Acceptance of medication was elicid with the following questions: �Would you take the pills described above if they reduced your risk of having a stroke by 45%? Hypernsive patients accepd antihypernsive medication with higher probability than non- hypernsive patients when presend the risk reduction model buthere was no differences between the other models purchase avanafil 50 mg overnight delivery erectile dysfunction remedies pump. Two-way communication However order avanafil 100 mg line erectile dysfunction pump youtube, iis nonough to provide understandable information avanafil 100mg otc erectile dysfunction treatment in ayurveda, buthe patienalso needs to be allowed to ask questions abouthe matrs thas/he perceives as important. This is also essential for successful sharing of information tailored according to needs. Patients have proposed posrs in the waiting room to show thathey are allowed to ask questions (Slowie 1999). Furthermore, in addition to the quantitative and qualitative aspects of information sharing, the communication process may also involve other kinds of problems. This is illustrad by the comments of a hypernsive patienabouthe attitudes of health care professionals: �Eye contacis important, nolooking athe watch. When confronting you with your illness, looking ayou, tone of voice� asking questions whether they come from a sheeor not� (Rose eal 2000). The comments of another informanhighlighthe same problem: �Physicians should lisn more to their patients. They are usually in a hurry, and they renew prescriptions and say �see you lar� athe same time. Offering information sources For overall treatment, iis also importanthapatients receive writn marial of high quality. In GreaBritain, ouof nineen patieninformation leaflets, none presend all the information considered importan(Fitzmaurice and Adams 2000). The corresponding percentages were 63% for measuring blood pressure and 58% for the importance of regular monitoring. Some patients may think they are complianven if they are not, the reason being thathey have nobeen given adequa instructions aboutheir treatmen(Kyngas eal. Iseems that, in the health care sysm, there would be a need to develop methods thaoffer more information to the patients aboutheir diseases. An example of this is 36 Hyvinkaa hospital in Finland, where a patienducation cenr offers information aboudifferendiseases and their treatmenin the form of books, brochures, videos, cd-roms, journals and on-line information (Valimaki eal 2002). Education and economic factors The results of several studies also suggesthageneral education is noassociad with compliance (Richardson eal. The same study also revealed compliance to be poorer among employed than unemployed people. However, a third study from the Unid Stas on hypernsive patients� employmensituation showed no association with compliance (Richardson eal. Perceptions of hypernsion To understand betr our hypernsive patients, we should become familiar with their views abouhypernsion. These reasons include several modifiable reasons shown to be associad with hypernsion, such as obesity, inadequa aerobic exercise, too much salin the diet, too much coffee or alcohol (Table 3) (Midgley eal. However, these reasons also include some personal views abouthe causes of hypernsion. Reason Prevalence (%) Family history 57 Obesity 42 Stress from work 41 Nonough exercise 37 General nsion and nervousness 30 Stress ahome 30 Eating the wrong foods 29 Too much salin die22 Age 20 Another disease 17 Gender 16 Too much caffeine 13 Alcohol 12 Smoking 8 Will of God 7 Fa 6 Bad luck 5 When a patienand a health care professional discuss, iis possible thathey do noven discuss the same disease. In high blood, the level of blood pressure was thoughto fluctua only slightly 38 overs weeks or months. In high-pernsion, on the other hand, blood pressure was thoughto rise suddenly, and the course of the disease was regarded as unpredictable and more dangerous than in high blood. The bestreatmenmethods were to avoid worries, relaxing, resting and staying quiet, whereas antihypernsive drugs were nothoughto be very useful. Patients have also repord thathey do nolike medicines, or thathey find them unnatural and prefer to use home remedies (e. Furthermore, the reasons for non-compliance may be associad with many other cultural and attitudinal factors (Delgado 2000). Role of patienknowledge Good knowledge abouhypernsion is an essential parof successful treatment, buunfortunaly, iseems thawe are far from an optimal situation in many cases. A Finnish study on 623 hypernsive patients from a priva clinic showed tha42% of the patients, according to their own opinion, had noreceived enough information abouthe adverse effects of antihypernsive drugs, and abouvery fifth had noreceived enough information abouthe duration of antihypernsive medication (Enlund eal 1991). A Swedish study on 33 hypernsive patients also showed deficiencies in patients� knowledges