Language, Literacy, and Communication

199
Language, Literacy, and Communication
Regarding Medication in an Anticoagulation
Clinic: Are Pictures Better Than Words?
Dean Schillinger, Edward L. Machtinger, Frances Wang, Lay-Leng Chen,
Karen Win, Jorge Palacios, Maytrella Rodriguez, Andrew Bindman
Abstract
Objective: Despite the importance of clinician-patient communication for safe
medication management, little is known about rates and predictors of medication
miscommunication. Measuring rates of miscommunication, as well as differences
between verbal and visual modes of assessment, can inform efforts to more
effectively communicate about medications. Methods: The researchers performed
a study among long-term warfarin users in an anticoagulation clinic to assess
concordance between patient and clinician reports of patient warfarin regimens.
Bilingual research assistants asked patients to (1) verbalize their prescribed
weekly warfarin regimen, and (2) identify this regimen from a digitized color
menu of warfarin pills. The researchers obtained clinician reports of patient
regimens from chart review. Patients were categorized as having regimen
concordance if there were no patient-clinician discrepancies in total weekly
dosage. Quantitative differences in concordance to the regimen were assessed
verbally or visually. The researchers then examined whether verbal and visual
concordance rates varied with the patient’s language and level of health literacy.
Results: Fifty percent of patients achieved verbal concordance and 66 percent
achieved visual concordance with clinicians regarding the weekly warfarin
regimen (P < 0.001). In adjusted models, being a Cantonese speaker and having
inadequate health literacy were associated with a lower odds ratio for verbal
concordance compared to being an English speaker and having adequate health
literacy (adjusted odds ratio [AOR] = 0.44, 95% confidence interval [CI] =
0.21–0.93, P = 0.03 and AOR = 0.50, 95% CI = 0.26–0.99, P = 0.04,
respectively). Neither language nor health literacy was associated with visual
discordance. Conclusion: Clinician-patient discordance regarding patients’
warfarin regimen was common, but occurred less frequently when patients
identified their regimen with a visual aid. Visual aids may improve the accuracy
of medication assessment and may be especially beneficial for patients with
communication barriers.
Introduction
Clinician-patient communication regarding medications is a fundamental
aspect of health care. Clinicians often need to adjust regimens based on their
assessment of what the patient has been taking and the health status of the patient.
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Drugs, such as oral anticoagulants, that have a narrow therapeutic window and
require long-term management with frequent dose adjustments require intensive
communication. Studies in ambulatory settings have demonstrated that
medication-related errors are common.1
Among older patients, oral anticoagulants
are associated with 10 percent of preventable adverse drug events.2
Effective
communication regarding medications can help avoid medication-related errors3, 4
and has been shown to promote medication adherence in chronic diseases.5
Little is known about the quality of clinician-patient communication regarding
medications or predictors of medication miscommunication. Studies in internal
medicine and cardiology private practices have found discrepancies between selfreported and chart-recorded medication dosages in more than half of patients on at
least one medication.4, 6 Among HIV-infected patients, approximately 25 percent
have a discordance between reports of their antiretroviral regimen and what is
recorded in the medical chart.7, 8 In these studies, age,6
regimen complexity,4, 7
and limited health literacy8
were associated with greater discordance. While not
all discordance is directly attributable to poor clinician-patient communication,
inadequate communication has been shown to predict discordance.4

We are unaware of any study that evaluated rates of medication discordance in
anticoagulant care. Because discordance between patient and clinician could put
patients at risk for poor outcomes, we carried out a study to determine rates of
clinician-patient concordance with a prescribed warfarin regimen. Given the
prevalence and implications of limited English proficiency9–11 and limited health
literacy, particularly among the elderly12 and patients with chronic conditions,13
we also set out to measure whether concordance rates vary by patients’ English
language fluency and health literacy. Since there is evidence in other settings that
clinician-patient communication improves with visual aids,14, 15 we also explored
whether concordance rates vary when patients report their regimen verbally or
identify their regimen by use of a visual aid. This research could influence
adherence assessment and medication counseling in routine clinical practice16, 17
and inform interventions to reduce medication-related errors.1
Methods
Setting and study participants
We enrolled patients in a cardiologist-supervised, pharmacist-staffed
anticoagulation clinic at San Francisco General Hospital (SFGH), the University
of California–San Francisco (UCSF)-affiliated public hospital of the City and
County of San Francisco. This clinic serves patients who are ethnically diverse
and of low socioeconomic status. For non-English speakers, professional
interpreter services are generally available.10 The majority of decisions regarding
anticoagulant care are made by anticoagulation clinic pharmacists via a standard
algorithm. Patients do not perform home International Normalized Ratio (INR)
self-testing. Samples for INR tests are drawn by hospital phlebotomists prior to
anticoagulation clinic visits; all values are entered into the hospital’s electronic
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201
database. After each visit, clinic pharmacists document the patient’s updated
regimen and indication for warfarin in the database, which also generates a paper
template for the medical record.
