Now That VHA Has Established Epilepsy Centers of Excellence, Will the Veterans Come?

by U.S. Medicine

June 12, 2013

By Pamela R. Kelly, MBA-HCM, Rizwana Rehman, PhD, Aatif M. Husain, MD

DURHAM, NC – Elaborating on the phrase coined by President Theodore Roosevelt “If you build it, they will come,” author Ron Adams1 asserts that they will come only if the need, cost and targeted market population are right for the right time. Adams provides guidance on market evaluation prior to building. As a government agency, VHA may not have privileges of conducting pre-evaluation market testing.

With recognized consensus that the price of freedom is truly not free, the care of our veterans remains a high priority, in the spirit of President Abraham Lincoln’s proclamation that the United States will “care for him who shall have borne the battle.” Deploying the Centers of Excellence (COE) concept is one of the options to improve specialized services. Public Law (PL) 110-387 mandated the establishment of the VA Epilepsy Centers of Excellence (ECoE).

Studies have been conducted on post-traumatic epilepsy (PTE) in various populations. According to one, penetrating brain injuries are associated with a 50% risk of PTE, compared with 30% in non-penetrating head injury.2 Studies on Vietnam War veterans indicate that the risk of PTE following war-related traumatic brain injury (TBI) is 53%.3 One study found that 12.6% of veterans inflicted with TBI had an initial onset of epilepsy up to 14 years after their injury.4

There is a possible association between post-traumatic stress disorder (PTSD), TBI and psychogenic nonepileptic seizures (PNES). A critical review of 17 studies on PNES patients reported that 10 out of the 17 documented higher rates of PTSD among PNES patients than the control groups.5

Another study of PNES-diagnosed veterans also revealed a higher rate of PTSD compared with veterans with epileptic seizures.6 In a retrospective study of TBI cohort where epilepsy was the initial diagnosis, 33% had experienced PNES.7 Current research indicates that PNES patients often are initially misdiagnosed with epilepsy and that prolonged video EEG monitoring (EMU) is the determining gold standard for diagnosis.8

It is commonly recognized that with the increasing number of veterans with TBI from recent military conflicts, the number of veterans with epilepsy will continue to increase in the foreseeable future. What is not as clearly recognized is that with the increasing number of PTSD and TBI patients entering the VA system, the number of patients with PNES is also greatly increasing. This represents a new patient population that must be evaluated in the ECoEs to ensure the best treatment for our war-injured veterans.

This article discusses the clinical perspective of seizures (or spells), population trends of seizure patients and prevalence of spells among TBI and PTSD cohorts in the VA prior to establishing ECoE to current status. Additionally, the ECoE strengths and challenges associated with meeting the quality specialized care standards expected for the veterans experiencing epileptic or nonepileptic seizures are discussed. Based on projected workload and the current status of the ECoE program, theory and data supported recommendations are offered in the spirit of program enhancements that might be exportable to other centers of excellence.

PNES Diagnosis Previously Delayed in Veterans

A 2011 study found that psychogenic non-epileptic seizures (PNES) went undiagnosed for much longer in veterans compared to civilians.

The delay, according to the authors, was associated with greater, cumulative antiepileptic drug (AED) treatment, according to the authors from the Portland, OR, VAMC.

“Psychogenic nonepileptic seizures (PNES) are frequently encountered in epilepsy monitoring units (EMU) and can result in significant long-term disability,” according to the study published in the journal Neurology. “We reviewed our experience with veterans undergoing seizure evaluation in the EMU to determine the time delay to diagnosis of PNES, the frequency of PNES, and cumulative antiepileptic drug (AED) treatment. We compared veterans with PNES to civilians with PNES studied in the same EMU.”

For the study, researchers reviewed records of 203 veterans and 726 civilians from a university affiliate admitted to one VAMC EMU over a 10-year interval, calculating the percentage of patients with PNES in each group. The two groups were compared for interval from onset of the habitual spells to EMU diagnosis, cumulative AED treatment, and other measures.

While PNES were identified in 25% of veterans and 26% of civilians admitted to the EMU, the delay from onset of spells to EMU diagnosis averaged 60.5 months for veterans compared to only 12.5 months for civilians.

On the other hand, cumulative AED treatment was four times greater for veterans with PNES as compared to civilians, according to the authors, who noted that 58% of veterans with PNES were thought to have seizures related to traumatic brain injury.

