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Concern about the link between opioid prescribing and preventable adverse drug events has led to a series of initiatives to reduce opioid use, with opioids identified as one of three high-priority drug classes targeted to reduce patient harms in the United States (US)âs National Action how can i get viagra Plan for Adverse Drug Event Prevention.1 Variation in opioid prescribing practices by physicians http://markgrigsby.biz/buy-amoxil-without-prescription/ has been observed, yet the reasons why these differences exist remain largely unknown. A better understanding of these differences may help how can i get viagra to improve prescribing practice for opioids. Sex and gender considerations in opioid prescribing practices have not been well studied and may help address this important knowledge gap.There is some evidence to suggest that sex and gender of physicians can affect prescribing practices for older how can i get viagra adults.2 Patient gender has also been related to the experience of health conditions, health-seeking behaviours and medication use.3â5 Sex (biologic), a term describing the physical characteristics and biological attributes of males, females and intersex individuals, influences biological manifestations of medical conditions and responses to drug therapy.5 In contrast, gender (sociocultural) refers to the socially constructed norms, behaviours and roles associated with being a man, woman or gender diverse person.6 While these concepts are related, they are often incorrectly interchanged.
Considering sex and gender, and how they intersect with key identity factors such as age, culture, race and ethnicity, is an analytical approach7 that can be applied to systematically explore the influence of sex and gender on prescribing practices, revealing potentially important differences or trends that would otherwise remain obscured. Such an approach provides the opportunity to inform prescribing practices in general, and pain management strategies how can i get viagra in particular. This will allow healthcare provision to be tailored to the unique needs of women, men and gender diverse people, including those in different age groups, acknowledging the evolution of health and medication needs across the life span.The study by Tamblyn and colleagues,8 published in this edition of the journal, underscores the utility and value of considering patient and provider sex how can i get viagra along with other key identity factors such as age, race and culture in all clinical research.
This study also presents the opportunity to how can i get viagra consider the wider role of patient and physician gender on prescribing, and why the inclusion of both sex and gender may be essential to uncovering important variations in clinical practice, and to capturing the diversity of health needs and experiences in patient populations.In their study, Tamblyn8 set out to explore the impact of physician characteristics, including clinical competence, specialty and country of origin, on opioid prescribing for chronic non-cancer pain. The authors examined the opioid prescribing patterns of a cohort of international medical graduates in the US who completed their Clinical Skills Assessment requirement for the Educational Commission for Foreign Medical Graduates between 1998 and 2004. They were managing older patients covered by the Medicare part D drug insurance programme who were receiving how can i get viagra care in an ambulatory setting for chronic non-cancer pain in 2014 and 2015.
Logistic and linear regression were used to explore the association of the prescribing physicianâs characteristics with opioid prescribing and the doses prescribed.Outcomes measured in the study included opioid prescribing within how can i get viagra 90 days of the clinical evaluation, whether the patient received a non-opioid intervention (eg, physiotherapy treatment or a non-steroidal anti-inflammatory drug) prior to the opioid prescription, and the opioid dose that was prescribed.8 The former outcome is particularly important, as opioids are not first-line therapy for chronic pain.9Notably, even though it was not identified as one of the primary variables of interest, the Tamblyn study8 revealed the importance of routinely stratifying data by sex. Further, the study underlines the importance of the collection and use of sex and age disaggregated data to better understand health status.10 More specifically, this study illustrates why it is important to consider provider sex in opioid prescribing, as well as gender-related sociocultural factors. First, there how can i get viagra are important physician and patient factors that relate to their sex and others that are gender related.
Most (61%) how can i get viagra of the prescribing physicians in this study were men. This is in part because medicine itself is gendered.11 While the proportion of female physicians has grown substantially over the past few decades, they remain under-represented in most specialties, especially those that are higher paying, including some of those explored within the present study.11 12Women are more likely than men to experience the chronic conditions that how can i get viagra cause pain.13 The most common chronic non-cancer conditions being managed in this study were back and neck pain, migraine/headaches, rheumatoid or osteoarthritis, and neuropathic pain. Each of these conditions occur more commonly in older women than in older men.
For example, compared with men of the same age, women aged 65 years and older in Canada are 1.9 times more likely to have been diagnosed with rheumatoid arthritis and are 1.4 times more likely to have been diagnosed with osteoarthritis.14 Migraine headaches are experienced by how can i get viagra almost twice as many women as men (7.4% of women compared with 3.4% of men)10 and neuropathic pain is similarly more prevalent among women.13 The predominance of older women experiencing these chronic non-cancer pain conditions may be one reason why more than 66% of the older patients being managed for chronic pain in the Tamblyn study were women. Unless these differences are examined using sex and age disaggregated data, important patterns in the characteristics of the prescribers and the differences in pain experienced by older women and men will remain hidden in the data.A second salient finding of this study was that the odds of prescribing an opioid for non-cancer chronic conditions was 11% higher for male physicians (OR 1.11, 95% CI 1.03 to 1.19).8 Further, for every 10% increase in the clinical encounter score (used to measure clinical competence), the how can i get viagra odds of prescribing an opioid decreased by 16% for female physicians (OR 0.84, 95%âCI 0.75 to 0.94), but not for male physicians (OR 0.99, 95%âCI 0.92 to 1.07).8 These findings align with the existing literature that reports on correlations between physician gender-related sociocultural factors and prescribing behaviour, patient care and clinical outcomes. Female physicians have been shown to prescribe medications at lower doses than how can i get viagra male physicians.15 The initiation of medications at low doses, using the âstart low, go slow approachâ, is a practice from geriatric medicine that minimises the risk of harm in older adults, as adverse events are often dose related.16 This was illustrated in a study of the initiation of drug therapy for the management of dementia.
