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IntroductionMinecraft is kamagra tablets for sale uk a computer game with no specific goals to accomplish my explanation. The gameworld consists of three-dimensional (3D) cubes and objects which the player (Steve) can mine and build into infinitely complex (and logically impossible) structures. Steve sometimes encounters other characters (‘mobs’), such as animals and hostile kamagra tablets for sale uk creatures.

He can ‘spawn’ and destroy them. While it looks like a harmless game of logical construction, it conveys some worryingly delusive ideas about the real world. The difference between real and imagined structures is at the heart of the age-old debate around categorising mental disorders.Classification in mental health has had various forms throughout kamagra tablets for sale uk history.

Mack and colleagues set out a history of psychiatric classification beginning in 2600 BC with Egyptian references to melancholia and hysteria. Through the kamagra tablets for sale uk Ancient Greeks with Hippocrates’ phrenitis, mania, melancholia, epilepsy, hysteria and Scythian disease. Through the Renaissance period.

Through to 19th-century psychiatry featuring Pinel (known as the first psychiatrist), Kraepelin (known for observational classification) and Freud (known for classifying neurosis and psychosis).1Although the history of psychiatric classification identifies some common trends such as the labels ‘melancholia’ and ‘hysteria’ which have survived millennia, the label ‘depression’ is relatively new. The earliest usage noted kamagra tablets for sale uk by Snaith is from 1899. €˜in simple pathological depression…the patient exhibits a growing indifference to his former pursuits…’.2 Snaith noted that early 20th-century psychiatrists like Adolf Meyer hoped that ‘depression’ would come to encompass a broad category under which descriptions of subtypes would emerge.

This did not happen until the kamagra tablets for sale uk middle of the 20th century. With the publication of the sixth International Classification of Diseases (ICD) in 1948 and the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952 and their subsequent revisions, the latter half of the 20th century has seen depression subtype labels proliferate. In their study of the social determinants of diagnostic labels in depression, McPherson and Armstrong illustrate how the codification of depression subtypes in the latter half of the 20th century has been shaped by the evolving context of psychiatry, including power struggles within the profession, a move to community care and the development of psychopharmacology.3During this period, McPherson and Armstrong describe how subsequent versions of the DSM served as battlegrounds for professional disputes and philosophical quarrels around categorisation of mental disorders.

DSM I and DSM II have been described as products of an American Psychiatric Association dominated by kamagra tablets for sale uk psychoanalytic psychiatrists.4 DSM III and DSM III-R have been described as a radical rejection of psychoanalytic thinking, a ‘neo-Kraepelinian revolution’, a reference to the observational descriptive techniques of 19th-century psychiatrist Emil Kraepelin who classified mental disorders into two broad categories. €˜dementia praecox’ and ‘manic-depression’.5 DSM III was seen by some as a turning point in the use of the medical model of mental illness, through provision of specific inclusion and exclusion criteria, and use of field trials and a multiaxial system.6 These latter technocratic additions to psychiatric labelling served to engender a much closer alignment between psychiatry, science and medicine.The codification of mental disorders in manuals has been described by Thomas Schacht as intrinsic to the relationship between science and politics and the way in which psychiatrists gain significant social power by aligning themselves to science.7 His argument drew on Szasz, who saw the mental health establishment as a therapeutic state. Zimbardo, who described psychiatric care as kamagra tablets for sale uk a controlling force.

And Foucault, who described the categorisation of the mentally ill as a force for isolating ‘the other’. Diagnostic critique has been further developed through a cultural relativist lens in that what Western psychiatrists classify as a depression is constructed differently in other cultures.8 Considering these limitations, some critics have gone so far as to argue that psychiatric diagnostic systems should be abolished.9Yet architects of DSM manuals have worked hard to ensure the technology of classification is regarded as genuine scientific activity with sound roots in philosophy of science. In their philosophical defence of DSM IV, Allen Frances and colleagues address their critics under the headings ‘nominalism vs realism’, ‘empiricism vs rationalism’ and ‘categorical vs dimensional’.10 The implication is that there are opposing stances in which a choice must be kamagra tablets for sale uk made or a middle ground forged by those reasonable enough to recognise the need for pragmatism in the service of clinical utility.

The nominalism–realism debate is illustrated using as metaphor three different stances a cricket umpire might take on calling strikes and balls. The discussion sets out two of these as kamagra tablets for sale uk extreme views. €˜at one extreme…those who take a reductionistically realistic view of the world’ versus ‘the solipsistic nominalists…might content that nothing exists’.

