Medical Care Expenditures Research Articles

Effect of long-term care insurance on medical expenditure and health status: National cohort study

BackgroundLong-term care insurance (LTCI) was implemented in China to solve the elderly care problems caused by the aging population. It is crucial to evaluate the effectiveness of LTCI implementation from the perspective of value-based healthcare.ObjectiveThis study aimed to investigate the impact of LTCI on medical care expenditure and health status in China.MethodsWe used staggered difference-in-differences (DID) analysis to analyze the effect of LTCI policy on medical expenditure and health status based on China Health and Retirement Longitudinal Study data from 2011 to 2018.ResultsOur findings confirmed the positive contribution of LTCI policies to medical expenditures and health status. We found that the implementation of LTCI significantly reduced inpatient and outpatient expenditure, scores of self-report of health, and CESD scores by 26.3%, 12.3%, 0.103, and 0.538, respectively. It also decreased ADL scores, but the decrease was not significant. The impact of LTCI on reducing inpatient expenditure was greater for individuals aged between 65 and 80 and those residing in urban areas and eastern cities. In terms of outpatient costs, the effect of LTCI was more pronounced among median and high-income people and people living in central and eastern cities. The impact of LTCI on self-report of health is stronger for rural populations, individuals under 80, and those in central and eastern cities. For ADL scores, LTCI affected those aged 65–80 the most. About the CESD scores, LTCI had a greater impact on rural populations, people aged 45–65, median income groups, and those in eastern cities.ConclusionsOur study underscored LTCI’s effectiveness in curbing medical expenditures and enhancing health status, offering valuable insights for future LTCI development in China and beyond. Accelerating the development of LTCI is conducive to improving the quality of life of the disabled elderly, enhancing the well-being of people’s livelihoods, and realizing the goal of value-based healthcare.

Trends of Korean medicine service utilization for lumbar disc herniation and spinal stenosis: A 10-year analysis of the 2010 to 2019 data.

This retrospective, cross-sectional, and descriptive study aimed to analyze the trend of utilizing traditional Korean medicine services in patients with lumbar disc herniation (LDH) and/or lumbar spinal stenosis (LSS). In this study, based on the national patient sample data provided by Health Insurance Review and Assessment Service (HIRA), the trend of Korean medicine service utilization was investigated, including the following information: demographic characteristics of the patients, the total expenditure, number of claim statements per category, medical care expenditure per category, and routes of visiting traditional Korean medicine institutions. The study population comprised patients who visited Korean medicine institutions at least once from January 2010 to December 2019, with LSS and LDH as the primary diagnosis. LDH patients who used traditional Korean medicine services for treatment increased by about 1.36 times. LDH and LSS patients under 45 years of age were more likely to be males, but women accounted for a higher percentage among those over 45 years of age. Overall, women accounted for a slightly higher percentage than their counterparts for both diseases. From details of treatments received that were extracted from the claims data, acupuncture treatment accounted for the highest percentage for both disorders. Moreover, 50.7% of the patients who visited Korean medicine institutions to treat the two diseases also visited conventional Western medicine institutions. These patients, who were diagnosed with their condition at a Korean medicine institution, visited a conventional institution and then returned; the conventional institutions were primarily used for examination (40.5%). Increased utilization of traditional Korean medicine services was confirmed among patients with LDH and/or LSS; in particular, a sharp increase was noted among patients with LSS. The results of this study will be useful as basic research data for clinicians, researchers, and policy makers.

Public hospital reform, family health consumption and health inequality: evidence from China Family Panel Studies.

