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This presentation was developed under tho guidance of Victor Lawrence Roberts, MD, MBA, FACP, FACE, Professor of Internal Medicine, University of Central Florida, College of Medicine, Orlando, FL. Collaboratives use systems approaches to improve quality of care and utilize evidence-based strategies including the Chronic Care Model, learning sessions, and a rapid improvement process. The Chronic Care Model is a population-based model that relies on knowing that patients have the disease, assuring that they receive evidence-based care, and actively aiding them in participating in their own care. The Health Resources and Services Administration’s Bureau of Primary Health Care (BPHC), in partnership with the Institute for Healthcare Improvement (IHI), the Centers for Disease Control and Prevention (CDC) and other professional networks, supports the implementation of Health Disparities Collaborative in federally-funded health centers throughout the country. State primary care associations are key partners in supporting the Health Disparities Collaborative.
Each health center that participates in the Health Disparities Collaborative forms a team, usually consisting of 3-5 staff (with a provider champion, other practitioners, and office staff), that attends a series of national learning sessions over 13 months. State cardiovascular health programs make significant public health contributions to both BPHC- and state-supported collaboratives.
The Arkansas Heart Disease and Stroke Prevention Section has participated in a number of activities designed to support the BPHC- and Arkansas Chronic Illness Collaborative.
The program partnered with the state’s CDC-funded Diabetes Prevention and Control Section, as well as the Community Health Centers, Inc.
The program supports training of new staff in health centers, which have already been through the Health Disparities Collaborative training and of satellite centers affiliated with previously trained primary center sites. The Collaborative benefits state cardiovascular health improvement efforts in a number of ways. From January to March 2009, the percentage of children under age 18 years who were uninsured at the time of interview was 8.2%. The Centers for Disease Control and Preventiona€™s (CDC) National Center for Health Statistics (NCHS) is releasing selected estimates of health insurance coverage for the civilian noninstitutionalized U.S. Three measures of lack of health insurance coverage are provided: (i) uninsured at the time of interview, (ii) uninsured at least part of the year prior to interview (which also includes persons uninsured for more than a year), and (iii) uninsured for more than a year at the time of interview.
For individuals with private health insurance, estimates are presented for enrollment in high deductible health plans (HDHPs), enrollment in consumer-directed health plans (CDHPs), and being in a family with a flexible spending account (FSA) for medical expenses. This report is updated quarterly and is part of the NHIS ER Program, which releases updated selected estimates that are available from the NHIS website.
Based on data from the January to March 2009 NHIS, Hispanic persons were considerably more likely than non-Hispanic white persons, non-Hispanic black persons, and non-Hispanic Asian persons to be uninsured at the time of interview, to have been uninsured for at least part of the past 12 months, and to have been uninsured for more than a year (Table 7). Approximately one-third of Hispanic persons were uninsured at the time of interview or had been uninsured for at least part of the past year, and more than one-fourth of Hispanic persons had been without health insurance coverage for more than a year. Lack of health insurance coverage was greatest in the South and West regions of the United States (Table 7).
Based on data from the first 3 months of 2009, among persons under age 65 with private health insurance, 21.4% with employer-based coverage were enrolled in a HDHP, compared with almost 50% of those with a private plan that was directly purchased or obtained through means other than an employer (Figure 4). During the first 3 months of 2009, among persons under age 65 with private health insurance, 20.1% were in a family that had an FSA for medical expenses (Figure 5). Public coverage rates among both children and adults aged 18-64 are higher now than in 1997 (Table 3). The percentage of poor children who were uninsured at the time of interview decreased from 1997 through March 2009 (Figure 8).
Among children, all poverty status groups experienced an increase in public coverage between 1997 and March 2009 (Table 5). The rate of private coverage among near poor children was 18.3 percentage points lower in the first 3 months of 2009 than in 1997 (Table 6). This report also includes estimates of three types of consumer-directed private health care. The 2009 health insurance estimates are being released prior to final data editing and final weighting, to provide access to the most recent information from NHIS. Due to small sample sizes, estimates based on less than a year of data may have large variances. NHIS is a comprehensive health survey that can be used to relate health insurance coverage to health outcomes and health care utilization.
The data for this report are derived from the Family Core component of the 1997-2009 NHIS, which collects information on all family members in each household. Point estimates, and estimates of their variances, were calculated using SUDAAN software to account for the complex sample design of NHIS.
