Public Service Loan Forgiveness Program

Melissa Luechtefeld, Doctor of Pharmacy Candidate Class of 2015 University of Missouri-Kansas City School of Pharmacy at MU

Melissa Luechtefeld, Doctor of Pharmacy Candidate Class of 2015
University of Missouri-Kansas City School of Pharmacy at MU

Do you have one of the following Direct Loan Program loans?1,2

  • Federal Direct Stafford/Ford Loans (Direct Subsidized Loans)
  • Federal Direct Unsubsidized Stafford/Ford Loans (Direct Unsubsidized Loans)
  • Federal Direct PLUS Loans (Direct PLUS Loans)—for parents and graduate or professional students

o   Parents may qualify for forgiveness of the PLUS loan if the parent borrower is employed by a public service organization, regardless of the student’s employer

  • Federal Direct Consolidation Loans (Direct Consolidation Loans)

Do you work for or plan to work full-time for one of the following public service organizations?1,2

  • Serving in a full-time AmeriCorps or Peace Corps position
  • A government organization, including a federal, state, local, or tribal organization, agency, or entity; a public, child, or family service agency; or a tribal college or university
  • A not-for-profit, tax exempt organization under section 501(c)(3) of the Internal Revenue Code
  • A private, not-for-profit organization (that is not a labor union or a partisan political organization) that provides one or more of the following public services:

o   Emergency management

o   Military service

o   Public safety

o   Law enforcement

o   Public interest law services

o   Early childhood education (including licensed or regulated health care, Head Start, and state-funded pre-kindergarten)

o   Public service for individuals with disabilities and the elderly

o   Public health (including nurses, nurse practitioners, nurses in a clinical setting, and full-time professionals engaged in health care practitioner occupations and health care support occupations)

o   Public education

o   Public library services

o   School library or other school-based services

If you answered yes to the two questions above, you are eligible for the Public Service Loan Forgiveness (PSLF) Program. This program was created to encourage individuals to seek employment full-time in public service jobs.

Facts about PSLF1,2

  • Participants will qualify for loan forgiveness:

o   After making 120 qualifying payments after October 1, 2007 on their loans

  • Since 120 payments must be made, the first forgiveness of loan balances will not be granted until October 2017

o   If employed full-time, as defined by employer and at least an annual average of 30 hours per week, not including time spent participating in religious instruction, worship services, or any form of proselytizing, by one of the above public service employers:

  • When making each of the 120 qualifying payments;
  • At the time of application for loan forgiveness; and
  • At the time the remaining balance on the eligible loans is forgiven
  • Part-time employment in more than one qualifying job simultaneously may meet the full-time requirement if a combined average of at least 30 hours per week are fulfilled

o   As long as loans for which forgiveness is requested are not in default

  • The program is available only for loans made and repaid under the Direct Loan Program. Other loans can become eligible for forgiveness if they are consolidated into a Direct Consolidation Loan, and only payments made on the Direct Consolidation Loan will count toward the 120 qualifying payments. The following loans can be consolidated:

o   Federal Family Education Loan (FFEL) Program loans, which include

  • Subsidized Federal Stafford Loans
  • Unsubsidized Federal Stafford Loans
  • Federal PLUS Loans—for parents and graduate or professional students
  • FFEL Consolidation Loans (excluding joint spousal consolidation loans)

o   Federal Perkins Loans

o   Certain Health Professions and Nursing Loans

  • Note: “To consolidate a Federal Perkins Loan or Health Professions or Nursing Loan into a Direct Consolidation Loan, you also must consolidate at least one FFEL Program loan or Direct Loan. If you are unsure about what kind of loans you have, check the U.S. Department of Education’s (ED’s) National Student Loan Data System (NSLDS) at www.nslds.ed.gov2

Specific Loan Repayment Requirements for Forgiveness under PSLF1,2

  • Qualifying payments are those made for the full scheduled installment amount no later than 15 days after the scheduled due date; the 120 required payments do not need to be made consecutively.
  • The 120 required payments must be made under one or more of the following Direct Loan Program

Repayment plans:

o   Income-Based Repayment (IBR) Plan (not available for Direct PLUS Loans made to parents or for Direct Consolidation Loans that repaid Direct or FFEL PLUS Loans made to parents)

o   Pay As You Earn Plan (not available for Direct PLUS Loans made to parents or for Direct Consolidation Loans that repaid Direct or FFEL PLUS Loans made to parents)

o   Income Contingent Repayment (ICR) Plan (not available for Direct PLUS Loans made to parents; however, Direct Consolidation Loans that repaid Direct or FFEL PLUS loans made to parents may be repaid under ICR)

o   10-Year Standard Repayment Plan

o   Any other Direct Loan Program repayment plan; but only payments that are at least equal to the monthly payment amount that would have been required under the 10-Year Standard Repayment Plan may be counted toward the required 120 payments