In 2017, China launched a comprehensive reform of public hospitals and eliminated drug markups, aiming to solve the problem of expensive medical treatment and allow poor and low-income people to enjoy basic health opportunities. This study attempts to evaluate the policy impact of public hospital reform on the health inequality of Chinese residents and analyze its micro-level mechanism from the perspective of household consumption structure. Studying the inherent causal connection between public hospital reform and health inequality is of paramount significance for strengthening China's healthcare policies, system design, raising the average health level of Chinese residents, and achieving the goal of ensuring a healthy life for individuals of all age groups. Based on the five waves of data from the China Family Panel Studies (CFPS) conducted in 2012-2020, We incorporates macro-level statistical indicators such as the time of public hospital reforms, health insurance surplus, and aging, generating 121,447 unbalanced panel data covering 27 provinces in China for five periods. This data was used to explore the impact of public hospital reform on health inequality. Logical and empirical tests were conducted to determine whether the reform, by altering family medical care and healthy leisure consumption expenditures, affects the micro-pathways of health inequality improvement. We constructed a two-way fixed model based on the re-centralized influence function (RIF_CI_OLS) and a chained mediation effects model to verify the hypotheses mentioned above. Public hospital reform can effectively improve the health inequality situation among Chinese residents. The reform significantly reduces household medical expenses, increases healthy leisure consumption, promotes the upgrading of family health consumption structure, and lowers the health inequality index. In terms of indirect effects, the contribution of the increase in healthy leisure consumption is relatively greater. Public hospital reform significantly alleviates health inequality in China, with household health consumption serving as an effective intermediary pathway in the aforementioned impact. In the dual context of global digitization and exacerbated population aging, enhancing higher education levels and vigorously developing the health industry may be two key factors contributing to this effect.

Trajectories of medical care expenditure in the last year of life associated with long-term care utilization in frail older adults: A retrospective cohort study.

Medical care and long-term care utilization in the last year of life of frail older adults could be a key indicator of their quality of life. This study aimed to identify the medical care expenditure (MCE) trajectories in the last year of life of frail older adults by investigating the association between MCE and long-term care utilization in each trajectory. The retrospective cohort study of three municipalities in Japan included 405 decedents (median age at death, 85 years; 189 women [46.7%]) from a cohort of 1,658 frail older adults aged ≥65 years who were newly certified as support level in the long-term care insurance program from April 2012 to March 2013. This study used long-term care and medical insurance claim data from April 2012 to March 2017. The primary outcome was MCE over the 12 months preceding death. Group-based trajectory modeling was conducted to identify the MCE trajectories. A mixed-effect model was employed to examine the association between long-term care utilization and MCE in each trajectory. Participants were stratified into four groups based on MCE trajectories over the 12 months preceding death as follows: rising (n = 159, 39.3%), persistently high (n = 143, 35.3%), minimal (n = 56, 13.8%), and descending (n = 47, 11.6%) groups. Home-based long-term care utilization was associated with increased MCE in the descending trajectory (coefficient, 1.48; 95% confidence interval [CI], 1.35-1.62). Facility-based long-term care utilization was associated with reduced MCE in the rising trajectory (coefficient, 0.59; 95% CI, 0.50-0.69). Both home-based (coefficient, 0.92; 95% CI, 0.85-0.99) and facility-based (coefficient; 0.53; 95% CI, 0.41-0.63) long-term care utilization were associated with reduced MCE in the persistently high trajectory. These findings may facilitate the integration of medical and long-term care models at the end of life in frail older adults.

Association between multimorbidity and utilization of medical and long-term care among older adults in a rural mountainous area in Japan.

With the accelerated population aging, multimorbidity has become an important healthcare issue. However, few studies have examined multimorbidity and its impact on the use of medical and long-term care services in Japan. Therefore, this study aimed to examine the association between multimorbidity and the use of medical and long-term care services among older adults living in the depopulated mountainous areas of Japan. A cross-sectional study was conducted using insurance claims data from late-stage medical insurance and long-term care insurance (April 2017 to March 2018) for older adults ≥75 years residing in a mountainous area in the Tottori prefecture. In addition to the descriptive analysis, multiple generalized linear regressions with family gamma and log-link functions were used to examine the association between the number of morbidities and total annual medical and long-term care expenditures. A total of 970 participants ≥75 years were included in the analysis. Participants who had two or more morbidities constituted 86.5% of the total sample. Furthermore, participants with mental disorders were found to have more comorbidities. The number of comorbidities is associated with higher medical and long-term care expenditures. Multimorbidity was dominant among late-stage older adults living in depopulated mountainous areas of Japan, and the number of morbidities was associated with higher economic costs of medical and long-term care services. Mitigating the impact of multimorbidity among older adults in depopulated regions of Japan is an urgent challenge. Future research should investigate the degree and effectiveness of social protections for vulnerable older adults living in remote areas.

A panel vector autoregression analysis for the dynamics of medical and long-term care expenditures.