Both of the June 2007 Early Release (ER) reports used final in-house design variables for estimating variance for the 2006 estimates.
Unless otherwise noted, all estimates shown meet the NCHS standard of having less than or equal to 30% relative standard error.
Health insurance coverage - The a€?private health insurance coveragea€? category excludes plans that pay for only one type of service, such as accidents or dental care. Two additional questions were added to the health insurance section of NHIS beginning with the third quarter of 2004.
Respondents who were considered insured at the time of interview were asked about periods of noncoverage in the past year. Of the 892 people (unweighted) who were eligible to receive the MCAREPRB question in the third and fourth quarters of 2004, 55.4% indicated that they were covered by Medicare. For persons with private health insurance, a new question regarding the annual deductible of each private health insurance plan was added beginning in 2007. Data on health insurance status were edited using an automated system based on logic checks and keyword searches. High deductible health plan (HDHP) - A HDHP is defined in 2009 as a private health plan with an annual deductible of not less than $1,150 for self-only coverage or $2,300 for family coverage. Consumer-directed health plan (CDHP) - A CDHP is defined as a HDHP with a special account to pay for medical expenses; unspent funds are carried over to subsequent years.
Health savings account (HSA) - An HSA is a tax-advantaged account or fund that can be used to pay for medical expenses.
The measures of HDHP enrollment, CDHP enrollment, and being in a family with a FSA for medical expenses are not mutually exclusive. Directly purchased coverage - Private insurance that was originally obtained through direct purchase or through other means not related to employment. Employer-based coverage - Private insurance that was originally obtained through a present or former employer or union or professional association. Education - The categories of education are based on the years of school completed or highest degree obtained for persons aged 18 years and over. Employment - Employment status is assessed at the time of interview and is obtained for persons aged 18 years and over. Hispanic or Latino origin and race - Hispanic or Latino origin and race are two separate and distinct categories. Poverty status - Poverty categories are based on the ratio of the familya€™s income in the previous calendar year to the appropriate poverty threshold (given the familya€™s size and number of children) defined by the U.S. See the NHIS Survey Description Documents for 1997-2007 (available from the NHIS website) for more information on the unknown income and unknown poverty status categories. In the 2007 NHIS, the family income section of the questionnaire was redesigned to improve the collection of income information and to reduce the amount of income nonresponse. Based on preliminary data from the first quarter of 2007, 56% of the respondents eligible for the modified income follow-up questions answered all the questions in the applicable path. Announcements about Early Releases, other new data releases, publications, or corrections related to the NHIS will be sent to members of the HISUSERS Listserv. Figure 8 is a line graph showing lack of health insurance at the time of interview, by poverty status, for children under age 18, from 1997 through March 2009.
1 A person was defined as uninsured if he or she did not have any private health insurance, Medicare, Medicaid, State Childrena€™s Health Insurance Program (CHIP), state-sponsored or other government-sponsored health plan, or military plan.
3 Beginning in the third quarter of 2004, two additional questions were added to the National Health Interview Survey (NHIS) insurance section to reduce potential errors in reporting Medicare and Medicaid status.
The Care Model (see Figure) envisions communities having supportive resources and policies, which are linked to health systems organized to provide good chronic illness care. The implementation of this comprehensive system leads to informed, activated patients, and prepared, proactive practice teams, and produces improved outcomes. This mission is highly complementary to the Heart Disease and Stroke Prevention Section aims of promoting the primary and secondary prevention of heart disease and stroke and eliminating health disparities.
These associations represent several types of health centers including those, which are federally funded. The sessions are designed to teach center teams how to implement the concepts of the Care Model, conduct rapid quality improvement, and utilize a clinical information system. These collaboratives use essentially the same methods as those used in the national effort. The major opportunity for such programs in these efforts is to assist with building capacity and spreading utilization of collaboratives. As health centers experience staff turnover, it is important that new staffs are trained in collaborative processes.
Almost 50% of persons with a private plan obtained by means other than through an employer were in a HDHP. For more information about NHIS and the Early Release (ER) Program, please see the Technical Notes and Additional Early Release Program Products sections of this report. Children were less likely than adults aged 18-64 to have been uninsured for more than a year (Figure 1). There was no significant change in private coverage for poor, near poor, and not poor children between 2008 and the first 3 months of 2009. Starting at age 18, younger adults were more likely than older adults to lack health insurance coverage. Conversely, private health care coverage rates among both children and adults aged 18-64 are lower now than in 1997. During the same period, the percentage of poor adults who were uninsured remained relatively stable (Figure 9).


