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France NICE October 2008 2nd Congress of European Academy of Paediatrics Bosnia and Herzegovina

France NICE October 2008 2nd Congress of European Academy of Paediatrics Bosnia and Herzegovina. Nice FRANCE 2008. RISKS MANAGEMENT OF HEALTH ECONOMY AT CHILDREN IN BOSNIA AND HERZEGOVINA.

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France NICE October 2008 2nd Congress of European Academy of Paediatrics Bosnia and Herzegovina

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  1. France NICE October 20082nd Congress of European Academy of Paediatrics Bosnia and Herzegovina .

  2. Nice FRANCE 2008. • .

  3. RISKS MANAGEMENT OF HEALTH ECONOMY AT CHILDREN IN BOSNIA AND HERZEGOVINA Bajraktarevic Adnan 1*, Trninic Slobodan 1*, Jatic Zaim 2*, Bajraktarevic-Mahmutovic Edisa 3*, Mahmutovic Emir 4*, Pasic Elma 5*, Sporisevic Lutvo 6* . Public Health Institution of Canton Sarajevo-Health Center Sarajevo 1*, Medical faculty Sarajevo 2*, Bosnia Reinsurance Company Sarajevo 3*, Faculty of Economy and Management University of Sarajevo 4*,University Sarajevo Institute for Psihology Department for Management in Health 5*, First medical Aid Sarajevo 6*.

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  5. ABSTRACT • OBJECTIVE : Every day we witness negative influence destroying human environment on human health specially on child as the most vulnarable. Children's age of life and child have it's special characteristics and it is very important for every personal life, families life and all humans community. METHODS: Investing money in ecologics preventive programmes for protecting healthy water , clear air, earth, healthy food bring excellent economics and health results in every country and political system, what directly has effect on health of children. RESULTS: Immunization's programmes - Programmes of Vaccination, except health benefits have large economics profit because of decreasing using of medicaments, restriction number of hospitalization, number of patients days at children. Programmes for prohibition and restriction of smoking, using opiate and alcohol, bring larges benefits for every child, family and human community. DISCUSSION: Restriction poverty , Social-Health Care of all children expecially orphans without parents is task of every government. Special place take programs of prevention and curing infections at children, Children's cancers , chronical diseases and similiar. CONSLUSION: Optimal treatment of mild and severe diseases of children can give less paying and better curing that it is task discipline of health economy , pharmaco-economy , that it is the most racional as it is used at the beginning of human life. Money , economics effects, costs and economics benefits are together every health practice and pediatrics too, but health economy has very important role for improving health of child. • Key words: Kids, Management, Profits-Benefits, Economy , Pediatrics.

  6. OBJECTIVE • Health system by economic health function gives information about costs and outcomes health programmes, for example : therapeutics procedures, diagnostics procedures, preventive programmes, drugs and products of health technology in kids(1). Costs increasing in Health system, and pediatrics too, regular distribution available money became right key for quality and efficiency in Health care(Table1). • Treatment costs and complications of tobacco smoking in USA are 137 billions US dollars, narcotics using 114.5 billions $, but alcohol the most expensive for Health system, from 175 to 184 billions $ per year. • Smoking is a big evil today, widely distribution until 70 % citiziens of Canton Sarajevo smoke tobacco and high percentage children in secondary school about 30%. Large number of suicids of teens who used alkohol, murders and criminal actions increased economic damages, becouse no programmes for prohibition, prevention alcohol narcotics and smoking are not expensive(2).

  7. OBJECTIVE • Millions of young Americans and Bosnianss lose lifes in hopeless narcotics what caused damages in hundreds billions $. Only 34% adults narcomans are alcoholics in same time, but only 4% kids narcomans are not alcoholics(3). • Developtment of clinical pharmacology on famous clinics, institutions, researching companies, faculties, pharmaceuticals factories enabled treatmans of uncured diseases as infectious, malignants and chronics until today(4,5). High investment brings higher economics results. Every day devolptment and improving of vaccina caused that more diseases as paralyses, diphteria, tuberculosis (except Bosnia) are almost disapeared, and other diseases as pertussis, rubeola, bacterial meningitis, parotitis, morbilli are rarely present(6-8). Complications and number of hospitalization days are quite decreased. • Economics care by social programmes , extra payment, humanitarian aid, orphans care, bring health and economics utilities and other benefits(9). • There are more kinds of health insurance on level of country and extra insurance, special and specific, regional, urban, private fonds, that different function and finance health and pediatrics protection depends from state and its economic power and system.

