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Trends in Pharmacologic Management of Hypertension in the United States

Trends in Pharmacologic Management of Hypertension in the United States Abstract Background: Two new classes of antihypertensive agents were introduced in the 1980s, but their effectiveness in preventing heart disease and stroke has not been demonstrated. Lack of evidence of their efficacy might reasonably be expected to discourage their widespread use in management of hypertension. Methods: Use of various classes of antihypertensive agents was estimated from published drug use information in an effort to estimate trends in antihypertensive drug use and evaluate the impact of these trends on costs of antihypertensive therapy in the United States. Results: Proportionate use of the five major antihypertensive drug classes shifted markedly between 1982 and 1993. Diuretics accounted for 56% of all hypertensive drug mentions in 1982 but only 27% in 1993, a relative decline of 52%. Use of β-blockers and central agents also declined during this period. Proportionate use of calcium antagonists showed the greatest gains, increasing from 0.3% to 27%, while the use of angiotensin-converting enzyme inhibitors increased from 0.8% to 24%. Given the higher costs of the newer agents, and assuming an estimated total cost of antihypertensive medications in 1992 of $7 billion, approximately $3.1 billion would have been saved had 1982 prescribing practices remained in effect in 1992. Conclusions: Use of calcium antagonists and angiotensin-converting enzyme inhibitors in hypertension has increased dramatically in the past 10 years. Without convincing evidence of the advantages of these agents, it is difficult to explain the continued decline in the use of less expensive agents, such as diuretics and β-blockers, which are the only antihypertensive agents proved to reduce stroke and coronary disease in hypertensive patients.(Arch Intern Med. 1995;155:829-837) References 1. National High Blood Pressure Education Program. The Fifth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med . 1993;153:154-183.Crossref 2. Stason WB. Cost and quality trade-offs in the treatment of hypertension. Hypertension . 1989;13( (suppl I) ):I-145—I-148.Crossref 3. Malcolm LA, Kawachi I, Jackson R, et al. Is the pharmacological treatment of mild to moderate hypertension cost effective in stroke prevention? N Z Med J . 1988;101:167-171. 4. Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. The 1988 Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med . 1988:48:1023-1038. 5. Treatment of Mild Hypertension Research Group. The Treatment of Mild Hypertension Study: a randomized, placebo-controlled trial of a nutritional-hygienic regimen along with various drug monotherapies. Arch Intern Med . 1991;151:1413-1423.Crossref 6. Diagnosis and Management of Hypertension: A Nationwide Survey of Physicians' Knowledge, Attitudes, and Reported Behavior . Washington, DC: US Dept of Health and Human Services; 1989. Publication 89-2968. 7. Gross TP, Wise RP, Knapp DE. Antihypertensive drug use: trends in the United States from 1973 to 1985. Hypertension . 1989;13( (suppl I) ):I-113—I-118.Crossref 8. IMS America. National Disease and Therapeutic Index . Ambler, Pa: IMS America; 1993. 9. World Health Organization. Manual of the International Classification of Diseases, Injuries, and Causes of Death . 1955 revision. Geneva, Switzerland: World Health Organization; 1957;1. 10. World Health Organization. Manual of the International Classification of Diseases, Injuries, and Causes of Death . 1975 revision. Geneva, Switzerland: World Health Organization; 1977;1. 11. Lilienfeld AM, Lilienfeld DE. Foundations of Epidemiology . 2nd ed. New York, NY: Oxford University Press; 1980:76-78. 12. 