Intraoperative hypotension in ambulatory surgery centers.

STUDY OBJECTIVES: To measure the incidence of intraoperative hypotension (IOH) during surgery in ambulatory surgery centers (ASCs) and describe associated characteristics of patients and procedures. DESIGN: Retrospective analysis. SETTING: 20 ASCs. PATIENTS: 16,750 patients having non-emergent, non-cardiac surgery; ASA physical status 2 through 4. INTERVENTIONS: None. MEASUREMENTS: We assessed incidence of IOH using the definition from the Centers for Medicare & Medicaid Services (CMS) Merit-based Incentive Payment System (MIPS)-mean arterial pressure (MAP) < 65 mmHg for at least 15 cumulative minutes-and three secondary definitions: minutes of MAP <65 mmHg, area under MAP of 65 mmHg, and time-weighted average MAP <65 mmHg. MAIN RESULTS: 30.9% of ASC cases had a MAP <65 mmHg for at least 15 min. The incidence of IOH varied significantly, and was higher among younger adults (age 18-39; 36.2%), females (35.2%), and patients with ASA physical status 2 (32.8%). IOH increased with increasing surgery length, even when time-weighted, and was higher among low complexity (30.6%) than moderate complexity (28.8%) procedures, and highest among high complexity procedures (44.1%). CONCLUSIONS: There was substantial occurrence of IOH in ASCs, similar to that described in academic hospital settings in previous literature. We hypothesize that this may reflect clinician preference not to intervene in perceived healthy patients or assumptions about ability to tolerate lower blood pressures on behalf of these patients. Future research will determine whether IOH in ACSs is associated with adverse outcomes to the same extent as described in more complex hospital-based surgeries.

Incidence of intraoperative hypotension during non-cardiac surgery in community anesthesia practice: a retrospective observational analysis.

BACKGROUND: Intraoperative hypotension (IOH) is well-described in the academic setting but not in community practice. IOH is associated with risk of postoperative morbidity and mortality. This is the first report of IOH in the community setting using the IOH measure definition from the Centers for Medicare and Medicaid Services Merit-based Incentive Payment System program. OBJECTIVES: To describe the incidence of IOH in the community setting; assess variation in IOH by patient-, procedure-, and facility-level characteristics; and describe variation in risk-adjusted IOH across clinicians. METHODS: Design Cross-sectional descriptive analysis of retrospective data from anesthesia records in 2020 and 2021. Setting Forty-five facilities affiliated with two large anesthesia providers in the USA. Participants Patients aged 18 years or older having non-emergent, non-cardiac surgery under general, neuraxial, or regional anesthesia. Cases were excluded based on criteria for the IOH measure: baseline mean arterial pressure (MAP) below 65 mmHg prior to anesthesia induction; American Society of Anesthesiologists (ASA) physical status classification of I, V, or VI; monitored anesthesia care only; deliberate induced hypotension; obstetric non-operative procedures; liver or lung transplant; cataract surgery; non-invasive gastrointestinal cases. Main outcomes IOH, using four definitions. Primary definition: binary assessment of whether the case had MAP < 65 mmHg for 15 min or more. Secondary definitions: total number of minutes of MAP < 65 mmHg, total area under MAP of 65 mmHg, time-weighted average MAP < 65 mmHg. RESULTS: Among 127,095 non-emergent, non-cardiac cases in community anesthesia settings, 29% had MAP < 65 mmHg for at least 15 min cumulatively, with an overall mean of 12.4 min < 65 mmHg. IOH was slightly more common in patients who were younger, female, and ASA II (versus III or IV); in procedures that were longer and had higher anesthesia base units; and in ambulatory surgery centers. Incidence of IOH varied widely across individual clinicians in both unadjusted and risk-adjusted analyses. CONCLUSION: Intraoperative hypotension is common in community anesthesia practice, including among patients and settings typically considered "low risk." Variation in incidence across clinicians remains after risk-adjustment, suggesting that IOH is a modifiable risk worth pursuing in quality improvement initiatives.

Application of the Spanish-Language Consultation and Relational Empathy (CARE) Measure to Assess Patient-Centered Care Among Latino Populations.