  • Note: Forgiveness of the remaining balance of a borrower’s eligible loans after the borrower has made 120 qualifying payments on these loans will be granted by the PSLF Program. On average, only borrowers making reduced monthly payments through the IBR, Pay As You Earn, or ICR repayment plans will have a remaining balance after the 120 payments are made on a loan.

How to Apply and Keep Track of Eligibility1,2

  • Complete the Employment Certification for Public Service Loan Forgiveness form, including employer’s certification of employment

o   Monitors progress toward making the 120 qualifying payments necessary to apply for PSLF

o   Allows completion of employer’s certification of employment while still working at the organization or shortly after leaving to confirm qualifying employment and Direct Loan payment eligibility

o   A list by state of eligible employers is not available; use this form to verify employment eligibility, or for a preliminary check, inquire with human resources to see if the organization meets the public service requirements previously listed

  • Submit the Employment Certification for Public Service Loan Forgiveness form annually to FedLoan Servicing, the PSLF servicer, at the address listed in Section 6 of the Employment Certification form

o   Submission can be done less frequently than annually to cover more than one year’s employment or for more than one employer

o   Periodic use of this form is not required, but highly suggested to help keep track of progress toward meeting PSLF eligibility requirements

o   If the form is not submitted periodically, submission of a form for each qualifying employer at the time of application for the forgiveness and when forgiveness is granted will be required

  • After the 120th qualifying payment is made, submit the PSLF application to receive loan forgiveness.

o   This application is currently under development, as the first borrowers will become eligible for forgiveness in October 2017

  • For more details on the PSLF Program, click here.

 

Melissa Luechtefeld, Doctor of Pharmacy Candidate Class of 2015
University of Missouri-Kansas City School of Pharmacy at MU

References

  1. Federal Student Aid. Public Service Loan Forgiveness. https://studentaid.ed.gov/repay-loans/forgiveness-cancellation/charts/public-service. Accessed October 10, 2014.
  2. Federal Student Aid. Public Service Loan Forgiveness Program. https://studentaid.ed.gov/sites/default/files/public-service-loan-forgiveness.pdf. December 2013. Accessed October 10, 2014.

 

Medicare Part D Late Enrollment Penalty

Melissa Luechtefeld, Pharm.D. Candidate 2015, UMKC School of Pharmacy, Columbia Campus

Melissa Luechtefeld, Pharm.D. Candidate 2015, UMKC School of Pharmacy, Columbia Campus

At the age of 65, patients become eligible for Medicare coverage, and with this eligibility comes pages upon pages of paperwork describing plan options, how to sign up, and rules and restrictions related to coverage. This can be particularly confusing for elderly patients with low health literacy, or those who are not tech savvy or do not have access to electronic versions of plan information to begin with. Vital pieces of information can easily be missed.

For patients turning 65 who are in good general health and take only over-the-counter medications along with one or two prescription medications daily, they may have opted out of Medicare Part D prescription drug coverage when they enrolled in a Medicare Part A and B plan. If the patient’s prescription medications are all on the $4 drug list at their retail pharmacy, their yearly out of pocket costs may have been significantly lower than the premium for a Medicare Part D plan.

What these patients may not have realized is when Part D drug coverage began in 2006, a penalty for late enrollment was initiated as well. This penalty is applicable if at any time after their initial enrollment period ends there is a span of 63 or more days in a row when the patient does not have Medicare Part D or any other creditable prescription drug coverage. The cost of this penalty depends on how long creditable prescription drug coverage was absent, and once calculated, it is then added to the patient’s Medicare Part D premium. For patients who are part of the Extra Help program, the late enrollment penalty does not apply. Extra Help is a Medicare program for those with limited income and resources; this program provides patients with assistance paying drug program costs including premiums, deductibles, and coinsurance.1