Study authors noted that 18 of the 50 veterans with non-epileptic seizures were from areas where an epilepsy monitoring unit was not available, but that issue has been addressed by the creation of the VA Epilepsy Centers of Excellence.

1 Salinsky M, Spencer D, Boudreau E, Ferguson F. Psychogenic nonepileptic seizures in US veterans. Neurology. 2011 Sep 6;77(10):945-50. doi: 10.1212/WNL.0b013e31822cfc46. PubMed PMID: 21893668.

Statistical Data Con’t

Uncertain Populations: There are no established ICD-09-CM codes for PNES patients, who generally are coded by neurologists using ICD-09-CM code 780.39. In addition, many patients coded with 780.02 (transient alteration of awareness), 780.2 (syncope and collapse) and 780.09 (alteration of consciousness other) could possibly be PNES patients. In the five-year time period FY 2007 – FY 2011, 288,793 patients had a diagnosis of the above codes. Among these patients, 26,835 patients had a diagnosis of TBI, while 65,113 patients also were diagnosed with PTSD. The estimated prevalence of 140.4 per 1,000 for above-mentioned ICD-9 codes among TBI cohort is consistent with previously estimated prevalence of spells in TBI. However, the prevalence of 70.7 per 1,000 of possible spells among PTSD is higher than that of seizures among PTSD cohort.

Discussion: Data analysis suggests that numbers of seizure, TBI and PTSD patients are increasing in the VA. Similarly numbers of seizure patients among TBI and PTSD cohorts also are rising. High prevalence of seizures among TBI cohort (approximately 140.2 per 1,000) echoes the previous studies done with regard to association of TBI and post-traumatic epilepsy. Prevalence of seizures among PTSD cohort (approximately 48.5 per 1,000 patients) is lower than TBI group but is still alarmingly high. This high prevalence could be attributed, in part, to a high percentage of PNES in this population.

According to VHA office of Public Health’s most recent epidemiology report13, 1,436,522 Operations Enduring Freedom, Iraqi Freedom and New Dawn (OEF/OIF/OND) soldiers have separated from the service since FY 2002, but only about 54% have sought healthcare in the VHA system. As more of them seek care at the VA, the need for specialized care of seizure patients to include TBI and PTSD cohorts will grow.

Data show that ECoEs consistently provide care to one-fifth of seizure patients. With specialized equipment and services, ECoE can play a pivotal role in providing specialized care to fulfill the needs of potential upsurge in the large number of patients with seizures.

ECoE Current Initiatives and Policies


An Institutes of Medicine (IoM) epilepsy report recommended validation and implementation of standardized processes for thorough analysis of the healthcare delivery for epilepsy.14 The importance of standardization is stated in PL 110-387 objectives for ECoEs. This includes establishment of consolidated patient accounting centers. To accomplish this task, standardized processes are imperative for accurate workload capture. Workload accuracy is critical for case ascertainment, utilization, cost and quality-of-life measurements in epilepsy.

Registry: The clinical care template is the largest project toward successful standardization of healthcare delivery throughout the VA ECoEs. Completion of the template will standardize the epilepsy care delivery, create an electronic note (eliminating freelance note), and data will be available for surveillance of patients and research. The template is aligned with both American Academy of Neurology recommended measures and National Institute of Health common data elements for epilepsy and TBI.15, 16 Implementation will allow consistent processes and collection of pertinent data. The template is expected to be adopted nationally.

Outreach and Access via Technology

Outreach and Access via technology The ECoE has established partnerships with DOD and Epilepsy Foundations in efforts to reach Veterans. The ECoE Advisory Committees provide valuable feedback for enhancing and improving the program. National education classes are offered to providers and patients via conference calls, and recorded versions are accessible on the ECoE website.17 Additionally, multiple technology projects positively impact the ECoE outlook. Telehealth leverages technology for remote services while sustaining quality, increasing access and reducing cost.

Tele-epilepsy: VA is a leader in the expansion of telehealth to specialty services.18 Tele-epilepsy clinics are operational in multiple ECoE sites nationally, with more clinics on the horizon. The response from patients and providers has been very positive. The most noteworthy factor is the reduced need for epilepsy patients to travel long distances for healthcare, decreasing challenges often encountered with obtaining transportation. Furthermore, many ECoE sites have established telephone clinics as a part of tele-epilepsy.