Female prescribers were more likely than their male counterparts to initiate cholinesterase inhibitor therapy at a lower-than-recommended dose and for a shorter duration.15 Previous literature on the prescribing of opioids similarly finds that female physicians prescribe opioids more sparingly than their male counterparts.17 When it comes to patientâclinician interactions, female physicians have been characterised as providing more patient-centred and empathetic care.18 19 Compared with their male counterparts, they have been shown to spend more time with patients, engage in more communicative and active partnerships, and provide more psychosocial support and counselling.19 Female physicians have also been shown to adhere more closely to clinical guidelines20 and practise more evidence-based medicine.21 These differences in care delivery and treatment provision may be linked to the more conservative prescribing practices of female physicians demonstrated in the present study and elsewhere.15 17The differences in opioid prescribing practices between male and female physicians observed in the Tamblyn study are not isolated to pain management or opioid prescribing. Rather, this study contributes to recent evidence from different clinical settings and specialties, suggesting that patients cared for by female physicians may have better clinical outcomes compared with how can i get viagra their male colleagues. For instance, when matched for patient, surgeon and hospital characteristics in a large population-based cohort study, patients of female surgeons identified as having 1 of 25 index procedures were found to experience lower risk of short-term postoperative death than those cared for by male surgeons.22 Similarly, female internists treating older adults hospitalised with a medical condition were found to provide significantly better outcomes than their male colleagues in terms of 30-day mortality and readmission rates.23Data on physician and patient sex how can i get viagra or gender-related sociocultural factors are often not reported on or described in research studies, making further synthesis of findings through meta-analysis difficult.24 Consistent reporting of this information can allow for aggregation of data and establishment of stronger correlations between prescriber sex and gender, and clinical outcomes.Finally, considering a sex-based and gender-based analytical approach that includes an intersection with cultural factors for both patients and prescribers may be key to a better understanding of opioid prescribing and pain management.
Gender-based psychosocial patient factors have been related to behavioural responses and expressions of perceived pain, which often reflect societal norms.25 As a social construct, gender is understood to be context specific and thus varying cultural expectations for pain management, potentially linked to country of origin, may influence how a patient experiences pain and a physicianâs likelihood of opioid prescribing for common pain problems. In the present study, Tamblyn found that while the prescriberâs country of origin did not influence the odds of opioid prescribing, US and Canadian physicians, both men and women, how can i get viagra prescribed opioids at higher doses.8 Therefore, the potential influence of cultural norms and gender in relation to clinical treatment and diagnosis of pain may also reveal disproportionate cross-national impacts that would otherwise remain hidden.This study has highlighted the importance of considering patient and prescriber sex, gender and other key identity factors including age and culture, in all research studies in order to better inform clinical care. Given the risks associated with potentially inappropriate opioid use in older adults, it is how can i get viagra worth exploring further how the more cautious practices of female physicians could offer a learning opportunity to optimise health outcomes for all.Ethics statementsPatient consent for publicationNot required.Ensuring patient safety in low-and-middle-income countries (LMICs) requires tailored approaches that are appropriate to the unique challenges faced by health systems in LMICs.
To date, the evidence on how to effectively improve patient safety in LMICs is limited and although we can how can i get viagra infer lessons from high-income countries (HICs), there are meaningful differences between HICs and LMICs that require careful study. The study by Hall et al1 in this issue of BMJ Quality &. Safety, which used implementation science methods to study what helped or hindered the roll-out of a patient safety programme in Guatemala, is therefore a welcome addition to this evidence base.1 Based on the findings from Hall et al,1 and the growing focus in the field of implementation how can i get viagra science to analyse mechanisms by which implementation strategies work (or do not work), we argue that patient safety endeavours globally should consider systems-level barriers and explicitly include tailored strategies to overcome them.2 LMICs have unique contextual factors that require interventions to be adapted, rather than directly transported from HICs.Mixed-methods implementation science studies like those employed in Hall et alâs paper1 are particularly helpful for increasing our understanding of how to translate systems thinking into real-world practice.
Hall et al1 how can i get viagra used the Consolidated Framework for Implementation Research (CFIR)3 to identify facilitators and barriers for implementation and inform the optimisation of patient safety implementation strategies in Guatemala. They evaluated implementation determinants acting across multiple levels, including how can i get viagra the individual, inner organisational context, and external environment which led to several insights related to the overall health system and context. The authors found that clinical staff were intrinsically motivated to provide high-quality and safe care for their patients, but often faced systems barriers of insufficient time, resources and staff to implement known evidence-based protocols.
Some of these are similar as experienced in HICs, but others unique for the how can i get viagra context of LMICs. In addition, due to the hierarchical structure of the system, staff mentioned the need how can i get viagra for increased governance and system/organizational-level structures to support and encourage patient safety.While the CFIR framework proved to be a helpful tool in the Hall et al1 study for identifying individual determinants, many existing implementation science theories, models and frameworks fail to consider the characteristics of the overall health system within which a discrete implementation strategy is embedded. For example, the current Expert Recommendations for Implementing Change compilation of implementation strategies has generated a list of 73 discrete implementation strategies that can be adopted for patient safety.4 Yet, we question whether any discrete implementation strategy canâor should beâdivorced from the overall system in which strategies operate.
Our group recently proposed a modified version of the CFIR framework how can i get viagra for use in LMICs, which includes a new domain focused on âCharacteristics of Systemsâ to address this gap. Systems design features such as the degree of centralisation, availability of supplies, public/private mix and how can i get viagra renumeration mechanisms can strongly influence the degree to which policies and practice are taken up and need to be considered when studying implementation success. Although we strongly advocate for the inclusion of a systems domain in both high-income and low-income settings, LMICs face unique systems-level contextual determinants, which warrant specific exploration in implementation science studies and local strategy adaptation to maximise implementation effectiveness.In contrast to many of the challenges facing high-income health systems, many health systems in LMICs are still focused on guaranteeing a minimum level of facilities, people and supplies, without which delivering how can i get viagra high-quality care may be nearly impossible.
Facility readiness surveys across 10 LMICs have shown that only 1% of health centres have all the diagnostics tests and medicines required to perform basic patient services.5 A similar assessment in Mozambique found that essential medicines for primary care were stocked out 20% of the time and upwards of 50% for mental health medications.6 With very limited trained human resources for primary healthcare, nurses in Mozambique are often forced to deliver sub-standard care as they race to evaluate 60 or more patients in a day and patients wait hours in the heat to be seen.7 Similarly, throughout the erectile dysfunction treatment viagra, providers in India,8 Nigeria,9 Brazil and around the world10 have had the impossible job of trying to deliver safe and effective care when their health systems have failed to guarantee basic supplies like oxygen, resulting in numerous preventable deaths. Providers cannot be expected to focus on preventing unnecessary when they do not have latex gloves or N95 masks to prevent themselves from how can i get viagra contracting erectile dysfunction treatment, Ebola or other infectious diseases. Similarly, we cannot expect to achieve high-quality mental healthcare with only one psychiatrist per 2âmillion people and when the antipsychotic medication a patient was prescribed last month is now out of stock in an entire province.11 When health systems how can i get viagra struggle to guarantee the basics needed to provide essential primary healthcare, providers cannot be expected to provide optimal care.