Szasz, who is characterised as holding particularly extreme views, is named as an archetypal solipsist. There is implied to be a degree of arrogance associated with this view in the illustrative example in which the umpire states ‘there are no balls and there are no strikes until kamagra tablets for sale uk I call them’. Frances therefore sets up a means of grouping two kinds of people as philosophical extremists who can be dismissed, while avoiding addressing the philosophical problems they pose.Frances provides little if any justification for the middle ground stance, ‘There are balls and there are strikes and I call them as I see them’, other than to focus on its clinical utility and the lack of clinical utility in the alternatives ‘naïve realism’ and ‘heuristically barren solipsism’.

The natural conclusion the reader is invited kamagra tablets for sale uk to reach is that a middle ground of a heuristic concept is naturally right because it is not extreme and is naturally useful clinically, without specifying in what way this stance is coherent, resolves the two alternatives, and in what way a heuristic construct that is not ‘real’ can be subject to scientific testing.Similarly, in discussing the ‘categorical vs dimensional’, Frances promotes the ‘prototype approach’. Those holding opposing views are labelled as ‘dualists’ or ‘dichotomisers’. The prototypical approach is again put forward as a clinically useful middle ground.

Illustrations are kamagra tablets for sale uk drawn from natural science. €˜a triangle and a square are never the same’, inciting the reader to consider science as value-free. The prototypical approach emerges as a natural solution, yet the authors do not address how a diagnostic prototype resolves the issues posed by the two alternatives, nor how a prototype can be kamagra tablets for sale uk subjected to natural science methods.The argument presented here is not a defence of solipsism or dualism.

Rather it aims to illustrate that if for pragmatic purposes clinicians and policymakers choose to gloss over the philosophical flaws in classification practices, it is then risky to move beyond the heuristic and apply natural science methods to these constructs adding multiple layers of technocratic subclassification. Doing so is more like playing Minecraft than cricket. The National Institute for Health and Care Excellence (NICE) guideline for depression is taken kamagra tablets for sale uk as an example of the philosophical errors that can follow from playing Minecraft with unsound heuristic devices, specifically subcategories of persistent forms of depression.

As well as serving a clinical purpose, diagnosis in medicine is a way of allocating resources for insurance companies and constructing clinical guidelines, which in turn determine rationing within the National Health Service. The consequences for recipients of healthcare are therefore kamagra tablets for sale uk significant. Clinical utility is arguably not being served at all and patients are left at risk of poor-quality care.Heterogeneity of persistent depressionAndrea Jobst and colleagues note that ‘because of their chronic clinical course, approximately 40% of CD [chronic depression] patients also fulfil criteria for TRD [treatment resistant depression]…usually defined by the number of non-successful biological treatments’.11 This position is reflected in the DSM VAmerican Psychiatric Association (2013), the European Psychiatric Association (EPA) guidance and the ICD-11(World Health Organisation, 2018), which all use a ‘persistent’ depression category, acknowledging a loosely defined mixed group of long-term, difficult-to-treat depressive conditions, often associated with dysthymia and comorbid common mental disorders, various personality traits and psychosocial disability.In contrast, the NICE 2018 draft guideline separates treatments into those for ‘new episodes’ of depression.

€˜further-line’ treatment of depression (equivalent to TRD), CD and ‘depression with co-morbidities’. The latter is subdivided into treatments for ‘complex depression’ and kamagra tablets for sale uk ‘psychotic depression’. These categories and subcategories introduce an unfortunate sense of certainty as though these labels represent real things.

An analysis follows of how these definitions play kamagra tablets for sale uk out in terms of grouping of randomised controlled trials in the NICE evidence review. Specifically, the analysis reveals the overlap between populations in trials which have been separated into discrete categories, revealing significant limitations to the utility of the category labels.The NICE definition of CD requires trial samples to meet the criteria for major depressive disorder (MDD) for 2 years. Dysthymia and double depression (MDD superimposed on dysthymia) were included.

If 75% of the trial population met these criteria, the trial was reviewed in the CD category.12 The definition of TRD (or ‘further-line treatments’) required that the trial sample had demonstrated a ‘limited response kamagra tablets for sale uk to previous treatment’ and randomised to the further-line treatment at this point. If 80% of the trial participants met these criteria, it was reviewed in the TRD category.13 Complex depression was defined as ‘depression co-existing with personality disorder’. To be classed as complex, 51% kamagra tablets for sale uk of trial participants had to have personality disorder (PD).14It is immediately clear from these definitions that there is a potential problem with attempting to categorise trial populations into just one of these categories.