Consortium: In order to enhance the sharing of specialty knowledge and services among providers, the national ECoE has speared-headed the initiative of creating a consortium using the hub-and-spokes model, which is expected to decrease gaps in access points for veterans seeking epilepsy specialized care. The ECoE consortium goal is to have representation from each state that will allow for sharing of resources to accomplish the mission.

VA Specialty Care Access Networks Extension for Community Healthcare Outcomes (Scan-ECHO): Scan-ECHO is an electronic consultation process between providers. The hub-and-spokes infrastructure of this technology-enhanced consultation system has the potential for sharing ECoE epileptologists’ knowledge nationally. Scan- ECHO will complement the consortium for practical application. Additionally, in lieu of funding, the Southeast Region established a monthly consultation call among regional ECoE epileptologists and is expanding to include non-ECoE epileptologists.


Unique regional boundary lines for the ECoE program pose some challenges with assessments and specific activities, as the boundaries are state and not VISN driven, a previously noted contrast to other programs. The challenges encompass uneven ECoE distributions across the nation. For example, in the Southeast Region, all ECoEs are in two East Coast states; however, the region covers states from the coast over to Louisiana and up to Missouri. The current program design is dependent on resources, affiliation and seizure-specialized services. Efficient communication, physical movement of patients and management of activities can become problematic and complex with large distances between ECoEs and other medical facilities. The Southeast Region adopted a nucleus leadership (clinical and administrative staff responsible for the coordination of standardized processes and referral communication) to complement national administrative core for orchestrating maximum efficiency. Other regions are following suit due to confirmed quality and sustained cost with this model.

Future Policy

Prior to the establishment of ECoE, specialized epilepsy healthcare was diverted to external (non-VA) providers when resources were unavailable. PL made provisions for funding to enhance resources within the VA. Justification of ECoE cost for Veterans care can be addressed with Cost-Based Analysis (CBA).

“CBA rests on the premise that a project or policy will improve social welfare if the benefits associated with it exceed the cost.”19 For epileptic specialized care, significant decrease in fees basis that surpasses the cost of VA care is a good predictor of sustainability.

Therefore, though monetizing the indirect cost for net benefit is challenging, a comprehensive evaluation is required to determine market-value differences. Congressional lobbying/trust lost, untreated patients (decreased life expectancy and quality of life changes), and appropriate resource utilization are examples of intangibles (net benefit= (indirect & direct value benefits) – (indirect and direct cost)).20 This process theory is appropriate for ensuring that all factors involved in the program’s cost are considered in the future decision-making.

Without the existence of COE, the specialized care needed will be fractured. The initiatives emphasize the need to work as a unit and as part of an organization to maximize limited specialized resources. Leveraging technology; strong referral and well-organized communication plans; and valid efficiency evaluation models to analyze the impact of these critical pieces are imperative for the success of the COE concept.


In the short time the PL 110-387 has been in effect, the VHA has responded remarkably to maximize specialized resources by establishing ECoEs to provide quality healthcare for veterans. The number of potential patients requiring services has mushroomed due to at least two factors; the high prevalence of PNES among PTSD patients and high prevalence of epilepsy among TBI patients. ECoEs play a significant role in providing services to these more complex veteran populations. Concrete determination of seizure types requires the clinical expertise of epileptologists and prolonged video EEG monitoring. The VHA ECoE program allows our country to take care of their own “who have borne the battle” has come about at the right time.

As current wars and conflicts ease and the VHA encourages initiatives to become a healthcare provider of choice, the number of veterans will continue to rise. We also should consider that, as mentioned before, recent surveillance of the veteran population indicates that a little less than half of the eligible veterans (46%) since FY 2002 have opted not to seek care in the VHA system. Improved marketing, healthcare reform outcomes and better access opportunities could result in an influx of veterans into the system, impacting specialty programs. Therefore, the foresight to build the ECoE program and efforts to enhance appear to be on target to meet the projected demands, which are based on factors associated with healthcare standards, cost and access. The IOM report on epilepsy included endorsement of centers of excellence in epilepsy.

According to experts, government perception of customers’ view about healthcare provisions and consolidations are the stimuli promoting the push to differentiate and deliver quality healthcare with limitations.21 Despite affordability, populations generally want quality healthcare. Therefore, the government has increasingly become more influential in funding and healthcare quality. VHA ECoE practices are exportable for other COE models. Aligned with Congress’ support of the VHA mission to provide quality care to our veterans, the ECoE meets needs of veterans plagued with seizures. The veterans will come for the program built on veteran-centric values.