Patient safety efforts must address underlying systems weaknesses and not only add burdenâor worseâblame providers who are trying the best they can to provide quality care under circumstances designed by the systems in which they operate.The financing of patient safety programmes is also important to consider, as it reflects priorities, potential for scale, as well as possible interruptions or delays in implementation. The Hall et al1 study identified the lack of how can i get viagra financial support and organisational incentives as a barrier to implementation effectiveness. LMICs continue to rely on significant contributions from donor assistance and are at greater how can i get viagra risk of a mismatch in the priorities of funding agents compared with HICs.12 Donor-assisted funds also tend to be earmarked and time-bound, restricting health systemsâ ability to flexibly use the funds and hampering a smooth transition from pilot stage to scaled implementation.
The modified CFIR that our group proposed includes these constructs, as well as the perceived ability for a programme to scale, particularly in LMICs where fragmented implementation efforts and pilots are rampant.It is also critical to consider the administrative design of health systems in LMICs as a construct in the modified CFIR, as how can i get viagra rolling out a patient safety programme in a highly centralised system versus one that is highly decentralised or even federated will influence implementation effectiveness. The Hall et al1 study found that providers were highly motivated on their own to focus on patient safety, but felt limited by their own decision-making autonomy, and lack of national or facility level policies and organisational support. If patient how can i get viagra safety efforts focus on isolated implementation strategies that are divorced from an understanding of the system within which it will be integrated, the results will be poor.Patient safety efforts also require that adverse events are reliably monitored, reported and properly incentivised.
According to WHO, âeach year 134âmillion adverse how can i get viagra events occur in hospitals in LMICs due to unsafe care, resulting in 2.6âmillion deaths,â13 yet those figures only capture reported events. Providers who participated in the Hall et al1 study felt that patient safety would not progress in their Guatemalan setting without accurate patient outcome how can i get viagra data, accountability, incentives aligned to outcomes and clear governing policies. The strength of the health information system in LMICs, the culture around reporting and the way leaders use those data are therefore critical determinants that we argued should be included in a modified CFIR.
Taking a systems lens would also how can i get viagra highlight that data reporting is linked with financing. The variables collected to monitor effectiveness of health programmes in LMICs are often dictated by donor priorities leading to proprietary, siloed systems and inefficiencies for how can i get viagra health workers,14 15 an issue which many donors are now trying to combat.16The field of implementation science can help us critically evaluate policies and norms that are considered essential for âsafeâ care in HICs, but which lack real-world evidence in LMICs. We need to recognise that HICs and LMICs may differ in their definition of âsafeâ and the way to minimise errors and adverse events may differ across settings.
For example, in Western countries, only physicians were initially allowed how can i get viagra to monitor HIV/AIDS treatmentâit was considered âunsafeâ for anyone else to do so. Yet, studies in LMICs have demonstrated that care can be effectively and safely administered by non-physician clinicians, such as nurses,17 an approach that may or may not how can i get viagra be accepted in HICs. We have seen the same how can i get viagra pattern demonstrated with task-sharing in family planning,18 mental health,19 20 surgical equipment21 and other non-communicable diseases.22 Implementation science can continue to build our understanding of what patient safety means in LMICs.How we achieve healthcare delivery with no adverse events in LMICs will differ across cultures and health systems contexts.
Implementers, researchers, managers and policy-makers should consider building patient safety programmes that use implementation strategies targeting the numerous barriers that exist at the provider level and also at the level of the health system as a whole. Future implementation research efforts to improve patient safety in LMICs should use frameworks, such as the expanded how can i get viagra CFIR adapted for LMICs, to evaluate determinants of patient safety at all levels with a specific focus on the systems domain. Without this holistic focus, narrowly defined patient safety programmes will likely how can i get viagra have limited effects to improve care for patients and their outcomes.
Worse, these programmes could demoralise the limited number of trained health providers who are already overburdened as they work on the front lines to ensure âhealth for allâ across LMICs.Ethics statementsPatient consent for publicationNot required..
Concern about the link between opioid prescribing and preventable adverse drug events has led to a series of initiatives to reduce opioid use, with opioids identified as one of best place to buy viagra online 2020 three Buy amoxil without prescription high-priority drug classes targeted to reduce patient harms in the United States (US)âs National Action Plan for Adverse Drug Event Prevention.1 Variation in opioid prescribing practices by physicians has been observed, yet the reasons why these differences exist remain largely unknown. A better understanding of these differences may help to improve prescribing practice for best place to buy viagra online 2020 opioids. Sex and gender considerations in opioid prescribing practices have not been well studied and may help address this important knowledge best place to buy viagra online 2020 gap.There is some evidence to suggest that sex and gender of physicians can affect prescribing practices for older adults.2 Patient gender has also been related to the experience of health conditions, health-seeking behaviours and medication use.3â5 Sex (biologic), a term describing the physical characteristics and biological attributes of males, females and intersex individuals, influences biological manifestations of medical conditions and responses to drug therapy.5 In contrast, gender (sociocultural) refers to the socially constructed norms, behaviours and roles associated with being a man, woman or gender diverse person.6 While these concepts are related, they are often incorrectly interchanged. Considering sex and gender, and how they intersect with key identity factors such as age, culture, race and ethnicity, is an analytical approach7 that can be applied to systematically explore the influence of sex and gender on prescribing practices, revealing potentially important differences or trends that would otherwise remain obscured.
Such an approach provides the opportunity to inform prescribing practices in general, and pain management strategies in particular best place to buy viagra online 2020. This will allow healthcare provision to be tailored to the best place to buy viagra online 2020 unique needs of women, men and gender diverse people, including those in different age groups, acknowledging the evolution of health and medication needs across the life span.The study by Tamblyn and colleagues,8 published in this edition of the journal, underscores the utility and value of considering patient and provider sex along with other key identity factors such as age, race and culture in all clinical research. This study also presents the opportunity to consider the wider role of patient and physician gender on prescribing, and why the inclusion of both sex and gender may be essential to uncovering important variations in clinical practice, and to capturing the diversity of health needs and experiences in patient populations.In their study, Tamblyn8 set out to explore the impact of physician characteristics, including clinical competence, specialty and country of origin, on opioid prescribing for chronic best place to buy viagra online 2020 non-cancer pain. The authors examined the opioid prescribing patterns of a cohort of international medical graduates in the US who completed their Clinical Skills Assessment requirement for the Educational Commission for Foreign Medical Graduates between 1998 and 2004.
