated. According to the HHS website, the following lists the issues that have been turned in according to frequency:
1. Misuse and disclosures of PHI 2. No protection in place of health information 3. Patient unable to access their health information 4. Using or disclosing more than the minimum necessary protected health information 5. No safeguards of electronic protected health information. (www.hhs.gov/enforcement, 2013)

The most common entities found to be required to take corrective action in order to be in voluntary compliance according to HHS are listed by frequency: 1.Private Practices 2.Hospitals 3.Outpatient Facilities 4.Group plans such as insurance groups 5.Pharmacies (hhs.gov/enforcement, 2013)

Health Insurance Portability and Accountability Act <hhs.gov/enforcement, 2013>

908

HITECH Act: Privacy Requirements


See the Privacy section of the Health Information Technology for Economic and Clinical Health Act (HITECH Act).

Effects on research and clinical care


The enactment of the Privacy and Security Rules has caused major changes in the way physicians and medical centers operate. The complex legalities and potentially stiff penalties associated with HIPAA, as well as the increase in paperwork and the cost of its implementation, were causes for concern among physicians and medical centers. An August 2006 article in the journal Annals of Internal Medicine detailed some such concerns over the implementation and effects of HIPAA.[]

Effects on research
HIPAA restrictions on researchers have affected their ability to perform retrospective, chart-based research as well as their ability to prospectively evaluate patients by contacting them for follow-up. A study from the University of Michigan demonstrated that implementation of the HIPAA Privacy rule resulted in a drop from 96% to 34% in the proportion of follow-up surveys completed by study patients being followed after a heart attack.[40] Another study, detailing the effects of HIPAA on recruitment for a study on cancer prevention, demonstrated that HIPAA-mandated changes led to a 73% decrease in patient accrual, a tripling of time spent recruiting patients, and a tripling of mean recruitment costs.[41] In addition, informed consent forms for research studies now are required to include extensive detail on how the participant's protected health information will be kept private. While such information is important, the addition of a lengthy, legalistic section on privacy may make these already complex documents even less user-friendly for patients who are asked to read and sign them. These data suggest that the HIPAA privacy rule, as currently implemented, may be having negative impacts on the cost and quality of medical research. Dr. Kim Eagle, professor of internal medicine at the University of Michigan, was quoted in the Annals article as saying, "Privacy is important, but research is also important for improving care. We hope that we will figure this out and do it right."[]

Effects on clinical care


The complexity of HIPAA, combined with potentially stiff penalties for violators, can lead physicians and medical centers to withhold information from those who may have a right to it. A review of the implementation of the HIPAA Privacy Rule by the U.S. Government Accountability Office found that health care providers were "uncertain about their legal privacy responsibilities and often responded with an overly guarded approach to disclosing information...than necessary to ensure compliance with the Privacy rule".[] Reports of this uncertainty continue.[42]

Costs of implementation
In the period immediately prior to the enactment of the HIPAA Privacy and Security Acts, medical centers and medical practices were charged with getting "into compliance". With an early emphasis on the potentially severe penalties associated with violation, many practices and centers turned to private, for-profit "HIPAA consultants" who were intimately familiar with the details of the legislation and offered their services to ensure that physicians and medical centers were fully "in compliance". In addition to the costs of developing and revamping systems and practices, the increase in paperwork and staff time necessary to meet the legal requirements of HIPAA may impact the finances of medical centers and practices at a time when insurance companies and Medicare reimbursement is

Health Insurance Portability and Accountability Act also declining.

909

Education and Training


Education and training of healthcare providers is paramount to correct implementation of the HIPAA Privacy and Security Acts. Effective training must describe the statutory and regulatory background and purpose of HIPAA and a general summary of the principles and key provisions of the Privacy Rule. Explain and define the type of entities that are covered by the Privacy Rule. The term business associate is defined, as are the requirements of the Privacy Rule when they carry out health care activities and functions on behalf of covered entities. Describes Privacy Rule provisions that address how entity organization may affect privacy functions, Describes the health information that is protected by the Privacy Rule. The presentation extensively describes the required and permitted uses and disclosures of PHI by a covered entity or its business associate, including situations where PHI may be used or disclosed without the individuals authorization and when such authorization is required. The Rules minimum necessary provisions and its requirements are explained. Summarizes the Privacy Rules provisions and requirements related to research. Describes when a covered entity may use and disclose PHI for research purposes and what research is affected. The presentation illustrates the relationship of the Privacy Rules research provisions to other research rules, such as the Common Rule. Describes the Privacy Rules administrative requirements for covered entities, such as policies and procedures, data safeguards, documentation and record retention, prohibition on retaliation, complaints to the covered entity, workforce training and sanctions.

HIPAA and drug and alcohol rehabilitation organizations


Special considerations for confidentiality are needed for health care organizations that offer federally-funded drug or alcohol rehabilitation services. Predating HIPAA by over a quarter century are the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970[43] and language amended by the Drug Abuse Office and Treatment Act of 1972.[][44]

Notable Violations
In 2012, two executives at Prime Healthcare Services disclosed a patient's chart to multiple media outlets without the patient's consent. The release was in response to a California Watch article on Prime Healthcare Services billing practices at Shasta Regional Medical Center. In this incident, Randall Hempling, the hospital CEO, and Dr. Marcia McCampbell, its chief medical officer, showed up at the offices of the Redding Record Searchlight with Darlene Courtois in order to refute an article which was about to be published. Courtois did not consent to this release as is required under HIPAA. The hospital admits that they did not have written consent, but instead claim that: "As far as we're concerned, the patient gave that permission when she gave her records to California Watch and was quoted on the record. That waived her privacy." But under HIPAA, there is no such thing as implied authorization.[45] The FBI has questioned Courtois in regard to this information release.[46]

A breakdown of the HIPAA violations that resulted in the illegal exposure of personal information.

Health Insurance Portability and Accountability Act

910

Legislative information
Pub.L. 104191 [1], 110Stat.1936 [2] H.R. 3103 [47]; H. Rept. 104-469, part 1; H. Rept. 104-736 S. 1028 [48]; S. 1698 [49]; S. Rept. 104-156 HHS Security Standards, 45 C.F.R. 160 [50], 162, and 164 HHS Standards for Privacy of Individually Identifiable Health Information, 45 C.F.R. 160 [50] and 164

References
[1] http:/ / www. law. cornell. edu/ jureeka/ index. php?doc=USPubLaws& cong=104& no=191 [2] http:/ / www. gpo. gov/ fdsys/ granule/ STATUTE-110/ STATUTE-110-Pg1936/ content-detail. html [3] 104th Congress, 1st Session, S.1028 (http:/ / www. gpo. gov/ fdsys/ pkg/ BILLS-104s1028is/ pdf/ BILLS-104s1028is. pdf) [4] Centers for Medicare and Medicaid Services (http:/ / www. cms. gov/ HIPAAGenInfo/ ) [14] Definitions of a Covered Entity (http:/ / hipaa. ohio. gov/ tools/ CEDefinition. pdf) [15] Terry, Ken "Patient Privacy - The New Threats" (http:/ / www. physicianspractice. com/ index/ fuseaction/ articles. details/ articleID/ 1299/ page/ 1. htm) Physicians Practice journal, volume 19, number 3, year 2009, access date July 2, 2009 [16] See 45 CFR Sections 160.102 and 160.103 (http:/ / www. medlawplus. com/ library/ legal/ hipaaprivacyreg. htm). [28] "How to File A Health Information Privacy Complaint with the Office for Civil Rights" (http:/ / www. ihs. gov/ AdminMngrResources/ HIPAA/ documents/ OCR_HIPAA_ComplaintFormInstructions. pdf) [30] "Spread of records stirs fears of privacy erosion" (http:/ / www. post-gazette. com/ pg/ 06362/ 749444-114. stm), December 23, 2006, by Theo Francis, The Wall Street Journal [32] http:/ / www. hhs. gov/ ocr/ privacy/ hipaa/ administrative/ omnibus/ index. html [33] CMS Transactions and Code Sets Regulations (http:/ / www. cms. gov/ TransactionCodeSetsStands/ 02_TransactionsandCodeSetsRegulations. asp#TopOfPage) [34] https:/ / www. cms. gov/ ElectronicBillingEDITrans/ 18_5010D0. asp [35] CSM.gov "Medicare & Medicaid Services" "Standards for Electronic Transactions-New Versions, New Standard and New Code Set - Final Rules" [36] "The Looming Problem in Healthcare EDI: ICD-10 and HIPAA 5010 migration" October 10, 2009 - Shahid N. Shah [38] Medical Privacy Law Nets No Fines. (http:/ / www. washingtonpost. com/ wp-dyn/ content/ article/ 2006/ 06/ 04/ AR2006060400672. html) Rob Stein: The Washington Post. [39] (http:/ / www. scmagazine. com/ feds-step-up-hipaa-enforcement-with-hospice-settlement/ article/ 274916/ ) Feds step up HIPAA enforcement with hospice settlement [42] "Keeping Patients Details Private, Even From Kin," New York Times, July 3, 2007. (http:/ / www. nytimes. com/ 2007/ 07/ 03/ health/ policy/ 03hipaa. html?ex=1341115200& en=19160c75b9633d68& ei=5090& partner=rssuserland& emc=rss) [43] Pub.L. 91-161; 42 U.S.C. 290dd-3 (1976); omitted and moved to 42 U.S.C. 290dd-2 (2006 through Pub.L. 102-321) [44] Pub.L. 92-255, 42 U.S.C. 290ee-3 (1976); omitted and moved to 42 U.S.C. 290dd-2 (2006 through Pub.L. 102-321) [46] http:/ / www. redding. com/ news/ 2012/ jan/ 10/ local-prime-patient-visited-by-feds/ [47] http:/ / hdl. loc. gov/ loc. uscongress/ legislation. 104hr3103 [48] http:/ / hdl. loc. gov/ loc. uscongress/ legislation. 104s1028 [49] http:/ / hdl. loc. gov/ loc. uscongress/ legislation. 104s1698 [50] http:/ / www. law. cornell. edu/ cfr/ text/ 45/ 160

External links
California Office of HIPAA Implementation (http://www.ohii.ca.gov/calohi/PrivacySecurity/HIPAA.aspx) (CalOHI) "HIPAA" (http://www.cms.hhs.gov/HIPAAGenInfo/), Centers for Medicare and Medicaid Services Congressional Research Service (CRS) reports regarding HIPAA (http://digital.library.unt.edu/govdocs/crs/ search/?q=hipaa&t=fulltext), University of North Texas Libraries Full text of the Health Insurance Portability and Accountability Act (PDF/TXT) (http://www.gpo.gov/fdsys/ search/pagedetails.action?granuleId=CRPT-104hrpt736&packageId=CRPT-104hrpt736) U.S. Government Printing Office Full text of the Health Insurance Portability and Accountability Act (HTM) (http://www.legalarchiver.org/ hipaa.htm) Legal Archiver

Health Insurance Portability and Accountability Act Office for Civil Rights page on HIPAA (http://www.hhs.gov/ocr/hipaa/) HIPAA documentation, resources and commentary (http://www.hipaa.com/)

911

Bureau of Health Professions


The Bureau of Health Professions is a part of the Health Resources and Services Administration (HRSA), of the United States Department of Health and Human Services. HRSA programs train health care professionals and place them where they are needed most. Grants support scholarship and loan repayment programs at colleges and universities to meet critical workforce shortages and promote diversity within the health professions.

Key Facts
HRSA closely tracks trends in the national healthcare workforce, and issues targeted grants to colleges and universities for scholarship, student loan and debt repayment programs designed to stimulate interest in clinical specialties in which shortages are expected. About 8,000 students graduate each year from these HRSA-supported institutions and one of every three goes to work serving the disadvantaged. HRSA promotes the recruitment, training and placement of minority candidates in Health Professional Shortage Areas (HPSAs) to ensure that the workforce is culturally sensitive and linguistically capable to serve patients of every background. HRSA is the lead federal agency responsible for collecting data, and certifying communities as Health Professional Shortage Areas. The designation takes into consideration such factors as the prevailing rate of poverty and infant mortality; the number of physicians per 1,000 residents; and travel distances to nearest available care. The HPSA designation determines eligibility for numerous federal and state aid programs, including the National Health Service Corps, Nursing Education Loan Repayment Program and Rural Health Clinic Certification.

History
HRSAs health professions programs began in June 1967 and were originally part of the Public Health Service. Over the next decade, these programs were transferred to the National Institutes of Health. By 1980 the programs were transferred to one of HRSAs predecessor agencies, the Health Resources Administration.

Nursing Recruitment and Retention Programs


With a national workforce shortage of 1 million nurses projected by 2025, HRSA supports academic and continuing education projects designed to recruit and retain a strong nursing workforce.

Bureau of Health Professions

912

Nurse Education, Practice, Quality and Retention Program


Program funds are used to increase enrollment in nursing programs, expand nursing practice to improve access to primary health care in medically underserved communities, and support efforts to promote the retention of nurses in the workforce.

Advanced Education Nursing Program


HRSA supports projects that enhance advanced nursing education and practice. This program encourages individuals to serve as nurse practitioners, clinical nurse specialists, nurse midwives, nurse anesthetists, nurse educators, nurse administrators or public health nurses.

Nursing Workforce Diversity Program


To increase nursing education opportunities for individuals from disadvantaged backgrounds, the program provides stipends and scholarships, pre-entry preparation, and retention activities for minority nursing students, pre-nursing students, and students in elementary and secondary schools.

Other Health Professions Programs


Health Careers Opportunity Program
The program is designed to increase the number of individuals from educationally and economically disadvantaged backgrounds who are studying and working in the health and allied health professions. This program also provides support needed to compete, enter, and graduate from health or allied health professions schools, graduate programs in behavior and mental health, and programs to train physician assistants.

Centers Of Excellence
The Centers of Excellence Program provides grants to health professional schools to support educational programs of excellence for underrepresented minority students. These programs strengthen our national capacity to train minority students in health professions.

Scholarships For Disadvantaged Students


HRSA provides funds to individuals from disadvantaged backgrounds to improve their education and graduation rates and improve their ranks in the health professions.

Training Programs
HRSA provides grants to institutions to expand the knowledge base of health professionals and support their continuing education. These funds also support students and faculty in programs designed to increase the number of nurses, pediatricians and primary care providers.

Area Health Education Centers


HRSA supports a network of more than 200 community-based training sites in 47 states and the District of Columbia that provide educational services to students, faculty and practitioners in underserved areas with the aim of increasing the supply of qualified providers in those communities.

Bureau of Health Professions

913

Geriatric Education Centers


Through Geriatric Education Centers, HRSA helps educate and train health professional faculty, students and practitioners in the diagnosis, treatment and prevention of disease, disability and other health problems of the aged.

Public Health Training Centers


The Public Health Training Centers Program strengthens the workforce by providing fundamental training in the core competencies of public health.

Children's Hospital Graduate Medical Education Payment Program


The Childrens Hospital Graduate Medical Education Payment Program provides federal support for direct and indirect graduate medical education of interns and residents in freestanding childrens teaching hospitals.

Practitioner Data Banks


National Practitioner Data Bank
The National Practitioner Data Bank is a clearinghouse that provides information to eligible organizations about malpractice payments, adverse licensure, clinical privilege, and other negative actions taken against health care practitioners and entities.

Healthcare Integrity and Protection Data Bank


The Healthcare Integrity and Protection Data Bank was merged into the National Practitioner Data Bank as of May 6, 2013, in accordance with 78 FR 20473 [1].

References
HRSA Bureau of Health Professions website [2]

References
[1] http:/ / www. gpo. gov/ fdsys/ pkg/ FR-2013-04-05/ pdf/ 2013-07521. pdf [2] http:/ / bhpr. hrsa. gov/

Health informatics

914

Health informatics
Health informatics (also called Health Information Systems, health care informatics, healthcare informatics, medical informatics, nursing informatics, clinical informatics, or biomedical informatics) is a discipline at the intersection of information science, computer science, and health care. It deals with the resources, devices, and methods required to optimize the acquisition, storage, retrieval, and use of information in health and biomedicine. Health informatics tools include computers, clinical guidelines, formal medical terminologies, and information and communication systems. It is applied to the areas of nursing, clinical care, dentistry, pharmacy, public health, occupational therapy, and (bio)medical research.

Electronic patient chart from a health information system

The international standards on the subject are covered by ICS 35.240.80[] in which ISO 27799:2008 is one of the core components.[] Molecular bioinformatics and clinical informatics have converged into the field of translational bioinformatics.

History
World wide use of computer technology in medicine began in the early 1950s with the rise of the computers.[] In 1949, Gustav Wagner established the first professional organization for informatics in Germany.[] The prehistory, history, and future of medical information and health information technology are discussed in reference.[] Specialized university departments and Informatics training programs began during the 1960s in France, Germany, Belgium and The Netherlands. Medical informatics research units began to appear during the 1970s in Poland and in the U.S.[] Since then the development of high-quality health informatics research, education and infrastructure has been a goal of the U.S. and the European Union.[] Early names for health informatics included medical computing, biomedical computing, medical computer science, computer medicine, medical electronic data processing, medical automatic data processing, medical information processing, medical information science, medical software engineering, and medical computer technology.[citation
needed]

The health informatics community is still growing, it is by no means a mature profession, but work in the UK by the voluntary registration body, the UK Council of Health Informatics Professions has suggested eight key constituencies within the domain - information management, knowledge management, portfolio/programme/project management, ICT, education and research, clinical informatics, health records(service and business-related), health informatics service management. These constituencies accommodate professionals in and for the NHS, in academia and commercial service and solution providers. Since the 1970s the most prominent international coordinating body has been the International Medical Informatics Association (IMIA).[1]

Health informatics

915

Medical informatics in the United States


Even though the idea of using computers in medicine emerged as technology advanced in the early 20th century, it was not until the 1950s that informatics began to have an effect in the United States.[] The earliest use of electronic digital computers for medicine was for dental projects in the 1950s at the United States National Bureau of Standards by Robert Ledley.[2] During the mid-1950s, the United States Air Force (USAF) carried out several medical projects on its computers while also encouraging civilian agencies such as the National Academy of Sciences - National Research Council (NAS-NRC) and the National Institutes of Health (NIH) to sponsor such work.[] In 1959, Ledley and Lee B. Lusted published Reasoning Foundations of Medical Diagnosis, a widely-read article in Science, which introduced computing (especially operations research) techniques to medical workers. Ledley and Lusteds article has remained influential for decades, especially within the field of medical decision making.[] Guided by Ledley's late 1950s survey of computer use in biology and medicine (carried out for the NAS-NRC), and by his and Lusted's articles, the NIH undertook the first major effort to introduce computers to biology and medicine. This effort, carried out initially by the NIH's Advisory Committee on Computers in Research (ACCR), chaired by Lusted, spent over $40 million between 1960 and 1964 in order to establish dozens of large and small biomedical research centers in the US.[] One early (1960, non-ACCR) use of computers was to help quantify normal human movement, as a precursor to scientifically measuring deviations from normal, and design of prostheses.[3] The use of computers (IBM 650, 1620, and 7040) allowed analysis of a large sample size, and of more measurements and subgroups than had been previously practical with mechanical calculators, thus allowing an objective understanding of how human locomotion varies by age and body characteristics. A study co-author was Dean of the Marquette University College of Engineering; this work led to discrete Biomedical Engineering departments there and elsewhere. The next steps, in the mid-1960s, were the development (sponsored largely by the NIH) of expert systems such as MYCIN and Internist-I. In 1965, the National Library of Medicine started to use MEDLINE and MEDLARS. Around this time, Neil Pappalardo, Curtis Marble, and Robert Greenes developed MUMPS (Massachusetts General Hospital Utility Multi-Programming System) in Octo Barnett's Laboratory of Computer Science [4] at Massachusetts General Hospital in Boston, another center of biomedical computing that received significant support from the NIH.[5] In the 1970s and 1980s it was the most commonly used programming language for clinical applications. The MUMPS operating system was used to support MUMPS language specifications. As of 2004[6], a descendent of this system is being used in the United States Veterans Affairs hospital system. The VA has the largest enterprise-wide health information system that includes an electronic medical record, known as the Veterans Health Information Systems and Technology Architecture (VistA). A graphical user interface known as the Computerized Patient Record System (CPRS) allows health care providers to review and update a patients electronic medical record at any of the VA's over 1,000 health care facilities. During the 1960s, Morris Collen, a physician working for Kaiser Permanente's Division of Research, developed computerized systems to automate many aspects of multiphasic health checkups. These system became the basis the larger medical databases Kaiser Permanente developed during the 1970s and 1980s.[7] The American College of Medical Informatics (ACMI) has since 1993 annually bestowed the Morris F. Collen, MD Medal for Outstanding Contributions to the Field of Medical Informatics.[8] In the 1970s a growing number of commercial vendors began to market practice management and electronic medical records systems. Although many products exist, only a small number of health practitioners use fully featured electronic health care records systems. Homer R. Warner, one of the fathers of medical informatics,[9] founded the Department of Medical Informatics at the University of Utah in 1968. The American Medical Informatics Association (AMIA) has an award named after him on application of informatics to medicine.

Health informatics Informatics Certifications Like other IT training specialties, there are Informatics certifications available to help informatics professionals stand out and be recognized. The American Nurses Credentialing Center (ANCC) offers a board certification in Nursing Informatics, the Radiology Informatics, the CIIP (Certified Imaging Informatics Professional) certification was created by ABII (The American Board of Imaging Informatics) which is sponsored by SIIM (the Society for Imaging Informatics in Medicine) in 2005. The CIIP certification requires documented experience working in Imaging Informatics, formal testing and is a limited time credential requiring renewal every five years. The exam tests for a combination of IT technical knowledge, clinical understanding, and project management experience thought to represent the typical workload of a PACS administrator or other radiology IT clinical support role. Certifications from PARCA (PACS Administrators Registry and Certifications Association) are also recognized. The five PARCA certifications are tiered from entry level to architect level.

916

Medical informatics in the UK


The broad history of health informatics has been captured in the book UK Health Computing : Recollections and reflections, Hayes G, Barnett D (Eds.), BCS (May 2008) by those active in the field, predominantly members of BCS Health and its constituent groups. The book describes the path taken as early development of health informatics was unorganized and idiosyncratic. In the early -1950s it was prompted by those involved in NHS finance and only in the early 1960s did solutions including those in pathology (1960), radiotherapy (1962), immunization (1963), and primary care (1968) emerge. Many of these solutions, even in the early 1970s were developed in-house by pioneers in the field to meet their own requirements. In part this was due to some areas of health services (for example the immunization and vaccination of children) still being provided by Local Authorities. Interesting, this is a situation which the coalition government propose broadly to return to in the 2010 strategy Equity and Excellence: Liberating the NHS (July 2010); stating: "We will put patients at the heart of the NHS, through an information revolution and greater choice and control with shared decision-making becoming the norm: no decision about me without me and patients having access to the information they want, to make choices about their care. They will have increased control over their own care records." These types of statements present a significant opportunity for health informaticians to come out of the back-office and take up a front-line role supporting clinical practice, and the business of care delivery. The UK health informatics community has long played a key role in international activity, joining TC4 of the International Federation of Information Processing (1969) which became IMIA (1979). Under the aegis of BCS Health, Cambridge was the host for the first EFMI Medical Informatics Europe (1974) conference and London was the location for IMIAs tenth global congress (MEDINFO2001).

Current state of health informatics and policy initiatives


Americas
Argentina Since 1997, the Buenos Aires Biomedical Informatics Group, a nonprofit group, represents the interests of a broad range of clinical and non-clinical professionals working within the Health Informatics sphere. Its purposes are: Promote the implementation of the computer tool in the healthcare activity, scientific research, health administration and in all areas related to health sciences and biomedical research. Support, promote and disseminate content related activities with the management of health information and tools they used to do under the name of Biomedical informatics.

Health informatics Promote cooperation and exchange of actions generated in the field of biomedical informatics, both in the public and private, national and international level. Interact with all scientists, recognized academic stimulating the creation of new instances that have the same goal and be inspired by the same purpose. To promote, organize, sponsor and participate in events and activities for training in computer and information and disseminating developments in this area that might be useful for team members and health related activities. The Argentinian health system is heterogeneous in its function, and because of that the informatics developments show a heterogeneous stage. Many private Health Care center have developed systems, such as the German Hospital of Buenos Aires, or the Hospital Italiano de Buenos Aires that also has a residence program for health informatics. Brazil The first applications of computers to medicine and healthcare in Brazil started around 1968, with the installation of the first mainframes in public university hospitals, and the use of programmable calculators in scientific research applications. Minicomputers, such as the IBM 1130 were installed in several universities, and the first applications were developed for them, such as the hospital census in the School of Medicine of Ribeiro Preto and patient master files, in the Hospital das Clnicas da Universidade de So Paulo, respectively at the cities of Ribeiro Preto and So Paulo campi of the University of So Paulo. In the 1970s, several Digital Corporation and Hewlett Packard minicomputers were acquired for public and Armed Forces hospitals, and more intensively used for intensive-care unit, cardiology diagnostics, patient monitoring and other applications. In the early 1980s, with the arrival of cheaper microcomputers, a great upsurge of computer applications in health ensued, and in 1986 the Brazilian Society of Health Informatics was founded, the first Brazilian Congress of Health Informatics was held, and the first Brazilian Journal of Health Informatics was published. In Brazil, two universities are pioneers in teaching and research in Medical Informatics, both the University of Sao Paulo and the Federal University of Sao Paulo offer undergraduate programs highly qualified in the area as well as extensive graduate programs (MSc and PhD) Canada Health Informatics projects in Canada are implemented provincially, with different provinces creating different systems. A national, federally-funded, not-for-profit organization called Canada Health Infoway was created in 2001 to foster the development and adoption of electronic health records across Canada. As of December 31, 2008 there were 276 EHR projects under way in Canadian hospitals, other health-care facilities, pharmacies and laboratories, with an investment value of $1.5-billion from Canada Health Infoway.[10] Provincial and territorial programmes include the following: eHealth Ontario was created as an Ontario provincial government agency in September 2008. It has been plagued by delays and its CEO was fired over a multimillion-dollar contracts scandal in 2009.[11] Alberta Netcare was created in 2003 by the Government of Alberta. Today the netCARE portal is used daily by thousands of clinicians. It provides access to demographic data, prescribed/dispensed drugs, known allergies/intolerances, immunizations, laboratory test results, diagnostic imaging reports, the diabetes registry and other medical reports. netCARE interface capabilities are being included in electronic medical record products which are being funded by the provincial government.

917

Health informatics United States In 2004, President George W. Bush signed Executive Order 13335 [12], creating the Office of the National Coordinator for Health Information Technology (ONCHIT) as a division of the U.S. Department of Health and Human Services (HHS). The mission of this office is widespread adoption of interoperable electronic health records (EHRs) in the US within 10 years. See quality improvement organizations for more information on federal initiatives in this area. The Certification Commission for Healthcare Information Technology (CCHIT), a private nonprofit group, was funded in 2005 by the U.S. Department of Health and Human Services to develop a set of standards for electronic health records (EHR) and supporting networks, and certify vendors who meet them. In July 2006, CCHIT released its first list of 22 certified ambulatory EHR products, in two different announcements.[13]

918

Europe
The European Union's Member States are committed to sharing their best practices and experiences to create a European eHealth Area, thereby improving access to and quality health care at the same time as stimulating growth in a promising new industrial sector. The European eHealth Action Plan plays a fundamental role in the European Union's strategy. Work on this initiative involves a collaborative approach among several parts of the Commission services.[14][15] The European Institute for Health Records is involved in the promotion of high quality electronic health record systems in the European Union.[16] UK There are different models of health informatics delivery in each of the home countries (England, Scotland, Northern Ireland and Wales) but some bodies like UKCHIP [17] (see below ) operate for those 'in and for' all the home countries and beyond. England NHS informatics in England was contracted out to several vendors for national health informatics solutions under the National Programme for Information Technology (NPfIT) label in the early-mid 2000's, under the auspices of NHS Connecting for Health (part of the Health and Social Care Information Centre as of 1 April 2013). NPfIT originally divided the country into five regions, with strategic 'systems integration' contracts awarded to one of several Local Service Providers (LSP). The various specific technical solutions were required to connect securely with the NHS 'Spine', a system designed to broker data between different systems and care settings).[16] NPfIT fell significant;ly was behind schedule and its scope and design were being revised in real time, exacerbated by media and political lambasting of the Programme's spend (past and projected) against proposed budget. In 2010 a consultation was launched as part of the new Conservative/Liberal Democrat Coalition Government's White Paper 'Liberating the NHS'. This initiative provided little in the way of innovative thinking, primarily re-stating existing strategies within the proposed new context of the Coalition's vision for the NHS. The degree of computerisation in NHS secondary care was quite high before NPfIT, and the programme stagnated further development of the install base - the original NPfIT regional approach provided neither a single, nationwide solution nor local health community agility or autonomy to purchase systems, but instead tried to deal with a hinterland in the middle. Almost all general practices in England and Wales are computerised under the 'GP Systems of Choice' (GPSoC) [18] programme, and patients have relatively extensive computerised primary care clinical records. System choice is the responsibility of individual GP practices and while there is no single, standardised GP system, GPSoC sets relatively rigid minimum standards of performance and functionality for vendors to adhere to. Interoperation between primary and secondary care systems is rather primitive. A focus on interworking (for interfacing and integration) standards is hoped will stimulate synergy between primary and secondary care in sharing necessary information to support the care of individuals. Notably successes to date are in electronic requesting and viewing test results, and in some areas GPs having access to digital X-Ray images from secondary care systems. Scotland has an approach to central connection

Health informatics under way which is more advanced than the English one in some ways. Scotland has the GPASS system whose source code is owned by the State, and controlled and developed by NHS Scotland. GPASS was accepted in 1984. It has been provided free to all GPs in Scotland but has developed poorly.[citation needed] Discussion of open sourcing it as a remedy is occurring. Wales Wales has a dedicated Health Informatics function that supports NHS Wales in leading on the new integrated digital information services and promoting Health Informatics as a career. More information at www.wales.nhs.uk/nwis Emerging Directions (European R&D) The European Commission's preference, as exemplified in the 5th Framework[19] as well as currently pursued pilot projects,[20] is for Free/Libre and Open Source Software (FLOSS) for healthcare. Another stream of research currently focuses on aspects of "big data" in health information systems. For background information on data-related aspects in health informatics see, e.g., the book "Biomedical Informatics" [21] by Andreas Holzinger.

919

Asia and Oceania


In Asia and Australia-New Zealand, the regional group called the Asia Pacific Association for Medical Informatics (APAMI)[22] was established in 1994 and now consists of more than 15 member regions in the Asia Pacific Region. Australia The Australasian College of Health Informatics (ACHI) is the professional association for health informatics in the Asia-Pacific region. It represents the interests of a broad range of clinical and non-clinical professionals working within the health informatics sphere through a commitment to quality, standards and ethical practice.[23] ACHI is an academic institutional member of the International Medical Informatics Association (IMIA)[24] and a full member of the Australian Council of Professions.[25] ACHI is a sponsor of the "e-Journal for Health Informatics",[26] an indexed and peer-reviewed professional journal. ACHI has also supported the "Australian Health Informatics Education Council" (AHIEC) since its founding in 2009.[27] Although there are a number of health informatics organisations in Australia, the Health Informatics Society of Australia[28] (HISA) is regarded as the major umbrella group and is a member of the International Medical Informatics Association (IMIA). Nursing informaticians were the driving force behind the formation of HISA, which is now a company limited by guarantee of the members. The membership comes from across the informatics spectrum that is from students to corporate affiliates. HISA has a number of branches (Queensland, New South Wales, Victoria and Western Australia) as well as special interest groups such as nursing (NIA), pathology, aged and community care, industry and medical imaging (Conrick, 2006). China At last 20 years, China performed a successful transition from its planned economy to a socialist market economy. Along this great and earth-shaking change, Chinas healthcare system also experienced a significant reform to follow and adapt to this historical revolution. In 2003, the data (released from Ministry of Health of the People's Republic of China (MoH)), indicated that the national healthcare-involved expenditure was up to RMB 662.33 billion totally, which accounted for about 5.56% of nation-wide gross domestic products. Before 1980s, the entire healthcare costs were covered in central government annual budget. Since that, the construct of healthcare-expended supporters started to change gradually. Most of the expenditure was contributed by health insurance schemes and private spending, which corresponded to 40% and 45% of total expenditure, respectively. Meanwhile the financially governmental contribution was decreased to 10% only. On the other hand, by 2004, up to 296,492 healthcare facilities were recorded in statistic summary of MoH, and an average of 2.4 clinical beds per 1000 people were mentioned as well.[]

Health informatics Health Informatics in China Along with the development of information technology since 1990s, healthcare providers realised that the information could generate significant benefits to improve their services by computerised cases and data, for instance of gaining the information for directing patient care and assessing the best patient care for specific clinical conditions. Therefore substantial resources were collected to build China's own health informatics system. Most of these resources were arranged to construct Hospital Information System (HIS), which was aimed to Proportion of Nation-wide Hospitals with HIS in minimise unnecessary waste and repetition, subsequently to promote China by 2004 the efficiency and quality-control of healthcare.[29] By 2004, China had successfully spread HIS through approximately 35-40% of nation-wide hospitals.[30] However, the dispersion of hospital-owned HIS varies critically. In the east part of China , over 80% of hospitals constructed HIS, in northwest of China the equivalent was no more than 20%. Moreover, all of the Centers for Disease Control and Prevention (CDC) above rural level, approximately 80% of healthcare organisations above the rural level and 27% of hospitals over town level have the ability to perform the transmission of reports about real-time epidemic situation through public health information system and to analysis infectious diseases by dynamic statistics.[31] Health Informatics Standards in China Collected information at different times, by different participants or systems could frequently lead to issues of misunderstanding, dis-comparing or dis-exchanging. To design an issues-minor system, healthcare providers realised that certain standards were the basis for sharing information and interoperability, however a system lacking standards would be a large impediment to interfere the improvement of corresponding information systems. Given that the standardisation for health informatics depends on the authorities, standardisation events must be involved with government and the subsequently relevant funding and supports were critical. In 2003, the Ministry of Health released the Development Lay-out of National Health Informatics (2003-2010)[32] indicating the identification of standardisation for health informatics which is combining adoption of international standards and development of national standards. In China , the establishment of standardisation was initially facilitated with the development of vocabulary, classification and coding, which is conducive to reserve and transmit information for premium management at national level. By 2006, 55 international/ domestic standards of vocabulary, classification and coding have served in hospital information system. In 2003, the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) and the ICD-10 Clinical Modification (ICD-10-CM) were adopted as standards for diagnostic classification and acute care procedure classification. Simultaneously, the International Classification of Primary Care (ICPC) were translated and tested in China s local applied environment.[33] Another coding standard, named Logical Observation Identifiers Names and Codes (LOINC), was applied to serve as general identifiers for clinical observation in hospitals. Personal identifier codes were widely employed in different information systems, involving name, sex, nationality, family relationship, educational level and job occupation. However, these codes within different systems are inconsistent, when sharing between different regions. Considering this large quantity of vocabulary, classification and coding standards between different jurisdictions, the healthcare provider realised that using multiple systems could generate issues of resource wasting and a non-conflicting national level standard was beneficial and necessary. Therefore, in late 2003, the health informatics group in Ministry of Health released three projects to deal with issues of lacking national health information standards, which were the Chinese National Health Information Framework and Standardisation, the Basic Data Set Standards of Hospital Information System and the Basic Data Set Standards of Public Health Information System.

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Health informatics

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Objectives of Chinese National Health Information Framework and Standardisation 1. Establish national health information framework and identify in what areas standards and guidelines are required 2. Identify the classes, relationships and attributes of national health information framework. Produce a conceptual health data model to cover the scope of the health information framework 3. Create logical data model for specific domains, depicting the logical data entities, the data attributes, and the relationships between the entities according to the conceptual health data model 4. Establish uniform represent standard for data elements according to the data entities and their attributes in conceptual data model and logical data model 5. Circulate the completed health information framework and health data model to the partnership members for review and acceptance 6. Develop a process to maintain and refine the China model and to align with and influence international health data models []

Comparison between China's EHR Standard and Segments of the ASTM E 1384 Standard Recently, researchers from local universities evaluated the performance of Chinas Electronic Health Record(EHR) Standard compared with the American Society for Testing and Materials Standard Practice for Content and Structure of Electronic Health Records in the United States (ASTM E 1384 Standard).[34]
Chinas EHR Standard H.01 Document identifier, H.02 Service object identifier, H.03Demographics, H.04 Contact person, H.05 Address, H.06 Contacts H.07 Medical insurance H.08 Healthcare institution, H.09 Healthcare practitioner H.10 Event summary S.01 Chief complaints S.02 Physical exam S.03 Present illness history S.04 Past medical history Seg4 Provider/Practitioners Seg5 Problem List, Seg14A Administrative/Diagnostic Summary Seg14B Chief Complaint Present Illness/Trauma Care Seg9 Assessments/Exams Seg14B Chief Complaint Present Illness/Trauma Care Seg5 Problem List, Seg6 Immunizations, Seg7 Exposure to Hazardous Substances, Seg8 Family/Prenatal/Cumulative Health/Medical/Dental Nursing History Seg11 Diagnostic Tests Seg5 Problem List, Seg14A Administrative/Diagnostic Summary Seg14E Procedures Seg12 Medications Seg2 Legal Agreements, Seg10 Care/Treatment Plans and Orders, Seg13 Scheduled Appointments/Events Seg9 Assessments/Exams Seg14C Progress Notes/Clinical Course, Seg14D Therapies, Seg14F Disposition Seg3 Financial Seg8 Family/Prenatal/Cumulative Health/Medical/Dental Nursing History, Seg14D Therapies Seg10 Care/Treatment Plans and Orders ASTM E 1384 Standard Seg1 Demographic/Administrative, Seg14A Administrative/Diagnostic Summary

S.05 Specific Exam, S.06 Lab data S.07 Diagnoses S.08 Procedures S.09 Medications S.10 Care/treatment plans

S.11 Assessments S.12 Encounters/episodes notes

S.13 Financial information S.14 Nursing service

S.15 Health guidance

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Seg11 Diagnostic Tests

S.16 Four diagnostic methods in Traditional Chinese medicine

The table above demonstrates details of this comparison which indicates certain domains of improvement for future revisions of EHR Standard in China. Detailedly, these deficiencies are listed in the following. 1. The lack of supporting on privacy and security. The ISO/TS 18308 specifies The EHR must support the ethical and legal use of personal information, in accordance with established privacy principles and frameworks, which may be culturally or jurisdictionally specific (ISO 18308: Health Informatics-Requirements for an Electronic Health Record Architecture, 2004). However this Chinas EHR Standard did not achieve any of the fifteen requirements in the subclass of privacy and security. 2. The shortage of supporting on different types of data and reference. Considering only ICD-9 is referenced as Chinas external international coding systems, other similar systems, such as SNOMED CT in clinical terminology presentation, cannot be considered as familiar for Chinese specialists, which could lead to internationally information-sharing deficiency. 3. The lack of more generic and extensible lower level data structures. Chinas large and complex EHR Standard was constructed for all medical domains. However, the specific and time-frequent attributes of clinical data elements, value sets and templates identified that this once-for-all purpose cannot lead to practical consequence.[35] Hong Kong In Hong Kong a computerized patient record system called the Clinical Management System (CMS) has been developed by the Hospital Authority since 1994. This system has been deployed at all the sites of the Authority (40 hospitals and 120 clinics), and is used by all 30,000 clinical staff on a daily basis, with a daily transaction of up to 2 millions. The comprehensive records of 7 million patients are available on-line in the Electronic Patient Record (ePR), with data integrated from all sites. Since 2004 radiology image viewing has been added to the ePR, with radiography images from any HA site being available as part of the ePR. The Hong Kong Hospital Authority placed particular attention to the governance of clinical systems development, with input from hundreds of clinicians being incorporated through a structured process. The Health Informatics Section in Hong Kong Hospital Authority[36] has close relationship with Information Technology Department and clinicians to develop healthcare systems for the organization to support the service to all public hospitals and clinics in the region. The Hong Kong Society of Medical Informatics (HKSMI) was established in 1987 to promote the use of information technology in healthcare. The eHealth Consortium has been formed to bring together clinicians from both the private and public sectors, medical informatics professionals and the IT industry to further promote IT in healthcare in Hong Kong.[37] New Zealand Health Informatics is taught at five New Zealand universities. The most mature and established is the Otago programme which has been offered for over a decade.[38] Health Informatics New Zealand (HINZ), is the national organisation that advocates for Health Informatics. HINZ organises a conference every year and also publishes an online journal- Healthcare Informatics Review Online. Saudi Arabia The Saudi Association for Health Information (SAHI) was established in 2006[39] to work under direct supervision of King Saud bin Abdulaziz University for Health Sciences to practice public activities, develop theoretical and applicable knowledge, and provide scientific and applicable studies.[40]

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Health Informatics Law


Health informatics law deals with evolving and sometimes complex legal principles as they apply to information technology in health-related fields. It addresses the privacy, ethical and operational issues that invariably arise when electronic tools, information and media are used in health care delivery. Health Informatics Law also applies to all matters that involve information technology, health care and the interaction of information. It deals with the circumstances under which data and records are shared with other fields or areas that support and enhance patient care. As many healthcare systems are making an effort to have patient records more readily available to them via the internet, it is important that providers be sure that there are a few security standards in place in order to make sure that the patients information is safe. They have to be able to assure confidentiality and the security of the people, process, and technology. Since there is also the possibility of payments being made through this system, it is vital that this aspect of their private information will also be protected through cryptography.

Clinical Informatics
Clinical Informatics is concerned with the use of information in health care by clinicians.[41][42] Clinical informaticians transform health care by analyzing, designing, implementing, and evaluating information and communication systems that enhance individual and population health outcomes, improve [patient] care, and strengthen the clinician-patient relationship. Clinical informaticians use their knowledge of patient care combined with their understanding of informatics concepts, methods, and health informatics tools to: assess information and knowledge needs of health care professionals and patients, characterize, evaluate, and refine clinical processes, develop, implement, and refine clinical decision support systems, and lead or participate in the procurement, customization, development, implementation, management, evaluation, and continuous improvement of clinical information systems.

Clinicians collaborate with other health care and information technology professionals to develop health informatics tools which promote patient care that is safe, efficient, effective, timely, patient-centered, and equitable. In October 2011 American Board of Medical Specialties (ABMS), the organization overseeing the certification of physician specialists in the United States, announces the creation of physician certification in Clinical Informatics. The first examination for board certification in the subspecialty of Clinical Informatics will be offered in October 2013 by American Board of Preventive Medicine.

Integrated data repository


Development of the field of clinical informatics lead to creation of large data sets with electronic health record data integrated with other data (such as genomic data). Large data warehouses of often described as integrated data repositories (for example, i2b2 framework) and abbreviated IDR. In research, deidentified IDRs can be used by researchers with less complex ethical oversight. IDRs with data of deceased patients were also suggested as a research resource that does not require IRB approval.[]

Translational bioinformatics
With the completion of the human genome and the recent advent of high throughput sequencing and genome-wide association studies of single nucleotide polymorphisms, the fields of molecular bioinformatics, biostatistics, statistical genetics and clinical informatics are converging into the emerging field of translational bioinformatics.[43][44][45] The relationship between bioinformatics and health informatics, while conceptually related under the umbrella of

Health informatics biomedical informatics,[46] has not always been very clear. The TBI community is specifically motivated with the development of approaches to identify linkages between fundamental biological and clinical information. Along with complementary areas of emphasis, such as those focused on developing systems and approaches within clinical research contexts,[47] insights from TBI may enable a new paradigm for the study and treatment of disease.

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Clinical Research Informatics


Clinical Research Informatics (or, CRI) takes the core foundations, principles, and technologies related to Health Informatics, and applies these to clinical research contexts. As such, CRI is a sub-discipline of sorts of Health Informatics, and interest and activities in CRI have increased greatly in recent years given the overwhelming problems associated with the explosive growth of clinical research data and information.[48] There are a number of activities within clinical research that CRI supports, including: more efficient and effective data collection and acquisition optimal protocol design and efficient management patient recruitment and management adverse event reporting regulatory compliance data storage, transfer, processing and analysis

Computational Health Informatics


Computational health informatics is a branch of Computer Science that deals specifically with computational techniques that are relevant in healthcare. Computational health informatics is also a branch of Health Informatics, but is orthogonal to much of the work going on in health informatics because computer scientist's interest is mainly in understanding fundamental properties of computation. Health informatics, on the other hand, is primarily concerned with understanding fundamental properties of medicine that allow for the intervention of computers. The health domain provides an extremely wide variety of problems that can be tackled using computational techniques, and computer scientists are attempting to make a difference in medicine by studying the underlying principles of computer science that will allow for meaningful (to medicine) algorithms and systems to be developed. Thus, computer scientists working in computational health informatics and health scientists working in medical health informatics combine to develop the next generation of healthcare technologies. Using computers to analyze health data has been around since the 1950s, but it wasn't until the 1990s that the first sturdy models appeared. The development of the internet has helped develop computational health informatics over the past decade. Computer models are used to examine various topics such as how exercise affects obesity, healthcare costs, and many more.[49] Examples of projects in computational health informatics include the COACH project.[50][51]

Health Informatics, Information Systems Education and Research


Bangladesh
In Bangladesh, University of Dhaka has approved a Masters' program in Health Informatics at Bangladesh Institute of Health Sciences [52] with support from the Rockefeller Foundation.[53]

Canada
University of Waterloo - David R. Cheriton School of Computer Science Master of Health Informatics (online professional degree), Master of Math thesis option with a research focus in computational health informatics, and undergraduate courses.[54]

Health informatics Ryerson University Health Informatics Dalhousie University Health Informatics in the Faculty of Computer Science University of Victoria School of Health Information Science University of Toronto Masters of Health Informatics Conestoga College Undergraduate degree in Health Informatics

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Saudi Arabia
King Saud bin Abdulaziz University for Health Sciences has Bachelor in Health Information Management, Bachelor in Health Information Systems, Master in Health Informatics at the College of Public Health and Health Informatics University of Ha'il has a Bachelor in Health Informatics at the College of Public Health and Health Informatics

Chile
Centre for Health Informatics[55]

Cuba
University of Medical Sciences of Cuba Health Informatics].Health Informatics in the Faculty of Computer Science[55] National Nursing Network Informtica. REDENFI Systems Research Centre[56]

Brazil
Federal University of So Paulo Technology in Health Informatics - So Paulo School of Medicine University of So Paulo Health Informatic - College of Medical Sciences of Ribeiro Preto

Netherlands, The
Bachelor of Science Medical Informatics (Dutch)] Faculty of Medicine - Academic Medical Center / University of Amsterdam[57] Master of Science Medical Informatics (English)] Faculty of Medicine - Academic Medical Center / University of Amsterdam[58] Research department Medical Informatics] Academic Medical Center / University of Amsterdam[59] Online e-learning Master Health Informatics for care professionals (HIZ) - starting September 2013

Sweden
Karolinska Institutet[60]

Switzerland
Competence Center Health Network Engineering at the University of St. Gallen[61]

Ireland
Health Information Systems Research Centre

USA
Bryan University Master of Science in Applied Health Informatics[62] IMS Institute for Healthcare Informations, a division of IMS Health [63] Online Master of Science in Medical Informatics at Northwestern University

Health informatics Oregon Health & Science University Biomedical Informatics Program - Master of Science, Master of Biomedical Informatics, PhD, online Graduate Certificate [64] Online Master of Science in Health Informatics at University of Illinois at Chicago Master of Science in Health Informatics and PhD in Informatics, Health Informatics track, at Indiana University-Purdue University Indianapolis[65] Master of Health Informatics at the University of Michigan Master of Science in Health Informatics at University of Missouri Professional Science Master's in Health Informatics and Health Information Technology Certificate at UNC Charlotte The University of Texas Health Science Center at Houston (UTHealth) School of Biomedical Informatics Master of Science in Health Care Informatics at University of Wisconsin Master of Science, Bachelor of Science Concentration, and Graduate Certificate in Health Informatics at the George Mason University Master of Science in Biomedical Informatics at Nova Southeastern University Master of Science in Health Informatics at Northeastern University, Boston, MA [66] Master of Science in Medical Informatics offered jointly between University of Rochester and Rochester Institute of Technology [67]

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References
[4] MGH - Laboratory of Computer Science (http:/ / www. lcs. mgh. harvard. edu/ ) [6] http:/ / en. wikipedia. org/ w/ index. php?title=Health_informatics& action=edit [12] http:/ / www. gpo. gov/ fdsys/ pkg/ FR-2004-04-30/ pdf/ 04-10024. pdf [13] Certification Commission for Healthcare Information Technology (July 18, 2006): CCHIT Announces First Certified Electronic Health Record Products (http:/ / www. cchit. org/ media/ press+ releases/ CCHIT+ Announces+ First+ Certified+ Electronic+ Health+ Record+ Products. htm). Retrieved July 26, 2006. [14] European eHealth Action Plan (http:/ / ec. europa. eu/ information_society/ activities/ health/ policy_action_plan/ index_en. htm) [15] European eHealth Action Plan i2010 (http:/ / ec. europa. eu/ information_society/ eeurope/ i2010/ index_en. htm) [17] http:/ / www. ukchip. org [18] http:/ / systems. hscic. gov. uk/ gpsoc [19] Cordis FP5web (http:/ / cordis. europa. eu/ fp5/ ) [20] European Patient Smart Open Services (http:/ / www. epsos. eu) [21] Holzinger, A. (2012). Biomedical Informatics, Lecture Notes to LV 444.152. Books on Demand, ISBN 978-3-8482-2219-3. [23] Australasian College of Health Informatics [25] ACHI Memberships (http:/ / www. ACHI. org. au) ACHI memberships: Professions Australia [26] eJHI - electronic Journal of Health Informatics (http:/ / www. ejhi. net/ ojs/ index. php/ ejhi/ about/ journalSponsorship) (open access journal) [27] Australian Health Informatics Education Council (AHIEC) (http:/ / www. AHIEC. org. au) AHIEC Auspicing Organisations [36] Health Informatics Section in Hong Kong Hospital Authority (http:/ / www. ha. org. hk/ hi/ Welcome. html) [37] eHealth Consortium (http:/ / www. iproa. org/ ProjectDetail. action?id=270) [48] Richesson, Rachel L., and James E. Andrews. 2012.Clinical research informatics. London: Springer. [52] http:/ / www. bihs. edu. bd/ [53] http:/ / www. buhs. x10. mx/ hi/ [54] http:/ / cs. uwaterloo. ca/ mhi/ [55] http:/ / www. centrodeinformaticaensalud. org [56] http:/ / www. sld. cu/ sitios/ redenfermeria/ [57] http:/ / www. uva. nl/ onderwijs/ bachelor/ bacheloropleidingen/ content/ medische-informatiekunde/ medische-informatiekunde. html [58] http:/ / www. uva. nl/ msc-medicalinformatics [59] http:/ / www. amc. nl/ web/ Research/ Departments/ Overview/ Medical-Informatics-KIK-1/ Medical-Informatics-KIK. htm [60] http:/ / ki. se/ ki/ jsp/ polopoly. jsp?d=31697& a=145608& l=en [61] http:/ / ehealth. iwi. unisg. ch [62] http:/ / bryanuniversity. edu/ applied-health-informatics-program-overview [63] http:/ / www. imshealth. com/ portal/ site/ ims/ menuitem. 5ad1c081663fdf9b41d84b903208c22a/ ?vgnextoid=e39f79d7f269e210VgnVCM10000071812ca2RCRD

Health informatics
[64] http:/ / www. ohsu. edu/ xd/ education/ schools/ school-of-medicine/ departments/ clinical-departments/ dmice/ educational-programs/ dmice-programs/ index. cfm [65] http:/ / informatics. iupui. edu/ health/ [66] http:/ / www. ccs. neu. edu/ graduate/ degree-programs/ m-s-in-health-informatics/ [67] http:/ / medinfomasters. org

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External links
Health informatics (http://www.dmoz.org/Health/Medicine/Informatics/) at the Open Directory Project e-Journal for Health Informatics (http://www.eJHI.net) Article about informatics (http://www.biomedcentral.com/1472-6947/9/24) UK Council for Health Informatics Professions, its principles, code and standards (http://www.ukchip.org) Healthcare Informatics Magazine (http://www.healthcare-informatics.com) Willison, Brian. Advancing Meaningful Use: Simplifying Complex Clinical Metrics Through Visual Representation. (http://piim.newschool.edu/_media/pdfs/PIIM-RESEARCH_AdvancingMeaningfulUse.pdf) Clinfowiki (http://www.clinfowiki.org/) Global Health Informatics Partnership (http://www.ghip.net/)

Health information technology


Health information technology (HIT) provides the umbrella framework to describe the comprehensive management of health information across computerized systems and its secure exchange between consumers, providers, government and quality entities, and insurers. Health information technology (HIT) is in general increasingly viewed as the most promising tool for improving the overall quality, safety and efficiency of the health delivery system (Chaudhry et al., 2006). Broad and consistent utilization of HIT will: Improve health care quality or effectiveness; Increase health care productivity or efficiency; Prevent medical errors and increase health care accuracy and procedural correctness; Reduce health care costs; Increase administrative efficiencies and healthcare work processes; Decrease paperwork and unproductive or idle work time; Extend real-time communications of health informatics among health care professionals; and Expand access to affordable care.

Interoperable HIT will improve individual patient care, but it will also bring many public health benefits including: Early detection of infectious disease outbreaks around the country; Improved tracking of chronic disease management; and Evaluation of health care based on value enabled by the collection of de-identified price and quality information that can be compared.

Concepts and Definitions


Health information technology (HIT) is the application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of health care information, data, and knowledge for communication and decision making (Brailer, & Thompson, 2004). Technology is a broad concept that deals with a species' usage and knowledge of tools and crafts, and how it affects a species' ability to control and adapt to its environment. However, a strict definition is elusive; "technology" can refer to material objects of use to humanity, such as machines, hardware or utensils, but can also encompass broader themes, including systems, methods of organization, and techniques. For HIT, technology represents computers and communications attributes

Health information technology that can be networked to build systems for moving health information. Informatics is yet another integral aspect of HIT. Informatics refers to the science of information, the practice of information processing, and the engineering of information systems. Informatics underlies the academic investigation and practitioner application of computing and communications technology to healthcare, health education, and biomedical research. Health informatics refers to the intersection of information science, computer science, and health care. Health informatics describes the use and sharing of information within the healthcare industry with contributions from computer science, mathematics, and psychology. It deals with the resources, devices, and methods required for optimizing the acquisition, storage, retrieval, and use of information in health and biomedicine. Health informatics tools include not only computers but also clinical guidelines, formal medical terminologies, and information and communication systems. Medical informatics, nursing informatics, public health informatics, and pharmacy informatics are subdisciplines that inform health informatics from different disciplinary perspectives. The processes and people of concern or study are the main variables.

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Implementation of HIT
The Institute of Medicines (2001) call for the use of electronic prescribing systems in all healthcare organizations by 2010 heightened the urgency to accelerate United States hospitals adoption of CPOE systems. In 2004, President Bush signed an Executive Order titled the Presidents Health Information Technology Plan, which established a ten-year plan to develop and implement electronic medical record systems across the US to improve the efficiency and safety of care. According to a study by RAND Health, the US healthcare system could save more than $81 billion annually, reduce adverse healthcare events and improve the quality of care if it were to widely adopt health information technology.[1] The American Recovery and Reinvestment Act, signed into law in 2009 under the Obama Administration, has provided approximately $19 billion in incentives for hospitals to shift from paper to electronic medical records. The American Recovery and Reinvestment Act has set aside $2 billion which will go towards programs developed by the National Coordinator and Secretary to help healthcare providers implement HIT and provide technical assistance through various regional centers. The other $17 billion in incentives comes from Medicare and Medicaid funding for those who adopt HIT before 2015. Healthcare providers who implement electronic records can receive up to $44,000 over four years in Medicare funding and $63,750 over six years in Medicaid funding. The sooner that healthcare providers adopt the system, the more funding they receive. Those who do not adopt electronic health record systems before 2015 do not receive any federal funding.[2] While electronic health records have potentially many advantages in terms of providing efficient and safe care, recent reports have brought to light some challenges with implementing electronic health records. The most immediate barriers for widespread adoption of this technology have been the high initial cost of implementing the new technology and the time required for doctors to train and adapt to the new system. There have also been suspected cases of fraudulent billing, where hospitals inflate their billings to Medicare. Given that healthcare providers have not reached the deadline (2015) for adopting electronic health records, it is unclear what effects this policy will have long term.[3]

Types of technology
In a recent study about the adoption of technology in the United States, Furukawa, and colleagues (2008) classified applications for prescribing to include electronic medical records (EMR), clinical decision support (CDS), and computerized physician order entry (CPOE). They further defined applications for dispensing to include bar-coding at medication dispensing (BarD), robot for medication dispensing (ROBOT), and automated dispensing machines (ADM). And, they defined applications for administration to include electronic medication administration records (EMAR) and bar-coding at medication administration (BarA).

Health information technology

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Electronic Health Record (EHR)


Although frequently cited in the literature the Electronic health record (EHR), previously known as the Electronic medical record (EMR), there is no consensus about the definition (Jha et al., 2008). However, there is consensus that EMRs can reduce several types of errors, including those related to prescription drugs, to preventive care, and to tests and procedures.[4] Recurring alerts remind clinicians of intervals for preventive care and track referrals and test results. Clinical guidelines for disease management have a demonstrated benefit when accessible within the electronic record during the process of treating the patient.[5] Advances in health informatics and widespread adoption of interoperable electronic health US medical groups' adoption of EHR (2005) records promise access to a patient's records at any health care site. A 2005 report noted that medical practices in the United States are encountering barriers to adopting an EHR system, such as training, costs and complexity, but the adoption rate continues to rise (see chart to right).[6] Since 2002, the National Health Service of the United Kingdom has placed emphasis on introducing computers into healthcare. As of 2005, one of the largest projects for a national EHR is by the National Health Service (NHS) in the United Kingdom. The goal of the NHS is to have 60,000,000 patients with a centralized electronic health record by 2010. The plan involves a gradual roll-out commencing May 2006, providing general practices in England access to the National Programme for IT (NPfIT), the NHS component of which is known as the "Connecting for Health Programme".[7] However, recent surveys have shown physicians' deficiencies in understanding the patient safety features of the NPfIT-approved software.[8]

Clinical point of care technology


Computerized Provider (Physician) Order Entry (CPOE) Prescribing errors are the largest identified source of preventable errors in hospitals. A 2006 report by the Institute of Medicine estimated that a hospitalized patient is exposed to a medication error each day of his or her stay.[] Computerized provider order entry (CPOE), formerly called Computer physician order entry, can reduce total medication error rates by 80%, and adverse (serious with harm to patient) errors by 55%.[9] A 2004 survey by Leapfrog [10] found that 16% of US clinics, hospitals and medical practices are expected to be utilizing CPOE within 2 years.[11] In addition to electronic prescribing, a standardized bar code system for dispensing drugs could prevent a quarter of drug errors.[] Consumer information about the risks of the drugs and improved drug packaging (clear labels, avoiding similar drug names and dosage reminders) are other error-proofing measures. Despite ample evidence of the potential to reduce medication errors, competing systems of barcoding and electronic prescribing have slowed adoption of this technology by doctors and hospitals in the United States, due to concern with interoperability and compliance with future national standards.[12] Such concerns are not inconsequential; standards for electronic prescribing for Medicare Part D conflict with regulations in many US states.[] And, aside from regulatory concerns, for the small-practice physician, utilizing CPOE requires a major change in practice work flow and an additional investment of time. Many physicians are not full-time hospital staff; entering orders for their hospitalized patients means taking time away from scheduled patients.[13]

Health information technology

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Technological Innovations, Opportunities, and Challenges


Handwritten reports or notes, manual order entry, non-standard abbreviations and poor legibility lead to substantial errors and injuries, according to the Institute of Medicine (2000) report. The follow-up IOM (2004) report, Crossing the quality chasm: A new health system for the 21st century, advised rapid adoption of electronic patient records, electronic medication ordering, with computer- and internet-based information systems to support clinical decisions.[14] However, many system implementations have experienced costly failures (Ammenwerth et al., 2006). Furthermore, there is evidence that CPOE may actually contribute to some types of adverse events and other medical errors.(Campbell et al., 2007) For example, the period immediately following CPOE implementation resulted in significant increases in reported adverse drug events in at least one study (Bradley, Steltenkamp, & Hite, 2006) and evidence of other errors have been reported.(Bates, 2005a; Bates, Leape, Cullen, & Laird, 1998; Bates; 2005b) Collectively, these reported adverse events describe phenomena related to the disruption of the complex adaptive system resulting from poorly implemented or inadequately planned technological innovation.

Technological Iatrogenesis
Technology may introduce new sources of error[15][16] Technologically induced errors are significant and increasingly more evident in care delivery systems. Terms to describe this new area of error production include the label technological iatrogenesis[17] for the process and e-iatrogenic[18] for the individual error. The sources for these errors include: Prescriber and staff inexperience may lead to a false sense of security; that when technology suggests a course of action, errors are avoided. Shortcut or default selections can override non-standard medication regimens for elderly or underweight patients, resulting in toxic doses. CPOE and automated drug dispensing was identified as a cause of error by 84% of over 500 health care facilities participating in a surveillance system by the United States Pharmacopoeia.[19] Irrelevant or frequent warnings can interrupt work flow. Healthcare information technology can also result in iatrogenesis if design and engineering are substandard, as illustrated in a 14-part detailed analysis done at the University of Sydney.[20]

References
[1] RAND Healthcare: Health Information Technology: Can HIT Lower Costs and Improve Quality? (http:/ / www. rand. org/ pubs/ research_briefs/ RB9136/ index1. html) Retrieved on July 8, 2006 [4] American College of Physicians Observer: How EMR software can help prevent medical mistakes (http:/ / www. acponline. org/ journals/ news/ sep04/ emr. htm) by Jerome H. Carter (September 2004) [7] NHS Connecting for Health: Delivering the National Programme for IT (http:/ / www. connectingforhealth. nhs. uk/ delivery/ ) Retrieved August 4, 2006 [10] http:/ / leapfroggroup. org/ [13] "Computerized Physician Order Entry: Coming to a Hospital Near You" (http:/ / www. physicianspractice. com/ blog/ content/ article/ 1462168/ 2052940) J. Scott Litton, Physicians Practice, March 2012. [20] A Study of An Enterprise Health Information System (http:/ / sydney. edu. au/ engineering/ it/ ~hitru/ index. php?option=com_content& task=view& id=91& Itemid=146)

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Further reading
Ammenwerth, E., Talmon, J., Ash, J. S., Bates, D. W., Beuscart-Zephir, M. C., Duhamel, A., Elkin, P. L., Gardner, R. M., & Geissbuhler, A. (2006). Impact of CPOE on mortality rates contradictory findings, important messages. Methods Inf Med, 45(6): 586-593. Ash, J. S., Sittig, D. F., Poon, E. G., Guappone, K., Campbell, E., & Dykstra, R. H. (2007). The extent and importance of unintended consequences related to computerized provider order entry. Journal of the American Medical Informatics Association, 14(4): 415-423. Bates, D. (2005a). Computerized Physician Order entry and medication errors: finding a balance. Journal of Biomedical Informatics, 38(4): 250-261. Bates, D.W. (2005b). Physicians and ambulatory electronic health records. Health Affairs, 24(5): 1180-1189. Bates, D. W., Leape, L. L., Cullen, D. J., & Laird, N. (1998). Effect of computerized physician order entry and a team intervention on prevention of serious medical errors. Journal of the American Medical Association, 280: 1311-1316. Bradley, V. M., Steltenkamp, C. L., & Hite, K. B. (2006). Evaluation of reported medication errors before and after implementation of computerized practitioner order entry. Journal Healthc Inf Manag, 20(4): 46-53. Brailer, D., & Thompson, T. (2004). Health IT strategic framework. Washington, DC: Department of Health and Human Services. Chaudhry, B. Wang, J., & Wu, S. et al., (2006). Systematic review: Impact of health information technology on quality, efficiency, and costs of medical care, Annals of Internal Medicine, 144(10), 742752. Campbell, E. M., Sittig, D. F., Ash, J. S., Guappone, K. P., & Dykstra, R. H. (2007). In reply to: e-Iatrogenesis: The most critical consequence of CPOE and other HIT. Journal of the American Medical Informatics Association. Edmunds M, Peddicord D, Detmer DE, Shortliffe E. Health IT Policy and Politics: A Primer on Moving Policy Into Action. Featured Session, American Medical Informatics Association Annual Symposium (2009). Available as a webinar at https://www.amia.org/amia-policy-101. Furukawa, M. F., Raghu, T. S., Spaulding, T. J., & Vinze, A. (2008). Health Affairs, 27, (3), 865-875. Institute of Medicine (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, D.C: National Academies Press. Jha, A. K., Doolan, D., Grandt, D., Scott, T. & Bates, D. W. (2008). The use of health information technology in seven nations. International Journal of Medical Informatics, corrected proof in-press. Kawamoto, K. H., Caitlin, A., Balas, E. A., & Lobach, D. F. (2005). Improving clinical practice using clinical decision support systems: A systematic review of trials to identify features critical to success. British Journal of Medicine, 330(7494): 765-774. Sidrov, J. (2006). It aint necessarily so: The electronic health record and the unlikely prospect of reducing healthcare costs. Health Affairs, 25(4): 1079-1085.

External links
Health Resources and Services Administration (HRSA) (http://www.hrsa.gov/healthit/) Health Information Technology (http://www.hhs.gov/healthit/) at US Department of Health & Human Services Healthcare Information Technology (http://www.ansi.org/standards_activities/standards_boards_panels/hisb/ hitsp.aspx?menuid=3) from American National Standards Institute (ANSI) Certification Commission for Healthcare Information Technology (CCHIT) (http://www.cchit.org/) Health Information Technology Videos (http://www.ehrtv.com/) Health IT Discussion Forum (http://www.healthinformaticsforum.com/) Hospital Management Information System (http://www.cdacnoida.in/HIS/index.asp) from Center for Development of Advanced Computing (C-DAC) (http://www.cdacnoida.in/)

Health information technology American Society of Health Informatics Managers (http://www.ashim.org/) Patient Safety Initiatives in India Using Health IT (http://thepatient.in/safety/) Health Information Technology Certification Programs (http://www.chcp.edu/online-programs/ health-information-technology) Health Information Technology Careers (http://www.healthinformationtechnologycareers.com/)

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Health Information Technology for Economic and Clinical Health Act


The Health Information Technology for Economic and Clinical Health Act, abbreviated HITECH Act, was enacted under Title XIII of the American Recovery and Reinvestment Act of 2009 (Pub.L. 1115 [107]). Under the HITECH Act, the United States Department of Health and Human Services is spending $25.9 billion to promote and expand the adoption of health information technology.[1] The Washington Post reported the inclusion of "as much as $36.5 billion in spending to create a nationwide network of electronic health records."[2] At the time it was enacted, it was considered "the most important piece of health care legislation to be passed in the last 20 to 30 years"[3] and the "foundation for health care reform."[3][4] The National Coordinator for Health Information Technology, Dr. Farzad Mostashari, has explained: "You need information to be able to do population health management. You can serve an individual quite well; you can deliver excellent customer service if you wait for someone to walk through the door and then you go and pull their chart. What you can't do with paper charts is ask the question, 'Who didn't walk in the door?'"[5]

Subtitle A--Promotion of Health Information Technology


Part 1--Improving Health Care Quality, Safety, and Efficiency
Electronic Health Records (EHR) The HITECH Act set meaningful use of interoperable EHR adoption in the health care system as a critical national goal and incentivized EHR adoption.[6][] The "goal is not adoption alone but 'meaningful use' of EHRs that is, their use by providers to achieve significant improvements in care."[] Title IV of the act promises maximum incentive payments for Medicaid to those who adopt and use "certified EHRs" of $63,750 over 6 years beginning in 2011. Eligible professionals must begin receiving payments by 2016 to qualify for the program. For Medicare the maximum payments are $44,000 over 5 years. Doctors who do not adopt an EHR by 2015 will be penalized 1% of Medicare payments, increasing to 3% over 3 years. In order to receive the EHR stimulus money, the HITECH act (ARRA) requires doctors to show "meaningful use" of an EHR system. As of June 2010, there are no penalty provisions for Medicaid.[7] Health information exchange (HIE) has emerged as a core capability for hospitals and physicians to achieve "meaningful use" and receive stimulus funding. Healthcare vendors are pushing HIE as a way to allow EHR systems to pull disparate data and function on a more interoperable level[citation needed]. Starting in 2015, hospitals and doctors will be subject to financial penalties under Medicare if they are not using electronic health records.[8] Meaningful use The main components of Meaningful Use are: The use of a certified EHR in a meaningful manner, such as e-prescribing. The use of certified EHR technology for electronic exchange of health information to improve quality of health care.

Health Information Technology for Economic and Clinical Health Act The use of certified EHR technology to submit clinical quality and other measures. In other words, providers need to show they're using certified EHR technology in ways that can be measured significantly in quality and in quantity.[9] The meaningful use of EHRs intended by the US government incentives is categorized as follows: Improve care coordination Reduce healthcare disparities Engage patients and their families Improve population and public health Ensure adequate privacy and security

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The Obama Administration's Health IT program intends to use federal investments to stimulate the market of electronic health records: Incentives: to providers who use IT Strict and open standards: To ensure users and sellers of EHRs work towards the same goal Certification of software: To provide assurance that the EHRs meet basic quality, safety, and efficiency standards The detailed definition of "meaningful use" is to be rolled out in 3 stages over a period of time until 2015. Details of each stage are hotly debated by various groups. Stage 1 was finalized in July 2010[10] while stage 2 was finalized in August 2012.[11] Stage 3 has not yet been finalized.[12] Meaningful use Stage 1 The first steps in achieving meaningful use are to have a certified electronic health record (EHR) and to be able to demonstrate that it is being used to meet the requirements. Stage 1 contains 25 objectives/measures for Eligible Providers (EPs) and 24 objectives/measures for eligible hospitals. The objectives/measures have been divided into a core set and menu set. EPs and eligible hospitals must meet all objectives/measures in the core set (15 for EPs and 14 for eligible hospitals). EPs must meet 5 of the 10 menu-set items during Stage 1, one of which must be a public health objective.[13] Full list of the Core Requirements and a full list of the Menu Requirements. Core Requirements: 1. Use computerized order entry for medication orders. 2. Implement drug-drug, drug-allergy checks. 3. Generate and transmit permissible prescriptions electronically. 4. Record demographics. 5. Maintain an up-to-date problem list of current and active diagnoses. 6. Maintain active medication list. 7. Maintain active medication allergy list. 8. Record and chart changes in vital signs. 9. Record smoking status for patients 13 years old or older. 10. Implement one clinical decision support rule. 11. Report ambulatory quality measures to CMS or the States. 12. Provide patients with an electronic copy of their health information upon request. 13. Provide clinical summaries to patients for each office visit. 14. Capability to exchange key clinical information electronically among providers and patient authorized entities. 15. Protect electronic health information (privacy & security) Menu Requirements: 1. Implement drug-formulary checks. 2. Incorporate clinical lab-test results into certified EHR as structured data.

Health Information Technology for Economic and Clinical Health Act 3. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, and outreach. 4. Send reminders to patients per patient preference for preventive/ follow-up care 5. Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, allergies) 6. Use certified EHR to identify patient-specific education resources and provide to patient if appropriate. 7. Perform medication reconciliation as relevant 8. Provide summary care record for transitions in care or referrals. 9. Capability to submit electronic data to immunization registries and actual submission. 10. Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission. To receive federal incentive money, CMS requires participants in the Medicare EHR Incentive Program to "attest" that during a 90-day reporting period, they used a certified EHR and met Stage 1 criteria for meaningful use objectives and clinical quality measures. For the Medicaid EHR Incentive Program, providers follow a similar process using their state's attestation system.[14] National Coordinator for Health Information Technology (HIT) There is established within the Department of Health and Human Services an Office of the National Coordinator for Health Information Technology (ONC). The National Coordinator is appointed by the Secretary and reports directly to the Secretary. The National Coordinator is responsible for the development of the Nationwide Health Information Network.[15] HIT Policy Committee The HIT Policy Committee recommends a policy framework for the development and adoption of a nationwide health information technology infrastructure that permits the electronic exchange and use of health information.[16] HIT Standards Committee The HIT Standards Committee recommends to the National Coordinator standards, implementation specifications, and certification criteria. The Standards Committee also harmonizes, pilot tests, and ensures consistency with the Social Security Act.

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Subtitle D--Privacy
Part 1--Improved Privacy Provisions and Security Provisions
The HITECH Act requires HIPAA covered entities to report data breaches affecting 500 or more individuals to HHS and the media, in addition to notifying the affected individuals.[17] This subtitle extends the complete Privacy and Security Provisions of HIPAA to business associates of covered entities.[18] This includes the extension of newly updated civil and criminal penalties to business associates. These changes are also required to be included in any business associate agreements with covered entities. On November 30, 2009, the regulations associated with the new enhancements to HIPAA enforcement took effect.[19] Another significant change brought about in Subtitle D of the HITECH Act, is the new breach notification requirements. This imposes new notification requirements on covered entities, business associates, vendors of personal health records (PHR) and related entities if a breach of unsecured protected health information (PHI) occurs. On April 27, 2009, the Department of Health and Human Services (HHS) issued guidance on how to secure protected health information appropriately.[20] Both HHS and the Federal Trade Commission (FTC) were required under the HITECH Act to issue regulations associated with the new breach notification requirements. The HHS rule was published in the Federal Register on August 24, 2009,[21] and the FTC rule was published on August 25,

Health Information Technology for Economic and Clinical Health Act 2009.[22] The final significant change made in Subtitle D of the HITECH Act, implements new rules for the accounting of disclosures of a patient's health information. It extends the current accounting for disclosure requirements to information that is used to carry out treatment, payment and health care operations when an organization is using an electronic health record (EHR). This new requirement also limits the timeframe for the accounting to three years instead of six as it currently stands. These changes took effect January 1, 2011, for organizations implementing EHRs between January 1, 2009 and January 1, 2011, and January 1, 2013, for organizations who had implemented an EHR prior to January 1, 2009. On July 14, 2010, HHS issued a rule that listed categories that included 701,325 entities and 1.5 million business associates who would have access to patient information without patient consent after the patient had given general consent to their medical practitioner's HIPAA release.[23][24]

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References
[1] HHS.gov/Recovery Recovery Act-Funded Programs (http:/ / www. hhs. gov/ recovery/ programs/ ) Information Technology (IT) section (http:/ / www. hhs. gov/ recovery/ programs/ #Health|Health), also known as HIT [2] The Machinery Behind Health-Care Reform (http:/ / www. washingtonpost. com/ wp-dyn/ content/ article/ 2009/ 05/ 15/ AR2009051503667. html), May 16, 2009 [3] Contractors hungry for stimulus (http:/ / ww2. gazette. net/ stories/ 07242009/ businew181942_32521. shtml), July 24, 2009 [4] Why and How Secretary Sebelius Should Avoid a Network Monopoly (http:/ / thehealthcareblog. com/ blog/ 2009/ 03/ 05/ why-and-how-secretary-sebelius-should-avoid-a-network-monopoly/ ), ADRIAN GROPPER MD, Mar 5, 2009 [5] ONC Chief: Meaningful Use of Meaningful Use Measures (http:/ / www. hhnmag. com/ hhnmag/ HHNDaily/ HHNDailyDisplay. dhtml?id=3950006848), July 23, 2012 [7] Habib JL. EHRs, meaningful use, and a model EMR (http:/ / dbt. consultantlive. com/ display/ article/ 1145628/ 1581538). Drug Benefit Trends. May 2010;22(4):99-101. [8] Pear, Robert. "Warnings Over Privacy of U.S. Health Network." New York Times, February 18, 2007. [10] HHS press release: Secretary Sebelius Announces Final Rules To Support Meaningful Use of Electronic Health Records http:/ / www. hhs. gov/ news/ press/ 2010pres/ 07/ 20100713a. html [11] HHS press release: HHS announces next steps to promote use of electronic health records and health information exchange http:/ / www. hhs. gov/ news/ press/ 2012pres/ 08/ 20120823b. html [12] http:/ / healthit. hhs. gov/ portal/ server. pt?open=512& objID=1325& parentname=CommunityPage& parentid=21& mode=2& in_hi_userid=10741& cached=true [13] http:/ / healthit. hhs. gov/ portal/ server. pt?CommunityID=1206& spaceID=399& parentname=& control=SetCommunity& parentid=& PageID=0& space=CommunityPage& in_hi_totalgroups=1& in_hi_req_ddfolder=6652& in_ra_topoperator=or& in_hi_depth_1=0& in_hi_req_page=20& control=advancedstart& in_hi_req_objtype=18& in_hi_req_objtype=512& in_hi_req_objtype=514& in_hi_req_apps=1& in_hi_revealed_1=0& in_hi_userid=8969& in_hi_groupoperator_1=or& in_hi_model_mode=browse& cached=false& in_ra_groupoperator_1=or& in_tx_fulltext=stage+ 1 [14] Torrieri, Marisa "Dealing with Meaningful Use Attestation Aggravation" (http:/ / www. physicianspractice. com/ meaningful-use/ content/ article/ 1462168/ 2009082). Physicians Practice. January 2012. [15] H.R. 1 (http:/ / thomas. loc. gov/ cgi-bin/ query/ z?c111:H. R. 1:/ ) Subtitle A, Sec. 3001. "The National Coordinator is responsible for the development of a nationwide health information technology infrastructure." [16] H.R. 1 (http:/ / thomas. loc. gov/ cgi-bin/ query/ z?c111:H. R. 1:/ ) Subtitle A, Sec. 3002. [18] 42 U.S.C. 17931 (http:/ / www. gpo. gov/ fdsys/ pkg/ USCODE-2009-title42/ html/ USCODE-2009-title42-chap156-subchapIII-partA-sec17931. htm) [19] HHS Strengthens HIPAA Enforcement (http:/ / www. hhs. gov/ news/ press/ 2009pres/ 10/ 20091030a. html) [20] Guidance for Securing Protected Health Information (http:/ / www. hhs. gov/ ocr/ privacy/ hipaa/ understanding/ coveredentities/ hitechrfi. pdf) [21] Health and Human Services Breach Notification Rule (http:/ / edocket. access. gpo. gov/ 2009/ pdf/ E9-20169. pdf) [22] Federal Trade Commission Breach Notification Rule (http:/ / edocket. access. gpo. gov/ 2009/ pdf/ E9-20142. pdf) [23] Federal Register Document 2010-16718 (https:/ / www. federalregister. gov/ articles/ 2010/ 07/ 14/ 2010-16718/ modifications-to-the-hipaa-privacy-security-and-enforcement-rules-under-the-health-information) tables under paragraphs 75 FR 40911 334 (http:/ / www. federalregister. gov/ a/ 2010-16718/ p-334), 376 (http:/ / www. federalregister. gov/ a/ 2010-16718/ p-376). [24] Health Freedom Watch Newsletter September 2010 (http:/ / www. forhealthfreedom. org/ Newsletter/ September2010. html), Proposed Changes to Privacy Rule Won't Ensure Privacy (http:/ / www. forhealthfreedom. org/ Newsletter/ September2010. html#Article3)

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External links
Congressional Budget Office Cost Estimate (http://www.cbo.gov/publication/20452), January 16, 2009 Congressional Research Service Report (http://opencrs.com/document/R40161/), February 23, 2009 Summary of HIPAA modifications (http://whatishipaa.org/hitech-act.php) Data Breaches Affecting 500 or More Individuals (http://www.hhs.gov/ocr/privacy/hipaa/administrative/ breachnotificationrule/breachtool.html)

Healthcare Information Technology Standards Panel


The American National Standards Institute (ANSI) Healthcare Information Technology Standards Panel (HITSP) was created in 2005 as part of efforts by the Office of the National Coordinator for Health Information Technology (ONC, part of the United States Department of Health and Human Services) to promote interoperability in health care by harmonizing health information technology standards. HITSP is chaired by John Halamka, MD, CIO of Harvard Medical School.

Membership
Membership is by organization and there is currently no cost to join. Volunteers commit time to working on standards harmonization efforts as prioritized by the American Health Information Community (AHIC).

Goals
According to their website, HITSP's mission is to "serve as a cooperative partnership between the public and private sectors for the purpose of achieving a widely accepted and useful set of standards specifically to enable and support widespread interoperability among healthcare software applications, as they will interact in a local, regional and national health information network for the United States." HITSP is generally organized around Use Cases, which are profiles of specific interoperability needs that have been identified by AHIC as being important national priorities. The initial 2006 Use Cases were: Consumer Empowerment Registration Summary Medication History Electronic Health Records (EHRs) Laboratory Result Reporting Biosurveillance Visit Utilization Clinical Data Lab and Radiology

The 2007 Use Cases are: Consumer Access to Clinical Information Access to Clinical Data Provider Permissions Personal Health Record (PHR) Transfer

Healthcare Information Technology Standards Panel Emergency Responder EHR On-site Care Emergency Care Definitive Care Provider Authentication and Authorization Medication Management Medication Reconciliation Ambulatory Prescriptions Contraindications Quality Hospital Measurement and Reporting Clinician Measurement and Reporting Feedback to Clinicians

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External links
Healthcare Information Technology Standards Panel website [1]

References
[1] http:/ / www. hitsp. org

HIV

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HIV
Human immunodeficiency virus

Scanning electron micrograph of HIV-1 (in green) budding from cultured lymphocyte. Multiple round bumps on cell surface represent sites of assembly and budding of virions.

Virus classification Group: Family: Genus: Group VI (ssRNA-RT) Retroviridae Lentivirus Species

Human immunodeficiency virus 1 Human immunodeficiency virus 2 Human immunodeficiency virus (HIV) is a lentivirus (slowly replicating retrovirus) that causes acquired immunodeficiency syndrome (AIDS),[][] a condition in humans in which progressive failure of the immune system allows life-threatening opportunistic infections and cancers to thrive. Infection with HIV occurs by the transfer of blood, semen, vaginal fluid, pre-ejaculate, or breast milk. Within these bodily fluids, HIV is present as both free virus particles and virus within infected immune cells. HIV infects vital cells in the human immune system such as helper T cells (specifically CD4+ T cells), macrophages, and dendritic cells.[1] HIV infection leads to low levels of CD4+ T cells through a number of mechanisms including: apoptosis of uninfected bystander cells,[2] direct viral killing of infected cells, and killing of infected CD4+ T cells by CD8 cytotoxic lymphocytes that recognize infected cells.[3] When CD4+ T cell numbers decline below a critical level, cell-mediated immunity is lost, and the body becomes progressively more susceptible to opportunistic infections.

Virology
Classification

HIV
Comparison of HIV species Species Virulence Infectivity Prevalence HIV-1 High HIV-2 Lower High Low Global Inferred origin Common Chimpanzee

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West Africa Sooty Mangabey

HIV is a member of the genus Lentivirus,[] part of the family Retroviridae.[] Lentiviruses have many morphologies and biological properties in common. Many species are infected by lentiviruses, which are characteristically responsible for long-duration illnesses with a long incubation period.[] Lentiviruses are transmitted as single-stranded, positive-sense, enveloped RNA viruses. Upon entry into the target cell, the viral RNA genome is converted (reverse transcribed) into double-stranded DNA by a virally encoded reverse transcriptase that is transported along with the viral genome in the virus particle. The resulting viral DNA is then imported into the cell nucleus and integrated into the cellular DNA by a virally encoded integrase and host co-factors.[] Once integrated, the virus may become latent, allowing the virus and its host cell to avoid detection by the immune system. Alternatively, the virus may be transcribed, producing new RNA genomes and viral proteins that are packaged and released from the cell as new virus particles that begin the replication cycle anew. Two types of HIV have been characterized: HIV-1 and HIV-2. HIV-1 is the virus that was initially discovered and termed both LAV and HTLV-III. It is more virulent, more infective,[4] and is the cause of the majority of HIV infections globally. The lower infectivity of HIV-2 compared to HIV-1 implies that fewer of those exposed to HIV-2 will be infected per exposure. Because of its relatively poor capacity for transmission, HIV-2 is largely confined to West Africa.[]

Structure and genome


HIV is different in structure from other retroviruses. It is roughly spherical[] with a diameter of about 120nm, around 60times smaller than a red blood cell, yet large for a virus.[5] It is composed of two copies of positive single-stranded RNA that codes for the virus's nine genes enclosed by a conical capsid composed of 2,000 copies of the viral protein p24.[] The single-stranded RNA is tightly bound to nucleocapsid proteins, p7, and enzymes needed for the development of the virion such as reverse transcriptase, proteases, ribonuclease and integrase. A matrix composed of the viral protein p17 surrounds the capsid ensuring the integrity of the virion particle.[]

Diagram of HIV

This is, in turn, surrounded by the viral envelope that is composed of two layers of fatty molecules called phospholipids taken from the membrane of a human cell when a newly formed virus particle buds from the cell. Embedded in the viral envelope are proteins from the host cell and about 70 copies of a complex HIV protein that protrudes through the surface of the virus particle.[] This protein, known as Env, consists of a cap made of three molecules called glycoprotein (gp) 120, and a stem consisting of three gp41 molecules that anchor the structure into the viral envelope.[] This glycoprotein complex enables the virus to attach to and fuse with target cells to initiate the infectious cycle.[] Both these surface proteins, especially gp120, have been considered as targets of future treatments or vaccines against HIV.[] The RNA genome consists of at least seven structural landmarks (LTR, TAR, RRE, PE, SLIP, CRS, and INS), and nine genes (gag, pol, and env, tat, rev, nef, vif, vpr, vpu, and sometimes a tenth tev, which is a fusion of tat env and rev), encoding 19 proteins. Three of these genes, gag, pol, and env, contain information needed to make the structural proteins for new virus particles.[] For example, env codes for a protein called gp160 that is broken down by a cellular protease to form gp120 and gp41. The six remaining genes, tat, rev, nef, vif, vpr, and vpu (or vpx in the

HIV case of HIV-2), are regulatory genes for proteins that control the ability of HIV to infect cells, produce new copies of virus (replicate), or cause disease.[] The two Tat proteins (p16 and p14) are transcriptional transactivators for the LTR promoter acting by binding the TAR RNA element. The TAR may also be processed into microRNAs that regulate the apoptosis genes ERCC1 and IER3.[][] The Rev protein (p19) is involved in shuttling RNAs from the nucleus and the cytoplasm by binding to the RRE RNA element. The Vif protein (p23) prevents the action of APOBEC3G (a cell protein that deaminates DNA:RNA hybrids and/or interferes with the Pol protein). The Vpr protein (p14) arrests cell division at G2/M. The Nef protein (p27) down-regulates CD4 (the major viral receptor), as well as the MHC class I and class II molecules.[][][] Nef also interacts with SH3 domains. The Vpu protein (p16) influences the release of new virus particles from infected cells.[] The ends of each strand of HIV RNA contain an RNA sequence called the long terminal repeat (LTR). Regions in the LTR act as switches to control production of new viruses and can be triggered by proteins from either HIV or the host cell. The Psi element is involved in viral genome packaging and recognized by Gag and Rev proteins. The SLIP element (TTTTTT) is involved in the frameshift in the Gag-Pol reading frame required to make functional Pol.[]

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Tropism
The term viral tropism refers to the cell types a virus infects. HIV can infect a variety of immune cells such as CD4+ T cells, macrophages, and microglial cells. HIV-1 entry to macrophages and CD4+ T cells is mediated through interaction of the virion envelope glycoproteins (gp120) with the CD4 molecule on the target cells and also with chemokine coreceptors.[] Macrophage (M-tropic) strains of HIV-1, or non-syncitia-inducing strains (NSI) use the -chemokine receptor CCR5 for entry and are, thus, able to replicate in macrophages and CD4+ T cells.[] This CCR5 coreceptor is used by almost all primary HIV-1 isolates regardless of viral genetic subtype. Indeed, macrophages play a key role in several critical aspects of HIV infection. They appear to be the first cells infected by HIV and perhaps the source of HIV production when CD4+ cells become depleted in the patient. Macrophages and microglial cells are the cells infected by HIV in the central nervous system. In tonsils and adenoids of HIV-infected patients, macrophages fuse into multinucleated giant cells that produce huge amounts of virus.

Diagram of the immature and mature forms of HIV

T-tropic isolates, or syncitia-inducing (SI) strains replicate in primary CD4+ T cells as well as in macrophages and use the -chemokine receptor, CXCR4, for entry.[][][] Dual-tropic HIV-1 strains are thought to be transitional strains of HIV-1 and thus are able to use both CCR5 and CXCR4 as co-receptors for viral entry. The -chemokine SDF-1, a ligand for CXCR4, suppresses replication of T-tropic HIV-1 isolates. It does this by down-regulating the expression of CXCR4 on the surface of these cells. HIV that use only the CCR5 receptor are termed R5; those that use only CXCR4 are termed X4, and those that use both, X4R5. However, the use of coreceptor alone does not explain viral tropism, as not all R5 viruses are able to use CCR5 on macrophages for a productive infection[] and HIV can also infect a subtype of myeloid dendritic cells,[] which probably constitute a reservoir that maintains infection when CD4+ T cell numbers have declined to extremely low levels.

HIV Some people are resistant to certain strains of HIV.[] For example, people with the CCR5-32 mutation are resistant to infection with R5 virus, as the mutation stops HIV from binding to this coreceptor, reducing its ability to infect target cells. Sexual intercourse is the major mode of HIV transmission. Both X4 and R5 HIV are present in the seminal fluid, which is passed from a male to his sexual partner. The virions can then infect numerous cellular targets and disseminate into the whole organism. However, a selection process leads to a predominant transmission of the R5 virus through this pathway.[][][] How this selective process works is still under investigation, but one model is that spermatozoa may selectively carry R5 HIV as they possess both CCR3 and CCR5 but not CXCR4 on their surface[] and that genital epithelial cells preferentially sequester X4 virus.[] In patients infected with subtype B HIV-1, there is often a co-receptor switch in late-stage disease and T-tropic variants appear that can infect a variety of T cells through CXCR4.[] These variants then replicate more aggressively with heightened virulence that causes rapid T cell depletion, immune system collapse, and opportunistic infections that mark the advent of AIDS.[] Thus, during the course of infection, viral adaptation to the use of CXCR4 instead of CCR5 may be a key step in the progression to AIDS. A number of studies with subtype B-infected individuals have determined that between 40 and 50 percent of AIDS patients can harbour viruses of the SI and, it is presumed, the X4 phenotypes.[][] HIV-2 is much less pathogenic than HIV-1 and is restricted in its worldwide distribution. The adoption of "accessory genes" by HIV-2 and its more promiscuous pattern of coreceptor usage (including CD4-independence) may assist the virus in its adaptation to avoid innate restriction factors present in host cells. Adaptation to use normal cellular machinery to enable transmission and productive infection has also aided the establishment of HIV-2 replication in humans. A survival strategy for any infectious agent is not to kill its host but ultimately become a commensal organism. Having achieved a low pathogenicity, over time, variants more successful at transmission will be selected.[]

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HIV

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Replication cycle

The HIV replication cycle

Entry to the cell HIV enters macrophages and CD4+ T cells by the adsorption of glycoproteins on its surface to receptors on the target cell followed by fusion of the viral envelope with the cell membrane and the release of the HIV capsid into the cell.[][]

Entry to the cell begins through interaction of the trimeric envelope complex (gp160 spike) and both CD4 and a chemokine receptor (generally either CCR5 or CXCR4, [][] but others are known to interact) on the cell surface. gp120 binds to integrin 47 activating LFA-1 the central integrin involved in the establishment of virological synapses, which facilitate efficient cell-to-cell spreading of HIV-1.[] The gp160 spike contains binding domains for both CD4 and chemokine receptors.[][] The first step in fusion involves the high-affinity attachment of the CD4 binding domains of gp120 to CD4. Once gp120 is bound with the CD4 protein, the envelope complex undergoes a structural change, exposing the chemokine binding domains of gp120 and allowing them to interact with the target chemokine receptor.[][] This allows for a more stable two-pronged attachment, which allows the N-terminal fusion peptide gp41 to penetrate the cell membrane.[][] Repeat sequences in gp41, HR1, and HR2 then interact, causing the collapse of the extracellular portion of gp41 into a hairpin. This loop structure brings the virus and cell membranes close together, allowing

Mechanism of Viral Entry/Membrane Fusion 1. Initial interaction between gp120 and CD4.2. Conformational change in gp120 allows for secondary interaction with CCR5. 3. The distal tips of gp41 are inserted in to the cellular membrane. 4. gp41 undergoes significant conformational change; folding in half and forming coiled-coils. This process pulls the viral and cellular membranes together, fusing them.

HIV fusion of the membranes and subsequent entry of the viral capsid.[][] After HIV has bound to the target cell, the HIV RNA and various enzymes, including reverse transcriptase, integrase, ribonuclease, and protease, are injected into the cell.[] During the microtubule-based transport to the nucleus, the viral single-strand RNA genome is transcribed into double-strand DNA, which is then integrated into a host chromosome. HIV can infect dendritic cells (DCs) by this CD4-CCR5 route, but another route using mannose-specific C-type lectin receptors such as DC-SIGN can also be used.[] DCs are one of the first cells encountered by the virus during sexual transmission. They are currently thought to play an important role by transmitting HIV to T-cells when the virus is captured in the mucosa by DCs.[] The presence of FEZ-1, which occurs naturally in neurons, is believed to prevent the infection of cells by HIV.[6] Replication and transcription Shortly after the viral capsid enters the cell, an enzyme called reverse transcriptase liberates the single-stranded (+)RNA genome from the attached viral proteins and copies it into a complementary DNA (cDNA) molecule.[] The process of reverse transcription is extremely error-prone, and the resulting mutations may cause drug resistance or allow the virus to evade the body's immune system. The reverse transcriptase also has ribonuclease activity that degrades the viral RNA during the synthesis of cDNA, as well as DNA-dependent DNA polymerase activity that creates a sense DNA from the antisense cDNA.[7] Together, the cDNA and its complement form a double-stranded viral DNA that is then transported into the cell nucleus. The integration of the viral DNA into the host cell's genome is carried out by another viral enzyme called integrase.[] This integrated viral DNA may then lie dormant, in the latent stage of HIV infection.[] To actively produce the virus, certain cellular transcription factors need to be present, the most important of which is NF-B (NF kappaB), which is upregulated when T-cells become activated.[] This means that those cells most likely to be killed by HIV are those currently fighting infection. During viral replication, the integrated DNA provirus is transcribed into mRNA, which is then spliced into smaller pieces. These small pieces are exported from the nucleus into the cytoplasm, where they are translated into the regulatory proteins Tat (which encourages new Reverse transcription of the HIV genome into virus production) and Rev. As the newly produced Rev protein double strand DNA accumulates in the nucleus, it binds to viral mRNAs and allows unspliced RNAs to leave the nucleus, where they are otherwise retained until spliced.[] At this stage, the structural proteins Gag and Env are produced from the full-length mRNA. The full-length RNA is actually the virus genome; it binds to the Gag protein and is packaged into new virus particles. HIV-1 and HIV-2 appear to package their RNA differently; HIV-1 will bind to any appropriate RNA, whereas HIV-2 will preferentially bind to the mRNA that was used to create the Gag protein itself. This may mean that HIV-1 is better able to mutate (HIV-1 infection progresses to AIDS faster than HIV-2 infection and is responsible for the majority of global infections). Recombination Two RNA genomes are encapsidated in each HIV-1 particle (see Structure and genome of HIV). Upon infection and replication catalyzed by reverse transcriptase, recombination between the two genomes can occur.[8][9] Recombination occurs as the single-strand (+)RNA genomes are reverse transcribed to form DNA. During reverse transcription the nascent DNA can switch multiple times between the two copies of the viral RNA. This form of recombination is known as copy-choice. Recombination events may occur throughout the genome. From 2 to 20

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HIV events per genome may occur at each replication cycle, and these events can rapidly shuffle the genetic information that is transmitted from parental to progeny genomes.[9] Viral recombination produces genetic variation that likely contributes to the evolution of resistance to anti-retroviral therapy.[10] Recombination may also contribute, in principle, to overcoming the immune defenses of the host. Yet, for the adaptive advantages of genetic variation to be realized, the two viral genomes packaged in individual infecting virus particles need to have arisen from separate progenitor parental viruses of differing genetic constitution. It is unknown how often such mixed packaging occurs under natural conditions.[11] Bonhoeffer et al.[12] suggested that template switching by the reverse transcriptase acts as a repair process to deal with breaks in the ssRNA genome. In addition, Hu and Temin[8] suggested that recombination is an adaptation for repair of damage in the RNA genomes. Strand switching (copy-choice recombination) by reverse transcriptase could generate an undamaged copy of genomic DNA from two damaged ssRNA genome copies. This view of the adaptive benefit of recombination in HIV could explain why each HIV particle contains two complete genomes, rather than one. Furthermore, the view that recombination is a repair process implies that the benefit of repair can occur at each replication cycle, and that this benefit can be realized whether or not the two genomes differ genetically. On the view that that recombination in HIV is a repair process, the generation of recombinational variation would be a consequence, but not the cause of, the evolution of template switching.[12] HIV-1 infection causes chronic ongoing inflammation and production of reactive oxygen species.[13] Thus, the HIV genome may be vulnerable to oxidative damages, including breaks in the single-stranded RNA. For HIV, as well as for viruses generally, successful infection depends on overcoming host defensive strategies that often include production of genome-damaging reactive oxygen. Thus, Michod et al.[14] suggested that recombination by viruses is an adaptation for repair of genome damages, and that recombinational variation is a byproduct that may provide a separate benefit. Assembly and release The final step of the viral cycle, assembly of new HIV-1 virions, begins at the plasma membrane of the host cell. The Env polyprotein (gp160) goes through the endoplasmic reticulum and is transported to the Golgi complex where it is cleaved by furin resulting in the two HIV envelope glycoproteins, gp41 and gp120.[15] These are transported to the plasma membrane of the host cell where gp41 anchors gp120 to the membrane of the infected cell. The Gag (p55) and Gag-Pol (p160) polyproteins also associate with the inner surface of the plasma membrane along with the HIV genomic RNA as the forming virion begins to bud from the host cell. The budded virion is still immature as the gag polyproteins still need to be cleaved into the actual matrix, capsid and nucleocapsid proteins. This cleavage is mediated by the also HIV assembling on the surface of an infected packaged viral protease and can be inhibited by antiretroviral drugs of macrophage. the protease inhibitor class. The various structural components then assemble to produce a mature HIV virion.[] Only mature virions are then able to infect another cell.

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HIV

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Genetic variability
HIV differs from many viruses in that it has very high genetic variability. This diversity is a result of its fast replication cycle, with the generation of about 1010 virions every day, coupled with a high mutation rate of approximately 3 x 105 per nucleotide base per cycle of replication and recombinogenic properties of reverse transcriptase.[][][] This complex scenario leads to the generation of many variants of HIV in a single infected patient in the course of one day.[] This variability is compounded when a single cell is simultaneously infected by two or more different strains of HIV. When simultaneous infection occurs, the The phylogenetic tree of the SIV and HIV genome of progeny virions may be composed of RNA strands from two different strains. This hybrid virion then infects a new cell where it undergoes replication. As this happens, the reverse transcriptase, by jumping back and forth between the two different RNA templates, will generate a newly synthesized retroviral DNA sequence that is a recombinant between the two parental genomes.[] This recombination is most obvious when it occurs between subtypes.[] The closely related simian immunodeficiency virus (SIV) has evolved into many strains, classified by the natural host species. SIV strains of the African green monkey (SIVagm) and sooty mangabey (SIVsmm) are thought to have a long evolutionary history with their hosts. These hosts have adapted to the presence of the virus,[] which is present at high levels in the host's blood but evokes only a mild immune response,[16] does not cause the development of simian AIDS,[17] and does not undergo the extensive mutation and recombination typical of HIV infection in humans.[18] In contrast, when these strains infect species that have not adapted to SIV ("heterologous" hosts such as rhesus or cynomologus macaques), the animals develop AIDS and the virus generates genetic diversity similar to what is seen in human HIV infection.[19] Chimpanzee SIV (SIVcpz), the closest genetic relative of HIV-1, is associated with increased mortality and AIDS-like symptoms in its natural host.[] SIVcpz appears to have been transmitted relatively recently to chimpanzee and human populations, so their hosts have not yet adapted to the virus.[] This virus has also lost a function of the Nef gene that is present in most SIVs; without this function, T cell depletion is more likely, leading to immunodeficiency.[] Three groups of HIV-1 have been identified on the basis of differences in the envelope (env) region: M, N, and O.[] Group M is the most prevalent and is subdivided into eight subtypes (or clades), based on the whole genome, which are geographically distinct.[] The most prevalent are subtypes B (found mainly in North America and Europe), A and D (found mainly in Africa), and C (found mainly in Africa and Asia); these subtypes form branches in the phylogenetic tree representing the lineage of the M group of HIV-1. Coinfection with distinct subtypes gives rise to circulating recombinant forms (CRFs). In 2000, the last year in which an analysis of global subtype prevalence was made, 47.2% of infections worldwide were of subtype C, 26.7% were of subtype A/CRF02_AG, 12.3% were of subtype B, 5.3% were of subtype D, 3.2% were of CRF_AE, and the remaining 5.3% were composed of other subtypes and CRFs.[] Most HIV-1 research is focused on subtype B; few laboratories focus on the other subtypes.[] The existence of a fourth group, "P", has been hypothesised based on a virus isolated in 2009.[] The strain is apparently derived from gorilla SIV (SIVgor), first isolated from western lowland gorillas in 2006.[] The genetic sequence of HIV-2 is only partially homologous to HIV-1 and more closely resembles that of SIVsmm.

HIV

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Diagnosis
Many HIV-positive people are unaware that they are infected with the virus.[] For example, in 2001 less than 1% of the sexually active urban population in Africa had been tested, and this proportion is even lower in rural populations.[] Furthermore, in 2001 only 0.5% of pregnant women attending urban health facilities were counselled, tested or receive their test results.[] Again, this proportion is even lower in rural health facilities.[] Since donors may therefore be unaware of their infection, donor blood and blood products used in medicine and medical research are routinely screened for HIV.[]

A generalized graph of the relationship between HIV copies (viral load) and CD4 counts over the average course of untreated HIV infection; any particular + individual's disease course may vary considerably. CD4 T cell count (cells per L) HIV RNA copies permL of plasma

HIV-1 testing is initially by an enzyme-linked immunosorbent assay (ELISA) to detect antibodies to HIV-1. Specimens with a nonreactive result from the initial ELISA are considered HIV-negative unless new exposure to an infected partner or partner of unknown HIV status has occurred. Specimens with a reactive ELISA result are retested in duplicate.[] If the result of either duplicate test is reactive, the specimen is reported as repeatedly reactive and undergoes confirmatory testing with a more specific supplemental test (e.g., Western blot or, less commonly, an immunofluorescence assay (IFA)). Only specimens that are repeatedly reactive by ELISA and positive by IFA or reactive by Western blot are considered HIV-positive and indicative of HIV infection. Specimens that are repeatedly ELISA-reactive occasionally provide an indeterminate Western blot result, which may be either an incomplete antibody response to HIV in an infected person or nonspecific reactions in an uninfected person.[] Although IFA can be used to confirm infection in these ambiguous cases, this assay is not widely used. In general, a second specimen should be collected more than a month later and retested for persons with indeterminate Western blot results. Although much less commonly available, nucleic acid testing (e.g., viral RNA or proviral DNA amplification method) can also help diagnosis in certain situations.[] In addition, a few tested specimens might provide inconclusive results because of a low quantity specimen. In these situations, a second specimen is collected and tested for HIV infection. Modern HIV testing is extremely accurate. A single screening test is correct more than 99% of the time.[]Wikipedia:Manual_of_Style_(dates_and_numbers)#Chronological_items The chance of a false-positive result in standard two-step testing protocol is estimated to be about 1 in 250,000 in a low risk population.[] Testing post exposure is recommended initially and at six weeks, three months, and six months.[]

Research
HIV/AIDS research includes all medical research which attempts to prevent, treat, or cure HIV/AIDS as well as fundamental research about the nature of HIV as an infectious agent and AIDS as the disease caused by HIV. Currently, no cure for HIV/AIDS exists. The most universally recommended method for the prevention of HIV/AIDS is to avoid blood-to-blood contact between people and to otherwise practice safe sex. The most recommended method for treating HIV is to receive attention from a doctor who would coordinate the patient's management of HIV/AIDS.

HIV Many governments and research institutions participate in HIV/AIDS research. This research includes behavioral health interventions, such as research into sex education, and drug development, such as research into microbicides for sexually transmitted diseases, HIV vaccines, and antiretroviral drugs. Other medical research areas include the topics of pre-exposure prophylaxis, post-exposure prophylaxis, and Circumcision and HIV. A hybrid virus, simian human immunodeficiency virus (SHIV), combining parts between HIV and SIV, was created in order to further study different aspects of HIV.[20]

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History
Discovery
AIDS was first clinically observed in 1981 in the United States.[] The initial cases were a cluster of injection drug users and gay men with no known cause of impaired immunity who showed symptoms of Pneumocystis carinii pneumonia (PCP), a rare opportunistic infection that was known to occur in people with very compromised immune systems.[] Soon thereafter, additional gay men developed a previously rare skin cancer called Kaposi's sarcoma (KS).[][] Many more cases of PCP and KS emerged, alerting U.S. Centers for Disease Control and Prevention (CDC) and a CDC task force was formed to monitor the outbreak.[] In the beginning, the CDC did not have an official name for the disease, often referring to it by way of the diseases that were associated with it, for example, lymphadenopathy, the disease after which the discoverers of HIV originally named the virus.[][] They also used Kaposi's Sarcoma and Opportunistic Infections, the name by which a task force had been set up in 1981.[] In the general press, the term GRID, which stood for gay-related immune deficiency, had been coined.[] The CDC, in search of a name, and looking at the infected communities coined the 4H disease, as it seemed to single out Haitians, homosexuals, hemophiliacs, and heroin users.[] However, after determining that AIDS was not isolated to the gay community,[] it was realized that the term GRID was misleading and AIDS was introduced at a meeting in July 1982.[] By September 1982 the CDC started using the name AIDS.[] In 1983, two separate research groups led by Robert Gallo and Luc Montagnier independently declared that a novel retrovirus may have been infecting AIDS patients, and published their findings in the same issue of the journal Science.[][] Gallo claimed that a virus his group had isolated from an AIDS patient was strikingly similar in shape to other human T-lymphotropic viruses (HTLVs) his group had been the first to isolate. Gallo's group called their newly isolated virus HTLV-III. At the same time, Montagnier's group isolated a virus from a patient Robert Gallo, co-discoverer of HIV presenting with swelling of the lymph nodes of the neck and physical weakness, two classic symptoms of AIDS. Contradicting the report from Gallo's group, Montagnier and his colleagues showed that core proteins of this virus were immunologically different from those of HTLV-I. Montagnier's group named their isolated virus lymphadenopathy-associated virus (LAV).[] As these two viruses turned out to be the same, in 1986, LAV and HTLV-III were renamed HIV.[21]

Origins
Both HIV-1 and HIV-2 are believed to have originated in non-human primates in West-central Africa and to have transferred to humans (a process known as zoonosis) in the early 20th century.[] HIV-1 appears to have originated in southern Cameroon through the evolution of SIV(cpz), a simian immunodeficiency virus (SIV) that infects wild chimpanzees (HIV-1 descends from the SIVcpz endemic in the chimpanzee subspecies Pan troglodytes troglodytes).[][] The closest relative of HIV-2 is SIV (smm), a virus of the sooty mangabey (Cercocebus atys atys), an old world monkey living in litoral West Africa (from southern Senegal to western Cte d'Ivoire).[] New World monkeys such as the owl monkey are resistant to HIV-1 infection, possibly because of a genomic fusion of two viral

HIV resistance genes.[94] HIV-1 is thought to have jumped the species barrier on at least three separate occasions, giving rise to the three groups of the virus, M, N, and O.[] There is evidence that humans who participate in bushmeat activities, either as hunters or as bushmeat vendors, commonly acquire SIV.[] However, SIV is a weak virus, and it is typically suppressed by the human immune system within weeks of infection. It is thought that several transmissions of the virus from individual to individual in quick Left to right: the African green monkey source of SIV, the sooty mangabey source of succession are necessary to allow it HIV-2 and the chimpanzee source of HIV-1 enough time to mutate into HIV.[] Furthermore, due to its relatively low person-to-person transmission rate, it can only spread throughout the population in the presence of one or more of high-risk transmission channels, which are thought to have been absent in Africa prior to the 20th century. Specific proposed high-risk transmission channels, allowing the virus to adapt to humans and spread throughout the society, depend on the proposed timing of the animal-to-human crossing. Genetic studies of the virus suggest that the most recent common ancestor of the HIV-1 M group dates back to circa 1910.[95] Proponents of this dating link the HIV epidemic with the emergence of colonialism and growth of large colonial African cities, leading to social changes, including a higher degree of sexual promiscuity, the spread of prostitution, and the concomitant high frequency of genital ulcer diseases (such as syphilis) in nascent colonial cities.[] While transmission rates of HIV during vaginal intercourse are low under regular circumstances they are increased many fold if one of the partners suffers from a sexually transmitted infection resulting in genital ulcers. Early 1900s colonial cities were notable due to their high prevalence of prostitution and genital ulcers to the degree that as of 1928 as many as 45% of female residents of eastern Kinshasa were thought to have been prostitutes and as of 1933 around 15% of all residents of the same city were infected by one of the forms of syphilis.[] An alternative view holds that unsafe medical practices in Africa during years following World War II, such as unsterile reuse of single use syringes during mass vaccination, antibiotic and anti-malaria treatment campaigns, were the initial vector that allowed the virus to adapt to humans and spread.[][96][] The earliest well documented case of HIV in a human dates back to 1959 in the Congo.[] The virus may have been present in the United States as early as 1966.[22]

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Notes
[5] Compared with overview in: Page 3 [8] Hu WS, Temin HM. (1990). Retroviral recombination and reverse transcription. Science 250(4985):1227-1233. PMID 1700865 [9] Charpentier C, Nora T, Tenaillon O, Clavel F, Hance AJ. (2006). Extensive recombination among human immunodeficiency virus type 1 quasispecies makes an important contribution to viral diversity in individual patients. J Virol 80(5):2472-2482. PMID 16474154 Free PMC Article [10] Nora T, Charpentier C, Tenaillon O, Hoede C, Clavel F, Hance AJ. (2007). Contribution of recombination to the evolution of human immunodeficiency viruses expressing resistance to antiretroviral treatment. J Virol 81(14):7620-7628. PMID 17494080 Free PMC Article [11] Chen J, Powell D, Hu WS. (2006). High frequency of genetic recombination is a common feature of primate lentivirus replication. J Virol 80(19):9651-9658. PMID 16973569 Free PMC Article [12] Bonhoeffer S, Chappey C, Parkin NT, Whitcomb JM, Petropoulos CJ. (2004). Evidence for positive epistasis in HIV-1. Science 2004 306(5701):1547-1550. Erratum in: Science. 2008 May 9;320(5877):746. PMID 15567861 Free Article [13] Isral N, Gougerot-Pocidalo MA. (1997). Oxidative stress in human immunodeficiency virus infection. Cell Mol Life Sci 53(11-12):864-870. PMID 9447238

HIV
[14] Michod RE, Bernstein H, Nedelcu AM (2008). Adaptive value of sex in microbial pathogens. Infect Genet Evol 8(3):267-285. PMID 18295550 http:/ / www. hummingbirds. arizona. edu/ Faculty/ Michod/ Downloads/ IGE%20review%20sex. pdf

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References Joint United Nations Programme on HIV/AIDS (UNAIDS) (2011). Global HIV/AIDS Response, Epidemic update and health sector progress towards universal access (http:/ / www. unaids. org/ en/ media/ unaids/ contentassets/ documents/ unaidspublication/ 2011/ 20111130_UA_Report_en. pdf). Joint United Nations Programme on HIV/AIDS.

External links
HIV/AIDS (http://www.dmoz.org/Health/Conditions_and_Diseases/Immune_Disorders/ Immune_Deficiency/AIDS//) at the Open Directory Project

Health Level 7
Health Level Seven (HL7), is a non-profit organization involved in the development of international healthcare informatics interoperability standards.[3] "HL7" also refers to some of the specific standards created by the organization (e.g., HL7 v2.x, v3.0, HL7 RIM).[] HL7 and its members provide a framework (and related standards) for the exchange, integration, sharing, and retrieval of electronic health information. The 2.x versions of the standards, which support clinical practice and the management, delivery, and evaluation of health services, are the most commonly used in the world.[1]

Organization
HL7 is an international community of healthcare subject matter experts and information scientists collaborating to create standards for the exchange, management and integration of electronic healthcare information.[2] HL7 promotes the use of such informatics standards within and among healthcare organizations to increase the effectiveness and efficiency of healthcare information delivery for the benefit of all.[citation needed] The HL7 community is organized in the form of a global organization (Health Level Seven, Inc.) and country-specific affiliate organizations: Health Level Seven, Inc. (HL7, Inc. ) is headquartered in Ann Arbor, Michigan.[] HL7 affiliate organizations, not-for-profit organizations incorporated in local jurisdictions, exist in over 40 countries. The first affiliate organization was created in Germany in 1993.[citation needed] The organizational structure of HL7 Inc. is as follows:[citation needed] The organization is managed by a Board of Directors, which comprises 10 elected positions and three appointed positions. The Chief Executive Officer (currently Charles Jaffe, MD, PhD) serves as an ex officio member of and reports to the Board of Directors. The Chief Technology Officer (currently John Quinn); and the Chief Operations Officer (currently Mark McDougall) report to the CEO and also serve as ex officio members on the Board of Directors. Members of HL7 are known collectively as "The Working Group". The Working Group is responsible for defining the HL7 standard protocol and is composed of Standing Administrative Committees and Working Groups. Standing Administrative committees focus on organizational or promotional activities, such as Education, Implementation, Marketing, Outreach Committee for Clinical Research, Publishing and Process Improvement and Tooling.

Health Level 7 Working groups are directly responsible for the content of the Standards, framing the actual language of the specifications.

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Origin
HL7 was founded in 1987 to produce a standard for hospital information systems. HL7, Inc. is a standards organization that was accredited in 1994 by the American National Standards Institute (ANSI).[3] HL7 is one of several American National Standards Institute accredited Standards Developing Organizations (SDOs) operating in the healthcare arena. Most SDOs produce standards (sometimes called specifications or protocols) for a particular healthcare domain such as pharmacy, medical devices, imaging or insurance (claims processing) transactions. Health Level Sevens domain is clinical and administrative data. Today, HL7 has been adopted by several national SDOs outside the United States. Those SDOs are consequently not accredited by ANSI. However, HL7 is now adopted by ISO as a centre of gravity in international standardization and accredited as a partnering organization for mutual issuing of standards. The first mutually published standard is ISO/HL7 21731:2006 Health informaticsHL7 version 3Reference information modelRelease 1. The name "Health Level-7" The name "Health Level-7" is a reference to the seventh layer of the ISO OSI Reference model also known as the application layer. The name indicates that HL7 focuses on application layer protocols for the health care domain, independent of lower layers. HL7 effectively considers all lower layers merely as tools.[3]

Collaboration
HL7 collaborates with other standards development organizations and national and international sanctioning bodies (e.g. ANSI and ISO), in both the healthcare and information infrastructure domains to promote the use of supportive and compatible standards. HL7 collaborates with healthcare information technology users to ensure that HL7 standards meet real-world requirements, and that appropriate standards development efforts are initiated by HL7 to meet emergent requirements.[citation needed] About 45% of the global membership (of either HL7 Inc. or an HL7 affiliate) is located in Europe, 35% in North America, 15% in Asia-Oceania and 5% elsewhere.[4]

HL7 standards
HL7 encompasses the complete life cycle of a standards specification including the development, adoption, market recognition, utilization, and adherence.[citation needed] Prior to April 2013, HL7 International asserted that business use of the HL7 standards required a paid organizational membership in HL7, Inc. HL7 Members could access standards for free, and non-members could buy the standards from HL7, ANSI, or for some standards, ISO. Most HL7 standards can now be deemed Open Standards, as since April 2013 they are available for free download.[5] On Sept 4, 2012, the HL7 Board of Directors had announced its intention to relax the HL7 IP policy and allow free access and implementation to promote adoption and interoperability,[6] as described in their press release.[7][8] The revenue model and business plan of HL7 is discussed in HL7's Strategic Initiatives and Implementation Proposal.[9] However, since the earlier policy as described in the Bylaws of October 2002[10] placed the HL7 protocol specifications in the Public Domain, and under 17 USC 102[11] there is no copyright protection for an "idea, procedure, process, system, method of operation, concept, principle, or discovery", this revised policy may not be enforceable.

Health Level 7 Hospitals and other healthcare provider organizations typically have many different computer systems used for everything from billing records to patient tracking. All of these systems should communicate with each other (or "interface") when they receive new information but not all do so. HL7 specifies a number of flexible standards, guidelines, and methodologies by which various healthcare systems can communicate with each other. Such guidelines or data standards are a set of rules that allow information to be shared and processed in a uniform and consistent manner. These data standards are meant to allow healthcare organizations to easily share clinical information. Theoretically, this ability to exchange information should help to minimize the tendency for medical care to be geographically isolated and highly variable.[citation needed] HL7 develops conceptual standards (e.g., HL7 RIM), document standards (e.g., HL7 CDA), application standards (e.g., HL7 CCOW), and messaging standards (e.g., HL7 v2.x and v3.0). Messaging standards are particularly important because they define how information is packaged and communicated from one party to another. Such standards set the language, structure and data types required for seamless integration from one system to another.[12] The Reference Information Model (RIM) and the HL7 Development Framework (HDF) are the basis of the HL7 Version 3 standards development process. RIM is the representation of the HL7 clinical data (domains) and the life cycle of messages or groups of messages.[] HDF is a project to specify the processes and methodology used by all the HL7 committees for project initiation, requirements analysis, standard design, implementation, standard approval process, etc.[13] HL7 standards:[14] Version 2.x Messaging Standard an interoperability specification for health and medical transactions Version 3 Messaging Standard an interoperability specification for health and medical transactions, based on RIM Version 3 Rules/GELLO a standard expression language used for clinical decision support Arden Syntax a grammar for representing medical conditions and recommendations as a Medical Logic Module (MLM) Clinical Context Object Workgroup (CCOW) an interoperability specification for the visual integration of user applications Claims Attachments a Standard Healthcare Attachment to augment another healthcare transaction Clinical Document Architecture (CDA) an exchange model for clinical documents, based on HL7 Version 3 Electronic Health Record (EHR) / Personal Health Record (PHR) in support of these records, a standardized description of health and medical functions sought for or available Structured Product Labeling (SPL) the published information that accompanies a medicine, based on HL7 Version 3

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HL7 version 2.x


The HL7 version 2 standard (also known as Pipehat) has the aim to support hospital workflows. It was originally created in 1989.[15] V2.x Messaging HL7 version 2 defines a series of electronic messages to support administrative, logistical, financial as well as clinical processes. Since 1987 the standard has been updated regularly, resulting in versions 2.1, 2.2, 2.3, 2.3.1, 2.4, 2.5, 2.5.1 and 2.6. The v2.x standards are backward compatible (e.g., a message based on version 2.3 will be understood by an application that supports version 2.6). HL7 v2.x messages use a human-readable (ASCII), non-XML encoding syntax based on segments (lines) and one-character delimiters.[16] Segments have composites (fields) separated by the composite delimiter. A composite can have sub-composites (subcomponents) separated by the sub-composite delimiter, and sub-composites can have sub-sub-composites (subcomponents) separated by the sub-sub-composite delimiter. The default delimiters are vertical bar or pipe (|) for the field separator, caret (^) for the component separator, and ampersand (&) for the

Health Level 7 subcomponent separator. The tilde (~) is the default repetition separator. The first field (composite) in each segment contains the 3-character segment name. Each segment of the message contains one specific category of information. Every message has MSH as its first segment, which includes a field that identifies the message type. The message type determines the expected segment names in the message.[17] The segment names for a particular message type are specified by the segment grammar notation used in the HL7 standards. The following is an example of an admission record. MSH is the header record, PID the Patient Identity, etc. The 5th field for the PID record is the patient's name.

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MSH|^~\&|MegaReg|XYZHospC|SuperOE|XYZImgCtr|20060529090131-0500||ADT^A01^ADT_A01|01052901 EVN||200605290901||||200605290900 PID|||56782445^^^UAReg^PI||KLEINSAMPLE^BARRY^Q^JR||19620910|M||2028-9^^HL70005^RA99113^^X GOODWIN CREST DRIVE^^BIRMINGHAM^AL^35 209^^M~NICKELLS PICKLES^10000 W 100TH AVE^BIRMINGHAM^AL^35200^^O |||||||0105I30001^^^99DEF^AN PV1||I|W^389^1^UABH^^^^3||||12345^MORGAN^REX^J^^^MD^0010^UAMC^L||678 90^GRAINGER^LUCY^X^^^MD^0010^UAMC^L|MED|||||A0||13579^POTTER^SHER MAN^T^^^MD^0010^UAMC^L|||||||||||||||||||||||||||200605290900 OBX|1|NM|^Body Height||1.80|m^Meter^ISO+|||||F OBX|2|NM|^Body Weight||79|kg^Kilogram^ISO+|||||F AL1|1||^ASPIRIN DG1|1||786.50^CHEST PAIN, UNSPECIFIED^I9|||A HL7 v2.x has allowed for the interoperability between electronic Patient Administration Systems (PAS), Electronic Practice Management (EPM) systems, Laboratory Information Systems (LIS), Dietary, Pharmacy and Billing systems as well as Electronic Medical Record (EMR) or Electronic Health Record (EHR) systems. Currently, HL7s v2.x messaging standard is supported by every major medical information systems vendor in the United States.[18]

HL7 version 3
The HL7 version 3 standard has the aim to support all healthcare workflows. Development of version 3 started around 1995, resulting in an initial standard publication in 2005. The v3 standard, as opposed to version 2, is based on a formal methodology (the HDF) and object-oriented principles. RIM - ISO/HL7 21731 The Reference Information Model[] (RIM) is the cornerstone of the HL7 Version 3 development process and an essential part of the HL7 V3 development methodology. RIM expresses the data content needed in a specific clinical or administrative context and provides an explicit representation of the semantic and lexical connections that exist between the information carried in the fields of HL7 messages. The RIM is essential to increase precision and reduce implementation costs. Models are available.[19] HL7 Development Framework - ISO/HL7 27931 The HL7 Version 3 Development Framework (HDF) is a continuously evolving process that seeks to develop specifications that facilitate interoperability between healthcare systems. The HL7 RIM, vocabulary specifications, and model-driven process of analysis and design combine to make HL7 Version 3 one methodology for development of consensus-based standards for healthcare information system interoperability. The HDF is the most current edition of the HL7 V3 development methodology. The HDF not only documents messaging, but also the processes, tools, actors, rules, and artifacts relevant to development of all HL7 standard specifications. Eventually, the HDF will encompass all of the HL7 standard specifications, including any new standards resulting from analysis of electronic health record architectures and requirements.

Health Level 7 HL7 specifications draw upon codes and vocabularies from a variety of sources. The V3 vocabulary work ensures that the systems implementing HL7 specifications have an unambiguous understanding of the code sources and code value domains they are using. V3 Messaging The HL7 version 3 messaging standard defines a series of electronic messages (called interactions) to support all healthcare workflows. HL7 v3 messages are based on an XML encoding syntax. 'COMMENT: Please insert sample HL7 version 3 Data Markup Example Here: '

953

Clinical Document Architecture - ISO/HL7 27932


The HL7 Clinical Document Architecture (CDA) is an XML-based markup standard intended to specify the encoding, structure and semantics of clinical documents for exchange.[20]

Methods applied by HL7


Services Aware Interoperability Framework
The HL7 Services-Aware Enterprise Architecture Framework (SAIF) provides consistency between all HL7 artifacts, and enables a standardized approach to Enterprise Architecture (EA) development and implementation, and a way to measure the consistency. SAIF is a way of thinking about producing specifications that explicitly describe the governance, conformance, compliance, and behavioral semantics that are needed to achieve computable semantic working interoperability. The intended information transmission technology might use a messaging, document exchange, or services approach. SAIF is the framework that is required to rationalize interoperability of other standards. SAIF is an architecture for achieving interoperability, but it is not a whole-solution design for enterprise architecture management.

Arden syntax
The Arden syntax is a language for encoding medical knowledge. HL7 adopted and oversees the standard beginning with Arden syntax 2.0. These Medical Logic Modules (MLMs) are used in the clinical setting as they can contain sufficient knowledge to make single medical decisions.[citation needed] They can produce alerts, diagnoses, and interpretations along with quality assurance function and administrative support. An MLM must run on a computer that meets the minimum system requirements and has the correct program installed. Then, the MLM can give advice for when and where it is needed.

MLLP
A large portion of HL7 messaging is transported by Minimal Lower Layer Protocol (MLLP), also known as Lower Layer Protocol (LLP).[21] For transmitting via TCP/IP, header and trailer characters are added to the message to identify the beginning and ending of the message because TCP/IP is a continuous stream of bytes. Hybrid Lower Layer Protocol (HLLP) is a variation of MLLP that includes a checksum to help verify message integrity. Amongst other software vendors, MLLP is supported by Microsoft[22] and Oracle.[23]

Health Level 7

954

CCOW
CCOW, or "Clinical Context Object Workgroup," is a standard protocol designed to enable disparate applications to share user context and patient context in real-time, and at the user-interface level. CCOW implementations typically require a CCOW vault system to manage user security between applications.

Functional EHR and PHR specifications


Functional specifications for an electronic health record.

Country specific aspects


Australia
HL7 Australia was established in 1998. Australia was an early adopter of the HL7 V2.x standards, which are now used ubiquitously in Australian public and private healthcare organisations. The localisation of the HL7 standards is undertaken in cooperation with the national standards body, Standards Australia. HL7 Australia closely cooperates with the National E-Health Transition Authority (NEHTA). HL7 Australia Standards Australia (IT-014 "Health Informatics")[24] National E-Health Transition Authority (NEHTA)[25] Australia has been selected to host the International HL7 Interoperability Conference in 2013. This will be a two day event in Sydney from 28 30 October 2013. Proposed themes for the event include: HL7/FHIR (Fast Healthcare Interoperability Resources), CDA implementation and innovation, Leveraging HL7v2.x investment, and Emerging developments: CIMI, clinical terminology & semantic web

Canada
HL7 within Canada is supported by the HL7 Canadian Constituency, which is hosted by the Canadian Health Infoway Standards Collaborative. Among its support for domestic and international activities are: Liaising with HL7 International; Supporting communication and correspondence domestically and international for specific HL7 items; Responding to inquiries from HL7 International; Planning and execution of HL7 Canada Constituency roles and responsibilities; Supporting domestic and international HL7 Canada meetings; Providing support to domestic input on international HL7 ballot and comment items; and Administering the HL7 Canada Constituency forum to facilitate member collaboration.[26]

Notable HL7 implementations currently include Prince Edward Island's drug information system (DIS).

Health Level 7

955

Finland
National Health Archive http://www.kanta.fi/en The Social Insurance Institution of Finland, together with other health and welfare bodies in Finland have been rolling out a national health care database based on HL7 CDA R2 and V3 messages. The system is knonn by the acronym KanTa which is an abbreviation of KANsallinen TerveysArkisto (National Health Archive). The word KANTA in Finnish means "base", "stem" or "heel". Currently (as at February 2013) the system holds details of all electronic prescriptions and all pharmacies in Finland are connected to the database. The system enables prescriptions to be written by any medically qualified doctor into the system and enables the patient to collect prescriptions from any pharmacy nationwide. Citizens can log into the system via the internet using an authentication service and see their own record. There is a choice of using a government controlled authorization system or using the same authentication service used for on-line banking. These services use one-time (i.e. non repeating log in identifiers) which minimizes the risk of phishing or other intercepts. By logging into the system, the patient can see what medicines have been prescribed, which doctor prescribed them and when, what prescriptions have been collected from which pharmacy and on which date, and what the price paid was. The latter is useful for patients taking expensive medications because there is a national ceiling on patient medical costs so that the government will 100% of costs over the ceiling under the social insurance program. The record also shows what the dose should be, the name of the doctor who prescribed the medication, and what quantities of prescribed medications are still available for collection, subject to controls around the amount of medication is allowed to store at home. The system alerts doctors and pharmacies to prevent simultaneous use of incompatible medicines. For regular prescriptions, when the last prescription is fulfilled, the pharmacist can ask the patient if he would like the doctor to be asked to repeat issue the prescription. If yes, the pharmacy issues the request electronically and the doctor must either renew, modify, or terminate the prescription within 8 days. The patient can choose to receive a text message to his/her mobile phone advising of the outcome. Still being rolled out is the second phase of the project which is to enable the national database to be used to store other patient medical records. This is subject to the patient consenting for the transfer of data from his home health service station into the national archive. Patients thus have control over their own records, though most are expected to see the benefits of having their records in a permanently available national register. Version 2 HL7 messaging is widely deployed in most hospitals and healthcare centers. CDA R1 is used in sharing patient records on a regional level. HL7 Finland national affiliate[27]

Germany
The German chapter of HL7 was founded in 1993. This is an entity for benefit to the public and registered as an association as HL7 e. V. Due to federal structure of operational administration in German healthcare, the standardization aspect is much behind the possibilities of the public economy and due to competitive interests in industry of low normative impact to healthcare information systems development. Currently HL7 in Germany operates as an informal cluster and collaborates with the national standardization body.[28] The voluntary membership in HL7 relies on personal interest and engagement of clinical users and mainly on industrial interest: Clinical memberships are in minority. There is low membership of governmental administration and thus low contribution to ongoing discussion e.g. on patient data records (EPA = elektronische Patientenakte) balancing data availability vs. data security. Impact on productivity for hospital information systems (called KIS = Krankenhaus-Informationssysteme in German) is of no importance yet, as the variability of HIS systems has not been challenged by HL7.

Health Level 7 Governmental funding for a broader adoption of HL7 does yet not exist in Germany, neither on federal level nor in most of the regional governments.

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India
HL7 India is active in conducting e-learning courses for HL7 and HL7 certification examinations. HL7 India[29]

Italy
HL7 Italia was established in 2003 and it is responsible for the localization of this standard in the Italian context. The aim is to stimulate and direct the regional and national contributions towards the standard development and to promote the modernization of Italian health IT. HL7 Italia members are suppliers of health IT market. Some Italian regions, regional In-Houses, Governative Agencies, Public Research Institutes, local Hospital departments and individual IT professionals are HL7 Italia members. HL7 Italia[30]

The Netherlands
AORTA - National Healthcare ICT infrastructure AORTA is the Dutch national infrastructure for the exchange of data between healthcare providers. AORTA uses HL7 version 3 messages and documents as its core mechanism for information exchange. The initial specifications were created in 2003. The Dutch Ministry of Health is working on a virtual national Electronic Patient Records (EPR) which will enable healthcare providers to share patient data. This development takes place in close collaboration with Nictiz, the National Information and Communication Technology Institute for Healthcare. Nictiz coordinates its efforts with regard to the usage of HL7 version 3 with the volunteers of HL7 the Netherlands. Almost all hospitals use HL7 version 2 to support hospital-internal workflows. EDIfact is being used to support workflows involving general practitioners (GPs/PCPs). EDIfact will be gradually replaced by HL7 version 3. HL7 the Netherlands[31] National Information and Communication Technology Institute for Healthcare (Nictiz)[32] AORTA whitepaper[33]

Pakistan
HLH - Health Life Horizon HLH (a national project) is being carried out at School of Electrical Engineering and Computer Sciences of National University of Sciences and Technology and is supported by Government of Pakistan with funds provided by National ICT R&D Fund. HLH basic theme is to target health care information exchange and interoperability using HL7 version 3. Though the penetration and use of HL7 in Pakistan is lower than the countries like US and that of Europe. But its getting popularity among the stakeholders in Pakistan. HLH Team members have been participating in HL7 International Working Group meetings and conferences for last two years. On Oct 1, 2010 HL7 International formally announced the Pakistan Chapter at the 24th Plenary and WGM in Cambridge, MA, USA.[34] Pakistan is now the 37th affiliate of HL7 International around the world. HL7 Pakistan is now officially authorized to give memberships to local organizations along with other privileges like certification, training, etc. Health Life Horizon (HLH)[35] HL7 Pakistan[36]

Health Level 7

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USA
Laika The Certification Commission for Healthcare Information Technology (CCHIT) has developed an open-source program called Laika to test EHR software for compliance with CCHIT interoperability standards. HIPAA HL7s initial involvement in the Health Insurance Portability and Accountability Act (HIPAA) legislation began in 1996 with the formation of the Attachments special interest group to standardize the supplemental information needed to support health care insurance, and other e-commerce transactions. The initial deliverable of this group was a set of six recommended Claims Attachments for the Notice of Proposed Rule Making (NPRM) process. Future attachment projects include, but are not limited to, Home Health, Skilled Nursing Facility, durable medical equipment (DME), end stage renal disease (ESRD), and Pre-Authorization and Referrals. The Attachment special interest group is responsible for implementing the Administrative Simplification provisions of HIPAA mandates, providing on-going support, and representing HL7 in the Designated Standards Maintenance Organization[37] (DSMO) efforts. Its purpose is to encourage the use of HL7 for uniform implementation of this supplemental information. This SIG coordinates industry input to produce and maintain guides for HL7 messages that can stand alone or be embedded within ANSI X12 transactions. ARRA and HITECH The American Recovery and Reinvestment Act of 2009 (ARRA) and Health Information Technology for Economic and Clinical Health Act (HITECH) legislation specified HL7 versions 2.3.1 and 2.5.1, and the HL7 Continuity of Care Document (CCD), as the healthcare standards to meet certain certification requirements.[38]

References
[3] http:/ / www. ansi. org/ ANSI

External links
HL7 Standards (http://hl7messaging.com/hl7-standards) HL7.org site (http://www.HL7.org/) Introduction to HL7 (http://www.HL7.com.au/FAQ.htm) How does HL7 work? (Video Introduction) (http://blog.interfaceware.com/hl7/how-does-hl7-work/) HL7.org EHR Page (http://www.HL7.org/EHR) Fast Healthcare Interoperability Resources (FHIR) (http://www.HL7.org/FHIR) What does HL7 enablement means? (http://www.ehrmarket.com/blog/2009/10/ what-does-hl7-enablement-means/) HL7 is a member of the Joint Initiative on SDO Global Health Informatics Standardization (http://www. global-ehealth-standards.com/) HL7 Tools Page (http://www.HL7.com.au/HL7-Tools.htm) Australian Healthcare Messaging Laboratory (AHML) - Online HL7 Message Testing and Certification (http:// www.AHML.au.org/) Comprehensive Implementation of HL7 v3 Specifications in Java (http://aurora.regenstrief.org/javasig) HL7 Programming Tutorial using Java (http://www.saravanansubramanian.com/Saravanan/ Articles_On_Software/Entries/2009/2/21_HL7_Programming_using_Java_A_Short_Tutorial.html) HL7 101: A Beginners Guide (http://www.fortherecordmag.com/archives/ftr_01082007p22.shtml) International HL7 Experts Consortium (http://www.HL7Experts.com/)

The Healthcare IT Interoperability Blog (http://www.ehrguy.com/) NIST HL7 Conformance Testing Framework (http://www.cs.duke.edu/~jgm/files/nist.2006.ppt)

Health Level 7 ICH-HL7 Regulated Product Submissions (http://globalsubmit.com/home/LearningCenter/ HL7RegulatedProductSubmissions/tabid/252/Default.aspx)

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Critical reviews
HL7 RIM: An Incoherent Standard (http://ontology.buffalo.edu/hl7/doublestandards.pdf) and The HL7 RIM Under Scrutiny - rebuttal (http://aurora.regenstrief.org/~schadow/Schadow-MIE06-r3.pdf) HL7 Watch Blog; critical review of HL7 (http://hl7-watch.blogspot.com/). See also the posted comments for attempted rebuttals to some of the earlier posts.

Open source tools


There are a number of FOSS based tools that can foster worldwide adoption of the HL7 standards The HL7 Tools Directory lists many FOSS tools and resources (http://www.HL7.com.au/HL7-Tools.htm) Mirth Connect, an Open Source HL7 Integration Engine for HL7 V2/V3, DICOM, NCPDP and X12. Freely available under MPL 1.1 license (http://www.mirthcorp.com/community/overview) The open health tools consortium (http://www.openhealthtools.org) The HL7 Java Special Interest Group's implementation of HL7 v3 (http://aurora.regenstrief.org/javasig) The Eclipse OHF project - v2 and v3 implementations (IDE type tools and run-time libraries) (http://www. eclipse.org/ohf) HAPI, An open-source, object-oriented HL7 2.x parser for Java (http://hl7api.sourceforge.net/) The Perl HL7 Toolkit, an Open-Source HL7 Perl module (http://hl7toolkit.sourceforge.net/) Pear (PHP) HL7 messaging API module (http://pear.php.net/package/Net_HL7) The eXcessively Simple HL7 v2 Processing Platform using XML and XSLT (http://aurora.regenstrief.org/ xhl7) The Ruby HL7 Library (http://rubyforge.org/projects/ruby-hl7) HL7 Java binding (http://xmlbeans.googlepages.com/) nule.org HL7 Utilities (http://nule.org/wp/?page_id=55) nHAPI open-source library for .NET (http://nhapi.sourceforge.net/home.php) HL7v3 Messaging Framework for .NET (http://everest.marc-hi.ca/) HL7 Analyst for .NET (http://hl7analyst.codeplex.com) HL7Kit Free Sender, HL7 Message Editor and Sender (http://www.hl7kit.com/hl7senderOpenSource.html)

Health maintenance organization

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Health maintenance organization


Health care in the United States Government Health Programs

Federal Employees Health Benefits Program Indian Health Service Veterans Health Administration Military Health System / TRICARE Medicare Medicaid / State Health Insurance Assistance Program (SHIP) State Children's Health Insurance Program (CHIP) Program of All-Inclusive Care for the Elderly (PACE) Prescription Assistance (SPAP) Private health coverage

Health insurance in the United States Consumer-driven health care


Flexible spending account (FSA) Health Reimbursement Account Health savings account

High-deductible health plan (HDHP) Medical savings account (MSA) Private Fee-For-Service (PFFS) Managed care (CCP) Health maintenance organization (HMO) Preferred provider organization (PPO) Medical underwriting

Health care reform law


Emergency Medical Treatment and Active Labor Act (1986) Health Insurance Portability and Accountability Act (1996) Medicare Prescription Drug, Improvement, and Modernization Act (2003) Patient Safety and Quality Improvement Act (2005) Health Information Technology for Economic and Clinical Health Act (2009) Patient Protection and Affordable Care Act (2010) State level reform

Massachusetts health care reform Oregon Health Plan Vermont health care reform SustiNet (Connecticut) Dirigo Health (Maine) Municipal health coverage

Fair Share Health Care Act (Maryland) Healthy Howard (Howard Co., Maryland) Healthy San Francisco

A health maintenance organization (HMO) is an organization that provides or arranges managed care for health insurance, self-funded health care benefit plans, individuals and other entities in the United States and acts as a liaison with health care providers (hospitals, doctors, etc.) on a prepaid basis. The Health Maintenance Organization Act of 1973 required employers with 25 or more employees to offer federally certified HMO options if the employer offers traditional healthcare options.[1] Unlike traditional indemnity insurance, an HMO covers care rendered by

Health maintenance organization those doctors and other professionals who have agreed by contract to treat patients in accordance with the HMO's guidelines and restrictions in exchange for a steady stream of customers. HMOs cover emergency care regardless of the health care provider's contracted status.