These populations are likely to overlap, whether or not a trial protocol sets out to explicitly record all of this information. The analysis below will illustrate this using examples from within the NICE review.Cataloguing complexity in trial populationsWithin the category of further-line treatments (TRD), 64 trials were reviewed. Comparisons within these trials were further subcategorised into ‘dose escalation strategies’, ‘augmentation strategies’ and ‘switching strategies’ kamagra tablets for sale uk.

In drilling down by way of illustration, this analysis considers the 51 trials in the augmentation strategy evidence review. Of these, two were classified by kamagra tablets for sale uk the reviewers as also fulfilling the criteria for CD but were not analysed in the CD category (Study IDs. Fonagy 2015 and Kocsis 200915).

About half of the trials (23/51) did not report the mean duration of episode, meaning that it is not possible to know what percentage of participants also met the criteria for CD. Of trials that did report episode duration, 17 reported a mean kamagra tablets for sale uk duration longer than 24 months. While the standard deviations varied in size or were unreported, the mean indicates a good likelihood that a significant proportion of the participants across these 51 trials met the criteria for CD.Details of baseline employment, trauma history, suicidality, physical comorbidity, axis I comorbidity and PD (all clinical indicators of complexity, severity and chronicity) were not collated by NICE.

For the present analysis, all 51 publications were examined and data compiled concerning clinical complexity in the trial populations. Only 14 of 51 trials kamagra tablets for sale uk report employment data. Of those that do, unemployment ranges from 12% to 56% across trial samples.

None of the trials report trauma kamagra tablets for sale uk history. About half of the trials (26/51) excluded people who were considered a suicide risk. The others did not.A large proportion of trials (30/51) did not provide any data on axis 1 comorbidity.

Of these, 18 did not exclude any diagnoses, while 12 excluded some (but not all) disorders kamagra tablets for sale uk. The most common diagnoses excluded were psychotic disorders, substance or alcohol abuse, and bipolar disorder (excluded in 26, 25 and 23 trials, respectively). Only 7 of 51 trials clearly kamagra tablets for sale uk stated that all axis 1 diagnoses were excluded.

This leaves only 13 studies providing any data about comorbidity. Of these, 9 gave partial data on one or two conditions, while 4 reported either the mean number of disorders (range 1.96–2.9) or the percentage of participants (range 68.1–96.7) with any comorbid diagnosis (Nierenberg 2003a, Nierenberg 2006, Watkins 2011a, Town 201715).The majority of trials (46/51) did not report the prevalence of PD. Many stated PD as an exclusion criterion but without defining a kamagra tablets for sale uk threshold for exclusion.

For example, PD could be excluded if it ‘impacted’ the depression, if it was ‘significant’, ‘severe’ or ‘persistent’. Some excluded certain PDs (such as antisocial or borderline) and not others but kamagra tablets for sale uk without reporting the prevalence of those not excluded. In the five trials where prevalence was clear, prevalence ranged from 0% (Ravindran 2008a15), where all PDs were excluded, to 87.5% of the sample (Town 201715).

Two studies reported the mean number of PDs. 2.0 (Nierenberg 2003a) and 0.85 (Watkins 2011a15).The majority of trials (43/51) did not report the prevalence of physical illness kamagra tablets for sale uk. Many stated illness as an exclusion criterion, but the definitions and thresholds were vague and could be interpreted in different ways.

For example, illness could be excluded if it was ‘unstable’, ‘serious’, ‘significant’, ‘relevant’, or kamagra tablets for sale uk would ‘contraindicate’ or ‘impact’ the medication. Of the eight trials reporting information about physical health, there was a wide variation. Four reported prevalence varying from 7.6% having a disability (Eisendrath 201615) to 90.9% having an illness or disability (Town 201715).

Four used kamagra tablets for sale uk scales of physical health. Two indicating mild problems (Nierenberg 2006, Lavretsky 201115) and two indicating moderately high levels of illness (Thase 2007, Fang 201015).The NICE review also divided trial populations into a dichotomy of ‘more severe’ and ‘less severe’ on the grounds that this would be a clinically useful classification for general practitioners. NICE applied a bespoke methodology for creating this dichotomy, abandoning validated measure thresholds in order first to generate two ‘homogeneous’ groups to ‘facilitate analysis’, and second to create an algorithm to ‘read across’ different measures (such as the Beck Depression Inventory, the Hamilton Rating Scale for Depression (HRSD) and the Montgomery-Asberg Depression Rating Scale).16 Examining kamagra tablets for sale uk trials which use more than one of these measures reveals problems in the algorithm.