Between March 2002 and June 2003, bilingual research assistants attempted
to enroll all eligible patients who attended an anticoagulation clinic appointment.
Consent to participate was obtained from patients prior to enrollment. Patients
were offered $5.00 for their participation. Patients were eligible if they were more
than 17 years old and spoke English, Spanish, or Chinese (Cantonese) fluently.
We first determined patients’ languages and diagnoses by querying the hospital’s
database. To isolate the impact of communication barriers on regimen
concordance from factors due to inexperience with warfarin or differences in
practice style or setting, we only included patients who reported being on warfarin
and under the care of the SFGH anticoagulation clinic for at least 3 months. We
excluded patients with any ICD-9 diagnosis of psychotic disorder, dementia,
blindness, or aphasia; those who were too ill to participate; or those who had
corrected vision of 20/100 or worse, as these conditions could interfere with
health literacy and concordance measurements. We also excluded patients who
were using warfarin preparations not on the SFGH or Medicaid formulary (as we
would be unable to accurately measure visual concordance with warfarin
preparations for which we had no digitized visual menu), patients who reported
being colorblind, and patients who had “medi-sets” or pillboxes filled by health
professionals. The protocol was approved by the UCSF Human Subjects
Committee and SFGH Research Committee.
Measures
Trained bilingual research assistants interviewed patients in the
anticoagulation clinic prior to their appointment.
Predictor variables
Research assistants obtained subjects’ demographic characteristics, including
each subject’s primary language and English fluency. Patients who reported
speaking English fluently were categorized as English speakers, regardless of
their primary language. For English and Spanish speakers, we measured health
literacy using the abbreviated version of the short-form Test of Functional Health
Literacy in Adults (s-TOFHLA, English and Spanish versions), a reliable,
validated measure of health-related literacy.13, 18–20 Using established convention,
we categorized patients as having inadequate FHL if the s-TOFHLA score was 0
to 16, marginal FHL if it was 17 to 22, and adequate FHL if it was 23 to 36.21
Because health literacy and patient recall may be influenced by unmeasured or
undiagnosed cognitive deficits,22, 23 we measured cognitive ability using the
Cognitive Abilities Screening Instrument, shortened version (s-CASI).24 The
s-CASI has been validated in international dementia studies, does not require
literacy,25 and has been shown to accurately measure cognition cross-culturally,
including among Asian-language speakers.26 We used an established cutoff of
≤19 points to categorize patients as having cognitive impairment.
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We obtained patients’ indications for chronic anticoagulation from an
anticoagulation clinic chart review.
Primary outcome measures: regimen concordance
Research assistants asked patients to (1) verbalize their weekly warfarin
regimen, and (2) identify this regimen from a digitized color menu of warfarin
pills (Figure 1). Specifically, patients were asked: “Can you tell me exactly how
you take your warfarin/Coumadin®?” and “Can you show me exactly what you
take by pointing to the warfarin/Coumadin® pill or pills?” All patients were
prompted to indicate which days of the week they take the medicine, the number
of pills they take on these days, and (for the verbal assessment only) the exact
number of milligrams per pill on each day. To ensure that our assessment
reflected the patient’s report as accurately as possible, each of the 7-day reports
was reviewed with the patient for his or her final agreement27 and the total weekly
dosage, in milligrams, was calculated separately for the verbal and visual reports.
We obtained clinicians’ regimen reports from chart reviews, and classified each
regimen as “complex” if the prescribed regimen deviated from taking the same
pill every day.
Figure 1. Digitized color menu of Coumadin®
pills (upper row) and warfarin pills (lower
row)
We categorized patients as having verbal concordance if there was no patientclinician discrepancy in the total weekly dosage of warfarin when the patient
verbalized the regimen, and visual concordance if there was no patient-clinician
discrepancy in the total weekly dosage when the patient identified the regimen
from the digitized pill menu. Our method of collecting reports of medication
regimen and determining concordance was similar to the few published studies of
drug regimen knowledge and discrepancy.6–8, 28 Because the primary goal of our
work was to inform communication related to medication assessment, we chose to
disentangle verbal from visual reports in assessing concordance, rather than use a
composite medication knowledge score employed for research purposes.8

Secondary outcome measure: self-reported adherence
Research assistants asked subjects to report their 7-day warfarin adherence
using a validated instrument29, 30 that asks patients to recall the number of days in
the past week they missed taking their medication. To encourage honest reporting,
each participant was first read a short script that described missing medication as
Language, Literacy, and Medication Compliance
203
common for patients with chronic illness. We categorized patients as having
perfect adherence if they reported missing no days of warfarin over the prior 7
days, based on their understanding of their regimen.
