General anesthesia is a drug-induced, reversible condition characterized by distinct behavioral and physiological features – including unconsciousness, amnesia, analgesia, and akinesia – as well as physiological stability of the autonomic, cardiovascular, respiratory, and thermoregulatory systems.¹ Research on the action of anesthetic drugs in the central nervous system provides some insight into the molecular and pharmacological principles that underlie general anesthesia.²

One potential molecular mechanism of general anesthesia involves GABA_A-mediated altered arousal.^2,3 Anesthetic drugs, such as propofol, sodium thiopental, methoxital, and etomidate, may induce sedation and unconsciousness by acting as agonists at GABA_A receptors, which are widely distributed throughout the brain.² When bound to their natural ligands, GABA_A receptors undergo a conformational change and form chloride channels, allowing chloride ions to flow down their concentration gradient into the cell.⁴ This hyperpolarizes the cell membrane and ultimately decreases the activity of neurons.⁴ Propofol – and similar anesthetic drugs – act as GABA_A receptor agonists by mimicking the biological activity of these natural ligands, i.e. opening chloride channels and decreasing neural activity. For example, during wakefulness, pyramidal neurons in the cortex receive a balance of excitatory input (from the major cholinergic, monoaminergic, and orexinergic arousal pathways) and inhibitory input (from local inhibitory interneurons). During GABA_A-mediated altered arousal, however, the activation of GABA_A receptors results in increased inhibitory input.² Because a small number of interneurons regulates a large number of pyramidal neurons, administration of GABA_A receptor agonists can lead to the inactivation of large regions of the brain.²

When administered for induction of general anesthesia, hypnotics rapidly reach the GABAergic neurons in the respiratory centers in the pons and medulla⁶ and arousal centers in the pons, midbrain, hypothalamus, and basal forebrain.⁷ The ensuing clinical signs are consistent with the inhibitory activity of GABAergic hypnotics.² For example, the loss of the oculocephalic and corneal reflexes is explained mechanistically by the biological action of hypnotic agents at the nuclei that control eye movements in the midbrain and pons.² Atonia, observed after bolus administration of propofol, may be attributed to agonistic activity in GABAergic circuits in the spinal cord and in the pontine and medullary reticular nuclei, which control anti-gravity muscles.² Similarly, the action of hypnotics on GABA_A interneurons in the respiratory control network in the ventral medulla provides a molecular explanation for apnea.² And finally, it is understood that GABAergic hypnotics contribute to sedation and unconsciousness by enhancing inhibitory activity at thalamic reticular neurons which project onto the cortex.²

The molecular principles of GABA_A-mediated altered arousal shed light on the behavioral and physiological effects of general anesthesia. As demonstrated above, the molecular activity of anesthetic drugs at GABAergic circuits provides an explanation for apnea, atonia, sedation, unconsciousness, and other clinical signs of general anesthesia. That said, further research is needed to achieve a more rigorous understanding of the mechanism of general anesthesia.

References

1. Brown EN, Lydic R, Schiff ND. “General anesthesia, sleep and coma.” N Engl J Med. 2010; 363(27): 2638–50.
2. Brown, Emery N et al. “General anesthesia and altered states of arousal: a systems neuroscience analysis.” Annual review of neuroscience vol. 34 (2011): 601-28.
3. Bowery NG, Hudson AL, Price GW. “GABAA and GABAB receptor site distribution in the rat central nervous system.” Neuroscience. 1987; 20 (2): 365–83.
4. Jakubowski, H. “Agonist and Antagonist of Ligand Binding to Receptor.” Biology LibreTexts.
5. Bai D, Pennefather PS, MacDonald JF, Orser BA. “The general anesthetic propofol slows deactivation and desensitization of GABA(A) receptors.” J Neurosci. 1999; 19(24): 10635–46.
6. Feldman JL, Mitchell GS, Nattie EE. “Breathing: rhythmicity, plasticity, chemosensitivity.” Annu Rev Neurosci. 2003; 26: 239–66.
7. Saper CB, Scammell TE, Lu J. “Hypothalamic regulation of sleep and circadian rhythms.” Nature. 2005; 437 (7063): 1257–63.

This week Amazon launched Amazon Care, an app-based healthcare service for current employees and their families in the Seattle area. As of Tuesday, individuals over 18 that are enrolled in an Amazon-sponsored health plan are able to request an invitation to Amazon Care.