abouthe effects of antihypernsive drugs (Kjellgren eal 1998). Some patients described the mechanism as follows: they keep the blood pressure down (33%), the diuretic decreases the amounof fluid/oedema in the body (21%), the drug dilas blood vessels (18%). There were also rare answers of the following kinds: they are beta blockers, slows/calms down the heart, makes blood thinner / prevents ifrom clotting, makes blood flow betr, makes the vessels hold, procthe kidneys, have some effecon the heart, affecthe velocity of blood, is tranquillising. In another Swedish study, parof hypernsive patients perceived the information on medicines as difficulto understand (Lisper eal 1997). An Australian study on 84 hypernsive patients and 58 normonsive controls, adjusd according to age, gender and education, showed thathere were no differences in the knowledge of hypernsion between the groups (Carney eal 1993). The same 39 study also showed thaolder people had less knowledge abouhypernsion than younger ones. Furthermore, 57% of hypernsive patients were satisfied with their currenknowledge, bu70% wand more information abouhypernsion. Home blood pressure measurements Several studies suggesthahome blood pressure measurements may improve compliance. In a large Japanese study on 777 patients who had a home blood pressure measuremendevice, compliance was betr among those who measured their blood pressure daily than among those who did nomeasure iaall (Ashida eal. In another study carried ouin Belgium, some patients received a home blood pressure measuremendevice and were asked to measure their blood pressure every morning (Smith and Diggle 1998). Compliance was betr among those who used their home blood pressure measuremendevice than among those who did nouse it. A study from Switzerland showed tha65% of hypernsive patients were complianbefore and 81% afr they received a home blood pressure measuremendevice (Edmonds eal. Lifestyle Irregular lifestyle, disturbances of every day life and the facthapatients do notake the medicines with them when they leave home for more than a day have also been repord as reasons for non-compliance (Balazovjech and Hnilica 1993, Shaw eal. Worries aboupride and nowanting to look weak or non- macho have been repord as reasons for noseeking help from professionals or close persons (Rose eal. Other factors In several studies, patients have repord the reason for non-compliance being forgetfulness (Cooper eal. Some patients have repord misunderstandings as a reason for their non-compliance (Cooper eal. Depression has also been found to explain parof non-compliance with antihypernsive medication (Wang eal. In a Swedish study of 33 hypernsive patients, the following reasons for complying were repord: trusin physicians (decisions concerning medication are beslefto professionals), avoidance of complications of hypernsion (stroke, hearattack, death, etc. In another study, nine ouof n patients repord their reason for taking antihypernsive medication to be a desire to achieve some good results (Benson and Britn 2003). Blood pressure in the population is continuous and distribud nearly according to the Gaussian curve, which means thathere are no two separa groups of persons with normal or high blood pressure (Beevers eal.

Babies with a favourable response to resuscitation should be referred to a neonatal high or intensive care unit order generic avanafil online impotence due to diabetes, if available 200 mg avanafil mastercard zolpidem impotence, for post resuscitation care order 200 mg avanafil with visa erectile dysfunction webmd. Babies, who, after resuscitation, are not completely normal, should be referred to a higher level for care using transport with necessary support, e. Retrograde infection from a fissured nipple and milk stasis are known risk factors. Any opportunity to perform screening should be taken; this includes taking pap smears during pregnancy. Contra-indications include: » endometrial cancer » coronary heart disease » breast cancer » women ≥ 60 years of age » thrombo-embolism » acute liver disease » porphyria cutaneatarda 6. Continuous combined preparations are often preferred if the woman had her last menstrual period (menopause) over a year ago, as they will not usually cause bleeding then. For women who are still menstruating or have recently stopped, sequentially opposed preparations are preferred and will result in regular menstrual periods, whereas continuous combined may result in irregular bleeding. Sequentially opposed therapy:  Estradiol valerate, oral, 1–2 mg daily for 21 days. The prevention and treatment of isoniazid toxicity in the therapy of pulmonary tuberculosis. Multiple malformation syndrome following fluconazole use in pregnancy: report of an additional patient. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Aspirin for prevention of preeclampsia in women with historical risk factors: a systematic review. Misoprostol to prevent and treat postpartum haemorrhage: a systematic review and meta- analysis of maternal deaths and dose-related effects. Neonatal resuscitation: Resuscitation Council: Algorithm for newborn resuscitation, 2012. The appropriate choice of family planning method should be decided on by the woman in consultation with the health care professional taking into consideration safety, efficacy, acceptability and access. Hormonal » Daily patient adherence is » Delayed return of injectable: not required. Hormonal oral: » Fertility returns 1-3 months » Daily adherence is progestin-only on discontinuing the pill. Hormonal oral: » Non-contraceptive benefits, » Daily patient adherence combined oral e. Insertion at menstruation may be easier for the patient resulting in less discomfort and spotting. The subdermal implant is an effective, safe, reversible and convenient long-term contraceptive method requiring minimal patient involvement and no regular follow-up. If the implant is inserted within 7 days of the onset of the menstrual cycle the contraceptive effect is achieved on the day of insertion. Progestin-only hormonal contraceptives are contraindicated in certain conditions e. These medicines include efavirenz, nevirapine, rifampicin, phenytoin, carbamazepine and phenobarbital. Women with implants on these medicines should be counseled to use additional contraceptive methods. Insertion of etonogestrel: » Insertion should only be performed with the preloaded applicator. While lifting the skin with the tip of the needle, slide the needle to its full length. The patient may remove the pressure bandage in 24 hours and the small bandage over the insertion site after 3–5 days. Insertion of levonorgestrel: » Clean the insertion site with an antiseptic solution. For pain after insertion:  Ibuprofen, oral, 400 mg 8 hourly as needed for up to 5 days. When to start the injection » The injection can be started anytime within the menstrual cycle but it is advisable to start during menses. Note: It is not necessary to shorten the dose interval when using rifampicin or any other enzyme inducing medicine. Late injection » If it has been < 2 weeks since the missed injection, the next injection can be given without loss of protection. Combination of estrogen and progestin in each pill Monophasic preparations: combination of estrogen and progestin in each pill, e. Progestin only Combined estrogen/progestin Contraindications Progestin only preparations Combination preparations are contraindicated in certain contraindicated in certain conditions. Contraindications include: Contraindications include: » Abnormal uterine bleeding » Women >35 years of unknown cause of age who smoke ≥ 15 » Myocardial infarction or cigarettes a day or have stroke risk factors for » Liver disease cardiovascular disease: » Cancer of the breast or - heart disease genital tract - liver disease » Known or suspected - thromboembolism pregnancy - certain cancers When to start the » Start anytime within the menstrual cycle, but it is advisable to pill start during menses. Antiretrovirals Nevirapine Lowering of Use dual contraceptive effect contraception i. Scenario Action One pill forgotten or if pill taken >3 hours Take pill as soon as remembered and late and unprotected sexual intercourse continue taking one pill daily at the has not occurred in the past 5 days. One pill forgotten or if taken > 3 hours Give emergency contraception (see late and unprotected sexual intercourse Section 7. Maintenance of ovulation inhibition with the 75-microg desogestrel-only contraceptive pill (Cerazette) after scheduled 12-h delays in tablet intake. Venous thromboembolism in pregnancy and the puerperium: incidence and additional risk factors from a London perinatal database. Copper-containing, framed intrauterine devices for contraception: a systematic review of randomized controlled trials. Subdermal implantable contraceptives versus other forms of reversible contraceptives or other implants as effective methods of preventing pregnancy. Depot medroxyprogesterone versus norethisterone oenanthate for long-acting progestogenic contraception. Counting the costs: comparing depot medroxyprogesterone acetate and norethisterone oenanthate utilisation patterns in South Africa. Oral contraceptives– lamotrigine interaction: Faculty of Family Planning and Reproductive Health Care Clinical Effectiveness Unit. The effect of doxycycline on serum levels of ethinylestradiol, norethindrone, and endogenous progesterone. Treatment and prevention strategies according to stages Estimation of the degree of kidney damage and staging is important to guide management and further prevent adverse outcomes of chronic kidney disease. Description Action Glomerular filtration Includes actions from rate preceding stages 2 (mL/minute/1. Send blood annually for measurement of creatinine in all patients at increased risk. If proteinuria persists quantify protein with a spot urine protein creatinine ratio.