They were managing older patients covered by the Medicare best place to buy viagra online 2020 part D drug insurance programme who were receiving care in an ambulatory setting for chronic non-cancer pain in 2014 and 2015. Logistic and linear regression were used to explore the association of the prescribing physicianâs characteristics with opioid prescribing and the doses prescribed.Outcomes measured in the study included opioid prescribing within 90 days best place to buy viagra online 2020 of the clinical evaluation, whether the patient received a non-opioid intervention (eg, physiotherapy treatment or a non-steroidal anti-inflammatory drug) prior to the opioid prescription, and the opioid dose that was prescribed.8 The former outcome is particularly important, as opioids are not first-line therapy for chronic pain.9Notably, even though it was not identified as one of the primary variables of interest, the Tamblyn study8 revealed the importance of routinely stratifying data by sex. Further, the study underlines the importance of the collection and use of sex and age disaggregated data to better understand health status.10 More specifically, this study illustrates why it is important to consider provider sex in opioid prescribing, as well as gender-related sociocultural factors. First, there are important best place to buy viagra online 2020 physician and patient factors that relate to their sex and others that are gender related.
Most (61%) of the prescribing physicians in this best place to buy viagra online 2020 study were men. This is in part best place to buy viagra online 2020 because medicine itself is gendered.11 While the proportion of female physicians has grown substantially over the past few decades, they remain under-represented in most specialties, especially those that are higher paying, including some of those explored within the present study.11 12Women are more likely than men to experience the chronic conditions that cause pain.13 The most common chronic non-cancer conditions being managed in this study were back and neck pain, migraine/headaches, rheumatoid or osteoarthritis, and neuropathic pain. Each of these conditions occur more commonly in older women than in older men. For example, compared with men of the same age, women aged 65 years and older in Canada are best place to buy viagra online 2020 1.9 times more likely to have been diagnosed with rheumatoid arthritis and are 1.4 times more likely to have been diagnosed with osteoarthritis.14 Migraine headaches are experienced by almost twice as many women as men (7.4% of women compared with 3.4% of men)10 and neuropathic pain is similarly more prevalent among women.13 The predominance of older women experiencing these chronic non-cancer pain conditions may be one reason why more than 66% of the older patients being managed for chronic pain in the Tamblyn study were women.
Unless these differences are examined using sex and age disaggregated data, important patterns in the characteristics of the prescribers and the differences in pain experienced by older women and men will remain hidden in the data.A best place to buy viagra online 2020 second salient finding of this study was that the odds of prescribing an opioid for non-cancer chronic conditions was 11% higher for male physicians (OR 1.11, 95% CI 1.03 to 1.19).8 Further, for every 10% increase in the clinical encounter score (used to measure clinical competence), the odds of prescribing an opioid decreased by 16% for female physicians (OR 0.84, 95%âCI 0.75 to 0.94), but not for male physicians (OR 0.99, 95%âCI 0.92 to 1.07).8 These findings align with the existing literature that reports on correlations between physician gender-related sociocultural factors and prescribing behaviour, patient care and clinical outcomes. Female physicians have been shown to prescribe medications at lower doses than male physicians.15 The initiation of medications at low doses, using the âstart low, go slow approachâ, is a practice from geriatric medicine that minimises the risk of harm in older adults, as adverse events are often dose related.16 This was illustrated in a study of the initiation of drug therapy best place to buy viagra online 2020 for the management of dementia. Female prescribers were more likely than their male counterparts to initiate cholinesterase inhibitor therapy at a lower-than-recommended dose and for a shorter duration.15 Previous literature on the prescribing of opioids similarly finds that female physicians prescribe opioids more sparingly than their male counterparts.17 When it comes to patientâclinician interactions, female physicians have been characterised as providing more patient-centred and empathetic care.18 19 Compared with their male counterparts, they have been shown to spend more time with patients, engage in more communicative and active partnerships, and provide more psychosocial support and counselling.19 Female physicians have also been shown to adhere more closely to clinical guidelines20 and practise more evidence-based medicine.21 These differences in care delivery and treatment provision may be linked to the more conservative prescribing practices of female physicians demonstrated in the present study and elsewhere.15 17The differences in opioid prescribing practices between male and female physicians observed in the Tamblyn study are not isolated to pain management or opioid prescribing. Rather, this study best place to buy viagra online 2020 contributes to recent evidence from different clinical settings and specialties, suggesting that patients cared for by female physicians may have better clinical outcomes compared with their male colleagues.
For instance, when matched for patient, surgeon and hospital characteristics in a large population-based cohort study, patients of female surgeons identified as having 1 of 25 index procedures were found to experience lower risk of short-term postoperative death than those cared for by male surgeons.22 Similarly, female internists treating older adults hospitalised with a medical condition were found to provide significantly better outcomes than their male colleagues in terms of 30-day mortality and readmission rates.23Data on physician and patient sex or gender-related sociocultural factors are often not reported on or best place to buy viagra online 2020 described in research studies, making further synthesis of findings through meta-analysis difficult.24 Consistent reporting of this information can allow for aggregation of data and establishment of stronger correlations between prescriber sex and gender, and clinical outcomes.Finally, considering a sex-based and gender-based analytical approach that includes an intersection with cultural factors for both patients and prescribers may be key to a better understanding of opioid prescribing and pain management. Gender-based psychosocial patient factors have been related to behavioural responses and expressions of perceived pain, which often reflect societal norms.25 As a social construct, gender is understood to be context specific and thus varying cultural expectations for pain management, potentially linked to country of origin, may influence how a patient experiences pain and a physicianâs likelihood of opioid prescribing for common pain problems. In the present study, Tamblyn found that while the prescriberâs country of origin did not influence the odds of opioid prescribing, US and Canadian physicians, both men and women, prescribed opioids at higher doses.8 Therefore, the potential influence of cultural norms and gender in relation to clinical treatment and diagnosis of pain may also reveal disproportionate cross-national impacts that would otherwise remain hidden.This study has highlighted best place to buy viagra online 2020 the importance of considering patient and prescriber sex, gender and other key identity factors including age and culture, in all research studies in order to better inform clinical care. Given the risks associated with potentially inappropriate opioid use in older best place to buy viagra online 2020 adults, it is worth exploring further how the more cautious practices of female physicians could offer a learning opportunity to optimise health outcomes for all.Ethics statementsPatient consent for publicationNot required.Ensuring patient safety in low-and-middle-income countries (LMICs) requires tailored approaches that are appropriate to the unique challenges faced by health systems in LMICs.