Acknowledgment: The authors thank Cheryl Strickland Management and Program Analyst VSSC for her support and help with data extraction.

Disclosure: Pamela R. Kelly is the regional administrative director at Southeast Epilepsy Centers of Excellence. Rizwana Rehman serves as Southeast Region statistician. Aatif Husain is regional director Southeast Epilepsy Centers of Excellence as well as director Durham Epilepsy Center of Excellence. Opinions expressed are solely of authors.

Statistical Data

Statistical Data

We present yearly and five years combined data for fiscal years 2007 (Oct. 1, 2006-Sept. 30, 2007) – FY 2011 (Oct. 1, 2010-Sept. 30, 2011) to describe trends of VA seizures and spells patients among TBI and PTSD patients. Additionally, prevalence estimates of spells among TBI and PTSD patients are provided.

Methods: The Veterans Service Support Center VHA administrative databases were used to extract counts of unique patients using International Classification of Diseases, Ninth Revision Clinical Modification (ICD-9-CM) 11 diagnoses codes. In order to assess more accurate counts of patients served by VHA all source files (VA Outpatient, VA Inpatient, Fee basis Outpatient and Fee basis Inpatient) were included. Patients with a particular disease were identified by ICD-9-CM diagnoses codes in primary or secondary positions. TBI diagnosis codes were adopted from TBI case definition of Armed Force Health Surveillance Center (AFHSC) consistent with DOD Standard Surveillance case definition of TBI.12 PTSD patients were identified by ICD-09-CM 309.81. To assess counts of seizures/spells patients ICD-09-CM 345.xx (epilepsy), 780.3x (convulsions), 649.4x (epilepsy codes used in pregnant women) were used. Numbers of unique patients were captured by removing duplicates, counting patients once despite multiple diagnoses in seizure group. For example patients with both diagnoses of 345.91 (epilepsy, unspecified, with intractable epilepsy) and 780.39 (other convulsions) in a particular fiscal year were counted only once in the seizure group. Parent Station (primary facility) of care was used to assess the ECoE workload.

Results: Figure 2a represents the yearly counts of seizure patients seen in the VA along with ECoE counts. It shows that the seizure population in the VA as well as among ECoEs is increasing, yet the percentage of patients seen in the ECoEs (approximately 19%) is generally consistent.

Figure 2b and Figure 2c illustrate yearly counts of TBI and PTSD patients who also experienced spells in the VA as well as those enrolled in the ECoEs. Figure shows increasing numbers of seizure patients among TBI and PTSD cohorts. According to the data, the ECoE program in its infancy is serving approximately 21% of TBI patients with spells and 20% of PTSD patients with spells.

Figure 2: FY 2007-2011 Counts of VA Seizure/Spells Patients

Table 1a presents the yearly counts of TBI and PTSD patients served in the VA from FY 2007 – FY 2011. Combined numbers of patients seen between FY 2007 – FY 2011 are included. Prevalence estimates of seizure/spells patients per 1,000 TBI or PTSD patients are included in Table 1b. These estimates are based upon numbers presented in Figure 2 and Table 1a. The yearly prevalence estimates show an alarming number of TBI and PTSD patients with seizures (approximately 114 per 1,000 TBI patients every year and 28 per 1,000 PTSD patients every year).

In the five-year time period FY 2007 – FY 2011, 26,781 TBI and 44,707 PTSD patients had spells. These statistics and Table 1a counts were used to calculate prevalence of seizures among TBI and PTSD patients for combined (FY 2007 – FY 2011) years. The prevalence of seizures among TBI patients based on five-year data is 140.2 per 1,000 patients; and for PTSD patients prevalence estimates are 48.5 per 1,000 patients. The prevalence of seizures among TBI patients is almost three times the prevalence among PTSD patients.

Table 1 – Prevalence (Per 1,000) of Seizure/Spells among TBI and PTSD Patients in the VA

Role of ECoE

When a patient is referred to an epilepsy center for seizure characterization, a complete history of seizures is obtained. Particular attention is given to whether the spells are stereotypic. Stereotypic seizures, however bizarre, are more likely to be epileptic seizures than non-stereotypic seizures. Patients undergo continuous video EEG monitoring in the epilepsy monitoring unit (EMU). Patients are observed continuously, often discontinuing AED medications. Typical seizures are video-recorded and EEG data is analyzed to determine if the seizure is epileptic. This type of expertise and EMUs generally are available only in only a few locations in the VA system, most representing the ECoE network.