Although medical and long-term care expenditures for older adults are closely related, providing rigorous statistical analysis for their dynamic relationship is challenging. In this research, we propose a novel approach using the panel vector autoregression model to reveal the realized patterns of the interdependence. As an empirical application, we analyze monthly panel data on individuals in a city of Japan, where social insurance covers many formal services for long-term care. Our estimation results indicate the existence of intertemporal transition from expensive acute medical care to reasonable at-home medical care, then to at-home long-term care. Under this context, the enhancement of formal long-term care sector in Japan might have played an important role in the suppression of the total care cost in spite for its rapid aging over the past 2decades. Additionally, we find that daycare plays multiple roles in Japanese long-term care, such as respite and rehabilitation, but there is no considerable transition from outpatient rehabilitation to daycare in the long-term care sector.

Automated quantification of macular edema in patients with diabetic macular edema and their response to anti-VEGF: A study protocol

Diabetes mellitus type 2 (T2DM) is the fastest-growing chronic condition. Diabetes mellitus can lead to a variety of complications, all of which have a significant impact on medical care expenditures as well as patient life span and wellbeing. The most prevalent microvascular ocular sequel of diabetes is diabetic retinopathy (DR), causing diffuse retinal edema from extensive capillary leakage and localized edema from microaneurysm leakage. A dilated capillary segment is also seen. It has been observed that the fluid first accumulates between the inner nuclear layers and the outer plexiform layer. Later, it may infiltrate the inner plexiform and nerve fiber layers, causing edema and affecting the retina’s total thickness. The fovea takes on a cystoid appearance on optical coherence tomography due to central fluid accumulation, and cystoid macular edema can be seen. Anti-vascular endothelial growth factor (anti-VEGF) medication is a cornerstone of DME treatment. Research has shown that drugs that attach to soluble VEGF can repair the blood-retinal barrier, alleviate macular edema, and enhance vision for the majority of DME patients. Ranibizumab is the only FDA-approved drug for DME, but bevacizumab is often used off-label and an FDA request for aflibercept is still pending. Regular injections are necessary for effective treatment, but new findings suggest that this requirement lessens after a year. The study aims to evaluate the impact of intravitreal Anti-VEGF injection by measuring the alterations in macular edema and relating it to the visual results. CTRI reference Number – REF/2023/07/071019

The economic costs of COVID‐19 in a rural Western US state

AbstractThe impact of the coronavirus disease‐2019 (COVID‐19) pandemic has been felt worldwide. While the United States appears to be on path to recovery, the economic burden and rising medical care expenditures associated with the pandemic remains in the trillions of dollars. Utilizing data from the US Department of Health and Human Services and FAIR Health, this study estimates the economic burden of COVID‐19 for Idaho was estimated through assessment of direct medical costs and indirect costs for years 2020–2021. Total direct medical hospital costs associated with COVID‐19, among adults, were estimated as the sum of hospital costs associated with inpatient visits. The cost of testing was included in the direct cost assessment, with data from the Idaho Division of Public Health and Medicare Administrative Contractor payment rates. To determine indirect absenteeism costs, daily cases were multiplied by 7 to account for days of missed productivity; this number was then multiplied by an employment‐adjusted average daily wage to obtain a lost productivity dollar value. Lastly, premature mortality costs were estimated based on the lost value of future earnings. Results show that in 2020, the associated direct and indirect costs of COVID‐19 amounted to over $608 million and increased to over $1.3 billion in 2021 for the state of Idaho. As the pandemic lingers on with new variants and mutations, rising costs will continue to place a heavy burden on many Idahoans, who are already often face disparate health outcomes and access to health care.

Trends in dental expenditures in Japan with a universal health insurance system.

The government of Japan has spent a significant amount on dental healthcare, but it remains unknown how the spending varies across age, type of service, and time. This study describes trends in dental expenditures in Japan. This descriptive study used two national data sources: Estimates of National Medical Care Expenditure and Survey on Economic Conditions in Health Care. We obtained annual total and average per capita dental expenditures by age in Japan from 1984 to 2020 and estimated the proportions of types of service from 1996 to 2021. All costs were adjusted for the 2020 Consumer Price Index (1 US dollar ≈ 100 yen in 2020). Total dental expenditures increased from 1.96 trillion yen in 1984 to 3.00 trillion yen in 2020. In particular, total and average per capita dental spending for older persons showed a rapid increase (total: from 185 billion yen in 1984 to 1.18 trillion yen in 2020; average per capita: from 15,500 yen in 1984 to 32,800 yen in 2020), contributing to the total amount increase. The crown restoration and prosthesis category amounted to 50.3% of the total expenditure in 1996, and this proportion declined to 32.4% by 2021. In 0-14 years persons, expenses on the crown restoration and prosthesis category decreased while the medical management category (mainly including fees for a management plan for oral diseases or oral functions) increased. In persons aged 65 years or older, expenses on the crown restoration and prosthesis category decreased, with increasing expenses in the medical management and at-home treatment categories. The amount of dental spending in Japan substantially increased from 1.96 trillion yen in 1984 to 3.00 trillion yen in 2020), a 1.53-fold increase. The observed changes in annual dental spending varied across age groups and types of service.