INTRODUCTION: Reliable and valid measures are needed to assess the patient-centeredness of clinical care among Latino populations. METHODS: We translated the Consultation and Relational Empathy (CARE) measure from English to Spanish and assessed its psychometric properties using data from 349 Latino parents/guardians visiting a pediatric clinic. Using confirmatory factor analysis, we examined the psychometric properties of the Spanish CARE measure. RESULTS: Internal reliability of the Spanish CARE measure was high (Omega coefficient = 0.95). Similar to the English-language CARE measure, factor analysis of the Spanish CARE measure yielded a single domain of patient-centeredness with high item loadings (factor loadings range from 0.79 to 0.96). CONCLUSION: This preliminary analysis supports the reliability and validity of the Spanish version of the CARE measure among Latinos in pediatric care settings. With further testing, the Spanish CARE measure may be a useful tool for tracking and improving the health care delivered to Latino populations.

Atypical vaginal location of endometriosis following repeated urogynaecological surgery.

We outline a case of vaginal endometriosis in scar tissue located in the distal part of the anterior vaginal wall close to the urethra following repeated urogynaecological surgery. Our case presents a 45-year-old woman diagnosed with pelvic endometriosis in her youth. She underwent several vaginal surgeries due to pelvic organ prolapse, symptoms of stress incontinence and decreased urinary flow. One year after her most recent vaginal surgery, she developed a tender lump in the lower part of the anterior vaginal wall. A urethral diverticulum was suspected, but a diagnostic puncture and biopsy unexpectedly showed histologically verified endometriosis. As the cyst recurred, surgical excision of all visible endometriosis tissue was performed. After 3 years of follow-up, the patient remained without recurrence. This case illustrates the risk of atypical implantation of endometriosis related to repeated urogynaecological surgery and that treatment requires surgery with thorough removal of all visible tissues.

Development and Evaluation of a Risk-Adjusted Measure of Intraoperative Hypotension in Patients Having Nonemergent, Noncardiac Surgery.

BACKGROUND: Intraoperative hypotension is common and associated with organ injury and death, although randomized data showing a causal relationship remain sparse. A risk-adjusted measure of intraoperative hypotension may therefore contribute to quality improvement efforts. METHODS: The measure we developed defines hypotension as a mean arterial pressure <65 mm Hg sustained for at least 15 cumulative minutes. Comparisons are based on whether clinicians have more or fewer cases of hypotension than expected over 12 months, given their patient mix. The measure was developed and evaluated with data from 225,389 surgeries in 5 hospitals. We assessed discrimination and calibration of the risk adjustment model, then calculated the distribution of clinician-level measure scores, and finally estimated the signal-to-noise reliability and predictive validity of the measure. RESULTS: The risk adjustment model showed acceptable calibration and discrimination (area under the curve was 0.72 and 0.73 in different validation samples). Clinician-level, risk-adjusted scores varied widely, and 36% of clinicians had significantly more cases of intraoperative hypotension than predicted. Clinician-level score distributions differed across hospitals, indicating substantial hospital-level variation. The mean signal-to-noise reliability estimate was 0.87 among all clinicians and 0.94 among clinicians with >30 cases during the 12-month measurement period. Kidney injury and in-hospital mortality were most common in patients whose anesthesia providers had worse scores. However, a sensitivity analysis in 1 hospital showed that score distributions differed markedly between anesthesiology fellows and attending anesthesiologists or certified registered nurse anesthetists; score distributions also varied as a function of the fraction of cases that were inpatients. CONCLUSIONS: Intraoperative hypotension was common and was associated with acute kidney injury and in-hospital mortality. There were substantial variations in clinician-level scores, and the measure score distribution suggests that there may be opportunity to reduce hypotension which may improve patient safety and outcomes. However, sensitivity analyses suggest that some portion of the variation results from limitations of risk adjustment. Future versions of the measure should risk adjust for important patient and procedural factors including comorbidities and surgical complexity, although this will require more consistent structured data capture in anesthesia information management systems. Including structured data on additional risk factors may improve hypotension risk prediction which is integral to the measure's validity.

Structural validity and reliability of the Danish self-report Strengths and Difficulties Questionnaire among male and female students in vocational education and training.