Statistical analyses
We separately calculated rates of patient-provider warfarin regimen
concordance when the patient reported their regimen verbally and visually, and
compared proportions using the chi-square test. We then stratified the results by
the communication barrier of interest (English, Cantonese, or Spanish language
among total sample; inadequate, marginal, and adequate health literacy among
English and Spanish speakers). To examine variation in regimen concordance by
language, we performed chi-square tests and generated unadjusted odds ratios
comparing the odds of achieving (a) verbal concordance, and (b) visual
concordance among Cantonese, Spanish, and English speakers. We performed
chi-square tests and generated unadjusted odds ratios comparing the odds of (a)
verbal concordance, and (b) visual concordance among those with inadequate
health literacy versus those with adequate heath literacy.
To isolate the independent effect of language and health literacy on
concordance, we used logistic regression analysis. Specifically, we assessed
bivariate relationships between the patient’s age (≤ or > median age),
race/ethnicity, sex, cognitive score (s-CASI ≤ or >19), regimen complexity
(complex versus straightforward), and—for health literacy analysis only—
language (English versus Spanish). We included significant covariates at P < 0.20
in multivariate models. For those variables that did not meet our criteria, but for
which there is support for inclusion in the literature, we forced them into adjusted
models one-by-one to examine what effect, if any, they had on the main effect.
We measured the difference in concordance rates when the report was
obtained through the verbal and visual modes, and examined whether the size of
the difference between verbal and visual concordance varied by language and
health literacy.
To examine the relationship between verbal and visual regimen concordance
and self-reported 7-day adherence, we performed separate multivariate analyses
as described above.
We estimated that there would be a 10 percent difference in concordance
when the regimen was reported verbally versus visually. Under this assumption,
we calculated that a sample of 194 patients would have 80 percent power to detect
this difference at P < 0.05.
Results
We approached 273 consecutive patients identified by the electronic database
as meeting eligibility criteria. Of these, 30 were excluded because they reported
being on nonformulary warfarin (n = 3), had their medications filled by a medi-set
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service or other health professional (n = 10), had visual acuity of 20/100 or worse
(n = 5), or were too ill to participate (n = 12). Twenty-six patients refused to
participate in the study and 23 patients consented but did not complete the
interview. The remaining 220 patients comprised our final sample. Patients who
refused to participate or did not complete the interview were not statistically
different from the study subjects in terms of their age, sex, language, or
race/ethnicity.
Fifty-seven percent of the patients spoke English, 24 percent Spanish, and 19
percent Cantonese. Among English and Spanish speakers (n = 178), 86 (48
percent) had inadequate health literacy, 23 (13 percent) had marginal health
literacy, and 69 (39 percent) had adequate health literacy. Most patients were
taking warfarin for atrial fibrillation (62 percent) and/or valvular heart disease (26
percent). Fifty-six percent of INRs over the prior 90 days were in the therapeutic
range (Table 1).
Table 1. Characteristics of patients (n = 220)
No. (%)
Age (median = 59)
≤ 59 113 (51)
> 60107 (49)
Sex
Female 110 (50)
Male 110 (50)
Language
English 126 (57)
Cantonese 42 (19)
Spanish 52 (24)
Race/Ethnicity
Asian 87 (39)
Black 31 (14)
Latino 61 (28)
White 41 (19)
Health Literacy* (n = 178)
Inadequate 86 (39)
Marginal 23 (11)
Adequate 69 (31)
Complex Regimen
Yes 84 (38)
No 136 (62)
Cognitive Score
>19 168 (76)
≤19 52 (24)
Indication for Warfarin**
Atrial Fibrillation 137 (62)
Prosthetic Valve 57 (26)
Prior Stroke/TIA 31 (14)
DVT/PE 29 (13)
Other 10 (5)
Percent of International Normalized Ratios (INRs) in therapuetic range over prior 90 days = 56%.
TIA = transient ischemic attack; DVT = deep-vein thrombosis; PE = pulmonary embolism.
* Sample is limited as health literacy cannot currently be measured among Cantonese-speaking
individuals.