Patient 36 (essential hypertension) The problem with the treatment of hypertension is that patients rarely experience any positive effect of the drugs discount avanafil line icd-9-cm code for erectile dysfunction, yet they have to take them for a long time generic 200 mg avanafil overnight delivery drugs for erectile dysfunction in nigeria. Adherence to treatment may be very poor if they are not told why they should take the drug generic avanafil 50 mg with mastercard erectile dysfunction protocol review article, and if treatment is not monitored regularly. The patient should be told that the drug prevents complications of high blood pressure (angina, heart attack, cerebral problems). You can also say that you will try to decrease the dosage after three months, or even stop the drug entirely. Patient 37 (boy with pneumonia) The patient’s mother should be told that the penicillin will need some time to kill the bacteria. If the course of treatment is stopped too soon, the stronger ones will survive, and cause a second, possibly more serious infection. Knowing that any side effects will disappear soon will increase the likelihood of adherence to treatment. She should also be told to contact you immediately if a rash, itching or rising fever occur. Patient 38 (migraine) In addition to other information the important instruction here is that the drug (preferably a suppository) should be taken 20 minutes before the analgesic, to prevent vomiting. Because of possible sedation and loss of coordination she should be warned not to drive a car or handle dangerous machinery. Drug will prevent complications of high blood pressure (angina, heart attack, cerebrovascular accident). Angina pectoris: decreases blood pressure, prevents the heart from working too hard, preventing chest pain. Angina pectoris: within one month, earlier if attacks occur more frequently, or become more severe. Angina pectoris: in case frequency or severity of the attacks increase, more diagnostic tests or other treatment are needed. Your personal formulary During your medical studies you should continue to expand your list of common complaints and diseases, with your P-drugs and P-treatments. However, very soon you will notice that many drugs are used for more than one indication. Examples are analgesics, certain antibiotics, and even more specific drugs like beta-blockers (used for hypertension and angina pectoris). You can, of course, repeat the necessary drug information with each disease or complaint, but it may be easier to make a separate section in your personal formulary where you collect the necessary information for each of your P-drugs. It is good advice to note the essential instructions and warnings with each P- drug in your personal formulary. If you do this for every new drug you learn to use, the formulary will be reasonably complete and ready for use by the time you finish your medical studies. An example of the contents of such a personal formulary is given on the previous page. Please note that this is not a published text, but should be your personal (handwritten? Effects of the drug Which symptoms will disappear; and when; how important is it to take the drug; what happens if it is not taken; 2. Side effects Which side effects may occur; how to recognize them; how long will they remain; how serious they are; what to do if they occur; 3. Instructions When to take; how to take; how to store; how long to continue the treatment; what to do in case of problems; 4. Warnings What not to do (driving, machinery); maximum dose (toxic drugs); need to continue treatment (antibiotics); 5. Next appointment When to come back (or not); when to come earlier; what to do with left-over drugs; what information will be needed; 6. Monitoring the treatment enables you to determine whether it has been successful or whether additional action is needed. To do this you need to keep in touch with your patient, and this can be done in two ways. Passive monitoring means that you explain to the patient what to do if the treatment is not effective, is inconvenient or if too many side effects occur. Active monitoring means that you make an appointment to determine yourself whether the treatment has been effective. You will need to determine a monitoring interval, which depends on the type of illness, the duration of treatment, and the maximum quantity of drugs to prescribe. At the start of treatment the interval is usually short; it may gradually become longer, if needed. Even with active monitoring the patient will still need the information discussed in Chapter 10. You should use the same criteria for monitoring the effect, but in practice they can be condensed into two questions: is the treatment effective? History taking, physical examination and laboratory tests will usually provide the information you need to determine the effectiveness of treatment. If the disease is not yet cured or chronic, and the treatment is effective and without side effects, it can be continued. If serious side effects have occurred you should reconsider your selected drug and dosage schedule, and check whether the patient was correctly 4 Except in cases in which a standard duration of treatment is crucial, such as with most antibiotics. Many side effects are dose Table 8: dependent, so you may try to lower the Some examples of drugs in which dose before changing to another drug. When you have Corticosteroids determined the reason for the treatment Hypnotics/sedatives failure you should look for solutions. So benzodiazepines the best advice is to go again through the barbiturates process of diagnosis, definition of Opiates therapeutic objective, verification of the suitability of the P-drug for this patient, instructions and warnings, and monitor- ing. Sometimes you will find that there is no real alternative to a treatment that has not been effective or has serious side effects. When you cannot determine why the treatment was not effective you should seriously consider stopping it. If you decide to stop drug treatment you should remember that not all drugs can be stopped at once. Exercise: patients 39-42 In the following cases, try to decide whether the treatment can be stopped or not. Review visit after pneumonia, treated with oral ampicillin (2 grams daily) for one week. Has been on prednisolone (50 mg daily) and indometacin (10 mg daily) for a long time. Epigastric pain and pyrosis over several months, for which he takes aluminum hydroxide tablets from time to time. During the consultation he complains that the epigastric pain and pyrosis have not disappeared; in fact they have become worse. The maintenance dose has already been decreased twice because her blood pressure had dropped to around normal. Had been prescribed temazepam for one week, (10 mg daily) because of sleeplessness after his wife died six months ago.