1992 Drug Topics Red Book . Oradell, NJ: Medical Economics Publishing; 1992. 13. Physicians' Desk Reference . 47th ed. Montvale, NJ: Medical Economics Data; 1993. 14. Menard J, Cornu P, Day M. Cost of hypertension treatment and the price of health. J Hum Hypertens . 1992;6:447-458. 15. Psaty BM, Savage PJ, Tell GS, et al. Temporal patterns of antihypertensive medication use among elderly patients. JAMA . 1993;270:1837-1841.Crossref 16. Dahlof B, Lindholm LH, Hansson L, Schersten B, Ekbom T, Wester PO. Morbidity and mortality in the Swedish Trial in Old Patients With Hypertension (STOP-Hypertension). Lancet . 1991;338:1281-1285.Crossref 17. SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension: final results of the Systolic Hypertension in the Elderly Program. JAMA . 1991;266: 3255-3264.Crossref 18. Medical Research Council Working Party. MRC trial of treatment in mild hypertension: principal results. BMJ . 1985;291:97-104.Crossref 19. Collins R, Peto R, MacMahon S, et al. Blood pressure, stroke, and coronary heart disease, part 2: short-term reductions in blood pressure: overview of randomized drug trials in their epidemiological context. Lancet . 1990;335:827-838.Crossref 20. Furberg CD, Cutler JA. Diuretic agents versus beta-blockers: comparisons of effects on mortality, stroke, and coronary events. Hypertension . 1989;13 ( (suppl I) ):I-57—I-61.Crossref 21. MRC Working Party. Medical Research Council trial of treatment of hypertension in older adults: principal results. BMJ . 1992;304:405-412.Crossref 22. Held PH, Yusuf S, Furberg CD. Calcium channel blockers in acute myocardial infarction and unstable angina: an overview. BMJ . 1989;299:1187-1192.Crossref 23. Yusuf S, Held P, Furberg C. Update of effects of calcium antagonists in myocardial infarction or angina in light of the second Danish Verapamil Infarction Trial (DAVIT-II) and other recent studies. Am J Cardiol . 1991;67:1295-1297.Crossref 24. Yusuf S, Wittes J, Friedman L. Overview of results of randomized clinical trials in heart disease, I: treatments following myocardial infarction. JAMA . 1988; 260:2088-2093.Crossref 25. The SOLVD Investigators. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med . 1991;325:293-302.Crossref 26. The SOLVD Investigators. Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. N Engl J Med . 1992;327:685-691.Crossref 27. Messerli FH, Oren S, Grossman E. Left ventricular hypertrophy and antihypertensive therapy. Drugs . 1988;35( (suppl 5) ):27-33.Crossref 28. Chobanian AV, Haudenschild CC, Nickerson C, et al. Anti-atherogenic effect of captopril in the Watanabe heritable hyperlipidemic rabbit. Hypertension . 1990; 15:327-331.Crossref 29. British Hypertension Society Working Party. Treating mild hypertension: agreement from the large trials. BMJ . 1989;298:694-698.Crossref 30. Zusman RM. Alternatives to traditional antihypertensive therapy. Hypertension . 1986;8:837-842.Crossref 31. O'Kelly BF, Massie BM, Tubau JF, Szlachcic J. Coronary morbidity and mortality, pre-existing silent coronary artery disease, and mild hypertension. Ann Intern Med . 1989;110:1017-1026.Crossref 32. National Heart, Lung, and Blood Institute. Report of the Task Force on Research in Hypertension . Bethesda, Md: US Dept of Health and Human Services, Public Health Service, National Institutes of Health; May 1991. 33. Oparil S. Antihypertensive therapy: efficacy and quality of life. N Engl J Med . 1993;328:959-961.Crossref 34. Lewis EJ, Hunsicker LG, Bain RP, Rohde RD. The effect of angiotensin converting enzyme inhibition in diabetic nephropathy. N Engl J Med . 1992;323: 1456-1462. 35. Marre M, Chatellier G, LeBlanc H, Guyene TT, Menard J, Passa P. Prevention of diabetic nephropathy with enalapril in normotensive diabetics with microalbuminuria. BMJ . 