Teaching clinical pharmacology and therapeutics with an emphasis on the therapeutic reasoning of undergraduate medical students Background The rational prescribing of drugs is an essential skill of medical doctors . Clinical pharmacologists play an important role in the development of these skills by teaching clinical pharmacology and therapeutics -LRB- CP&T -RRB- to undergraduate medical students . Although the approaches to teaching CP&T have undergone many changes over the last decennia , it is essential that the actual teaching of CP&T continues to be a major part of the undergraduate medical curriculum . Introduction The field of modern clinical pharmacology began to develop in the second half of the 19th century when physicians began to realise that agents such as heavy metals and plant extracts , then in use , more often made diseases worse instead of better -LSB- 1 -RSB- . In 1969 , a study group on clinical pharmacology was convened by the World Health Organisation -LRB- WHO -RRB- in order to demarcate the scope of this relatively new discipline -LSB- 2 -RSB- . They concluded that the tasks of the clinical pharmacologist include : -LRB- 1 -RRB- research into the action of drugs in humans , -LRB- 2 -RRB- services such as providing information on drugs and -LRB- 3 -RRB- teaching clinical pharmacology and therapeutics -LRB- CP&T -RRB- to medical students , hospital staff and physicians -LSB- 2 -RSB- . While both research and services are important areas of clinical pharmacology , it is in their roles as teachers of CP&T to medical students that clinical pharmacologists have an extremely important effect on the development of rational prescribing by medical doctors . However , despite this importance , the undergraduate teaching of CP&T has not , in contrast to the two other functions of the clinical pharmacologist , achieved an international level of recognition -LSB- 3 , 4 -RSB- . The lesser attention given to teaching CP&T is also reflected in the small number of scientific publications . For example , only about 20 articles on teaching CP&T were published in the European Journal of Clinical Pharmacology between 1980 and 2000 . In many medical schools , undergraduate students learn little about the therapeutic use of drugs and even after graduation , some doctors read little on the subject and rely too much on the promotional efforts and information from the pharmaceutical industry . As indicated by a survey conducted under the auspices of the WHO in 1989 , in European medical schools , an average of only 28 h was devoted to teaching clinical pharmacology , even though over 100 h were devoted to pharmacology -LSB- 5 , 6 -RSB- . However , the number of hours spent teaching CP&T is probably underestimated since clinical pharmacology and particularly therapeutics are taught implicitly during the clinical clerkships . The European Association of Clinical Pharmacology and Therapeutics -LRB- EACPT -RRB- was founded in 1993 to promote the field of CP&T . One of the important objectives of the EACPT was to develop CP&T in Europe by improving and harmonising the teaching of the rational use of drugs at the undergraduate and postgraduate levels . An Education Subcommittee of the EACPT was subsequently established in 1997 to increase the amount of attention given to as well as the quality of teaching CP&T . The first task of this subcommittee was to identify the educational requirements of medical students in terms of CP&T . A positive consequence of the expanded attention for the teaching of CP&T has been the substantial increase of scientific publications on teaching CP&T during the past decade : there have been about 32 articles published between 2000 and 2007 in the European Journal of Clinical Pharmacology , which is twice as many as during the preceding two decades . Unfortunately , despite the increasing amount of attention being given to the teaching of CP&T , CP&T educational programmes are still not optimal in many medical schools -LSB- 7 -RSB- . Nowadays , many graduates still feel insufficiently prepared to assume prescription responsibilities after graduation -LSB- 7 -RSB- . Therefore , it is important to improve the undergraduate teaching in CP&T . In this review , we shall endeavour to indicate the essential aspects of teaching CP&T to undergraduate medical students . To this end , we first describe what is known about the general learning objectives in CP&T that medical students should master before graduation . Subsequently , we focus on an essential -LRB- in our opinion -RRB- core learning objective : ` therapeutic decision-making ' . We go on to describe how medical students and physicians arrive at a therapeutic decision and discuss the possibilities of teaching medical students rational pharmacotherapy . Finally , we recommend approaches for organising , presenting and assessing CP&T in the undergraduate medical curriculum . From core learning objectives to competencies In many curricula , the teaching in clinical disciplines is centred on symptoms and diagnosis , and little or no time is given to the principles of drug treatment . In the past , CP&T was only taught as short courses in medical schools in which information was presented in the form of dogmatic indications of which drug to use and when . In some medical schools , however , clinical pharmacologists participated in basic pharmacology courses , usually given early in the clinical part of the curriculum -LSB- 4 -RSB- . Notwithstanding , much of the postgraduate and continuing education of the practicing physician has been left to the persuasive methods of the pharmaceutical industry -LSB- 1 -RSB- . It was only in 1989 that the Council for Medical Student Education in Clinical Pharmacology and Therapeutics stressed the importance of defining a core curriculum for clinical pharmacology in the medical curriculum . One year later , Nierenberg developed a core curriculum for medical students in CP&T -LSB- 9 -RSB- . Based on consensus between 40 clinical pharmacology teachers , Nierenberg formulated a list of core knowledge , skills and attitudes that every medical student should master before graduation in order to be able to prescribe effectively and safely -LSB- 8 , 9 -RSB- . Core knowledge in clinical pharmacology deals with the facts that are necessary to make rational and optimal therapeutic plans ; it includes the principles needed to organise these facts into useful information and to recognise when essential facts are missing -LSB- 5 , 8 -RSB- . Core skills are in many ways similar to core knowledge because knowledge must be learned and used as the medical student develops skill in practicing rational therapeutics . Core attitudes include attitudes about what constitutes valid information , what kind of information is likely to be in error and what new information must be continuously acquired from reliable sources . Based on the learning objectives as formulated by Nierenberg , a questionnaire on core learning objectives was subsequently developed in the United Kingdom by Walley -LSB- 10 -RSB- . Senior academic clinical pharmacologists who were active in teaching CP&T in the UK or Ireland assessed the relative importance of each learning objective as an element of a core curriculum . This resulted in a list of core knowledge , skills and attitudes -LSB- 11 -RSB- that largely matched the learning objectives as formulated by Nierenberg -LSB- 8 -RSB- . In addition to the approach of Nierenberg and Walley to defining the core curriculum in CP&T , Orme described two other approaches to developing a core curriculum for CP&T -LSB- 12 -RSB- . First , based on the WHO concept of an ` essential drug list ` , he developed two lists of drugs ; one list consisted of approximately 120 essential drugs that students would be expected to know in detail , and a shorter list consisted of drugs that students would be expected to be familiar with but were not required to know in any detail . This list of essential drugs was then examined by the Education Subcommittee of the EACPT . The second approach to defining a core curriculum for CP&T was the disease-based approach . Three types of disease process were defined : -LRB- 1 -RRB- 67 diseases that were common and that the student must know how to manage ; -LRB- 2 -RRB- 158 diseases that were less common but that students must be able to diagnose , after which the appropriate therapy could be found in the literature ; -LRB- 3 -RRB- 36 diseases that were rare but that students should be aware of . Defining a core curriculum for CP&T as presented by Nierenberg , Walley and Orme is important to defining the shape and boundary of the discipline and may be helpful as part of a medical student 's examination . However , in addition to knowledge , physicians must also have prescribing skills in order to prescribe rationally . Therefore , the WHO Action Programme on Essential Drugs has developed , in collaboration with the University of Groningen , a manual for undergraduate medical students on the principles of rational prescribing , the so-called Guide to Good Prescribing -LRB- GGP -RRB- . This manual provides a normative model for therapeutic reasoning and prescribing and provides a six-step guide to the process of rational prescribing that will be necessary throughout the clinical career of the medical student -LRB- Table 1 -RRB- . All six steps are based on the core learning objectives , knowledge , skills and attitudes as formulated by Nierenberg and Walley and on positive experience in the Netherlands -LSB- 13 , 14 -RSB- . Table 1World Health Organisation six-step model of rational prescribing -LSB- 18 -RSB- StepsDescriptionStep 1Define the patient 's problemStep 2Specify the therapeutic objectiveStep 3aChoose your standard treatment -LRB- P-drug -RRB- Step 3bVerify the suitability of your treatment -LRB- P-drug -RRB- Step 4Start the treatmentStep 5Give information , instructions and warningsStep 6Monitor -LRB- and stop ? -RRB- treatment In addition , the content is based on an observational study among general practitioners and clinicians in the Netherlands and on 10 years of experience with pharmacotherapy courses for medical students in Dutch medical faculties and abroad . The GGP has also been reviewed and examined by a large body of international experts in the teaching of pharmacotherapy . As reported by De Vries et al. , a short interactive training course in pharmacotherapy , using the GGP , was evaluated in a controlled study among 219 undergraduate international medical students -LSB- 15 -RSB- . This study indicated that undergraduate students who used the GGP performed significantly better than students who did not used the GGP . In addition , students not only remembered how to solve old problems , but they could also apply their skills to new problems , a so-called transfer effect . A new framework for the innovation of medical curricula has been recently introduced , called the CanMEDS . The CanMEDS framework describes aspects of competence related to seven roles of a clinical specialist : the role of Medical Expert , Communicator , Health Advocate , Collaborator , Manager , Scholar and Professional -LSB- 16 -RSB- . Despite the fact that many doctors agree with