Objective: The Strengths and Difficulties Questionnaire (SDQ) is a widely used mental health screening instrument among children and adolescents and increasingly used by welfare professionals in Denmark. However, the psychometric properties of the SDQ-self report (SDQ-S) among vocational education and training (VET) students are unknown. We assess the structural validity, internal consistency reliability, and test-retest reliability of the Danish SDQ-S among these students. Method: The SDQ-S was tested twice in a sample of VET students (sample N = 486; mean age = 17 years) with 10 to 14 days in-between. Using separate analyses for men (n = 371) and women (n = 115), structural validity was assessed using confirmatory factor analysis; internal consistency was assessed using composite reliability (CR); and test-retest reliability using Pearson's correlation. Results: Overall, the results provide inconsistent support for the five-factor first-order model, especially among males. CR was acceptable for all five scales except for Peer problems (among females and males) and Conduct (among males only). Test-retest reliability was satisfactory for all scales among females but for only two of the five scales (Conduct, Hyperactivity) among men. Conclusion: Overall, the SDQ-S is a more valid and reliable instrument among females. Results suggest caution in using the SDQ-S among VET students, in particular males.

Financial Toll of Untreated Perinatal Mood and Anxiety Disorders Among 2017 Births in the United States.

Objectives. To estimate the economic burden of untreated perinatal mood and anxiety disorders (PMADs) among 2017 births in the United States.Methods. We developed a mathematical model based on a cost-of-illness approach to estimate the impacts of exposure to untreated PMADs on mothers and children. Our model estimated the costs incurred by mothers and their babies born in 2017, projected from conception through the first 5 years of the birth cohort's lives. We determined model inputs from secondary data sources and a literature review.Results. We estimated PMADs to cost $14 billion for the 2017 birth cohort from conception to 5 years postpartum. The average cost per affected mother-child dyad was about $31 800. Mothers incurred 65% of the costs; children incurred 35%. The largest costs were attributable to reduced economic productivity among affected mothers, more preterm births, and increases in other maternal health expenditures.Conclusions. The US economic burden of PMADs is high. Efforts to lower the prevalence of untreated PMADs could lead to substantial economic savings for employers, insurers, the government, and society.

Continuing conversations about abortion and deprivation.

In 'Abortion and deprivation: a reply to Marquis', I argued that Marquis' argument about abortion encounters the Epicurean Challenge. In this essay, I continue the conversation begun there. I aim to motivate the Challenge further by examining Marquis' argument on his own terms and responding to objections about whom death deprives, whether we should focus on the action of killing or the result of death, and how harms suffered before existence compare to harms suffered after death. Finally, I suggest that perhaps the solution to the ethics of killing lies in considering another account of harm entirely-one that does not rely on deprivation.

Implementing Electronic Health Record Default Settings to Reduce Opioid Overprescribing: A Pilot Study.

Objective: To pilot test the effectiveness, feasibility, and acceptability of instituting a 15-pill quantity default in the electronic health record for new Schedule II opioid prescriptions. Design: A mixed-methods pilot study in two health systems, including pre-post analysis of prescribed opioid quantity and focus groups or interviews with prescribers and health system administrators. Methods: We implemented a 15-pill electronic health record default for new Schedule II opioids and assessed opioid quantity before and after implementation using electronic health record data on 6,390 opioid prescriptions from 448 prescribers. We then analyzed themes from focus groups and interviews with four staff members and six prescribers. Results: The proportion of opioid prescriptions for 15 pills increased at both sites after adding an electronic health record default, with one reaching statistical significance (from 4.1% to 7.2% at CHC, P = 0.280, and 15.9% to 37.2% at WVU, P < 0.001). The proportion of 15-pill prescriptions increased among high-prescribing departments and among most high- and low-frequency prescribers, except for low-frequency prescribers at CHC. Sites reported limited challenges in instituting the default, although ease of implementation varied by electronic health record vendor. Most prescribers were not aware of the default change and stated that they made prescribing decisions based on patient clinical characteristics rather than defaults. Conclusions: This pilot provides initial evidence that changing default settings can increase the number of prescriptions at the default level. This low-cost and relatively simple intervention could have an impact on opioid overprescribing. However, default settings should be selected carefully to avoid unintended consequences.

Abortion and deprivation: a reply to Marquis.