Of the 51 trials, there are 6 instances in which the study population falls into NICE’s more severe category according to one measure and into the less severe category according to another. In four of these trials, NICE chose the less severe category (Souza 2016, Watkins 2011a, Fonagy 2015, Town 201715). The other kamagra tablets for sale uk two trials were designated more severe (Barbee 2011, Dunner 200715).

Only 17 of 51 trials reported two or more depression scale measures, leaving much unknown about whether other study populations could count as both more severe and less severe.Absence of knowledge or knowledge of absence?. A key philosophical error in science is to confuse an absence of knowledge with knowledge of absence kamagra tablets for sale uk. It is likely that some of the study populations deemed lacking in complexity or severity could actually have high degrees of complexity and/or severity.

Data to demonstrate this may either fall foul of a guideline committee decision to prioritise certain information over other conflicting information (as in the severity algorithm). The information may be non-existent as kamagra tablets for sale uk it was not collected. It may be somewhere in the publication pipeline.

Or it may be sitting in a database with a research team that has run out of funds for supplementary kamagra tablets for sale uk analyses. Wherever those data are or are not, their absence from published articles does not define the phenomenology of depression for the patients who took part. As a case in point, data from the Fonagy 2015 trial presented at conferences but not published reveal that PD prevalence data would place the trial well within the NICE complex depression category, and that the sample had high levels of past trauma and physical condition comorbidity.

The trial also meets the guideline criteria for CD according to the guideline’s own appendices.17 Reported axis 1 comorbidity was high (75.2% had anxiety disorder, 18.6% had substance abuse disorder, 13.2% had eating disorder).18 The mean depression scores at baseline were 36.5 on the Beck Depression Inventory and 20.1 on the HRSD (severe and kamagra tablets for sale uk very severe, respectively, according to published cut-off scores). NICE categorised this population as less severe TRD, not CD and not complex.Notes1. Avram H kamagra tablets for sale uk.

Mack et al. (1994), “A Brief History of Psychiatric Classification. From the Ancients to DSM-IV,” Psychiatric kamagra tablets for sale uk Clinics 17, no.

P. Snaith (1987), “The Concepts of Mild Depression,” British Journal of Psychiatry 150, no. 3.

387.3. Susan McPherson and David Armstrong (2006), “Social Determinants of Diagnostic Labels in Depression,” Social Science &. Medicine 62, no.

Grob (1991), “Origins of DSM-I. A Study in Appearance and Reality,” The American Journal of Psychiatry. 421–31.5.

Wilson M. Compton and Samuel B. Guze (1995), “The Neo-Kraepelinian Revolution in Psychiatric Diagnosis,” European Archives of Psychiatry and Clinical Neuroscience 245, no.

Klerman (1984), “A Debate on DSM-III. The Advantages of DSM-III,” The American Journal of Psychiatry. 539–42.7.

Thomas E. Schacht (1985), “DSM-III and the Politics of Truth,” American Psychologist. 513–5.8.

Daniel F. Hartner and Kari L. Theurer (2018), “Psychiatry Should Not Seek Mechanisms of Disorder,” Journal of Theoretical and Philosophical Psychology 38, no.

4. 189–204.9. Sami Timimi (2014), “No More Psychiatric Labels.

Why Formal Psychiatric Diagnostic Systems Should Be Abolished,” Journal of Clinical and Health Psychology 14, no. 3. 208–15.10.

Allen Frances et al. (1994), “DSM-IV Meets Philosophy,” The Journal of Medicine and Philosophy. A Forum for Bioethics and Philosophy of Medicine 19, no.

(2016), “European Psychiatric Association Guidance on Psychotherapy in Chronic Depression Across Europe,” European Psychiatry 33. 20.12. National Institute for Health and Care Excellence (2018), Depression in Adults.

Treatment and Management. Draft for Consultation, https://www.nice.org.uk/guidance/gid-cgwave0725/documents/full-guideline-updated, 507.13. Ibid., 351–62.14.

Ibid., 597.15. Note that in order to refer to specific trials reviewed in the guideline, rather than the full citation, the Study IDs from column A in appendix J5 have been used. See www.nice.org.uk/guidance/gid-cgwave0725/documents/addendum-appendix-9 for details and full references.16.