Effects of a financial incentive scheme for dementia care on medical and long-term care expenditures: A propensity score-matched analysis using LIFE study data.

Japan introduced a financial incentive scheme in April 2016 to improve hospital-based dementia care, but its effectiveness remains unclear. This study aimed to investigate the scheme's impact on medical and long-term care (LTC) expenditures, as well as on changes in care needs levels and daily living independence levels among older persons one year after hospital discharge. We linked medical and LTC claims databases, and retrospectively identified patients who received LTC needs certification and daily living independence assessments in Fukuoka, Japan. Case patients (received care under the new scheme) were those admitted from April 2016 to March 2018, and control patients were those admitted from April 2014 to March 2016 (before the scheme was implemented). Through propensity score matching, we identified 260 case patients and 260 control patients, and compared using t-tests, and chi-square tests. The analyses found no significant differences between the case and control groups in medical expenditure (US$26,685 vs US$24,823, P = 0.37), LTC expenditure (US$16,870 vs US$14,374, P = 0.08), daily living independence level changes (26.5% vs 20.4%, P = 0.12), or care needs level changes (36.9% vs 30%, P = 0.11). The financial incentive scheme for dementia care did not demonstrate any beneficial effects on patients' healthcare expenditures or health conditions. Further studies are needed to examine the scheme's long-term effects.

Comparison of medical care expenditure between participants and non-participants of exercise class for middle-aged and elderly women

Objectives This study aimed to compare and verify the medical care expenditure of participants and non-participants of exercise classes for middle-aged and elderly women.Methods This study compares and analyzes the medical care expenditure of two groups. The total amount of outpatient treatment, pharmacies, and hospitalization expenditures will be referred to as medical care expenditure. The participating and control groups were 6,576 women aged between 60 and 69 years with a 4-year insurance by the National Health Insurance. The participating group composed 416 women who participated in the exercise class for 2 years and whose hospitalization and outpatient treatment expenditures for 1 year before the exercise class were 0 yen and <500,000 yen, respectively. The control group were matched with the participating group for 1:1 in age and medical care expenditure. Wilcoxon's signed rank test was used to compare the medical costs of the groups. The significance level was set at <5%.Result In comparing the medical care expenditure between years, both groups had increased medical care expenditure and there was no significant difference in the medical care expenditure between the groups within each year; however, the increased medical care expenditure was lower in the participating group than that in the control group. The outpatient treatment and pharmacies expenditures for aged <65 years who participated in ≥15 exercise classes in both years was significantly lower for the participating group compared to that of the control group of the same age group. The hospitalization expenditure was significantly lower in the participating group for all age groups and aged <65 years group after participating in exercise classes.Conclusion Women who continually participate in exercise classes could further reduce their medical care expenditure, especially for those aged ≤65 years.

Corrigendum: Comparison of medical care expenditure between participants and non-participants of exercise class for middle-aged and elderly women

Corrigendum: Comparison of medical care expenditure between participants and non-participants of exercise class for middle-aged and elderly women

The Natural History of Degenerative Cervical Myelopathy.