1988;297:1092-1095.Crossref 36. Materson BJ, Reda DJ, Cushman WC, et al, for the Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents. Single-drug therapy for hypertension in men. N Engl J Med . 1993;328:914-921.Crossref 37. Croog SH, Levine S, Testa MA, et al. The effects of antihypertensive therapy on the quality of life. N Engl J Med . 1986;314:1657-1664.Crossref 38. Multiple Risk Factor Intervention Trial Research Group. Baseline rest electrocardiographic abnormalities, antihypertensive treatment, and mortality in the Multiple Risk Factor Intervention Trial. Am J Cardiol . 1985;55:1-15.Crossref 39. Morgan DB, Davidson C. Hypokalemia and diuretics: an analysis of publications. BMJ . 1980;280:905-908.Crossref 40. Poole-Wilson PA. Diuretics, hypokalemia and arrhythmias in hypertensive patients: still an unresolved problem. J Hypertens . 1987;5( (suppl 3) ):S51-S55.Crossref 41. Rohlfing JJ, Brunzell JD. The effects of diuretics and adrenergic-blocking agents on plasma lipids. West J Med . 1986;145:210-218. 42. Grimm RH, Leon AS, Hunninghake DB, Lenz K, Hannan P, Blackburn H. Effect of thiazide diuretics on blood lipids and lipoproteins in mild hypertensive patients: a double-blind controlled trial. Ann Intern Med . 1981;94:7-11.Crossref 43. Lasser NL, Grandits G, Caggiula AW, et al. Effects of antihypertensive therapy on plasma lipids and lipoproteins in the Multiple Risk Factor Intervention Trial. Am J Med . 1984;76:52-66.Crossref 44. Weinberger MH. Antihypertensive therapy and lipids: evidence, mechanisms, and implications. Arch Intern Med . 1985;145:1102-1105.Crossref 45. Lehtonen JA. The effect of acebutolol on plasma lipids, blood glucose and serum insulin levels. Acta Med Scand . 1984;216:57-60.Crossref 46. Pollare T, Lithell H, Berne C. A comparison of the effects of hydrochlorothiazide and captropril on glucose and lipid metabolism in patients with hypertension. N Engl J Med . 1989;321:868-873.Crossref 47. Wassertheil-Smoller S, Blaufox D, Oberman A, et al, for the TAIM Research Group. Effect of antihypertensives on sexual function and quality of life: the TAIM Study. Ann Intern Med . 1991;114:613-620.Crossref 48. Siegel D, Hulley SB, Black DM, et al. Diuretics, serum and intracellular electrolyte levels, and ventricular arrhythmias in hypertensive men. JAMA . 1992; 267:1083-1089.Crossref 49. Papademetriou V, Burris JF, Notargiacomo A, Fletcher RD, Freis ED. Thiazide therapy is not a cause of arrhythmia in patients with systemic hypertension. Arch Intern Med . 1988;148:1272-1276.Crossref 50. Medical Research Council Working Party on Mild to Moderate Hypertension. Ventricular extrasystoles during thiazide treatment: substudy of MRC mild hypertension trial. BMJ . 1983;287;1249-1253. 51. Furberg CD, Byington RP. What do subgroup analyses reveal about differential response to beta-blocker therapy? Circulation . 1983;67( (suppl I) ):I-98—I-100. 52. Alderman MH. Which antihypertensive drugs first—and why! JAMA . 1992; 267:2786-2787.Crossref 53. Health Care Financing Administration. National health expenditures, 1991. Health Care Financ Rev . 1992;14:1-30. 54. Goodman LS, Gilman A, eds. The Pharmacologic Basis of Therapeutics . 5th ed. New York, NY: Macmillan Publishing Co Inc; 1975:44. 55. Third International Study of Infarct Survival (ISIS-3). A randomized comparison of streptokinase vs. tissue plasminogen activator vs. anistreplase and of aspirin plus heparin vs. aspirin alone among 41,299 cases of suspected acute myocardial infarction. Lancet . 1992;339:753-770.Crossref 56. Echt DS, Liebson PR, Mitchell LB, et al. Mortality and morbidity in patients receiving encainide, flecainide, or placebo: the Cardiac Arrhythmia Suppression Trial. N Engl J Med . 1991;324:781-788.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Trends in Pharmacologic Management of Hypertension in the United States