 

The application, through a partnership with Washington-based Oasis Medical Group, P.C., connects users with an affiliated doctor, nurse practitioner, or registered nurse. The name and license of the clinician is displayed in-app at the beginning of every interaction. Users can choose to hold their consultation via the Care Chat messaging platform or via a Video Care video call. Once connected, the assigned medical professional is available to diagnose the user, advise them on a treatment plan, or provide a referral. If adequate care is unable to be given, the clinician can also help identify next steps. Amazon Care keeps a record of this information and generates an invoice as well as a care summary.

 

In addition to the Care Chat and Video Care services, Amazon Care can also dispatch Mobile Care nurses for follow-up visits at preferred locations, like the home or office. Mobile Care nurses are equipped to provide on-site testing, physical exams, and vaccinations. They can also collect samples and perform other medical services that require an in-person visit. These visits can also be held in rooms on the Amazon campus or other locations within the designated operating area.

 

A third component to Amazon Care is their Care Courier service, which provides prescription drug delivery. This service allows users to receive their prescriptions within a projected window of two hours. Otherwise, prescriptions can be picked-up at a preferred pharmacy. Both Care Couriers as well as Mobile Care nurses wear Amazon Care uniforms and can be identified by an Oasis Medical badge.

 

The combination of these services allows Amazon Care to function much like a general practitioner, providing basic care. In its current model, the app is only able to handle acute urgent care needs, such as colds, infections, and minor injuries. This scope of care extends to preventative consultations, lab work, contraceptives, and STI testing. Clinicians can also advise on sexual health and travel health in addition to answering any general medical questions. Emergency services are not provided.

 

This virtual format and focus on telemedicine allow for diagnosis and treatment plans to be communicated efficiently, cutting down on waiting time and travel as well as creating access to healthcare. However at this time, Amazon Care is restricted to a set window of operation. It’s services are only available between 8 AM and 9 PM PDT from Monday through Friday and between 8 AM and 6 PM PDT on Saturday and Sunday.

 

A further restriction is employees must live and work in the pilot geographical area to be considered eligible. The app uses location-aware technology to determine whether users are within the area of service. For individuals that meet these requirements, enrollment is possible throughout the year. For eligible zip codes and compatible mobile devices, consult the Amazon Care website.

 

Sources:

https://amazon.care/

 

https://www.engadget.com/2019/09/25/amazon-care-is-a-new-app-based-health-service-for-its-employees/?guccounter=1

 

https://www.thetimes.co.uk/article/amazon-offers-healthcare-app-to-us-workers-hthkkpdcw

 

https://www.geekwire.com/2019/amazon-launches-demand-healthcare-service-seattle-area-employees/

 

https://www.adweek.com/digital/amazon-pushes-further-into-healthcare-with-amazon-care/

 

https://www.ft.com/content/bc058a64-df11-11e9-9743-db5a370481bc

 

https://www.businessinsider.com/amazon-launches-virtual-care-pilot-program-for-employees-in-seattle-2019-9

In 1980, Jimmy Carter established the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research as an effort to study the differences in availability of health services in the United States. In 1983, the Commission issued a report called Securing Access to Health Care, which aimed to provide an ethical framework for the evaluation of health policy in the United States.¹ From this initiative, and from examples in other countries, came hospital ethics committees (HECs). These committees, which deal with the moral and ethical aspects of medical practice, were designed originally to provide legal protection for medical personnel and hospitals, but have varying and diverse goals depending on the institution.² They differ from clinical research review boards, human subjects review committees and institutional review boards (IRBs) in that these other groups evaluate ethics of medical research, while HECs evaluate ethics of medical practice.

According to the American Medical Association (AMA), HECs serve to make recommendations about difficult, life-changing situations in the lives of patients, families, physicians and other health care professionals.³ In addition, many ethics committees facilitate ethics-related education and policy changes within their institutions.³ The AMA holds that HECs should adhere to the following guidelines: serve as advisors and educators rather than decision-makers, respect the rights and privacy of all participants and of committee deliberations, ensure that stakeholders have timely access to services, be structured appropriately to fit the institution and its patients, adopt and adhere to institutional policies and draw on resources of professional organizations.³ Other sources claim that ethics committees should approach ethical dilemmas with both code consistency—i.e., adhering to the rules and guidelines of the committee and hospital—and ethical consistency—i.e., suggesting decisions that are ethically acceptable.⁴ Clearly, HECs are held to high standards and strict guidelines by the AMA, as well as by individual researchers.