the importance of these aspects of competence and that many countries have already adopted the CanMEDS roles in their curricula , there is limited information on how these roles can be applied in an international context and in different specialities , such as CP&T . Therefore , before clinical pharmacology as a discipline can adopt the CanMEDS competencies , the core learning objectives as determined in the last decades will have to be translated into the CanMEDS competencies . In conclusion , in order to improve the competency of future doctors to prescribe effectively and safely , several clinical pharmacologists have attempted to determine what every medical student should master before graduation . A common feature of all of the competencies formulated is that all students must acquire a knowledge of the clinical pharmacology of essential drugs and diseases and must master prescribing skills in order to become competent in the rational prescription of drugs . Therapeutic decision-making Although , as described previously , there are many essential therapeutic skills , the final choice of a -LRB- drug -RRB- treatment for a patient can be looked upon as a core skill in therapeutics . In order to find effective ways to teach our future doctors , it is important to explore how expert doctors arrive at this final therapeutic decision . Therapeutic decision-making or therapeutic reasoning is , together with diagnostic reasoning , an important part of the process of clinical reasoning . Therapeutic reasoning can be defined as the step in clinical reasoning that pertains to the choice of therapy -LSB- 17 -RSB- . However , in contrast to the process of diagnostic reasoning , which has been investigated extensively , little is known about the process of therapeutic reasoning . To our knowledge , the first attempt to investigate therapeutic reasoning in real practice was a small observational study carried out in 1984 in the Netherlands . The results of this unpublished study constituted the basis for the development of the WHO six-step model -LSB- 18 -RSB- . Over 500 patient consultations by 25 general practitioners and 25 clinical specialists were observed and recorded . In addition , all doctors were interviewed about their therapeutic reasoning . Based on this study , it became evident that doctors generally based their choice of -LRB- drug -RRB- treatment on two steps : -LRB- 1 -RRB- doctors initially used treatment guidelines or drug formularies as a starting point ; -LRB- 2 -RRB- this was followed by a verification of the suitability of this treatment for the individual patient and a modification of the choice of treatment if necessary -LRB- for example , in case of co-morbidity or co-medication -RRB- . Moreover , it was also observed that the more experienced physicians knew more standard treatments by heart compared to less experienced physicians . The first study that described the process of how therapeutic decisions are made in practice in greater detail was performed by Denig -LSB- 19 -RSB- . By interviewing 169 different general practitioners and 72 hospital physicians , she studied how doctors arrive at a choice of drug and what factors influence this drug choice -LSB- 19 , 20 -RSB- . This study indicated that when a doctor is confronted with a diagnosis -- for example , a patient with both essential hypertension and a renal disorder -- he or she immediately thinks of a number of pharmacotherapeutic possibilities , referred to as the ` evoked set ' . Depending on the diagnosis , the ` evoked set ' consists of 1.7 -- 5 different pharmacotherapeutic options that are influenced by many factors , such as refresher courses , the literature , experience and advertisements from the pharmaceutical industry . The ultimate choice out of the ` evoked set ' for an individual patient may be either ` unreasoned ' -LRB- routine -RRB- or ` reasoned ' -LRB- evaluation of the different options -RRB- . However , how the final choice of treatment is made is still unknown . In contrast to the scarcity of information available on therapeutic decision-making , much research has been done on diagnostic reasoning . When an experienced doctor is confronted with a patient with certain symptoms and signs , so-called illness scripts are called up from memory . Illness scripts contain clinically relevant information on diseases , their consequences , the context in which diseases develop , including the personal circumstances , and the experience of the doctor with previous patients . These scripts are generated by the frequent solving of diagnostic clinical problems -LSB- 21 , 22 -RSB- . Based on recognition , experienced doctors are able to choose the right script for solving a specific diagnostic problem efficiently , particularly in routine cases -LSB- 23 -RSB- . In order to verify whether this is the right script for the individual patient , two types of diagnostic reasoning may be used -- analytical and non-analytical . Analytical reasoning is characterised as a slow and relatively time-consuming process that is carried out consciously and systematically and , if possible , evidence-based . Less or inexperienced doctors , such as medical students , mostly use this type of reasoning , mainly because they do not possess the ability to call up so-called ` illness scripts ' . In contrast to analytical reasoning , non-analytical reasoning is carried out rapidly and subconsciously and is based on experience and pattern recognition . This type of reasoning is used especially by experienced doctors . However , when an experienced doctor is confronted with a complex patient case , he or she will also use analytical reasoning . Based on the similarities between therapeutic and diagnostic reasoning , it is possible to construct a hypothetical model of therapeutic reasoning -LRB- Fig. 1 -RRB- -LSB- 24 -RSB- . When the diagnosis has been determined , one or more treatment scripts will be called up from the memory . In order to determine the right treatment , an analytical or non-analytical process , or a combination of both , will start . This process is similar to the process of diagnostic reasoning . The chosen treatment and its effect will contribute to the modification of the existing treatment scripts or may result in a new treatment script . Fig. 1Hypothetical model of therapeutic reasoning -LSB- 24 -RSB- However , in order to validate this hypothetical model , further research should be performed , particularly in terms of how experienced doctors arrive at their choice of treatment . In addition , we need to find out how these experienced doctors differ from less-experienced doctors , such as medical students and interns . The answers to these questions will provide more insight into how we should teach therapeutics to students although it can already be stated that early clinical practice will support the development of treatment scripts by undergraduate medical students . How to teach and learn therapeutics Gaining knowledge and at the same time applying this knowledge in practice is essential for learning in general and , presumably , also for the development of treatment scripts by medical students . This so-called context-learning seems to be more effective in many ways than sequential learning , in which learning and applying knowledge is separated -LSB- 22 , 25 , 26 -RSB- . The positive effect can be explained by theories from cognitive psychology and medical problem-solving -LSB- 22 , 26 -- 28 -RSB- . These theories suggest that the way in which knowledge is stored in the brain is essential for its recall and application . Therefore , storing pharmacotherapeutic knowledge in combination with the situation in which this knowledge will be applied benefits the speed and quality with which the information is recalled -LSB- 21 , 22 , 29 -RSB- . Context-learning is defined as learning in a setting that is similar to the setting of the future profession -LSB- 30 -RSB- . Context-learning is based on four basic principles : setting , repetition , feedback and responsibility -LSB- 30 -RSB- . The setting in which therapeutics is taught or learned should be the same as or as similar as possible to the setting of the future profession ; for medical students , this is the clinical setting , such as in primary health care , hospitals or nursing homes . This clinical setting gives students the opportunity to gain experience the same way doctors do , allowing them to generate networks of organised knowledge in their memory and to develop illness and treatment scripts -LSB- 31 -RSB- . Subsequently , students should be given the opportunity to repeat the therapeutic problem-solving process as much as possible . Repetition allows students to generate networks of organised knowledge in the brain . Frequent exposure to patients and pharmacotherapeutic problems gradually condense these networks into readily accessible therapeutic scripts . Furthermore , students should also receive feedback immediately after their performance to assure the condensation of correct therapeutic scripts . Argumentation and motivational feedback may be a rapid way to reveal the process of therapeutic thinking and its possible errors . Finally , students should be responsible for their own learning . It is the student 's own responsibility to repair any lack of knowledge or skills discovered during their clinical work and feedback sessions . Apart from the most extreme form of context-learning , which is the clinical setting , different variations with lower levels of concreteness of the context are possible , varying from role-playing sessions with standardised patients in a simulated practice setting to the solution of written patient problems in small working groups and patient demonstrations during lectures . However , there are many ways to improve the setting , such as by using real case histories instead of written patient problems or through the use of video materials , laboratory test results or roentgenograms . One possible approach to organising a context-learning programme in therapeutics is described by Vollebregt et al. -LSB- 32 -RSB- . These authors described a context-learning programme consisting of weekly-organized , role-playing sessions in the form of consulting hours . The role-playing sessions consist of three phases : consultation , argumentation and feedback . First , a ` student ' doctor must carry out three therapeutic consultations of 10 min each . Before the start of a consultation , the doctors are given a written patient case . Subsequently , the ` student ' patient and ` student ' assessor enter the consultation room , and the doctor has to choose and prescribe the -LRB- drug -RRB- treatment interactively with the patient . The second phase -LRB- argumentation -RRB- starts immediately after the consultations . In this phase , the doctor has to substantiate the chosen therapy . Finally , during the third phase , all students sit together and discuss the various -LRB- drug -RRB- treatments and the performance of the doctors , guided by a clinical pharmacologist . In addition to teaching therapeutics , assessing students ' therapeutic knowledge and skills is an essential component of the medical curriculum . In 1990 , Miller suggested a framework for clinical assessment -LRB- Fig. 2 -RRB- -LSB- 33 -RSB- . According to this framework , students , residents or physicians must have knowledge in order to carry out the required professional functions effectively . Students must also know how to use the knowledge that they have accumulated . For example , they must develop the skill that is needed to acquire information from a variety of human and laboratory sources , to analyse and interpret data and , finally , to translate such findings into a rational diagnostic or therapeutic plan . When this quality is functionally adequate , it is defined as a competence . Furthermore , students must not only be able to demonstrate that they know and know how , but also to show how they do it when confronted with a patient , which is called performance . Finally , it is important what a graduate actually does when functioning independently in clinical practice . According to Miller , this action component of professional behaviour is the most difficult to measure . Fig. 2 ` Pyramid ' by Miller as an illustrative framework for discussing the assessment of clinical skills , competence and performance -LSB- 33 -RSB- The Objective Structured Clinical Examination -LRB- OSCE -RRB- and structured clinical examinations in general are well-known and approved methods for assessing competence and performance -LSB- 34 -RSB- . As far as the OSCE is concerned , this has also been shown to be useful for assessing therapeutic competence . Nevertheless , it is important that the manner in which the students are assessed is as similar as possible to the approach used in teaching them . In conclusion , based on theories as to how physicians arrive at their therapeutic decisions , context-learning seems to be an effective way to teach CP&T to medical students . It is obvious that the ideal situation , i.e. real practice with real patients , is not always attainable , but various suboptimal forms of context-learning and assessment can be applied . Conclusions and recommendations In this document , the learning objectives of teaching CP&T to undergraduate medical students have been described , with an emphasis on therapeutic decision-making . Based on current theories of cognitive psychology and medical education , we have also discussed context-learning as an effective approach to teaching medical students how to prescribe rationally . Until recently , there were only two groups of people who were permitted to prescribe drugs -- registered medical practitioners and registered dental practitioners . Since 2006 , some nurses , pharmacists and physician assistants have also been able to prescribe drugs for medical conditions within their area of competence -LSB- 35 -RSB- . Consequently , given this increasing number of registered prescribers with different qualifications , it has become increasingly important to train prescribers sufficiently in how to choose and prescribe drugs rationally . In addition , most curricula are changing from discipline - and subject-based teaching to competence and integrated or problem-based learning , resulting in less visibility of CP&T . The importance of teaching CP&T is further supported by the fact that many graduates still feel insufficiently prepared to assume prescribing responsibilities after graduation -LSB- 7 -RSB- . Furthermore , many hospital admissions and even deaths are caused by possibly avoidable medication errors -LSB- 36 -RSB- . Clinical pharmacologists should play an important role in the development of prescribing skills by teaching CP&T to undergraduate medical students . It is recommended that they formulate a CP&T context-learning curriculum within the medical curriculum -- of course , in collaboration with physicians . This curriculum must be based on the final learning objectives of the CP&T education programme in which the required level of therapeutic competence of medical graduates has been determined . In addition , the curriculum must fulfil the criteria of context-learning , i.e. gaining knowledge and skills simultaneously in a -LRB- simulated -RRB- clinical practice setting . Furthermore , for the sake of clarity , it is stressed that the CP&T curriculum should be a visible part of the medical curriculum and that students must know , from the beginning , the required level of competence when they graduate . Current medical students often do not recognise the various CP&T teaching activities since they are scattered through the medical curriculum . A draft of a CP&T context-learning curriculum is presented in Fig. 3 . At the start of the curriculum , the emphasis lies on gaining CP&T knowledge and simultaneously learning to apply this knowledge by training skills in therapeutics . During this phase , little attention is given to the prescription of drugs in clinical practice . In the following study years , as CP&T knowledge and therapeutic skills increase , increased emphasis is given to prescribing in clinical practice , while the acquisition of knowledge and skills diminish . An example of a more specific CP&T curriculum is presented in Box 1 . Fig. 3A design of a clinical pharmacology and therapeutics -LRB- CP&T -RRB- context-learning curriculum -LRB- adapted from HJM van Rossum -RRB- In conclusion , effective undergraduate teaching of CP&T is essential to improve rational prescribing and will immunize students against factors that may induce irrational prescribing after graduation . Therefore , based on current knowledge about learning , cognitive psychology and research in therapeutic teaching , a CP&T curriculum should be a prominent part of the medical curriculum . The CP&T curriculum should also be linked to postgraduate and continuing education in order to maintain an optimal competence in rational prescribing after graduating . Finally , to achieve a CP&T curriculum , allies should be found because clinical pharmacologists can and should not work on this alone . Medical students are already allies ; they are interested in clinical pharmacology and really want to learn how to prescribe drugs rationally . Physicians should also become allies , since they can provide the clinical context for teaching and can prevent students from copying the bad prescribing habits of some of the physicians that train medical students . Associate clinical pharmacologists must collectively determine the current state and perspectives of the undergraduate education of CP&T in Europe . To this end , a European research project , which is organised jointly by the EACPT and British Pharmacological Society , has recently been started . Ultimately , clinical pharmacologists , students and physicians collectively may be able to convince the policy-makers , such as the faculty boards , of the need for a CP&T curriculum . Such a joint effort is truly necessary because , unfortunately , the following words , spoken by Miller in 1990 , are , to a great extent , still valid : `` It will not be easy to convince conservative medical faculties , reasonably comfortable with the current conventions that allow clinical impressions to substitute for systematic accumulation of behavioural evidence , that change -LRB- in teaching , ed . -RRB- is in order '' . Box 1 . Illustration of a CP&T curriculum Figure 4 shows the different learning activities and their mutual relations . The horizontal lines represent the three learning components : knowledge -LSB- upper line : basic pharmacology , clinical pharmacology , therapeutics -LRB- 1 -RRB- and therapeutics -LRB- 2 -RRB- -RSB- , clinical practice -LRB- middle line : video patients , patient demonstrations , observation of consultations and prescribing drugs -RRB- and skills -LSB- lower line : prescription , drug formulary , prescribing -LRB- 6-steps -RRB- and CP&T literature -RSB- . The vertical lines describe the simultaneous use of these three components in order to realise a context-learning curriculum . Fig. 4Outline of a CP&T curriculum Let us use the example of a clinical pharmacology department that provides a course of lectures in basic and clinical pharmacology during the first three years of a classical medical curriculum . The aim of the department is to expand its teaching activities and use the context-learning methodology as much as possible . Therefore , the lectures in basic and clinical pharmacology must be transformed according to the criteria of context-learning , i.e. by adding patient cases -LRB- clinical practice -RRB- and prescription writing -LRB- skills -RRB- . For example , the lecture about ` P-450-dependent oxidation ' is placed into the clinical context by presenting a video of a patient case illustrating a drug interaction as the result of a wrong drug choice -LRB- WHO step 3b -RRB- . The lecture concludes by discussing the patient case according to the six-step approach , including how to write a new prescription -LSB- 18 -RSB- . The clinical pharmacology lectures in the second and third year can be transformed in a similar way by presenting real patients , followed by lectures on different classes of drugs . Simultaneously with the clinical pharmacology lectures , students must develop a personal drug formulary by , for example , using an E-learning programme -LSB- 3 -RSB- . In the fourth year , students start on their clinical clerkships . In collaboration with their clinical colleagues , the clinical pharmacology department introduces a therapeutic assignment during these clerkships . Students must observe several consultations by clinicians in a structured way according to the WHO six-step approach and discuss these in small groups during therapeutic sessions with a clinical pharmacologist and/or physician . Concurrently , students must follow a skills training programme in order to learn how to prescribe rationally -LRB- six steps -RRB- . During the clinical clerkships in the fifth and sixth years , prescriptions written by the students are evaluated by a clinical pharmacologist in collaboration with a physician and pharmacist during therapeutic sessions . Finally , students must attend a course on how to evaluate CP&T literature and how they must apply this knowledge in practice . It is evident that in an integrated or problem-based medical curriculum it will be difficult to organise lectures . However , an advantage of this type of curriculum is that teaching is already centred on patient cases . As a result , clinical pharmacologists can introduce learning tasks with respect to basic and clinical pharmacology and therapeutics . In such a curriculum , it will probably be easier to train students in the six-step approach in small group-teaching sessions and practice prescribing in a clinical setting . Obviously , there are various possibilities for context-learning teaching activities , and the above-mentioned are just a few examples of these . More detailed information on how to determine learning objectives for therapeutics and on methods for teaching and assessing therapeutics can be found in the WHO Teacher 's Guide to Good Prescribing -LSB- 37 -RSB- . In addition , this guide also provides information on how to mobilise support for changing and implementing a CP&T curriculum and how to perform research in this field .