To date, the evidence on how to effectively improve patient safety in LMICs is limited and although we can infer lessons from high-income countries best place to buy viagra online 2020 (HICs), there are meaningful differences between HICs and LMICs that require careful study. The study by Hall et al1 in this issue of BMJ Quality &. Safety, which used implementation science methods to study what helped or hindered the roll-out of a patient safety programme in Guatemala, is therefore a welcome addition to this evidence base.1 Based on the findings from Hall et al,1 and the growing focus in the field of implementation science to analyse mechanisms by which implementation strategies work (or do not work), we argue that patient safety endeavours globally should consider systems-level barriers and explicitly include tailored strategies to overcome them.2 LMICs have unique contextual factors that require interventions to be adapted, rather than directly transported from HICs.Mixed-methods implementation science studies like those employed in Hall et best place to buy viagra online 2020 alâs paper1 are particularly helpful for increasing our understanding of how to translate systems thinking into real-world practice. Hall et al1 used the best place to buy viagra online 2020 Consolidated Framework for Implementation Research (CFIR)3 to identify facilitators and barriers for implementation and inform the optimisation of patient safety implementation strategies in Guatemala.
They evaluated implementation determinants acting across multiple levels, including the individual, inner organisational context, and external environment which best place to buy viagra online 2020 led to several insights related to the overall health system and context. The authors found that clinical staff were intrinsically motivated to provide high-quality and safe care for their patients, but often faced systems barriers of insufficient time, resources and staff to implement known evidence-based protocols. Some of these are similar as experienced in HICs, but others unique best place to buy viagra online 2020 for the context of LMICs. In addition, due to the hierarchical structure of the system, staff mentioned the need for increased governance and system/organizational-level structures to best place to buy viagra online 2020 support and encourage patient safety.While the CFIR framework proved to be a helpful tool in the Hall et al1 study for identifying individual determinants, many existing implementation science theories, models and frameworks fail to consider the characteristics of the overall health system within which a discrete implementation strategy is embedded.
For example, the current Expert Recommendations for Implementing Change compilation of implementation strategies has generated a list of 73 discrete implementation strategies that can be adopted for patient safety.4 Yet, we question whether any discrete implementation strategy canâor should beâdivorced from the overall system in which strategies operate. Our group recently proposed a modified version of the CFIR framework for use in LMICs, which includes a new domain focused on âCharacteristics of best place to buy viagra online 2020 Systemsâ to address this gap. Systems design features such as the best place to buy viagra online 2020 degree of centralisation, availability of supplies, public/private mix and renumeration mechanisms can strongly influence the degree to which policies and practice are taken up and need to be considered when studying implementation success. Although we strongly advocate for the inclusion of a systems domain in both high-income and low-income settings, LMICs face unique best place to buy viagra online 2020 systems-level contextual determinants, which warrant specific exploration in implementation science studies and local strategy adaptation to maximise implementation effectiveness.In contrast to many of the challenges facing high-income health systems, many health systems in LMICs are still focused on guaranteeing a minimum level of facilities, people and supplies, without which delivering high-quality care may be nearly impossible.
Facility readiness surveys across 10 LMICs have shown that only 1% of health centres have all the diagnostics tests and medicines required to perform basic patient services.5 A similar assessment in Mozambique found that essential medicines for primary care were stocked out 20% of the time and upwards of 50% for mental health medications.6 With very limited trained human resources for primary healthcare, nurses in Mozambique are often forced to deliver sub-standard care as they race to evaluate 60 or more patients in a day and patients wait hours in the heat to be seen.7 Similarly, throughout the erectile dysfunction treatment viagra, providers in India,8 Nigeria,9 Brazil and around the world10 have had the impossible job of trying to deliver safe and effective care when their health systems have failed to guarantee basic supplies like oxygen, resulting in numerous preventable deaths. Providers cannot be best place to buy viagra online 2020 expected to focus on preventing unnecessary when they do not have latex gloves or N95 masks to prevent themselves from contracting erectile dysfunction treatment, Ebola or other infectious diseases. Similarly, we cannot expect to achieve high-quality mental healthcare with only one psychiatrist per 2âmillion people and when the antipsychotic medication a patient was prescribed last month best place to buy viagra online 2020 is now out of stock in an entire province.11 When health systems struggle to guarantee the basics needed to provide essential primary healthcare, providers cannot be expected to provide optimal care. Patient safety efforts must address underlying systems weaknesses and not only add burdenâor worseâblame providers who are trying the best they can to provide quality care under circumstances designed by the systems in which they operate.The financing of patient safety programmes is also important to consider, as it reflects priorities, potential for scale, as well as possible interruptions or delays in implementation.
The Hall et best place to buy viagra online 2020 al1 study identified the lack of financial support and organisational incentives as a barrier to implementation effectiveness. LMICs continue to rely on significant contributions from donor assistance and are at greater risk of a mismatch in the priorities of funding best place to buy viagra online 2020 agents compared with HICs.12 Donor-assisted funds also tend to be earmarked and time-bound, restricting health systemsâ ability to flexibly use the funds and hampering a smooth transition from pilot stage to scaled implementation. The modified CFIR that our group proposed includes these constructs, as well as the perceived ability for a programme to scale, particularly in LMICs where fragmented implementation efforts and pilots are rampant.It is also critical to consider the administrative design of health systems in LMICs as a construct in the modified best place to buy viagra online 2020 CFIR, as rolling out a patient safety programme in a highly centralised system versus one that is highly decentralised or even federated will influence implementation effectiveness. The Hall et al1 study found that providers were highly motivated on their own to focus on patient safety, but felt limited by their own decision-making autonomy, and lack of national or facility level policies and organisational support.
If patient safety efforts focus on isolated implementation strategies that are divorced from an understanding of the system within which it will be integrated, best place to buy viagra online 2020 the results will be poor.Patient safety efforts also require that adverse events are reliably monitored, reported and properly incentivised. According to WHO, best place to buy viagra online 2020 âeach year 134âmillion adverse events occur in hospitals in LMICs due to unsafe care, resulting in 2.6âmillion deaths,â13 yet those figures only capture reported events. Providers who participated in the Hall et al1 study felt that best place to buy viagra online 2020 patient safety would not progress in their Guatemalan setting without accurate patient outcome data, accountability, incentives aligned to outcomes and clear governing policies. The strength of the health information system in LMICs, the culture around reporting and the way leaders use those data are therefore critical determinants that we argued should be included in a modified CFIR.