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Publisher
American Medical Association
Copyright
Copyright © 1995 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1995.00430080067009
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Abstract

Abstract Background: Two new classes of antihypertensive agents were introduced in the 1980s, but their effectiveness in preventing heart disease and stroke has not been demonstrated. Lack of evidence of their efficacy might reasonably be expected to discourage their widespread use in management of hypertension. Methods: Use of various classes of antihypertensive agents was estimated from published drug use information in an effort to estimate trends in antihypertensive drug use and evaluate the impact of these trends on costs of antihypertensive therapy in the United States. Results: Proportionate use of the five major antihypertensive drug classes shifted markedly between 1982 and 1993. Diuretics accounted for 56% of all hypertensive drug mentions in 1982 but only 27% in 1993, a relative decline of 52%. Use of β-blockers and central agents also declined during this period. Proportionate use of calcium antagonists showed the greatest gains, increasing from 0.3% to 27%, while the use of angiotensin-converting enzyme inhibitors increased from 0.8% to 24%. Given the higher costs of the newer agents, and assuming an estimated total cost of antihypertensive medications in 1992 of $7 billion, approximately $3.1 billion would have been saved had 1982 prescribing practices remained in effect in 1992. Conclusions: Use of calcium antagonists and angiotensin-converting enzyme inhibitors in hypertension has increased dramatically in the past 10 years. Without convincing evidence of the advantages of these agents, it is difficult to explain the continued decline in the use of less expensive agents, such as diuretics and β-blockers, which are the only antihypertensive agents proved to reduce stroke and coronary disease in hypertensive patients.(Arch Intern Med. 1995;155:829-837) References 1. National High Blood Pressure Education Program. The Fifth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med . 1993;153:154-183.Crossref 2. Stason WB. Cost and quality trade-offs in the treatment of hypertension. Hypertension . 1989;13( (suppl I) ):I-145—I-148.Crossref 3. Malcolm LA, Kawachi I, Jackson R, et al. Is the pharmacological treatment of mild to moderate hypertension cost effective in stroke prevention? N Z Med J . 1988;101:167-171. 4. Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. The 1988 Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med . 1988:48:1023-1038. 5. Treatment of Mild Hypertension Research Group. The Treatment of Mild Hypertension Study: a randomized, placebo-controlled trial of a nutritional-hygienic regimen along with various drug monotherapies. Arch Intern Med . 1991;151:1413-1423.Crossref 6. Diagnosis and Management of Hypertension: A Nationwide Survey of Physicians' Knowledge, Attitudes, and Reported Behavior . Washington, DC: US Dept of Health and Human Services; 1989. Publication 89-2968. 7. Gross TP, Wise RP, Knapp DE. Antihypertensive drug use: trends in the United States from 1973 to 1985. Hypertension . 1989;13( (suppl I) ):I-113—I-118.Crossref 8. IMS America. National Disease and Therapeutic Index . Ambler, Pa: IMS America; 1993. 9. World Health Organization. Manual of the International Classification of Diseases, Injuries, and Causes of Death . 1955 revision. Geneva, Switzerland: World Health Organization; 1957;1. 10. World Health Organization. Manual of the International Classification of Diseases, Injuries, and Causes of Death . 1975 revision. Geneva, Switzerland: World Health Organization; 1977;1. 11. Lilienfeld AM, Lilienfeld DE. Foundations of Epidemiology . 