  8. OBJECTIVE • Scientist Calman and Royston made investigation and linear scales of risks that could use in health insurance what is very important for determination of level life insurance, and detection epidemiologic situations and logaritam and linearic scalas risk in school, children's nurseries, hospitals. Except these studies of risk mortality , studies of kids morbidity are very important. Berger and Rosen devolped methods of estimation CV risk morbidity and VSCL(value statistical child life) depends for VSL (values statistical life in adults)(10). • Economic effects protection of water, ground and food are large specially in kids careless on investment becouse everything came back as economic benefit as a less number of morbidity, hospitalization days, costs sick leaves, absence from school(Table 2).

  9. TABLE 1. EXAMPLE FOR EDUCATION IN HEALTH ECONOMY EUROPEAN CENTER FOR PEACE AND DEVELOPTMENT (ECPD) UNIVERSITY OF UNITED NATIONS • 1. HEALTH POLITICS AND SYSTEME OF HEALTH CARE • Health, Health potencial, Health equipment, Health risks, Personal Health, Community Health, Heaylth and economics developtment. • Health care, promotion of Health, Diseases prevention, early diagnotics diseases , early intervetion, rehabilitation. • Primary Health care: definition, principes, primary Health care as basis and center of Health systeme. • Levels Health care, referal system, criteria and measure for value efficiacy of Health systeme. • Health politics : definition, carriers, elements for estabilished Health politics. • Health needs: methodology for establishing Health needs. • Basical packages Healt care, criteria and measure. • Health insurance, obligatory, additional, private. Correlation goverement and organization Health insurance, principals, organization, financial. • Health technology: definition, factors that influenced on developtment of Hedalth technology, problems in choices and implementing , mechanismus for adequate using. • Health services: principes of organization Health insitution and tasks in organization Health services, Health institution and theoretical models, acreditation Health institution. • Health stuff, education, specilizations for Health needs, licenced for work. • Regionalization of Health care and systeme of Health insurance, definition, principals; Health region as carrier of health care and Health insurance. • Reforms of Health system, principals and causing, instrumentsfor implentation, Ljubljana declaration. • Critical points on daily care in area of Health care and directions in equilibrim with needs and possibilities.

  10. . • 2. MANAGEMENT OF HEALTH SYSTEME • Concept, developtment and function of management. • Concept, developtment and function of Health management. • Succesfull /effective Health management and manager on different level of Health systeme and institution. • Colecting, analisys and prezentation statistical facts. • Identifikation problems, priority, barriers. • Strategije implemenation and aims for developtment of institutions. • Improving organization, impementing of action plan. • Improving motivation for work, communications, colaboration, advising i teams work. • Decisions and resolving problems. • Management and directory, choice and resolving conflicts human resurces. • Management human material financial sources and quality of work. • Supervision, controls and help on supervision. • Cost effective analyses. • Definitions and assesment of Health systeme/institution. • Management changes of tranzition. • Making vision, planning and program of developtment institution , department, team. • Assesment and estimation succesfull working and Health management. • Establishing (education) succesfull Health manager. • Management projects.

  11. 3. PLANNING, ORGANIZATION, FUNCIONS OF HEALTH SERVICES • Planning for health: place, role and importance. • Assesment different factors in process of planning. • Plan: main caracteristis of plan. • Obligatory conditions and rules for implementing of planning. • Process establishing of priority. • Choice of strategy for realization priority. • Coolecting adequate information about prices activities. • Financy : different forms of financing and sugestion for establishing budget. • 4. FINANCES AND BOOKKEEPING FOR MANAGER • Importence of management finances for effective working of Health systeme. • Different options of financing Health systeme and institution. • Assesment options for using and wellt finacial of Health services and institution. • Application of knowledges in concrete management situations. • Using of financial information for management decisions. • 5. INFORMATICS FOR MANAGERS AND HEALTH INFORMATION SYSTEM • Informatics: improving basic knowledges and skills from Word, Excel, PowerPointa, Internet Explorer... • Health system as basic for colecting, management and analyses facts. • Health information system-main caracteristics (levels, consists and types). • Health information system as planning and decisition. • Geographical informational system and decisions.