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O O O O O O O O O O O B O O O O O O O O B O O O O O B O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B B O O O O O O O O O O O O O O O O B O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O B O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O B O O O O O O O O O O O O O B O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O B O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O

education pharmacotherapy teaching undergraduate


The

Health

Benefit

Basket

in

Denmark

Until

when

the

new

legislation

on

health

care

becomes

effective

the

right

to

receive

free

health

care

services

in

Denmark

or

health

benefits

are

described

in

a

comprehensive

set

of

legislation

including

laws

executive

orders

and

legal

guidelines

This

contribution

provides

an

overview

of

the

current

main

legislation

regulating

the

Danish

health

benefit

basket

and

describes

the

regulatory

mechanisms

for

the

provision

of

curative

care

at

Danish

hospitals

and

primary

health

care

offices

Although

the

services

are

both

financed

and

planned

by

the

counties

they

differ

substantially

in

the

way

that

benefits

are

regulated

The

Danish

health

care

system

offers

a

vast

amount

of

benefits

and

entitlements

to

persons

living

in

Denmark

The

benefits

are

more

or

less

specified

health

services

provided

at

hospitals

or

in

primary

and

tertiary

health

care

institutions

Entitlements

are

rights

to

receive

these

services

free

of

charge

or

against

a

fee

covering

a

part

of

the

costs

The

benefits

and

entitlements

altogether

form

the

so-called

health

benefit

basket

or

basic

package

of

health

services

-LSB-

-RSB-

Although

the

notion

of

a

benefit

basket

is

not

commonly

used

in

Denmark

health

benefits

are

indeed

described

in

the

legislation

The

following

pages

provide

an

overview

of

the

laws

regulating

health

benefits

and

a

description

of

the

regulatory

mechanism

for

the

provision

of

curative

care

in

hospitals

and

in

primary

care

offices

Curative

care

services

are

financed

and

planned

by

the

counties

and

the

municipal

authorities

of

Copenhagen

and

Frederiksberg

and

there

are

considerable

differences

between

in

and

outpatient

services

in

the

way

in

which

benefits

are

regulated

and

services

are

provided

and

reimbursed

Table

provides

an

overview

of

the

four

most

important

laws

regulating

benefits

in

the

Danish

health

sector

Table

The

Danish

health

benefit

basket

overview

of

main

legislationHospital

Act

-LRB-

and

ancillary

legislation

-RRB-

Public

Health

Insurance

Act

-LRB-

and

ancillary

legislation

-RRB-

Medicines

Act

-LRB-

and

ancillary

legislation

-RRB-

Social

Services

Act

-LRB-

and

ancillary

legislation

-RRB-

Other

-LRB-

specific

-RRB-

legislationHC

Inpatient

curative

care

-LRB-

-RRB-

HC

Day-cases

of

curative

care

-LRB-

-RRB-

HC

Outpatient

care

-LRB-

-RRB-

-LRB-

-RRB-

HC

Curative

home

care

-LRB-

-RRB-

HC

Inpatient

rehabilitative

care

-LRB-

-RRB-

HC

Day

cases

of

rehabilitative

care

-LRB-

-RRB-

-LRB-

-RRB-

HC

Outpatient

rehabilitative

care

-LRB-

-RRB-

HC

Services

of

rehabilitative

home

care

-LRB-

-RRB-

-LRB-

-RRB-

HC

Inpatient

long-term

care

HC

Day

cases

of

long-term

care

HC

Clinical

laboratory

HC

Diagnostic

imaging

HC

Patient

transport

HC

All

other

miscellaneous

services

-LRB-

-RRB-

HC

Pharmaceuticals

etc.