Taking a systems lens would also highlight that data best place to buy viagra online 2020 reporting is linked with financing. The variables collected to monitor effectiveness of health programmes in LMICs are often dictated by donor priorities leading to proprietary, siloed systems and inefficiencies for health workers,14 15 an issue which many donors are now trying to combat.16The field of implementation science can help us critically evaluate policies and norms that are considered best place to buy viagra online 2020 essential for âsafeâ care in HICs, but which lack real-world evidence in LMICs. We need to recognise that HICs and LMICs may differ in their definition of âsafeâ and the way to minimise errors and adverse events may differ across settings. For example, in Western countries, only physicians were initially best place to buy viagra online 2020 allowed to monitor HIV/AIDS treatmentâit was considered âunsafeâ for anyone else to do so.
Yet, studies in LMICs have demonstrated that care can be effectively and safely administered by non-physician clinicians, such as nurses,17 an approach that may best place to buy viagra online 2020 or may not be accepted in HICs. We have seen the same best place to buy viagra online 2020 pattern demonstrated with task-sharing in family planning,18 mental health,19 20 surgical equipment21 and other non-communicable diseases.22 Implementation science can continue to build our understanding of what patient safety means in LMICs.How we achieve healthcare delivery with no adverse events in LMICs will differ across cultures and health systems contexts. Implementers, researchers, managers and policy-makers should consider building patient safety programmes that use implementation strategies targeting the numerous barriers that exist at the provider level and also at the level of the health system as a whole. Future implementation research efforts to improve patient safety in LMICs should use frameworks, such as the expanded CFIR adapted for LMICs, to evaluate determinants of patient safety at all levels with best place to buy viagra online 2020 a specific focus on the systems domain.
Without this best place to buy viagra online 2020 holistic focus, narrowly defined patient safety programmes will likely have limited effects to improve care for patients and their outcomes. Worse, these programmes could demoralise the limited number of trained health providers who are already overburdened as they work on the front lines to ensure âhealth for allâ across LMICs.Ethics statementsPatient consent for publicationNot required..
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Notice. The Centers for Medicare &. Medicaid Services (CMS) is announcing an opportunity for the public to comment on CMS' intention to collect information from the public. Under the Paperwork Reduction Act of 1995 (the PRA), federal agencies are required to publish notice in the Federal Register concerning each proposed collection of information (including each proposed extension or reinstatement of an existing collection of information) and to allow 60 days for public comment on the proposed action.
Interested persons are invited to send comments regarding our burden estimates or any other aspect of this collection of information, including the necessity and utility of the proposed information collection for the proper performance of the agency's functions, the accuracy of the estimated burden, ways to enhance the quality, utility, and clarity of the information to be collected, and the use of automated collection techniques or other forms of information technology to minimize the information collection burden. Comments must be received by April 25, 2022. When commenting, please reference the document identifier or OMB control number. To be assured consideration, comments and recommendations must be submitted in any one of the following ways.
1. Electronically. You may send your comments electronically to http://www.regulations.gov. Follow the instructions for âComment or Start Printed Page 9628 Submissionâ or âMore Search Optionsâ to find the information collection document(s) that are accepting comments.
2. By regular mail. You may mail written comments to the following address. CMS, Office of Strategic Operations and Regulatory Affairs, Division of Regulations Development, Attention.
Document Identifier/OMB Control Number. ___, Room C4-26-05, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. To obtain copies of a supporting statement and any related forms for the proposed collection(s) summarized in this notice, you may make your request using one of following. 1.
Access CMS' website address at website address at https://www.cms.gov/âRegulations-and-Guidance/âLegislation/âPaperworkReductionActof1995/âPRA-Listing. Start Further Info William N. Parham at (410) 786-4669. End Further Info End Preamble Start Supplemental Information Contents This notice sets out a summary of the use and burden associated with the following information collections.
More detailed information can be found in each collection's supporting statement and associated materials (see ADDRESSES ). CMS-10391âMethods for Assuring Access to Covered Medicaid Services Under 42 CFR 447.203 and 447.204 CMS-R-74 Income and Eligibility Verification System Reporting and Supporting Regulations CMS-R-306 Use of Restraint and Seclusion in Psychiatric Residential Treatment Facilities (PRTFs) for Individuals Under Age 21 and Supporting Regulations CMS-265-11 Independent Renal Dialysis Facility Cost Report CMS-10544 Good Cause Processes Under the PRA (44 U.S.C. 3501-3520), federal agencies must obtain approval from the Office of Management and Budget (OMB) for each collection of information they conduct or sponsor. The term âcollection of informationâ is defined in 44 U.S.C.
3502(3) and 5 CFR 1320.3(c) and includes agency requests or requirements that members of the public submit reports, keep records, or provide information to a third party. Section 3506(c)(2)(A) of the PRA requires federal agencies to publish a 60-day notice in the Federal Register concerning each proposed collection of information, including each proposed extension or reinstatement of an existing collection of information, before submitting the collection to OMB for approval. To comply with this requirement, CMS is publishing this notice. Information Collection 1.
Type of Information Collection Request. Extension of a currently approved collection. Title of Information Collection. Methods for Assuring Access to Covered Medicaid Services Under 42 CFR 447.203 and 447.204.
Use. Current regulations at 42 CFR 447.203(b) require states to develop an access monitoring review plan (AMRP) that is updated at least every three years for. Primary care services, physician specialist services, behavioral health services, pre and post-natal obstetric services (including labor and delivery), and home health services. When states reduce rates for other Medicaid services, they must add those services to the AMRP and monitor the effects of the rate reductions for 3 years.
If access issues are detected, a state must submit a corrective action plan to CMS within 90 days and work to address the issues within 12 months. Section 447.203(b)(7) requires that states have mechanisms to obtain ongoing beneficiary and provider feedback. A state is also required to maintain a record of data on public input and how the state responded to the input. Prior to submitting proposals to reduce or restructure Medicaid service payment rates, states must receive input from beneficiaries, providers, and other affected stakeholders on the extent of beneficiary access to the affected services.