  12. . • 6. HEALTH ECONOMICS • Health economics and its influence for efficacy and effective function health management and institutution. • Results of work in Health institution ; Input (material and nonmaterial); Output (service, income, profit) • Eficciacy and effection: definition, methods measurement in Health institution. • Management of costs: decrasing costs, minimizing costs. • Logistics concept of working in Healt institution . • Measurement of perfomances in Health institution. • Reinjering-developtment efficiacy and efectivity i Health institution. • 7. HEALTH TECHNOLOGY • Health technology , vision and task in improving of Health. • Assessment of Health technology and decisions. • Concept and analytic equipment. • Etics and rules aspects. • Menadžment visoko specijalizovanih zdravstvenih tehnologija. • 8. QUALITY OF WORK IN HEALTH INSTITUTION • Quality : concept of quality , definition and developtment. • Assessment quality of work in Health institution. • Mechanizmus for quality insuring. • Improvement quality of work in Heath institution. • Implementing ISO standards? Management of quality in Health institution (TQM) • 9. STRATEGICI MANAGEMENT AND MANAGEMENT INOVATION AND CHANGES • Strategic planning and anteception future • Merket and institutions of capital. • Management influences. • Public economy and bussines low for managers. • 10. ENGLISH AS BUSSINES LANGUAGE IN HEALTH

  13. Table 2 LABORATORY FOR FOOD INVESTIGATION

  14. METHODS • Authors compared facts from primary articles Americans doctors, pediatricians, economists, statistics experts and other experts, but and Australian, Croatian, Slovenian, Britanian, Indian, Germanian and authors from other countries with own expirience and Bosnian data. • Investing money in ecologics preventive programs for protecting healthy water , clear air, earth, healthy food bring excellent economics and health results in every country and political system, what directly has effect on health of children. Excellent estimation methods for values no commercial analyses in context benefit cost is CONITIGENT VALUATION (CV)-eventually values of standardization where parents asked questions about WILLINGS TO PAY-WTP for risks in health insurance on hypothetical questions. We made questionnare on 10 questions for risks in children's health and made scores from 0 to 5 points for every answer (only parents in Sarajevo with university-high education)(Picture 1). Results were ranged from terrible knowledge to excellent knowledge (six levels of scores)(Diagram 1, 2,3). Average value is 2,56 what is good-moderate knowledge for this difficult test(other education group more less values)(Diagram 4). Similiar methods made in USA for risks from mortality from different accidents of injuries during child life , that we used that scales and scopes.

  15. METHODS • Methods cleaning air and its BENEFITS AND COSTS OF THE CLEAN AIR ACT-USEPA A 1997 , i USEPA B i EPA analyles ozon and particuleres in air as EPA REGULATORY IMPACT ANALYSES FOR OZONES AND PARTICULARES showed benefits as bases documents in Bosnia and Herzegovina primary health and economic benefits for deacresing neonatal mortality from 27 to 8.8 promils what is greater success in economy in Bosnia and Herzegovina after the war and agression on ours country (11).

  16. METHODS • Every day control in Bosnian laboratories, water for drinking,water for swiming in public swiming pools , water in canalisations and rivers showed economics and health benefits in kids. Other analyses food in stores , markets, kindergartens, schools, factories, import officess, bakeries, and another important places for quality of health food for all people specially for children. Control of economic success in hospital, public health offices and health ministery have been a very important for poor country as Bosnia and Herzegovina. Bad side of this analyses was including only direct costs (drugs and other medicine, hospitalization, worh of professional health stuff) without enough elements for indirect costs( days of upsent parents from jobs), or additional costs( better quality of life and prolonged of life, decreasing number days upsent children from school)). Schedule of vaccination is a very important for every country and prevention of dangerous severe diseases, and improving new scheedule in 2008 is new benetits for children health and decreasing costs for 50 percent in pediatrics if we compare relative money now and before forty years.

