Infection Control Costs

Infection Control Costs - 10 Years Post-OSHA, March '99

Contents:

  1. Summary of Infection Control Costs - How much is spent on infection control per patient?
    1. What are infection control costs now, and who is bearing the cost?
    2. What has, and has not, changed due to OSHA regulations?
    3. What are some future challenges related to infection control costs?
  2. Disposable Infection Control Item Costs - Detailed chart outlines costs for disposable items
  3. Reusable Infection Control Costs - Detailed chart outlines costs for reusable items

Ten years have passed since dental clinicians first heard the term "OSHA Guidelines". The "Guidelines" later became U.S. law (Bloodborne Pathogen Standard). Although dentists’costs for compliance was a major issue, thorough & accurate cost analyses were absent. Instead dentists received expert "estimates" that differed so significantly it was impossible to know who, or what, to believe. In answer to many requests, CRA published a detailed cost analysis for infection control products, plus a listing of products with confirmed efficacy documented by CRA testing (May ‘92 CRA Newsletter).  CRA encouraged dentists to perform their own cost analysis by critiquing CRA’s numbers & adding costs for time staff spent performing infection control tasks, renovation of sterilization centers, & other office-specific costs.  Report below updates clinicians 10 years post-OSHA on 3 critical questions:

  1. What are infection control costs now, and who is bearing the costs?
  2. What has and has not changed due to OSHA regulations?
  3. What are some future challenges related to infection control costs?

 

1. Summary of infection control product costs

Chart below reports cost per patient of infection control products using suggested retail pricing, which is uniform throughout U.S. Costs of some products may be reduced by quantity purchases, special promotions, &/or different profit margins among distributors.

Pages 3-4 list products included in numbers below & show calculations.   To adapt costs to your office, do the following:

  1. Highlight products on pages 3-4 you use;
  2. Cross out products you do not use;
  3. Add products you use that are not listed;
  4. Add columns

Chart on page 3 provides the form needed to compute disposable item costs & chart on page 4 gives form for reusable item costs.

Summary of infection control product costs:
(based on 15 patients per day, 5 days per week, 48 weeks per year)

 

Cost Per
One Patient

Cost Per
15 Patient Day

Cost Per
75 Patient Week

Cost Per
300 Patient Month

Cost Per
3600 Patient Year

Costs for 1
Primary Care Clinician
(DDS or DH)

$9.31

$139.65

$698.25

2793

$33,516

Costs for 1
Person Assisting
DDS or DH

87˘

$13.05

$65.25

$261

$3,132

NOTE: Amounts in above table are not adjusted to reflect costs for: (1)Staff time &/or special infection control personnel; (2)Remodeling of sterilization area; & (3)Taxes, shipping, installation, or utilities. 

SUMMARY OF CHART: Cost of products used by 1 primary care clinician (DDS or DH) treating 1 patient is $9.31 per patient. Additional cost per patient for each assistant to the primary care clinician is 87˘. Therefore, cost per patient treated by 1 dentist & 1 dental assistant is $10.18.

Who is bearing Costs?

Ultimately, today patients & dentists are paying infection control costs. Most fee-for-service practices were forced long ago to raise fees to cover infection control costs. If third party payment groups pay at all, most pay only token amounts. Some have been unwilling to increase procedure allowances, calling infection control costs the dentist’s responsibility as a "cost of doing business". Although some third party payment groups allow direct billing for infection control costs, patients are hostile to "extra" charges, & often do not remit.

2. What has changed and what has not changed due to OSHA regulations?

 

Changed

   