In 'Why Abortion is Immoral', Don Marquis argues that abortion is wrong for the same reason that murder is wrong, namely, that it deprives a human being of an FLO, a 'future like ours,' which is a future full of value and the experience of life. Marquis' argument rests on the assumption that the human being is somehow deprived by suffering an early death. I argue that Marquis' argument faces the 'Epicurean Challenge'. The concept of 'deprivation' requires that some discernible individual exists who can be deprived. But if death involves total annihilation, then no discernible individual exists to be so deprived. I argue that the Epicurean Challenge must be addressed before it can be proven that Marquis is correct to claim that abortion and murder are wrong because they deprive someone of an FLO.

Association between Practice Participation in a Pediatric-focused Medical Home Learning Collaborative and Reduction of Preventable Emergency Department Visits by Publicly-insured Children in Massachusetts.

INTRODUCTION: This study evaluates the impact of practice participation in a pediatric patient-centered medical home learning collaborative on preventable emergency department (ED) visits among children in MassHealth (Massachusetts Medicaid/Children's Health Insurance Program). METHODS: Claims and enrollment data were extracted for child MassHealth members (aged 3-18) comprising 2 groups: members enrolled in a group of 13 child-serving practices that participated in an intensive, 29-month long patient-centered medical home learning collaborative (intervention group), and members enrolled in a group of 12 comparison practices with roughly similar panel size, type, and geographic location (comparison group). Preventable ED visits were identified using a modified version of the New York University ED algorithm. Two analyses were then conducted: (1) a repeat cross-sectional analysis among children enrolled in intervention or comparison group practices during baseline (first half of 2011) and follow-up (second half of 2013) periods; and (2) a longitudinal analysis among a subset of children enrolled for the full study period (2011-2013). Both analyses tested whether the effect of the intervention differed for children with versus without chronic conditions (effect modification). RESULTS: Preventable ED visits declined from baseline to follow-up among children in both intervention and comparison practices. In the cross-sectional analysis, the decrease was the same in both practice groups, and for children with versus without chronic conditions. The longitudinal analysis shows a statistically significantly greater decrease among children with chronic conditions enrolled in the intervention practices (P = 0.02). CONCLUSION: Children with chronic conditions might receive the greatest benefit from receiving care in a medical home setting.

The Early Awareness and Alert System in Sweden: History and Current Status.

Introduction: Over the past decades, early awareness and alert (EAA) activities and systems have gained importance and become a key early health technology assessment (HTA) tool. While a pioneer in HTA, Sweden had no national level EAA activities until 2010. We describe the evolution and current status of the Swedish EAA System. Methods: This was a historical analysis based on the knowledge and experience of the authors supplemented by a targeted review of published and gray literature as well as documents relating to EAA activities in Sweden. Key milestones and a description of the current state of the Swedish EAA System is presented. Results: Initiatives to establish a system for the identification and assessment of emerging health technologies in Sweden date back to the 1980s. In the 1990s, the Swedish Agency for HTA and Assessment of Social Services (SBU) supported the development of EuroScan as one of its founder members. In the mid-2000s, an independent regional initiative, driven by the Stockholm County Drug and Therapeutics Committee, resulted in the establishment of a regional horizon scanning function. By 2009, this work had expanded to a collaboration between the four biggest counties in Sweden. The following year it was further expanded to the national level and since then the Swedish EAA System has been carrying out identification, filtration and prioritization of new medicines, early assessment of the prioritized medicines, and dissemination of information. In 2015, the EAA System was incorporated into the Swedish national process for managed introduction and follow-up of new medicines. Outputs from the EAA System are now used to select new medicines for inclusion in this process. Conclusions: The Swedish EAA System started as a regional initiative and rapidly grew to become a national level activity. An important feature of the system today is its complete integration into the national process for managed introduction and follow-up of new medicines. The system will continue to evolve as a response both to the changing landscape of health innovations and to new policy initiatives at the regional, national and international level.

Diagnosis and Management of Borrelia turicatae Infection in Febrile Soldier, Texas, USA.

In August 2015, a soldier returned from field exercises in Texas, USA, with nonspecific febrile illness. Culture and sequencing of spirochetes from peripheral blood diagnosed Borrelia turicatae infection. The patient recovered after receiving doxycycline. No illness occurred in asymptomatic soldiers potentially exposed to the vector tick and prophylactically given treatment.

Identification and bioactive potential of marine microorganisms from selected Florida coastal areas.