However, the largest increase was seen among near poor children, for whom coverage by a public plan more than doubled during the same period.
As shown in Figure 10, among near poor children the percentage without health insurance and the percentage with private health insurance coverage have declined since 1997, while public coverage increased. Impact of Medicare and Medicaid probe questions on health insurance estimates from the National Health Interview Survey, 2004. Impact of income bracketing on poverty measures used in the National Health Interview Surveya€™s Early Release Program: Preliminary data from the 2007 NHIS [PDF - 358 KB].
Health, United States, 2008 with Chartbook Hyattsville, MD: National Center for Health Statistics.
Early release of selected estimates based on data from the January-March 2009 National Health Interview Survey. Wireless substitution: Early release of estimates based on data from the National Health Interview Survey, July-December 2008 [PDF - 358 KB]. To reflect different policy-relevant perspectives, different time frames are used to measure lack of insurance coverage.
Consumer-directed health care may enable individuals to have more control over when and how they access care, what types of care they use, and how much they spend on health care services. NHIS is a multistage probability sample survey of the civilian noninstitutionalized population of the United States. Data analyses for the January-March 2009 NHIS were based on 9,473 persons in the Family Core, which is approximately half the usual quarterly sample. ER reports other than the June 2007 update use ER interim design variables to estimate variance, with the exception of the state-level estimates, which use the final in-house design variables to estimate variance. Differences between percentages or rates were evaluated using two-sided significance tests at the 0.05 level. The a€?public health plan coveragea€? category includes Medicaid, State Childrena€™s Health Insurance Program (CHIP), state-sponsored or other government-sponsored health plans, Medicare, and military plans.
One question, MCAREPRB, was asked of persons aged 65 years and over who had not indicated that they had Medicare. For persons who did not have health insurance at the time of interview, a question was asked concerning the length of time since the respondent had coverage.
Method 2 estimates are based on responses to three questions (HIKIND, MCAREPRB, and MCAIDPRB). Of the 9,146 people (unweighted) who were eligible to receive the MCAIDPRB question in the third and fourth quarters of 2004, 3.0% indicated that they were covered by Medicaid.
For plans considered to be high deductible health plans (HDHPs), a follow-up question was asked regarding special accounts or funds used to pay for medical expenses: a health savings account (HSA) or a health reimbursement account (HRA). A person is considered to have a CDHP if there was a a€?yesa€? response to the following question: "With this plan, is there a special account or fund that can be used to pay for medical expenses? These accounts are offered by some employers to allow employees to set aside pre-tax dollars of their own money for their use throughout the year to reimburse themselves for their out-of-pocket expenses for health care. Only years completed in a school that advances a person toward an elementary or high school diploma, General Educational Development high school equivalency diploma (GED), college, university, or professional degree are included. Respondents were first asked to provide their combined family income before taxes from all sources for the previous calendar year in a dollar amount (from $0 to $999,995).
Questions used to collect income data from respondents who initially would not indicate the amount of their familya€™s income in the last calendar year were changed from using a flash card approach to using a set of unfolding brackets. Initial evaluations of the distribution of poverty among selected demographic variables in the first quarter of 2007 suggest that poverty estimates are generally comparable to years 2006 and earlier (17). Beginning with survey year 2007, the imputation procedure was modified to take into account the changes made to the income section.
Early Release of Selected Estimates Based on Data from the National Health Interview Survey (19) is published quarterly and provides estimates of 15 selected measures of health, including insurance coverage.
Health insurance coverage: Early release of estimates from the National Health Interview Survey, January-March 2009.
A person was also defined as uninsured if he or she had only Indian Health Service coverage or had only a private plan that paid for one type of service, such as accidents or dental care.
Persons aged 65 years and over not reporting Medicare coverage were asked explicitly about Medicare coverage, and persons under age 65 with no reported coverage were asked explicitly about Medicaid coverage. The impact of the new sample design on estimates presented in this report is expected to be minimal.
