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This randomized clinical trial examines whether programs aimed at matching resources to patient hypertension (i.e. high blood pressure) control lead to greater reduction in systolic blood pressure (top number of blood pressure reading) than simply having maintenance phone calls in addition to usual care. Answering this question will provide important evidence concerning the overall goal of sustained long-term implementation of the disease management programs as part of patient aligned care teams in the Veterans Affairs and other healthcare systems.
Project Objectives: The investigators are conducting a two-arm 18-month randomized clinical trial for patients with pharmaceutically treated hypertension for which systolic BP is not controlled (>/=140 mmHg for non-diabetic or >/=130 mmHg for diabetic patients). The primary aim will be to compare two treatment arms/strategies in terms of impact on systolic BP control: Arm 1 - An intervention arm using titrated disease management in which patients' hypertension control, assessed at baseline, 6 and 12 months, will be used to decide the resource intensity of strategies: 1) Medium/level 1 resource intensity strategy: a registered nurse will provide monthly tailored behavioral support telephone calls + home BP monitoring; 2) High/level 2 resource intensity strategy: a pharmacist will provide monthly tailored behavioral support telephone calls + home BP monitoring + pharmacist-directed medication management; and 3) Booster (low) resource intensity strategy: a license practice nurse (LPN) will provide bi-monthly, non-tailored behavioral support telephone calls to patients whose systolic BP comes under control. Arm 2 - A control arm, in which an LPN will provide bi-monthly non-tailored behavioral support telephone calls (same procedures as the booster (low) resource intensity strategy component of the titrated intervention).
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Titration Intervention | Experimental | The intervention arm includes three levels of resource intensity targeted to improve patients' systolic blood pressure (SBP) [top number of blood pressure measurement]. Medium/level 1 resource intensity: a registered nurse (RN) will provide monthly tailored behavioral support telephone calls + home BP monitoring. High/level 2 resource intensity: a pharmacist will provide monthly tailored behavioral support telephone calls + home BP monitoring + pharmacist-directed medication management. Booster (low) resource intensity: a licensed practical nurse (LPN) will provide non-tailored behavioral support telephone calls every two months to patients whose SBP comes under control. |
|
| LPN Control | Active Comparator | A LPN will provide behavioral support telephone calls that do not include goal setting and directed problem solving every two months (identical to booster (low) resource intensity component of the titrated intervention). The control arm will utilize the same procedures as the booster level for intervention patients for whom SBP comes under control. |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Booster/ low resource | Behavioral | A LPN will provide behavioral support telephone calls that do not include goal setting and directed problem solving every two months. |
|
| Measure | Description | Time Frame |
|---|---|---|
| Systolic Blood Pressure | Continuous change in systolic blood pressure was measured as the primary outcome. Mean systolic blood pressure was calculated by the average of 3 blood pressure measurements collected at the baseline study visits. | Baseline |
| Systolic Blood Pressure | Continuous change in systolic blood pressure was measured as the primary outcome. Mean systolic blood pressure was calculated by the average of 3 blood pressure measurements collected at the 6- month study visits. | 6 months |
| Systolic Blood Pressure | Continuous change in systolic blood pressure was measured as the primary outcome. Mean systolic blood pressure was calculated by the average of 3 blood pressure measurements collected at the12-month study visits. | 12 months |
| Systolic Blood Pressure | Continuous change in systolic blood pressure was measured as the primary outcome. Mean systolic blood pressure was calculated by the average of 3 blood pressure measurements collected at the18- month study visits. | 18 months |
| Measure | Description | Time Frame |
|---|---|---|
| Number of Participants With Hypertension Control | The investigators examined the difference in the degree of systolic BP control over the 18 months of the study between the intervention and control arms. Control was defined as SBP < 130mmHg for hypertensive patients with diabetes and < 140mmHg for patients without diabetes. Mean systolic blood pressure was calculated by the average of 3 blood pressure measurements collected at the baseline study visit. |
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Inclusion Criteria:
Patients must indicate that they both:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| George L Jackson, PhD MHA | Durham VA Medical Center, Durham, NC | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Durham VA Medical Center, Durham, NC | Durham | North Carolina | 27705 | United States |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 27417982 | Result | Jackson GL, Weinberger M, Kirshner MA, Stechuchak KM, Melnyk SD, Bosworth HB, Coffman CJ, Neelon B, Van Houtven C, Gentry PW, Morris IJ, Rose CM, Taylor JP, May CL, Han B, Wainwright C, Alkon A, Powell L, Edelman D. Open-label randomized trial of titrated disease management for patients with hypertension: Study design and baseline sample characteristics. Contemp Clin Trials. 2016 Sep;50:5-15. doi: 10.1016/j.cct.2016.07.009. Epub 2016 Jul 12. | |
| 29672720 |
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The study was conducted among patients receiving primary care at the Durham VAMC, including VA Community Based Outpatient Clinics (CBOC).
