COMMISSION: THE UNITED STAE BIPARTISAN COMMISSION ON COMPREHENSIVE HEALTH CAR Vivian W. Pinn-Wiggins, MD President, National Medical Association Washington, DC
Testimony given on behalf of the National Medical Association October 24, 1989
INTRODUCTION The National Medical Association (NMA) was founded in 1895 and represents over 16 000 physicians residing throughout the United States as well as in Puerto Rico and the Virgin Islands, most of whom are minorities, and of those, most are black (AfricanAmerican). The NMA recognizes among its founding objectives: the nurturing of the growth and diffusion of medical knowledge and the prompt universal delivery of this knowledge to all people by means of an adequate health care system. We are dedicated to improving the health care status for all Americans, yet we are primarily concerned about the plight of the poor and minority populations in this country. The NMA actively addresses issues that impact on the ability of its members to deliver quality health care and our patients' access to that care. We have aggressively sought to ensure equal access to, and availability of, quality health care services. During the past 94 years the NMA has had among its leaders and members those who are the primary providers to the people most affected by the policies addressed in this Commission. Therefore, we are most appreciative of the opportunity to share our observations and sugges-
Requests for reprints should be addressed to Dr Vivian W. Pinn-Wiggins, Professor and Chairman, Department of Pathology, Howard University College of Medicine, 520 W. Street, NW, Washington, DC. 20059 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 82, NO. 3
tions with you. As you requested, we have divided our testimony into two categories: assuring access to health care and assuring access to long-term care.
ASSURING ACCESS TO HEALTH CARE The health care delivery system in this country has been under careful scrutiny during the last decade, especially because of escalating health care costs. Legislation has been passed which has purposely changed the way medicine is practiced in this country and the ways in which health care reimbursement is determined. Unfortunately, much of this health care financing reform has inadvertently placed health care for the poor and minorities in jeopardy. In 1985, the Report of the Secretary's Task Force on Black and Minority Health published data documenting that blacks suffer disproportionately from diseases such as diabetes, hypertension, kidney disease, heart disease, and various forms of cancer. This report further documented that approximately 59 000 black Americans die unnecessarily each year because their health status is not the same as that of nonminority Americans. It is also noteworthy that these "excess deaths" are most often related to illnesses that are potentially preventable, treatable, or even curable. Data also outlined that this same patient population often obtains health care in one of two ways: the emergency room or clinics, either hospital or community based. Recent newspaper reports are certainly not "news" because we have long known that 169
PRESIDENT'S COLUMN
the disadvantaged and the minority populations too often use the hospital emergency room in the same way as others would use a private physician. Whereas most middle income patients benefit from preventive medical practices because of their access to either personal funds or health care coverage, many of our patients delay getting medical care until their illness becomes critical. At this stage, the clinic or emergency room often ends up treating a patient who is chronically ill or has a more advanced state of disease. The reasons for delay are often due to their actual or perceived inability to "purchase" quality medical services. Most importantly, however, is that when these underinsured, uninsured, or medically under served patients are finally seen, the result is an increased chance that they will have not one, but multiple illnesses requiring comprehensive and costly treatment. We have serious concerns regarding the prospective payment system, which pays a flat rate for medical treatment. This system does not adequately take into consideration the complications or severity of an illness. What, then, happens when a patient needs to be admitted to a hospital with heart disease, high blood pressure, and acute renal failure? What is the fiscal responsibility of and financial burden to those hospitals and physicians who have accepted the responsibility of taking care of them? How are they affected, or rather, how should they be affected by their voluntary humanistic services or their obligatory health care provision? In 1985, the House Ways and Means Committee contacted then Secretary of Health and Human Services, Margaret Heckler-the same Secretary who commissioned the Task Force Report on Minority Health-to express concerns over the special needs of hospitals that serve significantly disproportionate numbers of low income patients and Medicare beneficiaries. The Committee realized the potentially harmful impact the prospective payment system would have on these hospitals. They asked the Secretary to review evidence that was being compiled concerning the linkage between low income patients and higher Medicare costs per case, so that corrective action could be taken. The NMA maintains that this same type of deliberation be given to all medical legislation and regulation, not only because it is morally right, but also because it makes good sense. We, as minority physicians, are all mindful of the high, and still rising, costs of medical care in this country, and we all have a vested interest in bringing them under control. 170