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Operation
HMOs often require members to select a primary care physician (PCP), a doctor who acts as a "gatekeeper" to direct access to medical services but this is not always the case. PCPs are usually internists, pediatricians, family doctors, or general practitioners (GPs). Except in medical emergency situations, patients need a referral from the PCP in order to see a specialist or other doctor, and the gatekeeper cannot authorize that referral unless the HMO guidelines deem it necessary. "Open access" and "POS" (point of service) products are a combination of an HMO and traditional indemnity plan. The member(s) are not required to use a gatekeeper or obtain a referral before seeing a specialist. In that case, the traditional benefits are applicable. If the member uses a gatekeeper, the HMO benefits are applied. However, the beneficiary cost sharing (e.g., co-payment or coinsurance) may be higher for specialist care.[2] HMOs also manage care through utilization review. That means they monitor doctors to see if they are performing more services for their patients than other doctors, or fewer. HMOs often provide preventive care for a lower copayment or for free, in order to keep members from developing a preventable condition that would require a great deal of medical services. When HMOs were coming into existence, indemnity plans often did not cover preventive services, such as immunizations, well-baby checkups, mammograms, or physicals. It is this inclusion of services intended to maintain a member's health that gave the HMO its name. Some services, such as outpatient mental health care, are limited, and more costly forms of care, diagnosis, or treatment may not be covered. Experimental treatments and elective services that are not medically necessary (such as elective plastic surgery) are almost never covered. Other choices for managing care are case management, in which patients with catastrophic cases are identified, or disease management, in which patients with certain chronic diseases like diabetes, asthma, or some forms of cancer are identified. In either case, the HMO takes a greater level of involvement in the patient's care, assigning a case manager to the patient or a group of patients to ensure that no two providers provide overlapping care, and to ensure that the patient is receiving appropriate treatment, so that the condition does not worsen beyond what can be helped.

Cost containment
Although businesses pursued the HMO model for its alleged cost containment benefits, some research indicates that private HMO plans don't achieve any significant cost savings over non-HMO plans. Although out-of-pocket costs are reduced for consumers, controlling for other factors, the plans don't affect total expenditures and payments by insurers. A possible reason for this failure is that consumers might increase utilization in response to less cost sharing under HMOs.[3] Some[4] have asserted that HMOs (especially those run for profit) actually increase administrative costs and tend to cherry-pick healthier patients.

History
The earliest form of HMOs can be seen in a number of prepaid health plans. In 1910, the Western Clinic in Tacoma, Washington offered lumber mill owners and their employees certain medical services from its providers for a premium of $0.50 per member per month. This is considered by some to be the first example of an HMO. However, Ross-Loos Medical Group, established in 1929, is considered to be the first HMO in the United States; it was headquartered in Los Angeles and initially provided services for Los Angeles Department of Water and Power (DWP) and Los Angeles County employees. Approximately 500 DWP employees enrolled at a cost of $1.50 each per month. Within a year, the Los Angeles Fire Department signed up, then the Los Angeles Police Department, then

Health maintenance organization the Southern California Telephone Company (now AT&T Inc.), and more. By 1951, enrollment stood at 35,000 and included teachers, county and city employees. In 1982 through the merger of the Insurance Company of North America (INA) founded in 1792 and Connecticut General (CG) founded in 1865 came together to become CIGNA. Ross-Loos Medical Group, became now known as CIGNA HealthCare. Also in 1929 Dr. Michael Shadid created a health plan in Elk City, Oklahoma in which farmers bought shares for $50 to raise the money to build a hospital. The medical community did not like this arrangement and threatened to suspend Shadid's licence. The Farmer's Union took control of the hospital and the health plan in 1934. Also in 1929, Baylor Hospital provided approximately 1,500 teachers with prepaid care. This was the origin of Blue Cross. Around 1939, state medical societies created Blue Shield plans to cover physician services, as Blue Cross covered only hospital services. These prepaid plans burgeoned during the Great Depression as a method for providers to ensure constant and steady revenue. In 1970, the number of HMOs declined to less than 40. Paul M. Ellwood, Jr., often called the "father" of the HMO, began having discussions with what is today the U.S. Department of Health and Human Services that led to the enactment of the Health Maintenance Organization Act of 1973. This act had three main provisions: Grants and loans were provided to plan, start, or expand an HMO Certain state-imposed restrictions on HMOs were removed if the HMOs were federally certified Employers with 25 or more employees were required to offer federally certified HMO options alongside indemnity upon request This last provision, called the dual choice provision, was the most important, as it gave HMOs access to the critical employer-based market that had often been blocked in the past. The federal government was slow to issue regulations and certify plans until 1977, when HMOs began to grow rapidly. The dual choice provision expired in 1995. In 1971, Gordon K. MacLeod MD developed and became the director of the United States' first federal Health Maintenance Organization (HMO) program. He was recruited by Elliot Richardson, the secretary of the U.S. Department of Health, Education and Welfare.

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Types of HMOs
HMOs operate in a variety of forms. Most HMOs today do not fit neatly into one form; they can have multiple divisions, each operating under a different model, or blend two or more models together. In the staff model, physicians are salaried and have offices in HMO buildings. In this case, physicians are direct employees of the HMOs. This model is an example of a closed-panel HMO, meaning that contracted physicians may only see HMO patients. Previously this type of HMO was common, although currently it is nearly inactive.[5] In the group model, the HMO does not employ the physicians directly, but contracts with a multi-specialty physician group practice. Individual physicians are employed by the group practice, rather than by the HMO. The group practice may be established by the HMO and only serve HMO members ("captive group model"). Kaiser Permanente is an example of a captive group model HMO rather than a staff model HMO, as is commonly believed. An HMO may also contract with an existing, independent group practice ("independent group model"), which will generally continue to treat non-HMO patients. Group model HMOs are also considered closed-panel, because doctors must be part of the group practice to participate in the HMO - the HMO panel is closed to other physicians in the community.[6] If not already part of a group medical practice, physicians may contract with an independent practice association (IPA), which in turn contracts with the HMO. This model is an example of an open-panel HMO, where a physician may maintain their own office and may see non-HMO members. In the network model, an HMO will contract with any combination of groups, IPAs (Independent Practice Associations), and individual physicians. Since 1990, most HMOs run by managed care organizations with other lines of business (such as PPO, POS and indemnity) use the network model.

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Regulation
HMOs are regulated at both the state and federal levels. They are licensed by the states, under a license that is known as a certificate of authority (COA) rather than under an insurance license.[7] State and federal regulators also issue mandates, requirements for health maintenance organizations to provide particular products. In 1972 the National Association of Insurance Commissioners adopted the HMO Model Act, which was intended to provide a model regulatory structure for states to use in authorizing the establishment of HMOs and in monitoring their operation.[8]

Legal responsibilities
HMOs often have a negative public image due to their restrictive appearance. HMOs have been the target of lawsuits claiming that the restrictions of the HMO prevented necessary care. Whether an HMO can be held responsible for a physician's negligence partially depends on the HMO's screening process.[citation needed] If an HMO only contracts with providers meeting certain quality criteria and advertises this to its members, a court may be more likely to find that the HMO is responsible, just as hospitals can be liable for negligence in selecting physicians. However, an HMO is often insulated from malpractice lawsuits. The Employee Retirement Income Security Act (ERISA) can be held to preempt negligence claims as well. In this case, the deciding factor is whether the harm results from the plan's administration or the provider's actions. ERISA does not preempt or insulate HMOs from breach of contract or state law claims asserted by an independent, third-party provider of medical services.[9]

Organizations
Aetna Blue Cross Blue Shield Association CIGNA Kaiser Permanente Humana Health Net UnitedHealth Group WellPoint Magnacare

References
[1] Joseph L. Dorsey, "The Health Maintenance Organization Act of 1973(P.L. 93-222)and Prepaid Group Practice Plan," Medical Care, Vol. 13, No. 1, (Jan., 1975), pp. 19 [2] Peter R. Kongstvedt, "The Managed Health Care Handbook," Fourth Edition, Aspen Publishers, Inc., 2001, page 40 ISBN 0-8342-1726-0 [3] Jaeun Shin, Sangho Moon, "Do HMO Plans Reduce Expenditure in the Private Sector?", Economic Inquiry, Jan 2007. (http:/ / findarticles. com/ p/ articles/ mi_hb5814/ is_1_45/ ai_n29387922/ pg_1?tag=artBody;col1) [4] "Claim That HMO's Save Money Is Little More Than "Folklore," Health Affairs Study Finds," 2000. Physicians for a National Health Program. http:/ / www. pnhp. org/ news/ 2000/ march/ claim_that_hmos_sav. php [5] http:/ / www. managedcaremag. com/ archives/ 9907/ 9907. staffmodel. html [6] Peter R. Kongstvedt, "The Managed Health Care Handbook," 4th edition, Aspen Publishers, Inc., 2001, ISBN 0-8342-1726-0, pages 3526 [7] Peter R. Kongstvedt, "The Managed Health Care Handbook," Fourth Edition, Aspen Publishers, Inc., 2001, page 1322 ISBN 0-8342-1726-0 [8] O'Rourke, Paul F. (1974). Organizational aspects of prepaid health plans-HMO's. California. [9] United States District Court, N.D. Texas, Dallas Division. BAYLOR UNIVERSITY MEDICAL CENTER v. ARKANSAS BLUE CROSS BLUE SHIELD. No. Civ.A. 3:03-CV-2084-.Jan. 9, 2004.MEMORANDUM ORDER

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External links
America's Health Insurance Plans (http://www.ahip.org) - a trade organization HealthDecisions.org (http://www.healthdecisions.org) - Comprehensive resource for insurance news and information Health Maintenance Organisations in Nigeria: Place of Marketing (http://www.iroy.in/ hmo-marketing-in-nigeria) Medicare HMO Web Site (http://www.medicarehmo.com/) The high costs of for-profit care (http://www.cmaj.ca/cgi/content/full/170/12/1814) - an article that includes references to the excesses of HMO Chief Executive Officer pay in the U.S. Physician Salaries in USA (http://www.physician-salary.org) - A Snapshot

Health human resources


Health human resources (HHR) also known as human resources for health (HRH) or health workforce is defined as all people engaged in actions whose primary intent is to enhance health, according to the World Health Organization's World Health Report 2006.[1] Human resources for health are identified as one of the core building blocks of a health system.[2] They include physicians, nurses, midwives, dentists, allied health professions, community health workers, social health workers and other health care providers, as well as health management and support personnel those who may not deliver services directly but are essential to effective health system functioning, including health services managers, medical records and health information technicians, health economists, health supply chain managers, medical secretaries, and others. The field of health human resources deals with issues such as planning, development, performance, management, retention, information, and research on human resources for the health care sector. In recent years, raising awareness of the critical role of HRH in strengthening health system performance and improving population health outcomes has placed the health workforce high on the global health agenda.[3]

Global situation
The World Health Organization (WHO) estimates a shortage of almost 4.3 million physicians, midwives, nurses and support workers worldwide.[1] The shortage is most severe in 57 of the poorest countries, especially in sub-Saharan Africa. The situation was declared on World Health Day 2006 as a "health workforce crisis" the result of decades of underinvestment in health worker education, training, wages, working environment and management.

Shortages of skilled for health workers are also reported in many specific care areas. For example, there is an estimated shortage of 1.18 million mental health professionals, including 55,000 psychiatrists, 628,000 nurses in mental health settings, and 493,000 psychosocial care providers needed to treat mental disorders in 144 low- and middle-income countries.[4] Shortages of skilled birth attendants in many developing countries remains an important barrier to improving maternal health outcomes. Many countries, both developed and developing, report maldistribution of skilled health workers leading to shortages in rural and underserved areas. Regular statistical updates on the global HHR situation are collated in the WHO Global Atlas of the Health Workforce.[5] However the evidence base remains fragmented and incomplete, largely related to weaknesses in the underlying human resource information systems (HRIS) within countries.[6]

Nations identified with critical shortages of health care workers

Health human resources In order to learn from best practices in addressing health workforce challenges and strengthening the evidence base, an increasing number of HHR practitioners from around the world are focusing on issues such as HHR advocacy, surveillance and collaborative practice. Some examples of global HRH partnerships include: Health Workforce Information Reference Group (HIRG) [7] Global Health Workforce Alliance [8]

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Health workforce research


Health workforce research is the investigation of how social, economic, organizational, political and policy factors affect access to health care professionals, and how the organization and composition of the workforce itself can affect health care delivery, quality, equity, and costs. Many government health departments, academic institutions and related agencies have established research programs to identify and quantify the scope and nature of HHR problems leading to health policy in building an innovative and sustainable health services workforce in their jurisdiction. Some examples of HRH information and research dissemination programs include: Human Resources for Health [9] journal HRH Knowledge Hub, University of New South Wales, Australia [10] Center for Health Workforce Studies, University of Albany, New York [11] Canadian Institute for Health Information: Spending and Health Workforce [12] Public Health Foundation of India: Human Resources for Health in India [13] National Human Resources for Health Observatory of Sudan [14] OECD Human Resources for Health Care Study [15]

Health workforce policy and planning


In some countries and jurisdictions, health workforce planning is distributed among labour market participants. In others, there is an explicit policy or strategy adopted by governments and systems to plan for adequate numbers, distribution and quality of health workers to meet health care goals. For one, the International Council of Nurses reports:[16] The objective of HHRP [health human resources planning] is to provide the right number of health care workers with the right knowledge, skills, attitudes and qualifications, performing the right tasks in the right place at the right time to achieve the right predetermined health targets. An essential component of planned HRH targets is supply and demand modeling, or the use of appropriate data to link population health needs and/or health care delivery targets with human resources supply, distribution and productivity. The results are intended to be used to generate evidence-based policies to guide workforce sustainability.[17][18] In resource-limited countries, HRH planning approaches are often driven by the needs of targeted programmes or projects, for example those responding to the Millennium Development Goals.[19] The WHO Workload Indicators of Staffing Need (WISN) is an HRH planning and management tool that can be adapted to local circumstances.[20] It provides health managers a systematic way to make staffing decisions in order to better manage their human resources, based on a health workers workload, with activity (time) standards applied for each workload component at a given health facility.

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Global Code of Practice on the International Recruitment of Health Personnel


The main international policy framework for addressing shortages and maldistribution of health professionals is the Global Code of Practice on the International Recruitment of Health Personnel, adopted by the WHO's 63rd World Health Assembly in 2010.[21] The Code was developed in a context of increasing debate on international health worker recruitment, especially in some higher income countries, and its impact on the ability of many developing countries to deliver primary health care services. Although non-binding on Member States and recruitment agencies, the Code promotes principles and practices for the ethical international recruitment of health personnel. It also advocates the strengthening of health personnel information systems to support effective health workforce policies and planning in countries.

References
[1] World Health Organization. The world health report 2006: working together for health, Geneva, 2006 http:/ / www. who. int/ whr/ 2006 [2] World Health Organization. Health Systems Topics http:/ / www. who. int/ healthsystems/ topics/ en/ index. html [3] Grepin K, Savedoff WD. "10 Best Resources on ... health workers in developing countries." Health Policy and Planning, 2009; 24(6):479482 http:/ / heapol. oxfordjournals. org/ cgi/ content/ full/ 24/ 6/ 479 [4] Scheffler RM et al. Human resources for mental health: workforce shortages in low- and middle-income countries. Geneva, World Health Organization, 2011 available on http:/ / whqlibdoc. who. int/ publications/ 2011/ 9789241501019_eng. pdf [5] World Health Organization. Global Atlas of the Health Workforce [online database] available on http:/ / www. who. int/ globalatlas/ autologin/ hrh_login. asp [6] Dal Poz MR et al. (eds). Handbook on monitoring and evaluation of human resources for health, Geneva, World Health Organization, 2009 available on http:/ / www. who. int/ hrh/ resources/ handbook/ en/ index. html [7] http:/ / my. ibpinitiative. org/ HIRG [8] http:/ / www. who. int/ workforcealliance [9] http:/ / www. human-resources-health. com [10] http:/ / www. med. unsw. edu. au/ HRHweb. nsf [11] http:/ / chws. albany. edu/ [12] http:/ / www. cihi. ca/ CIHI-ext-portal/ internet/ EN/ Theme/ spending+ and+ health+ workforce/ cihi010658 [13] http:/ / hrhindia. org/ [14] http:/ / www. hrhobservatory. sd [15] http:/ / www. oecd. org/ document/ 54/ 0,2340,en_2649_37407_1935094_1_1_1_37407,00. html [16] International Council of Nurses. Health human resources planning. Geneva, 2008 http:/ / www. ichrn. com/ publications/ factsheets/ Health-Human-Resources-Plan_EN. pdf [17] Dal Poz MR et al. Models and tools for health workforce planning and projections. Geneva, World Health Organization, 2010 http:/ / whqlibdoc. who. int/ publications/ 2010/ 9789241599016_eng. pdf [18] Health Canada. Health Human Resource Strategy (HHRS). (http:/ / www. hc-sc. gc. ca/ hcs-sss/ hhr-rhs/ strateg/ index-eng. php) Accessed 12 April 2011. [19] Dreesch N et al. "An approach to estimating human resource requirements to achieve the Millennium Development Goals." Health Policy and Planning, 2005; 20(5):267276. [20] World Health Organization. Workload Indicators of Staffing Need (WISN): User's manual. Geneva, 2010 http:/ / www. who. int/ hrh/ resources/ wisn_user_manual/ en/ [21] International recruitment of health personnel: global code of practice. Resolution adopted by the Sixty-third World Health Assembly, Geneva, May 2010 available on http:/ / apps. who. int/ gb/ e/ e_wha63. html

External links
World Health Organization (http://www.who.int/hrh/en/) programme of work on health human resources Human Resources for Health Databases (http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=hhrdata_e), Canadian Institute for Health Information Human resources for health in developing countries (http://www.eldis.org/go/topics/dossiers/ human-resources-for-health) a dossier from the Institute for Development Studies Compendium of tools and guidelines (http://www.who.int/hrh/tools/en/index.html) for HRH situation analysis, planning, policies and management systems

Health human resources Online community of practice for HRH practitioners (http://my.ibpinitiative.org/HIRG) on strengthening health workforce information systems Human Resources for Health Global Resource Center (http://www.hrhresourcecenter.org/)- largest online collection of HRH research and materials, supported by the IntraHealth International-led CapacityPlus project HRIS strengthening implementation toolkit (http://www.capacityproject.org/hris/hris-toolkit/index.html) Africa Health Workforce Observatory (http://www.hrh-observatory.afro.who.int/) CapacityPlus (http://www.capacityplus.org/)--the USAID-funded global project uniquely focused on the health workforce needed to achieve the Millennium Development Goals.

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HRHIS
A Human Resource for Health Information System (HRHIS) also known within the health care sector as human resource information system (HRIS) is a system for collecting, processing, managing and disseminating data and information on human resource for health (HRH). Depending on the level of development of a country's health care system and the organization of its workforce, an HRHIS can be computerized or paper-based, and including information on numbers and distribution of health workers and track their career information.[1] It is usually an integral part of a comprehensive health management information system, and may be used to monitor and assess the performance of the overall health system. For example, in Tanzania the title Human Resource for Health Information System refers to an open-source software solution for HRH information management developed by the Department of Computer Science, University of Dar es Salaam for the Ministry of Health and Social Welfare (Tanzania), and funded by the Japan International Cooperation Agency (JICA) and other development partners.[2][3] The system supports the capture of data linked to any level in the organizational hierarchy and is customizable at both the input and output sides. In Canada, the HRHIS is composed of multiple computerized components, including the National Physician Database and the Registered Nurses Database.[4] Similar systems have been developed and implemented elsewhere. In Uganda, an open-source HRHIS was implemented under the request of the Ugandan Ministry of Health (MOH), to link and better manage a variety of independent sources of health workforce data, including data from censuses and other national surveys, MOH administrative records, district level sources, independent research studies, and health professional council data.[5] In Brazil, the national web-based HRHIS (known in Portuguese as sistema de informao e gesto de recursos humanos em sade[6]) was implemented by the Brazilian Ministry of Health under a process of health systems reform and decentralization, catalyzed by the availability of new information technologies at the level of local health organizations. Botswana developed its HRHIS in 1994, and Ministry of Health staff used the data as a basis for coordinated national workforce planning efforts with other agencies and ministries, such as the Department of Local Government which employs health workers in local regions.[7]

HRHIS in Tanzania
The Tanzania Ministry of Health and Social Welfare (MOHSW) identified health workforce information as a key area needing to be strengthened for fast tracking implementation of its Human Resource Strategic Plan.[8] The HRHIS was implemented as an effort to improve human resources for health (HRH) management. A situation analysis indicated the existence of several databases within and outside the ministry dealing with HRH, often with similar information fields. It was agreed these sources should be harmonized, and housed under Health Management Information System (HMIS) for consistency. The HRHIS software thus became part of the HMIS and was fully integrated with the District Health Information System (DHIS) software through import/export mechanisms.

HRHIS

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Tanzania HRHIS
Written in PHP

Operating system Linux Type Website Human Resource for Health Information System [9]

The HRHIS was built using free and open source technologies PHP (server scripting language), PostgreSQL (database management system) running on multi-platform (Windows, Linux) architecture, and designed to be user-friendly allowing administrators or authorized users to add additional elements as new needs arise. The initial database was populated with the minimum dataset as requested by the MOHSW. The HRHIS provided import/output mechanisms for data at different levels, such as national, regional, district or facility level. It was designed to provide flexibility to: Capture and store health personnel's data and history by organizational unit, cadre, and other characteristics; Add any number of datasets or elements required by any sector (such as the central health ministry, local governments, civil services or private providers); Update organizational unit details according to users' requirements (e.g. allowing additional regions, districts and health facilities to be added dynamically without entering into system codes); Generate web-enabled reports in different formats (general and aggregated), including graphical reporting. Since human resource information/data are personal and confidential, the HRHIS system was developed with high security measures for protecting the data entered. Security measures include a login mechanism such that only authorized personnel can use the system, and also a Users Administration functionality which allows the system administrator to limit users' access to certain functions. The system was built by UDSM developers and analysts considered conversant with the changing needs of the health sector and Tanzania's context. It is used in MOHSW headquarters, across the Coast region (regional level and all districts), and implementation is ongoing in Dar es Salaam, Kilimanjaro, Tanga, and Morogoro.

HRHIS in Canada
See also: Canadian Institute for Health Information databases

Canada National Physician Database (NPDB)


Stable release 2009 Type Website Human Resource for Health Information System [10]

The Canadian Institute for Health Information maintains several HRH databases as part of a comprehensive national HRHIS. They include:[4] Registered Physicians Database Registered Nurses Database Pharmacist Database Occupational Therapist Database Medical Radiation Technologist Database Medical Laboratory Technologist Database

Physiotherapist Database Scotts Medical Database.

HRHIS The databases capture and store information on workforce size, practice settings and regulatory environments, as well as trends in supply, demographics and education. They record information captured through transmission according to specifications from all provinces and territories, professional regulatory and licensing bodies, and/or educational institutions. Each database includes unique identifiers for tracking health professionals through time and as they move from one location to another; is accompanied by documentation on data quality; and is governed by security arrangements with respect to the protection of personal information of health professionals. The data are used by governments, researchers and professional associations for HRH planning.

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References
[1] Dal Poz MR et al., Handbook on monitoring and evaluation of human resources for health. (http:/ / www. who. int/ hrh/ resources/ handbook/ en/ index. html) Geneva, World Health Organization, 2009 [2] HISP Tanzania: Human Resource for Health Information Software (HRHIS). (http:/ / www. hisptanzania. or. tz/ hris. php) Health Information Systems Programme, 2009. Accessed 9 March 2011. [3] JICAs Cooperation on Human Resources for Health. (http:/ / www. jica. go. jp/ activities/ issues/ health/ pdf/ pamph_jinzai. pdf) Japan International Cooperation Agency, January 2011. Accessed 9 March 2011. [4] Canadian Institute for Health Information. Workforce. (http:/ / www. cihi. ca/ CIHI-ext-portal/ internet/ EN/ SubTheme/ spending+ and+ health+ workforce/ workforce/ cihi010671) Accessed 30 April 2012. [5] Spero JC et al., "Tracking and monitoring the health workforce: a new Human Resources Information System (HRIS) in Uganda." (http:/ / www. human-resources-health. com/ content/ 9/ 1/ 6) Human Resources for Health, 2011, 9(6). [6] Sistema de Informao e Gesto de Recursos Humanos em Sade (SIGRHS). (http:/ / obsnetims1. tempsite. ws/ sigrhs/ site/ manual. pdf) Ministerio de Saude do Brasil et al., 2010. Accessed 9 March 2011. [7] Using Human Resource for Health Data: Health policy and program planning examples from four African countries. (http:/ / pdf. usaid. gov/ pdf_docs/ PNADM275. pdf) United States Agency for International Development, 2008. Accessed 9 March 2011. [8] United Republic of Tanzania Ministry of Health and Social Welfare. Health Sector Strategic Plan III, July 2009June 2015. (http:/ / www. moh. go. tz/ documents/ Health_Sector_Strategic_Plan_III. pdf) Dar es Salem, 2009. [9] http:/ / www. hisptanzania. or. tz/ hris. php [10] http:/ / www. cihi. ca/ CIHI-ext-portal/ internet/ EN/ document/ spending+ and+ health+ workforce/ workforce/ physicians/ hhrdata_npdb

Further reading
Riley PL et al., "Information systems on human resources for health: a global review." (http://www. human-resources-health.com/content/10/1/7/abstract) Human Resources for Health 2012, 10:7. Published: 30 April 2012. Accessed: 30 April 2012.

External links
HRIS Strengthening Implementation Toolkit (http://www.capacityproject.org/hris/hris-toolkit/), USAID-supported Capacity Project University of Dar es Salaam, Computer Science unit (http://cs.udsm.ac.tz), Tanzania Health Information Systems Programme (http://www.hisptanzania.or.tz), Tanzania

Health Resources and Services Administration

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Health Resources and Services Administration


Health Resources and Services Administration

Agency overview Formed 1982

Preceding agencies Health Services Administration (1973-1982) Health Resources Administration (1973-1982) Jurisdiction Headquarters Employees Annual budget Agency executive Parent Agency Federal government of the United States Rockville, Maryland 1,400 $7.2 billion USD (2008) Mary Wakefield, PhD, RN, Administrator, Health Resources and Services Administration United States Department of Health and Human Services

The Health Resources and Services Administration (HRSA), is an agency of the U.S. Department of Health and Human Services located in Rockville, Maryland. It is the primary federal agency for improving access to health care services for people who are uninsured, isolated or medically vulnerable. Comprising six bureaus and 13 offices, HRSA provides leadership and financial support to health care providers in every state and U.S. territory. HRSA grantees provide health care to uninsured people, people living with HIV/AIDS, and pregnant women, mothers and children. They train health professionals and improve systems of care in rural communities. HRSA oversees organ, bone marrow and cord blood donation. It supports programs that prepare against bioterrorism, compensate individuals harmed by vaccination, and maintains databases that protect against health care malpractice and health care waste, fraud and abuse. Since 1943 the agencies that were HRSA precursors have worked to improve the health of needy people. HRSA was created in 1982, when the Health Resources Administration and the Health Services Administration were merged. On February 20, 2009, President Obama announced the appointment of Dr. Mary Wakefield, Director of the Center for Rural Health at the University of North Dakota, to oversee HRSA.

Goals
The agency lists seven goals:[1] Improve Access to Health Care. Improve Health Outcomes. Improve the Quality of Health Care. Eliminate Health Disparities. Improve the Public Health and Health Care Systems. Enhance the Ability of the Health Care System to Respond to Public Health Emergencies. Achieve Excellence in Management Practices

Health Resources and Services Administration

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Key facts
HRSA programs reach into every corner of America. The agency's $7 billion budget (FY 2008) provides direct health care to 23 million people. HRSAs health center program supports medical, oral and behavioral health services to uninsured and underinsured individuals through a nationwide network of community-based clinics and mobile medical vans. By bringing comprehensive primary and preventive health care services to inner-city and rural communities that otherwise would be without them, health centers improve the health of their communities and relieve pressure on overburdened hospital emergency rooms. The agency also recruits doctors, nurses, dentists and others to work in areas with too few health care professionals. HRSA funds life-sustaining medication and primary care to about half of the estimated number of people living with HIV/AIDS in the United States. The agency also furnishes funds and expertise that save and improve the lives of millions of mothers and children. HRSA oversees all organ, tissue and blood cell donations and is the federal agency primarily responsible for pediatric poison control. HRSA also maintains databases that track cases of health care malpractice and compensates individuals thought to be harmed by vaccinations. The agency monitors trends in the health care workforce and forecasts future demand. Scholarships and academic loan programs encourage greater minority participation in the health professions and seek to maintain an adequate supply of primary care professionals.

Primary Health Care


HRSA funds almost 1,110 health center grantees that operate more than 7,000 clinics and mobile medical vans. Health centers deliver primary and preventive care to over 16 million low-income patients in every state, the District of Columbia, Puerto Rico, the U.S. Virgin Islands and U.S. possessions in the Pacific.

HIV/AIDS
The agencys Ryan White HIV/AIDS Program provides primary care, support services and antiretroviral drugs for about 530,000 low-income people. The program also funds training, technical assistance and demonstration projects designed to slow the spread of the epidemic in high-risk populations. These services avert more costly in-patient care and improve the quality of life for those living with the virus.

Maternal and Child Health Bureau


HRSA administers a broad range of programs for pregnant women, mothers, infants, children, adolescents and their families and children with special health care requirements. The largest of the programs, the Maternal and Child Health Services Block Grant to States, supports local efforts to reduce infant mortality and childhood illness and control costs associated with poor pre- and neo-natal care. The Block Grant includes State Formula Block Grants, Special Projects of Regional and National Significance (SPRANS), and Community Integrated Service Systems (CISS) projects. Other vital missions include Universal Newborn Hearing Screening, Traumatic Brain Injury, Healthy Start, Sickle Cell Service Demonstrations, Family to Family Health Information Centers, Emergency Medical Services for Children, and autism. Among the most successful public health initiatives in U.S. history, HRSA's maternal and child health programs annually serve more than 34 million people. Maternal and Child Health Bureau [2]

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Rural Health
To make health care more accessible for the 60 million residents of rural America, HRSA funds programs that integrate and streamline existing rural health care institutions and aid in the recruitment and retention of physicians in rural hospitals and clinics. HRSAs telehealth program uses information technology to link isolated rural practitioners to medical institutions over great distances. Many of these activities are designed and operated out of the Agency's Office of Rural Health Policy.

Clinician Recruitment and Service


The agency strives to ensure a health care workforce that is diverse, well-trained and adequately distributed throughout the nation. In exchange for financial assistance through National Health Service Corps scholarships and student loan repayment programs, more than 28,000 clinicians have served in some of the most economically deprived and geographically isolated communities in America over the past 35 years.

Health Professions
Many regions of the countryand various health disciplinesface serious workforce shortages. HRSA safeguards the foundations of the U.S. health care system by targeting grants to academic institutions to support post-graduate faculty retention; administering scholarships to increase staff in critical specialties, such as nursing; and funding leadership development programs. These programs leverage the educations of about 10,000 clinicians annually.

Healthcare Systems
HRSA oversees the nations organ and tissue donation and transplantation systems, and a drug discount program for certain safety-net health care providers. The agency also supports the nations poison control centers and vaccine injury compensation programs, which distribute awards to individuals and families thought to have been injured by certain vaccines.

References
[1] HRSA - About HRSA (http:/ / www. hrsa. gov/ about/ default. htm) [2] http:/ / www. mchb. hrsa. gov

External links
Official website (http://www.hrsa.gov) The Health Center Program (http://bphc.hrsa.gov/) The HIV/AIDS Program (http://hab.hrsa.gov/) Maternal & Child Health (http://mchb.hrsa.gov/) Rural Health Policy (http://www.hrsa.gov/ruralhealth/index.html/) National Health Service Corps (http://nhsc.hrsa.gov/) Health Professions (http://bhpr.hrsa.gov/) Healthcare Systems (http://www.hrsa.gov/about/organization/bureaus/hsb/)

Health savings account

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Health savings account


Health care in the United States Government Health Programs

Federal Employees Health Benefits Program Indian Health Service Veterans Health Administration Military Health System / TRICARE Medicare Medicaid / State Health Insurance Assistance Program (SHIP) State Children's Health Insurance Program (CHIP) Program of All-Inclusive Care for the Elderly (PACE) Prescription Assistance (SPAP) Private health coverage

Health insurance in the United States Consumer-driven health care


Flexible spending account (FSA) Health Reimbursement Account Health savings account

High-deductible health plan (HDHP) Medical savings account (MSA) Private Fee-For-Service (PFFS) Managed care (CCP) Health maintenance organization (HMO) Preferred provider organization (PPO) Medical underwriting

Health care reform law


Emergency Medical Treatment and Active Labor Act (1986) Health Insurance Portability and Accountability Act (1996) Medicare Prescription Drug, Improvement, and Modernization Act (2003) Patient Safety and Quality Improvement Act (2005) Health Information Technology for Economic and Clinical Health Act (2009) Patient Protection and Affordable Care Act (2010) State level reform

Massachusetts health care reform Oregon Health Plan Vermont health care reform SustiNet (Connecticut) Dirigo Health (Maine) Municipal health coverage

Fair Share Health Care Act (Maryland) Healthy Howard (Howard Co., Maryland) Healthy San Francisco

A health savings account (HSA) is a tax-advantaged medical savings account available to taxpayers in the United States who are enrolled in a high-deductible health plan (HDHP).[][] The funds contributed to an account are not subject to federal income tax at the time of deposit. Unlike a flexible spending account (FSA), funds roll over and accumulate year to year if not spent. HSAs are owned by the individual, which differentiates them from company-owned Health Reimbursement Arrangements (HRA) that are an alternate tax-deductible source of funds

Health savings account paired with either HDHPs or standard health plans. HSA funds may currently be used to pay for qualified medical expenses at any time without federal tax liability or penalty. However, beginning in early 2011 OTC (over the counter) medications cannot be paid with HSA dollars without a doctor's prescription.[1] Withdrawals for non-medical expenses are treated very similarly to those in an individual retirement account (IRA) in that they may provide tax advantages if taken after retirement age, and they incur penalties if taken earlier. These accounts are a component of consumer-driven health care. Proponents of HSAs believe that they are an important reform that will help reduce the growth of health care costs and increase the efficiency of the health care system. According to proponents, HSAs encourage saving for future health care expenses, allow the patient to receive needed care without a gatekeeper to determine what benefits are allowed and make consumers more responsible for their own health care choices through the required High-Deductible Health Plan.[] Opponents of HSAs say they worsen, rather than improve, the U.S. health system's problems because people who are healthy will leave insurance plans while people who have health problems will avoid HSAs. There is also debate about consumer satisfaction with these plans.

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History
HSAs were established as part of the Medicare Prescription Drug, Improvement, and Modernization Act which was signed into law by President George W. Bush on December 8, 2003. They were developed to replace the Medical Savings Account system. A survey of employers published by the Kaiser Family Foundation in September 2008 found that 8% of covered workers were enrolled in a consumer-driven health plan (including both HSAs and Health Reimbursement Accounts), up from 4% in 2006. The study found that roughly 10 percent of firms offered such plans to their workers. Large firms were more likely to offer a high-deductible plan (18%), but enrollment was higher in small firms (8% of covered workers, versus 4% in larger firms).[2] As of 2012, these numbers had increased. Approximately 31% of firms offering health insurance offered an HSA (26%) or and HRA (5%) option. Large firms (38%) were somewhat more likely than small (31%) firms to offer such options. 11% of covered workers were in HSAs, while 8% were in HRAs. In small companies, 24% were in HDHPs vs 17% in larger firms.[3] A survey of health insurers performed by Americas Health Insurance Plans (AHIP) found that 4.5 million Americans were covered by HSA-qualified health plans as of January 2007. Of those, 3.4 million were covered through employer-sponsored plans, and 1.1 million were covered by individually purchased HSA-qualified plans. This represented an increase of 1.3 million since January 2006. In the individual market, 25% of new purchasers bought HSA-qualified plans. HSA-qualified plans represented 17% of new policies sold in the small group market and 8% of new policies sold in the large group market.[4] A follow-up survey by AHIP reported that the number of Americans covered by HSA-qualified plans had grown to 6.1 million as of January 2008 (4.6 million through employer-sponsored plans and 1.5 million covered by individually purchased HSA-qualified plans). HSA-qualified plans represented 27% of new purchases in the individual market, 31% of new enrollment in the small group market and 6% of new enrollment in the large group market.[5] In January 2008, market research firm Celent moderated its earlier projections, citing the HSA market's "disappointing early showing", and projected 12.5 million accounts by 2012.[6] A survey published by AHIP in May 2009 found that 8 million people were covered by HSA/High-Deductible health plans in January 2009. Of those, 1.8 million were covered by individual policies and approximately 6.2 million were covered by a group plan.[7] The Government Accountability Office (GAO) reported in April 2008 that many individuals enrolled in HSA-qualified health plans did not open tax-qualified HSA accounts, and individuals that had HSA accounts had higher incomes than others. According to the report, nationally representative surveys conducted by Blue Cross Blue Shield Association in 2005 to 2007 found that 42 to 49 percent of HSA-eligible plan enrollees did not open HSAs in those years. Based on an examination of Internal Revenue Service (IRS) data, GAO found that tax filers who

Health savings account reported HSA account activity had higher average incomes than other tax filers. Contributions into HSA accounts ($754 million in 2005) were roughly double withdrawals from the accounts ($366 million). Average contributions were also roughly twice average withdrawals ($2,100 versus $1,000). 41% of tax filers who made an HSA contribution did not make any withdrawals; 22% withdrew more than they contributed during the year.[8] Data released in 2012 indicate that the use of HSAs is increasing. Americas Health Insurance Plans (AHIP) reported in May 2012 that the number of people covered by an HSA-eligible HDHP more than doubled between January 2008 to January 2012 (going from 6.1 million to 13.5 million).[9] The split between group and individual plans was 11 million vs. 2.5 million, and the gender distribution of HSAs between male and female enrollees was an even 50%. Among individual plan holders, 51% were under age 40, and 49% were age 40 or over. The top five states with HSA/HDHP enrollment were California (1 million), Texas (0.76 million), Illinois (0.72 million), Ohio (0.66 million) and Florida (0.54 million). Also, a survey released in February 2012 by J. P. Morgan Chase of the 900,000 HSAs that it manages indicates that contributions to HSAs have been steadily increasing.[10] Between 2009 and 2011, the average Chase HSA balance rose by 11% annually, and the average employee contributions increased by 7% in 2011. Also, in 2011, 42% more dollars were transferred from HSA cash into HSA investment accounts than were transferred out.

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How they work


Deposits
Deposits to an HSA may be made by any policyholder of an HSA-eligible high-deductible health plan or by their employer, or any other person. If an employer makes deposits to such a plan on behalf of its employees, non-discrimination rules still applythat is, all employees must be treated equally. However, if contributions are made through a Section 125 plan, non-discrimination rules do not apply. Employers may treat full-time and part-time employees differently, and employers may treat individual and family participants differently. (The treatment of employees who are not enrolled in a HSA-eligible high-deductible plan is not considered for non-discrimination purposes.) Also, for 2007, employers may contribute more for non-highly compensated employees than highly compensated employees. Contributions from an employer or employee may be made on a pre-tax basis through an employer. If this option is not available through the employer, contributions may be made on a post-tax basis and then used to decrease gross taxable income on the following year's Form 1040. The main advantage of making pre-tax contributions is the Federal Insurance Contributions Act tax (FICA) and Medicare Tax deduction, which amounts to a savings of 7.65% (5.65% for the employee in 2011 due to Social Security rate holiday) each to the employer and employee (subject to limits of the Social Security Wage Base). The self-employed must pay self-employment tax on their contributions. Regardless of the method or tax savings associated with the deposit, the deposits may only be made for persons covered under an HSA-eligible high-deductible plan, with no other coverage beyond certain qualified additional coverage. Initially, the annual maximum deposit to an HSA was the lesser of the actual deductible or specified Internal Revenue Service (IRS) limits. Congress later abolished the limit based on the deductible and set statutory limits for maximum contributions. For example, the 2012 statutory limits are $3,100 for an individual and $6,250 for a family.[11] All contributions to an HSA, regardless of source, count toward the annual maximum. A catch-up provision also applies for plan participants who are age 55 or over, allowing the IRS limit to be increased.[] All deposits to an HSA become the property of the policyholder, regardless of the source of the deposit. Funds deposited but not withdrawn each year will carry over into the next year. If the policyholder ends their HSA-eligible insurance coverage, he or she loses eligibility to deposit further funds, but funds already in the HSA remain available for use. The Tax Relief and Health Care Act of 2006 signed into law on December 20, 2006, added a provision allowing a one-time rollover of IRA assets to be used to fund up to one year's maximum HSA contribution.

Health savings account State tax treatment of HSAs varies. Three statesAlabama, California and New Jerseydo not allow deductions of HSA contributions for state income taxes, and Wisconsin did not prior to 2011.[12][13] Contribution limits According to IRS Publication 969: Health Savings Accounts and Other Tax-Favored Health Plans [14], you can generally make contributions to your HSA for a given tax year until the deadline for filing your income tax returns for that year, which is typically April 15. All contributions to an HSA from both the employer and the employee count toward the annual maximum.
Year Contribution Limit (Single) $2,600 $2,650 $2,700 $2,850 $2,900 $3,000 $3,050 $3,050 $3,100 $3,250 $3,300 Contribution Limit (Family) $5,150 $5,250 $5,450 $5,650 $5,800 $5,950 $6,150 $6,150 $6,250 $6,450 $6,550 Catch-Up Contribution (55 or older) (Single and Family)

975

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 [15] [16] [17] [18] [19]

$500 $600 $700 $800 $900 $1,000 $1,000 $1,000 $1,000 $1,000 $1,000

Investments
Funds in an HSA can be invested in a manner similar to investments in an Individual Retirement Account (IRA). Investment earnings are sheltered from taxation until the money is withdrawn (and can be sheltered even then, as discussed in the section below). While HSAs can be "rolled over" from fund to fund, an HSA cannot be rolled into an IRA or a 401(k), and funds from these types of investment vehicles cannot be rolled into an HSA, except for the one-time IRA transfer mentioned earlier. Unlike some employer contributions to a 401(k) plan, all HSA contributions belong to the participant immediately, regardless of the deposit source. A person contributing to an HSA is under no obligation to contribute to his or her employer-sponsored HSA, although employers may require that payroll contributions be made only to the sponsored HSA plan.

Withdrawals
HSA participants do not have to obtain advance approval from their HSA trustee or their medical insurer to withdraw funds, and the funds are not subject to income taxation if made for qualified medical expenses. These include costs for services and items covered by the health plan but subject to cost sharing such as a deductible and coinsurance, or co-payments, as well as many other expenses not covered under medical plans, such as dental, vision and chiropractic care; durable medical equipment such as eyeglasses and hearing aids; and transportation expenses related to medical care. Through December 31, 2010, non-prescription, over-the-counter medications were also eligible.[][20] Beginning January 1, 2011 the Patient Protection and Affordable Care Act, also known as Health Care

Health savings account Reform, stipulates HSA funds can no longer be used to buy over-the-counter drugs without a doctor's prescription. There are several ways that funds in an HSA can be withdrawn. Some HSAs include a debit card, some supply checks for account holder use, and some allow for a reimbursement process similar to medical insurance. Most HSAs have more than one possible method for withdrawal, and the methods available vary from HSA to HSA. Checks and debits do not have to be made payable to the provider. Funds can be withdrawn for any reason, but withdrawals that are not for documented qualified medical expenses are subject to income taxes and a 20% penalty. The 20% tax penalty is waived for persons who have reached the age of 65 or have become disabled at the time of the withdrawal. Then, only income tax is paid on the withdrawal, and in effect the account has grown tax deferred (similar to an IRA). Medical expenses continue to be tax free. Prior to January 1, 2011, when new rules governing HSAs in the Patient Protection and Affordable Care Act went into effect, the penalty for non-qualified withdrawals was 10%. Account holders are required to retain documentation for their qualified medical expenses. Failure to retain and provide documentation could cause the IRS to rule withdrawals were not for qualified medical expenses and subject the taxpayer to additional penalties.[] There is no deadline for self-reimbursements of qualified medical expenses. High-income individuals can take advantage of this by paying for medical costs out of pocket, retaining receipts and allowing their accounts to grow tax-free. Money can then be withdrawn years later for any reason, up to the value of the receipts. [] When a person dies, the funds in their HSA are transferred to the beneficiary named for the account. If the beneficiary is a surviving spouse, the transfer is tax-free.

976

HSAs vs. other medical savings plans


Health savings accounts are similar to Medical savings account (Archer MSA) plans that were authorized by the federal government before HSA plans. HSAs can be used with some high-deductible health plans. HSAs came into being after legislation was signed by George W. Bush on December 8, 2003. The law went into effect on January 1, 2004. HSAs differ in several ways from MSAs. Perhaps the most significant difference is that employers of all sizes can offer an HSA account and insurance plan to employees. MSAs were limited to the self-employed and employers of 50 or fewer people.

Benefits
The premium for an HDHP generally is less than the premium for traditional health insurance. A higher deductible lowers the premium because the insurance company no longer pays for routine healthcare, and insurance underwriters believe that Americans who see a relationship between medical cost and their bank accounts will consume less medical care, shop for lower-cost options, and be more vigilant against excess and fraud in the health care industry. Introducing consumer-driven supply and demand and controlling inflation in health care and health insurance were among the government's goals in establishing these plans. With HSAs, in catastrophic situations, the maximum out-of-pocket expense liability can be less than that of a traditional health plan. This is because a qualified HDHP can cover 100% after the deductible, involving no coinsurance. HSAs also give the flexibility not available in some traditional health plans to pay on a pretax basis for qualified medical expenses not covered in standard or HSA insurance plans, which may include dental, orthodontic, vision, and other approved expenses.[21][22] HSA accounts also have an advantage over Flexible Spending Accounts (FSA) since deposits are not necessarily tied to expenses in a particular plan or calendar year. They are automatically rolled over for future medical expenses or may be used to reimburse qualified expenses from prior years as long as the expense was qualified under an HSA

Health savings account plan at the time that the expense was incurred.[23] Over time, if medical expenses are low and contributions are made regularly to the HSA, the account can accumulate significant assets that can be used for health care tax free or used for retirement on a tax-deferred basis. The HDHP plan, along with an HSA is the only health insurance plan option available that can possibly have a net gain of value during the year, provided the HSA funds are invested. A recent industry survey found that in July 2007 over 80% of HSA plans provided first-dollar coverage for preventive care. This was true of virtually all HSA plans offered by large employers and over 95% of the plans offered by small employers. It was also true of over half (59%) of the plans which were purchased by individuals. All of the plans offered first-dollar preventive care benefits included annual physicals, immunizations, well-baby and well-child care, mammograms and Pap tests; 90% included prostate cancer screenings and 80% included colon cancer screenings.[24]

977

Criticism
Some consumer organizations, such as Consumers Union, and many medical organizations, such as the American Public Health Association, oppose HSAs because, in their opinion, they benefit only healthy, younger people and make the health care system more expensive for everyone else. According to Stanford economist Victor Fuchs, "The main effect of putting more of it on the consumer is to reduce the social redistributive element of insurance."[25] Critics contend that low-income people, who are more likely to be uninsured, do not earn enough to benefit from the tax breaks offered by HSAs. These tax breaks are too modest, when compared to the actual cost of insurance, to persuade significant numbers to buy this coverage.[26] One industry study matched HSA account holders to the neighborhood income ("neighborhood" was defined as their census tract from the 2000 Census) and found that 3% of account holders lived in "low-income" neighborhoods (median incomes below $25,000 in 1999 dollars), 46% lived in lower-middle-income neighborhoods (median incomes between $25,000 and $50,000), 34% lived in middle-income neighborhoods (median incomes between $50,000 and $75,000), 12% lived in upper-income neighborhoods (median incomes between $75,000 and $100,000) and 5% lived in higher income neighborhoods (median incomes above $100,000).[27] In testimony before the US Senate Finance Committee's Subcommittee on Health in 2006, advocacy group Commonwealth Fund said that all evidence to date shows that health savings accounts and high-deductible health plans worsen, rather than improve, the US health system's problems.[28] HSA funds that are not held in savings accounts insured by the Federal Deposit Insurance Corporation are subject to market risk, as is any other investment. While the potential upside from investment gains can be viewed as a benefit, the subsequent downside, as well as the possibility of capital loss, may make the HSA a poor option for some.[29]

Consumer satisfaction
Consumer satisfaction results have been mixed. While a 2005 survey by the Blue Cross and Blue Shield Association found widespread satisfaction among HSA customers,[30] a survey published in 2007 by employee benefits consultants Towers Perrin came to the opposite conclusion; it found that employees currently enrolled in such plans were significantly less satisfied with many elements of the health benefit plan compared to those enrolled in traditional health benefit plans.[31] In 2006, a Government Accountability Office report concluded: "HSA-eligible plan enrollees who participated in GAO's focus groups generally reported positive experiences, but most would not recommend the plans to all consumers. Few participants reported researching cost before obtaining health care services, although many researched the cost of prescription drugs. Most participants were satisfied with their HSA-eligible plans and would recommend them to healthy consumers, but not to those who use maintenance medication, have a chronic condition,

Health savings account have children, or may not have the funds to meet the high deductible." [32] According to the Commonwealth Fund, early experience with HSA-eligible high-deductible health plans reveals low satisfaction, high out-of-pocket costs, and cost-related access problems.[28] A survey conducted with the Employee Benefit Research Institute found that people enrolled in HSA-eligible high-deductible health plans were much less satisfied with many aspects of their health care than adults in more comprehensive plans.[33] People in these plans allocate substantial amounts of income to their health care, especially those who have poorer health or lower incomes. Adults in high-deductible health plans are far more likely to delay or avoid getting needed care, or to skip medications, because of the cost. Problems are particularly pronounced among those with poorer health or lower incomes. Few Americans in any health plan have the information they need to make decisions. Just 12 to 16 percent of insured adults have information from their health plan about the quality or cost of care provided by their doctors and hospitals. Some policy analysts say that consumer satisfaction doesn't reflect quality of health care. Researchers at RAND Corporation and Department of Veterans Affairs asked 236 vulnerable elderly patients at two managed care plans to rate their care, then examined care in medical records, as reported in Annals of Internal Medicine. There was no correlation. "Patient ratings of health care are easy to obtain and report, but do not accurately measure the technical quality of medical care," said John T. Chan, UCLA, lead author.[34][35][36]

978

HSAs and health policy


According to a 2006 Zogby poll, seven in ten voters back Congressional action to allow HSA participants to pay for their insurance premiums using money in their savings plans.[37]

Notes and references


[2] Employer Health Benefits 2007 Annual Survey (http:/ / www. kff. org/ insurance/ 7672), Kaiser Family Foundation, 2007-09-11, accessed 2007-10-28 [4] Hannah Yoo, January 2007 Census Shows 4.5 Million People Covered by HSA/High-Deductible Health Plans (http:/ / www. ahipresearch. org/ PDFs/ FINAL AHIP_HSAReport. pdf), Americas Health Insurance Plans, April 2007 [5] Hannah Yoo, January 2008 Census Shows 6.1 Million People Covered by HSA/High-deductible Health Plans, (http:/ / www. ahipresearch. org/ pdfs/ 2008_HSA_Census. pdf) Americas Health Insurance Plans, April 2008 [6] Press Release for Report Entitled "HSAs: Moving Beyond the Growing Pains," (http:/ / www. celent. net/ PressReleases/ 20080107/ HSAGrowing. htm) Celent, January 7, 2008 [7] Hannah Yoo, January 2009 Census Shows 8 Million People Covered by HSA/High-deductible Health Plans, (http:/ / www. ahipresearch. org/ pdfs/ 2009hsacensus. pdf) Americas Health Insurance Plans, May 2009 [8] John E. Dicken, Director, Health Care, U.S. Government Accountability Office, "Health Savings Accounts: Participation Increased and Was More Common among Individuals with Higher Incomes," (http:/ / www. gao. gov/ new. items/ d08474r. pdf) Letter to Henry A. Waxman, Chairman of the House of Representatives Committee on Oversight and Government Reform and Pete Stark, Chairman of House of Representatives Subcommittee on Health Committee on Ways and Means, dated April 1, 2008 [9] Center for Policy Research, America's Health Insurance Plans, http:/ / www. ahip. org/ HSA2012/ [10] J. P. Morgan Chase, http:/ / www. jpmorgan. com/ visit/ hsasnapshot [14] http:/ / www. irs. gov/ pub/ irs-pdf/ p969. pdf [15] IRS Rev. Proc. 2009-29 (http:/ / www. irs. gov/ pub/ irs-drop/ rp-09-29. pdf) [16] IRS Rev. Proc. 2010-22 (http:/ / www. irs. gov/ pub/ irs-drop/ rp-10-22. pdf) [17] IRS Rev. Proc. 2011-32 (http:/ / www. irs. gov/ pub/ irs-drop/ rp-11-32. pdf) [18] IRS Rev. Proc. 2012-26 (http:/ / www. irs. gov/ pub/ irs-drop/ rp-12-26. pdf) [19] IRS Rev. Proc. 2013-25 (http:/ / www. irs. gov/ pub/ irs-drop/ rp-13-25. pdf) [20] HSA.pdf (http:/ / www. treasury. gov/ offices/ public-affairs/ hsa/ pdf/ HSA-Tri-fold-english-07. pdf) [21] Department of Treasury HSA FAQ (http:/ / www. treas. gov/ offices/ public-affairs/ hsa/ faq_using. shtml#hsa2) [22] HSA Basics (http:/ / www. treas. gov/ offices/ public-affairs/ hsa/ pdf/ HSA-Tri-fold-english-07. pdf) [23] US Treasury Notice 2004-50 Q&A #39 (http:/ / www. irs. gov/ irb/ 2004-33_IRB/ ar08. html#d0e1935)

Health savings account


[24] Thomas Wilder and Hannah Yoo, "A Survey of Preventive Benefits in Health Savings Account (HSA) Plans, July 2007," (http:/ / www. ahipresearch. org/ pdfs/ HSA_Preventive_Survey_Final. pdf) Americas Health Insurance Plans, November 2007 [27] Hannah Yoo and Christelle Chen, Estimated Income Characteristics of HSA Accountholders in 2008, (http:/ / www. ahipresearch. org/ pdfs/ HSAIncome2009. pdf) Americas Health Insurance Plans, May 2009 [28] Testimony, Committee on Finance, September 26, 2006 CMWF.org (http:/ / www. cmwf. org/ publications/ publications_show. htm?doc_id=405167) [32] Health Savings Accounts: Early Enrollee Experiences with Accounts and Eligible Health Plans, GAO-06-1133T, September 26, 2006 (http:/ / www. gao. gov/ docsearch/ abstract. php?rptno=GAO-06-1133T) [33] Fronstin, Paul. "Findings from the 2009 EBRI/MGA Consumer Engagement in Health Care Survey." EBRI Issue Brief no. 337, Dec. 2009 (http:/ / www. ebri. org/ pdf/ briefspdf/ EBRI_IB_12-2009_No337_CEHCS. pdf) [34] Wessel, David Capital: In health care, consumer theory falls flat (http:/ / online. wsj. com/ article/ SB115758434624755703. html) Wall Street Journal, 2006-09-07. [35] RAND Corporation (http:/ / www. rand. org/ news/ press. 06/ 05. 01. html), News Release, May 1, 2006, RAND study finds patients' ratings of their medical care do not reflect the technical quality of their care. [36] Patients' Global Ratings of Their Health Care Are Not Associated with the Technical Quality of Their Care (http:/ / www. annals. org/ cgi/ content/ abstract/ 144/ 9/ 665), John T. Chang, et al., Ann Intern Med. 2006 May 2;144(9):66572. [PMID16670136] [37] Zogby International (http:/ / www. zogby. com/ news/ ReadNews. dbm?ID=1105)

979

External links
U.S. Treasury site on HSAs (http://www.treas.gov/offices/public-affairs/hsa/) HSA Contribution limits for 2007 (http://www.ustreas.gov/offices/public-affairs/hsa/07IndexedAmounts. shtml) HSA Contribution limits for 2008 (http://www.ustreas.gov/offices/public-affairs/hsa/pdf/rp-2007-36.pdf) HSA Contribution limits for 2009 (http://www.ustreas.gov/press/releases/hp975.htm) List of Eligible Medical Expenses (http://www.irs.gov/publications/p502/ar02.html#d0e630) Federal Tax Savings from HSA contributions made in 2007 (http://www.ustreas.gov/offices/public-affairs/ hsa/pdf/hsa-examples_2007.pdf) IRS Forms for HSAs (http://www.ustreas.gov/offices/public-affairs/hsa/forms/) FAQs on HSAs: Frequently Asked Questions on Health Savings Accounts (http://www.actuary.org/pdf/ health/hsa_oct07.pdf) from the American Academy of Actuaries (October 2007)

Health Service Executive

980

Health Service Executive


Health Service Executive
Type Founded Public Sector 2005

Headquarters Dr. Steevens' Hospital, Dublin 8 Key people [1] Ambrose McLoughlin (Chairman ) [2] Tony O'Brien (Director General Designate ) 13 billion Euro (2010) 100,000 (2010) www.hse.ie [4] [3] [3]

Revenue Employees Website

The Health Service Executive (HSE) (Irish: Feidhmeannacht na Seirbhse Slinte) is responsible for the provision of healthcare providing health and personal social services for everyone living in Ireland, with public funds. The Executive was established by the Health Act, 2004 and came into official operation on 1 January 2005. It replaces the ten regional Health Boards, the Eastern Regional Health Authority and a number of other different agencies and organisations. The Minister for Health has overall responsibility for the Executive in Government. The HSE is Ireland's largest employer with over 67,000 direct employees, and another 40,000 in funded health care organisations. It has an annual budget of over 13 billion, more than any other public sector organisation.

HSE services
The HSE provides health and social services to everyone living in Ireland. Its services are delivered to young and old, in hospitals, health facilities and in communities across the country. The HSE website at www.hse.ie provides a wide range of information on the services provided, and information on how to access them.[5] The site provides a list of every public hospital in Ireland, along with the 8 designated Cancer Centres, in Hospitals & Cancer Control.[6] If you are looking for any Urgent Care or Out of Hours Services you will find many listed.[7] The wide range of care services provided in the community are available through the 32 Local Health Offices nationwide - the first port of call for community care in Ireland. Information is provided about Primary Care and the HSE's new primary care centres, which are opening all over the country and will be the future of the Irish health system.[8] You can read about older people services, or find forms and details for many benefits and schemes, including medical cards and the Drugs Payment Scheme. Contacts are provided for a wide range of children and family services, including child health and child protection services. The Births, Deaths, Marriages section show you how to register an event, or even buy a certificate online. Addiction services, disability services are listed, along with environmental health, public health, and sexual health services. Mental health services are undergoing significant transformation at the moment, and you can read about those changes. Finally, if you are wondering who can access health services in Ireland, details are provided on eligibility for health services.[8] The HSE also provides an information service by telephone, the HSE INFOLINE, callsave 1850 24 1850, open Monday to Saturday, 8 am to 8 pm.

Health Service Executive

981

Structure
The HSE's organisational structure is divided into some key areas: Integrated Services, which includes services delivering care in the community and acute hospital and ambulance services Quality and Clinical Care, which provides clinical leadership, national clinical services and quality and performance programmes Support Services, like HR, Finance, Communications, Estates and ICT, which enable the HSE to function efficiently and cost effectively.

Board of directors
The members of the New Interim HSE Board, as of 17 February 2013, were:[9] Dr. Ambrose McLoughlin, Chairman and Secretary General, Department of Health, Mr. Tony OBrien, Deputy CEO/Director General Designate, HSE Dr. Tony Holohan, Chief Medical Officer, Department of Health Mr. Paul Barron, Assistant Secretary, Primary Care & Eligibility Division, Department of Health

Ms. Bairbre NicAongusa, Assistant Secretary, Finance, Performance Evaluation, Information, EU International, Research & Resource Allocation Division, Dept of Health. Dr. Aine Carroll, HSE National Director, Clinical Strategy & Programmes (replaced Dr. Barry White) Dr. Philip Crowley, HSE National Director, Quality & Patient Safety Ms. Laverne McGuinness, HSE National Director, Integrated Services - Performance & Financial Management Mr. Jim Breslin, Secretary General of the Department of Children and Youth Affairs. Ms. Frances Spillane, Assistant Secretary, National Human Resources and Professional Regulation Division,Department of Health Ms. Geraldine Fitzpatrick, Assistant Secretary, Department of Health (replaced Mr. Brian Gilroy, former HSE National Director, Integrated Services Reconfiguration)

HSE regions
The HSE delivers its services through fifty public hospitals and thirty-two local health offices nationwide. The HSE is divided into four regions: HSE Dublin Mid-Leinster - (South Dublin, County Kildare, County Wicklow, County Longford, County Westmeath, County Laois and County Offaly) HSE Dublin North East - (North Dublin, County Meath, County Louth, County Cavan and County Monaghan) HSE South - (County Cork, County Kerry, South Tipperary, County Wexford, County Waterford, County Carlow and County Kilkenny) HSE West - (County Galway, County Mayo, County Roscommon, County Limerick, County Clare, North Tipperary, Donegal, Sligo, and County Leitrim) Each region is headed by a Regional Director of Operations, who is responsible for managing all services in that area.

Health Service Executive

982

News and criticism


The HSE is the subject of daily news reporting, and despite frequent negative media coverage they have yet to be disbanded[10][11] The HSE is working to modernise and improve how healthcare is delivered in Ireland, through the extension of the amount of care provided in the community, rather than in hospital, and also through the initiation of a wide range of clinical programmes. These clinical programme are led by hospital consultants, and are going to standardise the approach to our most grave and common healthcare challenges, like heart disease, diabetes and others. The HSE is frequently portrayed by the Irish media as an inefficient, top-heavy and excessively bureaucratic organisation. Mostly because they are.[12][13] Like any healthcare system across the world, the Irish health system has been involved in a number of serious health scandals, for example relating to cancer misdiagnoses in 2008.[14][15] The HSE has also been the subject of criticism for cutbacks, service cancellations etc., but has recently indicated that it is making good progress in saving costs and achieving its required 'break-even' budget position for 2010.[16] In March 2010, it emerged that 58,000 X-Ray radiographs had not been reviewed by a consultant radiologist.[17] An independent report into this incident at Tallaght Hospital is due to be published by the HSE during October 2010. In the same month, the Irish Medical Organisation stated that patients awaiting a HSE medical card were waiting up to six months to receive their card, and that their health was being put at risk as they could not afford medicines that they would have otherwise obtained had they received their card.[18] The HSE has since announced a new online system for medical card applications that will reduce turnaround time for routine applications to 15 days.[19] In May 2011, key forensic evidence in up to 25 sexual-assault cases may be challenged in court because of a major administrative blunder by the HSE. The victims -- some as young as 14 -- were told by gardai about the incident, in which a nurse who carried out their forensic tests was unregistered. This could lead to the evidence being challenged.[20] In July 2012, a damning secret report prepared for embattled Minister for Health James Reilly revealed the Health Service Executive (HSE) to be an organisation racked by "inertia", with "unrealistic" plans for cost cuts which could place patients' lives at risk.

References
[1] Chairperson page (http:/ / hse. ie/ eng/ about/ Who/ Board_Members/ ) on HSE Web site [2] News page (http:/ / www. hse. ie/ eng/ ) from the HSE Web site [3] HSE (http:/ / www. hse. ie/ eng/ staff/ Healthstat/ about/ ) Factfile [4] http:/ / www. hse. ie/ [5] http:/ / www. hse. ie [6] http:/ / www. hse. ie/ eng/ services/ Find_a_Service/ HospsCancer/ [7] http:/ / www. hse. ie/ eng/ services/ Find_a_Service/ outofhours/ [8] http:/ / www. hse. ie/ eng/ services/ Find_a_Service/ [9] http:/ / www. hse. ie/ eng/ about/ Who/ Board_Members/ [10] http:/ / www. hse. ie/ eng/ services/ Publications/ services/ Hospitals/ HSE_Emergency_Departments_. html [11] http:/ / www. hse. ie/ eng/ services/ Publications/ Your_Service,_Your_Say_Consumer_Affairs/ Reports/ Insight_07. html [12] http:/ / archives. tcm. ie/ businesspost/ 2007/ 11/ 25/ story28496. asp [13] http:/ / www. rte. ie/ news/ 2008/ 0922/ auditor. html [14] http:/ / www. irishtimes. com/ newspaper/ breaking/ 2008/ 0922/ breaking55. htm [15] http:/ / www. rte. ie/ news/ 2008/ 0401/ cancer. html [16] http:/ / saraburke. wordpress. com/ 2010/ 09/ 14/ hse-progress-is-slow-but-more-patients-are-not-waiting-longer/ [17] http:/ / breakingnews. ie/ ireland/ hse-confirms-investigation-into-tallaght-x-ray-scandal-449471. html [18] http:/ / www. rte. ie/ news/ 2010/ 0322/ health. html [19] http:/ / www. hse. ie/ eng/ services/ newscentre/ Campaigns/ medicalcardie. html [20] http:/ / www. independent. ie/ national-news/ blunder-by-hse-puts-sex-cases-in-doubt-2644479. html

Health Service Executive

983

External links
Health Service Executive (http://www.hse.ie) Health Information and Quality Authority (http://www.hiqa.ie)

Health Technology Assessment


Health Technology Assessment
Abbreviated title (ISO4) Health Technol Assess Language Edited by English Tom Walley Publication details Publisher Publication history Frequency Open access Impact factor (2011) National Co-Ordinating Centre for HTA (United Kingdom) 1997-present Weekly Yes 4.255

Indexing ISSN [1] 1366-5278 (print) [2] 2046-4924 (web) 36731562 [3] Links Journal homepage [5] Online archive [4]

OCLC number

Health Technology Assessment is a weekly peer-reviewed open access medical journal published by the National Institute for Health Research, part of the United Kingdom National Health Service. The journal was established in 1997 and the editor-in-chief is Tom Walley (National Institute for Health Research). According to the Journal Citation Reports, the journal has a 2011 impact factor of 4.255.[]

References
[1] [2] [3] [4] [5] http:/ / www. worldcat. org/ issn/ 1366-5278 http:/ / www. worldcat. org/ issn/ 2046-4924 http:/ / www. worldcat. org/ oclc/ 36731562 http:/ / www. hta. ac. uk/ research/ HTAjournal. shtml http:/ / www. hta. ac. uk/ project/ htapubs. asp

External links
Official website (http://www.hta.ac.uk/research/HTAjournal.shtml)

Incurred but not reported

984

Incurred but not reported


Incurred but not reported (IBNR) is a term in common use in insurance. IBNR reflects the total amount owed by the insurer to all valid claimants who have had a covered loss but have not yet reported it. Since the insurer knows neither how many of these losses (the frequency) have occurred, nor the severity of each loss, IBNR is necessarily an estimate. The quality of this estimation is often used as a tool in assessing the financial accounting skills of a given insurer. Insurers track IBNR by policy periods (when the policy incepted), along with other categorizations.The characteristics of IBNR makes it look more like a reserve or provision for the particular types of losses not reported, hence gives a better estimation of profits for the insurer's current business period. When a policy of insurance is written it will typically cover a defined (often 12 month) period from inception of the policy. When the policy is sold, a premium is paid by the insured party to the insurer. The number and cost of claims that will arise from the policy are unknown and unknowable amounts at inception. Indeed, at expiry of the policy there can be a high degree of uncertainty as to what the cost of claims will ultimately be. There might be some information available on incurred claims amounts but this can often be zero. The insurer will conduct a reserving exercise with a view to assessing what this ultimate cost will be. This enables them to assess the profitability of the business that they have written and are planning to write in the future. Typical reserving methods used to assess ultimate claims and hence IBNR reserves include: Incurred Chain Ladder Paid Chain Ladder Incurred Bornhuetter-Ferguson Paid Bornhuetter-Ferguson Exposure-based methods

Other methods such as the Average Cost Per Claim and Separation are sometimes used. Under Solvency II it has become fashionable to consider reserving on a stochastic claims reserving methods; see Outstanding claims reserves. There is an exceptionally low degree of agreement within general insurance as to what much of the terminology actually means. IBNR is a widely accepted term with a fairly standard meaning. This balancing item between the incurred claims and the ultimate claims is commonly referred to as the IBNR or the IBNR reserve. In pure terms, it only allows for those claims that have occurred before the valuation date but have not yet been reported to the insurer either directly or through the broker, hence the name. This pure usage is not used in practice. The more common usage includes reserves for items such as reopened claims, future claims on exposures to be written within the projection period, salvage and subrogation. The calculation of the IBNR reserve is a process that requires judgement and the results of which will remain uncertain for several years. The reserving process is typically done at an aggregate level. For example, at a class of business, underwriting year and currency level. It is important to try to achieve a homogeneous data grouping and to treat any special claims separately. For example, US Banks business written in 2001 needs to have any claims relating to the collapse of the Enron Corporation treated separately. Similarly, US Property Excess of Loss business written in 2004 and 2005 needs to have any claims relating to Hurricanes treated separately. Such reserving calculations should be performed at a gross of reinsurance level and also for outwards proportional reinsurance and outwards excess of loss reinsurance separately. Reserving is undertaken by actuaries who are professionally qualified people. The above description is appropriate for most of the world and reflects the practices in the London Market, although practices can differ.

International Statistical Classification of Diseases and Related Health Problems

985

International Statistical Classification of Diseases and Related Health Problems


The International Classification of Diseases (also known by the abbreviation ICD) is the United Nations-sponsored World Health Organizations "standard diagnostic tool for epidemiology, health management and clinical purposes."[1] The ICD is designed as a health care classification system, providing a system of diagnostic codes for classifying diseases, including nuanced classifications of a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or disease. This system is designed to map health conditions to corresponding generic categories together with specific variations, assigning for these a designated code, up to six characters long. Thus, major categories are designed to include a set of similar diseases. The International Classification of Diseases is published by the World Health Organization (WHO) and used worldwide for morbidity and mortality statistics, reimbursement systems, and automated decision support in health care. This system is designed to promote international comparability in the collection, processing, classification, and presentation of these statistics. As in the case of the analogous (but limited to mental and behavioral disorders) Diagnostic and Statistical Manual of Mental Disorders (DSM, currently in version 5), the ICD is a major project to statistically classify health disorders, and provide diagnostic assistance. The ICD is a core statistically-based classificatory diagnostic system for health care related issues of the WHO Family of International Classifications (WHO-FIC).[2] The ICD is revised periodically and is currently in its tenth revision. The ICD-10, as it is therefore known, was developed in 1992 to track health statistics. ICD-11[3] is planned for 2015[] and will be revised using Web 2.0 principles.[] Annual minor updates and triennial major updates are published by the WHO.[4] The ICD is part of a "family" of guides that can be used to complement each other, including also the International Classification of Functioning, Disability and Health which focuses on the domains of functioning (disability) associated with health conditions, from both medical and social perspectives.

Historical synopsis
In 1893, a French physician, Jacques Bertillon, introduced the Bertillon Classification of Causes of Death at a congress of the International Statistical Institute in Chicago.[5] A number of countries and cities adopted Dr. Bertillons system, which was based on the principle of distinguishing between general diseases and those localized to a particular organ or anatomical site, as used by the City of Paris for classifying deaths. Subsequent revisions represented a synthesis of English, German and Swiss classifications, expanding from the original 44 titles to 161 titles. In 1898, the American Public Health Association (APHA) recommended that the registrars of Canada, Mexico, and the United States also adopt it. The APHA also recommended revising the system every ten-years to ensure the system remained current with medical practice advances. As a result, the first international conference to revise the International Classification of Causes of Death convened in 1900; with revisions occurring every ten-years thereafter. At that time the classification system was contained in one book, which included an Alphabetic Index as well as a Tabular List. The book was small compared with current coding texts. The revisions that followed contained minor changes, until the sixth revision of the classification system. With the sixth revision, the classification system expanded to two volumes. The sixth revision included morbidity and mortality conditions, and its title was modified to reflect the changes: International Statistical Classification of Diseases, Injuries and Causes of Death (ICD). Prior to the sixth revision, responsibility for ICD revisions fell to the Mixed Commission, a group composed of representatives from the International Statistical Institute and the Health Organization of the League of Nations. In 1948, the World Health Organization (WHO) assumed responsibility for preparing and publishing the revisions to the ICD every ten-years. WHO sponsored the seventh and eighth revisions in 1957 and 1968, respectively. It later become clear that the established ten-year interval between revisions was too

International Statistical Classification of Diseases and Related Health Problems short.[5] The ICD is currently the most widely used statistical classification system for diseases in the world. International health statistics using this system are available at the Global Health Observatory (GHO) [6] ([7]) In addition, some countriesincluding Australia, Canada and the United Stateshave developed their own adaptations of ICD, with more procedure codes for classification of operative or diagnostic procedures.

986

Versions of ICD
ICD-6
The ICD-6, published in 1949, was the first to be shaped to become suitable for morbidity reporting. Accordingly the name changed from International List of Causes of Death to International Statistical Classification of Diseases. The combined code section for injuries and their associated accidents was split into two, a chapter for injuries, and a chapter for their external causes. With use for morbidity there was a need for coding mental conditions, and for the first time a section on mental disorders was added.[] [8]

ICD-7
The International Conference for the Seventh Revision of the International Classification of Diseases was held in Paris under the auspices of WHO in February 1955. In accordance with a recommendation of the WHO Expert Committee on Health Statistics, this revision was limited to essential changes and amendments of errors and inconsistencies.[8]

ICD-8
The Eighth Revision Conference convened by WHO met in Geneva, from 6 to 12 July 1965. This revision was more radical than the Seventh but left unchanged the basic structure of the Classification and the general philosophy of classifying diseases, whenever possible, according to their etiology rather than a particular manifestation. During the years that the Seventh and Eighth Revisions of the ICD were in force, the use of the ICD for indexing hospital medical records increased rapidly and some countries prepared national adaptations which provided the additional detail needed for this application of the ICD. In the USA, a group of consultants was asked to study the 8th revision of ICD (ICD-8) for its applicability to various users in the United States. This group recommended that further detail be provided for coding hospital and morbidity data. The American Hospital Associations Advisory Committee to the Central Office on ICDA developed the needed adaptation proposals, resulting in the publication of the International Classification of Diseases, Adapted (ICDA). In 1968, the United States Public Health Service published the International Classification of Diseases, Adapted, 8th Revision for use in the United States (ICDA-8). Beginning in 1968, ICDA-8 served as the basis for coding diagnostic data for both official morbidity [and mortality] statistics in the United States.[8][9]

International Statistical Classification of Diseases and Related Health Problems

987

ICD-9
The International Conference for the Ninth Revision of the International Classification of Diseases, convened by WHO, met in Geneva from 30 September to 6 October 1975. In the discussions leading up to the conference, it had originally been intended that there should be little change other than updating of the classification. This was mainly because of the expense of adapting data processing systems each time the classification was revised. There had been an enormous growth of interest in the ICD and ways had to be found of responding to this, partly by modifying the classification itself and partly by introducing special coding provisions. A number of representations was made by specialist bodies which had become interested in using the ICD for their own statistics. Some subject areas in the classification were regarded as inappropriately arranged and there was considerable pressure for more detail and for adaptation of the classification to make it more relevant for the evaluation of medical care, by classifying conditions to the chapters concerned with the part of the body affected rather than to those dealing with the underlying generalized disease. At the other end of the scale, there were representations from countries and areas where a detailed and sophisticated classification was irrelevant, but which nevertheless needed a classification based on the ICD in order to assess their progress in health care and in the control of disease. A field test with a bi-axial classification approach - one axis for anatomy, another for etiology - showed the impracticability of such approach for routine use. The final proposals presented to and accepted by the Conference retained the basic structure of the ICD, although with much additional detail at the level of the four digit subcategories, and some optional five digit subdivisions. For the benefit of users not requiring such detail, care was taken to ensure that the categories at the three digit level were appropriate. For the benefit of users wishing to produce statistics and indexes oriented towards medical care, the Ninth Revision included an optional alternative method of classifying diagnostic statements, including information about both an underlying general disease and a manifestation in a particular organ or site. This system became known as the dagger and asterisk system and is retained in the Tenth Revision. A number of other technical innovations were included in the Ninth Revision, aimed at increasing its flexibility for use in a variety of situations. It was eventually replaced by ICD-10, the version currently in use by the WHO and most countries. Given the widespread expansion in the tenth revision, it is not possible to convert ICD-9 data sets directly into ICD-10 data sets, although some tools are available to help guide users.[10] Publication of ICD-9 without IP restrictions in a world with evolving electronic data systems led to a range of products based on ICD-9, such as MeDRA or the Read directory.[8][9] ICPM When ICD-9 was published by the World Health Organization (WHO), the International Classification of Procedures in Medicine (ICPM) was also developed (1975) and published (1978). The ICPM surgical procedures fascicle was originally created by the United States, based on its adaptations of ICD (called ICDA), which had contained a procedure classification since 1962. ICPM is published separately from the ICD disease classification as a series of supplementary documents called fascicles (bundles or groups of items). Each fascicle contains a classification of modes of laboratory, radiology, surgery, therapy, and other diagnostic procedures. Many countries have adapted and translated the ICPM in parts or as a whole and are using it with amendments since then.[8][9]

International Statistical Classification of Diseases and Related Health Problems ICD-9-CM International Classification of Diseases, Clinical Modification (ICD-9-CM) is an adaption created by the U.S. National Center for Health Statistics (NCHS) and used in assigning diagnostic and procedure codes associated with inpatient, outpatient, and physician office utilization in the United States. The ICD-9-CM is based on the ICD-9 but provides for additional morbidity detail. It is updated annually on October 1.[11][12] It consists of two or three volumes: Volumes 1 and 2 contain diagnosis codes. (Volume 1 is a tabular listing, and volume 2 is an index.) Extended for ICD-9-CM Volume 3 contains procedure codes. ICD-9-CM only The NCHS and the Centers for Medicare and Medicaid Services are the U.S. governmental agencies responsible for overseeing all changes and modifications to the ICD-9-CM.

988

ICD-10
Work on ICD-10 began in 1983, and the new revision was endorsed by the Forty-third World Health Assembly in May 1990. The latest version came into use in WHO Member States starting in 1994.[13] The classification system allows more than 155,000 different codes and permits tracking of many new diagnoses and procedures, a significant expansion on the 17,000 codes available in ICD-9.[] Adoption was relatively swift in most of the world. Several materials are made available online by WHO to facilitate its use, including a manual, training guidelines, a browser, and files for download.[2] Some countries have adapted the international standard, such as the "ICD-10-AM" published in Australia in 1998 (also used in New Zealand),[14] and the "ICD-10-CA" introduced in Canada in 2000.[15] ICD-10-CM Adoption of ICD-10 has been slow in the United States. Since 1979,[16] the USA had required ICD-9-CM codes for Medicare and Medicaid claims, and most of the rest of the American medical industry followed suit. On 1 January 1999 the ICD-10 (without clinical extensions) was adopted for reporting mortality, but ICD-9-CM was still used for morbidity. Meanwhile, NCHS received permission from the WHO to create a clinical modification of the ICD-10, and has production of all these systems: ICD-10-CM, for diagnosis codes, is intended to replace volumes 1 and 2. Annual updates are provided. ICD-10-PCS, for procedure codes, is intended to replace volume 3. Annual updates are provided. On August 21, 2008, the US Department of Health and Human Services (HHS) proposed new code sets to be used for reporting diagnoses and procedures on health care transactions. Under the proposal, the ICD-9-CM code sets would be replaced with the ICD-10-CM code sets, effective October 1, 2013. On April 17, 2012 the Department of Health and Human Services (HHS) published a proposed rule that would delay, from October 1, 2013 to October 1, 2014,the compliance date for the ICD-10-CM and PCS.[17]

International Statistical Classification of Diseases and Related Health Problems ICD-10-CA ICD-10-CA is a clinical modification of ICD-10 developed by the Canadian Institute for Health Information for morbidity classification in Canada. ICD-10-CA applies beyond acute hospital care, and includes conditions and situations that are not diseases but represent risk factors to health, such as occupational and environmental factors, lifestyle and psycho-social circumstances.[15]

989

ICD-11
The World Health Organization is currently revising the International Classification of Diseases (ICD) towards the ICD-11. The development is taking place on an internet-based workspace, called iCAT (Collaborative Authoring Tool) Platform, somewhat similar to Wikipedia yet it requires more structure and peer review process. The WHO collaborates through this platform with all interested parties. The final draft of the ICD-11 system is expected to be submitted to WHO's World Health Assembly (WHA) for official endorsement by 2015. The beta draft[18] was made available online in May 2012 for initial consultation and commenting.[19] In ICD-11 each disease entity will have definitions that give key descriptions and guidance on what the meaning of the entity/category is in human readable terms - to guide users. This is an advancement over ICD-10, which had only title headings. The Definitions have a standard structure according to a template with standard definition templates and further features exemplified in a Content Model. The Content Model is a structured framework that captures the knowledge that underpins the definition of an ICD entity. The Content Model therefore allows computerization (with links to ontologies and SNOMED CT). Each ICD entity can be seen from different dimensions or parameters. For example, there are currently 13 defined main parameters in the Content Model (see below) to describe a category in ICD. 1. ICD Entity Title - Fully Specified Name 2. Classification Properties - disease, disorder, injury, etc. 3. Textual Definitions - short standard description 4. Terms - synonyms, other inclusion and exclusions 5. Body System/Structure Description - anatomy and physiology 6. Temporal Properties - acute, chronic or other 7. Severity of Subtypes Properties - mild, moderate, severe, or other scales 8. Manifestation Properties - signs, symptoms 9. Causal Properties - etiology: infectious, external cause, etc. 10. Functioning Properties - impact on daily life: activities and participation 11. Specific Condition Properties - relates to pregnancy etc. 12. Treatment Properties - specific treatment considerations: e.g. resistance 13. Diagnostic Criteria - operational definitions for assessment ICD exists in 41 Languages in electronic versions and its expression in multiple languages will be systematically pursued in ICD11.

Usage and current topics


History and usage in the United States
In the United States, the U.S. Public Health Service published The International Classification of Diseases, Adapted for Indexing of Hospital Records and Operation Classification (ICDA), completed in 1962 and expanding the ICD-7 in a number of areas to more completely meet the indexing needs of hospitals. The U.S. Public Health Service later published the Eighth Revision, International Classification of Diseases, Adapted for Use in the United States, commonly referred to as ICDA-8, for official national morbidity and mortality statistics. This was followed by the

International Statistical Classification of Diseases and Related Health Problems ICD, 9th Revision, Clinical Modification, known as ICD-9-CM, published by the U.S. Department of Health and Human Services and used by hospitals and other healthcare facilities to better describe the clinical picture of the patient. The diagnosis component of ICD-9-CM is completely consistent with ICD-9 codes, and remains the data standard for reporting morbidity. National adaptations of the ICD-10 progressed to incorporate both clinical code (ICD-10-CM) and procedure code (ICD-10-PCS) with the revisions completed in 2003. In 2009, the U.S. Centers for Medicare and Medicaid Services announced that it would begin using ICD-10 on April 1, 2010, with full compliance by all involved parties by 2013.[] The years for which causes of death in the United States have been classified by each revision as follows:
ICD-1 1900 ICD-2 1910 ICD-3 1921 ICD-4 1930 ICD-5 1939 ICD-6 1949 ICD-7 1958 ICD-8A 1968 ICD-9 1979 ICD-10 1999

990

Mental and behavioral disorders


The ICD includes a section classifying mental and behavioral disorders (Chapter V). This has developed alongside the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) and the two manuals seek to use the same codes. There are significant differences, however, such as the ICD including personality disorders in the same way as other mental disorders, while the DSM lists them on a separate 'axis'. The WHO is revising their classifications in these sections as part the development of the ICD-11 (scheduled for 2015), and an "International Advisory Group" has been established to guide this.[20] An international survey of psychiatrists in 66 countries comparing use of the ICD-10 and DSM-IV found that the former was more often used for clinical diagnosis while the latter was more valued for research.[21] The ICD is actually the official system for the US, although many mental health professionals do not realize this due to the dominance of the DSM. The US is due to adopt a modified version of the ICD-10 in 2013. Psychologists note that, "Serious problems with the clinical utility of both the ICD and the DSM are widely acknowledged."[22]

References
[1] http:/ / www. who. int/ classifications/ icd/ en/ access:26 June 2012 [2] World Health Organization. Family of International Classifications. (http:/ / www. who. int/ classifications/ en/ ) Accessed 12 July 2011. [3] ICD11 Alpha is already available online, at http:/ / apps. who. int/ classifications/ icd11/ browse/ f/ en#/ http%3A%2F%2Fwho. int%2Ficd%232772_712a6f06_71f2_48d0_919c_2b3cb8b7172d (retrieved Apr 15 - 11:02 UTC) [4] WHO. List of Official ICD-10 Updates. (http:/ / www. who. int/ classifications/ icd/ icd10updates/ en) [5] WHO. History of the development of the ICD. (http:/ / www. who. int/ entity/ classifications/ icd/ en/ HistoryOfICD. pdf) [6] http:/ / www. who. int/ gho/ en/ [7] WHOSIS. WHO Statistical Information System. (http:/ / www. who. int/ whosis/ en/ ) [8] ICD-10 Volume 2, online at www.who.int/classifications [9] Scientific Data Documentation, International Classification of Diseases-9-CM (http:/ / wonder. cdc. gov/ wonder/ sci_data/ codes/ icd9/ type_txt/ icd9cm. asp) [10] World Health Organization. FAQ on ICD. (http:/ / www. who. int/ classifications/ help/ icdfaq/ en/ ) Accessed 12 July 2011. [11] National Center for Health Statistics, CDC. ICD-9-CM Guidelines, Conversion Table, and Addenda (http:/ / www. cdc. gov/ nchs/ icd/ icd9cm_addenda_guidelines. htm). Classification of Diseases, Functioning, and Disability. Retrieved 2010-01-24. [12] InstaCode Institute. ICD-10 Demystified. (http:/ / www. instacode. com/ news-icd10-demystified. htm) [13] WHO. International Classification of Diseases (ICD). (http:/ / www. who. int/ classifications/ icd/ en/ ) [14] New Zealand Health Information Service. ICD-10-AM. (http:/ / www. nzhis. govt. nz/ moh. nsf/ pagesns/ 534) Accessed 12 July 2011. [15] Canadian Institute for Health Information. ICD-10-CA. (http:/ / www. cihi. ca/ cihi-ext-portal/ internet/ en/ document/ standards+ and+ data+ submission/ standards/ classification+ and+ coding/ codingclass_icd10) Accessed 12 July 2011. [16] http:/ / wonder. cdc. gov/ wonder/ sci_data/ codes/ icd9/ type_txt/ icd9cm. asp [18] http:/ / apps. who. int/ classifications/ icd11/ browse/ f/ en# [19] World Health Organization. "The International Classification of Diseases 11th Revision is due by 2015." (http:/ / www. who. int/ classifications/ icd/ revision/ en/ ) Accessed 21 June 2012.

International Statistical Classification of Diseases and Related Health Problems


[20] http:/ / www. who. int/ mental_health/ evidence/ en/

991

External links
Official website (http://www.who.int/classifications/icd/en/) at World Health Organization (WHO) ICD-10 online browser (http://apps.who.int/classifications/icd10) (WHO) ICD-10 online training direct access (http://apps.who.int/classifications/apps/icd/ICD10Training) (WHO) ICD-10 online training support (http://sites.google.com/site/icd10onlinetraining) (WHO) ICD-10-CM (http://www.cdc.gov/nchs/icd/icd10cm.htm) (USA modification) at Centers for Disease Control and Prevention ICD-11 Revision (http://sites.google.com/site/icd11revision/home) (WHO) Code Browser for ICD-9-CM, ICD-10-CM, ICD-10-PCS, HCPCS, DRGs (http://www.findacode.com/tools/ browse-a-code.php) ICD-9-CM to ICD-10-CM code conversions (http://www.ecodingnow.com/OnlineCodes/OnlineCodes/ i9toi10.html) ICD-9-CM and DRG on-line coding engine (http://www.icd9coding.com) Free ICD-9-CM Code search (https://drchrono.com/public_billing_code_search/) ICD-10 and ICD-10 PCS (http://www.med-code.info/?country=us&locale=us)

ICD-9 and ICD-10 code lookup (http://icdx.org)

ICD-10
ICD-10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD), a medical classification list by the World Health Organization (WHO). It codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases.[] The code set allows more than 14,400 different codes and permits the tracking of many new diagnoses. The codes can be expanded to over 16,000 codes by using optional sub-classifications. The detail reported by ICD can be further increased, with a simplified multi-axial approach, by using codes meant to be reported in a separate data field. The WHO provides detailed information about ICD online, and makes available a set of materials online, such as an ICD-10 online browser,[1] ICD-10 Training, ICD-10 online training,[2] ICD-10 online training support,[3] and study guide materials for download. The International version of ICD should not be confused with national Clinical Modifications of ICD that frequently include much more detail, and sometimes have separate sections for procedures. The US ICD-10 CM, for instance, has some 68,000 codes. The US also has ICD-10 PCS, a procedure code system not used by other countries that contains 76,000 codes.[] Work on ICD-10 began in 1983 and was completed in 1992.[]

ICD-10

992

List
The following is a List of ICD-10 codes.[1]

International Statistical Classification of Diseases and Related Health Problems 10th Revision
Chapter I II III IV V VI VII VIII IX X XI XII XIII XIV XV XVI XVII XVIII XIX XX XXI XXII Blocks A00B99 C00D48 D50D89 E00E90 F00F99 G00G99 H00H59 H60H95 I00I99 J00J99 K00K93 L00L99 Certain infectious and parasitic diseases Neoplasms Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism Endocrine, nutritional and metabolic diseases Mental and behavioural disorders Diseases of the nervous system Diseases of the eye and adnexa Diseases of the ear and mastoid process Diseases of the circulatory system Diseases of the respiratory system Diseases of the digestive system Diseases of the skin and subcutaneous tissue Title

M00M99 Diseases of the musculoskeletal system and connective tissue N00N99 O00O99 P00P96 Q00Q99 R00R99 S00T98 V01Y98 Z00Z99 U00U99 Diseases of the genitourinary system Pregnancy, childbirth and the puerperium Certain conditions originating in the perinatal period Congenital malformations, deformations and chromosomal abnormalities Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified Injury, poisoning and certain other consequences of external causes External causes of morbidity and mortality Factors influencing health status and contact with health services Codes for special purposes

National adoption for clinical use


Some 25 countries use ICD-10 for reimbursement and resource allocation in their health system. A few of them made modifications to ICD to better accommodate this use of ICD-10. The article below makes reference to some of these modifications. The unchanged international version of ICD-10 is used in about 110 countries ICD-10 for cause of death reporting and statistics.

Australia
1 July 1998 Victoria, New South Wales, Australian Capital Territory and Northern Territory implemented ICD-10-AM. 1 July 1999 Queensland, South Australia, Tasmania and Western Australia implemented ICD-10-AM.[4]

ICD-10

993

Canada
Canada introduced ICD-10-CA in 2000.[5]

China
China now using ICD-10 as diagnosis reference and ICD-9 as procedure reference. [citation needed]

France
France introduced a clinical addendum to ICD-10 in 2005. See also website of the ATIH.

Germany
Germany: ICD-10-GM (German Modification)

Korea
A Korean modification has existed since 2008.

Netherlands
The Dutch translation of ICD-10 is ICD10-nl, which was created by the WHO-FIC Netwerk in 1994.[6] There is an online dictionary [7].

South Africa
1 January 2005 Pretoria, Johannesburg, Cape town

Sweden
The current Swedish translation of ICD-10 was created in 1997. A clinical modification has added more detail and omits codes of the international version in the context of clinical use of ICD: The codes F64.1 (Dual-role transvestism), F64.2 (Gender identity disorder of childhood), F65.0 (Fetishism), F65.1 (Fetishistic transvestism), F65.5 (Sadomasochism), F65.6 (Multiple disorders of sexual preference) are not used in Sweden since 1 January 2009 according to a decision by the present Director General of The National Board of Health and Welfare, Sweden. The code O60.0 (Preterm labor without delivery) is not used in Sweden; instead, since 1 January 2009, the Swedish extension codes to O47 (False labor) are recommended for use.

Thailand
A Thai modifications exists since 2007. Now Ministry of Public Health have **ICD 10 TM**

United States
The deadline for the United States to begin using Clinical Modification ICD-10-CM for diagnosis coding and Procedure Coding System ICD-10-PCS for inpatient hospital procedure coding is currently October 1, 2014.[8] The deadline was previously October 1, 2013.[9][10] All HIPAA "covered entities" must make the change; a pre-requisite to ICD-10 is the adoption of EDI Version 5010 by January 1, 2012.[11] Enforcement of 5010 transition by the Centers for Medicare & Medicaid Services (CMS), however, was postponed by CMS until March 31, 2012, with the federal agency citing numerous factors, including slow software upgrades.[12] The implementation of ICD-10 has been subject to previous delays. In January 2009, the date was pushed back by two years, to October 1, 2013 rather than a prior proposal of October 1, 2011.[13]

ICD-10 Even though the deadline for ICD-10 has been pushed back repeatedly, CMS recommends that medical practices take several years to prepare for implementation of the new code set.[14] The basic structure of the ICD-10 code is the following: Characters 1-3 (the category of disease); 4 (etiology of disease); 5 (body part affected), 6 (severity of illness) and 7 (placeholder for extension of the code to increase specificity) .[15] Not only must new software be installed and tested, but medical practices must provide training for physicians, staff members, and administrators. They will also need to develop new practice policies and guidelines, and update paperwork and forms. Practices should also create crosswalks that will convert their most frequently used ICD-9 codes to the ICD-10 equivalents. Although the undertaking can seem overwhelming, especially to small practices,[16] technology can be a big help. Practices should check with their EHR vendors to make sure they understand the data storage requirements for the new code set; seek online training available through association websites and software-based instruction; and invest in additional technology, such as patient kiosks, to boost productivity.[17]

994

Language versions
Language versions should not be confused with clinical versions. ICD has been translated into 42 languages.

References
[1] ICD-10 online browser (http:/ / apps. who. int/ classifications/ icd10/ browse/ 2010/ en) [2] [3] [4] [5] ICD-10 training tool (http:/ / apps. who. int/ classifications/ apps/ icd/ icd10training/ ) ICD 10 Online Support (http:/ / sites. google. com/ site/ icd10onlinetraining) DRG and ICD information in Queensland (http:/ / www. health. qld. gov. au/ qcc/ documents/ resources/ icd_drg_qld11. pdf) "ICD10-CA" (http:/ / www. cihi. ca/ cihi-ext-portal/ internet/ en/ document/ standards+ and+ data+ submission/ standards/ classification+ and+ coding/ codingclass_icd10) [6] WHO - FIC Homepage (http:/ / www. rivm. nl/ who-fic/ ICD. htm) [7] http:/ / class. who-fic. nl/ browser. aspx?scheme=ICD10-nl. cla [8] . of . of . [9] "International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)" (http:/ / www. cdc. gov/ nchs/ icd/ icd10cm. htm). National Center for Health Statistics. Centers for Disease Control and Prevention (CDC). December 20, 2010. [10] "Overview ICD-10" (http:/ / www. cms. gov/ ICD10/ ). Centers for Medicare and Medicaid Services. [11] Noblis ICD-10 F.A.Q. (http:/ / www. noblis. org/ MissionAreas/ HI/ Solutions/ Pages/ ICD-10FAQ. aspx) [12] "Physicians Get Grace Period from CMS on HIPAA 5010 Enforcement" (http:/ / www. physicianspractice. com/ blog/ content/ article/ 1462168/ 1994128).Physicians Practice.November 18, 2011 [13] "Feds Delay ICD-10 for Two Years" (http:/ / blogs. wsj. com/ health/ 2009/ 01/ 15/ feds-delay-icd-10-for-two-years/ ). The Wall Street Journal. January 15, 2009. [14] "CMS.gov/ICD-10/Provider Resources" (http:/ / www. cms. gov/ Medicare/ Coding/ ICD10/ ProviderResources. html) accessed Aug 1, 2012. [15] "AHIMA ICD-10 CM Primer" (http:/ / www. jiteshchawla. org/ 1_11_ICD-10. html). [16] "Managing ICD-10 Conversions for Smaller Healthcare Providers" (http:/ / www. insidepatientfinance. com/ revenue-cycle-news/ managing-icd-10-conversions-for-smaller-healthcare-providers/ ) insidePatientFinance.com, Nov. 13, 2012. [17] "How Your Medical Practice Can Avoid ICD-10 Pitfalls" (http:/ / www. physicianspractice. com/ icd-10/ content/ article/ 1462168/ 2075228) Marisa Torrieri, Physicians Practice, June 2012.

http://www.jiteshchawla.org/1_11_ICD-10.html

International Classification of Functioning, Disability and Health

995

International Classification of Functioning, Disability and Health


International Classification of Functioning, Disability and Health, also known as ICF, is a classification of the health components of functioning and disability.

Disability

Disability portal Category: Disability Category: Disability lists

After nine years of international revision efforts coordinated by the World Health Organization (WHO), the World Health Assembly on May 22, 2001, approved the International Classification of Functioning, Disability and Health and its abbreviation of "ICF." This classification was first created in 1980 and then called the International Classification of Impairments, Disabilities, and Handicaps, or ICIDH[1] by WHO to provide a unifying framework for classifying the health components of functioning and disability. The ICF classification complements WHOs International Classification of Diseases-10th Revision (ICD), which contains information on diagnosis and health condition, but not on functional status. The ICD and ICF constitute the core classifications in the WHO Family of International Classifications (WHO-FIC).

Overview
The ICF is structured around the following broad components: Body functions and structure Activities (related to tasks and actions by an individual) and participation (involvement in a life situation) Additional information on severity and environmental factors Functioning and disability are viewed as a complex interaction between the health condition of the individual and the contextual factors of the environment as well as personal factors. The picture produced by this combination of factors and dimensions is of "the person in his or her world". The classification treats these dimensions as interactive and dynamic rather than linear or static. It allows for an assessment of the degree of disability, although it is not a measurement instrument. It is applicable to all people, whatever their health condition. The language of the ICF is neutral as to etiology, placing the emphasis on function rather than condition or disease. It also is carefully designed to be relevant across cultures as well as age groups and genders, making it highly appropriate for heterogeneous populations.

Benefits of ICF
There are benefits of using the ICF for both the client and the health professional. A major advantage for the client is the integration of the medical and social aspects of his or her health condition. All aspects of a persons life (development, participation, and environment) are incorporated into the ICF instead of solely focusing on his or her diagnosis. A diagnosis reveals little about ones functional abilities. Diagnoses are important for defining the cause and prognosis, but identifying the limitations of function is often the information used to plan and implement

International Classification of Functioning, Disability and Health interventions [2] Once a rehabilitation team is aware of the daily activities a client is required to participate in, the problem solving sequence set up by the ICF can be utilized. An occupational therapist, for example, would observe a client performing his or her daily activities and note the clients functional abilities. This information would then be used to determine the extent to which the individuals abilities can be improved through therapy and to what extent the environment can be changed to facilitate the individuals performance.[3] Intervention at one level (current abilities) has the potential to prevent or modify events at a succeeding level (participation). For example, teaching a deaf child manual signs will foster effective interaction and increase ones participation with his or her family.[3] Rehabilitation therapists will be empowered with the ICF not only in their daily work with their patients, but also when working with other medical disciplines; hospitals and other health care administrations; health authorities and policy makers.[4] All items are operationally defined with clear descriptions that can be applied to real life evaluations with clarity and ease.[5] The language used in the ICF helps facilitate better communication between these groups of people.

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Clinical relevance
Knowing how a disease affects ones functioning enables better planning of services, treatment, and rehabilitation for persons with long-term disabilities or chronic conditions. The current ICF creates a more integrative understanding of health forming a comprehensive profile of an individual instead of focusing on ones health condition.[6] The implications of using the ICF include emphasizing the strengths of individuals, assisting individuals in participating more extensively in society by the use of interventions aimed at enhancing their abilities, and taking into consideration the environmental and personal factors that might hamper ones participation.[3] Qualifiers: The ICF qualifiers may be best translated clinically as the levels of functioning seen in a standardized or clinic setting and in everyday environments.[7] Qualifiers support standardization and the understanding of functioning in a multidisciplinary assessment. They enable all team members to quantify the extent of problems, even in areas of functioning where one is not a specialist.[8] Without qualifiers codes have no inherent meaning. An impairment, limitation or restriction, is qualified from 0 (No problem; 0-4%), 1 (Mild problem: 5-24%, 2 (Moderate problem: 25-49%), 3 (Severe problem: 50-95%) to 4 (Complete problem: 96-100%). Environmental factors are quantified with a negative and positive scale denoting the extent to which the environment acts as a barrier or facilitator.[9] For insurance purposes, the qualifiers can describe the effectiveness of treatment. One can interpret the decreasing of a qualifier score to be an increase in the functional ability of a patient.

ICF Core Sets


An ICF Core Set can serve as a reference framework and a practical tool to classify and describe patient functioning in a more time efficient way. ICF Core Sets can be used along the continuum of care and over the course of a health condition.[8] The ICF classification includes more than 1,400 categories limiting its use in clinical practice.[10] It is time consuming for a clinician to utilize the main volume of the ICF with his or her patients. Only a fraction of the categories is needed. As a general rule, 20% of the codes will explain 80% of the variance observed in practice.[11] ICF Core Sets contain as few as possible, but as many ICF categories as necessary, to describe a patients level of functioning.[8] It is hypothesized that using an ICF Core Set will increase the inter-rater reliability when coding clinical cases as only the relevant categories for a particular patient will be utilized. Since all of the relevant categories are listed in an ICF Core Set, its use in multidisciplinary assessments protects health professionals from missing important aspects of functioning.[8]

International Classification of Functioning, Disability and Health

997

Children and Youth Version (ICF-CY)


As clinicians and researchers used the ICF, they became more aware of its limitations. The ICF lacks the ability to classify the functional characteristics of a developing child. Different ICF codes are needed across the first years of a childs life to capture the growth and development of a disability even when the childs diagnosis does not change.[12] The coding system can provide essential information about the severity of a health condition in terms of its impact on functioning. This can serve a significant role for providers caring for children with spectrum disorders such as autism or cerebral palsy.[13] Children with these conditions may have the same diagnosis, but their abilities and levels of functioning widely vary across and within individuals over time. The first draft of the ICF-CY was completed in 2003 and published in 2007. The ICF-CY was developed to be structurally consistent with the ICF for adults. A major difference between the ICF-CY and ICF is that the generic qualifiers from the adult ICF now include developmental aspects for children and youth in the ICF-CY. Descriptions of codes in the ICF-CY were revised and expanded and new content was added to previously unused codes. Codes were added to document characteristics as adaptability, responsivity, predictability, persistence, and approachability. Sensing and exploration of objects codes were expanded as well as the importance of learning.[2] Since a childs main occupation is playing, it is also important to include more codes in this area. Different levels of play have separate codes in the ICF-CY (solitary, onlooker, parallel). This contrasts with the adult ICF as only one code existed in regards to leisure or recreation. Changes in ICF-CY codes over time reflect developmental effects attributable to the childs interaction with the environment. Environmental factors influence functioning and development and can be documented as barriers or facilitators using the ICF-CY. The key environments of children and adolescents include their homes, day care centers, schools and recreation settings of playground, parks, and ball fields.[14] Children will transition between different environments many times as they grow. For example, a child will transition into elementary or high school or from one service setting or agency to another. Attention to these transitions of children with disabilities has been identified as an important role for health care providers.[14] A transition requires preparation and planning to find an appropriate and accommodating setting for a childs needs. With a coding system such as the ICF-CY, the transition will be smoother and interventions can start where the previous health provider left off.

External links
International Classification of Functioning, Disability and Health (ICF) [15] - WHO International Classification of Functioning, Disability and Health (ICF) [16] - CDC International Classification of Functioning, Disability and Health (ICF) [17] in the NCBO BioPortal [18] ICF case studies: Implementation of ICF in rehabilitation management [19]

Age based "developmental" code sets derived from the ICF CY can be found at *http:/ / www. icf-cydevelopmentalcodesets.com/ The Italian Portal of Classifications [20] is the ICF and ICF-CY browsing tool of the Italian Collaborating Centre of the World Health Organization for the Family of International Classifications

International Classification of Functioning, Disability and Health

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References
[1] http:/ / www. cdc. gov/ nchs/ about/ otheract/ icd9/ icfhome. htm [2] Lollar, D.J., & Simeonsson, R.J. (2005). Diagnosis to function: classification for children and youths. Developmental and Behavioral Pediatrics, 26, 323-330. [3] Bornman, J. (2004). The World Health Organizations terminology and classification: application to severe disability. Disability and Rehabiliation, 26, 182-188. [4] Stucki, G., Ewert, T., & Cieza, A. (2002). Value and application of the ICF in rehabilitation medicine. Disability and Rehabilitation, 24, 932-938. [5] stn, T. B., Chatterji, S., Bickenbach, J., Kostanjsek, N., & Schneider, M. (2003). The International Classification of Functioning, Disability and Health: A new tool for understanding disability and health. Disability and Rehabilitation, 25, 565571. [6] Hemmingsson, H., & Jonsson, H. (2005). An occupational perspective on the concept of participation in the international classification of functioning, disability and health some critical remarks. The American Journal of Occupational Therapy, 59, 569-576. [7] Reed, G., Lux, J., Bufka, L., Peterson, D., Threats, T., Trask, C., Stark, S., Jacobson, J., & Hawley, J. (2005). Operationalizing the International Classification of Functioning, Disability, and Health: A model to guide clinical thinking, practice and research in the field of cerebral palsy. Seminars in Pediatric Neurology, 11, 5-10. [8] Rauch, A., Cieza, A., & Stucki, G. (2008). How to apply the International Classification of Functioning Disability and Health (ICF) for rehabilitation management in clinical practice. European Journal of Physical and Rehabilitation Medicine, 44, 329-342. [9] World Health Organization. (2001). International Classification of Functioning, Disability and Health (ICF). Geneva: Author. [10] Arlinger, M., Stamm, T.A., Pisetsky, D.S., Yarboro, C.H., Cieza, A., Smolen, J.S., & Stucki, G. (2006). ICF core sets: how to specify impairment and function in systemic lupus erythematosus. Lupus, 15, 248-253. [11] Ustun, B., Chatterji, S., & Kostanjsek, N. (2004). Comments from WHO for the Journal of Rehabilitation Medicine special supplement on ICF core sets. Journal of Rehabiliation Medicine, (Suppl. 44), 7-8. [12] Simeonsson, R.J., Scarborough, A.A., & Hebbeler, K.M. (2006). ICF and ICD codes provide a standard language of disability in young children. Journal of Clinical Epidemiology, 59, 365-373. [13] Ogonowski, J., Kronk, R., Rice, C., & Feldman, H. (2004). Inter-rater reliability in assigning ICF codes to children with disabilities. Disability and Rehabilitation, 26, 353-361. [14] Simeonsson, R.J., Lollar, D., Hollowell, J., & Adams, M. (2000). Revision of the international classification of impairments, disabilities, and handicaps developmental issues. Journal of Clinical Epidemiology, 53, 113-124. [15] http:/ / www. who. int/ classifications/ icf/ en/ [16] http:/ / www. cdc. gov/ nchs/ icd/ icf. htm [17] http:/ / purl. bioontology. org/ ontology/ ICF [18] http:/ / bioportal. bioontology. org/ [19] http:/ / www. icf-casestudies. org [20] http:/ / www. reteclassificazioni. it

International Council of Nurses

999

International Council of Nurses


ICN
Full name Founded Members Country Key people International Council of Nurses 1899 135 International Judith Shamian, President David C.Benton, CEO

Office location Geneva, Switzerland Website www.icn.ch [1]

The International Council of Nurses (ICN) is a federation of more than 130 national nurses associations. It was founded in 1899 and was the first international organization for health care professionals. It is headquartered in Geneva, Switzerland. The organization's goals are to bring nurses' organizations together in a worldwide body, to advance the socio-economic status of nurses and the profession of nursing worldwide, and to influence global and domestic health policy. Membership is limited to one nursing organization per nation. In most cases, this is the national nurses' association (such as the American Nurses Association, the Slovak Chamber of Nurses and Midwives or the Nursing Association of Nepal).[2] In 2001, the ICN permitted its members to adopt alliance or collaborative structures to be more inclusive of other domestic nursing groups.[3] However, few member organizations have adopted the new structures.

History and organization


The ICN was founded in 1899 with Great Britain, the United States, and Germany as charter members.[4] The ICN is governed by a Council of National Representatives (CNR). The CNR is the governing body of the ICN and sets policy, admits members, selects a board of directors, and sets dues. As of 2013, there were 135 National Representatives (one for each member organization). National Representatives are selected by each member association. The CNR meets every two years. Between meetings of the CNR, the ICN is governed by a 16-member board of directors. Members of the board include the ICN president and 15 directors elected on the basis of proportional representation from the ICN's seven geographic areas. Directors are term-limited to two consecutive four-year terms of office. The board meets at least once a year, although it usually meets three to four times a year. The ICN has four officers. They include a president and three vice presidents. The officers function as an executive committee for the board, and as the board's budget and finance committee. The president is elected by the CNR. The president serves a four-year term of office, and is limited to one term in office. The vice presidents are elected from among the board members. The highest vote-getter is the First Vice President, the second-highest vote-getter the Second Vice President and the third-highest vote-getter the Third Vice President. Day-to-day operations of the ICN are overseen by a chief executive officer (CEO). In practice, the CEO exercises most of the power within the ICN.

International Council of Nurses

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Conferences and projects


The ICN hosts a quadrennial conference every four years in conjunction with the meeting of the CNR. The conference hosts a large number of professional practice workshops, poster sessions, luncheons, speaking events and plenary sessions. ICN hosts other conferences on an as-needed basis. Recent conferences have covered topics such as international nurse migration issues, regulation of the profession of nurses, rural nursing, leadership issues, advance practice issues, and workplace violence. The ICN sponsors International Nurses' Day every May 12 (the anniversary of Florence Nightingale's birthday). The ICN is an official supporting organization of Healthcare Information For All by 2015.

References
[1] http:/ / www. icn. ch [2] The ICN has been criticized for this restriction, as some ICN members are too financially insecure or organizationally immature to be effective participants. Other organizations may be unrepresentative of nurses in their home country, by virtue of membership size, or the nature of the membership (e.g., the American Nurses Association is dominated by managers rather than frontline nurses). [3] International Council of Nurses. From Vision to Action: ICN in the 21st Century. Geneva, Switzerland: ICN, 2003. (http:/ / www. icn. ch/ membership_structure. pdf) [4] Ross-Kerr, J.C. & Wood, M.J. (2003.) Canadian Nursing: Issues and Perspectives. (4th ed.) Toronto: Mosby.

External links
ICN Web site (http://www.icn.ch)

International Classification of Primary Care

1001

International Classification of Primary Care


International Classification of Primary Care
Author(s) Country Language Subject(s) Publisher WONCA International Classification Committee United Kingdom English Medicine Oxford University Press

Publication date 1987 (1st edition); 1998 (2 ed.) ISBN 0-19-262802-X

The International Classification of Primary Care (ICPC) is a classification method for primary care encounters. It allows for the classification of the patients reason for encounter (RFE), the problems/diagnosis managed, primary or general health care interventions, and the ordering of the data of the primary care session in an episode of care structure. It was developed by the WONCA International Classification Committee (WICC), and was first published in 1987 by Oxford University Press (OUP). A revision and inclusion of criteria and definitions was published in 1998. The second revision was accepted within the World Health Organization's (WHO) Family of International Classifications.[1] The classification was developed in a context of increasing demand for quality information on primary care as part of growing worldwide attention to global primary health care objectives, including the WHO's target of "health for all".[2]

History
The first version of ICPC, which was published in 1987, is referred to as ICPC-1. A subsequent revision which was published in the 1993 publication The International Classification of Primary Care in the European Community: With a Multi-Language Layer is known as ICPC-E. The 1998 publication, of version 2, is referred to as ICPC-2. The acronym ICPC-2-E, refers to a revised electronic version, which was released in 2000. Subsequent revisions of ICPC-2 are also labelled with a release date.

Structure
Chapters
The ICPC contains 17 chapters: A General and unspecified B Blood, blood forming organs, lymphatics, spleen D Digestive F Eye H Ear K Circulatory L Musculoskeletal N Neurological P Psychological

International Classification of Primary Care R Respiratory S Skin T Endocrine, metabolic and nutritional U Urology W Pregnancy, childbirth, family planning X Female genital system and breast Y Male genital system Z Social problems

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Components
The ICPC classification, within each chapter, is based on 3 components coming from 3 different classifications: Reason for Encounter Classification (1981) International Classification of Process in Primary Care (IC-Process-PC) (1985) International Classification of Health Problem in Primary Care (ICHPPC-2-d) (1976, 1983)

References
[1] World Health Organization. International Classification of Primary Care, Second edition (ICPC-2). (http:/ / www. who. int/ classifications/ icd/ adaptations/ icpc2/ en/ ) Geneva. Accessed 24 June 2011. [2] Bentsen BG. "International classification of primary care." Scand J Prim Health Care. 1986 Feb;4(1):43-50.

Bibliography
Bentzen N (ed). WONCA international glossary for general/family practice. Fam Pract. 1995; 12:267. (http:// www.ulb.ac.be/esp/wicc/letter_a.htm)

External links
WICC at WONCA (http://www.globalfamilydoctor.com/groups/WorkingParties/wicc.aspx) Primary Healthcare Classification Consortium (Classification Committee) (http://www.ph3c.org) ICPC-2e (http://www.kith.no/templates/kith_WebPage____1062.aspx) (by the Norwegian Centre for Informatics in Health and Social Care) University of Sydney Family Medicine Research Centre (http://sydney.edu.au/medicine/fmrc/icpc-2/) ICPC publication bibliography (http://sydney.edu.au/medicine/fmrc/icpc-2/publications/) International Primary Care Association (IPCA) (http://www.ipcauk.org)

Indian Dental Association

1003

Indian Dental Association


Indian Dental Association
Abbreviation Formation IDA 1945

Headquarters Mumbai, India Website www.ida.org.in [1]

Indian Dental Association (IDA) is a professional association of dentists in India.[2] Founded in 1945,[3] IDA aims both at the continuing education programs of working dentists as well as creating awareness among the Indian citizenry of the need of dental care.[4][5]

References
[1] http:/ / www. ida. org. in [2] Indian Dental Association Official Website. About IDA. (http:/ / www. ida. org. in/ AboutIDA/ Homepageaboutus. aspx) [3] Indian Dental Association Official Website. 'Our History'. (http:/ / www. ida. org. in/ MainConfig. aspx?ModuleId=105& id=63& CategoryId=3383& IsExpandable=true) [4] The Hindu. 'Start practising with latest equipment, dental students told'. (http:/ / www. thehindu. com/ todays-paper/ tp-national/ tp-tamilnadu/ article2608129. ece) [5] The Hindu. 'IDA Coimbatore screens over 19,000 people to create Guinness Record.' (http:/ / www. thehindu. com/ news/ cities/ Coimbatore/ article891591. ece?service=mobile)

Integrated delivery system


An integrated delivery system (IDS) is a network of health care organizations under a parent holding company. Some IDS have an HMO component, while others are a network of physicians only, or of physicians and hospitals. Thus, the term is used broadly to define an organization that provides a continuum of health care services.[1] There is some discussion over the efficiency and sustainability of IDS.[2] Integrated delivery systems are one example of the emergence of managed care organizations in the United States.

References IDS Vendors


ICA (HIT)

Irish Medical Organisation

1004

Irish Medical Organisation


The Irish Medical Organisation (Irish: Ceardchumann Dhochtir na hireann ) is a Professional association for Doctors in Ireland which also acts as a Trade Union representing doctors in negotiations with the Irish government. The IMO was formed in January 1984 through the amalgamation of the Irish Medical Association and the Irish Medical Union. It is the sole negotiating body on behalf of all doctors in Ireland, recognised for negotiating purposes under the Trade Union Act 1941.

History of Irish medical organisations


1839 - The Irish Medical Association
On 29 May 1839, a union of Physicians and Surgeons was formed at the Royal College of Surgeons in Dublin. "That it is therefore our opinion a legislative measure should be sought for by us, to unite the medical profession of Ireland into a co-operation upon such principles as shall constitute them one National Faculty, and thereby identify in feelings and interests, the greater mass of provincial practitioners with their metropolitan brethren"[1] On 7 June 1853, another congress was held in Dublin to re-establish the Association, and in 1882 it became incorporated as the Irish Medical Association.

1962 - The Irish Medical Union


In 1957 negotiations between the IMA and the Irish government over employment conditions for doctors broke down with the government announcing that the IMA was not a registered Trade Union and so could not be recognised as a negotiating partner. A debate began then within the organisation, between those who wanted to register as a trade union and those who felt that industrial trade union membership was incompatible with being a professional association with clinical/patient responsibilities or what was sometimes previously termed as a "learned profession". In 1962, the Irish Medical Union was established, initially, as a sub-section of the IMA and then became a break-away group under the presidency of Dr Johnny Cox, a general practitioner and farmer in Delvin, Co. Westmeath. The medical doctors' trade union was initially housed at the offices of the IMA in Fitzwilliam Place, Dublin 2, and later moved to separate offices in Northumberland Road, [Dublin 4], then Harcourt Street [Dublin 2], and finally, to Drumcondra, Dublin. Soon after this split the government agreed to engage in direct negotiations with the Irish Medical Association (IMA) without requiring it to formally register as a trade union. Following the creation of the breakaway IMO in 1962 this effectively divided medical doctors' representation in the Republic of Ireland for over two decades weakening their influence on emerging healthcare public policy and the formation of the state's Health Boards structures in 1970.

1984 - The Irish Medical Organisation


In January 1984 the IMA and the IMU amalgamated to become the Medical Union, a name which was later changed to the Irish Medical Organisation. Five years later an influential group of hospital consultants formed the Irish Hospital Consultants' Association (IHCA) to represent the specific interests of senior medical specialists. It was established in 1989 and maintains that it has 1,800 of Irish medical consultants/specialists within its ranks. Today the Irish Medical Organisation (IMO) is the sole negotiating body on behalf of all doctors in Ireland, recognised for negotiating purposes under the Trade Union Act 1941, though the IHCA also represents consultant

Irish Medical Organisation grades in official negotiations with the Health Service Executive HSE and the Department of Health. The role of the IMO is to represent doctors in Ireland and to provide them with all relevant services. It is organised into four 'craft groups': general practitioners; hospital consultants; 'junior' or non-consultant hospital medical employees; and public health medical doctor employees. It is also committed to the development of caring, efficient and effective health services in Ireland.

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Structure
The organisation is run by a chief executive, currently George McNeice. Departments include: industrial relations, research & policy, membership, operations, financial services and communications. The current President is Dr. Paul McKeown, a consultant in Public Health Medicine and a Senior Lecturer in Epidemiology and Public Health at the Royal College of Surgeons, Ireland. Dr McKeown has responsibility for surveillance and provision of expert advice on gastroenteric and zoonotic diseases, vectorborne disease and emerging disease. He has served on a number of national and international advisory and guidance groups in the area of infectious diseases, and is a participant in EU and international surveillance and research initiatives in the field of infectious disease.

Irish Medical Journal


The IMO is the publisher of the Irish Medical Journal.

Notes External links


Irish Medical Organisation Homepage (http://www.imo.ie/)

Independent practice association

1006

Independent practice association


An independent practice association (or IPA) is an association of independent physicians, or other organization that contracts with independent physicians, and provides services to managed care organizations on a negotiated per capita rate, flat retainer fee, or negotiated fee-for-service basis.[1][2]

Operation
An HMO or other managed care plan can contract with an IPA, which in turn contracts with independent physicians to treat members at discounted fees or on a capitation basis. The typical IPA encompasses all specialties, but an IPA can be solely for primary care or could be single specialty.[2] IPAs are typically formed as an LLC, S Corp, C Corp, or other stock entity. Their purpose is not to generate a profit for the shareholders although this can be done. The IPA assembles physicians in self-directed groups within a geographic region to invent and implement healthcare solutions, form collaborative efforts among physicians to implement these programs, and exert political influence upward within the medical community to effect positive change.[citation needed] Despite a perception that IPAs have been formed to negotiate as a group with insurance companies in an attempt to improve rates of compensation, under the Federal Trade Commission Act, they cannot do this for the physician's other insurance reimbursement. The IPA can only negotiate for the IPA members those services which are contracted on capitated members. "Messengers", specialists who are selected to represent individual practices, can be used by IPA members to review and discuss coding and compensation with health insurance companies. These professionals do not collectively bargain and can only do so if the doctors have reorganized under a single tax ID number which is not an IPA model.[citation needed]

References
[1] Margaret E. Lynch, Editor, "Health Insurance Terminology," Health Insurance Association of America, 1992, ISBN 1-879143-13-5 [2] Peter R. Kongstvedt, "The Managed Health Care Handbook," Fourth Edition, Aspen Publishers, Inc., 2001 ISBN 0-8342-1726-0

Bibliography
American Public Policy: An Introduction 7th Edition Essentials of Managed Care, 4th Ed, Peter Kongstvedt De Wolf W, and A Stanten. 1995. "The Independent Practice Association". JAMA : the Journal of the American Medical Association. 274, no. 22: 1761. Roth M. 1979. "Is an Independent Practice Association for You?" Physician's Management. 19, no. 1: 42-6. 2002. "LATE - REGULATORY PRECEDENT - The FTC OKs a Deal That Would Allow a Physician Independent Practice Association to Contract with Health Plans on Behalf of Its Competing Physicians". Modern Healthcare. 32, no. 8: 6.

Interprofessional education

1007

Interprofessional education
Interprofessional education (also known as inter-professional education or IPE) refers to occasions when students from two or more professions in health and social care learn together during all or part of their professional training with the object of cultivating collaborative practice[1] for providing client- or patient-centered health care.

Overview
Interprofessional learning involves students learning from students from other professions, as well as learning with students from other professions, for example in the classroom, and learning about other professions. Associated terms include "multi-professional education", "common learning", "shared learning", and "interdisciplinary learning." There is debate about the effectiveness of interprofessional education in enabling collaborative practice. Research and systematic reviews continue to identify some evidence of effectiveness in changing attitudes. But more empirical evidence of longer term impact is needed, particularly in respect of effects on service quality and service users and patients experience. Nevertheless, more evaluations of IPE have been conducted than for many other commonly accepted educational approaches.

WHO Study Group on Interprofessional Education & Collaborative Practice


Recognizing the importance of interprofessional education as one of the innovative approaches that can help tackle the global health workforce challenge, the World Health Organization (WHO) convened a WHO Study Group on Interprofessional Education & Collaborative Practice in 2007[2] to articulate a greater understanding of this issue within a global context. It was tasked with providing guidance to Member States on how they could use interprofessional collaboration to scale-up and build more flexible health workforces that enable local health needs to be met efficiently and effectively while maximizing resources. The WHO Study Group engaged various partners and undertook a program of work that culminated in the publication of WHOs Framework for Action on Interprofessional Education and Collaborative Practice[3] in March 2010. The Framework highlights the current status of interprofessional collaboration around the world, identifies the mechanisms that shape successful collaborative teamwork, and outlines a series of action items that policymakers can apply within their local health system. It provides strategies and ideas that can help health policymakers implement the elements of interprofessional education and collaborative practice that will be most beneficial in their own jurisdiction. The WHO Study Group consisted of almost 30 top education, practice and policy experts from across every region of the world. Overall leadership was provided by Co-Chairs Prof. John HV Gilbert (University of British Columbia & Canadian Interprofessional Health Collaborative) and Dr. Jean Yan (World Health Organization) and a secretariat led by Mr. Steven J. Hoffman (World Health Organization). Partners included the following organizations: Australasian Interprofessional Practice and Education Network [4] Canadian Interprofessional Health Collaborative [5] European Interprofessional Education Network [6] International Association for Interprofessional Education and Collaborative Practice [7] Journal of Interprofessional Care [8] National Health Sciences Students Association, Canada [9]

Nordic Interprofessional Network [10] The Network: Towards Unity for Health [11]

Interprofessional education UK Centre for the Advancement of Interprofessional Education [12]

1008

Medical School Curriculum


Interprofessional education (IPE) is becoming a more common component of medical school curriculum in the United States. IPE programs have existed transiently at various schools since the 1960s, but interprofessional education programs are growing, as they are increasingly viewed as a means of reducing medical errors and improving the health care system.[][13] The following medical schools currently have interprofessional programs as a part of their curriculum: University of Washington [14] University of Colorado Anschultz Medical Campus[15] University of Minnesota[16] University of Oklahoma Health Sciences Center[17] University of South Florida College of Medicine University of Virginia School of Medicine[18] Vanderbilt University School of Medicine[19] Virginia Commonwealth University School of Medicine[] Western University of Health Sciences[] Yale University School of Medicine University of Arizona Des Moines University Rosalind Franklin University of Medicine and Science College of Osteopathic Medicine, Nova Southeastern University University of Iowa Carver College of Medicine

References
[1] Centre for the Advancement of Interprofessional Education (CAIPE), 1997. Interprofessional education - a definition. London: CAIPE Bulletin 13, p.19. [2] World Health Organization, 2007. World Health Organization Study Group on Interprofessional Education and Collaborative Practice (http:/ / www. who. int/ hrh/ professionals/ announcement. pdf), accessed 15 April 2011. [3] World Health Organization, 2010. Framework for action on interprofessional education and collaborative practice (http:/ / www. who. int/ hrh/ resources/ framework_action/ en/ index. html). Geneva: WHO Press. [4] http:/ / www. aippen. net/ [5] http:/ / www. cihc. ca/ [6] http:/ / www. eipen. org/ [7] http:/ / www. interedhealth. org/ [8] http:/ / informahealthcare. com/ jic/ [9] http:/ / www. nahssa. ca/ [10] http:/ / www. nipnet. org/ [11] http:/ / www. the-networktufh. org/ home/ index. asp [12] http:/ / www. caipe. org. uk/ [14] http:/ / collaborate. uw. edu/

Interprofessional education

1009

External links
Resources and organisations: Center for Health Science Interprofessional Education, Research and Practice (http://collaborate.uw.edu/) CIHC: Canadian Interprofessional Health Collaborative (http://www.cihc.ca) CIHC Library (http://www.cihc.ca/library/) - A repository of interprofessional health and education materials CAIPE: Centre for the Advancement of Interprofessional Education (http://www.caipe.org.uk) EIPEN: European Interprofessional Education Network (http://www.eipen.org) Journal of Interprofessional Care (http://informahealthcare.com/jic/) Interprofessional Education and Practice, University of Arizona (http://ipep.arizona.edu/) APTR Healty People Curriculum Taskforce (http://www.aptrweb.org:)

JAMA (journal)

1010

JAMA (journal)
JAMA

Abbreviated title (ISO4) JAMA Discipline Language Edited by Medicine English Howard C. Bauchner Publication details Publisher Publication history Frequency Impact factor (2011) American Medical Association (United States) 1883present 48/year 30.026

Indexing ISSN [1] 0098-7484 (print) [2] 1538-3598 (web) Until 1960: [3] 0002-9955 82643544 JAMAAP 1124917 [5] [4]

LCCN CODEN OCLC number

Links Journal homepage [7] Online access [8] Online archive [6]

JAMA, The Journal of the American Medical Association, is a weekly peer-reviewed medical journal published by the American Medical Association. Since 2011, the editor-in-chief is Howard C. Bauchner (Boston University), who succeeded Catherine D. DeAngelis, who had served since 2000.[9] The journal was established in 1883, with Nathan Smith Davis as founding editor. The acronym JAMA was added in 1960. The journal has French and Spanish language editions.

JAMA (journal)

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Aims and scope


JAMA was established in 1883 by the American Medical Association and has been published continuously since then. It publishes original research, reviews, commentaries, editorials, essays, medical news, correspondence, and ancillary content (such as abstracts of the Morbidity and Mortality Weekly Report). The journal covers all aspects of the biomedical sciences.

Continuing medical education


Continuing Education Opportunities for Physicians is a semianual journal section providing lists for regional or national levels of continuing medical education (CME). JAMA has provided this information since 1937. Prior to 1955, the list was produced either quarterly or semiannually. Between 1955 and 1981, the list was available annually, as the number of CME offerings increased from 1,000 (1955) to 8,500 (1981). The AMA website states that webinars are available for CME.[]

Policy shift
After the controversial firing of an editor-in-chief, George D. Lundberg, a process was put in place to ensure editorial freedom. A seven member oversight committee was created to evaluate the editor-in-chief and to help ensure editorial independence. Since its inception, the committee has met at least once a year. Presently, JAMA states that article content should be attributed to authors and not the publisher.[10][11][12][10][13]

Abstracting and indexing


This journal is abstracted and indexed in:[14][15][] Index Medicus MEDLINE PubMed Chemical Abstracts Service - CASSI Science Citation Index Current Contents/Clinical Medicine Current Contents/Life Sciences BIOSIS Previews

According to the Journal Citation Reports, the journal has a 2011 impact factor of 30.026, ranking it third out of 153 journals in the category "Medicine, General & Internal".[]

References
[1] [2] [3] [4] [5] [6] [7] [8] [9] http:/ / www. worldcat. org/ issn/ 0098-7484 http:/ / www. worldcat. org/ issn/ 1538-3598 http:/ / www. worldcat. org/ issn/ 0002-9955 http:/ / lccn. loc. gov/ 82643544 http:/ / www. worldcat. org/ oclc/ 1124917 http:/ / jama. jamanetwork. com/ http:/ / jama. jamanetwork. com/ issue. aspx http:/ / jama. jamanetwork. com/ issues. aspx "New Editor in Chief Named at "Journal of the American Medical Association'" Chronicle of Higher Education, March 10, 2011 (http:/ / chronicle. com/ blogs/ ticker/ new-editor-in-chief-named-at-journal-of-the-american-medical-association/ 31246?sid=at& utm_source=at& utm_medium=en)

[10] Constance Holden, JAMA Editor Gets the Boot, Science Now, 15 January 1999 (http:/ / sciencenow. sciencemag. org/ cgi/ content/ full/ 1999/ 115/ 2) [11] Jerome P. Kassirer (1999) Editorial Independence (http:/ / content. nejm. org/ cgi/ content/ full/ 340/ 21/ 1671), NEJM, 340(21):1671-1672

JAMA (journal)
[12] JAMA & Archives Conditions of Use (http:/ / pubs. ama-assn. org/ misc/ conditions. dtl) [13] Editorial governance plan: Signatories of the Editorial Governance Plan, Editorial Governance for JAMA, June 1999; 281: 22402242. (http:/ / jama. ama-assn. org/ cgi/ content/ full/ 281/ 23/ 2240?maxtoshow=& HITS=10& hits=10& RESULTFORMAT=& fulltext=JOC& searchid=1& FIRSTINDEX=0& resourcetype=HWCIT)

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External links
Official website (http://jama.ama-assn.org/) American Medical Association Archives (http://pubs.ama-assn.org/)

The Journal of the American Osteopathic Association

1013

The Journal of the American Osteopathic Association


The Journal of the American Osteopathic Association
Abbreviated title (ISO4) J. Am. Osteopath. Assoc. Discipline Language Edited by Osteopathic medicine English Gilbert E. D'Alonzo Jr. Publication details Publisher Publication history Frequency American Osteopathic Association (United States) 1901present Monthly Indexing ISSN [1] 0098-6151 (print) [2] 1945-1997 (web) 90641783 JAOAAZ 01081714 [4] [3]

LCCN CODEN OCLC number

Links Journal homepage [6] Online access [7] Online archive [5]

The Journal of the American Osteopathic Association is a monthly peer-reviewed medical journal of the American Osteopathic Association.[8] The journal primarily publishes original research publications and editorial articles. The editor-in-chief is Gilbert E. D'Alonzo, Jr. (Temple University School of Medicine).[9] The journal is abstracted and indexed in PubMed/MEDLINE.[10] It publishes case reports, clinical images, editorials, meta-analyses, original research, and review articles on all major areas of medicine, with an emphasis on the musculoskeletal system and osteopathic manipulative medicine. The journal also publishes content on medical education, ethics, and health care reform. The journal was established in September 1901.[] It was published bimonthly for the first year; starting in 1902 it was published monthly.[]

The Journal of the American Osteopathic Association

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References
[1] [2] [3] [4] [5] [6] [7] http:/ / www. worldcat. org/ issn/ 0098-6151 http:/ / www. worldcat. org/ issn/ 1945-1997 http:/ / lccn. loc. gov/ 90641783 http:/ / www. worldcat. org/ oclc/ 01081714 http:/ / www. jaoa. org/ http:/ / www. jaoa. org/ current. shtml http:/ / www. jaoa. org/ contents-by-date. 0. shtml

External links
Official website (http://www.jaoa.org/)

Joint Commission

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Joint Commission
The Joint Commission
Type Industry Founded Non-profit organization Health care 1951

Headquarters Oakbrook Terrace, Illinois, United States Area served Website North America jointcommission.org [1]

The Joint Commission (TJC), formerly the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and previous to that the Joint Commission on Accreditation of Hospitals (JCAH),[2] is a United States-based nonprofit tax-exempt 501(c) organization[3] that accredits more than 20,000 health care organizations and programs in the United States.[] A majority of state governments have come to recognize Joint Commission accreditation as a condition of licensure and the receipt of Medicaid reimbursement. Surveys (inspections) typically follow a triennial cycle, with findings made available to the public in an accreditation quality report on the Quality Check Web site. The declared mission of the organization is 'To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value."[4] The Joint Commission was renamed Joint Commission on Accreditation of Hospitals in 1951, but it was not until 1965 that accreditation had any official impact. In 1965 the federal government decided that a hospital that met Joint Commission accreditation met the Medicare Conditions of Participation. Recently, Section 125 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) removed The Joint Commission's statutorily-guaranteed accreditation authority for hospitals, effective July 15, 2010. At that time, The Joint Commissions hospital accreditation program will be subject to Centers for Medicare and Medicaid Services (CMS) requirements for organizations seeking accrediting authority. To avoid a lapse in accrediting authority, The Joint Commission must submit an application for hospital accrediting authority consistent with these requirements and within a time frame that will enable CMS to review and evaluate their submission.[5] CMS will make the decision to grant deeming authority and determine the term. In 2008, the Joint Commission collected $165 million in revenue, mainly from the fees it charges U.S. health care organizations for evaluating their compliance with federal regulations. Its expenses during this period were $162 million. Its total return on investments in 2008 was -$27 million (a loss), and the total value of its investments was $83 million. In 2007, its collected revenue was $149 million. Its expenses were $148 million. Its total return on investments was $5 million, and the total value of its investments was $107 million. The Joint Commission's primary investments in 2007 and 2008 were in stocks (about 50% of investments) and trusts (about 40% of investments).[6] The Joint Commission is based in the Chicago suburb of Oakbrook Terrace, Illinois.[7]

Joint Commission

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History
The Joint Commission's predecessor organization was an outgrowth of the efforts of Ernest Codman to promote hospital reform based on outcomes management in patient care. Codmans efforts led to the founding of the American College of Surgeons Hospital Standardization Program. In 1951, a new entity, the Joint Commission on Accreditation of Hospitals was created by merging the Hospital Standardization Program with similar programs run by the American College of Physicians, the American Hospital Association, the American Medical Association, and the Canadian Medical Association. In 1987, the company was renamed the Joint Commission on Accreditation of Healthcare Organizations (JCAHO, pronounced "Jay-co").[8] In 2007, the Joint Commission on Accreditation of Healthcare Organizations underwent a major rebranding and simplified its name to The Joint Commission. The rebranding included the name, logo, and tag line change to "Helping Health Care Organizations Help Patients." The name change was part of an overall effort to make the name easier to remember and to position the commission to continue to be responsive to the needs of organizations seeking fee-based accreditation. The Joint Commission advocates the use of patient safety measures, the spread of information, the measurement of performance, and the introduction of public policy recommendations.[] Joint Commission International (JCI) was established in 1997 as a division of Joint Commission Resources, Inc. (JCR), a private, not-for-profit affiliate of The Joint Commission. Through international accreditation, consultation, publications and education programs, JCI extends The Joint Commission's mission worldwide by helping to improve the quality of patient care by assisting international health care organizations, public health agencies, health ministries and others evaluate, improve and demonstrate the quality of patient care and enhance patient safety in more than 60 countries.[9] International hospitals may seek accreditation to demonstrate quality, and JCI accreditation may be considered a seal of approval by medical travelers from the U.S.[10]

Operation
All member health care organizations are subject to a three-year accreditation cycle, while laboratories are surveyed every two years. With respect to hospital surveys, the organization does not make its findings public.[] However, it does provide the organization's accreditation decision, the date that accreditation was awarded, and any standards that were cited for improvement. Organizations deemed to be in compliance with all or most of the applicable standards are awarded the decision of Accreditation. The unannounced full survey is a key component of The Joint Commission accreditation process. "Unannounced" means the organization does not receive an advance notice of its survey date. The Joint Commission began conducting unannounced surveys on January 1, 2006. Surveys will occur 18 to 39 months after the organization's previous unannounced survey.[11] There has been criticism in the past from within the U.S. of the way the Joint Commission operates. The Commission's practice had been to notify hospitals in advance of the timing of inspections.[12] A 2007 article in the Washington Post noted that about 99% of inspected hospitals are accredited, and serious problems in the delivery of care are sometimes overlooked or missed.[13] Similar concerns have been expressed by the Boston Globe, stating that "The Joint Commission, whose governing board has long been dominated by representatives of the industries it inspects, has been the target of criticism about the validity of its evaluations."[] The Joint Commission over time has responded to these criticisms. However, when it comes to the international dimension, surveys undertaken by JCI still take place at a time known in advance by the hospitals being surveyed, and often after considerable preparation by those hospitals. Preparing for a Joint Commission survey can be a challenging process for any healthcare provider. At a minimum, a hospital must be completely familiar with the current standards, examine current processes, policies and procedures relative to the standards and prepare to improve any areas that are not currently in compliance. The hospital must be in compliance with the standards for at least four months prior to the initial survey. The hospital should also be in

Joint Commission compliance with applicable standards during the entire period of accreditation, which means that surveyors will look for a full three years of implementation for several standards-related issues.[14] As for the surveyors, the Joint Commission and JCI employ salaried individuals, people who generally work or have worked within health care services but who may devote half or less of their time for the accrediting organization. The surveyors travel to health care organizations to evaluate their operational practices and facilities (i.e., structure/input and process metrics) against established Joint Commission standards and elements of performance. Substantial time and resources are devoted by health care organizations ranging from medical equipment suppliers and staffing firms to tertiary care academic medical centers to prepare for and undergo Joint Commission surveys. There is growing concern, however, over the lack of verifiable progress towards meeting the organization's stated goals. Although the Joint Commission increasingly cites and demands "evidence-based medicine" in its regulatory requirements, there is a relative paucity of evidence demonstrating any significant quality improvement due to its efforts, while there is a growing body of literature showing no improvement or actual deterioration in quality despite the increasingly stringent and expensive requirements. [citation needed] Indeed, a facility requesting accreditation pays a substantial fee to the Joint Commission (the "accrediting" agency) and, upon receiving a "passing" grade is able to purchase associated momentos of accomplishment to display to the public. No other entity certifies the Joint Commission.