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| ID | Title | Description |
|---|---|---|
| FG000 | Titration Intervention | The intervention arm includes three levels of resource intensity targeted to improve patients' systolic blood pressure (SBP) [top number of blood pressure measurement]. Medium/level 1 resource intensity: a registered nurse (RN) will provide monthly tailored behavioral support telephone calls + home BP monitoring. High/level 2 resource intensity: a pharmacist will provide monthly tailored behavioral support telephone calls + home BP monitoring + pharmacist-directed medication management. Booster (low) resource intensity: a licensed practical nurse (LPN) will provide non-tailored behavioral support telephone calls every two months to patients whose SBP comes under control. Booster/ low resource: A LPN will provide behavioral support telephone calls that do not include goal setting and directed problem solving every two months. |
| FG001 | LPN Control | A LPN will provide behavioral support telephone calls that do not include goal setting and directed problem solving every two months (identical to booster (low) resource intensity component of the titrated intervention). The control arm will utilize the same procedures as the booster level for intervention patients for whom SBP comes under control. Booster/ low resource: A LPN will provide behavioral support telephone calls that do not include goal setting and directed problem solving every two months. |
| Title | Milestones | Reasons Not Completed | ||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Overall Study |
|
|
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| ID | Title | Description |
|---|---|---|
| BG000 | Titration Intervention | The intervention arm includes three levels of resource intensity targeted to improve patients' systolic blood pressure (SBP) [top number of blood pressure measurement]. Medium/level 1 resource intensity: a registered nurse (RN) will provide monthly tailored behavioral support telephone calls + home BP monitoring. High/level 2 resource intensity: a pharmacist will provide monthly tailored behavioral support telephone calls + home BP monitoring + pharmacist-directed medication management. Booster (low) resource intensity: a licensed practical nurse (LPN) will provide non-tailored behavioral support telephone calls every two months to patients whose SBP comes under control. Booster/ low resource: A LPN will provide behavioral support telephone calls that do not include goal setting and directed problem solving every two months. |
| Units | Counts |
|---|---|
| Participants |
|
| Title | Description | Population Description | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Denominator Units Selected | Denominators | Classes |
|---|---|---|---|---|---|---|---|---|---|
| Age, Continuous | Age at Baseline Visit |
| Type | Title | Description | Population Description | Reporting Status | Anticipated Posting Date | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Time Frame | Units Analyzed | Denominator Units Selected | Arm/Group Information | Denominators | Classes | Analyses | |||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Primary | Systolic Blood Pressure | Continuous change in systolic blood pressure was measured as the primary outcome. Mean systolic blood pressure was calculated by the average of 3 blood pressure measurements collected at the baseline study visits. | Posted | Mean | Standard Deviation | mmHg | Baseline |
|
18 months
It is expected that these patients will have a variety of episodes related to cardiovascular and related diseases such as diabetes, age, smoking and drinking. These may include, but are not limited to, heart attack, stroke, and complications of diabetes among those patients with the disease, the diagnosis of cancer and dementia, development of disease of the lung or liver.