Hospitals that treat low income patients often must write off millions of dollars on uncompensated care each year. Howard University Hospital, where I am Chairman of the Department of Pathology, writes off more than $30 million in uncompensated care each year. This amount is the second highest in the District of Columbia, preceded only by the District of Columbia General Hospital. The NMA has given careful thought to these problems and would like to make the following recommendations: 1. The DRG system should be reevaluated for its effect on the quality of care for the poor and minority patients, and a cost adjustment should be made for the severity of an illness and intensity of services when indicated. In addition, many of our patients lack adequate housing support systems for posthospital care. There needs to be some provision of stepped-down supportive services for low income patients. 2. There should be continued support for Medicaid, including adequate funding, reasonable physician reimbursement, physician participation in revisions of the program, and a refinement of the paper work required to create more efficient documentation. 3. The federal Medicaid regulations should be reevaluated so that each state would be required to make all the medically indigent eligible for prescription drugs for chronic diseases, such as hypertension, without the additional requirement for age, disability, or dependent children. 4. Special provisions should be made for those hospitals that operate at a loss because of the large proportion of Medicaid and Medicare patients they serve. 5. We should devise better strategies to increase the number of minorities in health-related professional fields because documentation shows that they are more likely to serve in medically underserved areas. Under the present health care system in the United States, numerous people are uninsured or underinsured, many of whom are below the poverty level. A significant percentage of black Americans still cannot obtain Medicaid. Many small business people cannot afford health insurance protection due to the high cost of premiums. Still others are uninsurable because of chronic disease conditions. It is estimated that 37 million Americans lack health insurance. Of those, 75% are members of working families, 15 million are women of childbearing age, and 11 million are children. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 82, NO. 3
PRESIDENT'S COLUMN
The National Medical Association reaffirms its position that affordable basic health care is a legal right for all citizens, and it supports a national health program that will provide health coverage to all Americans, regardless of income, race, sex, or ethnic origin. This program should also provide access to primary quality care with high professional standards. In keeping with this recommendation, the NMA proposes that a system of health care delivery and financing be considered, consisting of a mix of employer/employee contributions, general tax revenues, and subsidization of the cost of health care delivery for the poor. The NMA has supported a national health plan since 1978, with the benefits of guaranteed access. We also support comprehensive health care, with emphasis on prevention, freedom of choice between provider and patient, government assurance of quality medical care with representative minority participation, and compliance with Title VI of the Civil Rights Act.
ASSURING ACCESS TO LONG-TERM CARE The availability of health care resources for the chronically ill, most of whom are over 65 years of age, remains a major problem in our society. This is particularly true because many Medicare beneficiaries have the mistaken impression that the expenses of chronic illness are covered by the Medicare program. Many others mistakenly believe that private insurance plans will adequately cover long-term care expenses. They fail to realize that this is not necessarily true. The NMA's Board of Trustees recognizes this continuing problem. In 1988, it established a LongTerm Care Task Force to study the problem of long-term care and to make recommendations for a solution. We found that the definition for long-term care includes not only the elderly but also disabled persons, mentally retarded individuals, and those suffering from developmental, traumatic, or neurological disabilities. It also includes babies born of drug-addicted mothers who experience developmental or neurological disabilities.
Financing As you are aware, in 1965 the Medicare and Medicaid programs began to finance acute care medical services for the elderly. The financing of long-term care services has often fallen on the Medicaid program, primarily for nursing home services but also for home JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 82, NO. 3
and community based services. Thus, Medicaid, a program initially designed for low income women and their children, has become the major provider for middle income older people who have exhausted their assets to meet the devastating needs of long-term care. As this trend escalates, the NMA has expressed serious concern that the Medicaid program will not be able to expend funds for coverage and benefits for the low income mothers with young children because of strict budget constraints and the cost of financing long-term care services. During an era in which teenage and single parentage are on the rise and babies born of alcohol and drug-addicted parents are being abandoned in hospitals, the concern becomes even greater.