When the average dissolution of the reference product reaches 50% and does not reach 80% within the testing time point specified: the average dissolution of the test product are within that of the reference product ± 12% at the testing time specified and at an appropriate time point when the average dissolution of the reference product reaches about a half of the average dissolution at the testing time specified buy generic avanafil 200mg line impotence genetic. When the average dissolution of the reference product does not reach 50% within the testing time specified: the average dissolution of the test product are within that of the reference product ± 9% at the testing time specified and at an appropriate time point when the average dissolution of the reference product is about a half of the average dissolution at the testing time specified order avanafil 100mg online discount erectile dysfunction drugs. However order 50mg avanafil amex erectile dysfunction caused by medications, when the average dissolution of the reference product is not more than 10% within the testing time specified, the average dissolution of the test product is within that of the reference product ± 9% at the testing time specified only. When the average dissolution of the reference product reaches 80% within the testing time specified: the average dissolution of the test product are within that of the reference product ± 10% at three appropriate time points when the average dissolution of the reference product are around 30%, 50% and 80%. When the average dissolution of the reference product reaches 50% and does not reach 80% within the testing time point specified: the average dissolution of the test product are within that of the reference product ± 8% at the testing time specified and at an appropriate time point when the average dissolution of the reference product reaches about a half of the average dissolution at the testing time specified. When the average dissolution of the reference product does not reach 50% within the testing time specified: the average dissolution of the test product are within that of the reference product ± 6% at the testing time specified and at an appropriate time point when the average dissolution of the reference product is about a half of the average dissolution at the testing time specified. However, when the average dissolution of the reference product is not more than 10% within the testing time specified, the average dissolution of the test product is within that of the reference product ± 6% at the testing time specified only. Reporting of test results The shape, specific gravity and release mechanism of the test product should be described which do not differ significantly from those of the innovator product. The description of other results is the same as that for oral immediate products and enteric-coated products (Sec. Non-oral dosage forms The test for the products for topical use should be following the Guideline for Bioequivalence Studies of Generic Products for Topical Use an attachment of Division-Notification No. For other non-oral dosage forms, the test should be performed following the description below. Reference and test products Suitable release tests or alternative physicochemical tests should be performed for three lots of an innovator product from which one lot providing intermediate characteristics should be selected as a reference product. If the drug is administered as a liquid where the active ingredient dissolves, an appropriate lot can be used as a reference product. The lot size and drug content or potency follows the description for oral immediate release products and enteric-coated products. Bioequivalence studies The test should follow the bioequivalence test for oral immediate release products and enteric-coated products but the results of release or physicochemical tests are not used as supportive data for the assessment of bioequivalence. Pharmacodynamic and clinical studies Follow the description of the oral immediate release products and enteric-coated products. Appropriate animal studies will be allowed for products for topical use (skin, etc. For bactericides for external use, appropriate in vitro efficacy tests can be employed. Dissolution (release) tests or physicochemical tests Release or physicochemical characteristics should be compared between test and reference products by appropriate tests which will vary depending on the product. Reporting of test results Follow the description of the oral immediate release products and enteric-coated products. Dosage forms of which bioequivalence studies are waived Injections for intravenous administration, administered as an aqueous solution. Ti and Ri show the average dissolutions of the test and reference products at the time point (i), respectively, and n is the number of time points at which the average dissolution are compared. Adjusting dissolution curves with lag times The lag time is defined as the time when 5% of the labeled claim of the active ingredient dissolves from the product. A lag time should be determined for respective product by linear