Degenerative cervical myelopathy (DCM) is the most frequent cause of spinal cord dysfunction and injury in the adult population and leads to significant loss of quality of life and economic impact from its associated medical care expenditures and loss of work. Surgical intervention is recommended for patients manifesting progressing neurological signs and symptoms of myelopathy, but the optimal management in individuals who have mild and clinically stable disease manifestations is controversial. Understanding the natural history of DCM is, thus, important in assessing patients and identifying those most appropriately indicated for surgical management. Despite the attempts to rigorously perform studies of the natural history of these patients, most published investigations suffer from methodological weaknesses or are underpowered to provide definitive answers. Investigations of particular patient subsets, however, provide some clinical guidance as to which patients stand most to benefit from surgery, and these may include those with lower baseline mJOA scores, evidence of segmental hypermobility, cord signal changes on MRI, abnormal somatosensory or motor-evoked potentials, or the presence of certain inflammatory markers. Clinicians should assess patients with mild myelopathy and those harboring asymptomatic cervical spinal cord compression individually when making treatment decisions and an understanding of the various factors that may influence natural history may aid in identifying those best indicated for surgery. Further investigations will likely identify how variables that affect natural history can be used in devising more precise treatment algorithms.

How to cushion economic recession caused by the COVID-19 pandemic: Fiscal or monetary policies?

The outbreak of the COVID-19 pandemic has brought the global economy to a crisis: how to choose the optimal policy tools to cope with the external impacts has attracted worldwide attention. The research evaluates the effects of China's fiscal and monetary policies in promoting economic recovery by establishing a CGE model. Five representative countermeasures such as exempting value-added tax (VAT) and cutting loan rates are studied. The results indicate that: from the aspect of fiscal policies, increasing investment shows a better effect in boosting economy compared with exempting VAT and increasing medical care expenditures; however, the policy also causes price inflation (+0.45%) and crowding-out of enterprise investment (-0.03%). From the aspect of monetary policies, providing targeted loans to enterprises has a better boosting effect on economy compared with cutting loan rates. In the choice between fiscal or monetary policies, fiscal policies exert better effects (household income, +0.95%) when taking the improvement of residents' welfare as the objective. If taking promoting recovery of enterprises and boosting the economy as objectives, monetary policies are found to be better (GDP, +1.99%). Therefore, fiscal and monetary policies should be guided by different objectives and allowed to work in a synergistic manner.

Annual health care costs among Medicare Beneficiaries with essential tremor

IntroductionEssential tremor (ET) is one of the most common neurological disorders, affecting an estimated 2.2% of the entire US population. Despite its high prevalence and associated morbidity and mortality, there are no published data on the medical costs associated with ET care. MethodsThis is a retrospective secondary data analysis using the 5% Medicare claims data from 2016 to study age-eligible Medicare beneficiaries diagnosed with ET (diagnostic code G250) relative to a propensity score-matched group of comparison beneficiaries without ET (27,081 in each arm). Comparisons were matched within age strata and on the full set of Charlson comorbidity indicators, race, and sex. We examined encounter-level costs (amounts paid) and total annual costs of care (in constant $2021 dollars) adjusting for age, sex, race/ethnicity, provider specialty, setting, and the most common comorbidities, using a generalized linear model. ResultsThe final sample included 54,162 total beneficiaries, with an average age of 75, 65% female and 94% Non-Hispanic White. On average, Medicare beneficiaries with at least one outpatient or physician office visit with an ET diagnosis have $1068 (95% CI: $981, $1154) in additional direct medical care expenditures per year relative to statistically similar comparison beneficiaries of the same age. Across the population, we predicted aggregated additional spending attributable to ET among Medicare beneficiaries between $1.5 billion and $5.4 billion per year. ConclusionThe estimated direct medical costs among Medicare beneficiaries with an ET diagnosis aggregated to the population-level are non-trivial. These data begin to fill a gap in knowledge.

EE404 Associations of Comprehensive Stroke Center Scores with Medical and Long-Term Care Expenditures in Ischemic Stroke Patients after Hospital Discharge: J-Aspect & Life Study

Comprehensive stroke centers (CSCs) are facilities that can diagnose and treat stroke patients with intensive and advanced care. CSC capabilities can be assessed using CSC scores that are calculated based on a hospital’s fulfillment of 25 recommended items. This study aimed to investigate the relationships between CSC scores and medical and long-term care (LTC) expenditures in ischemic stroke patients after hospital discharge.

Sleep Apnea and Postoperative Medical Complications and Health Care Expenditures Following Open Reduction and Internal Fixation of Bimalleolar Ankle Fractures.