As they perform ethical consultations, develop institutional policy and educate health professionals, HECs face various challenges. For one, they must protect the interests of individual patients and broader institutions while remaining unbiased and independent.⁵ Also, HECs must convince health professionals to engage patients and their families in ethical decisions, such as engagement of the “do not resuscitate” policy.⁶ A third barrier for HECs is educating health professions students on the gravity of the decisions they make and the ethical dilemmas they may face throughout their careers.⁶ HECs may face backlash by students, professionals, patients and institutions for every recommendation they make.

Indeed, controversy exists about the effectiveness of HECs. Some claim that ethics committees undermine the trust established between a patient and a physician, as HECs imply that ethical decisions are too complex for practitioners and must be approached by a group.⁷ On the other hand, one study found that mental health professionals find HECs useful in dilemmas related to coercion, confidentiality, information and patient autonomy.⁸ Other health professionals see the value in HECs as means to avoid legal conflicts with patients and families.⁹ Overall, research on the effectiveness of HECs is lacking, and it remains unclear if HECs lead to better patient care.^10,11

In sum, HECs represent the move of the medical community from a scientific approach to a social one.² HECs, which adhere to policies laid out by national organizations and local institutions, aim to bring objectivity and ethical reasoning to life-changing dilemmas and to educate professionals on ethical decision-making. Future research is needed to understand health professionals’ relationships with HECs and to clarify the usefulness of HECs in improving patient care.

 

1. Bayer R. Ethics, politics, and access to health care: A critical analysis of the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Cardozo Law Review. 1984;6(2):303–320.
2. Rosner F. Hospital medical ethics committees: A review of their development. JAMA. 1985;253(18):2693–2697.
3. American Medical Association. Ethics Committees in Health Care Institutions: Code of Medical Ethics Opinion 10.7. AMA Principles of Medical Ethics: II, IV, VII 2019; https://www.ama-assn.org/delivering-care/ethics/ethics-committees-health-care-institutions.
4. Moore A, Donnelly A. The job of ‘ethics committees’. Journal of Medical Ethics. 2018;44(7):481–487.
5. Dörries A, Boitte P, Borovecki A, Cobbaut J-P, Reiter-Theil S, Slowther A-M. Institutional Challenges for Clinical Ethics Committees. HEC Forum. 2011;23(3):193.
6. Hajibabaee F, Joolaee S, Cheraghi MA, Salari P, Rodney P. Hospital/clinical ethics committees’ notion: An overview. Journal of Medical Ethics and History of Medicine. 2016;9:17.
7. Siegler M. Ethics Committees: Decisions by Bureaucracy. The Hastings Center Report. 1986;16(3):22–24.
8. Syse I, Førde R, Pedersen R. Clinical ethics committees – also for mental health care? The Norwegian experience. Clinical Ethics. 2016;11(2–3):81–86.
9. Marcus BS, Shank G, Carlson JN, Venkat A. Qualitative Analysis of Healthcare Professionals’ Viewpoints on the Role of Ethics Committees and Hospitals in the Resolution of Clinical Ethical Dilemmas. HEC Forum. 2015;27(1):11–34.
10. Hem MH, Pedersen R, Norvoll R, Molewijk B. Evaluating clinical ethics support in mental healthcare: A systematic literature review. Nursing Ethics. 2014;22(4):452–466.
11. Harari DY, Macauley RC. The Effectiveness of Standardized Patient Simulation in Training Hospital Ethics Committees. The Journal of Clinical Ethics. 2016;27(1):14–20.