The information is used by states to document that access to care is in compliance with section 1902(a)(30)(A) of the Social Security Act, to identify issues with access within a state's Medicaid program, and to inform any necessary programmatic changes to address issues with access to care. CMS uses the information to make informed approval decisions on State plan amendments that propose to make Medicaid rate reductions or restructure payment rates and to provide the necessary information for CMS to monitor ongoing compliance with section 1902(a)(30)(A). Beneficiaries, providers and other affected stakeholders may use the information to raise access issues to state Medicaid agencies and work with agencies to address those issues. Form Number.
CMS-10391 (OMB control number. 0938-1134). Frequency. Annually.
Affected Public. State, Local, or Tribal Governments). Number of Respondents. 51.
Total Annual Responses. 212. Total Annual Hours. 12,262.
(For questions regarding this collection contact Jeremy Silanskis at 410-786-1592.) 2. Type of Information Collection Request. Extension of a currently approved collection. Title of Information Collection.
Income and Eligibility Verification System Reporting and Supporting Regulations. Use. Section 1137 of the Social Security Act requires that States verify the income and eligibility information contained on the applicant's application and in the applicant's case file through data matches with the agencies and entities identified in this section. The State Medicaid/CHIP agency will report the existence of a system to collect all information needed to determine and redetermine eligibility for Medicaid and CHIP.
The State Medicaid/CHIP agency will attest to using the PARIS system in determining beneficiary eligibility in Medicaid or CHIP benefit programs. Form Number. CMS-R-74 (OMB control number. 0938-0467).
Frequency. Occasionally. Affected Public. State, Local, or Tribal Governments.
Number of Respondents. 55. Total Annual Responses. 3,241.
Total Annual Hours. 1,071. (For policy questions regarding this collection contact Stephanie Bell at 410-786-0617.) 3. Type of Information Collection Request.
Extension of a currently approved collection. Title of Information Collection. Use of Restraint and Seclusion in Psychiatric Residential Treatment Facilities (PRTFs) for Individuals Under Age 21 and Supporting Regulations. Use.
Psychiatric residential treatment facilities are required to report deaths, serious injuries and attempted suicides to the State Medicaid Agency and the Protection and Advocacy Organization. They are also required to provide residents the restraint and seclusion policy in writing, and to document in the residents' records all activities involving the use of restraint and seclusion. Form Number. CMS-R-306 (OMB control number.
0938-0833). Frequency. Occasionally. Affected Public.
Private sector (Business or other for-profits). Number of Respondents. 390. Total Annual Responses.
1,466,823. Total Annual Hours. 449,609. (For policy questions regarding this collection contact Kirsten Jensen at 410-786-8146.) 4.
Type of Information Collection Request. Reinstatement with change. Title of Information Collection. Independent Renal Dialysis Facility Cost Report.
Use. Under the authority of sections 1815(a) and 1833(e) of the Act, CMS requires that providers of services participating in the Medicare program submit information to determine costs Start Printed Page 9629 for health care services rendered to Medicare beneficiaries. CMS requires that providers follow reasonable cost principles under 1861(v)(1)(A) of the Act when completing the Medicare cost report (MCR). Regulations at 42 CFR 413.20 and 413.24 require that providers submit acceptable cost reports on an annual basis and maintain sufficient financial records and statistical data, capable of verification by qualified auditors.
ESRD facilities participating in the Medicare program submit these cost reports annually to report cost and statistical data used by CMS to determine reasonable costs incurred for furnishing dialysis services to Medicare beneficiaries and to effect the year-end cost settlement for Medicare bad debts. Form Number. CMS-265-11 (OMB control number. 0938-0236).
Frequency. Annually. Affected Public. Private Sector, Business or other for-profits, State, Local, or Tribal Governments).
Number of Respondents. 7,492. Total Annual Responses. 7,492.
Total Annual Hours. 494,472. (For questions regarding this collection contact Keplinger, Jill C at 410-786-4550.) 5. Type of Information Collection Request.
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One in 10 had tried it.âI donât think anyone truly understands the depth and breadth of the issues," said Ray Merenstein, who runs the Colorado chapter of the National Alliance on Mental Illness. Those who study rural mental health all agree the two biggest obstacles are access and best place to buy viagra online 2020 stigma.âHow can people actually get to it if they donât have transportation or if they have to take care of their kids and they donât have daycare?. " Merenstein said. ÂEven if we were able to reach each and every individual, itâs really important that we make sure theyâre comfortable talking about mental health and mental illness.ââI've got a bunch of friends," said Hamm, "and weâll go out and drink a few beers and hang out and watch the game or whatever it is weâre going to do. And, you know, that kind of seems to be just as good as best place to buy viagra online 2020 paying a bunch of money to somebody else.âThe mountains, the farms, and the traditions can all seem immovable.
But in Montana, officials are giving a push. The state has rolled out a mobile app for those fighting drug addiction. Theyâve deployed best place to buy viagra online 2020 extension agents to provide mental health resources for teenagers, and theyâve received a federal grant for programs like Brennanâs. Farmers and ranchers can receive vouchers for free counseling services, in-person or online.Itâs hard not to be seduced by the scenery. Itâs hard to break away when you spend your whole day on the acres you know best.
Thatâs whatâs being asked best place to buy viagra online 2020. To somehow make the discussion about mental health as much a part of life in Montana as the mountains.âIâve never been opposed to trying something new and stuff like that," Hamm said. "This is definitely one of the years where it might be worthwhile to check out."Start Preamble Centers for Medicare &. Medicaid Services, Health and Human Services best place to buy viagra online 2020 (HHS). Notice.
The Centers for Medicare &. Medicaid Services (CMS) is announcing an best place to buy viagra online 2020 opportunity for the public to comment on CMS' intention to collect information from the public. Under the Paperwork Reduction Act of 1995 (the PRA), federal agencies are required to publish notice in the Federal Register concerning each proposed collection of information (including each proposed extension or reinstatement of an existing collection of information) and to allow 60 days for public comment on the proposed action. Interested persons are invited to send comments regarding our burden estimates or any other aspect of this collection of information, including the necessity and utility of the proposed information collection for the proper performance of the agency's functions, the accuracy of the estimated burden, ways to enhance the quality, utility, and clarity of the information to be collected, and the use of automated collection techniques or other forms of information technology to minimize the information collection burden. Comments must be received by April 25, best place to buy viagra online 2020 2022.
When commenting, please reference the document identifier or OMB control number. To be assured consideration, comments and recommendations must be submitted in any one of the following ways. 1 best place to buy viagra online 2020. Electronically. You may send your comments electronically to http://www.regulations.gov.