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Alternatives in the United States


The Joint Commission is not a complete monopoly and while many states in the U.S. make use of their services, not all do. Some states have set up their own alternative assessment procedures; the Joint Commission is not recognized for state licensure in the states of Oklahoma (except for hospital-based outpatient mental health services), Pennsylvania, and Wisconsin. In California, The Joint Commission is part of a joint survey process with state authorities.[15] There are also other healthcare accreditation organizations in the U.S. unrelated to the Joint Commission.[16] These include the Community Health Accreditation Program (CHAP),[17] American Osteopathic Association (AOA), Healthcare Facilities Accreditation Program (HFAP),[18] Commission on Accreditation of Rehabilitation Facilities(CARF),[19] the Accreditation Commission for Health Care, Inc. (ACHC),[20] Utilization Review Accreditation Commission (URAC),[21] the "Exemplary Provider Program" of The Compliance Team,[22] the National Commission on Correctional Health Care[24] [23] and the Healthcare Quality Association on Accreditation (HQAA), who are recognised in the state of Ohio.[25] HFAP is older than the Joint Commission, having been in operation since 1945.[26] On September 26, 2008 the Centers for Medicare and Medicaid Services (CMS) granted deeming authority for hospitals to DNV Healthcare Inc. (DNVHC), an operating company of Det Norske Veritas (DNV), a Norwegian international company that has been operating in the U.S. since 1898.

Goals and initiatives


The stated mission of The Joint Commission is: "To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value" The company updates its accreditation standards and expands patient safety goals on a yearly basis, and posts them on its Web site for all interested persons to review, making this information and process transparent to all stakeholders ranging from institutions, to practitioners, to patients and their advocates. The purpose of The Joint Commissions National Patient Safety Goals is to promote specific improvements in patient safety. The Goals highlight problematic areas in health care and describe evidence and expert-based solutions to these problems. Recognizing that sound system design is intrinsic to the delivery of safe, high quality health care, the

Joint Commission Goals focus on system-wide solutions, wherever possible.[27] The NPSGs have become a critical method by which The Joint Commission promotes and enforces major changes in patient safety in thousands of participating health care organizations in the United States and around the world. The 2009 NPSGs include new regulations targeting the spread of infection due to multidrug-resistant organisms, catheter-related bloodstream infections (CRBSI), and surgical site infections (SSI). The new regulations for CRBSI and SSI prevention apply not only to hospitals, but also to ambulatory care and ambulatory surgery centers. Engaging patients in patient safety efforts is also a major new component of the NPSGs. The Universal Protocol to reduce surgical errors and existing regulations on medication reconciliation have also been modified for 2009, based on feedback received by The Joint Commission.[28]

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International healthcare accreditation


With the advent of medical tourism, international healthcare accreditation of hospitals located in countries around the world has increasingly grown in importance. Joint Commission International, or JCI, is one of the groups providing international healthcare accreditation services to hospitals around the world and brings income into the U.S.-based parent organization. This not-for-profit tax-exempt private corporation (a 501(c) organization) currently accredits hospitals in Asia, Europe, the Middle East and South America, and is seeking to expand its business further.[29] JCI also offers a variety of educational programs, especially "Practicums" more information, including attendance costs, is available through their Web site.[30] There are other accreditation organisations based in countries other than the USA which fulfill a similar internationally orientated role to JCI. These include: Accreditation Canada[31] The Australian Council on Healthcare Standards or ACHS[32] QHA Trent Accreditation (based in the United Kingdom)[33] In INDIA National Accreditation Board for Hospitals and Healthcare Providers or NABH[34]

Cost of accreditation
JCI publishes an average fee of US$ 46,000 for a full hospital survey.[35] Reimbursement for surveyors' travel, living expenses and accommodations is required in addition to the fee. There may be additional costs related to consultancy work etc. directed towards assisting a hospital to be successful in the accreditation process. Other international accreditors incur different levels of costs, some costing less than JCI.

Notes
[1] http:/ / www. jointcommission. org/ [2] A History of the Joint Commission on Accreditation of Hospitals (http:/ / jama. jamanetwork. com/ article. aspx?articleid=367766) James S. Roberts, MD; Jack G. Coale, MA; Robert R. Redman, MA, JAMA. 1987;258(7):936-940, [4] Facts About The Joint Commission (http:/ / www. jointcommission. org/ AboutUs/ Fact_Sheets/ joint_commission_facts. htm), The Joint Commission Web site [5] HHS Action Plan to Prevent Healthcare-Associated Infections 06222009 Section 8: Incentives and Oversight (http:/ / www. hhs. gov/ ophs/ initiatives/ hai/ 8-hai-plan-incentives-oversight. pdf) June 22, 2009 Excerpt: pages 5859 [6] "Financial Publications: Consolidated Financial Statements December 2008 and 2007." (http:/ / www. jointcommission. org/ AboutUs/ Financials. htm) The Joint Commission Web site [7] About Us (http:/ / www. jointcommission. org/ AboutUs/ directions. htm), Joint Commission. [11] (http:/ / www. 24x7mag. com/ issues/ articles/ 2008-01_05. asp/ ) [15] (http:/ / www. jointcommission. org/ NR/ rdonlyres/ C6A3B227-564E-46E3-A1D8-6CBF5DA6BEE5/ 0/ 9_07deeming. pdf) [23] http:/ / www. ncchc. org/ health-service-accreditation

Joint Commission
[24] [26] [30] [32] www.ncchc.org (http:/ / www. osteopathic. org/ index. cfm?PageID=lcl_hfovrview) http:/ / www. jointcommissioninternational. org/ Products-and-Services/ Practicum-Home/ http:/ / www. achs. org. au/

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African Society for Quality in Healthcare ASQH (http://www.ASQH.org/)

External links
The Joint Commission (http://www.jointcommission.org/) Joint Commission International (http://www.jointcommissioninternational.org/)

Lactate dehydrogenase
Lactate dehydrogenase
Identifiers EC number CAS number 1.1.1.27 [1] [2]

9001-60-9

Databases IntEnz BRENDA ExPASy KEGG MetaCyc PRIAM PDB structures Gene Ontology IntEnz view [3] [4] [5]

BRENDA entry NiceZyme view KEGG entry [6]

metabolic pathway profile [8] [9]

[7]

RCSB PDB AmiGO

PDBe

[10]

PDBsum

[11]

[12]

/ EGO

[13]

Search PMC articles [14]

PubMed articles [15] NCBI proteins [16]

Lactate dehydrogenase

1020

lactate dehydrogenase A (subunit M)

Human lactate dehydrogenase M4 (the isoenzyme found in skeletal muscle). From PDB 1I10 Identifiers Symbol Alt. symbols Entrez HUGO OMIM RefSeq UniProt LDHA LDHM 3939 6535 [18] [19] [20] [21]

[17]

150000

NM_005566 P00338 Other data [22]

EC number Locus

1.1.1.27

[23] [24]

Chr. 11 p15.4

lactate dehydrogenase B (subunit H)


Identifiers Symbol LDHB

Alt. symbols LDHL Entrez HUGO OMIM RefSeq UniProt 3945 6541 [25] [26] [27] [28]

150100

NM_002300 P07195 [29]

Other data EC number 1.1.1.27 [23]

Lactate dehydrogenase
[30]

1021
Locus

Chr. 12 p12.2-12.1

lactate dehydrogenase C
Identifiers Symbol Entrez HUGO OMIM RefSeq UniProt LDHC 3948 6544 [31] [32] [33] [34]

150150

NM_002301 P07864 [35]

Other data EC number 1.1.1.27 [23] Locus Chr. 11 p15.5-15.3 [36]

D-lactate dehydrogenase, membrane binding

crystal structure of d-lactate dehydrogenase, a peripheral membrane respiratory enzyme. Identifiers Symbol Pfam Pfam clan InterPro SCOP SUPERFAMILY Lact-deh-memb PF09330 CL0277 [37]

[38] [39]

IPR015409 1f0x 1f0x [40] [41]

Lactate dehydrogenase

1022

Available protein structures: Pfam PDB structures [42] [43] ; PDBe [44] ; PDBj [45]

RCSB PDB

PDBsum structure summary [46]

A lactate dehydrogenase (LDH or LD) is an enzyme (EC 1.1.1.27 variety of organisms, including plants and animals.

[47]

and EC 1.1.1.28

[48]

) present in a wide

Lactate dehydrogenases exist in four distinct enzyme classes. Two of them are cytochrome c-dependent enzymes, each acting on either D-lactate (EC 1.1.2.4) or L-lactate (EC 1.1.2.3). The other two are NAD(P)-dependent enzymes, each acting on either D-lactate (EC 1.1.1.28) or L-lactate (EC 1.1.1.27). This article is about the NAD(P)-dependent L-lactate dehydrogenase.

Reactions

Catalytic function of LDH

Lactate dehydrogenase catalyzes the interconversion of pyruvate and lactate with concomitant interconversion of NADH and NAD+. It converts pyruvate, the final product of glycolysis, to lactate when oxygen is absent or in short supply, and it performs the reverse reaction during the Cori cycle in the liver. At high concentrations of lactate, the enzyme exhibits feedback inhibition, and the rate of conversion of pyruvate to lactate is decreased. It also catalyzes the dehydrogenation of 2-Hydroxybutyrate, but it is a much poorer substrate than lactate. There is little to no activity with beta-hydroxybutyrate.

Interactive pathway map


Click on genes, proteins and metabolites below to link to respective articles. [49]

Lactate dehydrogenase

1023

Glycolysis and Gluconeogenesis edit [50]


[1] [2] [3] [4] [5] [6] [7] [8] [9] http:/ / www. chem. qmul. ac. uk/ iubmb/ enzyme/ EC1/ 1/ 1/ 27. html http:/ / tools. wmflabs. org/ magnustools/ cas. php?language=en& cas=9001-60-9& title= http:/ / www. ebi. ac. uk/ intenz/ query?cmd=SearchEC& ec=1. 1. 1. 27 http:/ / www. brenda-enzymes. org/ php/ result_flat. php4?ecno=1. 1. 1. 27 http:/ / www. expasy. org/ enzyme/ 1. 1. 1. 27 http:/ / www. genome. ad. jp/ dbget-bin/ www_bget?enzyme+ 1. 1. 1. 27 http:/ / biocyc. org/ META/ substring-search?type=NIL& object=1. 1. 1. 27 http:/ / priam. prabi. fr/ cgi-bin/ PRIAM_profiles_CurrentRelease. pl?EC=1. 1. 1. 27 http:/ / www. rcsb. org/ pdb/ search/ smartSubquery. do?smartSearchSubtype=EnzymeClassificationQuery& Enzyme_Classification=1. 1. 1. 27 [10] http:/ / www. ebi. ac. uk/ pdbe-srv/ PDBeXplore/ enzyme/ ?ec=1. 1. 1. 27 [11] http:/ / www. ebi. ac. uk/ thornton-srv/ databases/ cgi-bin/ enzymes/ GetPage. pl?ec_number=1. 1. 1. 27 [12] http:/ / amigo. geneontology. org/ cgi-bin/ amigo/ go. cgi?query=GO:0004459& view=details [13] http:/ / www. ebi. ac. uk/ ego/ DisplayGoTerm?id=GO:0004459& format=normal [14] http:/ / www. ncbi. nlm. nih. gov/ entrez/ query. fcgi?db=pubmed& term=1. 1. 1. 27%5BEC/ RN%20Number%5D%20AND%20pubmed%20pmc%20local%5Bsb%5D [15] http:/ / www. ncbi. nlm. nih. gov/ entrez/ query. fcgi?db=pubmed& term=1. 1. 1. 27%5BEC/ RN%20Number%5D [16] http:/ / www. ncbi. nlm. nih. gov/ protein?term=1. 1. 1. 27%5BEC/ RN%20Number%5D [17] http:/ / www. rcsb. org/ pdb/ explore/ explore. do?structureId=1I10 [18] http:/ / www. ncbi. nlm. nih. gov/ entrez/ query. fcgi?db=gene& amp;cmd=retrieve& amp;dopt=default& amp;list_uids=3939& rn=1 [19] http:/ / www. genenames. org/ data/ hgnc_data. php?hgnc_id=6535 [20] http:/ / www. omim. org/ 150000 [21] http:/ / genome. ucsc. edu/ cgi-bin/ hgTracks?Submit=Submit& position=NM_005566& rn=1 [22] http:/ / www. uniprot. org/ uniprot/ P00338 [23] http:/ / www. genome. jp/ dbget-bin/ www_bget?enzyme+ 1. 1. 1. 27 [24] http:/ / omim. org/ search?index=geneMap& search=11p15. 4 [25] http:/ / www. ncbi. nlm. nih. gov/ entrez/ query. fcgi?db=gene& amp;cmd=retrieve& amp;dopt=default& amp;list_uids=3945& rn=1 [26] http:/ / www. genenames. org/ data/ hgnc_data. php?hgnc_id=6541 [27] http:/ / www. omim. org/ 150100 [28] http:/ / genome. ucsc. edu/ cgi-bin/ hgTracks?Submit=Submit& position=NM_002300& rn=1 [29] http:/ / www. uniprot. org/ uniprot/ P07195 [30] http:/ / omim. org/ search?index=geneMap& search=12p12. 2-12. 1 [31] http:/ / www. ncbi. nlm. nih. gov/ entrez/ query. fcgi?db=gene& amp;cmd=retrieve& amp;dopt=default& amp;list_uids=3948& rn=1 [32] http:/ / www. genenames. org/ data/ hgnc_data. php?hgnc_id=6544

Lactate dehydrogenase
[33] [34] [35] [36] [37] [38] [39] [40] [41] [42] [43] [44] [45] [46] [47] [48] [49] [50] http:/ / www. omim. org/ 150150 http:/ / genome. ucsc. edu/ cgi-bin/ hgTracks?Submit=Submit& position=NM_002301& rn=1 http:/ / www. uniprot. org/ uniprot/ P07864 http:/ / omim. org/ search?index=geneMap& search=11p15. 5-15. 3 http:/ / pfam. sanger. ac. uk/ family?acc=PF09330 http:/ / pfam. sanger. ac. uk/ clan/ CL0277 http:/ / www. ebi. ac. uk/ interpro/ entry/ IPR015409 http:/ / scop. mrc-lmb. cam. ac. uk/ scop/ search. cgi?tlev=fa;& amp;pdb=1f0x http:/ / supfam. org/ SUPERFAMILY/ cgi-bin/ search. cgi?search_field=1f0x http:/ / pfam. sanger. ac. uk/ family/ PF09330?tab=pdbBlock http:/ / www. rcsb. org/ pdb/ search/ smartSubquery. do?smartSearchSubtype=PfamIdQuery& pfamID=PF09330 http:/ / www. ebi. ac. uk/ pdbe-srv/ PDBeXplore/ pfam/ ?pfam=PF09330 http:/ / pdbj. org/ searchFor?query=PF09330 http:/ / www. ebi. ac. uk/ thornton-srv/ databases/ cgi-bin/ pdbsum/ GetPfamStr. pl?pfam_id=PF09330 http:/ / enzyme. expasy. org/ EC/ 1. 1. 1. 27 http:/ / enzyme. expasy. org/ EC/ 1. 1. 1. 28 The interactive pathway map can be edited at WikiPathways: http:/ / www. wikipathways. org/ index. php/ Pathway:WP534

1024

Enzyme regulation
This protein may use the morpheein model of allosteric regulation.[]

Ethanol-induced hypoglycemia
Ethanol is dehydrogenated to acetaldehyde by alcohol dehydrogenase, and further into acetic acid by acetaldehyde dehydrogenase. During this reaction 2 NADH are produced. If large amounts of ethanol are present, then large amounts of NADH are produced, leading to a depletion of NAD+. Thus, the conversion of pyruvate to lactate is increased due to the associated regeneration of NAD+. Therefore, anion-gap metabolic acidosis (lactic acidosis) may ensue in ethanol poisoning. The increased NADH/NAD+ ratio also can cause hypoglycemia in a fasting individual who has been drinking and is dependent on gluconeogenesis to maintain blood glucose levels. Alanine and lactate are major gluconeogenic precursors that enter gluconeogenesis as pyruvate. The high NADH/NAD+ ratio shifts the lactate dehydrogenase equilibrium to lactate, so that pyruvate formed.

Enzyme isoforms
Functional lactate dehydrogenase are homo or hetero tetramers composed of M and H protein subunits encoded by the LDHA and LDHB genes, respectively: LDH-1 (4H)in the heart and in RBC (red blood cells) LDH-2 (3H1M)in the reticuloendothelial system LDH-3 (2H2M)in the lungs LDH-4 (1H3M)in the kidneys, placenta, and pancreas LDH-5 (4M)in the liver and striated muscle[1]

The five isoenzymes that are usually described in the literature each contain four subunits. The major isoenzymes of skeletal muscle and liver, M4, has four muscle (M) subunits, while H4 is the main isoenzymes for heart muscle in most species, containing four heart (H) subunits. The other variants contain both types of subunits. Usually LDH-2 is the predominant form in the serum. A LDH-1 level higher than the LDH-2 level (a "flipped pattern") suggests myocardial infarction (damage to heart tissues releases heart LDH, which is rich in LDH-1, into the bloodstream). The use of this phenomenon to diagnose infarction has been largely superseded by the use of Troponin I or T measurement.

Lactate dehydrogenase

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Genetics in humans
The M and H subunits are encoded by two different genes: The M subunit is encoded by LDHA, located on chromosome 11p15.4 (Online 'Mendelian Inheritance in Man' (OMIM) 150000 (http://omim.org/entry/150000)) The H subunit is encoded by LDHB, located on chromosome 12p12.2-p12.1 (Online 'Mendelian Inheritance in Man' (OMIM) 150100 (http://omim.org/entry/150100)) A third isoform, LDHC or LDHX, is expressed only in the testis (Online 'Mendelian Inheritance in Man' (OMIM) 150150 (http://omim.org/entry/150150)); its gene is likely a duplicate of LDHA and is also located on the eleventh chromosome (11p15.5-p15.3) Mutations of the M subunit have been linked to the rare disease exertional myoglobinuria (see OMIM article), and mutations of the H subunit have been described but do not appear to lead to disease.

Medical use
Tissue breakdown releases LDH, and therefore LDH can be measured as a surrogate for tissue breakdown, e.g. hemolysis. Other disorders indicated by elevated LDH include cancer, meningitis, encephalitis, acute pancreatitis, and HIV.

Hemolysis
In medicine, LDH is often used as a marker of tissue breakdown as LDH is abundant in red blood cells and can function as a marker for hemolysis. A blood sample that has been handled incorrectly can show false-positively high levels of LDH due to erythrocyte damage. It can also be used as a marker of myocardial infarction. Following a myocardial infarction, levels of LDH peak at 34 days and remain elevated for up to 10 days. In this way, elevated levels of LDH (where the level of LDH1 is higher than that of LDH2) can be useful for determining whether a patient has had a myocardial infarction if they come to doctors several days after an episode of chest pain.

Tissue turnover
Other uses are assessment of tissue breakdown in general; this is possible when there are no other indicators of hemolysis. It is used to follow-up cancer (especially lymphoma) patients, as cancer cells have a high rate of turnover with destroyed cells leading to an elevated LDH activity.

Exudates and transudates


Measuring LDH in fluid aspirated from a pleural effusion (or pericardial effusion) can help in the distinction between exudates (actively secreted fluid, e.g. due to inflammation) or transudates (passively secreted fluid, due to a high hydrostatic pressure or a low oncotic pressure). The usual criterion is that a ratio of fluid LDH versus upper limit of normal serum LDH of more than 0.6[] or [] indicates an exudate, while a ratio of less indicates a transudate. Different laboratories have different values for the upper limit of serum LDH, but examples include 200[] and 300[] IU/L.[2] In empyema, the LDH levels, in general, will exceed 1000 IU/L.

Lactate dehydrogenase

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Meningitis and encephalitis


High levels of lactate dehydrogenase in cerebrospinal fluid are often associated with bacterial meningitis. In the case of viral meningitis, high LDH, in general, indicates the presence of encephalitis and poor prognosis.

HIV
LDH is often measured in HIV patients as a non-specific marker for pneumonia due to Pneumocystis jiroveci (PCP). Elevated LDH in the setting of upper respiratory symptoms in an HIV patient suggests, but is not diagnostic for, PCP. However, in HIV-positive patients with respiratory symptoms, a very high LDH level (>600 IU/L) indicated histoplasmosis (9.33 more likely) in a study of 120 PCP and 30 histoplasmosis patients.[3]

Dysgerminoma
Elevated LDH is often the first clinical sign of a dysgerminoma. Not all dysgerminomas produce LDH, and this is often a non-specific finding.

Prokaryotes
A cap-membrane-binding domain is found in prokaryotic lactate dehydrogenase. This consists of a large seven-stranded antiparallel beta-sheet flanked on both sides by alpha-helices. It allows for membrane association.[]

References
[2] (http:/ / www. biomedcentral. com/ 1471-2466/ 2/ 1)

This article incorporates text from the public domain Pfam and InterPro IPR015409 (http:/ / www. ebi. ac. uk/ interpro/IEntry?ac=IPR015409)

Laboratory information management system

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Laboratory information management system


A Laboratory Information Management System (LIMS), sometimes referred to as a Laboratory Information System (LIS) or Laboratory Management System (LMS), is a software-based laboratory and information management system that offers a set of key features that support a modern laboratory's operations. Those key features include but are not limited to workflow and data tracking support, flexible architecture, and smart data exchange interfaces, which fully "support its use in regulated environments."[] The features and uses of a LIMS have evolved over the years from simple sample tracking to an enterprise resource planning tool that manages multiple aspects of laboratory informatics.[]

Laboratories around the world depend on a LIMS to manage data, assign rights, manage inventory, and more.

The definition of a LIMS is somewhat controversial: LIMSs are dynamic because the modern laboratory's requirements are rapidly evolving and needs often vary significantly from lab to lab. Therefore, a working definition of a LIMS ultimately depends on the interpretation by the individuals or groups involved. [] Dr. Alan McLelland of the Institute of Biochemistry, Royal Infirmary, Glasgow highlighted this problem in the late 1990s by explaining how a LIMS is perceived by an analyst, a laboratory manager, an information systems manager, and an accountant, "all of them correct, but each of them limited by the users' own perceptions."[] Historically the LIMS, LIS, and Process Development Execution System (PDES) have all performed similar functions. Historically the term "LIMS" has tended to be used to reference informatics systems targeted for environmental, research, or commercial analysis such as pharmaceutical or petrochemical work. "LIS" has tended to be used to reference laboratory informatics systems in the forensics and clinical markets, which often required special case management tools. The term "PDES" has generally applied to a wider scope, including, for example, virtual manufacturing techniques, while not necessarily integrating with laboratory equipment. In recent times LIMS functionality has spread even farther beyond its original purpose of sample management. Assay data management, data mining, data analysis, and electronic laboratory notebook (ELN) integration are all features that have been added to many LIMS,[] enabling the realization of translational medicine completely within a single software solution. Additionally, the distinction between a LIMS and a LIS has blurred, as many LIMS now also fully support comprehensive case-centric clinical data.[]

History
Up until the late 1970s, the management of laboratory samples and the associated analysis and reporting were time-consuming manual processes often riddled with transcription errors. This gave some organizations impetus to streamline the collection of data and how it was reported. Custom in-house solutions were developed by a few individual laboratories, while some enterprising entities at the same time sought to develop a more commercial reporting solution in the form of special instrument-based systems.[] In 1982 the first generation of LIMS was introduced in the form of a single centralized minicomputer, which offered laboratories the first opportunity to utilize automated reporting tools. As the interest in these early LIMS grew, industry leaders like Gerst Gibbon of the Federal Energy Technology Centre in Pittsburgh began planting the seeds through LIMS-related conferences. By 1988 the second-generation commercial offerings were tapping into relational databases to expand LIMS into more application-specific territory, and International LIMS Conferences were in full swing. As personal computers became more powerful and prominent, a third generation of LIMS emerged in the early 1990s. These new LIMS took advantage of the developing client/server architecture, allowing laboratories to

Laboratory information management system implement better data processing and exchanges.[] By 1995 the client/server tools had developed to the point of allowing processing of data anywhere on the network. Web-enabled LIMS were introduced the following year, enabling researchers to extend operations outside the confines of the laboratory. From 1996 to 2002 additional functionality was included in LIMS, from wireless networking capabilities and georeferencing of samples, to the adoption of XML standards and the development of Internet purchasing.[] As of 2012, some LIMS have added additional characteristics that continue to shape how a LIMS is defined. Examples include the addition of clinical functionality, electronic laboratory notebook (ELN) functionality, as well a rise in the software as a service (SaaS) distribution model.[]

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Technology
Operations
The LIMS is an evolving concept, with new features and functionality being added often. As laboratory demands change and technological progress continues, the functions of a LIMS will likely also change. Despite these changes, a LIMS tends to have a base set of functionality that defines it. That functionality can roughly be divided into five laboratory processing phases, with numerous software functions falling under each:[] the reception and log in of a sample and its associated customer data the assignment, scheduling, and tracking of the sample and the associated analytical workload the processing and quality control associated with the sample and the utilized equipment and inventory the storage of data associated with the sample analysis the inspection, approval, and compilation of the sample data for reporting and/or further analysis

There are several pieces of core functionality associated with these laboratory processing phases that tend to appear in most LIMS: Sample management The core function of LIMS has traditionally been the management of samples.[] This typically is initiated when a sample is received in the laboratory, at which point the sample will be registered in the LIMS. Some LIMS will allow the customer to place an "order" for a sample directly to the LIMS at which point the sample is generated in an "unreceived" state. The processing could then include a step where the sample container is registered and sent to the customer for the sample to be taken and then returned to the lab. The registration process may involve accessioning the sample and producing barcodes to affix to the sample container. Various other parameters such as clinical or A lab worker matches blood samples to phenotypic information corresponding with the sample are also often documents. With a LIMS, this sort of sample management is made more efficient. recorded. The LIMS then tracks chain of custody as well as sample location. Location tracking usually involves assigning the sample to a particular freezer location, often down to the granular level of shelf, rack, box, row, and column. Other event tracking such as freeze and thaw cycles that a sample undergoes in the laboratory may be required. Modern LIMS have implemented extensive configurability, as each laboratory's needs for tracking additional data points can vary widely. LIMS vendors cannot typically make assumptions about what these data tracking needs are, and therefore vendors must create LIMS that are adaptable to individual environments. LIMS users may also have regulatory concerns to comply with such as CLIA, HIPAA, GLP, and FDA specifications, affecting certain aspects

Laboratory information management system of sample management in a LIMS solution.[] One key to compliance with many of these standards is audit logging of all changes to LIMS data, and in some cases a full electronic signature system is required for rigorous tracking of field-level changes to LIMS data. Instrument and application integration Modern LIMS offer an increasing amount of integration with laboratory instruments and applications. A LIMS may create control files that are "fed" into the instrument and direct its operation on some physical item such as a sample tube or sample plate. The LIMS may then import instrument results files to extract data for quality control assessment of the operation on the sample. Access to the instrument data can sometimes be regulated based on chain of custody assignments or other security features if need be. Modern LIMS products now also allow for the import and management of raw assay data results.[] Modern targeted assays such as qPCR and deep sequencing can produce tens of thousands of data points per sample. Furthermore, in the case of drug and diagnostic development as many as 12 or more assays may be run for each sample. In order to track this data, a LIMS solution needs to be adaptable to many different assay formats at both the data layer and import creation layer, while maintaining a high level of overall performance. Some LIMS products address this by simply attaching assay data as BLOBs to samples, but this limits the utility of that data in data mining and downstream analysis. Electronic data exchange The exponentially growing volume of data created in laboratories, coupled with increased business demands and focus on profitability, have pushed LIMS vendors to increase attention to how their LIMS handles electronic data exchanges. Attention must be paid to how an instrument's input and output data is managed, how remote sample collection data is imported and exported, and how mobile technology integrates with the LIMS. The successful transfer of data files in Microsoft Excel and other formats, as well as the import and export of data to Oracle, SQL, and Microsoft Access databases is a pivotal aspect of the modern LIMS.[] In fact, the transition "from proprietary databases to standardized database management systems such as Oracle ... and SQL" has arguably had one of the biggest impacts on how data is managed and exchanged in laboratories.[] Additional functions Aside from the key functions of sample management, instrument and application integration, and electronic data exchange, there are numerous additional operations that can be managed in a LIMS. This includes but is not limited to:[][][] audit management fully track and maintain an audit trail barcode handling assign one or more data points to a barcode format; read and extract information from a barcode chain of custody assign roles and groups that dictate access to specific data records and who is managing them compliance follow regulatory standards that affect the laboratory customer relationship management handle the demographic information and communications for associated clients document management process and convert data to certain formats; manage how documents are distributed and accessed

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Laboratory information management system instrument calibration and maintenance schedule important maintenance and calibration of lab instruments and keep detailed records of such activities inventory and equipment management measure and record inventories of vital supplies and laboratory equipment manual and electronic data entry provide fast and reliable interfaces for data to be entered by a human or electronic component method management provide one location for all laboratory process and procedure (P&P) and methodology to be housed and managed as well as connecting each sample handling step with current instructions for performing the operation personnel and workload management organize work schedules, workload assignments, employee demographic information, training, and financial information quality assurance and control gauge and control sample quality, data entry standards, and workflow reports create and schedule reports in a specific format; schedule and distribute reports to designated parties time tracking calculate and maintain processing and handling times on chemical reactions, workflows, and more traceability show audit trail and/or chain of custody of a sample workflows track a sample, a batch of samples, or a "lot" of batches through its lifecycle

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Client-side options
A LIMS has utilized many architectures and distribution models over the years. As technology has changed, how a LIMS is installed, managed, and utilized has also changed with it. The following represents architectures which have been utilized at one point or another: Thick-client A thick-client LIMS is a more traditional client/server architecture, with some of the system residing on the computer or workstation of the user (the client) and the rest on the server. The LIMS software is installed on the client computer, which does all of the data processing. Later it passes information to the server, which has the primary purpose of data storage. Most changes, upgrades, and other modifications will happen on the client side. This was one of the first architectures implemented into a LIMS, having the advantage of providing higher processing speeds (because processing is done on the client and not the server) and slightly more security (as access to the server data is limited only to those with client software). Additionally, thick-client systems have also provided more interactivity and customization, though often at a greater learning curve. The disadvantages of client-side LIMS include the need for more robust client computers and more time-consuming upgrades, as well as a lack of base functionality through a web browser. The thick-client LIMS can become web-enabled through an add-on component.[]

Laboratory information management system Thin-client A thin-client LIMS is a more modern architecture which offers full application functionality accessed through a device's web browser. The actual LIMS software resides on a server (host) which feeds and processes information without saving it to the user's hard disk. Any necessary changes, upgrades, and other modifications are handled by the entity hosting the server-side LIMS software, meaning all end-users see all changes made. To this end, a true thin-client LIMS will leave no "footprint" on the client's computer, and only the integrity of the web browser need be maintained by the user. The advantages of this system include significantly lower cost of ownership and fewer network and client-side maintenance expenses. However, this architecture has the disadvantage of requiring real-time server access, a need for increased network throughput, and slightly less functionality. A sort of hybrid architecture that incorporates the features of thin-client browser usage with a thick client installation exists in the form of a web-based LIMS. Some LIMS vendors are beginning to rent hosted, thin-client solutions as "software as a service" (SaaS). These solutions tend to be less configurable than on premise solutions and are therefore considered for less demanding implementations such as laboratories with few users and limited sample processing volumes.

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Another implementation of the thin client architecture is the maintenance, warranty, and support (MSW) agreement. Pricing levels are typically based on a percentage of the license fee, with a standard level of service for 10 concurrent users being approximately 10 hours of support and additional customer service, at a roughly $200 per hour rate.[] Though some may choose to opt out of an MSW after the first year, it's often more economical to continue the plan in order to receive updates to the LIMS, giving it a longer life span in the laboratory. Web-enabled A web-enabled LIMS architecture is essentially a thick-client architecture with an added web browser component. In this setup, the client-side software has additional functionality that allows users to interface with the software through their device's browser. This functionality is typically limited only to certain functions of the web client. The primary advantage of a web-enabled LIMS is the end-user can access data both on the client side and the server side of the configuration. As in a thick-client architecture, updates in the software must be propagated to every client machine. However, the added disadvantages of requiring always-on access to the host server and the need for cross-platform functionality mean that additional overhead costs may arise. Web-based Arguably one of the most confusing architectures, web-based LIMS architecture is a hybrid of the thick- and thin-client architectures. While much of the client-side work is done through a web browser, the LIMS also requires the additional support of Microsoft's .NET Framework technology installed on the client device. The end result is a process that is apparent to the end-user through the Microsoft-compatible web browser, but perhaps not so apparent as it runs thick-client-like processing in the background. In this case, web-based architecture has the advantage of providing more functionality through a more friendly web interface. The disadvantages of this setup are more sunk costs in system administration and support for Internet Explorer and .NET technologies, and reduced functionality on mobile platforms.

Configurability
LIMS implementations are notorious for often being lengthy and costly.[] This is due in part to the diversity of requirements within each lab, but also to the inflexible nature of LIMS products for adapting to these widely varying requirements. Newer LIMS solutions are beginning to emerge that take advantage of modern techniques in software design that are inherently more configurable and adaptable particularly at the data layer than prior solutions. This means not only that implementations are much faster, but also that the costs are lower and the risk of obsolescence is minimized.

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Distinction between a LIMS and a LIS


Up until recently, the LIMS and laboratory information system (LIS) have exhibited a few key differences, making them noticeably separate entities. A LIMS traditionally has been designed to process and report data related to batches of samples from biology labs, water treatment facilities, drug trials, and other entities that handle complex batches of data. A LIS has been designed primarily for processing and reporting data related to individual patients in a clinical setting.[][] A LIMS needs to satisfy good manufacturing practice (GMP) and meet the reporting and audit needs of the U.S. Food and Drug Administration and research scientists in many different industries. A LIS, however, must satisfy the reporting and auditing needs of hospital accreditation agencies, HIPAA, and other clinical medical practitioners.[] A LIMS is most competitive in group-centric settings (dealing with "batches" and "samples") that often deal with mostly anonymous research-specific laboratory data, whereas a LIS is usually most competitive in patient-centric settings (dealing with "subjects" and "specimens") and clinical labs.

Standards
A LIMS covers standards such as: 21 CFR Part 11 from the Food and Drug Administration (United States) ISO/IEC 17025 ISO 15189 Good laboratory practice

Further reading
Gibbon, G.A. (1996). "A brief history of LIMS" [1] (PDF). Laboratory Automation and Information Management 32 (1): 15. doi:10.1016/1381-141X(95)00024-K [2]. Wood, Simon (September 2007). "Comprehensive Laboratory Informatics: A Multilayer Approach" [3] (PDF). American Laboratory. p.1. Jones, John (2012). "The LIMS Book & Buyer's Guide" [4]. Laboratory Informatics Institute,Inc.

References
[1] [2] [3] [4] http:/ / www. sciencedirect. com/ science/ article/ pii/ 1381141X9500024K http:/ / dx. doi. org/ 10. 1016%2F1381-141X%2895%2900024-K http:/ / www. starlims. com/ Intl/ AL-Wood-Reprint-9-07. pdf http:/ / www. limsbook. com

Length of stay

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Length of stay
Length of stay (LOS) is a term commonly used to measure the duration of a single episode of hospitalization. Inpatient days are calculated by subtracting day of admission from day of discharge. However, persons entering and leaving a hospital on the same day have a length of stay of one. (See hospital.) A popular statistic associated with length of stay is the average length of stay (ALOS), calculated by dividing the sum of inpatient days by the number of patients admissions with the same DRG classification. A variation in the calculation of ALOS could be consider only length of stay during the period under analysis. The prospective payment system in U.S. Medicare for reimbursing hospital care promotes shorter LOS by paying the same amount for procedures, regardless of days spent in the hospital.

Licensed practical nurse


Licensed practical nurse (LPN) is the term used in much of the United States and most Canadian provinces to refer to a nurse who cares for "people who are sick, injured, convalescent, or disabled under the direction of registered nurses and physicians".[1] The term licensed vocational nurse (LVN) is used in the U.S.states of California and Texas. Equivalent professions outside the United States are "registered practical nurse" (RPNs) in the Canadian province of Ontario, "enrolled nurses" (ENs) or "Division2 nurses" in Australia and New Zealand, and "state enrolled nurses" (SENs) in the United Kingdom. A person can generally become an LPN with one year of training. In terms of nursing education, the next step up is RN (registered nurse). RNs hold two-year Associates and four-year Bachelors degrees, both degree-holders must take and pass the same NCLEX-RN nursing exam to be considered Registered Nurses. In the United States an RN may enroll in an RN-to-BSN program, thereby completing his or her baccalaureate with another two years of study.

United States
According to the 20102011 Occupational Outlook Handbook published by the Department of Labor's Bureau of Labor Statistics, licensed practical nurses care for patients in many ways: Often, they provide basic bedside care. Many LPNs measure and record patients' vital signs such as weight, height, temperature, blood pressure, pulse, and respiratory rate. They also prepare and give injections and enemas, monitor catheters, dress wounds, and give alcohol rubs and massages. To help keep patients comfortable, they assist with bathing, dressing, and personal hygiene, moving in bed, standing, and walking. They might also feed patients who need help eating. Experienced LPNs may supervise nursing assistants and aides, and other LPNs. As part of their work, LPNs collect samples for testing, perform routine laboratory tests, and record food and fluid intake and output. They clean and monitor medical equipment. Sometimes, they help physicians and registered nurses perform tests and procedures. Some LPNs help to deliver, care for, and feed infants. LPNs also monitor their patients and report adverse reactions to medications or treatments. LPNs gather information from patients, including their health history and how they are currently feeling. They may use this information to complete insurance forms, pre-authorizations, and referrals, and they share information with registered nurses and doctors to help determine the best course of care for a patient. LPNs often teach family members how to care for a relative or teach patients about good health habits.[1]

Licensed practical nurse According to the Occupational Outlook Handbook, while most LPNs are generalists and will work in any area of health care, some LPNs work in specialized settings, such as nursing homes, doctor's offices, or in home care.[1] In some American states, LPNs are permitted to administer prescribed medicines, start intravenous fluids, and provide care to ventilator-dependent patients.[1] While about 18 percent of LPNs/LVNs in the United States worked part-time in 2008, most work a 40-hour week. The Occupational Outlook Handbook states that LPNs may have to work nights, weekends, and holidays; often stand for long periods and help patients move in bed, stand, or walk; and may face occupational hazards which include exposure to caustic chemicals, radiation, and infectious diseases; back injuries from moving patients; workplace stress; and sometimes confused, agitated, or uncooperative patients."[1] In May 2008, the median annual wages of LPNs/LVNs in the United States was $39,030, with the middle 50 percent earning between $33,360 and $46,710, the lowest 10 percent earning less than $28,260, and the highest 10 percent earning more than $53,580. Median annual wages differed by setting:[1]
Setting Employment services Nursing care facilities Home health care services Median annual wages $44,690 $40,580 $39,510

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General medical and surgical hospitals $38,080 Offices of physicians $35,020

According to the Occupational Outlook Handbook, in 2008 there were some 753,600 jobs held by LPNs/LVNs in the United States, with about 25 percent working in hospitals, 28 percent in nursing care facilities, and 12 percent in physicians' offices. Other LPNs/LVN worked for home health care services; employment services; residential care facilities; community care facilities; outpatient care centers; and federal, state, and local government agencies.[1] In the United States, employment of LPNs is projected to grow by 21 percent between 2008 and 2018, much faster than average. The growth is expected to be driven by the "long-term care needs of an increasing elderly population and the general increase in demand for healthcare services".[1] By contrast hospitals are phasing out licensed practical nurses.[2] In the United States, training programs to become a LPN/LVN last about one year and are offered by vocational/technical schools and by community colleges. The Occupational Outlook Handbook states that in order to be eligible for licensure, LPNs must complete a state-approved training program. A high school diploma or equivalent usually is required for acceptance into a training program, but some programs accept candidates without a diploma and some programs are part of a high school curriculum. According to the Occupational Outlook Handbook states that most programs include both classroom study (covering basic nursing concepts and subjects related to patient care, including anatomy, physiology, medical-surgical nursing, pediatrics, obstetrics nursing, pharmacology, nutrition, and first aid) and supervised clinical practice (usually in a hospital setting, but sometimes elsewhere).[1] The National Council Licensure Examination-Practical Nurse (NCLEX-PN), a computer-based national licensing exam developed and administered by the National Council of State Boards of Nursing, is the exam required to obtain licensure as a LPN/LVN. In many states, LPNs/LVNs are required to obtain continuing education credits throughout their career.[1]

Advancement
In some settings, LPNs/LVNs have opportunities for advancement, including the possibility of becoming credentialed in a certain area (such as IV therapy, gerontology, long-term care and pharmacology) or of becoming a charge nurse, responsible for overseeing the work of other LPNs and various unlicensed assistive personnel, such as nursing assistants.[1] Some LPNs/LVNs choose to undergo further education and become registered nurses. LPN-to-RN training programs ("bridge programs") exist for this purpose.[1] These include further classroom study to

Licensed practical nurse obtain at least an Associate of Science in Nursing (ASN) and clinical practice followed by another exam, the National Council Licensure Examination-Registered Nurse (NCLEX-RN). The origins of the practical/vocational nurse can be traced back to the practice of self-taught individuals who worked in home care in the past, assisting with basic care (ADLs such as bathing) and light housekeeping duties (such as cooking). Licensing standards for practical nurses came later than those for professional nurses; by 1945, 19 states and one territory had licensure laws, but only one state law covered practical nursing. By 1955, however, every state had licensing laws for practical nurses. Practical nurses who had been functioning as such at the time new standards were adopted usually granted a license by waiver, and exempt from new training requirements.[3] The first formal training program for practical nurses was developed at the Young Women's Christian Association (YWCA) in New York City in 1892. The following year this became the Ballard School of Practical Nursing (after Lucinda Ballard, an early benefactor) and was a three-month-long course of study concerned with the care of infants, children and the elderly and disabled. The curriculum included instruction in cooking and nutrition as well as basic science and nursing. The school closed in 1949 after the YWCA was reorganized. Other early practical nursing education program include the Thompson Practical Nursing School, established in 1907 in Brattleboro, Vermont, (still in operation today) and the Household Nursing School (later the Shepard-Gill School of Practical Nursing), established in 1918 in Boston. In 1930, there were still just 11 schools of practical nursing, but between 1948 and 1954, 260 more opened. The Association of Practical Nurse Schools (APNS) as founded in 1942, and the next year the name of the organization was changed to National Association for Practical Nurse Education and Service (NAPNAS), and the first planned curriculum for practical nurses as developed.[4]

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Canada
In Ontario, there are two basic types of nurses: registered nurses (RNs) must have a BScN in nursing, 4 years of university for entry to practice; while registered practical nurses (RPNs) must have a 2year diploma program for entry to practice. Many registered nurses were grandfathered in when this change occurred and have completed 2and 3year diploma programs. In Ontario RPNs have a greater scope of practice than most provinces. They can perform most tasks that an RN can do, however, the complexity of the patient's condition determines if the RPN is in charge of care, or receiving direction from an RN.

United Kingdom
The state enrolled nursing qualification can no longer be gained in Britain. Prior to the implementation of Project 2000 which radically altered the face of nurse education in the mid 1990s, SEN students used to be trained within two years. Their course was a simplified version of the longer training offered to state registered nurses (SRNs, later to be renamed RGNs, registered general nurses and now known as level-one nurses). Some auxiliary nurses with many years of experience were selected to progress to enrollment as a SEN. People training to be SRNs who failed their exams at the third attempt were also able to enter the nursing register as a SEN. No new SENs are trained in the UK today. The Nursing and Midwifery Council (the regulatory body for nurses in the UK) previously used to allow people to be added to the register as level two nurses if they are moving from a similar position from within the European Union, however this has now stopped. Level-two nurses from the EU wishing to gain entry to the Register in the UK must be willing to train as a first level (staff) nurse. This is by two different means: starting their training from scratch as a pre-registration student nurse, or by joining an existing cohort of student nurses starting their second year of training, and completing years 2 and 3 with them [5] Formerly, there was a large segregation between the "green" SENs and "blue" SRNs, which were the colour of uniform typically worn. SENs were very much complementary to the nursing team, however did not have the status of SRNs and were ineligible to be promoted, e.g.,to ward sister. Many SENs sat or re-sat the SRN exams, however a large number did not and were quite content being a SEN. Nowadays, the divide between level one and two nurses is diminishing due to the small number of SENs still in practice. The demise of the SEN is lamented by many who saw

Licensed practical nurse it as a balanced way to staff a ward. However, the divide also meant that potentially, the gap in clinical excellence could be too wide.[6] In many areas, ENs and SENs are being replaced with lesser qualified healthcare assistants educated to S/NVQ Level 3 or 4, being awarded titles such as Senior Healthcare Assistant, Senior Auxiliary Nurse, Senior Clinical Support Worker, Care Team Leader or Senior Care Assistant. Although originally viewed as a less qualified nurse, ENs and SENs are now able to hold the rank of Deputy Charge Nurse in the NHS and Deputy Home Manager in the private sector, as well as unit manager, both within the NHS and the private sector, and in some instances higher, technically out-ranking a staff nurse (first-level RN). Auxiliary nurses draw blood samples, change bandages, and record ECGs. At present, they work under the direct supervision of a registered nurse.

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Australia
The national Australian Health Practitioners Registration Authority issues permission to practise. Enrolled nurses (EN), or Division2 nurses, in Australia must now complete the Diploma of Nursing and usually spend 24months training, consisting of 36weeks theoretical component at TAFE colleges or private institutions, followed by practical experience in hospital wards for the remainder of the time. The majority of ENs eventually move on to attend university and become registered nurses, although a substantial number remain as ENs in public and private hospitals, and nursing homes. Trainee enrolled nurses (TENs) become employees of the hospital for the twelve month training period, meaning that, as well as gaining practical experience on the wards, they are paid for hours worked. This attracts a substantial number of applicants, who may wish to pursue nursing as a career, but are unable to afford to become full-time university students. As of 2009, however, the government has stopped working with the NSW Department of Health, and those wishing to become enrolled nurses are not being paid. The enrolled nurse programme also allows people to ascertain whether or not they are suited to nursing before they make the decision to study it at university level. The role of enrolled nurses in Australia has greatly increased in recent years in response to the continuing shortage of registered nurses in the Australian public health care system. In 2004, a medication endorsement certificate was introduced, allowing ENs to administer some oral medication (excluding schedule8 drugs of addiction) upon completion. Endorsement also permits the administration of some intravenous (IV) medications and fluids (intravenous therapy or IVT), as well as intramuscular (IM) and subcutaneous (SC) injections. Endorsed enrolled nurses (EENs) are also permitted to check & give S4D and S8 medications with a registered nurse. Most enrolled nurses working in public hospitals are permitted to conduct ECGs, collect pathology specimens, and routinely take a patient load under the direct supervision of a registered nurse. Despite the fact that the role of the EN in Australia has been greatly expanded in recent years, opportunities for career progression remain somewhat limited, and for this reason, many choose to go on and study to become registered nurses. In terms of financial remuneration, the earning capacity of an enrolled nurse is capped at five years of service, whereas registered nurses continue to eight years before salary capping is applied.

Licensed practical nurse

1037

References
[1] " Licensed Practical and Licensed Vocational Nurses (http:/ / www. bls. gov/ oco/ ocos102. htm)". Occupational Outlook Handbook, 2010-11 Edition. Bureau of Labor Statistics, United States Department of Labor. [3] Janice Rider Ellis and Celia Love Hartley, Nursing in today's world: Trends, issues & management (Lippincott Williams & Wilkins, 2004), pp. 194-195. [4] Lois White, Foundations of Basic Nursing (2004), pp. 46-47.

External links
The Nursing and Midwivery Council (UK) (http://www.nmc-uk.org) Australian Health Practitioners Registration Authority (http://www.ahpra.gov.au/) List of State Nursing Boards (http://www.lpntrainingprograms.org/state-nursing-boards) LPN To RN Programs (http://www.lpnprogramsguide.org/lpn-rn-programs/) Licensed Practical Nurse Programs (http://www.allnursingprograms.org/lpn-programs/) LPN Online 6 Week Classes (http://www.lpnu.info) Accredited Online LPN Programs (http://www.lpn-programs.info)

Long-term acute care facility


A long-term acute care facility is a hospital specializing in treating patients requiring extended hospitalization. In the United States, such institutions have proliferated since the 1980s, partly because of incentives created by Medicare reimbursement.[]

References

Long-term care

1038

Long-term care
This article is about a type of health and social care service. For specific information on providers of such services, see for example Personal care assistant and Geriatric care manager. Long-term care (LTC) is a variety of services which help meet both the medical and non-medical needs of people with a chronic illness or disability who cannot care for themselves for long periods of time. It is common for long-term care to provide custodial and non-skilled care, such as assisting with normal daily tasks like dressing, bathing, and using the bathroom. Increasingly, long-term care involves providing a level of medical care that requires the expertise of skilled practitioners to address the Old man at a nursing home in Norway. often multiple chronic conditions associated with older populations. Long-term care can be provided at home, in the community, in assisted living facilities or in nursing homes. Long-term care may be needed by people of any age, although it is a more common need for senior citizens.[1]

Types of long-term care


Long-term care can be provided formally or informally. Facilities that offer formal LTC services typically provide living accommodation for people who require on-site delivery of around-the-clock supervised care, including professional health services, personal care and services such as meals, laundry and housekeeping.[2] These facilities may go under various names, such as nursing home, personal care facility, residential continuing care facility, etc. Long-term care provided formally in the home, also known as home health care, can incorporate a wide range of clinical services (e.g. nursing, drug therapy, physical therapy) and other activities such as physical construction (e.g. installing hydraulic lifts, renovating bathrooms and kitchens). These services are usually ordered by a physician or other professional. Depending on the country and nature of the health and social care system, some of the costs of these services may be covered by health insurance or long-term care insurance. Informal long-term home care is care and support provided by family members, friends and other unpaid volunteers. It is estimated that 90% of all home care is provided informally by a loved one without compensation.[3]

Long-term care

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Needs for long-term care


Life expectancy is going up in most countries, meaning more and more people are living longer and entering an age when they may need care. Meanwhile birth rates are generally falling. Globally, 70 percent of all older people now live in low or middle-income countries.[4] Countries and health care systems need to find innovative and sustainable ways to cope with the demographic shift. As reported by John Beard, director of the World Health Organization's Department of Ageing and Life Course, "With the rapid ageing of populations, finding the right model for long-term care becomes more and more urgent."[1] The demographic shift is also being accompanied by changing social patterns, including smaller families, different residential patterns and increased female labour force participation. These factors often contribute to an increased need for paid care.[5] In many countries, the largest percentages of older persons needing LTC services still rely on informal home care, or services provided by unpaid caregivers (usually nonprofessional family members, friends or Nurse at a nursing home in Norway other volunteers). Estimates from the OECD of these figures often are in the 80 to 90 percent range; for example, in Austria, 80 percent of all older citizens.[6] The similar figure for dependent elders in Spain is 82.2 percent.[7] The US Centers for Medicare and Medicaid Services estimates that about 9 million American men and women over the age of 65 needed long-term care in 2006, with the number expected to jump to 12 million by 2020.[citation needed] It is anticipated that most will be cared for at home; family and friends are the sole caregivers for 70 percent of the elderly. A study by the U.S. Department of Health and Human Services says that four out of every ten people who reach age 65 will enter a nursing home at some point in their lives.[8] About 10 percent of the people who enter a nursing home will stay there five years or more.

Long-term care costs


A recent analysis indicates that Americans spent $119 billion on long-term care services for the elderly in 2009.[9] Nursing home spending accounts for the majority of long-term care expenditures, but home and community based care expenditures have increased over the past 25 years.[10] In 2012, the average annual cost of nursing home care in the United States was $81,030 for a semi-private room. The average annual cost for assisted living was $42,600. Home health aides were paid on average $21 per hour, and homemaker services averaged about $20 per hour. [11] The average cost of a nursing home for one year is more than the typical family has saved for retirement in a 401(k) or an IRA.[12] When the percentage of elderly individuals in the population rises to nearly 14% in 2040 as predicted, a huge strain will be put on caregivers' finances as well as continuing care retirement facilities and nursing homes because demand will increase dramatically.[13]

Long-term care

1040

Long-term care funding


Governments around the world have responded to growing long-term care needs to different degrees and at different levels.

Europe
Most Western European countries have put in place a mechanism to fund formal care and, in a number of Northern and Continental European countries, arrangements exist to at least partially fund informal care as well. Some countries have had publicly organized funding arrangements in place for many years: the Netherlands adopted the Exceptional Medical Expenses Act (ABWZ) in 1967, and in 1988 Norway established a framework for municipal payments to informal caregivers (in certain instances making them municipal employees). Other countries have only recently put in place comprehensive national programs: in 2004, for example, France set up a specific insurance fund for dependent older people. Some countries (Spain and Italy in Southern Europe, Poland and Hungary in Central Europe) have not yet established comprehensive national programs, relying on informal caregivers combined with a fragmented mix of formal services that varies in quality and by location.[3] In the 1980s, some Nordic countries began making payments to informal caregivers, with Norway and Denmark allowing relatives and neighbors who were providing regular home care to become municipal employees, complete with regular pension benefits. In Finland, informal caregivers received a fixed fee from municipalities as well as pension payments. In the 1990s, a number of countries with social health insurance (Austria in 1994, Germany in 1996, Luxembourg in 1999) began providing a cash payment to service recipients, who could then use those funds to pay informal caregivers.[3] In Germany, funding for long-term care is covered through a mandatory insurance scheme (or Pflegeversicherung), with contributions divided equally between the insured and their employers. The scheme covers the care needs of people who as a consequence of illness or disability are unable to live independently for a period of at least six months. Most beneficiaries stay at home (69%).[1] The country's LTC fund may also make pension contributions if an informal caregiver works more than 14 hours per week.[3]

North America
Canada In Canada, facility-based long-term care is not publicly insured under the Canada Health Act in the same way as hospital and physician services. Funding for LTC facilities is governed by the provinces and territories, which varies across the country in terms of the range of services offered and the cost coverage.[2] United States Long-term care is typically funded using a combination of sources including but not limited to family members, Medicaid, long-term care insurance and Medicare. One of these includes out-of-pocket spending, which often becomes exhausted once an individual requires more medical attention throughout the aging process and might need in-home care or be admitted into a nursing home. For many people, out-of-pocket spending for long-term care is a transitional state before eventually needing Medicaid coverage.[14] Personal savings can be difficult to manage and budget and often deplete rapidly. In addition to personal savings, individuals can also rely on an Individual retirement account, Roth IRA, Pension, Severance package or the funds of family members. These are essentially retirement packages that become available to the individual once certain requirements have been met. In 2008, Medicaid and Medicare accounted for approximately 71% of national long-term care spending in the United States. [15] Out-of-pocket spending accounted for 18% of national long-term care spending, private long-term care insurance accounted for 7%, and other organizations and agencies accounted for the remaining expenses. Moreover, 67% of all nursing home residents used Medicaid as their primary source of payment. [16]

Long-term care Currently, Medicaid is one of the dominant players in the nations long-term care market because there is a failure of private insurance and Medicare to pay for expensive long-term care services, such as nursing homes. For instance, 34% of Medicaid was spent on long-term care services in 2002. [17] In the US, Medicaid is a government program that will pay for certain health services and nursing home care for older people. In most states, Medicaid also pays for some long-term care services at home and in the community. Eligibility and covered services vary from state to state. Most often, eligibility is based on income and personal resources. Individuals eligible for Medicaid are typically not in the condition or capable of aging in place, and Medicaid's expenses are primarily concentrated on nursing home care. [18] Generally, Medicare does not pay for long-term care. Medicare pays only for medically necessary skilled nursing facility or home health care. However, certain conditions must be met for Medicare to pay for even those types of care. The services must be ordered by a doctor and tend to be rehabilatative in nature. Medicare specifically will not pay for custodial and non-skilled care. Medicare will typically cover only 100 skilled nursing days following a 3 day admission to a hospital. A 2006 study conducted by AARP found that most Americans are unaware of the costs associated with long-term care and overestimate the amount that government programs such as Medicare will pay.[19] Long-term care insurance protects individuals from asset depletion and includes a range of benefits with varying lengths of time. This type of insurance is designed to protect policyholders from the costs of long-term care services, and policies are determined using an "experience rating" and charge higher premiums for higher-risk individuals who have a greater change of becoming ill. [20] Residents of LTC facilities may have certain legal rights depending on the location of the facility.[citation needed]

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References
[1] "Defusing the demographic "time-bomb" in Germany." (http:/ / www. who. int/ bulletin/ volumes/ 90/ 1/ 12-020112. pdf) Bull World Health Organ 2012;90:67 | [2] Health Canada. Long-Term Facilities-Based Care. (http:/ / www. hc-sc. gc. ca/ hcs-sss/ home-domicile/ longdur/ index-eng. php) Accessed 3 January 2012. [3] Saltman, R.B., Dubois, H.F.W. and Chawla, M. (2006). The impact of aging on long-term care in Europe and some potential policy responses, International Journal of Health Services, 36(4): 719-746. [4] World Health Organization. Ageing and Life Course. (http:/ / www. who. int/ ageing/ en/ ) Accessed 3 January 2012. [5] London School of Economics and Political Science. Ageing and long-term care. (http:/ / www. euro. who. int/ __data/ assets/ pdf_file/ 0018/ 150246/ Eurohealth-Vol17-No-2-3-Web. pdf) Eurohealth 2011, 17(23). [6] OECD (2005). Long Term Care for Older People. Paris: OECD. [7] Costa-Font, J., and Patxot, C. (2005). The design of the long-term care system in Spain: Policy and financial constraints. Soc. Society 4:1, 1120. [8] U.S. Department of Health and Human Services. AHCPR Research on Long-term Care (http:/ / ahrq. hhs. gov/ research/ longtrm1. htm) [9] Kaye, H. S., Harrington, C., & LaPlante, M. P. (2010). Long-term care: who gets it, who provides it, who pays, and how much? Health Affairs, 29(1), 11-21. [10] Stone, R.I., & Benson, W.F., Financing and organizing health and long term care services. In Prohaska, T. R., Anderson, L. A., & Binstock, R. H. (Eds.). (2012). Public Health for an Aging Society. Boston. Johns Hopkins University Press. [11] 2012 MetLife Market Survey of Nursing Home, Assisted Living, Adult Day Services, and Home Care Costs (http:/ / www. metlife. com/ assets/ cao/ mmi/ publications/ studies/ 2012/ studies/ mmi-2012-market-survey-long-term-care-costs. pdf), Metlife Mature Market Institute [12] George Washington University. (2004). Retirement saving and long-term care needs: An overview. The Retirement Security Project. [13] Waters, R. (2009, 07 20). Elerly to Double to 14% of Global Population by 2040. http:/ / www. bloomberg. com/ apps/ news?pid=newsarchive& sid=axV6K65QoAg8. [14] Gale, W.G., Iwry, M., Orszag, P., Ahlstrom, A., Clements, E., Lambrew, J., Yumlinson, A. (2004) Retirement Saving and Long-Term Care Needs: An Overview. [15] Lewin Group. (2010). Individuals living in the community with chronic conditions and functional limitations: A closer look. Report prepared under contract #HHS-100-95-0046 for the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. [16] Gregory, S. R., & Gibson, M. J. (2002). Across the states: Profiles of long-term care (5th ed.). Washington, DC: AARP Public Policy Institute.

Long-term care
[17] O'Brien, E., & Elias, R. (2004). Medicaid and long-term care. Kaiser Commission on Medicaid and the Uninsured, Henry J. Kaiser Family Foundation. [18] Mulvey, J., & Li, A. (2002). Long Term Care Financing: Options for the Future. Benefits Quarterly, 18(2), 7-14. [19] AARP Press Center. Long-term care report (http:/ / www. aarp. org/ research/ press-center/ presscurrentnews/ long_term_care_report. html) [20] Amaradio, L. (1998). Financing Long-Term Care for Elderly Persons: What Are the Options? Journal of Health Care Finance, 25(2). 75-84.

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External links
US Government: Medicare - Long-term care. (http://www.medicare.gov/LongTermCare/Static/Home.asp) AMDA - Dedicated to Long Term Care Medicine (http://www.amda.com/index.cfm) California Partnership for Long-Term Care (http://www.rureadyca.org/) Medicare Part D Information (http://aging.ifas.ufl.edu) University of Florida/IFAS Extension Department of Family, Youth and Community Sciences The SCAN Foundation (http://www.thescanfoundation.org) (US-based foundation) Family Factors Involved in Making Long-Term Care Financing Decisions (http://fycs.ifas.ufl.edu/news/2006/ 05/family-factors-involved-in-making-long.html) University of Florida/IFAS Extension Department of Family, Youth and Community Sciences Family Caregiving Financial Resources (http://familycaregiving101.org/help/financial.cfm) List of county/state departments or local agencies for long-term caregivers in the US Long Term Care Medical Directors Association of Canada - Association canadienne des directeurs mdicaux en soins de longue dure (http://www.cmda.info) Canadian-based association of medical directors in the Long Term Care setting How much does long term care cost? (http://www.guidetolongtermcare.com/whatcost.html) Latest Cost of long term care survey (http://www.genworth.com/content/genworth/us/en/products/ long_term_care/long_term_care/cost_of_care.html) conducted for Genworth Financial Health-EU Portal (http://ec.europa.eu/health-eu/care_for_me/long_term_care/index_en.htm) Long-term Care in the EU Cost of care calculator for UK residents (http://www.payingforcare.co.uk/cost-of-care-calculator)

Lung volume reduction surgery

1043

Lung volume reduction surgery


Lung volume reduction surgery, or LVRS, can improve the quality of life for certain COPD and emphysema patients. Parts of the lung that are particularly damaged by emphysema are removed, allowing the remaining, relatively good lung to expand and work better. Conventional LVRS involves resection of the most severely affected areas of emphysematous, non-bullous lung (aim is for 20-30%). This is a surgical option involving a mini-thoracotomy for patients suffering end stage COPD due to underlying emphysema, and can improve lung elastic recoil as well as diaphragmatic function. Increased mortality, contraindicating the procedure, is noted in patients that have both: 1. FEV1 < 20% 2. DLCO < 20% or diffusely distributed emphysema on a CT scan The National Emphysema Treatment Trial (Fishman et al., 2003) was a large multicentre study (N = 1218) comparing LVRS with medical treatment. Results suggested that: 1. There was no overall survival advantage in the LVRS group, except for mainly upper-lobe emphysema + poor exercise capacity, and 2. Significant improvements were seen in exercise capacity in the LVRS group. Possible complications (Hopkins et al., 2006): Mortality at 90 days of 1.8% and survival at 3 and 5 years of 91.1% and 76% respectively. Prolonged air leak (mean duration post surgery until all ICC's removed is 10.9 +/- 8.0 days)

References
National Emphysema Treatment Trial Research Group; Alfred Fishman, Fernando Martinez, Keith Naunheim, Steven Piantadosi, Robert Wise, Andrew Ries, Gail Weinmann, Douglas E. Wood (2003-05-22). "A Randomized Trial Comparing Lung-VolumeReduction Surgery with Medical Therapy for Severe Emphysema" [1]. New England Journal of Medicine (Boston: Massachusetts Medical Society) 348 (21): 20592073. doi:10.1056/NEJMoa030287 [2]. ISSN0028-4793 [3]. OCLC1587974 [4]. PMID12759479 [5]. Retrieved 2009-07-13. Hopkins, P. M.; H. Seale, J. Walsh, R. Tam, F. Kermeen, S. Bell, K. McNeil (February 2006). "Long term results post conventional lung volume reduction surgery exceeds outcome of lung transplantation for emphysema". Journal of Heart and Lung Transplantation (St. Louis, Missouri: Mosby-Year Book) 25 (2): S61. doi:10.1016/j.healun.2005.11.053 [6]. ISSN1053-2498 [7]. OCLC22486861 [8].

References
[1] [2] [3] [4] [5] [6] [7] [8] http:/ / content. nejm. org/ cgi/ content/ full/ 348/ 21/ 2059 http:/ / dx. doi. org/ 10. 1056%2FNEJMoa030287 http:/ / www. worldcat. org/ issn/ 0028-4793 http:/ / www. worldcat. org/ oclc/ 1587974 http:/ / www. ncbi. nlm. nih. gov/ pubmed/ 12759479 http:/ / dx. doi. org/ 10. 1016%2Fj. healun. 2005. 11. 053 http:/ / www. worldcat. org/ issn/ 1053-2498 http:/ / www. worldcat. org/ oclc/ 22486861

Left without being seen

1044

Left without being seen


Left Without Being Seen (LWBS) is a healthcare term often used by emergency departments (ED) to designate a patient encounter that ended with the patient leaving the healthcare setting before the patient could be seen by a certified physician. Often the inclusion of this phrase in a medical record is the result of ED overcrowding (i.e. the patient could no longer wait in the ED to be seen by a physician, so they left without alerting a healthcare professional). Typically, those patients who leave an emergency department without being seen are not at an increased risk of death, and often do not require inpatient hospital admission.[][1]

References

Medicare Advantage
Medicare Advantage (MA) is a United States health insurance program of managed health care (Preferred Provider Organization(PPO) or Health maintenance organization(HMO)) that serves as a substitute for "Original Medicare" Parts A and B Medicare benefits. Medicare Part A provides payments for in-patient hospital services excluding those of physicians and surgeons. Part B provides payments to physicians and surgeons, as well as for medically necessary outpatient hospital services (such as ER, laboratory, x-rays and diagnostic tests) and certain durable medical equipment and supplies. Original Medicare claims payments are processed through the Centers for Medicare and Medicaid Services ("CMS"). In contrast, Medicare Advantage is offered by commercial insurance companies and HMO and PPO corporations, who receive compensation from the federal government, but do not process claims through the CMS. Most Medicare Advantage plans (sometimes referred to a "Part C") include the Part D prescription drug benefit plan, and are known as a Medicare Advantage Prescription Drug plan or "MAPD." Medicare Advantage originated with the passage of the Balanced Budget Act of 1997, which offered Medicare beneficiaries this option, instead of receiving these benefits through the original Medicare plan (Parts A and B). These programs were first known as Medicare+Choice or Part C plans. Pursuant to the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, the compensation and business practices changed for insurers that offer these plans, and "Medicare+Choice" plans became known as Medicare Advantage plans.[1]

Overview
Medicare has a standard benefit package that covers only medically necessary health care services. A person qualifies for Medicare coverage by reaching age 65. American citizens, nationals, and legal residents (who have been in the U.S. at least five years) who are "fully insured" (or whose spouse is fully insured) under the Social Security program receive Medicare Part A benefits without a monthly premium. Persons who are not so qualified pay a premium for Part A. All Medicare beneficiaries who enroll in Part B pay a monthly premium. For people who choose to enroll in a Medicare Advantage plan, Medicare pays the private health plan a set amount every month for each member ("capitation"). Enrollees may have to pay a monthly premium in addition to the Medicare Part B premium, but in areas with strong younger population demographics, many companies offer Medicare Advantage plans with no monthly premium in addition to the Medicare Part B premium which the beneficiary pays directly to Medicare. Medicare Advantage subscribers generally pay a fixed amount (a copayment of $20, for example) every time they see a doctor as opposed to meeting a deductible and paying a coinsurance (typically 20%) under Original Medicare. The copayment can be higher to see a specialist with a Medicare Advantage plan. Under Original Medicare the coinsurance remains 20%, but the actual amount out of pocket can be

Medicare Advantage higher since specialists generally charge more for services. The Medicare Advantage plans are required to offer a benefit package that is at least equal to Medicares and cover everything Medicare covers, but they do not have to cover every benefit in the same way. Plans that require higher out-of-pocket costs than Medicare for some benefits, like skilled nursing facility care, can balance their benefits package by offering lower copayments for doctor visits. A private plan may use some of the excess payments they receive from the government for each enrollee to offer supplemental benefits. Not only do most Medicare Advantage plans significantly reduce the out-of-pocket cost of health care to just a few thousand dollars annually, compared to tens of thousands of dollars an extended hospital stay could cost under Original Medicare, they also offer greatly expanded benefit packages, including dental, hearing, podiatry, chiropractic, acupuncture, and vision coverage, as well as health club memberships and other services which are also not covered by Medicare, such as transportation to and from clinic appointments. Once the out of pocket maximum is reached for an individual, the plan will pay 100% of services for the remainder of the calendar year, with no lifetime maximum, so long as individuals use in-network providers. Persons who enroll in a Medicare Advantage HMO cannot use certain specialist physicians or out-of-network providers without prior authorization from the HMO, except in emergencies. This can be a problem for people who need to use specialists or who are hospitalized and are forced to use out-of-network doctors while in the hospital. Enrolling in a PPO, if available, can help solve this dilemma, because PPO plans permit a subscriber to use any physician or hospital without prior authorization, but at somewhat higher expense. By law, however, if a patient's in-network physician orders tests or procedures that are not available or provided by any in-network facility or specialist's office, the Medicare Advantage plan must pay for the patient's procedures or services at an out-of-network location at no additional cost to the patient, so long as the necessary services are normally covered by Medicare. Most Medicare Advantage plans typically do not have annual deductibles, offering members "first-dollar" coverage instead. Original Medicare has a potentially recurring (more than once per calendar year) deductible for each hospital admission under Part A and an annual deductible for Part B. In 2006, enrollees in Medicare Advantage Private Fee-for-Service plans were offered a net extra benefit value (the value of the additional benefits minus any additional premium) of $55.92 a month more than the traditional Medicare benefit package; enrollees in other Medicare Advantage plans were offered a net extra benefit value of $71.22 a month more.[2] Enrollment in Medicare Advantage plans grew from 5.4 million in 2005 to 8.2 million in 2007. Enrollment grew by an additional 800,000 during the first four months of 2008. This represents 19% of people with Medicare. A third of those with Part D coverage are enrolled in a Medicare Advantage plan. Medicare Advantage enrollment is higher in urban areas; the enrollment rate in urban counties is twice that in rural counties (22% vs. 10%). Almost all Medicare beneficiaries have access to at least two Medicare Advantage plans; most have access to three or more. The number of organizations offering Fee-for-Service plans has increased dramatically, from 11 in 2006 to almost 50 in 2008. Eight out of ten beneficiaries (82%) now have access to six or more Private Fee-for-Service plans.[3] According to research by the Kaiser Family Foundation, 11.1 million people (approximately 25% of all Medicare beneficiaries) were enrolled in Medicare Advantage plans as of March 2010, up from 10.5 million in March 2009. In their report, Kaiser noted that while some Medicare beneficiaries have dozens of private Medicare Advantage plans available in their communities, enrollment is highly concentrated among a small number of firms in nearly all states.[4] The March 2012 Medpac Report to Congress Medicare Advantage status chapter reported an enrollment increase of 6% in 2011 to 12.1 million, 25% of all Medicare beneficiaries.[5] There is some evidence that Medicare Advantage plans design benefits so that they are unattractive to people with costly conditions or high risks of needing expensive treatments and steering them into traditional Medicare. This insulates Medicare Advantage plans from financial risk while shifting costs to the federal government. Medicare makes risk adjusted payments to private plans to avoid this, but it is unclear how effective that policy is.[6]

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Medicare Advantage

1046

Effects of the Health Reform


There is considerable confusion about what the Patient Protection and Affordable Care Act (or ACA) of 2010 did with respect to Medicare Advantage. As part of a broad set of reforms aimed to control the cost of Medicare, the ACA eliminated certain subsidies which the federal government first used to establish the Medicare Advantage program. The Obama administration launched an $8.35 billion demonstration project to postpone the majority of Medicare Advantage program cuts. According to the Government Accountability Office (GAO) this demonstration project will cost more than the combined previous 85 demonstration projects beginning in 1995. As of 2008, the federal government spent 12 percent more on Medicare Advantage than it did for comparable care under traditional Medicare.[7] These subsidies (which added an additional $14 billion to the Medicare program last year alone) will gradually be reduced until payments to Medicare Advantage are in line with the cost of traditional Medicare.[]

What is being measured?


The Medicare Advantage Plan Star Ratings system rates Medicare Advantage (MA) plans on a scale of 1 - 5 stars. There are different domains for MA plans versus Prescription Drug Plans (PDPs). For plans covering health services, the overall score for quality of those services covers 36 different topics in 5 categories: Staying healthy: screenings, tests, and vaccines: Includes how often members got various screening tests, vaccines, and other check-ups that help them stay healthy. Managing chronic (long-term) conditions: Includes how often members with different conditions got certain tests and treatments that help them manage their condition. Ratings of health plan responsiveness and care: Includes ratings of member satisfaction with the plan. Health plan member complaints and appeal: Includes how often members filed a complaint against the plan. Health plan telephone customer service: Includes how well the plan handles calls from members. For plans covering drug services, the overall score for quality of those services covers 17 different topics in 4 categories: Drug plan customer service: Includes how well the drug plan handles calls and makes decisions about member appeals. Drug plan member complaints and Medicare audit findings: Includes how often members filed a complaint about the drug plan and findings from Medicares audit of the plan. Member experience with drug plan: Includes member satisfaction information. Drug pricing and patient safety: Includes how well the drug plan prices prescriptions and provides updated information on the Medicare website. Includes information on how often members with certain medical conditions get prescription drugs that are considered safer and clinically recommended for their condition. For plans covering both health & drug services, the overall score for quality of those services covers all of the 53 topics listed above.

Medicare Advantage

1047

Where does the information for the Overall Plan Rating come from?
For quality of health services, the information comes from sources that include: Member surveys done by Medicare Information from clinicians Information submitted by the plans Results from Medicares regular monitoring activities

For quality of drug services, the information comes from sources that include: Results from Medicares regular monitoring activities Reviews of billing and other information that plans submit to Medicare Member surveys done by Medicare

References
[1] Medicare: Medicare Advantage - Kaiser Family Foundation (http:/ / www. kff. org/ medicare/ choice. cfm) [2] Mark Merlis, "The Value of Extra Benefits Offered by Medicare Advantage Plans in 2006," (http:/ / www. kff. org/ medicare/ upload/ 7744. pdf) The Kaiser Family Foundation, January 2008 [3] Marsha Gold, "Medicare Advantage in 2008," (http:/ / www. kff. org/ medicare/ upload/ 7775. pdf) The Kaiser Family Foundation, June 2008 [4] http:/ / www. kff. org/ medicare/ 8080. cfm [5] Medpac, "Chapter 12: The Medicare Advantage program: Status report" (http:/ / www. medpac. gov/ chapters/ Mar12_Ch12. pdf), March 2012 [6] Jason Brown, Mark Duggan, Ilyana Kuziemko, and William Woolston, ""How does Risk Selection Respond to Risk Adjustment? Evidence from the Medicare Advantage Program."" (http:/ / www. nber. org/ papers/ w16977) NBER Working Paper No. 16977, April 2011 [7] Brian Biles, Steve Guterman, and Emily Adrion, ""The Continuing Cost of Privatization: Extra Payments to Medicare Advantage."" (http:/ / www. commonwealthfund. org/ Publications/ Issue-Briefs/ 2008/ Sep/ The-Continuing-Cost-of-Privatization--Extra-Payments-to-Medicare-Advantage. aspx) The Commonwealth Fund, September 2008.

External links
Governmental links - current
CMS official web site (http://cms.hhs.gov) at cms.hhs.gov Medicare.gov (http://www.medicare.gov/) the official website for people with Medicare

Non-governmental links
Medicare & Medicaid Resources (http://www.agis.com/Eldercare-Basics/Legal-and-Financial/ Medicare-and-Medicaid/) Medicare information site Kaiser Family Foundation (http://www.kff.org/medicare) Wide range of free information, including a drug benefit calculator, about the Medicare program and other U.S. health issues. State Health Facts (http://www.statehealthfacts.org) Data on health care spending and utilization, including Medicare; provided by the Kaiser Family Foundation. Medicare - Alliance for Health Reform (http://www.allhealth.org/issues.asp?wi=7) The nonpartisan, nonprofit Alliance for Health Reform offers information about health reform, in a number of formats, to elected officials and their staffs, journalists, policy analysts and advocates. Social Security and Disability News Resource Center (http://www.ssdrc.com) How Stuff Works - Medicare (http://health.howstuffworks.com/medicare.htm)

Medication Administration Record

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Medication Administration Record


A Medication Administration Record[1] or MAR (eMAR for electronic versions) is the report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional. The MAR is a part of a patient's permanent record in their medical chart. The health care professional signs off on the record at the time that the drug or device is administered. MARs are commonly referred to as drug charts. Electronic versions may be referred to as e-MARs.

Format
The actual chart varies from hospital to hospital and country to country. However they are typically of the format: Administrative/Demographics Patient Name (often Surname, First name or similar) Patient Medical Record Number Ward +/- bed number Treating team details

Allergies Other, variable - weight, special diet, oxygen therapy, application time of topical local anaesthetic e.g. EMLA Prescription Details Drug name Dosage strength Route Frequency Medication indication / Diagnosis Prescribing doctor details, signature Day by day chart where carers/nurses administering medications can sign when medication has been given

Kardex
A kardex (plural kardexes) is a genericised trademark for a medication administration record.[2] The term is common in Ireland and the United Kingdom.

References
[2] http:/ / www. encyclopedia. com/ doc/ 1O62-Kardex. html

Medical College Admission Test

1049

Medical College Admission Test


The Medical College Admission Test (MCAT) is a computer-based standardized examination for prospective medical students in the United States and Canada. It is designed to assess problem solving, critical thinking, written analysis and knowledge of scientific concepts and principles. Prior to August 19, 2006, the exam was a paper-and-pencil test; since January 27, 2007, however, all administrations of the exam have been computer-based.

Today
The exam is offered 25 or more times per year at Prometric centers.[1] The number of administrations may vary each year. Most people who take the MCAT are undergraduates in college in their Junior or Senior year of college before they apply to medical school. Ever since the exam's duration was shortened to 4.55 hours, the test may be offered either in the morning or in the afternoon. Some test dates have both morning and afternoon administrations. The test consists of four sections, listed in the order in which they are administered on the day of the exam: Physical Sciences (PS) Verbal Reasoning (VR) Biological Sciences (BS) Trial Section (optional) The Verbal Reasoning, Physical Sciences, and Biological Sciences sections are in multiple-choice format. The passages and questions are predetermined, and thus do not change in difficulty depending on the performance of the test taker (unlike, for example, the Graduate Record Examination). The Physical Sciences section assesses problem-solving ability in general chemistry and physics and the Biological Sciences section evaluates these abilities in the areas of biology and organic chemistry. The Verbal Reasoning section evaluates the ability to understand, evaluate, and apply information and arguments presented in prose style. The Biological Sciences section most directly correlates to success on the USMLE Step 1 exam, with a correlation coefficient of .553 vs .491 for Physical Sciences and .397 for Verbal Reasoning.[2] Predictably, MCAT composite scores also correlate with USMLE Step 1 success.[3]

Administration
Section Physical Sciences Verbal Reasoning Biological Sciences Questions Minutes 52 40 52 70 60 70 45

Trial Section (optional) 32

The Physical Sciences section is administered first (prior to the April 2003 MCAT, Verbal Reasoning was the first section of the exam). It is composed of 52 multiple-choice questions related to general chemistry and physics. The majority of the multiple-choice questions are divided into passage sets. Passage-based questions are implemented to evaluate "text comprehension, data analysis, ability to evaluate an argument, or apply knowledge from the passage to other contexts." Examinees are allotted 70 minutes to complete this section of the exam. The Verbal Reasoning section follows the Physical Sciences section and an optional 10 minute break. Exam takers have 60 minutes to answer 40 multiple-choice questions evaluating their comprehension, evaluation, and application of information gathered from written passages. Unlike the Physical and Biological Sciences sections, the Verbal Reasoning section is not supposed to require specific content knowledge in order to perform well. After Verbal Reasoning, there is an optional 10 minute break followed by the Biological Sciences section. Examinees have 70 minutes to answer 52 multiple-choice questions related to organic chemistry and biology.

Medical College Admission Test Beginning in 2013, the Writing Sample was removed in order to make room for a new Trial Section that will test examinees in either: biochemistry, biology, chemistry, and physics or in psychology, sociology, and biology. The new Trial Section is optional and will be in effect from 2013 to 2014 only. The Trial Section is not scored and is not be a part of the exam taker's composite score.[4] Exam takers have a total of 45 minutes to answer 32 multiple-choice questions. The Trial Section is merely an option to examinees who choose not to void their exam after the Biological Sciences section.

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Scoring
Scores for the three multiple-choice sections range from 1 to 15. The numerical scores from each multiple-choice section are added together to give a composite score. The maximum composite score is 45. According to the AAMC, the average 2008 MCAT score for U.S. medical school applicants was 28.1P, while for matriculants it was 30.9P.[5] There is no penalty for incorrect multiple choice answers (which is not the case in many other standardized tests). Thus, guessing is preferable to leaving an answer choice blank. Students preparing for the exam are encouraged to try to balance their subscores; physical, verbal, and biological scores of 12, 13, and 11 respectively may be looked upon more favorably than 14, 13, and 9, even though both combinations yield the same composite score. The standard deviation is 2.0-3 per section depending on the year and form of the exam.[6] 2012 percentiles The average scaled score in 2012 was 25.2 with a standard deviation of 6.4. The chart below lists the scaled scores along with their percentiles for 89,452 test takers in 2012:
Scaled Score (4531) Percentile Scaled Score (3016) Percentile Scaled Score (153) Percentile 45 44 43 42 41 40 39 38 37 36 35 34 33 32 31 99.9 99.9 99.9 99.9 99.9 99.8 99.6 99.1 98.4 97.4 95.8 93.7 91.0 87.5 83.4 30 29 28 27 26 25 24 23 22 21 20 19 18 17 16 78.7 73.3 67.6 61.5 55.4 49.3 43.3 37.6 32.1 27.2 22.7 18.7 15.3 12.5 10.0 15 14 13 12 11 10 9 8 7 6 5 4 3 7.9 6.1 4.6 3.4 2.4 1.6 1.1 0.7 0.4 0.2 0.1 0.0 0.0

Medical College Admission Test

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History[]
The Moss Test: 192846
In the 1920s, dropout rates in US medical schools soared from 5% to 50%, leading to the development of a test that would measure readiness for medical school. Physician F.A. Moss and his colleagues developed the "Scholastic Aptitude Test for Medical Students" consisting of true-false and multiple choice questions divided into 6-8 subtests. Topics tested included visual memory, memory for content, scientific vocabulary, scientific definitions, understanding of printed material, premedical information, and logical reasoning. The score scale varied from different test forms. Though it had been criticized at the time for testing only memorization ability and thus only readiness for the first two years of medical school, later scholars denied this. In addition to stricter medical school admission procedures and higher educational standards, the national dropout rate among freshman medical students decreased from 20% in 1925-1930 to 7% in 1946.

A simpler test: 194662


Advancements in test measurement technology, including machine scoring of tests, and changed views regarding test scores and medical school readiness reflected the evolution of the test in this period. The test underwent three major changes. It now had only four sub tests, including verbal ability, quantitative ability, science achievement, and understanding modern society. Questions were all in multiple-choice format. Each subtest was given a single score, and the total score was derived from the sum of the scores from the subtests. The total score ranged from 200800. The individual scores helped medical school admission committees to differentiate the individual abilities among their candidates. Admission committees, however, did not consider the "understanding modern society" section to be of great importance, even though it was created to reward those with broad liberal arts skills, which included knowledge of history, government, economics, and sociology. Committees placed greater emphasis on scores on the scientific achievement section as it was a better prediction of performance in medical school. From 1946 to 1948, the test was called the "Professional School Aptitude Test" before finally changing its name to the "Medical College Admission Test" when the developer of the test, the Graduate Record Office (under contract with the AAMC) merged with the newly formed Educational Testing Service (ETS). In 1960, the AAMC transferred its contract over to The Psychological Corporation, which was then in charge of maintaining and developing the test.

Status quo: 196277


From 1962 to 1977, the MCAT retained much of its previous format, though the "understanding modern society" section was renamed as "general information" due to its expanded content. Handbooks at the time criticized the test as only a measure of intellectual achievement and not of personal characteristics expected of physicians. Responding to this criticism, admission committees took different approaches in measuring personal characteristics among their applicants.

Phase Four: 197791


During phase four, the MCAT underwent several changes. The "general information" section was eliminated and a broader range of knowledge was tested. At this point, topics tested included scientific knowledge, science problems, reading skills analysis, and quantitative skills analysis. Individual scores were reported for biology, chemistry, and physics rather than a composite science score, thus six different scores for the whole test were reported. The score scale changed to 115 as opposed to 200800 from previous versions of the test. Cultural and social bias was minimized. Though the AAMC claimed the new version intended to evaluate "information gathering and analysis, discerning and formulating relationships, and other problem-solving skills," no research supported this claim.

Medical College Admission Test

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New changes: 19922013


In 1992 the test changed again, and assumed its current form. Though the test was still divided into four subtests, they were renamed as the verbal reasoning, biological sciences, physical sciences, and writing sample sections. Questions retained the multiple-choice format, though the majority of the questions are divided into passage sets. Passage-based questions were implemented to evaluate "text comprehension, data analysis, ability to evaluate an argument, or apply knowledge from the passage to other contexts." A new scoring scale was also implemented. The total composite score, which ranges from 345, is based on the individual scores of the verbal reasoning, biological sciences, and physical sciences, which each have a score range of 115. The writing sample, which consists of two essays to be written within 30 minutes for each, is graded on a letter scale from J-T with T being the highest attainable score. On July 18, 2005, the AAMC announced that it would offer the paper-and-pencil version of the MCAT only through August 2006. A subset of testing sites offered a computer-based version of the full-length exam throughout 2005 and 2006. The present, shorter, computer-based version of the test debuted in January 2007. The exam is now offered numerous times annually, and scored more quickly.[7][8]

MR5 and the upcoming 2015 test


The MR5 advisory committee was appointed by AAMC in fall 2008.[9] Highlights of the MR5 process were surveys of what undergraduate institutions teach and surveys of medical school faculty in which they ranked undergraduate subjects for importance in medical school curricula of the future. Late in 2011, the MR5 recommendations were formalized as core competencies that will be tested in 2015.[10] MR5 recommendations were enacted by the AAMC in 2012. The largest changes will consist of testing in biochemistry, multicultural/behavioral concepts, and critical analysis/reasoning from the humanities. Because college freshmen, entering in fall 2012, will be taking a new MCAT, undergraduate premedical advisers are now studying the MR5 documents to translate core competencies to be tested into premedical course recommendations at their campuses. The MR5 MCAT revision has the potential to lead to changes in mathematics, physics, psychology, sociology, and general education recommendations in addition to changes in biology, chemistry and biochemistry. One scientific society to weigh in on the new MCAT vis a vis the undergraduate curriculum is the American Society for Biochemistry and Molecular Biology. Though ASBMB noted that the premedical curriculum in mathematics, physics, social sciences and the humanities is likely to change, the society confined its recommendations to coursework in biology, chemistry and biochemistry.[11]

Policies
Like some other professional exams (e.g. the Graduate Management Admission Test (GMAT) or the Law School Admissions Test (LSAT)), the MCAT may be voided on the day of the exam if the exam taker is not satisfied with his or her performance. It can be voided at any time during the exam, or during a five-minute window that begins immediately after the end of the last section. The decision to void can only be based on the test taker's self-assessment, as no scoring information is available at the timeit takes 3035 days for scores to be returned. The AAMC prohibits the use of calculators, timers, or other electronic devices during the exam.[12] Cellular phones are also strictly prohibited from testing rooms and individuals found to possess them are noted by name in a security report submitted to the AAMC. The only item that may be brought into the testing room is the candidate's photo ID. If a jacket or sweater is worn, it may not be removed in the testing room.[13] It is no longer a rule that students must receive permission from the AAMC if they wish to take the MCAT more than three times in total. The limit with the computerized MCAT is three times per year, with no lifetime limit. An examinee can register for only one test date at a time, and must wait two days after testing before registering for a new test date.

Medical College Admission Test Scaled MCAT exam results are made available to examinees approximately thirty days after the test via the AAMC's MCAT Testing History (THx) [14] Web application. Examinees do not receive a copy of their scores in the mail. Nor are examinees given their raw scores. MCAT THx is also used to transmit scores to medical schools, application services and other organizations (at no cost).

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Preparation
Like most standardized tests, there are a variety of preparatory materials and courses available. The AAMC itself also offers a select few tests for purchase at their website [15] and one free sample test on their main website [16]. Some students taking the MCAT use a test preparation company. Students who do not use these courses often rely on material from university text books, MCAT preparation books, sample tests, and free web resources. Taking undergraduate courses like physics, general chemistry, biology, organic chemistry, and English can help in preparation for MCAT.

References
[4] http:/ / www. aamc. org/ students/ download/ 63060/ data/ mcatessentials. pdf [7] Medical College Admission Test Will Convert to Computer-Based Format (http:/ / www. aamc. org/ newsroom/ pressrel/ 2005/ 050718. htm) [8] What is changing on the MCAT? (http:/ / www. kaptest. com/ oneoff/ mcat-test-change/ computer-based-mcat-information. jhtml) [9] AAMC MCAT MR Initiative (https:/ / www. aamc. org/ initiatives/ mr5/ ) [10] 2015 MCAT Preview (https:/ / www. aamc. org/ students/ download/ 266006/ data/ 2015previewguide. pdf) [11] Response to the new MCAT: ASBMB premedical curriculum recommendations (http:/ / www. asbmb. org/ asbmbtoday/ asbmbtoday_article_print. aspx?id=16052) [14] https:/ / services. aamc. org/ mcatthx/ [15] http:/ / www. e-mcat. com/ [16] http:/ / www. aamc. org/ mcat

Further reading
Julian, E (2005). "Validity of the Medical College Admission Test for predicting medical school performance". Academic Medicine 80 (10): 9107. doi: 10.1097/00001888-200510000-00010 (http://dx.doi.org/10.1097/ 00001888-200510000-00010). PMID 16186610 (http://www.ncbi.nlm.nih.gov/pubmed/16186610). Simonton, W. Kyle (2006). "Accommodations for the Disabled During Administration of the MCAT, Individual State Interests Versus National Uniformity". Journal of Legal Medicine 27 (3): 305322. doi: 10.1080/01947640600870890 (http://dx.doi.org/10.1080/01947640600870890). PMID 16959654 (http:// www.ncbi.nlm.nih.gov/pubmed/16959654).

External links
Association of American Medical Colleges (http://www.aamc.org/) AAMC: Medical College Admission Test (MCAT) Web Site (http://www.aamc.org/students/mcat/start.htm) AAMC: MCAT Student Manual (http://www.aamc.org/students/mcat/about/start.htm)

Managed care

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Managed care
Health care in the United States Government Health Programs

Federal Employees Health Benefits Program Indian Health Service Veterans Health Administration Military Health System / TRICARE Medicare Medicaid / State Health Insurance Assistance Program (SHIP) State Children's Health Insurance Program (CHIP) Program of All-Inclusive Care for the Elderly (PACE) Prescription Assistance (SPAP) Private health coverage

Health insurance in the United States Consumer-driven health care


Flexible spending account (FSA) Health Reimbursement Account Health savings account

High-deductible health plan (HDHP) Medical savings account (MSA) Private Fee-For-Service (PFFS) Managed care (CCP) Health maintenance organization (HMO) Preferred provider organization (PPO) Medical underwriting

Health care reform law


Emergency Medical Treatment and Active Labor Act (1986) Health Insurance Portability and Accountability Act (1996) Medicare Prescription Drug, Improvement, and Modernization Act (2003) Patient Safety and Quality Improvement Act (2005) Health Information Technology for Economic and Clinical Health Act (2009) Patient Protection and Affordable Care Act (2010) State level reform

Massachusetts health care reform Oregon Health Plan Vermont health care reform SustiNet (Connecticut) Dirigo Health (Maine) Municipal health coverage

Fair Share Health Care Act (Maryland) Healthy Howard (Howard Co., Maryland) Healthy San Francisco

The term managed care or managed health care is used in the United States to describe a variety of techniques intended to reduce the cost of providing health benefits and improve the quality of care ("managed care techniques") for organizations that use those techniques or provide them as services to other organizations ("managed care organization" or "MCO"), or to describe systems of financing and delivering health care to enrollees organized around managed care techniques and concepts ("managed care delivery systems").

Managed care ...intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on inpatient admissions and lengths of stay; the establishment of cost-sharing incentives for outpatient surgery; selective contracting with health care providers; and the intensive management of high-cost health care cases. The programs may be provided in a variety of settings, such as Health Maintenance Organizations and Preferred Provider Organizations.[1] The growth of managed care in the U.S. was spurred by the enactment of the Health Maintenance Organization Act of 1973. While managed care techniques were pioneered by health maintenance organizations, they are now used by a variety of private health benefit programs. Managed care is now nearly ubiquitous in the U.S, but has attracted controversy because it has largely failed in the overall goal of controlling medical costs. Proponents and critics are also sharply divided on managed care's overall impact on the quality of U.S. health care delivery.

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History
Paul Starr suggests in his analysis of the American health care system (i.e., The Social Transformation of American Medicine) that Richard Nixon, advised by the "father of Health Maintenance Organizations", Dr. Paul M. Ellwood, Jr., was the first mainstream political leader to take deliberate steps to change American health care from its longstanding not-for-profit business principles into a for-profit model that would be driven by the insurance industry. In 1973, Congress passed the Health Maintenance Organization Act, which encouraged rapid growth of Health Maintenance Organizations (HMOs), the first form of managed care. Managed care plans are widely credited with subduing medical cost inflation in the late 1980s by reducing unnecessary hospitalizations, forcing providers to discount their rates, and causing the health-care industry to become more efficient and competitive.[2] Managed care plans and strategies proliferated and quickly became nearly ubiquitous in the U.S. However, this rapid growth led to a consumer backlash. Because many managed care health plans are provided by for-profit companies, their cost-control efforts created widespread perception that they were more interested in saving money than providing health care.[2] In a 2004 poll by the Kaiser Family Foundation, a majority of those polled said they believed that managed care decreased the time doctors spend with patients, made it harder for people who are sick to see specialists, and had failed to produce significant health care savings. These public perceptions have been fairly consistent in polling since 1997.[3] The backlash included vocal critics, including disgruntled patients and consumer-advocacy groups, who argued that managed care plans were controlling costs by denying medically necessary services to patients, even in life-threatening situations, or by providing low-quality care. The volume of criticism led many states to pass laws mandating managed-care standards.[2] Meanwhile, insurers responded to public demands and political pressure by beginning to offer other plan options with more comprehensive care networksaccording to one analysis, between the years 1970 and 2005 the share of personal health expenditures paid directly out-of-pocket by U.S. consumers fell from about 40 percent to 15 percent.[citation needed] So although consumers faced rising health insurance premiums over the period, lower out-of-pocket costs likely [citation needed] encouraged consumers to use more health care. Data indicating whether this increase in use was due to voluntary or optional service purchases or the sudden access lower-income citizens had to basic healthcare is not available here at this time.[4] By the late 1990s, U.S. per capita health care spending began to increase again, peaking around 2002.[5] Despite managed care's mandate to control costs, U.S. healthcare expenditures has continued to outstrip the overall national income, rising about 2.4 percentage points faster than the annual GDP since 1970.[6] Nevertheless, according to the trade association America's Health Insurance Plans, 90 percent of insured Americans are now enrolled in plans with some form of managed care.[7] The National Directory of Managed Care Organizations, Sixth Edition profiles more than 5,000 plans, including new consumer-driven health plans and health savings accounts.

Managed care

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Managed care techniques


One of the most characteristic forms of managed care is the use of a panel or network of health care providers to provide care to enrollees. Such integrated delivery systems typically include one or more of the following: A set of designated doctors and health care facilities, known as a provider network, which furnish an array of health care services to enrollees Explicit standards for selecting providers Formal utilization review and quality improvement programs An emphasis on preventive care Financial incentives to encourage enrollees to use care efficiently[8][9][10] Provider networks can be used to reduce costs by negotiating favorable fees from providers, selecting cost effective providers, and creating financial incentives for providers to practice more efficiently.[9] A survey issued in 2009 by America's Health Insurance Plans found that patients going to out-of-network providers are sometimes charged extremely high fees.[11][12] Other managed care techniques include disease management, case management, wellness incentives, patient education, utilization management and utilization review. These techniques can be applied to both network-based benefit programs and benefit programs that are not based on a provider network. The use of managed care techniques without a provider network is sometimes described as "managed indemnity."

Managed care organizations (MCOs)


There is a continuum of organizations that provide managed care, each operating with slightly different business models. Some organizations are made of physicians, while others are combinations of physicians, hospitals, and other providers. Here is a list of common MCOs: Group practice without walls Independent practice association Management services organization Physician practice management company

Types of network-based managed care programs


There are several types of network-based managed care programs. These range from more restrictive to less restrictive, and include:

Managed Care in a Public Setting: (MCPS)


Proposed by Dr. Richard Evan Steele, the concept is described in the book Managed Care in a Public Setting by Dr. Steele published in June, 2013 by Nova Science Publishers, NY., NY. The proposed system encompasses both health care and social services in a comprehensive system that provides answers for those seeking to balance the myriad challenges of balancing care, cost and social conscience. Not yet put in practice, the concept provides a compelling roadmap for all of those looking for melding the best of the US managed care movement and the socially funded European systems in a community based system fueled by positive incentive structures for the lowest effective level of care and the highest possible quality of care. This can be achieved by changing the focus of care and social services away from the ultra-specialized, evidence based concept to a highly tuned, flexible and technically advanced primary care system. See Steele RE, Managed Care in a Public Setting, Nova Science Publishers, NY., NY. A video presentation of the book can be found by searching for the title on internet search engines.

Managed care

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Health Maintenance Organization: (HMO)


Proposed in the 1960s by Dr. Paul Elwood in the "Health Maintenance Strategy", the HMO concept was promoted by the Nixon Administration as a fix to rising health care costs and set in law as the Health Maintenance Organization Act of 1973. As defined in the act, a federally qualified HMO would in exchange for a subscriber fee (premium) allow members access to a panel of employed physicians or a network of doctors and facilities including hospitals. In return the HMO received mandated market access and could receive federal development funds. HMOs are licensed at the state level, under a license that is known as a certificate of authority (COA) rather than under an insurance license.[13] In 1972, the National Association of Insurance Commissioners adopted the HMO Model Act, which was intended to provide a model regulatory structure for states to use in authorizing the establishment of HMOs and in monitoring their operations. In practice, an HMO is a coordinated delivery system that combines both the financing and delivery of health care for enrollees. In the design of the plan, each member is assigned a "gatekeeper", a primary care physician (PCP) who is responsible for the overall care of members assigned to him/her. Specialty services require a specific referral from the PCP to the specialist. Non-emergency hospital admissions also required specific pre-authorization by the PCP. Typically, services are not covered if performed by a provider not an employee of or specifically approved by the HMO, unless it is an emergency situation as defined by the HMO. Financial sanctions for use of emergency facilities in non-emergent situations were once an issue; however, prudent layperson language now applies to all emergency-service utilization and penalties are rare. Since the 1980s, under the ERISA Act passed in Congress in 1974 and its preemptive effect on state common law tort lawsuits that "relate to" Employee Benefit Plans, HMOs administering benefits through private employer health plans have been protected by Federal law from malpractice litigation on the grounds that the decisions regarding patient care are administrative rather than medical in nature. See Cigna v. Calad, 2004.

Independent Practice Association (IPA)


An Independent Practice Association is a legal entity that contracts with a group of physicians to provide service to the HMO's members. Most often, the physicians are paid on a basis of capitation, which in this context means a set amount for each enrolled person assigned to that physician or group of physicians, whether or not that person seeks care. The contract is not usually exclusive, allowing individual doctors or the group to sign contracts with multiple HMOs. Physicians who participate in IPAs usually also serve fee-for-service patients not associated with managed care. Usually has a governing board to determine the best forms of practices.

Preferred Provider Organization (PPO)


Rather than contract with the various insurers and third party administrators, providers may contract with preferred provider organizations. A membership allows a substantial discount below their regularly charged rates from the designated professionals partnered with the organization. Preferred provider organizations themselves earn money by charging an access fee to the insurance company for the use of their network (unlike the usual insurance with premiums and corresponding payments paid either in full or partially by the insurance provider to the medical doctor). In terms of using such a plan, unlike an HMO plan, which has a copayment cost share feature (a nominal payment generally paid at the time of service), a PPO generally does not have a copay and instead offers a deductible and a coinsurance feature. The deductible must be paid in full before any benefits are provided. After the deductible is met, the coinsurance benefits apply. If the PPO plan is an 80% coinsurance plan with a $1,000 deductible, then the patient will pay 100% of the allowed provider fee up to $1,000. After this amount has been paid by the patient, the insurer will pay 80% of subsequent fees and the patient will pay the remaining 20%. Charges above the allowed amount are not payable by the patient or insurer but instead are written off as a discount by the physician.

Managed care Because the patient is picking up a substantial portion of the "first dollars" of coverage, PPO are the least expensive types of coverage [14].

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Point Of Service (POS)


A POS plan utilizes some of the features of each of the above plans. Members of a POS plan do not make a choice about which system to use until the point at which the service is being used. In terms of using such a plan, a POS plan has levels of progressively higher patient financial participation as the patient moves away from the more managed features of the plan. For example, if the patient stays in a network of providers and seeks a referral to use a specialist, they may have a copayment only. However, if they use an out of network provider, but do not seek a referral, they will pay more, and so on. POS plans are becoming more popular because they offer more flexibility and freedom of choice than standard HMOs.

Private Fee-For-Service (PFFS)


There are basically two types of Health Insurance: Fee-for-Service (Indemnity) and Managed Care. Health Insurance policies may vary from low cost to all-inclusive, meeting different demands of customers. Which Health Insurance type and plan you choose largely depends on your needs, preferences and budget. Fee-for-Service is a traditional kind of health care policy wherein insurance companies pay medical staff fees for each service provided to an insured patient. Fee-for-service plans offer a wide choice of doctors and hospitals. Fee-for-Service coverage falls into Basic and Major Medical Protection categories. Basic protection deals with costs of a hospital room, hospital services, care and supplies, cost of surgery in or out of hospital, and doctor visits. Major Medical Protection covers costs of serious illnesses and injuries, which usually require long-term treatment and rehabilitation period. Basic and Major Medical Insurance coverage combined are called a Comprehensive Health Care Plan. It is vitally important to know your insurance policy, since some services can be limited and some not covered at all.

Managed care in indemnity insurance plans


Many "traditional" or "indemnity" health insurance plans now incorporate some managed care features such as precertification for non-emergency hospital admissions and utilization reviews. These are sometimes described as "managed indemnity" plans.

Impacts
The overall impact of managed care remains widely debated. Proponents argue that it has increased efficiency, improved overall standards, and led to a better understanding of the relationship between costs and quality. They argue that there is no consistent, direct correlation between the cost of care and its quality, pointing to a 2002 Juran Institute study which estimated that the "cost of poor quality" caused by overuse, misuse, and waste amounts to 30 percent of all direct health care spending.[5] The emerging practice of evidence-based medicine is being used to determine when lower-cost medicine may in fact be more effective. Critics of managed care argue that "for-profit" managed care has been an unsuccessful health policy, as it has contributed to higher health care costs (25-33% higher overhead at some of the largest HMOs), increased the number of uninsured citizens, driven away health care providers, and applied downward pressure on quality (worse scores on 14 of 14 quality indicators reported to the National Committee for Quality Assurance).[15] The most common managed care financial arrangement, capitation, places health care providers in the role of micro-health insurers, assuming the responsibility for managing the unknown future health care costs of their patients. Small insurers, like individual consumers, tend to have annual costs that fluctuate far more than larger

Managed care insurers. The term "Professional Caregiver Insurance Risk[16][17] explains the inefficiencies in health care finance that result when insurance risks are inefficiently transferred to health care providers who are expected to cover such costs in return for their capitation payments. As Cox (2006) demonstrates, providers cannot be adequately compensated for their insurance risks without forcing managed care organizations to become price uncompetitive vis-a-vis risk retaining insurers. Cox (2010) [18] shows that smaller insurers have lower probabilities of modest profits than large insurers, higher probabilities of high losses than large insurers, provide lower benefits to policyholders, and have far higher surplus requirements. All these effects work against the viability of health care provider insurance risk assumption.

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Notes and references


[1] Managed Care Programs (http:/ / www. ncbi. nlm. nih. gov/ mesh?term=managed care). National Library of Medicine. [2] The backlash against managed care (http:/ / findarticles. com/ p/ articles/ mi_m1154/ is_n7_v86/ ai_20797610/ pg_2), Nation's Business, July 1998, accessed 2007-10-05 [3] Kaiser Public Opinion Spotlight: The Public, Managed Care, and Consumer Protections (http:/ / www. kff. org/ spotlight/ managedcare/ index. cfm), June 2004, accessed 2007-10-05. [4] Health Care Costs: A Primer (http:/ / www. kff. org/ insurance/ upload/ 7670. pdf), Kaiser Family Foundation Health Care Marketplace Project, August 2007, accessed 2007-10-05 [5] The Factors Fueling Rising Healthcare Costs 2006 (http:/ / www. ahipbelieves. com/ media/ The Factors Fueling Rising Healthcare Costs. pdf), report prepared by Price Waterhouse Coopers for America's Health Insurance Plans, January 2006, accessed 2007-10-05 [6] Trends in Health Care Costs and Spending (http:/ / www. kff. org/ insurance/ 7692. cfm), Kaiser Family Foundation Health Care Marketplace Project, September 2007, accessed 2007-10-05 [8] Peter R. Kongstvedt, "The Managed Health Care Handbook," Fourth Edition, Aspen Publishers, Inc., 2001, page 3, ISBN 0-8342-1726-0 [9] Managed Care: Integrating the Delivery and Financing of Health Care - Part A, Health Insurance Association of America, 1995, page 9 ISBN 1-879143-26-7 [10] Margaret E. Lynch, Editor, "Health Insurance Terminology," Health Insurance Association of America, 1992, ISBN 1-879143-13-5 [11] THE VALUE OF PROVIDER NETWORKS AND THE ROLE OF OUT-OF-NETWORK CHARGES IN RISING HEALTH CARE COSTS: A SURVEY OF CHARGES BILLED BY OUT-OF-NETWORK PHYSICIANS, (http:/ / www. ahipresearch. org/ PDFs/ ValueSurvey/ AllStatesReport. pdf) America's Health Insurance Plans, August 2009 [12] Gina Kolata, "Survey Finds High Fees Common in Medical Care ," (http:/ / www. nytimes. com/ 2009/ 08/ 12/ health/ policy/ 12insure. html) The New York Times, August 11, 2009 [13] Peter R. Kongstvedt, "The Managed Health Care Handbook," Fourth Edition, Aspen Publishers, Inc., 2001, page 1322 ISBN 0-8342-1726-0 [14] http:/ / www. kff. org/ insurance/ 7527/ upload/ 7527. pdf [15] (Himmelstein, Woolhandler, Hellander, Wolfe, 1999; HMO honor roll, 1997; Kuttner, 1999) [16] Cox, T. (2006). Professional caregiver insurance risk: A brief primer for nurse executives and decisionmakers. Nurse Leader, 4(2): 48-51. [17] http:/ / drtcbear. servebbs. net:81/ ~PCIR/ [18] Cox, T. (2010). Legal and ethical implications of health care provider insurance risk assumption. JONAS Healthcare Law, Ethics and Regulation. 12(4):106-16.

External links
The American Journal of Managed Care (http://www.ajmc.com/) - an independent, peer-reviewed publication dedicated to disseminating clinical information to managed care physicians, clinical decision makers, and other healthcare professionals. Managed Healthcare Executive (http://www.managedhealthcareexecutive.com/mhe/) - a magazine for senior-level decision makers. Medical Economics (http://www.memag.com/memag/) The Health Care Crisis, Part I (http://www.pinkyshow.org/archives/episodes/060110/060110_healthcare. html) - a Pinky Show online video about MCOs and their relationship to the health care crisis.

Doctor of Medicine

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Doctor of Medicine
Doctor of Medicine (M.D., from the Latin Medicinae Doctor meaning "Teacher of Medicine") is a terminal degree for physicians and surgeons. In some countries it is a professional doctorate where training is entered after obtaining between 90 and 120 credit hours of university level work (see second entry degree) and in most cases after obtaining a Bachelor's Degree. In other countries, such as India, Egypt, the United Kingdom and Germany, the M.D. is a research degree equivalent to a Ph.D.. In Britain, Egypt, Pakistan, India, Ireland, and many Commonwealth nations, the medical degree is instead the MBBS i.e., Bachelor of Medicine, Bachelor of Surgery (MBChB, MB BChir, BM BCh, MB BCh, MBBS, BMBS, BMed, BM) and M.D. is a higher level of attainment.[citation needed]

A navy physician examining a patient

History of the medical degree


According to Sir John Bagot Glubb, Syed Faride and S. M. Imamuddin, the first medical schools to issue academic degrees and diplomas were the teaching Bimaristan (Hospitals) of the medieval Islamic world. The first of these institutions was opened in Baghdad during the time of Harun al-Rashid. They then appeared in Egypt from 872 and then in Islamic Spain, Persia and the Maghreb thereafter. Physicians and surgeons at these hospital-universities gave lectures on Medicine to medical students and then a medical diploma or degree was issued to students who were qualified to be practicing physicians.[1][][2] According to Douglas Guthrie,[3] who bases his account on L Thorndike,[4] medical men were first called "Doctor" at the Medical School of Salerno. He states that the Emperor Frederick II decreed in 1221 that no one should practice medicine until he had been publicly examined and approved by the masters of Salerno. The course lasted 5 years, and to start one had to be 21 years old and show proof of legitimacy and of three years study of logic. The course was followed by a year of supervised practice. After the laureation ceremony the practitioners could call themselves "magister" or "doctor."

A military emergency physician demonstrating intubation technique

Academic degrees for physicians by country


United States and Canada
The initial medical schools that granted the MD degree (Doctor of Medicine) were Columbia, Penn, Harvard, Maryland, and McGill.[5] These first few North American medical schools that were established
Surgeons performing cardiothoracic surgeries

Doctor of Medicine were (for the most part) founded by physicians and surgeons who had been trained in England and Scotland. University medical education in England culminated with the MB qualification, and in Scotland the M.D., until in the mid-19th century the public bodies who regulated medical practice at the time required practitioners in Scotland as well as England to hold the dual Bachelor of Medicine and Bachelor of Surgery degrees (MB BS/MBChB/MB BChir/BM BCh etc.). North American Medical schools switched to the tradition of the Ancient universities of Scotland and began granting the M.D. title rather than the MB beginning in the late 18th century. The Columbia University College of Physicians and Surgeons in New York (which at the time was referred to as King's College of Medicine) was the first American University to grant the M.D. degree instead of the MB.[6] In the United States, MDs are awarded by medical schools as Professional Doctorate [7][8][9] and is accredited by the Liaison Committee on Medical Education (LCME), an independent body sponsored by the Association of American Medical Colleges and the American Medical Association (AMA).[10][] Admission to medical schools in the United States is highly competitive, with about 17,800 out of approximately 47,000 applicants receiving at least one acceptance to any medical school in recent application years. Before entering medical school, many schools require that students must complete a four-year undergraduate degree and take the Medical College Admission Test (MCAT); however, some medical schools require only a certain amount of undergraduate coursework (but not degree completion) before the start of the medical curriculum.[11] Before graduating from a medical school and achieving the Doctor of Medicine degree, most schools require their students to take the United States Medical Licensing Examination (USMLE) Step 1 and both the Clinical Knowledge and Clinical Skills parts of Step 2. The M.D. degree is typically earned in four years. Following the awarding of the M.D., physicians who wish to practice in the United States are required to complete at least one internship year (PGY-1) and pass the USMLE Step 3. In order to receive Board Eligible or Board Accredited status in a specialty of medicine such as general surgery or internal medicine, then undergo additional specialized training in the form of a residency. Those who wish to further specialize in areas such as cardiology or interventional radiology then complete a fellowship. Depending upon the physician's chosen field, residencies and fellowships involve an additional three to eight years of training after obtaining the M.D. This can be lengthened with additional research years, which can last one, two, or more years. The Doctor of Osteopathic Medicine or D.O. degree is the only other legal and professional equivalent to the M.D. degree in the United States and Canada.[12] The differences between the M.D. and the D.O. degrees lie in the distinctive osteopathic philosophy and osteopathic manipulative treatment (OMT). In Canada, the M.D. is the basic medical degree required to practice medicine. McGill University Faculty of Medicine is the only medical school in Canada to award M.D., C.M. degrees (abbreviated MDCM). MDCM is from the Latin "Medicinae Doctorem et Chirurgiae Magistrum" meaning "Doctor of Medicine and Master of Surgery". Research physicians Even though the M.D. and D.O. are first professional degrees and not doctorates of research (i.e., a Ph.D.), many holders of the M.D. or D.O. degree conduct clinical and basic scientific research and publish in peer-reviewed journals during training and after graduation. Combined medical and research training is offered through programs granting MD/PhD or DO/Ph.D. degrees. The National Institutes of Health (NIH) through its Medical Scientist Training Program funds M.D./Ph.D. training programs at many universities. Some MDs and DOs choose a research career and receive funding from the NIH as well as other sources such as the Howard Hughes Medical Institute. A few even go on to become Nobel Laureates.[13] The United States Department of Education and the National Science Foundation do not include the M.D. or other professional doctorates among the degrees that are equivalent to research doctorates.[14][15]

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Doctor of Medicine

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UK, Ireland and some Commonwealth countries


The entry-level first professional degree in these countries for the practice of medicine is that of Bachelor of Medicine and Bachelor of Surgery (MBBS, MB, MB BCh BAO, BMBS, MBBChir, or MBChB). This degree typically requires between four and six years of study and clinical training, and is equivalent to the North American MD degree. Due to the UK code for higher education, first degrees in medicine comprise an integrated programme of study and professional practice spanning several levels. The qualifications themselves typically meet the expectations for higher education qualification at level 7 (the UK master's degree). These degrees may retain, for historical reasons, "Bachelor of Medicine, Bachelor of Surgery" and are abbreviated to MBChB or MBBS.[16] In the UK, Ireland and many Commonwealth countries, the M.D. is a postgraduate research degree in medicine. At some universities, this takes the form of a first doctorate, analogous to the Ph.D., awarded upon submission of a thesis and a successful viva. The thesis may consist of new research undertaken on a full- or part-time basis, with much less supervision (in the UK) than for a Ph.D., or a portfolio of previously published work.[17]
NHS Medical Career Grades Old system Year 1: Year 2: Year 3: Year 4: Year 5: Years 6-8: Year 9: Consultant total time in training: minimum 7-9 years Training may be extended by pursuing medical research (usually two-three years), usually with clinical duties as well Pre-registration house officer (PRHO) - one year Senior house officer (SHO) a minimum of two years, although often more Specialist registrar four to six years GP registrar- one year General practitioner total time in training: 4 years Consultant total time in training: minimum 8 years New system (Modernising Medical Careers) Foundation Doctor (FY1 and FY2) - 2 years

Specialty Registrar (StR) in a hospital speciality: minimum six years

Specialty Registrar (GPST) in general practice: three years General practitioner total time in training: 5 years

Optional

Training is competency based, times shown are a minimum. Training may be extended by obtaining an Academic Clinical Fellowship for research or by dual certification in another speciality.

In order to be eligible to apply for an M.D. degree from a UK or Commonwealth University one must hold either an MBBS, MBChB, or an equivalent US-MD degree and must usually have at least 5-years of postgraduate experience. Therefore graduates from the MBBS or MBChB degrees do not hold doctorates; however, physicians holding these degrees are referred to as 'Doctor' as they are fully licensed as medical practitioners. In some commonwealth nations these interns are designated as House Officers. At some other universities (especially older institutions such as Oxford, Dublin, Cambridge and St Andrews) the MD is a higher doctorate (similar to a DSc) awarded upon submission of a portfolio of published work representing a substantial contribution to medical research.[18] The University of Cambridge is proposing to introduce a new degree of Med.Sc.D. (more akin to the ScD degree) awarded on the basis of a career's contribution to the science or art of medicine, rather than a thesis, for which a candidate may be awarded the M.D. degree.[19] In the case where the MD is awarded (either as a first or higher doctorate) for previously published research, the candidate is usually required to be either a graduate or a full-time member of staff, of several years' standing of the university in question.[20]

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Denmark
In Denmark, basic medical education is given in four universities: University of Copenhagen, Aarhus University, University of Southern Denmark and Aalborg University. The duration of basic medical education is six years and the course leads to the degree of Candidate of Medicine. Students are given the degree Doctor of Medicine (M.D.) after swearing the Hippocratic Oath upon graduation.[21] Medical school is usually followed by a year residency called clinical basic education (Danish: Klinisk basisuddannelse or just KBU) which upon completion grants the right to practices medicine without supervision.

France
Medical studies in France are organized as follow: Right after graduating from High School with a Baccalaureat, any student can register at a university of medicine (there are about 30 of them throughout the country). At the end of first year, an internal ranking examination takes place in each of these universities in order to implement the numerus clausus. First year consists mainly of theoretical classes such as biophysics and biochemistry, anatomy, ethics or histology. Passing first year is commonly considered as challenging and requires hard and continuous work. Each student can only try twice. For example, the Universit Ren Descartes welcomes about 2000 students in first year and only 300 after numerus clausus. The second and third year are usually mainly quite theoretical although the teachings are often accompanied by placements in the field (e.g. internships as nurses or in the emergency room, depending on the university). During 4th, 5th and 6th years, medical students get a special status called 'Externe' (In some universities, such as Pierre et Marie Curie, the 'Externe' status is given starting in the 3rd year). They work as interns every morning at the hospital plus a few night shifts a month and study in the afternoon. Each internship lasts between 3 and 4 months and takes place in a different department. Med students get 5 weeks off a year. At the end of sixth year, they need to pass a national ranking exam, which will determine their specialty. Indeed, the first student gets to choose first, then the second et cetera. Usually students work pretty hard during 5th and 6th years in order to train properly for the national ranking exam. During these years, actual practice at the hospital and some theoretical courses are meant to balance the training. Such externs' average wage stands between 100 and 300 euros a month. After that ranking exams, students can start as residents in the specialty they have been able to pick. That is the point from which they also start getting paid. Towards the end of the medical program, French medical students are provided with more responsibilities and are required to defend a thesis. At the conclusion of the thesis defense, French medical students receive a State Diploma of Doctor of Medicine (MD) or diplme d'Etat de docteur en mdecine. Every new doctor must then proceed to a Diploma of Specialized Studies (diplme d'tudes spcialises) to mark his specialty. Some students may also receive a Diploma of Specialized Complementary Studies (diplme d'tudes spcialises complmentaires).[22]

Germany

Doctor of Medicine

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In Germany, admission to medical schools is currently administered jointly by the Stiftung fr Hochschulzulassung (SfH), a centralized federal organization, and the universities themselves. The most important criterion for admission is the Numerus clausus, the final GPA scored by the applicant on the Abitur (highest secondary school diploma). However, in light of the recent gain in influence of medical schools in regards to applicant selection, additional criteria are being The University of Freiburg Faculty of Medicine used to select students for admission. These criteria vary among medical faculties and the final Abitur GPA is always a core indicator and strongly influences admission. Admission remains highly competitive. A very small number of slots per semester are reserved for selected applicants which already hold a university degree (Zweitstudium) and for medical officer candidates (Sanittsoffizieranwrter). The first two years of medical school consist of the so-called pre-clinical classes. During this time, the students are instructed in the basic sciences (e.g. physics, chemistry, biology, anatomy, physiology, biochemistry, etc.) and must pass a federal medical exam (Erster Abschnitt der rztlichen Prfung), administered nationally. Upon completion, the students advance to the clinical stage, where they receive three years of training and education in the clinical subjects (e.g., internal medicine, surgery, obstetrics and gynecology, pediatrics, pharmacology, pathology, etc.). The last year of medical school consists of the so-called "practical year" (Praktisches Jahr, PJ). Students are required to spend three four-month clerkships, two of them in a hospital (internal medicine and surgery) as well as one elective, which can be one of the other clinical subjects (e. g. family medicine, anesthesiology, neurology, pediatrics, radiology etc.). After at least six years of medical school, the students graduate with a final federal medical exam (Zweiter Abschnitt der rztlichen Prfung). Graduates receive the license to practice medicine and the professional title of physician (Arzt). The academic degree Doctor of Medicine (Dr. med., an equivalent to the MD)is awarded if the graduate has, in addition, successfully completed a scientific study and dissertation. Many medical students opt to perform their thesis during their studies at medical school, but only a fraction of them is able to finish the dissertation-process during their studies. If physicians wish to open up a doctor's office, they are required to further complete residency in order to fulfill the federal requirements of becoming Facharzt (specialized in a certain field of medicine like internal medicine, surgery, pediatrics etc.). There are 36 medical faculties in Germany.

Netherlands and Belgium


In the Netherlands and Belgium, medical students receive respectively 6 and 7 years of university education prior to their graduation. In the Netherlands, students receive three years of preclinical training, followed by three years of clinical training (co-assistentschappen, or co-schappen for short) in hospitals. At one medical faculty, that of Utrecht University, clinical training already begins in the third year of medical school. After 6 years, students graduate as Basisartsen (comparable to Doctors of Medicine). As a result of the Bologna process, medical students in the Netherlands now receive a bachelor's degree after three years in medical school and a master's degree upon graduation. Prospective students can apply for medical education directly after finishing the highest level of secondary school, vwo; previous undergraduate education is not a precondition for admittance. The Belgian medical education is much more based on theoretical knowledge than the Dutch system. In the first 3 years, which are very theoretical and lead to a university bachelor degree, general scientific courses are taken such as chemistry, biophysics, physiology, biostatistics, anatomy, virology, etc. To enter the bachelor course in Flanders, prospective students have to pass an exam, as a result of the numerus clausus. In the French-speaking part of Belgium, only the best students that pass the first year of the bachelor course in medicine are admitted to the second

Doctor of Medicine and third year. After the bachelor courses, students are allowed to enter the 'master in medicine' courses, which consist of 4 years of theoretical and clinical study. In general, the first 2 master years are very theoretical and teach the students in human pathology, diseases, pharmacology. The third year is a year full of internships in a wide range of specialities in different clinics. The seventh, final year serves as a kind of 'pre-specialization' year in which the students are specifically trained in the specialty they wish to pursue after medical school. This contrasts with the Dutch approach, in which graduates are literally 'basic doctors' (basisartsen) who have yet to decide on a specialty.

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Sweden
Medical education in Sweden begins with a five-and-a-half-year undergraduate university program leading to the degree "Master of Science in Medicine" (Swedish: Lkarexamen). Following this, the National Board of Health and Welfare requires a minimum of 18 months of clinical internship (Swedish: Allmntjnstgring) before granting a medical license to be fully qualified as Doctor of Medicine (MD).[23] This internship consists of surgery (36 months), internal medicine (36 months), psychiatry (three months) and family medicine (six months). Upon receiving a license to practice, a physician is able to apply for a post to start specialist training. There are currently 52 recognized medical specialties in Sweden. The specialist training has a duration of minimum five years, which upon completion grants formal qualification as a specialist.

Australia
Historically Australian medical schools have followed the British tradition by conferring MBBS degrees to medicine graduates. The notable exception is the Bachelor of Medicine (BMed) joint program of the University of Newcastle and the University of New England. Australian MBBS degrees are graduate-entry Bachelor's degrees at Level 7 of the Australian Qualifications Framework (AQF) and take four years to complete. The Newcastle/New England BMed is again an exception, being a five-year undergraduate-entry Level 7 degree. A recent revision to the AQF permits certain Level 9 Master's degree programs to use "Doctor of" in the degree title. As a result, several Australian universities are in the process of revising their Level 7 Bachelor's degrees to become Level 9 Master's degrees with the title Doctor of Medicine (MD). The University of Melbourne was the first to introduce the MD degree in 2011, and many other Australian universities are in the process of replacing their MBBS degrees with MDs.
University University of Melbourne Flinders University University of Western Australia University of Sydney Griffith University [25] Degree MD MD [24] MD MD MD [27] MD MD Previous degree Duration MBBS MBBS MBBS MBBS MBBS MBBS MBBS MBBS 4 years 4 years 4 years 4 years 4 years 4 years 4 years 6 years 6 years 6 years 4 years Entry level Postgraduate Postgraduate Postgraduate Postgraduate Postgraduate Postgraduate Postgraduate Year available 2011 2013 2014 2014 2014 2015 2013

[26]

University of Queensland University of Adelaide

[28]

[29] BMed/MD University of New South Wales University of Newcastle [] [] [30]

Undergraduate 2014 (TBC) Undergraduate 2015 (TBC) Undergraduate 2015 (TBC) Postgraduate 2014

BMedSci/MD BMed BMedSci/MD BMed MChD MBBS

University of New England

Australian National University

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Many universities previously offered an MD as an AQF Level 10 doctoral degree akin to the PhD or as a higher doctorate. Since the introduction of the Master's level MD, universities have renamed their previous medical research doctorates. For instance, the University of Melbourne renamed its research degree the Doctor of Medical Science (DMedSci).

Malaysia
In Malaysia, M.D. are awarded by both private and public universities, mostly are trained as a 5 years course but recently with the establishment of Perdana University in collaboration with John Hopkins Medical School the 4 years graduate entry medical degree is beginning to replace the 5 years program. Example of universities in Malaysia offering M.D. are University Sains Malaysia, National University of Malaysia, University Putra Malaysia, UCSI University & etc.

Argentina
In Argentina the First Degree of Physician or Medic Title (Ttulo de Mdico)[31] is equivalent to the North American M. D. Degree with 6 years of intensive studies followed by usually three or four years of the residency as a major specialty in a particular empiric field, compounded of internships, social services and sporadic research. Only by holding a Medical Title the postgraduate student might apply for the Doctor degree through a Doctorate in Medicine program approved by the National Commission for University Evaluation and Accreditation.[32]

India
The MBBS (Bachelor of Medicine/Bachelor of Surgery) degree represents the first (graduation) level of training required to be licensed as a physicians, and the MS or MD degree is a higher postgraduate degree, representative of specialty training. The equivalent training in the US or Canada would be completion of a medical (post-graduate) degree. Eligibility for the MS or MD course is restricted to medical graduates holding the MBBS degree. The MBBS course is for five and a half years, and training is obtained in medical disciplines (e.g.: Internal Medicine, Radiology, Pathology, etc.). After three years of study and the successful completion of an examination, which includes both theoretical and practical elements, in a pre-clinical or clinical subject of a non-surgical nature the candidate receives MD degree, whereas in a pre-clinical or clinical subject of a surgical nature i.e.,anatomy, general surgery, orthopaedics and gynaecology the candidate receives the equivalent degree Master of Surgery (MS). The research element is not very prominent in India, as this is primarily a clinical qualification resembling the professional doctorates of the USA. In general surgery, orthopaedics and gynaecology and in a pre-clinical subject like anatomy the equivalent degree is Master of Surgery (MS). A third alternate qualification, termed DNB [Diplomate of National Board], is considered equivalent to the MD and MS degrees. This can be obtained by passing the exam conducted by the National Board of Examinations after completing 3 years of post-MBBS residency training in teaching hospitals recognised by the board. After obtaining the first postgraduate degree, that is MD/MS/DNB, one can go for further specialisation in medical or surgical fields.This involves a highly competitive entrance examination. Course has three years of additional training and study and then after passing an examination, both theory and practical, the degree awarded is DM (Doctor of Medicine), like DM in Cardiology, Neurology, Nephrology, Gastroenterology, NeuroRadiology,Critical Care, Pulmonology, Hematology, Medical Oncology, Cardioanaesthesia, and Neuroanaesthesia. For surgical superspecialities the degree awarded is MCh (Magister Chirurgiae), like MCh in Cardiac Thoracic and Vascular Surgery, Neurosurgery,Gastrosurgery,Urology,Plastic Surgery,Pediatric Surgery etc.DM and Mch are Doctorate degrees. A third alternate qualification is DNB (superspecialties), offered by National Board of Examinations, like DNB in Cardiology, Neurology, Cardiac Surgery, Neurosurgery. The DM and MCh degrees are super-specialties and are very high ranked/prestigious.

Doctor of Medicine Following DM or Mch,one can further go for a third postdoctorate degree that is, postdoctoral fellowship programs of one year duration in specific subspecialities like Cardiac Electrophysiology,Invasive cardiology,Pediatric cardiology, Epilepsy, stroke, electroencephalography,movement disorders,neuromuscular disorders,cerebrovacular surgery, skull base surgery,pediatric cardiac surgery etc. offered by prestigious government institutes. In Ayurveda, B.A.M.S in Naturopathy and Yoga, Bachelor of Naturopathy and Yoga, B.N.Y.S[33] in Unani, Bachelor of Unani Medicine and Surgery BUMS in Siddha BSMS in homoeopathy B.H.M.S are the basic qualification for practicing Ayurveda,Unani,Homoeo&Sidha. The B.A.M.S, B.U.M.S, B.S.M.S and B.H.M.S are 6-year degree (including internship called house surgeoncy) course after 12 years of formal education at a C.C.I.M approved colleges. M.D (Ayu)(Ayurveda vachaspati)and other related M.D master degrees has to be done after B.A.M.S, B.N.Y.S., B.U.M.S, B.S.M.S or B.H.M.S in a specialty, and it takes 3 years (including submission of a thesis) to complete the course.Ayurveda M.D (Ayu) (Ayurveda vachaspati) is a Master degree accepted by the C.C.I.M.After completion of M.D (Ayu)(Ayurveda vachaspati) can follow higher level PhD programmes.

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Iran
In Iran, Medical education begins after high school. No pre-med course or BSc degree is required. The eligibility is determined through the rank applicants obtain in the public university entrance exam being held every year throughout the country. The entry to medical school is so competitive and only students with the highest rank are accepted into medical program. The primary medical degree is completed in 7-7.5 years. Medical graduates are awarded a certificate in general medicine, called "Professional Doctorate in Medicine" validated by the "Ministry of health and Medical Education of Iran". All physicians will obtain licence and medical council registration number from the "Medical Council of Iran" before they officially begin to practice. They may subsequently specialize in a specific medical field at medical schools offering the necessary qualifications. Academically, Degree of "Professional Doctorate in Medicine" is evaluated as Master's degree in Iran and graduates are allowed to enroll in PhD programs directly after obtaining medical degree.

Pakistan
In Pakistan equivalent degree is MBBS (bachelors of medicine and bachelors of surgery). MBBS is awarded as the basic medical qualification after completing five years of study. This comprises two years of basic science subjects including anatomy, physiology, and biochemistry, with a particular emphasis on human anatomy. Subsequently, there are three years of clinical internship and courses on medicine surgery and pharmacology. Finally, the student is required to work for one year under a professor, before one is awarded Degree of MBBS with license to practice. For specialization, one has to pass Fellow of College of Physicians & Surgeons Pakistan (FCPS) exam-1 in field in of specialization and obtain an internship in the field for 36 years. Next, one can take the FCPS exam part 2, which includes intensive practical exams. Upon successful completion a fellow of the relevant specialty is awarded. Tough entry tests are passed successfully before entering into a medical college. Medical colleges and foreign medical qualifications are supervised by the Pakistan Medical and Dental Council (PMDC). Specialized degrees are awarded by the Pakistan College of Physicians and Surgeons. In basic medical sciences such as Anatomy, Physiology, Biochemistry, Pathology etc. the research postgraduate degree awarded by many universities is M.Phil., which has a pre-requirement of at least two years of Demonstratorship in relevant subject in a recognized Medical College. The Mphil course is 24 years and is a research postgraduate degree, containing submission and defence of research thesis in basic sciences similar to MD degree program in India. Many universities in conjunction with tertiary hospitals offer coursework MD and MS degrees as well.

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Philippines
The Dominicans, under the Spanish Government, established the oldest Medical School in the Philippines in 1871, known as the Faculty of Medicine and Surgery (at that time was one with the University of Santo Tomas Faculty of Pharmacy, also considered the oldest school of Pharmacy in the Philippines) of the Pontifical and Royal University of Santo Tomas in Intramuros, Manila. Medical education in the Philippines became widespread under the American administration. The Americans, led by the insular government's Secretary of the Interior, Dean Worcester, built the University of the Philippines - College of Medicine and Surgery in 1905. By 1909, nursing instruction was also begun at the Philippine Normal School. At present there are a number of medical schools in the Philippines, notable examples include the University of the Philippines Manila, Our Lady of Fatima University, Far Eastern University - Nicanor Reyes Medical Foundation, Saint Louis University (Baguio), De La Salle Health Sciences Institute, University of Santo Tomas, Pamantasan ng Lungsod ng Maynila, University of the East Ramon Magsaysay Memorial Medical Center, St. Luke's College of Medicine-William H. Quasha Memorial, Cebu Doctors' University, Cebu Institute of Medicine, Mindanao State University-College of Medicine, Southwestern University, West Visayas State University in Iloilo City, Davao Medical School Foundation in Davao City, Xavier University - Ateneo de Cagayan, Dr. Jose P. Rizal School of Medicine in Cagayan De Oro and University of Northern Philippines (Vigan City). In 1994, the Zamboanga Medical School Foundation was founded. Currently, it is now known as the Ateneo de Zamboanga University School of Medicine [34]. It is an innovative medical school which patterned its curriculum from the College of Medicine in the University of New Mexico and the University of Calgary in Canada yet, evolving it to be suitable and unique to the Philippine setting. It is the only medical school in the Philippines offering a 5-year program integrating degrees of Doctor of Medicine and Master of Public Health. On 2007, the Ateneo School of Medicine and Public Health was established. It is the first medical school in the country to offer a double degree program leading to the degrees Doctor of Medicine and Masters in Business Administration. Any college graduate may apply for medical school given that they satisfy the requirements set by the institutions. There is also a test known as the National Medical Admission Test or NMAT. Scores are given on a percentile basis and a high ranking is a must to enter the top medical schools in the country.[35] In most institutions, medical education lasts for four years. Basic subjects are taken up in the first and second years, while clinical sciences are studied in the second and third years. In their fourth year, students rotate in the various hospital departments, spending up to two months each in the fields of internal medicine, surgery, obstetrics and gynecology, and pediatrics, and several weeks in the other specialties. After this, students graduate with a Doctorate in Medicine (MD) and apply for postgraduate internship (PGI) in an accredited hospital of their choice. After PGI, the student is eligible to take the Medical Licensure Examination. Passing the examinations confers the right to practice medicine as well as to apply in a Residency Training Program.

Romania
Romanian medical school lasts for 6 years (including clinical practice) and concludes with a final licensing examination (licena). The degree awarded is that of Doctor-medic (Medical Doctor), abbreviated as "MD", or more commonly "Dr." (although this is not correct, and should be written "dr."[citation needed]).[36]

Sri Lanka
In Sri Lanka, MBBS degree is the degree to be held for one to be licensed as a physicians by the Sri Lanka Medical Council. MD degree is a higher postgraduate degree and in Sri Lanka awarded by the Postgraduate Institute of Medicine after completion of a postgraduate course and examinations. The MD degree in Sri Lanka is representative of specialty training in clinical, para clinical and preventive medicine (e.g., General Medicine, Cardiology,

Doctor of Medicine Nephrology, Oncology, para clinical such as microbiology, haematology and preventive such as Community Medicne .). Entry for the MD course open only for medical graduates holding the MBBS degree (with a duration of five and a half years), and training is obtained in medical disciplines that are non-surgical in nature (e.g., Internal Medicine, Radiology, Pathology, etc.). After three or four years of study and the successful completion of an examination with written as well as cases and viva examinations, the MD degree in the respective field of Study is awarded. In Community medicine and Medical Administration, part I examination consists of a theoretical exam while the degree is cofered after completion of a thesis as n PhD. This thesis has to be completed within a period of five years. After successfully defending the academic thesis, MD degree is conferred to the candidate,The MD degree holder is certified as a Board certified specialist by the respective board of study of the Postgraduate Institute of Medicine after he/she undergoes 24 years of local and foreign training depending on the specialty/subspecialty selected. In Ayurveda, Bachelor of Ayurveda, Medicine and Surgery B.A.M.S in Unani, Bachelor of Unani Medicine and Surgery BUMS in Sidha,Bachelor of Sidha Medicine and Surgery BSMS are the basic qualification for practicing Ayurveda,Unani,&Sidha. The B.A.M.S, B.U.M.S, and B.S.M.S are 6-year degree (including internship) courses accepted by the University Grants Commission (Sri Lanka). M.D (Ayu)(Ayurveda vachaspati) can be done after B.A.M.S,as a speciality, and it takes 3 years (including submission of a thesis) to complete the course.Ayurveda M.D (Ayu) (Ayurveda vachaspati) is a Master degree accepted by University Grants Commission (Sri Lanka),after completion of MPhil can follow PhD level programmes in Sri Lanka.