National Institute for Health and Care Excellence (2018), Depression in Adults. Treatment and Management. Second Consultation on Draft Guideline – Stakeholder Comments Table, https://www.nice.org.uk/guidance/gid-cgwave0725/documents/consultation-comments-and-responses-2, 420–1.17.

National Institute for Health and Care Excellence (2018), Depression in Adults, appendix J5.18. Peter Fonagy et al. (2015), “Pragmatic Randomized Controlled Trial of Long-Term Psychoanalytic Psychotherapy for Treatment-Resistant Depression.

The Tavistock Adult Depression Study (TADS),” World Psychiatry 14, no. 3. 312–21.19.

American Psychological Association (2018), Clinical Practice Guideline for the Treatment of Depression in Children, Adolescents, and Young, Middle-aged, and Older Adults. Draft.20. Jacqui Thornton (2018), “Depression in Adults.

Campaigners and Doctors Demand Full Revision of NICE Guidance,” BMJ 361. K2681..

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Start Preamble Centers for Medicare kamagra oral jelly female &. Medicaid Services (CMS), HHS. Final rule kamagra oral jelly female.

Correction. This document corrects a typographic error that appeared in the final rule published in the Federal Register on November 8, 2021 entitled “Medicare Program. End-Stage Renal Disease Prospective Payment System, Payment for Renal Dialysis Services Furnished to Individuals With Acute Kidney Injury, End-Stage Renal Disease Quality Incentive Program, and End-Stage Renal Disease Treatment kamagra oral jelly female Choices Model.” This correction is effective January 1, 2022.

Start Further Info Start Printed Page 70983 ESRDPayment@cms.hhs.gov, for issues related to the ESRD PPS and coverage and payment for renal dialysis services furnished to individuals with AKI. ESRDApplications@cms.hhs.gov, for issues related to the kamagra oral jelly female Transitional Add-On Payment Adjustment for New and Innovative Equipment and Supplies (TPNIES). Delia Houseal, (410) 786-2724, for issues related to the ESRD QIP.

ETC-CMMI@cms.hhs.gov, for issues related to the ESRD Treatment Choices (ETC) Model. End Further Info End Preamble kamagra oral jelly female Start Supplemental Information I. Background In FR Doc.

2021-23907 of November 8, 2021 (86 FR 61874), there was a typographic error that is identified and corrected by the Correction of Errors section below. The correction in this document is effective as if it had been included in the document published November 8, kamagra oral jelly female 2021. Accordingly, the correction is effective January 1, 2022.

II. Summary of Error On page 61874, in the third sentence of the first column, we inadvertently left the number “412” in the CFR citation at the top of the document. Therefore, the number “412” should be deleted.

III. Waiver of Proposed Rulemaking We ordinarily publish a notice of proposed rulemaking in the Federal Register to provide a period for public comment before the provisions of a rule take effect in accordance with section 553(b) of the Administrative Procedure Act (APA) (5 U.S.C. 553(b)).

However, we can waive this notice and comment procedure if the Secretary finds, for good cause, that the notice and comment process is impracticable, unnecessary, or contrary to the public interest, and incorporates a statement of the finding and the reasons therefore in the notice. Section 553(d) of the APA ordinarily requires a 30-day delay in effective date of final rules after the date of their publication in the Federal Register. This 30-day delay in effective date can be waived, however, if an agency finds for good cause that the delay is impracticable, unnecessary, or contrary to the public interest, and the agency incorporates a statement of the findings and its reasons in the rule issued.

We believe that this correcting document does not constitute a rule that would be subject to the notice and comment or delayed effective date requirements. This document corrects a typographic error and does not make substantive changes to the policies or payment methodologies that were adopted in the final rule. Thus, this correcting document is intended to ensure that the information is accurately reflected in the final rule.

Even if this were a rulemaking to which the notice and comment and delayed effective date requirements applied, we find that there is good cause to waive such requirements. Undertaking further notice and comment procedures to incorporate the correction in this document into the calendar year (CY) 2022 End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) final rule or delaying the effective date of the correction would be contrary to the public interest because it is in the public interest to ensure that the rule accurately reflects our policies as of the date they take effect. Further, such procedures would be unnecessary because we are not making any substantive revisions to the final rule, but rather, we are simply correcting the Federal Register document to reflect the policies that we previously proposed, received public comment on, and subsequently finalized in the CY 2022 ESRD PPS final rule.