Estimates based on this smaller sample size for the first quarter have larger variances making it more difficult to detect significant differences between estimates.
Specific quality measures are tracked using the clinical information systems mentioned above. The health centers serve as primary care safety net providers, dedicated to assuring access to comprehensive primary care for underserved populations and eliminating health disparities. Learning sessions are conducted within states, and clinical information tools similar to PECS are used. This is also needed as centers, which were trained in other topics, expand their focus to include cardiovascular issues.
One-time funds were used to conduct chart reviews and support initial patient data entry in order to develop these patient management databases.
Second, health centers become champions for community resources, policies, and environmental changes, which reinforce patients’ ability to manage their own care. An estimated 20.1% of persons with a private plan were in a family with a flexible spending account (FSA) for medical expenses. Based on January to March 2009 data, 39.4% of poor adults aged 18-64 were covered by a public plan (Table 5). Among poor adults aged 18-64, 19.1% were covered by private health insurance in the first 3 months of 2009.
Among adults in age groups 18-24, 25-34, and 35-44 years, men were more likely than women to lack health insurance coverage at the time of interview.
These rates are two to more than three times as high as those for persons with more than a high school education. There was a significant increase in enrollment in HDHPs without HSAs between 2007 and March 2009.
This is an increase from 2007, when 16.7% of persons under age 65 with private insurance were in a family with a FSA. Consumer-directed health plans: Early enrollee experiences with health savings accounts and eligible health plans. The measure of uninsured at the time of interview provides an estimate of persons who at any given time may experience barriers to obtaining needed health care. National attention to consumer-directed health care has increased following the enactment of the Medicare Prescription Drug Improvement and Modernization Act of 2003 (P.L. Occasionally, due to decisions made for the final data editing and weighting, estimates based on preliminary editing procedures may differ by more than 0.3 percentage points from estimates based on final files. The survey is conducted continuously throughout the year for NCHS by interviewers of the U.S. Because NHIS is conducted throughout the year, yielding a nationally representative sample each week, data can be analyzed weekly or quarterly to monitor health insurance coverage trends. The fundamental structure of the new 2006 NHIS sample design is very similar to the previous 1995-2005 NHIS sample design.
Logistic regression was used to evaluate the significance of time trends in the percentage of health insurance coverage.
A small number of persons were covered by both public and private plans and were included in both categories. INCLUDE those that pay for only one type of service (nursing home care, accidents, or dental care).
Respondents who originally classified themselves as uninsured, but whose classification was changed to Medicare or Medicaid on the basis of a a€?yesa€? response to either probe question, subsequently received appropriate follow-up questions concerning periods of noncoverage for insured respondents. The tabulation of a€?uninsured for more than a yeara€? using Method 1 excludes respondents whose classification was changed to Medicare or Medicaid by either probe question because these individuals did not receive the question concerning duration of noncoverage for persons who are uninsured. Lastly, a new question was added about family enrollment in a flexible spending account (FSA) for medical expenses. For 2007 and 2008, the annual deductible for self-only coverage was $1,100 and for family coverage was $2,200. The funds contributed to the account are not subject to federal income tax at the time of deposit.
Education in other schools or home schooling is counted only if the credits are accepted in a regular school system. Hispanic or Latino origin includes persons of Mexican, Puerto Rican, Cuban, Central and South American, or Spanish origins. The 2004 estimates of coverage by poverty status were recalculated using the final microdata.
Respondents who did not know or refused to state an amount were then asked if their combined family income in the previous calendar year was $20,000 or more, or less than $20,000. As a result of the changes in questions, the 2007 and 2008 poverty ratio variable has fewer missing values compared with prior years. The imputed income files are released a few months after the annual release of NHIS microdata and are not available for the ER updates.
Other measures of health include estimates of usual place to go for medical care, obtaining needed medical care, influenza vaccination, pneumococcal vaccination, obesity, leisure-time physical activity, current smoking, alcohol consumption, HIV testing, general health status, personal care needs, serious psychological distress, diagnosed diabetes, and asthma episodes and current asthma. Data are based on household interviews of a sample of the civilian noninstitutionalized population. Estimates of uninsurance for 2004 were calculated without using the additional information from these questions (noted as Method 1) and with the responses to these questions (noted as Method 2). Observed changes between the last two data points should be reevaluated when the next quarter of data becomes available. Finally, larger health centers, which participate in the national learning sessions often, are affiliated with smaller satellite health centers; these satellite centers need the opportunity to be trained in collaborative methods.