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Republic of China (Taiwan)


The medical education in the Republic of China (Taiwan) is usually 7 years (6-year learning plus 1-year internship) in duration, starting right after high schools. The first 2 years in the 7-year system is composed of basic sciences and liberal art courses. Doctor-patient classes are emphasized, and most schools require compulsory amounts of volunteer hours. Clinical sciences are compressed into a two-year program in the 3rd and 4th years. The duration of clerkships and internships varies from school to school, but all of them end at the 7th grade. Taiwans medical education began in 1897 and is over 100 years old now.Students graduate with a Doctor of Medicine (MD) degree. Starting from the year 2013, incoming students will have a 6+2 year curriculum, in which the first 6 years are oriented similarly as before and the last two years are Post Graduate Years; this change aims to increase primary care capabilities of medical school graduates.[37]

Singapore
The Yong Loo Lin School of Medicine at the National University of Singapore confers MB BS. The American Duke University also has a medical programme based in Singapore (Duke-NUS Graduate Medical School), but it follows the North-American model of styling its degree Doctor of Medicine (MD) at masters degree level.[]

Thailand
The Thai medical education is 6 years system, consisting of 1 year in basic-science, 2 years in pre-clinical training, and 3 years for clinical training. Upon graduation, all medical students must pass national medical licensing examinations and a university-based comprehensive test. After medical school, newly graduated doctor are under contract to spend a year of internship and 2 years of tenure in rural areas before they are eligible for any other residency positions or specialized training. The students will receive Doctor of Medicine (MD) degree. However the degree is equivalent to Master's degree in Thailand.

Doctor of Medicine

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Tunisia
In Tunisia, education is free for all Tunisian citizens and for foreigners who have scholarships. The oldest Medical school is a faculty of the University of Tunis. There are four medicine faculties situated in the major cities of Tunis, Sfax, Sousse and Monastir. Admission is bound to the success and score in the baccalaureate examination. Admission score threshold is very high, based on competition among all applicants throughout the nation. Medical school curriculum consists of five years. The first two years are medical theory, containing all basic sciences related to medicine, and the last three years consists of clinical issues related to all medical specialties. During these last three years, the student gets the status of "Externe". The student has to attend at the university hospital every day, rotating around all wards. Every period is followed by a clinical exam regarding the student's knowledge in that particular specialty. After those five years, there are two years on internship, in which the student is a physician but under the supervision of the chief doctor; the student rotates over the major and most essential specialties during period of four months each. After that, student has the choice of either passing the residency national exam or extending his internship for another year, after which he gains the status of family physician. The residency program consists of four to five years in the specialty he qualifies, depending on his score in the national residency examination under the rule of highest score chooses first. Whether the student chooses to be a family doctor or a specialist, he has to make a doctorate thesis, which he will be defending in front of a jury, after which he gains his degree of Doctor of Medicine (MD).

Cambodia
After 6 years of general medical education (a foundation year + 5 years), all students will graduate with Bachelor of Medical Sciences (BMedSc) . This degree does not allow graduates to work independently as Physician, but it is possible for those who wish to continue to master's degrees in other fields relating to medical sciences such as Public Health, Epidemiology, Biomedical Science, Nutrition... Medical graduates, who wish to be fully qualified as physician must do as below: General Practitioner's (GP) course is of 8 years ( BMedSc + 2-year internship). Clinical rotation in the internship is modulated within 4 main disciplines (general medicine, surgery, gynecology, pediatrics).The medical degree awarded is Doctor of Medicine (MD) (equivalent to master's degree). After graduating with BMedSc; any students, who wishes enter Specialist Training Programs, are required to sit for a rigorous and contesting Entrance Exam. It lasts 9 to 10 years from the beginning of medical school (BMedSc + 3 4 years of specialization) to the award of DES (Diplme d'Etudes Spcialises) or in English meaning "Diploma of Specialized Studies"; which graduates are officially entitled as (after thesis defense) Doctorate in Medicine with Specialization (MD-Specialization) "Professional Doctorate" and is considered as higher than MD (General Medicine). All Medical graduates must complete Thesis Defense and pass the National Licensing Exam to become either GPs or Medical Specialists.

Equivalent degrees in other countries


In Russia, medical schools in Russia offer a 6-year curriculum leading to award Doctor of Medicine (MD) "Physician". In the Dominican Republic, it is known as "DOCTOR EN MEDICINA" (DOCTOR IN MEDICINE). In 1511 the Spanish Catholic church founded the first university of the Americas in Santo Domingo present capital of modern day Dominican Republic and name it UNIVERSIDAD SANTO TOMAS DE AQUINO (today UNIVERSIDAD AUTONOMA DE SANTO DOMINGO). In 1630 this university graduated the first medical doctors of the Americas and amongst the graduates some Native Americans included.

Doctor of Medicine In Italy, the title of "Dottore in Medicina e Chirurgia" (literally "Doctor in Medicine and Surgery") is awarded by a preventive selection ("test a numero chiuso"): only about 10% of the students pass this test. Students have to complete six years of medical school and have to pass a final state examination (called "abilitazione") to acquire the right to work as a physician; finally they can use the title "Dott." or "Dr." before the name. All Doctors then must enroll themselves to a schools of specialization (literally "scuole di specializzazione") that, after the winning of the competition in the field that each doctors choose, last four years at least The Czech and Slovak title MUDr. (Medicinae Universae doctor or doktor medicny) is a professional doctorate granted upon completion of six years pregraduate Master's study at medical schools. The postgraduate academic research degree in medicine is a PhD degree. In Poland the title of lekarz (physician, medic) or "lek." (previously lekarz medycyny or "lek. med.") is granted after completing a 6-year Master's medical program (although students apply to it directly after graduating high school).[] In contrast, a higher doctoral academic research degree in medicine resembling a PhD is named "dr n. med." or doktor nauk medycznych (Doctor of Medical Sciences). Specialization is valued similarly to a specialization in the English system and is a pre-requisite for a "dr. n. med." which is usually defined within the same field. The Danish and Norwegian Candidatus medicinae or Candidata medicinae degrees (cand. med.) is awarded after completing a six-year medical programme, to which students apply directly upon finishing secondary school. The programme usually includes a small thesis. However, the cand. med. degree must not be confused with the previous Danish and Norwegian Dr. Med. degree, which is a separate degree from the Ph.D. and represents a higher degree of medical research experience. It typically consists of at least 56 original publications. In Mexico, schools of medicine award the "Titulo de Medico Cirujano" degree after completing either six or seven years of study. This curriculum includes a rotating internship year and a year of social service providing care to an underserved community. In Nepal, a MBBS degree is awarded. In Greece, after a six-year study, a medical student acquires his medical degree and the right to use ".", (Dr.) before his name. This is considered equivalent to the M.D. title. In mainland China, some medical schools award MBBS to foreign students while all medical schools award Bachelor of Medicine to nationals. MD is a higher academic research degree. In Colombia, the medicine faculties of the universities awards the title of "Medico Cirujano" after taking 10 semesters of studies on "all clinic and surgery discipline a two semester on internship. After receiving the degree there is a mandatory year "obliged social work" were the doctors practice as GP in the countryside. Residency programs last between 34 years depends on the specialty. In Sudan the awarded degree in most of the medical schools is, Bachelor of Medicine and Basic Surgery (MBBS). In schools that are based on the English system of medical teaching, the degree is granted after six years of studying. As for the schools that are adopting the American system, they grant their students the degree of MBBS in only five years. In Turkey, the title of "Tp Doktoru" (literally "Doctor of Medicine") is awarded upon completion of six years continuous study started with five years university education include three years basic sciences, two years clinical courses followed by one year of internship in university hospitals. In Indonesia, the title of "dokter" (dr.) is awarded after a Medical student received their Bachelor in Medicine (Sarjana Kedokteran; S. Ked) after 3-3.5 years of study (at least) and 1.52 years of clinical course in university hospitals. After a medical student finished those five years of study and take Hippocrates Oath, The title of Dokter (Dr.) is entitled before their name. Then they need to take Ujian Kompetensi Dokter Indonesia (UKDI, test to get license to practice medicine as general practitioner) then take a year-long internship course in primary health care clinics (also known as Puskesmas) or primary hospitals all over the country to practice as general practitioner under supervision of senior doctors. Those who wished to further their study into specialties can take graduate course of medicine of their preference and will be entitled with "Specialist of ..." after their name (e.g.: Sp.A for

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Doctor of Medicine Spesialis Anak = Pediatrician). graduate course of medicine is equal with residency program which is required the candidates to study for four years and hospital internship. (Note: dr. (dokter) is used for medical graduates, while Dr. (Doktor) is used for PhD holders.. In Serbia and Croatia, the title of "doktor medicine" (abbreviated "dr. med.") is awarded upon completion of six years of study at a Faculty of Medicine ("medicinski fakultet") directly after high school.

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Other postgraduate clinical degrees


There is also a similar advanced professional degree to the postgraduate MD: the Master of Surgery (usually ChM or MS, but MCh in Scotland, Ireland, Wales and at Oxford and MChir at Cambridge). The equivalence of these degrees, but their differing names, prevents the need for surgeons (addressed as Mr. in the UK) having to revert to the title Dr., which they once held as new MBBS graduates. In Ireland, where the basic medical qualification includes a degree in obstetrics, there is a similar higher degree of Master of the Art of Obstetrics (MAO). A Master of Midwifery was formerly examined by the Worshipful Society of Apothecaries of London (hence MMSA) but fell into abeyance in the 1960s; in this case the term Master referred not to a university degree but rather a professional rank that is common among craft guilds. In East Africa, the medical schools in Kenya, Tanzania and Uganda award the degree of Master of Medicine (MMed) degree in both surgical and medical specialty disciplines following a three-year period of instruction. In West Africa, the West African College of Physicians and the West African College of Surgeons award the Fellowship of the West African College of Physicians (FWACP) and the Fellowship of the West African College of Surgeons (FWACS) in medical and surgical disciplines respectively after a minimum of four-year residency training period.

References
[1] [3] [4] [5] Sir John Bagot Glubb (cf. Dr. A. Zahoor (1999), Quotations on Islamic Civilization (http:/ / www. cyberistan. org/ islamic/ quote2. html)) Douglas Guthrie, A History of Medicine. London: Thomas Nelson 1945, p. 107 L Thorndike, History of Magic and Experimental Science. New York 1934 41, Vol. 2 of 6 Crawford DS Montreal, medicine and William Leslie Logie: McGill's first graduate and Canada's first medical graduate. 175th. anniversary. Osler Library Newsletter No. 109, 2008. pp 17 (http:/ / www. mcgill. ca/ files/ library/ No1092008. pdf). [6] Columbia.edu (http:/ / www. columbia. edu/ about_columbia/ history. html) [13] ED.gov (http:/ / www. ed. gov/ about/ offices/ list/ ous/ international/ usnei/ us/ edlite-professional-studies. html) [14] http:/ / www2. ed. gov/ about/ offices/ list/ ous/ international/ usnei/ us/ doctorate. doc [16] The UK quality code for higher education (http:/ / www. bris. ac. uk/ esu/ assessment/ annex/ annex-level7descriptor. html) [17] See, for example, Otago.ac.nz (http:/ / www. otago. ac. nz/ courses/ qualifications/ md. html) [18] CF Hawkins, "Write the MD Thesis" in "How To Do It" London: British Medical Association 2nd ed. 1985 ISBN 0-7279-0186-9 [20] See, for example, UQ.edu.au (http:/ / www. uq. edu. au/ study/ program. html?acad_prog=7504) [31] Coneau.edu.ar (http:/ / www. coneau. edu. ar/ index. php?idioma=en) Comisin Nacional de Evaluacin y Acreditacin Universitaria. [32] National Commission for University Evaluation and Accreditation (http:/ / www. coneau. gov. ar/ index. php?idioma=en) [33] http:/ / indianmedicine. nic. in/ index3. asp?sslid=277& subsublinkid=94& lang=1 [34] http:/ / som. adzu. edu. ph/ [37] Medical Education in Taiwan (http:/ / ntumc-studentambassadors. blogspot. com/ 2012/ 12/ introduction-of-taiwanese-medical-system. html)

http:/ / www. ips. um. edu. subpilihan=Doctor_of_Medicine_(MD)

my/

?modul=Programmes_Offered&

pilihan=Faculties&

Doctor of Medicine

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Further reading
Biabangardi, Zinab; Baradaran (2006). JCEHP 26 (3).

Medicare Payment Advisory Commission


The Medicare Payment Advisory Commission (MedPAC) is an independent US federal body. MedPAC was established by the Balanced Budget Act of 1997 (P.L. 105-33). Its primary role is to advise the US Congress on issues affecting the administration of the Medicare program. Specifically the commission's mandate is to advise the US Congress on payments to private health plans participating in Medicare and health providers serving Medicare beneficiaries. MedPAC is also relied on by Medicare administrators and policy makers to evaluate beneficiary's access to care and the quality of care received. MedPAC's mandate is broad enough that it can also evaluate other issues affecting Medicare.[1] MedPAC produces two major reports to the United States Congress each year that contain recommendations to improve Medicare.[1] For example, its June 2008 report to Congress, "Reforming the Delivery System," made several recommendations along "a path to bundled payment."[][]

References
[1] MedPAC. About MedPAC. (http:/ / www. medpac. gov/ about. cfm) Retrieved 2010-03-16.

External links
Official MedPAC website (http://www.medpac.gov)

Medical Expenditure Panel Survey


The Medical Expenditure Panel Survey (MEPS) is a family of surveys intended to provide nationally-representative estimates of health expenditure, utilization, payment sources, health status, and health insurance coverage among the noninstitutionalized, nonmilitary population of the United States. This series of government-produced data sets can be used to examine how individuals interact with the medical care system in the United States. MEPS is administered by the Agency for Healthcare Research and Quality (AHRQ) in three components: the core Household Component, the Insurance/Employer Component, and the Medical Provider Component. Only the Household Component is available for download on the Internet. These components provide comprehensive national estimates of health care use and payment by individuals, families, and any other demographic group of interest.[1]

History
MEPS was modeled after the National Medical Expenditure Survey (NMES) and the National Medical Care Utilization and Expenditure Survey (NMCUES), which were conducted in 1977 (NMES-1), 1980 (NMCUES), and 1987 (NMES-2). Each of these surveys was tasked with the goal of providing data on a representative sample of Americans' every interaction with the medical care system. Although the NMES and NMCUES were sampled independently from the U.S. population, each new MEPS sample is drawn from the outgoing National Health Interview Survey panel.[2][3] MEPS is generally considered the direct descendent of these surveys, and prestigious peer-reviewed journals commonly publish articles that examine trends calculated between MEPS and its predecessors.[4][5]

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Research Topics
The Medical Expenditure Panel Survey can be used for a wide range of topics related to the U.S. healthcare system, including Access to Care, Children's Health, Chronic Conditions, Health Insurance, Health Disparities, Women's Health, Prescription Drugs, Individuals with Disabilities, and the Elderly. AHRQ continually produces chartbooks, statistical briefs, and fact sheets using MEPS data which shed light on these various facets of how the American healthcare system functions, what patients experience, how they behave, and who pays for the cost of care.[6]

Data Accessibility
The MEPSnet Query Tools [7] interactive table builder allows non-statisticians to select a data year and medical variable(s) of interest, and produce descriptive statistics and crosstabulations of Household Component and Insurance Component data from the AHRQ website.

Data Available
The current publicly available Medical Expenditure Panel Survey - Household Component data set consists of six files which describe the demographics and characteristics of the survey population and eight event-level files which capture all interactions with the U.S. medical system.[8]

Household Component Full-Year Files


The six full-year files include: The Full-Year Consolidated Data files (released annually in November) The main person-level file of the Household Component data set, which includes all demographic and medical characteristics, as well as patient-reported responses to the main survey questions. Since the survey involves five interview rounds over the two-year panel, data from interview rounds 1, 2, and 3 are included for individuals in their first of two years, and data from interview rounds 3, 4, and 5 are included for individuals in their second of two years. These single-year consolidated datafiles can be thought of as the first half of one two-year panel survey stacked on top of the second half of another two-year panel survey.[9] The Full-Year Population Characteristics files (released annually in May) A skeleton version of the person-level consolidated file, which gets released six months before the Consolidated file of the same year but does not include any income or medical expenditure variables.[10] The Medical Conditions files (released annually in November) The medical condition-level file, which can be linked to both the person-level files and the event-level files. Unlike the medical event-level files, which describe a solitary encounter with the U.S. healthcare system, records within the Medical Conditions files contain a distinct ICD-9 code, Clinical Classification Code, and describe only one ailment (illness or injury). In order to view all medical events during the calendar year associated with a particular condition, a many-to-one join can be executed between this file and zero, one, or more of the event-level files' records (on CONDIDX). The medical condition records in this file can also be merged with a many-to-one join to the person-level files (on DUPERSID), where each person may have zero, one, or multiple matching condition records.[11] The Jobs files (released annually in May) The jobs-level data file contains information about each job that each MEPS-HC survey respondent held over the course of the calendar year, including wages, hours, industry, and occupation, as well as various healthcare-related survey questions (such as offers of employer-sponsored insurance, sick day availability, etc.). This file can be merged with the full-year *person-level file (on DUPERSID), with one match per unique job an individual held during the calendar year. It can also be merged with the Person Round Plan file, matching (on JOBSIDX) wherever a private health insurance plan was obtained through a place of employment.[12]

Medical Expenditure Panel Survey The Person Round Plan (PRPL) files (released annually in October) This health insurance plan by interview date file contains information about each private insurance plan covering each individual surveyed, with one record per interview date (three annually). Private health insurance plans include physician/hospital, dental, vision, medigap, and prescription drugs. This file contains health insurance-specific information, such as an edited monthly out-of-pocket insurance premium, source of coverage and premium payment, as well as some questions about the planholder's satisfaction with the plan. Although this file can be merged with both person-level files (on DUPERSID) and the Jobs files (on JOBSIDX), this file contains one record per person, per plan, per interview and therefore does not easily condense into one-to-one merges. As an analytic shortcut, data users might simply limit this data set to each unique person-plan's first interview record of the year; the first interview number (RN) available for each distinct establishment identifier and policyholder identifier combination (ESTBIDX + PHLDRIDX).[13] The Longitudinal Weight files (released annually in December) This person-level file mirrors the main Consolidated files in terms of contents, except that it contains survey responses for all five rounds and therefore contains half as many observations. The two-year, five-interview survey data aggregated into this file is designed to be representative of two years' worth of medical behavior of the U.S. noninstitutionalized population over the period specified.[14]

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Household Component Event Files


The eight event-level files generally contain one record per event, and contain various information pertaining to the specific type of event. Each record contains one or more ICD-9 codes to describe and categorize the type of medical encounter experienced by the surveyed individual. The event-level files also contain the breakdown of spending by payor associated with the event and a date (or start and end dates) that the event took place. Each of these event files can be joined with the person-level files in a many-to-one match (on DUPERSID), where an individual with zero medical events during the calendar year would generate zero matches, but an individual with two doctor visits and a dental visit would generate three matches across all of the event files. The event-level files can also be joined with the condition files (on CONDIDX) to determine what medical expenditure can be associated with particular conditions. The eight files include: The Prescribed Medicines files (released annually in October) - This file contains one household-reported prescribed medicine purchase during the calendar year. Prescription purchases are then verified by the prescribing pharmacy. In addition to the expenditure information, this file contains characteristics of the medication, such as the National Drug Code (NDC) identifier, the drug name, and the Multum Lexicon category. Prescribed medical events may be more difficult to analyze, since the strength of the drug and quantity purchased may vary, despite two separate prescription-events being the same chemical substance. Prescribed medical events may also be more difficult to analyze, since, unlike other recorded medical events, a pharmacy encounter does not guarantee that the medication has been administered (i.e. that the patient stuck to his or her drug regiment). This file should be thought of as containing one record per pharmacy encounter.[15] The Dental Visits files (released annually in August) - The file contains one record for each dental visit during the calendar year. It includes dental-specific information such as the type of provider seen, if the visit was due to an accident, reason for the dental event, and any medication was prescribed.[16] The Other Medical Expenses files (released annually in August) This file contains one record for each medical expense that does not fit into any of the other event type categories. The events and expenditures captured in this file are overwhelmingly recorded as Glasses and Contact Lenses, with Durable Medical Equipment (such as Orthopedic items, Prostheses, Hearing Devices) also included.[17] The Hospital Inpatient Stays files (released annually in October) This file contains hospitalization-specific information including the date of and reason for the stay, the types of services received, and any procedure(s) undertaken during the hospital inpatient stay.[18]

Medical Expenditure Panel Survey The Emergency Room Visits files (released annually in September) This file contains emergency room-specific information including the date of and reason for the visit, the types of services received, and any procedures(s) undertaken during the visit. Since many E.R. visits continue into Inpatient Hospital admissions, the spending incurred during any E.R. visit resulting in an Inpatient Hospital Admission gets transferred to the Hospital Inpatient Stays event file (identifiable using the ERHEVIDX variable) and the medical expenditure cannot be divided out between pre- and post-admission.[19] The Outpatient Visits files (released annually in September) This file contains information about each visit to an outpatient hospital setting, including type of test or treatment being provided, whether or not a physician was seen (and if so what specialty), and what condition or diagnosis the visit was related to.[20] The Office-based Visits files (released annually in September) This file captures each office-based encounter of all sampled individuals. This file contains all necessary descriptive information about visits to Primary Care Physicians, specialist physicians, and non-physician medical providers (such as Nurse Practitioners and Physical Therapists) that occurred outside of a hospital setting. In addition to the general event visit information, this file includes certain details about any preventive services, tests, and vaccinations received.[21] The Home Health Visits files (released annually in August) This file contains one record for each time that a certified home health medical practitioner visits a sampled individual. In addition to the standard event file variables, this file contains information about the home health medical provider's credentials and skills, the length of the visit, and the type(s) of care received. This file includes medical visits by hospice providers, which are generally paid for home-based care through the Medicare Hospice benefit.[22][23]

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Publications
The Medical Expenditure Panel Survey is commonly the subject of analysis in articles on health policy and health services in research journals such as Health Affairs, JAMA, Health Services Research, and the New England Journal of Medicine.[24]

Methodology
Noninstitutionalized civilian Americans (both citizens and non-citizens) are sampled at the household, allowing for analyses of medical behavior at the family-level as well as the individual-level. Each year, households containing a total of approximately 15,000 individuals are sub-sampled from the National Health Interview Survey's two year panel. These individuals are then followed with five in-person interviews (rounds) over the course of two years during which a complete demographic profile is collected, all medical encounters are documented, and patient-reported subjective questions regarding topics like satisfaction with care are obtained.[25] MEPS employs a complex survey sample design in order to oversample certain population groups of interest; this survey design must be accounted for (using either the Taylor Series Linearization method or the Balanced repeated replication method) to appropriately calculate the standard errors.[26]

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External links
Medical Expenditure Panel Survey website [27] step-by-step how to analyze the Medical Expenditure Panel Survey with free tools website [28]

References
[1] http:/ / aspe. hhs. gov/ hsp/ 06/ catalog-ai-an-na/ MEPS. htm [2] http:/ / cloud9. norc. uchicago. edu/ faqs/ meps. htm [3] http:/ / www. cdc. gov/ nchs/ products/ elec_prods/ subject/ nmcues. htm [4] http:/ / content. nejm. org/ cgi/ content/ full/ 348/ 2/ 130 [5] http:/ / jama. ama-assn. org/ cgi/ content/ full/ 287/ 2/ 203 [6] http:/ / www. meps. ahrq. gov/ mepsweb/ data_stats/ MEPS_topics. jsp [7] http:/ / www. meps. ahrq. gov/ mepsweb/ data_stats/ meps_query. jsp [8] http:/ / www. meps. ahrq. gov/ mepsweb/ data_stats/ download_data_files. jsp [9] http:/ / www. meps. ahrq. gov/ mepsweb/ data_stats/ download_data_files_detail. jsp?cboPufNumber=HC-113 [10] http:/ / www. meps. ahrq. gov/ mepsweb/ data_stats/ download_data_files_detail. jsp?cboPufNumber=HC-107 [11] http:/ / www. meps. ahrq. gov/ mepsweb/ data_stats/ download_data/ pufs/ h112/ h112doc. shtml [12] http:/ / www. meps. ahrq. gov/ mepsweb/ data_stats/ download_data/ pufs/ h108/ h108doc. shtml [13] http:/ / www. meps. ahrq. gov/ mepsweb/ data_stats/ download_data/ pufs/ h111/ h111doc. shtml [14] http:/ / www. meps. ahrq. gov/ mepsweb/ data_stats/ download_data/ pufs/ h114/ h114doc. shtml [15] http:/ / www. meps. ahrq. gov/ mepsweb/ data_stats/ download_data/ pufs/ h110a/ h110adoc. shtml [16] http:/ / www. meps. ahrq. gov/ mepsweb/ data_stats/ download_data/ pufs/ h110b/ h110bdoc. shtml [17] http:/ / www. meps. ahrq. gov/ mepsweb/ data_stats/ download_data_files_detail. jsp?cboPufNumber=HC-110C [18] http:/ / www. meps. ahrq. gov/ mepsweb/ data_stats/ download_data/ pufs/ h110d/ h110ddoc. shtml [19] http:/ / www. meps. ahrq. gov/ mepsweb/ data_stats/ download_data/ pufs/ h110e/ h110edoc. shtml [20] http:/ / www. meps. ahrq. gov/ mepsweb/ data_stats/ download_data/ pufs/ h110f/ h110fdoc. shtml [21] http:/ / www. meps. ahrq. gov/ mepsweb/ data_stats/ download_data/ pufs/ h110g/ h110gdoc. shtml [22] http:/ / www. meps. ahrq. gov/ mepsweb/ data_stats/ download_data/ pufs/ h110h/ h110hdoc. shtml [23] http:/ / www. medicare. gov/ publications/ pubs/ pdf/ 02154. pdf [24] http:/ / scholar. google. com/ scholar?q=%22Medical+ Expenditure+ Panel+ Survey%22+ AND+ %28JAMA+ OR+ %22Health+ Affairs%22+ OR+ NEJM+ OR+ %22Health+ Services+ Research%22%29& hl=en& as_sdt=0& as_vis=1& oi=scholart [25] http:/ / www. meps. ahrq. gov/ mepsweb/ data_files/ publications/ mr1/ mr1. shtml [26] http:/ / www. meps. ahrq. gov/ mepsweb/ survey_comp/ standard_errors. jsp [27] http:/ / www. meps. ahrq. gov/ mepsweb/ [28] http:/ / www. asdfree. com/ search/ label/ medical%20expenditure%20panel%20survey%20%28meps%29

Magnetic resonance imaging

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Magnetic resonance imaging


Magnetic resonance imaging (MRI), nuclear magnetic resonance imaging (NMRI), or magnetic resonance tomography (MRT) is a medical imaging technique used in radiology to visualize internal structures of the body in detail. MRI makes use of the property of nuclear magnetic resonance (NMR) to image nuclei of atoms inside the body. MRI can create more detailed images of the human body than are possible with X-rays. An MRI scanner is a device in which the patient lies within a large, powerful magnet where the magnetic field is used to align the magnetization of some atomic nuclei in the body, and radio frequency magnetic fields are applied to systematically alter the alignment of this magnetization.[1] This causes the nuclei to produce a rotating magnetic field detectable by the scannerand this information is recorded to construct an image of the scanned area of the body.[2] Magnetic field gradients cause nuclei at different locations to precess at different speeds, which allows spatial information to be recovered using Fourier analysis of the measured signal. By using gradients in different directions, 2D images or 3D volumes can be obtained in any arbitrary orientation.

Sequential sections from an MRI of the brain, concurrently showing slices through transverse, sagittal, and coronal planes (left to right).

MRI provides good contrast between the different soft tissues of the body, which makes it especially useful in imaging the brain, muscles, the heart, and cancers compared with other medical imaging techniques such as computed tomography (CT) or X-rays. Unlike CT scans or traditional X-rays, MRI does not use ionizing radiation.[]

Para-sagittal MRI of the head, with aliasing artifacts (nose and forehead appear at the back of the head)

How MRI works


MRI machines make use of the fact that body tissue contains lots of water, and hence protons (1H nuclei), which will be aligned in a large magnetic field.[] Each water molecule has two hydrogen nuclei or protons. When a person is inside the powerful magnetic field of the scanner, the average magnetic moment of many protons becomes aligned with the direction of the field. A radio frequency current is briefly turned on, producing a varying electromagnetic field. This electromagnetic field has just the right frequency, known as the resonance frequency, to be absorbed and flip the spin of the protons in the magnetic field. After the electromagnetic field is turned off, the spins of the protons return to thermodynamic equilibrium and the bulk magnetization becomes realigned with the static magnetic field. During this relaxation, a radio frequency signal (electromagnetic radiation in the RF range) is generated, which can be measured with receiver coils.

Medical MRI scanner

Information about the origin of the signal in 3D space can be learned by applying additional magnetic fields during the scan. These additional magnetic fields can be used to generate detectable signals only from specific locations in

Magnetic resonance imaging the body (spatial excitation) and/or to make magnetization at different spatial locations precess at different frequencies, which enables k-space encoding of spatial information. The 3D images obtained in MRI can be rotated along arbitrary orientations and manipulated by the doctor to be better able to detect tiny changes of structures within the body.[3] These fields, generated by passing electric currents through gradient coils, make the magnetic field strength vary depending on the position within the magnet. Because this makes the frequency of the released radio signal also dependent on its origin in a predictable manner, the distribution of protons in the body can be mathematically recovered from the signal, typically by the use of inverse Fourier transform.

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Protons in different tissues return to their equilibrium state at different relaxation rates. Different tissue variables, including spin density, T1 and T2 relaxation times, and flow and spectral shifts, can be used to construct images.[][4] By changing the settings on the scanner, this effect is used to create contrast between different types of body tissue or between other properties, as in fMRI and diffusion MRI. MRI is used to image every part of the body, and is particularly useful for tissues with many hydrogen nuclei and little density contrast, such as the brain, muscle, connective tissue and most tumors.

Magnetic field
MRI scans require a magnetic field with two properties, uniform field density and strength. The magnetic field cannot vary more than 1/10,000 of 1% and field strength ranges (depending on the scanner) from 0.2 to 3 teslas in strength in scanners currently used clinically, with research scanners investigating higher field strengths such as 7 teslas. The lower field strengths can be achieved with permanent magnets, which are often used in "open" MRI scanners for claustrophobic patients.[5] Higher field strengths can be achieved only with superconducting magnets. An MRI with a 3.0 tesla strength magnet may be referred to as a "3-T MRI" or "3-tesla MRI" Since the gradient coils are within the bore of the scanner, there are large forces between them and the main field coils, producing most of the hammering noise that is heard during operation. Without efforts to damp this noise, it can approach 130 decibels (dB) with strong fields [6] (see also the subsection on acoustic noise).

Contrast agents and implants


MRI contrast agents may be injected intravenously to enhance the appearance of blood vessels, tumors or inflammation. Contrast agents may also be directly injected into a joint in the case of arthrograms: MRI images of joints. Unlike CT, MRI uses no ionizing radiation and is generally a very safe procedure. Nonetheless the strong magnetic fields and radio pulses can affect metal implants, including cochlear implants and cardiac pacemakers. There are many electronically activated devices that have approval from the US FDA to permit MRI procedures in patients under highly specific MRI conditions (see www.MRIsafety.com). In the case of cochlear implants, the US FDA has approved some implants for MRI compatibility. In the case of cardiac pacemakers, the results can sometimes be lethal,[7] so patients with such implants are generally not eligible for MRI.

Prepolarized MRI
In 2001, a research team at Stanford invented a new technique which came to be called "Prepolarized MRI" or PMRI.[8] The team demonstrated that the magnets do not have to be both uniform and strong. Rather, two magnets can be used together, where one is strong and the other one is uniform.[] The first magnet in a PMRI scanner is strong, but not uniform. This magnet creates a very strong magnetic field which varies in uniformity by as much as 40%. This is the "prepolarize" component. A second much weaker (requiring only the electric power necessary to run two hairdryers) but far more precise magnet then creates a homogeneous magnetic field. These two magnets can be ordinary copper wound magnets, greatly lowering the cost of an MRI scanner.[] Because the magnetic field is "tuned" by the second magnet, a PMRI scan can be obtained immediately adjacent to a metal prosthetic, unlike an MRI scan.[9]

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History
In 1952, Herman Carr produced a one-dimensional MRI image as reported in his Harvard PhD thesis.[10][11][12] In the Soviet Union, Vladislav Ivanov filed (in 1960) a document with the USSR State Committee for Inventions and Discovery at Leningrad for a Magnetic Resonance Imaging device,[13] although this was not approved until the 1970s.[14] In a 1971 paper in the journal Science,[15] Raymond Damadian, an Armenian-American physician, scientist, and professor at the Downstate Medical Center State University of New York (SUNY), reported that tumors and normal tissue can be distinguished in vivo by nuclear magnetic resonance ("NMR"). He suggested that these differences could be used to diagnose cancer, though later research would find that these differences, while real, are too variable for diagnostic purposes. Damadian's initial methods were flawed for Raymond Damadian's "Apparatus and method for detecting cancer in tissue." practical use,[] relying on a point-by-point scan of the entire body and using relaxation rates, which turned out not to be an effective indicator of cancerous tissue.[] While researching the analytical properties of magnetic resonance, Damadian created the world's first magnetic resonance imaging machine in 1972. He filed the first patent for an MRI machine, U.S. patent #3,789,832 on March 17, 1972, which was later issued to him on February 5, 1974.[16] The National Science Foundation notes, "The patent included the idea of using NMR to 'scan' the human body to locate cancerous tissue."[17] However, it did not describe a method for generating pictures from such a scan or precisely how such a scan might be done.[][] Meanwhile, Paul Lauterbur expanded on Carr's technique and developed a way to generate the first MRI images, in 2D and 3D, using gradients. In 1973, Lauterbur published the first nuclear magnetic resonance image[][] and the first cross-sectional image of a living mouse in January 1974.[] In the late 1970s, Peter Mansfield, a physicist and professor at the University of Nottingham, England, developed a mathematical technique that would allow scans to take seconds rather than hours and produce clearer images than Lauterbur had. Damadian, along with Larry Minkoff and Michael Goldsmith, performed the first MRI body scan of a human being on July 3, 1977,[18][19] studies which they published in 1977.[][] and in 1979 Richard S. Likes filed patent *4,307,343 [20]. In 1980 Paul Bottomley joined the GE Research Center in Schenectady, NY, and his team ordered the highest field-strength magnet then available a 1.5T system and built the first high-field and overcame problems of coil design, RF penetration and signal-to-noise ratio to build the first whole-body MRI/MRS scanner.[] The results translated into the highly successful 1.5T MRI product-line, with over 20,000 systems in use today. Bottomley performed the first localized MRS in the human heart and brain. After starting a collaboration on heart applications with Robert Weiss at Johns Hopkins, Bottomley returned to the university in 1994 as Russell Morgan Professor and director of the MR Research Division.[21] Although MRI is most commonly performed at 1.5 T, higher fields such as 3T are gaining more popularity because of their increased sensitivity and resolution. In research laboratories, human studies have been performed at up to 9.4 T[22] and animal studies have been performed at up to 21.1T.[23]

2003 Nobel Prize


Reflecting the fundamental importance and applicability of MRI in medicine, Paul Lauterbur of the University of Illinois at Urbana-Champaign and Sir Peter Mansfield of the University of Nottingham were awarded the 2003 Nobel Prize in Physiology or Medicine for their "discoveries concerning magnetic resonance imaging". The Nobel citation acknowledged Lauterbur's insight of using magnetic field gradients to determine spatial localization, a discovery that allowed rapid acquisition of 2D images. Mansfield was credited with introducing the mathematical formalism and developing techniques for efficient gradient utilization and fast imaging. The actual research that won

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the prize was done almost 30 years before, while Paul Lauterbur was at Stony Brook University in New York.[citation
needed]

The award was vigorously protested by Raymond Vahan Damadian, founder of FONAR Corporation, who claimed that he invented the MRI, and that Lauterbur and Mansfield had merely refined the technology. A group called "The Friends of Raymond Damadian" (formed by Damadian's company, FONAR[24]), took out full-page advertisements in the New York Times and The Washington Post entitled "The Shameful Wrong That Must Be Righted", demanding that he be awarded at least a share of the Nobel Prize.[25]

Applications
In clinical practice, MRI is used to distinguish pathologic tissue (such as a brain tumor) from normal tissue. One advantage of an MRI scan is that it is harmless to the patient. It uses strong magnetic fields and non-ionizing electromagnetic fields in the radio frequency range, unlike CT scans and traditional X-rays, which both use ionizing radiation.[citation needed] While CT provides good spatial resolution (the ability to distinguish two separate structures at a small distance from each other), MRI provides comparable resolution with far better contrast resolution (the ability to distinguish the differences between two similar but not identical tissues).[] The basis of this ability is the complex library of pulse sequences that the modern medical MRI scanner includes, each of which is optimized to provide image contrast based on the chemical sensitivity of MRI.[] For example, with particular values of the echo time (TE) and the repetition time (TR), which are basic parameters of image acquisition, a sequence takes on the property of T2-weighting. On a T2-weighted scan, water- and fluid-containing tissues are bright (most modern T2 sequences are actually fast T2 sequences) and fat-containing tissues are dark. The reverse is true for T1-weighted images. Damaged tissue tends to develop edema, which makes a T2-weighted sequence sensitive for Effects of TR and TE on MR signal. pathology, and generally able to distinguish pathologic tissue from normal tissue. With the addition of an additional radio frequency pulse and additional manipulation of the magnetic gradients, a T2-weighted sequence can be converted to a FLAIR sequence, in which free water is now dark, but edematous tissues remain bright. This sequence in particular is currently the most sensitive way to evaluate the brain for demyelinating diseases, such as multiple sclerosis.[] The typical MRI examination consists of 520 sequences, each of which is chosen to provide a particular type of information about the subject tissues. This information is then synthesized by the interpreting physician.[]

Basic MRI scans


T1-weighted MRI T1-weighted scans refer to a set of standard scans that depict differences in the spin-lattice (or T1) relaxation time of various tissues within the body. T1 weighted images can be acquired using either spin echo or gradient-echo sequences. T1-weighted contrast can be increased with the application of an inversion recovery RF pulse. Gradient-echo based T1-weighted sequences can be acquired very rapidly because of their ability to use short inter-pulse repetition times (TR). T1-weighted sequences are often collected before and after infusion of T1-shortening MRI contrast agents. In the brain T1-weighted scans provide appreciable contrast between gray and white matter. In the body, T1 weighted scans work well for differentiating fat from waterwith water appearing darker and fat brighter.[26]

Magnetic resonance imaging T2-weighted MRI T2-weighted scans refer to a set of standard scans that depict differences in the spin-spin (or T2) relaxation time of various tissues within the body. Like the T1-weighted scan, fat is differentiated from water, but in this case fat shows darker, and water lighter. For example, in the case of cerebral and spinal study, the CSF (cerebrospinal fluid) will be lighter in T2-weighted images. These scans are therefore particularly well suited to imaging edema, with long TE and long TR. Because the spin echo sequence is less susceptible to inhomogeneities in the magnetic field, these images have long been a clinical workhorse.[citation needed] T*2-weighted MRI T* 2 (pronounced "T 2 star") weighted scans use a gradient echo (GRE) sequence, with long T and long T . The E R gradient echo sequence used does not have the extra refocusing pulse used in spin echo so it is subject to additional losses above the normal T2 decay (referred to as T2), these taken together are called T* 2. This also makes it more prone to susceptibility losses at air/tissue boundaries, but can increase contrast for certain types of tissue, such as venous blood.[citation needed] Spin density weighted MRI Spin density, also called proton density, weighted scans try to have no contrast from either T2 or T1 decay, the only signal change coming from differences in the amount of available spins (hydrogen nuclei in water). It uses a spin echo or sometimes a gradient echo sequence, with short TE and long TR.[citation needed]

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Specialized MRI scans


Diffusion MRI Diffusion MRI measures the diffusion of water molecules in biological tissues.[27] Clinically, diffusion MRI is useful for the diagnoses of conditions (e.g., stroke) or neurological disorders (e.g., multiple sclerosis), and helps better understand the connectivity of white matter axons in the central nervous system.[28] In an isotropic medium (inside a glass of water for example), water molecules naturally move randomly according to turbulence and Brownian motion. In biological tissues however, where the Reynolds number is low enough for flows to be laminar, the diffusion may be anisotropic. For example, a molecule inside the axon of a neuron has a low probability of crossing the myelin membrane. Therefore the molecule moves principally along the axis of the neural fiber. If it is known that molecules in a particular voxel diffuse principally in one direction, the assumption can be made that the majority of the fibers in this area are parallel to that direction.[citation needed]
[]

DTI image

The recent development of diffusion tensor imaging (DTI) enables diffusion to be measured in multiple directions and the fractional anisotropy in each direction to be calculated for each voxel. This enables researchers to make brain maps of fiber directions to examine the connectivity of different regions in the brain (using tractography) or to examine areas of neural degeneration and demyelination in diseases like multiple sclerosis. Another application of diffusion MRI is diffusion-weighted imaging (DWI). Following an ischemic stroke, DWI is highly sensitive to the changes occurring in the lesion.[29] It is speculated that increases in restriction (barriers) to water diffusion, as a result of cytotoxic edema (cellular swelling), is responsible for the increase in signal on a DWI

Magnetic resonance imaging scan. The DWI enhancement appears within 510 minutes of the onset of stroke symptoms (as compared with computed tomography, which often does not detect changes of acute infarct for up to 46 hours) and remains for up to two weeks. Coupled with imaging of cerebral perfusion [30], researchers can highlight regions of "perfusion/diffusion mismatch" that may indicate regions capable of salvage by reperfusion therapy. Like many other specialized applications, this technique is usually coupled with a fast image acquisition sequence, such as echo planar imaging sequence. Magnetization transfer MRI Magnetization transfer (MT) refers to the transfer of longitudinal magnetization from free water protons to hydration water protons in NMR and MRI. In magnetic resonance imaging of molecular solutions, such as protein solutions, two types of water molecules, free (bulk) and hydration (bound), are found. Free water protons have faster average rotational frequency and hence fewer fixed water molecules that may cause local field inhomogeneity. Because of this uniformity, most free water protons have resonance frequency lying narrowly around the normal proton resonance frequency of 63MHz (at 1.5 teslas). This also results in slower transverse magnetization dephasing and hence longer T2. Conversely, hydration water molecules are slowed down by interaction with solute molecules and hence create field inhomogeneities that lead to a wider resonance frequency spectrum. In free liquids, protons, which may be viewed classically as small magnetic dipoles, exhibit translational and rotational motions. These moving dipoles disturb the surrounding magnetic field. However, on long enough time-scales (which may be nanoseconds) the average field caused by the motion of protons is zero. This is known as "motional averaging" or narrowing and is characteristic of protons moving freely in liquid. On the other hand, protons bound to macromolecules, such as proteins, tend to have a fixed orientation and so the average magnetic field in close proximity to such structures does not average to zero. The result is a spatial pattern in the magnetic field that gives rise to a residual dipolar coupling (range of precession frequencies) for the protons experiencing the magnetic field. The wide frequency distribution appears as a broad spectrum that may be several kHz wide. The net signal from these protons disappears very quickly, in inverse proportion to the width, due to the loss of coherence of the spins, i.e., T2 relaxation. Due to exchange mechanisms such as spin transfer or proton chemical exchange, the (incoherent) spins bound to the macromolecules continually switch places with (coherent) spins in the bulk media and establish a dynamic equilibrium. Magnetization transfer: Although there is no measurable signal from the bound spins, or the bound spins that exchange into the bulk media, their longitudinal magnetization is preserved and may recover only via the relatively slow process of T1 relaxation. If the longitudinal magnetization of just the bound spins can be altered, then the effect can be measured in the spins of the bulk media due to the exchange processes. The magnetization transfer sequence applies RF saturation at a frequency that is far off resonance for the narrow line of bulk water but still on resonance for the bound protons with a spectral linewidth of kHz. This causes saturation of the bound spins which exchange into the bulk water, resulting in a loss of longitudinal magnetization and hence signal decrease in the bulk water. This provides an indirect measure of macromolecular content in tissue. Implementation of magnetization transfer involves choosing suitable frequency offsets and pulse shapes to saturate the bound spins sufficiently strongly, within the safety limits of specific absorption rate for RF irradiation. T1rho MRI T1 (T1rho): Molecules have a kinetic energy that is a function of the temperature and is expressed as translational and rotational motions, and by collisions between molecules. The moving dipoles disturb the magnetic field but are often extremely rapid so that the average effect over a long time-scale may be zero. However, depending on the time-scale, the interactions between the dipoles do not always average away. At the slowest extreme the interaction time is effectively infinite and occurs where there are large, stationary field disturbances (e.g., a metallic implant). In

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Magnetic resonance imaging this case the loss of coherence is described as a "static dephasing". T2* is a measure of the loss of coherence in an ensemble of spins that includes all interactions (including static dephasing). T2 is a measure of the loss of coherence that excludes static dephasing, using an RF pulse to reverse the slowest types of dipolar interaction. There is in fact a continuum of interaction time-scales in a given biological sample, and the properties of the refocusing RF pulse can be tuned to refocus more than just static dephasing. In general, the rate of decay of an ensemble of spins is a function of the interaction times and also the power of the RF pulse. This type of decay, occurring under the influence of RF, is known as T1. It is similar to T2 decay but with some slower dipolar interactions refocused, as well as static interactions, hence T1T2.[31] Fluid attenuated inversion recovery (FLAIR) Fluid Attenuated Inversion Recovery (FLAIR)[32] is an inversion-recovery pulse sequence used to nullify the signal from fluids. For example, it can be used in brain imaging to suppress cerebrospinal fluid (CSF) so as to bring out periventricular hyperintense lesions, such as multiple sclerosis (MS) plaques. By carefully choosing the inversion time TI (the time between the inversion and excitation pulses), the signal from any particular tissue can be suppressed. Magnetic resonance angiography Magnetic resonance angiography (MRA) generates pictures of the arteries to evaluate them for stenosis (abnormal narrowing) or aneurysms (vessel wall dilatations, at risk of rupture). MRA is often used to evaluate the arteries of the neck and brain, the thoracic and abdominal aorta, the renal arteries, and the legs (called a "run-off"). A variety of techniques can be used to generate the pictures, such as administration of a paramagnetic contrast agent (gadolinium) or using a technique known as "flow-related enhancement" (e.g., 2D and 3D time-of-flight sequences), where most of the signal on an image is due to blood that recently moved into that plane, see also FLASH MRI. Techniques involving phase accumulation (known as phase contrast angiography) can also be used to generate flow velocity maps easily Magnetic resonance angiography and accurately. Magnetic resonance venography (MRV) is a similar procedure that is used to image veins. In this method, the tissue is now excited inferiorly, while the signal is gathered in the plane immediately superior to the excitation planethus imaging the venous blood that recently moved from the excited plane.[] Magnetic resonance gated intracranial CSF dynamics (MR-GILD) Magnetic resonance gated intracranial cerebrospinal fluid (CSF) or liquor dynamics (MR-GILD) technique is an MR sequence based on bipolar gradient pulse used to demonstrate CSF pulsatile flow in ventricles, cisterns, the aqueduct of Sylvius, and the entire intracranial CSF pathway. It is a method for analyzing CSF circulatory system dynamics in patients with CSF obstructive lesions such as normal pressure hydrocephalus. It also allows visualization of both arterial and venous pulsatile blood flow in vessels without the use of contrast agents.[33][34]
Diastolic time data acquisition (DTDA). Systolic time data acquisition (STDA).

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Magnetic resonance spectroscopy Magnetic resonance spectroscopy (MRS) is used to measure the levels of different metabolites in body tissues. The MR signal produces a spectrum of resonances that corresponds to different molecular arrangements of the isotope being "excited". This signature is used to diagnose certain metabolic disorders, especially those affecting the brain,[35] and to provide information on tumor metabolism.[36] Magnetic resonance spectroscopic imaging (MRSI) combines both spectroscopic and imaging methods to produce spatially localized spectra from within the sample or patient. The spatial resolution is much lower (limited by the available SNR), but the spectra in each voxel contains information about many metabolites. Because the available signal is used to encode spatial and spectral information, MRSI requires high SNR achievable only at higher field strengths (3 T and above).[citation needed] Functional MRI Functional MRI (fMRI) measures signal changes in the brain that are due to changing neural activity. The brain is scanned at low resolution but at a rapid rate (typically once every 23 seconds). Increases in neural activity cause changes in the MR signal via T* [37] 2 changes; this mechanism is referred to as the BOLD (blood-oxygen-level dependent) effect. Increased neural activity causes an increased demand for oxygen, and the vascular system actually overcompensates for this, increasing the amount of oxygenated hemoglobin relative to deoxygenated hemoglobin. Because deoxygenated hemoglobin attenuates the MR signal, the vascular A fMRI scan showing regions of activation in response leads to a signal increase that is related to the neural activity. orange, including the primary visual cortex (V1, The precise nature of the relationship between neural activity and the BA17). BOLD signal is a subject of current research. The BOLD effect also allows for the generation of high resolution 3D maps of the venous vasculature within neural tissue. While BOLD signal analysis is the most common method employed for neuroscience studies in human subjects, the flexible nature of MR imaging provides means to sensitize the signal to other aspects of the blood supply. Alternative techniques employ arterial spin labeling (ASL) or weighting the MRI signal by cerebral blood flow (CBF) and cerebral blood volume (CBV). The CBV method requires injection of a class of MRI contrast agents that are now in human clinical trials. Because this method has been shown to be far more sensitive than the BOLD technique in preclinical studies, it may potentially expand the role of fMRI in clinical applications. The CBF method provides more quantitative information than the BOLD signal, albeit at a significant loss of detection sensitivity.[citation needed]

Magnetic resonance imaging Real-time MRI Real-time MRI refers to the continuous monitoring ("filming") of moving objects in real time. While many different strategies have been developed over the past two decades, a recent development reported a real-time MRI technique based on radial FLASH and iterative reconstruction that yields a temporal resolution of 20 to 30 milliseconds for images with an in-plane resolution of 1.5 to 2.0mm. The new method promises to add important information about diseases of the joints and the heart. In many cases MRI examinations may become easier and more comfortable for patients.[citation needed] Interventional MRI
Real-time MRI of a human heart at a resolution The lack of harmful effects on the patient and the operator make MRI of 50 ms well-suited for "interventional radiology", where the images produced by a MRI scanner are used to guide minimally invasive procedures. Of course, such procedures must be done without any ferromagnetic instruments.[citation needed]

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A specialized growing subset of interventional MRI is that of intraoperative MRI in which the MRI is used in the surgical process. Some specialized MRI systems have been developed that allow imaging concurrent with the surgical procedure. More typical, however, is that the surgical procedure is temporarily interrupted so that MR images can be acquired to verify the success of the procedure or guide subsequent surgical work.[citation needed] Radiation therapy simulation Because of MRI's superior imaging of soft tissues, it is now being utilized to specifically locate tumors within the body in preparation for radiation therapy treatments. For therapy simulation, a patient is placed in a specific, reproducible, body position and scanned. The MRI system then computes the precise location, shape and orientation of the tumor mass, correcting for any spatial distortion inherent in the system. The patient is then marked or tattooed with points that, when combined with the specific body position, permits precise triangulation for radiation therapy.[citation needed] Current density imaging Current density imaging (CDI) endeavors to use the phase information from images to reconstruct current densities within a subject. Current density imaging works because electrical currents generate magnetic fields, which in turn affect the phase of the magnetic dipoles during an imaging sequence.[citation needed] These experiences have highlighted the importance of whole body magnetic resonance imaging in early diagnosis of pathologies, because when patients show manifestations through X-ray and CT, their prognosis already may be unfavorable or grim.[citation needed] Magnetic resonance guided focused ultrasound In MRgFUS therapy, ultrasound beams are focused on a tissueguided and controlled using MR thermal imagingand due to the significant energy deposition at the focus, temperature within the tissue rises to more than 65 C (150 F), completely destroying it. This technology can achieve precise ablation of diseased tissue. MR imaging provides a three-dimensional view of the target tissue, allowing for precise focusing of ultrasound energy. The MR imaging provides quantitative, real-time, thermal images of the treated area. This allows the physician to ensure that the temperature generated during each cycle of ultrasound energy is sufficient to cause thermal ablation within the desired tissue and if not, to adapt the parameters to ensure effective treatment.[38]

Magnetic resonance imaging Multinuclear imaging Hydrogen is the most frequently imaged nucleus in MRI because it is present in biological tissues in great abundance, and because its high gyromagnetic ratio gives a strong signal. However, any nucleus with a net nuclear spin could potentially be imaged with MRI. Such nuclei include helium-3, lithium-7, carbon-13, fluorine-19, oxygen-17, sodium-23, phosphorus-31 and xenon-129. 23Na and 31P are naturally abundant in the body, so can be imaged directly. Gaseous isotopes such as 3He or 129Xe must be hyperpolarized and then inhaled as their nuclear density is too low to yield a useful signal under normal conditions. 17O and 19F can be administered in sufficient quantities in liquid form (e.g. 17O-water) that hyperpolarization is not a necessity.[citation needed] Multinuclear imaging is primarily a research technique at present. However, potential applications include functional imaging and imaging of organs poorly seen on 1H MRI (e.g., lungs and bones) or as alternative contrast agents. Inhaled hyperpolarized 3He can be used to image the distribution of air spaces within the lungs. Injectable solutions containing 13C or stabilized bubbles of hyperpolarized 129Xe have been studied as contrast agents for angiography and perfusion imaging. 31P can potentially provide information on bone density and structure, as well as functional imaging of the brain. Multinuclear imaging holds the potential to chart the distribution of lithium in the human brain, this element finding use as an important drug for those with conditions such as bipolar disorder.[citation needed] Susceptibility weighted imaging (SWI)

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Susceptibility weighted imaging (SWI), is a new type of contrast in MRI different from spin density, T1, or T2 imaging. This method exploits the susceptibility differences between tissues and uses a fully velocity compensated, three dimensional, RF spoiled, high-resolution, 3D gradient echo scan. This special data acquisition and image processing produces an enhanced contrast magnitude image very sensitive to venous blood, hemorrhage and iron storage. It is used to enhance the detection and diagnosis of tumors, vascular and neurovascular diseases (stroke and hemorrhage, multiple sclerosis, Alzheimer's), and also detects traumatic brain injuries that may not be diagnosed using other methods.[39] Other specialized MRI techniques New methods and variants of existing methods are often published when they are able to produce better results in specific fields. Examples of these recent improvements are T* 2-weighted turbo spin-echo (T TSE MRI), double inversion recovery MRI (DIR-MRI) or phase-sensitive inversion 2 recovery MRI (PSIR-MRI), all of them able to improve imaging of brain lesions.[40][41] Another example is MP-RAGE (magnetization-prepared rapid acquisition with gradient echo),[42] which improves images of multiple sclerosis cortical lesions.[43]

Molecular imaging of disease biomarkers by MRI


MRI has the advantages of having very high spatial resolution and is very adept at morphological imaging and functional imaging. MRI does have several disadvantages though. First, MRI has a sensitivity of around 103 mol/L to 105 mol/L which, compared to other types of imaging, can be very limiting. This problem stems from the fact that the difference between atoms in the high energy state and the low energy state is very small. For example, at 1.5 teslas, a typical field strength for clinical MRI, the difference between high and low energy states is approximately 9 molecules per 2 million. Improvements to increase MR sensitivity include increasing magnetic field strength, and hyperpolarization via optical pumping or dynamic nuclear polarization. There are also a variety of signal amplification schemes based on chemical exchange that increase sensitivity.[citation needed] To achieve molecular imaging of disease biomarkers using MRI, targeted MRI contrast agents with high specificity and high relaxivity (sensitivity) are required. To date, many studies have been devoted to developing targeted-MRI contrast agents to achieve molecular imaging by MRI. Commonly, peptides, antibodies, or small ligands, and small protein domains, such as HER-2 affibodies, have been applied to achieve targeting. To enhance the sensitivity of the

Magnetic resonance imaging contrast agents, these targeting moieties are usually linked to high payload MRI contrast agents or MRI contrast agents with high relaxivities.[44]

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Portable instruments
Portable magnetic resonance instruments are available for use in education and field research. Using the principles of Earth's field NMR, they have no powerful polarizing magnet, so that such instruments can be small and inexpensive. Some can be used for both EFNMR spectroscopy and MRI imaging.[45] The low strength of the Earth's field results in poor signal to noise ratios (SNR), requiring long scan times to capture spectroscopic data or build up MRI images. However, the extremely low noise floor of SQUID-based MRI detectors[46] and the low density of thermal noise in the low-frequency operating range (tens of kiloHertz) may result in usable SNR approaching that of mid-field conventional instruments. Further, the ultra-low field technologies enable electron spin resonance detection, and potentially imaging, at safe operating frequencies.[47] Research with atomic magnetometers has addressed the possibility of cheap and portable MRI instruments without a large magnet.[48][49]

MRI versus CT
The use of X-rays, a type of ionizing radiation, in computed tomography (CT) allows for examination of tissues composed of elements of a higher atomic number than the surrounding tissues. MRI, in contrast, uses non-ionizing radio frequency (RF) signals to acquire images and is best suited for soft tissue (although MRI can also be used to visualize bones, teeth[] and even fossils[]). Since CT scans use ionizing radiation (X-rays) to produce images, there is a risk of damage to DNA that can subsequently cause cancer. In 2007, it was estimated that 0.4% of current cancers in the United States were due to CTs performed in the past, and that in the future this figure may increase to as high as 1.52% based on past rates of CT usage.[] Unlike CT, MRI does not use ionizing radiation, although it is associated with other risks.[50] Contrast in CT images is generated purely by X-ray attenuation, while a variety of properties may be used to generate contrast in MR images. By varying the scanning parameters, tissue contrast can be altered to enhance different features in an image (see Applications for more details). Both CT and MR images may be enhanced by using contrast agents. Contrast agents for CT contain elements of a high atomic number relative to the tissue being investigated, such as iodine or barium, while contrast agents (such as gadolinium and manganese) for MRI have paramagnetic properties that are used to alter tissue relaxation times. Commonly used MRI contrast agents may be contraindicated in people with significant permanent or transient kidney dysfunction.[] CT and MRI scanners are able to generate multiple two-dimensional cross-sections (tomographs, or "slices") of tissue and three-dimensional reconstructions. MRI can generate cross-sectional images in any plane (including oblique planes). In the past, CT was limited to acquiring images in the axial plane (or near axial plane), and so these images were called Computed Axial Tomography scans (CAT scans). However, the development of multi-detector CT scanners with near-isotropic resolution allows the CT scanner to produce data that can be retrospectively reconstructed in any plane with minimal loss of image quality. For purposes of tumor detection and identification in the brain, MRI is generally superior.[51][52] However, in the case of solid tumors of the abdomen and chest, CT is often preferred as it less affected by motion artifacts. Furthermore, CT usually is more widely available, faster, and less expensive. MRI is also best suited for cases when a patient is to undergo several exams in the short term, since it does not expose the patient to the hazards of ionizing radiation. However MRI is usually contraindicated if the patient has any type of medical implant, such as vagus nerve stimulators, implantable cardioverter-defibrillators, loop recorders, insulin pumps, cochlear implants, deep brain stimulators, metallic foreign bodies (e.g., shrapnel or shell fragments), or metallic implants such as surgical prostheses. These devices can malfunction or heat up during an MRI scan, so CT scans are considered the safer option for these patients.[citation needed]

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Economics of MRI
Standard 1.5 tesla MRI scanners used to cost between US$1 million and US$1.5 million. Standard 3.0 tesla MRI scanners would often cost between US$2 million and US$2.3 million. Construction of MRI suites could cost up to US$500,000 or more, depending on project scope. PMRI scanners today now cost a great deal less, around US$50,000.[53] MRI scanners have become significant sources of revenue for healthcare providers in the US. This is because of favorable reimbursement rates from insurers and federal government programs. Insurance reimbursement is provided in two components, an equipment charge for the actual performance and operation of the MRI scan and a professional charge for the radiologist's review of the images and/or data. In the US Northeast, an equipment charge might be $3,500 and a professional charge might be $350,[54] although the actual fees received by the equipment owner and interpreting physician are often significantly less and depend on the rates negotiated with insurance Looking through an MRI scanner. companies or determined by the Medicare fee schedule. For example, an orthopedic surgery group in Illinois billed a charge of $1,116 for a knee MRI in 2007, but the Medicare reimbursement in 2007 was only $470.91.[55] Many insurance companies require advance approval of an MRI procedure as a condition for coverage. In the US, the Deficit Reduction Act of 2005 significantly reduced reimbursement rates paid by federal insurance programs for the equipment component of many scans, shifting the economic landscape. Many private insurers have followed suit.[citation needed] In the United States, an MRI of the brain with and without contrast billed to Medicare Part B entails, on average, a technical payment of US$403 and a separate payment to the radiologist of US$93.[56] In France, the cost of an MRI exam is approximately 150 euros. This covers three basic scans including one with an intravenous contrast agent as well as a consultation with the technician and a written report to the patient's physician. [citation needed] In Japan, the cost of an MRI examination (excluding the cost of contrast material and films) ranges from US$155 to US$180, with an additional radiologist professional fee of US$17.[57] In India, the cost of an MRI examination including the fee for the radiologist's opinion comes to around Rs 30004000 (US$5060), excluding the cost of contrast material.

Safety
A number of features of MRI scanning can give rise to risks. These include: Powerful magnetic fields Radio waves Cryogenic liquids Noise Claustrophobia.

In addition, in cases where MRI contrast agents are used, these also typically have associated risks.

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Overuse
Medical societies issue guidelines for when physicians should use MRI on patients and recommend against overuse. MRI can detect health problems or confirm a diagnosis, but medical societies often recommend that MRI not be the first procedure for creating a plan to diagnose or manage a patient's complaint. A common case is to use MRI to seek a cause of low back pain; the American College of Physicians, for example, recommends against this procedure as unlikely to result in a positive outcome for the patient.[][] Nevertheless, MRI has the advantage of not utilizing ionizing radiation to create medical images, unlike other imaging modalities such as CT and conventional radiography.

Magnetic field

MR-Safe sign

MR-Conditional sign

MR-Unsafe sign Some types of medical implants are generally considered contraindications for MRI examinations, while others may be acceptable for patients under high specific MRI conditions. Patients are therefore always asked for complete information about all implants before entering the room for an MRI scan. Several deaths have been reported in patients with pacemakers who have undergone MRI scanning without appropriate precautions.[58] To reduce such risks, implants are increasingly being developed to make them able to be safely scanned,[59] and specialized protocols have been developed to permit the safe scanning of selected implants and pacing devices. Cardiovascular stents are considered safe, however.[60] Ferromagnetic foreign bodies such as shell fragments, or metallic implants such as surgical prostheses and ferromagnetic aneurysm clips are also potential risks. Interaction of the magnetic and radio frequency fields with such objects can lead to trauma due to movement of the object in the magnetic field or thermal injury from radio-frequency induction heating of the object.[61] Titanium and its alloys are safe from attraction and torque forces produced by the magnetic field, though there may be some risks associated with Lenz effect forces acting on titanium implants in sensitive areas within the subject, such as stapes implants in the inner ear. In the United States a classification system for implants and ancillary clinical devices has been developed by ASTM International and is now the standard supported by the US Food and Drug Administration: MR-Safe The device or implant is completely non-magnetic, non-electrically conductive, and non-RF reactive, eliminating all of the primary potential threats during an MRI procedure.

Magnetic resonance imaging MR-Conditional A device or implant that may contain magnetic, electrically conductive or RF-reactive components that is safe for operations in proximity to the MRI, provided the conditions for safe operation are defined and observed (such as 'tested safe to 1.5 teslas' or 'safe in magnetic fields below 500 gauss in strength'). MR-Unsafe Nearly self-explanatory, this category is reserved for objects that are significantly ferromagnetic and pose a clear and direct threat to persons and equipment within the magnet room. The very high strength of the magnetic field can also cause "missile-effect" accidents, where ferromagnetic objects are attracted to the center of the magnet, and there have been incidents of injury and death.[62][63] To reduce the risk of projectile accidents, ferromagnetic objects and devices are typically prohibited in the proximity of the MRI scanner and patients undergoing MRI examinations are required to remove all metallic objects, often by changing into a gown or scrubs, and ferromagnetic detection devices are used at some sites.[][64] There is no evidence for biological harm from even very powerful static magnetic fields.[65]

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Peripheral nerve stimulation (PNS)


The rapid switching on and off of the magnetic field gradients is capable of causing nerve stimulation. Volunteers report a twitching sensation when exposed to rapidly switched fields, particularly in their extremities.[66][67] The reason the peripheral nerves are stimulated is that the changing field increases with distance from the center of the gradient coils (which more or less coincides with the center of the magnet).[68] Although PNS was not a problem for the slow, weak gradients used in the early days of MRI, the strong, rapidly switched gradients used in techniques such as EPI, fMRI, diffusion MRI, etc. are indeed capable of inducing PNS. American and European regulatory agencies insist that manufacturers stay below specified dB/dt limits (dB/dt is the change in field per unit time) or else prove that no PNS is induced for any imaging sequence. As a result of dB/dt limitation, commercial MRI systems cannot use the full rated power of their gradient amplifiers.

Heating caused by absorption of radio waves


Every MRI scanner has a powerful radio transmitter to generate the electromagnetic field which excites the spins. If the body absorbs the energy, heating occurs. For this reason, the transmitter rate at which energy is absorbed by the body has to be limited (see Specific absorption rate).

Acoustic noise
Switching of field gradients causes a change in the Lorentz force experienced by the gradient coils, producing minute expansions and contractions of the coil itself. As the switching is typically in the audible frequency range, the resulting vibration produces loud noises (clicking or beeping). This is most marked with high-field machines[69] and rapid-imaging techniques in which sound pressure levels can reach 120 dB(A) (equivalent to a jet engine at take-off),[70] and therefore appropriate ear protection is essential for anyone inside the MRI scanner room during the examination.[71]

Cryogens
As described in Physics of Magnetic Resonance Imaging, many MRI scanners rely on cryogenic liquids to enable the superconducting capabilities of the electromagnetic coils within. Though the cryogenic liquids used are non-toxic, their physical properties present specific hazards.[citation needed] An unintentional shut-down of a superconducting electromagnet, an event known as "quench", involves the rapid boiling of liquid helium from the device. If the rapidly expanding helium cannot be dissipated through an external vent, sometimes referred to as a 'quench pipe', it may be released into the scanner room where it may cause displacement of the oxygen and present a risk of asphyxiation.[72]

Magnetic resonance imaging Oxygen deficiency monitors are usually used as a safety precaution. Liquid helium, the most commonly used cryogen in MRI, undergoes near explosive expansion as it changes from a liquid to gaseous state. The use of an oxygen monitor is important to ensure that oxygen levels are safe for patient/physicians. Rooms built for superconducting MRI equipment should be equipped with pressure relief mechanisms[73] and an exhaust fan, in addition to the required quench pipe. Because a quench results in rapid loss of cryogens from the magnet, recommissioning the magnet is expensive and time-consuming. Spontaneous quenches are uncommon, but a quench may also be triggered by an equipment malfunction, an improper cryogen fill technique, contaminants inside the cryostat, or extreme magnetic or vibrational disturbances.[74][75]

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Contrast agents
The most commonly used intravenous contrast agents are based on chelates of gadolinium. In general, these agents have proved safer than the iodinated contrast agents used in X-ray radiography or CT. Anaphylactoid reactions are rare, occurring in approx. 0.030.1%.[76] Of particular interest is the lower incidence of nephrotoxicity, compared with iodinated agents, when given at usual dosesthis has made contrast-enhanced MRI scanning an option for patients with renal impairment, who would otherwise not be able to undergo contrast-enhanced CT.[77] Although gadolinium agents have proved useful for patients with renal impairment, in patients with severe renal failure requiring dialysis there is a risk of a rare but serious illness, nephrogenic systemic fibrosis, which may be linked to the use of certain gadolinium-containing agents. The most frequently linked is gadodiamide, but other agents have been linked too.[78] Although a causal link has not been definitively established, current guidelines in the United States are that dialysis patients should only receive gadolinium agents where essential, and that dialysis should be performed as soon as possible after the scan to remove the agent from the body promptly.[79][80] In Europe, where more gadolinium-containing agents are available, a classification of agents according to potential risks has been released.[81][82] Recently, a new contrast agent named gadoxetate, brand name Eovist (US) or Primovist (EU), was approved for diagnostic use: this has the theoretical benefit of a dual excretion path.[83]

Pregnancy
No effects of MRI on the fetus have been demonstrated.[84] In particular, MRI avoids the use of ionizing radiation, to which the fetus is particularly sensitive. However, as a precaution, current guidelines recommend that pregnant women undergo MRI only when essential. This is particularly the case during the first trimester of pregnancy, as organogenesis takes place during this period. The concerns in pregnancy are the same as for MRI in general, but the fetus may be more sensitive to the effectsparticularly to heating and to noise. However, one additional concern is the use of contrast agents; gadolinium compounds are known to cross the placenta and enter the fetal bloodstream, and it is recommended that their use be avoided.[citation needed] Despite these concerns, MRI is rapidly growing in importance as a way of diagnosing and monitoring congenital defects of the fetus because it can provide more diagnostic information than ultrasound and it lacks the ionizing radiation of CT. MRI without contrast agents is the imaging mode of choice for pre-surgical, in-utero diagnosis and evaluation of fetal tumors, primarily teratomas, facilitating open fetal surgery, other fetal interventions, and planning for procedures (such as the EXIT procedure) to safely deliver and treat babies whose defects would otherwise be fatal.[citation needed]

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Claustrophobia and discomfort


Despite being painless, MRI scans can be unpleasant for those who are claustrophobic or otherwise uncomfortable with the imaging device surrounding them. Older closed bore MRI systems have a fairly long tube or tunnel. The part of the body being imaged must lie at the center of the magnet, which is at the absolute center of the tunnel. Because scan times on these older scanners may be long (occasionally up to 40 minutes for the entire procedure), people with even mild claustrophobia are sometimes unable to tolerate an MRI scan without management. Some modern scanners have larger bores (up to 70cm) and scan times are shorter. This means that claustrophobia could be less of an issue, and more patients may now find MRI to be a tolerable procedure.[citation needed] Nervous patients may find the following strategies helpful: Advance preparation visiting the scanner to see the room and to practice lying on the table visualization techniques chemical sedation general anesthesia Coping while inside the scanner having a loved one in the room to hold hands, give reassurance, etc. holding a "panic button" closing the eyes as well as covering them (e.g., with a washcloth or eye mask) Many newer MRI systems place a diagonal mirror above the eyes to allow the patient to look down the tunnel rather than at the bore wall immediately above their face.[citation needed] Alternative scanner designs, such as open or upright systems, can also be helpful where these are available. Though open scanners have increased in popularity, they produce inferior scan quality because they operate at lower magnetic fields than closed scanners. However, commercial 1.5 tesla open systems have recently become available, providing much better image quality than previous lower field strength open models.[85] For babies and other young children, chemical sedation or general anesthesia are the norm, as these subjects cannot be expected or instructed to hold still during the scanning session. Obese patients and pregnant women may find the MRI machine to be a tight fit. Pregnant women may also have difficulty lying on their backs for an hour or more without moving.[citation needed]

Guidance
Safety issues, including the potential for biostimulation device interference, movement of ferromagnetic bodies, and incidental localized heating, have been addressed in the American College of Radiology's White Paper on MR Safety, which was originally published in 2002 and expanded in 2004. The ACR White Paper on MR Safety has been rewritten and was released early in 2007 under the new title ACR Guidance Document for Safe MR Practices [86]. In December 2007, the Medicines and Healthcare Products Regulatory Agency (MHRA), a UK healthcare regulatory body, issued their Safety Guidelines for Magnetic Resonance Imaging Equipment in Clinical Use [87]. In February 2008, the Joint Commission, a US healthcare accrediting organization, issued a Sentinel Event Alert #38 [88] , their highest patient safety advisory, on MRI safety issues. In July 2008, the United States Veterans Administration, a federal governmental agency serving the healthcare needs of former military personnel, issued a substantial revision to their MRI Design Guide,[89] which includes physical and facility safety considerations.

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The European Physical Agents Directive


The European Physical Agents (Electromagnetic Fields) Directive is legislation adopted by the European Parliament and Council on 29 April 2004. Originally scheduled to be required by the end of 2008, each individual state within the European Union must include this directive in its own law by the end of 2012. Some member nations passed complying legislation and are now attempting to repeal their state laws in expectation that the final version of the EU Physical Agents Directive will be substantially revised prior to the revised adoption date.[citation needed] The directive applies to occupational exposure to electromagnetic fields (not medical exposure) and was intended to limit workers acute exposure to strong electromagnetic fields, as may be found near electricity substations, radio or television transmitters or industrial equipment. However, the regulations impact significantly on MRI, with separate sections of the regulations limiting exposure to static magnetic fields, changing magnetic fields and radio frequency energy. Field strength limits are given, which may not be exceeded. An employer may commit a criminal offense by allowing a worker to exceed an exposure limit, if that is how the directive is implemented in a particular member state.[citation needed] The directive is based on the international consensus of established effects of exposure to electromagnetic fields, and in particular the advice of the European Commissions's advisor, the International Commission on Non-Ionizing Radiation Protection (ICNIRP). The aims of the Directive, and the ICNIRP guidelines it is based on, are to prevent exposure to potentially harmful fields. The actual limits in the directive are very similar to the limits advised by the Institute of Electrical and Electronics Engineers, with the exception of the frequencies produced by the gradient coils, where the IEEE limits are significantly higher.[citation needed] Many Member States of the EU already have either specific EMF regulations or (as in the UK) a general requirement under workplace health and safety legislation to protect workers against electromagnetic fields. In almost all cases the existing regulations are aligned with the ICNIRP limits so that the directive should, in theory, have little impact on any employer already fulfilling the legal responsibilities.[citation needed] The introduction of the directive has brought to light an existing potential issue with occupational exposures to MRI fields. There are at present very few data on the number or types of MRI practice that might lead to exposures in excess of the levels of the directive.[90][91] There is a justifiable concern amongst MRI practitioners that if the directive were to be enforced more vigorously than existing legislation, the use of MRI might be restricted, or the working practices of MRI personnel might have to change. In the initial draft a static field strength limit of 2 T was specified. This has since been removed from the regulations, and whilst it is unlikely to be restored without a strong justification, some restriction on static fields may be reintroduced after the matter has been considered more fully by ICNIRP. The effect of such a limit might be to restrict the installation, operation and maintenance of MRI scanners with magnets of 2 T and stronger. As the increase in field strength has been instrumental in developing higher resolution and higher performance scanners, this would be a significant step back.[citation needed] Individual government agencies and the European Commission have now formed a working group to examine the implications of the directive on MRI and to try to address the issue of occupational exposures to electromagnetic fields from MRI.[citation needed]

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References
[20] http:/ / patft. uspto. gov/ netacgi/ nph-Parser?Sect1=PTO1& Sect2=HITOFF& d=PALL& p=1& u=%2Fnetahtml%2FPTO%2Fsrchnum. htm& r=1& f=G& l=50& s1=4,307,343. PN. & OS=PN/ 4,307,343& RS=PN/ 4,307,343 [21] http:/ / icmic. rad. jhmi. edu/ icmicpersonnel/ BIOBottomleyP. pdf [26] "T1 Weighted" (http:/ / www. mr-tip. com/ serv1. php?type=db1& dbs=T1 Weighted), www.mr-tip.com [30] http:/ / www. trauma. org/ archive/ neuro/ cpp. html [46] http:/ / www. freshpatents. com/ -dt20110901ptan20110210738. php [47] NASA Technical Brief (http:/ / www. techbriefs. com/ component/ content/ article/ 6598) [54] Stamford Hospital price quotation October 2008, Stamford CT US [56] Current Procedural Terminology code #70553 "2010 Medicare Part B National Summary Data File" (https:/ / explore. data. gov/ Health-and-Nutrition/ Part-B-National-Summary-Data-File-CY2010/ 5vgw-8z3q). Data.gov, An Official Website of the United States Government. [62] Randal C. Archibold, " Hospital Details Failures Leading to M.R.I. Fatality (http:/ / query. nytimes. com/ gst/ fullpage. html?res=9C04E4D91731F931A1575BC0A9679C8B63)," The New York Times, August 22, 2001 [63] Donald G. McNeil Jr, " M.R.I.'s Strong Magnets Cited in Accidents (http:/ / www. nytimes. com/ 2005/ 08/ 19/ health/ 19magnet. html)," The New York Times, August 19, 2005. [69] "The Evolution of Magnetic Resonance Imaging: 3T MRI in Clinical Applications" (http:/ / www. eradimaging. com/ site/ article. cfm?ID=426), Terry Duggan-Jahns, www.eradimaging.com [71] The Open University 2007: Understanding Cardiovascular Diseases, course book for the lesson SK121 Understanding cardiovascular diseases (http:/ / www3. open. ac. uk/ courses/ bin/ p12. dll?C01SK121), printed by Cambridge University Press, ISBN 978-0-7492-2677-0 (can be found at OUW (http:/ / www. ouw. co. uk/ )), pages 220 and 224. [73] International Electrotechnical Commission 2008: Medical Electrical Equipment Part 2-33: Particular requirements for basic safety and essential performance of magnetic resonance equipment for medical diagnosis, manufacturers' trade standards (http:/ / webstore. iec. ch/ Webstore/ webstore. nsf/ 0/ EC11496F487C406DC125742C000B2805), published by International Electrotechnical Commission, ISBN 2-8318-9626-6 (can be found for purchase at ). [77] " ACR guideline (http:/ / www. guideline. gov/ summary/ summary. aspx?doc_id=8283), 2005" [80] " FDA Public Health Advisory: Gadolinium-containing Contrast Agents for Magnetic Resonance Imaging (http:/ / www. fda. gov/ cder/ drug/ advisory/ gadolinium_agents. htm)" [81] (http:/ / www. mhra. gov. uk/ home/ idcplg?IdcService=GET_FILE& dID=35149& noSaveAs=0& Rendition=WEB) [86] http:/ / www. acr. org/ SecondaryMainMenuCategories/ quality_safety/ MRSafety/ safe_mr07. aspx [87] http:/ / www. mhra. gov. uk/ home/ idcplg?IdcService=GET_FILE& dDocName=CON2033065& RevisionSelectionMethod=LatestReleased [88] http:/ / www. jointcommission. org/ SentinelEvents/ SentinelEventAlert/ sea_38. htm [91] HSE 2007, RR570:Assessment of electromagnetic fields around magnetic resonance (MRI) equipment (http:/ / www. hse. gov. uk/ research/ rrpdf/ rr570. pdf). MCL-T Ltd, London

Further reading
Guadalupe Portal; Aliosvi Rodriguez Whole body magnetic resonance imaging in early diagnosis in Trinidad BMJ (2010) ISSN 1756-1833 url = http://www.bmj.com/rapid-response/2011/12/19/ re-whole-body-magnetic-resonance-imaging Simon, Merrill; Mattson, James S (1996). The pioneers of NMR and magnetic resonance in medicine: The story of MRI. Ramat Gan, Israel: Bar-Ilan University Press. ISBN0-9619243-1-4. Haacke, E Mark; Brown, Robert F; Thompson, Michael; Venkatesan, Ramesh (1999). Magnetic resonance imaging: Physical principles and sequence design. New York: J. Wiley & Sons. ISBN0-471-35128-8. Lee SC, Kim K, Kim J, et al. (June 2001). "One micrometer resolution NMR microscopy". J. Magn. Reson. 150 (2): 20713. Bibcode: 2001JMagR.150..207L (http://adsabs.harvard.edu/abs/2001JMagR.150..207L). doi: 10.1006/jmre.2001.2319 (http://dx.doi.org/10.1006/jmre.2001.2319). PMID 11384182 (http://www.ncbi. nlm.nih.gov/pubmed/11384182).

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External links
A Peer-Reviewed, Critical Introduction (http://www.magnetic-resonance.org/). European Magnetic Resonance Forum (EMRF)/The Round Table Foundation (TRTF); Peter A. Rinck (editor) A Guided Tour of MRI: An introduction for laypeople (http://www.magnet.fsu.edu/education/tutorials/ magnetacademy/mri/) National High Magnetic Field Laboratory The Basics of MRI (http://www.cis.rit.edu/htbooks/mri/). Underlying physics and technical aspects. Video: What to Expect During Your MRI Exam (http://www.imrser.org/PatientVideo.html) from the Institute for Magnetic Resonance Safety, Education, and Research (IMRSER) International Society for Magnetic Resonance in Medicine (http://www.ismrm.org) Srinivas M, Heerschap A, Ahrens ET, Figdor CG, de Vries IJ (July 2010). "(19)F MRI for quantitative in vivo cell tracking" (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2902646). Trends Biotechnol. 28 (7): 36370. doi: 10.1016/j.tibtech.2010.04.002 (http://dx.doi.org/10.1016/j.tibtech.2010.04.002). PMC 2902646 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2902646). PMID 20427096 (http://www.ncbi. nlm.nih.gov/pubmed/20427096). Blue Plaque commemorating the manufacture of the first commercial MRI whole body scanner at Osney Mead, Oxford (http://www.oxfordshireblueplaques.org.uk/plaques/mri.html) Royal Institution Lecture MRI: A Window on the Human Body (http://www.vega.org.uk/video/ programme/73) Animal Imaging Database (AIDB) (http://aidb.crbs.ucsd.edu/sand/index.jsp) How MRI works explained simply using diagrams (http://www.howequipmentworks.com/physics/ medical_imaging/mri/magnetic_resonance_imaging.html)

Master of Science in Nursing


A Master of Science in Nursing (MSN) is an advanced-level postgraduate degree for registered nurses and is considered an entry-level degree for nurse educators and managers. The degree also may prepare a nurse to seek a career as a nurse administrator, health policy expert, or clinical nurse leader. The MSN may be used as a prerequisite for doctorate-level nursing education, and previously was required to become an advanced practice registered nurse such as a nurse practitioner, clinical nurse specialist, nurse anesthetist, or nurse midwife. The master's level advanced practice registered nurse programs have already, or are in the process of, transitioning to the requirements of the Doctor of Nursing Practice. This graduate-level degree may focus on one or more of many different advanced nursing specialties such as acute care, adult, family, geriatrics, neonatal, palliative care, pediatric, psychiatric, obstetrics and gynecological nursing, etc.

External links
CCNE - Commission on Collegiate Nursing Education [1] - Accrediting body that "ensures the quality and integrity of baccalaureate and graduate education programs preparing effective nurses."

References
[1] http:/ / www. aacn. nche. edu/ Accreditation/

Master of Social Work

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Master of Social Work


The Master of Social Work (MSW) is a master's degree in the field of social work.

Canada
In Canada, the MSW is considered a professional master's degree and is offered through a number of different universities. Most schools are accredited by the Canadian Association of Schools of Social Work (C.A.S.W.E). All students entering an MSW program are required to have a recognized bachelor degree in a related field. Generally, students with a Bachelor of Social Work would enroll in a 1-year program, whereas those with other undergraduate degrees (Bachelor of Arts, Bachelor of Science, etc.) would enroll in a 2-year program. The oldest social work program in Canada is offered at the University of Toronto through the Factor-Inwentash Faculty of Social Work. Social work students at the UofT choose from a number of specializations (i.e. gerontology, children and their families, mental health, social service administration, social justice and diversity), and have opportunities to pursue their MSW's with a variety of collaborative programs, such as Addiction Studies, Sexual Diversity Studies, and Asia-Pacific Studies, to name a few.[1][2] Students could also pursue their MSW degrees in combination with either a Master of Health Science or a Juris Doctor.[3] Canadian Universities that offer the MSW: Universit Laval Carleton University Wilfrid Laurier University University of Toronto Ryerson University York University McGill University University of British Columbia University of Windsor University of Manitoba McMaster University Dalhousie University Memorial University Lakehead University University of Victoria University of Calgary Universit de Moncton

United Kingdom
In the United Kingdom, clinical social work suffered a decline after the 1980s following an internal professional battle regarding 'radical social work,' which attacked the alleged psychologising and individualising tendencies of 'casework'. Up to this point psychiatric social work had been a strong tradition with roots in psychoanalytic casework and psychoanalytic psychotherapy. Today, there is still a hunger among new entrants to social work, and many experienced practitioners, for a therapeutically oriented style of practice, but few training programmes offer in-depth experience or tuition of this kind. The Tavistock Clinic in London remains the leading centre for the study of clinically oriented social work and offers programmes up to and including Professional Doctorate level. The Journal of Social Work Practice represents the main organ of research and scholarly output in this area in the UK.

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United States
In the United States, MSW degrees must be received from a graduate school that has been approved by the Council on Social Work Education (CSWE) should the graduate seek future licensure. The MSW typically requires two years of full-time graduate study in combination with two years (900-1200 cumulative hours) of internship,[4] also referred to as field practicum, education, or experience. While some students obtain a Bachelor of Social Work (BSW) before pursuing a Master's, most MSW programs accept applicants with undergraduate degrees in a broad range of liberal arts degrees. Some MSW programs provide BSW graduates with an advanced standing option, allowing them to complete an MSW in a shorter period of time (typically 1 year). Most MSW programs allow students to choose a clinical or direct practice track, which focuses on direct practice with clients, or a macro practice track, with a focus on political advocacy, community organizing, policy analysis and/or human services management. While the clinical track tends to be more popular, there has been a resurgence in community practice concentrations recently. There are also opportunities at many universities to obtain joint degrees, such as an US MSW and a Public Administration degree, MSW and Public Health, or US MSW and Law. The MSW practice scope has broadened in recent years to include the specialty practice areas of geriatrics and work with veterans. In some schools the curriculum is based on a generalist model which integrates the facets of the various practice areas within social work. The MSW is considered a terminal practice degree in the field of social work. The DSW (Doctorate of Social Work) and Ph.D in social work are the final degrees offered in the field of social work. The DSW is considered the professional doctoral degree, while the Ph.D in social work is viewed as the research or academic doctoral degree. As most MSW graduates do not pursue a further degree in the field, there are few DSW programs available in the United States. Though Master of Social Work is by far the most common degree title used by graduate social work schools in the United States, it is not universal. For example, Columbia University School of Social Work offers an M.S. degree in social work, the School of Social Service Administration of the University of Chicago confers an M.A. degree, and the University of Texas confers the MSSW (Master of Science in Social Work) degree. The Mandel School of Applied Social Sciences at Case Western Reserve University confers the MSSA (Master of Science in Social Administration) degree. Clark Atlanta University's Whitney M. Young School of Social work is also credited with creating the administration of social work from the "Afro-centric" perspective. Clark Atlanta's school of social work has also had various stalwarts in the profession affiliated with it such as W.E.B. DuBois, Dorcas Bowles, Whitney Young, Hattie Mitchell, Naomi Ward and Rufus Lynch.

References
[1] http:/ / www. socialwork. utoronto. ca/ programs/ msw/ 2year/ yr2. htm [2] http:/ / www. socialwork. utoronto. ca/ programs/ msw/ mswcollab. htm [3] http:/ / www. socialwork. utoronto. ca/ programs/ msw/ mswcombined. htm

External links
Association of Social Work Boards (http://www.aswb.org/) Council on Social Work Education (http://www.cswe.org/) National Association of Social Workers (http://www.socialworkers.org/) The New Social Worker Magazine (http://www.socialworker.com/)

Medical laboratory scientist

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Medical laboratory scientist


Medical laboratory scientist

Medical Laboratory Scientist at the National Institutes of Health preparing DNA samples. Occupation Names Medical/Clinical Laboratory Scientist Medical/Clinical Laboratory Technologist Medical Technologist

Activity sectors

Allied Health, Biomedical research Description

Competencies

Analytical skills, quality control and knowledge of laboratory medicine and technology. Associate of Science in Medical Technology (Technician) Bachelor of Science in Medical Technology (Technologist/Scientist) Master of Science often for Education/Management Roles Doctor of Philosophy often for Management/Directorship Roles

Education required

A medical laboratory scientist (MLS) (also referred to as a medical technologist, a clinical scientist, or clinical laboratory technologist) is a healthcare professional who performs chemical, hematological, immunologic, microscopic, and bacteriological diagnostic analyses on body fluids such as blood, urine, sputum, stool, cerebrospinal fluid (CSF), peritoneal fluid, pericardial fluid, and synovial fluid, as well as other specimens. Medical laboratory scientists work in clinical laboratories at hospitals, doctor's offices, reference labs, and biotechnology labs.

Educational requirements
In the United States, a medical laboratory scientist (MLS), or Medical Technologist (MT) typically earns a bachelor's degree in clinical laboratory science, biomedical science, medical technology or in a life / biological science (biology, biochemistry, microbiology, etc.), in which case certification from an accredited training program is also required. In most four-year medical laboratory degree programs, the student attends classroom courses for three years and clinical rotations are completed in their final year of study. This combination is called a 3+1 program. There are also 2+2 programs which specialize in accepting students who have completed their lower division coursework and completing their last two years of study in the CLS program. A 4+1 program would typically be completed after a student has completed a bachelor's degree and usually takes place primarily in a clinical site rather than a college. In clinical rotations, the student experiences hands-on learning in each discipline of the laboratory

Medical laboratory scientist and, under supervision, performs diagnostic testing in a functioning laboratory. With limited compensation, a student in the clinical phase of training usually works 40 hours per week for 20 to 52 weeks, experiencing work as a full-time employee. In the United States, a similar two-year degree qualifies the graduate to work as a medical laboratory technician (MLT). Depending on the state where employment is granted, the job duties are very similar, but MLTs receive training more exclusively in laboratory sciences without the basic science coursework the MLS often takes. The shorter training time is attractive to many students, but there are disadvantages to this route. For example, MT's, MLS's and CLSs usually earn higher salaries than MLTs, and some institutions do not employ MLTs at all. In the United States, the term medical laboratory technician (MLT) may apply to persons who are trained to operate equipment and perform tests under the supervision of the certified medical technologist or laboratory scientist in their departments. The entry-level for most medical laboratory technicians is an associate degree and some states require license which can be acquired after completing necessary education and clinical requirements.[1] In Canada, three-year college programs are offered that include seven semesters, two of them comprising an unpaid internship. The student graduates before taking a standard examination (such as the Canadian Society for Medical Laboratory Science, or CSMLS, exam) to be qualified as a medical laboratory technologist.[2] Many MLTs go on to receive a bachelor of science degree after they are certified, but a few university programs affiliate with a college MLT program to allow students to graduate with both MLT certification and a degree.

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Certification and licensing


Medical laboratory scientists who are certified and in good standing with the approved National Medical Laboratory Science Council or the American Society for Clinical Pathology (ASCP) are entitled to use the credential "MLS" after their names. They are entitled to use the title "Scientist." Formerly before the merger between ASCP and the National Credentialing Agency for Laboratory Personnel (NCA), medical laboratory scientists certified by (ASCP) were entitled to use the credential "MT" (for medical technologist)[3][4] and if credentialed by (NCA), the credential "CLS" (Clinical Laboratory Scientist) was used.[5] Those certified by the Department of Health Services (HHS MLS foraging for cells. formally HEW), the American Association of Bioanalysts (AAB) and the American Medical Technologists (AMT) are still entitled to use the credential "MT."[6] Additional certifying agencies include the National Healthcareer Association, National Phlebotomy Association, the National Center for Competency Testing, and the Accrediting Bureau of Health Education Schools. However the NCA and ASCP have now merged into the major certification agency.[7] In the United States, the Clinical Laboratory Improvement Amendments (CLIA '88) define the level of qualification required to perform tests of various complexity.[8] Clinical Laboratory Scientists, Medical Technologists and Medical Laboratory Scientists are the highest level of qualification, and are generally qualified to perform the most complex clinical testing including HLA testing (also known as tissue typing) and blood type reference testing. In addition to the national certification, 12 states (California, Florida, Georgia, Hawaii, Louisiana, Montana, Nevada, North Dakota, Rhode Island, Tennessee, West Virginia and New York) and Puerto Rico also require a state license. Minnesota, Texas, Illinois, Massachusetts, Michigan, Vermont, Washington, New Jersey, Iowa, Utah, Ohio, South Carolina, Wyoming, Pennsylvania, Virginia, South Dakota, Delaware, Missouri, and Alaska are currently attempting to obtain licensure. All states require documentation from a professional certification agency before issuing state

Medical laboratory scientist certification. A person applying for state certification may also be expected to submit fingerprints, education and training records, and competency certification. Some states also require completion of a specified number of continuing education contact hours prior to issuing or renewing a license. Some states recognize another state's license if it is equal or more stringent, but currently California does not recognize any other state license.[9] In the UK, medical laboratory scientists are known as "biomedical scientists" and must hold an honours degree from a university accredited by the Institute of Biomedical Science before they can embark upon a period of in-house training of at least 1 year before being assessed by the IBMS for state registration purposes. The title "biomedical scientist" is a protected title and can only be used by a person registered on the Health Professions Council register.T

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Specialty areas
Most Medical Laboratory Scientists are generalists, skilled in all areas of the clinical laboratory. However some are specialists, qualified by unique undergraduate education or additional training to perform more complex analyses than usual within a specific field. Specialties include clinical biochemistry, hematology, coagulation, microbiology, bacteriology, toxicology, virology, parasitology, mycology, immunology, immunohematology (blood bank), histopathology, histocompatibility, cytopathology, genetics, cytogenetics, electron microscopy, and IVF labs. Medical Technologists specialty may use additional credentials, such as "SBB" (Specialist in Blood Banking) from the American Association of Blood Banks, or "SH" (Specialist in Hematology) from the ASCP. These additional notations may be appended to the base credential, for example, "MLS(ASCP)SBB". In the United States, Medical Laboratory Scientists can be certified and employed in infection control. These professionals monitor and report infectious disease findings to help limit iatrogenic and nosocomial infections. They may also educate other healthcare workers about such problems and ways to minimize them.[10]

Further education
A Medical Laboratory Scientist may pursue higher education to advance or further specialize in their career. Master of Science, Master of Business Administration, Master of Health Administration for specialization, education and management roles. Doctor of Philosophy for management and directorship roles in the clinical laboratory as well as for academic research and professorship.

Job duties
Medical Laboratory Scientists work in all areas of the clinical laboratory including blood banking, chemistry, hematology, immunology, histology and microbiology. They perform a full range of laboratory tests from simple prenatal blood tests, to more complex tests to uncover diseases such as HIV/AIDS, diabetes, and cancer. They are also responsible for confirming the accuracy of test results, and reporting laboratory findings to pathologists and other physicians. The information that a Medical Laboratory Scientist gives to the doctor influences the medical treatment a patient will receive. Medical Laboratory Scientists operate complex electronic equipment, computers, and precision instruments costing millions of dollars.[11]
MLS in his work environment.

Medical laboratory scientist A Medical Laboratory Scientist analyzes human fluid samples using techniques available to the clinical laboratory, such as manual white blood cell differentials, bone marrow counts, analysis via microscopy, and advanced analytical equipment. Medical Laboratory Scientists assist doctors and nurses in choosing the correct lab tests and ensure proper collection methods. Medical Laboratory Scientists then receive the patient specimens, analyze the specimens, interpret and report results. A Pathologist may confirm a diagnostic result, but often the Medical Laboratory Scientist is responsible for interpreting and communicating critical patient results[12] to the physician. Medical Laboratory Scientists must recognize anomalies in their test results and know how to correct problems with the instrumentation. They monitor, screen, and troubleshoot analyzers featuring the latest technology available on the market. The MLS performs equipment validations, calibrations, quality controls, "STAT" or run-by-run assessment, statistical control of observed data, and recording normal operations. To maintain the integrity of the laboratory process, the medical laboratory scientist recognizes factors that could introduce error and rejects contaminated or sub-standard specimens, as well as investigates discrepant results. Common tests performed by Medical Laboratory Scientists are complete blood count (CBC), comprehensive metabolic panel (CMP), electrolyte panel, liver function tests (LFT), renal function tests (RFT), thyroid function test (TFT), urinalysis, coagulation profile, lipid profile, blood type, semen analysis (for fertility and post-vasectomy studies), serological studies and routine cultures. In some facilities that have few phlebotomists, or none at all, (such as in rural areas) Medical Laboratory Scientists may perform phlebotomy on patients, as this skill is part of the clinical training.

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Role in the healthcare process


A Medical Laboratory Scientist's role is to provide accurate laboratory results in a timely manner. Safeguards, such as experimental controls, calibration of laboratory instruments, delta checks (monitoring of significant changes within a normal series of results, formerly known as the "previous patients check"[13]), and periodic surveys from the College of American Pathologists (CAP), ensure accuracy. Laboratory results aid clinical practitioners in confirming or ruling out diagnoses, monitoring chronic disease changes, and analyzing the effects of medical therapies. Case to case study of patient care & prognostic value.

Job title
The informal abbreviations of job titles may be a source of confusion. Medical Laboratory Scientist (ASCP) and Medical Technologists (AMT) or (AAB) are often called "med techs" (based on the era in which they were known as "medical technologists"), but this shorthand term is shared by other healthcare employees, including pharmacy techs, x-ray techs and, formerly, respiratory techs, (now called respiratory therapists) and medical laboratory technicians (MLTs). There is a formal distinction between an MLT and an MT/CLS that is not always understood by others. Both may be certified or registered by one or more nationally-recognized professional organizations, but technicians have a two-year associates degree, and may have less classroom training than other professionals. MTs and CLSs have a bachelors degree and usually do more difficult, complex analyses than technicians are trained to do[citation needed]. Scientists and technologists generally earn a higher income than technicians do and have more opportunities for advancement.

Russian MLS prepares the analyses in ELISA laboratory

Medical laboratory scientist Much of the confusion could also be from the fact that the NCA and the ASCP certification agencies had different titles (clinical laboratory scientist and medical technologist respectively) but with the merging into a "newer" ASCP and that organization choosing the name "Medical Laboratory Scientist ", it can be said that finally the field has a "unified" title, however, the AMT still continues to use the title Medical Technologist.

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External links
[14] Canadian Society for Medical Laboratory Science [15] U.S. Department of Labor information on Clinical Laboratory Technologists and Technicians [16] American Association for Clinical Chemistry [17] American Society of Clinical Pathology [18] American Society of Clinical Laboratory Science [19] National Credentialing Agency for Laboratory Personnel [20] National Accrediting Agency for Clinical Laboratory Science [21] Medical Technologist Continuing Education [22] AIMS: Australian Institute of Medical Scientists [23] New Zealand Institute of Medcial Laboratory Science [24]

Greek Association of Medical Laboratory Technologists [25]

References
[1] [2] [3] [4] [5] [6] (http:/ / www. pulseuniform. com/ nursing/ medical-technicians. asp) ASCP certification requirements (http:/ / www. ascp. org/ FunctionalNavigation/ certification/ GetCertified/ TechnicianCertification. aspx) ASCP career information (http:/ / www. ascp. org/ certification/ CertifyingExaminations/ ) AAB certification requirements (http:/ / www. aab. org/ mt. htm) National Credentialing Agency for Laboratory Personnel (http:/ / www. nca-info. org/ ) Letter to the editor of [[Advance for Medical Laboratory Professionals (http:/ / community. advanceweb. com/ blogs/ mt_1/ archive/ 2009/ 10/ 19/ letter-to-the-editor-amt-s-view-of-the-ascp-nca-merger. aspx)] from the executive director of AMT] [7] (http:/ / www. ascp. org/ MainMenu/ AboutASCP/ Newsroom/ NewsReleases/ ASCP-BOR-and-NCA-Form-Single-Certification-Agency. aspx) [8] Clinical Laboratory Improvement Amendments (http:/ / www. fda. gov/ cdrh/ clia/ ) [9] ASCLS licensing information (http:/ / www. ascls. org/ jobs/ grads/ personnel_licensure. asp) [10] [\http:/ / www. cbic. org/ certification/ candidate-handbook/ 2012-eligibility-requirements] [11] http:/ / www. ascp. org/ pdf/ TheMedicalTechnologistandMedicalLaboratoryTechnician. aspx [12] Responsibilities of Medical Laboratory Scientist (http:/ / www. medicallaboratory-technician. com/ medical-lab-technician-new-career-prospects/ ) [13] Arkansas State University Hematology Course Overview (http:/ / www. clt. astate. edu/ wwilliam/ hem_i_qa_qc. htm) [14] http:/ / www. naacls. org/ docs/ guide_dcls. pdf [15] http:/ / www. csmls. org [16] http:/ / www. bls. gov/ oco/ ocos096. htm [17] http:/ / www. aacc. org/ [18] http:/ / www. ascp. org/ [19] http:/ / www. ascls. org/ [20] http:/ / www. nca-info. org/ [21] http:/ / www. naacls. org/ [22] http:/ / www. labce. com/ medical_technologist. aspx [23] http:/ / www. aims. org. au/ c/ [24] http:/ / www. nzimls. org. nz/ [25] http:/ / www. petie. gr/

http://www.cms.hhs.gov/CLIA/10_Categorization_of_Tests.asp#TopOfPage http://dhi.health.state.nm.us/CLIA/index.php http://www.naacls.org/docs/guide_dcls.pdf

National Association of County and City Health Officials

1104

National Association of County and City Health Officials


There is also NACCHO (National Aboriginal Community Controlled Health Organisation)
Mission: Purpose: Formation: To be a leader, partner, catalyst, and voice for local public health departments. Health, equity, and security for all people in their communities 1960's

Membership: 2,800 local health departments Location: Website: Washington, DC www.naccho.org [1]

The National Association of County and City Health Officials ( NACCHO [1]) is the Washington, DC-based organization representing 2,800 local public health departments in the U.S. These city, county, metropolitan, district, and tribal departments work every day to protect and promote health and well-being for all people in their communities by coordinating programs and services that make it easier for people to be healthy and safe from public health emergencies.

Purpose
NACCHO provides leadership, up-to-date information, subject matter expertise, and other resources to strengthen local health departments program work in a wide array of public health and safety areas including the following: Community Health topics such as chronic disease prevention, tobacco control, health and disability, infectious disease prevention and control, immunization, injury prevention, maternal and child health, adolescent health, and health equity. Environmental Health topics such as the public health effects of climate change, food safety, environmental health tracking and assessment, and environmental justice. Public Health Infrastructure and Systems topics such as: accreditation and quality improvement, community health status indicators, public health informatics, performance standards, public health law, and regionalization of public health services. Public Health Preparedness topics such as local readiness for pandemic influenza, Medical Reserve Corps, Project Public Health Ready, and Strategic National Stockpile. Local health departments look to NACCHO for the following: Grant assistance for emergency preparedness, food safety, HIV/AIDS prevention, and other programmatic work taking place at the local level. Resources and easy-to-use tools in many subject areas, including accreditation, epidemiology, healthy community design, influenza, emergency preparedness, and quality improvement. Regional and national training courses, meetings and conferences that help local health department staff connect to and learn from one another. Access to marketing and branding materials, such as the public health logo, that can help them raise the visibility and perceived value of governmental public health. Local health departments are encouraged to use the public health logo in their own communities to link their work to other health departments across the country. Advocacy with federal policymakers about the importance of allocating adequate resources for local public health; passage of sound public health legislation, and support of sensible policies to address the myriad of health challenges facing communities.

National Association of County and City Health Officials

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Vision
Health, equity, and security for all people in their communities

Mission
To be a leader, partner, catalyst, and voice for local public health departments.

History
The history of NACCHO dates back to the 1960s, with the formation of the National Association of County Health Officials (NACHO), an independent affiliate of the National Association of Counties. As the U.S. federal, state, and local public health systems continued to expand, NACHO combined with the U.S. Conference of Local Health Officers, an organization affiliated with the United States Conference of Mayors, to form the National Association of County and City Health Officials (NACCHO) in 1994. This unified organization more closely represents all governmental local health departments, including counties, cities, city/counties, districts, and townships. In 2001, NACCHO expanded its scope to include tribal public health agencies serving tribal communities on reservation lands and in 2012 to include counties and cities in the U.S. territories. Today, active membership in NACCHO continues to grow with about 1,500 local health departments.

Governance
NACCHO is governed by a 27-member Board of Directors composed of health officials from around the country elected by their peers, a representative for Tribal health departments, and ex-officio members representing the National Association of Counties, of which NACCHO is an affiliate, and the U.S. Conference of Mayors. The Board of Directors meets four times a year. The NACCHO Executive Committee includes four NACCHO officers and three Board members representing different geographic regions and population size. Approximately 380 NACCHO members serve on 40 committees and workgroups. Most committees meet by conference call and have one face-to-face meeting each year

Executive Director
Robert M. Pestronk became the executive director of NACCHO in November 2008. Mr. Pestronk received an MPH from the University of Michigan, School of Public Health with concentrations in human nutrition and health planning and administration. He received a BA in politics from Princeton University. Prior to his position at NACCHO, Mr. Pestronk served as Health Officer in Genesee County, Michigan for 22 years where, among other accomplishments, he was recognized for establishing the 26,000 member Genesee Health Plan, some of Michigans earliest public and work place tobacco control regulations, and Genesee Countys Public Health week conference; introducing a culture of efficacy, efficiency, accountability, and quality improvement within his department; reducing infant mortality rates and the racial disparity among those rates; increasing foundation and federal funding for the departments work; involving local residents and his board in three five-year cycles of successful departmental strategic planning; and creating productive relationships with university and community-based organizations. His health department was fully accredited by the state of Michigan. Mr. Pestronk has been honored by the University of Michigan, School of Public Health as a Distinguished Alumnus, and he was the first recipient of the John H Romani Award from the Department of Health Management and Policy at the School of Public Health. The American Lung Association, Genesee Valley, has honored him as Professional of the Year and subsequently as Health Advocate of the Year. Mr. Pestronks published work includes articles in the Journal of Public Health Management and Practice, the Journal of Law, Medicine & Ethics, the Journal of the American Public Health Association, Health Education and

National Association of County and City Health Officials Behavior, Public Health Reports, and the Journal of the American Academy of Nurse Practitioners. Chapters in books include those published by the American Public Health Association and Oxford University Press.
[2]

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1. http://www.naccho.org

References
[1] http:/ / www. naccho. org [2] References

National Board for Respiratory Care

1107

National Board for Respiratory Care


National Board for Respiratory Care
Type Industry Founded non-profit organization Health care 1960

Headquarters Olathe, Kansas, United States Area served Website United States http:/ / www. nbrc. org/

The National Board for Respiratory Care (NBRC) Inc. is a non-profit organization[1] formed in 1986 with the purpose of awarding and maintaining credentialing for Respiratory therapists in the United States. The NBRC is the only organization in the United States which develops certification examinations for Registered Respiratory Therapists (RRTs) and Certified Respiratory Therapists (CRTs). The NBRC also offers additional specialization credentialing for respiratory practitioners that hold its certifications. The CRT and RRT designations are the standard credential in respiratory care for licensure requirements in the portions of the United States that have enacted a Respiratory Care Act. States that license respiratory therapists sometimes require the practitioner to maintain their NBRC credentialing to maintain their license to practice.[] The NBRC is headquartered in Olathe, Kansas. It has been in the Kansas City metropolitan area since 1974. Both the NBRC and Applied Measurement Professionals, Inc. (AMP), are located at 18000 W. 105th St., Olathe, Kansas 66061-7543.[2]

Certification levels
Entry level certification
Certification is the entry level and is separated as such by the NBRC. Certified Respiratory Therapists and Certified Pulmonary Function Technologists require oversight and supervision by their advanced-practice counterparts.

Advanced practice certification


The term the NBRC uses to designate an advanced practitioner is "registered" and the addition to an advanced practitioner registry which is not permanent but has a re-certification fee associated with it. Registered Respiratory Therapist and Registered Pulmonary Function Technologist are currently the advanced credentialings maintained by the NBRC.

Specialties
The NBRC has sub-specialties for the Respiratory Therapist designations. Both the CRT and the RRT are eligible to sit for additional credentialing but the CRT still requires the same supervision by the RRT in clinical applications. Sleep Disorders Specialist The sleep disorder specialist (RRT-SDS or CRT-SDS) is a credential recognized by the American Academy of Sleep Medicine for the role of Scoring in sleep studies. Neonatal & Pediatric Specialist The neonatal and pediatric specialist (RRT-NPS or CRT-NPS) is a respiratory therapist that may work in advanced care in pediatrics and neonatology centers and units. Adult Critical Care Specialist The adult critical care specialist is only available to the RRT (RRT-ACCS) that is a pulmonary and hemodymanic specialist in intensive medicine in adult practice.

National Board for Respiratory Care

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Testing
The NBRC owns its own testing corporation, the for-profit company Applied Measurement Professionals.[3] AMP is a private stock corporation located in the Kansas City metropolitan area. AMP was incorporated in the state of Kansas in 1982 as a wholly owned subsidiary of the National Board for Respiratory Care (NBRC) Inc.

Examinations maintained by the NBRC


Respiratory Therapist NBRC-ELE The Entry Level Examination is the initial test that awards the Certified Respiratory Therapist credential. NBRC-WRE The Written Registry Examination is an advanced test used alongside the CSE to grant credential for the Registered Respiratory Therapist. NBRC-CSE The Clinical Simulation Examination is a test in which the test-taker accepts the role as an autonomous respiratory therapist handling all sorts of intervention and therapy. Specialization of the Respiratory Therapist NBRC-SSE Sleep Specialist Examination, an examination for Sleep Disorder Specialization. NBRC-ACCSE Adult Critical Care Specialist Examination NBRC-NPSE Neonatal and Pediatric Specialist Examination Pulmonary Function Technologist NBRC-CPFTE Certification examination for Pulmonary Function Technology NBRC-RPFTE Registry examination.

Related organizations
Institute for Credentialing Excellence (ICE) National Commission for Certifying Agencies (the NBRC maintains accreditation of its programs through this organization and ICE) American Association of Respiratory Care (AARC)[4] Commission on Accreditation of Allied Health Education Programs Commission on Accreditation for Respiratory Care Lambda Beta Society American Thoracic Society American Society of Anesthesiologists American College of Chest Physicians

National Board for Respiratory Care

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External links
National Board for Respiratory Care [5]

References
[1] [2] [3] [4] [5] http:/ / www. nbrc. org/ LinkClick. aspx?fileticket=HJdjQ3HXDg4%3d& tabid=57& mid=382 http:/ / www. nbrc. org/ Home/ AboutNBRC/ tabid/ 73/ Default. aspx http:/ / www. nbrc. org/ LinkClick. aspx?fileticket=pY3QCd7Ufq0%3D& tabid=57& mid=382 ; AMP website, http:/ / www. goamp. com/ . AARC website, http:/ / www. aarc. org/ http:/ / www. nbrc. org/

The New England Journal of Medicine

1110

The New England Journal of Medicine


The New England Journal of Medicine
Abbreviated title (ISO4) N. Engl. J. Med. Discipline Language Edited by Medicine English Jeffrey M. Drazen Publication details Publisher Publication history Massachusetts Medical Society (United States) The New England Journal of Medicine and Surgery (18121826); The New England Medical Review and Journal (1827); The Boston Medical and Surgical Journal (18281927); The New England Journal of Medicine (1928present) 51.658

Impact factor (2012)

Indexing ISSN [3] 0028-4793 (print) [1] 1533-4406 (web) Links Journal homepage [2]

The New England Journal of Medicine (NEJM) is an English-language peer-reviewed medical journal published by the Massachusetts Medical Society and it is among the most prestigious in the world. It describes itself as the oldest continuously published medical journal in the world.[7] The journal publishes editorials, papers on original research, review articles, correspondence, and case reports, and has a special section called "Images in Clinical Medicine".

The New England Journal of Medicine

1111

History
In September 1811, John Collins Warren, a Boston physician,[3] along with James Jackson, submitted a formal prospectus to establish the New England Journal of Medicine and Surgery and Collateral Branches of Science as a medical and philosophical journal.[4] Subsequently, the first issue of the New England Journal of Medicine and Surgery and the Collateral Branches of Medical Science was published in January 1812.[5] The journal was published quarterly.

January 1814 edition of the Journal.

On April 29, 1823, another publication, the Boston Medical Intelligencer, appeared under the stewardship of Jerome V.C. Smith.[][6]

1823 Boston Medical Intelligencer.

The New England Journal of Medicine

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The Intelligencer ran into financial troubles in the spring of 1827, and the editors of the New England Journal of Medicine and Surgery and the Collateral Branches of Medical Science purchased it in February 1828 merging the two publications to form the Boston Medical and Surgical Journal,[] published weekly. The Massachusetts Medical Society purchased it in 1921 for $1[7] and renamed it in 1928 the New England Journal of Medicine.

Logo
The journals logo depicts the Rod of Asclepius. The dates on the logo represent the founding of the components of the New England Journal of Medicine: 1812 for the New England Journal of Medicine and Surgery and Collateral Branches of Medical Science, 1823 for the Boston Medical Intelligencer, 1828 for the Boston Medical and Surgical Journal, and 1928 for the New England Journal of Medicine.

200th anniversary in 2012


Notable articles from the course of the New England Journal of Medicine's history include:
1828 Boston Medical and Surgical Journal.

In November 1846, Henry Jacob Bigelow, a Boston surgeon, reported a breakthrough in the search for surgical anesthetics with the first uses of inhaled ether in 1846. This allowed patients to remain sedated during operations ranging from dental extraction to amputation.[] "A patient has been rendered completely insensible during an amputation of the thigh, regain consciousness after a short interval," Bigelow wrote. "Other severe operations have been performed without the knowledge of the patients." In June 1906, James Homer Wright published an article that described how he stained and studied bone marrow with descriptions of what are now known as megakaryocytes and platelets.[] In October 1872, a lecture by C.E. Brown-Sequard was published that proposed the then-revolutionary idea that one cerebral hemisphere can influence both sides of the body. The neurologist would go on to describe what is now known as the Brown-Sequard syndrome.[] In June 1948, Sidney Farber reported promising results in treatment of early childhood leukemia. Based on anecdotal evidence that children with acute leukemia worsened if they were given folic acid, he worked on blocking folic acid metabolism. His team gave 16 infants and children with acute lymphoblastic leukemia a folic acid inhibitor, aminopterin - 10 showed improvement by clinical and hematologic parameters after three months.[] In his article, Farber advised receiving the results cautiously: "It is again emphasized that these remissions are temporary in character and that the substance is toxic and may be productive of even greater disturbances than have been encountered so far in our studies," he wrote. "No evidence has been mentioned in this report that would justify the suggestion of the term 'cure' of acute leukemia in children." In November 1952, cardiologist Paul Zoll published an early report on resuscitation of the heart. "The purpose of this report is to describe the successful use in 2 patients of a quick, simple, effective and safe method of arousing the heart from ventricular standstill by an artificial, external, electric pacemaker," he wrote. "For the first time it was possible to keep a patient alive during ventricular asystole lasting for hours to days. This procedure may prove valuable in many clinical situations."[] In February 1973, NEJM published the first report of polyp removal using a colonoscope and introduced a procedure during screening to reduce cancer risk. The authors reported on 218 patients, from whom they removed

The New England Journal of Medicine 303 polyps (at one or more procedures per patient).[] In December 1981, two landmark articles[][] described the clinical course of four patients - first reported in the CDC's June 1981 Morbidity and Mortality Weekly Reportwith the disease that would come to be known as AIDS. In April 2001, Druker et al. reported a targeted therapy for chronic myelogenous leukemia. Based on the knowledge that BCR-ABL, a constitutively activated tyrosine kinase, causes CML, the authors tested with success an inhibitor of this tyrosine kinase in patients who had failed first-line therapy. The finding helped begin the era of designing cancer drugs to target specific molecular abnormalities.[]

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Website
On April 25, 1996, NEJM announced their new website, which published each week the abstracts for research articles and the full text of editorials, cases, and letters to the editor. After print publishing for 184 years this was the NEJM's first use of the Internet for electronic publication.[] The website was launched several months earlier in 1996, but the editors wanted proof that weekly electronic publication would work. Only then was an announcement approved for publication on the editorial page. Two years later, online publication extended to include the full text of all articles.[8] Since its launch, NEJM has added to its website: Videos in Clinical Medicine, peer-reviewed educational videos to teach procedures requiring skilled techniques and specialized physical examination.[] Interactive Medical Cases, which mimic a clinical encounter by presenting the patient's history with results of the physical examination and laboratory and radiographic tests. Multiple-choice questions throughout test the taker's knowledge.[] NEJM Archive, the entire collection of the journal's published material.

Influence
The website for the George Polk Awards noted that its 1977 award to the New England Journal of Medicine "provided the first significant mainstream visibility for a publication that would achieve enormous attention and prestige in the ensuing decades."[9] The journal usually has the highest impact factor of the journals of clinical medicine (including the Journal of the American Medical Association, and The Lancet); in 2012, the impact factor was 51.658, according to the Journal Citation Reports, the first research journal to break 50.Wikipedia:VerifiabilityWikipedia:Citing sources#What information to include

Ingelfinger rule
The New England Journal of Medicine requires that articles it publishes not have been published or released elsewhere. Referred to as the Ingelfinger rule, this policy protects the originality of content. The rule was first described in a 1969 editorial by Franz Ingelfinger, the editor-in-chief at that time.[10] Most medical journals have similar rules in place.

Vioxx correction controversy


In the early 2000s, the New England Journal of Medicine was involved in a controversy around problems with research on the drug Vioxx. A study was published in the journal in November 2000 which noted an increase in myocardial infarction amongst those taking Vioxx.[11] According to Richard Smith, the former editor of the British Medical Journal, concerns about the correctness of that study were raised with the journal's editor, Jeff Drazen, as

The New England Journal of Medicine

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early as August 2001. That year, both the US Food and Drug Administration and the Journal of the American Medical Association also cast doubt on the validity of the data interpretation that had been published in the NEJM.[] Merck withdrew the drug from market in September 2004. In December 2005, NEJM published an expression of concern about the original study following discovery that the authors knew more about certain adverse events than they disclosed at the time of publication. From the Expression of Concern: "Until the end of November 2005, we believed that these were late events that were not known to the authors in time to be included in the article published in the Journal on November 23, 2000. It now appears, however, from a memorandum dated July 5, 2000, that was obtained by subpoena in the Vioxx litigation and made available to the Journal, that at least two of the authors knew about the three additional myocardial infarctions at least two weeks before the authors submitted the first of two revisions and 4 1/2 months before publication of the article."[] During the five-year period between publication and Expression of Concern, it has been estimated that Merck paid NEJM as much as US$836,000 for article reprints that Merck used for promotional purposes.[12] The journal was publicly rebuked for its response to the research issues in editorials appearing in publications including the British Medical Journal[] and the Journal of the Royal Society of Medicine.[]

Open access policy


NEJM provides delayed free online access to its research articles (it does so six months after publication, and maintains that access dating back to 1990).[13] This delay does not apply to readers from the least developed countries, for whom the content is available at no charge for personal use.[14] NEJM also has two podcast features, one with interviews of doctors and researchers that are publishing in the journal, and another summarizing the content of each issue. Other offerings include Continuing Medical Education, Videos in Clinical Medicine (showing videos of medical procedures), and the weekly Image Challenge.

Editors
Walter Prentice Bowers, 19211937 Robert Nason Nye, 19371947 Joseph Garland, 19471967 Franz J. Ingelfinger, 19671977 Arnold S. Relman, 19771991 Jerome P. Kassirer, 19911999 Marcia Angell, 19992000 Jeffrey M. Drazen, 2000present

References
[1] http:/ / www. worldcat. org/ issn/ 1533-4406 [2] http:/ / www. nejm. org/ [9] The George Polk Awards for Journalism (http:/ / www. brooklyn. liu. edu/ polk/ history. html) [11] . [12] Trudo Lemmens & Ron A. Bouchard, "Regulation of Pharmaceuticals in Canada" in Jocelyn Downie et al., eds., Canadian Health Law and Policy (Canada: LexisNexis, 2007) at 336. [13] . [14] .

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External links
Official website (http://www.nejm.org/) Mller, D. C.; Duff, E. M. C.; Stern, K. L. (2012). "Timeline: 200 Years of the New England Journal of Medicine". New England Journal of Medicine 366 (1): e3. doi: 10.1056/NEJMp1114819 (http://dx.doi.org/10. 1056/NEJMp1114819). PMID 22216863 (http://www.ncbi.nlm.nih.gov/pubmed/22216863).

Non-communicable disease
A non-communicable disease, or NCD, is a medical condition or disease, which by definition is non-infectious and non-transmissible among people. NCDs may be chronic diseases of long duration and slow progression, or they may result in more rapid death such as some types of sudden stroke. They include autoimmune diseases, heart disease, stroke, many cancers, asthma, diabetes, chronic kidney disease, osteoporosis, Alzheimer's disease, cataracts, and more. While sometimes (incorrectly) referred to as synonymous with "chronic diseases", NCDs are distinguished only by their non-infectious cause, not necessarily by their duration. Some chronic diseases of long duration, such as HIV/AIDS, are caused by transmissible infections. Chronic diseases require chronic care management as do all diseases that are slow to develop and of long duration. The World Health Organization (WHO) reports NCDs to be by far the leading cause of mortality in the world, representing over 60% of all deaths. Out of the 36 million people who died from NCDs in 2005, half were under age 70 and half were women.[1] Of the 57 million global deaths in 2008, 36 million were due to NCDs.[2] That is approximately 63% of total deaths worldwide. Risk factors such as a person's background, lifestyle and environment are known to increase the likelihood of certain NCDs. Every year, at least 5 million people die because of tobacco use and about 2.8 million die from being overweight. High cholesterol accounts for roughly 2.6 million deaths and 7.5 million die because of high blood pressure.

Causes and risk factors


Risk factors such as a person's background; lifestyle and environment are known to increase the likelihood of certain non-communicable diseases. They include age, gender, genetics, exposure to air pollution, and behaviours such as smoking, unhealthy diet and physical inactivity which can lead to hypertension and obesity, in turn leading to increased risk of many NCDs.Most NCDs are considered preventable because they are caused by modifiable risk factors. The WHO's World Health Report 2002 identified five important risk factors for non-communicable disease in the top ten leading risks to health. These are raised blood pressure, raised cholesterol, tobacco use, alcohol consumption, and overweight.The other factors associated with higher risk of NCDs include a person's economic and social conditions, also known as the "social determinants of health." It has been estimated that if the primary risk factors were eliminated, 80% of the cases of heart disease, stroke and type 2 diabetes and 40% of cancers could be prevented. Interventions targeting the main risk factors could have a significant impact on reducing the burden of disease worldwide. Efforts focused on better diet and increased physical activity have been shown to control the prevalence of NCDs "Environmental diseases" NCDs include many environmental diseases, covering a broad category of avoidable and unavoidable human health conditions caused by external factors, such as sunlight, nutrition, pollution, and lifestyle choices. The diseases of affluence are non-infectious diseases with environmental causes. Examples include: Many types of cardiovascular disease (CVD) Chronic obstructive pulmonary disease (COPD) caused by smoking tobacco Diabetes mellitus type 2

Non-communicable disease Lower back pain caused by too little exercise Malnutrition caused by too little food, or eating the wrong kinds of food (e.g. scurvy from lack of Vitamin C) Skin cancer caused by radiation from the sun

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Inherited diseases
Genetic disorders are caused by errors in genetic information that produce diseases in the affected people. The origin of these genetic errors can be: Spontaneous errors or mutations to the genome: A change in chromosome numbers, such as Down syndrome. A defect in a gene caused by mutation, such as Cystic fibrosis. An increase in the amount of genetic information, such as Chimerism or Heterochromia. Cystic fibrosis is an example of an inherited disease that is caused by a mutation on a gene. The faulty gene impairs the normal movement of sodium chloride in and out of cells, which causes the mucus-secreting organs to produce abnormally thick mucus. The gene is recessive, meaning that a person must have two copies of the faulty gene for them to develop the disease. Cystic fibrosis affects the respiratory, digestive and reproductive systems, as well as the sweat glands. The mucus secreted is very thick and blocks passageways in the lungs and digestive tracts. This mucus causes problems with breathing and with the digestion and absorption of nutrients. Inherited genetic errors from parents: Dominant genetic diseases, such as Huntingtons, require the inheritance of one erroneous gene to be expressed. Recessive genetic diseases, such as TaySachs, require the inheritance of two erroneous genes to be expressed.

NCDs and global health


Referred to as a lifestyle disease, because the majority of these diseases are preventable illnesses, the most common causes for non-communicable diseases (NCD) include tobacco use (smoking), alcohol abuse, poor diets (high consumption of sugar, salt, saturated fats, and trans fatty acids) and physical inactivity. Currently, NCD kills 36 million people a year, a number that by some estimates is expected to rise by 1724% within the next decade.Non-Communicable Diseases Deemed Development Challenge of Epidemic Proportions in Political Declaration Adopted During Landmark General Assembly Summit Historically, many NCDs were associated with economic development and were so-called a "diseases of the rich"The burden of non communicable diseases in developing countries.However, with an estimated 80% of the four main types of NCDs cardiovascular diseases, cancers, chronic respiratory diseases and diabetes now occurring in low- and middle-income countries.Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases and with two-thirds of people who are affected by diabetes now residing in developing nations, NCD can no longer be considered just a problem affecting affluent estimation of the economic impact of chronic noncommunicable diseases in selected countries.New WHO report: deaths from noncommunicable diseases on the rise, with developing world hit hardes.As previously stated, in 2008 alone, NCD's were the cause of 63% of deaths worldwide; a number that is expected to rise considerably in the near future if measures are not taken. If present growth trends are maintained, by 2020, NCDs will attribute to 7 out of every 10 deaths in developing countries, killing 52 million people annually worldwide by 2030.With statistics such as these, it comes as no surprise that international entities such as the World Health Organization & World Bank Human Development Network have identified the prevention and control of NCDs as an increasingly important discussion item on the global health agenda. Thus, should policy makers and communities mobilize and make prevention and targeted treatment of such diseases a priority, sustainable measures can be implemented to stagnate (and eventually even reverse) this emerging global health threat. Potential measures currently being discussed by the(World Health Organization)-Food and Agriculture

Non-communicable disease Organization includes reducing the levels of salt in foods, limiting inappropriate marketing of unhealthy foods and non-alcoholic beverages to children, imposing controls on harmful alcohol use, raising taxes on tobacco, and curbing legislation to curb smoking in public places.

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NCDs and the United Nations


The World Health Organization is the specialized agency of the United Nations (UN) that acts as coordinating authority on international public health issues, including NCDs. In May 2008, the 193 Member States of the WHO approved a six-year plan to address non-communicable diseases, especially the rapidly increasing burden in low- and middle-income countries.The plan calls for raising the priority given to NCDs in international development work'. During the 64th session of the United Nations General Assembly in 2010, a resolution was passed to call for a high-level meeting of the General Assembly on the prevention and treatment NCDs with the participation of heads of state and government. The resolution also encouraged UN Member States to address the issue of non-communicable diseases at the 2010 Review Summit for the Millennium Development Goals.

Global Non-communicable Disease Network


In order to better coordinate efforts around the globe, in 2009 the WHO announced the launch of the Global Non-communicable Disease Network (NCDnet).[3] NCDnet will consist of leading health organizations and experts from around the world in order to fight against diseases such as cancer, cardiovascular disease, and diabetes. Ala Alwan, assistant director-general for Non-communicable Diseases and Mental Health at the WHO, said: "integrating the prevention of non-communicable diseases and injuries into the national and global development agendas is not only achievable but also a priority for developing countries."[]

NCD Alliance
The NCD Alliance is a global partnership founded in May 2009 by four international federations representing cardiovascular disease, diabetes, cancer, and chronic respiratory disease. The NCD Alliance brings together roughly 900 national member associations to fight non-communicable disease. Long term aims of the Alliance include:[4] 1. 2. 3. 4. 5. 6. NCD/disease national plans for all A tobacco free world Improved lifestyles Strengthened health systems Global access to affordable and good quality medicines and technologies Human rights for people with NCDs.

Economics of NCDs
Previously, chronic NCDs were considered a problem limited mostly to high income countries, while infectious diseases seemed to affect low income countries. The burden of disease attributed to NCDs has been estimated at 85% in industrialized nations, 70% in middle income nations, and nearly 50% in countries with the lowest national incomes.[] In 2008, chronic NCDs accounted for more than 60% (over 35 million) of the 57 million deaths worldwide. Given the global population distribution, almost 80% of deaths due to chronic NCDs worldwide now occur in low and middle income countries, while only 20% occur in higher income countries. National economies are reportedly suffering significant losses because of premature deaths or inability to work resulting from heart disease, stroke and diabetes. For instance, China is expected to lose roughly $558 billion in national income between 2005 and 2015 due to early deaths. In 2005, heart disease, stroke and diabetes caused an estimated loss in international dollars of national income of 9 billion in India and 3 billion in Brazil.[]

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Absenteeism and presenteeism


The burden of chronic NCDs including mental health conditions is felt in workplaces around the world, notably due to elevated levels of absenteeism, or absence from work because of illness, and presenteeism, or productivity lost from staff coming to work and performing below normal standards due to poor health. For example, the United Kingdom experienced a loss of about 175 million days in 2006 to absence from illness among a working population of 37.7 million people. The estimated cost of absences due to illness was over 20 billion pounds in the same year.[5] The cost due to presenteeism is likely even larger, although methods of analyzing the economic impacts of presenteeism are still being developed. Methods for analyzing the distinct workplace impacts of NCDs versus other types of health conditions are also still being developed.

Key NCDs
Cancer
For the vast majority of cancers, risk factors are environmental or lifestyle-related, thus cancers are mostly preventable NCD.[] Greater than 30% of cancer is preventable via avoiding risk factors including: tobacco, being overweight or obesity, low fruit and vegetable intake, physical inactivity, alcohol, sexually transmitted infections, and air pollution.[] Infectious agents are responsible for some cancers, for instance almost all cervical cancers are caused by human papillomavirus infection.

Cardiovascular disease
The first studies on cardiovascular health were performed in 1949 by Jerry Morris using occupational health data and were published in 1958.[6] The causes, prevention, and/or treatment of all forms of cardiovascular disease remain active fields of biomedical research, with hundreds of scientific studies being published on a weekly basis. A trend has emerged, particularly in the early 2000s, in which numerous studies have revealed a link between fast food and an increase in heart disease. These studies include those conducted by the Ryan Mackey Memorial Research Institute, Harvard University and the Sydney Center for Cardiovascular Health. Many major fast food chains, particularly McDonald's, have protested the methods used in these studies and have responded with healthier menu options. A fairly recent emphasis is on the link between low-grade inflammation that hallmarks atherosclerosis and its possible interventions. C-reactive protein (CRP) is a common inflammatory marker that has been found to be present in increased levels in patients at risk for cardiovascular disease.[7] Also osteoprotegerin which involved with regulation of a key inflammatory transcription factor called NF-B has been found to be a risk factor of cardiovascular disease and mortality.[8][9]

Diabetes
Type 2 Diabetes Mellitus is an banana which is largely preventable and manageable but difficult to cure. Management concentrates on keeping blood sugar levels as close to normal ("euglycemia") as possible without presenting undue patient danger. This can usually be with close dietary management, exercise, and use of appropriate medications (insulin only in the case of type 1 diabetes mellitus. Oral medications may be used in the case of type 2 diabetes, as well as insulin). Patient education, understanding, and participation is vital since the complications of diabetes are far less common and less severe in people who have well-managed blood sugar levels.[10][11] Wider health problems may accelerate the deleterious effects of diabetes. These include smoking, elevated cholesterol levels, obesity, high blood pressure, and lack of regular exercise.

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Chronic kidney disease


Although chronic kidney disease (CKD) is not currently identified as one of WHO's main targets for global NCD control, there is compelling evidence that CKD is not only common, harmful and treatable but also a major contributing factor to the incidence and outcomes of at least three of the diseases targeted by WHO (diabetes, hypertension and CVD).[12] CKD strongly predisposes to hypertension and CVD; diabetes, hypertension and CVD are all major causes of CKD; and major risk factors for diabetes, hypertension and CVD (such as obesity and smoking) also cause or exacerbate CKD. In addition, among people with diabetes, hypertension, or CVD, the subset who also have CKD are at highest risk of adverse outcomes and high health care costs. Thus, CKD, diabetes and cardiovascular disease are closely associated conditions that often coexist; share common risk factors and treatments; and would benefit from a coordinated global approach to prevention and control.

Further reading
Lower GM, Kanarek MS (June 1982). "The mutation theory of chronic, noninfectious disease: relevance to epidemiologic theory" [13]. Am. J. Epidemiol. 115 (6): 80317. PMID7046429 [14].

References
[13] http:/ / aje. oxfordjournals. org/ cgi/ pmidlookup?view=long& pmid=7046429 [14] http:/ / www. ncbi. nlm. nih. gov/ pubmed/ 7046429

External links
"Confronting Chronic Diseases: Evidence for Action" (http://www.medicc.org/mediccreview/index. php?issue=18). MEDICC Review 13 (4). October 2011. WHO website on non-communicable diseases (http://www.who.int/topics/chronic_diseases/en/) WHO Regional Office for the Eastern Mediterranean website on non-communicable diseases (http://www.emro. who.int/entity/noncommunicable-diseases/) "NCDnet Global Noncommunicable Disease Network" (http://www.who.int/ncdnet/en/index.html). World Health Organization. The NCD Alliance (http://ncdalliance.org/aboutus) NCD Action Network (http://ncdaction.org)

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National Health Service


The National Health Service (NHS) may refer to one or more of the four publicly funded healthcare systems within the United Kingdom. The systems are primarily funded through general taxation rather than requiring private insurance payments. The services provide a comprehensive range of health services, the vast majority of which are free at the point of use for residents of the United Kingdom. The four systems are quite independent, and operate under different management, rules, and political authority.[1] The individual systems are: National Health Service (England) Health and Social Care in Northern Ireland (HSCNI) NHS Scotland NHS Wales Only the English NHS is officially called the "National Health Service" though the other three services are often referred to as "the NHS". All of the services were founded in 1948, based on legislation passed in 1946, 1947 and 1948. NHS Wales was part of the same structure as England until it became independent in 1969.
Leaflet concerning the launch of the NHS in England and Wales.

History
The Government elected in 1945 had made manifesto commitments[] to implement the recommendations of the Beveridge Report of 1942. The report's recommendation to create "comprehensive health and rehabilitation services for prevention and cure of disease"[] was implemented across the United Kingdom by 1948. The services were initially funded through general taxation and National Insurance as part of the introduction of a wider Welfare State. They were initially free at the point of use, although some prescription charges were soon introduced in response to economic difficulties. These charges are still in place with the English NHS, but not in the other three systems. In the UK Parliament at Westminster, the new health services were established through two Acts: The National Health Service Act 1946, creating the National Health Service in England and Wales The National Health Service (Scotland) Act 1947, creating the National Health Service in Scotland From 1969 the National Health Service in Wales became a separate entity under the Secretary of State for Wales. In the Parliament of Northern Ireland at Stormont: Health Services Act (Northern Ireland) 1948, creating a Health Service in Northern Ireland. Following devolution in the United Kingdom from 1998, control over the non-English services passed to the devolved national governments, with the UK Government retaining control over the NHS in England.

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Structure
Each system operates independently, and is politically accountable to the relevant government: the Scottish Government, Welsh Government, the Northern Ireland Executive, and the UK Government which is responsible for England's NHS. Despite their separate funding and administration, there is no discrimination when a resident of one country of the United Kingdom requires treatment in another, although a patient will often be returned to their home area when they are fit to be moved. The financial and administrative consequences are dealt with by the organisations involved and no personal involvement by the patient is required. Treatment of persons not resident in the United Kingdom is subject to mostly uniform arrangements made by or delegated to the UK Department of Health rather than any individual health service. Foreign nationals always receive treatment free at the time of use for emergencies. Foreign nationals also receive free treatment if they have been legally resident in the UK for 12 months, have recently arrived to take up permanent residence, are claiming asylum or have other legal resident status. Citizens of European Economic Area nations, as well as those from countries with which the UK has a reciprocal arrangements, are also entitled to free treatment by using the European Health Insurance Card.[2][3] Foreign nationals may be subject to an interview to establish their nationality and residence status, which must be resolved before non-emergency treatment can commence. Patients who do not qualify for free treatment are asked to pay in advance, or to sign a written undertaking to pay. Treatment for injuries caused in a road traffic accident has been chargeable since the 1930s, but such charges were not generally enforced until the Road Traffic (NHS Charges) Act 1999 [4] came into force to direct the charges to the insurers of the vehicles involved. This necessarily involves patients in the charging process even though they are not personally billed for treatment.

Funding
Each National Health Service is mainly funded from general taxation (with a much smaller amount from National Insurance contributions) with expenditure for 2012/13 planned to be; 108.9 billion for National Health Service (England)[5] 3.9bn for Health and Social Care in Northern Ireland[6] 9.38bn for NHS Scotland[7] 5.3bn for NHS Wales[8]

The UK Parliament sets the overall budget available to the NHS in England. Additionally, Parliament allocates a block grant to each devolved national government to spend on local needs. Each devolved government may choose how much of its block grant to spend on its health care system.