The ocean, with its rich untapped chemical biodiversity, continues to serve as a source of potentially new therapeutic agents. The evaluation of the diversity of cultivable microorganisms from the marine sponge Halichondria panicea and ocean sediment samples were examined and their potential as sources of antimicrobial and antiproliferative agents were investigated. The marine sponge and sediments were collected at different depths (0.9-6 meters) and locations in Florida, including Florida Keys, Port St. Joe in Pensacola, Pensacola Bay, Pensacola Beach, and Fort Pickens. Twenty-one cultivatable isolates were grouped according to their morphology and identified using 16S rRNA molecular taxonomy. The bacterial community identified consisted of members belonging to the Actinobacteria, Bacteroidetes, Proteobacteria (Alpha- and Gamma-classes) and Firmicutes phylogeny. Seven of the microbes exhibited mild to significant cytotoxic activities against five microbial indicators but no significant cytotoxic activities were observed against the pancreatic (PANC-1) nor the multidrug-resistant ovarian cancer cell lines (NCI/ADR). This work reaffirms the phyla Actinobacteria and Proteobacteria as sources of potential bioactive natural product candidates for drug discovery and development.

What Factors Influence States' Capacity to Report Children's Health Care Quality Measures? A Multiple-Case Study.

Objectives The objective of this study was to describe factors that influence the ability of state Medicaid agencies to report the Centers for Medicare & Medicaid Services' (CMS) core set of children's health care quality measures (Child Core Set). Methods We conducted a multiple-case study of four high-performing states participating in the Children's Health Insurance Program Reauthorization Act (CHIPRA) Quality Demonstration Grant Program: Illinois, Maine, Pennsylvania, and Oregon. Cases were purposively selected for their diverse measurement approaches and used data from 2010 to 2015, including 154 interviews, semiannual grant progress reports, and annual public reports on Child Core Set measures. We followed Yin's multiple-case study methodology to describe how and why each state increased the number of measures reported to CMS. Results All four states increased the number of Child Core Set measures reported to CMS during the grant period. Each took a different approach to reporting, depending on the available technical, organizational, and behavioral inputs in the state. Reporting capacity was influenced by a state's Medicaid data availability, ability to link to other state data systems, past experience with quality measurement, staff time and technical expertise, and demand for the measures. These factors were enhanced by CHIPRA Quality Demonstration grant funding and other federal capacity building activities, as hypothesized in our conceptual framework. These and other states have made progress reporting the Child Core Set since 2010. Conclusion With financial support and investment in state data systems and organizational factors, states can overcome challenges to reporting most of the Child Core Set measures.

Spillover of Ratings of Patient- and Family-Centered Care.

As primary care models increasingly include nonphysician team members, more attention should be paid to patient- and family-centered care (PFCC) among medical assistants (MAs). The aims of this article are to describe parent perceptions of PFCC by MAs and assess associations between MA PFCC and other perceptions of their care experience. To assess PFCC, we administered the CARE (Consultation and Relational Empathy) measure to the parent/guardian of 360 children following a primary care visit. Perceptions of PFCC by MAs were significantly associated with 6 of 7 other measures of patient experience, including PFCC by the physician, treatment by the receptionist, and satisfaction with wait time. Each team member can potentially shape perceptions of care in ways that could "spill over" into other parts of the visit.

Chromosome and Linear Plasmid Sequences of a 2015 Human Isolate of the Tick-Borne Relapsing Fever Spirochete, Borrelia turicatae.

The sequences of the complete linear chromosome and 7 linear plasmids of the relapsing fever spirochete Borrelia turicatae are presented in this report. The 925,547 bp of chromosome and 380,211 bp of plasmid sequence were predicted to contain a total of 1,131 open reading frames, with an average G+C content of 29.7%.

Associations between practice-reported medical homeness and health care utilization among publicly insured children.