Not Changed

A. Clinician’s appearance - Changed to face masks, eye protection, gloves, & clothing that does not resemble street clothes.   A. Lack of research & evidence for concepts, & products used in the concepts - Fear of legal issues if infections were tied to procedures or products has stymied research.
B. Operatory’s appearance - Changed by barriers, cleared countertops, & few decorative adornments.   B. Number & complexity of procedures - Dental assistant’s time is still challenged significantly by the many procedures necessary between patients to renew the operatory for the next patient.
C. Infection control center - Is enlarged & a busy hub of activity.   C. No efficacy testing & grading of infection control products- CRA tests show most infection control products fail to deliver protection expected & promised, jeopardizing safety of both patients & clinicians.
D. Increasing number of items sterilized or covered with barriers, rather than "wiped" with disinfectant - Handpieces & attachments & suction valves (notable exception is air-water syringe).   D. No standardization of procedures - Time, effort, & money could be saved by standardizing techniques, & stipulating yearly certification, similar to CPR program.
E. Less use of "cold sterilization".   E. No manufacturing standards for products requiring disinfection &/or sterilization - 10 years later dentists continue to be victims of handpieces not upgraded for sterilization; impression materials that cannot be disinfected without distortion; & dental units, chairs, & cabinetry that do not tolerate efficacious disinfectants.
F. Increasing number of single-patient use items - Almost all restorative & preventive products can now be found in single-use packaging, which can help control organism transfer between patients, but increases costs & waste.   F. Infection control leaders who lack clinical experience & basic science qualifications, yet dictate policies, procedures & product use - "Hands-on" experience in both clinical practice & microbiology research is critical to avoid serious leadership errors.
G. Industry attitude toward problems once dismissed as insignificant - Control of dental unit waterline colonization is now viewed as a new business opportunity.   G. Lack of full report on all healthcare workers infected with HIV. Clear definition of all criteria used to delete each case from the total count needed.
H. Infection control products have become significant income for industry. - Products itemized in this report show gross income to industry of $4.7 billion per year for dentists alone!   H. Denial of infectivity of HIV by Americans with Disabilities Act, after CDC & OSHA declared HIV a dangerous & infectious bloodborne pathogen
I. Open hostility by dentists to increased time & costs dissipated to resignation. - Patient demands for infection control compelled adoption.      


3. What are some future challenges related to infection control costs?

A. ADDITIONAL REQUIREMENTS FROM STATE OSHA’S — National OSHA has made no additions to the Bloodborne Pathogen Standard since enactment in Dec. ‘91. However, some state OSHA’s have added substantially to the national requirements, & are continuing to do so. (Today, state OSHA’s exist in 23 states & 2 territories. They can add to, but not subtract from, national requirements. Contact OSHA or CRA for listing of state OSHA’s).

B. DENTAL UNIT WATERLINE TREATMENT is not part of OSHA requirements or the Bloodborne Pathogen Standard. In Dec. ‘95, the American Dental Association's Board of Trustees set a goal of >200 cfu/ml in dental unit water by the year 2000 to encourage industry to provide solutions to this long standing problem. However, entrepreneurs keep trying to shift responsibility to the dentists, so they can transform a flaw in dental equipment design into a lucrative business. Dentists need to resist intimidation, & insist on a one-time permanent fix from the companies who sold them their dental units flawed in design by many feet of small diameter water lines which cause the high colony counts in the water. Published research confirms industry has been aware of this problem for +30 years & has chosen not to correct it.

C. DENTAL HANDPIECE REPAIR continues to be a major infection control cost, 10 years later, even though technology is available today to minimize the problems. What can be done to encourage handpiece companies to make durable handpieces that require no lubrication by clinicians, when present flaws & lubricant sales bring in over $100 million every year?

D. INFECTION CONTROL IS BIG BUSINESS. This report demonstrates that infection control products have become a major income source for dental industry ($33,500 per year x 140,000 dentists in the U.S. = about $4.7 billion per year just for infection control products used by dentists alone). These numbers indicate there will be pressure to continue infection control at present level indefinitely, & expand it if possible. Since they are paying for it dearly, it is valid for clinicians & patients to expect all infection control products to achieve their intended function. Yet testing shows clearly that almost all infection control products fail to meet expectations & promotional claims, in spite of costs.

CRA CONCLUSIONS:
Data in this report indicate cost for infection control products alone is about $9.31 for a DDS or DH working without a dental assistant. Costs are increased about 87˘ per patient for each dental assistant. These costs do not include the significant cost of staff time to perform infection control procedures. For a 240 day work year, treating 15 patients per day costs of over $33,500 are incurred for products used by dentists alone. Today, patients & dentists are bearing costs. Significant additional costs are possible due to additional requirements by state OSHA’s & dental unit waterline upgrades, if dental equipment companies do not assume responsibility for microbial colonization due to their unit’s design flaw.


Disposable Infection Control Item Costs
(Calculated for 1 clinician or 1 patient.)