References
[4] [5] [6] [7] http:/ / www. legislation. gov. uk/ ukpga/ 1999/ 3/ contents http:/ / www. nhs. uk/ NHSEngland/ thenhs/ about/ Pages/ overview. aspx http:/ / www. hscboard. hscni. net/ board/ meetings/ Meetings%202012/ 20120628%20-%20June%202012 http:/ / www. scotland. gov. uk/ Publications/ 2012/ 09/ 7829/ 5/ Item%2006%20-%20Annual%20Budget%202012-13%20-%20PDF%20182KB. pdf [8] https:/ / statswales. wales. gov. uk/ Catalogue/ Health-and-Social-Care/ Health-Finance/ NHS-Programme-Budget/ NHSExpenditure-by-BudgetCategory-Year

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Further reading
Gorsky, Martin. "The British National Health Service 1948-2008: A Review of the Historiography," Social History of Medicine, Dec 2008, Vol. 21 Issue 3, pp 437460 Hacker, Jacob S. "The Historical Logic of National Health Insurance: Structure and Sequence in the Development of British, Canadian, and U.S. Medical Policy," Studies in American Political Development, April 1998, Vol. 12 Issue 1, pp 57130 Rivett G C From Cradle to Grave - the first 50 years of the NHS. King's Fund, London, 1998 Stewart, John. "The Political Economy of the British National Health Service, 1945-1975: Opportunities and Constraints," Medical History, Oct 2008, Vol. 52 Issue 4, pp 453470 Valier, Helen K. "The Manchester Royal Infirmary, 1945-97: a microcosm of the National Health Service," Bulletin of the John Rylands University Library of Manchester, 2005, Vol. 87 Issue 1, pp 167192 Webster, Charles. "Conflict and Consensus: Explaining the British Health Service," Twentieth Century British History, April 1990, Vol. 1 Issue 2, pp 115151 Webster, Charles. Health Services since the War. 'Vol. 1:' Problems of Health Care. The National Health Service before 1957 (1988) 479pp

External links
NHS Choices (http://www.nhs.uk/) official website for England's NHS Health and Social Care in Northern Ireland (http://www.n-i.nhs.uk/) official website for Health & Personal Social Services in Northern Ireland NHS Scotland (http://www.show.scot.nhs.uk/) official website for NHS Scotland Health in Wales (http://www.wales.nhs.uk/) official website for NHS Wales Birth of the national Health Service (http://www.bbc.co.uk/archive/nhs) BBC archive collection of programmes and documents

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National Institutes of Health


Coordinates: 39.000443N 77.102394W [1]

National Institutes of Health (NIH)

National Institutes of Health logo

Aerial photo of the NIH Mark O. Hatfield Clinical Research Center, Bethesda, Maryland Agency overview Formed Preceding Agency Headquarters Annual budget Agency executive Parent Agency Child agencies 1887 Hygienic Laboratory Bethesda, Maryland, U.S. US$30.9bn (as of 2010[2])
[]

Francis S. Collins, Director Department of Health & Human Services National Cancer Institute National Institute of Allergy and Infectious Diseases National Heart, Lung, and Blood Institute National Library of Medicine Website www.nih.gov
[3]

The National Institutes of Health (NIH) is an agency of the United States Department of Health and Human Services and is the primary agency of the United States government responsible for biomedical and health-related research. Its science and engineering counterpart is the National Science Foundation. It comprises 27 separate institutes, centers, and offices which includes the Office of the Director. Francis S. Collins is the current Director. As of 2003, the NIH was responsible for 28%about US$26.4 billionof the total biomedical research funding spent annually in the U.S., with most of the rest coming from industry.[] The NIH's research is divided into two parts: the NIH Extramural Research Program is responsible for the funding of biomedical research outside the NIH, while the NIH Intramural Research Program (IRP) is the internal research

National Institutes of Health program of the NIH, known for its synergistic approach to biomedical science.[4] With 1,200 principal investigators and more than 4,000 postdoctoral fellows in basic, translational, and clinical research, the IRP is the largest biomedical research institution on earth.[5] The unique funding environment of the IRP facilitates opportunities to conduct both long-term and high-impact science that would otherwise be difficult to undertake. With rigorous external reviews ensuring that only the most innovative research secures funding,[6] the IRP is responsible for many scientific accomplishments, including the discovery of fluoride to prevent tooth decay, the use of lithium to manage bipolar disorder, and the creation of vaccines against hepatitis, Haemophilus influenzae (HIB), and human papillomavirus.[7] Intramural research is primarily conducted at the main campus in Bethesda, Maryland, and the surrounding communities. The National Institute on Aging and the National Institute on Drug Abuse are located in Baltimore, Maryland, and the National Institute of Environmental Health Sciences is located in the Research Triangle region of North Carolina. The National Institute of Allergy and Infectious Diseases (NIAID) maintains its Rocky Mountain Labs in Hamilton, Montana,[8] with an emphasis on BSL3 and BSL4 laboratory work. The goal of NIH research is to acquire new knowledge to help prevent, detect, diagnose, and treat disease and disability, from the rarest genetic disorder to the common cold. The NIH mission is to uncover new knowledge that will lead to better health for everyone. NIH works toward that mission by conducting research in its own laboratories, supporting the research of non-federal scientists (in universities, medical schools, hospitals, and research institutions throughout the country and abroad), helping in the training of research investigators, and fostering communication of medical and health sciences information.

1124

Institutes
Name Acronym Description Research and training aimed to eliminate the suffering and death due to cancer. Research goals include striving to understand, treat, and ultimately prevent infectious, immunologic, and allergic diseases. The NIAID-funded Influenza Genome Sequencing Project is a collaborative effort designed to increase the genome knowledge base of influenza and help researchers understand [9] how flu viruses evolve, spread and cause disease. Provides leadership for a national research program designed to understand, treat, and ultimately prevent infectious and inherited craniofacial-oral-dental diseases and disorders. Est. 1937 1948

National Cancer Institute NCI National Institute of Allergy and Infectious Diseases NIAID

National Institute of Dental and Craniofacial Research National Institute of Diabetes and Digestive and Kidney Diseases National Heart, Lung, and Blood Institute

NIDCR

1948

NIDDK

Conducts and supports research and provides leadership for a national program in diabetes, endocrinology, and metabolic diseases, digestive diseases and nutrition, and kidney, urologic, and hematologic diseases. Provides leadership for a national program in diseases of the heart, blood vessels, lung, and blood; blood resources; and sleep disorders. Also has administrative responsibility for the NIH Women's Health Initiative. Understanding, treatment, and prevention of mental illnesses through basic research on the brain and behavior, and through clinical, epidemiological, and services research. Supports and conducts research, both basic and clinical, on the normal and diseased nervous system, fosters the training of investigators in the basic and clinical neurosciences, and seeks better understanding, diagnosis, treatment, and prevention of neurological disorders.

1948

NHLBI

1948

National Institute of Mental Health National Institute of Neurological Disorders and Stroke National Library of Medicine

NIMH

1949

NINDS

1950

NLM

NLM collects, organizes, and makes available biomedical science information to investigators, 1956 educators, and practitioners and carries out programs designed to strengthen medical library services in the United States. The NLM established the National Center for Biotechnology Information (NCBI) which is a central repository of biological information and includes the PubMed literature database and the gene database GenBank. The NCBI is one of the largest components of the NLM.

National Institutes of Health

1125
NICHD researches fertility, pregnancy, growth, development, and medical rehabilitation for the promotion of all aspects of child health. 1962

National Institute of NICHD Child Health and Human Development National Institute of General Medical Sciences NIGMS

NIGMS supports basic biomedical research not targeted to specific diseases, funds studies on genes, 1962 proteins, and cells, supports research training programs that produce the next generation of biomedical scientists, has special programs to encourage underrepresented minorities to pursue biomedical research careers. Conducts and supports research that helps prevent and treat eye diseases and other disorders of vision. 1968 Research on how environmental exposures, genetic susceptibility, and age interact to affect an individual's health. 1969

National Eye Institute National Institute of Environmental Health Sciences National Institute on Alcohol Abuse and Alcoholism National Institute on Drug Abuse National Institute on Aging National Institute of Arthritis and Musculoskeletal and Skin Diseases National Institute of Nursing Research National Institute on Deafness and Other Communication Disorders National Human Genome Research Institute National Institute of Biomedical Imaging and Bioengineering National Institute on Minority Health and Health Disparities

NEI NIEHS

NIAAA

NIAAA research is focused on improving the treatment and prevention of alcoholism and alcohol-related problems.

1970

NIDA

NIDA supports and conducts research on drug abuse and addiction prevention, treatment, and policy.

1973

NIA

Undertakes research on the biomedical, social, and behavioral aspects of the aging process, prevention 1974 of age-related diseases and disabilities, promotion of better quality of life for all older Americans. NIAMS supports research into causes, treatment, and prevention of arthritis and musculoskeletal and skin diseases, the training of basic and clinical scientists to carry out this research, and the dissemination of information on research progress in these diseases. 1986

NIAMS

NINR

NINR supports clinical and basic research to establish a scientific basis for the care of individuals across the life span. Conducts and supports biomedical research and research training on normal mechanisms as well as diseases and disorders of hearing, balance, smell, taste, voice, speech, and language.

1986

NIDCD

1988

NHGRI

Supports the NIH component of the Human Genome Project. NHGRI's Intramural Research Program develops and implements technology for understanding, diagnosing, and treating genetic diseases.

1989

NIBIB

Promotes fundamental discoveries, design and development, and translation and assessment of technological capabilities in biomedical imaging and bioengineering, enabled by relevant areas of information science, physics, chemistry, mathematics, materials science, and computer sciences. Promotes minority health, conducts and supports research, training, research infrastructure, fosters emerging programs, disseminates information, and reaches out to minority and other health disparity communities.

2000

NIMHD

2010

Centers of the NIH


In addition to being divided by research area, NIH has many operating groups called centers operating across all of the Institutes.

National Institutes of Health

1126

Name Center for Scientific Review Clinical Center

Acronym CSR

Description The CSR is the focal point at NIH for the conduct of initial peer review of grant and fellowship applications, implements ways to conduct referral and review. The clinical research facility of the National Institutes of Health; provides patient care, services, and environment needed to initiate and support conduct of and training in clinical research. NCATS aims to catalyze the generation of innovative methods and technologies that will enhance the development, testing and implementation of diagnostics and therapeutics across a wide range of human diseases and conditions.

Est. 1946

CC

1953

National Center for Advancing Translational [10] Sciences Center for Information Technology

NCATS

2012

CIT; formerly The CIT incorporates computers into the biomedical programs and administrative DCRT, OIRM, procedures of the NIH by conducting computational biosciences research, developing TCB computer systems, and providing computer facilities. FIC Promotes and supports scientific research and training internationally to reduce disparities in global health. Offers quality assurance to the National Cancer Institute (NCI) that all participating institutions in NCI sponsored cooperative groups are following the guidelines for the physics-related aspects of their protocols.

1964

John E. Fogarty International Center Radiological Physics Center

1968

RPC

1968

Quality Assurance Review Center

QARC

Provides radiotherapy quality assurance and diagnostic imaging data management for all 1977 of the National Cancer Institute (NCI) sponsored cooperative groups. It also contracts privately with the pharmaceutical industry for its services in clinical trials involving anti-cancer drugs. Established as a national resource for molecular biology information, NCBI creates public databases, conducts research in computational biology, develops software tools for analyzing genome data, and disseminates biomedical information all for the better understanding of molecular processes affecting human health and disease. Exploring complementary and alternative medical practices in the context of rigorous science, training researchers, disseminating authoritative information. 1988

National Center for Biotechnology Information

NCBI

National Center for Complementary and Alternative Medicine Dale and Betty Bumpers Vaccine Research [11] Center Bioinformatics Resource Centers

NCCAM

1992

VRC

The mission of the Vaccine Research Center (VRC) is to conduct research that facilitates the development of effective vaccines for human disease. The primary focus [12] of research is the development of vaccines for AIDS. Provides genomic, proteomic, biochemical, and microbiological data from a wide range of emerging/re-emerging pathogens (NIAID Category A, B, and C). Contains eight sub-centers (the BRCs) each dedicated to a different group of pathogens. Data are presented in a database format accessible by Web interfaces, together with tools for analysis.

1999

[13][14]

BRC

2004

National Centers for Biomedical Computing Center for Tissue Regeneration and Engineering at Dayton

NCBC

Be the core of the networked national effort to build the computational infrastructure for 2004 biomedical computing in the nation. Focused on human tissue regeneration and nanotechnology. 2006

TREND

Office of the Director


The Office of the Director is the central office at NIH. The OD is responsible for setting policy for NIH and for planning, managing, and coordinating the programs and activities of all the NIH components. Program offices in the Office of the Director are responsible for stimulating specific areas of research throughout NIH and for planning and supporting research and related activities. Current program areas are: minority health, women's health, AIDS research, disease prevention, and behavioral and social sciences research.[15] In July 2009, President Barack Obama

National Institutes of Health nominated Dr. Francis S. Collins, M.D., PhD, to be the Director of the NIH. On August 7, 2009, the US Senate confirmed Dr. Collins by unanimous vote. Program offices within the Office of the Director fund research through the institutes:
Full name Office of Extramural Research Office of Intramural Research Office of Management Office of Administration Acronym OER Role

1127

provides guidance to institutes in research and training programs conducted through extramural (grant, contract, cooperative agreement) programs coordinates research conducted directly by NIH personnel through intramural programs

OIR

OM

responsible for management and financial functions of the NIH

OA

advises the NIH Director and staff on administration and management; develops and implements policies, and provides oversight in the areas of information resources management, management assessment, grant administration and contract management, procurement, and logistics formulates scientific policy for, and recommends allocation of research resources for AIDS research at NIH

Office of AIDS Research Office of Biotechnology Activities Office of Behavioral and Social Sciences Research Office of Communications and Public Liaison Office of Community Liaison Office of Disease Prevention Office of Intramural Training and Education Office of Equal Opportunity and Diversity Management Office of Financial Management

OAR

OBA

"monitors scientific progress in human genetics research in order to anticipate future developments, including ethical, legal, and social concerns, in basic and clinical research involving Recombinant DNA, Genetic [16] Technologies, and Xenotransplantation" advises the NIH Director and other key officials on matters relating to research on the role of human behavior in the development of health, prevention of disease, and therapeutic intervention

OBSSR

OCPL

advises the Director and communicates information about NIH policies, programs, and research results to the general public

OCL

advises the Director, plans, directs and oversees activities to promote collaboration between NIH and its community, and ensures effective communication on policy and programs involving the community coordinates NIH activities regarding the application of research to disease prevention, nutrition and medical practice provides a comprehensive guide to postdoctoral training opportunities available at the NIH

ODP

OITE

OEODM

advises the Director and NIH staff on matters related to equal employment opportunity programs and policies

OFM

advises the NIH Director and staff and provides leadership and direction for NIH financial management activities; develops policies and instructions for budget preparation and presentation and administers allocation of funds and manages a system of fund and budgetary controls advises the NIH Director and staff on human resource management; directs central human resource management services; and provides NIH leadership and planning on human resource program development [17] provides legislative analysis, policy development, and liaison with the United States Congress provides the National Institutes of Health (NIH) and its constituent Institutes and Centers (ICs) with the methods and information necessary to manage their large and complex scientific portfolios, identifies in concert with multiple other inputs important areas of emerging scientific opportunities or rising public health challenges, and assists in the acceleration of investments in these areas, focusing on those involving multiple ICs

Office of Human Resources Office of Legislative Policy and Analysis Office of Portfolio Analysis and Strategic Initiatives

OHR

OLPA

OPASI

National Institutes of Health

1128
serves as a focal point for women's health research at the NIH. The ORWH promotes, stimulates, and supports efforts to improve the health of women through biomedical and behavioral research. ORWH works in partnership with the NIH institutes and centers to ensure that women's health research is part of the scientific framework at NIH and throughout the scientific community coordinates science education activities at the NIH and develops and sponsors science education projects in house. These programs serve elementary, secondary, and college students and teachers and the public. Free curriculum supplements developed in collaboration with curriculum writers, NIH divisions, and NIH scientists [18] are available online and in hard copy at Curriculum Supplements. The OSE has also developed an interactive health and medical science career exploration web site for middle school and high school students [19] called LifeWorks. Other educational resources from throughout the NIH are found on the OSE main page. [20] manages the wide range of NIH and FDA intramural inventions as mandated by the Federal Technology Transfer Act and related legislation. The mission of the NIH OTT is to improve public health through the management of inventions made by NIH and FDA scientists and the development of intellectual property policies for NIH's intramural and extramural research programs. In doing so, OTT serves a leading role in public sector biomedical technology transfer policy and practice. Other resources and information can be found [21] on the OTT main page supports research on rare diseases and collaborates with related organizations such as the National Organization for Rare Disorders. The Office of Rare Diseases was first established within the Office of the Director in 1993, [22] and then by public law statute in 2002. mission is to strengthen knowledge and understanding of dietary supplements by evaluating scientific information, stimulating and supporting research, disseminating research results, and educating the public. Created in 1995 as authorized by the Dietary Supplement Health and Education Act of 1994 (Public Law [23] 103-417, DSHEA).

Office of Research on ORWH Women's Health

Office of Science Education

OSE

Office of Technology Transfer

OTT

Office of Rare Diseases

ORDR

Office of Dietary Supplements

ODS

History
NIH's roots extend back to a Marine Hospital Service in the late 1790s that provided medical relief to sick and disabled men in the U.S. Navy. By 1870, a network of marine hospitals had developed and was placed under the charge of a medical officer within the Bureau of the Treasury Department. In the late 1870s, Congress allocated funds to investigate the causes of epidemics like cholera and yellow fever, and it created the National Board of Health, making medical research an official government initiative.[25] In 1887, a laboratory for the study of bacteria, the Hygienic Laboratory, was established at the Marine Hospital in New York.[26][27] In the early 1900s, Congress began appropriating funds for the Marine Hospital Service. By 1922, this organization changed its Ida A. Bengtson, a bacteriologist who in 1919 name to Public Health Services and established a Special Cancer was the first woman hired to work in the Investigations laboratory at Harvard Medical School. This marked the [24] Hygienic Laboratory. beginning of a partnership with universities. In 1930, the Hygienic Laboratory was re-designated as the National Institutes of Health by the Ransdell Act and was given $750,000 to construct two NIH buildings. Over the next few decades, Congress would increase its funding tremendously to the NIH, and various institutes and centers within the NIH were created for specific research programs.[28]

National Institutes of Health In 1967, the Division of Regional Medical Programs [29] was created to administer grants for research for heart disease, cancer, and strokes. That same year, the NIH director lobbied the White House for increased federal funding in order to increase research and the speed with which health benefits could be brought to the people. An advisory committee was formed to oversee further development of the NIH and its research programs. By 1971, cancer research was in full force and President Nixon signed the National Cancer Act, initiating a National Cancer Program, President's Cancer Panel, National Cancer Advisory Board, and 15 new research, training, and demonstration centers.

1129

Clinical Center Building 10

The funding of NIH has often been a source of contention in Congress, serving as a proxy for the political currents of the time. This contention was seen most dramatically during the 1980s, when President Reagan repeatedly tried to cut funding for research, only to see Congress partly restore funding. The political contention over NIH funding slowed the nations's response to the AIDS epidemic; while AIDS was reported in newspaper articles from 1981, no funding was provided for research on the disease. In 1984, National Cancer Institute scientists found implications that "variants of a human cancer virus called HTLV-III are the primary cause of acquired immunodeficiency syndrome (AIDS)," a new epidemic that gripped the nation.[30] But it was not until July 1987, as NIH celebrated its 100th anniversary, that President Reagan announced a committee to research the HIV epidemic. By the 1990s, the focus of the NIH committee had shifted to DNA research, and the Human Genome Project was launched. In 2009, President Obama reinstated federally funded stem-cell research, revoking the ban imposed by President Bush in 2001. From logistical restructuring, to funding increases, to research prioritization, to government expansion and political influence, the history of the National Institutes of Health is extensive and full of change. The NIH has grown to encompass nearly 1 percent of the federal government's operating budget. The NIH now controls more than 50 percent of all funding for health research, and 85 percent of all funding for health studies in universities.[31]

How NIH Obtains Funding


To allocate funds, the NIH must first obtain its budget from Congress. This process begins with IC leaders collaborating with scientists to determine the most important and promising research areas within their fields. IC leaders discuss research areas with NIH management who then develops a budget request for continuing projects, new research proposals, and new initiatives from the Director. NIH submits its budget request to HHS, and HHS considers this request within the parameters of its overall budget. Many adjustments and appeals occur between NIH and HHS before the agency submits NIH's budget request to the Office of Management and Budget (OMB). OMB determines what amounts and research areas are approved for incorporation into the President's final budget. The President then sends NIH's budget request to Congress in February for the next fiscal year's allocations.[32] The House and Senate Appropriations Subcommittees deliberate and by fall, Congress usually appropriates funding. This process takes approximately 18 months before the NIH can allocate any actual funds.[33]

How NIH Allocates Funding


NIH employs five broad decision criteria in its funding policy. First, ensure the highest quality of scientific research by employing an arduous peer review process. Second, seize opportunities that have the greatest potential to yield new knowledge and that will lead to better prevention and treatment of disease. Third, maintain a diverse research portfolio in order to capitalize on major discoveries in a variety of fields such as cell biology, genetics, physics, engineering, and computer science. Fourth, address public health needs according to the disease burden (e.g., prevalence and mortality). And fifth, construct and support the scientific infrastructure (e.g., well-equipped

National Institutes of Health laboratories and safe research facilities) necessary to conduct research.[34] In 2007 the director of the agency stated ,,responsibilities for identifying ... FCOIs (financial conflict of interest) must remain with grantee institutions but institutions that administer grants have no interest to identify grantee's conflicts of interest.[35] The NIH issued dozens of waivers for NIH's advisory committee members up to 2012. Such waivers exempt a conflicted government employee from ethics laws. Since 2005 the US Office of Government Ethics had documented only three times where the NIH consulted with the office as required by law, and none of the waivers in question had to do with a member of an advisory committee.[36] Advisory committee members advise the Institute on policy and procedures affecting the external research programs and provide a second level of review for all grant and cooperative agreement applications considered by the Institute for funding.[37]

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Funding Policy Changes


The NIH funding policy has changed in several significant ways over time. First, the amount of money given to the NIH has increased, most significantly in the last few decades. For example, in 1999, Congress increased the NIH's budget by $2.3 billion.[] (to $17.2 billion in 2000)[] In 2009 Congress again increased the NIH budget to $31 billion in 2010.[] These budgetary increases have allowed NIH to fund more research. The proportion of funding allocated to the individual ICs does not change much over time, but the overall amount of funding each IC receives has increased significantly.[38] Second, with the creation of the various ICs, the responsibility to allocate funding to researchers has shifted from the OD and Advisory Committee to the individual ICs. Additionally, Congress increasingly sets apart funding for particular causes. In the 1970s, Congress began to earmark funds specifically for cancer research and in the 1980s there was a significant amount allocated for AIDS/HIV research.[] Congress has continued to play an active role in allotting funds for specified research. These are some of the most significant changes in NIH funding policy over the last century. A few of the key issues in evaluating NIH funding policy were previously mentioned in the paper as the five criteria the NIH has established. Three of the criteria are particularly relevant. First, is the NIH ensuring the highest quality of research by fairly implementing their peer review process and allocating extramural research funds? Second, is the NIH maximizing opportunities to produce research that yields new knowledge that will lead to better disease prevention and treatment? Next, are public health needs being addressed according to the public disease burden; in other words, are the most important needs of society being met rather than those of special interest groups. These are the most important issues in evaluating NIH funding policy.

Stakeholders
Many groups are highly invested in NIH funding. General Public: One of the goals of the NIH is to "expand the base in medical and associated sciences in order to ensure a continued high return on the public investment in research."[39] Taxpayer dollars funding NIH are from the taxpayers, making them the primary beneficiaries of advances in research. Thus, the general public is a key stakeholder in the decisions resulting from the NIH funding policy. Congress theoretically represents the public interest as the NIH Advisory Committee allocates to the NIH, and the funds to the Director.[40] However, many in the general public do not feel their interests are being accurately represented. As a result, individuals have formed patient advocacy groups to represent their own interests.[41] Patient advocacy groups tend to focus on specific aspects of health care or diseases. Advocates get involved in many different areas such as organizing awareness campaigns, promoting patients' rights, and enhancing health policy initiatives. Most importantly, patient advocacy groups are often involved with advisory panels to ensure that current projects and those projects being considered for funding will directly impact patients' lives, improve delivery of care, and provide support for tertiary care. Advocacy groups strive to promote a health care system that is beneficial for all parties involved. Through congressional

National Institutes of Health representation, NIH Advisory Committee efforts, and patient advocacy groups, the public is able to influence funding allocation as well as the policy itself.[42] Extramural Researchers and Scientists: Other important stakeholders of the NIH funding policy are the researchers and scientists themselves. Extramural researchers differ from intramural researchers in that they are not employed by the NIH but must apply for funding. Throughout the history of the NIH, the amount of funding received has increased, but the proportion to each IC remains relatively constant. The individual ICs then decide who will receive the grant money and how much will be allotted. Research funding is important to extramural researchers for multiple reasons. Without the help of an NIH grant (or a similar type of funding), researchers and scientists are unable to pursue their own research interests but are obliged to follow the agenda of the company or university for which they work. This could potentially hinder discoveries in novel research areas. In 2000, Brian Jacobs and Lars Lefgren researched extensively the impact of NIH grants on basic research and development, and the careers of grant recipients. For the period of 19802000, they reviewed all postdoctoral research grants and standard research grants for those who received funding and those who did not.[8] Jacobs and Lefgren found that scientists who received postdoctoral research grants were 20 percent more likely to be published within the first five years after receiving the grant.[8] They also found that scientists who received grants were 11 percent more likely to have one publication and 23 percent more likely to have five publications. Due to the 'publish or perish' standard that many researchers face, NIH funding can have a great impact on researchers' careers.[8] Receiving a standard research grant also has a significant impact on researchers. Young scientists who receive a first-time grant (R01) usually produce more than one additional publication in the five-year period after they receive the grant. Those who receive an NIH grant will typically receive $252,000 more in NIH funding in the following six to ten years,[8] and a statistically significant relationship exists between scientists receiving NIH grants and their research productivity throughout their careers. Policy changes on who receives funding also significantly affect researchers. For example, the NIH has recently attempted to approve more first-time NIH R01 applicants, or the research grant applications of young scientists. To encourage the participation of young scientists who potentially think outside the box, the application process has been shortened and made easier.[43] In addition, first-time applicants are being offered more funding for their research grants than those who have received grants in the past.[44] Although this change provides greater opportunities for young scientists, it also places older, more experienced scientists at a funding disadvantage.

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Research
NIH devotes 10% of its funding to research within its own facilities (intramural research). The institution gives 80% of its funding in research grants to extramural (outside) researchers. The extramural funding consists of about 50,000 grants to more than 325,000 researchers at more than 3000 institutions.[45] In FY 2010[2], NIH spent US$10.7bn (not including temporary funding from the American Recovery and Reinvestment Act of 2009) on clinical research, US$7.4bn on genetics-related research, US$6.0bn on prevention research, US$5.8bn on cancer, and US$5.7bn on biotechnology.[]

NIH Interagency Pain Research Coordinating Committee


February 13, 2012 the National Institutes of Health (NIH) announced a new group of individuals assigned to research pain. This committee is composed of researchers from different organizations and will focus to "coordinate pain research activities across the federal government with the goals of stimulating pain research collaboration and providing an important avenue for public involvement" ("Members of new," 2012). With a committee such as this research will not be conducted by each individual organization or person but instead a collaborating group which will increase the information available. With this hopefully more pain management will be available including techniques for arthritis sufferers.

National Institutes of Health

1132

NIH Toolbox
In September 2006, a contract for the NIH Toolbox for the Assessment of Neurological and Behavioral Function (www.nihtoolbox.org [46]) was initiated by the NIH Blueprint for Neuroscience Research (www.neuroscienceblueprint.nih.gov) to develop a set of state-of-the-art measurement tools to enhance collection of data in large cohort studies and to advance the biomedical research enterprise. The NIH Toolbox was officially rolled out to the research community on September 1011, 2012 at a public conference "Unveiling the NIH Toolbox" held in Bethesda, MD and Washington, DC. Scientists from more than 100 institutions nationwide contributed to the development of the NIH Toolbox. The construction of NIH Toolbox assessments is based, where possible, on Item Response Theory and adapted for testing by computer.

Economic impact
In 2000, a report from a Joint Economic Committee of Congress outlined the benefits of NIH research. It noted that some econometric studies had given its research, which was funded at $16 billion a year in 2000, a rate of return of 25 to 40 percent per year. It also found that of the 21 drugs with the highest therapeutic impact on society introduced between 1965 and 1992, public funding was "instrumental" for 15.[47]

Commercial partnerships
In 2011 and 2012, the OIG published a series of audit reports revealing that throughout the fiscal years 2000-2010, institutes under the aegis of the NIH, did not comply with the time and amount requirements specified in appropriations statutes, in awarding federal contracts to commercial partners, committing the federal government to tens of millions of dollars of expenditure ahead of appropriation of funds from Congress.[48][49][50][51][52][53][54][55]

Grant Allocation Racial Bias


In 2011, a paper published in Science found that black researchers were 10% less likely to win NIH R01 grants (the oldest and most widely-used) than white researchers, after controlling for "educational background, country of origin, training, previous research awards, publication record, and employer characteristics." It also found that black researchers are significantly less likely to resubmit an unapproved grant than white researchers.[56] The study lead and economist Donna Grant said that grant reviewers do not have access to the applicant race, but may infer it from biographies or names. She also speculated that the decreased re-submission rate may be due to lack of mentoring. The study, which was commissioned by the NIH, included in its analysis 83,000 grant applications, made between 2000 and 2006.[] Dr. Otis W. Brawley, chief medical officer at the American Cancer Society and a black man, commented on the cause of the disparity as one unrelated to racism per se, but rather to the reviewers' unconscious tendency to more likely give the benefit of the doubt to someone they are familiar with, in a scientific world where black researchers tend to keep a lower profile than other groups. The study did not reveal similar difficulties for members of other races and ethnic groups (e.g., Hispanics).[]

National Institutes of Health

1133

References
[1] [2] [3] [6] [7] [8] http:/ / tools. wmflabs. org/ geohack/ geohack. php?pagename=National_Institutes_of_Health& params=39. 000443_N_-77. 102394_E_ http:/ / en. wikipedia. org/ w/ index. php?title=National_Institutes_of_Health& action=edit http:/ / www. nih. gov Blue Ribbon Panel Reviews http:/ / sourcebook. od. nih. gov/ sci-review/ blue-ribbon-toc. htm NIH Sourcebook http:/ / sourcebook. od. nih. gov/ oir/ IRP_transition. pdf About NIAID (http:/ / www3. niaid. nih. gov/ about/ organization/ dir/ overview. htm)" (accessed January 14, 2007). National Institute of Allergy and Infectious Diseases. [10] http:/ / www. ncats. nih. gov [12] NIAID.nih.gov (http:/ / www3. niaid. nih. gov/ about/ organization/ vrc/ about/ goals. htm) [13] NIAID.nih.gov (http:/ / www3. niaid. nih. gov/ about/ organization/ vrc/ about/ meetings. htm) [14] NIAID.nih.gov (http:/ / www3. niaid. nih. gov/ about/ organization/ vrc/ about/ background. htm) [16] About OBA (http:/ / www4. od. nih. gov/ oba/ aboutoba. htm) [18] http:/ / science. education. nih. gov/ CurriculumSupplements [19] http:/ / science. education. nih. gov/ Life_Works [20] http:/ / science. education. nih. gov [21] http:/ / www. ott. nih. gov [29] http:/ / profiles. nlm. nih. gov/ ps/ retrieve/ Collection/ CID/ RM [46] http:/ / www. nihtoolbox. org

External links
Official website (http://www.nih.gov) US Scientific Grant Funding Database (http://search.engrant.com/) Regional Medical Programs (http://profiles.nlm.nih.gov/ps/retrieve/Collection/CID/RM) Collection of information on NIH's Regional Medical Programs, from the National Library of Medicine

National Institute of Mental Health

1134

National Institute of Mental Health


National Institute of Mental Health

Agency overview Formed Headquarters Annual budget April 14, 1949 Bethesda, Maryland, U.S. $1.5 billion (2010)

Agency executives Thomas R. Insel, Director Philip S. Wang, Deputy Director Parent Agency National Institutes of Health Website
[1] [1]

The National Institute of Mental Health (NIMH) is one of 27 institutes and centers that make up the National Institutes of Health (NIH). The NIH, in turn, is an agency of the United States Department of Health and Human Services and is the primary agency of the United States government responsible for biomedical and health-related research. NIMH is the largest research organization in the world specializing in mental illness. Thomas R. Insel is the current Director of NIMH. The institute was first authorized by the U.S. Government in 1946, when then President Harry Truman signed into law the National Mental Health Act, although the institute was not formally established until 1949.[2] NIMH is a $1.5 billion enterprise, supporting research on mental health through grants to investigators at institutions and organizations throughout the United States and through its own internal (intramural) research effort. The mission of NIMH is "to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery, and cure."[3] In order to fulfill this mission, NIMH "...must foster innovative thinking and ensure that a full array of novel scientific perspectives are used to further discovery in the evolving science of brain, behavior, and experience. In this way, breakthroughs in science can become breakthroughs for all people with mental illnesses."[4]

Research priorities
NIMH has identified four overarching strategic objectives for itself: Promote discovery in the brain and behavioral sciences to fuel research on the causes of mental disorders Chart mental illness trajectories to determine when, where and how to intervene Develop new and better interventions that incorporate the diverse needs and circumstances of people with mental illnesses Strengthen the public health impact of NIMH-supported research[5]

National Institute of Mental Health

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History
Mental health had traditionally been a state responsibility, but after World War II there was increasing lobbying for a federal (national) initiative. Attempts to create a National Neuropsychiatric Institute failed. Robert H. Felix, then head of the Division of Mental Hygiene, orchestrated a movement to include mental health policy as an integral part of federal biomedical policy. Congressional subcommittees were held and the National Mental Health Act was signed into law in 1946. This aimed to support the research, prevention and treatment of psychiatric illness, and called for the establishment of a National Advisory Mental Health Council (NAMHC) and a National Institute of Mental Health. On April 15, 1949, the NIMH was formally established, with Felix as director. Funding for the NIMH grew slowly and then, from the mid-1950s, dramatically. The institute took on a highly influential role in shaping policy, research and communicating with the public, legitimizing the importance of new advances in biomedical science, psychiatric and psychological services, and community-based mental health policies.[6]

Psychology

Outline History Subfields

Basic types

Abnormal Biological Cognitive Comparative Cultural Differential Developmental Evolutionary Experimental Mathematical Personality Positive Quantitative Social

Applied psychology

Applied behavior analysis Clinical Community Consumer Educational Environmental Forensic Health Industrial and organizational Legal Military Occupational health

National Institute of Mental Health


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Political Religion School Sport

Lists

Disciplines Organizations Psychologists Psychotherapies Publications Research methods Theories Timeline Topics Psychology portal

In 1955 the Mental Health Study Act called for "an objective, thorough, nationwide analysis and reevaluation of the human and economic problems of mental health."[citation needed] The resulting Joint Commission on Mental Illness and Health prepared a report, "Action for Mental Health", resulting in the establishment of a cabinet-level interagency committee to examine the recommendations and determine an appropriate federal response. In 1963, Congress passed the Mental Retardation Facilities and Community Mental Health Centers Construction Act, beginning a new era in Federal support for mental health services. NIMH assumed responsibility for monitoring the Nation's community mental health centers (CMHC) programs. During the mid-1960s, NIMH launched a campaign on special mental health problems. Part of this was a response to President Lyndon Johnson's pledge to apply scientific research to social problems. The Institute established centers for research on schizophrenia, child and family mental health, suicide, as well as crime and delinquency, minority group mental health problems, urban problems, and later, rape, aging, and technical assistance to victims of natural disasters. Alcohol abuse and alcoholism did not receive full recognition as a major public health problem until the mid-1960s, when the National Center for Prevention and Control of Alcoholism was established as part of NIMH; a research program on drug abuse was inaugurated within NIMH with the establishment of the Center for Studies of Narcotic and Drug Abuse. In 1967, NIMH separated from NIH and was given Bureau status within PHS. However, NIMH's intramural research program, which conducted studies in the NIH Clinical Center and other NIH facilities, remained at NIH under an agreement for joint administration between NIH and NIMH. DHEW Secretary John W. Gardner transferred St. Elizabeths Hospital, the Federal Government's only civilian psychiatric hospital, to NIMH. In 1968, NIMH became a component of PHS's Health Services and Mental Health Administration (HSMHA). In 1970 the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act (P.L. 91-616) established the National Institute of Alcohol Abuse and Alcoholism within NIMH. In 1972, the Drug Abuse Office and Treatment Act established a National Institute on Drug Abuse within NIMH. In 1973, NIMH went through a series of organizational moves. The Institute temporarily rejoined NIH on July 1 with the abolishment of HSMHA. Then, the DHEW secretary administratively established the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) composed of the National Institute on Alcohol Abuse and Alcoholism, the National Institute on Drug Abuse, and NIMH as the successor organization to HSMHA. ADAMHA was officially established in 1974.

National Institute of Mental Health The President's Commission on Mental Health in 1977 reviewed the mental health needs of the nation and to make recommendations to the President as to how best meet these needs in 1978. In 1980 The Epidemiologic Catchment Area (ECA) study, an unprecedented research effort that entailed interviews with a nationally representative sample of 20,000 Americans was launched. The field interviews and first wave analyses were completed in 1985. Data from the ECA provided a picture of rates of mental and addictive disorders and services usage. The Mental Health Systems Act based on recommendations of the President's Commission on Mental Health and designed to provide improved services for persons with mental disorders was passed. NIMH participated in development of the National Plan for the Chronically Mentally Ill, a sweeping effort to improve services and fine-tune various Federal entitlement programs for those with severe, persistent mental disorders. In 1987, Administrative control of St. Elizabeth's Hospital was transferred from the NIMH to the District of Columbia. NIMH retained research facilities on the grounds of the hospital. The NIMH Neuroscience Center and the NIMH Neuropsychiatric Research Hospital, located on the grounds of St. Elizabeth's Hospital, were dedicated in 1989. In 1992, Congress passed the ADAMHA Reorganization Act, abolishing ADAMHA. The research components of NIAAA, NIDA and NIMH rejoined NIH, while the services components of each institute became part of a new PHS agency, the Substance Abuse and Mental Health Services Administration [7] (SAMHSA). The return to NIH and the loss of services functions to SAMHSA necessitated a realignment of the NIMH extramural program administrative organization. New offices were created for research on Prevention, Special Populations, Rural Mental Health and AIDS. In 1994 The House Appropriations Committee mandated that the director of NIH conduct a review of the role, size, and cost of all NIH intramural research programs (IRP). NIMH and the National Advisory Mental Health Council (NAMHC) initiated a major study of the NIMH Intramural Research Program. The planning committee recommended continued investment in the IRP and recommended specific administrative changes; many of these were implemented upon release of the committee's final report; other changes for example, the establishment of a major new program on Mood and Anxiety Disorders have been introduced in the years since. In 1996 NIMH, with the NAMHC, initiated systematic reviews of a number of areas of its research portfolio, including the genetics of mental disorders; epidemiology and services for child and adolescent populations; prevention research; clinical treatment and services research. At the request of the National Institute for Mental Health director, the NAMH Council established programmatic groups in each of these areas. NIMH (National Institute of Mental Health) continued to implement recommendations issued by these Workgroups. In 1997, NIMH realigned its extramural organizational structure to capitalize on new technologies and approaches to both basic and clinical science, as well as changes that had occurred in health care delivery systems, while retaining the Institute's focus on mental illness. The new extramural organization resulted in three research divisions: Basic and Clinical Neuroscience Research; Services and Intervention Research; and Mental Disorders, Behavioral Research and AIDS. Between 1997 and 1999 NIMH refocused career development resources on early careers and added new mechanisms for clinical research. In 1999 The NIMH Neuroscience Center/Neuropsychiatric Research Hospital was relocated from St. Elizabeth's Hospital in Washington, D.C. to the NIH Campus in Bethesda, Maryland, in response to the recommendations of the 1996 review of the NIMH (National Institute of Mental Health) Intramural Research Program by the IRP Planning Committee. The first White House Conference on Mental Health, held June 7, in Washington, D.C., brought together national leaders, mental health scientific and clinical personnel, patients, and consumers to discuss needs and opportunities. The National Institute on Mental Health developed materials and helped organize the conference.

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National Institute of Mental Health U.S. Surgeon General David Satcher released The Surgeon General's Call To Action To Prevent Suicide, in July, and the first Surgeon General's Report on Mental Health, in December. NIMH, along with other Federal agencies, collaborated in the preparation of both of these landmark reports. Since the appointment of Thomas R. Insel as Director of NIMH in 2002, the institute has undergone organizational changes to better target mental health research needs (the expansion from three extramural divisions to five divisions, with the two new divisions focusing on adult and child translational research). NIMH also weathered several years of controversy due to conflict of interest and ethics violations by some of its intramural investigators. This situation cast light on an area that affected all of NIH, and resulted in more stringent rules about conflict of interest for all of NIH. Recently, Congressional interest turned to ethics and conflict of interest concerns with external investigators who receive NIMH or other NIH support. Current federal law has responsibility for managing and monitoring conflict of interests for external investigators with their home institutions/organizations. NIH responded to these new concerns by initiating a formal process for seeking public input and advice that will likely result in a change to the rules for monitoring and managing conflict of interest concerns for externally supported investigators. Finally, the past decade has also been marked by exciting scientific breakthroughs and efforts in mental illness research, as new genetic advances and bioimaging methodologies have increased understanding of mental illnesses. Two notable consequences of these advances are the Institute's collaboration with the Department of Army to launch the Study To Assess Risk and Resilience in Service Members (STARRS), a Framingham-like effort scheduled to last until 2014 [8] and the Research Domain Criteria (RDoC) effort,which seeks to define basic dimensions of functioning (such as fear circuitry or working memory) to be studied across multiple levels of analysis, from genes to neural circuits to behaviors, cutting across disorders as traditionally defined.[9]

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Noted researchers
In 1970, Julius Axelrod, a NIMH researcher, won the Nobel Prize in Physiology or Medicine for research into the chemistry of nerve transmission for "discoveries concerning the humoral transmitters in the nerve terminals and the mechanisms for their storage, release and inactivation." He found an enzyme that terminated the action of the nerve transmitter, noradrenaline in the synapse and which also served as a critical target of many antidepressant drugs. In 1984, Norman E. Rosenthal, a psychiatrist and NIMH researcher, pioneered seasonal affective disorder, coined the term SAD, and began studying the use of light therapy as a treatment.[10][11][12][13] He received the Anna Monika Foundation Award for his research on seasonal depression.[14] Louis Sokoloff, a NIMH researcher, received the Albert asker award in Clinical Medical Research for developing a new method of measuring brain function that contributed to basic understanding and diagnosis of brain diseases. Roger Sperry, a NIMH research grantee, received the Nobel Prize in Medicine or Physiology for discoveries regarding the functional specialization of the cerebral hemispheres, or the "left" and "right" brain. Eric Kandel and Paul Greengard, each of whom have received NIMH support for more than three decades, shared the Nobel Prize in Physiology or Medicine with Sweden's Arvid Carlsson. Kandel received the prize for his elucidating research on the functional modification of synapses in the brain. Initially using the sea slug as an experimental model but later working with mice, he established that the formation of memories is a consequence of short and long-term changes in the biochemistry of nerve cellsGreengard was recognized for his discovery that dopamine and a number of other transmitters can alter the functional state of neuronal proteins, and also that such changes could be reversed by subsequent environmental signals. Nancy Andreasen, a psychiatrist and long-time NIMH grantee, won the National Medal of Science for her groundbreaking work in schizophrenia and for joining behavioral science with neuroscience and neuroimaging. The Presidential Award is one of the nation's highest awards in science. Aaron Beck, a psychiatrist, received the 2006 Albert Lasker Award for Clinical Medical Research. Often called Americas Nobels, the Laskers are the nations most distinguished honor for outstanding contributions to basic and clinical medical research. Beck developed cognitive therapya form of psychotherapywhich transformed the

National Institute of Mental Health understanding and treatment of many psychiatric conditions, including depression, suicidal behavior, generalized anxiety, panic attacks and eating disorders.[15] In 2010, Mortimer Mishkin was awarded the National Medal of Science. Mishkin is chief of the NIMH's Section on Cognitive Neuroscience, and acting chief of its Laboratory of Neuropsychology. He is the first NIMH intramural scientist to receive the medal. Due in part to work spearheaded by Mishkin, science now understands much about the pathways for vision, hearing and touch, and about how those processing streams connect with brain structures important for memory.[16]

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NIMH directors
Name Robert H. Felix Stanley F. Yolles Bertram S. Brown Herbert Pardes Shervert H. Frazier Lewis L. Judd Frederick K. Goodwin Years served 19491964 19641970 19701977 19771984 19841986 19881992 19921994

Rex William Cowdry (acting) 19941996 Steven Hyman 19962001

Richard K. Nakamura (acting) 20012002 Thomas R. Insel 2002 present

In popular culture
A children's novel Mrs. Frisby and the Rats of NIMH by Robert C. O'Brien, published in 1971, features a society of intelligent rats that had presumably escaped from a laboratory at NIMH. The novel was later adapted into a critically acclaimed animated feature film entitled The Secret of NIMH by animator and director Don Bluth.

Notes and references


[1] [2] [5] [6] http:/ / www. nimh. nih. gov/ index. shtml http:/ / www. nih. gov/ about/ almanac/ archive/ 1999/ organization/ nimh/ history. html http:/ / www. nimh. nih. gov/ about/ strategic-planning-reports/ index. shtml Grob, GN. (1996) Creation of the National Institute of Mental Health. (http:/ / www. pubmedcentral. nih. gov/ articlerender. fcgi?tool=pubmed& pubmedid=8711108) Public Health Reports. 1996 JulAug; 111(4): 378381. [7] http:/ / www. samhsa. gov/ [8] http:/ / www. nimh. nih. gov/ health/ topics/ suicide-prevention/ suicide-prevention-studies/ army-study-to-assess-risk-and-resilience-in-servicemembers-army-starrs-a-partnership-between-nimh-and-the-us-army. shtml [9] http:/ / www. nimh. nih. gov/ research-funding/ rdoc. shtml [10] Psych Central, Book Review June 2011 (http:/ / psychcentral. com/ lib/ 2011/ transcendental-meditation-what-is-it-and-how-does-it-work/ ) Retrieved July 2011 [11] NY Times, Health Scientists Find Ways to Reset Biological Clocks in Dim Winter, Jane E. Brody, Dec 29 1993 (http:/ / www. nytimes. com/ 1993/ 12/ 29/ health/ scientists-find-ways-to-reset-biological-clocks-in-dim-winer. html) Retrieved July 2011 [12] CNN, Insiders Guide: Season Affective Disorder, Paul Sussman, Nov 2 2007 (http:/ / articles. cnn. com/ 2007-11-02/ world/ ww. insider. sad_1_winter-depression-sad-sufferers-light-therapy?_s=PM:WORLD) Retrieved July 2011 [13] (http:/ / articles. cnn. com/ 2000-01-03/ health/ sad. wmd_1_seasonal-affective-disorder-people-in-northern-latitudes-consecutive-winters?_s=PM:HEALTH) The blue season, January 03, 2000, Chris Cosgrove, Retrieved July 2011

National Institute of Mental Health


[14] Self Pub Bio (http:/ / normanrosenthal. com/ biography. html), retrieved July 2011 [15] http:/ / www. upenn. edu/ almanac/ volumes/ v53/ n05/ ab. html [16] http:/ / www. nimh. nih. gov/ science-news/ 2010/ nimhs-dr-mortimer-mishkin-to-be-awarded-national-medal-of-science. shtml

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Further reading
Psychology and the National Institute of Mental Health: A Historical Analysis of Science, Practice, and Policy, Edited by Wade E. Pickren, PhD and Stanley F. Schneider, PhD, American Psychological Association, 2004, ISBN 1-59147-164-8

External links
Official website (http://www.nimh.nih.gov/) National Institutes of Health (http://www.nih.gov/) U.S. Department of Health and Human Services (http://www.dhhs.gov/) Substance Abuse and Mental Health Services Administration (SAMSHA) (http://www.samhsa.gov/) Mental Health: A Report from the Surgeon General (http://www.surgeongeneral.gov/library/mentalhealth/ home.html) 2001

Culture, Race and Ethnicity: A Supplement to the Surgeon General's Report (http://www.surgeongeneral.gov/ library/mentalhealth/cre/) World Health Organization: Global Burden of Disease Study (http://www.who.int/topics/ global_burden_of_disease/en/)

National Institute for Occupational Safety and Health


The National Institute for Occupational Safety and Health (NIOSH) is the U.S. federal agency responsible for conducting research and making recommendations for the prevention of work-related injury and illness. NIOSH is part of the Centers for Disease Control and Prevention (CDC) within the U.S. Department of Health and Human Services.

NIOSH logo

NIOSH is headquartered in Washington, D.C., with research laboratories and offices in Cincinnati, Ohio; Morgantown, West Virginia; Pittsburgh, Pennsylvania; Denver, Colorado; Anchorage, Alaska; Spokane, Washington; and Atlanta, Georgia.[1] NIOSH is a professionally diverse organization with a staff of 1,400 people representing a wide range of disciplines including epidemiology, medicine, industrial hygiene, safety, psychology, engineering, chemistry, and statistics. The director of NIOSH is John Howard. The Occupational Safety and Health Act, signed by President Richard M. Nixon, on December 29, 1970, created both NIOSH and the Occupational Safety and Health Administration (OSHA). NIOSH was established to help ensure safe and healthful working conditions by providing research, information, education, and training in the field of occupational safety and health. NIOSH provides national and world leadership to prevent work-related illness, injury, disability, and death by gathering information, conducting scientific research, and translating the knowledge gained into products and services.[2]

National Institute for Occupational Safety and Health

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Strategic goals
NIOSH abides by a strategic plan for meeting institutional goals and allocating resources. The Institute has three overarching goals:[3] Conduct research to reduce work-related illnesses and injuries Promote safe and healthy workplaces through interventions, recommendations and capacity building Enhance global workplace safety and health through international collaborations The goals are supported by NIOSH's program portfolio. The portfolio categorizes Institute efforts into 8 groups representing industrial sectors. The program portfolio further subdivides efforts into 24 cross sectors.

NIOSH authority
Unlike its counterpart, the Occupational Safety and Health Administration, NIOSH is not a regulatory agency. It does not issue safety and health standards that are enforceable under U.S. law. Rather, NIOSH's authority under the Occupational Safety and Health Act [29 CFR 671] is to "develop recommendations for health and safety standards", to "develop information on safe levels of exposure to toxic materials and harmful physical agents and substances", and to "conduct research on new safety and health problems". NIOSH may also "conduct on-site investigations (Health Hazard Evaluations) to determine the toxicity of materials used in workplaces" and "fund research by other agencies or private organizations through grants, contracts, and other arrangements".[4] NIOSH was intended to function as an agency at the same level as, and independent from, the Centers for Disease Control. NIOSH was initially placed within the Centers for Disease Control in order to obtain administrative support from the Centers until NIOSH was ready to assume those responsibilities for itself; the Centers, however, never relinquished control and the original intent of the Act never came to pass. Also, pursuant to its authority granted to it by the Mine Safety and Health Act of 1977, NIOSH may "develop recommendations for mine health standards for the Mine Safety and Health Administration", "administer a medical surveillance program for miners, including chest Xrays to detect pneumoconiosis (black lung disease) in coal miners", "conduct on-site investigations in mines similar to those authorized for general industry under the Occupational Safety and Health Act; and "test and certify personal protective equipment and hazard-measurement instruments".[4]

NIOSH publications
Alerts are put out by the agency to request assistance in preventing, solving, and controlling newly identified occupational hazards. They briefly present what is known about the risk for occupational injury, illness, and death. Criteria Documents contain NIOSH's recommendations for the prevention of occupational diseases and injuries. These documents are submitted to the Occupational Safety and Health Administration or the Mine Safety and Health Administration for consideration in their formulation of legally-binding safety and health standards. Current Intelligence Bulletins analyze new information about occupational health and safety hazards. The National Agricultural Safety Database is published by NIOSH and contains citations and summaries of scholarly journal articles and reports about agricultural health and safety. The Fatality Assessment and Control Evaluation (FACE) program publishes occupational fatality data. Data is used to publish fatality reports by specific sectors of industry and types of fatal incidents.[5] The NIOSH Power Tools Database contains sound power levels, sound pressure levels, and vibrations data for a variety of common power tools that have been tested by NIOSH researchers.

National Institute for Occupational Safety and Health

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NIOSH Education and Research Centers


NIOSH Education and Research Centers are multidisciplinary centers supported by the National Institute for Occupational Safety and Health for education and research in the field of occupational health. Through the centers, NIOSH supports academic degree programs and research opportunities.[6] The ERCs, distributed in regions across the United States, establish academic, labor, and industry research partnerships.[7] The research conducted at the centers is related to the National Occupational Research Agenda (NORA) established by NIOSH.[8] Founded in 1977, NIOSH ERCs are responsible for nearly half of post-baccalaureate graduates entering occupational health and safety fields. The ERCs focus on industrial hygiene, occupational health nursing, occupational medicine, occupational safety, and other areas of specialization.[9] At many ERCs, students in specific disciplines have their tuition paid in full and receive additional stipend money. ERCs provide a benefit to local businesses by offering reduced price assessments to local businesses.

Current Education and Research Centers


University of Alabama at Birmingham & Auburn University -Deep South Center for Occupational Safety & Health [10] University of California, Berkeley University of California, Los Angeles University of Cincinnati Mountain & Plains ERC in Colorado Harvard School of Public Health University of Illinois at Chicago University of Iowa Johns Hopkins University University of Michigan University of Minnesota Mount Sinai School of Medicine University of North Carolina University of South Florida University of Texas University of Utah - The Rocky Mountain Center for Occupational and Environmental Health [11] University of Washington

References
[1] NIOSH Divisions, Labs, and Offices (http:/ / www. cdc. gov/ niosh/ im-rsch. html) [2] About NIOSH (http:/ / www. cdc. gov/ niosh/ about. html). National Institute of Occupational Safety and Health. [3] NIOSH Strategic Plan Outline 2004-2009 (http:/ / www. cdc. gov/ niosh/ docs/ strategic/ ). National Institute for Occupational Safety and Health. [4] National Institute for Occupational Safety and Health (US) About NIOSH (http:/ / www. cdc. gov/ niosh/ about. html) [5] National Institute for Occupational Safety and Health (US) NIOSH Publications by Category (http:/ / www. cdc. gov/ niosh/ pubs/ type. html) [6] NIOSH Education and Research Centers (ERCs) (http:/ / www. cdc. gov/ niosh/ oep/ centers. html). National Institute for Occupational Safety and Health. July, 2008. Accessed February 13, 2009 [7] NIOSH ERC - Great Lakes Center (http:/ / www. uic. edu/ sph/ glakes/ ce/ index. html). University of Illinois at Chicago. Accessed February 13, 2009 [8] Education and Research Center (ERC): About ERC (http:/ / eh. uc. edu/ erc/ ). University of Cincinnati, Department of Environmental Health. September 15, 2008. Accessed February 13, 2009 [9] NIOSH Announces New Name for Centers to Reflect Education, Research Mission (http:/ / www. cdc. gov/ NIOSH/ updates/ ercna. html). National Institute for Occupational Safety and Health. Update, January 22, 1998. Accessed February 13, 2009 [10] http:/ / www. soph. uab. edu/ dsc [11] http:/ / medicine. utah. edu/ rmcoeh

National Institute for Occupational Safety and Health

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External links
NIOSH Homepage (http://www.cdc.gov/niosh) NIOSH Facebook page (http://www.facebook.com/pages/ NIOSH-National-Institute-for-Occupational-Safety-and-Health/28902055276) NIOSH Flickr page (http://www.flickr.com/photos/niosh/) NIOSH Twitter page (https://twitter.com/niosh/) NIOSH YouTube page (http://www.youtube.com/user/NIOSHSafetyVideos) NIOSH Myspace page (http://www.myspace.com/niosh) Global Environmental and Occupational Health e-Library (http://www.geolibrary.org) online database of environmental health and occupational health and safety training materials NIOSH Power Tools Database (http://wwwn.cdc.gov/niosh-sound-vibration/) online database of sound and vibrations data for various power tools Safe-in-Sound Excellence in Hearing Loss Prevention Award (http://www.safeinsound.us)

United States National Library of Medicine


The United States National Library of Medicine (NLM), operated by the United States federal government, is the world's largest medical library.[1] Located in Bethesda, Maryland, the NLM is a division of the National Institutes of Health. Its collections include more than seven million books, journals, technical reports, manuscripts, microfilms, photographs, and images on medicine and related sciences including some of the world's oldest and rarest works. The current director of the NLM, since 1984, is Donald A.B. Lindberg.[2]

Entrance to the NLM

PubMed, Index Medicus, and NCBI


Since 1879, the NLM has published the Index Medicus, a monthly guide to articles in nearly five thousand selected journals. The last issue of Index Medicus was printed in December 2004, but this information is offered in the freely accessible PubMed amongst the more than fifteen million MEDLINE journal article references and abstracts going back to the 1960s and 1.5 million references going back to the 1950s.[3] The NLM also runs the National Center for Biotechnology Information (NCBI), which houses biological databases (PubMed among them) that are freely accessible on the Internet through the Entrez search engine.[4]
The glowing facade of the National Library of Medicine at night. HMD Prints & Photos, Z AD6 U56 C25 no. M298a box 57 ins.

United States National Library of Medicine

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Toxicology and Environmental Health Program


The Toxicology and Environmental Health Program was established at the NLM in 1967 and is charged with developing computer databases compiled from the medical literature and from the files of governmental and nongovernmental organizations.[5] The program has implemented several information systems for chemical emergency response and public education, such as the Toxicology Data Network (TOXNET), TOXMAP, Tox Town, Wireless Information System for Emergency Responders (WISER), Toxmystery, and the Household Products Database. These resources are accessible without charge on the Web.

View of the National Library of Medicines main reading room, with a Mondrian-influenced modernist design. HMD Prints & Photos, PP059772.6.

Radiation Exposure
The United States National Library of Medicine Radiation Emergency Management System (REMM) [6] provides: Guidance for health care providers, primarily physicians, about clinical diagnosis and treatment of radiation injury during radiological and nuclear emergencies Just-in-time, evidence-based, usable information with sufficient background and context to make complex issues understandable to those without formal radiation medicine expertise Web-based information that can be downloaded in advance, so that it would be available during an emergency if the internet is not accessible. REMM is produced by the United States Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response, Office of Planning and Emergency Operations, in cooperation with the National Library of Medicine, Division of Specialized Information Services, with subject matter experts from the National Cancer Institute, the Centers for Disease Control and Prevention, and many US and international consultants.[6]

Main reading room

Extramural Division

The Extramural Division provides grants to support research in medical information science and to support planning and development of computer and communications systems in medical institutions. Research, publications, and exhibitions on the history of medicine and the life sciences are also supported by the History of Medicine Division. In April 2008 the current exhibition Against the Odds: Making a Difference in Global Health was launched.

The gleaming new reading room of the History of Medicine Division, in the National Library of Medicine on the National Institutes of Health campus, Bethesda, Maryland. HMD Prints & Photos, PP059772.5.

United States National Library of Medicine

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History
For details of the pre-1956 history of the Library, see Library of the Surgeon General's Office. The precursor of the NLM, established in 1836, was the Library of the Surgeon General's Office, a part of the office of the Surgeon General of the United States Army. The Armed Forces Institute of Pathology and its Medical Museum were founded in 1862 as the Army Medical Museum. Throughout their history the Library of the Surgeon General's Office and the Army Medical Museum often shared quarters. From 1866 to 1887, they were housed in Ford's Theatre after production there was stopped after the assassination of President Abraham Lincoln. In 1956, the library collection was transferred from the control of the U.S. Department of Defense to the Public Health Service of the Department of Health, Education and Welfare and renamed the National Library of Medicine, through the instrumentality of Frank Bradway Rogers, who was the Director from 1956 to 1963. The library moved to its current quarters in Bethesda, Maryland, on the campus of the National Institutes of Health, in 1962.

History of Medicine reading room

Further reading
Miles, Wyndham D., A History of the National Library of Medicine: The Nation's Treasury of Medical Knowledge; U. S. Government Printing Office, 1992.

Interior view of the Binding Section. HMD Prints & Photos, PP059772.4.

Notes and references


[2] Director, NLM (https:/ / www. nlm. nih. gov/ about/ welcome. html) [6] Radiation Emergency Management System (REMM) (http:/ / www. remm. nlm. gov/ index. html)

External links
Coordinates: 38.9951N 77.0993W (http:/ / tools. wmflabs. org/ geohack/ geohack. php?pagename=United_States_National_Library_of_Medicine& params=38.9951_N_-77.0993_E_) Official website (https://www.nlm.nih.gov/)

View of front entrance of the new National Library of Medicine building under construction, in Bethesda, Maryland. HMD Prints & Photos, Z AD6 U56 C32 no. 27 box 58 ins.

ClinicalTrials.gov (http://clinicaltrials.gov) Developed to provide information about clinical research AIDSinfo.nih.gov (http://aidsinfo.nih.gov) A comprehensive resource providing HIV/AIDS treatment and clinical trial information

United States National Library of Medicine SIS (http://sis.nlm.nih.gov/) (Specialized Information Services), division for information resources and services in toxicology, environmental health, chemistry, HIV/AIDS, and specialized topics in minority health Milestones in NLM History (https://apps.nlm.nih.gov/175/milestones. cfm)

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Logo

Official seal

Omnibus Budget Reconciliation Act of 1993

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Omnibus Budget Reconciliation Act of 1993


Omnibus Budget Reconciliation Act

Long title Colloquial acronym(s) Nickname(s) Enacted by the Effective

Omnibus Budget Reconciliation Act OBRA-93 Deficit Reduction Act of 1993, Revenue Reconciliation Act of 1993 103rd United States Congress August 10, 1993 Citations

Public Law Stat.

103-66

[1]

107 Stat. 312 through 685 Stat. 1025 (374 pages) Legislative history [2] [3] ) by Martin Olav Sabo (DMN) on May 25,

Introduced in the House as the "Omnibus Budget Reconciliation Act of 1993" (H.R. 2264 1993 Committee consideration by: Budget Passed the House on May 27, 1993 (219-213 Passed the Senate on June 25, 1993 (5049 [4] )

[5]

) with amendment [6] ) ) with further amendment

House agreed to Senate amendment on August 5, 1993 (218-216 Senate agreed to House amendment on August 6, 1993 (51-50 Signed into law by President Bill Clinton on August 10, 1993

[7]

The Omnibus Budget Reconciliation Act of 1993 (or OBRA-93[8]) was a federal law that was enacted by the 103rd United States Congress and signed into law by President Bill Clinton. It has also been referred to, unofficially, as the Deficit Reduction Act of 1993. Part XIII, which dealt with taxes and is also called the Revenue Reconciliation Act of 1993.

Specifics
It created 36 percent and 39.6 income tax rates for individuals in the top 1.2% of the wage earners.[9] It created a 35 percent income tax rate for corporations. The cap on Medicare taxes was repealed. Transportation fuels taxes were raised by 4.3 cents per gallon. The taxable portion of Social Security benefits was raised. The phase-out of the personal exemption and limit on itemized deductions were permanently extended.

Part IV Section 14131: Expansion of the Earned Income Tax Credit and added inflation adjustments

Omnibus Budget Reconciliation Act of 1993

1148

Alternatives
Some alternatives to the bill included a proposal by Senator David Boren (D-OK), which among other things would have kept much of the tax increase on upper-income payers but would have eliminated all energy tax increases while also scaling back the Earned Income Tax Credit. It was endorsed by Bill Cohen (R-ME), Bennett Johnston (D-LA), and John Danforth (R-MO). Boren's proposal never passed committee. Clinton himself claimed he had an alternative tax proposal that favored taxes on energy, but later passed a bill that raised income taxes on middle income and higher income Americans because of no Republican support for the budget. Later in 1995 he expressed belief that he had raised taxes too much (In 1997 he later cut the capital gains tax from 28 to 20%).[10][11] Another proposal was offered in the House of Representatives by John Kasich (R-OH). He sponsored an amendment that would have reduced the deficit by cutting $355 billion in spending with $129 billion of the cuts coming from entitlement programs (the actual bill cut entitlement spending by only $42 billion). The amendment would have eliminated any tax increases. The amendment failed by a 138-295 vote with many Republicans voting against the amendment and only six Democrats voting in favor of the amendment.

Legislative history
Ultimately every Republican in Congress voted against the bill, as did a number of Democrats. Vice President Al Gore broke a tie in the Senate on both the Senate bill and the conference report. The House bill passed 219-213 on Thursday, May 27, 1993.[4] The House passed the conference report on Thursday, August 5, 1993, by a vote of 218 to 216 (217 Democrats and 1 independent (Sanders (I-VT)) voting in favor; 41 Democrats and 175 Republicans voting against).[12] The Senate passed the conference report on the last day before their month's vacation, on Friday, August 6, 1993, by a vote of 51 to 50 (50 Democrats plus Vice President Gore voting in favor, 6 Democrats (Lautenberg (D-NJ), Bryan (D-NV), Nunn (D-GA), Johnston (D-LA), Boren (D-OK), and Shelby (D-AL) now (R-AL)) and 44 Republicans voting against). President Clinton signed the bill on August 10, 1993.

References
[1] http:/ / www. gpo. gov/ fdsys/ pkg/ BILLS-103hr2264enr/ pdf/ BILLS-103hr2264enr. pdf [2] http:/ / thomas. loc. gov/ cgi-bin/ bdquery/ z?d103:HR02264:@@@S [3] http:/ / hdl. loc. gov/ loc. uscongress/ legislation. 103hr2264 [4] http:/ / clerk. house. gov/ evs/ 1993/ roll199. xml [5] http:/ / www. senate. gov/ legislative/ LIS/ roll_call_lists/ roll_call_vote_cfm. cfm?congress=103& session=1& vote=00190 [6] http:/ / clerk. house. gov/ evs/ 1993/ roll406. xml [7] http:/ / www. senate. gov/ legislative/ LIS/ roll_call_lists/ roll_call_vote_cfm. cfm?congress=103& session=1& vote=00247 [8] . [12] http:/ / www. govtrack. us/ congress/ vote. xpd?vote=h1993-406

The government was able to raise additional revenue, which {when combined with the spending cuts passed by the GOP Congress in 1997 in the Balanced Budget Act} helped balance the budget and by the end of the 1990s began to reduce privately held public debt.[5]

Omnibus Budget Reconciliation Act of 1993

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External links
Full text of the Act (http://www.scribd.com/doc/76345306/PL-103-66-Revenue-Reconciliation-Act-of-1993) Senate roll call vote (http://www.senate.gov/legislative/LIS/roll_call_lists/roll_call_vote_cfm. cfm?congress=103&session=1&vote=00247) House roll call vote (http://clerk.house.gov/evs/1993/roll406.xml) Summary of OBRA-93 (http://www.realestateagent.com/real-estate-glossary/Insurance/ Omnibus-budget-reconciliation-act-of-.html) nysscpa.org (http://www.nysscpa.org/cpajournal/old/14522914.htm)

Drug overdose

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Drug overdose
Drug overdose
Classification and external resources

Activated carbon is a commonly used agent for decontamination of the gastrointestinal tract in overdoses. ICD-10 ICD-9 DiseasesDB MeSH T36 960 [1] [3] -T50 [2] [4]

-979

3971

[5] [6]

D015537

The term drug overdose (or simply overdose or OD) describes the ingestion or application of a drug or other substance in quantities greater than are recommended[7] or generally practiced.[8] An overdose may result in a toxic state or death.[8]

Classification
The word "overdose" implies that there is a common safe dosage and usage for the drug; therefore, the term is commonly only applied to drugs, not poisons, though even certain poisons are harmless at a low enough dosage. Drug overdoses are sometimes caused intentionally to commit suicide or as self-harm, but many drug overdoses are accidental, the result of intentional or unintentional misuse of medication. Intentional misuse leading to overdose can include using prescribed or unprescribed drugs in excessive quantities in an attempt to produce euphoria. Usage of illicit drugs of unexpected purity, in large quantities, or after a period of drug abstinence can also induce overdose. Cocaine users who inject intravenously can easily overdose accidentally, as the margin between a pleasurable drug sensation and an overdose is small.[9] Unintentional misuse can include errors in dosage caused by failure to read or understand product labels. Accidental overdoses may also be the result of over-prescription, failure to recognize a drug's active ingredient, or unwitting ingestion by children[10] A common unintentional overdose in young children involves multi-vitamins containing iron. Iron is a component of the hemoglobin molecule in blood, used to transport oxygen to living cells. When taken in small amounts, iron allows the body to replenish hemoglobin, but in large amounts it causes severe pH imbalances in the body. If this overdose is not treated with chelation therapy, it can lead to death or permanent coma.

Drug overdose The term 'overdose' is often misused as a descriptor for adverse drug reactions or negative drug interactions due to mixing multiple drugs simultaneously.

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Signs and symptoms


Toxidrome[]
Symptoms anticholinergic cholinergic opioid sympathomimetic BP ~ ~ HR up ~ RR ~ Temp up Pupils bowel sounds diaphoresis up down up down up down down up down up down

unchanged unchanged down down up down down up down down up ~

down down up up

sedative-hypnotic down down

Signs and symptoms of an overdose varies depending on the drug or toxin exposure. The symptoms can often be divided into differing toxidromes. This can help one determine what class of drug or toxin is causing the difficulties. Symptoms of opioid overdoses include slow breathing, heart rate and pulse.[11] Opioid overdoses can also cause pinpoint pupils, and blue lips and nails due to low levels of oxygen in the blood. A person experiencing an opioid overdose might also have muscle spasms, seizures and decreased consciousness. A person experiencing an opiate overdose usually will not wake up even if their name is called or if they are shaken vigorously.

Causes
The drugs or toxins which are most frequently involved in overdose and death (grouped by ICD-10): Acute alcohol intoxication (F10) Ethyl Alcohol Methanol poisoning Ethylene glycol poisoning Opioid overdose (F11) Among sedative-hypnotics (F13) Barbiturate overdose (T42.3) Benzodiazepine overdose (T42.4) Uncategorized sedative-hypnotics (T42.6) Ethchlorvynol (Placidyl) GHB Glutethimide (Doriden) Methaqualone Ketamine (T41.2) Among Stimulants (F14-F15) Cocaine overdose (T40.5) Amphetamine overdose (T43.6) Methamphetamine (T43.6) Among Tobacco (F17) Nicotine (T65.2) Among Poly drug use (F19)

Drug overdose Drug "cocktails" (Speedballs) Medications Aspirin poisoning (T39.0) Paracetamol toxicity (T39.1) Tricyclic antidepressant overdose (T43.0) Vitamin poisoning Pesticide poisoning (T60) Organophosphate poisoning DDT

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Diagnosis
Determination of the substance which has been taken may often be determined by asking the person. However, if they will not, or cannot, due to an altered level of consciousness, provide this information, a search of the home or questioning of friends and family may be helpful. Examination for toxidromes, drug testing, or laboratory test may be helpful. Other laboratory test such as glucose, urea and electrolytes, paracetamol levels and salicylate levels are typically done. Negative drug-drug interactions have sometimes been misdiagnosed as an acute drug overdose, occasionally leading to the assumption of suicide.[12]

Prevention
The distribution of naloxone to injection drug users and other opioid drug users decreases the risk of death from overdose.[13] CDC estimates that US programs for drug users and their caregivers prescribing take-home doses of naloxone and training on its utilization are estimated to have reversed 10,000 opioid overdose deaths.[14][15] Healthcare institution-based naloxone prescription programs have also helped reduce rates of opioid overdose in the US state of North Carolina, and have been replicated in the US military.[16][17] Nevertheless, scale-up of healthcare-based opioid overdose interventions is limited by providers insufficient knowledge and negative attitudes towards prescribing take-home naloxone to prevent opioid overdose.[18] Programs training police and fire personnel in opioid overdose response using naloxone have also shown promise in the US.[19][20]

Management
Stabilization of the ABCs are the initial treatment of an overdose. Ventilation is considered when there is a low respiratory rate or when blood gases show the person to be hypoxic. Monitoring of the patient should continue before and throughout the treatment process, with particular attention to temperature, pulse, respiratory rate, blood pressure, urine output, electrocardiography (ECG) and O2 saturation.[] Poison control centers and Medical toxicologists are available in many areas to provide guidance in overdoses to both physicians and the general public.

Antidotes
Specific antidotes are available for certain overdoses. For example, Naloxone is the antidote for opiates such as heroin or morphine. Charcoal is frequently recommended if available within one hour of the ingestion and the ingestion is significant.[] Gastric lavage, syrup of ipecac, and whole bowel irrigation are rarely used.[]

Epidemiology and Statistics


The National Center for Health Statistics report that 19,250 people died of accidental poisoning in the U.S. in the year 2004 (8 deaths per 100,000 population).[21]

Drug overdose In 2008 testimony before a Senate subcommittee, Medical Epidemiologist Dr. Leonard J. Paulozzi[22] of the Centers for Disease Control and Prevention stated that in 2005 more than 22,000 American lives were lost due to overdoses, and the number is growing rapidly. Dr. Paulozzi also testified that all available evidence suggests that unintentional overdose deaths are related to the increasing use of prescription drugs, especially opioid painkillers.[23] However, the vast majority of overdoses are also attributable to alcohol. It is very rare for a victim of an overdose to have consumed just one drug. Most overdoses occur when drugs are ingested in combination with alcohol. [24] In 2008, already 30,000 deaths were caused by drug overdoses in the US, 15,000 were caused by prescribed opioid pain relievers. 80% of the world's supply is consumed in the US, accounting for 5% of the world's population. In 2009, already 37,000 deaths were attributed to drug overdose, more than the number of traffic fatalities. [25][26][27]

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References
[1] [2] [3] [4] [5] [6] [7] http:/ / apps. who. int/ classifications/ icd10/ browse/ 2010/ en#/ T36 http:/ / apps. who. int/ classifications/ icd10/ browse/ 2010/ en#/ T50 http:/ / www. icd9data. com/ getICD9Code. ashx?icd9=960 http:/ / www. icd9data. com/ getICD9Code. ashx?icd9=979 http:/ / www. diseasesdatabase. com/ ddb3971. htm http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2013/ MB_cgi?field=uid& term=D015537 http:/ / www. treatment-now. com/ resources/ definitions/

[8] http:/ / www. uphs. upenn. edu/ addiction/ berman/ glossary/ [9] Study on fatal overdose (http:/ / www. biomedcentral. com/ 1471-2458/ 7/ 31) in New-York City 1990-2000, visited May 11, 2008 [10] "What to do with leftover medicines". Medicines Talk, Winter 2005. Available at http:/ / www. nps. org. au/ consumers/ publications/ medicines_talk/ mt14/ what_to_do_with_left-over_medicines2 [12] Column - Fatal Drug-Drug Interaction As a Differential Consideration in Apparent Suicides (http:/ / www. preskorn. com/ columns/ 0207. html) [21] National Center for Health Statistics (http:/ / www. cdc. gov/ nchs/ fastats/ acc-inj. htm) [22] Centers for Disease Control and Prevention (http:/ / www. cdc. gov/ media/ subtopic/ sme/ paulozzi. htm) [23] Centers for Disease Control and Prevention (http:/ / www. cdc. gov/ washington/ testimony/ 2008/ t20080312a. htm) [24] http:/ / www. peele. net/ lib/ heroinoverdose. php [25] Painkiller addiction: the plague that is sweeping the US (http:/ / www. guardian. co. uk/ society/ 2012/ nov/ 28/ painkiller-addiction-plague-united-states), The Guardian, 2012-11-28. [26] Vital Signs: Overdoses of Prescription Opioid Pain Relievers --- United States, 1999--2008 (http:/ / www. cdc. gov/ mmwr/ preview/ mmwrhtml/ mm6043a4. htm?s_cid=mm6043a4_w), CDC, 2011-11-04 [27] Drug deaths now outnumber traffic fatalities in U.S., data show (http:/ / articles. latimes. com/ 2011/ sep/ 17/ local/ la-me-drugs-epidemic-20110918), L.A. Times, 2012-11-17

Further reading
Nelson, Lewis H.; Flomenbaum, Neal; Goldfrank, Lewis R.; Hoffman, Robert Louis; Howland, Mary Deems; Neal A. Lewin (2015). Goldfrank's toxicologic emergencies. New York: McGraw-Hill, Medical Pub. Division. ISBN0-07-143763-0. Olson, Kent C. (2004). Poisoning & drug overdose. New York: Lange Medical Mooks/McGraw-Hill. ISBN0-8385-8172-2.

External links
Fact sheets on illicit drugs, overdose prevention, detox and harm reduction strategies. (http://www.quihn.org. au)

Post-anesthesia care unit

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Post-anesthesia care unit


"PACU" redirects here. For the fish, see Pacu. A post-anesthesia care unit, often abbreviated PACU and sometimes referred to as post-anesthesia recovery or PAR, is a vital part of hospitals, ambulatory care centers, and other medical facilities. It is an area, normally attached to operating theater suites, designed to provide care for patients recovering from anesthesia, whether it be general anesthesia, regional anesthesia, or local anesthesia.

Common activities
The PACU staff, generally composed of highly trained nurses are charged with many vital tasks for the care of post-anesthesia and post-operative patients. These essential activities include: monitoring vital signs (heart rate, blood pressure, temperature and respiratory rate) managing post-operative pain. treating symptoms of postoperative nausea and vomiting (or PONV) treating postanesthetic shivering monitoring surgical site(s) for excessive bleeding, discharge, swelling, hematoma, redness, etc.

These common activities may often need supplementing with more intensive care or treatment. This may require : Preparation and education for the use of Patient Controlled Analgesia (PCA) units Preparation and establishment of IV, epidural or perineural infusions Preparation and establishment of invasive monitoring such as arterial lines, central venous lines, ventriculostomies, etc.

Post-operative complications
Occasionally, serious life threatening complications, such as laryngospasm, respiratory arrest, or malignant hyperthermia can arise post-anesthesia. Patients are cared for with interdisciplinary measures from Anesthesiologists, Certified Nurse Anesthetists or CRNA's, PACU nurses and Surgeons. Patients may remain or have to be re-intubated due to anaphylaxis, pulmonary edema, pneumothorax, or complications from surgery such as extended operative time and long-term exposure to anesthesia and narcotics. Unless complications occur, most patients will only stay in the PACU for a few hours, before returning home or to another department of the hospital.

External links
Ketamine: Emergency Applications [1] (eMedicine.com) - discusses laryngospasm. Wikipedia:Link rot

References
[1] http:/ / www. emedicine. com/ emerg/ topic802. htm

Personal Care Assistant

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Personal Care Assistant


This article deals with employed personal assistants of disabled (primarily mobility impaired) individuals. For the more general concept of (unpaid) caregiving among relatives or friends of a disabled individual, please see caregiver; for the employed assistants of developmentally disabled individuals, see direct support professional. For personal assistants in business and related fields, see the article personal assistant.

Disability

Disability portal Category: Disability Category: Disability lists

A Personal Care Assistant (PCA) - variously known under alternate names such as caregiver, personal care attendant, patient care assistant, personal support worker and home care aide - is a paid, employed person who helps persons who are disabled or chronically ill with their activities of daily living (ADLs) whether within the home, outside the home, or both. They assist clients with personal, physical mobility and therapeutic care needs, usually as per care plans established by a rehabilitation health practitioner, social worker or other health care professional.[1] While there is no single definition or professional title for PCAs, in general they may be distinguished as persons who carry out their work as part of the formal health and social services labour market, in contrast to relatives, friends and others who are unpaid for their caregiving activities. Personal Care Assistants may help with daily activities, such as helping the individual bathe, eat, prepare meals and maintain their home. Personal Care Assistants may provide rehabilitative assistance for individuals who have had surgery or been ill. In-home hospice care may also be provided.[2]

Training and employment


Personal care assistants provide routine health and personal care support and assistance with activities of daily living to patients with physical impairments or disabilities in private homes, nursing care facilities, and other residential settings. According to the International Standard Classification of Occupations, they usually do not require extensive health care knowledge or training to practice their profession, but typically require a high level of manual dexterity and good interpersonal communication skills.[3] Personal care assistants help clients with mobility restrictions to get out of bed, bathe, dress, and groom. They may provide some basic health-related services, such as checking the patient's pulse rate, temperature, and respiration rate; helping with simple prescribed exercises; and assisting with medications administration. They may advise families and patients on nutrition, cleanliness, and household tasks. Depending on the clients' needs, they may change simple dressings, provide skin care, or assist with braces and artificial limbs. Some accompany clients to doctors' appointments or on other errands, and may also provide light housekeeping and homemaking tasks.[4] A PCA may be either independently contracted on a freelance basis directly by the person needing the assistance or their family, or employed by a larger staff network of care providers, such as in an assisted living facility, or employed by a private, government-operated or community-based organization that systematically dispatches providers of personal care to persons in need. The PCA may work exclusively with one client, or have a number of

Personal Care Assistant different clients. Some PCAs work with clients with long-term care needs, while others may primarily help discharge hospital patients who have relatively short-term needs. There is no single model for how a PCA may be employed or paid, just like there is no single model for a larger health and social care system. The services of a PCA may be paid directly for some clients under a universal coverage health care system. Or financial assistance programs for the disabled may exist amidst the structure of a country's welfare system, with 'supplement' schemes meant to provide individuals with funds to enable PCA care. Or PCAs may be wholly self-employed and only work for clients who can pay set fees. Because a PCA does not generally provide round-the-clock care or stay overnight at a client's residence, most PCAs work in shifts to meet individual clients' needs. In some countries, PCAs must receive formal training and pass a competency test in areas such as personal hygiene, safe transfer techniques, reading and recording vital signs, infection control, and basic nutrition in order to qualify to work for certified personal care service agencies that receive reimbursement from social insurance programs, such as Medicare or Medicaid in the United States.[4]

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Current issues
Around the world, demand for PCA services are expected to rise sharply over the next three decades with population ageing and rapid increases in the number of persons reaching the oldest age groups and in need of personal assistance and long-term care.[5] In some developed countries, a careers rights movement has developed in which, its PCAs claim, there does not exist adequate program funding to give rise to adequate pay for the often very intense and physically demanding work. The fact that most persons who are disabled or chronically ill tend to have very limited individual financial resources to pay, or even to supplement, the PCAs' wages themselves, means that this lack of funding for all parties possibly creates stressful work environments for both the workers and their clients.

References
[1] World Health Organization: Classifying health workers. Geneva, WHO, 2010. [3] International Labour Organization: International Standard Classification of Occupations, ISCO-2008: Minor group 532-Personal care workers in health services. Geneva, ILO, 2010. [4] US Bureau of Labor Statistics: Occupational Outlook Handbook, 2010-11 Edition: Home Health Aides and Personal and Home Care Aides http:/ / www. bls. gov/ oco/ ocos326. htm [5] OECD: Long-term Care for Older People. Paris, OECD http:/ / www. oecd. org/ document/ 50/ 0,3343,en_2649_33929_35195570_1_1_1_37407,00. html

NHS primary care trust

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NHS primary care trust


An NHS primary care trust (PCT) was a type of NHS trust, part of the National Health Service in England. PCTs were largely administrative bodies, responsible for commissioning primary, community and secondary health services from providers. Until 31 May 2011 they also provided community health services directly. Collectively PCTs were responsible for spending around 80% of the total NHS budget. Primary Care Trusts were abolished on 31 March 2013 as part of the Health and Social Care Act 2012, with their work taken over by clinical commissioning groups.

A Primary Care Trust may commission community health centres.

PCTs held their own budgets and set their own priorities, within the overriding priorities and budgets set by the relevant Strategic Health Authority, and the Department of Health. They provided funding for general practitioners and medical prescriptions; they also commissioned hospital and mental health services from appropriate NHS provider trusts or from the private sector. Many PCTs used the naming style "NHS", followed by the geographical area, to make it easier for local people to understand the management of the NHS locally.

Management
PCTs were managed by a team of executive directors headed by a chief executive. These directors are members of the trust's board, together with non-executive directors appointed after open advertisement. The chairman of a trust was a non-executive director. Other board members included the chair of the trust's Professional Executive Committee (PEC) (elected from local GPs, community nurses, pharmacists, dentists etc.). The financial budgets, and much of the agenda, of PCTs were effectively determined by directives from the strategic health authority (SHA) or the Department of Health.

Restructuring
In 2005 the Government announced that the number of strategic health authorities and primary care trusts would be reduced, the latter by about 50%. The result is that, as of 1 October 2006, there are 152 PCTs (reduced from 303) in England, with an average population of just under 330,000 per trust. After these changes, about 70% of PCTs are coterminous with local authorities having social service responsibilities, which increasingly facilitates joint planning.[1] On 12 July 2010, Andrew Lansley unveiled a new health white paper (which eventually became law as the Health and Social Care Act 2012)[] describing significant structural changes to the NHS under the Conservative and Liberal Democrat coalition government. Among the changes announced, PCTs were to be abolished by 2013 with new GP-led commissioning consortia, Clinical Commissioning Groups, taking on the responsibilities they formerly held.[2] The public health aspects of PCT business would become the responsibility of local councils. Facilities owned by PCTs would transfer to NHS Property Services. Strategic health authorities would also be abolished under these plans. Following widespread criticism of the plans, on April 4, 2011, the Government announced a "pause" in the progress of the Health and Social Care Bill to allow the government to 'listen, reflect and improve' the proposals.[3][4] The Health and Social Care Act 2012 received Royal Assent on the 27th March 2012[] and PCTs were formally abolished on the 31st March 2013.

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References
[1] Local health bodies face shake-up (http:/ / news. bbc. co. uk/ 1/ hi/ health/ 4987430. stm) BBC News, May 16 2006 [2] http:/ / www. guardian. co. uk/ politics/ 2010/ jul/ 12/ radical-nhs-reform-plans [3] Coalition to 'pause, listen and reflect' on NHS reform (http:/ / www. epolitix. com/ latestnews/ article-detail/ newsarticle/ coalition-to-pause-listen-and-reflect-on-nhs-reform/ ) ePolitix.com, published 2011-04-06, accessed 2011-04-06 [4] Government to "pause, listen, reflect and improve" NHS reform plans (http:/ / www. guardian. co. uk/ society/ 2011/ apr/ 06/ government-pause-listen-reflect-improve-nhs-reform) guardian.co.uk, published 2011-04-06, accessed 2011-04-06

External links
NHS Confederation - Primary Care Trust Network (http://www.nhsconfed.org/pctn) International Primary Care Association (http://www.ipcauk.org)

Primary health care


Primary health care, often abbreviated as "PHC", has been defined as "essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination".[1] In other words, PHC is an approach to health beyond the traditional health care system that focuses on health equity-producing social policy.[2][3] PHC includes all areas that play a role in health, such as access to health services, environment and lifestyle.[]

Public ambulatory care facility in Maracay, Venezuela, providing ambulatory care sensitive conditions for adequate primary health care.

This ideal model of health care was adopted in the declaration of the International Conference on Primary Health Care held in Alma Ata, Kazakhstan in 1978 (known as the "Alma Ata Declaration"), and became a core concept of the World Health Organization's goal of Health for all.[] The Alma-Ata Conference mobilized a "Primary Health Care movement" of professionals and institutions, governments and civil society organizations, researchers and grassroots organizations that undertook to tackle the "politically, socially and economically unacceptable" health inequalities in all countries. There were many factors that inspired PHC; a prominent example is the Barefoot doctors of China.[][4][5]

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Goals and principles


The ultimate goal of primary health care is better health for all. The WHO has identified five key elements to achieving that goal:[] reducing exclusion and social disparities in health (universal coverage reforms); organizing health services around people's needs and expectations (service delivery reforms); integrating health into all sectors (public policy reforms); pursuing collaborative models of policy dialogue (leadership reforms); and increasing stakeholder participation.

A primary health care worker in Saudi Arabia, 2008

Behind these elements lies a series of basic principles identified in the Alma Ata Declaration that should be formulated in national policies in order to launch and sustain PHC as part of a comprehensive health system and in coordination with other sectors:[1] Equitable distribution of health care according to this principle, primary care and other services to meet the main health problems in a community must be provided equally to all individuals irrespective of their gender, age, caste, color, urban/rural location and social class. Community participation in order to make the fullest use of local, national and other available resources. Community participation was considered sustainable due to its grass roots nature and emphasis on self-sufficiency, as opposed to targeted (or vertical) approaches dependent on international development assistance.[] Health workforce development comprehensive health care relies on adequate numbers and distribution of trained physicians, nurses, allied health professions, community health workers and others working as a health team and supported at the local and referral levels. Use of appropriate technology medical technology should be provided that is accessible, affordable, feasible and culturally acceptable to the community. Examples of appropriate technology include refrigerators for vaccine cold storage. Less appropriate could include, in many settings, body scanners or heart-lung machines, which benefit only a small minority concentrated in urban areas, are generally not accessible to the poor, but draw a large share of resources.[] Multi-sectional approach recognition that health cannot be improved by intervention within just the formal health sector; other sectors are equally important in promoting the health and self-reliance of communities. These sectors include, at least: agriculture (e.g. food security); education; communication (e.g. concerning prevailing health problems and the methods of preventing and controlling them); housing; public works (e.g. ensuring an adequate supply of safe water and basic sanitation); rural development; industry; community organizations (including Panchayats or local governments, voluntary organizations, etc.). In sum, PHC recognizes that health care is not a short-lived intervention, but an ongoing process of improving people's lives and alleviating the underlying socioeconomic conditions that contribute to poor health. The principles link health and development, advocating political interventions, rather than passive acceptance of economic conditions.[]

Primary health care

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Approaches
The primary health care approach has seen significant gains in health were applied even when adverse economic and political conditions prevail.[] Although the declaration made at the Alma-Ata conference deemed to be convincing and plausible in specifying goals to PHC and achieving more effective strategies, it generated numerous criticisms and reactions worldwide. Many argued the declaration did not have clear targets, was too broad, and was not attainable because of the costs and aid needed. As a result, PHC approaches have evolved in different contexts to account for disparities in resources and local priority health problems; this is alternatively called the Selective Primary Health Care (SPHC) approach.

The hospital ship USNSMercy(T-AH-19) in Manado, Indonesia, during Pacific Partnership 2012.

Selective PHC
After the year 1978 Alta Alma Conference, the Rockefeller Foundation held a conference in 1979 at its Bellagio conference center in Italy to address several concerns. Here, the idea of Selective Primary Health Care was introduced as a strategy to complement comprehensive PHC. It was based on a paper by Julia Walsh and Kenneth S. Warren entitled Selective Primary Health Care, an Interim Strategy for Disease Control in Developing Countries.[6] This new framework advocated a more economical feasible approach to PHC by only targeting specific areas of health, and chosing the most effective treatment plan in terms of cost and effectivness. One of the foremost examples of SPHC is "GOBI" (growth monitoring, oral rehydration, breastfeeding, and immunization),[][7] focusing on combating the main diseases in developing nations.

GOBI-FFF
Selective PHC approach consists of techniques known collectively under the acronym "GOBI-FFF". It focuses on severe population health problems in certain developing countries, where a few diseases are responsible for high rates of infant and child mortality. Health care planning is employed to see which diseases require most attention and, subsequently, which intervention can be most effectively applied as part of primary care in a least-cost method. The targets and effects of Selective PHC are specific and measurable. The approach aims to prevent most health and nutrition problems before they begin:[8][9] Growth monitoring: the monitoring of how much infants grow within a period, with the goal to understand needs for better early nutrition.[] Oral rehydration therapy: to combat dehydration associated with diarrhoea Breastfeeding Immunization Family planning (birth spacing) Female education Food supplementation: for example, iron and folic acid fortification/supplementation to prevent deficiencies in pregnant women.

Primary health care

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PHC and population aging


Given global demographic trends, with the numbers of people age 60 and over expected to double by 2025, PHC approaches have taken into account the need for countries to address the consequences of population ageing. In particular, in the future the majority of older people will be living in developing countries that are often the least prepared to confront the challenges of rapidly ageing societies, including high risk of having at least one chronic non-communicable disease, such as diabetes and osteoporosis.[10] According to WHO, dealing with this increasing burden requires health promotion and disease prevention intervention at community level as well as disease management strategies within health care systems.

PHC and mental health


Some jurisdictions apply PHC principles in planning and managing their health care services for the detection, diagnosis and treatment of common mental health conditions at local clinics, and organizing the referral of more complicated mental health problems to more appropriate levels of mental health care.[11]

Background and controversies


Barefoot Doctors
The "Barefoot doctors" of China were an important inspiration for PHC because they illustrated the effectiveness of having a health care professional at the community level with community ties. Barefoot doctors were a diverse array of village health workers who lived in rural areas and received basic health care training. They stressed rural rather than urban health care, and preventive rather than curative services. They also provided a combination of western and traditional medicines. They had close community ties, were relatively low-cost, and perhaps most importantly they encouraged self-reliance through advocating prevention and hygiene practices.[] The program experienced a massive expansion of rural medical services in China, with the number of barefoot doctors increasing dramatically between the early 1960s and the Cultural Revolution (1964-1976).

Criticisms
Although many countries were keen on the idea of primary health care after the Alma Ata conference, the Declaration itself was criticized for being too idealistic and having an unrealistic time table.[] More specific approaches to prevent and control diseases - based on evidence of prevalence, morbidity, mortality and feasibility of control (cost-effectiveness) - were subsequently proposed. The best known model was the Selective PHC approach (described above). Selective PHC favoured short-term goals and targeted health investment, but it did not address the social causes of disease. As such, the SPHC approach has been criticized as not following Alma Ata's core principle of everyone's entitlement to health care and health system development.[] In Africa, the PHC system has been extended into isolated rural areas through construction of health posts and centers that offer basic maternal-child health, immunization, nutrition, first aid, and referral services.[12] Implementation of PHC is said to be affected after the introduction of structural adjustment programs by the World Bank.[12]

Primary health care

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References
[1] World Health Organization. Declaration of Alma-Ata. (http:/ / www. paho. org/ English/ DD/ PIN/ alma-ata_declaration. htm) Adopted at the International Conference on Primary Health Care, Alma-Ata, USSR, 612 September 1978. [2] Starfield, Barbara. "Politics, primary healthcare and health." J Epidemiol Community Health 2011;65:653655 [3] Public Health Agency of Canada. About Primary Health Care. (http:/ / hc-sc. gc. ca/ hcs-sss/ prim/ about-apropos-eng. php) Accessed 12 July 2011. [6] Walsh, Julia A., and Kenneth S. Warren. 1980. Selective primary health care:An interim strategy for disease control in developing countries. Social Science & Medicine. Part C: Medical Economics 14 (2):145-163 [7] http:/ / www. ncbi. nlm. nih. gov/ pmc/ articles/ PMC1448553/ [8] Rehydration Project. UNICEF's GOBI-FFF Programs. (http:/ / rehydrate. org/ facts/ gobi-fff. htm) Accessed 16 June 2011. [9] World Health Organization. World Health Report 2005 (http:/ / www. who. int/ whr/ 2002/ chapter5/ en/ index5. html), Chapter 5: Choosing Interventions to Reduce Specific Risks. Geneva, WHO Press. [10] World Health Organization. Older people and Primary Health Care (PHC). (http:/ / www. who. int/ ageing/ primary_health_care/ en/ index. html) Accessed 16 June 2011. [11] Department of Health, Provincial Government of the Western Cape. Mental Health Primary Health Care (PHC) Services. (http:/ / www. westerncape. gov. za/ eng/ directories/ services/ 11505/ 6435) Accessed 16 June 2011. [12] Pfeiffer, J. 2003. International NGOs and primary health care in Mozambique: the need for a new model of collaboration. Social Science & Medicine 56(4):725-738.

Further reading
WHO (1978). "Alma Ata 1978: Primary Health Care". HFA Sr. (1). WHO (2008). The World Health Report 2008: Primary Health Care, Now More Than Ever (http://www.who. int/whr/2008/en/index.html). McGilvray, James C. (1981). The Quest for Health and Wholeness. Tbingen: German Institute for Medical Missions. ISBN0-7289-0014-9. Socrates Litsios (2002). "The Long and Difficult Road to Alma-Ata: A Personal Reflection". International Journal of Health Services 32 (4): 709732. doi: 10.2190/RP8C-L5UB-4RAF-NRH2 (http://dx.doi.org/10. 2190/RP8C-L5UB-4RAF-NRH2). PMID 12456122 (http://www.ncbi.nlm.nih.gov/pubmed/12456122). Socrates Litsios (November 1994). "The Christian Medical Commission and the Development of WHO's Primary Health Care Approach" (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1448555). American Journal of Public Health 94 (11): 18841893. doi: 10.2105/AJPH.94.11.1884 (http://dx.doi.org/10.2105/AJPH.94.11. 1884). PMC 1448555 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1448555). PMID 15514223 (http:// www.ncbi.nlm.nih.gov/pubmed/15514223). Gatrell, A.C. (2002) Geographies of Health: an Introduction, Oxford: Blackwell.

External links
Declaration of Alma-Ata (http://www.paho.org/English/DD/PIN/alma-ata_declaration.htm). WHO European Observatory on Health Systems and Policies (http://www.euro.who.int/observatory).

Protected health information

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Protected health information


Protected health information (PHI) is any information about health status, provision of health care, or payment for health care that can be linked to a specific individual. This is interpreted rather broadly and includes any part of a patient's medical record or payment history. PHI is often sought out in datasets for de-identification before researchers share the dataset publicly. When researchers remove PHI from a dataset they do so in an attempt to preserve privacy for research participants.

United States
Under the US Health Insurance Portability and Accountability Act (HIPAA), PHI that is linked based on the following list of 18 identifiers must be treated with special care:[1] 1. Names 2. All geographical identifiers smaller than a state, except for the initial three digits of a zip code if, according to the current publicly available data from the Bureau of the Census: the geographic unit formed by combining all zip codes with the same three initial digits contains more than 20,000 people; and [t]he initial three digits of a zip code for all such geographic units containing 20,000 or fewer people is changed to 000 3. Dates (other than year) directly related to an individual 4. Phone numbers 5. Fax numbers 6. Email addresses 7. Social Security numbers 8. Medical record numbers 9. Health insurance beneficiary numbers 10. Account numbers 11. Certificate/license numbers 12. Vehicle identifiers and serial numbers, including license plate numbers; 13. Device identifiers and serial numbers; 14. Web Uniform Resource Locators (URLs) 15. Internet Protocol (IP) address numbers 16. Biometric identifiers, including finger, retinal and voice prints 17. Full face photographic images and any comparable images 18. Any other unique identifying number, characteristic, or code except the unique code assigned by the investigator to code the data

De-identification versus anonymization


Anonymization is a process in which PHI elements are eliminated or manipulated with the purpose of hindering the possibility of going back to the original data set.[2] This involves removing all identifying data to create unlinkable data.[3] De-identification under the Health Insurance Portability and Accountability Act Privacy rule occurs when data has been stripped of common identifiers by two methods: 1. The removal of 18 specific identifiers (Safe Harbor Method): Names Geographic data All elements of dates Telephone numbers FAX numbers

Protected health information Email addresses Social Security numbers Medical record numbers Health plan beneficiary numbers Account numbers Certificate/license numbers Vehicle identifiers and serial numbers including license plates Device identifiers and serial numbers Web URLs Internet protocol addresses Biometric identifiers (i.e. retinal scan, fingerprints) Full face photos and comparable images Any unique identifying number, characteristic or code

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2. Obtain the expertise of an experienced statistical expert to validate and document the statistical risk of re-identification is very small (Statistical Method).[4][5] De-identified data is coded and there is still a link to the original, fully identified data set remains and is kept by an honest broker. Links exist in coded de-identified data making the data considered indirectly identifiable and not anonymized. Coded de-identified data is not protected by the HIPAA Privacy Rule, but is protected under the Common Rule. The purpose of de-identification and anonymization is to use health care data in larger increments, for research purposes. Universities, government agencies, and private health care entities use such data for research, development and marketing purposes.[6]

References
[2] [3] [4] [5] [6] http:/ / www. uclalawreview. org/ pdf/ 57-6-3. pdf http:/ / healthcare. partners. org/ phsirb/ hipaaglos. htm#g3 https:/ / www. cdt. org/ healthprivacy/ 20090625_deidentify. pdf http:/ / www. hipaa. edu/ ResearcGuide/ deidentification. html http:/ / healthcare. partners. org/ phsirb/ hipaaglos. htm#g3

Further reading
Full text of the Health Insurance Portability and Accountability Act (PDF/TXT) (http://www.gpo.gov/fdsys/ search/pagedetails.action?granuleId=CRPT-104hrpt736&packageId=CRPT-104hrpt736) U.S. Government Printing Office What does PHI include? (http://www.hipaa.com/2009/09/ hipaa-protected-health-information-what-does-phi-include/)

United States Public Health Service

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United States Public Health Service


United States Public Health Service

Seal of the United States Public Health Service

Flag of the United States Public Health Service Agency overview Formed Jurisdiction Headquarters 1798 Federal government of the United States Washington, D.C.

Agency executive Dr. Howard K. Koh, Assistant Secretary for Health Parent Agency Department of Health and Human Services Website www.USPHS.gov
[1]

The Public Health Service Act of 1944 structured the United States Public Health Service (PHS) as the primary division of the Department of Health, Education and Welfare (HEW), which later became the United States Department of Health and Human Services. The PHS comprises all Agency Divisions of Health and Human Services and the Commissioned Corps. The Assistant Secretary for Health (ASH) oversees the PHS and the United States Public Health Service Commissioned Corps.[2][3]

Agencies
Agencies within the Public Health Service Agency for Healthcare Research and Quality (AHRQ) Agency for Toxic Substances and Disease Registry (ATSDR) Centers for Disease Control and Prevention (CDC) Food and Drug Administration (FDA) Health Resources and Services Administration (HRSA) Indian Health Service (IHS) National Institutes of Health (NIH) Substance Abuse and Mental Health Services Administration (SAMHSA)

United States Public Health Service

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United States Public Health Service Commissioned Corps


The United States Public Health Service Commissioned Corps employs more than 6,000 public health professionals for the purpose of delivering public health promotion and disease prevention programs and advancing public health science. Members of the Commissioned Corps often serve on the frontlines in the fight against disease and poor health conditions. As one of the United States seven uniformed services, the PHS Commissioned Corps fills public health leadership and service roles within federal government agencies and programs. The PHS Commissioned Corps includes officers drawn from many professions, including environmental and occupational health, medicine, nursing, dentistry, pharmacy, psychology, social work, hospital administration, health record administration, nutrition, engineering, science, veterinary, health information technology, and other health-related occupations. Officers of the Corps wear uniforms similar to those of the United States Navy with special PHSCC insignia, and the Corps uses the same commissioned officer ranks as the United States Navy, Coast Guard and NOAA Corps from ensign to admiral, uniformed services pay grades O-1 through O-10 respectively.

Mission
The mission of the U.S. Public Health Service Commissioned Corps is to protect, promote, and advance the health and safety of the United States. According to the PHSCC, this mission is achieved through rapid and effective response to public health needs, leadership and excellence in public health practices, and advancement of public health science.

History
The origins of the Public Health Service can be traced to the passage, by the 5th Congress, of An Act for the Relief of Sick and Disabled Seamen in 1798. The earliest marine hospitals created to care for the seamen were located along the East Coast, with Boston being the site of the first such facility; later they were also established along inland waterways, the Great Lakes, and the Gulf of Mexico and Pacific Coasts. Funding for the hospitals was provided by a mandatory tax of about 1% of the wages of all maritime sailors.[4][] A reorganization in 1870 converted the loose network of locally controlled hospitals into a centrally controlled Marine Hospital Service, with its headquarters in Washington, D.C. The position of Supervising Surgeon (later Surgeon General) was created to administer the Service, and John Maynard Woodworth was appointed as the first incumbent in 1871. He moved quickly to reform the system and adopted a military model for his medical staff, instituting examinations for applicants and putting his physicians in uniforms. Woodworth created a cadre of mobile, career service physicians who could be assigned as needed to the various marine hospitals. The commissioned officer corps (now known as the Commissioned Corps of the U.S. Public Health Service or the Public Health Service Commissioned Corps) was established by legislation in 1889. At first open only to physicians, over the course of the twentieth century, the Corps expanded to include veterinarians, dentists, physician assistants, sanitary engineers, pharmacists, nurses, environmental health officers, scientists, and other health professionals. The scope of activities of the Marine Hospital Service also began to expand well beyond the care of merchant seamen in the closing decades of the nineteenth century, beginning with the control of infectious disease. Quarantine was originally a state function rather than federal, but the National Quarantine Act of 1878 vested quarantine authority to the Marine Hospital Service and the National Board of Health.[5] The National Board was not reauthorized by Congress in 1883 and its powers reverted to the Marine Hospital Service.[5] Over the next half a century, the Marine Hospital Service increasingly took over quarantine functions from state authorities. As immigration increased dramatically in the late nineteenth century, the Federal Government also took over the processing of immigrants from the states, beginning in 1891. The Marine Hospital Service was assigned the responsibility for the medical inspection of arriving immigrants at sites such as Ellis Island in New York.

United States Public Health Service Commissioned officers played a major role in fulfilling the Service's commitment to prevent disease from entering the country. Because of the broadening responsibilities of the Service, its name was changed in 1902 to the Public Health and Marine Hospital Service, and again in 1912 to just the Public Health Service. The Service continued to expand its public health activities as the nation entered the twentieth century, with the Commissioned Corps leading the way. As the century progressed, PHS commissioned officers served their country by controlling the spread of contagious diseases such as smallpox and yellow fever, conducting important biomedical research, regulating the food and drug supply, providing health care to underserved groups, supplying medical assistance in the aftermath of disasters, and in numerous other ways. Today the mission of the Commissioned Corps of the PHS is "Protecting, promoting, and advancing the health and safety of the Nation."

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Tuskegee Study of Untreated Syphilis in the Black Male


In 1932, the Public Health Service, working with the Tuskegee Institute, began a study to record the natural history of syphilis in hopes of justifying treatment programs for blacks. It was called the "Tuskegee Study of Untreated Syphilis in the Negro Male". The study initially involved 600 black men 399 with syphilis, 201 who did not have the disease. The study was conducted without the benefit of patients' informed consent. Researchers told the men they were being treated for "bad blood," a local term referring to several ailments, including syphilis, anemia, and fatigue. In truth, they did not receive the proper treatment needed to cure their illness. In exchange for taking part in the study, the men received free medical exams, free meals, and burial insurance. Although originally projected to last 6 months, the study actually went on for 40 years. It has been called "arguably the most infamous biomedical research study in U.S. history."[6] Note that a USPHS physician who took part in the Tuskegee program, John Charles Cutler, was in charge of the U.S. government's syphilis experiments in Guatemala, in which Guatemalan prisoners, soldiers, orphaned children, and others were deliberately infected with syphilis and other sexually-transmitted diseases from 1946-1948 in order to study the disease, in a project funded by a grant from the National Institutes of Health. President Clinton apologized to Guatemala for this program in 2010.

Emergency response since 1999


Commissioned Corps emergency response teams are managed by the Office of the Surgeon General. They are trained and equipped to respond to public health crises and national emergencies, such as natural disasters, disease outbreaks, or terrorist attacks. The teams are multidisciplinary and are capable of responding to domestic and international humanitarian missions. Officers have responded to many such emergencies in the past, including: 1999hospital center at Fort Dix, NJ, for Kosovo refugees 2001terrorist attacks 2001anthrax attacks 2004/2005tsunami and earthquake in Indonesia 2005hurricanes Katrina and Rita 2006earthquake in Hawaii[7] 2006medicine contamination in Panama[7] 2008- Hurricanes Gustav and Ike[7] 2009- Tsunami and earthquake in American Samoa[7] 2010- Earthquake in Haiti[7] 2010- Deepwater Horizon oil spill response[7]

United States Public Health Service 2011- Tsunami in Japan[7] 2012 - Hurricane/Superstorm Sandy - NY/NJ

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Notes and references


This article is based on the public domain text History of the Commissioned Corps, PHS [8]
[1] [2] [3] [5] http:/ / www. usphs. gov/ Organizational Chart of Health & Human Services, 2007 US Department of Health and Human Services. Office of the Assistant Secretary for Health (ASH) (http:/ / www. hhs. gov/ ash/ ) Smillie, W. G. The National Board of Health, 1879-1883 (http:/ / www. ncbi. nlm. nih. gov/ pmc/ articles/ PMC1527526/ ) American Journal of Public Health and The Nation's Health (1943) 33(8):925-930. [7] US Department of Health and Human Services. Emergency Response at Commissioned Corps (http:/ / www. usphs. gov/ AboutUs/ emergencyresponse. aspx) [8] http:/ / www. usphs. gov/ html/ history. html

Further reading
Blue, Rupert (September 1917). "Conserving The Nation's Man Power: How The Government Is Sanitating The Civil Zones Around Cantonment Areas. A Nation-Wide Campaign For Health" (http://books.google.com/ ?id=edYKAAAAYAAJ&pg=RA1-PA255). National Geographic Magazine. XXXII (3): 255278. Hendrick, Burton J. (April 1916). "The Mastery Of Pellagra: How The Doctors Of The United States Public Health Service Have Found A Way Of Curing And Preventing It" (http://books.google.com/ ?id=09_Sr9emceQC&pg=PA633). The World's Work: A History of Our Time XXXI: 633639. Retrieved 2009-08-04. Leupp, Constance D. (August 1914). "Removing The Blinding curse Of The Mountains: How Dr. McMullen, Of The Public Health Service Is Organizing The War Against Trachoma In The Appalachians" (http://books. google.com/?id=zegeQtMn9JsC&pg=PA426). The World's Work: A History of Our Time XLIV (2): 426430. Retrieved 2009-08-04. Annual Report Of The Surgeon General Of The Public Health. Washington: Government Printing Office. Selected Years: 1902 (http://books.google.com/books?id=F1za2dZDCMUC), 1903 (http://books.google. com/books?id=y8osAAAAYAAJ), 1904 (http://books.google.com/books?id=E88TAAAAIAAJ), 1905 (http://books.google.com/books?id=mKkqAAAAMAAJ), 1906 (http://books.google.com/ books?id=7PsLYwyD94sC), 1907 (http://books.google.com/books?id=O3naKViUgQ4C), 1908, 1909 (http://books.google.com/books?id=pms9E2APHKUC), 1910 (http://books.google.com/ books?id=L_UTAAAAIAAJ), 1911 (http://books.google.com/books?id=wopIwxBKws0C)

External links
U.S. Public Health Service (http://www.usphs.gov/) Office of the Surgeon General (http://www.surgeongeneral.gov/) Office of the Public Health Service Historian (http://lhncbc.nlm.nih.gov/apdb/phsHistory/) PHS history and WWII women's uniforms in color (http://www.blitzkriegbaby.de/) WWII US women's service organizations (WAC, WAVES, ANC, NNC, USMCWR, PHS, SPARS, ARC and WASP)

Peripherally inserted central catheter

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Peripherally inserted central catheter


A peripherally inserted central catheter (PICC or PIC line) is a form of intravenous access that can be used for a prolonged period of time (e.g. for long chemotherapy regimens, extended antibiotic therapy, or total parenteral nutrition). First described in 1975,[1] it is an alternative to subclavian lines, internal jugular lines or femoral lines which have higher rates of infection. Subclavian and internal jugular line placements may result in pneumothorax (air in the pleural space of lung).

Chest X-ray showing tip of PICC line in the superior vena cava

Typical PICC line: Note the manual clamp at top.

Insertion
A PICC is inserted in a peripheral vein, such as the cephalic vein, basilic vein, or brachial vein and then advanced through increasingly larger veins, toward the heart until the tip rests in the distal superior vena cava or cavoatrial junction. PICCs are usually inserted by physicians, physician assistants (in the USA), radiologist assistants (in the USA), nurse practitioners, or specially trained certified registered nurses and radiologic technologists using ultrasound, chest radiographs, and fluoroscopy to aid in their insertion and to confirm placement. PICC insertion is a sterile procedure, but does not require the use of an operating room. When done at bedside (that is, in the patient's room), a suitable sterile

Illustration of fully inserted PICC. See full [2] animation showing insertion and comparing to the central venous catheter (CVC).

Peripherally inserted central catheter field must be established and maintained throughout the procedure. For this reason, visitors are normally requested to leave the room until the insertion is complete, and some form of skin preparation should be used to clean patient skin. The insertable portion of a PICC varies from 25 to 60cm in length, that being adequate to reach the desired tip position in most patients. Some lines are designed to be trimmed to the desired length before insertion; others are simply inserted to the needed depth with the excess left outside. As supplied, the line has a guide wire inside. This wire is provided to stiffen the (otherwise very flexible) line so it can be threaded through the veins. The wire is removed and discarded after insertion. The PICC is also provided with a "wing" having holes for either sutures or an adhesive securement device such as Statlock. Other new technologies which may provide advantages are being introduced to the market, such as the SecurAcath subcutaneous securement technology and Grip-Lok securement device. Securing the catheter prevents postinsertion movement of the line, as that could place the tip in an unsafe position.

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Usage
PICCs can remain in situ for extended periods of time, from seven days to a year, although little information is available with respect to viability timeframes. They are used in both the hospital and community settings. PICCs can be used for intravenous delivery of total parenteral nutrition (TPN), chemotherapy, antibiotics or other medications, and can also be used for blood sampling if the lumen is 4 French or larger in size (Arrow and Bard manufacturers guidelines). To maintain patency, PICC management should include regular flushing with normal saline and "locking" with heparin or normal saline when not in use. The type of locking procedure depends on the type of PICC and bung; Groshong PICCs have a three-way valve at the tip so the use of a heparin lock is not necessary, and there are no clamps on the external length. In comparison, Arrow PICCs have clamps on the exterior line and require a heparin lock. The use of heparin to maintain line patency, though, is questionable, and currently randomized clinical control trials are investigating this further. Heparin locks have been associated with complications, including heparin-induced thrombocytopaenia. [3] Other complications may include catheter occlusion, phlebitis, haemorrhage, thrombosis and infection. Urokinase or low-dose tPA (Alteplase or Cathflo) may be used to lyse obstructions. The type of occlusion (caused by medication precipitate or by thrombus), may determine which drug will be used in an attempt to clear the line. To decrease the risk of infection, particularly a blood stream infection, those involved in the management of the PICC must adhere to strict infection control procedures.[4] Blood pressure should not be taken on the arm with a PICC, [5] which is a problem if there are reasons not to take pressure on the other arm, such as a dialysis shunt, absence, cast, infection, lymph node removal, etc. Blood pressure readings on legs are not comparable to arms.[6] Certain types of PICCs have recently been approved by the FDA for use in power injection. These types, often referred to as power-injectable PICCs, are designed to withstand the high pressures associated with radiocontrast studies. PICCs can also be used to measure central venous pressure, which is a rough estimate of the right atrial pressures of the heart and can give valuable information about fluid status of the patient.

Peripherally inserted central catheter

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Removal
In most cases, removal of a PICC is a simple procedure. Generally, the catheter line can be safely and quickly removed by a trained nurse, even in the patient's own home, in a matter of minutes. After removal, the insertion site is normally bandaged with sterile gauze and kept dry for a few days, during which the wound can close and begin healing. Usually, a smaller adhesive bandage can be placed over the wound site after the gauze is removed if the wound is slow to heal.

References
[2] http:/ / blausen. com/ index-wiki. php?word=Peripherally-inserted+ Central+ Catheter+ %28PICC%29 [3] http:/ / clinicaltrials. gov/ ct2/ show/ related/ NCT00994136 [4] Guidelines for the Prenention of Intravascular Catheter-Related Infections, Centre for Disease Control 2011; Infusion Nurses Standards, 2010).Centre for Disease Control [5] U Wisconsin, Preparing and Caring (http:/ / www. uwhealth. org/ healthfacts/ B_EXTRANET_HEALTH_INFORMATION-FlexMember-Show_Public_HFFY_1104449359467. html), accessed July 24, 2013 [6] Measuring Blood Pressure in Legs (http:/ / www. medscape. com/ viewarticle/ 471829), by Erica Brownfield, MD, accessed July 24, 2013

Further reading
Bender, C.M., Rosenzweig, M. & Green, E. (2006) Cancer. In S. Goldsworthy & M.A. Barry. Medical-Surgical Nursing in Canada: Assessment and Management of Clinical Problems. (1st Canadian ed). Mosby: Toronto. ISBN 0-7796-9969-6.

External links
Description and images of PICC line insertion (http://www.cancerbackup.org.uk/Treatments/Chemotherapy/ Linesports/PICCline)

Prospective payment system

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Prospective payment system


A prospective payment system (PPS) is a means of determining insurance reimbursement to hospitals based on predetermined prices, commonly from Medicare. Payments are typically based on codes provided on the insurance claim.[1] Examples of these codes include: Diagnosis-related groups for hospital inpatient claims Ambulatory Payment Classification for hospital outpatient claims Current Procedural Terminology for other outpatient claims The PPS was established by the Center for Medicare and Medicaid Services (CMS) in 1983, specifically to address expensive hospital care. Regardless of services provided, payment was of an established fee. The idea was to encourage hospitals to tame increasingly expensive hospital care.

References

Quality-adjusted life year


The quality-adjusted life year (QALY) is a measure of disease burden, including both the quality and the quantity of life lived.[1][2] It is used in assessing the value for money of a medical intervention. The QALY model requires utility independent, risk neutral, and constant proportional tradeoff behaviour.[3] The QALY is based on the number of years of life that would be added by the intervention. Each year in perfect health is assigned the value of 1.0 down to a value of 0.0 for being dead. If the extra years would not be lived in full health, for example if the patient would lose a limb, or be blind or have to use a wheelchair, then the extra life-years are given a value between 0 and 1 to account for this.[citation needed] Under certain methods, such as the EQ-5D, QALY can be negative number.

Use
The QALY is often used in cost-utility analysis to calculate the ratio of cost to QALYs saved for a particular health care intervention. This is then used to allocate healthcare resources, with an intervention with a lower cost to QALY saved (incremental cost effectiveness) ratio ("ICER") being preferred over an intervention with a higher ratio.[citation
needed]

Meaning
The meaning and usefulness of the QALY is debated.[8][4][5] Perfect health is hard, if not impossible, to define. Some argue that there are health states worse than being dead, and that therefore there should be negative values possible on the health spectrum (indeed, some health economists have incorporated negative values into calculations). Determining the level of health depends on measures that some argue place disproportionate importance on physical pain or disability over mental health.[citation needed] The effects of a patient's health on the quality of life of others (e.g. caregivers or family) do not figure into these calculations.[citation needed]

Quality-adjusted life year

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Calculation
The QALY is a measure of the value of health outcomes. Since health is a function of length of life and quality of life, the QALY was developed as an attempt to combine the value of these attributes into a single index number. The basic idea underlying the QALY is simple: it assumes that a year of life lived in perfect health is worth 1 QALY (1 Year of Life 1 Utility value = 1 QALY) and that a year of life lived in a state of less than this perfect health is worth less than 1. In order to determine the exact QALY value, it is sufficient to multiply the utility value associated with a given state of health by the years lived in that state. QALYs are therefore expressed in terms of "years lived in perfect health": half a year lived in perfect health is equivalent to 0.5 QALYs (0.5 years 1 Utility), the same as 1 year of life lived in a situation with utility 0.5 (e.g. bedridden) (1 year 0.5 Utility). QALYs can then be incorporated with medical costs to arrive at a final common denominator of cost/QALY. This parameter can be used to develop a cost-effectiveness analysis of any treatment. Nevertheless, a salient problem of the QALY calculation relies on the numerical nature of its constituent parts. The appropriateness of the QALY arithmetical operation is compromised by the essence of the utility scale: while life-years are expressed in a ratio scale with a true zero, the utility is an interval scale where 0 is an arbitrary value for being dead. In order to be able to obtain coherent results, both scales would have to be expressed in the same units of measurement. The different nature of these two factors jeopardises the meaning and interpretation of QALYs. A simple general linear transformation of the utility scale suffices to demonstrate that the results of the multiplication are not invariant. Mathematically, the solution to these limitations happens through an alternative calculation of QALYs by means of operations with complex numbers rooted in the well known Pythagorean theorem. [8]

Weighting
The "weight" values between 0 and 1 are usually determined by methods such as:[citation needed] Time-trade-off (TTO): Respondents are asked to choose between remaining in a state of ill health for a period of time, or being restored to perfect health but having a shorter life expectancy. Standard gamble (SG): Respondents are asked to choose between remaining in a state of ill health for a period of time, or choosing a medical intervention which has a chance of either restoring them to perfect health, or killing them. Visual analogue scale (VAS): Respondents are asked to rate a state of ill health on a scale from 0 to 100, with 0 representing being dead and 100 representing perfect health. This method has the advantage of being the easiest to ask, but is the most subjective. Another way of determining the weight associated with a particular health state is to use standard descriptive systems such as the EuroQol Group's EQ5D questionnaire, which categorises health states according to the following dimensions: mobility, self-care, usual activities (e.g. work, study, homework or leisure activities), pain/discomfort and anxiety/depression.[citation needed] However, the weight assigned to a particular condition can vary greatly, depending on the population being surveyed. Those who do not suffer from the affliction in question will, on average, overestimate the detrimental effect on quality of life, compared to those who are afflicted.[citation needed]

Debate
The method of ranking interventions on grounds of their cost per QALY gained ratio (or ICER) is controversial because it implies a quasi-utilitarian calculus to determine who will or will not receive treatment.[6] However, its supporters argue that since health care resources are inevitably limited, this method enables them to be allocated in the way that is approximately optimal for society, including most patients. Another concern is that it does not take into account equity issues such as the overall distribution of health states. Also, many would argue that all else being equal, patients with more severe illness should be prioritised over patients with less severe illness if both would get

Quality-adjusted life year the same absolute increase in utility.[7] QALYs were invented by two health economists in 1956: Christopher Cundell and Carlos McCartney.[8]

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References
[1] National Institute for Health and Clinical Excellence - Measuring effectiveness and cost effectiveness: the QALY (http:/ / www. nice. org. uk/ newsroom/ features/ measuringeffectivenessandcosteffectivenesstheqaly. jsp) [2] Entry for "QALY" in the Oxford University's Bandolier Journal (http:/ / www. medicine. ox. ac. uk/ bandolier/ booth/ glossary/ QALY. html) [8] http:/ / www. medfak. ni. ac. rs/ Acta%20facultatis/ 2011/ 4-2011/ 1. pdf

Quality improvement organizations


Quality Improvement Organizations (QIOs) monitor the appropriateness, effectiveness, and quality of care provided to Medicare beneficiaries. They are private contractor extensions of the federal government that work under the auspices of the U.S. Centers for Medicare and Medicaid Services (CMS). In recent years QIOs have undertaken to facilitate continual improvement of health care services within their constituent communities in addition to their original and ongoing statutory audit/inspection role of medical peer review, i.e., akin to the traditional function of quality assurance. This shift in emphasis began in the mid-1990s and has accelerated into the 21st century. Originally known as PROs (Peer Review Organizations), their name was officially changed to QIOs as per the Federal Register on May 24, 2002 in large part to reflect this new emphasis on population-based quality improvement. CMS contracts with QIOs in three-year cycles, referred to as "Statements of Work" (SOWs). QIOs are staggered into three categories (round 1, round 2, and round 3) - each of these three groups start their contract cycle at slightly different times (usually offset by several months). QIOs are currently in their Tenth SOW, which started in August, 2011 (for round 1 QIOs). The 9SOW continued the theme of "transformational change" to be achieved through accelerating the rate of quality improvement, raising the bar for performance, and facilitating profound cultural change by incorporating Health Information Technologies. An example of current QIO quality improvement work is that of the federal Doctor's Office Quality Information Technology initiative (DOQ-IT) (Unknown 2009), which: promotes the adoption of electronic health record systems and information technology in small-to-medium sized physician offices with a vision of enhancing access to patient information, decision support, and reference data, as well as improving patient-clinician communications. Another example is: national coordination and support of the Surgical Care Improvement Project (SCIP)[1], a hospital based quality improvement initiative led by CMS that focuses on reducing the rate of adverse outcomes of common surgical procedures. This is an effort endorsed by the Centers for Disease Control (CDC), the American College of Surgeons (ACS), the American Hospital Association (AHA), and a large number of professional societies that include physicians, pharmacists, nurses, anesthesiologists, and others. It is estimated that adoption of all the "bundles" of suggested care in the areas of surgical site infection, cardiovascular care, venous thromboembolism prevention, and pulmonary care, could reduce the rate of surgical morbidity and mortality by 25% by the year 2010. QIOs also help coordinate and facilitate the timely submission of data for public reporting of institution-specific quality measure performance information that is available on CMS websites such as "Nursing Home Compare" and "Hospital Compare". In recent years, QIO hospital work has tended to reinforce and complement that of the Institute for Healthcare Improvement (based in Cambridge, MA). The QIOs are represented nationally by the American Health Quality Association.

Quality improvement organizations

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QIO Listings
There are 53 QIO contracts. The companies holding these contracts are listed below by state/territory: Alabama - AQAF Alaska - Mountain-Pacific Quality Health Foundation Arizona - Health Services Advisory Group Arkansas - Arkansas Foundation for Medical Care California - Health Services Advisory Group Colorado - Colorado Foundation for Medical Care Connecticut - Qualidigm [2] Delaware - Quality Insights of Delaware District of Columbia - Delmarva Foundation for Medical Care Florida - FMQAI [3] Georgia - Georgia Medical Care Foundation [4] Hawaii - Mountain-Pacific Quality Health Foundation Idaho - Qualis Health Illinois - Illinois Foundation for Quality Health Care Indiana - Health Care Excel Iowa - Iowa Foundation for Medical Care Kansas - Kansas Foundation for Medical Care, Inc. Kentucky - Health Care Excel Louisiana - eQ Health Solutions Maine - Northeast Health Care Quality Foundation Maryland - Delmarva Foundation for Medical Care Massachusetts - MassPRO [5] Michigan - MPRO Minnesota - Stratis Health Mississippi - Information & Quality Healthcare http://www.iqh.org - QIO Website http://www.msqio.org Missouri - Primaris [6] Montana - Mountain-Pacific Quality Health Foundation Nebraska - CIMRO of Nebraska Nevada - HealthInsight http://www.healthinsight.org/ New Hampshire - Northeast Health Care Quality Foundation New Jersey - Healthcare Quality Strategies, Inc. New Mexico - New Mexico Medical Review Association dba HealthInsight http://www.healthinsight.org/ New York - IPRO North Carolina - The Carolinas Center for Medical Excellence North Dakota - North Dakota Health Care Review Ohio - Ohio KePRO Oklahoma - Oklahoma Foundation for Medical Quality

Quality improvement organizations Oregon - Acumentra Health Pennsylvania - Quality Insights of Pennsylvania Puerto Rico - Quality Improvement Professional Research Organization, Inc. Rhode Island - Healthcentric Advisors South Carolina - The Carolinas Center for Medical Excellence South Dakota - South Dakota Foundation for Medical Care Tennessee - Qsource [7] Texas - TMF Health Quality Institutehttp://texasqio.tmf.org/ Utah - HealthInsight http://www.healthinsight.org/ Vermont - Northeast Health Care Quality Foundation Virgin Islands - Virgin Islands Medical Institute Virginia - Virginia Health Quality Center Washington - Qualis Health West Virginia - WVMI Quality Insights Wisconsin - MetaStar Wyoming - Mountain-Pacific Quality Health Foundation

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References & notes


Unknown (2009), Doctor's Office Quality Information Technology (DOQ-IT) [8], QualityNet, retrieved 30 June 2009

External links
QIOs [9], from the CMS website American Health Quality Association [10] Medicare Quality Improvement Community [11] Online resources to support quality improvement in Medicare. Institute for Healthcare Improvement [12] Not for profit group that promotes national and worldwide quality improvement and sponsors conferences, education and training, and publications in this area. Mississippi QIO [13]

References
[1] http:/ / www. medqic. org/ scip/ [2] http:/ / www. qualidigm. org [3] http:/ / www. fmqai. com [4] http:/ / www. gmcf. org [5] http:/ / www. masspro. org/ [6] http:/ / www. primaris. org [7] http:/ / www. qsource. org [8] http:/ / www. qualitynet. org/ dcs/ ContentServer?cid=1143577170595& pagename=QnetPublic%2FPage%2FQnetTier2& c=Page [9] http:/ / www. cms. hhs. gov/ QualityImprovementOrgs/ [10] http:/ / www. ahqa. org/ [11] http:/ / www. medqic. org/ [12] http:/ / www. ihi. org/ [13] http:/ / www. msqio. org/

Resource-based relative value scale

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Resource-based relative value scale


Resource-based relative value scale (RBRVS) is a schema used to determine how much money medical providers should be paid. It is partially used by Medicare in the United States and by nearly all Health maintenance organizations (HMOs). RBRVS assigns procedures performed by a physician or other medical provider a relative value which is adjusted by geographic region (so a procedure performed in Manhattan is worth more than a procedure performed in Dallas). This value is then multiplied by a fixed conversion factor, which changes annually, to determine the amount of payment. RBRVS determines prices based on three separate factors: physician work (54%), practice expense (41%), and malpractice expense (5%).[1][2]

Example
For example, in 2005, a generic 99213 Current Procedural Terminology (CPT) code was worth 1.39 Relative Value Units, or RVUs. Adjusted for North Jersey, it was worth 1.57 RVUs. Using the 2005 Conversion Factor of $37.90, Medicare paid 1.57 * $37.90 for each 99213 performed, or $59.50. Most specialties charge 200400% of Medicare rates for their procedures and collect between 5080% of those charges, after contractual adjustments and write-offs.[citation needed]

Criticism
The RBRVS system has been criticized on a number of grounds: Paying based on effort rather than effect skews incentives, leading to overuse of complicated procedures without consideration for outcomes.[] Contrast with evidence-based medicine (EBM), which is based on outcomes. According to this critique, RBRVS misaligns incentives: because the medical value to the patient of a service is not included in how much is paid for the service, there is no financial incentive to help the patient, nor to minimize costs. Rather, payment is partly based on difficulty of the service (the "physician work" component), and thus a profit-maximizing physician is incentivized to provide maximally complicated services, with no consideration for effectiveness. One effect attributed to RBRVS is a lack of primary care physicians (PCPs) at the expense of specialists because specialist services require more effort and specialized training, they are paid more highly, incentivizing physicians to specialize, leading to a lack of PCPs. The Specialty Society Relative Value Scale Update Committee (RUC) is largely privately run, an example of regulatory capture.[] RUC is secretive, with the meetings being closed to the public and uninvited observers.[][3] The data are effectively copyrighted by the AMA, but its use is required by statute. Although the RBRVS system is mandated by the Centers for Medicare and Medicaid Services (CMS) and the data for it appears in the Federal Register, the American Medical Association (AMA) maintains that their copyright of the CPT allows them to charge a license fee to anyone who wishes to associate RVU values with CPT codes. The AMA receives approximately $70 million annually from these fees, making them reluctant to allow the free distribution of tools and data that might help physicians calculate their fees accurately and fairly.

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History
RBRVS was created at Harvard University in their national RBRVS study from December 1985 and published on September 29, 1988. William Hsiao was the principal investigator who organized a multi-disciplinary team of researchers, which included statisticians, physicians, economists and measurement specialists, to develop the RBRVS. In 1988 the results were submitted to the Health Care Financing Administration (today CMS) to be used in the American Medicare system. In December of the following year, President George H. W. Bush signed into law the Omnibus Budget Reconciliation Act of 1989, switching Medicare to an RBRVS payment schedule. This took effect on January 1, 1992. Starting in 1991, the AMA has updated RBRVS continually. As of May 2003, over 3500 corrections have been submitted to CMS.

Procedure
Committees
Physicians bill their services using procedure codes developed by a seventeen member committee known as the CPT Editorial Panel. The AMA nominates eleven of the members while the remaining seats are nominated by the Blue Cross and Blue Shield Association, the Health Insurance Association of America, CMS, and the American Hospital Association. The CPT Committee issues new codes twice each year. A separate committee, the Specialty Society Relative Value Scale Update Committee (RUC),[] meets three times a year to set new values,[] determines the Relative Value Units (RVUs) for each new code, and revalues all existing codes at least once every five years. The RUC has 29 members, 23 of whom are appointed by major national medical societies. The six remaining seats are held by the Chair (an AMA appointee), an AMA representative, a representative from the CPT Editorial Panel, a representative from the American Osteopathic Association, a representative from the Health Care Professions Advisory Committee and a representative from the Practice Expense Review Committee. Anyone who attends its meetings must sign a confidentiality agreement.

Price setting
The RBRVS for each CPT code is determined using three separate factors: physician work, practice expense, and malpractice expense. The average relative weights of these are: physician work (52%), practice expense (44%), malpractice expense (4%).[2] A method to determine the physician work value was the primary contribution made by the Hsiao study. The RUC examines each new code to determine a relative value by comparing the physician work of the new code to the physician work involved in existing codes. The practice expense, determined by the Practice Expense Review Committee, consists of the direct expenses related to supplies and non-physician labor used in providing the service, and the pro rata cost of the equipment used. In addition, there is an amount included for the indirect expenses. In the development of the RBRVS, the physician work (including the physician's time, mental effort, technical skill, judgment, stress and an amortization of the physician's education), the practice expense and the malpractice expense are factored into the result. The calculation of the fee includes a geographic adjustment. The RBRVS does not include adjustments for outcomes, quality of service, severity, or demand.

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References
[1] Percentages are average percentage contributions of each factor, as computed by the Government Accountability Office in 2005, as per reference. [2] Medicare physician fees geographic adjustment indices are valid in design, but data and methods need refinement. Washington, DC: Government Accountability Office, March 2005. (Publication no. GAO-05-119.)

Hsiao, W. C. et al. (29 September 1988). "Results and policy implications of the resource-based relative-value study" (http://content.nejm.org/cgi/content/abstract/319/13/881). New England Journal of Medicine 319 (13): 881888. doi: 10.1056/NEJM198809293191330 (http://dx.doi.org/10.1056/NEJM198809293191330). PMID 3045557 (http://www.ncbi.nlm.nih.gov/pubmed/3045557). Hsiao, W. C. et al. (29 September 1988). "Estimating physicians' work for a resource-based relative-value scale" (http://content.nejm.org/cgi/content/abstract/319/13/835). New England Journal of Medicine 319 (13): 835841. doi: 10.1056/NEJM198809293191305 (http://dx.doi.org/10.1056/NEJM198809293191305). PMID 3412414 (http://www.ncbi.nlm.nih.gov/pubmed/3412414). Goodson, John D. (2007). "Unintended Consequences of Resource-Based Relative Value Scale Reimbursement" (http://jama.ama-assn.org/cgi/content/extract/298/19/2308). Journal of the American Medical Association 298 (19): 23082310. doi: 10.1001/jama.298.19.2308 (http://dx.doi.org/10.1001/jama.298.19.2308). PMID 18029836 (http://www.ncbi.nlm.nih.gov/pubmed/18029836).

External links
RBRVS entry (http://bphc.hrsa.gov/chc/simis/CHC_MISGlossary. asp?returnpage=<%=ReturnPageTemp%#R) in glossary of terms on the hrsa.gov (http://www.hrsa.gov/) website (broken) Physician Fee Schedule Calculations (http://www.cms.hhs.gov/PhysicianFeeSched/) from Center for Medicaid and Medicare Services website (broken) Medicare RBRVS: The Physicians' Guide (http://www.aardvarkforms.com/ AMA-Medicare-RBRVS-The-Physicians-Guide-p-16372.html) - a print publication giving details on Medicare's use of RBRVS "Physician Panel Prescribes the Fees Paid by Medicare," The Wall Street Journal, October 26, 2010 (http:// online.wsj.com/article/SB10001424052748704657304575540440173772102. html?mod=WSJ_hp_MIDDLENexttoWhatsNewsThird)

Radiology information system

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Radiology information system


A radiology information system (RIS) is a computerized database used by radiology departments to store, manipulate, and distribute patient radiological data and imagery. The system generally consists of patient tracking and scheduling, result reporting and image tracking capabilities. RIS complements HIS (Hospital Information Systems), and is critical to efficient workflow to radiology practices.

Basic Features
Radiology information systems commonly support the following features: Patient Registration and scheduling Patient List Management Interface with modality via Worklist. Radiology Department workflow management Request and document scanning Result(s) Entry Reporting and printout Result(s) Delivery including faxing and e-mailing of clinical reports Patient Tracking Interactive Documents Technical Files Creation Modality and Material management.

Additional Features
In addition a RIS often supports the following: Appointment booking PACS workflow Custom report creation HL7 interfaces with a PACS. HL7 also enables communication between HIS and RIS in addition to RIS and PACS. Billing Rule engines

Robert Wood Johnson Foundation

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Robert Wood Johnson Foundation


The Robert Wood Johnson Foundation

Founded Founder(s)

1972 Robert Wood Johnson II

Headquarters Princeton, New Jersey Key people Area served Focus(es) Risa Lavizzo-Mourey Health and Health Care Healthcare Reform, Quality, Childhood Obesity, Building Human Capital, Vulnerable Populations, Public Health, Pioneer, Coverage Grantmaking and Social Change 283 www.rwjf.org [1]

Method(s) Employees Website

The Robert Wood Johnson Foundation (RWJF) is the United States' largest philanthropy devoted exclusively to health and health care; it is based in Princeton, New Jersey.[2] The foundation's mission is to improve the health and health care of all Americans. The foundation has $9.2 billion in assets, generating grants approaching $400 million a year[3] to "address the nations most complex health and health care issues. The Foundation aims to use these private resources in the service of the public, and in a way that prompts new public policy, inspires action from the private sector, and changes systems for delivering the best health care to the most people."[4]

History
Robert Wood Johnson II built the family firm of Johnson & Johnson into the world's largest health products maker. He died in 1968. He established the foundation at his death with 10,204,377 shares of the companys stock.[7][5]

Leadership
Currently, the Foundation is led by Risa Lavizzo-Mourey, who was selected to serve as president and CEO in December 2002. Prior to Lavizzo-Mourey's tenure, Steve Schroeder served as the Foundation's president from 1990 2002. Under the leadership of Schroeder, the foundation played a major role in curbing tobacco use in the US, spending $446 million from 1991 to 2003 toward that goal, and it plans to use those experiences to shape its attack on childhood obesity. Since 1995, the number of adult and teenage smokers has declined 12.6 percent and 18 percent, respectively.[7]

Robert Wood Johnson Foundation

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Grantmaking areas
These interest areas include: Childhood Obesity: Reversing the childhood obesity epidemic by 2015 by improving access to affordable healthy foods and increasing opportunities for physical activity in schools and communities across the United States. In April 2007, the foundation committed $500 million to reversing the childhood obesity epidemic. The President and CEO is personally committed to reversing this epidemic by 2015; she is quoted saying the following: Combined with a lack of safe playgrounds and cutbacks in school physical education programs, the absence of healthy food alternatives is one of the factors leading to an alarming increase in childhood obesity rates across the United States. These rates have soared among all age groups of children, more than quadrupling among those between the ages of 6 to 11 in the past 40 years. Today, more than 33% of children in the United Statesapproximately 25 million kidsare reported to be overweight or obese. The crisis is particularly acute in minority and low-income populations, which have significantly higher rates of obesity. The Robert Wood Johnson Foundation has been working over the past several years to support programs that offer potential for wide-scale change in communities and schools. These include efforts to bring supermarkets back to under served communities and programs to improve nutrition, physical activity, and staff wellness in schools nationwide. The Foundation partnered with the Food Trust, a non-profit in Philadelphia, whose mission is to ensure that everyone has access to affordable, nutritious food. The Food Trusts research on childhood obesity led the Philadelphia school system to ban soda vending machines from all of its schools, the strongest measure in the country.[6] Health Insurance Coverage: Ensuring that everyone in America has stable, affordable health care coverage through the development of policies and programs to expand health coverage and maximize enrollment in existing coverage programs. Public Health: Strengthening the practice of public health and the implementation of policies to ensure the system can fulfill its vital role in protecting the safety and health of all Americans. Quality/Equality: Helping communities set and achieve ambitious goals to improve the quality of health care in ways that matter to all patients and their families, and in particular to patients from specific racial and ethnic backgrounds who often experience lower-quality care. Human Capital: Fostering a diverse group of promising scholars and professionals through leadership development, training and research to ensure that our nation has a sufficient, well-trained workforce to meet our needs. Vulnerable Populations: Supporting promising new ideas that address health and health care problems that intersect with social factorshousing, poverty and inadequate educationand affect society's most vulnerable people, including low-income children and their families, frail older adults, adults with disabilities, the homeless, those with HIV/AIDS, and those with severe mental illness. Pioneer Portfolio: Promoting fundamental breakthroughs in health and health care through innovative projects, including those from nontraditional sources and fields. The Foundations Pioneer portfolio focuses developing and implementing new ideas in new and unexpected ways, or new methodologies that inform the future of health and health care. The portfolio seeks disruptive ideas from all fields and invests in innovators who are looking to make long term social change. One example of a pioneering endeavor that fits into the portfolio is using video games to promote health. Although video games are often linked to the physical inactivity, Pioneer team is examining how video games can be used to help kids increase their physical activity level. The team is also examining whether or not an X Prize can be used to foster new ways of thinking about health and health care.[7]

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Criticism
The American Beverage Institute, a restaurant industry trade group which opposes many anti-drunk-driving measures, and the Center for Consumer Freedom, a coalition of restaurant and food companies (quoting the American Beverage Institute), have labeled RWJF as anti-alcohol or neo-prohibitionist.[8][9]

References
[1] http:/ / www. rwjf. org [3] http:/ / dynamodata. fdncenter. org/ 990s/ 990search/ ffindershow. cgi?id=JOHN015 [4] http:/ / content. healthaffairs. org/ cgi/ search?ck=nck& andorexactfulltext=and& resourcetype=1& disp_type=& author1=dentzer& fulltext=& pubdate_year=& volume=& firstpage= [6] onPhilanthropy: Articles: Robert Wood Johnson Foundation Takes Aim at Childhood Obesity (http:/ / www. onphilanthropy. com/ site/ News2?page=NewsArticle& id=7033)

External links
Robert Wood Johnson Foundation (http://www.rwjf.org/index.jsp) Local Initiative Funding Partners (http://www.lifp.org) RWJ Health Policy Fellowships (http://www.healthpolicyfellows.org/home.php) RWJF Health and Society Scholars (http://www.healthandsocietyscholars.org)

Registered nurse
A registered nurse (RN) is a nurse who has graduated from a nursing program at a college or university and has passed a national licensing exam.[] A registered nurse's scope of practice is determined by the school and by the government responsible for health care in the region. These bodies outline what is legal practice for registered nurses and what tasks they may or may not perform. In general, registered nurses help individuals, families, and groups to achieve health and prevent disease. They care for the sick and injured in hospitals and other health care facilities, physicians' offices, private homes, public health agencies, schools, camps, and industry. Some registered nurses are employed in private practice, and a few work at home for healthcare companies.[][1] Nurses must have the ability to get along with other people and must communicate well. They must provide, without prejudice, the best care possible for every client. Especially during critical moments, the nurse must be self-controlled and efficient and show problem solving ability. Registered nurses supervise the nursing care of clients.