Creditable prescription drug coverage refers to coverage from a current or former employer or union that is expected to pay an average of at least as much as Medicare’s standard prescription drug coverage. If the patient has this kind of coverage at the time they become eligible for Medicare, they can keep their coverage without having to pay a penalty upon deciding to switch to Medicare Part D later. Patients already enrolled in Medicare had until the end of their Part D initial enrollment period in 2006 to sign up for a Part D program without incurring a penalty. Plans should update patients yearly in a letter or newsletter informing them whether or not their coverage is considered creditable. Patients should be advised to keep this correspondence because they may need it if they try to join a Medicare drug plan down the road. When patients newly join a Medicare drug plan, they will received a letter if it is believed they went 63 days in a row without drug coverage. This letter will provide them with an opportunity to inform Medicare about their past creditable drug coverage, avoiding penalty fees if criteria are successfully met.1-3

The cost of the penalty is calculated by multiplying 1 percent of the “national base beneficiary premium,” or the average of all Part D plans nationwide in any given year ($32.42 in 2014 and $33.13 in 2015), by the number of full, uncovered months the patient was eligible but did not join a Medicare Prescription Drug Plan or did not have creditable coverage. After rounding to the nearest $0.10, the penalty is added t­­­o the patient’s monthly premium. After joining a Part D plan, the plan will tell the patient if they owe a penalty and what their premium will be. Patients will pay this premium for as long as they have a Medicare drug plan.1-3

For patients who do not agree with their late enrollment penalty, an appeal process exists. A reconsideration request form will be sent to the patient by their Medicare drug plan. Proof that supports their case, such as information about previous creditable prescription drug coverage, can be submitted to ratify the appeal.

It is impossible to predict exactly when taking out prescription drug coverage will be more cost-effective for patients over the age of 65 versus paying cash for generic medications, as each patient’s healthcare needs are unique. Nevertheless, it is important to consider the longer patients wait to enroll in a prescription plan after they become eligible for Medicare, the higher the penalty, as the national base beneficiary premium is trending upward each year.

Pharmacist awareness of the late enrollment penalty is beneficial because retail pharmacists who see patients over the age of 65 paying cash for their monthly medications have the perfect opportunity to make an intervention. Oftentimes these patients will be asking for price-matching and closely watching how much they are charged each month. Pharmacists can ask these patients about their healthcare coverage, specifically if they have Medicare Part A and B, and then they can educate these patients on prescription coverage options, explain the late enrollment penalty, and direct patients to Medicare.gov for more information on ways to avoid penalties and maximize the use of their money. Affordable medication leads to increased adherence, improved chronic disease state management, a healthier patient population, and an opportunity for pharmacists to achieve their goal of providing optimal patient-centered care.

Melissa Luechtefeld, Doctor of Pharmacy Candidate Class of 2015
University of Missouri-Kansas City School of Pharmacy at MU

Sources:

  1. Centers for Medicare & Medicaid Services. What’s the Part D late enrollment penalty? http://www.medicare.gov/part-d/costs/penalty/part-d-late-enrollment-penalty.html. Accessed October 2, 2014.
  2. Centers for Medicare & Medicaid Services. The Part D Late Enrollment Penalty. http://www.cms.gov/Outreach-and-Education/Outreach/Partnerships/downloads/11222-P.pdf. January 1, 2014. Accessed October 2, 2014.
  3. Barry P. (2008). Paying for the Part D Late Penalty. AARP Bulletin. Retrieved from http://www.aarp.org/health/medicare-insurance/info-12-2008/ask_ms_medicare_paying_for_the_part_d_late_penalty.html.

 

How to Put Together a Successful Pharmacy Health Fair Booth

Written by Molly Norburg, PBA Health18507383_ml

So you decided to register your independent pharmacy for a local health fair? You’ll want to assemble a first-rate booth for the event. With a little preparation, you can put together a successful and memorable presentation that brings in new patients. If you’re willing to put in the work ahead of time, you’ll find everything will go more smoothly on the big day. Use these three steps to put together a successful health fair booth.

1. Start by setting a goal

First, it’s important to establish an objective. Do you want to attract new patients? Educate participants? Promote a specific service? Pinpointing what you want to achieve, as well as the type of person you want to engage, will result in a more coordinated, and ultimately successful, plan of action for the event.

2. Set strategies to meet your goal

Next, decide how you will execute that plan. There are countless ways to engage passerby at health fairs, but that doesn’t mean you should use all of them. While you may be tempted to cram all kinds of information or entertainment onto your table, a cluttered booth can actually repel attendees and make it difficult for you to deliver your message. Instead, hone in on just a few facets you want to promote. Need some ideas? Try these.