A.
PRODUCT CATEGORY
(listed in alphabetical order)

B.
BRAND†

C.
PURCHASE§
SOURCE

D.
SOURCE
TELEPHONES

E.
PACKAGED PRICING
& COST PER ITEM

F.
AMOUNT NEEDED

G.
COST PER PATIENT

1. BAG, BIOHAZARD

Stick-on Bag
Unimed-Midwest

Schein

800-372-4346
516-843-5500

$18.99 / 100 9"x10" bags
($0.19 each)

1 / patient

19˘

2. BAG, BIOHAZARD

Infectious Waste
Disposal Systems, Winfield

Schein

800-372-4346
516-843-5500

$46.89 / 250 25"x34" bags
($0.19 each)

1 / day

1˘

3. BARRIER, ADHESIVE FILM SHEETS (LIGHT, HANDLES, SWITCH, EQUIP. CONTROLS)

Cover-all
Pinnacle

Darby

800-448-7323
954-978-3055

$20.95 / 1200 4"x6" sheets
($0.02 each)

8 / patient

16˘

4. BARRIER, HOSE COVER

Silverware Bags

National Bag

800-247-6000
330-425-2600

$52.80 / 5000 3 1/2"x10" covers
($0.01 each)

6 / patient

6˘

5. BARRIER, PATIENT BIB w/o ALLIGATOR CLIP

Sani-Tab Chain-Free
Crosstex

Schein

800-372-4346
516-843-5500

$27.99 / 400 bibs
($0.07 each)

1 / patient

7˘

6. BARRIER, PATIENT CHAIR ARMS

Saran Wrap

Local grocery
or discount stores

-

$2.17 / 250 sq. ft.
($0.01 / sq. ft., 1.5 sq. ft. / arm)

2 / patient

3˘

7. BARRIER, PATIENT CHAIR BACK

Garment Bags

National Bag

800-247-6000
330-425-2600

$45.80 / 510 21"x4"x38" bags
($0.09 each)

1 / patient

9˘

8. BARRIER, TREATMENT TRAY COVER

Tray Cover Sleeves
Patterson

Patterson

800-328-5536
612-686-1600

$17.95 / 500 covers
($0.04 each)

2 / patient

8˘

9. BARRIER, X-RAY TUBE COVER

Garment Bags

National Bag

800-247-6000
330-425-2600

$45.80 / 510 21"x4"x38" bags
($0.09 each)

1 / patient

9˘

10. CLEANER, VACUUM LINE

Purevac
Sultan

Schein

800-372-4346
516-843-5500

$49.99 / 118 uses
($0.42 / use)

1 / patient

42˘

11. DISINFECTANT, ENVIRONMENTAL SURFACE

Lysol Spray

Local grocery
or discount stores

-

$3.78 / 18 oz can
($0.21 / oz @ .07 oz / sq. ft.)

40 sq. ft. / patient

59˘

12. DISINFECTANT, PRE-TREATMENT MOUTHRINSE

Pro-Select
0.12% chlorhexidine

Pro-Dentec

800-228-5595
870-698-2300

$4.95 / 16 oz bottle
($0.31 / oz, 2 rinses @ 1/2 oz each)

1 / patient

31˘

*13. EYE PROTECTION, PATIENT

Rollens

Rollens

800-898-7474
303-840-2238

$35.00 / 100 lenses
($0.35 each)

1 / patient

35˘

*14. FACE MASK

Magic Arch

Alpha ProTech

800-749-1363
520-281-0127

$18.00 / 50 masks
($0.36 each)

1 / clinician

36˘

15. GLOVES, OPERATING

Latex Exam Gloves

Ammex

800-274-7354
425-251-4000

$5.95 / 100 gloves
($0.06 each)

2 / clinician

12˘

16. GLOVES, PLASTIC

Copolymer Utility Glove

Schein

800-372-4346
516-843-5500

$5.49 / 100 gloves
($0.05 each)

1 / day

1˘

*17. HANDWASH, CHLORHEXIDINE

Bactoshield

Steris Corporation

800-444-9009
440-354-2600

$34.75 / 128 oz bottl
($0.27 / oz, 1/4 oz / wash)

2 / clinician

14˘

18. MONITOR, 1 CHEMICAL VAPOR STERILIZER & 1 STEAM STERILIZER

Economy Mail-in Sterilizer Monitoring - SPS Medical

Schein

800-372-4346
516-843-5500

$164.79 / 52 tests
($3.17 / test plus 33˘ postage)