For these reasons, we believe there is good cause to waive the requirements for notice and comment and delay in effective date. IV. Correction of Errors In FR Doc.

2021-23907 of November 8, 2021 (86 FR 61874), make the following correction. On page 61874, in the first column. In the third sentence, remove the number “412” from the CFR citation.

Start Signature Karuna Seshasai, Executive Secretary to the Department, Department of Health and Human Services. End Signature End Supplemental Information [FR Doc. 2021-26914 Filed 12-13-21.

8:45 am]BILLING CODE 4120-01-PThe Centers for Medicare &. Medicaid Services (CMS) is taking critical steps to ensure pregnant and postpartum individuals have access to equitable, comprehensive maternity care. In support of Vice President Kamala Harris’ Call to Action to Reduce Maternal Mortality and Morbidity announced on December 7, 2021, CMS is encouraging hospitals to implement evidence-based patient safety practices for managing obstetric emergencies along with interventions to address other key contributors to maternal health disparities.“Becoming a parent in America should not mean risking lives – especially among low-income women, especially in communities of color,” said Health and Human Services Secretary Xavier Becerra.

€œI am proud that the Biden-Harris Administration is committed to addressing the nation’s crisis in pregnancy-related deaths and health disparities. At HHS, we will continue to ensure safe pregnancies and improve maternal health outcomes for all new parents.” “There is no greater priority than ensuring pregnant and postpartum individuals receive the best possible care, and the Biden-Harris Administration is committed to working with the provider community and beyond to make that happen,” said CMS Administrator Chiquita Brooks-LaSure. €œToo many individuals ̶ a disproportionate share of them people of color ̶ experience unnecessary pregnancy-related complications and deaths.

We must do everything we can to change that.” In support of delivering equitable, high-quality maternity care, CMS encourages hospitals to review their policies and procedures for incorporation, where appropriate, of best practices. One such evidence-based practice for improving patient safety and quality of care, referred to as “maternal safety bundles,” has been successful in driving improvements ̶ particularly with obstetric hemorrhage, severe hypertension in pregnancy, and non-medically indicated Cesarean deliveries. These bundles have also been associated with narrowing the racial disparity gap in certain perinatal outcomes.

Today’s guidance is the latest in a series of actions CMS has pursued to further advance the safety and quality of maternal care. As part of Vice President Harris’ recent Call to Action, CMS announced the intent to propose a designation to further drive hospital improvements in perinatal health outcomes and maternal health equity. Beginning on October 1, 2021, CMS adopted a new quality measure for the Hospital Inpatient Quality Reporting Program that asks hospitals to attest to whether they participate in a statewide or national perinatal quality improvement collaborative, and whether they have implemented patient safety practices or bundles to improve maternal outcomes.

Initially based on data reported by hospitals on this measure, and in combination with data reported by hospitals on other measures in the future, a hospital could receive a “Birthing-Friendly” designation on the CMS Care Compare website. This could not only further advance maternity care safety and quality, but also provide information to consumers and their families in a user-friendly way as they consider options for where to seek care. In addition, CMS encourages states to take advantage of the American Rescue Plan’s (ARP’s) option to provide 12 months of postpartum coverage to pregnant individuals who are enrolled in Medicaid or the Children’s Health Insurance Program (CHIP) beginning April 2022.

A recent report by HHS’ Office of the Assistant Secretary for Planning and Evaluation (ASPE) showed the dramatic impact if states extended Medicaid postpartum coverage to 12 months. If every state adopted an extension ̶ as proposed in the Build Back Better Act ̶ then the number of Americans getting coverage for a full year postpartum would roughly double, extending coverage for an estimated 720,000 in a given year. Over half of pregnancy-related deaths occur immediately after delivery and up to one year postpartum.

The ARP’s option represents another tool in combatting disparities in maternal health driven by interruptions in postpartum care continuity and access. For a copy of the Medicaid State Health Official Letter on the postpartum extension option, please visit. Https://www.medicaid.gov/federal-policy-guidance/downloads/sho21007.pdf.

Each year in the U.S., approximately 700 women die from pregnancy-related complications, and over 25,000 experience severe complications of pregnancy. There are significant racial, ethnic, and geographic disparities in maternal morbidity and mortality as well. Black and American Indian/Alaska Native women die from pregnancy-related causes at a rate 2-3 times higher and experience severe complications at a rate nearly two times higher than their white, Asian Pacific Islander, and Hispanic counterparts.