Get hands-on

Patients often only associate pharmacists with prescription filling. Destroy that barrier by getting hands-on with visitors at the health fair. Provide brown bag medication reviews or mini health screenings for glucose levels, blood pressure or cholesterol. These quick services offer valuable health information to passerby and also establish your credibility as a health care expert.

Run a promotion

Use the allure of a promotion and free products at the health fair to engage potential patients. Hand out coupons to drive visitors to your front end. Coordinate a raffle for a $100 gas card to add names, phone numbers or email addresses to your mailing list. Run a giveaway of free branded products, like water bottles or key chains, to draw maximum attention to your booth. You could also run a social media campaign at the health fair where every person who ‘likes’ your Facebook page or follows your Twitter receives a freebie gift.

Use visuals

Stand out from the crowd with eye-catching visuals, like a colorful branded poster or tablecloth. Then, capture the curiosity of attendees by offering a glimpse into your pharmacy’s everyday operations. Do a mock demonstration of compounding (using common kitchen ingredients) or counting medication. Show off your bubble packaging or branded prescription bottles. Replace drugs with candy for a fun twist.

Deliver information

Hand out brochures that showcase your pharmacy and the services you offer. You can put together an array of brochures on anything from “Getting To Know Your Community Pharmacy” to “The Importance of Local Business.” Providing straightforward information is a great option for more introverted pharmacists who still want to deliver a message. You could also do Medicare Part D reviews (check out a great tool for this) and hand out information about the negative affects of mail order to showcase the vital services independents provide.

3. Put it all together

When the day of the health fair arrives, put all your planning in motion. Multiple staff members should man your booth, if possible. This ensures that you’re prepared in the event of bathroom breaks or rush periods. Dress professionally and uniformly. The white coat can be a great attention-grabber, but branded polos or dress shirts are also a good option. It’s often helpful to memorize and be comfortable with a short introduction or conversation starter so when participants walk by, you aren’t at a loss for words.

All in all, do your best to radiate a positive, energetic mood. If you appear friendly and engaging, attendees will feel more inclined to approach your booth and benefit from your hard work.

This post was originally published by PBA Health, a pharmacy services organization based in Kansas City, Mo. View the original article here.

Since September is Falls Prevention Awareness Month, it is a great time to hold a health fair and falls screenings in your area. Visit MORx.com for tips and tools for holding falls screenings.

Prescription Drug Abuse

Jennifer Richter, Pharm.D. Candidate 2015, UMKC School of Pharmacy, Columbia Campus

Jennifer Richter, Pharm.D. Candidate 2015, UMKC School of Pharmacy, Columbia Campus

With the FDA recently reporting about the rescheduling of hydrocodone combination products to CII, it brings attention to a topic that is an increasing problem: prescription drug abuse. In 2011 alone, the Centers for Disease Control and Prevention (CDC) reported that “about 1.4 million emergency department visits involved the nonmedical use of pharmaceuticals,” with many of the medications reported as anti-anxiety, insomnia, and benzodiazepines.1 The CDC also reports that prescription opioid abuse costs the US around $55.7 billion annually in lost productivity, healthcare costs, and criminal justice costs.1 In Missouri, health care providers are writing 95 pain killer prescriptions per 100 people, which in relation to the rest of the US, is average.1 Even more disturbing, in 2010, one in every 20 people over the age of 12 reported using prescription painkillers without a medical need.

Young Adults

Prescription drug abuse affects people of all ages, and is something that is difficult to predict. A survey conducted in 2010 by the Substance Abuse and Mental Health Services Administration (SAMHSA) concluded that people ages 12-25 years report the highest incidence of nonmedical prescription drug use.2 The same survey showed that “2.7% of 8th graders, 7.7% of 10th graders, and 8.0% of 12th graders had abused Vicodin.”2 While this might contribute to the argument that the rescheduling of hydrocodone products will eliminate this problem, the SAMHSA survey also has some statistics about OxyContin, which currently has the same CII scheduling that hydrocodone containing products will occupy; in fact “2.1% of 8th graders, 4.6% of 10th graders, and 5.1% of 12th graders” had experimented with OxyContin according to the 2010 survey.2 This may indicate that the scheduling of these medications does not limit access as it should.