Follow the instructions for âComment or Start Printed Page 9628 Submissionâ or âMore Search Optionsâ to find best place to buy viagra online 2020 the information collection document(s) that are accepting comments. 2. By regular mail. You may best place to buy viagra online 2020 mail written comments to the following address. CMS, Office of Strategic Operations and Regulatory Affairs, Division of Regulations Development, Attention.
Document Identifier/OMB Control Number. ___, Room C4-26-05, 7500 Security Boulevard, best place to buy viagra online 2020 Baltimore, Maryland 21244-1850. To obtain copies of a supporting statement and any related forms for the proposed collection(s) summarized in this notice, you may make your request using one of following. 1. Access CMS' website address at website best place to buy viagra online 2020 address at https://www.cms.gov/âRegulations-and-Guidance/âLegislation/âPaperworkReductionActof1995/âPRA-Listing.
Start Further Info William N. Parham at (410) 786-4669. End Further Info End Preamble Start Supplemental Information Contents This notice sets out a summary of the best place to buy viagra online 2020 use and burden associated with the following information collections. More detailed information can be found in each collection's supporting statement and associated materials (see ADDRESSES ). CMS-10391âMethods for Assuring Access to Covered Medicaid Services Under 42 CFR 447.203 and 447.204 CMS-R-74 Income and Eligibility Verification System Reporting and Supporting Regulations CMS-R-306 Use of Restraint and Seclusion in Psychiatric Residential Treatment Facilities (PRTFs) for Individuals Under Age 21 and Supporting Regulations CMS-265-11 Independent Renal Dialysis Facility Cost Report CMS-10544 Good Cause Processes Under the PRA (44 U.S.C.
3501-3520), federal agencies must obtain approval from the Office best place to buy viagra online 2020 of Management and Budget (OMB) for each collection of information they conduct or sponsor. The term âcollection of informationâ is defined in 44 U.S.C. 3502(3) and 5 CFR 1320.3(c) and includes agency requests or requirements that members of the public submit reports, keep records, or provide information to a third party. Section 3506(c)(2)(A) of the PRA requires federal agencies to publish a 60-day best place to buy viagra online 2020 notice in the Federal Register concerning each proposed collection of information, including each proposed extension or reinstatement of an existing collection of information, before submitting the collection to OMB for approval. To comply with this requirement, CMS is publishing this notice.
Information Collection 1. Type of Information Collection best place to buy viagra online 2020 Request. Extension of a currently approved collection. Title of Information Collection. Methods for Assuring Access to Covered Medicaid Services Under 42 best place to buy viagra online 2020 CFR 447.203 and 447.204.
Use. Current regulations at 42 CFR 447.203(b) require states to develop an access monitoring review plan (AMRP) that is updated at least every three years for. Primary care services, best place to buy viagra online 2020 physician specialist services, behavioral health services, pre and post-natal obstetric services (including labor and delivery), and home health services. When states reduce rates for other Medicaid services, they must add those services to the AMRP and monitor the effects of the rate reductions for 3 years. If access issues are detected, a state must submit a corrective action plan to CMS within 90 days and work to address the issues within 12 months.
Section 447.203(b)(7) requires that states have mechanisms to obtain ongoing beneficiary and provider feedback best place to buy viagra online 2020. A state is also required to maintain a record of data on public input and how the state responded to the input. Prior to submitting proposals to reduce or restructure Medicaid service payment rates, states must receive input from beneficiaries, providers, and other affected stakeholders on the extent of beneficiary access to the affected services. The information is best place to buy viagra online 2020 used by states to document that access to care is in compliance with section 1902(a)(30)(A) of the Social Security Act, to identify issues with access within a state's Medicaid program, and to inform any necessary programmatic changes to address issues with access to care. CMS uses the information to make informed approval decisions on State plan visit this web-site amendments that propose to make Medicaid rate reductions or restructure payment rates and to provide the necessary information for CMS to monitor ongoing compliance with section 1902(a)(30)(A).
Beneficiaries, providers and other affected stakeholders may use the information to raise access issues to state Medicaid agencies and work with agencies to address those issues. Form Number best place to buy viagra online 2020. CMS-10391 (OMB control number. 0938-1134). Frequency.
Annually. Affected Public. State, Local, or Tribal Governments). Number of Respondents. 51.
Total Annual Responses. 212. Total Annual Hours. 12,262. (For questions regarding this collection contact Jeremy Silanskis at 410-786-1592.) 2.
Type of Information Collection Request. Extension of a currently approved collection. Title of Information Collection. Income and Eligibility Verification System Reporting and Supporting Regulations. Use.
Section 1137 of the Social Security Act requires that States verify the income and eligibility information contained on the applicant's application and in the applicant's case file through data matches with the agencies and entities identified in this section. The State Medicaid/CHIP agency will report the existence of a system to collect all information needed to determine and redetermine eligibility for Medicaid and CHIP. The State Medicaid/CHIP agency will attest to using the PARIS system in determining beneficiary eligibility in Medicaid or CHIP benefit programs. Form Number. CMS-R-74 (OMB control number.
0938-0467). Frequency. Occasionally. Affected Public. State, Local, or Tribal Governments.
Number of Respondents. 55. Total Annual Responses. 3,241. Total Annual Hours.
1,071. (For policy questions regarding this collection contact Stephanie Bell at 410-786-0617.) 3. Type of Information Collection Request. Extension of a currently approved collection. Title of Information Collection.
Use of Restraint and Seclusion in Psychiatric Residential Treatment Facilities (PRTFs) for Individuals Under Age 21 and Supporting Regulations. Use. Psychiatric residential treatment facilities are required to report deaths, serious injuries and attempted suicides to the State Medicaid Agency and the Protection and Advocacy Organization. They are also required to provide residents the restraint and seclusion policy in writing, and to document in the residents' records all activities involving the use of restraint and seclusion. Form Number.
CMS-R-306 (OMB control number. 0938-0833). Frequency. Occasionally. Affected Public.
Private sector (Business or other for-profits). Number of Respondents. 390. Total Annual Responses. 1,466,823.
Total Annual Hours. 449,609. (For policy questions regarding this collection contact Kirsten Jensen at 410-786-8146.) 4. Type of Information Collection Request. Reinstatement with change.
Title of Information Collection. Independent Renal Dialysis Facility Cost Report. Use. Under the authority of sections 1815(a) and 1833(e) of the Act, CMS requires that providers of services participating in the Medicare program submit information to determine costs Start Printed Page 9629 for health care services rendered to Medicare beneficiaries.
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