Pregnant people who live in rural communities are at higher risk for severe maternal morbidity and about 60% more likely to die from pregnancy-related causes than those living in urban settings. However, two out of three pregnancy-related deaths are considered preventable. To see the Quality, Safety, and Oversight memo, please visit.

Https://www.cms.gov/files/document/qso-22-05-hospitals.pdf. ### Get CMS news at cms.gov/newsroom, sign up for CMS news via email and follow CMS on Twitter @CMSgov.

Start Preamble Centers kamagra tablets for sale uk for http://neocapital.com.ec/?page_id=2 Medicare &. Medicaid Services (CMS), HHS. Final rule kamagra tablets for sale uk.

Correction. This document corrects a typographic error that appeared in the final rule published in the Federal Register on November 8, 2021 entitled “Medicare Program. End-Stage Renal Disease Prospective Payment System, Payment for Renal Dialysis Services Furnished to Individuals With Acute Kidney Injury, End-Stage Renal Disease Quality Incentive Program, and End-Stage Renal Disease Treatment Choices kamagra tablets for sale uk Model.” This correction is effective January 1, 2022.

Start Further Info Start Printed Page 70983 ESRDPayment@cms.hhs.gov, for issues related to the ESRD PPS and coverage and payment for renal dialysis services furnished to individuals with AKI. ESRDApplications@cms.hhs.gov, for issues related to the Transitional Add-On Payment Adjustment for New and Innovative Equipment kamagra tablets for sale uk and Supplies (TPNIES). Delia Houseal, (410) 786-2724, for issues related to the ESRD QIP.

ETC-CMMI@cms.hhs.gov, for issues related to the ESRD Treatment Choices (ETC) Model. End Further kamagra tablets for sale uk Info End Preamble Start Supplemental Information I. Background In FR Doc.

2021-23907 of November 8, 2021 (86 FR 61874), there was a typographic error that is identified and corrected by the Correction of Errors section below. The correction in this document is effective as if it had been kamagra tablets for sale uk included in the document published November 8, 2021. Accordingly, the correction is effective January 1, 2022.

II. Summary of Error On page 61874, in the third sentence of the first column, we inadvertently left the number “412” in the CFR citation at the top of the document. Therefore, the number “412” should be deleted.

III. Waiver of Proposed Rulemaking We ordinarily publish a notice of proposed rulemaking in the Federal Register to provide a period for public comment before the provisions of a rule take effect in accordance with section 553(b) of the Administrative Procedure Act (APA) (5 U.S.C. 553(b)).

However, we can waive this notice and comment procedure if the Secretary finds, for good cause, that the notice and comment process is impracticable, unnecessary, or contrary to the public interest, and incorporates a statement of the finding and the reasons therefore in the notice. Section 553(d) of the APA ordinarily requires a 30-day delay in effective date of final rules after the date of their publication in the Federal Register. This 30-day delay in effective date can be waived, however, if an agency finds for good cause that the delay is impracticable, unnecessary, or contrary to the public interest, and the agency incorporates a statement of the findings and its reasons in the rule issued.

We believe that this correcting document does not constitute a rule that would be subject to the notice and comment or delayed effective date requirements. This document corrects a typographic error and does not make substantive changes to the policies or payment methodologies that were adopted in the final rule. Thus, this correcting document is intended to ensure that the information is accurately reflected in the final rule.

Even if this were a rulemaking to which the notice and comment and delayed effective date requirements applied, we find that there is good cause to waive such requirements. Undertaking further notice and comment procedures to incorporate the correction in this document into the calendar year (CY) 2022 End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) final rule or delaying the effective date of the correction would be contrary to the public interest because it is in the public interest to ensure that the rule accurately reflects our policies as of the date they take effect. Further, such procedures would be unnecessary because we are not making any substantive revisions to the final rule, but rather, we are simply correcting the Federal Register document to reflect the policies that we previously proposed, received public comment on, and subsequently finalized in the CY 2022 ESRD PPS final rule.

For these reasons, we believe there is good cause to waive the requirements for notice and comment and delay in effective date. IV. Correction of Errors In FR Doc.

2021-23907 of November 8, 2021 (86 FR 61874), make the following correction. On page 61874, in the first column. In the third sentence, remove the number “412” from the CFR citation.

Start Signature Karuna Seshasai, Executive Secretary to the Department, Department of Health and Human Services. End Signature End Supplemental Information [FR Doc. 2021-26914 Filed 12-13-21.