Additionally, and particularly for those collaboratives implemented among community health centers and health education centers, they constitute a specific strategy for addressing health disparities among vulnerable populations. Estimates based on this smaller sample size for the first quarter have larger variances, and this should be taken into account when evaluating these finding. However, the observed increase in CDHP enrollment between 2007 and March 2009 was not significant. Approximately 8% of private health plans are obtained through means other than an employer for persons under age 65 (estimates not shown).
The estimate of persons who were uninsured at any time in the year prior to interview provides an annual caseload of persons who may experience these barriers.
Oversampling of the black and Hispanic populations has been retained, and the new sample design also oversamples the Asian population.
Terms such as a€?greater thana€? and a€?less thana€? indicate a statistically significant difference. A person was defined as a€?uninsureda€? if he or she did not have any private health insurance, Medicare, Medicaid, CHIP, state-sponsored or other government-sponsored health plan, or military plan at the time of interview. Estimates for 2004 are presented using Method 2 in the figures and both Method 1 and Method 2 in the tables. Unlike Flexible Spending Accounts (FSAs), funds roll over and accumulate year to year if not spent. Race is based on the family respondenta€™s description of his or her own race background as well as the race background of other family members. The revised estimates were released in the March 2006 ER update, and continue to be used in subsequent ER updates. If they again refused to answer or said that they did not know, they were not asked any more questions about their family income. These questions utilize a series of income intervals, and respondents answering the complete path of questions would answer either two or three questions.
Wireless Substitution: Early Release of Estimates from the National Health Interview Survey (20) is published in May and December and provides selected estimates of telephone coverage in the United States.
Respondents who were reclassified as a€?covereda€? by the additional questions received the appropriate follow-up questions concerning periods of noncoverage for insured respondents.
The establishment of the databases helped qualify the centers to participate in either a BPHC Health Disparities or the Arkansas Chronic Illness Collaborative. Large variances make it more difficult to detect significant differences between estimates.
This measure includes persons who have insurance at the time of interview, but who had a period of noncoverage in the year prior to interview, as well as those who are currently uninsured and who may have been uninsured for a long period of time.
In 2007, three additional questions were added to the health insurance section of NHIS to monitor enrollment in consumer-directed health care among persons with private health insurance. In addition, persons 65 aged years and over have a higher probability of being selected as a sample adult.
The weights for the 1997-1999 NHIS data were derived from 1990-census-based population estimates. Terms such as a€?similara€? and a€?no differencea€? indicate that the estimates being compared were not significantly different.
Estimates using Method 1 for the a€?uninsured for more than a yeara€? measure excluded persons whose classification was changed from uninsured to either Medicare or Medicaid coverage by either additional probe question. Additional information on the impact of these two probe questions on health insurance estimates can be found in a€?Impact of Medicare and Medicaid probe questions on health insurance estimates from the National Health Interview Survey, 2004a€? (2).
For conciseness, the text, tables, and figures in this report use shorter versions of the 1997 Office of Management and Budget (OMB) race and Hispanic or Latino origin terms. The first follow-up income question asks a respondent if the familya€™s income is less than $50,000.
These reclassified respondents were excluded in the tabulation of a€?uninsured for more than a yeara€? using Method 1 in 2004.
Although Lyrica is known to have anti-anxiety properties, it is not exactly known how the drug works to treat seizures and nerve pain.
Observed changes between the last two data points should be reevaluated when the next quarter of data become available. Married or widowed adults were more likely to have coverage than those who were divorced, separated, living with a partner, or never married. Finally, the measure of lack of coverage for more than a year provides an estimate of those with a persistent lack of coverage who may be at high risk of not obtaining preventive services as well as care for illness and injury.
Weights for the 2000-2008 NHIS data were derived from 2000-census-based population estimates. Lack of comments regarding the difference between any two estimates does not necessarily mean that the difference was tested and found to be not significant.
The analyses excluded persons with unknown health insurance status (about 1% of respondents each year). As a result, these respondents did not receive the follow-up question concerning how long had it been since they had coverage.