HC

Therapeutic

devices

etc.

-LRB-

-RRB-

-LRB-

-RRB-

HC

Maternal

and

child

care

-LRB-

-RRB-

HC

School

health

services

HC

Prevention

of

communicable

diseases

-LRB-

-RRB-

HC

Prevention

of

noncommunicable

diseases

-LRB-

-RRB-

HC

Occupational

health

services

HC

All

other

services

Legal

statusLawLawLawLawLawsDecision

makerCounty

physicianCounty

GPCounty

GP

-LRB-

physician

-RRB-

Municipality

countyCounty

municipality

GPPurposeEntitlements

delegation

and

defining

responsibility

of

countiesEntitlements

reimbursement

copaymentRole

of

Danish

Medicines

Agency

process

of

approval

of

medicinesEntitlements

delegation

and

defining

responsibility

of

counties

and

municipalitiesEntitlements

defining

roles

and

responsibilities

of

actors

etcPositive/negative

definition

of

benefitsPositivePositivePositivePositivePositive

Degree

of

-LRB-

and

-RRB-

-LRB-

and

-RRB-

-LRB-

and

-RRB-

itemized

goods

procedures

indicationsNot

itemizedProcedures

-LRB-

indications

-RRB-

-LRB-

Goods

-RRB-

-LRB-

Goods

indications

-RRB-

IndicationsUpdatingNoNoNoNoNoCriteria

used

for

defining

benefits

Need

Costs

Effectiveness

Cost-effectiveness

Budget

Other

a

All

necessary

areas

of

care

are

described

services

are

linked

to

specific

itemsThe

Hospital

Act

establishes

the

regulatory

framework

for

all

types

of

inpatient

care

and

day

care

patient

transport

maternity

care

ambulatory

and

rehabilitative

care

provided

at

hospitals

-LRB-

Bekendtgørelse

af

lov

om

sygehusvaesenet

LBK

March

-RRB-

The

law

delegates

the

responsibility

for

the

planning

providing

and

financing

of

hospital

services

to

the

county

council

A

number

of

executive

orders

and

directives

further

specify

this

law.The

Public

Health

Insurance

Act

-LRB-

PHIA

-RRB-

and

its

supplementary

legislation

provides

the

regulatory

frame

for

entitlements

to

outpatient

care

and

to

some

extent

to

rehabilitative

care

ancillary

services

for

outpatients

maternity

and

child

care

and

reimbursement

of

pharmaceuticals

-LRB-

Lov

om

offentlig

sygesikring

LOV

July

og

DSK

January

og

LOV

og

May

og

LOV

June

og

LOV

November

og

LOV

December

og

LOV

December

og

LOV

December

og

LOV

December

-RRB-

Benefits

and

services

are

further

specified

in

a

number

of

executive

orders

as

well

as

in

the

used

fee

schedule.The

Medicines

Act

regulates

the

population

's

access

to

pharmaceuticals

and

specifies

the

process

of

approval

of

medicines

by

the

Danish

Medicines

Agency

marketing

authorizations

etc.

-LRB-

Bekendtgørelse

af

lov

om

laegemidler

LBK

July

-RRB-

The

Consolidated

Social

Services

Act

provides

the

regulatory

frame

for

social

services

-LRB-

Bekendtgørelse

af

lov

om

social

service

LBK

June

-RRB-

The

law

delegates

the

planning

financing

and

provision

responsibility

to

the

counties

for

the

specialized

care

and

to

municipalities

for

the

less

specialized

care

This

law

covers

the

long-term

inpatient

outpatient

and

home

care

It

also

describes

the

provision

responsibility

for

rehabilitative

care

not

following

a

hospital

treatment

and

also

regulates

the

entitlement

to

therapeutic

devices

nonacute

patient

transport

and

other

services

Danish

legislation

on

health

care

furthermore

contains

a

number

of

specific

laws

dealing

with

preventive

services

for

example

for

children

-LRB-

Forebyggende

sundhedsordninger

for

børn

og

unge

LOV

June

-RRB-

with

explicit

and

specific

definitions

of

benefits

The

main

decision

makers

in

the

Danish

health

sector

at

political

and

administrative

levels

are

the

local

governing

bodies

responsible

for

the

service

hence

the

elected

politicians

for

the

county

and

the

municipal

councils

At

clinical

level

especially

the

general

practitioner

plays

a

very

important

gate-keeper

role

but

hospital

physicians

are

also

important

in

defining

medical

needs

Most

benefits

are

explicitly

but

vaguely

defined

by

the

law

leaving

it

to

decision

makers

to

specify

which

services

to

offer

to

patients

The

Hospital

Act

states

that

the

county

shall

provide

hospital

treatment

free

of

charge

for

its

citizens

-LRB-

Sect.

-RRB-

The

degree

of

explicitness

is

described

as

all

necessary

-LRB-

-RRB-

by

all

laws

some

laws

further

describe

areas

of

care

-LRB-

-RRB-

and

some

are

linked

to

items

-LRB-

-RRB-

The

PHIA

and

the

Social

Services

Act

are

to

some

extent

more

explicit

by

linking

benefits

to

items

This

contribution

is

confined

to

curative

health

services

and

the

description

of

benefits

in

curative

health

services

in

Denmark

is

divided

into

three

sections

First

the

main

actors

along

with

their

roles

and

responsibilities

are

outlined

and

differences

between

in

and

outpatient

services

are

emphasized

Second

benefits

in

the

hospital

sector

are

described

and

third

an

outline

of

benefits

under

the

Health

Care

Reimbursement

Scheme

-LRB-

HCRS

-RRB-

for

outpatient

services

is

provided

Benefits

are

described

with

regard

to

the

legislation

and

other

regulatory

mechanisms

defining

them

how

they

are

classified

and

how

the

fee

schedule

under

the

HCRS

a

benefit

catalogue

is

structured

Main

actors

in

defining

benefits

their

roles

and

responsibilities

The

Danish

Parliament

-LRB-

Folketing

-RRB-

legislates

on

health

care

The

Minister

for

the

Interior

and

Health

is

responsible

for

further

specifying

the

law

setting

rules

in

certain

areas

and

initiating

reforms

and

bills

Unless

it

is

explicitly

mentioned

that

the

Minister

is

empowered

to

specify

the

law

it

can

only

be

changed

by

the

Folketing

Regarding

outpatient

care

the

Minister

must

approve

all

negotiated

agreements

between

the

Health

Care

Reimbursement

Negotiation

Committee

-LRB-

HCRNC

-RRB-

and

the

health

personnel

trade

unions

The

National

Board

of

Health

-LRB-

NBH

-RRB-

is

a

subdivision

of

the

Ministry

of

the

Interior

and

Health

The

NBH

is

responsible

for

supervising

and

providing

advice

to

health

care

persons

-LRB-

the

Danish

word

sundhedspersoner

used

in

the

legislation

refers

to

all

types

of

health

care

professionals

-RRB-

and

health

administrative

authorities

for

elaborating

and

issuing

guidelines

and

reference

programs

as

well

as

for

monitoring

and

documenting

health

services

Guidelines

from

the

NBH

define

the

current

best

practice

within

specific

health

care

programs

or

interpret

the

law

The

health

care

persons

are

for

their

part

obliged

to

show

clinical

diligence

and

act

according

to

best

practice

According

to

the

Hospital

Act

the

counties

and

the

Copenhagen

Hospital

Corporation

are

responsible

for

the

planning

and

financing

of

hospital

services

-LRB-

Sect.