8:45 am]BILLING CODE 4120-01-PThe Centers for Medicare &. Medicaid Services (CMS) is taking critical steps to ensure pregnant and postpartum individuals have access to equitable, comprehensive maternity care. In support of Vice President Kamala Harris’ Call to Action to Reduce Maternal Mortality and Morbidity announced on December 7, 2021, CMS is encouraging hospitals to implement evidence-based patient safety practices for managing obstetric emergencies along with interventions to address other key contributors to maternal health disparities.“Becoming a parent in America should not mean risking lives – especially among low-income women, especially in communities of color,” said Health and Human Services Secretary Xavier Becerra.

€œI am proud that the Biden-Harris Administration is committed to addressing the nation’s crisis in pregnancy-related deaths and health disparities. At HHS, we will continue to ensure safe pregnancies and improve maternal health outcomes for all new parents.” “There is no greater priority than ensuring pregnant and postpartum individuals receive the best possible care, and the Biden-Harris Administration is committed to working with the provider community and beyond to make that happen,” said CMS Administrator Chiquita Brooks-LaSure. €œToo many individuals ̶ a disproportionate share of them people of color ̶ experience unnecessary pregnancy-related complications and deaths.

We must do everything we can to change that.” In support of delivering equitable, high-quality maternity care, CMS encourages hospitals to review their policies and procedures for incorporation, where appropriate, of best practices. One such evidence-based practice for improving patient safety and quality of care, referred to as “maternal safety bundles,” has been successful in driving improvements ̶ particularly with obstetric hemorrhage, severe hypertension in pregnancy, and non-medically indicated Cesarean deliveries. These bundles have also been associated with narrowing the racial disparity gap in certain perinatal outcomes.

Today’s guidance is the latest in a series of actions CMS has pursued to further advance the safety and quality of maternal care. As part of Vice President Harris’ recent Call to Action, CMS announced the intent to propose a designation to further drive hospital improvements in perinatal health outcomes and maternal health equity. Beginning on October 1, 2021, CMS adopted a new quality measure for the Hospital Inpatient Quality Reporting Program that asks hospitals to attest to whether they participate in a statewide or national perinatal quality improvement collaborative, and whether they have implemented patient safety practices or bundles to improve maternal outcomes.

Initially based on data reported by hospitals on this measure, and in combination with data reported by hospitals on other measures in the future, a hospital could receive a “Birthing-Friendly” designation on the CMS Care Compare website. This could not only further advance maternity care safety and quality, but also provide information to consumers and their families in a user-friendly way as they consider options for where to seek care. In addition, CMS encourages states to take advantage of the American Rescue Plan’s (ARP’s) option to provide 12 months of postpartum coverage to pregnant individuals who are enrolled in Medicaid or the Children’s Health Insurance Program (CHIP) beginning April 2022.

A recent report by HHS’ Office of the Assistant Secretary for Planning and Evaluation (ASPE) showed the dramatic impact if states extended Medicaid postpartum coverage to 12 months. If every state adopted an extension ̶ as proposed in the Build Back Better Act ̶ then the number of Americans getting coverage for a full year postpartum would roughly double, extending coverage for an estimated 720,000 in a given year. Over half of pregnancy-related deaths occur immediately after delivery and up to one year postpartum.

The ARP’s option represents another tool in combatting disparities in maternal health driven by interruptions in postpartum care continuity and access. For a copy of the Medicaid State Health Official Letter on the postpartum extension option, please visit. Https://www.medicaid.gov/federal-policy-guidance/downloads/sho21007.pdf.

Each year in the U.S., approximately 700 women die from pregnancy-related complications, and over 25,000 experience severe complications of pregnancy. There are significant racial, ethnic, and geographic disparities in maternal morbidity and mortality as well. Black and American Indian/Alaska Native women die from pregnancy-related causes at a rate 2-3 times higher and experience severe complications at a rate nearly two times higher than their white, Asian Pacific Islander, and Hispanic counterparts.

Pregnant people who live in rural communities are at higher risk for severe maternal morbidity and about 60% more likely to die from pregnancy-related causes than those living in urban settings. However, two out of three pregnancy-related deaths are considered preventable. To see the Quality, Safety, and Oversight memo, please visit.

Https://www.cms.gov/files/document/qso-22-05-hospitals.pdf. ### Get CMS news at cms.gov/newsroom, sign up for CMS news via email and follow CMS on Twitter @CMSgov.

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