  17. METHODS • New programs for reducing consumation of alcohol, tobacco and narcotics using in Youth and children in Bosnia and Herzegovina consisted restrictive and juridice acts, and educational improving knowledge in schools. Actions for parents ceasing of smoking and reducing of passive smoking decreased chronic lungs diseases in children for 2 percent only for one years of stoping tobacco in Bosnian homes(12-15). • Health insurance became a great probleme becouse the war, destroying, transition of public health systeme and economic systeme made a big changes in health care in kids, too. Now in 2007-2008 only 69% people and their kids have obligatory health insurance what is 20 percent less if we compare 1984 year (89%).

  18. PICTURE 1QUESTIONNARRE FOR HEALTH RISKS IN CHILDREN-INSURANCE INVESTIGATION-questions and answers • 1. WHAT IS THE MAIN RISKS FOR KIDS IN NEWBORN PERIOD? • OPTION ORDERS-congenital disease, sepsis, pulmonary-lung infections, car crashes, leukemia, intertrigo perigenitalis • 2. WHAT IS THE MAIN RISKS FOR KIDS IN PERIOD SMALL CHILDREN (1-4 YEARS)? • OPTION ORDERS-accidental poisoning, oncologic disease, severe pneumonia, viral meningitis, car crashes, tonsillopharyngitis. • 3.WHAT IS THE MAIN RISKS FOR CHILDREN IN PREESCHOOL PERIOD (5-6 YEARS)? • OPTION ORDERS; severe accidental injuries, car crashes, diabetes mellitus, pneumonia, anemia, common cold. • 4. WHAT IS THE MAIN RISKS FOR CHILDREN IN PRIMARY SCHOOL PERIOD BEFORE PUBERTET (6-11 YEARS)? • OPTION ORDERS: car crashes, malignom, meningitis, severe diarrhea, uncomplicated varicella, mild urinary infection. • 5. WHAT IS THE MAIN RISKS FOR CHILDREN IN PRIMARY SCHOOL IN PUBERTET (12-15 YEARS)? • OPTION ORDERS: narcotics, accidental injuries, smoking, sexual infectious diseases, rubeola, flu. • 6. WHAT IS THE MAIN RISKS FOR CHILDREN IN SECONDARY SCHOOL?(15-18 YEARS)? • OPTION ORDERS: alcohol, AIDS, oncologic disease, sports injuries, flu, common cold. • 7. CAN YOU PUT ORDER THE SAFEST MEDICAMENTS IN „HOME PHARMACY“?THE WORST FIRST, LAST THE SAFEST. • OPTION ORDERS: Diazepam, Pylomid (metoklopramid klorid), Ibuprofen, Paracetamol, Herbal sirup, Multivitamin. • 8. WHAT CHILDREN NEEDS IN EDUCATION IN SCHOOL FOR PROTECTION THEIR LIFES AND HEALTH? PUT IMPORTANT ORDER! • OPTION ORDERS: Education in traffic security, Sports, Diatery-food planning, Biology-Sexual education, Fire education, geography. • 9. WHAT IS THE MOST DANGEROUS FOR HEALTH IN SCHOOL FOR YOUR CHILD?PUT ORDER THDE MOST OFTEN. • OPTION ORDERS: traffic in way to school, hepatitis A, bad boys-company, estimation values of pupil from professors, bad air in classroom, common cold. • 10. CAR CRASHES AND YOUR CHILD. PUT ORDER THE MOST OFTEN-DANGEROUS INJURIES AND CHANGES. • OPTION ORDERS: Injuring of HEAD, Injuring of NECK and SPINE, Injuring of CHEST, Injuring of ABDOMEN, Injuring of EXTREMITIES, Mild FEARS and mild Insomnia. • Explanation- 0 true 0 point, 1 true 1 point, 2 trues 2 points, 3 trues 3 points, 4 trues 4 point, 5 trues 5 points,6 trues 6 points. • RESULTS OF PARENTS KNOWLEDGES: 0-10 points terrible(0),11-20 bad(1), 21-30 enough(2), 31-40 good-moderate(3), 41-50 very well(4), 51-60excellent(5).