Sleep Apnea (SA) is a common sleep disorder that increases postoperative morbidity. There is limited research on how SA influences outcomes following operative fixation of ankle fractures. Therefore, the aim of this study was to determine whether patients who undergo surgical fixation for bimalleolar ankle fractures have higher rates of medical complications and health care expenditures. A retrospective review from January 1, 2005 to March 31, 2014 was conducted using the parts A and B Medicare Data from PearlDiver database. Patients with and without SA on the day of the primary open reduction and internal fixation (ORIF) of their bimalleolar ankle fractures were queried using the International Classification of Diseases, Ninth Revision codes. Welch'st-tests were used to compare costs of care. A multivariate binomial logistic regression model was used to calculate the odds ratio (OR) of adverse events. A P-value <.001 was considered statistically significant. There were 20 560 patients (SA = 3150; comparison cohort = 17 410) who underwent ORIF for bimalleolar ankle fractures during the study period. Sleep apnea patients were found to have significantly higher rates and odds of 90-day medical complications (21.42% vs 7.47%, OR: 3.11, P < .0001) and 90-day costs of care ($7213.12 vs $5415.79, P < .0001). This research demonstrates an increased risk of postoperative medical complications and health care costs among patients with SA undergoing ORIF for bimalleolar ankle fractures. Therapeutic, Level IV: Retrospective.

Secondary fracture prevention: global approaches

Osteoporotic fractures, a major cause of disability and associated medical care expenditures, are expected to continue to increase worldwide. Adults who sustain primary osteoporotic fractures are more likely to sustain additional subsequent fractures, but few receive interventions to prevent those secondary fractures. Fracture liaison service models have been developed to systematically streamline preventative care for patients who have sustained a primary fragility fracture, proving cost-effective and efficacious. These programs have been developed in many countries, with varying degrees of success. There continues to be a need to better understand the various approaches to fracture liaison service programs in different regions enabling best practices to be adopted, successful approaches to be shared, and common obstacles to be addressed. The reports in this supplement address the status of fracture liaison service programs in different countries, focusing on national standards and guidelines, successes and barriers, and future directions. This work represents a collaborative effort of member societies of the International Orthopaedic Trauma Association (IOTA), an international association of orthopaedic societies dedicated to the promotion of musculoskeletal trauma care through advancements in patient care, research, and education. The expectation is that the information in these reports will aid efforts to address the growing need for fragility fracture programs.

Identification of individuals benefiting from the kakaritsuke-yakuzaishi (family pharmacist) system in Japan: a retrospective cohort study using an employment-based health insurance claims database

BackgroundThe kakaritsuke-yakuzaishi system (henceforth, the family pharmacist system) which provides more health services than those by general pharmaceutical practice, was implemented in Japan in April 2016. To distribute medical resources and medical care expenditures appropriately, identifying the possible major beneficiaries of this system is essential. By analyzing administrative claims data through this retrospective cohort study, we identified modifiers of the potential benefits of the system. Further, we integrated the identified modifiers into a scoring system that indicates the possible benefitting subpopulations.MethodsWe obtained data about individuals under 75 years old routinely using community pharmacies in Japan from the JMDC database. We classified the individuals as users or non-users. We used claims related to “choufukutouyaku-sougosayoutou-boushi-kasan (additional therapeutic duplication and drug interaction [TDDI] prevention fees)” filed between April 2018 and March 2020, which indicate that individuals’ prescriptions were modified to adjust leftover drugs or to avoid TDDI as indicators of potential benefit. We estimated adjusted absolute risk differences and 95% confidence intervals for product terms using multiple generalized linear regression models. We included the factors whose 95% confidence interval lower limits did not reach 0 in the multiple logistic regression models for developing a scoring system.ResultsThe eligible cohort included 162,340 individuals (1,214 users and 161,126 non-users). The leftover drugs adjustment significantly increased for individuals prescribed antidepressants. However, as only one modifier was identified, we did not develop a scoring system for the leftover drugs adjustment. For TDDI prevention, the following factors were included in the scoring system: being female, being prescribed ≥ 6 drug types, using ≥ 2 medical institutions, and being prescribed proton pump inhibitors, antibiotics, probiotics, or traditional Japanese herbal medicines. The developed scoring system for TDDI prevention scored “female” and “traditional Japanese herbal medicines prescription” factors higher than other factors.ConclusionsIndividuals who are female or prescribed traditional Japanese herbal medicines, or antidepressants may benefit significantly from the family pharmacist system.

Smoking, selection, and medical care expenditures

Smoking, selection, and medical care expenditures