Early Detection and Prevention The belief that disability and aging are synonymous causes many elderly people to accept ill health as a normal consequence of longevity. This problem is greatly exacerbated in the minority community because many minorities have come to believe that illness is also synonymous with being born poor. The NMA firmly believes that preventing long-term disability by early detection, through health screening programs, is an efficient use of public dollars. Programs should be funded in order to educate the public as to availability of services, such as Meals on Wheels, adult day care centers, and free feeding programs and transportation, all of which can improve their general health status and supportive needs. There needs to be better coordination of information regarding services available through physicians' offices, clinics, community agencies, or civic offices in order to increase the use of primary medical care, increase the emphasis on physical fitness, foster nutrition programs, provide physical and mental activity, and create a total environmental approach to health care. Although health screening programs are not routinely funded nor provided by health programs, the NMA believes that, in keeping with our federal government's desire for health promotion and disease prevention, much can be done to improve the health status of all Americans and to decrease the cost of long-term health care through comparatively minor costs of health screening programs. There are some specific tests documented to be particularly important because the diseases for which they screen are common and can be treated, prevented, or cured. Mammography for detecting breast cancer for which the mortality rates have been increasing, PAP smears to detect cervical 171
PRESIDENT'S COLUMN
cancers, testing for tuberculosis which has begun to appear more commonly again in inner city areas, rectal examinations (both digital and for occult blood) for early detection of colorectal cancer, and a simple blood pressure check to prevent severe cardiovascular diseases, strokes, myocardial infarctions, and endstage renal disease. Any new health legislation, especially if it is concerned about cost containment in health care and the cost for long-term care, should consider funding these and similar screening methods for early detection and prevention of chronic diseases that will require expensive long-term care. The care of the hospitalized disabled and the elderly is another concern. It is not uncommon that following prolonged hospitalization, the elderly and the disabled may become more debilitated and dependent. Special geriatric or gerontology units are needed in acute hospitals staffed by trained specialists who are concerned about rehabilitation of the long-term care patient. The NMA's philosophy is that as part of illness prevention, multidisciplinary teams involving family members should be expanded. We suggest considering a means to recognize families who devote their time to the care of the disabled long-term care patient in the home setting, but are forced to sacrifice their incomeproducing jobs when they assume this responsibility. The NMA believes that the concept of respite care should be expanded and funded as part of a program to expand the role of the family in the delivery of long-term care. The traditional organizations in the black community, such as churches, sororities/ fraternities, and private clubs, are viewed by the NMA as vital resources. These organizations have been, and should be, involved in the needs of persons requiring long-term care in home and community-based settings.
Training The NMA is concerned about the lack of training of health professional to meet the needs of minority and poor patients and the medically indigent, especially those with long-term care needs. From the physician to the home health aide or visiting nurse, from the administrator to the social worker, new or expanded programs for training are needed. The NMA recommends that a concerted effort be made for all
172
health professional schools to develop curricula that stress the needs of long-term care patients, including their cultural and social requirements as well. The need for public funding of such educational programs is critical. Special emphasis should be made on selection characteristics of professionals going into the field of long-term care in order that those selected will be better equipped to deal with the frustrations and, at times, seemingly unrewarding demands of that field. Medical schools and hospitals should assure that physicians are trained in current approaches to longterm care and the need for coordinated and comprehensive health care delivery for such patients.
Long-Term Care Facilities The role and function of long-term care facilities, such as nursing homes, home health agencies, community residence facilities, and day care centers, need to be reexamined and reassessed. Greater emphasis should be on rehabilitation and restoration of function, not on warehousing and maintaining the status quo. The nursing care at such facilities is a serious problem because much of this care takes place in urban and rural settings. The NMA also suggests that Medicare and Medicaid programs should require more frequent physician visits to nursing home patients, rather than the existing 30- to 60-day requirement. In addition, yearly assessment and yearly evaluation by regulatory agencies charged with the evaluation certification of long-term care facilities must be stressed. This standardization and tighter control are recommended for various home health agencies and any provider of long-term care services.