-RRB-

and

for

providing

free

hospital

treatment

for

their

citizens

-LRB-

Sect.

-RRB-

The

providers

of

hospital

services

may

be

county-owned

hospitals

private

hospitals

or

foreign

hospitals

-LRB-

Sect.

-RRB-

Regarding

outpatient

care

the

county

reimburses

the

services

provided

by

private

specialists

and

general

practitioners

-LRB-

GPs

-RRB-

County

representatives

in

a

subcommittee

under

the

HCRNC

decide

on

the

actual

supply

of

services

for

example

who

is

allowed

to

establish

a

private

practice

in

which

county

A

county

health

plan

coordinating

health

services

in

the

county

is

to

be

elaborated

every

years

-LRB-

Hospital

Act

Sect.

PHIA

Sect.

-RRB-

The

plan

includes

a

description

of

the

county

's

population

health

status

-LRB-

premise

of

the

plan

-RRB-

the

physical

capacity

of

the

county

hospitals

including

how

and

where

specialties

are

represented

and

the

number

of

beds

and

employees

etc.

in

each

specialty

Furthermore

preventive

services

outpatient

services

and

cooperation

between

GPs

specialists

dentists

and

the

hospital

sector

cooperation

with

municipalities

ambulance

services

and

local

emergency

services

are

coordinated

and

described

in

the

plan

The

NBH

supervises

and

comments

on

the

plan

However

the

counties

are

not

in

any

legal

sense

obliged

to

follow

the

advice

provided

by

the

NBH

Hospital

and

clinical

department

managers

have

considerable

freedom

within

the

legal

clinical

and

economic

framework

set

by

their

superiors

at

national

and

county

level

The

heads

of

department

may

therefore

establish

treatment

protocols

and

indications

for

treatment

for

different

patient

categories

as

well

as

set

up

guidelines

for

prioritizing

between

patients

on

waiting

lists

In

general

the

Danish

legislation

is

rather

vague

with

regard

to

the

specification

of

services

and

very

often

leaving

decisions

about

benefits

to

medical

judgement

Thus

physicians

play

a

certain

role

in

the

definition

of

benefits

Especially

the

GP

is

important

as

she/he

is

responsible

for

referring

patients

from

general

practice

to

practically

all

parts

of

the

health

sector

Definition

of

benefits

Hospital

care

Benefits

provided

in

the

Danish

hospital

sector

are

defined

at

four

levels

of

decision

making

at

national

level

by

means

of

legislation

at

county

level

by

planning

and

supply

control

and

at

hospital

and

clinical

level

by

local

guidelines

and

clinical

decision

making

According

to

the

Hospital

Act

citizens

have

the

right

to

free

hospital

treatment

-LRB-

Sect.

-RRB-

at

any

hospital

in

the

country

-LRB-

Sect.

-RRB-

which

they

choose

If

the

waiting

time

for

treatment

exceeds

months

they

have

the

right

to

be

treated

at

a

private

hospital

in

Denmark

or

abroad

at

their

county

's

expense

-LRB-

Sect.

g

-RRB-

The

Act

includes

inpatient

care

hospital

ambulatory

-LRB-

day

-RRB-

care

and

in

some

cases

home

care

for

somatic

and

mental

patients

Benefits

are

explicitly

but

vaguely

formulated

by

the

law

In

principle

patients

are

entitled

to

any

treatment

that

is

clinically

indicated

but

in

practice

limitations

apply

At

national

level

the

Hospital

Act

and

its

amendments

directly

or

indirectly

specify

which

services

to

offer

-LRB-

positive

definition

of

benefits

-RRB-

or

not

to

offer

-LRB-

negative

definitions

of

benefits

-RRB-

to

whom

and

under

which

circumstances

Positive

definition

of

benefits

-LRB-

examples

-RRB-

For

persons

suffering

from

a

life-threatening

disease

defined

as

patients

with

certain

heart

conditions

or

cancer

patients

a

maximum

national

waiting

time

is

defined.The

county

offers

a

breast

examination

-LRB-

mammography

-RRB-

to

women

aged

years

every

second

year

-LRB-

Hospital

Act

Sect.