2nd ed. New York, NY: Oxford University Press; 1980:76-78. 12. 1992 Drug Topics Red Book . Oradell, NJ: Medical Economics Publishing; 1992. 13. Physicians' Desk Reference . 47th ed. Montvale, NJ: Medical Economics Data; 1993. 14. Menard J, Cornu P, Day M. Cost of hypertension treatment and the price of health. J Hum Hypertens . 1992;6:447-458. 15. Psaty BM, Savage PJ, Tell GS, et al. Temporal patterns of antihypertensive medication use among elderly patients. JAMA . 1993;270:1837-1841.Crossref 16. Dahlof B, Lindholm LH, Hansson L, Schersten B, Ekbom T, Wester PO. Morbidity and mortality in the Swedish Trial in Old Patients With Hypertension (STOP-Hypertension). Lancet . 1991;338:1281-1285.Crossref 17. SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension: final results of the Systolic Hypertension in the Elderly Program. JAMA . 1991;266: 3255-3264.Crossref 18. Medical Research Council Working Party. MRC trial of treatment in mild hypertension: principal results. BMJ . 1985;291:97-104.Crossref 19. Collins R, Peto R, MacMahon S, et al. Blood pressure, stroke, and coronary heart disease, part 2: short-term reductions in blood pressure: overview of randomized drug trials in their epidemiological context. Lancet . 1990;335:827-838.Crossref 20. Furberg CD, Cutler JA. Diuretic agents versus beta-blockers: comparisons of effects on mortality, stroke, and coronary events. Hypertension . 1989;13 ( (suppl I) ):I-57—I-61.Crossref 21. MRC Working Party. Medical Research Council trial of treatment of hypertension in older adults: principal results. BMJ . 1992;304:405-412.Crossref 22. Held PH, Yusuf S, Furberg CD. Calcium channel blockers in acute myocardial infarction and unstable angina: an overview. BMJ . 1989;299:1187-1192.Crossref 23. Yusuf S, Held P, Furberg C. Update of effects of calcium antagonists in myocardial infarction or angina in light of the second Danish Verapamil Infarction Trial (DAVIT-II) and other recent studies. Am J Cardiol . 1991;67:1295-1297.Crossref 24. Yusuf S, Wittes J, Friedman L. Overview of results of randomized clinical trials in heart disease, I: treatments following myocardial infarction. JAMA . 1988; 260:2088-2093.Crossref 25. The SOLVD Investigators. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med . 1991;325:293-302.Crossref 26. The SOLVD Investigators. Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. N Engl J Med . 1992;327:685-691.Crossref 27. Messerli FH, Oren S, Grossman E. Left ventricular hypertrophy and antihypertensive therapy. Drugs . 1988;35( (suppl 5) ):27-33.Crossref 28. Chobanian AV, Haudenschild CC, Nickerson C, et al. Anti-atherogenic effect of captopril in the Watanabe heritable hyperlipidemic rabbit. Hypertension . 1990; 15:327-331.Crossref 29. British Hypertension Society Working Party. Treating mild hypertension: agreement from the large trials. BMJ . 1989;298:694-698.Crossref 30. Zusman RM. Alternatives to traditional antihypertensive therapy. Hypertension . 1986;8:837-842.Crossref 31. O'Kelly BF, Massie BM, Tubau JF, Szlachcic J. Coronary morbidity and mortality, pre-existing silent coronary artery disease, and mild hypertension. Ann Intern Med . 1989;110:1017-1026.Crossref 32. National Heart, Lung, and Blood Institute. Report of the Task Force on Research in Hypertension . Bethesda, Md: US Dept of Health and Human Services, Public Health Service, National Institutes of Health; May 1991. 33. Oparil S. Antihypertensive therapy: efficacy and quality of life. N Engl J Med . 1993;328:959-961.Crossref 34. Lewis EJ, Hunsicker LG, Bain RP, Rohde RD. The effect of angiotensin converting enzyme inhibition in diabetic nephropathy. N Engl J Med . 1992;323: 1456-1462. 35. Marre M, Chatellier G, LeBlanc H, Guyene TT, Menard J, Passa P. Prevention of diabetic nephropathy with enalapril in normotensive diabetics with microalbuminuria. BMJ . 