If a patient undergoing a seizure characterization evaluation is found to have epileptic seizures, his or her medications are changed and optimized. When no reasonable medication alternatives exist, surgical treatment is considered. If the seizures are thought to be nonepileptic, the epileptologist determines whether the episodes are physiologic or psychogenic. PNES is diagnosed in the vast majority of these cases.

In the VA population, PNES commonly is seen as a comorbid condition with other prevalent disorders such PTSD and/or TBI. As noted previously, many of these patients have been treated for months to years with AEDs because of an erroneous epilepsy diagnosis. These AEDs have many potential adverse effects that may make management of the underlying disorder more difficult. When epileptologists discontinue these unnecessary and potentially harmful medications, they facilitate optimal treatment of the underlying condition. Though these patients are not diagnosed with having epilepsy, they clearly need specialty care by an ECoE to help clarify their diagnosis and guide treatment. Many ECoE sites find that approximately one-fourth of patients undergoing video-EEG monitoring end up being diagnosed with PNES. 9

Figure 1(a): Epilepsy Centers of Excellence Regional Map

Establishing the VA ECoE

Establishing the VA ECoE The Veterans Mental Health and Other Care Improvements Act of 2008 (PL 110-387/s.2162)10 orders the Secretary of Veterans Affairs and the VHA on specific provisions of healthcare to maximize and centralize resources for veterans diagnosed with spells, specifically epilepsy, through establishment of ECoEs. The ECoE program is expected to leverage technology, enhance affiliation, expand research opportunities and improve access for specialized quality care. Efforts to utilize lean processes encompassing good financial stewardship maximizing efficiency are essential for veteran-centric care. A successful program hinges on the collaborations of multiple stakeholder partnerships which include the DOD, epilepsy organizations and Congress.

ECoC Infrastructure

As shown in the ECoE regional map (Figure 1a), 16 ECoE sites nationally divided into four regions are in operation and managed by a national clinical director and four regional directors. The fenced congressional funding is distributed among the established sites. To meet specifications outlined in the law and to ensure similar representational strength across the nation, the regional boundary lines are state driven and not aligned with Veterans Integrated Service Network (VISN) (Figure 1b), as the case may be for many other VA programs.


Figure 1(b): Veterans Health Administration (VHA) Veterans Integrated Service Network (VISN) Map

Seizure Perspective

Patients are referred to an epilepsy center and an epileptologist for many reasons, usually after experiencing seizures or spells with uncertain etiology. Often, patients have been diagnosed as having epilepsy by a primary-care physician, psychiatrist or general neurologist, and antiepileptic drugs (AEDs) have been used unsuccessfully to control these seizures. In some instances, patients may have taken AEDs for years or decades before being referred to epilepsy center for “seizure (or spell) characterization.”

Characterization helps determine if the patient’s spell episodes are due to an epileptic disorder or other etiology. If the seizures are found to be epileptic, treatment with appropriate AED or surgery is considered. If the seizures are nonepileptic, they can be either physiologic no-nepileptic seizures or PNES. Physiologic nonepileptic seizures are spells that may occur due to a sleep disorder, cardiac arrhythmia or other such medical condition. PNES are much more common, and often occur with depression, anxiety disorder (such as PTSD), or other mental health disorder.

Life with Seizures

The diagnosis of epilepsy carries with it a need for potentially lifelong therapy with AEDs, but also brings a list of psychosocial limitations. Foremost among these is the restriction from driving. This leads to confinement if public transportation is not available, few employment options and social isolation. All these combined result in more limited medical care due to accessibility challenges. When patients with epilepsy find employment, they are dismissed if they have a seizure at work, as they are considered a liability to themselves and their place of work. Therefore, many patients with epilepsy seek disability assistance. The assessment and treatment by epileptologists and relevant resources often result in successful treatment of seizures, frequently removing some social obstacles to leading productive lives.