SUMMARY Finally, let me emphasize that the National Medical Association stands ready to assist the Congress in structuring and implementing any new programs that may result from this gathering. We do have a concern regarding the lack of basic race-specific data, including the extent of long-term care problems in the black communities. It is widely believed that an improved data base to assess the needs and to deal with the issues confronting the black and other minority or economically disadvantaged patient would greatly help to improve existing modes of treatment and outcome.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 82, NO. 3
Testimony given on behalf of the National Medical Association October 24, 1989
INTRODUCTION The National Medical Association (NMA) was founded in 1895 and represents over 16 000 physicians residing throughout the United States as well as in Puerto Rico and the Virgin Islands, most of whom are minorities, and of those, most are black (AfricanAmerican). The NMA recognizes among its founding objectives: the nurturing of the growth and diffusion of medical knowledge and the prompt universal delivery of this knowledge to all people by means of an adequate health care system. We are dedicated to improving the health care status for all Americans, yet we are primarily concerned about the plight of the poor and minority populations in this country. The NMA actively addresses issues that impact on the ability of its members to deliver quality health care and our patients' access to that care. We have aggressively sought to ensure equal access to, and availability of, quality health care services. During the past 94 years the NMA has had among its leaders and members those who are the primary providers to the people most affected by the policies addressed in this Commission. Therefore, we are most appreciative of the opportunity to share our observations and sugges-
Requests for reprints should be addressed to Dr Vivian W. Pinn-Wiggins, Professor and Chairman, Department of Pathology, Howard University College of Medicine, 520 W. Street, NW, Washington, DC. 20059 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 82, NO. 3
tions with you. As you requested, we have divided our testimony into two categories: assuring access to health care and assuring access to long-term care.
ASSURING ACCESS TO HEALTH CARE The health care delivery system in this country has been under careful scrutiny during the last decade, especially because of escalating health care costs. Legislation has been passed which has purposely changed the way medicine is practiced in this country and the ways in which health care reimbursement is determined. Unfortunately, much of this health care financing reform has inadvertently placed health care for the poor and minorities in jeopardy. In 1985, the Report of the Secretary's Task Force on Black and Minority Health published data documenting that blacks suffer disproportionately from diseases such as diabetes, hypertension, kidney disease, heart disease, and various forms of cancer. This report further documented that approximately 59 000 black Americans die unnecessarily each year because their health status is not the same as that of nonminority Americans. It is also noteworthy that these "excess deaths" are most often related to illnesses that are potentially preventable, treatable, or even curable. Data also outlined that this same patient population often obtains health care in one of two ways: the emergency room or clinics, either hospital or community based. Recent newspaper reports are certainly not "news" because we have long known that 169
PRESIDENT'S COLUMN
the disadvantaged and the minority populations too often use the hospital emergency room in the same way as others would use a private physician. Whereas most middle income patients benefit from preventive medical practices because of their access to either personal funds or health care coverage, many of our patients delay getting medical care until their illness becomes critical. At this stage, the clinic or emergency room often ends up treating a patient who is chronically ill or has a more advanced state of disease. The reasons for delay are often due to their actual or perceived inability to "purchase" quality medical services. Most importantly, however, is that when these underinsured, uninsured, or medically under served patients are finally seen, the result is an increased chance that they will have not one, but multiple illnesses requiring comprehensive and costly treatment. We have serious concerns regarding the prospective payment system, which pays a flat rate for medical treatment. This system does not adequately take into consideration the complications or severity of an illness. What, then, happens when a patient needs to be admitted to a hospital with heart disease, high blood pressure, and acute renal failure? What is the fiscal responsibility of and financial burden to those hospitals and physicians who have accepted the responsibility of taking care of them? How are they affected, or rather, how should they be affected by their voluntary humanistic services or their obligatory health care provision? In 1985, the House Ways and Means Committee contacted then Secretary of Health and Human Services, Margaret Heckler-the same Secretary who commissioned the Task Force Report on Minority Health-to express concerns over the special needs of hospitals that serve significantly disproportionate numbers of low income patients and Medicare beneficiaries. The Committee realized the potentially harmful impact the prospective payment system would have on these hospitals. They asked the Secretary to review evidence that was being compiled concerning the linkage between low income patients and higher Medicare costs per case, so that corrective action could be taken. The NMA maintains that this same type of deliberation be given to all medical legislation and regulation, not only because it is morally right, but also because it makes good sense. We, as minority physicians, are all mindful of the high, and still rising, costs of medical care in this country, and we all have a vested interest in bringing them under control. 170