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| ID | Title | Description | Deaths (Affected) | Deaths (At Risk) | Serious Events (Affected) | Serious Events (At Risk) | Other Events (Affected) | Other Events (At Risk) |
|---|---|---|---|---|---|---|---|---|
| EG000 | Titration Intervention | The intervention arm includes three levels of resource intensity targeted to improve patients' systolic blood pressure (SBP) [top number of blood pressure measurement]. Medium/level 1 resource intensity: a registered nurse (RN) will provide monthly tailored behavioral support telephone calls + home BP monitoring. High/level 2 resource intensity: a pharmacist will provide monthly tailored behavioral support telephone calls + home BP monitoring + pharmacist-directed medication management. Booster (low) resource intensity: a licensed practical nurse (LPN) will provide non-tailored behavioral support telephone calls every two months to patients whose SBP comes under control. Booster/ low resource: A LPN will provide behavioral support telephone calls that do not include goal setting and directed problem solving every two months. |
| Term | Organ System | Source Vocabulary | Assessment Type | Notes | Statistical Information |
|---|---|---|---|---|---|
| ER Visit | Renal and urinary disorders | Systematic Assessment |
| Term | Organ System | Source Vocabulary | Assessment Type | Notes | Statistical Information |
|---|---|---|---|---|---|
| ER Visit | Cardiac disorders | Systematic Assessment |
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| Title | Organization | Phone | Extension | |
|---|---|---|---|---|
| Dr. George Lee Jackson, PhD MHA | Durham VA Medical Center, Durham, NC | 919-286-0411 | 7091 | George.Jackson3@va.gov |
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| Type | Includes Protocol | Includes SAP | Includes ICF | Document Label | Document Date | Document Uploaded Date | Document File Name |
|---|---|---|---|---|---|---|---|
| Prot | Yes | No | No | Study Protocol | Mar 4, 2016 | Aug 17, 2018 | Prot_000.pdf |
| ICF | No | No | Yes | Informed Consent Form | Aug 25, 2014 | Aug 17, 2018 | ICF_001.pdf |
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| ID | Term |
|---|---|
| D006973 | Hypertension |
| ID | Term |
|---|---|
| D014652 | Vascular Diseases |
| D002318 | Cardiovascular Diseases |
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| ID | Term |
|---|---|
| D007117 | Immunization, Secondary |
| D003470 | Culture Media |
| ID | Term |
|---|---|
| D007114 | Immunization |
| D007167 | Immunotherapy |
| D056747 | Immunomodulation |
| D001691 | Biological Therapy |
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|
| Booster/ low resource | Behavioral | A LPN will provide behavioral support telephone calls that do not include goal setting and directed problem solving every two months. |
|
|
| Medium/Level 1 resource intensity | Behavioral | Monthly tailored RN delivered calls + home BP monitoring. |
|
|
| High/Level 2 resource intensity | Behavioral | Pharmacist delivered telephone behavioral self-management support + Home BP monitoring with feedback to pharmacist + Algorithmic medication changes directed by pharmacist (with physician backup). |
|
|
| Baseline |
| Number of Participants With Hypertension Control | The investigators examined the difference in the degree of systolic BP control over the 18 months of the study between the intervention and control arms. Control was defined as SBP < 130mmHg for hypertensive patients with diabetes and < 140mmHg for patients without diabetes. Mean systolic blood pressure was calculated by the average of 3 blood pressure measurements collected at the 6-month study visit. | 6 months |
| Number of Participants With Hypertension Control | The investigators examined the difference in the degree of systolic BP control over the 18 months of the study between the intervention and control arms. Control was defined as SBP < 130mmHg for hypertensive patients with diabetes and < 140mmHg for patients without diabetes. Mean systolic blood pressure was calculated by the average of 3 blood pressure measurements collected at the 12-study visit. | 12 months |
| Number of Participants With Hypertension Control | The investigators examined the difference in the degree of systolic BP control over the 18 months of the study between the intervention and control arms. Control was defined as SBP < 130mmHg for hypertensive patients with diabetes and < 140mmHg for patients without diabetes. Mean systolic blood pressure was calculated by the average of 3 blood pressure measurements collected at the18- month study visit. | 18 months |