1988;297:1092-1095.Crossref 36. Materson BJ, Reda DJ, Cushman WC, et al, for the Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents. Single-drug therapy for hypertension in men. N Engl J Med . 1993;328:914-921.Crossref 37. Croog SH, Levine S, Testa MA, et al. The effects of antihypertensive therapy on the quality of life. N Engl J Med . 1986;314:1657-1664.Crossref 38. Multiple Risk Factor Intervention Trial Research Group. Baseline rest electrocardiographic abnormalities, antihypertensive treatment, and mortality in the Multiple Risk Factor Intervention Trial. Am J Cardiol . 1985;55:1-15.Crossref 39. Morgan DB, Davidson C. Hypokalemia and diuretics: an analysis of publications. BMJ . 1980;280:905-908.Crossref 40. Poole-Wilson PA. Diuretics, hypokalemia and arrhythmias in hypertensive patients: still an unresolved problem. J Hypertens . 1987;5( (suppl 3) ):S51-S55.Crossref 41. Rohlfing JJ, Brunzell JD. The effects of diuretics and adrenergic-blocking agents on plasma lipids. West J Med . 1986;145:210-218. 42. Grimm RH, Leon AS, Hunninghake DB, Lenz K, Hannan P, Blackburn H. Effect of thiazide diuretics on blood lipids and lipoproteins in mild hypertensive patients: a double-blind controlled trial. Ann Intern Med . 1981;94:7-11.Crossref 43. Lasser NL, Grandits G, Caggiula AW, et al. Effects of antihypertensive therapy on plasma lipids and lipoproteins in the Multiple Risk Factor Intervention Trial. Am J Med . 1984;76:52-66.Crossref 44. Weinberger MH. Antihypertensive therapy and lipids: evidence, mechanisms, and implications. Arch Intern Med . 1985;145:1102-1105.Crossref 45. Lehtonen JA. The effect of acebutolol on plasma lipids, blood glucose and serum insulin levels. Acta Med Scand . 1984;216:57-60.Crossref 46. Pollare T, Lithell H, Berne C. A comparison of the effects of hydrochlorothiazide and captropril on glucose and lipid metabolism in patients with hypertension. N Engl J Med . 1989;321:868-873.Crossref 47. Wassertheil-Smoller S, Blaufox D, Oberman A, et al, for the TAIM Research Group. Effect of antihypertensives on sexual function and quality of life: the TAIM Study. Ann Intern Med . 1991;114:613-620.Crossref 48. Siegel D, Hulley SB, Black DM, et al. Diuretics, serum and intracellular electrolyte levels, and ventricular arrhythmias in hypertensive men. JAMA . 1992; 267:1083-1089.Crossref 49. Papademetriou V, Burris JF, Notargiacomo A, Fletcher RD, Freis ED. Thiazide therapy is not a cause of arrhythmia in patients with systemic hypertension. Arch Intern Med . 1988;148:1272-1276.Crossref 50. Medical Research Council Working Party on Mild to Moderate Hypertension. Ventricular extrasystoles during thiazide treatment: substudy of MRC mild hypertension trial. BMJ . 1983;287;1249-1253. 51. Furberg CD, Byington RP. What do subgroup analyses reveal about differential response to beta-blocker therapy? Circulation . 1983;67( (suppl I) ):I-98—I-100. 52. Alderman MH. Which antihypertensive drugs first—and why! JAMA . 1992; 267:2786-2787.Crossref 53. Health Care Financing Administration. National health expenditures, 1991. Health Care Financ Rev . 1992;14:1-30. 54. Goodman LS, Gilman A, eds. The Pharmacologic Basis of Therapeutics . 5th ed. New York, NY: Macmillan Publishing Co Inc; 1975:44. 55. Third International Study of Infarct Survival (ISIS-3). A randomized comparison of streptokinase vs. tissue plasminogen activator vs. anistreplase and of aspirin plus heparin vs. aspirin alone among 41,299 cases of suspected acute myocardial infarction. Lancet . 1992;339:753-770.Crossref 56. Echt DS, Liebson PR, Mitchell LB, et al. Mortality and morbidity in patients receiving encainide, flecainide, or placebo: the Cardiac Arrhythmia Suppression Trial. N Engl J Med . 1991;324:781-788.Crossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Apr 24, 1995

References