Hospitals that treat low income patients often must write off millions of dollars on uncompensated care each year. Howard University Hospital, where I am Chairman of the Department of Pathology, writes off more than $30 million in uncompensated care each year. This amount is the second highest in the District of Columbia, preceded only by the District of Columbia General Hospital. The NMA has given careful thought to these problems and would like to make the following recommendations: 1. The DRG system should be reevaluated for its effect on the quality of care for the poor and minority patients, and a cost adjustment should be made for the severity of an illness and intensity of services when indicated. In addition, many of our patients lack adequate housing support systems for posthospital care. There needs to be some provision of stepped-down supportive services for low income patients. 2. There should be continued support for Medicaid, including adequate funding, reasonable physician reimbursement, physician participation in revisions of the program, and a refinement of the paper work required to create more efficient documentation. 3. The federal Medicaid regulations should be reevaluated so that each state would be required to make all the medically indigent eligible for prescription drugs for chronic diseases, such as hypertension, without the additional requirement for age, disability, or dependent children. 4. Special provisions should be made for those hospitals that operate at a loss because of the large proportion of Medicaid and Medicare patients they serve. 5. We should devise better strategies to increase the number of minorities in health-related professional fields because documentation shows that they are more likely to serve in medically underserved areas. Under the present health care system in the United States, numerous people are uninsured or underinsured, many of whom are below the poverty level. A significant percentage of black Americans still cannot obtain Medicaid. Many small business people cannot afford health insurance protection due to the high cost of premiums. Still others are uninsurable because of chronic disease conditions. It is estimated that 37 million Americans lack health insurance. Of those, 75% are members of working families, 15 million are women of childbearing age, and 11 million are children. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 82, NO. 3
PRESIDENT'S COLUMN
The National Medical Association reaffirms its position that affordable basic health care is a legal right for all citizens, and it supports a national health program that will provide health coverage to all Americans, regardless of income, race, sex, or ethnic origin. This program should also provide access to primary quality care with high professional standards. In keeping with this recommendation, the NMA proposes that a system of health care delivery and financing be considered, consisting of a mix of employer/employee contributions, general tax revenues, and subsidization of the cost of health care delivery for the poor. The NMA has supported a national health plan since 1978, with the benefits of guaranteed access. We also support comprehensive health care, with emphasis on prevention, freedom of choice between provider and patient, government assurance of quality medical care with representative minority participation, and compliance with Title VI of the Civil Rights Act.
ASSURING ACCESS TO LONG-TERM CARE The availability of health care resources for the chronically ill, most of whom are over 65 years of age, remains a major problem in our society. This is particularly true because many Medicare beneficiaries have the mistaken impression that the expenses of chronic illness are covered by the Medicare program. Many others mistakenly believe that private insurance plans will adequately cover long-term care expenses. They fail to realize that this is not necessarily true. The NMA's Board of Trustees recognizes this continuing problem. In 1988, it established a LongTerm Care Task Force to study the problem of long-term care and to make recommendations for a solution. We found that the definition for long-term care includes not only the elderly but also disabled persons, mentally retarded individuals, and those suffering from developmental, traumatic, or neurological disabilities. It also includes babies born of drug-addicted mothers who experience developmental or neurological disabilities.
Financing As you are aware, in 1965 the Medicare and Medicaid programs began to finance acute care medical services for the elderly. The financing of long-term care services has often fallen on the Medicaid program, primarily for nursing home services but also for home JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 82, NO. 3
and community based services. Thus, Medicaid, a program initially designed for low income women and their children, has become the major provider for middle income older people who have exhausted their assets to meet the devastating needs of long-term care. As this trend escalates, the NMA has expressed serious concern that the Medicaid program will not be able to expend funds for coverage and benefits for the low income mothers with young children because of strict budget constraints and the cost of financing long-term care services. During an era in which teenage and single parentage are on the rise and babies born of alcohol and drug-addicted parents are being abandoned in hospitals, the concern becomes even greater.