2 tests / week

9˘

19. MONITOR, GLUTARALDEHYDE

Cidex
J&J

Schein

800-372-4346
516-843-5500

$15.99 / 15 strip bottle
($1.07 / strip)

1 strip / 2 days

4˘

20. NEEDLE RECAPPER

"Scoop technique"
requires no product

-

-

-

-

0

*21. PAPER TOWELS

Bounty

Local grocery
or discount stores

-

$5.74 / 8 rolls of 96 sheets
($0.01 / square)

7 squares / clinician

7˘

22. PROPHY ANGLE, DISPOSABLE

Allpro

Allpro

800-243-2285
303-466-8911

$158.00 / 500 angles
($0.32 each)

1 / patient

32˘

23. PUMICE, PREDOSE  DISPENSING FOR DENTURE CLEANING

Flour of Pumice

Patterson

800-328-5536
612-686-1600

$3.50 / 1 lb
($0.22 / oz 1/8 lb / denture)

1 / denture

3˘

24. RUBBER DAM

Heavy weight 6x6

Coltene / Whaledent

800-221-3046
201-512-8000

$13.03 / 36 dams
($0.36 / dam)

1 / patient

36˘

25. SPONGE, 4"X4" GAUZE FOR USE WITH ENVIRONMENTAL
      SURFACE DISINFECTANT

Nu-Gauze
J&J

Schein

800-372-4346
516-843-5500

$9.99 / 200 sponges
($0.05 each)

4 / patient

20˘

26. STERILIZATION, BAG OR POUCH

Schein

Schein

800-372-4346
516-843-5500

$10.49 / 3 1/2"x9" bags
($0.05 each)

2 / patient

10˘

27. STERILIZATION, CASSETTE WRAP

Autoclave Wrap
Fox Converting

Patterson

800-328-5536
612-686-1600

$47.30 / 500 20"x20" sheets
($0.09 / sheet & 1 sheet / cassette)

1 / patient

9˘

28. TIP, HIGH VELOCITY SUCTION

Patterson

Patterson

800-328-5536
612-686-1600

$1.65 / 50 tips
($0.03 each)

1 / patient

3˘

29. TIP, SALIVA EJECTOR

Super-Dent Deluxe

Darby

800-448-7323
954-978-3055

$2.65 / 100 tips
($0.03 each)

1 / patient

3˘

30. TRAP, DISPOSABLE HIGH VELOCITY SUCTION

Evac-U-Trap
Pinnacle

Schein

800-372-4346
516-843-5500

$80.99 / 12 traps
($6.75 / trap)

1 trap / 75 patients

9˘

31. WASTE DISPOSAL, SHARPS

Mail Sharps Medical Waste

Sharps
Compliance

800-772-5657
713-432-0300

$58.95 / three 1-gallon containers
($19.65 / container)

1 / 300 patients

7˘

TOTAL COST
AT INITIAL PURCHASE

$1,010.32

TOTAL COST
PER PATIENT

$4.60

* Items needed for person(s) assisting primary care DDS or DH.
† Brands listed were selected based on quality at reasonable cost.
§ Purchase sources listed were selected based on national availability at reasonable cost.

 

Reusable Infection Control Item Costs
(Calculated for 1 clinician or 1 patient.)

A.
Product Category
(Listed in alphabetical order)

B.
Brand

C.
Purchase Source

D.
Source Telephones

E.
Cost Per Item

F.
†Mfr. Estimated Use-Life With Reasonable Care

G.
Cost of Upkeep
Per Day

H.
Cost Per Day

I.
‡Cost Per Patient

1. AIR PURIFIER (IN 1 OPERATORY)

Fantom

Clestra Cleanroom

800-253-7872
315-452-5200

$759 each

1920 days (Motor rated for 8 years)

$0.33 (Prefilter changed every 2 months & HEPA filter every 5 years)

73˘

5˘

*2. BARRIER PROTECTIVE CLOTHING (FLUID RESISTANT)

Clinic Jacket

Pro-Safe Prof. Linens

888-881-4497
970-245-7870

$32.80 each

240 days

$0.20 (Detergent for 1 automatic washer load / day)

34˘

2˘

3. CASSETTE INSTRUMENT

Stainless Steel
Instr. Cassette

Tuttnauer USA

800-624-5836
516-737-4850

$73.99 each (4 1/2 " x 8 1/2" x 1 1/2")

1680 days
(7 year warranty)

None

4˘

1˘

4. CLEANER, ULTRASONIC

T13.7C
(3.5 gallon)

Health Sonics

800-342-3096
925-455-7899

$1218.50 each (includes unit lid & basket)

2400 days
(10 years)

$4.78 (Daily change of 6 oz detergent cleaner concentrate @ 80˘ / oz)

$5.29

35˘

*5. CONTINUING EDUCATION

State and local professional organizations - one infection control course per year.