Unfortunately, when restrictions for epilepsy patients are imposed erroneously, such as on patients with PNES who are misdiagnosed as having epilepsy, the complications can be devastating. Not only are they subject to same restrictions as patients with epilepsy, they also are burdened by their underlying diagnosis and its restrictions (such as TBI or PTSD). Many of these patients have received disability and other benefits usually reserved for epilepsy patients. When they are correctly diagnosed, their treatment is complicated further because their disability assessments likely were based incorrectly on having epilepsy.

The best way to minimize these complications in PNES is to diagnosis early and avoid years of erroneous treatment for epilepsy. In the VA, this can be accomplished by an ECoE Network to which referrals from other VA hospitals are facilitated.


1 Adams, R. If You Build It Will They Come? John Wiley & Sons Inc., Hoboken, NJ; 2010.

2 Diaz-Arrastia, R, Agostini, MA, Madden, CJ, & Van Ness, PC. Posttraumatic Epilepsy: The Endophenotypes of a Human Model of Epileptogenis. Epilepsia. 2009;50 (2): 14-20.

3 Salazar, AM, Jabbari, B, Vance, SC, Grafman, J, Amin, D, & Dillion, JD. Epilepsy After Penetrating Head Injury. I. Clinical correlates: a report of the Vietnam head injury study. Neurology. 1985; 35: 1406-1414.

4 Raymont, V, Salazar, AM, Lipsky, R, Goldman, D, Tasick, G, & Grafman, J. Correlates of Posttraumatc Epilepsy 35 years Following Combat Brain Injury. Neurology 2010; 75: 224-229.

5 Fiszman, A, Vieira S, Nunes R, D’Andrea, I, & Figuiera, I. Traumatic Events and Posttraumatic Stress Disorder in Patients With Psychogenic Nonepileptic Seizures: A Critical Review. Epilepsy and Behavior. 2004; 5:818-825.

6 Dworetsky B, Stahonja-Packard, A, Shanahan, C, Paz, J, Schauble, B, & Bromfield, E. Characteristics of Male Veterans With Pshycogenic Nonepileptic Seizures. Epilepsia 2005; 46:1418-1422.

7 Hudak AM, Trived, K, Harper, CR, Booker, K, Caesar, RR, Agostini, M, Van Ness, PC, & Diaz-Arrastia, R. Evaluation of Seizure-like Episodes in Survivors of Moderate to Severe Traumatic Brain Injury. Journal Head Trauma Rehabilitation. 2004; 19: 290-295.

8 Benbadis, S, O’Neill, E, Tatum, W, & Heriaud, L. Outcome of Prolonged Video-EEG Monitoring at a Typical Referral Epilepsy Center. Epilepsia. 2004;45 (9): 1150-1153.

9 Salinsky, M, Spencer, D, Boudreau, E, & Ferguson, F. Psychogenic Nonepileptic Seizures in US Veterans. Neurology. 2011; 77: 945-950.

10 Public Law 110-387. The Veterans Mental Health And Other Care Improvements Act (2008).

11 The International Classification of Diseases, Ninth Revision, Clinical Modification. Vol. 1 and 2. 3rd ed. Hyattsville, MD. Dept. of Health and Human Services; 1989.

12 AFHSC Surveillance Case Definitions

13 VHA Office Public Health Epidemiology. Analysis of VA Health Care Utilization among Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) Veterans. 2012.

14 Institute of Medicine. Epilepsy Across the Spectrum: Promoting Health and Understanding. 2012.

15 Fountain NB, Van Ness, PC, Swaub-Eng, R, Tonn, S, & Bever Jr, CT. Quality Improvement in neurology: AAN epilepsy quality measures, Neurology. 2011; 76: 94-99.

16 National Institute of Health – NINDS Common Data Elements. (updated April 9, 2012).

17 VHA Epilepsy Centers of Excellence.

18 Adam Darkins, et al. Care Coordination/Home Telehealth: The Systematic Implementation of Health Informatics, Home Telehealth, and Disease Management to Support the Care of Veteran Patients with Chronic Conditions, Telemedicine and e-Health, 2008; 14(10).

19 Folland, S, Goodman, AC, & Stano, M. The economics of health and health care (6th ed.). Upper Saddle River, NJ: Prentice Hall. 2010.

20 Issel, LM. Health Program: Planning and Evaluation: A Practical Systematic Approach For Community Health (2nd ed.). Sudbury MA: Jones and Barlett. 2009.

21 Wechsler, J. Healthcare Measures to Congressional Agenda. Managed Healthcare Executive. 2007;17(4): 12.

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