Medicaid Fraud

A review of five states (California, Illinois, New York, North Carolina, and Texas) conducted by the Government Accountability Office in 2006 and 2007 “found 65,000 instances of Medicaid beneficiaries improperly obtaining potentially addictive drugs at a cost of about $63 million.”2 The same survey also found thousands of instances in which prescriptions were written for patients that were dead or were called in by people posing as prescribers.2 One area where rescheduling hydrocodone products may help is prescription fraud. As a CII, prescribers and nurses may no longer call in prescriptions for hydrocodone products, and handwritten prescriptions must be brought into the pharmacy in order to be filled. Patients may also be “locked-in” with pharmacies in order to be sure patients do not fill prescriptions at multiple locations however, “doctor-shopping” may still occur; and without a prescription drug monitoring program, the full extent of abuse may not be recognized.

Prescription Drug Monitoring Program

49 out of 50 states in the United States have implemented an operational Prescription Drug Monitoring Program (PDMP); Missouri is the last state withholding from the national movement of creating a program that would make illicit use and abuse of controlled substances much more difficult. The aim of a PDMP is to help with the legitimate prescribing of controlled substances, to prevent diversion and/or abuse, and to identify public trends in use and abuse of controlled prescriptions.3 Having a state-wide system that logs dispensed controlled substances allows for prescribers and pharmacists alike to have knowledge of their patients’ filling habits, and would also allow for suspicious activity to be checked by health professionals. The fact that Missouri is alone in having no operational PDMP makes us susceptible to illegal activity within our own borders; it also creates access for patients crossing state-lines to take advantage of the lack of oversight. Although many of the opponents of a PDMP fear the invasion of privacy that a logging system imposes, the implications of increased drug abuse and misuse and the need to continue the legitimate prescribing of medications used in chronic pain should impede those fears.

Without a PDMP in place, physicians and pharmacists lack information that would help the fight against prescription drug abuse, and patients who use those same medications for a legitimate purpose are scrutinized because of controlled substance use. Missouri needs to take a step in the right direction, and join the rest of the nation by putting a PDMP in place to put a damper on prescription drug abuse.

Jennifer Richter, PharmD Candidate 2015
University of Missouri – Kansas City, MU site
MPA Rotation Student, August 2014

References:

  1. Centers for Disease Control and Prevention. Prescription drug overdose. http://www.cdc.gov/homeandrecreationalsafety/overdose/index.html. July 3, 2014. Accessed August 27, 2014.
  2. Kirschner N, Ginsburg J, Sulmasy LS. Prescription drug abuse: executive summary of a policy position paper from the American college of physicians. Annals of Int Med. 2014; 160(3) 198-213.
  3. Drug Enforcement Agency. Prescription drug monitoring program: questions and answers. http://www.deadiversion.usdoj.gov/faq/rx_monitor.htm. October 2011. Accessed August 28, 2014.

The Million Hearts Initiative

MPA Jennifer Richter

MPA rotation student Jennifer Richter.

 

Cardiovascular disease is the leading cause of death in America with around 800,000 deaths yearly.1 Americans also suffer from over 2 million heart attacks or strokes every year, and the damage is nearly $444 million dollars to our health care system and losses in productivity.1 Therefore, in 2011, the Department of Health and Human Services and several federal, state, and local agencies collaborated on the Million HeartsTM initiative to target cardiovascular disease.1 The goal is to use both clinical and community interventions to prevent a total of 1 million heart attacks and strokes by 2017.2 This goal works in concert with the American Heart Association’s much more aggressive goal of preventing approximately 4 million cardiac events by 2020.2 These lofty goals show how important it is to collaborate on health quality measures with other professionals for the benefits of our patients.

The aim of the Million HeartsTM initiative is to impassion patients to care for their own heart health through healthy diet, exercise, and medication adherence, and to also get clinicians to target guideline indicated goals for measures of heart health.1 The Centers for Disease Control and Prevention (CDC) is recommending the use of four markers to promote better health: aspirin use when indicated, blood pressure control, cholesterol control, and smoking cessation (ABCS).1 The initiative also attempts to enhance health through policies: improvement of clinician reporting of goal-directed measures within the Physician Quality Reporting System, increasing insurance coverage of preventive services, and distribution of grant funding to implement local services to reduce chronic diseases through education and screenings.2 This is a massive undertaking for these agencies and requires the work of every health care professional to ensure all targets are met.