The Society for Ambulatory Anesthesia (SAMBA) strives to be the leader in perioperative—i.e., before and after surgery—of the ambulatory surgical patient.¹ Ambulatory anesthesia is used for ambulatory surgery, which is a surgical procedure where the patient does not need to stay overnight in a hospital (outpatient, office-based and non-operating room procedures), and it includes general, regional, local and sedation anesthetics.² Tens of millions of ambulatory surgery procedures, including endoscopy and cataract surgery, are performed per year,³ and the number and variety of procedures are rapidly growing.² Because of the rising popularity of ambulatory surgery, ambulatory anesthesia and SAMBA are important factors in today’s medical system. According to SAMBA, its goals are to advance the practice of ambulatory anesthesia, to promote high ethical and professional standards, to provide professional guidance for the practice of perioperative care of ambulatory surgical patients and to foster and encourage education and research.¹ Its officers are medical doctors,⁴ while its board of directors includes lawyers, medical doctors and businesspeople.⁵ Members can include physicians, scientists, teachers, non-physician providers of ambulatory anesthesia care, anesthesiology residents and honorary contributors.⁶ Overall, SAMBA represents a diverse group of professionals who aim to improve and learn about the quickly growing field of ambulatory anesthesia.

Given SAMBA’s missions to educate physicians and patients about ambulatory anesthesiology and to provide guidance to ambulatory anesthesia providers,⁷ SAMBA provides its members with events, meetings, fellowships, webinars, research awards and other opportunities.⁸ Its fellowship curriculum, developed by the Fellowship Taskforce for the SAMBA Ambulatory Anesthesiology Fellowship Program and approved by the SAMBA board in October 2009, aims to provide trainees with competencies ranging from patient care to medical knowledge, as well as skills in surgeries from ophthalmologic to pediatric procedures.⁹ Also, SAMBA hosts a several-day meeting every year¹⁰—in fact, SAMBA itself was formally established at a 1985 meeting of the American Society of Anesthesiologists (ASA).¹¹ Meeting lectures include sessions on obstructive sleep apnea, dealing with an active shooter in an ambulatory surgery center (ASC), preparing for disasters and ceasing the prescription of opioids, and are led by practitioners, directors of ASCs, ASA and industry leaders and more.¹⁰ Clearly, SAMBA focuses on educating and providing opportunities for professionals to further the improvement of ambulatory anesthesiology.

In addition to providing educational and professional development opportunities, SAMBA establishes standards for safe practices. For example, a multidisciplinary committee of SAMBA compiled guidelines for the management of postoperative nausea and vomiting (PONV) for all ambulatory anesthesiology workers,¹² and more recently for perianesthesia nurses specifically.¹³ Another systematic literature review by SAMBA established consensus on perioperative blood glucose management in diabetic patients undergoing ambulatory surgery.¹⁴ By using scientific evidence to establish best practices, SAMBA illustrates standardized work, which is a quality improvement tool that serves as the current best way to safely achieve the best patient outcomes.¹⁵ The development of protocols and guidelines has been controversial in that many physicians consider standardization harmful to many vital aspects of medicine^16,17; however, evidence-based practice has been widely popularized in the past 20 years¹⁸ and allows health professionals to combine systematic research with their own experiences.¹⁹ In short, SAMBA continues to adopt contemporary medical strategies by integrating evidence-based guidelines into ambulatory anesthesia.

Today, with 70 to 80 percent of surgeries performed on a day-surgery basis nationally, SAMBA focuses on advancing ambulatory anesthesiology, measuring outcomes and developing evidence-based standards, specifically emphasizing education and research.²⁰ SAMBA provides learning and improvement opportunities to its members and establishes standardized practices based on scientific evidence. Going forward, SAMBA will need to stay apace with the rapidly changing specialty of ambulatory anesthesiology, while also investigating if its guidelines fit patients’ and physicians’ needs.

1.         Society for Ambulatory Anesthesia. About Us. 2019; https://sambahq.org/about-us/.

2.         UC Davis Health. Ambulatory anesthesia. 2019; https://health.ucdavis.edu/anesthesiology/specialties/ambulatory.html.

3.         Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the United States, 2006. 2009.

4.         Society for Ambulatory Anesthesia. Officers. 2019; https://sambahq.org/about-us/officers/.

5.         Society for Ambulatory Anesthesia. Board of Directors. 2019; https://sambahq.org/about-us/board-of-directors/.

6.         Society for Ambulatory Anesthesia. Membership Categories. 2019; https://sambahq.org/membership/membership-categories/.

7.         Walsh MT. SAMBA–Building for the Future of Ambulatory Anesthesia. ASA Newsletter. 2017;81(2):56–57.

8.         Society for Ambulatory Anesthesia. SAMBA. 2019; https://sambahq.org.

9.         Society for Ambulatory Anesthesia. Fellowship Curriculum. 2019; https://sambahq.org/education-research/fellowship-curriculum/.