  19. RESULTS • Immunization's programmes - Programmes of Vaccination, except health benefits have large economics profit because of decreasing using of medicaments, restriction number of hospitalization, number of patients days at children. Programes for prohibition and restriction of smoking, using opiate and alcohol, bring larges benefits for every child, family and human community. • But results in Texas showed that 26 American kids died for whooping cough only in period 1999-2004, approximatly 3 to 4 Bosnians died from same disease in this period, but proposing were about 11. That was a big result if we compare period before 30 years or during the war 92-95 more than 10 times more. (16). Trends of smoking after program of avoiding tobaco made big results and decreasing percenatge from 36% to 22 % in secondary school children. Comparing adults(70%) and medical stuff (51%) it was a terible number too.

  20. RESULTS • Passive smoking is a big probleme in USA (43%) and Bosnia and Herzegovina 57% too. (33% passive smoking as both parent or 51% mothers and 53% fathers smokers). Only educational programmes and taxes for tobaco made decreasing numbers in secondary school for 14 %. It is 38% more chance in newborns that mothers smoke that they would be hospitalized, but newborn beetween 6 and 9 months and two and half more often. Children who take alcohol more often accepted in hospital than other children and stayed more 29%. • Cars crashes caused children that used alkohol and cost USA 3.7 billions $ per year. There are more than 4 million children and Youth who used alcohol only in United States. Curing program from narcotics in hospital lasts 3 to 6 months but it followed after. American goverment's program raised from 1981 to 2006 from 1.5 billion $ to 18.5 billions $ and 35% more every year(similiar in Bosnia but more less money-no exactly facts).

  21. RESULTS • Costs of health insurance increased every day in every country (USA 9.9%, Bosnia 5% of national budget)(17). Pediatrics cost increased in US the more than 74%, but similiar is in Bosnia and Herzegovina and European countries. • Costs for kids hospitalization were in CHOP Philadelphia 1,200-,1800 $ , intesive care 3,100 $. But on Pediatrics Clinic Sarajevo more less 90-160 $, intesive care 300 $ per day. • There are possible changes about apsolute or relative risks if we compare external or internal scope test. Model that basis on analyses only direct costs is simple analyses costs, that right pharmaco-economics analyses need to calculate and additional values every procedures(18). The most published pharmacoeconomics studies are analyeses of cost studies(19).

  22. RESULTS • There are only particular pharmaco-economics studies that mentioned only about costs but no results and success of treatment. It is clearly that this studies are very important becouse influences on limit acount or budget impact studies that must be basis for decision in shortly time in pediatrics. • Newer vaccine were moer expensive but better quality of vaccination gave big economics saves and results in 2005 in USA and Bosnia 2007-2008. • Big suicidals of teen ages as alcoholic kids users, homocidal, crimes robberies increased economics damages , that no program for restriction and prevention of alcohol , narcotics and smoking were not expensive bacouse benefits were more(20).

  23. Figure 1 Graphic Percentage Knowledge of parents of kids health risks

  24. Figure 2 GraphicsDiagram of values for knowledges parents for kids risks for Health

  25. Figure 3 GraphicsPart of values of knowledges sums for kids risks2.563 AVARAGE VALUE OF KNOWLEDGE OF HIGH EDUCATED PARENTS IN SARAJEVO

  26. Figure 4 GraphicsDistribution of profesionality of parents knowledges in Health kids risks

  27. LEGEND Explanation Graphic 4 Distribution of profesionality of parents (UNIVERSITY LEVEL) knowledges(2.56) in Health kids risks • 1. MEDICINE 149 • 2. PHARMACY 51 • 3. LOW-JUSTICE 98 • 4. EDUCATION 147 • 5. ECONOMY 202 • 6. POLITICS SCIENCE-JOURNALISM 24 • 7. TECHICAL FACULTY 253 • 8. ART 26 • 9. OTHER UNIVERSITY 50

  28. DISCUSSION • Restriction poverty , Social-Health Care of all children expecially orphans without parents is task of every government. Special place take programs of prevention and curing infections at children, Children's cancers , chronical diseases and similiar. Child is not only „litlle human“, but it is not treated as adult in „small size“(21- 23). It is not possible make scientific reasearch and experiments becouse low's procedures couldn't allow permission for that purppose, but another problem is specific parents opinion in Bosnia and Herzegovina. Better education of pediatricians, more efforts on jobs, using the best modern diagnostics and therapeutics procedures, newer medical equipment, efficial quality medicaments, training medical stuff, the best pediatrics offices and hospitals and other factors must be in systeme pediatrics care with excellent organization and cordination.