Early Detection and Prevention The belief that disability and aging are synonymous causes many elderly people to accept ill health as a normal consequence of longevity. This problem is greatly exacerbated in the minority community because many minorities have come to believe that illness is also synonymous with being born poor. The NMA firmly believes that preventing long-term disability by early detection, through health screening programs, is an efficient use of public dollars. Programs should be funded in order to educate the public as to availability of services, such as Meals on Wheels, adult day care centers, and free feeding programs and transportation, all of which can improve their general health status and supportive needs. There needs to be better coordination of information regarding services available through physicians' offices, clinics, community agencies, or civic offices in order to increase the use of primary medical care, increase the emphasis on physical fitness, foster nutrition programs, provide physical and mental activity, and create a total environmental approach to health care. Although health screening programs are not routinely funded nor provided by health programs, the NMA believes that, in keeping with our federal government's desire for health promotion and disease prevention, much can be done to improve the health status of all Americans and to decrease the cost of long-term health care through comparatively minor costs of health screening programs. There are some specific tests documented to be particularly important because the diseases for which they screen are common and can be treated, prevented, or cured. Mammography for detecting breast cancer for which the mortality rates have been increasing, PAP smears to detect cervical 171
PRESIDENT'S COLUMN
cancers, testing for tuberculosis which has begun to appear more commonly again in inner city areas, rectal examinations (both digital and for occult blood) for early detection of colorectal cancer, and a simple blood pressure check to prevent severe cardiovascular diseases, strokes, myocardial infarctions, and endstage renal disease. Any new health legislation, especially if it is concerned about cost containment in health care and the cost for long-term care, should consider funding these and similar screening methods for early detection and prevention of chronic diseases that will require expensive long-term care. The care of the hospitalized disabled and the elderly is another concern. It is not uncommon that following prolonged hospitalization, the elderly and the disabled may become more debilitated and dependent. Special geriatric or gerontology units are needed in acute hospitals staffed by trained specialists who are concerned about rehabilitation of the long-term care patient. The NMA's philosophy is that as part of illness prevention, multidisciplinary teams involving family members should be expanded. We suggest considering a means to recognize families who devote their time to the care of the disabled long-term care patient in the home setting, but are forced to sacrifice their incomeproducing jobs when they assume this responsibility. The NMA believes that the concept of respite care should be expanded and funded as part of a program to expand the role of the family in the delivery of long-term care. The traditional organizations in the black community, such as churches, sororities/ fraternities, and private clubs, are viewed by the NMA as vital resources. These organizations have been, and should be, involved in the needs of persons requiring long-term care in home and community-based settings.
Training The NMA is concerned about the lack of training of health professional to meet the needs of minority and poor patients and the medically indigent, especially those with long-term care needs. From the physician to the home health aide or visiting nurse, from the administrator to the social worker, new or expanded programs for training are needed. The NMA recommends that a concerted effort be made for all
172
health professional schools to develop curricula that stress the needs of long-term care patients, including their cultural and social requirements as well. The need for public funding of such educational programs is critical. Special emphasis should be made on selection characteristics of professionals going into the field of long-term care in order that those selected will be better equipped to deal with the frustrations and, at times, seemingly unrewarding demands of that field. Medical schools and hospitals should assure that physicians are trained in current approaches to longterm care and the need for coordinated and comprehensive health care delivery for such patients.
Long-Term Care Facilities The role and function of long-term care facilities, such as nursing homes, home health agencies, community residence facilities, and day care centers, need to be reexamined and reassessed. Greater emphasis should be on rehabilitation and restoration of function, not on warehousing and maintaining the status quo. The nursing care at such facilities is a serious problem because much of this care takes place in urban and rural settings. The NMA also suggests that Medicare and Medicaid programs should require more frequent physician visits to nursing home patients, rather than the existing 30- to 60-day requirement. In addition, yearly assessment and yearly evaluation by regulatory agencies charged with the evaluation certification of long-term care facilities must be stressed. This standardization and tighter control are recommended for various home health agencies and any provider of long-term care services.
SUMMARY Finally, let me emphasize that the National Medical Association stands ready to assist the Congress in structuring and implementing any new programs that may result from this gathering. We do have a concern regarding the lack of basic race-specific data, including the extent of long-term care problems in the black communities. It is widely believed that an improved data base to assess the needs and to deal with the issues confronting the black and other minority or economically disadvantaged patient would greatly help to improve existing modes of treatment and outcome.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 82, NO. 3