Registered nurse

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Education
Canada
In all Canadian provinces except Quebec, new registered nurses are required to have a BScN. [2] This is either achieved through a 4 year university (or collaborative) program or through a bridging program for existing RPNs/LPNs. Some universities also offer compressed programs for applicants already holding a bachelor's degree in another field.

United States
In the United States a registered nurse is a clinician who has completed at least an associate degree in nursing and has successfully completed the NCLEX-RN examination for initial licensure. Associate degree's in nursing are frequently take 3 years to complete because of the increased volume of undergraduate coursework related to the profession of nursing. Bachelor of Science in Nursing degrees include more thorough coursework in leadership and community health.

Economics
As of 2011, there are 2.24 million registered nurses in China.[3] In 2008 the US had approximately 3 million nurses [4] and Canada had just over 250,000. In the US and Canada this works out to approximately 8 nurses per 1000 people.

References
[2] http:/ / www. cna-aiic. ca/ en/ becoming-an-rn/ [4] http:/ / bhpr. hrsa. gov/ healthworkforce/ rnsurveys/ rnsurveyfinal. pdf

Registered Health Information Technician

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Registered Health Information Technician


Registered Health Information Technician (RHIT) is a professional certification administered by the American Health Information Management Association (AHIMA) in the United States. Passing the exam results in licensure as a health information technician. To be eligible, an individual must achieve an associate degree approved by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM) or graduate from a foreign association that has a reciprocity agreement with AHIMA.[1][2][3] The health information technician is responsible for organizing comprehensively and accurately the medical record of each patient. They ensure that all the necessary forms are present, properly identified, signed and filed. Health information technicians are able to translate complex data into understandable, interesting and simplified information for the general public. They take the medical records produced by the health care provider and translate them into a code that identifies each diagnoses and procedure utilized in treating the patient.[4][5] RHIT's can further their career advancement by completing a CAHIIM-accredited Baccalaureate degree in health information management, and take a national credential exam in health information administration as a certified Registered Health Information Administrator (RHIA).[6]

References
[1] Registered Health Information Technician (RHIT) (http:/ / www. ahima. org/ certification/ rhit. aspx) . [2] Registered Health Information Technician Education Requirements (http:/ / education-portal. com/ registered_health_information_technician. html). [3] PayScale - Health Information Technology Salary - RHIT Salary (http:/ / www. payscale. com/ research/ US/ Job=Registered_Health_Information_Technician_(RHIT)/ Hourly_Rate). [4] Health Information Technology Careers (http:/ / www. healthinformationtechnologycareers. com/ ) [5] Health information careers (http:/ / www. mshealthcareers. com/ careers/ healthinfo. htm) [6] Health information careers Baccalaureate Degree RHIA (http:/ / www. hicareers. com/ Pathways/ baccalaureate_degree. aspx)

Regional Health Information Organization

1186

Regional Health Information Organization


A Regional Health Information Organization (RHIO, pronounced rio), also called a Health Information Exchange Organization, is a multistakeholder organization created to facilitate a health information exchange (HIE) the transfer of healthcare information electronically across organizations among stakeholders of that region's healthcare system. The ultimate objective is to improve the safety, quality, and efficiency of healthcare as well as access to healthcare through the efficient application of health information technology. RHIOs are also intended to support secondary use of clinical data for research as well as institution/provider quality assessment and improvement.[1] RHIO stakeholders include smaller clinics, hospitals, medical societies, major employers and payers. RHIOs are intended to be key to the proposed US Nationwide Health Information Network (NHIN).[2]

Background/Motivations
The US system of Healthcare is highly complex and fragmented, with use of multiple information technology systems and vendors incorporating different standards. In contrast with other developed nations, healthcare accounts for a disproportionate percentage of the US GDP, and there is a concern about the economic viability of Medicare.[3] Despite this significant expenditure, there is evidence of inefficiency, waste and medical errors, with a 2001 estimate by the Institute of Medicine of between 44,000-98,000 annual deaths due to medical errors.[4] While numerous possible causes for this situation exist, much waste (e.g., duplication of laboratory tests) and medical errors (e.g., adverse drug reactions) are traceable to inability of healthcare providers (who are not the patients' primary providers) to access patients' existing medical information in a timely manner when needed: better and more ubiquitous health information technology might be part of the overall solution. In 2004 President George Bush issued an executive order for the development and nationwide implementation of an interoperable health information technology infrastructure to improve the quality and efficiency of health care with the goal that most Americans will have an EHR by 2014.[5] In July 2004 the United States Department of Health and Human Services released their vision of how Americas healthcare system could be rebuilt during the next decade.[6] An aspect of the federal effort is the creation of the Office of the National Coordinator for Health Information Technology.[7] One of the roles of ONC is to facilitate RHIO development. The planning stage of RHIO formation involves 1) identification of a shared vision/motivation,2) creating a governance structure 3) identifying a technology and network infrastructure for data integration, 4) defining standards for data sharing, protection of data, and business practices to ensure patient protection during data exchange 5) defining educational and business strategies to ensure sustainability of the effort. Finally, RHIOs must implement the proposed strategies.

Types of RHIO Architecture


The two broad types of architecture, Centralized and Federated, correspond to the "Data Warehouse" and "Federated database system" models of data integration. In the Centralized configuration (e.g., The Santa Cruz Community and the Michigan UP Network), all providers send their data to the RHIO's central repository on a periodic basis (daily), while in the Federated model or Record Locator service, the data stays at its original location, and the RHIO only has a "pointer" to that information. The pros and cons of each architecture follow from the approaches. For the Centralized design, once data is centralized and restructured into a uniform data model, it is easier to query and analyze: however, because movement and restructuring is generally a complex batch process involving the well-known steps of "extract, transform, load", the centralized data may be somewhat out of date if the (logistically challenging) target of daily updates is not achieved. Also, there may be concerns among the individual RHIO participants who originate the raw data that they

Regional Health Information Organization are giving up "control" and "ownership" once the data is copied to a central site. Also, creation of the central repository requires close collaboration to determine exactly what data will be centralized and how it will be structured. Federated systems, where the RHIO software merely has information on which patient's data is available at what locations, are often more politically feasible than Centralized systems. However, designing a protocol by which the RHIO can query (heterogeneously structured) individual provider data stores is technically challenging, and the software at the individual sites must ensure authenticate electronic requests to ensure that they are legitimate and authorized: no standards that can be used for this purpose currently exist. A federated setup requires greater network bandwidth than the centralized approach, because a request by a user of the central RHIO software can be farmed out to multiple provider systems. The Centralized and Federated approaches are not mutually exclusive, and hybrid setups can be employed. In one proposed hybrid model, the health record trust), all data for each patient would stay in a single repository (the data bank), but patients could choose which data bank to use for their records.[8]

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Current Status
Of the more than 190 RHIOs in various stages of development (2009), a 2009 survey found that 57 RHIOs actively exchange data used by healthcare stakeholders.[9] RHIO initiatives exist at two levels, larger (statewide) and smaller (local and rural). Compared to local RHIOs, state-level initiatives, because of the larger number of stakeholders and patient base, and consequent financial strength, have a greater likelihood of being able to utilize national-level expertise both in health IT and policy-making. Most operational RHIO efforts tend to be larger efforts, though the risk of political battles and consequent failure is also amplified if several large stakeholders choose not to cooperate with each other. Compared to state-level RHIOs, stakeholders tend to be more heterogeneous with respect to line of business, use of technology and size. Rural RHIOs have a subscriber base of less than 100,000. The presence of numerous, smaller organizations with relatively limited IT budgets translates to numerous challenges due to the diseconomies of small scale. There is limited access to skilled technology professions, and health IT vendors pay less attention to small customers. Many stakeholders continue to deploy legacy software from long-defunct vendors and some may not deploy IT at all. In addition, stakeholders may be less IT-savvy, and even availability of high-speed Internet connectivity may not be assured. A significant sustainability challenge for smaller RHIOs involves funding. Some support models (e.g., used by Northwest, Louisville KY) are based on shared, subscription-based use of commercial health information software, and the shared use of scarce resources such as information technology professionals, who are unaffordable for smaller organizations acting individually. Irrespective of size, certain challenges remain, such as interoperability standards, as well as consistent standards with respect to privacy, security and appropriate use of the data. Currently, privacy/security issues vary across states, and federal efforts to ensure uniformity are desirable.

Examples of RHIOs
INPC/ IHIE
The Indianapolis Network for Patient Care (INPC)[10][11][12], operational since 1994, connects all five major hospital systems in greater Indianapolis. All INPC participants now deliver registration records, all laboratory tests, text reports, mediciation history and all UB92 records (diagnosis, length of stay, and procedure codes) for hospital admissions and emergency room visits to separate electronic medical record vaults in a central INPC server using a federated data store model. The message exchange standard that is used is HL7. The computer system standardizes all clinical data as it arrives at the INPC vault, laboratory, radiology, and other study test results are mapped to a set

Regional Health Information Organization of common test codes LOINC with standard units of measure, and patients with multiple medical record numbers are linked. Implementation has been simplified because each participating institution uses the same data model and term dictionary which contain the codes, names (and other attributes) for tests, drugs, coded answers, etc. The data for any participating patient seen in any of the region's 11 emergency rooms can be presented as one virtual medical record.[13]. Stakeholders/ participants in this RHIO include: major and regional hospital systems, regional and national reference laboratories, state, federal, and private payors, pharmacy benefit management claims respository services, major physician practice organizations, individual providers, state government (Dept. of Health), major academic research institutions, and others. The statewide Indiana Health Information Exchange [14], which uses the expertise of the same medical informatics/IT team as the INPC, combines clinical data in combination with administrative (claims) data to support electronic delivery of test reports to physician offices using faxes, printers, and e-mail, as well as Clinical Quality Services, which provide a "report card" (and incentives) on established quality messures to physicians, practice groups, employers, and payers. The IHIE is a rare example of a self-sustaining HIE (not reliant on government grants). Stakeholder satisfaction with this RHIO is apparently high[15]

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CalRHIO
CalRHIO is an example of an RHIO failure due to political/turf battles: it became defunct as of January 8, 2010. Following over a year of feuding with California e-Health Collaborative (CAeHC) for California State designation of a state-wide HIE entity, both organizations were turned down by the state government in December 2009; large stakeholders such as Medicity Inc. and Kaiser Permanente subsequently followed suit and withdrew financial support. Reasons for CalRHIO's failure have been attributed to a limited business model dependent on state-entity designation.[16]

Other States
In some states (e.g., Kansas), an alternative to a stakeholder-consortium-based state-level RHIO is being considered, namely direct involvement of the state governments in creating the RHIO infrastructure. This approach builds on the strengths of state governments as major employers and purchasers of healthcare services (e.g., University of Alabama, Birmingham, is Alabama's largest employer). Similarly, TennCare in Tennessee has roots in addressing the states uninsured/underinsured population and is consequently more state driven. Utahs efforts are based on the states prior efforts to process healthcare claims. Recent federal efforts (e.g., at the Veterans Administration) are aimed at creating a federal employee based electronic health record system, which might be considered a national RHIO.

References
[2] White House website (http:/ / georgewbush-whitehouse. archives. gov/ infocus/ technology/ economic_policy200404/ chap3. html) Transforming Health Care: The Presidents Health Information Technology Plan, Promoting Innovation and Competitiveness: A new generation of innovation, April 27, 2004. [3] CNN.com (http:/ / www. cnn. com/ 2006/ HEALTH/ 02/ 22/ health. carecosts. ap/ index. html) U.S. health costs on unyielding rise, Associated Press, February 22, 2006. [4] L. T. Kohn, J. M. Corrigan, and M. S. Donaldson, eds., To Err Is Human: Building a Safer Health System. Institute of Medicine. 2000. Washington, D.C: National Academy Press. [6] The Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Health Care, Tommy Thompson and Dr. David Brailer, Department of Health and Human Services, July 21, 2004. [7] ONC (http:/ / www. os. dhhs. gov/ healthit/ ) Office of the National Coordinator for Health Information Technology [8] Castro, Daniel, Improving Health Care: How a Dose of IT May Be Just What the Doctor Ordered, The Information Technology and Innovation Foundation, October, 2007, http:/ / www. itif. org/ files/ HealthIT. pdf

Regional Health Information Organization


[9] eHealth Initiative Migrating Toward Meaningful Use: The State of Health Information Exchange A Report Based on the Results of the eHealth Initiatives 2009 Sixth Annual Survey of Health Information Exchange. (http:/ / www. ehealthinitiative. org/ ehealth-initiative-releases-results-2009-survey-health-information-exchange. html) [10] http:/ / www. regenstrief. org/ medinformatics/ inpc/ [11] http:/ / www. pubmedcentral. nih. gov/ articlerender. fcgi?artid=225997 [12] http:/ / content. healthaffairs. org/ cgi/ gca?allch=& SEARCHID=1& FULLTEXT=Indiana+ Network+ For+ Patient+ Care& FIRSTINDEX=0& hits=10& RESULTFORMAT=& gca=healthaff%3B24%2F5%2F1214& allchb= [13] http:/ / www. pubmedcentral. nih. gov/ articlerender. fcgi?artid=1480174 [14] http:/ / www. ihie. com/ [15] Why these doctors love their RHIO. Medical Economics, url: http:/ / www. memag. com/ memag/ article/ articleDetail. jsp?id=182803

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External links
Office of the National Coordinator for Health Information Technology (http://www.os.dhhs.gov/healthit/) AHRQ National Resource Center for Health Information Technology (http://healthit.ahrq.gov/) Core RHIO Business Requirements (http://www.healthunity.com/handbook_busreq.aspx)

Current RHIOs
Some of the currently self-sustaining RHIOs to date (Source: First Consulting Group): Healthcare Information Xchange of New York (HIXNY) http://www.hixny.org Long Island Patient Exchange (LIPIX) http://www.lipix.org http://www.grrhio.org/Rochester, New York HealthBridge, Greater Cincinnati area (Ohio, Kentucky and Indiana) Indiana Health Information Exchange (http://www.ihie.com) Indianapolis Network for Patient Care- Regenstrief INPC (http://www.regenstrief.org/medinformatics/inpc/) [Adirondack Regional Community Health Information Exchange or ARCHIE http://www. archiehealthexchange.org/]

Other RHIOs/CHINs/HIEs: e-Health Network of Long Island www.ehealthnetworkli.org (http://ehealthnetworkli.org) Medical Information Network North Sound www.min-ns.org (http://min-ns.org) Bronx Regional Health Information Organization www.bronxrhio.org (http://www.bronxrhio.org) Colorado Regional Health Information Organization www.corhio.org (http://www.corhio.org) Keystone Health Information Exchange (KeyHIE) (http://www.keyhie.org) Maryland's Chesapeake Regional Information Systems for our Patients (http://www.crisphealth.org/) Michigan UP Healthcare Network MidSouth eHealth Alliance (http://www.midsoutheha.org) Massachusetts SHARE (Simplifying Healthcare Among Regional Entities) (http://www.mahealthdata.org/ ma-share) Santa Barbara County Care Data Exchange Santa Cruz Physician Medical Group (IPA) Southern Tier HealthLink New York (http://www.sthlny.com) Taconic Health Information Network and Community (IPA) (New York) Quality Health Network, Grand Junction, CO CareSpark (Central Appalachian Region VA, TN, NC and KY) PeaceHealth (Alaska, Oregon and Washington)

Western New York Clinical Information Exchange (WNYCIE) - HealtheLink (http://www.wnyhealthelink. com) East Kern County Integrated Technology Association (EKCITA) (http://www.ekcita.org)

Regional Health Information Organization

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RHIO Vendors
ICA (HIT)

Substance Abuse and Mental Health Services Administration

The front of the SAMHSA building in Rockville, MD

United States Substance Abuse and Mental Health Services Administration


Agency overview Formed Jurisdiction Headquarters 1992 Federal government of the United States Rockville, Maryland

Agency executive Pamela S. Hyde, J.D, Administrator, Substance Abuse and Mental Health Services Administration" Parent Agency Department of Health and Human Services Website www.samhsa.gov
[1]

The Substance Abuse and Mental Health Services Administration (SAMHSA) is a branch of the U.S. Department of Health and Human Services. It is charged with improving the quality and availability of prevention, treatment, and rehabilitative services in order to reduce illness, death, disability, and cost to society resulting from substance abuse and mental illnesses. The Administrator of SAMHSA reports directly to the Secretary of the U.S. Department of Health and Human Services. SAMHSA's headquarters building is located in Rockville, Maryland.

Substance Abuse and Mental Health Services Administration

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History
SAMHSA was established in 1992 by Congress as part of a reorganization of the Federal administration of mental health services; the new law renamed the former Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA). ADAMHA had passed through a series of name changes and organizational arrangements throughout its history:[2] Narcotics Division (1929-30) Division of Mental Hygiene (1930-43) Mental Hygiene Division, Bureau of Medical Services (1943-49) NIMH, National Institutes of Health (NIH, 1949-67) NIMH (1967-68) NIMH, Health Services and Mental Health Administration (1968-73) NIMH, NIH (1973) National Institute on Alcohol Abuse and Alcoholism, NIMH (1970-73) ADAMHA, established 1973.

Congress directed SAMHSA to target effectively substance abuse and mental health services to the people most in need and to translate research in these areas more effectively and rapidly into the general health care system.[3] Charles Curie was SAMHSA's Director until his resignation in May 2006. In December 2006 Terry Cline was appointed as SAMHSA's Director. Dr. Cline served through August 2008. Rear Admiral Eric Broderick served as the Acting Director upon Dr. Cline's departure,[4] until the arrival of the succeeding Administrator, Pamela S. Hyde, J.D. in November 2009.[5]

Organization
SAMHSA's mission is to reduce the impact of substance abuse and mental illness on American's communities. To accomplish its work, SAMHSA administers a combination of competitive, formula, and block grant programs and data collection activities. The Agency's programs are carried out through: The Center for Mental Health Services (CMHS) which focuses on prevention and treatment of mental disorders. The Center for Substance Abuse Prevention (CSAP) which seeks to prevent and reduce the abuse of illegal drugs, alcohol, and tobacco. The Center for Substance Abuse Treatment (CSAT) which supports the provision of effective substance abuse treatment and recovery services. The Center for Behavioral Health Statistics and Quality (CBHSQ) which has primary responsibility for collection, analysis and dissemination of behavior health data. Together these units support U.S. States, Territories, Tribes, communities, and local organizations through grant and contract awards. They also provide national leadership in promoting the provision of quality behavioral-health services. Major activities to improve the quality and availability of prevention, treatment, and recovery-support services, are funded through competitive Programs of Regional and National Significance grants. A number of supporting offices complement the work of the four Centers: [6] The Office of the Administrator (OA) The Office of Policy, Planning, and Innovation (OPPI) The Office of Behavioral Health Equity (OBHE) The Office of Financial Resources (OFR)

The Office of Management, Technology, and Operations (OMTO) The Office of Communications (OC)

Substance Abuse and Mental Health Services Administration

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SAMHSA's Strategic Direction


In 2010, SAMHSA identified 8 Strategic Initiatives to focus the Agency's work. Below are the 8 areas and goals associated with each category: [7] Prevention of Substance Abuse and Mental Illness - Create prevention-prepared communities in which individuals, families, schools, workplaces, and communities take action to promote emotional health; and, to prevent and reduce mental illness, substance (including tobacco) abuse, and, suicide, across the lifespan Trauma and Justice - Reduce the pervasive, harmful, and costly public-health impacts of violence and trauma by integrating trauma-informed approaches throughout health and behavioral healthcare systems; also, to divert people with substance-abuse and mental disorders away from criminal-/juvenile-justice systems, and into trauma-informed treatment and recovery. Military Families Active, Guard, Reserve, and Veteran - Support of our service men & women, and their families and communities, by leading efforts to ensure needed behavioral health services are accessible to them, and successful outcomes. Health Reform - Broaden health coverage and the use of evidence-based practices to increase access to appropriate and high quality care; also, to reduce existing disparities between: the availability of substance abuse and mental disorders; and, those for other medical conditions. Housing and Homelessness - To provide housing for, and to reduce the barriers to accessing recovery-sustaining programs for, homeless persons with mental and substance abuse disorders (and their families) Health Information Technology for Behavioral Health Providers - To ensure that the behavioral-health provider network -- including prevention specialists and consumer providers -- fully participate with the general healthcare delivery system, in the adoption of health information technology. Data, Outcomes, and Quality Demonstrating Results - Realize an integrated data strategy that informs policy, measures program impact, and results in improved quality of services and outcomes for individuals, families, and communities. Public Awareness and Support - Increase understanding of mental and substance abuse prevention & treatment services, to achieve the full potential of prevention, and, to help people recognize and seek assistance for these health conditions with the same urgency as any other health condition. Their budget for the Fiscal Year 2010 was about $3.6 billion. It was re-authorized for FY2011.

Controversy
In February 2004, the administration was accused of requiring the name change of an Oregon mental health conference from "Suicide Prevention Among Gay/Lesbian/Bisexual/Transgender Individuals" to "Suicide Prevention in Vulnerable Populations."[8][9] In 2002, then-President George W. Bush established the New Freedom Commission on Mental Health. The resulting report was intended to provide the foundation for the federal government's Mental Health Services programs. However, many experts and advocates were highly critical of its report, "Achieving the Promise: Transforming Mental Health Care in America".[10]

Substance Abuse and Mental Health Services Administration

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Notes
[1] http:/ / www. samhsa. gov [2] Records of the Alcohol, Drug Abuse, and Mental Health Administration [ADAMHA] (http:/ / www. archives. gov/ research/ guide-fed-records/ groups/ 511. html), National Archives and Records Administration, n.d. Accessed 2012-07-18. [3] "SAMHSA: Agency Overview" (http:/ / samhsa. gov/ About/ background. aspx) [4] "SAMHSA Agency Biographies: Acting Administrator of SAMHSA" (http:/ / www. samhsa. gov/ About/ bio_broderick. aspx) [5] "SAMHSA Administrator Biography" (http:/ / www. samhsa. gov/ About/ bio_hyde. aspx) [6] "SAMHSA: Agency Overview" (http:/ / www. samhsa. gov/ About/ background. aspx) [7] "SAMHSA's 10 Strategic Initiatives" (http:/ / www. samhsa. gov/ About/ strategy. aspx) [8] Joe Crea, Feb 25, 2005. "Suicide prevention workshop retains gay title" (http:/ / www. washblade. com/ 2005/ 2-25/ news/ national/ prevention. cfm), Washington Blade. [9] February 26, 2005. "Northwest: Oregon: Workshop's Original Title Restored" (http:/ / query. nytimes. com/ gst/ fullpage. html?res=9D0DE4D8143DF935A15751C0A9639C8B63), The New York Times. [10] For the opposition to this report see: New Freedom Commission on Mental Health#Opposition.

References
"National Institute of Mental Health : Important Events in NIMH History" (http://www.nih.gov/about/ almanac/archive/1998/organization/nimh/history.html) "Substance Abuse and Mental Health Services Administration: Justification of Estimates for Appropriations Committees" (http://www.samhsa.gov/Budget/FY2011/SAMHSA_FY11CJ.pdf), Fiscal Year 2011, Department of Health and Human Services "Federal agency caught in uproar over workshop title" (http://web.archive.org/web/20081017081210/http:// advocate.com/news_detail_ektid03200.asp), The Advocate, February 2005 (archived 2008)

External links
Substance Abuse and Mental Health Services Administration (SAMHSA) (http://www.samhsa.gov/) Co-Occurring and Homeless Activities Branch (CHAB) (SAMHSA) (http://chab.samhsa.gov/User/Public. aspx?userId=df7ac8c6-da4e-4b1d-85de-dda5e926ccaf) National Institute of Mental Health : Important Events in NIMH History (http://www.nih.gov/about/almanac/ archive/1998/organization/nimh/history.html) Federal agency caught in uproar over workshop title (http://advocate.com/news_detail_ektid03200. asp)Wikipedia:Link rot

Birth attendant

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Birth attendant
A birth attendant, also known as "skilled birth attendant" ("SBA"), is a midwife, physician, obstetrician, nurse, or other health care professional who provides basic and emergency health care services to women and their newborns during pregnancy, childbirth and the postpartum period. Birth attendants are trained to be present at ("attend") childbirth, whether the delivery takes place in a health care institution or at home, to recognize and respond appropriately to medical complications, and to implement interventions to help prevent them in the first place including through prenatal care.[1]

Birth attendant versus birth assistant


A distinction must be made between "birth attendant" and others who may provide support and care during pregnancy and childbirth, based on professional training and skills, practice regulations, as well as nature of care delivered. Birth attendants are typically trained to perform clinical functions for basic and emergency obstetric and neonatal care, including administration of parenteral antibiotics, oxytocics and anticonvulsants; manual removal of placenta; removal of retained products of placenta; assisted vaginal delivery; and newborn resuscitation.[2] Depending on the legal scope of practice, this may also include performing cesarean sections. A birth assistant, also known as a doula, "birth worker", "labor support person", or "childbirth educator" is someone other than the above who provides emotional support and general care and advice to women and families during pregnancy and childbirth.[3] A doula usually offers support services to the family in the weeks following the birth ("postpartum doula") and may also assist during labor and childbirth ("birth doula"). In many developing countries, a traditional birth attendant (TBA), also known as a traditional midwife, is a person who provide basic pregnancy and birthing care and advice based primarily on experience and knowledge acquired informally through the traditions and practices of the communities where they originated.[3] They usually have no modern health care training and are not typically subject to professional regulation.

References
[1] World Health Organization. 2002. Global action for skilled attendants for pregnant women. http:/ / www. who. int/ making_pregnancy_safer/ documents/ who_fch_rhr_0203/ en/ index. html [2] Gupta N et al. Human resources for maternal, newborn and child health: from measurement and planning to performance for improved health outcomes. (http:/ / www. human-resources-health. com/ content/ 9/ 1/ 16/ abstract) Human Resources for Health 2011, 9:16 [3] World Health Organization. 2010. Classifying health workers. http:/ / www. who. int/ hrh/ statistics/ Health_workers_classification. pdf

External links
World Health Organization: Making Pregnancy Safer (http://www.who.int/making_pregnancy_safer/en/)

State Children's Health Insurance Program

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State Children's Health Insurance Program


The State Children's Health Insurance Program (SCHIP) now known more simply as the Children's Health Insurance Program (CHIP)[1] is a program administered by the United States Department of Health and Human Services that provides matching funds to states for health insurance to families with children.[2] The program was designed to cover uninsured children in families with incomes that are modest but too high to qualify for Medicaid. At its creation in 1997, CHIP was the largest expansion of taxpayer-funded health insurance coverage for children in the U.S. since Medicaid began in the 1960s. The statutory authority for CHIP is under title XXI of the Social Security Act. It was sponsored by Senator Edward Kennedy in a partnership with Senator Orrin Hatch[] with support coming from First Lady Hillary Rodham Clinton during the Clinton administration.[][][] States are given flexibility in designing their CHIP eligibility requirements and policies within broad federal guidelines. Some states have received authority through waivers of statutory provisions to use CHIP funds to cover the parents of children receiving benefits from both CHIP and Medicaid, pregnant women, and other adults. CHIP covered 7.6 million children during federal fiscal year 2010, and every state has an approved plan.[3] Despite CHIP, the number of uninsured children continued to rise, particularly among families that cannot qualify for CHIP. An October 2007 study by the Vimo Research Group found that 68.7 percent of newly uninsured children were in families whose incomes were 200 percent of the federal poverty level or higher as more employers dropped dependents, or dropped coverage altogether due to annual premiums nearly doubling between 2000 and 2006. Vimo cites the Kaiser Commission on Medicaid and the Uninsured when it says 48 percent of the newly uninsured were not eligible for any kind of public coverage, and that only those in the lowest income bracket might offset the loss of employer-sponsored coverage with increases in Medicaid and SCHIP. [] In FY 2008, the program faced funding shortfalls in several states.[4] During the administration of George W. Bush, two attempts to expand funding for the program failed when President Bush vetoed them. Mr. Bush argued that such efforts were steps toward federalization of health care, and would "steer the program away from its core purpose of providing insurance for poor children and toward covering children from middle-class families."[5] On February 4, 2009, President Barack Obama signed the Children's Health Insurance Reauthorization Act of 2009, expanding the healthcare program to an additional 4 million children and pregnant women, including for the first time legal immigrants without a waiting period.

History

State Children's Health Insurance Program

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Health care in the United States Government Health Programs


Federal Employees Health Benefits Program Indian Health Service Veterans Health Administration Military Health System / TRICARE Medicare Medicaid / State Health Insurance Assistance Program (SHIP) State Children's Health Insurance Program (CHIP) Program of All-Inclusive Care for the Elderly (PACE) Prescription Assistance (SPAP) Private health coverage

Health insurance in the United States Consumer-driven health care


Flexible spending account (FSA) Health Reimbursement Account Health savings account

High-deductible health plan (HDHP) Medical savings account (MSA) Private Fee-For-Service (PFFS) Managed care (CCP) Health maintenance organization (HMO) Preferred provider organization (PPO) Medical underwriting

Health care reform law


Emergency Medical Treatment and Active Labor Act (1986) Health Insurance Portability and Accountability Act (1996) Medicare Prescription Drug, Improvement, and Modernization Act (2003) Patient Safety and Quality Improvement Act (2005) Health Information Technology for Economic and Clinical Health Act (2009) Patient Protection and Affordable Care Act (2010) State level reform

Massachusetts health care reform Oregon Health Plan Vermont health care reform SustiNet (Connecticut) Dirigo Health (Maine) Municipal health coverage

Fair Share Health Care Act (Maryland) Healthy Howard (Howard Co., Maryland) Healthy San Francisco

As a part of the fallout from the failed 1993 Clinton health care plan, both Democratic Senator Ted Kennedy and the Clinton administration were looking for smaller initiatives for publicly funded health care that could gain bipartisan support.[] Kennedy was intrigued by a children's health insurance plan in Massachusetts that had passed in 1996, and met with a Boston Medical Center pediatrics director and a Massachusetts state legislator to discuss the feasibility of a national initiative.[] Kennedy also saw using an increase in tobacco taxes as a way to pay for the expanded coverage.[] Thus, in October 1996, Kennedy introduced a bill to provide health care coverage for children of the

State Children's Health Insurance Program working poor, to be financed via a 75 cents a pack cigarette tax increase.[]

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Meanwhile, in December 1996 First Lady Hillary Rodham Clinton examined several possible such initiatives and decided expanding health care insurance to children who had none was the one to advance,[] especially as its focus on children would be politically popular.[] Indeed, a different variant of this approach, dubbed "Kids First", had been envisioned as a backup plan during the original 1993 Task Force on National Health Care Reform meetings.[][6] Additionally, Hillary Clinton had discussed an SCHIP-ish program with a White House health policy coordinator during the time her full-blown health care plan had suffered political failure.[] The new initiative was proposed at Bill Clinton's January 1997 State of the Union address, with the stated goal of coverage up to five million children.[][] Kennedy continued to write much of the bill, using the increase in tobacco taxes to pay the $20 billion price tag.[] In March 1997, Kennedy brought Republican Senator Orrin Hatch onto the legislation as co-sponsor; Kennedy and Hatch had worked together as an "odd couple" in the Senate before, and here Hatch said that "Children are being terribly hurt and perhaps scarred for the rest of their lives" and that "as a nation, as a society, we have a moral responsibility" to provide coverage.[] Hatch's role would infuriate some Republican colleagues[][7] and conservative commentators.[8] The First Lady did not hold news conferences or testify before Congress on behalf of the bill.[] An initial objection of Republicans in the Senate was that proposing to pay for the services by raising the federal tax on cigarettes, from 24 cents a pack to 67 cents a pack, ignored the likely consequence that sale of tobacco products would decrease and tax revenues would increasingly fall short of those needed to pay for the expansion of benefits.[] Kennedy and Hatch scoffed at the objection, with the former saying, "If we can keep people healthy and stop them from dying, I think most Americans would say 'Amen; isn't that a great result?' If fewer people smoke, states will save far more in lower health costs than they will lose in revenues from the cigarette tax."[] Republicans also criticized the bill as an open-ended entitlement program, although it was structured as a block grant rather than an entitlement;[] Senate Majority Leader Trent Lott was an early opponent of the measure, calling it a "big-government program" that would not pass.[] Then the bill had to comply with the existing balanced budget agreement between Congress and the White House, something that Lott said it did not.[] Pressure was on to reduce the amount of grants involved, with $16 billion a possible compromise; Hillary Clinton instead argued for $24 billion.[][] The Clinton administration had a deal with the Republican leadership in Congress that forbade the administration from backing any amendments to the budget resolution.[] Thus, Bill Clinton phoned members of Congress and asked that they kill the children's health insurance provision when it came to the floor.[] On May 22, it was so done, with the necessary cigarette tax amendment defeated by a 5545 margin.[] Hillary Clinton defended her husband's action at the time, saying "He had to safeguard the overall budget proposal,"[] but Kennedy was surprised and angered by it,[] considering it a betrayal,[] and saying that his calls to Bill Clinton and Vice President Al Gore had not been returned.[] Hatch was also upset, saying that Lott may have been bluffing and that, "I think the President and the people in the White House caved here."[] Kennedy did not give up on the measure, saying: "We shall offer it again and again until we prevail. It's more important to protect children than to protect the tobacco industry."[] Both Bill and Hillary Clinton argued for including the children's health insurance in subsequent legislation.[] The bill was indeed revived by Kennedy and Hatch a month after its initial defeat.[] Organizations from the Children's Defense Fund to the Girl Scouts of the USA lobbied for its passage, putting public pressure on Congress;[] Hillary Clinton was pushing for it as well,[] with Kennedy urging her to use her influence within the White House.[] SCHIP was then passed and signed into law by Bill Clinton on August 5, 1997[] as part of the Balanced Budget Act of 1997, to take effect the following month.[9] At a press conference following the signing, Kennedy thanked Hatch, Senate Minority Leader Tom Daschle, Children's Defense Fund head Marian Wright Edelman, Bill Clinton, and Hillary Clinton.[] About the latter, Kennedy said, "Mrs. Clinton ... was of invaluable help, both in the fashioning and the shaping of the program and also as a clear advocate."[]

State Children's Health Insurance Program SCHIP is located at Title IV, subtitle J of H.R. 2015 [105th] Balanced Budget Act of 1997. H.R. 2015 was introduced and sponsored by Rep John Kasich [R-OH] with no cosponsors.[10] On 25 June 1997, H.R. 2015 passed House Vote Roll #241 mainly among partisan lines, 270 ayes and 162 nays, with most Democrats in the House of Representatives in opposition. On the same day, the bill passed in the Senate, with a substitute amendment, by unanimous consent. After a conference between the House and Senate, passage in both House (Roll #345: 346-85) and Senate (Roll #209: 85-15) on the conference substitute became more bipartisan.

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State administration
Like Medicaid, SCHIP is a partnership between federal and state governments. The programs are run by the individual states according to requirements set by the federal Centers for Medicare and Medicaid Services. States may design their SCHIP programs as an independent program separate from Medicaid (separate child health programs), use SCHIP funds to expand their Medicaid program (SCHIP Medicaid expansion programs), or combine these approaches (SCHIP combination programs). States receive enhanced federal funds for their SCHIP programs at a rate above the regular Medicaid match. By February 1999, 47 states had set up SCHIP programs, but it took effort to get children enrolled.[] That month, the Clinton administration launched the "Insure Kids Now" campaign, designed to get more children enrolled;[11] the campaign would fall under the aegis of the Health Resources and Services Administration. By April 1999, some 1 million children had been enrolled, and the Clinton administration set a goal of raising the figure to 2.5 million by 2000.[12] States with separate child health programs follow the regulations described in Section 42 of the Code of Federal Regulations, Section 457. Separate child health programs have much more flexibility than Medicaid programs. Separate programs can impose cost sharing, tailor their benefit packages, and employ a great deal of flexibility in eligibility and enrollment matters. The limits to this flexibility are described in the regulations, and states must describe their program characteristics in their SCHIP state plans. Out of 50 state governors, 43 support SCHIP renewal.[13] Some states have incorporated the use of private companies to administer portions of their SCHIP benefits. These programs, typically referred to as Medicaid managed care, allow private insurance companies or health maintenance organizations to contract directly with a state Medicaid department at a fixed price per enrollee. The health plans then enroll eligible individuals into their programs and become responsible for assuring SCHIP benefits are delivered to eligible beneficiaries. In Ohio, SCHIP funds are used to expand eligibility for the state's Medicaid program. Thus all Medicaid rules and regulations (including cost sharing and benefits) apply. Children from birth through age 18 who live in families with incomes above the Medicaid thresholds in 1996 and up to 200% of the federal poverty level are eligible for the SCHIP Medicaid expansion program. In 2008, the maximum annual income needed for a family of four to fall within 100% of the federal poverty guidelines was $21,200, while 200% of the poverty guidelines was $42,400.[14] Other states have similar SCHIP guidelines, with some states being more generous or restrictive in the number of children they allow into the program.[15] With the exception of Alaska, Idaho, North Dakota and Oklahoma, all states have a minimum threshold for coverage at 200% of the federal poverty guidelines. North Dakota currently has the lowest at 160%. New York currently has the highest at 400% of the federal poverty guidelines.[16] SCHIP Medicaid expansion programs typically use the same names for the expansion and Medicaid programs. Separate child health programs typically have different names for their programs. A few states also call the SCHIP program by the term "Children's Health Insurance Program" (CHIP). States are allowed to use Medicaid and SCHIP funds for premium assistance programs that help eligible individuals purchase private health insurance. As of 2008 relatively few states had premium assistance programs, and enrollment was relatively low. Interest in this approach remained high, however.[17] In August 2007, the Bush Administration announced a rule requiring states (as of August 2008) to sign up 95% of families with children, earning 200% of the federal poverty level, before using the funds to serve families earning

State Children's Health Insurance Program more than 250% of the federal poverty level. The federal government said that 9 out the 17 states that offer benefits to higher-earning families were already compliant. Opponents of this rule argued that signing up higher-income families makes lower-income families more likely to sign up, and that the rule was incompassionate toward children who would otherwise go without medical insurance.[18]

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Implementations
California: California Healthy Families Program

Debate over impacts


SCHIP has cost the federal government $40 billion over its first 10 years, and the debate over its fiscal impacts reflects the larger debate in the U.S. over the government's role in health care. In 2007, researchers from Brigham Young University and Arizona State found that children who drop out of SCHIP cost states more money because they shift away from routine care to more frequent emergency care situations.[19] The conclusion of the study is that an attempt to cut the costs of a state healthcare program could create a false savings because other government organizations pick up the tab for the children who lose insurance coverage and later need care. Detractors of the program focus on the impact to the private health insurance industry. In a 2007 analysis by the Congressional Budget Office, researchers determined that "for every 100 children who gain coverage as a result of SCHIP, there is a corresponding reduction in private coverage of between 25 and 50 children." The CBO speculates this is because the state programs offer better benefits at lower cost to enrollees than the private alternatives.[24] A briefing paper by libertarian think-tank Cato Institute estimated the "crowding out" of private insurers by the public program could be as much as 60%.[20]

Reauthorization
SCHIP was created in 1997 as a ten-year program; to continue past federal fiscal year 2007, passage of a reauthorization bill was required. The first two reauthorization bills to pass through Congress would also expand the program's scope; President George W. Bush vetoed them as improper expansions. A two-year reauthorization bill was signed into law by the President in December 2007 that would merely extend current SCHIP services without expanding any portion of the program. With the 2008 Presidential and Congressional elections bringing Democrats to a majority in both houses of Congress and to the Oval Office, SCHIP was reauthorized and expanded in the same bill through fiscal year 2013.

2007 reauthorization
HR 976 In 2007, both houses of Congress passed a bipartisan measure to expand the SCHIP program, H.R. 976 [21]. The measure would have expanded coverage to over 4 million more participants by 2012, while phasing out most state expansions in the program that include any adults other than pregnant women. The bill called for a budget increase for five years totaling $35 billion, increasing total SCHIP spending to $60 billion for the five-year period. Opposition to HR 976 focused on the $35 billion increase in government health insurance as well as $6.5 billion in Medicaid benefits to illegal immigrants. Originally intended to provide health care coverage to low-income children, HR 976 was criticized as a giveaway that would have benefited adults as well as non-U.S. citizens.[22][23][][][] The program expansion was to have been funded by sharply increasing federal excise taxes on tobacco products.[] On the other hand, opponents said this proposed expansion was for families with annual incomes up to $82,600 (400 percent of the federal poverty level)[]

State Children's Health Insurance Program On October 3, 2007, President Bush vetoed the bill,[] stating that he believed it would "federalize health care", expanding the scope of SCHIP much farther than its original intent.[][24] The veto was the fourth of his administration.[] After his veto, Bush said he was open to a compromise that would entail more than the $5 billion originally budgeted, but would not agree to any proposal drastically expanding the number of children eligible for coverage.[25] On October 18, 2007, the House of Representatives fell 13 votes short (273156) of the two-thirds majority required to override the president's veto, although 44 Republicans joined 229 Democrats in supporting the measure.[] HR 3963 Within a week of the failed veto override vote, the House passed a second bill attempting a similar expansion of SCHIP. According to Democrats, the second bill, H.R. 3963 [26], created firmer caps on income eligibility, prevented adults from joining, and banned children of illegal immigrants from receiving benefits. According to its opponents, however, this second proposed expansion was for families with annual incomes up to $62,000 (300 percent of the federal poverty level).[] The Senate passed the measure on November 1, 2007, but on December 12, 2007, Bush vetoed this bill as well, saying it was "essentially identical" to the earlier legislation,[27] and a House vote in January 2008 failed to override the veto. Pub.L. 110173 [28], which extended SCHIP funding through March 31, 2009, and the President signed it into law on December 21, 2007.

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2009 reauthorization
In the wake of President Barack Obama's inauguration and the Democrats' increased majorities in both houses of Congress, legislative leaders moved quickly to break the political stalemate over SCHIP expansion. On January 14, 2009, the House passed H.R. 2 [29] on a vote of 290-138. The bill authorized spending an added $32.8 billion to expand the health coverage program to include about 4 million more children, including coverage of legal immigrants[] with no waiting period for the first time. A cigarette tax increase of 62 centsbringing the total tax on a pack of cigarettes to $1.01an increase of tax on chewing tobacco from $0.195/lb. to $0.50/lb.as well as tax increases on other tobacco products[30] will fund the program's expansion. On January 29, the Senate passed the house bill by a 66-32 margin, with two amendments.[31] The House accepted the amended version on a vote of 290 to 135,[] and President Obama signed the bill into law as Pub.L. 1113 [32] on February 4, 2009.[33]

Arizona rescission
In early 2010, Arizona Governor Jan Brewer, along with the House and Senate of the state passed a budget that eliminated S-CHIP, known as KidsCare in Arizona. As of 22 April 2010, the state assembly, after learning they will lose federal matching and stimulus funds, is looking at restoring some of the program, but not allowing new enrollment. [34]

References
[2] Sultz, H., & Young, K. Health Care USA Understanding its Organization and Delivery pg. 257 [10] H.R. 2015 [105th]: Balanced Budget Act of 1997 (GovTrack.us) (http:/ / www. govtrack. us/ congress/ bill. xpd?bill=h105-2015) [13] Overriding the SCHIP Veto by the Numbers (http:/ / www. americanprogress. org/ issues/ 2007/ 10/ schip_numbers. html) Center for American Progress. [14] Federal Register, Vol. 73, No. 15, January 23, 2008, pp. 3971-3972. Also see "US Department of Health and Human Services Poverty Guidelines" (http:/ / aspe. hhs. gov/ poverty/ index. shtml) [15] "Medicaid and SCHIP Program Eligibility Rules by State" (http:/ / ccf. georgetown. edu/ index/ medicaid-and-schip-programs) [16] (http:/ / ccf. georgetown. edu/ wp-content/ uploads/ 2012/ 04/ Eligibility-by-State. pdf) [17] Joan Alker, "Choosing Premium Assistance: What Does State Experience Tell Us?" (http:/ / www. kff. org/ medicaid/ upload/ 7782. pdf), The Kaiser Family Foundation, May 2008 [18] Proposal Favoring SCHIP's Poorest Kids Criticized (http:/ / www. npr. org/ templates/ story/ story. php?storyId=89521878)

State Children's Health Insurance Program


[21] http:/ / hdl. loc. gov/ loc. uscongress/ legislation. 110hr976 [22] Congressman Robert B. Aderholt : News Releases : Aderholt Opposes $35 Billion Expansion of Government Health Insurance: SCHIP Bill Includes $6.5 Billion Giveaway For Illegal Immigrants (http:/ / aderholt. house. gov/ ?sectionid=20& sectiontree=6,20& itemid=649) [23] Political posturing obscures the issue Insuring health care for poor children should be highest priority as Congress votes By Rep (http:/ / www. virginiafoxx. com/ political_posturing_obscures_the. htm) [24] White House web site (http:/ / georgewbush-whitehouse. archives. gov/ news/ releases/ 2007/ 09/ 20070928-9. html) [26] http:/ / hdl. loc. gov/ loc. uscongress/ legislation. 110hr3963 [28] http:/ / www. law. cornell. edu/ jureeka/ index. php?doc=USPubLaws& cong=110& no=173 [29] http:/ / hdl. loc. gov/ loc. uscongress/ legislation. 111hr2 [32] http:/ / www. law. cornell. edu/ jureeka/ index. php?doc=USPubLaws& cong=111& no=3 [34] http:/ / azcapitoltimes. com/ news/ 2010/ 10/ 04/ critics-bash-brewer-for-inconsistent-behavior-on-child-health-care/

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"Low Cost Health Insurance for Families & Children" (http://www.cms.hhs.gov/LowCostHealthInsFamChild/ ). Centers for Medicare and Medicaid services. United States Department of Health and Human Services. 2007-09-24. Retrieved 2008-01-06. "Ohio Medicaid Basics / Understanding Ohio's Medicaid program" (http://web.archive.org/web/ 20070927010601/http://www.healthpolicyohio.org/publications/medicaidbasics.html). Health Policy Institute of Ohio. 2007-02. Archived from the original (http://www.healthpolicyohio.org/publications/ medicaidbasics.html) on 2007-09-27. Retrieved 2008-01-06. Rodham Clinton, Hillary (1997-08-05). "Our Chance for Healthier Children" (http://query.nytimes.com/gst/ fullpage.html?res=9A0CE7D7103DF936A3575BC0A961958260). The New York Times. Retrieved 2008-01-06.

External links
SCHIP at the Center for Medical and Medicare Services (http://www.medicaid.gov/ Medicaid-CHIP-Program-Information/By-Topics/Childrens-Health-Insurance-Program-CHIP/ Childrens-Health-Insurance-Program-CHIP.html) United States Social Security Administration (http://www.ssa.gov/OP_Home/ssact/title21/2100.htm) Heritage Foundation's SCHIP-related research (http://www.heritage.org/Research/healthcare/SCHIP/) EasterSeals.com's coverage of SCHIP (http://www.easterseals.com/schip) Kaiser Family Foundation resources on SCHIP (http://www.kff.org/medicaid/index.cfm) Georgetown University Center for Children and Families resources on SCHIP (http://ccf.georgetown.edu/ index/schipreauthorization)

State Food and Drug Administration

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State Food and Drug Administration


The State Food and Drug Administration (SFDA) (Chinese: ) is founded on the basis of the State Drug Administration. The State Food and Drug Administration is directly under the State Council of the People's Republic of China, which is in charge of comprehensive supervision on the safety management of food, health food and cosmetics and is the competent authority of drug regulation in mainland China. On July 10, 2007, Zheng Xiaoyu, the former head of China's State Food And Drug Administration, was executed for taking bribes from various firms in exchange for state licenses related to product safety.[1]

Main responsibilities
1. To organize relevant authorities to draft laws and regulations on the safety management of food, health food and cosmetics; organize relevant authorities to formulate comprehensive supervision policy, work plan and supervise its implementation. 2. To exercise comprehensive supervision on the safety management of food, health food and cosmetics in accordance with laws; organize and coordinate supervision work on the safety of food, health food and cosmetics carried out by relevant authorities. 3. To organize and carry out investigation and impose punishment on serious safety accidents of food, health food and cosmetics; delegated by the State Council, organize, coordinate and conduct specific law-enforcement campaigns over safety of food, health food and cosmetics nationwide; organize, coordinate and collaborate with relevant authorities in carrying out emergency rescue work on serious safety accidents of food, health food and cosmetics. 4. To draft law and regulations on administration of medical devices and supervise their enforcement; take charge of registration and regulation of medical devices; draft relevant national standards, draw up and revise professional standards of medical devices, manufacturing practice and supervise their implementation. 5. To be in charge of drug registration, draw up, revise and promulgate national standard of drugs; draw up criteria for marketing authorization of health food; review and approve health food; set up classification system for prescription drugs and OTC drugs; establish and improve ADR monitoring system; be responsible for drug reevaluation, review drugs to be withdrawn and formulate a national essential medicines list. 6. To draft and revise good practices for drug research, manufacturing, distribution and use, and supervise their implementation. 7. To control the quality of drugs and medical devices in manufacturers, distributors and medical institutions; release national quality bulletin on drugs and medical devices on a regular basis; investigate and punish illegal activities of producing and selling counterfeit and inferior drugs and medical devices in accordance with law. 8. To regulate radioactive pharmaceuticals, narcotics, toxics, psycho -tropics, and other controlled drugs and devices in accordance with law. 9. To draw up and improve qualification system for licensed pharmacist, supervise and direct the registration of licensed pharmacist. 10. To direct national drug regulation and comprehensive supervision on the safety management of food, health food and cosmetics. 11. To carry out exchanges and cooperation in drug regulation, relevant safety management of food, health food and cosmetics with foreign governments and international organizations. 12. To undertake other work assigned by the State Council. The State Food and Drug Administration is not responsible for regulating pharmaceutical ingredients manufactured and exported by chemical companies. This regulatory hole, which has resulted in considerable international news coverage unfavorable to China, has been known for a decade, but failure of Chinese regulatory agencies to cooperate has prevented effective regulation.[2]

State Food and Drug Administration

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Commissioner
Commissioner: Mr. Li Yin Deputy Commissioners: Mr. Zhen, Mr. Jiping Li & Mr. Zhenjia Bian

Contact
State Food and Drug Administration Address: 26 Xuanwumen Xidajie, Beijing, 100053, P.R. China Fax: 86-010-68310909

References
[1] China food safety head executed (http:/ / news. bbc. co. uk/ 1/ hi/ world/ asia-pacific/ 6286698. stm) [2] "Chinese Chemicals Flow Unchecked to World Drug Market" (http:/ / www. nytimes. com/ 2007/ 10/ 31/ world/ asia/ 31chemical. html) article reported by Walt Bogdanich, Jake Hooker and Andrew W. Lehren and written by Mr. Bogdanich in the New York Times October 31, 2007

Further reading
Dali Yang, "Regulatory Learning and Its Discontents in China: Promise and Tragedy at the State Food and Drug Administration," in John Gillespie and Randall Peerenboom, eds., Pushing Back Globalization, Routledge, 2009.

External links
China State Food And Drug Administration (http://www.dmoz.org/Regional/Asia/China/Health/) at the Open Directory Project International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use (http://www.ich.org) (ICH)

Medicare Sustainable Growth Rate

1204

Medicare Sustainable Growth Rate


The Medicare Sustainable Growth Rate (SGR) is a method currently used by the Centers for Medicare and Medicaid Services (CMS) in the United States to control spending by Medicare on physician services.[1] Enacted by the Balanced Budget Act of 1997 to amend Section 1848(f) of the Social Security Act, the SGR replaced the Medicare Volume Performance Standard (MVPS), which was the previous method that CMS used in an attempt to control costs.[] Generally, this is a method to ensure that the yearly increase in the expense per Medicare beneficiary does not exceed the growth in GDP.[2] Every year, the CMS sends a report to the Medicare Payment Advisory Commission, which advises the U.S. Congress on the previous year's total expenditures and the target expenditures. The report also includes a conversion factor that will change the payments for physician services for the next year in order to match the target SGR. If the expenditures for the previous year exceeded the target expenditures, then the conversion factor will decrease payments for the next year. If the expenditures were less than expected, the conversion factor would increase the payments to physicians for the next year. On March 1 of each year, the physician fee schedule is updated accordingly. The implementation of the physician fee schedule update to meet the target SGR can be suspended or adjusted by Congress, as has been done regularly in the past (a doc fix).[3] Physician groups, including the American Medical Association, lobby for a permanent reform to the SGR so that physician payment rates are not subject to annual cuts (a permanent doc fix).

Formula
Section 1848(f)2 of the Social Security Act specifies the formula for calculating the SGR.[] There are four factors used in calculating the SGR: 1. 2. 3. 4. The estimated percentage change in fees for physicians services. The estimated percentage change in the average number of Medicare fee-for-service beneficiaries. The estimated 10-year average annual percentage change in real GDP per capita. The estimated percentage change in expenditures due to changes in law or regulations.

Prior to the enactment of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA), the SGR was calculated using a single year's real GDP per capita. Since the MMA was enacted in 2003, the SGR is calculated using a 10-year annual average growth in real GDP per capita.

Conversion factor
In order to meet the target SGR for the next calendar year, the physician fee schedule is updated accordingly. The update is calculated using two factors: 1. One plus the Medicare Economic Index (MEI) 2. One plus the Update Adjustment Factor (UAF) The MEI measures the weighted average price change for various inputs involved with producing physicians services.[] The UAF compares actual and target expenditures, and is determined by a formula that includes the target and actual expenditures and the SGR. By law, the UAF can not exceed -7.0%.[]

Past adjustments
2000 - 2009 adjustments Section 101 of the Tax Relief and Health Care Act of 2006 (MIEA-TRHCA) provided a 1-year update of 0% for the conversion factor for CY 2007 and specified that the conversion factor for CY 2008 must be computed as if the 1-year update had never applied. Section 101 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) provided a 6-month increase of 0.5% in the CY 2008 conversion factor, from January 1, 2008, through

Medicare Sustainable Growth Rate June 30, 2008, and specified that the conversion factor for the remaining portion of 2008 and the conversion factors for CY 2009 and subsequent years must be computed as if the 6-month increase had never applied. Section 131 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) extended the increase in the CY 2008 conversion factor that was applicable for the first half of the year to the entire year, provided for a 1.1% increase to the CY 2009 conversion factor, and specified that the conversion factors for CY 2010 and subsequent years must be computed as if the increases had never applied.[] 2010 - 2013 adjustments

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The estimated SGR to go into effect on March 1, 2010 was -8.8%, and the conversion factor for the physician fee schedule was -21.3%.[] On March 3, 2010, Congress delayed the enforcement of the conversion factor until April 1, 2010 with the passage of the Temporary Extension Act of 2010.[4][5] On April 15, 2010, Congress enacted the Continuing Extension Act of 2010 to again delay the implementation and extended the 2009 rate to June 1, 2010.[6] On June 25, 2010, President Obama signed the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010 that not only delayed implementation of the conversion factor until December 1, 2010 but also increased reimbursements by 2.2%.[] The 2.2% increase was retroactive to June 1, 2010, and expired on November 30, 2010. On December 16, 2010, President Obama signed the Medicare and Medicaid Extenders Act of 2010 into law, delaying the implementation of the SGR until January 1, 2012.[] This prevented a 25% decrease in Medicare reimbursements from taking effect on January 1, 2011.[] When President Obama signed the Middle Class Tax Relief and Job Creation Act of 2012 on February 22, 2012, the implementation of the conversion factor was again delayed until January 1, 2013, when the cut was estimated to be 27.4%.[7][8][] Congress passed the American Taxpayer Relief Act of 2012 on January 1, 2013, which states in section 601 that the conversion factor for 2013 "shall be zero percent."[9] This delays the implementation of the conversion factor until January 1, 2014.

Previous MVPS/SGRs and conversion factors


The table on the left is a table of past years' SGR.[] Prior to the MMA, the MVPS was in use instead of the SGR. The Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 (BBRA) changed the calculation from fiscal year (FY) to calendar year (CY). The table on the right is a list of the actual yearly MEI and physician fee update conversion factor. The physician update reflects a weighted average for FY 1991-1993 when there were two different updates (one for surgery and one for other services), and for FY 1994 through FY 1997 when there were three different updates (for surgery, primary care, and other services).[] The Balanced Budget Act of 1997 consolidated service-specific updates so that starting in FY 1998, primary care, surgical, and nonsurgical services were updated by the same rate.[10]

Medicare Sustainable Growth Rate

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Year

MVPS/SGR

Year Physician MEI increase Physician update 1992 3.2% 1993 2.7% 1994 2.3% 1995 2.1% 1996 2.0% 1997 2.0% 1998 2.2% 1999 2.3% 2000 2.4% 2001 2.1% 2002 2.6% 2003 3.0% 2004 2.9% 2005 3.1% 2006 2.8% 2007 2.1% 2008 1.8% 2009 1.6% 2010 1.2% 2011 0.4% 2012 0.6% 2013 0.8% est 1.9% 1.4% 7.0% 7.5% 0.8% 0.6% 2.3% 2.3% 5.5% 5.0% 4.8% 1.7% 1.5% 1.5% 0.2% 0.0% 0.5% 1.1% 1.3% 0.9% 0.0% 0.0%

FY 1990 9.1% FY 1991 7.3% FY 1992 10.0% FY 1993 10.0% FY 1994 9.4% FY 1995 7.5% FY 1996 1.8% FY 1997 -0.3% FY 1998 3.2% FY 1999 4.2% FY 2000 6.9% CY 2000 7.3% CY 2001 4.5% CY 2002 8.3% CY 2003 7.3% CY 2004 6.6% CY 2005 4.2% CY 2006 1.5% CY 2007 3.5% CY 2008 4.5% CY 2009 6.4% CY 2010 8.9% CY 2011 4.7%

References
[3] Ezra Klein (June 26, 2010). " What to do about the doc fix? (http:/ / voices. washingtonpost. com/ ezra-klein/ 2010/ 06/ what_to_do_about_the_doc_fix. html)" The Washington Post Accessed July 27, 2011. [7] http:/ / www. kaiserhealthnews. org/ stories/ 2011/ december/ 15/ faq-doc-fix. aspx [8] http:/ / www. kaiserhealthnews. org/ Daily-Reports/ 2012/ February/ 17/ sgr-doc-fix. aspx

Nursing home

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Nursing home
A nursing home, convalescent home, skilled nursing facility (SNF), care home, rest home or intermediate care[1] provides a type of residential care. They are a place of residence for people who require continual nursing care and have significant deficiencies with activities of daily living.[citation needed] Nursing aides and skilled nurses are usually available 24 hours a day. Residents include the elderly and younger adults with physical or mental disabilities. Residents in a skilled nursing facility may also receive Christmas at a nursing home in Norway. physical, occupational, and other rehabilitative therapies following an accident or illness. Some nursing homes assist people with special needs, such as Alzheimer patients.[2] Residents may have specific legal rights depending on the nation the facility is in.

Canada
Quebec
Long-term care facilities exist under three types, public, subsidized and private. Public and subsidized differ only in their ownership, all other aspects of funding, admission criteria, cost to the individuals are all regulated by the Quebec Ministry of Health and Social Services.[] Private facilities are completely independent from government ownership and funding, they have their own admission criteria. They must maintain certain provincialWikipedia:Please clarify standards and require licensing from the ministry.

United Kingdom
In 2002 nursing homes became known as care homes with nursing, and residential homes became known as care homes.[3] In the United Kingdom care homes and care homes with nursing are regulated by different organisations in England, Scotland, Wales and Northern Ireland. To enter a care home, a candidate patient needs an assessment of needs and of their financial condition from their local council. The candidate may also have an assessment by a nurse, should the patient require nursing care. The cost of a care home is means tested in England. As of April 2009 in England, the lower capital limit is 13,500. At this level, all income from pensions, savings, benefits and other sources, except a "personal expenses allowance" (currently 21.90), will go to paying the care home fees. The local council pays the remaining contribution provided the room occupied is not more expensive than the local council's normal rate, currently 364.48 for Hampshire for example. If the resident is paying more than this the council will not pay anything and contributions from a third party or charity must be found or the resident move to a cheaper care home. Between the lower and the upper capital limits, the resident pays their income less personal expenses allowance + 1/week for every 250 capital between lower and higher limit. The council pays the

Nursing home rest, subject to the same conditions as before. It is therefore preferable to find a home within the council's limit if council funding is likely to be required to avoid a forced move later. Patients with capital over more than 23,000 pay the full cost of the care home, until the total value of their assets fall below the threshold.[4] Patients who require additional nursing care are assessed for this.[5] and receive additional financial support (103.80 weekly) through the National Health Service (NHS). This is known as Funded Nursing Care. The NHS has full responsibility for funding the whole placement if the resident in a care home with nursing meets the criteria for NHS continuing Health Care. This is identified by a multidisciplinary assessment process.[6] Care homes for adults in England are regulated by Care Quality Commission, which replaced the Commission for Social Care Inspection, and each care home is inspected at least every three years. In Wales the Care Standards Inspectorate for Wales has responsibility for oversight, In Scotland Social Care and Social Work Improvement Scotland otherwise known as the Care Inspectorate, and in Northern Ireland the Regulation and Quality Improvement Authority in Northern Ireland. In May 2010, the Coalition Government announced the formation of an independent commission on the funding of long-term care, which was due to report within a 12-month time frame on the financing of care for an Ageing population. It delivered its recommendations on Monday 4 July 2011. The Care Quality Commission have themselves implemented a re-registration process, completed in October 2010, which will result in a new form of regulation being outlined in April 2011. [7]

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United States
In the United States, there are three main types of nursing facilities (NFs).

Intermediate care facility (ICF)


An intermediate care facility (ICF) is a health care facility for individuals who are disabled, elderly, or non-acutely ill, usually providing less intensive care than that offered at a hospital or skilled nursing facility. Typically an ICF is privately paid by the individual or by the individual's family. An individual's private health insurance and/or a third party service like a hospice company may cover the cost. Board and Care Home: Are special facilities designed to provide those who require assisted living services both living quarters and proper care. Often referred to as residential care homes, these facilities can either be located in a small residential home or a large modern facility. In fact, a large majority of board and care homes are designed to room less than 6 people. Board and care homes are typically staffed by licensed professionals, including nurses, doctors and other medical professionals. These facilities are highly regulated in order to ensure that the best possible care is being provided for the residents. Board and care homes offer residents 24 hour assistance, making them a highly popular choice for those in need of regular assistance.

Nursing home

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Assisted living facility (ALF)


Assisted living residences or assisted living facilities (ALFs) are housing facilities for people with disabilities. These facilities provide supervision or assistance with activities of daily living (ADLs); ALFs are an eldercare alternative on the continuum of care for people, for whom independent living is not appropriate but who do not need the 24-hour medical care provided by a nursing home and are too young to live in a retirement home. Assisted living is a philosophy of care and services promoting independence and dignity.[8]

Skilled nursing facility (SNF)

Rest home for seniors in esk Tn, Czech Republic

A skilled nursing facility (SNF) is a nursing home certified to participate in, and be reimbursed by Medicare. Medicare is the federal program primarily for the aged (65+) who contributed to Social Security and Medicare while they were employed. Medicaid is the federal program implemented with each state to provide health care and related services to those who are below the poverty line. Each state defines poverty and, therefore, Medicaid eligibility. Those eligible for Medicaid maybe low-income parents, children, including State Children's Health Insurance Programs (SCHIPs) and maternal-child wellness and food programs.[citation needed] seniors, and people with disabilities. The Centers for Medicare and Medicaid Services (CMS) is the component of the U.S. Department of Health and Human Services (DHHS) that oversees Medicare and Medicaid. A large portion of Medicare and Medicaid dollars is used each year to cover nursing home care and services for the elderly and disabled. State governments oversee the licensing of nursing homes. In addition, States have a contract with CMS to monitor those nursing homes that want to be eligible to provide care to Medicare and Medicaid beneficiaries. Congress established minimum requirements for nursing homes that want to provide services under Medicare and Medicaid. These requirements are broadly outlined in the Social Security Act, which also entrusts the Secretary of Health and Human Services with the responsibility of monitoring and enforcing these requirements. The Centers for Medicare and Medicaid Services is also charged with the responsibility of working out the details of the law and how it will be implemented, which it does by writing regulations and manuals.[9]

Typical nursing home staff


Administration Once a patient has moved into the nursing home, their relatives may not have significant contact with the administration team, unless there are specific concerns that arise. Depending on the size of the nursing home, the administration staff may be very small, consisting of only a handful or people, or it may have dozens of staff responsible for individual departments (i.e.,accounting, human resources, etc.). Most states require nursing home administrators to have a license to run a facility.[citation needed]

Nursing home Support personnel Some staff members focus solely on caring for the buildings and grounds. Custodians, maintenance staff, and groundskeepers, for example, keep the inside and outside of the building in clean, working order. Additional support personnel also include people who may have some contact with the patient in the nursing home, but it may not be daily or even regularly. For example, nursing homes may have an activities director who is responsible for planning and implementing holiday events, daily and weekly educational and social activities, coordinating special visitors and religious services. Larger facilities may have multiple staff members, such as chaplains or activity assistants, who take on some of those roles. Physical therapy staff may also be available, depending on the home.[citation needed] Direct care staff The direct care staff have direct, daily contact with the patient. The following are types of direct care staff included in all nursing homes: Registered nurse (RN) Licensed practical nurse (LPN) or licensed vocational nurse (LVN) Certified nursing assistant (CNA) Staffing requirements Federal law requires all nursing homes to provide enough staff to adequately care for residents. There is no current federal standard for optimal nursing home staffing levels. The nursing home must have at least one RN for at least 8 straight hours a day, 7 days a week, and either an RN or LPN/LVN on duty 24 hours per day. Certain states may have additional staffing requirements. CNAs provide care to nursing home residents twenty four hours per day, seven days a week.[10]

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Services

Nurse at a nursing home in Norway

Nursing homes offer the most extensive care a person can get outside a hospital. Nursing homes offer help with custodial carelike bathing, getting dressed, and eatingas well as skilled care given by a registered nurse and includes medical monitoring and treatments. Skilled care also includes services provided by specially trained professionals, such as physical, occupational, and respiratory therapists.[citation needed] The services nursing homes offer vary from facility to facility. Services include: Room and board Monitoring of medication Personal care (including dressing, bathing, and toilet assistance) 24-hour emergency care Social and recreational activities

Occupational Therapy
Some of the individuals that are housed in a nursing home need ongoing occupational therapy. Occupational Therapists (OTs) and Occupational Therapy Assistants (OTAs) "promote the health and participation of people, organizations, and populations through engagement in occupation" (American Occupational Therapy Association [AOTA], 2008). OTs and OTAs provide intervention in areas of occupation such as: activities of daily living (ADLs) including bathing, dressing, grooming; instrumental activities of daily living (IADLs) including home and financial

Nursing home management, rest and sleep, education, work, play, leisure, and social participation (AOTA, 2008). They also develop and implement health and wellness programs to prevent injuries, maintain function, and improve safety of residents. For example, OTs and OTAs can take a leadership role in developing and implementing programs to educate clients on compensatory techniques for low vision, customized exercise programs, or strategies to prevent falls. Occupational therapy practitioners may also consult with other staff within the facility or in the community on a variety of topics related to increasing safe engagement in activities. Occupational therapy practitioners can provide a variety of services to short- and long-term residents of a SNF. Based on a client-centered evaluation, the occupational therapist, the client, caregivers, and/or significant others develop collaborative goals to identify strengths and deficits and address barriers that hinder occupational performance in multiple areas. The intervention plan is designed to promote a clients optimal function for transition to home, another facility, or long-term care.

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Physical therapy
Some of the individuals that are housed in a nursing home need ongoing physical therapy. This can be for any number of reasons. Perhaps a person has motor skills that never fully developed or have stopped functioning for some reason. Perhaps an individual has undergone a surgery or medical procedure that requires some manner of physical restitution on a personal level. Nursing homes offer specialists that are well versed in the field of rebuilding muscle or helping one regain their confidence when it comes to doing something physical. This is one of the most common therapies that are done in these nursing homes.[citation needed]

Medical needs
Nearly all residents in a nursing home have the need for some type of medical need. It can be anything from basic care of a medical inadequacy to something more specialized such as someone that is missing an appendage. These nursing facilities can take care of just about any medical need that needs to be taken care of. Most of the staff at these nursing homes has ample training in how to deal with patients that have some manner of specialized need. In fact, the staff that interacts with the patients the most are normally registered nurses that have spent years training for any situation that they may encounter during a patients stay at one of these nursing homes.[citation needed]

Companionship
Payment for nursing home care can be made through Medicare, Medicaid, private insurance, and personal funds. Medicare is a federal health insurance program providing health care benefits to all Americans age 65 and over. Insurance protection intended to cover major hospital care is provided without regard to income. Medicare will only provide 100 days of nursing care, and only if a person requires skilled care and is referred by a doctor when discharged from the hospital. If a person needs custodial care alone, Medicare will not cover it. Medicare only pays for skilled care in a nursing facility that has a Medicare license. Medicaid is a joint federal/state health insurance program providing medical care benefits to low income Americans who meet certain requirements. Nursing home care is covered through Medicaid, but the requirements and covered services vary widely from state to state. To become eligible for Medicaid coverage, people usually have to spend all of their assets first. This means that they might pay for nursing home care out of pocket initially. Once their money runs out, Medicaid would kick in. It's a good idea to work with a lawyer who specializes in elder law when determining Medicaid eligibility. Private long-term care insurance is a health insurance option that, if purchased, supplements Medicare coverage. Private long-term care insurance policies vary greatly. Each policy has its own eligibility requirements, restrictions, costs, and benefits.

Nursing home

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Regulations and oversight


Centers for Medicare & Medicaid Services (CMS) efforts to improve patient safety for nursing home residents. CMS has a number of initiatives underway to improve care across settings, including by ensuring better care transitions. CMS is committed to ensuring that every Medicare and Medicaid beneficiary receives seamless, high-quality health care, both within health care settings such as nursing homes, and among health care settings during care transitions. More than 3million Americans rely on services provided by nursing homes at some point during the year and 1.4million Americans reside in the nations 15,800 nursing homes on any given day. Those individuals, and an even larger number of their family members, friends, and relatives, must be able to count on nursing homes to provide reliable, high-quality care. A number of divisions within CMS work together to promote nursing home safety and quality improvement, address reimbursement issues, and enforce Medicare Conditions of Participation. The combined levers of technical assistance, payment reform, oversight, and enforcement create a powerful system that promotes safety and quality care in nursing homes. To ensure that nursing homes meet both federal and state standards, CMS conducts initial and ongoing inspections of all facilities participating in Medicare and Medicaid. The Survey and Certification process plays a critical role in ensuring basic levels of quality and safety for Medicare and Medicaid beneficiaries by monitoring nursing home compliance with federal and state requirements. Within the Survey and Certification Group, the Division of Nursing Homes focuses on optimizing the health, safety, and quality of life for people living in nursing homes, through close coordination with other divisions. Approximately 5,000 federal and state surveyors conduct on-site surveys of certified nursing homes on average every 12months to assure basic levels of quality and safety for beneficiaries. CMS has undertaken several initiatives over the past several years to improve the effectiveness of the annual nursing home surveys, as well as to improve the investigations prompted by complaints from consumers or family members about nursing homes. CMS acts to combine, coordinate, and mobilize people and techniques through a partnership approach. Survey agencies, ombudsmen, quality improvement organizations (QIOs), and other partners are committed to the common endeavor of promoting quality and safety in nursing homes. Although these entities have different responsibilities, their distinct roles can be coordinated in a number of ways to achieve better results than can be achieved by any one agency alone. Collectively, CMS work to enhance quality and safety in nursing homes is focused in five major areas: 1) enhancing consumer engagement; 2) strengthening survey processes, standards and enforcement; 3) promoting quality improvement; 4) creating strategic approaches through partnerships; and 5) advancing quality through innovation and demonstrations. Through coordinating and aligning these initiatives, CMS is working to spearhead ongoing improvements in quality and safety in nursing homes.[11]

Consumer choices
Current trends are to provide people with significant needs for long term supports and services with a variety of living arrangements. Indeed, research in the United States as a result of the Real Choice Systems Change Grants, shows that some people are able to return to their own homes in the community. Private nursing agencies may be able to provide live-in nurses to stay and work with patients in their own homes. Trends In 2012 in the U.S. a few nursing homes are beginning to change the way they are managed and organized to create a more resident-centered environment, so they are more "home-like" and less institutional or "hospital-like". In these homes, units are replaced with a small set of rooms surrounding a common kitchen and living room. The staff giving care is assigned to one of these "households". Residents have more choices about when they wake, when they eat, and their schedule for the day. They also have access to pets. The facilities utilizing these models may refer to such changes as the "Culture Shift" or "Culture Change" occurring in the Long Term Care, or LTC, industry. Sometimes this kind of nursing home is called a "greenhouse".[citation needed]

Nursing home

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User reviews
In addition to the Medicare Ratings, after the advent of social internet, websites have made it possible for families and seniors to submit user reviews about nursing homes. The largest such a repository of user reviews in the United States can be found in the external links section.[citation needed]

Quality of life
Task-oriented care In 1953, Eleanor Lambertson and her colleagues proposed a system of team nursing to overcome the fragmentation of care resulting from the task-oriented functional approach. Team nursing responds to the needs of both the patient and the staff. The team leader's function is to stimulate the team to learn and develop new skills. The team leader instructs the team members, supervises them, and provides assignments that offer them potential for growth. Team nursing is characterized by the following:[citation needed] Direct patient care accomplished by a specific group of nurses and allied health care workers Accomplished by using the nursing process Comprehensive, holistic nursing care when the team functions at a high level of efficiency Composed of a team leader who coordinates patient care and supervises team members, who are responsible for total care given to an assigned group or number of patients Requires cooperation and effective communication with all staff members Basic to team nursing are the team conference, nursing care plan, and leadership skills. The conference is led by the team leader, and all personnel assigned to the team should be included. The team leader should discuss the needs of the patients, establish goals, individualize the plan of care for each patient, instruct the team members, and follow up on all directions previously given to the team. The nursing care plan is a written guide that organizes information about a patient's health. It focuses on the actions that must be taken to address the patient's identified nursing diagnoses and meet the stated goals. It provides for continuity of care by a constantly changing nursing staff. The team leader starts the care plan as soon as the patient is admitted to the medical treatment facility. In response to changes in the patient's condition, and evaluation of goal achievement, the nursing care plan is updated and revised throughout the patient's hospital stay. Resident-oriented care With resident-oriented care, residents are able to make more choices and decisions about their lifestyle. Their families are more involved in the residents care, and employees have a greater degree of participation with the residents. Resident-oriented care combines the clinical models of care with a flexible social models.[citation needed] As Nursing Facility implements this approach to elder care, CMS strives to respond to each resident's spiritual, physical, and emotional needs. Every member of a facility's team care for the residents, from administrators to the nurse aides. For example, all call lights are answered immediately. Whoever is close when the call is placed answers, and this could be a member of the administration.[12] Scientific findings In September 2011 researchers conducted interviews with 378 adults aged 60 and over who were receiving services from an aging services center in Rochester, New York. Participants in the study were asked questions from validated survey instruments to determine their present state of well-being and social situation. Areas covered included anxiety levels, other mental disorders, social support, physical health and disability, and if the individuals had experienced stressful life events recently.[citation needed] It was found that anxiety is common in the elderly, affecting an estimated 1 in 10 older adults. If left untreated, it can turn into depression, cause significant disability, and boost health care costs. More than 10 million older adults

Nursing home receive services from approximately 30,000 local and state aging services agencies. More than a quarter of this group had significant levels of anxiety, according to a new study. Of 377 participants with complete data, 27.3 percent had significant symptoms of anxiety. Those with anxiety were more often younger and had lower incomes compared with non-anxious participants. There was a significant correlation between anxiety and depression, with more than half (54 percent) of those suffering from anxiety also having depression. Factors also associated with anxiety included higher levels of pain, having five or more medical conditions, and experiencing recent stressful life events. The study's findings support greater interventions to identify anxiety in this service population and to link aging services with primary care and behavioral health providers. In January 2012 it was found that clinical informational monitoring tool helps reduce adverse drug events in nursing home settings In nursing homes, 40 percent of residents use at least nine different medications, and adverse drug events (ADEs) are common. ADEs may be preventable with adequate medication monitoring. The use of the Geriatric Risk Assessment Med Guide (GRAM), a clinical informational tool that implements prospective monitoring plans, markedly reduced the risk of potential delirium in newly admitted and long-stay nursing home residents, according to a new study. Potential hospitalizations and deaths due to ADEs and mortality were also reduced, but the effect was weaker in longer-stay residents. There was no effect of the monitoring system on the incidence of falls.[13] Kate L. Lapane, Ph.D., of Virginia Commonwealth University, worked with Janice Feinberg, Pharm.D., J.D., of the American Society of Consultant Pharmacists Foundation that developed the tool, and colleagues to test the GRAM software in 26 nursing homes during 2003-2004. This technology was designed to assist health care professionals with expertise in geriatric pharmacol therapy in problem identification when evaluating complex medication regimens of older adults. It was used to engage consultant pharmacists and nursing staff to identify residents at risk for delirium and falls, implement proactive medication monitoring plans as appropriate, and provide reports to assist consultant pharmacists in conducting the medication regimen review.[citation needed] The researchers point out that systems using information technology to improve the monitoring stage of the medication-use process are sparse. How to pay for such services has yet to be determined, because information technology adoption in nursing homes has been slow.

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In February 2012 it was found that older residents in Veterans Affairs (VA) Community Living Centers (CLCs), the equivalent of nursing homes, often fail to get optimal treatment with antidepressants, concludes a new study.[citation needed] It found that 25 percent of the 877 residents with depression did not receive antidepressant drugs. In addition, 58 percent of the 654 residents with depression and receiving antidepressant medication had evidence of possible inappropriate use (most commonly, potential drug-drug or drug-disease interactions). Among the 2,815 residents without diagnosed depression, 42 percent received at least one antidepressant drug. Depressed black residents were about half as likely as depressed whites to experience potential inappropriate use, while depressed residents with cancer were less likely to experience either possible under use or inappropriate use.[citation needed] The researchers also found that non-depressed residents who received anti-psychotic drugs without a diagnosis of schizophrenia and or those with a history of stroke or anxiety were about 1.5times more likely to be given an antidepressant. The findings were based on data on 3,692 veterans admitted to 133 VA CLCs over a 17-month period ending in early June 2005. The CLCs were from 21 VA regions across the United States.[citation needed] In March 2012 it was found that depression is quite common in the elderly, and can lead to reduced life expectancy, hospitalization, and even suicide.[citation needed] Both drugs and psychotherapy are effective in treating depression, although their combined use has been shown to be more effective than either one alone. A new study found that depression diagnosis and treatment rates have increased over time. In addition, drugs have become the preferred method of treatment over psychotherapy.[citation needed] Researchers analyzed national Medicare data from 1992 to 2005 on fee-for-service Medicare beneficiaries who lived in the community. They identified individuals with a diagnosis of depression and the types of treatment they received. Between 1992 to 1995 and 2002 to 2005, the overall annual rates of depression in this group doubled from

Nursing home 3.2percent to 6.3percent. Along with this increase in diagnosis was an increase in treatment. Antidepressant use increased from 53.7percent to 67.1percent. At the same time, the use of psychotherapy declined from 26.1percent to 14.8percent. Among those 85 years of age and older, the increased use of antidepressants was greatest, rising from 42 percent to 65 percent. By 2005, less than half of patients with major depressive disorder received psychotherapy. Only 5.6percent of patients with other depression diagnoses were treated in this manner.[citation
needed]

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References
[5] for example, the Hampshire nursing limit for 2009 was 483 weekly [6] as detailed on the Department of Health website

"Effect of a pharmacist-led multicomponent intervention focusing on the medication monitoring phase to prevent potential adverse drug events in nursing homes," by Dr. Lapane, Carmel M. Hughes, Ph.D., Lori A. Daiello, Pharm.D., and others in the Journal of the American Geriatric Society 59, pp.12381245, 2011. "Potential underuse, overuse, and inappropriate use of antidepressants in older veteran nursing home residents," by Joseph T. Hanlon, Pharm.D., M.S., Xiaoqiang Wang, M.S., Nicholas G. Castle, Ph.D., and others in the August 2011 Journal of the American Geriatric Society 59(8), pp.14121420. "Diagnosis and treatment of depression in older community-dwelling adults: 1992-2005," by Ayse Akincigil, Ph.D., Mark Olfson, M.D., James T. Walkup, Ph.D., and others in the Journal of the American Geriatrics Society 59(6), pp. 1042-1051, 2011. "Implications of the accuracy of MEPS prescription drug data for health services research," by Dr. Hill, Dr. Zuvekas, and Mr. Zodet, in the Fall 2011 Inquiry 48(3), pp.242259. Reprints (Publication No. 12-R026) are available from the AHRQ Publications Clearinghouse.

External links
Australia Aged Care Home Finder Australia (http://www.haaa.com.au/facility_search.aspx) - Department of Health and Ageing Australia United Kingdom Care Home Review Service (http://www.carehome-reviewer.com/) Reviews, ratings and CQC's inspection reports of care homes in the UK MHA Charity providing care (http://www.mha.org.uk) Amongst the largest charities in Britain, providing services and specialist dementia care to older people for nearly 70 years Directory of Care Homes and Care Agencies (http://www.carehomes.net/) Directory of Nursing Homes, Care Homes and Care Agencies United States Nursing Home Compare Tool (http://www.medicare.gov/NHCompare) Medicare's past performance results of every certified nursing home in the USA (http://www.amysnursinghomes.com/)- Comprehensive Nursing Homes Directory (http://www.nursinghomes.org/services-provided-at-nursing-homes-today/)- Today's nursing home services provided Occupational Therapy' (http://www.aota.org/Practitioners-Section/RDP/Tools/SNFs.aspx?FT=.pdf)

Special needs plan

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Special needs plan


A special needs plan (or SNP, often pronounced snip) is a category of the US Medicare Advantage plan designed to attract and enroll Medicare beneficiaries who fall into a certain special needs demographic. There are two types of SNPs. The exclusive SNP enrolls only those beneficiaries who fall into the special needs demographic. The other type is the disproportionate share SNP. Disproportionate share SNPs enroll a greater percentage of the target special needs population as compared to a national percentage of the target population. Under the federal Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Congress identified special needs individuals as (1) institutionalized, or (2) dually eligible, or (3) individuals with severe or disabling chronic conditions. More specifically, special needs individuals include: Institutionalized beneficiaries, defined as those who reside or are expected to reside for 90 days or longer in a long term care facility (defined as either: skilled nursing facility (SNF)/NF, ICF or inpatient psychiatric facility), or those living in the community but requiring an equivalent level of care to those residing in a long term care facility. Dually eligible beneficiaries, definied as individuals who are entitled to Medicare Part A and/or Part B and are eligible for some form of Medicaid benefit. Beneficiaries with chronic conditions, defined as individuals who have acquired one or more disabling chronic conditions, including, but not limited to: cardiovascular disease, diabetes, congestive heart failure, osteoarthritis, mental disorders, ESRD, and HIV/AIDS.

Supplemental Security Income


Supplemental Security Income (or SSI) is a United States government program that provides stipends to low-income people who are either aged (65 or older), blind, or disabled.[1] Although administered by the Social Security Administration,[2] SSI is funded from the U.S. Treasury general funds,[1] not the Social Security trust fund. SSI was created in 1974 to replace federal-state adult assistance programs that served the same purpose. The restructuring of these programs was intended to standardize the eligibility requirements and level of benefits.[3] The new federal program was incorporated into Title XVI (Title 16) of the Social Security Act.[4] Today the program provides benefits to approximately eight million Americans.

Disability

Disability portal Category: Disability Category: Disability lists

History
The legislation creating the program was a result of President Nixon's effort to reform the nation's welfare programs. At that time, each state had similar programs under the Aid to the Blind, Aid to the Permanently and Totally Disabled, and Aid to the Elderly. The Nixon Administration thought these programs should be federalized and run by the Social Security Administration. Thus, SSI was created to eliminate the differences between the states including different disability standards and income and resources requirements, which many perceived as irrational

Supplemental Security Income or unfair. President Richard Nixon signed the Social Security Amendments of 1972 on October 30, 1972 which created the SSI Program. The SSI program officially began operations in January 1974 by federalizing states' programs, designating the Social Security Administration (SSA) to administer the SSI program. SSA was selected because it had been administering a nationwide disability program under the Social Security Disability Insurance Benefits (DIB) program since 1956 under the Old Age, Survivors, and Disability Insurance (OASDI) programs associated with FICA payroll taxes.

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Eligibility
In order to be eligible to receive SSI benefits, individuals must prove the following:[5] They are 65+ years of age or blind or disabled. and They legally reside in one of the 50 states, the District of Columbia, Northern Mariana Islands, or are the child of military parent(s) assigned to permanent duty outside of the US, or are a student (certain restrictions apply) temporarily abroad. and They have income and resources within certain limits (see subsections). and They have applied for the benefits. An individual may be ineligible if he or she is a resident of a public institution from the first day of a month through the last day of the same month,[6] fails to apply for all other benefits for which they may be eligible (including Social Security benefits), has an unsatisfied warrant or violates parole conditions, fails to give SSA permission to contact any financial institution for financial records, or is outside the US for 30 consecutive days (with some exclusions).[5] Numerous restrictions have been placed on who is eligible for the benefit, which is considered a welfare benefit. However, unlike social security benefits (Title II), earned work credits are not a requirement for SSI.[7] If insured for disability and not currently receiving benefits, an applicant for SSI also applies for Social Security Disability Insurance Benefits (DIB), and the standard by which applicants are judged to be disabled is virtually the same for both SSI and DIB The decision as to whether an individual is disabled is made by the various state Disability Determination Services (DDS), which contract with the federal government to make such determinations. Although the DDS's are state agencies, they follow federal rules. This arrangement arose from the inception of OASDI, when some key members of Congress considered the Social Security Disability program should be administered employing federalism, fearing expansion of the federal government.

Aged, Disabled, or Blind


In order to be eligible for SSI, a person must meet the definition of being aged, disabled, or blind. Aged - Being deemed aged consists of attaining the age of 65 or older.[5] The Social Security Administration, like the United States Government in general, follows English common law and considers a person to attain an age the day before their birthday.[8] Disabled - Being deemed disabled consists of meeting the general disability definition used by the Social Security Administration: "Disability means inability to engage in any SGA [substantial gainful activity] by reason of any medically determinable physical or mental impairment which can be expected to result in death, or has lasted or can be expected to last for a continuous period of not less than 12 months."

Supplemental Security Income "The 1967 amendments specified that workers shall be determined to be under a disability only if the physical or mental impairment or impairments are of such severity that the individual is not only unable to do his previous work but cannot, considering his age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy. This is regardless of whether any of these are true: Such work exists in the immediate area in which the claimant lives. A specific job vacancy exists. The claimant would be hired if they applied for work. "The statute also specifies that 'work which exists in the national economy means work which exists in significant numbers either in the region where such individuals lives or in several regions of the country.'"[9] Substantial gainful activity (SGA), for the year 2013, is the ability to earn $1040 gross income in a month's period for most disabled individuals, and $1740 for those whose disability includes blindness.[10] In addition, children under the age of 18 can be determined to be disabled for SSI purposes "if the individual has a medically determinable impairment or combination of impairments that causes marked or severe functional limitation(s), and can be expected to result in death, or has lasted or can be expected to last for a continuous period of not less than 12 months."[11] Blind - Being deemed blind consists of meeting the following definition: "central visual acuity of 20/200 or less in the better eye with the use of a correcting lens. An eye which has a limitation in the field of vision such that the widest diameter of the visual field subtends an angle no greater than 20 degrees should also be considered as having a central visual acuity of 20/200 or less."[11] In addition, for SSI purposes, an individual is considered blind regardless of the period of time they are expected to be blind or if they are performing substantial gainful activity.[11]

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Income
One of the requirements to receive SSI is that the individual's income must be below certain limits.[12] These limits may vary based on the state in which the individual lives, his/her living arrangement, the number of people living in the residence, and the type of income. The limit varies on all of these factors and is described below, in the section on benefit computation.

Resources
Another requirement for SSI is that the individual's resources are below a certain limit. This amount is $2,000 for a single individual and $3,000 for an individual and their spouse (whether the spouse is eligible for SSI or not), $4,000 for a child applicant with one parent living in the household, and $5,000 for a child applicant with two parents living in the household.[13] However, conditional benefits may be paid if a substantial portion of the resources are considered non-liquid, resources that cannot be sold within 20 working days,[14] if they agree to sell the resources at their current market value within a specified period and repay the money after the non-liquid property is sold.[15] However, not all actual resources are counted in calculating an individual's or couple's resources for SSI purposes.[16] The resource limits were originally set at $1500 for an individual and $2500 for couples in 1974,[17] and were not linked to inflation. In 1987 the limits were raised to $1800/$2700, in 1988 to $1900/$2850 and in 1989 to $2000/$3000.[18] Under current law they will remain at present levels indefinitely.

Supplemental Security Income

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Residency
SSI benefits are not paid solely to US citizens, but may also be paid to aliens legally residing in the United States.[5] Conversely, citizens may find themselves ineligible because they do not currently reside within the United States;[19] exceptions apply for children of military parent(s) who were born overseas, were disabled or became blind overseas, or first applied for benefits overseas[20] and for students studying abroad who were eligible for SSI in the month prior to leaving the US, whose absence will be for less than 1 year, and who are studying to enhance their ability to perform substantial gainful activity, sponsored by an educational institution in the US, and would not be available to the individual in the US.[21] Several restrictions apply to the eligibility of aliens however. These include being in a "qualified alien" category and meeting an exception condition.[22] There are seven categories of qualified aliens based on Department of Homeland Security (DHS) immigration statuses. This includes:[23] those admitted as Lawfully admitted for permanent residence (LAPR) those granted conditional entry pursuant to section (a)(7) of the Immigration and Nationality Act (INA) those paroled into the US under section 212(d)(5) of the INA for a period of at least 1 year those who are refugees admitted to the US under section 207 of the INA those granted asylum under section 208 of the INA those whose deportation is being withheld under sections 243(h) or 241(b)(3) of the INA

Cuban/Haitian entrants under section 501(e) of the Refugee Education Assistance Act of 1980. There are 5 exception conditions. These include:[24] having already been receiving SSI on 8/22/1996 having 40 qualifying credits (using SSI as a supplement to Retirement or Disability Insurance Benefits) when in LAPR status being a veteran, active duty member of the U. S. military service, or being the spouse or dependant child of an individual who is having been lawfully residing in the US on 8/22/1996 and being blind and disabled (excluding aged individuals)

Collateral Consequences of Warrants, Parole, and Probation


Since Congress enacted fugitive felons and parole/probation violation provisions in 1996, the Social Security Administration has suspended benefits and charged overpayments to individuals receiving SSI on the basis of outstanding warrants.[] Enforcement of the provisions greatly increased in 2000, as SSA reached agreements with local law enforcement to match databases.[] Individuals who are (1) fleeing to avoid prosecution or incarceration for a felony or (2) violating probation or parole are statutorily prohibited from receiving SSI or Title II Social Security benefits.[25] The Social Security Administration interpreted the statutes broadly to include individuals whose names were matched against a warrant database.[] Some individuals lost benefits even though the warrant in question was for a different person.[26][] For others, the presence of a warrant did not necessarily mean that an individual was "fleeing," or that the individual had violated probation or parole.[26] As a result of two legal cases (Martinez v. Astrue and Clark v. Astrue), the SSA may not suspend benefits based merely on the evidence that a warrant had been issued.[27][28] Back benefits were owed to hundreds of thousands of recipients.[][29]

Supplemental Security Income

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Benefit details
Payments for SSI are made for the first day of the month, unless the first of the month is on a Weekend or a legal holiday, in which case the payment is made on the first day prior that is not a weekend or a legal holiday. The minimum benefit is $1 (USD).[30] The SSI program, or Title XVI of the Social Security Act 1611, provides monthly federal cash assistance of up to $698 for an individual and $1,011 for a couple (as of 2011) to help meet the costs of basic needs of food, shelter and clothing. In most states, SSI eligibility usually assures concurrent access to important medical coverage under the various state Medicaid programs and sometimes access to Section 8 housing benefits. In some states, supplemental payments are made by the state, increasing the cash assistance available through SSI. For example, the state of California, through its State Supplementation Program (SSP), increases the cash assistance by $171 per month for a disabled or aged individual with access to cooking facilities in 2011, making the total SSI benefit $845 per month.[31] SSI takes the income and resources of the applicant or recipient into consideration. People who have qualified for Social Security disability benefits may receive SSI during the 5-month waiting period, if they meet the income and resource requirements. The resource limit for single individuals is $2000 and, for married individuals, is $3000. Resources include anything that is cash or can be turned into cash, such as art, mineral rights, stocks or other investments, and real property. In some situations, however, these resources can be excluded. SSI benefits are generally reduced dollar-for-dollar by any unearned income, such as TANF, alimony, unemployment insurance, Social Security Disability or Retirement benefits. Earned income, from wages or self-employment, is treated more favorably; e.g., a person who earns a wage of $750 per month may still be eligible, while someone who receives $750 per month in alimony may be ineligible. It is permissible, subject to regulations, to be employed and yet continue to receive SSI. Even if a person no longer receives SSI, due their wage or self-employment income being too high, they may still be eligible for Medicaid benefits, under what are referred to as 1619 provisions. An examination of eligibility for SSI also considers the income of "deemors," e.g., a spouse who lives with the recipient, a parent or parents who live with a child recipient (recipient under the age of 18) or, in some cases, the sponsor of an alien. Social Security determines the first month of potential eligibility for SSI by the date of the intent to file an application for benefits as expressed to the Social Security Administration, and an application is filed within 60 days of the date of that expressed intention. To begin the process, people wishing to be considered must contact Social Security (there is a toll-free telephone number) to set up a disability interview. No online application for SSI is currently available; however, one may apply for Social Security Disability or Retirement benefits online and add the application for SSI via a telephone-scheduled interview. Calls placed on the last day of the month, where the interview is scheduled for the second week of the following month, will result in SSI eligibility being retroactive to the month in which the call was made to set up the appointment, although the first check will not be received until the next month. For example, a person calls on 31 January to set up an appointment for February. January will be the month-of-application for determination purposes, but the first benefit check will be issued in February. Medicaid benefits usually begin the first month in which both medical and financial requirements are met. An immigrant, in order to qualify for SSI, must have been a legal resident of the United States before the Welfare Reform Act of 1996 took effect (August 22, 1996). Those who arrived after that date may be denied by SSI benefits. However, the regulations governing alien eligibility for SSI are complex and contain many exceptions; for instance, asylees, refugees, spouses of a member of the U.S. military, and some LAPR may be qualified aliens. A person who has been in LAPR status for at least 5 years, has a valid I-551Wikipedia:Please clarify issued by the Bureau of Citizenship and Immigration, and has been employed in the United States, may qualify. People wishing to learn whether they might qualify for SSI should contact the Social Security Administration to schedule an appointment for an interview.

Supplemental Security Income A person who is incarcerated for an entire calendar month is ineligible for benefits. If the person is in a medical facility, where at least 50% of their costs are paid by Medicaid, then their benefit may be reduced to $30.

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Calculation
Calculation of an SSI benefit begins with the Federal Benefit Rate (FBR). The FBR for 2012 is $710.00 for an individual and $1,048 for a couple.[32] The initial benefit levels for SSI in 1972 was the same as the average monthly benefit as a retired worker under the Social Security retirement benefits program. In August 1974 Congress established legislation to automatically increase SSI benefits by the same percentage and at the same time as Social Security retirement, survivors, and disability benefits.[33] The benefit payable to a couple is smaller than the combined benefits payable to two individuals in order to take account of the fact that two people living together can live more economically than if each lived alone. However, the reduced SSI couple benefit applies only to those who are legally married, which gives beneficiaries an incentive not to marry.[34] An issue of importance has been additional household costs caused by the disability of a beneficiary. The original concept of SSI was to ensure a minimum income. Research on household needs incluldes examining potential options to meet those needs.[35] A major purpose of allowing a certain amount of assets was: to cover major costs of an urgent nature, such as to replace a furnace or another essential appliance. The costs of such items have increased considerably since 1989.[36]

Federal Living Arrangements


There are 4 living arrangements for SSI: A, B, C, and D. Living arrangement A is for an individual that has rental liability or buys their food separate from the rest of the household. Living arrangement B is for an individual that has no rental liability and does not buy his food separately. This is the most disadvantageous living arrangement. An individual will have a minimum charge of income deducted from their check. This is done because it is considered that an individual is being given income in the form of free housing and food. An individual in living arrangement B status will also be subject to more periodic reviews called redeterminations. This is done because it is common for a person in living arrangement B to eventually obtain rental liability or buy their food separately. Living arrangement C is for children living with at least one of their parents. In some cases it may be possible a child has another living arrangement. This happens when the child does not live with either parent. Living arrangement D is for individuals in facility where the medicaid pays over 50%. A person is only due a check of $50.00 per month. This is because it considered that the individual has all his basic needs met.

Supplemental Security Income

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Beneficiaries by age
Age 65 or older - 2,051,848 Between ages 18 64 - 4,691,651 Under age 18 - 1,258,533 Total Beneficiaries 8,002,032

Beneficiaries and Costs


Year Beneficiaries Dollars 1974 - 3,996,064 - $5,096,813,000 1975 - 4,314,275 - $5,716,072,000 1980 - 4,142,017 - $7,714,640,000 1985 - 4,138,021 - $10,749,938,000 1990 - 4,817,127 - $16,132,959,000 1991 - 5,118,470 - $17,95,639,000 1992 - 5,566,189 - $21,682,410,000 1993 - 5,984,330 - $23,991,153,000 1994 - 6,295,786 - $25,291,087,000 1995 - 6,514,134 - $27,037,280,000 1996 - 6,613,718 - $28,252,474,000 1997 - 6,494,985 - $28,370,568,000 1998 - 6,566,069 - $29,408,208,000 1999 - 6,556,634 - $30,106,132,000 2000 - 6,601,686 - $30,671,699,000 2001 - 6,688,489 - $32,165,856,000 2002 - 6,787,857 - $33,718,999,000 2003 - 6,902,364 - $34,693,278,000 2004 - 6,987,845 - $36,065,358,000 2005 - 7,113,879 - $37,235,000,000 2006 - 7,235,583 - $38,889,000,000 2007 - 7,359,525 - $41,205,000,000 2008 - 7,520,501 - $43,040,000,000 2009 - 7,676,686 - $44,906,000,000

Payee assignment
Generally, the person qualifying for benefits is determined to be capable of managing their own financial affairs, and the benefits may be disbursed directly to them. In the case of persons who have a diagnosed mental impairment which interferes with their ability to manage their own finances, the Social Security Administration may require that the person assign someone to be their representative payee. This person will receive the benefits on behalf of the disabled individual, and disburse them directly to payors such as landlords, or to the disabled person, while providing money management assistance (help with purchasing items, limiting spending money, etc.). The representative payee generally does not charge a fee for this service, especially if its a friend or relative. Social service agencies who are assigned as payee are prohibited from charging a fee, though some private payee agencies do provide the service for a small fee. Some states and counties have representative payee agencies (also called substitute payee programs) which receive the benefits on behalf of the disabled person's social worker, and disburse the benefits per the social worker's instructions.

Supplemental Security Income

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Potential Residual Benefits to Other Programs


Once an individual qualifies for Supplemental Security Income they automatically become eligible for several other assistance programs as allowed by Federal and State law. An SSI recipient can receive benefits from all programs listed and they serve as a safety net for those on the program. Medicaid In order to help with the purchase of medicine and hospital care for the aged, blind, and disabled. Qualified Medicare Beneficiaries (QMB) Food Stamps (SNAP) for the purchase of food. Depends on the individuals state of residence on how much they may receive in food stamps. Housing choice voucher program, more commonly known as HUD Section 8. SSI recipients automatically are entitled to Section 8 Housing as they meet the low income criteria yet they have to be approved by the Department of Housing and Urban Development.

Notes
[1] (SSA "Supplemental Security Income (SSI)" p. 2) [2] (SSA "Teleservice Representative Basic Training Curriculum: Supplemental Security Income" p. 5) [3] (SSA "Teleservice Representative Basic Training Curriculum: Supplemental Security Income" p. 7) [4] (SSA "Teleservice Representative Basic Training Curriculum: Supplemental Security Income" p. 27) [5] (SSA POMS SI 00501.001) [6] (SSA POMS SI 00520.001) [7] (SSA "Teleservice Representative Basic Training Curriculum: Supplemental Security Income" p. 9) [8] (SSA POMS RS 00615.015) [9] (SSA POMS DI 10105.065) [10] (SSA POMS DI 10501.015.B/C) [11] (SSA POMS DI 11055.005) [12] (SSA POMS SI 00810.001) [13] (SSA POMS SI 01110.003) [14] (SSA POMS SI 01110.300) [15] (SSA POMS 01150.200) [16] (SSA POMS SI 01110.210) [17] (24 CFR 416.1205) [18] http:/ / www. socialsecurity. gov/ OP_Home/ handbook/ handbook. 21/ handbook-2166. html [19] (SSA POMS SI 00501.410) [20] (SSA POMS SI 00501.415) [21] (SSA POMS SI 00501.411) [22] (SSA POMS SI 00502.100) [23] (SSA POMS SI 00502.100A.2) [24] (SSA POMS SI 00502.100A.3) [25] 42 U.S.C. 1382(e)(4) (SSI); 402(x) (Title II) [26] Urban Justice Project. Social Insecurity.http:/ / www. urbanjustice. org/ pdf/ projects/ Social_Insecurity_10_07. pdf [27] Clark v. Astrue,602 F.3d (2d Cir. 2010) [28] Martinez v. Astrue settlement, available at http:/ / www. nsclc. org/ wp-content/ uploads/ 2011/ 06/ Martinez-v-Astrue-Settlement-Agreement. pdf [29] http:/ / www. nsclc. org/ index. php/ tag/ clark-v-astrue/ [30] (SSA POMS SI 02001.005) [31] http:/ / ssa. gov/ pubs/ 11125. html [32] http:/ / www. ssa. gov/ oact/ cola/ SSI. html [33] Schieber, Sylvester J. & others. SOCIAL SECURITY ADVISORY BOARD. 2008.STATEMENT ON THE SUPPLEMENTAL SECURITY INCOME PROGRAM. Washington, D.c.: ssab.gov [34] Schieber, Sylvester J. & others. SOCIAL SECURITY ADVISORY BOARD. 2008.STATEMENT ON THE SUPPLEMENTAL SECURITY INCOME PROGRAM. Washington, D.c.: ssab.gov [35] Schieber, Sylvester J. & others. SOCIAL SECURITY ADVISORY BOARD. 2008.STATEMENT ON THE SUPPLEMENTAL SECURITY INCOME PROGRAM. Washington, D.c.: ssab.gov [36] Schieber, Sylvester J. & others. SOCIAL SECURITY ADVISORY BOARD. 2008.STATEMENT ON THE SUPPLEMENTAL SECURITY INCOME PROGRAM. Washington, D.c.: ssab.gov

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References
'Social Security Administration (SSA)'. "SSA's Program Operations Manual System (POMS)". https://s044a90. ssa.gov/apps10/poms.nsf/partlist!OpenView (https://s044a90.ssa.gov/apps10/poms.nsf/ partlist!OpenView). Accessed March 27, 2007. Note: this is the public version of POMS, the internal version is not available to the public 'Social Security Administration (SSA)'. "Supplemental Security Income (SSI)". Publication No. 05-11000. August 2005. 'Social Security Administration (SSA)'. 'Teleservice Representative Basic Training Curriculum: Supplemental Security Income'. Publication No. 25-1560. April 2006. Social Security Administration http://www.ssa.gov/history/briefhistory3.html (Beneficiaries and Costs Information) http://www.ssa.gov/history/1970.html (Chronology) http://www.ssa.gov/ssi/text-other-ussi.htm http://www.hud.gov/offices/pih/programs/hcv/homeownership/ http://www.statehealthfacts.org/comparemaptable.jsp?cat=4&ind=253#notes-1 http://www.socialsecurity.gov/policy/docs/statcomps/ssi_sc/2009/table01.html http://www.gpoaccess.gov/usbudget/fy11/pdf/budget/social.pdf http://www.ssa.gov/policy/docs/statcomps/ssi_monthly/2010-06/table02.pdf ##This is a 404 Error## http://www.ssa.gov/policy/docs/statcomps/ssi_monthly/2010-09/table02.pdf ##This is a 404 Error## http://www.ssa.gov/policy/docs/statcomps/ssi_monthly/2010-10/table02.pdf ##This is a 404 Error## http://www.ssa.gov/policy/docs/statcomps/ssi_monthly/2010-11/table02.pdf ##This is a 404 Error## http://www.ssa.gov/policy/docs/statcomps/ssi_monthly/2011-02/table01.pdf ##This is a 404 Error##

External links
Social Security Administration webpage with information on SSI (http://www.socialsecurity.gov/ssi/index. htm/) The Social Security Act (http://www.ssa.gov/OP_Home/ssact/comp-toc.htm) Title XVI in particular (http://www.ssa.gov/OP_Home/ssact/title16b/1600.htm) SSI Calculator (http://www.abil.org/ssi-calculator)

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Selective serotonin reuptake inhibitor


Selective serotonin reuptake inhibitor
Drug class

Serotonin Use Biological target ATC code Depression Serotonin transporter N06AB External links MeSH AHFS/Drugs.com Consumer Reports D017367 [1] [2] [3]

Drug Classes

Best Buy Drugs

Selective serotonin re-uptake inhibitors or serotonin-specific reuptake inhibitor[] (SSRIs) are a class of compounds typically used as antidepressants in the treatment of depression, anxiety disorders, and some personality disorders. SSRIs are believed to increase the extracellular level of the neurotransmitter serotonin by inhibiting its reuptake into the presynaptic cell, increasing the level of serotonin in the synaptic cleft available to bind to the postsynaptic receptor. They have varying degrees of selectivity for the other monoamine transporters, with pure SSRIs having only weak affinity for the noradrenaline and dopamine transporter. SSRIs are the first class of psychotropic drugs discovered using the process called rational drug design, a process that starts with a specific biological target and then creates a molecule designed to affect it.[] They are the most widely prescribed antidepressants in many countries.[] The efficacy of SSRIs in mild or moderate cases of depression has been disputed.[][][]

Medical uses
The main indication for SSRIs is major depressive disorder (also called "major depression", "clinical depression" and often simply "depression"). SSRIs are frequently prescribed for anxiety disorders, such as social anxiety disorder, panic disorders, obsessivecompulsive disorder (OCD), eating disorders, chronic pain and occasionally, for posttraumatic stress disorder (PTSD). They are also frequently used to treat depersonalization disorder, although generally with poor results.[4]

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Depression
Antidepressants are recommended by the National Institute for Clinical Excellence (NICE) as a first-line treatment of severe depression and for the treatment of mild-to-moderate depression that persists after conservative measures such as cognitive therapy.[] They recommend against their routine use in those who have chronic health problems and mild depression.[] There has been controversy regarding the efficacy of antidepressants in treating depression depending on its severity and duration. A comprehensive review conducted by NICE concluded that antidepressants have no advantage over placebo in the treatment of short term mild depression, but that the available evidence supported the use of antidepressants in the treatment of dysthymia and other forms of chronic mild depression.[5] Two meta-analyses of clinical trials published in 2008 and 2011 found that in mild and moderate depression, the effect of SSRIs is small or none compared to placebo, while in very severe depression the effect of SSRIs is between "relatively small " and "substantial".[][] Unlike the NICE study, these studies did not discriminate between the acutely and chronically depressed. The 2008 meta-analysis combined 35 clinical trials submitted to the U.S. Food and Drug Administration (FDA) before licensing of four newer antidepressants (including the SSRIs paroxetine and fluoxetine, the non-SSRI antidepressant nefazodone, and the SNRI (serotonin and norepinephrine reuptake inhibitor) venlafaxine). The authors attributed the relationship between severity and efficacy to a reduction of the placebo effect in severely depressed patients, rather than an increase in the effect of the medication.[] Some researchers have questioned the statistical basis of this study suggesting that it underestimates the effect size of antidepressants.[][] A 2010 review reached similar conclusions: in mild and moderate depression, specifically that the effect of SSRI is very small or none compared to placebo, while it is clinically significant in very severe depression.[][6] However, this analysis included only 6 studies out of the over 2,000 that have been done, involved just 2 medications, and did not involve studies with placebo washout periods typically used as controls.[][] SSRIs are recommended by NICE over tricyclics due to their superior tolerability.[7] One study showed that SSRIs have greater adverse effects than TCAs in the elderly, though the authors caution that more research is needed.[] There does not appear to be a substantial differences in efficacy among the various second generation antidepressants (SSRIs and SNRIs).[8]

Generalized anxiety disorder


SSRIs are recommended by the National Institute for Health and Clinical Excellence (NICE) for the treatment of generalized anxiety disorder (GAD) that has failed to respond to conservative measures such as education and self-help activities. GAD is a common disorder of which the central feature is excessive worry about a number of different events. Key symptoms include excessive anxiety about multiple events and issues, and difficulty controlling worrisome thoughts that persists for at least 6 months. Antidepressants provide a modest-to-moderate reduction in anxiety in GAD,[] and are superior to placebo in treating GAD.[] The efficacy of different antidepressants is similar.[][]

Obsessive compulsive disorder (OCD)


SSRIs are recommended for the second line treatment of adult obsessive compulsive disorder patients with mild functional impairment and as first line treatment for those with moderate or severe impairment. In children, SSRIs can be considered as a second line therapy in those with moderate-to-severe impairment, with close monitoring for psychiatric adverse effects.[9] SSRIs are efficacious in the treatment of OCD; patients treated with SSRIs are about twice as likely to respond to treatment as those treated with placebo.[10][11]

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Eating disorders
Anti-depressants are recommended as an alternative or additional first step to self-help programs in the treatment of bulimia nervosa.[] SSRIs (fluoxetine in particular) are preferred over other anti-depressants due to their acceptability, tolerability, and superior reduction of symptoms in short term trials. Long term efficacy remains poorly characterized. Similar recommendations apply to binge eating disorder.[] SSRIs provide short term reductions in binge eating behavior, but have not been associated with significant weight loss.[] Clinical trials have generated mostly negative results for the use of SSRI's in the treatment of anorexia nervosa.[] Treatment guidelines from the National Institute of Health and Clinical Excellence[] recommend against the use of SSRIs in this disorder. Those from the American Psychiatric Association note that SSRIs confer no advantage regarding weight gain, but that they may be used for the treatment of co-existing depressive, anxiety, or obsessive-compulsive disorders.[]

Stroke recovery
SSRIs have been used in the treatment of stroke patients, including those with and without symptoms of depression. A recent meta analysis of randomized, controlled clinical trials found a statistically significant effect of SSRIs on dependence, neurological deficit, depression, and anxiety. There was no statistically significant effect on death, motor deficits, or cognition.[12]

Premature ejaculation
A general disadvantage of SSRIs in treating premature ejaculation is that they require continuous daily treatment to delay ejaculation significantly.[] For the occasional "on-demand" treatment, a few hours before coitus, clomipramine gave better results than paroxetine in one study,[] while in another study both sertraline and clomipramine were indistinguishable from the pausesqueeze technique and inferior to paroxetine.[] The most recent research, conducted in 2007, suggests that on-demand treatment with sildenafil (Viagra) offers a dramatic improvement in ejaculation delay and sexual satisfaction as compared with daily paroxetine,[] with on-demand sertraline, paroxetine or clomipramine,[] and with the pausesqueeze technique.[][]

Adverse effects
General side effects are mostly present during the first 14 weeks while the body adapts to the drug (with the exception of sexual side effects, which tend to occur later in treatment). In fact, it often takes 68 weeks for the drug to begin reaching its full potential (the slow onset is considered a downside to treatment with SSRIs). Almost all SSRIs are known to cause one or more of these symptoms: nausea/vomiting drowsiness or somnolence headache (very common as a short-term side effect) bruxism extremely vivid or strange dreams dizziness mydriasis (pupil dilation) changes in appetite insomnia and/or changes in sleep excessive diarrhea

weight loss/gain (measured by a change in bodyweight of 7 pounds) increased risk of bone fractures by 1.7 fold[13]

Selective serotonin reuptake inhibitor changes in sexual behaviour (see the next section) increased feelings of depression and anxiety (which may sometimes provoke panic attacks) mania tremors autonomic dysfunction including orthostatic hypotension, increased or reduced sweating akathisia suicidal ideation (thoughts of suicide) photosensitivity[14] paresthesia cognitive disorders Syndrome of inappropriate antidiuretic hormone hypersecretion

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Many side effects disappear after the adaptation phase, when the antidepressant effects begin to come to prominence. However, despite being called general, the side effects and their durations are highly individual and drug-specific. Usually the treatment is begun with a small dose to see how the patient's body reacts to the drug, after that either the dose can be adjusted (e.g. Prozac in the UK is begun at a 20mg dose, and then adjusted as necessary to 40mg or 60mg). Should the drug prove ineffective, or the side effects intolerable to the patient, another common route is to switch treatment to either another SSRI, or an SNRI.[15] Mania or hypomania is a possible side effect. Users with some type of bipolar disorder are at a much higher risk, however SSRI-induced mania in patients previously diagnosed with unipolar depression can trigger a bipolar episode; however, according to DSM IV-TR, the diagnosis of bipolar disorder requires that the individuals symptoms must not stem from medication side effects, toxins, drug abuse, or another general medical condition.

Sexual dysfunction
Main article: Post-SSRI sexual dysfunction SSRIs can cause various types of sexual dysfunction such as anorgasmia, erectile dysfunction, and diminished libido.[16] It can last for months, years, or sometimes indefinitely after the discontinuation of SSRIs. Initial studies found sexual side effects not significantly different from placebo, but since these studies relied on unprompted reporting, the frequency was probably underestimated. In more recent studies, doctors have specifically asked about sexual difficulties, and found that they are present in between 17% and 41%[17][18] of patients, although the lack of placebo control in these studies means they are likely underestimates. This is because release of extracellular concentrations of serotonin in the brain decreases dopamine and norepinephrine leading to erectile and/or sexual dysfunction. Release of postsynaptic 5-HT2 and 5-HT3 receptors decreases dopamine and norepinephrine release from the substantia nigra. A number of drugs are not associated with sexual side effects (such as bupropion, mirtazapine, tianeptine, agomelatine and moclobemide,[19][20] some of which are also not associated with weight gain). A small number of case reports have appeared in the literature suggesting that in rare cases, sexual dysfunction may persist after discontinuing treatment.[21] On the other hand, the effect of SSRIs to slow down sexual stimulation may be used as treatment; SSRIs have been proposed as a drug to treat premature ejaculation.[22] The Andean herbaceous biennial plant Lepidium meyenii (also known as "maca") was found to be effective for alleviating SSRI-induced sexual dysfunction on a small double-blind, randomized, parallel group dose-finding pilot study.[23] There is no FDA-approved treatment for SSRI-induced sexual dysfunction and there has been a lack of randomized, placebo-controlled, double-blind studies of potential treatments. There is evidence for the following management strategies: for erectile dysfunction, the addition of a PDE5 inhibitor such as sildenafil; for decreased libido, possibly adding or switching to bupropion; and for overall sexual dysfunction, switching to nefazodone.[24]

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Cardiovascular
Cardiovascular side effects are very rare with SSRI use, with a reported incidence of less than 0.0003 percent.[25] SSRIs inhibit cardiac and vascular sodium, calcium and potassium channels and prolong QT intervals.[26] A number of large studies of patients without known pre-existing heart disease have reported no EKG changes related to SSRI use.[] More recently, however, concerns about cardiac problems have led to a reduction in the recommended maximum dose of two types of SSRI's. The recommended maximum daily dose of citalopram was reduced to 40mg. for most people and 20mg. for those older than age 60 and some others.[27] The recommended maximum daily dose of escitalopram was reduced to 10mg. for those older than age 65; the maximum daily dose for most other people remained unchanged at 20mg.[28][29] In overdose, fluoxetine has been reported to cause sinus tachycardia, myocardial infarction, junctional rhythms and trigeminy. Some authors have suggested electrocardiographic monitoring in patients with severe pre-existing cardiovascular disease who are taking SSRI's.[30]

Discontinuation syndrome
Antidepressants such as SSRIs have some dependence producing effects, most notably a withdrawal syndrome. Their dependence producing properties (depending on the antidepressant) may not be as significant as other psychotropic drugs such as benzodiazepines; however, withdrawal symptoms nonetheless may be quite severe and even debilitating. SSRIs have little abuse potential, but discontinuation can produce disturbing withdrawal symptoms that may be indistinguishable from a reoccurrence of the original illness.[31] Since physical dependence is a reality, discontinuation should be discussed with a medical practitioner before beginning treatment with this class of drugs. When discontinuing an SSRI or SNRI some doctors may switch the patient to fluoxetine due to its much longer half-life. This may avoid many of the severe withdrawal symptoms associated with SSRI/SNRI discontinuation. This can be done either by administering a single 20mg dose of fluoxetine or by beginning on a low dosage of fluoxetine and slowly tapering down. Any SSRI or SNRI may be requested in liquid form, which allows very gradual tapering. Alternatively, a patient wishing to stop taking an SSRI/SNRI may visit a compounding pharmacy where his or her prescription may be re-arranged into progressively smaller dosages. For example the lowest dose of cymbalta that can normally be prescribed is 20mg in gel capsules; a compounding pharmacist may divide this into doses of 20, 15, 10, 5 and 2.5mg so that a proper tapered reduction may take place.

Suicide risk
Children and adolescents Several studies have found that SSRI use is related to a higher risk of suicidal behavior in children and adolescents.[32][][] For instance, a 2004 U.S. Food and Drug Administration (FDA) analysis of clinical trials on children with major depressive disorder found statistically significant increases of the risks of "possible suicidal ideation and suicidal behavior" by about 80%, and of agitation and hostility by about 130%;[] More infrequently, studies have been inconclusive.[33] however, a recent comparison of aggression and hostility occurring during treatment with fluoxetine to placebo in children and adolescents found that no significant difference between the fluoxetine group and a placebo group.[34] There is also evidence that higher rates of SSRI prescriptions are associated with lower rates of suicide in children, though since the evidence is correlational, the true nature of the relationship is unclear.[] In 2004, the Medicines and Healthcare products Regulatory Agency (MHRA) in the United Kingdom judged fluoxetine (Prozac) to be the only antidepressant that offered a favorable risk-benefit ratio in children with depression, though it was also associated with a slight increase in the risk of self-harm and suicidal ideation.[35] Only two SSRIs are licensed for use with children in the UK, sertraline (Zoloft) and fluvoxamine (Luvox), and only for the treatment of obsessivecompulsive disorder. Fluoxetine is not licensed for this use.[]

Selective serotonin reuptake inhibitor Adults It is unclear whether or not SSRIs affect the risk of suicidal behavior for adults. A 2005 meta-analysis of drug company data found no evidence that SSRIs increased the risk of suicide; however, important protective or hazardous effects could not be excluded.[36] Also among high-risk adult patients, antidepressant drug treatment does not seem related to suicide attempts and death.[] A 2005 review observed that suicide attempts are increased in those who use SSRIs as compared to placebo and compared to therapeutic interventions other than tricyclic antidepressants. No difference risk of suicide attempts was detected between SSRIs versus tricyclic antidepressants.[37] On the other hand, a 2006 review suggests that the widespread use of antidepressants in the new "SSRI-era" appear to have led to highly significant decline in suicide rates in most countries with traditionally high baseline suicide rates. The decline is particularly striking for women who, compared with men, seek more help for depression. Recent clinical data on large samples in the US too have revealed a protective effect of antidepressant against suicide.[38] A 2006 meta analysis of random controlled trials suggests that SSRIs increase suicide ideation compared with placebo. However, the observational studies suggests that SSRIs did not increase suicide risk more than older antidepressants. The researchers stated that if SSRIs increase suicide risk in some patients, the number of additional deaths is very small because ecological studies have generally found that suicide mortality has declined (or at least not increased) as SSRI use has increased.[39] An additional meta-analysis by the FDA in 2006 found an age-related effect of SSRI's. Among adults younger than 25 years, results indicated that there was a higher risk for suicidal behavior. For adults between 25 and 64, the effect appears neutral on suicidal behavior but possibly protective for suicidal behavior for adults between the ages of 25 and 64. For adults older than 64, SSRI's seem to reduce the risk of both suicidal behavior.[32] Suicide warnings The FDA findings resulted in a black box warning on SSRI and other antidepressant medications regarding the increased risk of suicidal behavior in patients younger than 24.[40] Similar precautionary notice revisions were implemented by the Japanese Ministry of Health.[41] In 2004 the Medicines and Healthcare products Regulatory Agency in the United Kingdom issued a warning about increases in 'insomnia, agitation, weight loss, headache, tremor, loss of appetite, self-harm and suicidal thoughts' when the medications are used with children and adolescents.[42]

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The introduction of a warning regarding the association between SSRIs and suicide by the FDA in 2004 led to a dramatic decrease in prescriptions of these medications to young people. Originally, there were concerns that the decrease in prescriptions caused by the warnings could increase the number of teenage suicides in the US.[] However, the most recent data from the US National Center for Health Statistics put these concerns to rest. The suicide rates for persons younger than 25 has actually decreased between 2004 and 2007.Wikipedia:No original research [43][44]

Pregnancy and breastfeeding


SSRI use during pregnancy is associated with an increased rate of miscarriages, birth defects, persistent pulmonary hypertension of the newborn, newborn behavioral syndrome, and possibly long term behavioral problems.[45] The risk of spontaneous abortion is increased about 1.7 fold.[46] The FDA issued a statement on July 19, 2006 stating nursing mothers on SSRIs must discuss treatment with their physicians. However, the medical literature on the safety of SSRIs has determined that some SSRIs like Sertraline and Paroxetine are considered safe for breastfeeding.[47][48][49] Maternal SSRI use may be associated with autism.[50]

Selective serotonin reuptake inhibitor Neonatal abstinence syndrome Neonatal abstinence syndrome is a withdrawal syndrome in newborn babies. It has been documented in SSRI treatment. By November 2003, a total of 93 cases of SSRI use associated with either neonatal convulsions or withdrawal syndrome had been reported. Subsequently, the authors of a Lancet study concluded that doctors should avoid or cautiously manage the prescribing of these drugs to pregnant women with psychiatric disorders.[51] Neuropsychological changes due to SSRI use in infancy Since the early 80's scientists have used a technique called neonatal clomipramine to produce animals used in depression research. If rats are given the tricyclic antidepressant clomipramine when 821 days old, they develop behavioural changes in adulthood that resemble depression in humans.[][] In 1997 Lundbeck found that treatment with the SSRI LU-10-134-C, which only differs from their product citalopram by two atoms could give similar results as clomipramine.[] Later it was found that neonatal citalopram and escitalopram makes persistent changes in the serotonergic transmission of the brain resulting in behavioral changes,[][] which are reversed by treatment with antidepressants.[] By treating normal and knockout mice lacking the serotonin transporter with fluoxetine scientists showed that normal emotional reactions in adulthood, like a short latency to escape foot shocks and inclination to explore new environments were dependent on active serotonin transporters during the neonatal period.[52][53] But when young mice were treated with the SNRI desimipramine they developed to normal adults, which suggests that serotonin and noradrenaline have different effects in the developing brain. For humans, the developmental stage sensitive to SSRI:s corresponds with the last trimester to the first years of life. A study showed that 4-year old children perinatally exposed to SSRIs behave normally. However, the young mice and rats also seem normal until they reach puberty and develop behavioural disturbances.[54][] The mechanism is currently unknown, but it seems that early life overstimulation of the 5-HT1 receptor that regulates serotonin production results in low serotonin production after puberty.[55] Persistent pulmonary hypertension Persistent pulmonary hypertension (PPHN) is a serious and life-threatening, but rare, lung condition that occurs soon after birth of the newborn. Newborn babies with PPHN have high pressure in their lung blood vessels and are not able to get enough oxygen into their bloodstream. About 1 to 2 babies per 1000 babies born in the U.S. develop PPHN shortly after birth, and often they need intensive medical care. One study has found that PPHN is six times more common in babies whose mothers take an SSRI antidepressant after the 20th week of the pregnancy compared to babies whose mothers do not take an antidepressant.[56] A population-based cohort study, which included 1.6 million live births in five Nordic countries, of women with filled SSRI prescriptions later than the 20th week gestation by last menstrual period demonstrated an increased risk of persistent pulmonary hypertension (PPHN) compared to control infants (adjusted RR 2.1, 95% CI 1.5-3). The increased risk of PPHN was of similar magnitude for the SSRI class of drugs (Fluoxetine, Citalopram, Paroxetine, Sertraline, Escitalopram). This study showed that the absolute risk of PPHN would only increase the incidence from 0.1 to 0.3 percent of live-births with late prenatal SSRI exposure.[57]

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Selective serotonin reuptake inhibitor

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Bleeding tendencies
SSRIs appear to increase the risk of bleeding.[] This includes an increased risk of GI bleeding, post operative bleeding,[] and intracranial bleeding.[58] SSRIs are known to cause platelet dysfunction.[59][60]

Overdose
SSRIs appear safer in overdose when compared with traditional antidepressants, such as the tricyclic antidepressants. This relative safety is supported both by case series and studies of deaths per numbers of prescriptions.[] However, case reports of SSRI poisoning have indicated that severe toxicity can occur[] and deaths have been reported following massive single ingestions,[] although this is exceedingly uncommon when compared to the tricyclic antidepressants.[] Because of the wide therapeutic index of the SSRIs, most patients will have mild or no symptoms following moderate overdoses. The most commonly reported severe effect following SSRI overdose is serotonin syndrome; serotonin toxicity is usually associated with very high overdoses or multiple drug ingestion.[] Other reported significant effects include coma, seizures, and cardiac toxicity.[] Treatment for SSRI overdose is mainly based on symptomatic and supportive care. Medical care may be required for agitation, maintenance of the airways, and treatment for serotonin syndrome. ECG monitoring is usually indicated to detect any cardiac abnormalities.

Contraindications and drug interaction


One major contraindication of SSRIs is the concomitant use of MAOIs (monoamine oxidase inhibitors). This is likely to cause severe serotonin syndrome/toxidrome. People taking SSRIs should also avoid taking pimozide (an antipsychotic diphenylbutylpiperidine derivative). Tramadol hydrochloride (or Ultram, Ultracet) can, in rare cases, produce seizures when taken in conjunction with an SSRI or tricyclic antidepressant. Liver impairment is another contraindication for medications of this type. SSRIs may increase blood levels and risk of toxicities of certain medications: 1. highly protein-bound medications like warfarin (coumadin) and digoxin 2. antiarrhythmic agents like propafenone (Rythmol) or flecainide (Tambocor) 3. beta blockers like metoprolol (Toprol xl) or propranolol (Inderal) 4. Tricyclic antidepressants like amitriptyline (Elavil, Endep) etc. 5. triptans like sumatriptan (Imitrex, Imigran) etc. 6. benzodiazepines like alprazolam (Xanax) or diazepam (Valium)[citation needed] 7. carbamazepine (Tegretol) 8. cisapride (Propulsid) 9. clozapine (Clozaril) 10. ciclosporin (Neoral) 11. haloperidol (Haldol) 12. phenytoin (Dilantin) 13. pimozide (Orap) 14. theophylline (Theo-dur) Certain drugs may increase toxicities of SSRIs: 1. alcohol and other CNS depressants 2. methylene blue dye 3. diuretics (water pills) 4. MAOIs possibly fatal serotonin syndrome/toxidrome 5. sympathomimetic drugs like pseudoephedrine (Sudafed)

Selective serotonin reuptake inhibitor 6. lithium 7. sibutramine (Meridia) 8. MDMA (ecstasy) 9. zolpidem (ambien)[61] 10. dextromethorphan (cough suppressant) increased risk of serotonin syndrome/toxidrome 11. tramadol (synergistic serotoninergic effect said to increase risk of seizure or serotonin syndrome/toxidrome) 12. pethidine/meperidine increased risk of serotonin syndrome/toxidrome 13. herbal Saint John's wort or yohimbe increased risk of serotonin syndrome/toxidrome Painkillers of the NSAIDs drug family may interfere and reduce efficiency of SSRIs:[62][63] 1. Aspirin 2. Ibuprofen (Advil, Nurofen) 3. Naproxen (Aleve) SSRIs also directly interfere with ligands of 5-HT receptors, like the psychedelics and entactogens. SSRIs strongly diminish the effects of tryptamines (e.g. psilocybin and LSD), and phenethylamines (e.g. the 2C family), and almost completely eliminate the serotonergic effects of MDxx (e.g. MDMA). The exact mechanism that causes this interaction is still unclear. [citation needed]

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List of agents
Drugs in this class include (trade names in parentheses): citalopram (Celexa, Cipramil, Cipram, Dalsan, Recital, Emocal, Sepram, Seropram, Citox, Cital) dapoxetine (Priligy) escitalopram (Lexapro, Cipralex, Seroplex, Esertia) fluoxetine (Depex, Prozac, Fontex, Seromex, Seronil, Sarafem, Ladose, Motivest, Flutop, Fluctin (EUR), Fluox (NZ), Depress (UZB), Lovan (AUS), Prodep (IND)) fluvoxamine (Luvox, Fevarin, Faverin, Dumyrox, Favoxil, Movox, Floxyfral) indalpine (Upstene) (discontinued) paroxetine (Paxil, Seroxat, Sereupin, Aropax, Deroxat, Divarius, Rexetin, Xetanor, Paroxat, Loxamine, Deparoc) sertraline (Zoloft, Lustral, Serlain, Asentra, Tresleen) zimelidine (Zelmid, Normud) (discontinued)
Selective serotonin reuptake inhibitors (SSRIs)

Dapoxetine Citalopram Escitalopram

Fluoxetine

Fluvoxamine

Sertraline

Paroxetine Zimelidine Indalpine

Selective serotonin reuptake inhibitor

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Related agents
SSRIs form a subclass of serotonin uptake inhibitors, which includes other non-selective inhibitors as well. Serotonin-norepinephrine reuptake inhibitors, serotonin-norepinephrine-dopamine reuptake inhibitors and selective serotonin reuptake enhancers are also serotonergic antidepressants.

Mechanism of action
SSRIs are believed to act by inhibiting the reuptake of serotonin after being released in synapses. How much an individual will respond to this, however, also depends on genetics. In addition, several other mechanisms are suggested for the desired effect, e.g. neuroprotection and anti-inflammatory and immunomodulatory factors. Taken together, SSRI has several advantages compared with tricyclic antidepressants (TCA)s and 5-HT-prodrugs. However, the latter might be required in addition to SSRIs in certain situations.

Basic understanding
In the brain, messages are passed between two nerve cells via a chemical synapse, a small gap between the cells. The (presynaptic) cell that sends the information releases neurotransmitters (including serotonin) into that gap. The neurotransmitters are then recognized by receptors on the surface of the recipient (postsynaptic) cell, which upon this stimulation, in turn, relays the signal. About 10% of the neurotransmitters are lost in this process; the other 90% are released from the receptors and taken up again by monoamine transporters into the sending (presynaptic) cell (a process called reuptake). To stimulate the recipient cell, SSRIs inhibit the reuptake of serotonin. As a result, the serotonin stays in the synaptic gap longer than it normally would, and may repeatedly stimulate the receptors of the recipient cell. The current model of SSRIs (the Monoamine Hypothesis) assumes that a lower homeostatic level of serotonin is primarily responsible for depression. While this holds in cases of major depression, minor to moderate cases are not as clear cut, and may in fact be caused by excess serotonin in specific areas of the brain. Some current research points to more than just a single type of chemical signaling - the classic synapse model involving serotonin. Astrocytes are "helper cells" in the brain that do not participate directly in chemical signaling, but play a part in homeostasis for many chemical levels in the brain. Recent research[64] suggests that serotonin is one of the hormones regulated by astrocytes, and that astrocytes actually uptake, package, and resend serotonin in a way similar to neuronal axons, but do not have corresponding post-synaptic terminals, therefore appearing to function only to control the local levels of serotonin in the cerebrospinal fluid. Still more research illustrates that the current model for the antidepressant activity of SSRIs may be misdirected, as a drug that works entirely opposite to SSRIs - Tianeptine, a selective serotonin reuptake enhancer - also exhibits antidepressant activity, especially in patients resistant to SSRI therapy. The effect of an SSRE in comparison to an SSRI requires that the nature of serotonin signaling in the areas of the brain related to mood and cognition needs further elucidation. If serotonin firing is regularly phasic (related to brain waves), or rapid and discrete, then SSRIs simply compress the signal potential at affected receptors (bringing down the maximum potential and bring up the minimum) by causing a constant leftover signal (serotonin left in the synaptic gap) coupled with weaker subsequent signals (due to the decrease in presynaptic serotonin available to send new signals). By this hypothetical model, SSREs increase the signal potential separation (min to max) at affected 5-HT sites by reducing the level of free cerebrospinal serotonin and increasing the amount uptaken into axons to send new signals.

Selective serotonin reuptake inhibitor

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Pharmacodynamics
SSRIs inhibit the reuptake of the neurotransmitter serotonin (5-hydroxytryptamine or 5-HT) into the presynaptic cell, increasing levels of 5-HT within the synaptic cleft. However, there is one counteracting effect: high serotonin levels will not only activate the postsynaptic receptors, but also flood presynaptic autoreceptors, which serve as a feedback sensor for the cell. Activation of the autoreceptors (by agonists like serotonin) triggers a throttling back of serotonin production. The resulting serotonin deficiency persists for some time, as the transporter inhibition occurs downstream to the cause of the deficiency and therefore, is not able to counterbalance the serotonin deficiency. The body adapts gradually to this situation by lowering (downregulating) the sensitivity of the autoreceptors.[65] Another adaptive process provoked by SSRIs is the downregulation of postsynaptic serotonin 5-HT2A receptors. After the use of an SSRI, since there is more serotonin available, the response is to decrease the number of postsynaptic receptors over time and in the long run, this modifies the serotonin/receptor ratio. This downregulation of 5-HT2A occurs when the antidepressant effects of SSRIs become apparent. Also, deceased suicidal and otherwise depressed patients have had more 5-HT2A receptors than normal patients. These considerations suggest that 5-HT2A overactivity is involved in the pathogenesis of depression.[] Most of the serotonin receptors on the surface of the cell are coupled to a G-protein inside it. These proteins activate or inhibit second messengers, which in turn affect transcription factors. Transcription factors are proteins that fit to the beginning of a gene and tell the cell to start using it. These (slowly proceeding) neurophysiological adaptations of the brain tissue are the reason why usually several weeks of continuous SSRI use is necessary for the antidepressant effect to become fully manifested,[] and why increased anxiety is a common side effect in the first few days or weeks of use.

Role in BDNF release


SSRIs act on signal pathways such as cAMP (Cyclic AMP) on the postsynaptic neuronal cell, which leads to the release of Brain Derived Neurotrophic Factor (BDNF). BDNF enhances the growth and survival of cortical neurons and synapses.[66]

Pharmacogenetics
Large bodies of research are devoted to using genetic markers to predict whether patients will respond to SSRIs or have side effects that will cause their discontinuation, although these tests are not yet ready for widespread clinical use.[67] Single-nucleotide polymorphisms of the 5-HT(2A) gene correlated with paroxetine discontinuation due to side effects in a group of elderly patients with major depression, but not mirtazapine (a non-SSRI antidepressant) discontinuation.[68]

Neuroprotection
Studies have suggested that SSRIs may promote the growth of new neural pathways or neurogenesis in rats.[69] Also, SSRIs may protect against neurotoxicity caused by other compounds (for instance fenfluramine) as well as from depression itself. SSRIs have been found to induce programmed cell death in Burkitt lymphoma and the brain tumors neuroblastoma and glioma with minimal effect on normal tissue.[70][71]

Anti-inflammatory and immunomodulation


Recent studies show pro-inflammatory cytokine processes take place during depression, mania and bipolar disorder, in addition to somatic disease (such as autoimmune hypersensitivity) and it is possible that symptoms manifest in these psychiatric illnesses are being attenuated by pharmacological effect of antidepressants on the immune system.[72][73][74][75][76]

Selective serotonin reuptake inhibitor SSRIs have demonstrated immunomodulatory and anti-inflammatory effects against pro-inflammatory cytokine processes, specifically on the regulation of Interferon-gamma (IFN-gamma) and Interleukin-10 (IL-10), as well as TNF-alpha and Interleukin-6 (IL-6). Antidepressants have also been shown to suppress TH1 upregulation.[77][78][79][80] Future serotonergic antidepressants may be made to specifically target the immune system by either blocking the actions of pro-inflammatory cytokines or increasing the production of anti-inflammatory cytokines.[81]

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SSRIs versus TCAs


SSRIs are described as 'selective' because they affect only the reuptake pumps responsible for serotonin, as opposed to earlier antidepressants, which affect other monoamine neurotransmitters as well, and as a result, SSRIs have fewer side effects. There appears no significant difference in effectiveness between SSRIs and tricyclic antidepressants, which were the most commonly used class of antidepressants before the development of SSRIs.[82] However, SSRIs have the important advantage that their toxic dose is high, and, therefore, they are much more difficult to use as a means to commit suicide. Further, they have fewer and milder side effects. Tricyclic antidepressant also have a higher risk of serious cardiovascular side effects, which SSRIs lack.