$200 each
($100 tuition & $100 time)

240 days

None

83˘

6˘

6. DISINFECTANT CONTAINER

EuroTray

Darby

800-448-7323
954-978-3055

$49.75 each

960 days
(4 years)

None

5˘

1˘

7. DISINFECTANT, INSTRUMENT IMMERSION

Protec-Top

Darby

800-448-7323
954-978-3055

$14.95 / 128 oz bottle (12˘ / oz)

28 days

None

53˘

4˘

8. DISINFECTION,. WATERLINE

Odyssey I

Tuttnauer USA

800-624-5836
516-737-4850

$1295 each

2400 days
(10 years)

$0.99 (Silver catalyst, ozone generator, o-rings, 1L distilled H2O/ day)

$1.53

10˘

9. DRYER INSTRUMENT

Sahara

SciCan USA

800-572-1211
412-281-6780

$1230 each

2400 days
(10 years)

None

51˘

3˘

10. DISPENSER VACUUM LINE CLEANER

Turbo-Vac Dispenser Pinnacle

Patterson

800-328-5536
612-686-1600

$30.25 each

1200 days
(5 years)

None

3˘

1˘

*11. EYE PROTECTION, CLINICIAN

Googles Eye Glasses

Schein

800-372-4346
516-843-5500

$0.88 each frame (10 pk)
$0.56 each lens (100 pk)

20 days = frames
1 day = lenses

None

60˘

4˘

12. FOOT CONTROLS, WATER

Double Foot Control

Kohler

800-456-4537

$289.25 each

4800 days
(20 years)

None

6˘

1˘

13. GARBAGE CAN WITH LID

Rubbermaid

Rubbermaid

800-347-9800
540-667-8700

$67.16 each
(8 gal capacity)

1200 days
(5 years)

None

6˘

1˘

14. GLOVES, NITRILE UTILITY

Asep-Gluv Health Sonics

Patterson

800-328-5536
612-686-1600

$5.32 / pair
($2.66 / glove)

10 days
(Sterilized 15x / day)

None

53˘

4˘

15. HAND ANTISEPTIC DISPENSER, AUTOMATIC

Sure Shot

Herrco

800-522-3678
914-486-0150

$99 each

480 days
(2 year warranty)

None

21˘

1˘

16. HANDPIECE CLEANER / LUBRICATOR

Assistina

Adec

800-547-1883
503-538-7478

$1720 each

200 days
(Lifetime - 30 yrs)

$0.52 (Filters, oil & cleaner)

76˘

5˘

17. HANDPIECE, HIGH SPEED 430 SWL

StarBrite LF

DentalEZ-Star

800-275-3320
717-291-1161

$825 each
(w/o swivel)

240 days
(Sterilized 2.5x/day)

None

$16.50

$1.10

18. HANDPIECE, HIGH SPEED REPAIR 430 SWL

StarBrite LF

DentalEZ-Star

800-275-3320
717-291-1161

$299 each

240 days
(Sterilized 2.5x/day)

None

$1.99

13˘

19. HANDPIECE, LOW SPEED

Rhino XP w/ motor sheath & latch head

Dentsply / Midwest

800-800-7202
847-640-4800

$1035 each
(motor, sheath, & latch head)

240 days
(Sterilized 2.5x/day)

None

$20.70

$1.38

20. HANDPIECE, LOW SPEED PROPHY

Straight Handpiece Kit

Lares

800-347-3289
530-345-1767

$419 each

240 days
(Sterilized 2.5x/day)

None

$6.29

42˘

21. HANDPIECE, LOW SPEED REPAIR SERVICE

Rhino XP

Dentsply / Midwest

800-800-7202
847-640-4800

$249 / moto
$57 / strait sheath
$72 / latch head

Motor @ 600 days, sheath @ 360 days, head @ 240 days (Sterilized 2x / day)

None

$4.37

29˘

22. RUBBER DAM, CLAMP

Clamp set (NW, PW, A, L, E, C)