| Cost Effectiveness | One of our secondary research questions was: "If the intervention results in greater reduction in SBP than the control group, is it cost effective?" Intervention results did not show statistically significant differences between arms, therefore cost effectiveness analysis was not appropriate. While cost effectiveness was not analyzed because it was a null trial, the investigators would have used resource utilization and cost data from VA data sets to measure VA outpatient and inpatient utilization and costs by arms over 18 months. The investigators would have examined hypertension-related outpatient pharmacy prescription counts and costs in order to compare them to total outpatient pharmacy costs and the investigators would have examined inpatient utilization and costs. | Over 18 months of study intervention |
| Number of Participants Who Did Not Achieve Medication Adherence | The investigators assessed adherence using patient self-report on a modified Morisky scale using 4 items:
A response of YES to any one of the 4 items indicated non-adherence, and responses of all no indicated adherence. The numbers in the descriptive tables reflect number non-adherent. | Baseline |
| Number of Participants Who Did Not Achieve Medication Adherence | The investigators assessed adherence using patient self-report on a modified Morisky scale using 4 items:
A response of YES to any one of the 4 items indicated non-adherence, and responses of all no indicated adherence. The numbers in the descriptive tables reflect number non-adherent. | 6 months |
| Number of Participants Who Did Not Achieve Medication Adherence | The investigators assessed adherence using patient self-report on a modified Morisky scale using 4 items:
A response of YES to any one of the 4 items indicated non-adherence, and responses of all no indicated adherence. The numbers in the descriptive tables reflect number non-adherent. | 12 months |
| Number of Participants Who Did Not Achieve Medication Adherence | The investigators assessed adherence using patient self-report on a modified Morisky scale using 4 items:
A response of YES to any one of the 4 items indicated non-adherence, and responses of all no indicated adherence. The numbers in the descriptive tables reflect number non-adherent. | 18 months |
| Result |
| Jackson GL, Stechuchak KM, Weinberger M, Bosworth HB, Coffman CJ, Kirshner MA, Edelman D. How Views of the Organization of Primary Care Among Patients with Hypertension Vary by Race or Ethnicity. Mil Med. 2018 Sep 1;183(9-10):e583-e588. doi: 10.1093/milmed/usx111. |
| Patient moved, no longer eligible |
|
| BG001 | LPN Control | A LPN will provide behavioral support telephone calls that do not include goal setting and directed problem solving every two months (identical to booster (low) resource intensity component of the titrated intervention). The control arm will utilize the same procedures as the booster level for intervention patients for whom SBP comes under control. Booster/ low resource: A LPN will provide behavioral support telephone calls that do not include goal setting and directed problem solving every two months. |
| BG002 | Total | Total of all reporting groups |
| Standard Deviation |
| years |
|
| Sex: Female, Male | Count of Participants | Participants |
|
| OG001 | LPN Control | A LPN will provide behavioral support telephone calls that do not include goal setting and directed problem solving every two months (identical to booster (low) resource intensity component of the titrated intervention). The control arm will utilize the same procedures as the booster level for intervention patients for whom SBP comes under control. Booster/ low resource: A LPN will provide behavioral support telephone calls that do not include goal setting and directed problem solving every two months. |
|
|
| Primary | Systolic Blood Pressure | Continuous change in systolic blood pressure was measured as the primary outcome. Mean systolic blood pressure was calculated by the average of 3 blood pressure measurements collected at the 6- month study visits. | 30 out of the 192 participants in the Titration Intervention group and 22 out of the 193 in the LPN control group had missing blood pressure measurement at 6 months due to not completing the assessment. One additional participant in the LPN control had missing blood pressure measurement at 6 months due to not being able to get a reading. | Posted | Mean | Standard Deviation | mmHg | 6 months |
|
|
|
|
| Primary | Systolic Blood Pressure | Continuous change in systolic blood pressure was measured as the primary outcome. Mean systolic blood pressure was calculated by the average of 3 blood pressure measurements collected at the12-month study visits. | Analysis Population Description: Analysis Population Description: 53 out of the 192 participants in the Titration Intervention group and 34 out of the 193 in the LPN control group had missing blood pressure measurement at 12 months due to not completing the assessment. | Posted | Mean | Standard Deviation | mmHg | 12 months |
|
|
|
|
| Primary | Systolic Blood Pressure | Continuous change in systolic blood pressure was measured as the primary outcome. Mean systolic blood pressure was calculated by the average of 3 blood pressure measurements collected at the18- month study visits. | 37 out of the 192 participants in the Titration Intervention group and 33 out of the 193 in the LPN control group had missing blood pressure measurement at 18 months due to not completing the assessment. | Posted | Mean | Standard Deviation | mmHg | 18 months |