-RRB-

However

this

benefit

is

accompanied

by

a

clause

stating

that

the

Minister

will

decide

when

this

service

is

to

be

implemented

in

the

counties

The

service

is

expected

to

be

implemented

by

Today

it

is

only

offered

in

three

counties.Patients

with

a

clinically

defined

need

for

rehabilitation

have

the

right

to

receive

a

plan

from

the

hospital

describing

when

and

where

rehabilitation

is

to

take

place

at

discharge

and

who

will

coordinate

between

the

county

and

municipal

providers

-LRB-

Hospital

Act

Bekendtgørelse

om

udarbejdelse

af

genoptraeningsplaner

ved

udskrivning

fra

sygehus

BEK

December

-RRB-

Negative

definition

of

benefits

-LRB-

examples

-RRB-

Induced

abortions

after

week

of

pregnancy

are

only

allowed

after

permission

from

the

Minister

of

Justice

and

upon

medical

or

social

indication

-LRB-

Bekendtgørelse

af

lov

om

svangerskabsafbrydelse

og

fosterreduktion

LBK

June

og

BEK

June

og

VEJ

June

-RRB-

Sterilization

can

not

be

provided

to

persons

below

the

age

of

years

-LRB-

Bekendtgørelse

af

Lov

om

sterilisation

og

kastration

LBK

July

og

BEK

December

-RRB-

Unmarried

women

and

women

over

the

age

of

years

are

exempt

from

in

vitro

fertilization

treatment

by

a

physician

-LRB-

specialist

Lov

om

Kunstig

befrugtning

i

forbindelse

med

laegelig

behandling

diagnostik

forskning

mv

LOV

June

Bekendtgørelse

om

kunstig

befrugtning

BEK

September

-RRB-

Free

choice

of

private

hospitals

-LRB-

in

the

case

the

waiting

time

for

treatment

at

county

hospitals

exceeds

the

limit

of

months

-RRB-

does

not

include

transplantation

sterilization

reproductive

health

services

hearing

aid

cosmetic

surgery

sex

change

psychiatric

treatment

alternative

treatment

or

treatment

characterized

as

research

-LRB-

Bekendtgørelse

om

amtskommuners

betaling

for

sygehusbehandling

ved

en

anden

amtskommunes

sygehusvaesen

BEK

June

-RRB-

In

general

conventional

treatments

not

included

in

the

benefit

package

are

not

offered

For

patients

suffering

from

life-threatening

cancer

a

referral

needs

to

be

approved

by

a

board

of

specialists

a

Second

Opinion

Panel

established

under

the

NBH

-LRB-

information

available

at

opinion.aspx

accessed

August

-RRB-

If

the

alternative

such

as

conventional

treatment

is

approved

by

the

board

the

expenses

are

covered

by

a

special

government

grant

However

nonconventional

treatment

such

as

a

spa

therapy

zone

therapy

and

homeopathy

are

not

included

in

the

benefit

package

-LSB-

-RSB-

Financial

instruments

Hospitals

are

financed

by

the

counties

through

tax

revenue

and

block

grants

from

the

state

Following

the

annual

negotiations

between

the

counties

and

the

government

on

the

level

of

taxation

and

size

of

block

grant

the

government

has

introduced

new

financial

measures

as

a

means

to

influence

the

development

of

the

health

sector

Special

block

grants

are

earmarked

to

high

priority

areas

such

as

heart

surgery

and

cancer

treatment

These

grants

accompany

recommendations

from

the

NBH

on

treatment

improvements

and

expansion

of

the

capacity

as

described

in

the

Heart

Plan

and

the

Cancer

Plan

Furthermore

with

the

aim

of

shortening

waiting

lists

a

provision

of

activity-based

funding

for

additional

production

has

been

made

available

from

for

counties

which

can

document

an

increase

in

their

activity

-LRB-

Hospital

Act

-LRB-

Cirkulaer

om

udbetaling

af

statstilskud

i

til

øget

aktivitet

på

sygehusområdet

CIR

January

Bekendtgørelse

om

økonomiske

rammer

for

frit

valg

til

private

specialsygehuse

BEK

June

-RRB-

Financial

restrictions

are

imposed

on

the

counties

as

their

obligation

to

finance

care

at

certain

private

hospitals

including

hospices

sclerosis

hospitals

arthritis

sanatoria

and

brain

rehabilitation

hospitals

is

limited

to

a

certain

annual

amount

Thus

patients

are

either

referred

to

a

waiting

list

or

must

pay

for

the

treatment

themselves

at

a

private

clinic

At

county

level

the

counties

determine

the

content

and

costs

of

hospital

activity

through

the

use

of

detailed

budgets

enabling

them

to

specify

treatments

offered

technologies

used

service

standards

and

capacity

available

There

is

an

indirect

regulation

of

benefits

available

to

county

inhabitants

through

the

control

of

the

supply

In

principle

the

county

can

decide

not

to

offer

a

certain

treatment

for

example

in

vitro

fertilization

treatment

to

women

who

have

already

had

one

child

by

this

means

or

an

expensive

cancer

treatment

However

the

patient

can

choose

to

be

treated

in

another

county

due

to

the

right

of

free

choice

of

hospital

with

the

home

county

having

to

pay

for

it

which

actually

displays

certain

limitations

to

the

county

's

planning

freedom

In

the

hospital

sector

there

are

no

benefit

catalogues

as

such

However

a

wide

number

of

classifications

are

used

to

document

the

activity

and

prices

based

on

diagnosis-related

groups

-LRB-

DRG

-RRB-

DRGs

are

used

for

the

remuneration

of

hospital

services

provided

in

other

counties

or

at

private

hospitals

Outpatient

services

the

Health

Care

Reimbursement

Scheme

Unlike

hospital

services

benefits

regarding

outpatient

services

are

under

the

HCRS

explicitly

and

specifically

detailed

by

the

law

and

in

a

fee

schedule

negotiated

on

services

and

prices

between

the

private

providers

and

the

HCRNC

The

PHIA

states

that

primary

health

care

is

available

to

-LRB-

almost

-RRB-

everyone

with

a

permanent

address

in

Denmark

All

citizens

must

choose

between

insurance

groups

I

and

II

with

a

trade-off

in

terms

of

free

choice

of

the

provider

and

the

size

of

reimbursement

Persons

in

group

I

more

than

of

the

population

are

entitled

to

free

services

from

GPs

and

to

partial

reimbursement

of

dentist

services

physiotherapy

treatment

etc.

With

a

few

exceptions

public

reimbursement

of

specialist

and

paramedic

services

are

subject

to

GP

referral

Persons

in

group

II

fewer

than

of

the

population

have

a

wider

choice

of

providers

but

are

less

entitled

to

reimbursement

Everyone

receives

a

personal

card

clearly

stating

the

entitlements

to

the

services

-LRB-

PHIA

Bekendtgørelse

om

valgfri

indplacering

i

sygesikringsgrupper

udstedelse

af

sygesikringsbevis

mv

BEK

March

Bekendtgørelse

om

begraensning

i

adgang

til

ydelser

efter

sygesikringsloven

for

visse

persongrupper

BEK

March

og

BEK

af

February

-RRB-

A

large

number

of

executive

orders

and

the

fee

schedule

for

reimbursement

of

private

providers

further

specify

entitlements

and

benefits

laid

down

by

the

PHIA

-LRB-

PHIA

Bekendtgørelse

om

befordringsgodtgørelse

efter

sygesikringsloven

BEK

January

Bekendtgørelse

om

tilskud

efter

sygesikringsloven

til

fodbehandling

BEK

March

Bekendtgørelse

om

tilskud

efter

sygesikringsloven

til

kiropraktisk

behandling

BEK

March

Bekendtgørelse

om

tilskud

efter

sygesikringsloven

til

fysioterapeutisk

behandling

BEK

May

Bekendtgørelse

om

tilskud

efter

sygesikringsloven

til

psykologbehandling

for

saerligt

udsatte

grupper

BEK

June

Bekendtgørelse

om

tilskud

efter

sygesikringsloven

til

sondeernaering

og

andre

ernaeringspraeparater

BEK

June

Bekendtgørelse

om

tilskud

efter

den

offentlige

sygesikring

til

betaling

af

briller

til

børn

under

år

BEK

December

Bekendtgørelse

af

lov

om

tandpleje

LBK

December

og

BEK

December

Bekendtgørelse

om

tilskud

efter

sygesikringsloven

til

tandpleje

BEK

March

Bekendtgørelse

om

adgang

til

laegehjaelp

efter

sygesikringsloven

BEK

March

-RRB-

Some

benefits

are

defined

very

explicitly

e.g.

a

specific

maximum

amount

in

Danish

crowns

to

be

covered

for

spectacle

lenses

and

spectacle

frames

-LRB-

BEK

Decemberr

see

above

-RRB-

while

others

are

defined

in

more

general

or

vague

terms

e.g.

proportional

reimbursement

of

negotiated

fee

for

physiotherapy

treatment

-LRB-

PHIA

BEK

May

see

above

-RRB-

or

proportional

reimbursement

of

negotiated

rates

for

dental

treatment

-LRB-

LBK

December

og

BEK

December

see

above

BEK

March

see

above

-RRB-

There

are

positively

defined

benefits

-LRB-

e.g.

the

right

to

spectacle

lenses

and

frames

-RRB-

and

exclusions

through

negatively

defined

benefits

e.g.

a

service

excluded

from

reimbursement

from

the

public

travel

insurance

benefits

-LRB-

Bekendtgørelse

om

befordringsgodtgørelse

efter

sygesikringsloven

BEK

January

-RRB-

While

for

example

GP

services

ear

nose

and

throat

medicine

psychiatric

and

oculist

services

are

free

of

charge

for

patients

dentist

services

are

only

partly

covered

by

public

funds

Some

services

are

regulated

by

legislation

but

not

included

in

the

benefit

basket

unless

certain

specific

criteria

are

fulfilled

-LRB-

e.g.