interpolation, and then respective dissolution curve is obtained by 22 adjusting dissolution curve with the lag time. Average dissolution curves of the test and reference products are obtained, which can be used for the assessment of similarity and equivalence in dissolution curves. R eference product Testproduct 4)Ifth ereisgeneticpolymorph ism,subjectswith h igh erclearancesh ouldbeemployed. Dissolutiontest Isth ere Isth euseof asignificantdifferencein Y es Y es dissolutionbetweentestand druglimitedto aspecific referenceproductsundera population? N o N o Isth ere asignificantdifferencein B ioequivalencestudyin B ioequivalencestudyinsubjects Y es dissolutionbetweentestand 3,4) from th especialpopulation3,4) ach lorh ydricsubjects reference products atpH 6. N o Innovatordrug G enericdrug Dissolutiontestof3 lots A lotofindustrialscaleornotlessth an1/10 scale R eferenceproduct Testproduct Dissolutiontest A re th e N o dissolutionprofilesbetweentestand referenceproducts similar? Y es Y es Y es A dd-onstudy A regeometricmean N o ratiosofA U C andC max with in90-110%? Th edissolutionfrom referenceproductssh ouldbeover85% with inth e Dissolutiontest specifiedtestingtimeinatleastonetestcondition. Isth ere Isth e Y es Y es alagtimeindissolutionof Y es differenceofaveragelagtimes A redissolutioncurves referenceortest betweentestandreference adjusted with th elag product? N o N o N o N otsimilar N o A djustmentsof dissolutionprofiles with lagtimes Isth e Doesth e Isth e N o differenceof Doeth e Doesth e N o N o N o averagedissolutionof averagedissolutionof averagedissolutionof averagedissolutionof dissolutionswith in 9% atth e referenceproductreach 85% referenceproductbetween specifiedtimeandth etimepointwh ere referenceproductreach 85% referenceproductreach 85% with inth especified 50 and85% atth especified referenceproductdissolution with in15 min? Y es Y es Isth e Isth e A t15 min differenceof Isth e N o differenceof isth eaveragedissolution differenceof Y es dissolutionswith in 15% at N o dissolutionswith in 15% at N o oftestproduct 85%? Y es Y es N otsimilar Y es N otsimilar N otsimilar Y es N otsimilar Similar1) 1) Similar1) Similar1) 1) Similar Similar 1) Ifth eresultsmeetoneofth efollowingcriteria F ig. Y es Y es Isth e Isth e differenceof Y es differenceof dissolutionswith in 12% atth e N o dissolutionswith in 15% at3 time N o specifiedtimeandth etimepointwh ere pointswh erereferenceproduct referenceproductdissolution dissolutionare 30,50 and80%? Y es N otsimilar N otsimilar Y es Similar1 Similar1) N otsimilar 1) ) Similar F ig. Th eaveragedissolutionofreferenceproductssh ouldbeover80% with inth e Dissolutiontest specifiedtestingtimeinatleastonetestcondition. Isth e differenceof Doesth e Isth e N o N o dissolutionswith in 6% atth e No averagedissolutionof averagedissolutionof specifiedtimeandth etimepointwh ere referenceproductreach 80% with in referenceproductbetween50-80% referenceproductdissolution th especifiedtesting atth especifiedtestingtime? Y es Y es Yes Isth e differenceof Isth e dissolutionswith in 8% atth e N o differenceof N o specifiedtimeandth etimepointwh ere dissolutionswith in 10% at3 time referenceproductdissolution pointswh erereferenceproduct isah alfofth atatth especified dissolutionare 30,50 and80%? Y es Y es N otequivalent N otequivalent 1) Equivalent1) 1) Equivalent N otequivalent Equivalent . As we discuss later, the program was designed to correct an unintended consequence of Which Providers Can Participate in 340B? Some lawmakers involved in the covered entity categories, including six hospital categories and ten categories tied to federal grant programs. Summary Points • The 340B Drug Pricing Program lowers drug prices for specifc categories of “covered entity” hospitals and clinics. Covered entities can access 340B drug pricing for all of their eligible patients, including those with insurance. For example, federally qualifed health centers are eligible for 340B Which Drugs Are Covered by 340B? Eligibility in the six hospital covered entity Drugs that are included in bundled payments to hospitals for categories hinges on statutory criteria within 340B and the Social inpatient care are not included. For example, the defnition of “critical access hospi- diseases (“orphan drugs”) were excluded from 340B for the new tal” follows Section 1820(c)(2) of the act. For example, sole community hospitals and tion Drug Rebate Program, manufacturers are able to obtain state rural referral centers are eligible to participate in 340B if they meet Medicaid coverage for their prescription drugs by entering into an the appropriate statutory defnitions and if they are eligible for at agreement with the Centers for Medicare and Medicaid Services least an 8-percent disproportionate share adjustment. While eligibility to participate in the 340B program is defned at the level of the health care facility rather than the individual, not 2 every individual receiving care at a covered entity can receive drugs calculated for each National Drug Code (i. Te Health Resources and tion of active ingredient, formulation, manufacturer, and package).

S. Grim. Newberry College.