SSRIs versus 5-HT-Prodrugs


Serotonin cannot be administered directly because when ingested orally, it will not cross the bloodbrain barrier, and therefore would have no effect on brain functions. Also, serotonin would activate every synapse it reaches, whereas SSRIs only enhance a signal that is already present, but too weak to come through. The selectivity of the membrane can be reduced for a drug by injecting it in a concentrated sugar solution. The high osmotic pressure of the sugar solution causes the endothelial cells of the capillaries to shrink, which opens gaps between their tight junctions and makes the barrier more permeable. As a result the drug can enter the brain tissue. SSRIs together with 5-HT-Prodrugs Biosynthetic serotonin is made from tryptophan, an amino acid. In 1989, the Food and Drug Administration made tryptophan available by prescription only, in response to an outbreak of eosinophilia-myalgia syndrome caused by impure L-tryptophan supplements sold over-the-counter. With current standards, L-tryptophan is again available over the counter in the US as well as supplement 5-HTP, which is a direct precursor to serotonin.

Society and culture


Criticism
In late 2004 media attention was given to a proposed link between SSRI use and juvenile suicide. For this reason, the use of SSRIs in pediatric cases of depression is now recognized by the United States FDA as warranting a cautionary statement to the parents of children who may be prescribed SSRIs by a family doctor. The FDA's currently required packaging insert for SSRIs includes a warning (known as a "black box warning") that a pooled analysis of placebo controlled trials of 9 antidepressant drugs (including multiple SSRIs) resulted in a risk of suicidal behavior that was twice that of placebo. At the same time, in adults SSRIs do not increase the risk of suicide.[] Critics of SSRIs claim that the widely disseminated television and print advertising of SSRIs promotes an inaccurate message, oversimplifying what these medications actually do and deceiving the public.[83] The criticism stems from questions about the validity of claims that SSRIs work by 'correcting' chemical imbalances. Without accurately measuring patients' neurotransmitter levels to allow for continuous monitoring during treatment, it is impossible to know if one is correctly targeting a deficient neurotransmitter (i.e. correcting an imbalance), reaching a desirable level, or even introducing too much of a particular neurotransmitter. Thus it has been argued

Selective serotonin reuptake inhibitor that SSRIs can actually cause chemical imbalances and abnormal brain states, as evidenced by the fact that many report problems of sexual dysfunction, whose effects last long after the medication has been discontinued. Hence, it is purported that when a patient discontinues an SSRI, they may have a chemical imbalance due to the rapid cessation of the drug that causes the discontinuation syndrome.[84] One possible mechanism is by inhibition of dopaminergic neurotransmission.[85] Biopsychiatrists believe that, among other factors, the balance of neurotransmitters in the brain is a biological regulator of mental health. In this theory, emotions within a "normal" spectrum reflect a proper balance of neurochemicals, but abnormally extreme emotions, such as clinical depression, reflect an imbalance. PsychiatristsWikipedia:Avoid weasel words claim that medications regulate neurotransmitters, and many if not most psychiatrists also claim they treat abnormal personalities by removing a neurochemical excess or replenishing a deficit.[citation needed] On the other hand, Elliot Valenstein, a psychologist and neuroscientist, claims that the broad biochemical assertions and assumptions of mainstream psychiatry are not supported by evidence.[86] One controversial critic of antidepressants, Peter Breggin, a physician who opposes the overuse of prescription medications to treat patients for mental health issues, predicted iatrogenic issues that SSRIs incur on a significant percentage of patients. Another prominent SSRI critic is David Healy. A widely reported meta-analysis combined 35 clinical trials submitted to the U.S. Food and Drug Administration (FDA) before licensing of four newer antidepressants (including the SSRIs paroxetine and fluoxetine, and two non-SSRI antidepressants nefazodone and venlafaxine). The authors found that although the antidepressants were statistically superior to placebo they did not exceed the NICE criteria for a 'clinically significant' effect. For more detail, see the section "Efficacy". A study in The New England Journal of Medicine on a possible publication bias regarding the efficacy of SSRI medications in the treatment of depression suggests that their effectiveness and risk-benefit ratios may be greatly exaggerated. Of 74 studies registered with the United States FDA, 37 with positive results were published in academic journals, while 22 studies with negative results were not published and 11 with negative results were published in a way that conveyed a positive outcome (one positive study was not published and three negative studies were published with results that were portrayed as negative). Overall, 94% of studies actually published were positive outcomes; when published and unpublished studies were included for analysis, the percentage of positive outcomes was 51%.[] Although controversial, the existence of an SSRI-related withdrawal syndrome mimicking depression may inflate the therapeutic effect size reported in long-term (more than 6 months) placebo controlled trials of SSRIs, due to a reliance on randomized discontinuation designs. Discontinuation trials are a variant of the classic 2-arm placebo controlled randomized controlled trials used in shorter placebo controlled studies of SSRIs.[87][88]

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Regulation
All SSRIs are approved in the U.S. for use with psychiatric disorders as outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM IV). Approved uses for SSRIs vary by country and are determined by the overseeing branch of government in charge of regulating drugs. In the U.S., the Food and Drug Administration (FDA) approves drugs after trial results have been submitted by the pharmaceutical companies. In Europe, drugs can be approved either by the European Medicines Agency for human consumption throughout the European Union or by the regulatory agencies of individual countries for use within those countries.[citation needed]. In Canada, the drug approval process is carried out by Health Canada.

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Lawsuits
Hundreds of lawsuits have been filed against drug manufacturers seeking compensation for harm attributed to the use of SSRIs. Suits based on product liability, for example, often allege failure to adequately warn users of potential side effects. Manufacturers have defended many suits on the merits and settled many others. In 2005, the U.S. FDA asked manufacturers to include black box warnings on antidepressant drug packaging.[89] Though a 2007 study[90] purportedly showed that the black box "warnings discouraged use of antidepressants in children and adolescents and... led to increases in suicide rates as a result of untreated depression" an article in the New York Times[91] that ran two weeks later questioned the results of the study, claiming that the data did not support a causal link between the black box warning and increased rates of suicide.

References
[1] http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2011/ MB_cgi?field=uid& term=D017367 [2] http:/ / www. drugs. com/ drug-class/ ssri-antidepressants. html [3] http:/ / www. consumerreports. org/ health/ best-buy-drugs/ antidepressants. htm [15] A landmark study in the use of anti-depressants and their role in step-therapy can be found in the STAR*D trial. [28] [ref1 UNIQ-nowiki-0-5e7e650f2491d5e3-QINU (http:/ / www. mhra. gov. uk/ Safetyinformation/ DrugSafetyUpdate/ CON137769) [32] (page 54) [34] Meta-Analysis of Aggression and/or Hostility-Related Events in Children and Adolescents Treated with Fluoxetine Compared with Placebo (http:/ / www. liebertonline. com/ doi/ abs/ 10. 1089/ cap. 2006. 0138) Journal of Child and Adolescent Psychopharmacology. October 2007, 17(5): 713-718. . [51] Medicalnewstoday.com (http:/ / www. medicalnewstoday. com/ medicalnews. php?newsid=19631) Medical News Today - Lancet Press Release. Feb 05 2005 [56] FDA.gov (http:/ / www. fda. gov/ CDER/ DRUG/ advisory/ SSRI_PPHN200607. htm), FDA Public Health Advisory - Treatment Challenges of Depression in Pregnancy [57] (http:/ / www. bmj. com/ highwire/ filestream/ 557867/ field_highwire_article_pdf/ 0. pdf), Kieler H, Artama M, Engeland A, Ericsson O, Furu K, Gissler M, Nielsen RB, Norgaard M, Stephansson O, Valdimarsdottir U, Zoega H, Haglund B." Selective serotonin reuptake inhibitors during pregnancy and risk of persistent pulmonary hypertension in the newborn: population based cohort study from the five Nordic countries" BMJ 2012;344:d8012 [58] http:/ / www. neurology. org/ content/ early/ 2012/ 10/ 17/ WNL. 0b013e318271f848. abstract Selective serotonin reuptake inhibitors and brain hemorrhage [66] Kolb, Bryan and Wishaw Ian. An Introduction to Brain and Behavior. New York: Worth Publishers 2006, Print. [89] Center for Drug Evaluation and Research Antidepressant Use in Children, Adolescents, and Adults (http:/ / www. fda. gov/ cder/ drug/ antidepressants). Retrieved September 30, 2008.

External links
PROZAC Product/Prescribing Information (http://pi.lilly.com/us/prozac.pdf) at Eli Lilly and Company Barry Yeoman Putting Science in the Dock (http://www.barryyeoman.com/articles/courtroom.html), The Nation at barryyeoman.com Serotonin uptake inhibitors (http://www.nlm.nih.gov/cgi/mesh/2011/MB_cgi?mode=&term=Serotonin+ uptake+inhibitors) at the US National Library of Medicine Medical Subject Headings (MeSH)

Temporary Assistance for Needy Families

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Temporary Assistance for Needy Families


Department of Health and Human Services

Official seal

HHS Logo Program overview Preceding Program Aid to Families with Dependent Children Jurisdiction Annual budget Federal government of the United States $17.28 billion (2011) Website TANF
[2] [1]

Temporary Assistance for Needy Families (TANF /tnf/) is one of the United States of America's federal assistance programs. It began on July 1, 1997,[3] and succeeded the Aid to Families with Dependent Children (AFDC) program, providing cash assistance to indigent American families with dependent children through the United States Department of Health and Human Services. This cash benefit is often referred to simply as "welfare." TANF was created by the Personal Responsibility and Work Opportunity Act instituted under President Bill Clinton in 1996. The Act provides temporary financial assistance while aiming to get people off of that assistance, primarily through employment. There is a maximum of 60 months of benefits within one's lifetime, but some states have instituted shorter periods.[4] The reform granted states wide discretion of how to distribute TANF entitlements. States also have the authority to eliminate payments to recipients altogether. Under the new act, TANF recipients are required to find a job within 24 months of receiving aid.[5] In enforcing the 60-month time limit, some states place limits on the adult portion of the assistance only, while still aiding the otherwise eligible children in the household.

Background
Fueled in part by the increased number of welfare caseloads and rate of non-marital births, conservatives critiqued programs that provided assistance to the poor, particularly AFDC. They argued that such programs were ineffective, promoted dependency on the government, and encouraged behaviors detrimental to escaping from poverty.[6] Beginning with President Ronald Reagans administration and continuing through the first few years of the Clinton administration, growing dissatisfaction with AFDC, particularly the rise in welfare caseloads, led an increasing

Temporary Assistance for Needy Families number of states to seek waivers from AFDC rules to allow states to more stringently enforce work requirements for welfare recipients. The 27 percent increase in caseloads between 1990 and 1994 accelerated the push by states to implement more radical welfare reform.[7] States that were granted waivers from AFDC program rules to run mandatory welfare-to-work programs were also required to rigorously evaluate the success of their programs. As a result, many types of mandatory welfare-to-work programs were evaluated in the early 1990s. While reviews of such programs found that almost all programs led to significant increases in employment and reductions in welfare rolls, there was little evidence that income among former welfare recipients had increased. In effect, increases in earnings from jobs were offset by losses in public income, leading many to conclude that these programs had no anti-poverty effects.[8] However, the findings that welfare-to-work programs did have some effect in reducing dependence on government increased support among policymakers for moving welfare recipients into employment.[9] While liberals and conservatives agreed on the importance of transitioning families from government assistance to jobs, they disagreed on how to accomplish this goal. Liberals thought that welfare reform should expand opportunities for welfare mothers to receive training and work experience that would help them raise their families' living standards by working more and at higher wages.[9] Conservatives emphasized work requirements and time limits, paying little attention to whether or not families' incomes increased. More specifically, conservatives wanted to impose a five-year lifetime limit on welfare benefits and provide block grants for states to fund programs for poor families.[10] Conservatives argued that welfare to work reform would be beneficial by creating role models out of mothers, promoting maternal self-esteem and sense of control, and introducing productive daily routines into family life. Furthermore, they argued that reforms would eliminate welfare dependence by sending a powerful message to teens and young women to postpone childbearing. Liberals responded that the reform sought by conservatives would overwhelm severely stressed parents, deepen the poverty of many families, and force young children into unsafe and unstimulating child care situations. In addition, they asserted that welfare reform would reduce parents' ability to monitor the behaviors of their children, leading to problems in child and adolescent functioning.[11] In 1992, as a presidential candidate, Bill Clinton pledged to end welfare as we know it by requiring families receiving welfare to work after two years. As president, Clinton was attracted to welfare expert and Harvard University Professor David Ellwoods proposal on welfare reform and thus Clinton eventually appointed Ellwood to co-chair his welfare task force. Ellwood supported converting welfare into a transitional system. He advocated providing assistance to families for a limited time, after which recipients would be required to earn wages from a regular job or a work opportunity program.[9] Low wages would be supplemented by expanded tax credits, access to subsidized children care and health insurance, and guaranteed child support. In 1994, Clinton introduced a welfare reform proposal that would provide job training coupled with time limits and subsidized jobs for those having difficulty finding work, but it was defeated.[10] Later that year, when Republicans attained a Congressional majority in November 1994, the focus shifted toward the Republican proposal to end entitlements to assistance, repeal AFDC and instead provide state with blocks grants.[12] The debates in Congress about welfare reform centered around five themes:[12] Reforming Welfare to Promote Work and Time Limits: The welfare reform discussions were dominated by the perception that the then-existing cash assistance program, AFDC, did not do enough to encourage and require employment, and instead incentivized non-work. Supporters of welfare reform also argued that AFDC fostered divorce and out-of-wedlock birth, and created a culture of dependency on government assistance. Both President Clinton and Congressional Republicans emphasized the need to transform the cash assistance system into a work-focused, time-limited program. Reducing Projected Spending: Republicans argued that projected federal spending for low-income families needed to be reduced because it was too high and that this reduction was necessary to reduce federal spending.

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Temporary Assistance for Needy Families

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Promoting Parental Responsibility: There was broad agreement among politicians that both parents should support their children. For custodial parents, this meant an emphasis on work and cooperation with child support enforcement. For non-custodial parents, it meant a set of initiatives to strengthen the effectiveness of the child support enforcement. Addressing Out-of-Wedlock Birth: Republicans argued that out of wedlock birth was presenting an increasingly serious social problem and that the federal government should work to reduce out-of-wedlock births.

President Bill Clinton signing welfare reform legislation.

Promoting Devolution: A common theme in the debates was that the federal government had failed and that states were more successful in providing for the needy, and thus reform needed to provide more power and authority to states to shape such policy. After the Senate voted 74-24 [13] and the House voted 256-170 [14] in favor of welfare reform legislation, formally known as the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), Clinton signed the bill into law on August 22, 1996. PRWORA replaced AFDC with TANF and dramatically changed the way the federal government and states determine eligibility and provide aid for needy families. Prior to 1997, the federal government designed the overall program requirements and guidelines, while states administered the program and determined eligibility for benefits. Since 1997, states have been given block grants and both design and administer their own programs. Access to welfare and amount of assistance varied quite a bit by state and locality under AFDC, both because of the differences in state standards of need and considerable subjectivity in caseworker evaluation of qualifying "suitable homes."[15] However, welfare recipients under TANF are actually in completely different programs depending on their state of residence, with different social services available to them and different requirements for maintaining aid.[16]

State implementations
States have large amounts of latitude in how they implement TANF programs.[17][18] [] [] [19] California: CalWORKs

Funding and eligibility


PRWORA replaced AFDC with TANF and ended entitlement to cash assistance for low-income families, meaning that some families may be denied aid even if they are eligible. Under TANF, states have broad discretion to determine who is eligible for benefits and services. In general states must use funds to serve families with children, with the only exceptions related to efforts to reduce non-marital childbearing and promote marriage. States cannot use TANF funds to Evolution of monthly AFDC and TANF benefits in the USA (in 2006 [20] assist most legal immigrants until they have been in the dollars) country for at least 5 years. TANF sets forth the following work requirements in order to qualify for benefits:[21]

Temporary Assistance for Needy Families 1. Recipients (with few exceptions) must work as soon as they are job ready or no later than two years after coming on assistance. 2. Single parents are required to participate in work activities for at least 30 hours per week. Two-parent families must participate in work activities 35 or 55 hours a week, depending upon circumstances. 3. Failure to participate in work requirements can result in a reduction or termination of benefits to the family. 4. States, in fiscal year 2004, have to ensure that 50 percent of all families and 90 percent of two-parent families are participating in work activities. If a state meets these goals without restricting eligibility, it can receive a caseload reduction credit. This credit reduces the minimum participation rates the state must achieve to continue receiving federal funding. While states are given more flexibility in the design and implementation of public assistance, they must do so within various provisions of the law:[22] 1. Provide assistance to needy families so that children may be cared for in their own homes or in the homes of relatives; 2. end the dependence of needy parents on government benefits by promoting job preparation, work, and marriage; 3. prevent and reduce the incidence of out-of-wedlock pregnancies and establish annual numerical goals for preventing and reducing the incidence of these pregnancies; 4. and encourage the formation and maintenance of two-parent families. Funding for TANF underwent several changes from its predecessor, AFDC. Under AFDC, states provided cash assistance to families with children, and the federal government paid half or more of all program costs.[12] Federal spending was provided to states on an open-ended basis, meaning that funding was tied to the number of caseloads. Federal law mandated that states provide some level of cash assistance to eligible poor families but states had broad discretion in setting the benefit levels. Under TANF, states qualify for block grants. The [21] TANF Program Spending funding for these block grants are fixed and the amount each state receives is based on the level of federal contributions to the state for the AFDC program in 1994 [23] States are required to maintain their spending for welfare programs at 80 percent of their 1994 spending levels, with a reduction to 75 percent if states meet other work-participation requirements. States have greater flexibility in deciding how they spend funds as long as they meet the provisions of TANF described above. In July 2012, the Department of Health and Human Services released a memo notifying states that they are able to apply for a waiver for the work requirements of the TANF program. Critics claim the waiver would allow states to provide assistance without having to enforce the work component of the program.[24] The administration has stipulated that any waivers that weaken the work requirement will be rejected.[25] The DHHS granted the waivers after several Governors requested more state control.[26] The DHHS agreed to the waivers on the stipulation that they continue to meet all Federal requirements.[27] States were given the right to submit their own plans and reporting methods only if they continued to meet Federal requirements and if the state programs proved to be more effective.

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Impact of TANF
Discussions about the effectiveness of TANF by policymakers and proponents of welfare reform has centered on the rapid decline in the number of families on welfare since TANF went into effect. Indeed, if measured by the reduction in welfare caseloads, TANF has been a success. Between 1996 and 2000, the number of welfare recipients plunged by 6.5 million, or 53% nationally. Furthermore, the number of caseloads was lower in 2000 than at any time since 1969, and the percentages of persons receiving public assistance income (less than 3%) was the lowest on record.[28]

Temporary Assistance for Needy Families Since the implementation of TANF occurred during a period of strong economic growth, there are questions about how much of the decline in caseloads is attributable to TANF program requirements. First, the number of caseloads began declining after 1994, the year with the highest number of caseloads, well before the enactment of TANF, suggesting that TANF was not solely responsible for the caseload decline.[7] Research suggests that both changes in welfare policy and economic growth played a substantial role in this decline, and that no larger than one-third of the decline in caseloads is attributable to TANF [28][29] While declining caseloads dominates discussion about TANFs effect, declining caseloads are an incomplete and misleading indicator of TANFs success. Caseload reductions indicate less reliance on government assistance, but they do not account for the well-being of poor families and children. As such, other factors have been taken into account in assessing the impact of TANF: work, earnings, and poverty of former welfare-recipients; marriage and fertility of mothers; well-being of mothers; and child well-being.

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Work, earnings, and poverty


One of the major goals of TANF was to increase work among welfare recipients. During the post-welfare reform period, employment did increase among single mothers. Single mothers with children showed little changes in their labor force participation rates throughout the 1980s and into the mid-1990s, but between 1994-1999, their labor force participation rose by 10 percent.[7] Among welfare recipients, the percentage that reported earnings from employment increased from 6.7 percent in 1990 to 28.1 percent by 1999.[7] While employment of TANF recipients increased in the early years of reform, it declined in the later period after reform, particularly after 2000. From 2000-2005, employment among TANF recipients declined by 6.5 percent.[30] Among welfare leavers, it was estimated that close to two-thirds worked at a future point in time [31][32] About 20 percent of welfare leavers are not working, without a spouse, and without any public assistance.[30] Leavers who left welfare because of sanctions (time limits or failure to meet program requirements) fared comparably worse than those who left welfare voluntarily. Sanctioned welfare recipients have employment rates that are, on average, 20 percent below those who left for reasons other than sanctions.[33] While the participation of many low-income single parents in the labor market has increased, their earnings and wages remained low, and their employment was concentrated in low-wage occupations and industries. Over three quarters (78 percent) of employed low-income single parents were concentrated in 4 typically low-wage occupations: service; administrative support and clerical; operators, fabricators, and laborers; and sales and related jobs.[34] While the average income among TANF recipients increased over the early years of reform, it has become stagnant in the later period; for welfare leavers, their average income remained steady or declined in the later years.[30] Studies that compared household income (includes welfare benefits) before and after leaving welfare find that between one-third and one-half of welfare leavers had decreased income after leaving welfare.[29][35] During the 1990s, poverty among single-mother and their families declined rapidly from 35.4 percent in 1992 to 24.7 percent in 2000, a new historic low.[7] However, due to the fact that low-income mothers who left welfare are likely to be concentrated in low-wage occupations, the decline in public assistance caseloads has not translated easily into reduction in poverty. The number of poor female-headed families with children dropped from 3.8 million to 3.1 million between 1994 and 1999, a 22 percent decline compared to a 48 percent decline in caseloads.[28] As a result, the share of working poor in the U.S. population rose, as some women left public assistance for employment but remained poor.[7] Most studies have found that poverty is quite high among welfare leavers. Depending on the source of the data, estimates of poverty among leavers vary from about 48 percent to 74 percent [31][36] TANF requirements have led to massive drops in the number of people receiving cash benefits since 1996,[37] but there has been little change in the national poverty rate during this time. [38] The table below shows these figures along with the annual unemployment rate.[39][40][41]

Temporary Assistance for Needy Families

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Average monthly TANF recipients, percent of U.S. families in poverty and unemployment rate
Year Average monthly TANF recipients Poverty rate (%) Annual unemployment rate (%) 1996 12,320,970 (see note) 1997 10,375,993 1998 8,347,136 1999 6,824,347 2000 5,778,034 2001 5,359,180 2002 5,069,010 2003 4,928,878 2004 4,748,115 2005 4,471,393 2006 4,166,659 2007 3,895,407 2008 3,795,007 2009 4,154,366 2010 4,375,022 11.0 10.3 10.0 9.3 8.7 9.2 9.6 10.0 10.2 9.9 9.8 9.8 10.3 11.1 11.7 5.4 4.9 4.5 4.2 4.0 4.7 5.8 6.0 5.5 5.1 4.6 4.5 5.4 8.1 8.6

Note: 1996 was the last year for the AFDC program, and is shown for comparison. All figures are for calendar years. The poverty rate for families differs from the official poverty rate.

Marriage and fertility


A major impetus for welfare reform was concern about increases in out-of-wedlock births and declining marriage rates, especially among low-income women. The major goals of the 1996 legislation included reducing out-of-wedlock births and increasing rates and stability of marriages.[7] The long-term rise in single-parent families ended after TANF went into effect, and the upward rise in divorce rates also stopped or slightly reversed while nonmarital fertility rates stabilized. Since the enactment of TANF, the share of children living in single-mother families decreased from almost 22 percent of all children in 1997 to 19 percent in 2002, and the share of children living in cohabiting families rose from 5 to 6 percent.[42] However, studies have produced only modest or inconsistent evidence that marital and cohabitation decisions are influenced by welfare program policies. Schoeni and Blank (2001) found that pre-1996 welfare waivers were associated with modest increases in probabilities of marriage.[43] However, a similar analysis of post-TANF effect revealed less consistent results. Nationally, only .4 percent of closed cases gave marriage as the reason for leaving welfare.[28] Using data on marriage and divorces from 1989-2000 to examine the role of welfare reform on marriage and divorce, Bitler (2004) found that both state waivers and TANF program requirements were associated with reductions in transitions into marriage and reductions from marriage to divorce.[44] In other words, individuals who were not married were more likely to stay unmarried, and those who were married were more likely to stay married. Her explanation behind this, which is consistent with other studies,[45][46] is that after reform single women were required to work more, increasing their income and reducing their incentive to give up independence for marriage, whereas for married women, post-reform there was potentially a significant increase in the amount of hours they would have to work when single, discouraging divorce.

Temporary Assistance for Needy Families In addition to marriage and divorce, welfare reform was also concerned about unwed childbearing. Specific provisions in TANF were aimed at reducing unwed childbearing. For example, TANF provided cash bonuses to states with the largest reductions in unwed childbearing that are not accompanied by more abortions. States were also required to eliminate cash benefits to unwed teens under age 18 who did not reside with their parents. TANF allowed states to impose family caps on the receipt of additional cash benefits from unwed childbearing. Between 1994 and 1999, unwed childbearing among teenagers declined 20 percent among 15-17 year olds and 10 percent among 18-19 year olds.[28] In a comprehensive cross-state comparison, Horvath-Rose & Peters (2002) studied nonmarital birth ratios with and without family cap waivers over the 1986-1996 period, and they found that family caps reduced nonmarital ratios [47] Any fears that family caps would lead to more abortions was allayed by declining numbers and rates of abortion during this period.[48]

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Child well-being
Proponents of welfare reform argued that encouraging maternal employment will enhance childrens cognitive and emotional development. A working mother, proponents assert, provides a positive role model for her children. Opponents, on the other hand, argued that requiring women to work at low pay puts additional stress on mothers, reduces the quality time spent with children, and diverts income to work-related expenses such as transportation and childcare.[28] Evidence is mixed on the impact of TANF on child welfare. Duncan & Chase-Lansdale (2001) found that the impact of welfare reform varied by age of the children, with generally positive effects on school achievement among elementary-school age children and negative effects on adolescents, especially with regards to risky or problem behaviors.[49] Another study found large and significant effects of welfare reform on educational achievement and aspirations, and on social behavior (i.e. teacher assessment of compliance and self-control, competence and sensitivity). The positive effects were largely due to the quality of childcare arrangement and afterschool programs that accompanied the move from welfare to work for these recipients.[50] Yet another study found that substitution from maternal care to other informal care had caused a significant drop in performance of young children.[51] In a program with less generous benefits, Kalili et al. (2002) found that maternal work (measured in months and hours per week) had little overall effect on childrens antisocial behavior, anxious/depressed behavior or positive behavior. They find no evidence that children were harmed by such transitions; if anything, their mothers report that their children are better behaved and have better mental health.[52] Synthesizing findings from an extensive selection of publications, Golden (2005) reached the conclusion that children's outcomes were largely unchanged when examining children's developmental risk, including health status, behavior or emotional problems, suspensions from school, and lack of participation in extracurricular activities.[42] She argues that contrary to the fears of many, welfare reform and an increase in parental work did not seem to have reduced children's well-being overall. More abused and neglected children had not entered the child welfare system. However, at the same time, improvement in parental earnings and reductions in child poverty had not consistently improved outcomes for children.

Mother well-being
While the material and economic well-being of welfare mothers after the enactment of TANF has been the subject of countless studies, their mental and physical well-being has received little attention. Research on the latter has found that welfare recipients face mental and physical problems at rates that are higher than the general population.[53] Such problems which include depression, anxiety disorder, post-traumatic stress disorder, and domestic violence mean that welfare recipients face many more barriers to employment and are more at risk of welfare sanctions due to noncompliance with work requirements and other TANF regulations [28] Research on the health status of welfare leavers have indicated positive results. Findings from the Womens Employment Study, a longitudinal survey of welfare recipients in Michigan, indicated that women on welfare but not working are more likely to have mental health and other problems than are former welfare recipients now working.[53][54] Similarly, interviews with now employed welfare recipients find that partly as a result of their increased material resources from working, the

Temporary Assistance for Needy Families women felt that work has led to higher self-esteem, new opportunities to expand their social support networks, and increased feelings of self-efficacy.[55] Furthermore, they became less socially isolated and potentially less prone to depression. At the same time, however, many women were experiencing stress and exhaustion from trying to balance work and family responsibilities.

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Reauthorization
Enacted in July 1997, TANF was set for reauthorization in Congress in 2002. However, Congress was unable to reach an agreement for the next several years, and as a result, several extensions were granted to continue funding the program. TANF was finally reauthorized under the Deficit Reduction ACT (DRA) of 2005. DRA included several changes to the original TANF program. It raised work participation rates, increased the share of welfare recipients subject to work requirements, limited the activities that could be counted as work, prescribed hours that could be spent doing certain work activities, and required states to verify activities for each adult beneficiary.[56] In February 2009, as part of the American Recovery and Reinvestment Act of 2009 (ARRA), Congress created a new TANF Emergency Fund (TANF EF), funded at $5 billion and available to states, territories, and tribes for federal fiscal years 2009 and 2010. The original TANF law provided for a Contingency Fund (CF) funded at $2 billion which allows states meeting economic triggers to draw additional funds based upon high levels of state MOE spending. This fund was expected to (and did) run out in FY 2010. The TANF Emergency Fund provided states 80 percent of the funding for spending increases in three categories of TANF-related expenditures in FYs 2009 or 2010 over FYs 2007 or 2008. The three categories of expenditures that could be claimed were basic assistance, non-recurrent short-term benefits, and subsidized employment.[57] The third category listed, subsidized employment, made national headlines[58] as states created nearly 250,000 adult and youth jobs through the funding.[59] The program however expired on September 30, 2010 on schedule with states drawing down the entire $5 billion allocated by ARRA.[60] TANF was scheduled for reauthorization again in 2010. However, Congress did not work on legislation to reauthorize the program and instead they extended the TANF block grant through September 30, 2011 as part of the Claims Resolution Act.[61] During this period Congress once again did not reauthorize the program but passed a three month extension through December 31, 2011.

Notes
[1] U.S Department of Health and Human Services. 2012. "TANF FY 2012 Budget." Accessed 2/25/2013 from http:/ / www. acf. hhs. gov/ sites/ default/ files/ olab/ tanf. pdf [2] http:/ / www. acf. hhs. gov/ programs/ ofa/ tanf/ index. html [3] U.S> Department of Health and Human Services. 2011. "TANF." Accessed 12/9/2011 from http:/ / www. acf. hhs. gov/ programs/ ofa/ tanf/ about. html [4] http:/ / cqresearcherblog. blogspot. com/ 2009/ 08/ are-safety-nets-working. html Are "Safety Nets" Working. CQ Researcher Blog [6] Mead, Lawrence M. (1986). Beyond Entitlement: The Social Obligations of Citizenship. New York: Free Press. [7] Blank, Rebecca. 2002. Evaluating Welfare Reform in the United States. Journal of Economic Literature, American Economic Association 40(4): 1105-116 [8] Bloom, Dan and Charles Michalopoulos. 2001. How Welfare and Work Policies Affect Employment and Income: A Synthesis of Research. New York: Manpower Demonstration Research Corporation [9] Danziger, Sheldon. 1999. Welfare Reform Policy from Nixon to Clinton: What Role for Social Science? Paper prepared for Conference, The Social Science and Policy Making. Institute for Social Research, University of Michigan, March 1314, 1998. Accessed 12/11/2011 from http:/ / www. fordschool. umich. edu/ research/ pdf/ Isrconference. pdf [10] Institute for Policy Research. Northwestern University. A Look Back at Welfare Reform. 2008. 30(1) accessed 10/11/2011 from http:/ / www. northwestern. edu/ ipr/ publications/ newsletter/ iprn0801/ dppl. html [11] Duncan, Greg J. and P. Lindsay Chase-Lansdale. 2001. For Better and for Worse: Welfare Reform and the Well-being of Children Families. In For Better and for Worse: Welfare Reform and the Well-being of children and Families. New York: Russell Sage Foundation [12] Greenberg, Mark et al. 2000. Welfare Reauthorization: An Early Guide to the Issues. Center for Law and Social Policy [13] http:/ / www. senate. gov/ legislative/ LIS/ roll_call_lists/ roll_call_vote_cfm. cfm?congress=104& session=2& vote=00232 [14] http:/ / clerk. house. gov/ evs/ 1996/ roll331. xml

Temporary Assistance for Needy Families


[15] Lieberman, Robert. Shifting the Color Line: Race and the American Welfare State. Boston: Harvard University Press, 2001. [16] Kaufman, Darren S. "Aid to Families with Dependent Children (ADFC)." in Encyclopedia of Health Care Management, ed. Michael J. Stahl. SAGE Publications, 2003, p. 17 [20] 2008 Indicators of Welfare Dependence (http:/ / aspe. hhs. gov/ hsp/ indicators08/ apa. shtml#ftanf2) Figure TANF 2. [21] Schott, Liz. 2011. Policy Basics: An Introduction to TANF. Center on Budget and Policy Priorities. Accessed 11/2/2011 from http:/ / www. cbpp. org/ cms/ index. cfm?fa=view& id=936 [22] U.S. Department of Health and Human Services. About TANF.U.S. Department of Health and Human Services. Accessed 11/2/2011 from http:/ / www. acf. hhs. gov/ programs/ ofa/ tanf/ about. html [23] Loprest, Pamela, Stefanie Schmidt, and Anne Dryden White. 2000. Welfare Reform under PRWORA: Aid to Children with Working Families? in Tax Policy and the Economy edited by James M. Poterba: 157-203 [26] http:/ / www. americanprogressaction. org/ issues/ poverty/ news/ 2012/ 09/ 06/ 36418/ 3-reasons-why-republican-governors-asked-to-reform-their-welfare-programs/ [27] http:/ / www. acf. hhs. gov/ programs/ ofa/ resource/ policy/ im-ofa/ 2012/ im20120 [28] Lichter, Daniel T. and Rukamalie Jayakody. 2002. Welfare Reform: How Do We Measure Success? Annual Review of Sociology 28:117-141 [29] Bavier, Richard. 2001. "Welfare Reform Data from the Survey of Income and Program Participation." Monthly Labor Review (July): 13-24 [30] Acs, Gregory and Pamela Loprest. 2007. TANF Caseload Composition and Leavers Synthesis Report. The Urban Institute [31] Moffitt, Robert A. and Jennifer Roff. 2000. The Diversity of Welfare Leavers, Welfare Children, and Families: A Three City Study. John Hopkins University Policy Brief 00-02 [32] Devere, Christine. 2001. Welfare Reform Research: What Do We Know About Those Who Leave Welfare? CRS Report for Congress. Washington, D.C.: Congressional Research service [33] Tweedie, Jack. 2001. Sanctions and Exists: What States Know about Families that leave Welfare Because of Sanctions and Time Limits. In For Better and for Worse: Welfare Reform and the Well-being of Children Families. New York: Russell Sage Foundation [34] Peterson, Janice et al. 2002. Life After Welfare Reform: Low-income Single Parent Families, Pre- and Post-TANF. Institute for Womens Policy Research #D446 [35] Cancian, Maria. 2000. Before and After TANF: The Economic Well-Being of Women Leaving Welfare. Institute for Research on Poverty. Special Report no.77 [36] Loprest, Pamela. 2001. How Are Families that Left Welfare Doing? A Comparison of Early and Recent Welfare Leavers. Series B, No B-36, Assessing the New Federalism Project. Washington, D.C.: Urban Institute. April [40] TANF - Caseload Data (http:/ / www. acf. hhs. gov/ programs/ ofa/ data-reports/ caseload/ caseload_current. htm) - US Department of Health and Human Services, Administration for Children and Families, Office of Family Assistance [41] Number Below Poverty Level and Rate - Historical Data (http:/ / www. census. gov/ hhes/ www/ poverty/ data/ historical/ families. html) US Census, 2010 [42] Golden, Olivia. 2005. Assessing the New Federalism, Eight Years Later. Urban Institute [43] Schoeni, Robert F. and Rebecca M. Blank. 2000. "What Has Welfare Reform Accomplished? Impacts on Welfare Participation, Employment, Income, Poverty, and Family Structure." National Bureau of Economic Research Working Paper 7627. Cambridge, MA: NBER [44] Bitler, Marianne. 2004. The Impact of Welfare Reform on Marriage and Divorce. Demography 41(2):213-236 [45] Harknett, K. and L.A> Gennetian. 2003. "How An Earning Supplement Can Affect Union Formation Among Low-Income Single Mothers." Demography 40:451-78 [46] Ellwood, D.T. and C. Jencks. 2001. "The Growing Differences in Family Structure: What Do We Know? Where Do We Look for Answers?" Unpublished manuscript, John F. Kennedy School of Government, Harvard University, Cambridge, MA. [47] Horvath-Rose, A. and HE Peters. 2002. Welfare waivers and nonmarital fertility. in For Better and For Worse: Welfare Reform and Well-Being of Children and Families. New York: Russell Sage Foundation, 222-245 [48] Henshaw, SK. 2001. Birth and abortion data. In Data Needs for Measuring Family and Fertility Change After Welfare REform ed. DJ Basharov. College Park, MD: Welfare Reform Academy [49] Duncan, G.J. and L. Chase-Lansdale. 2002. For Better and For Worse: Welfare Reform and the Well-Being of Children and Families. New York: Russell Sage Foundation. [50] Mistry, R.S., D.A. Crosby, AC Huston, and DM Casey, M Ripke. 2002. Lessons from New Hope: the impact on children's well-being of a work-based anti-poverty program for parents. See Duncan and Chase-Landsdale 2002 [51] Bernal, R. and M.P. Keane 2011. "Child care choices and children's cognitive achievement: The case of single mothers". Journal of Labor Economics, Vol. 29, No. 3 (July 2011), pp. 459-512 [52] Kalili, Ariel et al. 2001. Does Maternal Employment Mandated by Welfare Reform Affect Childrens Behavior? In For Better and for Worse: Welfare Reform and the Well-being of Children Families. New York: Russell Sage Foundation [53] Danziger SK. 2001. Why some fail to achieve economic security: Low job skills and mental health problems are key barriers. Forum 4(2):1-3 [54] Pollack, H., S. Danziger, R. Jayakody, and K. Seefeldt. 2001. Drug testing welfare recipients: false positives, false negatives, unanticipated opportunities. Working Paper, Poverty Training Center, University of Michigan, Ann Arboe [55] London, A. S., Scott, E. K., Edin, K. and Hunter, V. (2004), Welfare Reform, Work-Family Tradeoffs, and Child Well-Being. Family Relations, 53: 148158

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Temporary Assistance for Needy Families


[56] Zedlewski, Sheila and Olivia Golden. 2010. Next Steps for Temporary Assistance for Needy Families. The Urban Institute: Brief(11) accessed December 12/2011 from http:/ / www. urban. org/ UploadedPDF/ 412047_next_steps_brief11. pdf [61] Center for Law and Social Policy. 2010. "TANF Reauthorization." Accessed 12/12/2011 from http:/ / www. clasp. org/ federal_policy/ pages?id=0021

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External links
TANF Fact Sheet at HHS (http://www.acf.hhs.gov/opa/fact_sheets/tanf_factsheet.html) Welfare Reform and Single Mothers (Yale Economic Review) (http://web.archive.org/web/19960101-re_/ http://www.yaleeconomicreview.com/issues/spring2005/welfarereform.php) Congressional Research Service Report on TANF (http://www.opencrs.com/document/96-902/) The Center for Law and Social Policy (http://www.clasp.org/issues?type=temporary_assistance) Numbers On Welfare See Sharp Increase (http://online.wsj.com/article/SB124562449457235503. html#mod=rss_whats_news_us) by Sara Murray, The Wall Street Journal, June 21, 2009 Welfare's safety net hard to measure among states (http://www.washingtonpost.com/wp-dyn/content/story/ 2010/10/02/ST2010100204060.html) by Amy Goldstein, "The Washington Post", October 2, 2010

Transcranial Doppler

1249

Transcranial Doppler
Transcranial Doppler
Diagnostics ICD-9-CM 88.71 [1] MeSH D017585 [2]

The Transcranial Doppler (TCD) and the more recent Transcranial Color Doppler (TCCD) are tests that measures the velocity of blood flow through the brain's blood vessels. Used to help in the diagnosis of emboli, stenosis, vasospasm from a subarachnoid hemorrhage (bleeding from a ruptured aneurysm), and other problems, this relatively quick and inexpensive test is growing in popularity in the United States. TCD is effective to detect Sickle Cell Disease, (in order) established for Ischemic cerebrovascular disease, Subarachnoid hemorrhage, Arteriovenous malformations and Cerebral circulatory arrest and possibly useful for Perioperative monitoring and Menigeal infection.[3] The equipment used for these tests is becoming increasingly portable, making it possible for a clinician to travel to a hospital, doctor's office or nursing home for both inpatient and outpatient studies. It is often used in conjunction with other tests such as MRI, MRA, carotid duplex ultrasound and CT scans.
Transcranial Doppler insonation of the cerebral circulation

Methods
Two methods of recording may be used for this procedure. The first uses "B-mode" imaging, which displays a 2-dimensional image as seen by the ultrasound probe. Once the desired blood vessel is found, blood flow velocities may be measured with a pulsed Doppler effect probe, which graphs velocities over time. Together, these make a duplex test. The second method of recording uses only the second probe function, relying instead on the training and experience of the clinician in finding the correct vessels.
Transcranial doppler ultrasound analyzer of blood velocity

Applications of TCD
Clinical routine transcranial Doppler (TCD) ultrasound examination of the intracranial arteries was demonstrated to be possible in 1982 by Aaslid and colleagues.[4] The value obtained for a particular artery is the velocity of blood flowing through the vessel, and unless the diameter of that vessel is established by some other means it is not possible to determine the actual blood flow. Thus TCD is primarily a technique for measuring relative changes in flow. The clinical utility of the technique is now well established for a number of different disease processes. The technology assessment report of the American Academy of Neurology published in 1990 stated that TCD has

Transcranial Doppler established value in the assessment of patients with intracranial stenosis, collaterals, subarachnoid hemorrhage, and brain death.[5]

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How it works
Blood flow velocity is recorded by emitting a high-pitched sound wave from the ultrasound probe, which then bounces off of various materials to be measured by the same probe. A specific frequency is used (usually a multiple of 2 MHz), and the speed of the blood in relation to the probe causes a phase shift, wherein the frequency is increased or decreased. This frequency change directly correlates with the speed of the blood, which is then recorded electronically for later analysis. Normally a range of depths and angles must be measured to ascertain the correct velocities, as recording from an angle to the blood vessel yields an artificially low velocity. Because the bones of the skull block the transmission of ultrasound, regions with thinner walls insonation windows must be used for analyzing. For this reason, recording is performed in the temporal region above the cheekbone/zygomatic arch, through the eyes, below the jaw, and from the back of the head. Patient age, gender, race and other factors affect bone thickness, making some examinations more difficult or even impossible. Most can still be performed to obtain acceptable responses, sometimes requiring using alternate sites from which to view the vessels.

Implantable transcranial Doppler


Sometimes a patients history and clinical signs suggest a very high risk of stroke. Occlusive stroke causes permanent tissue damage over the following three hours (maybe even 4.5 hours[6]), but not instantly. Various drugs (e.g. aspirin, streptokinase, and tissue plasminogen activator (TPA) in ascending order of effectiveness and cost) [7][8][9] can reverse the stroke process. The problem is how to know immediately that a stroke is happening. One possible way is the use of an implantable transcranial Doppler device "operatively connected to a drug delivery system".[10] Battery-powered, it would use an RF link to a portable computer running a spectral analysis routine together with input from an oximeter (monitoring the degree of blood oxygenation, which a stroke might impair) to make the automatic decision to administer the drug.

Functional transcranial Doppler (fTCD)


Functional transcranial doppler sonography (fTCD) is a neuroimaging tool for measuring cerebral blood flow velocity changes due to neural activation during cognitive tasks. Functional TCD uses pulse-wave Doppler technology to record blood flow velocities in the anterior, middle, and posterior cerebral arteries. Similar to other neuroimaging techniques such as functional magnetic resonance imaging or positron emission tomography, fTCD is based on a close coupling between regional cerebral blood flow changes and neural activation. Due to a continuous monitoring of blood flow velocity, TCD offers an excellent temporal resolution in comparison to other neuroimaging techniques. The technique is noninvasive and easy to apply. Blood flow velocity measurements are robust against movement artifacts. Since its introduction the technique has contributed substantially to the elucidation of the hemispheric organization of cognitive, motor, and sensory functions in adults and children. fTCD has been particularly useful for the study of cerebral lateralization of major brain functions such as language, facial processing, color processing, intelligence processing and gender-related differences.[11][12][13][14][15][16][][17][18] Moreover, most established neuroanatomical substrates for brain function are perfused by the major cerebral arteries that could be directly insonated.

Transcranial Doppler

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Functional Transcranial Doppler Spectroscopy (fTCDS)


Conventional fTCD has limitations for the study of cerebral lateralization. For example, it may not differentiate the lateralising effects due to stimulus characteristics from those due to light responsiveness, and does not distinguish between flow signals emanating from cortical and subcortical branches of the cerebral arteries of the circle of Willis. Each basal cerebral artery of the circle of Willis gives origin to two different systems of secondary vessels. The shorter of these two is called the ganglionic system, and the vessels belonging to it supply the thalami and corpora striata; the longer is the cortical system, and its vessels ramify in the pia mater and supply the cortex and subjacent brain substance. Furthermore, the cortical branches are divisible into two classes: long and short. The long or medullary arteries Spectral density plots right and left middle cerebral arteries pass through the grey substance and cross-amplitude plots in men. penetrate the subjacent white substance to the depth of 34cm. The short vessels are confined to the cortex. Both cortical and ganglionic systems do not communicate at any point in their peripheral distribution, but are entirely independent of each other, having between the parts supplied by the two systems, a borderline of diminished nutritive activity.[19] While, the vessels of the ganglionic system are terminal vessels, the vessels of the cortical arterial system are not so strictly terminal. Blood flow in these two systems in the middle cerebral artery (MCA) territory supplies 80% of both Facial Paradigms hemispheres,[20] including most neural substrates implicated in facial processing, language processing and intelligence processing at cortical and subcortical structures. The measurements of mean blood flow velocity (MFV) in the MCA main stem could potentially provide information about downstream

Transcranial Doppler changes at cortical and subcortical sites within the MCA territory. Each distal arm of the MCA vascular system could be separated into near and far distal reflection sites for the cortical and ganglionic (subcortical) systems, respectively. To accomplish this objective, one method is to apply Fourier analysis to the periodic time series of MFV acquired during cognitive stimulations. Fourier analysis would yield peaks representing pulsatile energy from reflection sites at various harmonics, which are multiples of the fundamental frequency.[21][22] McDonald in 1974 showed that the first five harmonics usually contain 90% of the entire pulsatile energy within the system of pressure/flow oscillations in the peripheral circulation. It could be presumed that each arm of the vascular system represents a single viscoelastic tube terminated by impedance, creating a single reflection site.[23] Psychophysiologic stimulation induced vasomotor activity at each terminal site sets up a standing sinusoidal wave oscillation, comprising a summation of waves due to effects of incident, reflected, and re-reflected waves from distal to proximal point of measurement. fTCDS studies are performed with the participant placed in a supine posture with their head up at about 30 degrees. The probe holder headgear (e.g. LAM-RAK, DWL, Sipplingen, Germany) are used with a base support on two earplugs and on the nasal ridge. Two 2-MHz probes are affixed in the probe holder and insonation performed to determine the optimal position for continuous monitoring of both MCA main stems at 50mm depth from the surface of the probe. A serial recording of MFV for each stimulus is acquired and latter used for Fourier analysis. Fourier transform algorithm uses standard software (for example, Time series and forecasting module, STATISTICA, StatSoft, Inc.). The most efficient standard Fourier algorithm requires that the length of the input series is equal to a power of 2. If this is not the case, additional computations have to be performed. To derive the required time series, the data were averaged in 10-second segments for 1-minute duration or each stimulus, yielding 6 data points for each participant and a total of 48 data points for all eight men and women, respectively. Smoothing the periodogram values was accomplished using a weighted moving average transformation. Hamming window was applied as a smoother.[24][25] The spectral density estimates, derived from single series Fourier analysis, were plotted, and the frequency regions with the highest estimates were marked as peaks. The origins of the peaks are of interest in order to determine the reliability of the present technique. The fundamental (F), cortical (C) or memory (M), and subcortical (S) peaks occurred at regular frequency intervals of 0.125, 0.25, and 0.375, respectively. These frequencies could be converted to Hz, assuming that the fundamental frequency of cardiac oscillation was the mean heart rate. The fundamental frequency (F) of the first harmonic could be determined from the mean heart rate per second. For example, a heart rate of 74 bpm, suggests 74 cycles/60 or 1.23Hz. In other words, the F-, C-, and S-peaks occurred at multiples of the first harmonic, at second and third harmonics, respectively. The distance of the reflection site for F-peak could be presumed to emanate from a site at D1 = wavelength/4 = cf/4 = 6.15 (m/s)/(41.23Hz) = 125cm, where c is the assumed wave propagation velocity of the peripheral arterial tree according to McDonald, 1974. Given the vascular tortuosity, the estimated distance approximates that from the measurement site in the MCA main stem, to an imaginary site of summed reflections from the upper extremities, close to the finger tips when stretched sideways.[] The C-peak occurred at the second harmonic, such that the estimated arterial length (using common carotid c = 5.5m/s)[26] was given by D2 = wavelength/8 = cf2/8 = 28cm, and a frequency f of 2.46Hz. The distance approximates the visible arterial length from the main stem of the MCA, through vascular tortuosity and around the cerebral convexity, to the end vessels at distal cortical sites such as the occipito-temporal junction on carotid angiograms of adults.[] The S-peak occurred at the third harmonic, and may have arisen from an estimated site at D3= wavelength/16 = cf3/16 = 9.3cm and a frequency f3 of 3.69Hz. The latter approximates the visible arterial length of the lenticulostriate vessels from the main stem of the MCA on carotid angiograms.[27] Although not displayed, the fourth harmonic would be expected to arise from the MCA bifurcation in closest proximity to the measurement site in the main stem of the MCA. The pre-bifurcation length from the measurement point would be given by D4 = wavelength/32 = cf4/32 = 3.5cm and a frequency f4 of 4.92Hz. The calculated distance approximates that of the segment of MCA main stem just after the carotid bifurcation, where probably the ultrasound sample volume was placed, to the MCA bifurcation. Thus, these estimates approximate actual lengths. However, it has been suggested that the estimated distances may not correlate exactly with known morphometric dimensions of the arterial tree according to Campbell et al., 1989. The method

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Transcranial Doppler was first described by Philip Njemanze in 2007, and was referred to as functional transcranial Doppler spectroscopy (fTCDS).[] fTCDS examines spectral density estimates of periodic processes induced during mental tasks, and hence offers a much more comprehensive picture of changes related to effects of a given mental stimulus. The spectral density estimates would be least affected by artefacts that lack periodicity, and filtering would reduce the effect of noise.[28] The changes at the C-peak may show cortical long-term potential (CLTP) or cortical long-term depression (CLTD), which has been proposed to be suggest equivalents of cortical activity during learning[] and cognitive processes. The flow velocity tracings are monitored during paradigm 1 comprising a checkerboard square as object perception are compared to whole face (paradigm 2) and facial element sorting task (paradigm 3). Fast Fourier transform calculations are used to obtain the spectral density and cross amplitude plots in the left and right middle cerebral arteries. The C-peak also called memory (M-peak) cortical peak could be seen arising during paradigm 3, a facial element sorting task requiring iterative memory recall as a subject constantly spatially fits the puzzle by matching each facial element in paradigm 3 to that stored in memory (Paradigm 2) before proceeding to form the picture of the whole face.

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References
[1] http:/ / icd9cm. chrisendres. com/ index. php?srchtype=procs& srchtext=88. 71& Submit=Search& action=search [2] http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2011/ MB_cgi?field=uid& term=D017585 [6] DeNoon, Daniel J. (2009). Immediate Treatment Best, but Even Late Treatment with tPA May Help (http:/ / www. webmd. com/ stroke/ news/ 20090528/ stoke-treatment-window-widens). WebMD Health News. [10] Njemanze, Philip Chidi (2003). Implantable telemetric transcranial Doppler device. . [19] Gray, H., & Clemente, C. D. (1984). Grays anatomy of the human body. 30th American Edition . Philadelphia: Lippincott Williams & Wilkins. [20] Toole, J. F. (1990). Cerebrovascular disorders. New York: Raven Press. [21] McDonald, D. A. (1974). Blood flow in arteries pp. 311350. Baltimore: Williams & Wilkins Co. [25] Brigham, E. O. (1974). The fast Fourier transform. New York: Prentice-Hall. [28] Njemanze P.C. Transcranial Doppler spectroscopy for assessment of brain cognitive functions. , August 12, 2004

External links
Transcranial Doppler Computer Model for Training and Education (http://www.transcranial.com). Dr. Paul Syme, University of Edinburgh (http://www.geriatric.med.ed.ac.uk/paul_syme.htm#publications).

Third-party administrator

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Third-party administrator
A Third Party Administrator (TPA) is an organization that processes insurance claims or certain aspects of employee benefit plans for a separate entity.[1] This can be viewed as "outsourcing" the administration of the claims processing, since the TPA is performing a task traditionally handled by the company providing the insurance or the company itself. Often, in the case of insurance claims, a TPA handles the claims processing for an employer that self-insures its employees. Thus, the employer is acting as an insurance company and underwrites the risk. The risk of loss remains with the employer, and not with the TPA. An insurance company may also use a TPA to manage its claims processing, provider networks, utilization review, or membership functions. While some third-party administrators may operate as units of insurance companies, they are often independent. Third party administrators also handle many aspects of other employee benefit plans such as the processing of retirement plans and flexible spending accounts. Many employee benefit plans have highly technical aspects and difficult administration that can make using a specialized entity such as a TPA more cost effective than doing the same processing in house.

Health care
Third party administrators are prominent players in the managed care industry and have the expertise and capability to administer all or a portion of the claims process. They are normally contracted by a health insurer or self-insuring companies to administer services, including claims administration, premium collection, enrollment and other administrative activities. A hospital or provider organization desiring to set up its own health plan will often outsource certain responsibilities to a TPA. For example, an employer may choose to help finance the health care costs of its employees by contracting with a TPA to administer many aspects of a self-funded health care plan.

Commercial general liability


This term is also now commonly used in commercial general liability (CGL) policies or so called "casualty" business. In these instances the liability policies are written with a large (in excess of $50,000) self insured retention (SIR) that operates somewhat like a deductible, but rather than being paid at the end of a claim (when a loss payment is made to a claimant) the money is paid up front by the insured for costs, expenses, attorney fees etc. as the claim moves forward. If there is a settlement or verdict within the SIR then that is also paid by the insured up to the limit of the SIR, before the insurer steps in and pays its portion. The TPA acts like a claims adjuster for the insurance company and sometimes works in conjunction with the inside insurance company claims adjuster or an outside claims investigator as well as the defense counsel. The defense counsel in some situations is selected by the TPA. The point is that the larger the SIR the more responsibility the TPA has over the control of the way the claim is handled and ultimately resolved. Some self insured retentions are in the millions of dollars and the TPAs are large multinational non-insurance entities that handle all the claims. In some cases the insured sets up an entire department within their company (and staffs it with claim savvy people) to act as the TPA as opposed to hiring a commercial

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Retirement plans
Retirement plans such as a 401(k) are often partly managed by an investment company. Instead of handling all the plan contributions by employees, distributions to employees, and other aspects of plan processing, the investment company may contract with a third party administrator to handle much of the administrative work and only handle the remaining investment work.

References External links


Healthcare Crisis Glossary (http://www.pbs.org/healthcarecrisis/glossary.htm) Michigan Statutory Definition (http://www.michigan.gov/cis/0,1607,7-154-10555_22535_22904---,00.html)

Tension headache

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Tension headache
Tension headache
Classification and external resources

Tension-type headaches can be aggravated by temporomandibular joint dysfunction. ICD-10 ICD-9 DiseasesDB MedlinePlus eMedicine MeSH G44.2 [2] [3] [5] [6] [7] , 339.1 [4]

[1]

307.81 12554

000797

article/1142908 D018781 [8]

A tension headache (renamed a tension-type headache by the International Headache Society in 1988) is the most common type of primary headache. The pain can radiate from the lower back of the head, the neck, eyes, or other muscle groups in the body. Tension-type headaches account for nearly 90% of all headaches. Approximately 3% of the population has chronic tension-type headaches.[9]

Signs and symptoms


Tension-type headache pain is often described as a constant pressure, as if the head were being squeezed in a vice. The pain is frequently bilateral which means it is present on both sides of the head at once. Tension-type headache pain is typically mild to moderate, but may be severe.

Frequency and duration


Tension-type headaches can be episodic or chronic.[10] Episodic tension-type headaches are defined as tension-type headaches occurring fewer than 15 days a month, whereas chronic tension headaches occur 15 days or more a month for at least 6 months. Tension-type headaches can last from minutes to days, months or even years, though a typical tension headache lasts 46 hours.

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Cause
Various precipitating factors may cause tension-type headaches in susceptible individuals:[11] Stress: usually occurs in the afternoon after long stressful work hours or after an exam Sleep deprivation Uncomfortable stressful position and/or bad posture Irregular meal time (hunger) Eyestrain

One half of patients with tension-type headaches identify stress or hunger as a precipitating factor.[citation needed] Tension-type headaches may be caused by muscle tension around the head and neck. One of the theories says that the main cause for tension-type headaches and migraine is teeth clenching which causes a chronic contraction of the temporalis muscle.[citation needed] Another theory is that the pain may be caused by a malfunctioning pain filter which is located in the brain stem. The view is that the brain misinterprets information--for example from the temporal muscle or other muscles--and interprets this signal as pain. One of the main neurotransmitters that is probably involved is serotonin. Evidence for this theory comes from the fact that chronic tension-type headaches may be successfully treated with certain antidepressants such as amitriptyline. However, the analgesic effect of amitriptyline in chronic tension-type headache is not solely due to serotonin reuptake inhibition, and likely other mechanisms are involved. Recent studies of nitric oxide (NO) mechanisms suggest that NO may play a key role in the pathophysiology of CTTH.[12] The sensitization of pain pathways may be caused by or associated with activation of nitric oxide synthase (NOS) and the generation of NO. Patients with chronic tension-type headache have increased muscle and skin pain sensitivity, demonstrated by low mechanical, thermal and electrical pain thresholds. Hyperexcitability of central nociceptive neurons (in trigeminal spinal nucleus, thalamus, and cerebral cortex) is believed to be involved in the pathophysiology of chronic tension-type headache.[13] Recent evidence for generalized increased pain sensitivity or hyperalgesia in CTTH strongly suggests that pain processing in the central nervous system is abnormal in this primary headache disorder. Moreover, a dysfunction in pain inhibitory systems may also play a role in the pathophysiology of chronic tension-type headache.[14]

Prevention
Tricyclics have been found to be more effective than SSRIs but have greater side effects.[15] Evidence is insufficient for the use of propranolol and muscle relaxants for prevention of tension headaches.[16]

Treatment
Episodic tension-type headaches generally respond well to over-the-counter analgesics such as ibuprofen, paracetamol/acetaminophen, and aspirin. Analgesic/sedative combinations are widely used (e.g., analgesic/antihistamine combinations like Syndol, Mersyndol and Percogesic, analgesic/barbiturate combinations such as Fiorinal). Frequent use of analgesics may, however, lead to medication overuse headache. The first-line treatment for chronic tension type headache is amitriptyline, whereas mirtazapine and venlafaxine are second-line treatment options.[] Other medication options include topiramate and sodium valproate (as prophylaxis).[] Biofeedback techniques may also help.[17][] Botulinum toxin is a treatment trialled by some people with tension-type headache, though results are varied. [citation
needed]

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Acupuncture
Acupuncture may be useful in those with frequent or chronic tension headaches.[18]

Manual therapy
People with tension-type headache often use spinal manipulation, soft tissue therapy, and myofascial trigger point treatment. A 2006 systematic review found no rigorous evidence supporting manual therapies for tension headache.[19] A 2005 structured review found only weak evidence for the effectiveness of chiropractic manipulation for tension headache, and that it was probably more effective for tension headache than for migraine.[20] A 2004 Cochrane review found that spinal manipulation may be effective for migraine and tension headache, and that spinal manipulation and neck exercises may be effective for cervicogenic headache.[21] Two other systematic reviews published between 2000 and May 2005 did not find conclusive evidence in favor of spinal manipulation.[22]

Epidemiology
Tension headaches affect about 1.4billion people (20.8% of the population) and are more common in women than men (23% to 18% respectively).[23]

Prognosis
Tension headaches that do not occur as a symptom of another condition may be painful, but are not harmful. It is usually possible to receive relief through treatment. Tension headaches that occur as a symptom of another condition are usually relieved when the underlying condition is treated. Frequent use of pain medications in patients with tension-type headache may lead to the development of medication overuse headache or rebound headache.

References
[2] http:/ / apps. who. int/ classifications/ icd10/ browse/ 2010/ en#/ G44. 2 [3] http:/ / www. icd9data. com/ getICD9Code. ashx?icd9=307. 81 [4] http:/ / www. icd9data. com/ getICD9Code. ashx?icd9=339. 1 [5] http:/ / www. diseasesdatabase. com/ ddb12554. htm [6] http:/ / www. nlm. nih. gov/ medlineplus/ ency/ article/ 000797. htm [7] http:/ / emedicine. medscape. com/ article/ 1142908-overview [8] http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2013/ MB_cgi?field=uid& term=D018781 [10] as PDF (http:/ / www. i-h-s. org/ upload/ ct_clas/ ihc_II_main_no_print. pdf)

External links
American Council for Headache Education (http://www.achenet.org) National Headache Foundation (http://www.headaches.org) World Headache Alliance (http://www.w-h-a.org)

Therapy

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Therapy
Therapy
Intervention MeSH D013812 [1]

Therapy (Latin therapa; Greek: ) literally means "curing, healing"[2] and is the attempted remediation of a health problem, usually following a diagnosis. In the medical field, it is synonymous with the word "treatment". Among psychologists, the term may refer specifically to psychotherapy or "talk therapy". As a rule, each therapy has indications and contraindications. Preventive therapy or prophylactic therapy is a treatment that is intended to prevent a medical condition from occurring. For example, many vaccines prevent infectious diseases. An abortive therapy is a treatment that is intended to stop a medical condition from progressing any further. A medication taken at the earliest signs of a disease, such as at the very symptoms of a migraine headache, is an abortive therapy. A supportive therapy is one that does not treat or improve the underlying condition, but instead increases the patient's comfort.[3] Supportive treatment may be used in palliative care.

Adverse effects
Main articles: Adverse drug reaction and Adverse effect In addition to (or in place of) the intended therapeutic effect of a treatment, a therapist may cause undesired (adverse) effects as well. When an adverse effect is weaker than the therapeutic effect, one commonly speaks of a "side effect". An adverse effect may result from an unsuitable or incorrect dosage or procedure (which could be due to medical error). Some adverse effects occur only when starting, increasing or discontinuing a treatment. Using a drug or other medical intervention which is contraindicated may increase the risk of adverse effects. Patients sometimes quit a therapy because of its adverse effects. The severity of adverse effects ranges from nausea to death. Common adverse effects include alteration in body weight, change in enzyme levels, loss of function, or pathological change detected at the microscopic, macroscopic or physiological level. Adverse effects may cause a reversible or irreversible change, including an increase or decrease in the susceptibility of the individual to other chemicals, foods, or procedures (e.g. drug interaction).

Difference between preventions, treatments, and cures


A prevention or preventive measure is a way to avoid an injury, sickness, or disease in the first place, and generally it will not help someone who is already ill (though there are exceptions). For instance, many babies in developed countries are given a polio vaccination soon after they are born, which prevents them from contracting polio. But the vaccination does not work on patients who already have polio. A treatment or cure is applied after a medical problem has already started. A treatment treats a problem, and may lead to its cure, but treatments often ameliorate a problem only for as long as the treatment is continued, especially in chronic diseases. For example, there is no cure for AIDS, but treatments are available to slow down the harm done by HIV and delay the fatality of the disease. Treatments don't always work. For example, chemotherapy is a treatment for some types of cancer. In some cases, chemotherapy may cause a cure, but not in all cases for all cancers. When nothing can be done to stop or improve a medical condition, beyond efforts to make the patient more comfortable, the condition is said to be untreatable. Some untreatable conditions naturally resolve on their own; others do not.

Therapy Cures are a subset of treatments that reverse illnesses completely or end medical problems permanently. Many diseases that cannot be cured are still treatable.

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Types of therapies
By therapy composition
Treatments can be classified according to the method of treatment: by matter by drug: pharmacotherapy, chemotherapy, mesotherapy by medical device by gene: gene therapy by gold: chrysotherapy (aurotherapy) by hormone: hormone therapy by organism: biotherapy by virus: virotherapy by bacteriophage: phage therapy by maggot: maggot therapy by ozone: ozonotherapy by salt: speleotherapy by serum: serotherapy by smell: aromatherapy by water: hydrotherapy

by energy by electric energy by electricity: electrotherapy by electromagnetic radiation: electromagnetic therapy by magnetic energy: magnet therapy by light: phototherapy by mechanical: manual therapy as massotherapy & therapy by exercise as in physiotherapy by sound: Cymatic therapy, music therapy by radiation: radiotherapy by temperature by heat: thermotherapy by cold: cryotherapy by human interaction by counseling, such as psychotherapy by education by psychoeducation by information therapy by physical therapy/occupational therapy, massage therapy, or acupuncture by lifestyle modifications, such as avoiding unhealthy food or maintaining a predictable sleep schedule by coaching by animal interaction by fish: ichthyotherapy

Therapy by horse: equine therapy, hippotherapy by meditation by reading by bibliotherapy

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First or second line


Treatment decisions often follow formal or informal algorithmic guidelines. A first-line therapy (sometimes called induction therapy or primary therapy)[4] is usually recommended on the basis of clinical evidence for its efficacy in the population at large.[citation needed] If a first-line therapy either fails to resolve the issue or produces intolerable side effects, additional agents (second-line therapies) may be substituted or added to the treatment regimen.[citation needed]

References
[1] http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2011/ MB_cgi?field=uid& term=D013812 [2] Online Etymology Dictionary, Therapy (http:/ / www. etymonline. com/ index. php?allowed_in_frame=0& search=therapy& searchmode=none) [4] National Cancer Institute > Dictionary of Cancer Terms > first-line therapy (http:/ / www. cancer. gov/ dictionary/ ?CdrID=346494) Retrieved July 2010

External links
"Chapter Nine of the Book of Medicine Dedicated to Mansur, with the Commentary of Sillanus de Nigris" (http:/ /www.wdl.org/en/item/7384) is a Latin book by Rhazes, from 1483, that is known for it's 9th chapter, which is about therapeutics

UnitingCare Health
UnitingCare Health is a large not-for-profit private hospital group in Australia. It is composed over 5 separate facilities: Wesley Hospital (Brisbane) St Andrew's War Memorial Hospital The Sunshine Coast Private Hospital St Stephen's Hospital, Maryborough St Stephen's Hospital, Hervey Bay

UNICEF

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UNICEF

United Nations Children's Emergency Fund


(Arabic)

(Chinese)

Fonds des Nations unies pour l'enfance


(French)


(Russian)

Fondo de Naciones Unidas para la Infancia


(Spanish)

UNICEF Logo Org type Acronyms Head Status Established Headquarters Website Parent org Fund UNICEF Anthony Lake Active December 1946 New York, USA UNICEF official site ECOSOC [1]

The United Nations Children's Fund (UNICEF; /junsf/ EW-ni-sef)[2] is a United Nations Programme headquartered in New York City, that provides long-term humanitarian and developmental assistance to children and mothers in developing countries. It is one of the members of the United Nations Development Group and its Executive Committee.[3] UNICEF was created by the United Nations General Assembly on December 11, 1946, to provide emergency food and healthcare to UNICEF Flag children in countries that had been devastated by World War II. In 1953, UNICEF became a permanent part of the United Nations System and its name was shortened from the original United Nations International Children's Emergency Fund but it has continued to be known by the popular acronym based on this previous title.

UNICEF

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UNICEF relies on contributions from governments and private donors and UNICEF's total income for 2008 was $3,372,540,239.[4] Governments contribute two thirds of the organization's resources; private groups and some 6 million individuals contribute the rest through the National Committees. It is estimated that 91.8% of their revenue is distributed to Program Services.[5] UNICEF's programs emphasize developing community-level services to promote the health and well-being of children. UNICEF was awarded the Nobel Peace Prize in 1965 and the Prince of Asturias Award of Concord in 2006. Most of UNICEF's work is in the field, with staff in over 190 countries and territories. More than 200 country offices carry out UNICEF's mission through a program developed with host governments. Seventeen regional offices provide technical assistance to country offices as needed.

UNICEF School in a box contains basic educational items for 1 teacher and 80 students

Overall management and administration of the organization takes place at its headquarters in New York. UNICEF's Supply Division is based in Copenhagen and serves as the primary point of distribution for such essential items as vaccines, antiretroviral medicines for children and mothers with HIV, nutritional supplements, emergency shelters, educational supplies, among others. A 36-member Executive Board establishes policies, approves programs and oversees administrative and financial plans. The Executive Board is made up of government representatives who are elected by the United Nations Economic and Social Council, usually for three-year terms. Following the reaching of term limits by Executive Director of UNICEF Carol Bellamy, former United States Secretary of Agriculture Ann Veneman became executive director of the organization in May 2005, with an agenda to increase the organization's focus on the Millennium Development Goals. She was succeeded in May 2010, by Anthony Lake. UNICEF is an intergovernmental organization (IGO) and thus is accountable to those governments. UNICEFs salary and benefits package[6] is based on the United Nations Common System.

UNICEF National Committees


There are National Committees in 36 [industrialized] countries worldwide, each established as an independent local non-governmental organization. The National Committees raise funds from the private sector. UNICEF is not funded exclusively by voluntary contributions, and the National Committee collectively raise around one-third of UNICEF's annual income. This comes through contributions from corporations, civil society organizations and more than 6 million individual donors worldwide. They also rally many different partners including the media, national and local government officials, NGOs, specialists such as doctors and lawyers, corporations, schools, young people and the general public on issues related to childrens rights

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Promotion and fundraising


In the United States, Canada and some other countries, UNICEF is known for its "Trick-Or-Treat for UNICEF" program in which children collect money for UNICEF from the houses they trick-or-treat on Halloween night, sometimes instead of candy. UNICEF is present in 191 countries and territories around the world. UNICEF designated 1979 as the "Year of the Child" and many celebrities including David Gordon, David Essex, Alun Davies and Cat Stevens gave a performance at a benefit concert celebrating the Year of the Child Concert in December 1979. Many people in developed countries first hear about UNICEF's work through the activities of 36 National Committees for UNICEF. These non-governmental organizations (NGO) are primarily responsible for fundraising, selling UNICEF greeting cards and products, creating private and public partnerships, advocating for childrens rights, and providing other invaluable support. The U.S. Fund for UNICEF is the oldest of the National Committees, founded in 1947.[7] New Zealand appointed, in 2005, 18-year-old Hayley Westenra, a talented, world famous opera and pop singer as their Ambassador to UNICEF, in an effort to enlist the youth of the world in supporting UNICEF. Westenra has made several trips to visit underprivileged children in developing countries on behalf of UNICEF, in an effort to publicize their plight, and has engaged in fund-raising activities in support of the UNICEF mission. On 19 April 2007, Grand Duchess Maria Teresa of Luxembourg was appointed UNICEF Eminent Advocate for Children,[8] in which role she has visited Brazil (2007),[9] China (2008),[10] and Burundi (2009).[11] In 2009, the British retailer Tesco used Change for Good as advertising, which is trade marked by UNICEF for charity usage but is not trademarked for commercial or retail use. This prompted the agency to say, "it is the first time in Unicefs history that a commercial entity has purposely set out to capitalise on one of our campaigns and subsequently damage an income stream which several of our programmes for children are dependent on. They went on to call on the public who have childrens welfare at heart, to consider carefully who they support when making consumer choices.[12] [13]

Sponsorship
On 7 September 2006, an agreement between UNICEF and the Spanish Catalan association football club FC Barcelona was reached whereby the club would donate 1.5 million euros per year to the organization for five years. As part of the agreement, FC Barcelona will wear the UNICEF logo on the front of their shirts, which will be the first time a football club sponsored an organization rather than the other way around. It is also the first time in FC Barcelona's history that they have had another organization's name across the front of their shirts. In January 2007, UNICEF struck a partnership with Canada's national tent pegging team. The team was officially re-flagged as "UNICEF Team Canada", its riders wear UNICEF's logo in competition, and team members promote and raise funds for UNICEF's campaign against childhood HIV-AIDS.[14] When the team became the 2008 tent pegging world champions, UNICEF's flag was raised alongside the Canadian flag at the games, the first time in the history of international Grand Prix equestrian competition that a non-state flag has flown over the medal podium.[15]

Lionel Messi wearing a Barcelona shirt showing the UNICEF logo

The Swedish club Hammarby IF followed the Spanish and Canadian lead on 14 April 2007,[16] also raising funds for UNICEF and displaying the UNICEF name on their sportswear. The Danish soccer club Brondby IF will do likewise from the summer of 2008.

UNICEF Australian A-League club Sydney FC announced they would also enter into a partnership with UNICEF raising funds for children in the Asia-Pacific region, and would also display the UNICEF logo for the remainder of the 2011-12 A-League season.[17] Race driver Jacques Villeneuve has occasionally placed the UNICEF logo on the #27 Bill Davis Racing pickup truck in the NASCAR Craftsman Truck Series. In Botswana, UNICEF has funded the development of new state-of-the-art HIV/AIDS education for every schoolchild in Botswana from nonprofit organization TeachAIDS.[18] UNICEF recently announced a landmark partnership with Scottish club Rangers F.C. UNICEF will partner the Rangers Charity Foundation and have pledged to raise 300,000 by 2011.[19] In 2010, UNICEF created a partnership with Phi Iota Alpha, making them the first Greek Lettered Organization UNICEF has ever worked with. In 2011, Phi Iota Alpha raised over $20,000 for the Tap Project and the Trick or Treats for UNICEF Campaign.

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Trick-or-Treat UNICEF box


Since 1950, when a group of children in Philadelphia, Pennsylvania, donated $17 they received on Halloween to help post-World War II victims, the Trick-or-Treat UNICEF box has become a tradition in North America during the fall.[20] These small orange boxes are handed to children at schools and other locations (such as Hallmark Gold Crown Stores) before 31 October. To date, the Trick-or-Treat for UNICEF campaign has collected approximately $91 million (CAD) in Canada and over $167 million (USD) in the USA.[21]

Cartoons for Children's Rights


In 1994, UNICEF held a summit encouraging animation studios around the world to create individual animated spots demonstrating the international rights of children. Cartoons for Children's Rights is the collection of animated shorts based on UNICEFs Convention on the Rights of the Child.

Corporate partnership
To raise money to support its Education and Literacy Programmes, UNICEF collaborates with companies worldwide encompassing international as well as small- and medium-sized businesses. Since 2005, the organization has been supported by Montblanc, working colloabratively to help the worlds children getting better access to education.[citation needed] According to Vaccine News Daily, Merck & Co. has partnered with UNICEF in June 2013 to decrease maternal mortality, HIV and tuberculosis prevalence in South Africa. Merck's program "Merck for Mothers" will give $500 million worldwide for programs that improve health for expectant mothers and their children.[22]

Corporate Social Responsibility


UNICEF works directly with companies to improve their business practices, bringing them in line with obligations under international law, and ensuring that they respect children's rights in the realms of the marketplace, workplace and the community. In 2012, UNICEF worked with Save the Children and The UN Global Compact to develop the Children's Rights and Business Principles and now these guidelines form the basis UNICEF's advice to companies. UNICEF works with companies seeking to improve their social sustainability by guiding them through a due diligence process where issues throughout their supply chain, such as child labour, can be identified and actions to ratify them are put in place.[citation needed]

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Facilities
UNICEF World Warehouse
The old UNICEF World Warehouse is a large facility in Denmark, which hosts UNICEF deliverable goods as well as co-hosts emergency goods for United Nations High Commissioner for Refugees (UNHCR) and the International Federation of Red Cross and Red Crescent Societies (IFRC). Until 2012 the housing facilities was a 25,000m2 warehouse at Marmormolen in Copenhagen. With construction of a 45,000m2 UN-city that is to house all UN activities in Copenhagen under one roof,[] the warehouse service has been relocated to outer parts of Copenhagen Freeport. In addition to the goods, the facility houses the UNICEF Supply Division which manages strategic transport hubs in Dubai, Panama and Shanghai.[23] The warehouse contains a variety of items, e.g., special food supplies like the Plumpy'nut, water purification tablets, dietary and vitamin supplements, and the "School in a box" (illustrated above). On 2 November 2011, Crown Prince Frederik and Crown Princess Mary of Denmark, with The Duke and Duchess of Cambridge, visited the warehouse[24] to highlight the crisis in East Africa.[25]
The UNICEF research centre in Florence

One of the gates to the old UNICEF World Warehouse

UNICEF Innocenti Research Centre


UNICEF Innocenti Research Centre in Florence, Italy, was established in 1988, to strengthen the research capability of the United Nations Children's Fund and to support its advocacy for children worldwide. The centre, formally known as the International Child Development Centre, has as its prime objectives to improve international understanding of issues relating to children's rights, to promote economic policies that advance the cause of children, and to help facilitate the full implementation of the United Nations Convention on the Rights of the Child in industrialized and developing countries. The programme for 20062008 was approved by UNICEF Executive Board in September 2005. It reaffirms the centre's academic freedom and the focus of IRC's research on knowledge gaps, emerging questions and sensitive issues which are relevant to the realization of children's rights, in developing and industrialized countries. It capitalizes on IRC's role as an interface between UNICEF field experience, international experts, research networks and policy makers and is designed to strengthen the centre's institutional collaboration with regional academic and policy institutions, pursuing the following goals: Generation and communication of strategic and influential knowledge on issues affecting children and the realization of their rights; Knowledge exchange and brokering; Support to UNICEF's advocacy, policy and programme development in support of the Millennium Agenda Securing and strengthening the centre's institutional and financial basis. Three interrelated strategies will guide the achievement of these goals: Evidence-based analysis drawing on quantitative and qualitative information, the application of appropriate methodologies, and the development of recommendations to assess and inform advocacy and policy action.

UNICEF Enhanced partnerships with research and policy institutions and development actors, globally and at regional level, in developing and industrialized countries. Communication and leveraging of research findings and recommendations to support policy development and advocacy initiatives through strategic dissemination of studies and contribution to relevant events and fora.[26]

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Criticism
UNICEF has been criticized at times for its focus or for specific policies. In 2004, the editorial in the Lancet argued that UNICEF's rights-based approach to child welfare, based upon the Convention on the Rights of the Child, whilst in accordance with international development policy, leads to a lower emphasis on child survival and mortality.[] One reason that UNICEF has such a poor track record regarding child survival and mortality is its policy of preferring that children stay in orphanages in their birth countries rather than be adopted by foreign parents.[27][28] Psychologists and scientists have rejected such prioritization of "cultural heritage" over the love of a family, however.[29] International adoptions all over the world have plummeted since UNICEF has taken an increasingly active role in discouraging international adoption in the past 15, despite reliable estimates that there are at least 10 million adoptable orphans in need of families.[30][31] Recently, major news outlets such as US News have begun to investigate UNICEF's practice of giving huge cash payments to developing countries in exchange for their closure of their international adoption programs, and have even labeled UNICEF a "villain" for the extent of its negative impact on orphans.[32] One great concern is that the child mortality rate has not decreased in some areas and has actually increased. The highest rates were found in sub-Saharan Africa. This was difficult to understand, but even more concerning was that over 60% of these deaths were and remain preventable. [] There was an estimated 19,000 children that died every day in 2011. It is important to recognize that overall the least developed countries have consistently had higher rates of under-5 Mortality than more affluent countries. (Currie, 1) Not only are these deaths preventable but the coverage levels for these interventions are appallingly low in the 42 countries that account for 90% of child deaths.
[]

References
[1] [3] [4] [5] http:/ / www. unicef. org/ Executive Committee (http:/ / www. undg. org/ index. cfm?P=23). Undg.org. Retrieved on 2012-03-26. UNICEF Annual Report 2008 (http:/ / www. unicef. org/ publications/ files/ UNICEF_Annual_Report_2008_EN_072709. pdf). unicef.org Charity Navigator Rating United States Fund for UNICEF (http:/ / www. charitynavigator. org/ index. cfm?bay=search. summary& orgid=4617). Charitynavigator.org. Retrieved on 2012-03-26. [6] United Nations Salaries, Allowances, Benefits and Job Classification (http:/ / www. un. org/ Depts/ OHRM/ salaries_allowances/ ). Un.org. Retrieved on 2012-03-26. [7] US Fund for UNICEF (http:/ / www. unicefusa. org/ site/ c. duLRI8O0H/ b. 25933/ k. 8DDD/ US_Fund_for_UNICEF__US_Fund_for_UNICEF. htm), unicefusa.org [8] Press centre HRH Grand Duchess of Luxembourg becomes Eminent Advocate for Children (http:/ / www. unicef. org/ media/ media_39402. html). UNICEF. Retrieved on 2012-03-26. [9] Brazil UNICEF Eminent Advocate for Children visits AIDS projects in So Paulo (http:/ / www. unicef. org/ aids/ brazil_42137. html). UNICEF. Retrieved on 2012-03-26. [10] China Summer camp aims to help children in China affected by AIDS (http:/ / www. unicef. org/ aids/ china_45156. html). UNICEF. Retrieved on 2012-03-26. [11] Burundi Grand Duchess Maria Teresa of Luxembourg visits Burundi (http:/ / www. unicef. org/ infobycountry/ burundi_50003. html). UNICEF. Retrieved on 2012-03-26. [12] Unicef accuses Tesco of misusing charity slogan (http:/ / www. irishtimes. com/ newspaper/ ireland/ 2009/ 0725/ 1224251305112. html). The Irish Times, Jul 25, 2009 (2009-07-07). Retrieved on 2012-03-26. [13] Tesco in clash with Unicef Irish, Business (http:/ / www. independent. ie/ business/ irish/ tesco-in-clash-with-unicef-1841427. html). Independent.ie. July 26, 2009. Retrieved on 2012-03-26. [14] UNICEF Team Canada (http:/ / www. maharaj. org/ tentpegging. shtml), maharaj.org [15] Newstrack India "International Tent Pegging", January 14, 2008 [16] UNICEF, Hammarby strikes partnership (http:/ / www. hammarbyfotboll. se/ se/ aktuellt/ artiklar/ rticleid=30364), hammarbyfotboll.se

UNICEF
[23] UNICEF Supply and Logistics: Warehouse Operations (http:/ / www. unicef. org/ supply/ index_warehouse. html) [24] William and Kate in Denmark: Kate Middleton and Prince William join Crown Prince Frederik and Crown Princess Mary at UNICEF center in Copenhaagen (http:/ / www. hellomagazine. com/ royalty/ 201111026456/ kate-and-mary-in-denmark/ ). hellomagazine.com (2011-11-02). Retrieved on 2012-03-26. [25] BBC News William and Kate in Unicef visit to Denmark aid centre (http:/ / www. bbc. co. uk/ news/ uk-15549476). Bbc.co.uk (2011-11-02). Retrieved on 2012-03-26. [26] Innocenti Research Centre (http:/ / www. unicef-irc. org/ ), UNICEF-irc.org [27] Bartholet article on human rights and adoption (http:/ / dash. harvard. edu/ bitstream/ handle/ 1/ 3228398/ IA-GlPol72409. pdf?sequence=2) [28] STUCK Documentary on barriers to international adoption (https:/ / bothendsburning. org/ ) [29] Children adopted internationally thriving (http:/ / www. ksl. com/ ?nid=1011& sid=24707891) [30] Why I Won't Buy UNICEF Holiday Cards (http:/ / communities. washingtontimes. com/ neighborhood/ red-thread-adoptive-family-forum/ 2011/ dec/ 5/ why-i-wont-buy-unicef-holiday-cards/ ) [31] International Adoptions Plummet After Hague Convention (http:/ / www. nytimes. com/ imagepages/ 2012/ 12/ 29/ opinion/ 29blow-ch. html?ref=opinion) [32] The Tragedy of Children Left in Limbo - US News (http:/ / www. usnews. com/ opinion/ blogs/ peter-roff/ 2013/ 05/ 17/ bureaucracy-keeps-adopted-children-stuck-in-international-limbo)

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External links
UNICEF (http://www.unicef.org/) UNICEF Cartoons for Children's Rights (http://www.unicef.org/crcartoons/) UNICEF Innocenti Research Centre (http://www.unicef-irc.org/) UNICEF Mozambique (http://www.unicef.org.mz/) United Nations Rule of Law: The United Nations Children's Fund (http://www.unrol.org/article. aspx?article_id=15), on the rule of law work conducted by the United Nations Children Fund. Intelligent Giving profile of UNICEF UK (http://www.intelligentgiving.com/charity/1072612) Unicef Breastfeeding Support Forum (http://www.babyfriendly.org.uk/items/resource_detail. asp?item=481) UNICEF Goodwill Ambassador Femi Kuti speaks out against the suffering of Zimbabwean children (http:// www.i-newswire.com/pr17775.html) UNICEF Child protection from violence, exploitation and abuse: Child labour (http://www.unicef.org/ protection/index_childlabour.html) UN Practitioner's Portal on HRBA Programming Resources on rights of the child (http://hrbaportal.org/ ?page_id=3173), UN centralised webportal on the Human Rights-Based Approach to Development Programming.
Awards and achievements Precededby Martin Luther King, Jr. Nobel Peace Prize Laureate 1965 Succeededby Ren Cassin 1968

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United States Agency for International Development


United States Agency for International Development

Agency overview Formed November 3, 1961

Preceding Agency International Cooperation Administration Headquarters Employees Ronald Reagan Building Washington, D.C. 3,909 (2012)

Agency executives Rajiv Shah, Administrator Donald Steinberg, Deputy Administrator Sean Carroll, Chief Operating Officer Website usaid.gov
[1]

Footnotes
[2][3]

The United States Agency for International Development (USAID) is the United States federal government agency primarily responsible for administering civilian foreign aid. USAID seeks to "extend a helping hand to those people overseas struggling to make a better life, recover from a disaster or striving to live in a free and democratic country."[] USAID's stated goals include providing "economic, development and humanitarian assistance around the world in support of the foreign policy goals of the United States".[4] It operates in Africa, Asia, Latin America and Europe. President John F. Kennedy created USAID in 1961 by executive order to implement development assistance programs in the areas authorized by the Congress in the Foreign Assistance Act.[5] The Congress updates this authorization through annual funds appropriation acts, and other legislation. Although technically an independent federal agency, USAID operates subject to the foreign policy guidance of the President, Secretary of State, and the National Security Council.[]

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USAID's goals
USAID's decentralized network of resident field missions makes the Agency an effective manager of USG programs in low-income countries. These programs serve a range of purposes.[6] Disaster relief Poverty relief Technical cooperation on global issues, including the environment U.S. bilateral interests Socioeconomic development

Disaster relief
Some of the U.S. Government's earliest foreign aid programs provided relief in crises created by war. In 1915, USG assistance through the Commission for Relief of Belgium headed by Herbert Hoover prevented starvation in Belgium after the German invasion. After 1945, the European Recovery Program championed by Secretary of State George Marshall (the "Marshall Plan") helped rebuild war-torn Western Europe. In our era, USAID leads USG relief efforts after wars and natural disasters through its Office of U.S. Foreign Disaster Assistance. Privately funded U.S. NGOs and the U.S. military also play major roles in disaster relief overseas.

USAID Packages are delivered by United States Coast Guard personnel

Poverty relief
After 1945, many newly independent countries needed assistance to relieve the chronic deprivation afflicting their low-income populations. USAID and its predecessor agencies have continuously provided poverty relief in many forms, including assistance to public health and education services targeted at the poorest. USAID has also helped manage agricultural commodity assistance provided by the U.S. Department of Agriculture. In addition, USAID provides funding to NGOs to supplement private donations in relieving chronic poverty.

Global issues
Technical cooperation between nations is essential for addressing a range of cross-border interests like communicable diseases, environmental issues, trade and investment cooperation, safety standards for traded products, money laundering, and so forth. The USG has specialized agencies dealing with such areas, such as the Centers for Disease Control and the Environmental Protection Agency. USAID's special ability to administer programs in low-income countries supports all USG civilian agencies' work on these vital global concerns. Environment Among these global interests, environmental issues attract high attention. Since 1991 USAID has been providing environment assistance to 45 countries.[7] U.S. environmental regulation laws[8] require that programs sponsored by USAID should be both economically and environmentally sustainable. USAID focuses on ensuring the protection of world resources that are currently most threatened and threatening for future generations. These resources include land and water and forests. USAID also focuses on managing and preparing people for the risks associated with global climate change.[9] USAID uses capacity building to address climate change in developing countries. Capacity building involves raising awareness about the impending threats caused by climate change. It also involves education, outreach and technical skills training as well as workshops that teach about clean energy, and sustainable agriculture.

United States Agency for International Development USAID uses a capacity building technique because they have found that directly involved peoples carry out the most successful environmental campaigns. The direct involvement of trained stakeholders; means that projects will be continued even after USAIDs direct representatives have left.[10]

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U.S. bilateral interests


To support U.S. geopolitical interests, USAID is often called upon to administer exceptional financial grants to allies. Also, when U.S. troops are in the field, USAID can supplement the "Civil Affairs" programs that the U.S. military conducts to win the friendship of local populations and thus to undermine insurgent support. In these circumstances, USAID may be directed by specially appointed diplomatic officials of the State Department, as in Afghanistan and Pakistan during operations against al-Qaeda. USAID can also be called upon to support projects of U.S. constituents that have exceptional interest.

Socioeconomic development
To help low-income nations achieve self-sustaining socioeconomic development, USAID assists them in improving management of their own resources. USAID's assistance for socioeconomic development centers on providing technical advice, training, scholarships, commodities, and financial assistance. Through grants and contracts, USAID mobilizes the technical resources of the private sector, other USG agencies, universities, and NGOs to participate in this assistance. Programs of the various types above frequently reinforce one another. For example, the Foreign Assistance Act requires USAID to use funds appropriated for geopolitical purposes ("Economic Support Funds") to support socioeconomic development to the maximum extent possible.

Modes of assistance
Although USAID formerly provided loans, all assistance is now provided as nonreimbursable grants. USAID delivers both technical assistance and financial assistance.[11]

Technical assistance
Technical assistance includes technical advice, training, scholarships, construction, and commodities. Technical assistance is contracted or procured by USAID and provided in-kind to recipients. For technical advisory services, USAID draws on experts from other USG agencies, as well as contracting with experts from the private sector. Scholarships to U.S. universities are complemented by technical assistance to developing country universities, including establishing partnerships with U.S. universities Commodity assistance is essential to disaster relief, and many host-government leaders have drawn on USAID's technical assistance for development of IT systems and computer hardware procurement to strengthen their institutions. The various forms of technical assistance are frequently coordinated as capacity building packages for development of local institutions.

Financial assistance
Financial assistance supplies cash to developing country organizations to supplement their budgets. USAID also provides financial assistance to local and international NGOs who in turn give technical assistance in developing countries. In recent years, the USG has increased its emphasis on financial rather than technical assistance. In 2004, the Bush Administration created the Millennium Challenge Corporation as a new foreign aid agency that is mainly restricted to providing financial assistance. In 2009, the Obama Administration initiated a major realignment of USAID's own programs to emphasize financial assistance, referring to it as "government-to-government" or "G2G" assistance.

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USAID's internal organization


USAID is organized around country development programs managed by resident USAID offices in developing countries ("USAID missions"), supported by USAID's global headquarters in Washington, DC.[12]

Country development programs


USAID plans its work in each country around an individual country development program managed by a resident mission. Missions work in over fifty countries, consulting with their government and non-governmental organizations to identify programs that will receive USAID's assistance. As part of this process, the missions conduct socioeconomic analysis, design projects, award contracts and grants, administer projects (including evaluation and reporting), and manage flows of funds. As countries develop and need less assistance, USAID shrinks and ultimately closes its resident missions. Since USAID's founding in 1961, it has closed its missions in a number of countries that had achieved a substantial level of prosperity, including South Korea, Turkey, Tunisia, and Costa Rica. USAID also closes missions when requested by host countries for political reasons. In September 2012, the U.S. closed USAID/Russia at that country's request. Its mission in Moscow had been in operation for two decades.[13] On May 1, 2013, the President of Bolivia, Evo Morales, asked USAID to close its mission, which had worked in the country for 49 years.[14]) USAID missions are led by Mission Directors and are staffed both by USAID Foreign Service Officers and by development professionals from the country itself; the host-country professionals form the majority of the staff. The length of a Foreign Service Officer's "tour" in most countries is four years, to provide enough time to develop in-depth knowledge about the country. (Shorter tours of one or two years are usual in countries of exceptional hardship or danger.) The Mission Director is a member of the U.S. Embassy's "Country Team" under the direction of the U.S. Ambassador. As the missions work in an unclassified environment with relative frequent public interaction, they have frequently been located in independent offices in the business districts of capital cities. Since the passage of the foreign affairs consolidation law in 1998 and the bombings of U.S. Embassies in east Africa in the same year, missions have gradually been moved into compounds alongside U.S. Embassy chancery buildings.

USAID/Washington
The country programs are supported by USAID's headquarters in Washington, D.C., "USAID/Washington," where about half of USAID's Foreign Service Officers work on rotation from foreign assignments, alongside USAID's Civil Service staff and top leadership. USAID is headed by an Administrator appointed by the President and confirmed by the Senate. The current USAID Administrator is Rajiv Shah, appointed by President Barack Obama. USAID/Washington helps define overall USG civilian foreign assistance policy and budgets, working with the State Department, the Congress, and other federal government agencies. It is organized into "Bureaus" covering geographical areas, development subject areas, and administrative functions. Each Bureau is headed by an Assistant Administrator appointed by the President. Geographical bureaus: AFRSub-Saharan Africa ASIAAsia LACLatin America & the Caribbean E&EEurope and Eurasia

MEthe Middle East OAPAAfghanistan and Pakistan Functional bureaus:

United States Agency for International Development GHGlobal Health E3Economic Growth, Education, and the Environment DCHADemocracy, Conflict, and Humanitarian Assistance BFSFood Security

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Headquarters bureaus: MManagement LPALegislative and Public Affairs PPLPolicy, Planning, and Learning. [15] Independent oversight of USAID activities is provided by its Office of Inspector General, U.S. Agency for International Development, which conducts criminal and civil investigations, financial and performance audits, reviews, and inspections of USAID activities around the world.

USAID staffing
USAID's global "direct-hire" staffthose with career contractsincludes Civil Service staff in Washington as well as U.S. Foreign Service Officers. The size of this staff was about 3,900 in 2012. An additional 400 U.S. staff work under contracts for shorter periods, typically two to three years. (By comparison, the State Department's U.S. workforce currently numbers about 19,000.) USAID's host-country staff, who normally receive one-year contracts that are renewed annually, comprised fifty-seven percent of the Agency's global workforce in 2009.[16] USAID Foreign Service Officers are selected competitively for specific job openings on the basis of academic qualifications and experience in development programs.[17][18] In 2008, USAID launched the "Development Leadership Initiative" to reverse the decline in USAID's Foreign Service Officer staffing, which had fallen to fewer than 1,000 worldwide.[19] USAID's goal was to double the number of Foreign Service Officers by 2012.[20] USAID currently has about 1,700 Foreign Service Officers (compared to 13,000 in the State Department).

Inside a USAID field Mission


While USAID can have as little presence in a country as a single person assigned to the U.S. Embassy, a full USAID mission in a larger country may have twenty or more USAID Foreign Service Officers and a hundred or more professional and administrative employees from the country itself. This staff is usually based in the Mission's central office in the country's capital city. The USAID Mission and its staff are only a small part of the overall development-assistance effort that USAID finances. In many countries, the NGOs and firms that deliver USAID-financed assistance employ hundreds of staff, almost entirely recruited from the country itself. The projects these NGOs and firms are assisting are carried out by the country's own communities, firms, NGOs, and government agencies, whose total staff implementing USAID-assisted projects may number in the tens of thousands. The USAID Mission's staff is divided into specialized offices in three groups: assistance management offices; the Mission Director's and the Program office; and the contracting, financial management, and facilities offices.

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Assistance management offices


Called "technical" offices by USAID staff, these offices design and manage the technical and financial assistance that USAID provides to their local counterparts' projects. The technical offices that are frequently found in USAID Missions include Health and Family Planning, Education, Environment, Democracy, and Economic Growth. Health and Family Planning Examples of projects assisted by Health and Family Planning offices are projects for eradication of communicable diseases, strengthening of public health systems focusing on maternal-child health including family planning services, HIV-AIDS monitoring, delivery of medical supplies including contraceptives and HIV vaccines, and coordination of Demographic and Health Surveys. This assistance is primarily targeted to the poor majority of the population and corresponds to USAID's poverty relief objective, as well as strengthening the basis for socioeconomic development. Education USAID's Education offices mainly assist the national school system, emphasizing broadening coverage of quality basic education to reach the entire population. Examples of projects often assisted by Education offices are projects for curriculum development, teacher training, and provision of improved textbooks and materials. Larger programs have included school construction. Education offices often manage scholarship programs for training in the U.S., while assistance to the country's universities and professional education institutions may be provided by Economic Growth and Health offices. The Education office's emphasis on school access for the poor majority of the population corresponds to USAID's poverty relief objective, as well as to the socioeconomic development objective in the long term. Environment Examples of projects assisted by Environment offices are projects for tropical forest conservation, protection of indigenous people's lands, regulation of marine fishing industries, pollution control, reduction of greenhouse gas emissions, and helping communities adapt to climate change. Environment assistance corresponds to USAID's objective of technical cooperation on global issues, as well as laying a sustainable basis for USAID's socioeconomic development objective in the long term. Democracy Examples of projects assisted by Democracy offices are projects for the country's political institutions, including elections, political parties, legislatures, and human rights organizations. Counterparts include the judicial sector and civil-society organizations that monitor government performance. Democracy assistance received its greatest impetus at the time of the creation of the successor states to the USSR starting in about 1990, corresponding both to USAID's objective of supporting U.S. bilateral interests and to USAID's socioeconomic development objective. Economic growth Examples of projects often assisted by Economic Growth offices are projects for improvements in agricultural techniques and marketing (the Mission may have a specialized "Agriculture" office), development of microfinance industries, streamlining of Customs administrations (to accelerate growth of exporting industries), and modernization of government regulatory frameworks for industry in various sectors (telecommunications, agriculture, and so forth). In USAID's early years and in some larger programs, Economic Growth offices have financed economic infrastructure like roads and electrical power plants. Economic Growth assistance is thus quite diverse in terms of potential sectors where it works. It corresponds to USAID's socioeconomic development objective and is the source of sustainable poverty reduction. Economic Growth offices also occasionally manage assistance to poverty relief projects, such as to government programs that provide "cash transfer" payments to low-income families. Special assistance offices Some USAID Missions have specialized technical offices for areas like counter-narcotics assistance or assistance in conflict zones.

United States Agency for International Development Disaster assistance on a large scale is provided through USAID's Office for U.S. Foreign Disaster Assistance. Rather than having a permanent presence in country Missions, this office has supplies pre-positioned in strategic locations to respond quickly to disasters when and where they occur.

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The Office of the Mission Director and the Program Office


The Mission Director's signature authorizes technical offices to provide assistance according to the designs and budgets they propose. With the help of the Program Office, the Mission Director ensures that designs are consistent with USAID policy for the country, including budgetary earmarks by which Washington directs that funds be used for certain general purposes such as public health or environmental conservation. The Program Office compiles combined reports to Washington to support budget requests to Congress and to verify that budgets were used as planned.

Contracting, financial management, and facilities offices


While the Mission Director is the public face and key decision-maker for an impressive array of USAID technical capabilities, arguably the offices that make USAID preeminent among U.S. government agencies in the ability to concretely follow through on assistance agreements are the Missions' "support" offices. Contracting offices Commitments of U.S. government funds to NGOs and firms that deliver USAID's assistance can only be made in compliance with carefully designed contracts and grant agreements executed by warranted Contracting Officers, not by the technical officers who design assistance. (The Mission Director is authorized to commit financial assistance directly to the country's government agencies.) Financial management offices Funds can be committed only when the Mission's Controller certifies their availability for the stated purpose. "FM" offices assist technical offices in financial analysis and in developing detailed budgets for inputs needed by projects assisted. They evaluate potential recipients' management abilities before financial assistance can be authorized and then review implementers' expenditure reports with great care. This office often has the largest number of staff of any office in the Mission. Facilities offices Called the "Executive Office" in USAID (sometimes leading to confusion with the Embassy's Executive Office, which is the office of the Ambassador), "EXO" has traditionally provided logistical support for Mission offices, including personnel recruitments and management, computers, transportation, office space, and housing for U.S. staff. Increasing integration into Embassies' chancery complexes, and the State Department's recently increased role in managing USAID, is expanding the importance of coordination between USAID's EXO and the overall Embassy's General Services Office in dividing up responsibilities for specific kinds of support to the USAID Mission.

USAID's history
U.S. Government foreign aid agencies before USAID
Before the Second World War, a notable example of U.S. Government foreign assistance was its contribution to the 1915 Committee for Relief in Belgium headed by Herbert Hoover, to prevent starvation in Belgium after the German invasion. During this period, however, U.S. assistance in low-income countries was often the product of private initiative, including prominently the Rockefeller Foundation's assistance for breeding improved maize and wheat varieties and its support for public health initiatives. World War II stimulated a sustained U.S. Government foreign aid effort. One of the USG's responses to the shock of Germany's occupation of France in 1940 was the creation of the Office of Inter-American Affairs, or OIAA, to

United States Agency for International Development ensure that German influence would not grow in the Western Hemisphere. Under State Department oversight, the OIAA's more than 1,000 employees undertook a variety of programs including technical assistance projects for economic stabilization, food supply, health, and sanitation. OIAA, which ended in 1946, furnished the model for President Truman's global "Point Four Program." Announced as the fourth element of Truman's overall foreign policy in January, 1949, Point Four was to provide technical knowledge to aid the growth of underdeveloped countries around the world. In 1950, the Technical Cooperation Administration (TCA) was established within the Department of State to run the Point Four program. Point Four's technical development program for underdeveloped areas complemented the Marshall Plan, which the U.S. had created in 1948 to help rebuild war-torn Western Europe. Implemented by the Economic Cooperation Administration (ECA), the Marshall Plan also expanded its reconstruction finance to strategic parts of the Middle East and Asia.[] In addition to Point Four and the Marshall Plan, the Fulbright Program of academic exchanges was established in 1946, globalizing the wartime program of exchange visits between professionals from Latin America and the United States. In light of the Korean War, Congress passed in October 1951 the Mutual Security Act and created the Mutual Security Agency (MSA) to better coordinate civilian assistance with military assistance. The MSA absorbed both the Marshall Plan (replacing ECA) and Point Four (with the Technical Cooperation Administration becoming an agency within MSA). In 1953 at the end of the Korean War, the incoming Eisenhower Administration established the Foreign Operations Administration (FOA) as an independent government agency outside the Department of State to consolidate economic and technical assistance, including both the MSA and the TCA, on a world-wide basis. The new majority in Congress also required a 25 per cent reduction in staff, which fell mainly on TCA, as in general the Foreign Operations Administration adopted the organization and procedures inherited from the Marshall Plan. In 1955, foreign aid was brought back under the administrative control of the Department of State and FOA was renamed the International Cooperation Administration (ICA). In 1956, the Senate conducted a study of foreign aid with the help of a number of independent experts. The result, stated in a 1959 amendment to the Mutual Security Act, declared that development in low-income regions was a U.S. objective along with and additional to other foreign-policy interests, attempting thus to clarify development assistance's relationship with the effort to contain Communism. In 1957, the Development Loan Fund was established within ICA to manage ICA's portfolio of loans for development projects. In 1959, the Development Loan Fund became an independent agency. (Pre-1961 reorganizations can be traced here: http:/ / www. archives. gov/ research/ guide-fed-records/ groups/ 469. html#469.7.)

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USAID's creation
In 1961, the Congress approved the Foreign Assistance Act of 1961 with President Kennedy's support, which retained the 1959 policy of international development as an independent U.S. objective and added an emphasis on the need for long-term efforts. Organizationally, the Act called for merging the ICA, the Development Loan Fund, and other foreign aid entities into a new agency. To implement the Act, a new Agency for International Development, or A.I.D. (subsequently re-branded as USAID), was created within the State Department. Its internal organization was adjusted to emphasize country-by-country programming. As in the previous change in Administration in 1953, a major reduction in staff took place. The Peace Corps was also established at this time. In addition, the Fulbright educational and cultural exchange program was strengthened by the Fulbright-Hays Act of 1961.

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"New Directions" in the 1970s


During the early 1970s, foreign aid became one of the focal points in Legislative-Executive differences over the Vietnam War.[21] In September 1970, President Nixon proposed abolishing USAID and replacing it with three new institutions: one for development loans, one for technical assistance and research, and one for trade, investment and financial policy. Consistent with this approach, in early 1971 President Nixon transferred the administration of private investment programs from USAID to the Overseas Private Investment Corporation (OPIC), which had been established by foreign aid legislation at the end of 1969. The Congress did not act on the President's proposal for replacing USAID, but rather adopted in 1973 a proposal supported by USAID management for "New Directions" in foreign aid. By amending the Foreign Assistance Act, the Congress provided that U.S. aid should emphasize "Basic Human Needs": food and nutrition; population planning and health; and education and human resources development. President Nixon signed the New Directions act into law (PL 93-189) in December 1973. In 1974, a further amendment of the Foreign Assistance Act prohibited assistance for police, thus ending USAID's involvement in Public Safety programs in Latin America, which in the 1960s were, along with the Vietnam War, part of the U.S. Government's anti-Communist strategy.

Evolving organizational linkages between USAID and the State Department


While foreign aid has always operated within the framework of U.S. foreign policy, the organizational linkages between the Department of State and USAID have been reviewed on many occasions. In 1978, legislation drafted at the request of Senator Hubert Humphrey was introduced to create a Cabinet-level International Development Cooperation Agency (IDCA), whose intended role was to supervise USAID in place of the State Department. However, although IDCA was established by Executive Order in September 1979, it did not in practice make USAID independent.[] In 1995, legislation to abolish USAID was introduced by Senator Jesse Helms, the Chairman of the Senate Foreign Relations Committee, who aimed to replace USAID with a grant-making foundation.[22] Although the House of Representatives passed a bill abolishing USAID, the measure did not become law.[23] However, in order to gain Congressional cooperation for his foreign affairs agenda President Clinton adopted in 1997 a State Department proposal to integrate more foreign affairs agencies into the Department. The "Foreign Affairs Agencies Consolidation Act of 1998" (Division G of PL 105-277) abolished the Arms Control and Disarmament Agency and the United States Information Agency, which formerly maintained American libraries overseas, and IDCA. Although the law authorized the President to abolish USAID, President Clinton did not exercise this option.[23] In 2003, President Bush established PEPFAR, the President's Emergency Plan for AIDS Relief, putting USAID's HIV/AIDS programs under the direction of the State Department's new Office of the Global AIDS Coordinator.[24] In 2004, the Bush Administration created the Millennium Challenge Corporation (MCC) as a new foreign aid agency to provide financial assistance to a limited number of countries selected for good performance in socioeconomic development.[25] The MCC also finances some USAID-administered development assistance projects. In January 2006, Secretary of State Condoleezza Rice created the Office of the Director of U.S. Foreign Assistance ('F') within the State Department. Under a Director with the rank of Deputy Secretary, F's purpose was to ensure that foreign assistance would be used as much as possible to meet foreign policy objectives.[26] F integrated foreign assistance planning and resource management across State and USAID, directing all USAID offices' budgets according to a detailed "Standardized Program Structure" comprising hundreds of "Program Sub-Elements." USAID accordingly closed its Washington office that had been responsible for development policy and budgeting. On September 22, 2010, President Barack Obama signed a Presidential Policy Determination (PPD) on Global Development. Although the PPD is classified, indicating that revealing it would damage U.S. national security, it was described in an unclassified fact sheet. The PPD promised to elevate the role of development assistance within

United States Agency for International Development U.S. policy and rebuild "USAID as the U.S. Governments lead development agency." It also established an Interagency Policy Committee on Global Development led by the National Security Staff and added to U.S. development efforts an emphasis on innovation.[27] On December 21, 2010, Secretary of State Clinton released the Quadrennial Diplomacy and Development Review (QDDR), which reaffirmed the plan to re-build USAID's Foreign Service staffing while also emphasizing the increased role that staff from the State Department and domestic agencies would play in implementing U.S. assistance. In addition, it laid out a program for a future transfer of health sector assistance back from the State Department to USAID.[28] Consistent with this evolving policy environment, USAID re-created in mid-2010 a development planning office, the Bureau of Policy, Planning, and Learning,[29] and on November 23, 2010, announced the creation of a new Bureau for Food Security[30] to lead the implementation of President Obama's Feed the Future Initiative, which had formerly been managed by the State Department.

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USAID Forward
Since 2009, USAID has been implementing a group of measures under the name "USAID Forward"[] to strengthen its performance in a number of areas.[31] Project Implementation ("Implementation and procurement reform") Increase the contracts and grants awarded to local organizations in USAID's host countries. Increase the use of small businesses. Include metrics in implementation agreements to increase focus on institutional capacity building. Use host country project implementation systems where appropriate. Talent management Expand professional roles for USAID's professional staff recruited from host countries ("Foreign Service Nationals"). Improve hiring and training practices, as well as providing better incentives. Policy capacity

USAID Administrator Rajiv Shah

Create the Bureau of Policy, Planning and Learning (PPL) and expand research on evidence-based development policies. Re-emphasize science and technology and reintroduce a culture of research, knowledge-sharing and evaluation. Monitoring and Evaluation Expand use of independent and scientific project evaluations. Budget management Re-create an Office of Budget and Resource Management to ensure that budget procedures align resources with country strategies and toward programs that are demonstrating meaningful results. Science and technology: Upgrade USAID's internal S&T capabilities, expand technical expertise, and improve staff access to analytical tools like Geospatial Information Systems. Drawing from the examples of major S&T initiatives of the past, like oral rehydration therapies and the Green Revolution, develop a set of Grand Challenges for Development to focus the Agency and its development

United States Agency for International Development partners on scientific and technical barriers that limit development progress. Build S&T capacity in developing countries through cooperative research grants, improved access to scientific knowledge, and higher education and training opportunities. Innovation Foster innovative development solutions by connecting USAID staff to leading innovators in the private sector and academia. Create "Development Innovation Ventures" to fund and pilot innovations.

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Budgetary resources for USAID


The 20 Countries with the Largest Budgets for U.S. Economic Assistance in Fiscal Year 2012
Nation Afghanistan Pakistan Jordan Ethiopia Haiti Kenya Iraq Democratic Republic of Congo Uganda Tanzania Somalia West Bank and Gaza Ghana Bangladesh Colombia Indonesia Liberia Yemen Mozambique India Billions of Dollars 2.24 0.97 0.48 0.45 0.31 0.31 0.28 0.24 0.22 0.21 0.20 0.20 0.19 0.18 0.18 0.17 0.16 0.16 0.16 0.15

The cost of supplying USAID's assistance includes the agency's "Operating Expenses," $1.35 billion in fiscal year 2012, and "Bilateral Economic Assistance" program costs, $20.83 billion in fiscal year 2012 (the vast bulk of which was administered by USAID). Up-to-date details of the budget for USAID's assistance and other aspects of the USG's foreign assistance are available from USAID's budget webpage, http:/ / www. usaid. gov/ results-and-data/ budget-spending. This page contains a link to the U.S. Government's Foreign Operations budget (the "150 Account"), which shows the budgets of all International Affairs programs and operations for civilian agencies, including USAID. This page has a link to a "Where Does the Money Go?" table, which shows the recipients of USAID's financial assistance (foreign

United States Agency for International Development governments as well as NGOs), the totals that were spent for various countries, and the sources (U.S. government agencies, universities, and private companies) from which USAID procured the goods and services that it provided as technical assistance. U.S. assistance budget totals are shown along with other countries' total assistance budgets in tables in a webpage of the Organization for Economic Cooperation and Development, http:/ / www. oecd. org/ development/ stats/ statisticsonresourceflowstodevelopingcountries.htm. At the Earth Summit in Rio de Janeiro in 1992, most of the world's governments adopted a program for action under the auspices of the United Nations Agenda 21, which included an Official Development Assistance (ODA) aid target of 0.7% of gross national product (GNP) for rich nations, specified as roughly 22 members of the OECD and known as the Development Assistance Committee (DAC). However, most countries do not adhere to this target, as the OECD's table indicates that the DAC average ODA in 2011 was 0.31% of GNP. The U.S. figure for 2011 was 0.20% of GNP, which still left the U.S. as the largest single source of ODA among individual countries.

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USAID bilateral assistance in the news


Haiti
Response to 2010 Haiti earthquake Dr. Rajiv Shah became Administrator of USAID, shortly before the January 2010 earthquake in Haiti. In response, USAID and other agencies, began working to help Haiti recover and rebuild. Together with the international community and the Government of Haiti, Dr. Shah led USAID to help provide safer housing for almost 200,000 displaced Haitians; supported vaccinations for more than 1 million people; cleared more than 1.3 million cubic meters of the approximately 10 million cubic meters of rubble generated; helped more than 10,000 farmers double the yields of staples like corn, beans, and sorghum; and provided short-term employment to more than 350,000 Haitians, injecting more than $19 million into the local economy. USAID has provided nearly $42 million to help combat cholera, helping to decrease the number of cases requiring hospitalization and reduce the case fatality rate.

Iraq
USAID has been a major partner in the United States Government's (USG) reconstruction and development effort in Iraq. As of June 2009[32], USAID has invested approximately $6.6 billion on programs designed to stabilize communities; foster economic and agricultural growth; and build the capacity of the national, local, and provincial governments to represent and respond to the needs of the Iraqi people.[33] Rebuilding Iraq C-SPAN 4 Part Series In June 2003, C-SPAN followed USAID Admin. Andrew Natsios as he toured Iraq. The special program C-SPAN produced aired over four nights.[34]

Lebanon
USAID has periodically supported the Lebanese American University and the American University of Beirut financially, with major contributions to the Lebanese American University's Campaign for excellence.[]

Bolivia
In 2008, the coca growers union affiliated with Bolivian President Evo Morales ejected the 100 employees and contractors from USAID working in the Chapare region, citing frustration with U.S.[35] efforts to persuade them to switch to growing unviable alternatives. From 1998 to 2003, Bolivian farmers could receive USAID funding for help planting other crops only if they eliminated all their coca, according to the Andean Information Network. Other rules, such as the requirement that participating communities declare themselves "terrorist-free zones" as required by U.S. law irritated people, said Kathryn Ledebur, director of the organization. "Eradicate all your coca and then you

United States Agency for International Development grow an orange tree that will get fruit in eight years but you don't have anything to eat in the meantime? A bad idea," she said. "The thing about kicking out USAID, I don't think it's an anti-American sentiment overall but rather a rejection of bad programs". President Evo Morales expelled USAID from Bolivia on May 1st, 2013 for allegedly seeking to undermine his government. [36]

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East Africa
On September 19, 2011, Dr. Rajiv Shah, along with Dr. Jill Biden and Ad Council, launched the "FWD" campaign to raise awareness about that year's severe drought in East Africa. Through TV and internet ads as well as social media initiatives, FWD encouraged Americans to spread awareness about the crisis, support the humanitarian organizations that were conducting relief operations, and consult the Feed the Future global initiative for broader solutions. Celebrities Geena Davis, Uma Thurman, Josh Hartnett and Chanel Iman took part in the campaign via a series of Public Service Announcements. Corporations like Cargill, General Mills, PepsiCo. and General Mills also signed on to support FWD.[37]

Controversies and criticism


USAID and U.S. foreign economic assistance in general have been the subject of debate, controversy, and criticism continuously since the 1950s.

Controversy over goals


Those who advocate that poverty relief should be the primary goal of foreign aid may criticize the choice of geopolitical influence as the goal of a given budget allocation. But the budget for povery relief may be criticized in turn by advocates of environmental conservation, if they feel that it leaves little funding free for environmental projects. Focusing on the environment, on the other hand, may seem premature to advocates of socioeconomic development who see that as the key to realizing all the other goals, including poverty reduction and environmental protection. These are debates that are arbitrated in Washington by the Congress and the Administration before budgets are decided and before USAID staff undertake detailed programming in the field. In practice, the programs that USAID implements in each country pursue a mix of goals, each of which has value to some stakeholder of foreign aid.

Controversy over modes of assistance


Some feel that USAID overemphasizes technical assistance and should instead provide more financial assistance (budget support, or debt relief). They argue that financial assistance allows recipients to spend as they like with less influence from donors. Others feel that financial assistance does not result in durable improvements and that person-to-person technical assistance has the advantage of sharing knowledge and experience regarding techniques that have worked before, leading to permanent improvements. In practice, many USAID missions find that their counterparts appreciate having both forms of aid: an assistance package that includes some financial assistance for things that can simply be bought and some technical assistance to confront problems and issues whose solutions are not so clear.

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Criticism of the cost of delivering USAID assistance


USAID is frequently criticized for paying the full market cost of expert services that it provides to counterparts. Those service providers generally are higher paid than the average person in low-income, developing countries. While the majority of the staff working on USAID-financed projects are from the country where the work is being carried out, USAID is able to recruit from anywhere in the world to get the right person for specific tasks, including widely recognized experts in many cases. USAID uses competition to arrive at market rates for the staff it recruits, and has experimented with volunteer programs for expertise from high paid professions. Questions are fequently asked as to whether it is a good practice to recruit project specialists under limited-term contracts (which can last from a few weeks to two or three years), rather than relying more predominantly on career U.S. Government employees (who have twenty- or thirty-year employment contracts). A perceived shift from USAID employees to contractors caused comment in the 1960s and has been debated continuously since then.

Economic interests
USAID states that "U.S. foreign assistance has always had the twofold purpose of furthering America's foreign policy interests in expanding democracy and free markets while improving the lives of the citizens of the developing world." However, non-government organization watch groups have noted that as much as 40% of aid to Afghanistan has found its way back to donor countries through awarding contracts at inflated costs.[38] Although USAID officially selects contractors on a competitive and objective basis, watch dog groups, politicians, foreign governments and corporations have occasionally accused the agency of allowing its bidding process to be unduly influenced by the political and financial interests of its current Presidential administration. Under the Bush administration, for instance, it emerged that all five implementing partners selected to bid on a $600 million Iraq reconstruction contract enjoyed close ties to the administration.[39][40]

Political interests
Some critics[41][42][43][44] say that the US government gives aid to reward political and military partners rather than to advance genuine social or humanitarian causes abroad. William Blum has said that in the 1960s and early 1970s USAID has maintained "a close working relationship with the CIA, and Agency officers often operated abroad under USAID cover."[45] The 1960s-era Office of Public Safety, a now-disbanded division of USAID, has been mentioned as an example of this, having served as a front for training foreign police in counterinsurgency methods (including torture techniques).[46] Folha de So Paulo, Brazil's largest newspaper, accused USAID of trying to influence political reform in Brazil in a way that would have purposely benefited right-wing parties. USAID spent $95,000 US in 2005 on a seminar in the Brazilian Congress to promote a reform aimed at pushing for legislation punishing party infidelity. According to USAID papers acquired by Folha under the Freedom of Information Critical graffiti on a USAID Advertisement Act, the seminar was planned so as to coincide with the eve of talks in saying "We dont need your aid", West Bank, Jan that country's Congress on a broad political reform. The papers read 2007 that although the "pattern of weak party discipline is found across the political spectrum, it is somewhat less true of parties on the liberal left, such as the [ruling] Worker's Party." The papers also expressed a concern about the "'indigenization' of the conference so that it is not viewed as providing a U.S. perspective." The event's main sponsor was the International Republican Institute.[47]

United States Agency for International Development In the summer of 2012, ALBA countries (Venezuela, Cuba, Ecuador, Bolivia, Nicaragua, San Vicente y Las Granadinas, Dominica, Antigua y Barbuda) called on its members to expel USAID from their countries. [48]

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Influence on the United Nations


Several studies suggest that foreign aid is used as a political weapon for the U.S. to elicit desired actions from other nations. A state's membership of the U.N. Security Council can give a considerable raise of U.S. assistance.[49] In 1990 when the Yemeni Ambassador to the United Nations, Abdullah Saleh al-Ashtal, voted against a resolution for a U.S.-led coalition to use force against Iraq, U.S. Ambassador to the UN Thomas Pickering walked to the seat of the Yemeni Ambassador and retorted: "That was the most expensive No vote you ever cast". Immediately afterwards, USAID ceased operations and funding in Yemen.[50][51]

Renouncing terrorism
USAID requires NGOs to sign a document renouncing terrorism, as a condition of funding. Issam Abdul Rahman, media coordinator for the Palestinian Non-Governmental Organizations' Network, a body representing 135 NGOs in the West Bank and Gaza Strip, said his organization "takes issue with politically conditioned funding." In addition, the PFLP, considered a terrorist organization by the United States, said that the USAID condition was nothing more than an attempt to impose political solutions prepared in the kitchens of Western intelligence agencies to weaken the rights and principles of Palestinians, especially the right of return.[52]

Renouncing prostitution and sex trafficking


In 2003, Congress passed a law providing federal government funds to private groups to help fight AIDS and other diseases all over the world through USAID grants. However, one of the conditions imposed by the law on grant recipients was a requirement to have "a policy explicitly opposing prostitution and sex trafficking".[53] In 2013, the U.S. Supreme Court ruled that the requirement violated the First Amendment's prohibition against compelled speech in Agency for International Development v. Alliance for Open Society International, Inc.[54]

References
[1] http:/ / usaid. gov/ [2] Best Places to Work in the Federal Government (http:/ / www. bestplacestowork. org/ BPTW/ rankings/ agency. php?code=AM00& q=scores_small) [3] USAID: USAID History (http:/ / www. usaid. gov/ about_usaid/ usaidhist. html) [8] USAID.gov (http:/ / www. usaid. gov/ our_work/ environment/ climate/ policies_prog/ capacity. html) [16] See GAO report number GAO-10-496 of June 2010. [19] http:/ / budgetinsight. files. wordpress. com/ 2009/ 02/ kunder-testimony-feb25. pdf [21] Sartorius, Rolf H. and Vernon W. Ruttan, "The Source of the Basic Human Needs Mandate," The Journal of Developing Areas 23 (April 1989), pages 331-362. [23] http:/ / pdf. usaid. gov/ pdf_docs/ PCAAA780. pdf [28] USAID.gov (http:/ / www. usaid. gov/ qddr/ QDDR_ExecutiveSummary. pdf) [31] USAID.gov (http:/ / www. usaid. gov/ press/ factsheets/ 2010/ fs101118. html), USAID Press Release on USAID Forward Reform Agenda. [32] http:/ / en. wikipedia. org/ w/ index. php?title=United_States_Agency_for_International_Development& action=edit [33] USAID Assistance for Iraq : Accomplishments (http:/ / www. usaid. gov/ iraq/ accomplishments/ ) [34] C-Span: Rebuilding Iraq (http:/ / www. c-span. org/ iraq/ iraq_rebuild. asp) [35] Andean Information Network, 27 June 2008, "Bolivian coca growers cut ties with USAID" (http:/ / ain-bolivia. org/ 2008/ 06/ bolivian-coca-growers-cut-ties-with-usaid/ ) [36] BBC News, May 1 2013, "Bolivian President Evo Morales expels USAid" (http:/ / www. bbc. co. uk/ news/ world-latin-america-22371275) [37] "New PSAs: 'FWD' Awareness About the Horn of Africa Crisis" (http:/ / adage. com/ article/ goodworks/ psas-fwd-awareness-horn-africa-crisis/ 230640/ ). Ad Age. October 26, 2011 [38] Richard Norton-Taylor 40% of Afghan aid returns to donor countries, says report (http:/ / www. guardian. co. uk/ world/ 2008/ mar/ 25/ afghanistan. internationalaidanddevelopment1) guardian.co.uk 25 March 2008 [39] Barbara Slavin Another Iraq deal rewards company with connections (http:/ / www. usatoday. com/ money/ world/ iraq/ 2003-04-17-iraqdeal_x. htm) USA Today 4/17/2003

United States Agency for International Development


[40] Mark Tran Halliburton misses $600m Iraq contract (http:/ / www. guardian. co. uk/ business/ 2003/ mar/ 31/ iraq. usnews) guardian.oc.uk 31 March 2003 [45] William Blum, Killing hope : U.S. military and CIA interventions since World War II (http:/ / books. google. com/ books?id=-IbQvd13uToC) Zed Books, 2003, ISBN 978-1-84277-369-7 pp. 142 (http:/ / books. google. com/ books?id=-IbQvd13uToC& pg=PA142), 200 (http:/ / books. google. com/ books?id=-IbQvd13uToC& pg=PA200), 234 (http:/ / books. google. com/ books?id=-IbQvd13uToC& pg=PA234). [46] Michael Otterman, American torture: from the Cold War to Abu Ghraib and beyond (Carlton, Vic.: Melbourne University Press, 2007), p. 60. [48] ALBA Expels USAID from Member Countries (http:/ / venezuelanalysis. com/ news/ 7069) Retrieved 2012-09-16 [50] Hornberger, Jacob" But Foreign Aid Is Bribery! And Blackmail, Extortion, and Theft Too! (http:/ / www. fff. org/ comment/ com0309q. asp)" September 26, 2003 [51] U.S. State Department, Country Fact Sheets - Background Note: Yemen (http:/ / www. state. gov/ r/ pa/ ei/ bgn/ 35836. htm#relations). 12 March 2012

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Further reading
Bollen, Kenneth; Paxton, Pamela; Morishima, Rumi (June 2005). "Assessing international evaluations: An example from USAIDs DemocracyandGovernance Programs" (http://www.irss.unc.edu/odum/content/pdf/ Bollen_Paxton_Morishima2005AJE.pdf) (PDF). American Journal of Evaluation 26 (2): 189203. doi: 10.1177/1098214005275640 (http://dx.doi.org/10.1177/1098214005275640). Evaluation performed on behalf of the Social Science Research Council (SSRC), at the request of and with funding from the Strategic and Operational Research Agenda (SORA) of USAID (Office of Democracy and Governance in the Bureau for Democracy, Conflict, and Humanitarian Assistance), according to the National Research Council (2008, p.28). National Research Council, Committee on Evaluation of USAID DemocracyAssistance Programs (2008). Goldstone, JackA, ed. Improving democracyassistance: Building knowledge through evaluations and research (http://www.nap.edu/catalog/12164.html). pp.xvi+336. ISBN978-0-309-11736-4. Individuals can download the complete report (pdf format) for private use. (http://www.nap.edu/catalog/12164.html)

External links
USAID website (http://usaid.gov/) Records of the Agency for International Development (AID) (http://www.archives.gov/research/ guide-fed-records/groups/286.html) in the National Archives USAID Overview video short (http://www.youtube.com/watch?v=uA65UJIqMKI) USAID Development Innovation Ventures (http://www.usaid.gov/div) USAID-produced Lebanon television short for 2007 public affairs campaign (http://www.youtube.com/ watch?v=624Tcc21OmI) USAID-sponsored and financed anti-human trafficking music video (http://www.youtube.com/ watch?v=-xHfBAKMcCc) Highlights of President Kennedy's Act for International Development, Bureau of Public Affairs, U.S. Dept. of State, June 1961 (http://pdf.usaid.gov/pdf_docs/PCAAB618.pdf) Historical bibliography of the United States Agency for International Development, USAID Center for Development Information and Evaluation (CDIE), April 1995 (http://pdf.usaid.gov/pdf_docs/PNABU368. pdf) USAID primer : what we do and how we do it, USAID, rev. January 2006 (http://pdf.usaid.gov/pdf_docs/ PDACG100.pdf) Access over 167,000 USAID documents, reports and publications through USAID's Development Experience Clearinghouse (DEC) (http://dec.usaid.gov) Access over 9,100 USAID project descriptions, 19461996, through USAID's Development Experience Clearinghouse (DEC) (http://dec.usaid.gov/index.cfm?p=projects.projectSearch)

United States Agency for International Development U.S. Overseas Loans and Grants, Obligations and Loan Authorizations (http://gbk.eads.usaidallnet.gov/), USAID annual report to U.S. Congress FrontLines--the employee news publication of USAID (https://dec.usaid.gov/dec/search/SearchResults. aspx?q=KERvY3VtZW50cy5Eb2N1bWVudF9UaXRsZTooZnJvbnRsaW5lcykp& qcf=ODVhZjk4NWQtM2YyMi00YjRmLTkxNjktZTcxMjM2NDBmY2Uy) The US and Foreign Aid Assistance (http://www.globalissues.org/TradeRelated/Debt/USAid.asp), article by Anup Shah EM-DAT: The OFDA/CRED International Disaster Database (http://www.emdat.be) CE-DAT: The Complex Emergency Database (http://www.cedat.be) Eurodad: Aid Effectiveness, Conditionality, Aid Accounting (http://www.eurodad.org/) Albert H. Huntington Jr. (AID Staff Member), Collection of Documents Related to Foreign Aid, Dwight D. Eisenhower Presidential Library (http://www.eisenhower.archives.gov/Research/Finding_Aids/H.html) US Aid to Pakistan by the Numbers - Center for American Progress (http://www.americanprogress.org/issues/ 2008/08/pakistan_aid_numbers.html) US Aid to Afghanistan by the Numbers - Center for American Progress (http://www.americanprogress.org/ issues/2008/08/left_behind.html) Myth: More US aid will help the hungry (http://www.globalissues.org/article/11/ myth-more-us-aid-will-help-the-hungry) USAID Armenia (http://armenia.usaid.gov/) GVEP International Moseley, W.G. 2006. Americas Lost Vision: The Demise of Development. International Herald Tribune. Pg. 7, August 9. (http://www.nytimes.com/2006/08/08/opinion/08iht-edmoseley.2420617.html) Breaking Open the Black Box: Increasing Aid Transparency and Accountability in Haiti (http://www.cepr.net/ documents/publications/haiti-aid-accountability-2013-04.pdf), from the Center for Economic and Policy Research, April 2013

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United States Pharmacopeia

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United States Pharmacopeia


United States Pharmacopeia
Type Founded Nonprofit 1820

Headquarters Rockville, Maryland, USA Key people Website Roger L. Williams, M.D. usp.org [2] [1] , Chief Executive Officer

The United States Pharmacopeia (USP) is the official pharmacopeia of the United States, published dually with the National Formulary as the USP-NF. The United States Pharmacopeial Convention (usually also called the USP) is the nonprofit organization that owns the trademark and copyright to the USP-NF and publishes it every year. Prescription and overthecounter medicines and other health care products sold in the United States are required to follow the standards in the USP-NF. USP also sets standards for food ingredients and dietary supplements.

Product qualitystandards and verification


USP establishes written (documentary) and physical (reference) standards for medicines, food ingredients, dietary supplement products and ingredients. These standards are used by regulatory agencies and manufacturers to help to ensure that these products are of the appropriate identity, as well as strength, quality, purity, and consistency. Prescription and over-the-counter medicines available in the United States must, by federal law, meet USP-NF public standards, where such standards exist. Many other countries use the USP-NF instead of issuing their own pharmacopeia, or to supplement their government pharmacopeia. USP's standards for food ingredients can be found in its Food Chemicals Codex (FCC). The FCC is a compendium of standards used internationally for the quality and purity of food ingredients like preservatives, flavorings, colorings and nutrients. While the FCC is recognized in law in countries like Australia, Canada and New Zealand, it currently does not have broad legal recognition in the United States. USP obtained the FCC from the Institute of Medicine in 2006. The IOM had published the first five editions of the FCC. USP also conducts verification programs for dietary supplement products and ingredients. These are testing and audit programs. Products that meet the requirements of the program can display the USP Verified Dietary Supplement Mark on their labels. This is different from seeing the letters USP alone on a dietary supplement label, which means that the manufacturer is claiming to adhere to USP standards. USP does not test such products as it does with USP Verified products.

Healthcare information
USP develops information relating to various aspects of drug use and disseminates this information to practitioners, pharmacists, and others who make decisions about health care. One such initiative is the development of a drug classification system that Medicare Prescription Drug Benefit plans may use to develop their formularies. USP also plays a role in the naming of both pharmaceutical ingredients and products. This has a place in law via USPs membership in the United States Adopted Names Council. The council is tri-sponsored by the American Medical Association, the American Pharmacists Association and USP.

United States Pharmacopeia

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Promoting the Quality of Medicines Program


The Promoting the Quality of Medicines (PQM) Program is a $35 million cooperative agreement with the U.S. Agency for International Development (USAID), a U.S. government agency. The programs work is implemented by USP. Its purpose is to improve drug quality and the appropriate use of drugs in countries in Asia, Africa and Latin America. It is focused on medicines intended to treat malaria, HIV/AIDS and tuberculosis. Much of the PQM Programs activities are designed to reduce the presence of substandard and counterfeit medicines, which pose threats to the lives of individual patients who take them and can contribute to growth of drug-resistant strains of these diseases.

International agreements and offices


USP works internationally, largely through agreements with other pharmacopeias, as well as regulatory bodies, manufacturer associations and others. In recent years, USP signed a series of Memoranda of Understanding (MOU) with groups including the pharmacopoeia Commission [3], the Chinese Pharmacopoeia Commission, nine countries belonging to the Association of Southeast Asian Nations (ASEAN), and the Federal Service on Surveillance in Healthcare and Social Development of the Russian Federation (Roszdravnadzor) [4]. USP also operates an international office in Switzerland, and offices and laboratories in Brazil, India and China.

Notes and references


[1] [2] [3] [4] http:/ / www. usp. org/ about-usp/ leadership/ executive-team/ roger-l-williams http:/ / www. usp. org/ http:/ / ipc. nic. in/ Pakistan http:/ / www. roszdravnadzor. ru/

External links
US Pharmacopeia (http://www.usp.org) The International Pharmacopoeia (http://www.who.int/medicines/publications/pharmacopoeia/en/) Medicines Compendium (http://www.usp-mc.org/)

URAC

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URAC
URAC
Type Industry Founded Nonprofit Healthcare 1990

Headquarters Washington, DC, United States Key people Products Employees Website Kylanne Green, President and CEO Accreditation, Education and Measurement Services over 60 http:/ / www. urac. org

URAC, formerly known as the Utilization Review Accreditation Commission, is a nonprofit organization promoting healthcare quality by accrediting healthcare organizations.

Mission
URAC's mission is to promote continuous improvement in the quality and efficiency of health care management through processes of accreditation, education and measurement.

History
In the late 1980s concerns grew over the lack of uniform standards for utilization review (UR) services. UR is the process where organizations determine whether health care is medically necessary for a patient or an insured individual. As a result of this public concern, URAC was founded in 1990 with a mission to improve the quality and accountability of health care organizations using UR programs. From conception, the founders of URAC recognized that an accreditation organization would not be accepted by regulators, health care providers and consumers if controlled by industry interests. To avoid this, several operating principles were incorporated into URAC's structure and bylaws. First, URAC was set up as an organization independent of any particular stakeholder group. Second, the governing board of directors was established with representatives from all affected constituencies: consumers, providers, employers, regulators and industry experts. Today, over 500 committee volunteers and paid staff help run the organization. In the mid-to-late 1990s, URAC's mission expanded to cover a larger range of service functions found in various health care settings including the accreditation of integrated systems such as health plans to smaller organizations offering specialty services.

URAC

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Accreditation
URAC's accreditation process consists of a review of policies and procedures and an onsite visit to the applicant organization to determine that it is, in fact, operating according to its stated policies. If an applicant organizations passes their review, an accreditation is awarded with a valid period of two to three years after which the organization must go through the review process again to maintain its accredited status. URAC accredits many types of health care organizations across the care continuum including health plans (HMOs, PPOs, etc.), health care management organizations (disease management, case management, patient-centered health care homes, health call centers, Independent review organizations, etc.), and health websites.

Accreditation programs
Case Management Claims Processing Consumer Education & Support Drug Therapy Management Core Comprehensive Wellness Health Content Provider Health Web Site

Credentials Verification Organization Health Network

Disease Management

Health Call Center

Health Plan

Health Provider Credentialing Health Utilization Management Independent Review Organization Specialty Pharmacy Mail Service Pharmacy

HIPAA Privacy

HIPAA Security

Medicare Advantage Deeming Program Workers' Compensation Health Network

Pharmacy Benefit Management

Provider Performance Measurement and Public Reporting

Uniform External Review

Workers' Compensation Workers' Compensation Property Patient Centered Health Care Utilization Management and Casualty Pharmacy Benefit Home [PCHCH] Practice Management Achievement

Patient Centered Health Care Home [PCHCH] Auditor Certification

Health Insurance Marketplace Health Plan Accreditation


Beginning in 2014, the Affordable Care Act (ACA) will ensure almost every American has health insurance and access to an expanded choice of health plans through Health Insurance Marketplaces, otherwise known as Exchanges. The law also requires every Exchange to be composed of health plan issuers accredited by an HHS-approved accrediting entity. URACs Health Plan Accreditation program has proudly earned this HHS approval, making it eligible to accredit issuers participating on Exchanges in all 50 states and the District of Columbia. URACs accreditation signifies an issuer has undergone and passed a rigorous, independent, top-to-bottom review of every aspect of its operation, including the quality of care and level of service they provide their enrollees.

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Accreditation standards development


URAC standards are developed by a committee of experts representing diverse interests in the health care community: employers, health care providers, health care organizations, insurers, and the public interest. When new standards are developed, experts from that particular area of health care delivery participate on the committee. URAC always circulates draft standards for public comment so that anyone can have input in the standards development process.