10.       Society for Ambulatory Anesthesia. Annual Meeting. 2019; https://sambahq.org/meetings/2019-meeting/.

11.       Rodriguez LV, Belani KG. Society for Ambulatory Anesthesia (SAMBA) Update. ASA Newsletter. 2019;83(2):50–51.

12.       Gan TJ, Meyer TA, Apfel CC, et al. Society for Ambulatory Anesthesia Guidelines for the Management of Postoperative Nausea and Vomiting. Anesthesia & Analgesia. 2007;105(6):1615–1628.

13.       Hooper VD. SAMBA Consensus Guidelines for the Management of Postoperative Nausea and Vomiting: An Executive Summary for Perianesthesia Nurses. Journal of PeriAnesthesia Nursing. 2015;30(5):377–382.

14.       Joshi GP, Chung F, Vann MA, et al. Society for Ambulatory Anesthesia consensus statement on perioperative blood glucose management in diabetic patients undergoing ambulatory surgery. Anesthesia and Analgesia. 2010;111(6):1378–1387.

15.       Jankowski CJ, Walsh MT. Quality Improvement in Ambulatory Anesthesia: Making Changes that Work for You. Anesthesiology Clinics. 2019;37(2):349–360.

16.       Hung D, Martinez M, Yakir M, Gray C. Implementing a Lean Management System in Primary Care: Facilitators and Barriers From the Front Lines. Quality Management in Health Care. 2015;24(3):103–108.

17.       Hartzband P, Groopman J. Medical Taylorism. New England Journal of Medicine. 2016;374(2):106–108.

18.       Guyatt G, Cairns J, Churchill D, et al. Evidence-Based Medicine: A New Approach to Teaching the Practice of Medicine. JAMA. 1992;268(17):2420–2425.

19.       Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence based medicine: What it is and what it isn’t. BMJ. 1996;312(7023):71–72.

20.       Valedon A. The Society for Ambulatory Anesthesia in 2017: Advancing Outpatient Preoperative Care and Serving our Members. ASA Newsletter. 2018;82(2):60–63.

The Healthcare Effectiveness Data and Information Set (HEDIS) is a set of standardized performance measures that allows consumers and purchasers to reliably compare health plans.¹ HEDIS was established by the National Committee for Quality Assurance (NCQA), a health care accreditor that aims to establish scientifically supported health care, to study how well health plans and doctors implement such research-based care and to identify organizations that make patient care better.² NCQA partners with the Centers for Medicare & Medicaid Services (CMS) to use HEDIS to allow Medicaid, Medicare and commercial health plans to compare their performance and quality of care with other health plans.³ Specifically, NCQA and CMS use HEDIS measures to evaluate Medicare Advantage (MA) plans, which are Medicare health plans offered by private companies including health maintenance organizations (HMOs), preferred provider organizations (PPOs), private fee-for-service plans, Special Needs Plans (SNPs) for individuals with disabling conditions and Medicare Medical Savings Account (MSA) plans.⁴ HEDIS provides a standard way to compare health care plans across the board, ranging from the various types of Medicare Advantage plans to state-wide Medicaid plans to private commercial health plans.³

According to NCQA, HEDIS includes more than 90 measures across six domains: Effectiveness of Care, Access/Availability of Care, Experience of Care, Utilization and Risk Adjusted Utilization, Health Plan Descriptive Information and Measures Collected Using Electronic Clinical Data Systems.⁵ Some examples of HEDIS measures include childhood immunization status, emergency department utilization and identification of alcohol and other drug services.⁶ For most of these measures, the percentage of plans (separated into commercial, Medicare and Medicaid) that submit data to NCQA are listed yearly on the NCQA website.^6,7 Given that more than 190 million people are enrolled in health plans that report data using HEDIS,² consumers can benefit from NCQA’s online transparency.