  29. DISCUSSION • The leading respiratory diseases and neonatologic disturbances are increased number in all over the world and it needs better expensive treatman as other diseases.(24). Early diagnostic cardial congenital diseases allow only expensive eqiupment. Quality multi-components vaccination is imperative newer age and future (25). Prices of this vaccines are about 60 $, and that is not expensive for prevention many diseases(more than 10-100 times more money). AIDS is the biggest problem in world and very expensive treatment is very important (more than 45 millions in 2007 and more than 5-6 millions kids) Only kids malignoms take a half million $ per child. The best screening is the best prevention and economic measure with money and lifes saving. Economics program of protection ground, air, water and food needs larger investigation (33$ per sample in Croatia, and 19$ in Bosnia)(26,27). • In rapidly developtment of health economic , it is very difficult to make quality analyses costs and cost-effectiveness analysis (CEA), but more harder cost-utility anlysis (CUA). The most published articles were only cost studies. These are only partial pharmaco-economics analyses becouse they consist only costs but not effectiveness of treatment. It is clearly that studies about limited calculaction and “budget impact” studies must be basis for decisions in pediatrics.

  30. CONSLUSIONS • Children are the most important and vulerable part of every world nation and country. From economical aspect invested money in children presents the best investition. Optimal treatment of mild and severe diseases of children can give less paying and better curing that it is task discipline of health economy , pharmaco-economy , that it is the most racional as it is used at the beginning of human life(28,29). Money , economics effects, costs and economics benefits are together every health practice and pediatrics too, but health economy has very important role for improving health of child. Bosnia and Herzegovina sa social country in phasis of trazition and after war reconstruction need to give the best attention on care of children's health (physical, psychical, social and educational health). Goverment must to take startegic decision about level experts and financial actions that it would make from declarative statements to concretes actions. Health Economic has task that in pediatrics with increasing costs gives quality and the best protection of kids health(30). Base for decisions about costs are informations about costs results in every day medical pediatrics practice.

  31. Literature-References • 1.Robert T.Gunby Jr, MD, Healthy Vision 2010, Texas Med.Association, Journal of Texas Med. Association, November 2005, Austin Texas USA, Vol 11, 9-15. • 2. Dickie M., Nestor D.; 1998, Valuation of Evironmenal Health Effects in Children:A Survey, Upbulished Preliminary Draft. • 3. U.S. Dept. of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies. 2003. National Household Survey on Drug Abuse, 2001. Research Triangle Park, NC: Research Triangle Institute. • 4. Mc Kee M: Mossialos E,Impact of Menaged Care of Clinical Research, Pharmacoeconomics, 1998, 14: 19-25. • 5. Rosenthal PJ, Goldsmith RS. In Katzung BG ed. Basic and Clinical Pharmacology: McGraw Hill, 8th edn. 882-902 • 6. World Health Organization. The Children´s Vaccine Initiative and Global Programme for Vaccines and Immunization. Recomendations from Special Advisory Group of Experts. Wkly Epidemiol. Rec 1996; 71:261-6. • 7. Decker M., Edwards KM. Combinnation vaccines : Problems and promise The Journal of Pediatrics 200, 137/3;291-94. • 8. Combination Vaccines for Childhood Immunization. Recommendations of Advisory Committee on Immunizattion Practices /ACIP/, the American Acedemy of Pediatrics /AAP/. MMWR Morb Mortal Wkly Rep 1999; 48;1-13 • 9. Bergstrom TC /1996/, Economics in a Family Way, Journal of Economic Literature , 34 /4/ 1903-1934 • 10. Fisher Ann, Laurainne G. Chestnut,Danel M. Viollete,The Value of Reducing Risks of Death : A Note of New Evidence , Journal of Policy Analysis and Menagment, Vol 8 /1/1989, 88- 100. • 11. Green D, Jackovitz K.E., , Kahneman D and Mc Fadden D.,Referendum Contigent Valuation, Anchoring, and Willings to Pay for Public Goods, Resource and Energy Economics 20/June 1998/ , 85-116. • 12. Behan DF at al; Economics Effects of Environmental of Tobacco Smoke, Sociaty of Actuaries, March 2005, New York ,USA. • 13. Murray AB, Morrison BJ The decrease in severity of asthma in children of parents who smoke since the parents have been exposing them to less cigarette smoke. J Allergy Clin Immunol. 1993; 91:102-110 • 14. Owen MJ, Baldwin CD, Swank PR, Pannu AK, Johnson DL, Howie VM Relation of infant feeding practices, cigarette smoke exposure, and group child care to the onset and duration of otitis media with effusion in the first two years of life. J Pediatr. 1993; 123:702-711