Education
Educational programs include workshops, conferences, webinars and audio conferences for individuals and companies in the health care industry to learn about best practices in URAC accreditation in addition to the latest updates on issues at the forefront of health care directly from industry experts and URAC staff. Many of URAC's educational programs have been approved for Nursing CEU's, CCM CEU's and other continuing education credits.[citation needed]

External links
URAC website [1]

References
[1] http:/ / www. urac. org/

World Health Organization

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World Health Organization

World Health Organization Organisation mondiale de la Sant Organizacin Mundial de la Salud

Flag of the World Health Organization Org type Acronyms Specialized agency of the United Nations WHO OMS Margaret Chan Active 7 April 1948

Head Status Established

Headquarters Geneva, Switzerland Website Parent org www.who.int [1]

United Nations Economic and Social Council (ECOSOC)

The World Health Organization (WHO) is a specialized agency of the United Nations (UN) that is concerned with international public health. It was established on 7 April 1948, with its headquarters in Geneva, Switzerland. WHO is a member of the United Nations Development Group. Its predecessor, the Health Organization, was an agency of the League of Nations. The constitution of the World Health Organization had been signed by all 61 countries of the United Nations by 22 July 1946, with the first meeting of the World Health Assembly finishing on 24 July 1948. It incorporated the Office International d'Hygine Publique and the League of Nations Health Organization. Since its creation, it has been responsible for playing a leading role in the eradication of smallpox. Its current priorities include communicable diseases, in particular, HIV/AIDS, malaria and tuberculosis; the mitigation of the effects of non-communicable diseases; sexual and reproductive health, development, and aging; nutrition, food security and healthy eating; occupational health; substance abuse; and drive the development of reporting, publications, and networking. WHO is responsible for the World Health Report, a leading international publication on health, the worldwide World Health Survey, and World Health Day (7th-April of every Year). Its links with the International Atomic Energy Agency and distribution of contraception have both proved controversial, as have guidelines on healthy eating and the 2009 flu pandemic.

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History
Establishment
The use of the word "world", rather than "international", emphasized the truly global nature of what the organization was seeking to achieve.[] The constitution of the World Health Organization had been signed by all 61 countries of the United Nations by 22 July 1946. It thus became the first specialised agency of the United Nations to which every member subscribed.[] Its constitution formally came into force on the first World Health Day on 7 April 1948, when it was ratified by the 26th member state.[2] The first meeting of the World Health Assembly finished on 24 July 1948, having secured a budget of US$5million (then GBP1,250,000) for the 1949 year. Andrija Stampar was the Assembly's first president, and G. Brock Chisholm was appointed Director-General of WHO, having served as Executive Secretary during the planning stages.[] Its first priorities were to control the spread of malaria, tuberculosis and sexually transmitted infections, and to improve maternal and child health, nutrition and environmental hygiene. Its first legislative act was concerning the compilation of accurate statistics on the spread and morbidity of disease.[] The logo of the World Health Organization features the Rod of Asclepius as a symbol for healing.[3]

Operational history
WHO established an epidemiological information service via telex in 1947, and by 1950 a mass tuberculosis inoculation drive (using the BCG vaccine) was under way. In 1955, the malaria eradication programme was launched, although it was later altered in objective. 1965 saw the first report on diabetes mellitus and the creation of the International Agency for Research on Cancer. WHO moved into its headquarters building in 1966. The Expanded Programme on Immunization was started in 1974, as was the control programme into onchocerciasis an important partnership between the Food and Agriculture Organization (FAO), the United Nations Development Three former directors of the Global Smallpox Eradication Programme read the news that Programme (UNDP), and World Bank. In the following year, the smallpox had been globally eradicated, 1980 Special Programme for Research and Training in Tropical Diseases was also launched. In 1976, the World Health Assembly voted to enact a resolution on Disability Prevention and Rehabilitation, with a focus on community-driven care. The first list of essential medicines was drawn up in 1977, and a year later the ambitious goal of "health for all" was declared. In 1986, WHO started it global programme on the growing problem of HIV/AIDS, followed two years later by additional attention on preventing discrimination against sufferers and UNAIDS was formed in 1996. The Global Polio Eradication Initiative was established in 1988.[] In 1958, Viktor Zhdanov, Deputy Minister of Health for the USSR, called on the World Health Assembly to undertake a global initiative to eradicate smallpox, resulting in Resolution WHA11.54.[] At this point, 2 million people were dying from smallpox every year. In 1967, the World Health Organization intensified the global smallpox eradication by contributing $2.4 million annually to the effort and adopted a new disease surveillance method.[4][5] The initial problem the WHO team faced was inadequate reporting of smallpox cases. WHO established a network of consultants who assisted countries in setting up surveillance and containment activities.[6] The WHO also helped contain the last European outbreak in Yugoslavia in 1972.[7] After over two decades of fighting smallpox, the WHO declared in 1980 that the disease had been eradicated the first disease in history to be eliminated by human effort.[8] In 1998, WHO's Director General highlighted gains in child survival, reduced infant mortality, raised life expectancy and reduced rates of "scourges" such as smallpox and polio on the fiftieth anniversary of WHO's founding. He, did, however, accept that more had to be done to assist maternal health and that progress in this area had been slow.[9]

World Health Organization Cholera and malaria have remained problems since WHO's founding, although in decline for a large part of that period.[10] In the twenty-first century, the Stop TB Partnership was created in 2000, along with the UN's formulation of the Millennium Development Goals. The Measles initiative was formed in 2001, and credited with reducing global deaths from the disease by 68% by 2007. In 2002, The Global Fund to Fight AIDS, Tuberculosis and Malaria was drawn up to improve the resources available.[] In 2006, the organization endorsed the world's first official HIV/AIDS Toolkit for Zimbabwe, which formed the basis for a global prevention, treatment and support plan to fight the AIDS pandemic.[11]

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Current projects
Overall focus
The WHO's Constitution states that its objective "is the attainment by all peoples of the highest possible level of health".[12] WHO fulfils its objective through its functions as defined in its Constitution: (a) to act as the directing and co-ordinating authority on international health work; (b) to establish and maintain effective collaboration with the United Nations, specialized agencies, governmental health administrations, professional groups and such other organizations as may be deemed appropriate; (c) to assist Governments, upon request, in strengthening health services; (d) to furnish appropriate technical assistance and, in emergencies, necessary aid upon the request or acceptance of Governments; (e) to provide or assist in providing, upon the request of the United Nations, health services and facilities to special groups, such as the peoples of trust territories; (f) to establish and maintain such administrative and technical services as may be required, including epidemiological and statistical services; (g) to stimulate and advance work to eradicate epidemic, endemic and other diseases; (h) to promote, in co-operation with other specialized agencies where necessary, the prevention of accidental injuries; (i) to promote, in co-operation with other specialized agencies where necessary, the improvement of nutrition, housing, sanitation, recreation, economic or working conditions and other aspects of environmental hygiene; (j) to promote co-operation among scientific and professional groups which contribute to the advancement of health; (k) to propose conventions, agreements and regulations, and make recommendations with respect to international health matters and to perform. WHO currently defines its role in public health as follows:[13] providing leadership on matters critical to health and engaging in partnerships where joint action is needed; shaping the research agenda and stimulating the generation, translation and dissemination of valuable knowledge; setting norms and standards and promoting and monitoring their implementation; articulating ethical and evidence-based policy options; providing technical support, catalyzing change, and building sustainable institutional capacity; and monitoring the health situation and assessing health trends.

The 20122013 budget further identified thirteen areas among which funding was distributed.[]

Communicable diseases
Two of those thirteen areas related to communicable diseases: the first, to reduce the "health, social and economic burden" of communicable diseases in general; the second to combat HIV/AIDS, malaria and tuberculosis in particular.[] In terms of HIV/AIDS, WHO works within the UNAIDS network and considers it important that it works in alignment with UNAIDS objectives and strategies. It also strives to involve sections of society other than health to help deal with the economic and social effects of the disease.[14] In line with UNAIDS, WHO has set itself the interim task between 2009 and 2015 of reducing the number of those aged 1524 years who are infected by 50%; reducing new HIV infections in children by 90%; and reducing HIV-related deaths by 25%.[15]

World Health Organization Although WHO dropped its commitment to a global malaria eradication campaign in the 1970s as too ambitious, it retains a strong commitment to malaria control. WHO's Global Malaria Programme works to keep track of malaria cases, and future problems in malaria control schemes. WHO is to report, likely in 2015, as to whether RTS,S/AS01, currently in research, is a viable malaria vaccine. For the time being, insecticide-treated mosquito nets and insecticide sprays are used to prevent the spread of malaria, as are antimalarial drugs particularly to vulnerable people such as pregnant women and young children.[16] WHO's help has contributed to a 40% fall in the number of deaths from tuberculosis between 1990 and 2010, and since 2005, it claims that over 46 million people have been treated and an estimated 7 million lives saved through practices advocated by WHO. These include engaging national governments and their financing, early diagnosis, standardising treatment, monitoring of the spread and impact of tuberculosis and stabilising the drug supply. It has also recognised the vulnerability of victims of HIV/AIDS to tuberculosis.[17] WHO aims to eradicate polio. It has also been successful in helping to reduce cases by 99% since the Global Polio Eradication Initiative was launched in 1988, which partnered WHO with Rotary International, the US Centers for Disease Control and Prevention (CDC) and the United Nations Childrens Fund (UNICEF), as well as smaller organizations. It works to immunize young children and prevent the re-emergence of cases in countries declared "polio-free".[18]

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Non-communicable diseases
Another of the thirteen areas is aimed at the prevention and reduction of "disease, disability and premature from chronic noncommunicable diseases, mental disorders, violence and injuries and visual impairment".[][19]

Life and lifestyle


WHO also works to "reduce morbidity and mortality and improve health during key stages of life, including pregnancy, childbirth, the neonatal period, childhood and adolescence, and improve sexual and reproductive health and promote active and healthy aging for all individuals".[][20] It also tries to prevent or reduce risk factors for"health conditions associated with use of tobacco, alcohol, drugs and other psychoactive substances, unhealthy diets and physical inactivity and unsafe sex".[][21][22] WHO works to improve nutrition, food safety and food security and to ensure this has a positive effect on public health and sustainable development.[]

Emergency work in the world


When any sort of disaster or emergency occurs, it is WHO's stated objective to reduce any consequences it may have on world health and its social and economic implications.[]

Health policy
WHO also addresses government health policy with two aims: firstly, "to address the underlying social and economic determinants of health through policies and programmes that enhance health equity and integrate pro-poor, genderresponsive, and human rights-based approaches" and secondly "to promote a healthier environment, intensify primary prevention and influence public policies in all sectors so as to address the root causes of environmental threats to health".[] In terms of health services, WHO looks to improve "governance, financing, staffing and management" and the availability and quality of evidence and research to guide policy making. It also strives to "ensure improved access, quality and use of medical products and technologies".[]

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Governance and support


The remaining two of WHO's thirteen identified policy areas relate to the role of WHO itself: firstly, "to provide leadership, strengthen governance and foster partnership and collaboration with countries, the United Nations system, and other stakeholders in order to fulfill the mandate of WHO in advancing the global health agenda" and secondly "to develop and sustain WHO as a flexible, learning organization, enabling it to carry out its mandate more efficiently and effectively".[]

Other work
The WHO and the World Bank constitute the core team responsible for administering the International Health Partnership (IHP+). The IHP+ is a group of partner governments, development agencies, civil society and others committed to improving the health of citizens in developing countries. Partners work together to put international principles for aid effectiveness and development cooperation into practice in the health sector.[23] In addition, the WHO has also promoted road safety.[24] Each year, the organization marks World Health Day focusing on a specific health promotion topic, timed to match the anniversary of WHO's founding. Recent themes have been drug resistance (2011) and ageing (2012).[25] As part of the United Nations, the World Health Organization supports work towards the Millennium Development Goals.[26] Of the eight Millennium Development Goals, three reducing child mortality by two-thirds, to reduce maternal deaths by three-quarters, and to halt and begin to reduce the spread of HIV/AIDS relate directly to WHO's scope; the other five inter-relate and have an impact on world health.[27]

Data handling and publications


The organization relies on contributions from renowned scientists and professionals to inform its work, such as the WHO Expert Committee on Biological Standardization,[28] the WHO Expert Committee on Leprosy,[29] and the WHO Study Group on Interprofessional Education & Collaborative Practice.[30] WHO has also worked on global initiatives in surgery, including emergency and essential surgical care,[31] trauma care,[32] and safe surgery.[33] The WHO Surgical Safety Checklist is in current use worldwide in the effort to improve patient safety.[34] WHO runs the Alliance for Health Policy and Systems Research, targeted at improving health policy and systems.[35] WHO aims to improve access to health research and literature in developing countries such as through the HINARI network.[36] The organization has published tools for monitoring the capacity of national health systems[37] and health workforces.[38] The Global Health Observatory (GHO) has been the WHO's main portal which provides access to data and analyses for key health themes by monitoring health situations around the globe.[39] The World Health Organization works to provide the needed health and well-being evidence through a variety of data collection platforms, including the World Health Survey covering almost 400,000 respondents from 70 countries,[40] and the Study on Global Ageing and Adult Health (SAGE) covering over 50,000 persons over 50 years old in 23 countries.[41] The Country Health Intelligence Portal (CHIP), has also been developed to provide an access point to information about the health services that are available in different countries.[42] The information gathered in this portal is utilized by the countries to set priorities for future strategies or plans, implement, monitor, and evaluate it. The WHO Assessment Instrument for Mental Health Systems (WHO-AIMS), the WHO Quality of Life Instrument (WHOQOL), and the Service Availability and Readiness Assessment (SARA) provide guidance for data collection.[43] Collaborative efforts between WHO and other agencies, such as through the Health Metrics Network, also aim to provide sufficient high-quality information to assist governmental decision making.[44] WHO promotes the development of capacities in member states to use and produce research that addresses their national needs, including through the Evidence-Informed Policy Network (EVIPNet).[45] The Pan American Health Organization (PAHO/AMRO) became the first region to develop and pass a policy on research for health approved in September 2009.[46]

World Health Organization The organization develops and promotes the use of evidence-based tools, norms and standards to support member states to inform health policy options. It oversees the implementation of the International Health Regulations, and publishes a series of medical classifications; of these, three are overreaching "reference classifications": the International Statistical Classification of Diseases (ICD), the International Classification of Functioning, Disability and Health (ICF) and the International Classification of Health Interventions (ICHI).[47] Other international policy frameworks produced by WHO include the International Code of Marketing of Breast-milk Substitutes (adopted in 1981),[48] Framework Convention on Tobacco Control (adopted in 2003)[49] and the Global Code of Practice on the International Recruitment of Health Personnel (adopted in 2010).[50] The WHO regularly publishes a World Health Report, its leading publication, including an expert assessment of a specific global health topic.[51] Other publications of WHO include the Bulletin of the World Health Organization,[52] the Eastern Mediterranean Health Journal (overseen by EMRO),[53] the Human Resources for Health (published in collaboration with BioMed Central),[54] and the Pan American Journal of Public Health (overseen by PAHO/AMRO).[55]

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Structure
The World Health Organization is a member of the United Nations Development Group.[56]

Membership
As of 2013[57], the WHO has 194 member states: all Member States of the United Nations except Liechtenstein, as well as the Cook Islands and Niue.[] (A state becomes a full member of WHO by ratifying the treaty known as the Constitution of the World Health Organization.) As of 2013[57], it also had two associate members, Puerto Rico and Tokelau.[58] Non-members of the WHO include Liechtenstein and Countries by World Health Organization other states with limited diplomatic recognition.[] Several other entities membership status have been granted observer status. Palestine is an observer as a "national liberation movement" recognised by the League of Arab States under United Nations Resolution 3118. The Holy See also attends as an observer, as does the Order of Malta.[] In 2010, Taiwan was invited under the name of "Chinese Taipei".[59] WHO Member States appoint delegations to the World Health Assembly, WHO's supreme decision-making body. All UN Member States are eligible for WHO membership, and, according to the WHO web site, "other countries may be admitted as members when their application has been approved by a simple majority vote of the World Health Assembly".[] In addition, the UN observer organizations International Committee of the Red Cross and International Federation of Red Cross and Red Crescent Societies have entered into "official relations" with WHO and are invited as observers. In the World Health Assembly they are seated along the other NGOs.[]

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Assembly and Executive Board


The World Health Assembly is the legislative and supreme body of WHO. Based in Geneva, it typically meets yearly in May. It appoints the Director-General every five years, and votes on matters of policy and finance of WHO, including the proposed budget. It also reviews reports of the Executive Board and decides whether there are areas of work requiring further examination. The Assembly elects 34 members, technically qualified in the field of health, to the Executive Board for three-year terms. The main functions of the Board are to carry out the decisions and policies of the Assembly, to advise it and to facilitate its work.[]

WHO Headquarters in Geneva

Regional offices
The regional divisions of WHO were created between 1949 and 1952, and are based on article 44 of WHO's constitution, which allowed the WHA to "establish a [single] regional organization to meet the special needs of [each defined] area". Many decisions are made at regional level, including importance discussions over WHO's budget, and in deciding the members of the next assembly, which are designated by the regions.[60]

Each region has a Regional Committee, which generally meets once a year, normally in the autumn. Representatives attend from each member or associative member in each region, including those states that are not fully recognised. For example, Palestine attends meetings of the Eastern Mediterranean Regional office. Each region also has a regional office.[60] Each Regional Office is headed by a Regional Director, who is elected by the Regional Committee. The Board must approve such appointments, although as of 2004, it had never overruled the preference of a regional committee. The exact role of the board in the process has been a subject of debate, but the practical effect has always been small.[60] Since 1999, Regional Directors serve for a once-renewable five-year term.[61] Each Regional Committee of the WHO consists of all the Health Department heads, in all the governments of the countries that constitute the Region. Aside from electing the Regional Director, the Regional Committee is also in charge of setting the guidelines for the implementation, within the region, of the health and other policies adopted by the World Health Assembly. The Regional Committee also serves as a progress review board for the actions of WHO within the Region. The Regional Director is effectively the head of WHO for his or her Region. The RD manages and/or supervises a staff of health and other experts at the regional offices and in specialized centers. The RD is also the direct supervising authorityconcomitantly with the WHO Director-Generalof all the heads of WHO country offices, known as WHO Representatives, within the Region.

Regional offices and regions of the WHO: Africa; HQ: Brazzaville, Republic of CongoCongoPan American Health OrganizationAmericas; HQ: Washington, DC, United States of AmericaUSAEastern MediterraneanMed.; HQ: Cairo, EgyptEurope; HQ: Copenhagen, DenmarkSouth East Asia; HQ: New Delhi, IndiaWestern Pacific; HQ: Manila, Philippines

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Regional Offices of WHO


Region Africa Headquarters Notes Website AFRO [63] EURO [64] SEARO [66]

Brazzaville, Republic AFRO includes most of Africa, with the exception of Egypt, Sudan, South Sudan, Tunisia, [62][] of Congo Libya, Somalia and Morocco (all fall under EMRO). Copenhagen, Denmark. New Delhi, India EURO includes most of Europe and Israel. []

Europe

South-East Asia

North Korea is served by SEARO.

[65]

Eastern Mediterranean

Cairo, Egypt

Eastern Mediterranean Regional office includes the countries of Africa that are not included EMRO [68] in AFRO, as well as the countries of the Middle East, except for Israel. Pakistan is served [67] by EMRO. WPRO covers all the Asian countries not served by SEARO and EMRO, and all the [69] countries in Oceania. South Korea is served by WPRO. Also known as the Pan American Health Organization (PAHO), and covers the [71] Americas. WPRO [70] AMRO [72]

Western Pacific

Manila, Philippines.

The Americas

Washington D.C., USA.

People Former Directors-General of WHO[73]


Name Brock Chisholm Marcolino Gomes Candau Halfdan T. Mahler Hiroshi Nakajima Gro Harlem Brundtland Lee Jong-wook Anders Nordstrm* Years of tenure 19481953 19531973 19731988 19881998 19982003 20032006 2006

*Acting Director-General following the death of Lee Jong-wook while in office

The head of the organization is the Director-General, appointed by the World Health Assembly.[] The current Director-General is Margaret Chan, who was appointed on 9 November 2006.[74] On 18 January 2012, Chan was nominated by the WHO's Executive Board for a second term. If confirmed by the World Health Assembly in May 2012, Dr Chan will remain Director-General until the end of June 2017.[75] WHO employs 8,500 people in 147 countries.[76] In support of the principle of a tobacco-free work environment the WHO does not recruit cigarette smokers.[77] The organization has previously instigated the Framework Convention on Tobacco Control in 2003.[78] The WHO operates "Goodwill Ambassadors", members of the arts, sport or other fields of public life aimed at drawing attention to WHO's initiatives and projects. There are currently five Goodwill Ambassadors (Jet Li, Nancy Brinker, Peng Liyuan, Yohei Sasakawa and the Vienna Philharmonic Orchestra) and a further ambassador associated with a partnership project (Craig David).[79]

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Country and liaison offices


The World Health Organization operates 147 country offices in all its regions.[] It also operates several liaison offices, including those with the European Union, United Nations and a single office covering the World Bank and International Monetary Fund. It also operates the International Agency for Research on Cancer in Lyon, France, and the WHO Centre for Health Development in Kobe, Japan.[80] Additional offices include those in Pristina; the West Bank and Gaza; the USMexican Border Field Office in El Paso; the Office of the Caribbean Program Coordination in Barbados; and Northern Micronesia office.[] There will generally be one WHO country office in the capital, occasionally accompanied by satellite-offices in the provinces or sub-regions of the country in question. The country office is headed by a WHO Representative (WR). As of 2010[57], the only WHO Representative outside Europe to be a national of that country was for the Libyan Arab Jamahiriya ("Libya"); all other staff were international. Those in the Region for the Americas, they are referred to as PAHO/WHO Representatives. In Europe, WHO Representatives also serve as Head of Country Office, and are nationals with the exception of Serbia; there are also Heads of Country Office in Albania, the Russian Federation, Tajikistan, Turkey, and Uzbekistan.[] The WR is member of the UN system country team which is coordinated by the UN System Resident Coordinator. The country office consists of the WR, and several health and other experts, both foreign and local, as well as the necessary support staff.[] The main functions of WHO country offices include being the primary adviser of that country's government in matters of health and pharmaceutical policies.[81]

Financing and partnerships


The WHO is financed by contributions from member states and outside donors. As of 2012[57], the largest annual assessed contributions from member states came from the United States ($110million), Japan ($58million), Germany ($37million), United Kingdom ($31million) and France ($31million).[82] The combined 20122013 budget has proposed a total expenditure of $3,959million, of which $944million (24%) will come from assessed contributions. This represented a significant fall in outlay compared to the previous 20092010 budget, adjusting to take account of previous underspends. Assessed contributions were kept the same. Voluntary contributions will account for $3,015million (76%), of which $800million is regarded as highly or moderately flexible funding, with the remainder tied to particular programmes or objectives.[83] In recent years, the WHO's work has involved increasing collaboration with external bodies.[84] As of 2002[57], a total of 473 NGOs had some form of partnership with WHO. There were 189 partnerships with international non-governmental organization (NGO) in formal "official relations" the rest being considered informal in character.[85] Partners include the Bill and Melinda Gates Foundation[86] and the Rockefeller Foundation.[87]

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Controversies
IAEA Agreement WHA 1240
In 1959, the WHO signed Agreement WHA 1240 with the International Atomic Energy Agency (IAEA). The agreement states that the WHO recognises the IAEA as having responsibility for peaceful nuclear energy without prejudice to the roles of the WHO of promoting health. However, the following paragraph adds: "whenever either organization proposes to initiate a programme or activity on a subject in which the other organization has or may have a substantial interest, the first party shall consult the other with a view to adjusting the matter by mutual agreement".[88] The nature of this statement has led some pressure groups and activists (including Women in Europe Demonstration on Chernobyl disaster day near WHO in Geneva for a Common Future) to believe that the WHO is restricted in its ability to investigate the effects on human health of radiation caused by the use of nuclear power and the continuing effects of nuclear disasters in Chernobyl and Fukushima. They believe WHO must regain what they see as "independence".[89][90][91]

Roman Catholic Church and AIDS


In 2003, the WHO denounced the Roman Curia's health department's opposition to the use of condoms, saying: "These incorrect statements about condoms and HIV are dangerous when we are facing a global pandemic which has already killed more than 20million people, and currently affects at least 42million."[92] As of 2009[57], the Catholic Church remains opposed to increasing the use of contraception to combat HIV/AIDS.[93] At the time, the World Health Assembly President, Guyana's Health Minister Leslie Ramsammy, condemned Pope Benedict's opposition to contraception, saying he was trying to "create confusion" and "impede" proven strategies in the battle against the disease.[94]

Intermittent preventive therapy


The aggressive support of the Bill & Melinda Gates Foundation for intermittent preventive therapy of malaria which included the commissioning of a report from the Institute of Medicine triggered a memo from the former WHO malaria chief Akira Kochi.[95]

Diet and sugar intake


Some of the research undertaken or supported by WHO to determine how people's lifestyles and environments are influencing whether they live in better or worse health can be controversial, as illustrated by a 2003 joint WHO/FAO report on nutrition and the prevention of chronic non-communicable disease,[96] which recommended that sugar should form no more than 10% of a healthy diet. This report led to lobbying by the sugar industry against the recommendation, to which the WHO/FAO responded by including in the report the statement "The Consultation recognized that a population goal for free sugars of less than 10% of total energy is controversial", but also stood by its recommendation based upon its own analysis of scientific studies.[97]

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2009 influenza pandemic


In 2007, the WHO organized work on pandemic influenza vaccine development through clinical trials in collaboration with many experts. A pandemic involving the H1N1 influenza virus was declared by Director-General Margaret Chan in April 2009. By the post-pandemic period critics claimed the WHO had exaggerated the danger, spreading "fear and confusion" rather than "immediate information".[98] Industry experts countered that the 2009 pandemic had led to "unprecedented collaboration between global health authorities, scientists and manufacturers, resulting in the most comprehensive pandemic response ever undertaken, with a number of vaccines approved for use three months after the pandemic declaration. This response was only possible because of the extensive preparations undertaken in during the last decade".[99]

References
[1] http:/ / www. who. int [24] WHO. Decade of Action for Road Safety 20112020 (http:/ / www. who. int/ roadsafety/ decade_of_action/ en/ ) [43] See respectively:* * * [57] http:/ / en. wikipedia. org/ w/ index. php?title=World_Health_Organization& action=edit [60] Burci, Vignes (2004). pp. 5357. [63] http:/ / www. afro. who. int [64] http:/ / www. euro. who. int [66] http:/ / www. searo. who. int [68] http:/ / www. emro. who. int [70] http:/ / www. wpro. who. int [72] http:/ / www. paho. org [96] Report of a Joint FAO/WHO Consultation. Diet, nutrition and the prevention of chronic diseases. Geneva: World Health Organization; 2003 (WHO Technical Report Series 916). [98] WHO admits errors in handling flu pandemic: Agency accused of overplaying danger of the virus as it swept the globe. (http:/ / www. msnbc. msn. com/ id/ 36421914/ ) Posted by msnbc.com [99] Abelina A et al. "Lessons from pandemic influenza A(H1N1): The research-based vaccine industrys perspective." (http:/ / www. evm-vaccines. org/ IMG/ pdf/ Lessons_from_pandemic_influenza. pdf) Vaccine 29 (2011) 11351138.

External links
www.who.int (http://www.who.int/) - Website World Health Organization (https://plus.google.com/+who/posts) on Google+

Walter Reed Army Institute of Research

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Walter Reed Army Institute of Research


This article is about the U.S. Army medical research institute (not the hospital). Otherwise, see Walter Reed (disambiguation). The Walter Reed Army Institute of Research (WRAIR) is the largest biomedical research facility administered by the U.S. Department of Defense. The institute is centered at the Forest Glen Annex, part of the unincorporated Silver Spring urban area in Maryland just north of Washington, DC, but it is a subordinate unit of the U.S. Army Medical Research and Materiel Command (USAMRMC), headquartered at nearby Fort Detrick, Maryland. At Forest Glen, the WRAIR has shared a large, modern laboratory and administrative facility the Sen Daniel K. Inouye Building, also known as Building 503 with the Naval Medical Research Center since 1999.

The "Daniel Inouye Building", Walter Reed Army Institute of Research, Silver Spring, Maryland, USA

Official mandate
Basic and applied medical research supporting U.S. military operations is the focus of WRAIR leaders and scientists. The institute fosters a unique understanding of military medical needs and environments, including the exposures (diseases and physical stresses) that troops encounter and the performance requirements of a deployed military force. Despite the focus on the military, however, the institute has historically also addressed and solved a variety of non-military medical problems prevalent in the United States and the wider world. It is particularly well known for advances in the field of tropical and infectious disease medicine.[citation needed] WRAIR Mission Conduct biomedical research that is responsive to Department of Defense and U.S. Army requirements and delivers life saving products including knowledge, technology, and medical materiel that sustain the combat effectiveness of the warfighter. WRAIR Vision Be the premier Department of Defense biomedical research organization, constantly relevant, integrating basic research and advanced technology that protects, projects, and sustains the warfighter today, invents global medical solutions for the future, and keeps the warfighter on point for the Nation. WRAIR Goals Be the warfighter's choice for military medical research, fulfilling the needs of the Department of Defense; Ensure that our organization and business practices are flexible, dynamic, and agile in order to respond to medical requirements in support of traditional and non-traditional Defense missions throughout the world; Enhance professional and personal development to keep our people competent and relevant. Gain a competitive edge in our unique core capabilities in support of evolving Defense health needs and missions

Walter Reed Army Institute of Research through empowerment of individuals and collective excellence; Embrace new technologies to speed the delivery of life saving products to the warfighter.

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Divisions and Subordinate Units of the WRAIR


Divisions at the Daniel K. Inouye Building
The Walter Reed Army Institute of Research hosts two Centers of Excellence for Military Psychiatry and Neuroscience and for Infectious Disease Research which are headquartered in Silver Spring, Maryland. Center for Military Psychiatry and Neuroscience Behavioral Biology Blast Induced Neurotrauma Brain Trauma Neuroprotection and Neurorestoration Military Psychiatry Research Transition Office

Center for Infectious Disease Research Bacterial and Rickettsial Diseases Entomology Program United States Military HIV Research Program Military Malaria Research Program Preventive Medicine Program Viral Diseases

Office of Science Education and Strategic Communications: Research Marketing Gains in Education of Mathematics & Science (GEMS) Students in 7th to 12th grade get an opportunity to participate in an internship for one to four weeks in an Army laboratory and learn technical skills. Advanced courses in subsequent years build upon prior experience. Science & Engineering Apprentice Program (SEAP) A cooperative education (work/study) program for high school students looking at a possible career in science and engineering. The program offers hands-on experience and mentoring in Army research and development activities in an actual Army laboratory. Science & Engineering Apprentice Program-College Qualified Leaders (SEAP-CQL) Paid internships for undergraduates seeking experience in Army research. The Walter Reed Army Institute of Research supports and collaborates on all other Army Educational Research Programs including the Mobile Discovery Center, the Junior Solar Spring, eCybermission, Uninitiates Introduction to Engineering (UNITE), Research & Engineering Apprentice Program (REAP), International Science & Engineering Fair (INTEL-ISEF), Internships Science & Engineering Program (ISEP), Junior Science & Humanities Symposium (JSHS), Women in Science Project (WISP), Career Related Experience in Science & Technology (CREST), Consortium Research Fellows Program (CRFP), and Science, Mathematics and Research for Transformation Defense Scholarshop for Service Program (SMART). Research Support: Preventive Medicine and Pathology Pilot Bioproduction Facility Clinical Trials Center Veterinary Medicine

Walter Reed Army Institute of Research Division of Human Subjects Protection DMAVS, Library and Statistical Services Information Management Logistics Office of Quality Activities Operations and Security Personnel Resource Management Safety

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WRAIR Pilot Lot Production Facility


The Pilot Bioproduction Facility (PBF) was established in 1958 as the Department of Biologics Research and is now located at the Walter Reed Army Institute of Research. The PBF mission is research, development, production, and testing of vaccines for human use.[1] The PBF at the Forest Glen Annex is a multi-use facility designed and operated for production of vaccines in compliance with the current Good Manufacturing (cGMP) regulations. Compliance with cGMP ensures that products prepared in the facility will be safe, potent, and reproducible. Since inception, the PBF has specialized in developing vaccines for Department of Defense mission-related disease threats. The PBF follows all federal regulations that apply to biological products and has expertise in the development and production of vaccines for the prevention of a variety of infectious diseases. Projects for public and private partners are accomplished through inter-agency and cooperative agreements. Vaccines are produced that will protect Soldiers against diseases that they might encounter in areas of deployment. These include vaccines to prevent dengue fever, malaria, meningitis, cholera, shigellosis, hepatitis A, and HIV. The PBF places compliance, cleanliness, and safety as top priorities in the production process of a vaccine. Once the vaccine is tested for safety, potency, and identity, the vaccine is released for use in approved human clinical studies. Several of the PBF's experimental vaccines have progressed on to advanced clinical testing. Although vaccine development process is complex, the expert[citation needed] PBF staff strives to ensure each step is completed successfully. The PBF has received awards and accolades for its role in developing vaccines for diseases such as hepatitis A and meningitis.[citation needed]

Global Platforms
United States Army Medical Research Unit- Europe (USAMRU-E) United States Army Medical Research Unit- Kenya (USAMRU-K) United States Army Medical Research Unit-Brazil (USAMRU-B) (decommissioned in 1997) United States Army Medical Component of Armed Forces Research Institute of Medical Sciences (USAMC-AFRIMS)

Walter Reed Army Institute of Research

1305

History of the WRAIR


For the pre-1953 history of WRAIR's predecessor institutions, see Army Medical School. The WRAIR traces its institutional heritage back to the Army Medical School, founded by U.S. Army Surgeon General George Sternberg in 1893, by some reckonings the first school of public health and preventive medicine in the world. The organization name was officially changed to the Walter Reed Army Institute of Research in 1953. Through the 20th century, medical discoveries continued to be found by Army researchers from the Army Medical School as U.S. military presence grew across the globe. Between 1900 and World War I (WWI), they showed that the cause of dengue fever was a filterable virus. They showed that parasites cause amebic dysentery and discovered a treatment for it. A vaccine against typhoid and a simple test for syphilis were developed. Chlorination as a method to disinfect drinking water was invented by Institute researchers. These and other advances in medicine, sanitation and hygiene were used by troops during WWI. By WWI, Army researchers from the Army Medical School were working in Asia and the Americas.[2] Into World War II (WWII), investigations into dengue, malaria, combat stress, wound treatment, chemical weapons, and military dentistry continued in preparation for the US military to meet new challenges and threats. One such threat was Japanese encephalitis and the Institute was responsible for developing the first vaccine to combat it. Since the end of WWII, WRAIR has evolved to continue serving Soldiers. The risks of nuclear weapons and chemical or biological warfare were added as new military health threats in the post-WWII era. As well, WRAIR researchers have contributed considerable gains in global medicine. For example, the Institute is responsible for the development of vaccines to prevent hepatitis A, meningococcal meningititis, and adenovirus that caused respiratory disease. In addition, WRAIR researchers have produced two highly effective antimalarial drugs and are currently working on an effective malaria vaccine.[3] WRAIR's medical contributions protect military and civilian populations worldwide.

Notes
[1] https:/ / wrair-www. army. mil/ Pilot_Bioproduction_Facility/ Welcome/ [2] https:/ / wrair-www. army. mil/ index. php?view=100years [3] https:/ / wrair-www. army. mil/ index. php?view=100years

External links
WRAIR Official Website (http://wrair-www.army.mil/) WRAIR Clinical Trials Center Website (http://www.wrairclinicaltrials.com/index_j.htm) This article contains information that originally came from US Government publications and websites and is in the public domain.

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Adverse drug reaction Source: http://en.wikipedia.org/w/index.php?oldid=562504771 Contributors: Acdx, Acewillett, Adverseevents, Ahmad510, Ajordanl, Akshaypharmd, Andy M. 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Zahnrad, Zangar, Zazou, Zereshk, Zgyorfi, ZiggyGT, Zippy, Zxc890, , weizhe, 1125 anonymous edits Blood glucose monitoring Source: http://en.wikipedia.org/w/index.php?oldid=566183041 Contributors: 7, AMackenzie, Adamixoye, Andy Maybury, Arcadian, Badgettrg, Baobabtree, Bernfarr, Blue2nyc, Calaka, Casliber, ChemGardener, Chowbok, ChrisGualtieri, CopperKettle, David-i98, Davidruben, Deltapi1049, Dr.Manesh, Dsault, Ebaker88, Essin, FactCheckerOne, Gaius Cornelius, Gioto, Ground Zero, Henry Delforn (old), Hmbr, Hyperion777, JGPDLTLJ, Jbrauker, Jcrew211, JeffJonez, Jimfbleak, Jofors, Kpjas, Ksero, MBirkholz, Manuelhp42, Martpeacock, Mbbradford, Mdaoust, Mikael Hggstrm, Miquonranger03, Moggie2002, Mpulier, Naniwako, Netha Hussain, Notepadpage, Nsaa, Oceanblue1205, Pegasi195, Peter McGinley, Polacrilex, Postal1, Rich Farmbrough, Rod57, Rsabbatini, Sgwfmk8, Shadowjams, Sinbaddasail0r, Spanglej, Squidonius, Tolly4bolly, Tomabt2, Tomas62, Trebor7, Truchti, Una Smith, Uncle Milty, Uthbrian, Vahagn Petrosyan, W.F.Galway, WhatamIdoing, 63 anonymous edits Congressional Budget Office Source: http://en.wikipedia.org/w/index.php?oldid=562948682 Contributors: 2D, AaronSw, Anders.Warga, Andy Marchbanks, Apatens, Arthur Rubin, Atif.t2, Bdell555, Billyboy01, Bloompicayune, Brabblebrex, CWenger, Cantons-de-l'Est, CapitalR, Commander Nemet, CommonsDelinker, CopperSquare, Cornell1890, Cybercobra, Dauster, Dgabbard, Dumaka, FRCP11, Fingers-of-Pyrex, Foreen, Ghs72, GoldRingChip, GreySuit, Haeinous, Jesse V., Jjb, JohnCD, Kevlar67, Kslays, Lukehowell, Mgerity, NekoDaemon, Nemesis63, Pjthepiano, Pmsyyz, Polmandc, Postdlf, Proofer47, Redemtionboy, Rnb, Runnerupnj, SS451, Sebmol, Smallman12q, Somedifferentstuff, Specter100, Steinsky, Tlabshier, Tneeley, Ulric1313, Urbanrenewal, VanBuren, Xenophrenic, 46 anonymous edits Certification Commission for Healthcare Information Technology Source: http://en.wikipedia.org/w/index.php?oldid=561443723 Contributors: Aspooner, Awillmore, Bearcat, Chronulator, 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Obiwankenobi, PigFlu Oink, Pvosta, Shaggyjacobs, Sstrader, Tom Morris, Versageek, Wrennj9, 12 anonymous edits Clostridium difficile Source: http://en.wikipedia.org/w/index.php?oldid=565724493 Contributors: 2over0, A Bertheim, AWhiteC, Abductive, Acdx, Adr11iano, Alansohn, AlexsandraSmart, Alison, Analgesic, Andrew73, Andrewman327, AnnaJune, Anthony Appleyard, Arcadian, AxelBoldt, Axeman89, Axl, Azhyd, BD2412, BMcCJ, Badgettrg, Baxil, Betdud, Biosthmors, Blackskyshining, Boffob, Bristol6or7, Bugsguy, CDN99, CJLillis, CRGreathouse, CTZMSC3, CanisRufus, Canthusus, Cburnett, Ceyockey, CharlesKiddell, Chicgeek, Cholmes75, Chowbok, Chris Capoccia, Chris the speller, Cleduc, ClockworkSoul, Cmitchelloneal, Colinf123, Corruptcopper, Culturejam, D1ff1c1le, Dah31, Daniel Mietchen, Davewild, Dcoetzee, Deflective, Delldot, Denisarona, Deor, Dewritech, Dj stone, Djc7118, Docrishi, Dougdragon, Download, Drlawley, Drmies, Drphilharmonic, Drravikanojia, Dspradau, Dulciana, Dvvndrpl, E A S, Eak435s, 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Hybrid, The Thing That Should Not Be, TheAMmollusc, TheRingess, Thorwald, Tim1965, Tinman44, Tinton5, Tisdalepardi, Tocino, Tommy12345, Tricky Wiki44, Trilobite, Trivialist, Tt chatter, TylerDurden8823, Uriel8, Valerius Tygart, Vikingstad, Viriditas, VolatileChemical, Warrior4321, WatchAndObserve, Wdfarmer, Wervo, WhisperToMe, Woodshed, Woohookitty, WriterHound, Yilloslime, ZayZayEM, Zeamays, Zsero, , , 282 anonymous edits Chargemaster Source: http://en.wikipedia.org/w/index.php?oldid=566729177 Contributors: Brzstudent, Cherkash, Cirt, Drbogdan, HaeB, Jeffq, PatrickHoefler, PinkAmpersand, Rosemaryholliday, The Rambling Man, Wbm1058, Woodshed Clinical data repository Source: http://en.wikipedia.org/w/index.php?oldid=504361402 Contributors: Assadarat, Danim, Edward, MarkMoffitt, Mendaliv, Ph.eyes, Sadads, Tomfulton, WhatamIdoing, Ydam, 6 anonymous edits Acute assessment unit Source: http://en.wikipedia.org/w/index.php?oldid=565000865 Contributors: Brenont, Dr Gangrene, Dsp13, Elliotf9, Espoo, Followthecops, Jfdwolff, Neko244, Neobeatnik, Panthro, Reinyday, Rjwilmsi, SimonP, Thomas Blomberg, UKWikiGuy, Volutin, 43 anonymous edits Tricare Source: http://en.wikipedia.org/w/index.php?oldid=564616697 Contributors: Ajpeters, Aleksandr Grigoryev, Anon lynx, Appraiser, Argon233, Bahamut0013, CJKreklow, Cgingold, Christopher Mahan, CrownP, EastTN, ElKevbo, GnarlyLikeWhoa, Goodrule, Historian 1000, Hmains, Hu02138, JPKirkpatrick, John Broughton, Jondiego, Julius Sahara, Koavf, LilHelpa, Litchic, MER-C, Magicwombat, Materialscientist, Mitsukai, Mmi2412, Nhzero, Nono64, PaulHanson, Pearle, Pesco, Peter.C, Ph.eyes, Prowler08, Quidam65, R'n'B, Reston10, Ringbang, Rougher07, Runningonbrains, Sdlawhon, Skapur, Skrowffo, Srich32977, TMLutas, Tdhowell2112, Tolly4bolly, Tricarehealth, Trivialist, Uaflyer, UnseemlyWeasel, Wrelwser43, 98 anonymous edits Veterans Health Administration Source: http://en.wikipedia.org/w/index.php?oldid=558813227 Contributors: 1722Eye, Andy Marchbanks, Antisoapbox, Antony-22, Arthena, Ashtango5, Bender235, CJKreklow, CapitalR, ChrisGualtieri, CliffC, Closeapple, Cmcnicoll, Common Man, Cornellrockey, Dancter, Dumaka, Dumelow, Ffirehorse, Green Giant, Hajatvrc, Hugo999, JDoorjam, Jeffme, Jeltz, Jgrandfield, JoJan, JustAGal, Ken Gallager, Kerowyn, Klemen Kocjancic, Kthickman, Lafille, Lwalt, Mandarax, Marketdiamond, Materialscientist, MerlinsMagic, Mineral, MrOllie, Nbauman, OtisTwinbo, Paine Ellsworth, Pearle, Perspectoff, Pfalstad, Remuel, Retanollo, Rjwilmsi, Rougher07, SDY, SergeantHippyZombie, Shortride, Specious, Station1, Student7, The Anome, Thryduulf, Vegaswikian, Veteran101, WhaleyTim, Who, Woohookitty, X-factor, Xnike315x, Zam21288, Zoicon5, , 73 anonymous edits Community health center Source: http://en.wikipedia.org/w/index.php?oldid=558750320 Contributors: Bender235, Bestsrvc, Biscuittin, Cattus, DavidRobertCollett, DexDor, Donthequail, FieldsTom, Gary King, Materialscientist, Moonriddengirl, Obiwankenobi, Petersam, Raimundo Pastor, Rjwilmsi, Vasurra, Verne Equinox, Vpca, Wireless friend, 18 anonymous edits College of Healthcare Information Management Executives Source: http://en.wikipedia.org/w/index.php?oldid=529875560 Contributors: CatherineMunro, Jesse V., Jsfouche, Klemen Kocjancic, Malcolma, Mhilliard99, Obiwankenobi, Pegship, Revco2k, 4 anonymous edits Heart failure Source: http://en.wikipedia.org/w/index.php?oldid=566516112 Contributors: 2602:306:BCA7:2FE0:A1C6:ADA7:9E41:FA5B, 9eyedeel, Aaron Walkhouse, Acebulf, Acroterion, Aeusoes1, Afr77, Ahoerstemeier, Alansohn, Alex.tan, Alexisfan, Allens, Almazi, Altenmann, Andrew c, Andrewr47, Anim8cme, Animeronin, Ann Stouter, Anta111, Anupamgahalout, Aojinglu, April13salix, Aqua lem, Arcadian, Arjayay, Aswang, Atomskninja, Atrzcins, Awolf1, Axl, BService, Badgerzilla, Badgettrg, Barroso123, Bart133, Bbbfn, Beatlemania159, Beeswaxcandle, Beetstra, Belton1, Benbest, Bigbluefish, Bijaykm21, Bobjgalindo, Bork, BoundaryRider, Brianga, Bryan Derksen, 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Heresiarch, William Avery, Wimt, Wlodzimierz, Wtmitchell, Xdenizen, Ykchandra, Zidane tribal, Zilliput, 594 anonymous edits Consolidated Omnibus Budget Reconciliation Act of 1985 Source: http://en.wikipedia.org/w/index.php?oldid=563777810 Contributors: 121a0012, 4wajzkd02, Aaronw, Ahsen, Andrew Gray, Argon233, Arichnad, Beland, Brontegirl, Business07, Cdjcon, Cgingold, Crzrussian, Cybercobra, DanJ7a, Delldot, Dewritech, Dragoon91, Eastlaw, Edward, Eldendor, Etudenc, Famspear, Foxtrotfarm, GoldRingChip, Gorwell, Ground Zero, Indon, Infoman99, Jjsupercobra, JohnManuel, Kuralyov, Loopy48, Lunalot, Moverton, Mr. COBRA, Mtmelendez, Mulp, Nopetro, Notinasnaid, Pchov, Quackslikeaduck, Quebec99, Rick Lehtinen, Rjwilmsi, RossPatterson, SandyGeorgia, SchuminWeb, SixBlueFish, Srleffler, Timrem, Uzkaphiel, Vanished user psdfiwnef3niurunfiuh234ruhfwdb7, Voidxor, Vurias, Woohookitty, Xanzzibar, Yellowdesk, Zeppelin462, 83 anonymous edits Council of governments Source: http://en.wikipedia.org/w/index.php?oldid=552666537 Contributors: 7401jason, Bdb484, Eastlaw, GoldRingChip, Gooday.1, Hooperbloob, Kbdank71, LouI, Mais oui!, Mfw113, Mjrmtg, Mmmm2446, Pegship, Rexwevk, Tostroski, Whitepaw, 8 anonymous edits Cost of living Source: http://en.wikipedia.org/w/index.php?oldid=556445424 Contributors: 16@r, Adamovicmladen, Aewold, Aff123a, Alansohn, AlbertaSunwapta, AlbertusIII, Angela, Ariel Pontes, Auntof6, Bamatama, Barek, BarrelProof, Bkwillwm, Bovineone, CanadianLinuxUser, Cburnett, Chealer, Ckatz, Commo1, Davodd, Dentren, DerHexer, Dorftrottel, DreamGuy, Elonka, Erntab72, Essent, Faradayplank, Flooda, Flying fanatic, Friedbeef, Funandtrvl, Gary King, Gerferg, Henry W. 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Turner, EagerToddler39, Edcolins, EdiOnjales, Elipongo, Espoo, Evans1982, Everything's so blurry, Fabrictramp, Finchbook01, Gcz79, GreatWhiteNortherner, Henrib736, Henroid100, Icenine378, J04n, JHunterJ, Jake Wartenberg, JayC, Jcedoz, Jennstarks, John of Reading, Jojhutton, Joseph Solis in Australia, Jov04sh, K. Korotkov, KapitanCookie, Kedlav, Kelslachelle, Khazar2, Labtechtc, Leafyplant, Lendorien, Leon3289, Luna Santin, Lyjusinski, Maddiekate, Materialscientist, McSly, Mdbabumia777, Mmarie15, Mucky38302, NMChico24, Neurolysis, Neutrality, Newsaholic, Ozmaweezer, Page54, Peny113, Per84, Pharos, Postoak, Pyrrhus16, Qwfp, Reign of Toads, RenamedUser01302013, Rrburke, ScorpianPK, Scottalter, Shady aly, Smithkn, Sophus Bie, Southparkave, Springbreak04, Stevecalloway, Timwestover, True54, TylerDurden8823, Tymmster, Versus22, WhatamIdoing, WikHead, Wikibruger, Wikipelli, Wtmitchell, Yenkaz, Ykmoon, 337 anonymous edits National Association of County and City Health Officials Source: http://en.wikipedia.org/w/index.php?oldid=560887624 Contributors: Bearcat, CastAStone, Edward, Giraffedata, GoodDay, GrahamHardy, NACCHOWEB, NAHID, Paul foord, Tassedethe, Wouterstomp, 6 anonymous edits National Board for Respiratory Care Source: http://en.wikipedia.org/w/index.php?oldid=506772495 Contributors: Buster40004, ChrisGualtieri, EoGuy, Je.rrt, Pulmonological, R'n'B, Steamroller Assault, Wpollard, 14 anonymous edits The New England Journal of Medicine Source: http://en.wikipedia.org/w/index.php?oldid=561193913 Contributors: 3Bananas, Aa77zz, Al3xil, Amfootball, Andy Marchbanks, Balaji Ravichandran, BalticPat22, Bender235, BookWorm34, Chupacabras, Clifflandis, DGG, Da Vynci, Danelo, David Gerard, Davidb928, Divinenephron, Editora7, Edward Hyde, Enozkan, Epiding, Ericblazek, Erikd7, Espresso Addict, F.chiodo, Feezo, Finlux, GCNYC, Ghaly, Ghostexorcist, Gobonobo, Good Olfactory, Grahammcmahon, Guillaume2303, HMSSolent, Headbomb, JeffDrazen, Jesanj, Jfdwolff, JimJonesap, Jmh649, Karada, Khazar2, LOL, Lambdoid, LaszloWalrus, Leonard Finger, LincolnSt, Lipothymia, Lquilter, MadGuy7023, Mais oui!, Mr Bungle, MuanN, Nbauman, Nikanop, NorthBySouthBaranof, Oaktree b, OhanaUnited, Ossip Groth, Outriggr, Paisa, Pascal.Tesson, Pfrishauf, Ph.eyes, Phoebe, Pointillist, Polarlys, PrincessofLlyr, Proud2bAmerican, Prowsej, Randykitty, RekishiEJ, Rjwilmsi, Rosenzweig, Schoen, Sdason, Shinjuku7, Shisha-Tom, Skittleys, Srich32977, TakuyaMurata, Tangerine99, Tcsouthpaw, Tzahy, WLU, Wavelength, WhatamIdoing, Will Beback, Wmahan, Woohookitty, Zujua, , 71 anonymous edits Non-communicable disease Source: http://en.wikipedia.org/w/index.php?oldid=564366376 Contributors: 69ingcats, Abhishekitmbm, Alansohn, Ashia605134, Bhaby qouh, Bytelemed, Capricorn42, ChrisGualtieri, Chriswaterguy, Cranmills, Declan Clam, Demonicdays81, Ellyrobi, Fat&Happy, Friginator, FunnyPika, Gaius Cornelius, Gareth Griffith-Jones, Gatorgirl7563, Genioussrk, Geog362JenVla, Giridhar, Glacialfox, Greensburger, Guptan99, H.sanat, HexaChord, Idontthinkthisisoffensive, Immunize, Intermittentgardener, It Is Me Here, J.delanoy, Janvo, Jim1138, KerathFreeman, Lag722, MER-C, Madhero88, Mangoe, Marnhagues98, Materialscientist, Mato, Myanw, Ohnoitsjamie, Philip Trueman, Pinethicket, Polmandc, Ponyo, Purplewowies, RDBrown, Rjwilmsi, Rsrikanth05, SURIV, Samwb123, Sav vas, Sbharris, Skagedal, Sriharsh1234, Stanqo, Tgeairn, The wub, Tobias Bergemann, Total-MAdMaN, True Pagan Warrior, WhatamIdoing, WnHsBeast, Worldrrecordd, Wousifou7, Zimmil, Zodon, 160 anonymous edits National Health Service Source: http://en.wikipedia.org/w/index.php?oldid=564633144 Contributors: 200cake, 2D, Alansohn, Aleksmot, Aoso0ck, BD2412, BananaFiend, Barryob, BenJWoodcroft, Bomph, Bons, Breadandcheese, Brookie, CanadianLinuxUser, Catfish61, Chamal N, Chase me ladies, I'm the Cavalry, Chromenano, D.M. from Ukraine, D0nnie Dark0 96, Dirkbb, Doomsday28, Douglas the Comeback Kid, DrSearch, Drutton57, Druzhnik, Ecoleg, Efelante planante Efelante, Epbr123, Excirial, Exurbis67, Favonian, Fishiehelper2, Flatterworld, Fondls, Frehley, F, G-Man, George Ponderevo, Gnevin, Grundle2600, Gsarwa, Gymnophoria, Hauskalainen, Iridescent, J.delanoy, JaT, Jade0970, Jamie S, JasonAQuest, Jauerback, JaySherman88, Jennavecia, Jmcc150, Jpbowen, Justme89, Jza84, Kaihsu, Keith D, Khukri, Kierant, Kinu, Kuru, Legis, LincolnSt, Lucasreddinger, MBRZ48, Mais oui!, Marcos, Matthewrbowker, Mattythewhite, Mauls, Melonkelon, Merlinsorca, Mogism, Mtaylor848, Myasuda, Nationalstudentsurvey, Nmg20, Oliknibbs, Omutumo, Optimist on the run, Ottawakismet, Owain, Phantomsteve, Pol098, R'n'B, RFBailey, Raimundo Pastor, Rayman60, Rbakker99, Responsible?, Richard75, Rjensen, Roadnote, Rsrikanth05, Rwendland, SDC, Salavat, Scroggie, Sharkli, Sir Arthur Williams, Sky4t0k, Smifis, Somedifferentstuff, Steve Milburn, Tainter, Thom2002, Tim!, Tolly4bolly, Tom Morris, Unreal7, Widr, Wikipelli, Ysgol Rhiwabon, Zagubov, 174 , anonymous edits National Institutes of Health Source: http://en.wikipedia.org/w/index.php?oldid=562890790 Contributors: -- April, 12345urbana, 2over0, 4Jays1034, AAMiller, AED, APTEM, Acroterion, Aetatis, Ajoyprabhu, Al E., All Male Action, Alysonwonderlan, AndrewDressel, Andrewman327, Andy Marchbanks, Antony-22, Barney Bruchstein, Bdragon, 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Mrpeach, NCATS2, NLMOCPL, Nectarflowed, Neutrality, Nihiltres, Nikki, Nnemo, Nono64, Nopetro, Notta skeptic, Npho, Oaktree b, Ohconfucius, Old Guard, PFHLai, Papillonderecherche, PaulHanson, PaweS, Pearle, Ph.eyes, Policymatters09, Postdlf, Proteins, Qmwne235, Quantumash, Randomalb, Remember, Rentaferret, Rjanag, Rm1271, RockPoetry, Sakaton, Sardanaphalus, SchreyP, Sciencedude14, Sebwite, Shaggorama, Shogatetus, SilverStar, Slof, Temporaluser, Texas141, The Anome, The Nut, The Red Peacock, The Transhumanist, Theflyer, Tikiwont, TimVickers, Tony1, Twang, Two Hearted River, Ulflarsen, Utcursch, Vianello, WAS 4.250, Wasted Time R, WatsonCN, WhisperToMe, Ydorb, Yerpo, Zereshk, 136 anonymous edits National Institute of Mental Health Source: http://en.wikipedia.org/w/index.php?oldid=557090292 Contributors: Afterwriting, Ageyban, Albert109, Alereon, Barticus88, Chowbok, Chris the speller, Clairano, Clindberg, Colonies Chris, DGG, Eastlaw, Elwikipedista, Epolk, Eubulides, EverSince, Felipe P, Finn-Zoltan, Gamaliel, Gcurrier563, George100, Geraldk, Gilliam, GreenReaper, Gtrmp, HectorMoffet, Howsa12, Icenine0, Jengod, Jt, Kate, Keithbob, Leefogel, Marechal Ney, Markworthen, Mcminno782, Mercurywoodrose, Michaelzeng7, NIMHpress, Nkocharh, Ost316, Paddles, PeaceNT, Petersam, Rick Block, Ronz, S. 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Sullivan, Sandyocean, Sardanaphalus, SidP, Swpb, The Anome, TheBlueFlamingo, Theflyer, Tinton5, , 47 anonymous edits National Institute for Occupational Safety and Health Source: http://en.wikipedia.org/w/index.php?oldid=559646984 Contributors: Adhcgeo, Alan Liefting, Anna Frodesiak, Beetstra, CMoretz, Cacycle, Chetan0203, Chrissy385, CopperSquare, Cypherquest, DSA9, Davidl53, Dekimasu, Drmies, Dzlot, Eastlaw, Eequor, Emilheilborn, Epolk, Fdacosta, FieldMarine, FredAmes, Funandtrvl, GabeIglesia, Haeinous, Hsh8, Hu12, Irf5, JZNIOSH, Jahiegel, Jprg1966, Kelapstick, Kumioko (renamed), Laroach, Lotje, Micki.baron, MoodyGroove, Mxheil, Novasource, PaulHanson, Pearle, Physchim62, Postdlf, Pzavon, Rjwilmsi, Ssd, Texture, Tim!, Tinton5, Tisdalepardi, Viriditas, Vveridian, WTRiker, Whitesaint, Whkoh, Worksafe, 41 anonymous edits United States National Library of Medicine Source: http://en.wikipedia.org/w/index.php?oldid=565796485 Contributors: Bigredbrain, Brout8, Centrx, Clairano, Clifflandis, Clindberg, ColetteHochstein, DGtal, Daveb, DavidReilly, Dcirovic, Diciassettedimaggio, Djembayz, Dpbalazs, Eastlaw, Epolk, Falcor7, French Librarian, Guillaume2303, HazyM, Hmdpsych, Hugh2414, Icairns, Ida Shaw, JamesAM, Jengod, Joseaperez, Ken.wootton, KnightRider, Leeearnest, Lexor, LinDrug, Lunchboxhero, M4gnum0n, MarcoTolo, Marian Librarian, Museumscribe, Nick C, Noisy, Nolispanmo, Nurg, Officiallyover, Omassey, Petersam, Philosophypsychiatry, Prolog, Ragesoss, RayAYang, RedWolf, Remember the dot, Rich Farmbrough, Rick Block, SBhawk, Samrosie, Sardanaphalus, Shore7, Smallbones, Stevey7788, Streltzer, Theflyer, Valerius Tygart, Wael Nassar, Wavelength, Yobol, Ytraere, Ytrottier, Zereshk, Zzuuzz, 28 anonymous edits

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Omnibus Budget Reconciliation Act of 1993 Source: http://en.wikipedia.org/w/index.php?oldid=558016423 Contributors: AgenorMoE, Alana Smithy, Astuishin, Behun, Calwatch, Cheeseburrito, Dalekemm, Dauster, Dpv, Ed Price, Edward, Free-encyclopedia, Gbbinning, GoldRingChip, Ground Zero, Harksaw, Headhill, Jameshands, Jaraalbe, Loodog, Mcduff, Mmann1988, Moverton, Oatmeal batman, Ofus, Reinoe, RobyWayne, Slon02, Staszek Lem, Tastyummy, Thargor Orlando, Wikiz876, Wknight94, Woohookitty, 68 anonymous edits Drug overdose Source: http://en.wikipedia.org/w/index.php?oldid=566809648 Contributors: 16@r, 5 albert square, AbsolutDan, Accounting4Taste, Acdx, Albert0, Alfio, Angelito7, Anxietycello, Aphid360, Arcadian, Asaravia1, Avyshue, BD2412, Barrykmorris, Bdoggio, Belton1, Bobmack89x, Bobo192, Bordechr000, Borgx, Brandonm2, Brunton, C6541, CJHURST7000, COMPFUNK2, CSWarren, Cacycle, Caltas, CanadianLinuxUser, Carabinieri, CardinalDan, ChrisGualtieri, Coder Dan, Coppertwig, Cuthbertwong, Cyan, 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Rjwilmsi, Rmashhadi, Roastytoast, RootSword, Sam42, Scottalter, Seven of Nine, Shirt58, Shoshonna, SimonP, Specter01010, Sylvea, T1n0, Teamabby, Technopat, Th1rt3en, The Anome, The Rambling Man, The Thing That Should Not Be, ThurnerRupert, Tide rolls, Tom Morris, Tonkie67, TravelingCat, Urod, Uthbrian, Viriditas, WacoJacko, Wikieditor06, Wirehead, Wouterstomp, XtinaS, Yaluen, Zandperl, Zone46, 299 anonymous edits Post-anesthesia care unit Source: http://en.wikipedia.org/w/index.php?oldid=555449796 Contributors: Acdx, Dresdnhope, Facts707, Gemty, Genuine918, Hawaiian717, Jsfouche, Kyoko, Mereda, Mfranck, Natalya, Nephron, Nen, Omnivee, Ormanagement, Pablo X, Primetime, Reinyday, Some standardized rigour, Swissxarmyxgirl, Theo10011, 14 anonymous edits Personal Care Assistant Source: http://en.wikipedia.org/w/index.php?oldid=562683182 Contributors: -1g, BuzyBody, Cosmos1745, Edward, Funnyfarmofdoom, Guptan99, Hamoudafg, Hauskalainen, Jmh649, Kikodawgzzz, Kyng, LilHelpa, Malcolma, PTJoshua, Rpyle731, SeventhHell, Wavelength, 7 anonymous edits NHS primary care trust Source: http://en.wikipedia.org/w/index.php?oldid=548623952 Contributors: Anthonyhcole, Apau98, Armouredduck, Batmanand, BlueStar303, Caramcd, Cloudbound, Dumelow, Everyking, Gabbe, Hezy12, Kaihsu, Mais oui!, Malcolma, Mandarax, Marek69, Millstream3, Paul Gard, PaulHanson, Philosophicles, Pjbeef, Rd232, Rjwilmsi, Ross Burgess, RuthLivingstone, Smerus, TimBentley, Waggers, Wereon, Woohookitty, 42 anonymous edits Primary health care Source: http://en.wikipedia.org/w/index.php?oldid=566837921 Contributors: AED, Abanima, Amt10, BD2412, Becritical, Bertberry, Blathnaid, Bleaney, Bobjgalindo, Bovineone, Brasenose, Brothejr, Cforrester101, Chairman S., Chinawhitecotton, Chriswaterguy, Citations, Cyclozodiac, Danielroberts, David1217, Dbmulder, DemonicPartyHat, Draeco, Edward, Ellaliao, Eubulides, Eumolpo, Fianaw, Fuzzypillow7, Guptan99, Hopsyturvy, Htonl, I dream of horses, Iridescent, Jaydenm, Jesanj, Jomonoe123, Jpbowen, Kalyan gnp, Kavibhalla, Kca68, Khukri, Kofiannansrevenge, Korrawit, Kwx913, MER-C, Mac, Mandarax, Markneth, Mcapdevila, Millstream3, Mindmatrix, Mogism, Mololom, Namazu-tron, Naniwako, Neelix, Nopetro, Np5377, Parvagilla, PaulHanson, Paulkweaver, Pax:Vobiscum, Prashanthns, Princeattractive, Raimundo Pastor, Ramanjanda, Renamed user 39932kk3, Rettetast, Rich Farmbrough, Rjr-17, Rjwilmsi, RobDe68, RuhNaimi, San taunk, Sfmammamia, Shanekruger, Sherry007020, Shiftchange, Snigbrook, Stevewetson, Supotmails, Tedder, TheCatalyst31, Thl9015, Tintenfischlein, Tolly4bolly, Versageek, Vmenkov, Widr, Wklee, Wlahead, Zeitlupe, Ziphon, Zoyanazni, 77 anonymous edits Protected health information Source: http://en.wikipedia.org/w/index.php?oldid=548853861 Contributors: Atomician, Bluerasberry, Dr.saptarshi, Hohenloh, JeepdaySock, Kbierce, Malcolma, Michael Hardy, Morrillonline, Niels Olson, Orenburg1, Pieper923, Rdjfraser, Rillian, Scoobylover, 17 anonymous edits United States Public Health Service Source: http://en.wikipedia.org/w/index.php?oldid=552550600 Contributors: 76student, Aeusoes1, Akerans, AstroNomer, Avoided, AzureCitizen, Before My Ken, Bensonme, Biruitorul, Bnash108, Bobbiejopiper, Calabe1992, Calathan, CambridgeBayWeather, Cbjohnny, Clairano, ClubOranje, Comp25, Consciousnessbliss, Corysn123, Cuprum17, Curps, Dcfowler1, Emperorbma, Epolk, Fry1989, GABaker, Gcsnowhawk, Glenlarson, GoldRingChip, Illegitimate Barrister, Infrogmation, Jcembree, Jeffq, John Broughton, Jrtayloriv, Jselanikio, JuniperisCommunis, Kdar, KillerChihuahua, Kjkolb, Kristenq, Liverpool5555, Mauls, Militaryace, Monedula, MrDolomite, Mulad, Mxn, Neovu79, Night Gyr, PaulHanson, Pearle, Phs1798, Pwforaker, Pzavon, Rjwilmsi, Rob110178, Rougher07, SDMFAnthony, Sardanaphalus, Saros136, Schmiteye, Shell Kinney, Spitfire, Streltzer, Tedickey, Tfine80, Theflyer, Usphsstacey, Vegaswikian, Zeamays, 106 anonymous edits Peripherally inserted central catheter Source: http://en.wikipedia.org/w/index.php?oldid=566304721 Contributors: Ageekgal, Blueridge9, Ceyockey, Chris the speller, Chrisrtrvi, Clinical Cases, Connk, DKqwerty, Dcoetzee, DocWatson42, Download, Dreamdasher, Dwayne, Eeekster, Enkyo2, Evand, Fratrep, Gigemag76, Hooperbloob, InvictaHOG, J. Wawyn, JackWasey, Jamesmcmahon0, Jayqq, Jbyers2, Jfdwolff, Juliahd, KrakatoaKatie, Kyoko, La Pianista, Lynstar1, Maddiekate, Mandarax, Marinov84, Mikael Hggstrm, NCurse, Numbersinstitute, Pefozzy, Pinkfud, Popezilla, Puffin, RDBrown, RPGP, Reach Out to the Truth, Rmosler2100, Robert1947, Salicaceae, Sarahlawsarah, SchuminWeb, Summeree, Vaxiouse, WhatamIdoing, Withazee, 70 anonymous edits Prospective payment system Source: http://en.wikipedia.org/w/index.php?oldid=539826423 Contributors: Css86, Jesanj, Racklever, Thealliedhacker, Woohookitty Quality-adjusted life year Source: http://en.wikipedia.org/w/index.php?oldid=564759203 Contributors: Atimm, Bibit (usurped), Biker Biker, Chipuni, Chris Capoccia, Dnasp, DocEcon, EdW UK, Erianna, Fairandbalanced, Findfunds, Funandtrvl, Gigacephalus, Gnusmas, GregorB, Hauskalainen, Haywardmedical, Honeydew, Jarble, John Quiggin, Lambiam, Last Polar Bear, Laura.kudrna, Lilac Soul, Marcika, MartinPoulter, Mgumn, Mikael Hggstrm, Millstream3, Mojomama, Norman-Fried, Nsaa, Ofol, Pattigustafson, Ph.eyes, Prietol, Pstevens, Qnc, Qwertyca, Rjwilmsi, Rod57, Ruyur, Segsegreyjanra, Snowmanradio, Tamfang, Theopolisme, Thryduulf, Uncle G, Vincej, 35 anonymous edits Quality improvement organizations Source: http://en.wikipedia.org/w/index.php?oldid=559290196 Contributors: Anazem, AxelBoldt, Ceyockey, Dancter, DaveGorman, Donama, Dpv, Edward, Funandtrvl, Imogenne, Jason Quinn, Jnhaswell, Khazar2, Mahmoud F Nassar, Malcolmxl5, Medtimer, Mikeblas, Oleg Alexandrov, Pearle, QuiteUnusual, Sbrownback, SpuriousQ, Thkerms, Vegaswikian, Wikinfo1112, 46 anonymous edits Resource-based relative value scale Source: http://en.wikipedia.org/w/index.php?oldid=565462291 Contributors: Abrech, Alansohn, Argon233, BradPatrick, Cmcnicoll, DabMachine, Dhsiao, Drrwinters, Elukenich, Freshfields, Hmains, Jacobsmoore, Jesanj, Jiang, Jnc, John of Reading, Josephbrophy, LittleDan, Lschofield, Michaelbeebe, Nbarth, Officiallyover, Ohnoitsjamie, Pagrashtak, PaulHanson, R'n'B, R000t, Rjwilmsi, SWAdair, Shawnnicholsonca, Skapur, Topbanana, Trailblazer ch, Zigger, 30 anonymous edits Radiology information system Source: http://en.wikipedia.org/w/index.php?oldid=552900158 Contributors: Amdescombes, Anthony Appleyard, BD2412, Ceejayoz, Erkan Yilmaz, Fred.Pendleton, Hamoudafg, Hawkinsbiz, Heathd, HotHabanero, Ihealthbuzz, Kentikin, Kku, Kr-val, Menlong.Wang, Obiwankenobi, P.gibellini, Pak21, Publicoption, Solar scorch, Tonyteri, UkPaolo, WhatamIdoing, Woohookitty, Zabdiel, 35 anonymous edits Robert Wood Johnson Foundation Source: http://en.wikipedia.org/w/index.php?oldid=559644884 Contributors: Aarose1, Ajax151, Asprose, Autarch, Brilliant Pebble, BrokenSegue, Charlie Damron, Chheath, Cybercobra, Cypherquest, DJ Clayworth, David Justin, Disavian, Dvansickle, Dwlsports, Edward, Flowanda, Glebeda, Gobonobo, Goethean, GoingBatty, GoldRingChip, Ground Zero, Hemotropic, Isaac Sanolnacov, J1r2, JTSchreiber, Jeisenberg, John Quiggin, Kane5187, Lamro, LeaW, Mean as custard, Mootros, Nrojas0131, Nunquam Dormio, Orlady, Pegship, Pgillman, Philanthrogrl, Philanthrogrl33, Philippe, Pvosta, RBBrittain, RWJF, Richard Arthur Norton (1958- ), Rjwilmsi, Rockdowner, RussBlau, Rwjfuser1, Scottrobbie, Spalding, Student7, SummerPhD, Syrthiss, Teeetotalling Student, The myoclonic jerk, TonyTheTiger, Trivialist, Velocipedus, Visite fortuitement prolonge, Whiterox, 72 anonymous edits Registered nurse Source: http://en.wikipedia.org/w/index.php?oldid=567011041 Contributors: 9letters, ABF, ARA, Abraham, Acgator09, Addihockey10, AdjustShift, Aking, Alansohn, Ale700, Allens, Am088, AmandaEuans, Amaury, Anne, AnonGuy, Appraiser, Ashlie123, Ashlux, Avoided, Ayrton Prost, Az29, BP7865, BPeddle, Baa, Basie, Blethering Scot, Brightdayler, BullRangifer, Butwhatdoiknow, Cab88, Cahk, CanadianLinuxUser, Cattus, Chris the speller, Chzz, ClubApotheosis, Cmhbob, Cody5, Complex (de), Courcelles, Coutcin, Ctbolt, Cuzzies, DARTH SIDIOUS 2, DMacks, DakotaDAllen, Darklilac, Dasani, Davandron, Daveswagon, Davidprior, Debigboy, Deborahdotk, Dencybk, Devons1972, Dgym71, Discospinster, Doelleri, Drawn Some, Drmies, Echuck215, EdwinHJ, ElKevbo, ElationAviation, Enigma55, Falcon8765, Feedintm, Feliz Flor, Fernweh.us, Flowanda, Flyguy649 - 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Registered Health Information Technician Source: http://en.wikipedia.org/w/index.php?oldid=552319908 Contributors: Bidmus, Dshun, Guitargabe21, Malcolma, Mheart, Obiwankenobi, PamD, Pjoef, Ronark, 1 anonymous edits Regional Health Information Organization Source: http://en.wikipedia.org/w/index.php?oldid=556217157 Contributors: Aboutmovies, Adavidb, Alucard (Dr.), Arcadian, Bearcat, Cdbrandt, Cohesion, Corhio-baker, Dana boomer, Dmeranda, Download, Emilyspape, Futurekansas, GLHamilton, Giraffedata, Iki-turso, JoeSmack, Jpeg007, Kimchi.sg, LWG, Ligulem, MPerdomo, Manomohan, Mogism, Numinousity, Obankston, Oemmler, Optigan13, Poohunter, Prakash Nadkarni, Rjwilmsi, Rrburke, Salimaleikoum, Sommers, Splash, Spritetrain, Sthlny, Synergy, Thane, The Illusive Man, Thisrunson, Tridium, 57 anonymous edits Substance Abuse and Mental Health Services Administration Source: http://en.wikipedia.org/w/index.php?oldid=554580188 Contributors: Alison9, Amiaheroyet, Bobo192, Docu, Dysprosia, Eastlaw, FatHanna, Flavoredair, GregorB, Iridescent, Lynne Jorgensen, Materialscientist, Novangelis, Nyttend, Oxymoron83, Pearle, Pegship, Postdlf, Remember, SAMHSA New Media, Sardanaphalus, Scarpy, Seyfertfan, Sheogorath, SidP, Tanthalas39, Template namespace initialisation script, Tetsuo, TheParanoidOne, TruthbringerToronto, Voidxor, WhatamIdoing, Wikiklrsc, Zach99998, ^demon, 39 anonymous edits Birth attendant Source: http://en.wikipedia.org/w/index.php?oldid=533348527 Contributors: Delicious carbuncle, Drumzandspace2000, Guptan99, Laraterese, Mr.Atoz, NawlinWiki, Pegship, PomegranateMary, Rjwilmsi, Rshumway, Sddoula, Tolabor, Una Smith, WLU, WhatamIdoing, Zodon, 8 anonymous edits State Children's Health Insurance Program Source: http://en.wikipedia.org/w/index.php?oldid=557816905 Contributors: Abe.Froman, Americanprogress, Andrew c, Argon233, Arjun01, Art8641, Asherkobin, AutoGeek, Balonkey, Beetstra, Beland, Benjiho, Butterfly6822, Cast, Cbrons, Censoredchinese, Chaudtheclod, Chris the speller, Colonies Chris, CopperSquare, Cremepuff222, DMCer, Dauster, Dchorner, Desk Jockey, DirkvdM, Dmol, DroEsperanto, EastTN, Eddroid, Electiontechnology, Elenapearl, Emerson7, Erich gasboy, Erikespe, Flawdlogic, Flockmeal, Frankywong2000, Gaius Cornelius, Glane23, Gloriamarie, GoldRingChip, Good Olfactory, Ground Zero, Grundle2600, Guest2625, Guyzero, Gwhitman, HRSAOC, HangingCurve, Hellno2, Herenthere, Hitherebrian, Infoworker, Int21h, Ishicola, Itinerant1, JEB90, Jackhammer111, JeffersonThought, Jeffhall318, Jergen, Jersey Devil, Jersyko, Jgh32, Joncnunn, Keekeek, Keilana, KevinPiper, Koavf, Kumioko (renamed), Kuralyov, LawnBoy7, Libertybrewcity, MKil, Maximus Rex, Metroid690, Mhym, Mike Serfas, Mineral, Mrbill66, Nedwilliams, Nixeagle, Nopetro, Nummymuffin, Optigan13, Postdlf, Prothonotar, Pseudo-Richard, QKat, Quackslikeaduck, Raprchju, Rjwilmsi, Scjessey, Sfmammamia, Shangrilaista, Simesa, SimonP, SimpleParadox, Sirkan, SouthernNights, Stealthound, SteveSims, Superm401, T. Ruth Bixbey, The Librarian at Terminus, The Transhumanist, Therefore, Timc, TimidGuy, USER-cacophony, Walk the cat, Ward3001, Wasatch Guy, Wasted Time R, WhisperToMe, Wiki emma johnson, Xyz or die, Yonghokim, Ziadhn, 191 anonymous edits State Food and Drug Administration Source: http://en.wikipedia.org/w/index.php?oldid=544078240 Contributors: Alan Liefting, Alfie66, Cattus, Charles Matthews, Dekimasu, Fred Bauder, F, G716, God iz Ded, Jiang, Karada, Kollision, MartinYoung, Miffy bunny, Nanahoshi, Pearle, Ph.eyes, Pvosta, Sardanaphalus, Talismanmurphy, Timrollpickering, Utc-100, WUCEB, WhisperToMe, Zigger, 8 anonymous edits Medicare Sustainable Growth Rate Source: http://en.wikipedia.org/w/index.php?oldid=530966394 Contributors: Acgator09, Cmcnicoll, Eastlaw, Jesanj, LilHelpa, Miriamlaugesen, Mulp, Rich Farmbrough, 2 anonymous edits Nursing home Source: http://en.wikipedia.org/w/index.php?oldid=563596005 Contributors: 2600:1010:B11B:B742:816D:FD32:B27D:24CA, AbbyKelleyite, Adavidb, Afterlaws, Agarff, Alison, Allyn, Alotoknowledge, Altenmann, Amdaltc, Anna o, Apatens, Argon233, Assistedlivingguru, Atlant, Austin Matthews, BW95, Bddmagic, Beewms, Bender235, Binksternet, Biologic, Brksmith, BrodyEdwards, Burlywood, BuzyBody, Calltech, CambridgeBayWeather, Caringeditor, Cesay, Chris G, Chris the speller, Ciotog, Clicketyclack, CliffC, Craig Collins-Young, Crayvella, Csutoras, Ctiefel, DJ Clayworth, Darwinek, Devil Master, Dl2000, Dpv, Drm310, Dshafrir, Dust Filter, Dwight Burdette, Dyns, EastTN, Edowdy, Epastore, Epbr123, ErikaLeigh, Espoo, Excirial, Fayenatic london, Flewis, Flowanda, Franklinatlantic, Furrykef, Gaia Octavia Agrippa, Gmaxwell, GnarlieBrown, Graham87, Grutness, Guaranamania, Haeinous, Hmrox, Ingolfson, Iqubalasad, J.delanoy, JDODL, Jaclynallmonalfa, Jason Quinn, Jdgator1000, Jeb.rodgers, Jechternacht, Jimb12345, Jimzeigler, John of Reading, Johndillonmission, Johnfbrady, Jpbowen, Jrutberg, Jvdura, Jwhiteh, Jwhiteh2, Kigali1, Kintetsubuffalo, KrakatoaKatie, Lapappey, Lapatord, LeadSongDog, Leevanjackson, Legacyproject, Levineps, LilHelpa, Lotje, Ltcguy, MUjA, Manway, Manxruler, Margaret Havnermeyer, Marksdaman, MastCell, Matilda, Max937, Melonkelon, Mikegman, Mikemea, Monkeyman, Mormegil, MorrisRob, Navy II, Nexusmn, North Wolf Inuit, Northamerica1000, Notedgrant, Ohnoitsjamie, Orion Minor, OurBigCircle, PCAndrew, Pacula, Paul A, Pdcook, Philip Trueman, ProveIt, Quandaryus, Qvpedia, R'n'B, RJASE1, RJaguar3, Ranantha, Reaper Eternal, Redjw, Residentialcarehome, Retire58, Riana, Rjwilmsi, Rocky2011, Rossumcapek, Rothorpe, Schomynv, Scottalter, Sheridan, SimonP, SiobhanHansa, Smartbugmedia, Spiorad, StaticGull, Stickee, Student7, Sundiiiaaa, Svetovid, Syra987, THB, TRATTOOO, Tatterfly, Tazman1989, Tentinator, Thededalus, Themfromspace, Thomas Bjrkan, Timpaws, Tinton5, Tivitowner, Tomorrow's Guides, Versageek, Vsmith, WhisperToMe, Wikiklrsc, Wikimichael1979, Wmakins, Xyannix, Yuan.C.Lee, 282 anonymous edits Special needs plan Source: http://en.wikipedia.org/w/index.php?oldid=498662607 Contributors: Jaymirage, Rich Farmbrough, Tony1, Vegaswikian, 5 anonymous edits Supplemental Security Income Source: http://en.wikipedia.org/w/index.php?oldid=566335222 Contributors: A E Francis, Andrew Gray, Argon233, AutoGeek, Bdfischer, Bender235, Big Cowboy Kev, BoMica4, Boneyard, Briaboru, Bwrs, Cbustapeck, Chester Markel, DH85868993, DUESEST, Edward, Fat&Happy, Fivestones, Frongle, G Clark, Gaius Cornelius, Gbleem, Grundle2600, Hadal, Hellno2, Hmains, Jahiegel, Jason Quinn, Jlschutze, JoeSmack, Johannes1989, K-UNIT, Kikodawgzzz, Kilonum, King Vegita, Logan, MarkS, Mercy11, Patrickdavidson, PaulHanson, Rfc1394, Rich Farmbrough, Rjwilmsi, Sannse, Sarge, Scott Illini, Shamrock13, Shultz, Shultz III, Shultz IV, Sipfrancine, Stephaniesoftball, Stormwriter, Sue Gardner, SummerPhD, The wub, Thedavid, Timrollpickering, Tirkfl, Traverlaw, Truth4Sale, Vgranucci, Voyager7711, W5WMW, Whatelse, Woohookitty, WriterHound, 79 anonymous edits Selective serotonin reuptake inhibitor Source: http://en.wikipedia.org/w/index.php?oldid=567092299 Contributors: "alyosha", 00AgentBond93, 130.94.122.xxx, 15.253, 168..., 213.253.39.xxx, 24.93.53.xxx, A. B., Aaron Schulz, Abrech, Adamd1008, Adw2000, Aerugo, Agjchs, Albwus, Aleenf1, Alessandra Napolitano, Alfred Bertheim, Algotroll, Altimmons, Altmentalities, AmiLynch, Amyphilo, Andycjp, Animated Cascade, AnnaFrance, Annejo1, Anthonyhcole, Anypodetos, Aplomado, Arcadian, Ari x, Arstchnca, Arteitle, Arthena, Atomer9, Avb, AxelBoldt, Axxaer, BD2412, BLewis, Barryhilligan, Barticus88, Basket of Puppies, Beetstra, Before My Ken, Bernalano, Boghog, Brian Crawford, Cacycle, Candicejvs, Catdude, Cedders, Ceyockey, Cgenese, ChemNerd, Chemgirl131, Chetu85, Chiliboy82, Chris Capoccia, Chrisballinger, Chrislk02, Ciphergoth, Closeapple, Colonel Warden, CommonsDelinker, Conversion script, Copyeditor42, Coroebus, Correogsk, CountryMama27, Cryptic C62, Cult Handsome Seriously Silly, Custardninja, Custoo, DJBarney24, Dan Polansky, DanBealeCocks, Danhash, Danielfullerton, Dareu2move, Dave souza, Daverocks, David Hedlund, DavidFisher, Davidruben, Dawn Bard, Dccarroll, Dcirovic, DeadEyeArrow, Deanshan2, Dehughes, Deli nk, Delirium, Deor, Deshad111, DevonTree, Dianadeister, Digfarenough, DionneH, Discospinster, DisillusionedBitterAndKnackered, Dj stone, Djdavi, Dogface, Doldrums, Domitius, Doobins, Draicone, Dsmithsmithy, Dub8lad1, Edgar181, Editor182, Eequor, ElBenevolente, Enzo Aquarius, Epolk, Ermacora, Esamb, Eve Hall, Everything Is Numbers, F-402, FT2, Fenice, Feour, Flume, Fortnern, Frap, FreddoR, Fullerton.daniel, Funandtrvl, Gaff, Galaxiaad, Genie, Gigemag76, Gingras, Gleng, Gobonobo, Googie man, GorillaWarfare, Gpvos, Graham87, Grebaldar, GridEpsilon, Ground Zero, Guybrush, H-Vergilius, H8jd5, Haakon.kierulf, Haloaskew, Hazard-SJ, Headwes, Helgihg, Ian Pitchford, Ich, Identity11024, Ino5hiro, Itsmejudith, J.delanoy, Jake13jake, Jakebarrington, James R. 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Third-party administrator Source: http://en.wikipedia.org/w/index.php?oldid=537153624 Contributors: Abpa, Altzinn, Benji64, Cmcnicoll, Echuck215, Editor233, Fisherjs, Frap, Funandtrvl, Hmwith, Ian Pitchford, John Vandenberg, John wesley, Kickyandfun, Malik Shabazz, Mean as custard, MeritainHealth, NameIsRon, Pgc512, Sephiroth kills, Srfraley, Taxman, Tetfsu, Vegaswikian, ZuluPapa5, 27 anonymous edits Tension headache Source: http://en.wikipedia.org/w/index.php?oldid=566013343 Contributors: 11943e, Airplaneman, Alansohn, Anassagora, Andycjp, Anthonyhcole, Apers0n, Arcadian, Aris riyanto, Arnesh, Arteitle, Backpainadvisor, Blehfu, Brian Schlosser42, DanielRigal, Deli nk, Docwalsh, DragonLord, Drchazz, Fireice, Fredrik, FreplySpang, Furrykef, Gnikhil, Gwernol, Hydra Rain, Invertzoo, Jarich, Jeder1, Jfdwolff, Jgro, Jmarchn, Jmh649, Joefromrandb, Junkyardprince, Jurriaan Schulman, K1ll3rb1u3, Khaledhany, L337p4wn, Lesion, Macrakis, Marblespire, Matt Millar, Mattisse, Metadox, Metasquares, 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File:EdinburghRoyalInfirmary.jpg Source: http://en.wikipedia.org/w/index.php?title=File:EdinburghRoyalInfirmary.jpg License: Creative Commons Attribution-Share Alike 2.0 Generic Contributors: Lisa Jarvis Image:Ed st marys hospital rochester.JPG Source: http://en.wikipedia.org/w/index.php?title=File:Ed_st_marys_hospital_rochester.JPG License: GNU Free Documentation License Contributors: Akinom, Jonathunder, Roke, Sanandros, Xnatedawgx File:Emergency room sign.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Emergency_room_sign.jpg License: GNU Free Documentation License Contributors: Coolcaesar at en.wikipedia File:Accident and Emergency (sign).png Source: http://en.wikipedia.org/w/index.php?title=File:Accident_and_Emergency_(sign).png License: GNU Free Documentation License Contributors: DragonflySixtyseven, Farzeymedic File:KM Transplantat.JPEG Source: http://en.wikipedia.org/w/index.php?title=File:KM_Transplantat.JPEG License: Creative Commons Attribution-ShareAlike 3.0 Unported Contributors: Dietzel65, John Bergenholtz, 1 , anonymous edits Image:Bone marrow biopsy.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Bone_marrow_biopsy.jpg License: Public Domain Contributors: Photographers Mate 2nd Class Chad McNeeley file:Commons-logo.svg Source: http://en.wikipedia.org/w/index.php?title=File:Commons-logo.svg License: logo Contributors: Anomie File:Great Seal of the United States (obverse).svg Source: http://en.wikipedia.org/w/index.php?title=File:Great_Seal_of_the_United_States_(obverse).svg License: Public Domain Contributors: U.S. Government File:Barack Obama reacts to the passing of Healthcare bill.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Barack_Obama_reacts_to_the_passing_of_Healthcare_bill.jpg License: Public Domain Contributors: Pete Souza File:Obama signing health care-20100323.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Obama_signing_health_care-20100323.jpg License: Creative Commons Attribution 2.0 Contributors: Keith Ellison File:PPACA Premium Chart.jpg Source: http://en.wikipedia.org/w/index.php?title=File:PPACA_Premium_Chart.jpg License: Public Domain Contributors: Congressional Research Service File:PPACA Premium CRS.jpg Source: http://en.wikipedia.org/w/index.php?title=File:PPACA_Premium_CRS.jpg License: Public Domain Contributors: Congressional Research Service File:Joint blog close PS-0774.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Joint_blog_close_PS-0774.jpg License: Public Domain Contributors: White House (Pete Souza) File:9.12 tea party in DC.jpg Source: http://en.wikipedia.org/w/index.php?title=File:9.12_tea_party_in_DC.jpg License: Creative Commons Attribution-Sharealike 3.0 Contributors: NYyankees51 File:111th Congress 1st session Senate roll call 396.svg Source: http://en.wikipedia.org/w/index.php?title=File:111th_Congress_1st_session_Senate_roll_call_396.svg License: Creative Commons Attribution-Sharealike 3.0 Contributors: Kurykh File:111th Congress roll call 165.svg Source: http://en.wikipedia.org/w/index.php?title=File:111th_Congress_roll_call_165.svg License: Creative Commons Attribution-Sharealike 3.0 Contributors: Kurykh File:Obama signs health care-20100323.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Obama_signs_health_care-20100323.jpg License: Creative Commons Attribution 2.0 Contributors: Pete Souza File:Insurance Exchanges, State Status.png Source: http://en.wikipedia.org/w/index.php?title=File:Insurance_Exchanges,_State_Status.png License: Creative Commons Zero Contributors: This image: Sb101 (talk) (Uploads) File:U.S. Healthcare Costs as a Percentage of GDP.png Source: http://en.wikipedia.org/w/index.php?title=File:U.S._Healthcare_Costs_as_a_Percentage_of_GDP.png License: GNU Free Documentation License Contributors: Farcaster File:U.S. National Healthcare Expenditures - Annual Percent Change.png Source: http://en.wikipedia.org/w/index.php?title=File:U.S._National_Healthcare_Expenditures_-_Annual_Percent_Change.png License: GNU Free Documentation License Contributors: Farcaster File:CBO - Budget Impact of Affordable Care Act - March 2012.png Source: http://en.wikipedia.org/w/index.php?title=File:CBO_-_Budget_Impact_of_Affordable_Care_Act_-_March_2012.png License: Public Domain Contributors: Congressional Budget Office File:Medicaid Expansion By State.png Source: http://en.wikipedia.org/w/index.php?title=File:Medicaid_Expansion_By_State.png License: Creative Commons Zero Contributors: Sb101 (talk) (Uploads) Image:Cancer ad 1938.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Cancer_ad_1938.jpg License: Public Domain Contributors: Uncredited WPA artist. New York : Federal Art Project, between 1936 and 1938. Image:Hope Lodge W32 jeh.JPG Source: http://en.wikipedia.org/w/index.php?title=File:Hope_Lodge_W32_jeh.JPG License: Public Domain Contributors: Jim.henderson File:Universal North Building.JPG Source: http://en.wikipedia.org/w/index.php?title=File:Universal_North_Building.JPG License: Creative Commons Attribution-Sharealike 3.0 Contributors: AgnosticPreachersKid File:Flag of the United States.svg Source: http://en.wikipedia.org/w/index.php?title=File:Flag_of_the_United_States.svg License: Public Domain Contributors: Anomie File:President George H W Bush Signing of the ADA (Americans with Disabilities Act) Bill 1990.gif Source: http://en.wikipedia.org/w/index.php?title=File:President_George_H_W_Bush_Signing_of_the_ADA_(Americans_with_Disabilities_Act)_Bill_1990.gif License: Public Domain Contributors: President Bush. Office of Speechwriting. File:Handicapped Accessible sign.svg Source: http://en.wikipedia.org/w/index.php?title=File:Handicapped_Accessible_sign.svg License: Public Domain Contributors: Damian Yerrick, Fry1989, Jeff G., Lensovet, Ltljltlj, NE2, Ned Scott, Nickel Chromo, Thisisbossi, Wknight94, Wutsje, J, 12 anonymous edits File:Drano Lake accessible fishing platform signage.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Drano_Lake_accessible_fishing_platform_signage.jpg License: Creative Commons Attribution 2.0 Contributors: FlickreviewR, OttawaAC, Werewombat File:Bush signs in ADA of 1990.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Bush_signs_in_ADA_of_1990.jpg License: Public Domain Contributors: Denniss, Infrogmation, Nikkimaria, Werewombat File:Studying1.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Studying1.jpg License: Creative Commons Attribution-Sharealike 3.0 Contributors: Atlasowa, Dbachmann, Jmh649, WhatamIdoing File:Illu cerebrum lobes.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Illu_cerebrum_lobes.jpg License: Public Domain Contributors: Arcadian, Danhash, Was a bee File:Ritalin.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Ritalin.jpg License: Public Domain Contributors: ABF, Editor182, Eug, J o File:Folder Hexagonal Icon.svg Source: http://en.wikipedia.org/w/index.php?title=File:Folder_Hexagonal_Icon.svg License: GNU Free Documentation License Contributors: Anomie, Mifter File:Drug-induced hepatitis low mag.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Drug-induced_hepatitis_low_mag.jpg License: Creative Commons Attribution-Sharealike 3.0 Contributors: Nephron Image:AED open cutout.jpg Source: http://en.wikipedia.org/w/index.php?title=File:AED_open_cutout.jpg License: Creative Commons Attribution 3.0 Contributors: User:Owain.davies Image:CPR training-03.jpg Source: http://en.wikipedia.org/w/index.php?title=File:CPR_training-03.jpg License: Creative Commons Attribution-Sharealike 2.0 Contributors: Rama Image:AED Oimachi 06z1399sv.jpg Source: http://en.wikipedia.org/w/index.php?title=File:AED_Oimachi_06z1399sv.jpg License: GNU Free Documentation License Contributors: User:Cory Image:Automated External Defibrillator (symbol).svg Source: http://en.wikipedia.org/w/index.php?title=File:Automated_External_Defibrillator_(symbol).svg License: unknown Contributors: Anime Addict AA, Bohme, Cosmo1976, DragonflySixtyseven, Flominator, INeverCry, Nevit, Nickel Chromo, Owain.davies, Stefan-Xp, Torsch, 1 anonymous edits Image:Defib Checks.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Defib_Checks.jpg License: Public Domain Contributors: Owain.davies Image:Defib electrode placement.png Source: http://en.wikipedia.org/w/index.php?title=File:Defib_electrode_placement.png License: Creative Commons Attribution 3.0 Contributors: Owain Davies Image:Welfare Benefits Payments Graph.gif Source: http://en.wikipedia.org/w/index.php?title=File:Welfare_Benefits_Payments_Graph.gif License: Public Domain Contributors: United States Department of Health and Human Services File:SinusRhythmLabels.svg Source: http://en.wikipedia.org/w/index.php?title=File:SinusRhythmLabels.svg License: Public Domain Contributors: Created by Agateller (Anthony Atkielski), converted to svg by atom.

Image Sources, Licenses and Contributors


File:RapidAFib150.jpg Source: http://en.wikipedia.org/w/index.php?title=File:RapidAFib150.jpg License: Creative Commons Attribution-Sharealike 3.0 Contributors: User:Jmh649 File:Afib ecg.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Afib_ecg.jpg License: Creative Commons Attribution-ShareAlike 3.0 Unported Contributors: J. Heuser File:Heart conduct sinus.gif Source: http://en.wikipedia.org/w/index.php?title=File:Heart_conduct_sinus.gif License: Creative Commons Attribution-ShareAlike 3.0 Unported Contributors: User:JHeuser File:Heart conduct atrialfib.gif Source: http://en.wikipedia.org/w/index.php?title=File:Heart_conduct_atrialfib.gif License: Creative Commons Attribution-ShareAlike 3.0 Unported Contributors: User:JHeuser File:AhimaLogo.png Source: http://en.wikipedia.org/w/index.php?title=File:AhimaLogo.png License: Creative Commons Zero Contributors: Pmanske File:Red_Ribbon.svg Source: http://en.wikipedia.org/w/index.php?title=File:Red_Ribbon.svg License: GNU Free Documentation License Contributors: Gary van der Merwe File:Symptoms of acute HIV infection.svg Source: http://en.wikipedia.org/w/index.php?title=File:Symptoms_of_acute_HIV_infection.svg License: Public Domain Contributors: Mikael Hggstrm File:Symptoms of AIDS.svg Source: http://en.wikipedia.org/w/index.php?title=File:Symptoms_of_AIDS.svg License: Creative Commons Zero Contributors: Mikael Hggstrm File:AIDS Poster If You're Dabbling in Drugs 1989.jpg Source: http://en.wikipedia.org/w/index.php?title=File:AIDS_Poster_If_You're_Dabbling_in_Drugs_1989.jpg License: Public Domain Contributors: Original uploader was Grcampbell at en.wikipedia (Original text : NIH) File:HIV Virion-en.png Source: http://en.wikipedia.org/w/index.php?title=File:HIV_Virion-en.png License: Public domain Contributors: US National Institute of Health (redrawn by en:User:Carl Henderson) File:HIV-budding-Color.jpg Source: http://en.wikipedia.org/w/index.php?title=File:HIV-budding-Color.jpg License: Public Domain Contributors: Photo Credit: C. Goldsmith Content Providers: CDC/ C. Goldsmith, P. Feorino, E. L. Palmer, W. R. McManus File:Hiv-timecourse.png Source: http://en.wikipedia.org/w/index.php?title=File:Hiv-timecourse.png License: GNU Free Documentation License Contributors: Bukk, Dirk Hnniger, Emw, Jurema Oliveira, Optigan13, Phoenix-forgotten, Ranveig, RicHard-59, Sanao, Sigve, Werieth, 4 anonymous edits File:AIDS Clinic, McLeod Ganj, 2010.jpg Source: http://en.wikipedia.org/w/index.php?title=File:AIDS_Clinic,_McLeod_Ganj,_2010.jpg License: Creative Commons Attribution-Sharealike 3.0 Contributors: User:John Hill File:Abacavir (Ziagen) 300mg.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Abacavir_(Ziagen)_300mg.jpg License: GNU Free Documentation License Contributors: Bastique, Edgar181, J o, LX, Mattes, Oks, 1 anonymous edits File:HIV-AIDS world map - DALY - WHO2004.svg Source: http://en.wikipedia.org/w/index.php?title=File:HIV-AIDS_world_map_-_DALY_-_WHO2004.svg License: Creative Commons Attribution-Sharealike 2.5 Contributors: Lokal_Profil File:AIDS_and_HIV_prevalence.svg Source: http://en.wikipedia.org/w/index.php?title=File:AIDS_and_HIV_prevalence.svg License: Public Domain Contributors: Escondites Permission= PD-self File:Mmwr-aids-July1981-report-101.png Source: http://en.wikipedia.org/w/index.php?title=File:Mmwr-aids-July1981-report-101.png License: Public Domain Contributors: Alan, Bluerasberry, Scray, Wiki-ny-2007 File:Robert Gallo.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Robert_Gallo.jpg License: Public domain Contributors: NIH File:SIV primates.jpg Source: http://en.wikipedia.org/w/index.php?title=File:SIV_primates.jpg License: Creative Commons Attribution-Sharealike 3.0 Contributors: Barcelona.Zoologico.Mangabey.Gris.jpg: Year of the dragon Chlorocebus_pygerythrus_Grne_Meerkatze.JPG: Yoky Schimpanse_zoo-leipig.jpg: Thomas Lersch derivative work: Graham Colm (talk) File:Ryan White.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Ryan_White.jpg License: Creative Commons Attribution 3.0 Contributors: Original uploader was Wildhartlivie at en.wikipedia File:Life expectancy in some Southern African countries 1958 to 2003.png Source: http://en.wikipedia.org/w/index.php?title=File:Life_expectancy_in_some_Southern_African_countries_1958_to_2003.png License: GNU Free Documentation License Contributors: Created by Xed File:American Medical Association HQ.JPG Source: http://en.wikipedia.org/w/index.php?title=File:American_Medical_Association_HQ.JPG License: GNU Free Documentation License Contributors: Original uploader was Pinotgris at en.wikipedia File:Saving_Lives_with_SMS_for_Life.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Saving_Lives_with_SMS_for_Life.jpg License: Creative Commons Attribution 2.0 Contributors: Jeffrey Gluck from USA Image:Asclepius staff.svg Source: http://en.wikipedia.org/w/index.php?title=File:Asclepius_staff.svg License: Public Domain Contributors: AnonMoos, Lusanaherandraton, Popolon, VIGNERON, 2 anonymous edits File:American Public Health by Matthew Bisanz.JPG Source: http://en.wikipedia.org/w/index.php?title=File:American_Public_Health_by_Matthew_Bisanz.JPG License: GNU Lesser General Public License Contributors: MBisanz talk File:Aspartate transaminase.png Source: http://en.wikipedia.org/w/index.php?title=File:Aspartate_transaminase.png License: GNU Free Documentation License Contributors: en:User:Blastwizard File:Aspartate aminotransferase reaction.png Source: http://en.wikipedia.org/w/index.php?title=File:Aspartate_aminotransferase_reaction.png License: Creative Commons Attribution-Sharealike 3.0 Contributors: Benzenamino File:Aspartate aminotransferase.png Source: http://en.wikipedia.org/w/index.php?title=File:Aspartate_aminotransferase.png License: Creative Commons Attribution-Sharealike 3.0 Contributors: User:Benzenamino File:Aspartate aminotransferase mechanism.png Source: http://en.wikipedia.org/w/index.php?title=File:Aspartate_aminotransferase_mechanism.png License: Creative Commons Attribution-Sharealike 3.0 Contributors: Benzenamino File:Fruit wholesalers in Haikou.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Fruit_wholesalers_in_Haikou.jpg License: Creative Commons Zero Contributors: User:Anna Frodesiak File:AYUSH Logo.jpg Source: http://en.wikipedia.org/w/index.php?title=File:AYUSH_Logo.jpg License: Creative Commons Attribution-Sharealike 3.0 Contributors: User:Lpachuau File:Coronary artery bypass surgery Image 657C-PH.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Coronary_artery_bypass_surgery_Image_657C-PH.jpg License: Public Domain Contributors: Fran Rogers, Gothika, Jacklee, Morning2k, Patho, SunOfErat Image:Heart saphenous coronary grafts.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Heart_saphenous_coronary_grafts.jpg License: Creative Commons Attribution 2.5 Contributors: Patrick J. 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Image Sources, Licenses and Contributors


File:Acupuncture1-1.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Acupuncture1-1.jpg License: Public Domain Contributors: Kyle Hunter (= original uploader Kphunter at en.wikipedia) File:Chiropractic spinal adjustment.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Chiropractic_spinal_adjustment.jpg License: Creative Commons Attribution-Sharealike 2.0 Contributors: Michael Dorausch from Venice File:Fallerjfa.JPG Source: http://en.wikipedia.org/w/index.php?title=File:Fallerjfa.JPG License: Creative Commons Attribution-Sharealike 3.0 Contributors: User:Ramon FVelasquez File:Bangladesh Prayer.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Bangladesh_Prayer.jpg License: Creative Commons Attribution 2.0 Contributors: Hasan Iqbal Wamy from Dhaka, Bangladesh Image: Cap logo.gif Source: http://en.wikipedia.org/w/index.php?title=File:Cap_logo.gif License: Copyrighted free use Contributors: Industry Canada File:JamestownCAPsite.jpg Source: http://en.wikipedia.org/w/index.php?title=File:JamestownCAPsite.jpg License: Creative Commons Attribution-Sharealike 2.0 Contributors: Hyfen at en.wikipedia File:Rosies ct scan.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Rosies_ct_scan.jpg License: Creative Commons Attribution 3.0 Contributors: rosiescancerfund.com File:CT US4115698 Fig1.jpg Source: http://en.wikipedia.org/w/index.php?title=File:CT_US4115698_Fig1.jpg License: unknown Contributors: User:Tom Toyosaki File:CT ScoutView.jpg Source: http://en.wikipedia.org/w/index.php?title=File:CT_ScoutView.jpg License: Creative Commons Zero Contributors: Hg6996 File:Computed tomography of human brain - large.png Source: http://en.wikipedia.org/w/index.php?title=File:Computed_tomography_of_human_brain_-_large.png License: unknown Contributors: Blurpeace, CountingPine, Herald Alberich, Julia W, Llorenzi, Mikael Hggstrm, Nevit, Takabeg, Was a bee, Wickey-nl Image:Bonereconstruction.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Bonereconstruction.jpg License: GNU Free Documentation License Contributors: Original uploader was Zgyorfi at en.wikipedia Image:SADDLE PE.JPG Source: http://en.wikipedia.org/w/index.php?title=File:SADDLE_PE.JPG License: Public Domain Contributors: Image:Wilms Tumor CTScan.OGG Source: http://en.wikipedia.org/w/index.php?title=File:Wilms_Tumor_CTScan.OGG License: Public Domain Contributors: Jarekt File:CT Scan of Dale Mahalko's brain-skull.jpg Source: http://en.wikipedia.org/w/index.php?title=File:CT_Scan_of_Dale_Mahalko's_brain-skull.jpg License: Creative Commons Attribution-Sharealike 3.0 Contributors: User:DMahalko Image:ct-internals.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Ct-internals.jpg License: GNU Free Documentation License Contributors: Bjecas, Delldot, Hehkuviini, Nevit, 8 anonymous edits Image:Ct-workstation-neck.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Ct-workstation-neck.jpg License: GNU Free Documentation License Contributors: en:User:ChumpusRex File:Synchrotron microtomography of Atelopus franciscus head - pone.0022080.s003.ogv Source: http://en.wikipedia.org/w/index.php?title=File:Synchrotron_microtomography_of_Atelopus_franciscus_head_-_pone.0022080.s003.ogv License: Creative Commons Attribution 2.5 Contributors: Boistel R, Aubin T, Cloetens P, Langer M, Gillet B, Josset P, Pollet N, Herrel A Image:RIMG0277.JPG Source: http://en.wikipedia.org/w/index.php?title=File:RIMG0277.JPG License: Creative Commons Attribution-ShareAlike 3.0 Unported Contributors: User:Philipcosson Image:emi1010.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Emi1010.jpg License: Public domain Contributors: Philipcosson File:Blood Glucose Testing.JPG Source: http://en.wikipedia.org/w/index.php?title=File:Blood_Glucose_Testing.JPG License: GNU Free Documentation License Contributors: David-i98 Image:glucose meters.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Glucose_meters.jpg License: Public Domain Contributors: Original uploader was Christidy at en.wikipedia File:CCU_IN_A_HOSPITAL_2013-06-10_08-08.jpg Source: http://en.wikipedia.org/w/index.php?title=File:CCU_IN_A_HOSPITAL_2013-06-10_08-08.jpg License: Creative Commons Attribution-Sharealike 3.0 Contributors: User:Zuhairali image:Intensivstation (01) 2007-03-03.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Intensivstation_(01)_2007-03-03.jpg License: Creative Commons Attribution-Sharealike 2.5 Contributors: Norbert Kaiser File:Respiratory therapist.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Respiratory_therapist.jpg License: Creative Commons Attribution-Sharealike 3.0 Contributors: User:Rcp.basheer File:ICU1a.jpg Source: http://en.wikipedia.org/w/index.php?title=File:ICU1a.jpg License: Public Domain Contributors: Peter Rimar

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File:US Navy 030423-N-6967M-090 A central computer system monitors the heart rates of each patient in the Intensive Care Unit (ICU) to ensure a quick.jpg Source: http://en.wikipedia.org/w/index.php?title=File:US_Navy_030423-N-6967M-090_A_central_computer_system_monitors_the_heart_rates_of_each_patient_in_the_Intensive_Care_Unit_(ICU)_to_ensure_a_quick.jpg License: Public Domain Contributors: Downtowngal File:Sick baby with nurses.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Sick_baby_with_nurses.jpg License: Creative Commons Attribution 3.0 Contributors: Tradimus File:Clinicians in Intensive Care Unit.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Clinicians_in_Intensive_Care_Unit.jpg License: Creative Commons Attribution-Sharealike 3.0 Contributors: User:Calleamanecer file:Clostridium_difficile_01.png Source: http://en.wikipedia.org/w/index.php?title=File:Clostridium_difficile_01.png License: Public Domain Contributors: Content Providers(s): CDC/Dr. Holdeman file:Clostridium difficile 01.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Clostridium_difficile_01.jpg License: Public Domain Contributors: Original uploader was MarcoTolo at en.wikipedia File:Colonic pseudomembranes low mag.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Colonic_pseudomembranes_low_mag.jpg License: Creative Commons Attribution-Sharealike 3.0 Contributors: Nephron File:Clostridium difficile EM.png Source: http://en.wikipedia.org/w/index.php?title=File:Clostridium_difficile_EM.png License: Public Domain Contributors: CDC/ Lois S. Wiggs File:How C. difficile spreads.png Source: http://en.wikipedia.org/w/index.php?title=File:How_C._difficile_spreads.png License: Public Domain Contributors: Smallman12q file:US CDC logo.svg Source: http://en.wikipedia.org/w/index.php?title=File:US_CDC_logo.svg License: Trademarked Contributors: Centers for Disease Control and Prevention; specific persons unknown File:CDC HDR I.jpg Source: http://en.wikipedia.org/w/index.php?title=File:CDC_HDR_I.jpg License: unknown Contributors: Original uploader was Nrbelex at nl. en.wikipedia File:CDC Headquarters PHIL 10693.tif Source: http://en.wikipedia.org/w/index.php?title=File:CDC_Headquarters_PHIL_10693.tif License: Public Domain Contributors: File:Arlen Specter Headquarters Building PHIL 7971.tif Source: http://en.wikipedia.org/w/index.php?title=File:Arlen_Specter_Headquarters_Building_PHIL_7971.tif License: Public Domain Contributors: File:Tom Harkin Global Communications Center PHIL 8876.tif Source: http://en.wikipedia.org/w/index.php?title=File:Tom_Harkin_Global_Communications_Center_PHIL_8876.tif License: Public Domain Contributors: Image:US-TRICARE-Logo.svg Source: http://en.wikipedia.org/w/index.php?title=File:US-TRICARE-Logo.svg License: Public Domain Contributors: U.S. Government Image:2008-07-15 Durham VA Medical Center.jpg Source: http://en.wikipedia.org/w/index.php?title=File:2008-07-15_Durham_VA_Medical_Center.jpg License: Creative Commons Attribution-Share Alike Contributors: Ildar Sagdejev (Specious) Image:JerichoHealthCentre20050326 CopyrightKaihsuTai.jpg Source: http://en.wikipedia.org/w/index.php?title=File:JerichoHealthCentre20050326_CopyrightKaihsuTai.jpg License: Creative Commons Attribution-ShareAlike 3.0 Unported Contributors: User:Kaihsu File:CHIMElogo.png Source: http://en.wikipedia.org/w/index.php?title=File:CHIMElogo.png License: Creative Commons Attribution-Sharealike 3.0 Contributors: User:Mhilliard99 File:Heartfailure.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Heartfailure.jpg License: Public Domain Contributors: , ; originally uploaded by at en.wikipedia. Image:Elevated JVP.JPG Source: http://en.wikipedia.org/w/index.php?title=File:Elevated_JVP.JPG License: Creative Commons Attribution-Sharealike 3.0 Contributors: James Heilman, MD Image:Pulmonaryedema09.JPG Source: http://en.wikipedia.org/w/index.php?title=File:Pulmonaryedema09.JPG License: Creative Commons Attribution-Sharealike 3.0 Contributors: James Heilman, MD File:Psi2.svg Source: http://en.wikipedia.org/w/index.php?title=File:Psi2.svg License: Public Domain Contributors: Arjen Dijksman, Badseed, Beao, Bouncey2k, Gdh, Herbythyme, Imz, Jack Phoenix, KillOrDie, Nagy, Proteins, Remember the dot, Wutsje, 27 anonymous edits File:Development of the neural tube.png Source: http://en.wikipedia.org/w/index.php?title=File:Development_of_the_neural_tube.png License: Public Domain Contributors: user:Looie496 created file, original artist unknown File:4 week embryo brain.jpg Source: http://en.wikipedia.org/w/index.php?title=File:4_week_embryo_brain.jpg License: Public Domain Contributors: Kurzon

Image Sources, Licenses and Contributors


File:Central nervous system.svg Source: http://en.wikipedia.org/w/index.php?title=File:Central_nervous_system.svg License: Public Domain Contributors: Camilaastrid, Cohesion, Ericalens, Grm wnr, Jmarchn, Mani1, Meno25, Palnatoke, Tryphon, Was a bee, Wouterhagens, Xxxx00, 48 anonymous edits Image:Enfrentamientos en Puente Presidente Ibez.JPG Source: http://en.wikipedia.org/w/index.php?title=File:Enfrentamientos_en_Puente_Presidente_Ibez.JPG License: unknown Contributors: B1mbo File:Centrilobular emphysema 865 lores.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Centrilobular_emphysema_865_lores.jpg License: Public Domain Contributors: Dr. Edwin P. Ewing, Jr. File:Emphysema.png Source: http://en.wikipedia.org/w/index.php?title=File:Emphysema.png License: Creative Commons Attribution-Sharealike 3.0 Contributors: User:Blausenmedical Image:Emphysema low mag.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Emphysema_low_mag.jpg License: Creative Commons Attribution-Sharealike 3.0 Contributors: Nephron File:COPD.JPG Source: http://en.wikipedia.org/w/index.php?title=File:COPD.JPG License: Creative Commons Attribution-Sharealike 3.0 Contributors: James Heilman, MD File:Bullus emphasemaCT.png Source: http://en.wikipedia.org/w/index.php?title=File:Bullus_emphasemaCT.png License: Creative Commons Attribution-Sharealike 3.0 Contributors: James Heilman, MD File:Barrowchest.JPG Source: http://en.wikipedia.org/w/index.php?title=File:Barrowchest.JPG License: Creative Commons Attribution-Sharealike 3.0 Contributors: James Heilman, MD Image:BullaCXR.PNG Source: http://en.wikipedia.org/w/index.php?title=File:BullaCXR.PNG License: Creative Commons Attribution-Sharealike 3.0 Contributors: James Heilman, MD File:Chronic obstructive pulmonary disease world map - DALY - WHO2004.svg Source: http://en.wikipedia.org/w/index.php?title=File:Chronic_obstructive_pulmonary_disease_world_map_-_DALY_-_WHO2004.svg License: Creative Commons Attribution-Sharealike 2.5 Contributors: Lokal_Profil File:US_Consumer_Price_Index_Graph.svg Source: http://en.wikipedia.org/w/index.php?title=File:US_Consumer_Price_Index_Graph.svg License: GNU Free Documentation License Contributors: Original image by User:donarreiskoffer, new SVG version made with Gnumeric (from original data; now covers 1913-2006) File:CPR training-04.jpg Source: http://en.wikipedia.org/w/index.php?title=File:CPR_training-04.jpg License: Creative Commons Attribution-Sharealike 2.0 Contributors: Rama File:CPR training-03.jpg Source: http://en.wikipedia.org/w/index.php?title=File:CPR_training-03.jpg License: Creative Commons Attribution-Sharealike 2.0 Contributors: Rama File:Insulfation2.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Insulfation2.jpg License: unknown Contributors: Image by Rama

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File:US Navy 030425-N-2382W-004 Lt. 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Image Sources, Licenses and Contributors


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Attribution 2.0 Contributors: Jason Bain Image:DFVAC 1970s Cadillac Miller Meteor color .jpg Source: http://en.wikipedia.org/w/index.php?title=File:DFVAC_1970s_Cadillac_Miller_Meteor_color_.jpg License: GNU Free Documentation License Contributors: Badger 151, DanTD, Herranderssvensson, Infrogmation, Mjrmtg, Morio Image:DFVAC 1948 Cadillac Miller Meteor front passenger quarter.jpg Source: http://en.wikipedia.org/w/index.php?title=File:DFVAC_1948_Cadillac_Miller_Meteor_front_passenger_quarter.jpg License: GNU Free Documentation License Contributors: Analog in a Digital World, Badger 151, Darwinius, Herranderssvensson, Infrogmation, Mjrmtg, Theodulf, 2 anonymous edits File:Modena ambulance.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Modena_ambulance.jpg License: Creative Commons Attribution-Sharealike 2.0 Contributors: Roberto Ferrari from Campogalliano (Modena), Italy File:An ambulance in Kiev.jpg Source: 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Mutter / Otolaryngologist Mani Zadeh, MD Image:Sharplan 40C.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Sharplan_40C.jpg License: Creative Commons Attribution-Sharealike 3.0 Contributors: Etan J. Tal file:Environmental Protection Agency logo.svg Source: http://en.wikipedia.org/w/index.php?title=File:Environmental_Protection_Agency_logo.svg License: Public Domain Contributors: Awg1010, Clindberg, Cpicon92, Fry1989, Giggy, Illegitimate Barrister, Mattes, Rocket000, Vipersnake151, 1 anonymous edits file:Flag of the United States Environmental Protection Agency.svg Source: http://en.wikipedia.org/w/index.php?title=File:Flag_of_the_United_States_Environmental_Protection_Agency.svg License: Public Domain Contributors: User:Fry1989

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Image Sources, Licenses and Contributors


Image:Epaheadquarters.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Epaheadquarters.jpg License: GNU Free Documentation License Contributors: Original uploader was Coolcaesar at en.wikipedia Image:Closeup of EPA Bldg., Washington, D.C. IMG 4757.JPG Source: http://en.wikipedia.org/w/index.php?title=File:Closeup_of_EPA_Bldg.,_Washington,_D.C._IMG_4757.JPG License: Creative Commons Attribution 3.0 Contributors: Billy Hathorn

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File:BURNING DISCARDED AUTOMOBILE BATTERIES. (FROM THE SITES EXHIBITION. FOR OTHER IMAGES IN THIS ASSIGNMENT, SEE FICHE... - NARA 553841.jpg Source: http://en.wikipedia.org/w/index.php?title=File:BURNING_DISCARDED_AUTOMOBILE_BATTERIES._(FROM_THE_SITES_EXHIBITION._FOR_OTHER_IMAGES_IN_THIS_ASSIGNMENT,_SEE_FICHE..._-_N License: Public Domain Contributors: JustSomePics

File:SMOKESTACKS OF THE HOLMES ROAD INCINERATOR, NO LONGER POLLUTE THE ATMOSPHERE. THE PLANT PREVIOUSLY BURNED OLD... - NARA 557411.jpg Source: http://en.wikipedia.org/w/index.php?title=File:SMOKESTACKS_OF_THE_HOLMES_ROAD_INCINERATOR,_NO_LONGER_POLLUTE_THE_ATMOSPHERE._THE_PLANT_PREVIOUSLY_BURNED_OLD..._-_ License: Public Domain Contributors: JustSomePics Image:Regions of the United States EPA.svg Source: http://en.wikipedia.org/w/index.php?title=File:Regions_of_the_United_States_EPA.svg License: Creative Commons Attribution-ShareAlike 3.0 Unported Contributors: Blank_US_Map.svg: User:Theshibboleth derivative work: Ninjatacoshell (talk) File:OSV Bold.jpg Source: http://en.wikipedia.org/w/index.php?title=File:OSV_Bold.jpg License: Creative Commons Attribution-Sharealike 3.0 Contributors: Rtphokie (talk). Original uploader was RadioFan at en.wikipedia Image:EPA WTC 2001-10-10.jpg Source: http://en.wikipedia.org/w/index.php?title=File:EPA_WTC_2001-10-10.jpg License: Public Domain Contributors: Photo by Mike Rieger/ FEMA News Photo File:Pigment stone extraction.png Source: http://en.wikipedia.org/w/index.php?title=File:Pigment_stone_extraction.png License: Creative Commons Attribution 2.5 Contributors: Original uploader was Samir (The Scope) at en.wikipedia Image:ERCP stone.jpg Source: http://en.wikipedia.org/w/index.php?title=File:ERCP_stone.jpg License: GNU Free Documentation License Contributors: [:en:User:Samir (The Scope) Image:ERCP dilatation.png Source: http://en.wikipedia.org/w/index.php?title=File:ERCP_dilatation.png License: Copyrighted free use Contributors: DrM!KEY file:Food and Drug Administration logo.svg Source: http://en.wikipedia.org/w/index.php?title=File:Food_and_Drug_Administration_logo.svg License: Public Domain Contributors: U.S. file:Ritalin-SR-20mg-1000x1000.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Ritalin-SR-20mg-1000x1000.jpg License: GNU Free Documentation License Contributors: en:User:Sponge File:Share of Federal Revenue from Different Tax Sources (Individual, Payroll, and Corporate) 1950 - 2010.gif Source: http://en.wikipedia.org/w/index.php?title=File:Share_of_Federal_Revenue_from_Different_Tax_Sources_(Individual,_Payroll,_and_Corporate)_1950_-_2010.gif License: Creative Commons Attribution-Sharealike 3.0 Contributors: User:Guest2625 File:Effective Payroll Tax rate for Different Income Percentiles (2010).gif Source: http://en.wikipedia.org/w/index.php?title=File:Effective_Payroll_Tax_rate_for_Different_Income_Percentiles_(2010).gif License: Creative Commons Attribution-Sharealike 3.0 Contributors: User:Guest2625 File:Historical Payroll Tax Rates.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Historical_Payroll_Tax_Rates.jpg License: Creative Commons Attribution-Sharealike 3.0 Contributors: User:Guest2625 Image:2007ACGME-2.PNG Source: http://en.wikipedia.org/w/index.php?title=File:2007ACGME-2.PNG License: Public domain Contributors: Joxemai Image:2007ACGME-3.PNG Source: http://en.wikipedia.org/w/index.php?title=File:2007ACGME-3.PNG License: Public domain Contributors: Joxemai File:Poor mother and children, California 1936 by Dorothea Lange.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Poor_mother_and_children,_California_1936_by_Dorothea_Lange.jpg License: Public Domain Contributors: Djembayz, FSII, Infrogmation, Man vyi, Martin H., Origamiemensch, Ranveig, Romary, Severino666, 2 anonymous edits File:Number in Poverty and Poverty Rate 1959 to 2011. United States..PNG Source: http://en.wikipedia.org/w/index.php?title=File:Number_in_Poverty_and_Poverty_Rate_1959_to_2011._United_States..PNG License: Public Domain Contributors: New worl File:Poverty Rates by Age 1959 to 2011. United States..PNG Source: http://en.wikipedia.org/w/index.php?title=File:Poverty_Rates_by_Age_1959_to_2011._United_States..PNG License: Public Domain Contributors: New worl File:Homeless children in US 2006-10.png Source: http://en.wikipedia.org/w/index.php?title=File:Homeless_children_in_US_2006-10.png License: Public Domain Contributors: CLDunlap, Mrwojo, Stefan4 File:Camden NJ poverty.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Camden_NJ_poverty.jpg License: Public Domain Contributors: Original uploader was Phillies1fan777 at en.wikipedia

File:TWO YOUTHS IN UPTOWN, CHICAGO, ILLINOIS, A NEIGHBORHOOD OF POOR WHITE SOUTHERNERS. THE INNER CITY TODAY IS AN... - NARA - 555950.jpg Source: http://en.wikipedia.org/w/index.php?title=File:TWO_YOUTHS_IN_UPTOWN,_CHICAGO,_ILLINOIS,_A_NEIGHBORHOOD_OF_POOR_WHITE_SOUTHERNERS._THE_INNER_CITY_TODAY_IS_AN..._-_NAR License: Public Domain Contributors: Closeapple, Denniss, Origamiemensch

File:BLACK YOUTHS PLAY BASKETBALL AT STATEWAY GARDENS' HIGHRISE HOUSING PROJECT ON CHICAGO'S SOUTH SIDE. THE COMPLEX HAS... - NARA 556162.jpg Source: http://en.wikipedia.org/w/index.php?title=File:BLACK_YOUTHS_PLAY_BASKETBALL_AT_STATEWAY_GARDENS'_HIGHRISE_HOUSING_PROJECT_ON_CHICAGO'S_SOUTH_SIDE._THE_COMPLEX_HA License: Public Domain Contributors: file:US-FederalTradeCommission-Seal.svg Source: http://en.wikipedia.org/w/index.php?title=File:US-FederalTradeCommission-Seal.svg License: Public Domain Contributors: U.S. Government file:Flag of the United States Federal Trade Commission.png Source: http://en.wikipedia.org/w/index.php?title=File:Flag_of_the_United_States_Federal_Trade_Commission.png License: unknown Contributors: Illegitimate Barrister File:ApexBuildingHighsmith.jpg Source: http://en.wikipedia.org/w/index.php?title=File:ApexBuildingHighsmith.jpg License: Public Domain Contributors: Carol M. Highsmith (born 1946) file:US-GovernmentAccountabilityOffice-Seal.svg Source: http://en.wikipedia.org/w/index.php?title=File:US-GovernmentAccountabilityOffice-Seal.svg License: Public Domain Contributors: U.S. Government file:US-GovernmentAccountabilityOffice-Logo.svg Source: http://en.wikipedia.org/w/index.php?title=File:US-GovernmentAccountabilityOffice-Logo.svg License: Public Domain Contributors: U.S. Government file:Flag of the United States Government Accountability Office.png Source: http://en.wikipedia.org/w/index.php?title=File:Flag_of_the_United_States_Government_Accountability_Office.png License: unknown Contributors: Illegitimate Barrister Image:US-GeneralAccountingOffice-Seal.svg Source: http://en.wikipedia.org/w/index.php?title=File:US-GeneralAccountingOffice-Seal.svg License: Public Domain Contributors: U.S. Government File:GAO DC Headquarters.jpg Source: http://en.wikipedia.org/w/index.php?title=File:GAO_DC_Headquarters.jpg License: GNU Free Documentation License Contributors: Coolcaesar at en.wikipedia File:Map of countries by GDP (nominal) in US$.png Source: http://en.wikipedia.org/w/index.php?title=File:Map_of_countries_by_GDP_(nominal)_in_US$.png License: Creative Commons Attribution-Sharealike 3.0 Contributors: User:Quite vivid blur file:Gdpercapita.PNG Source: http://en.wikipedia.org/w/index.php?title=File:Gdpercapita.PNG License: Creative Commons Attribution-Sharealike 3.0 Contributors: User:Quandapanda File:Emblem-money.svg Source: http://en.wikipedia.org/w/index.php?title=File:Emblem-money.svg License: GNU General Public License Contributors: perfectska04 File:BNP perhoofd 2012.PNG Source: http://en.wikipedia.org/w/index.php?title=File:BNP_perhoofd_2012.PNG License: Creative Commons Attribution-Sharealike 3.0 Contributors: User:Sadib File:Gdpercapita.PNG Source: http://en.wikipedia.org/w/index.php?title=File:Gdpercapita.PNG License: Creative Commons Attribution-Sharealike 3.0 Contributors: User:Quandapanda File:GDP Categories - United States.png Source: http://en.wikipedia.org/w/index.php?title=File:GDP_Categories_-_United_States.png License: Public Domain Contributors: Ronhjones Image:Gdp real growth rate 2007 CIA Factbook.PNG Source: http://en.wikipedia.org/w/index.php?title=File:Gdp_real_growth_rate_2007_CIA_Factbook.PNG License: Creative Commons Attribution-ShareAlike 3.0 Unported Contributors: Sbw01f

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Image:Stomach colon rectum diagram.svg Source: http://en.wikipedia.org/w/index.php?title=File:Stomach_colon_rectum_diagram.svg License: Public Domain Contributors: Indolences created it on the English Wikipedia. Image:Digestive system diagram edit.svg Source: http://en.wikipedia.org/w/index.php?title=File:Digestive_system_diagram_edit.svg License: Public Domain Contributors: Mariana RuizLadyofHats, edited by Joaquim Alves Gaspar File:Gut wall.svg Source: http://en.wikipedia.org/w/index.php?title=File:Gut_wall.svg License: Creative Commons Attribution 3.0 Contributors: Original uploader was Auawise at en.wikipedia (Original text : uaWise (Operibus anteire)) File:Slit lamp examination.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Slit_lamp_examination.jpg License: Creative Commons Attribution-Sharealike 3.0 Contributors: User:PFrankoZ Image:Shushrut statue.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Shushrut_statue.jpg License: Creative Commons Attribution-Sharealike 3.0 Contributors: Alokprasad at en.wikipedia Image:Franois Pourfour du Petit.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Franois_Pourfour_du_Petit.jpg License: Public Domain Contributors: Mu, Shakko File:Dr Forlenze.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Dr_Forlenze.jpg License: Public Domain Contributors: Jacques Antoine Vallin File:Allvar Gullstrand 02.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Allvar_Gullstrand_02.jpg License: Public Domain Contributors: Unknown (Bain News Service, publisher) File:Bates and Assistant.png Source: http://en.wikipedia.org/w/index.php?title=File:Bates_and_Assistant.png License: Public Domain Contributors: William H. Bates File:Edward Jenner.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Edward_Jenner.jpg License: Public Domain Contributors: Painter: unknown File:DivinoValles.jpg Source: http://en.wikipedia.org/w/index.php?title=File:DivinoValles.jpg License: Public Domain Contributors: Ecummenic, Frank C. Mller, Raimundo Pastor, Yrithinnd File:Rod of Asclepius2.svg Source: http://en.wikipedia.org/w/index.php?title=File:Rod_of_Asclepius2.svg License: Creative Commons Attribution-ShareAlike 3.0 Unported Contributors: Rod_of_asclepius.png: CatherineMunro derivative work: hazmat2 File:Newborn Examination 1967.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Newborn_Examination_1967.jpg License: GNU Free Documentation License Contributors: Nevit Dilmen File:Great Ormond Street Hospital.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Great_Ormond_Street_Hospital.jpg License: Creative Commons Attribution-Share Alike 2.0 Generic Contributors: Nigel Cox File:HCUP's 30-Day Readmission Rates to U.S. Hospitals, 2010 Infographic.jpg Source: http://en.wikipedia.org/w/index.php?title=File:HCUP's_30-Day_Readmission_Rates_to_U.S._Hospitals,_2010_Infographic.jpg License: Public Domain Contributors: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project File:Anna Fischer-Dueckelmann - Die Frau als Hausaerztin.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Anna_Fischer-Dueckelmann_-_Die_Frau_als_Hausaerztin.jpg License: Public Domain Contributors: Dr. med. Anne Fischer-Dckelmann (1856-1917) uploader Claas Augner File:Hipaa.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Hipaa.jpg License: Creative Commons Attribution-Sharealike 3.0 Contributors: User:Mpelletier1 File:Hipaa Violations by Type - Pie Chart.png Source: http://en.wikipedia.org/w/index.php?title=File:Hipaa_Violations_by_Type_-_Pie_Chart.png License: Creative Commons Attribution-Sharealike 3.0 Contributors: User:Mpelletier1 File:Sshot fever.png Source: http://en.wikipedia.org/w/index.php?title=File:Sshot_fever.png License: GNU Free Documentation License Contributors: Original uploader was SeaLion at en.wikipedia. Later version(s) were uploaded by Ruud Koot, Eliashc at en.wikipedia. File:Proportion of nation-wide hospitals with HIS.tif Source: http://en.wikipedia.org/w/index.php?title=File:Proportion_of_nation-wide_hospitals_with_HIS.tif License: GNU Free Documentation License Contributors: Toni Lee (Tong Li) Image:EHRadoption.gif Source: http://en.wikipedia.org/w/index.php?title=File:EHRadoption.gif License: GNU Free Documentation License Contributors: User:Ryanjo file:HIV-budding-Color.jpg Source: http://en.wikipedia.org/w/index.php?title=File:HIV-budding-Color.jpg License: Public Domain Contributors: Photo Credit: C. Goldsmith Content Providers: CDC/ C. Goldsmith, P. Feorino, E. L. Palmer, W. R. McManus File:HIV Mature and Immature.PNG Source: http://en.wikipedia.org/w/index.php?title=File:HIV_Mature_and_Immature.PNG License: Public Domain Contributors: Drs. Louis E. Henderson and Larry Arthur. NIH 1994 File:HIV gross cycle only.png Source: http://en.wikipedia.org/w/index.php?title=File:HIV_gross_cycle_only.png License: GNU Free Documentation License Contributors: Original uploader was Raul654 at en.wikipedia Later version(s) were uploaded by Grcampbell, Renegadeviking, Disparity at en.wikipedia. image:HIV Membrane fusion panel.svg Source: http://en.wikipedia.org/w/index.php?title=File:HIV_Membrane_fusion_panel.svg License: Creative Commons Attribution-Sharealike 3.0 Contributors: User:Adenosine File:Reverse Transcription.png Source: http://en.wikipedia.org/w/index.php?title=File:Reverse_Transcription.png License: GNU Free Documentation License Contributors: Original uploader was Crenim at en.wikipedia File:HIV on macrophage.png Source: http://en.wikipedia.org/w/index.php?title=File:HIV_on_macrophage.png License: Creative Commons Attribution 2.5 Contributors: see Source File:HIV-SIV-phylogenetic-tree.svg Source: http://en.wikipedia.org/w/index.php?title=File:HIV-SIV-phylogenetic-tree.svg License: Public Domain Contributors: Kuiken, C., Foley, B., Hahn, B., Marx, P., McCutchan, F., Mellors, J. W., Mullins, J., Wolinsky, S. & Korber, B. (1999). A compilation and analysis of nucleic acid and amino acid sequences. In Human Retroviruses and AIDS. Los Alamos, New Mexico: Theoretical Biology and Biophysics Group, Los Alamos National Laboratory. File:Hiv-timecourse copy.svg Source: http://en.wikipedia.org/w/index.php?title=File:Hiv-timecourse_copy.svg License: Creative Commons Zero Contributors: User:Sigve Image:SOWM2010 critical shortage.svg Source: http://en.wikipedia.org/w/index.php?title=File:SOWM2010_critical_shortage.svg License: Public Domain Contributors: BlankMap-World6.svg: Canuckguy (talk) and many others derivative work: Mike Serfas (talk) file:hrsa_Logo_only.gif Source: http://en.wikipedia.org/w/index.php?title=File:Hrsa_Logo_only.gif License: Public Domain Contributors: salexander1 File:Journal of the American Medical Association (cover).jpg Source: http://en.wikipedia.org/w/index.php?title=File:Journal_of_the_American_Medical_Association_(cover).jpg License: unknown Contributors: Gobonobo, Guillaume2303 File:Lactate dehydrogenase M4 (muscle) 1I10.png Source: http://en.wikipedia.org/w/index.php?title=File:Lactate_dehydrogenase_M4_(muscle)_1I10.png License: Public Domain Contributors: Fvasconcellos, TimVickers File:PDB 1f0x EBI.jpg Source: http://en.wikipedia.org/w/index.php?title=File:PDB_1f0x_EBI.jpg License: unknown Contributors: File:LDH reaction.png Source: http://en.wikipedia.org/w/index.php?title=File:LDH_reaction.png License: GNU Free Documentation License Contributors: Cwbm (commons), Kpengboy, R. Engelhardt, Raul6, TimVickers File:Magnify-clip.png Source: http://en.wikipedia.org/w/index.php?title=File:Magnify-clip.png License: Public Domain Contributors: User:Erasoft24 File:Icos Laboratories.JPG Source: http://en.wikipedia.org/w/index.php?title=File:Icos_Laboratories.JPG License: Creative Commons Attribution-Sharealike 3.0 Contributors: JW File:Lab worker with blood samples.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Lab_worker_with_blood_samples.jpg License: Creative Commons Attribution-Sharealike 3.0,2.5,2.0,1.0 Contributors: Mike Blyth File:Nursing home.JPG Source: http://en.wikipedia.org/w/index.php?title=File:Nursing_home.JPG License: Creative Commons Attribution-Sharealike 3.0 Contributors: User:Thomas Bjrkan File:Nursing home corridor.JPG Source: http://en.wikipedia.org/w/index.php?title=File:Nursing_home_corridor.JPG License: Creative Commons Attribution-Sharealike 3.0 Contributors: User:Thomas Bjrkan

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File:US Navy 100908-N-4044H-203 Cmdr. Peter Shumaker, a doctor embarked aboard the Royal Australian Navy landing ship heavy HMAS Tobruk (L50), examines .jpg Source: http://en.wikipedia.org/w/index.php?title=File:US_Navy_100908-N-4044H-203_Cmdr._Peter_Shumaker,_a_doctor_embarked_aboard_the_Royal_Australian_Navy_landing_ship_heavy_HMAS_Tobruk_(L50),_examines License: Public Domain Contributors: File:Emergency care for trauma course at the Kabul Ataturk Military Hospital.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Emergency_care_for_trauma_course_at_the_Kabul_Ataturk_Military_Hospital.jpg License: Creative Commons Attribution 2.0 Contributors: ISAF Headquarters Public Affairs Office from Kabul, Afghanistan File:Ijn surgeon.JPG Source: http://en.wikipedia.org/w/index.php?title=File:Ijn_surgeon.JPG License: Public Domain Contributors: Original uploader was IJNMis01 at en.wikipedia File:UniKlinik (Freiburg) 4.jpg Source: http://en.wikipedia.org/w/index.php?title=File:UniKlinik_(Freiburg)_4.jpg License: Creative Commons Attribution-Sharealike 3.0 Contributors: user:Joergens.mi

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File:BrainMRI3planes.gif Source: http://en.wikipedia.org/w/index.php?title=File:BrainMRI3planes.gif License: Creative Commons Attribution-Sharealike 3.0 Contributors: User:Brainscandude File:Structural MRI animation.ogv Source: http://en.wikipedia.org/w/index.php?title=File:Structural_MRI_animation.ogv License: Creative Commons Attribution-Sharealike 3.0 Contributors: Structural.gif: Dwayne Reed (talk) Original uploader was Dwayne Reed at en.wikipedia derivative work: Sherool (talk) File:MRI-Philips.JPG Source: http://en.wikipedia.org/w/index.php?title=File:MRI-Philips.JPG License: Creative Commons Attribution 3.0 Contributors: Jan Ainali Image:Damadian invention.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Damadian_invention.jpg License: unknown Contributors: Shizhao, WikipediaMaster, Zereshk, 1 anonymous edits File:TR TE.jpg Source: http://en.wikipedia.org/w/index.php?title=File:TR_TE.jpg License: Public Domain Contributors: Rdiolg File:Illus dti.gif Source: http://en.wikipedia.org/w/index.php?title=File:Illus_dti.gif License: Copyrighted free use Contributors: Lipothymia, 2 anonymous edits File:mra1.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Mra1.jpg License: GNU Free Documentation License Contributors: Original uploader was Ofirglazer at en.wikipedia Image:MRI-DTDA.psd.jpg Source: http://en.wikipedia.org/w/index.php?title=File:MRI-DTDA.psd.jpg License: Public Domain Contributors: Dr Philip C. 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