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|
|
| Secondary | Number of Participants With Hypertension Control | The investigators examined the difference in the degree of systolic BP control over the 18 months of the study between the intervention and control arms. Control was defined as SBP < 130mmHg for hypertensive patients with diabetes and < 140mmHg for patients without diabetes. Mean systolic blood pressure was calculated by the average of 3 blood pressure measurements collected at the baseline study visit. | Mean systolic blood pressure in control (units: participants) | Posted | Count of Participants | Participants | Baseline |
|
|
|
| Secondary | Number of Participants With Hypertension Control | The investigators examined the difference in the degree of systolic BP control over the 18 months of the study between the intervention and control arms. Control was defined as SBP < 130mmHg for hypertensive patients with diabetes and < 140mmHg for patients without diabetes. Mean systolic blood pressure was calculated by the average of 3 blood pressure measurements collected at the 6-month study visit. | 30 out of the 192 participants in the Titration Intervention group and 22 out of the 193 in the LPN control group had missing blood pressure measurement at 6 months due to not completing the assessment. One additional participant in the LPN control had missing blood pressure measurement at 6 months due to not being able to get a reading. | Posted | Count of Participants | Participants | 6 months |
|
|
|
|
| Secondary | Number of Participants With Hypertension Control | The investigators examined the difference in the degree of systolic BP control over the 18 months of the study between the intervention and control arms. Control was defined as SBP < 130mmHg for hypertensive patients with diabetes and < 140mmHg for patients without diabetes. Mean systolic blood pressure was calculated by the average of 3 blood pressure measurements collected at the 12-study visit. | 53 out of the 192 participants in the Titration Intervention group and 34 out of the 193 in the LPN control group had missing blood pressure measurement at 12 months due to not completing the assessment. | Posted | Count of Participants | Participants | 12 months |
|
|
|
|
| Secondary | Number of Participants With Hypertension Control | The investigators examined the difference in the degree of systolic BP control over the 18 months of the study between the intervention and control arms. Control was defined as SBP < 130mmHg for hypertensive patients with diabetes and < 140mmHg for patients without diabetes. Mean systolic blood pressure was calculated by the average of 3 blood pressure measurements collected at the18- month study visit. | 37 out of the 192 participants in the Titration Intervention group and 33 out of the 193 in the LPN control group had missing blood pressure measurement at 18 months due to not completing the assessment. | Posted | Count of Participants | Participants | 18 months |
|
|
|
|
| Secondary | Cost Effectiveness | One of our secondary research questions was: "If the intervention results in greater reduction in SBP than the control group, is it cost effective?" Intervention results did not show statistically significant differences between arms, therefore cost effectiveness analysis was not appropriate. While cost effectiveness was not analyzed because it was a null trial, the investigators would have used resource utilization and cost data from VA data sets to measure VA outpatient and inpatient utilization and costs by arms over 18 months. The investigators would have examined hypertension-related outpatient pharmacy prescription counts and costs in order to compare them to total outpatient pharmacy costs and the investigators would have examined inpatient utilization and costs. | Intervention results did not show statistically significant differences between arms, therefore cost effectiveness analysis is not appropriate. | Posted | Over 18 months of study intervention |
|
|
| Secondary | Number of Participants Who Did Not Achieve Medication Adherence | The investigators assessed adherence using patient self-report on a modified Morisky scale using 4 items:
A response of YES to any one of the 4 items indicated non-adherence, and responses of all no indicated adherence. The numbers in the descriptive tables reflect number non-adherent. | The numbers in the descriptive tables reflect #non-adherent. | Posted | Count of Participants | Participants | Baseline |
|
|
|
| Secondary | Number of Participants Who Did Not Achieve Medication Adherence | The investigators assessed adherence using patient self-report on a modified Morisky scale using 4 items:
A response of YES to any one of the 4 items indicated non-adherence, and responses of all no indicated adherence. The numbers in the descriptive tables reflect number non-adherent. | 30 out of the 192 participants in the Titration Intervention group and 21 out of the 193 in the LPN control group had missing medication adherence at 6 months due to not completing the assessment. The numbers in the descriptive tables reflect #non-adherent. | Posted | Count of Participants | Participants | 6 months |
|
|
|
|
| Secondary | Number of Participants Who Did Not Achieve Medication Adherence | The investigators assessed adherence using patient self-report on a modified Morisky scale using 4 items:
A response of YES to any one of the 4 items indicated non-adherence, and responses of all no indicated adherence. The numbers in the descriptive tables reflect number non-adherent. | 53 out of the 192 participants in the Titration Intervention group and 34 out of the 193 in the LPN control group had missing medication adherence at 12 months due to not completing the assessment. The numbers in the descriptive tables reflect #non-adherent. | Posted | Count of Participants | Participants | 12 months |
|
|
|
|
| Secondary | Number of Participants Who Did Not Achieve Medication Adherence | The investigators assessed adherence using patient self-report on a modified Morisky scale using 4 items:
A response of YES to any one of the 4 items indicated non-adherence, and responses of all no indicated adherence. The numbers in the descriptive tables reflect number non-adherent. | 37 out of the 192 participants in the Titration Intervention group and 33 out of the 193 in the LPN control group had missing medication adherence at 18 months due to not completing the assessment. The numbers in the descriptive tables reflect #non-adherent. | Posted | Count of Participants | Participants | 18 months |
|
|
|
|
| 3 |
| 192 |
| 40 |
| 192 |
| 117 |
| 192 |
| EG001 | LPN Control | A LPN will provide behavioral support telephone calls that do not include goal setting and directed problem solving every two months (identical to booster (low) resource intensity component of the titrated intervention). The control arm will utilize the same procedures as the booster level for intervention patients for whom SBP comes under control. Booster/ low resource: A LPN will provide behavioral support telephone calls that do not include goal setting and directed problem solving every two months. | 2 | 193 | 9 | 193 | 112 | 193 |
| ER Visit | Infections and infestations | Systematic Assessment |
|
| ER Visit | Cardiac disorders | Systematic Assessment |
|
| ER Visit | Endocrine disorders | Systematic Assessment |
|
| Heart Attack | Cardiac disorders | Systematic Assessment |
|
| Hospitalization Other | Cardiac disorders | Systematic Assessment |
|
| Hospitalization Other | Blood and lymphatic system disorders | Systematic Assessment |
|
| Hospitalization Other | Gastrointestinal disorders | Systematic Assessment |
|
| Hospitalization Other | General disorders | Systematic Assessment |
|
| Hospitalization Other | Infections and infestations | Systematic Assessment |
|
| Hospitalization Other | Injury, poisoning and procedural complications | Systematic Assessment |
|
| Hospitalization Other | Musculoskeletal and connective tissue disorders | Systematic Assessment |
|
| Hospitalization Other | Neoplasms benign, malignant and unspecified (incl cysts and polyps) | Systematic Assessment |
|
| Hospitalization Other | Renal and urinary disorders | Systematic Assessment |
|
| Hospitalization Other | Respiratory, thoracic and mediastinal disorders | Systematic Assessment |
|
| Hospitalization Other | Surgical and medical procedures | Systematic Assessment |
|
| Hospitalization Other | Vascular disorders | Systematic Assessment |
|
| Other | Cardiac disorders | Systematic Assessment |
|
| Other | Neoplasms benign, malignant and unspecified (incl cysts and polyps) | Systematic Assessment |
|
| Other | Hepatobiliary disorders | Systematic Assessment |
|
| Other | Vascular disorders | Systematic Assessment |
|
| ER Visit | Gastrointestinal disorders | Systematic Assessment |
|
| ER Visit | General disorders | Systematic Assessment |
|
| ER Visit | Infections and infestations | Systematic Assessment |
|
| ER Visit | Injury, poisoning and procedural complications | Systematic Assessment |
|
| ER Visit | Musculoskeletal and connective tissue disorders | Systematic Assessment |
|
| ER Visit | Respiratory, thoracic and mediastinal disorders | Systematic Assessment |
|
| Hospitalization Other | Cardiac disorders | Systematic Assessment |
|
| Hospitalization Other | Surgical and medical procedures | Systematic Assessment |
|
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| D013812 |
| Therapeutics |
| D007158 | Immunologic Techniques |
| D008919 | Investigative Techniques |
| D019995 | Laboratory Chemicals |
| D020313 | Specialty Uses of Chemicals |
| D020164 | Chemical Actions and Uses |
| D004864 | Equipment and Supplies |