psychologist

counseling

chiropody

and

chiropractic

services

-LRB-

BEK

af

March

see

above

BEK

af

March

see

above

BEK

June

see

above

-RRB-

Table

provides

an

overview

of

the

main

services

under

the

HCRS

showing

the

extent

and

criteria

for

coverage

and

whether

the

services

are

subject

to

a

referral

from

the

GP.Table

Benefits

regarding

outpatient

services

according

to

the

Health

Care

Reimbursement

Scheme

Services

fully

partially

or

not

covered

by

public

fundsType

of

service/providerCoverage

by

public

fundsCoverage

for

special

groupsReferral

from

GP

required

-LRB-

Group

I

insured

-RRB-

General

practiceFull

Dentist

servicesPartialFull

coverage

for

children

at

school

age

disabled

low

income

elderlyNoTube

feeding/nutritional

preparationsFull

YesPhysiotherapyPartialFull

coverage

for

patients

with

specific

diagnoses

-LRB-

muscular-skeletal

-RRB-

YesPsychiatristFull

YesPsychologistNone

-LRB-

partial

-RRB-

Partial

coverage

for

persons

exposed

to

traumatic

incidentsYesChiropodistPartialPartial

coverage

for

diabetics

and

low-income

elderlyYesChiropractorPartial

YesOpthalmologistsFull

NoEar-nose-throat

physiciansFull

NoDieticiansNone

NoOther

specialistsFull

Yes

Other

specialists

whose

services

are

fully

part

of

the

benefit

basket

upon

GP

referral

include

anesthetists

specialists

in

dermatology

and

venereal

diseases

specialists

in

diagnostic

radiology

gynecologists

obstetricians

internists

surgeons

biochemists

neurologists

orthopedics

specialists

in

pathological

anatomy

or

plastic

surgery

pediatricians

rheumatologists

and

specialists

in

tropical

medicine

or

laboratory

examinations

The

fee

schedule

Whereas

the

laws

describe

mainly

the

extent

to

which

outpatient

services

are

included

in

the

benefit

basket

for

example

the

proportion

of

public

funding

and

the

criteria

for

coverage

the

fee

schedule

negotiated

between

the

HCRNC

and

the

health

personnel

trade

unions

specifies

the

services

for

which

the

providers

are

paid

Since

the

schedule

lists

services

which

are

reimbursed

from

public

funds

and

are

therefore

provided

free

of

charge

to

the

patients

the

fee

schedule

may

in

an

indirect

way

be

regarded

as

a

benefit

catalogue

-LRB-

Sygesikringens

Forhandlingsudvalg

takstkatalog

April

-RRB-

Items

in

the

fee

schedule

are

negotiated

every

years

while

the

tariffs

are

revised

twice

a

year

Health

technology

assessments

cost-effectiveness

analyses

and

clinical

studies

are

adduced

by

the

professional

committees

and

included

in

the

negotiation

but

they

are

not

mandatory

Criteria

for

the

decisions

concerning

the

inclusion

or

the

exclusion

of

an

item

are

neither

systematic

nor

public

An

example

of

an

argument

over

the

inclusion

of

services

regards

progress

in

treatment

methods

-LRB-

substitution

of

outdated

services

with

more

up-to-date

procedures

-RRB-

There

is

usually

a

reimbursement

rate

when

benefits

such

as

those

for

contraceptive

advice

from

the

GP

are

specifically

stated

by

the

law

-LRB-

A.

Bonne

HCRNC

personal

communication

-RRB-

The

catalogue

is

divided

into

specialties

with

a

subdivision

into

type

of

services

offered

-LRB-

items

-RRB-

Items

may

be

directly

linked

to

the

legislation

that

specifies

the

benefits

for

example

antenatal

care

consultation

and

first

child

health

check-up

at

the

age

of

weeks

-LRB-

general

practice

-RRB-

They

are

also

directly

linked

to

the

logic

applied

by

the

legislation

for

example

following

certain

age

groups

certain

timing

-LRB-

week

first

and

second

consultations

etc.

-RRB-

or

specific

agreement

such

as

on

working

hours

or

transport

fees

for

the

professional

group

involved

When

the

legislation

does

not

specify

the

benefits

items

are

either

linked

to

consultation

type

-LRB-

visits

-RRB-

goods

-LRB-

e.g.

laboratory

tests

-RRB-

procedures

-LRB-

e.g.

spirometry

-RRB-

or

even

indications

-LRB-

e.g.

podiatry

for

diabetics

-RRB-

in

some

rare

cases

There

is

generally

no

specification

of

the

technology

to

be

used

with

a

few

exceptions

Concluding

remarks

The

Danish

benefit

basket

for

curative

services

is

regulated

directly

by

law

and

influenced

indirectly

by

more

soft

regulatory

mechanisms

In

the

hospital

sector

which

is

the

main

part

of

the

health

sector

in

terms

of

expenditure

the

law

delegates

the

responsibility

for

providing

financing

organizing

and

planning

services

to

the

counties

Thus

there

may

be

regional

variations

in

the

services

offered

Benefits

are

explicitly

defined

but

not

specified

by

the

law

In

principle

all

clinically

indicated

hospital

services

are

included

in

the

benefit

basket

However

central

initiatives

such

as

legislation

on

the

patient

's

free

choice

of

hospital

waiting

time

guarantees

for

some

patient

groups

and

financial

constraints

influence

the

counties

decisions

and

narrow

the

room

for

regional

variation

Regarding

outpatient

services

the

picture

differs

slightly

as

benefits

in

the

HCRS

are

regulated

at

central

level

through

explicit

and

specific

legislation

while

being

further

specified

in

agreements

about

items

and

tariffs

between

county

and

provider

representatives

In

the

Danish

health

sector

will

be

subject

to

a

structural

reform

which

will

significantly

influence

the

way

in

which

health

services

are

financed

and

organized

The

current

political

layer

of

counties

will

be

abolished

and

be

replaced

by

five

regions

responsible

for

providing

hospital

services

but

without

the

taxation

rights

that

they

have

today

The

municipalities

will

merge

into

fewer

units

assume

financing

responsibilities

for

more

health

services

than

today

and

will

purchase

hospital

services

from

the

regions

The

reform

's

immediate

impact

on

health

benefits

is

hard

to

predict

but

there

will

be

some

modification

as

to

legislation

at

least

A

law

the

Health

Act

-LRB-

Sundhedsloven

LOV

nr

June

-RRB-

recently

passed

by

the

Folketing

collects

the

previous

vast

amount

of

legislation

on

health

care

into

a

single

document

Among

other

things

the

goals

of

Danish

health

care

services

for

example

that

citizens

should

have

easy

and

equal

access

to

health

care

have

now

been

made

explicit

The

rights

to

health

care

services

do

not

change

fundamentally

nor

do

decision

makers

and

their

roles

and

responsibilities

The

Act

contains

many

clauses

empowering

the

Minister

for

the

Interior

and

Health

to

set

specific

rules

thus

giving

the

Minister

much

more

decision-making

power

than

today

However

the

Health

Act

provides

a

regulatory

framework

with

explicitly

mentioned

rights

to

health

services

not

being

different

from

what

is

outlined

here

The

specification

of

benefits

will

still

take

place

at

the

lower

levels

of

decision

making

by

specifications

of

the

law

by

the

Minister

by

the

National

Board

of

Health

in

agreements

between

regions

and

municipalities

through

a

payment

schedule

or

at

clinical

level

O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O B I O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 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