BACKGROUND: The patient-centered medical home (PCMH) is widely promoted as a model to improve the quality of primary care and lead to more efficient use of health care services. Few studies have examined the relationship between PCMH implementation at the practice level and health care utilization by children. Existing studies show mixed results. METHODS: Using practice-reported PCMH assessments and Medicaid claims from child-serving practices in 3 states participating in the Children's Health Insurance Program Reauthorization Act of 2009 Quality Demonstration Grant Program, this study estimates the association between medical homeness (tertiles) and receipt of well-child care and nonurgent, preventable, or avoidable emergency department (ED) use. Multilevel logistic regression models are estimated on data from 32 practices in Illinois (IL) completing the National Committee for Quality Assurance's (NCQA) medical home self-assessment and 32 practices in North Carolina (NC) and South Carolina (SC) completing the Medical Home Index (MHI) or Medical Home Index-Revised Short Form (MHI-RSF). RESULTS: Medical homeness was not associated with receipt of age-appropriate well-child visits in either sample. Associations between nonurgent, preventable, or avoidable ED visits and medical homeness varied. No association was seen among practices in NC and SC that completed the MHI/MHI-RSF. Children in practices in IL with the highest tertile NCQA self-assessment scores were less likely to have a nonurgent, preventable, or avoidable ED visit than children in practices with low (odds ratio 0.65; 95% confidence interval 0.47-0.92; P < .05) and marginally less likely to have such a visit compared with children in practices with medium tertile scores (odds ratio 0.72, 95% confidence interval 0.52-1.01; P = .06). CONCLUSIONS: Higher levels of medical homeness may be associated with lower nonurgent, preventable, or avoidable ED use by publicly insured children. Robust longitudinal studies using multiple measures of medical homeness are needed to confirm this observation.

Measuring self-efficacy to use vaginal microbicides: the Microbicide Use Self-Efficacy instrument.

UNLABELLED: Objectives To evaluate the psychometric properties of the Microbicide Use Self-Efficacy (MUSE) instrument and to examine correlates of self-efficacy to use vaginal microbicides among a sample of racially and ethnically diverse women living in the north-eastern United States. METHODS: Exploratory and confirmatory factor analytic methods were used to explore and determine the dimensionality and psychometric properties of the MUSE instrument. Construct validity was assessed by examining the relationships of the MUSE instrument to key sexual behaviour, partner communication, relationship and psychosocial variables. RESULTS: Two dimensions of self-efficacy to use microbicides were psychometrically validated and identified as 'Adherence and Access' and 'Situational Challenges.' The two four-item subscales measuring Adherence and Access and Situational Challenges had reliability coefficients of 0.78 and 0.85, respectively. Correlates of the two measures were tested at a Bonferroni-adjusted α level of P=0.001, and 19 of 43 variables analysed were found to significantly relate to Adherence and Access, whereas 16 of 43 variables were significantly related to Situational Challenges. Of the 35 significant relationships, 32 were in the domains of partner communication, partner relationships, and behavioural and psychosocial variables. CONCLUSIONS: The MUSE instrument demonstrated strong internal validity, reliability and initial construct validity. The MUSE instrument can be a useful tool in capturing the multidimensional nature of self-efficacy to use microbicides among diverse populations of women.

The process of identifying, solving and preventing drug related problems in the LIMM-study.

OBJECTIVE: To avoid negative effects of drug treatment and need for additional medical care, drug treatment must be individualised. Our research group has developed a model for clinical pharmacy which improves several aspects of the patient's drug treatment. This study describes the process behind these improvements, i.e. drug related problems identified by pharmacists within a clinical pharmacy service. SETTING: Three wards at a department of internal medicine. METHOD: Pharmacists performed systematic interventions during the patient's hospital stay, aiming to identify, solve and prevent drug related problems in the elderly. Identified drug related problems were put forward to the health care team and discussed. Information on identified problems, and their outcomes was collected and analysed. A questionnaire was used to evaluate the health care personnel's attitudes towards the process. MAIN OUTCOME MEASURE: The number of drug related problems identified by the clinical pharmacists, the proportion of problems discussed with the physicians, the proportion of problems adjusted by the physicians and whether pharmacists and physicians prioritised any subgroup of drug related problems when choosing which problems to address. Finally, we wanted to evaluate the health care personnel's attitudes towards the model. RESULTS: In total, 1,227 problem were identified in 190 patients. The pharmacists discussed 685 (55.8%) of the identified problems with the physicians who accepted 438 (63.9%) of the suggestions. There was no significant difference in which subgroup to put forward and which to adjust. There was a high response rate (84%) to the questionnaire, and the health care personnel estimated the benefits to be very high, both for the patients and for themselves. CONCLUSION: The process for identifying, solving and preventing drug related problems was good and the different types of problems were considered equally important. The addition of a clinical pharmacy service was considered very useful. This suggests that the addition of our clinical pharmacy service to the hospital setting add skills of great importance.