Dentsply Preventive Care

800-989-8826
717-767-8502

$10.85 each

240 days
(1 year)

None

5˘

1˘

23. RUBBER DAM, INSTRUMENT

Punch #01251 Forceps #01252

Coltene / Whaledent

800-221-3046
201-512-8000

$99 each punch
$55 each forceps

1200 days
(5 years)

None

13˘

1˘

24. STERILIZER, CHEMICAL VAPOR

Chemiclave 5500

EC Barnstead / Thermolyne

800-553-0039
319-556-2241

$4238 each

2400 days
(10 years @ 4 uses / day)

$1.90 ($1 Vapo-Steril; 32˘ filter; 10˘ cleaning supplies; & 48˘ liners)

$3.67

24˘

25. STERILIZER, STEAM

StatIM 2000

SciCan USA

800-572-1211
412-281-6780

$4350 each

2400 days
(10 years @ 10 uses / day)

$1.15 (30˘ distilled H2O; 85˘ for gasket replacement)

$2.96

20˘

26. TIP, AIR WATER SYRINGE (METAL REUSABLE)

Syringe Tips Adec - 5 pk

Patterson

800-328-5536
612-686-1600

$5.39 each
($26.95 / 5 pk)

400 days
(Sterilized 3x / day)

None

7˘

1˘

*27. VIDEO TECHNIQUE

Professional organizations & private companies

$100 each

480 days
(2 years)

None

21˘

1˘

*28. VACCINE, HEPATITIS

Recombivax HB

Merck & Co.

800-637-2579
215-652-5000

$157 / 3 dose vial
(injection cost extra)

7200 days
(Lifetime CDC -no booster recommended)

1/2˘ (Cost of antibody titer analysis once / lifetime @ $40 / test)

3˘

1˘

*29. VACCINE, INFLUENZA

Flushield

Wyeth / Lederle Labs.

800-358-7443

$8 each

240 days (1 year)

None

3˘

1˘

30. VALVE, SALIVA EJECTOR

Autoclavable Saliva Valve

Den-Serv-Co / Dent. Dynamics

800-873-7403
719-597-9070

$26 each
(stainless steel)

7200 days
(Lifetime- 30 years)

$0.03 (50˘ / o-ring every 3 mo & $4.50 rubber end 1x / year)

3˘

1˘

31. VALVE, SUCTION

Vacuum Valve

Den-Serv-Co / Dent. Dynamics

800-873-7403
719-597-9070

$30 each
(stainless steel)

7200 days
(Lifetime - 30 years)

$0.01 (50˘ / o-ring every 3 mo)

1˘

1˘

32. WASHER & DRYER, CLOTHES

Kenmore

Sears

Local stores

$968 / set of washer & dryer

2400 days
(10 years)

None

40˘

3˘

TOTAL COST AT INITIAL PURCHASE $20,174.57

TOTAL COST PER PATIENT

$4.71

†  1 year = 240 days, allowing 1 month vacation plus weekends off work.
‡  Cost per use per patient is total cost amortized over estimated use-life, & depreciation is not included.
*  Items needed for person(s) assisting primary care DDS or DH.

Products published in the CRA Newsletter have been selected on the basis of merit from hundreds of products under evaluation. CRA conducts research at 3 levels: (1) Multiple-user field evaluations, (2) Controlled long-term clinical research, & (3) Basic science laboratory research. Over 400 clinical field evaluators are located throughout the world & 48 full-time employees work at the institute. All professional staff volunteer their time. Neither the Director nor the Evaluators receives a salary. A product must meet at least one of the following standards to be reported in this publication: (1) Innovative & new on the market; (2) Less expensive, but meets the use standards; (3) Unrecognized, valuable classic; & (4) Superior to others in its broad classification. Your results may differ from CRA Evaluators or other researchers on any product because of differences in preferences, techniques, batches of products, & environments. CRA is a non-profit corporation using a unique volunteer structure to produce objective, factual data. All proceeds are used to support the work of CRA & the CRA Foundation, a tax exempt foundation. This Newsletter or portions thereof may not be duplicated without permission of CLINICAL RESEARCH ASSOCIATES. Annual English subscription $52 in U.S. & $54 (U.S. Funds) in other languages &/or countries, or $5 per issue.

 

Copyright © 1998 Clinical Research Associates. All rights reserved.
Revised: May 13, 1999.