Due to their ubiquity, HEDIS measures can be used not only by health professionals, health plan administrators and consumers, but also by researchers. For example, a recent study by Hechter et al. used HEDIS measures of treatment initiation and engagement to compare alcohol and other drugs (AOD) use disorder in patients with or without human immunodeficiency virus (HIV).⁸ Another study by Mosen et al. compared patients who receive dental care to those who do not by using HEDIS measures.⁹ Meanwhile, Ng-Mak and Rajagopalan used HEDIS measures, such as those for cardiovascular and diabetes screening, to examine quality of care received by individuals with severe mental illness.¹⁰ Clearly, researchers use HEDIS measures to evaluate patients and their outcomes.

Nevertheless, it is unclear if HEDIS measures are accurate indicators of quality of patient care and patient outcomes. For example, Harman et al. linked a plan’s HEDIS performance to changes in enrollee health, finding that improved quality of diabetes care can result in better patient health.¹¹ However, Harris et al. found that specification validity (i.e., the ability of a measure to adequately capture care processes and patients) of HEDIS measures was excellent for records from residential and outpatient addiction programs, but more modest and highly variable across non-addiction settings.¹² Additionally, one study by Crans Yoon et al. found that compliance with the HEDIS Medication Management for people with Asthma (MMA) measure was not related to improvement in asthma outcomes.¹³ Thus, though the use of HEDIS measures in research is widespread, it remains to be seen if they can precisely or accurately depict patient outcomes in diverse settings.

Overall, HEDIS provides a standardized way for consumers, health professionals and researchers to compare performance across commercial, Medicare and Medicaid health plans. Given the popularity of HEDIS measures, future research should explore the association between compliance on HEDIS measures and real-life quality of care and patient outcomes across a variety of specialties.

1.         Centers for Medicare & Medicaid Services. Healthcare Effectiveness Data and Information Set (HEDIS). July 2017; https://www.cms.gov/Medicare/Health-Plans/SpecialNeedsPlans/SNP-HEDIS.html#targetText=NCQA%20established%20Healthcare%20Effectiveness%20Data,comparison%20of%20health%20plan%20performance.

2.         National Committee for Quality Assurance. About NCQA: Learn more about the National Committee for Quality Assurance (NCQA). 2019; https://www.ncqa.org/about-ncqa/.

3.         Beaton T. How HEDIS, CMS Star Ratings, CQMs Impact Healthcare Payers. HealthPayerIntelligence News. December 2017.

4.         Centers for Medicare & Medicaid Services. Medicare Advantage Plans. 2019; https://www.medicare.gov/sign-up-change-plans/types-of-medicare-health-plans/medicare-advantage-plans.

5.         National Committee for Quality Assurance. HEDIS and Performance Measurement. 2019; https://www.ncqa.org/hedis/.

6.         National Committee for Quality Assurance. HEDIS Measures and Technical Resources. 2019; https://www.ncqa.org/hedis/measures/.

7.         National Committee for Quality Assurance. HEDIS 2019 Data Submission Timeline. 2019; https://www.ncqa.org/hedis/data-submission/hedis-2019-data-submission-timeline/.

8.         Hechter RC, Horberg MA, Weisner C, et al. Healthcare Effectiveness Data and Information Set (HEDIS) measures of alcohol and drug treatment initiation and engagement among people living with the human immunodeficiency virus (HIV) and patients without an HIV diagnosis. Substance Abuse. 2019:1–9.

9.         Mosen D, Pihlstrom D, Snyder J, Smith N, Shuster E, Rust K. Association of Dental Care with Adherence to HEDIS Measures. The Permanente Journal. 2016;20(1):33–40.

10.       Ng-Mak D, Rajagopalan K. Examining quality of care for individuals treated for mental health using the HEDIS mental health quality measures. Current Medical Research and Opinion. 2019;35(1):87–95.

11.       Harman JS, Scholle SH, Ng JH, et al. Association of Health Plans’ Healthcare Effectiveness Data and Information Set (HEDIS) Performance With Outcomes Of Enrollees With Diabetes. Medical Care. 2010;48(3):217–223.

12.       Harris AHS, Ellerbe L, Phelps TE, et al. Examining the Specification Validity of the HEDIS Quality Measures for Substance Use Disorders. Journal of Substance Abuse Treatment. 2015;53:16–21.

13.       Crans Yoon A, Crawford W, Sheikh J, Nakahiro R, Gong A, Schatz M. The HEDIS Medication Management for People with Asthma Measure is Not Related to Improved Asthma Outcomes. The Journal of Allergy and Clinical Immunology: In Practice. 2015;3(4):547-552.