Funds may be used to pay for qualified medical expenses at any time without federal tax liability. Thus, NHIS respondents fell into one of four categories with respect to combined family income information: (i) those willing to supply a dollar amount, (ii) those who indicated their combined family income from a fairly detailed set of intervals, (iii) those who said that their combined family income was either $20,000 or more, or less than $20,000, and (iv) those unwilling to provide any information whatsoever. It may be related to pregabalin’s ability to bind certain parts of calcium channels in the central nervous system.Lyrica UsesPregabalin is primarily used to treat epilepsy, fibromyalgia and nerve pain. These three measures of lack of coverage are not mutually exclusive, and a given individual may be counted in more than one of the measures. For a more complete description of consumer-directed health care, see a€?Definitions of selected termsa€? below. However, they were asked the questions concerning noncoverage in the past 12 months for insured persons. However, the flash card approach had a very low item response rate (15%-18%), and this led to income variables such as poverty ratio having relatively high levels of missing data (approximately 30% item nonresponse rate).
It treats a certain type of epileptic seizure called partial seizures, relieves the pain associated with fibromyalgia and alleviates the chronic nerve pain associated with shingles and diabetes.Although Lyrica may be an effective anxiety medication due to its anti-anxiety properties, it’s not officially approved for anxiety treatment at present.
All estimates beginning in 2005 are calculated by using the two additional questions (Method 2).
Another possible off-label use for the drug is to relieve moderate pain, such as that commonly experienced after a dental procedure.How Lyrica WorksThis medication helps to relieve pain associated with fibromyalgia and helps to treat patients who suffer from seizures known as partial seizures. It contains an active ingredient known as Pregabalin which helps to control and prevent seizures by preventing excess electrical activity in the brain. Lyrica is normally prescribed to patients as an additional treatment when other medications have been unsuccessful in controlling their seizures.
It is also not recommended that this medication be used with alcohol or if the patient will be requiring anesthetic. This medication should be used with caution in patients suffering from diabetes, kidney conditions or heart conditions. Patients should inform their doctor of other medications they are using before starting to use Lyrica. This will assist their doctor in making informed decisions regarding their particular dosage of the medication.It is important for the patient to follow their dosage instruction precisely in order to avoid unpleasant side effects or withdrawal symptoms. An angiotensin receptor blocker (ARB), Diovan keeps the blood vessels open by blocking the hormones that cause the vessels to constrict.When blood vessels stay open without interference, the chance blood clots and disturbances in circulation are greatly diminished.
Diovan is generally prescribed to people with excessively high blood pressure or those that have a history of congestive heart failure or heart attacks.
For this reason, this medication is used to prevent the onset of symptoms associated with cardiovascular diseases.Individuals who are at risk of cardiovascular disease or heart attacks may benefit from this pharmaceutical drug. Diovan works in the body by blocking the amount of angiotensin II that causes the blood vessels to constrict. Therefore, this drug enhances circulation throughout the whole body that can prevent the formation of chronic pain, inflammation, and diseases of other organ systems.Diovan promotes healthy blood flow and can also reduce sodium retention, resulting in improved heart functions and decreased blood pressure. Millions of individuals are prescribed Diovan each year, with the majority of patients being men and women over the age of 40.Diovan UsesThe most common condition treated by Diovan is hypertension, or high blood pressure. Early side effects are similar to the symptoms associated with the beginning stages of hypertension and will usually lessen as the body becomes use to the increased flow of blood. Diovan is also prescribed to patients with congestive heart failure and to individuals who have suffered from a heart attack. Studies have found that Diovan may lower the risk of type II diabetes in glucose intolerant individuals and could prevent kidney damage in patients with diabetes. Diovan may also be effective in treating and preventing Alzheimer’s.Diovan is available in several dosages in both pill and liquid forms.
It is important to take the medication exactly as prescribed by your doctor and to take it at the same time each day. Shake the liquid Diovan well before use and store it at room temperature for up to 30 days or in the refrigerator for as many as 75 days. If you miss a dose, it is okay to take it any time as long as it isn’t time for the next dose. It can be taken with or without food.How Does Diovan Work?Diovan is generally prescribed to individuals who suffer from compromised immune and cardiovascular systems due to cellular imbalances.
Consequently, Diovan has been prescribed to patients over twelve million times in the USA.Since hypertension is one of the most common health conditions among Americans, Diovan is used to lower blood pressure to an acceptable range.



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