  32. Literature-References • 15. Klonoff-Cohen HS, Edelstein SL, Lefkowitz ES, The effect of passive smoking and tobacco exposure through breast milk on sudden infant death syndrome. JAMA. 1995; 273:795-798 • 16. Erin A. Flanagan-Klygis, Lisa Sharp, and Joel E. Frader ; Dismissing the Family Who Refuses Vaccines: A Study of Pediatrician Attitudes Arch Pediatr Adolesc Med. 2005;159:929-934 • 17. RESEARCH FINDINGS ON THE ECONOMY-AND HEALTH -INSURANCE COVERAGE-Summaries of Studies by the Urban Institute and-The Center for Studying Health System Change-April 23, 2004 • 18. Mercep I. , Katić M., Kern . Francetić .A model for monitoring Drug prescribing in geneal practice. Lijec Vjesn.1997, 119:/11-12/; 336-343. • 19. Robin R.. Jenkins,Nicole Owens, Lanelle Wiggins, Environmental Protection Agency, Office of Policy, Economic and Policy Analysis Divison,Valing of Statistical Child's Life : The case of Bycicle Safety Helest , Working Paper, Marchl 1999, Spring Silver Holiday Inn in Silver Spring , Maryland, • 20. National Center for Health Statistics. National Hospital Ambulatory Medical Survey 2000; Vol 4 April 2002, Washinghton D.C. USA • 21. Biggar JR, Miotti RG, Taha TE et al. Perinatal intervention trial in Africa: effect of a birth canal cleansing intervention to prevent HIV transmission. Lancet 1996; 347 : 1647-1650 • 22. American Acedemy of Pediatrics. Committee on Infectious Diseases. Reassessment of indications for ribavirin therapy in respiratory syncytial virus infections. Pediatrcs 1996;97:137-40. • 23. Ong TJ, Mehta A, Ogston S, Mukhopadhyay S. Prediction of lung function in the inadequately nourished. Arch Dis Child 1998; July; 79(1) : 18-21.  • 24. Simoes E. RSV and subsequent lower respiratory tract infections in devolping countries. The Journal of Pediatrics 1999, 6:657-60. • 25. Wren C. Technological advances and assessment of children with murmurs. Arch Dis Child 2002; 87 (4): 300-301 • 26. Bhatnagar S, Bhandari N, Mouli U C, Bhan M K. Concensus Statement of IAP National Task Force: Status Report on Management of Acute Diarrhea. Indian Pediatr 2004; 41: 335-348.  • 27. Gunnarsdottir I, Thorsdottir I: Relationship between growth and feeding in infancy and body mass index at the age of 6 years. Inter J Obesity 2003;27:1523 • 28. Staehler M., Hammer C, Meiser B., Reichart B. Procalcitonin a new marker for differential diagnosis. Trans Proc 1997; 29:584-5. • 29. Vouri E., Peltola H., Kallio MJT, Leinonen M., Heidman K., SE-TU Study Group. Etiology of pneumonia and other comon childhood infections requiring hospitalization and parenteral antimicrobiological therapy. Clin Infect. Dis 1998:27:566-72. • 30Leslie, LK, Miotto MB, , Liu, GC, Ziemnik S, Cabrera AG, Calma S, Huang K, Slaw K. Training Young Pediatricians as Leaders for the 21st Century PEDIATRICS Vol. 115 No. 3 March 2005, pp. 765-773 (doi:10.1542/peds.2004-1223)

  33. THANKS!!!

  34. Nice France 2008 • . DR MED ADNAN BAJRAKTAREVICPEDIATRICIAN SARAJEVOBOSNIA AND HERZEGOVINATHANKS!!!

  35. Nice France 2008 • .

  36. A. Transcriber has to enter. Details of patient visit based on Doctor’s andwritten notes B. Reduction in Medical errors

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