Several organizations in Missouri have teamed-up with the Million HeartsTM campaign, including the American Heart Association, the American Stroke Association, the Missouri Department of Health and Senior Services, the Missouri Primary Care Association, Primaris, and your very own Missouri Pharmacy Association.3 They have worked together to create some guidance on how providers and pharmacists can help achieve the 2017 goal. Since community pharmacists do not have access to health records and labs, it’s important not to over-step the physician-patient relationship when trying to assess medications for individual patients. However, pharmacists should be available for open conversations with patients about goal achievements, the meaning of blood pressure and cholesterol numbers, diet and exercise, and barriers to medication adherence.3

  • Appropriate aspirin use: Aspirin use is not for everyone and the benefits must be weighed against the risks for every individual patient. The US Services Preventive Task Force has issued a recommendation on aspirin use that is gender and age specific.4 Many patients will pick aspirin up from over the counter, and this can be an important discussion to have with a patient, who can then discuss the recommendation with their doctor.
  • Hypertension: According to the CDC, 1/3 of all Americans have hypertension, which equates to nearly 67 million people, and only 47% of those have their blood pressure under control.5 It is important for pharmacists to be educated on the new hypertension treatment guidelines to offer the most up to date information when needed by prescribers. It is also imperative to spend time with patients who need help controlling blood pressure. Some patients may need help with medication adherence and taking medications at the proper time of day. Some patients may not be able to understand what the diagnosis of hypertension really means or how it can affect their health. Other patients may need that extra push into incorporating a healthy diet and aerobic exercise into their daily routine. Whatever the issue, increased time with our patients allows our patients to realize that we are willing to help them, which will increase the likelihood of their return and willingness to discuss their health.
  • Hyperlipidemia: According to the CDC, 71 million Americans have been diagnosed with high LDL and only 1/3 of those patients have their condition controlled. New guidelines for cholesterol management were released in 2013, and it’s important to note that these guidelines have done away with targeted goals and have suggested statins for first-line use.7 With this is mind, pharmacists should be ready to indicate the previous goals and to supplement physician knowledge with the new guidelines and how these differ. These are also important to take into account for discussions with patients, as their medications may have recently changed without much preamble from their doctor to reflect the new guidelines. As with hypertension, indicating proper diet, exercise, and medication adherence is appropriate for these patients as well.
  • Smoking cessation: In 2011, the CDC reports that 19% of the adult population were smokers.8 Studies have shown that even a brief clinical encounter with a patient discussing smoking cessation increases the rate of successful cessation by 50%.1 Pharmacists should be prepared to offer counseling sessions and insight to nicotine replacement products to assist patients in a difficult journey. It’s important to familiarize yourself with the tools at your disposal to assist your patients in becoming ready to quit.

Using the ABCS that have been set forward by the Million HeartsTM initiative, health care professionals can assist and empower patients to better care for their own health in a way that is manageable. More opportunities exist for pharmacists and physicians who are looking for other ways to expand the reach of the Million HeartsTM campaign, because together, we’ve got a million hearts to save.

Jennifer Richter, PharmD Candidate 2015
University of Missouri – Kansas City, MU site
MPA Rotation Student, August 2014

References:

  1. Freiden T, Berwick D. The Million HeartsTM initiative: Preventing heart attacks and strokes. N Engl J Med. 2011; 365:e27.
  2. Tomaselli GF, Harty M, Horton K, Schoeberl M. The American Heart Association and the Million HeartsTM initiative: a presidential advisory from the American Heart Association. Circulation. 2011; 124:1795-1799.
  3. Primaris. Million HeartsTM in Missouri pharmacy champion role. http://www.heart.org/idc/groups/heart-public/@wcm/@mwa/documents/downloadable/ucm_461052.pdf. June 2012. Accessed August 15, 2014.
  4. US Preventive Services Task Force. Aspirin for the Prevention of Cardiovascular Disease, Topic Page. http://www.uspreventiveservicestaskforce.org/uspstf/uspsasmi.htm. October 2013. Accessed August 18, 2014.
  5. Centers for Disease Control and Prevention. High blood pressure facts. http://www.cdc.gov/bloodpressure/facts.htm. July 7, 2014. Accessed August 18, 2014.
  6. Centers for Disease Control and prevention. Cholesterol fact sheet. http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_cholesterol.htm. July 26, 2013. Accessed August 18, 2014.
  7. Stone NJ, Robinson J, Lichtenstein AH, Bairey Merz CN, Lloyd-Jones DM, Blum CB, McBride P, Eckel RH, Schwartz JS, Goldberg AC, Shero ST, Gordon D, Smith Jr SC, Levy D, Watson K, Wilson PWF. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults. Circulation. 2013.
  8. Centers for Disease Control and Prevention. Trends in current cigarette smoking among high school students and adults, United States, 1965–2011. http://www.cdc.gov/tobacco/data_statistics/tables/trends/cig_smoking/index.htm. November 14, 2013. Accessed August 18, 2014.