** Totals sum to >100% as patients may have more than one indication.
Language, Literacy, and Medication Compliance
205
Figure 2 shows verbal concordance rates, both overall and stratified by
language and health literacy. Overall, 50 percent of patients’ verbal reports of
their weekly warfarin regimen were concordant with clinicians’ reports. Verbal
concordance was lower for Cantonese than English speakers (38 percent versus
56 percent, OR = 0.48, 95% CI = 0.23–0.97, P = 0.04). The difference in verbal
concordance between Spanish and English speakers did not reach statistical
significance (44 percent versus 56 percent, OR = 0.61, 95% CI = 0.32–1.18, P =
0.14). Verbal concordance was lower for patients with inadequate versus adequate
health literacy (42 percent versus 64 percent, OR = 0.41, 95% CI = 0.21–0.78,
P < 0.01), but was similar when patients with marginal health literacy and
adequate health literacy (61 percent versus 64 percent, OR = 0.88, 95% CI =
0.33–2.33, P = 0.80) were compared. In multivariate models, the only covariate
significant at P < 0.20 was patient age. After adjusting for age, both Cantonese
language and inadequate health literacy were independently associated with lower
rates of verbal concordance (AOR = 0.44, 95% CI = 0.21–0.93, P = 0.03 and
AOR = 0.50, 95% CI = 0.26–0.99, P = 0.04, respectively). Forcing other
covariates into each model, such as the complexity of the regimen or the cognitive
score, did not alter the main effect.
Figure 2. Patient-physician concordance rates via verbal assessment of medication
regimen, stratified by language and health literacy
50%
38%
44%
66%
42%
61% 64%
0
20
40
60
80
100
Overall Cantonese Spanish English Inadequate Marginal Adequate
Rate of Concordance (%)
Language Health Literacy
*P < 0.05 comparing Cantonese to English speakers in adjusted models
**P < 0.05 comparing patients with inadequate to adequate health literacy in adjusted models
* **
Figure 3 shows visual concordance rates, both overall and stratified by
language and health literacy. Two-thirds (66 percent) of patients’ visual reports of
their regimen were concordant with clinicians’ reports (P < 0.001 for difference in
concordance between verbal and visual modes). Unlike verbal concordance,
visual concordance was not different for Cantonese and English speakers (74
percent versus 66 percent, OR = 1.46, 95% CI = 0.67–3.19, P = 0.34) or Spanish
and English speakers (62 percent versus 66 percent, OR = 0.83, 95% CI =
0.42–1.62, P = 0.58). Among English and Spanish speakers, the visual
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concordance was lower for patients with inadequate versus adequate health
literacy (57 percent versus 74 percent, OR = 0.47, 95% CI = 0.24–0.93, P = 0.03),
but was not different between patients with marginal health literacy and adequate
health literacy (65 percent versus 74 percent, OR = 0.66, 95% CI = 0.24–1.82, P =
0.42). In multivariate models, the only covariates that remained significant at P <
0.20 were patient age and cognitive score. After adjustment, neither Cantonese
language nor inadequate health literacy was associated with lower rates of visual
concordance (AOR = 1.46, 95% CI = 0.66–3.23, and AOR = 0.56, 95% CI =
0.27–1.14, P = 0.11 respectively).
Figure 3. Patient-physician concordance rates via visual assessment of medication
regimen, stratified by language and health literacy
74%
65%
57%
66% 62%
74%
66%
0
20
40
60
80
100
Overall Cantonese Spanish English Inadequate Marginal Adequate
Rate of Concordance (%)
Language Health Literacy
*P < 0.05 comparing visual concordance rates to verbal concordance rates
*
When patient reports of their regimen were shifted from verbal to visual
modes, this was associated with greater patient-provider concordance across all
patient subgroups. The improvement appeared to be greatest for those patients
with communication barriers; for example, among patients who were verbally
discordant (n = 110, Figure 4), Cantonese speakers were more likely than English
speakers to become concordant when they reported their regimen with a visual aid
(45 percent versus 16 percent raw improvement, OR = 4.38, 95% CI = 2.02–9.48,
P < 0.001). Similarly, patients with inadequate health literacy were more likely
than patients with adequate health literacy to be concordant when they used a
visual aid, although this difference was not statistically significant (21 percent
versus 13 percent raw improvement, OR = 1.77, 95% CI = 0.74–4.22, P = 0.20).
Overall, 183 patients (83.2 percent) reported perfect, 7-day adherence to their
warfarin regimen. In multivariate analyses that adjusted for language, cognitive
score, and regimen complexity, neither verbal nor visual concordance was
associated with patient reports of 7-day adherence (AOR = 1.39, P = 0.42 and
AOR = 0.43, P = 0.09, respectively).
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207
Figure 4. Change in concordance rates when regimen assessed visually, among
patients with verbal discordance (n = 110)
13% 13%
21% 19% 17%
45%
0
10
20
30
40
50
Cantonese Spanish English Inadequate Marginal Adequate
Improvement in Concordance Rate (%)
*
Language Health Literacy
*p < 0.05 comparing improvement in concordance rates to English speakers
Discussion
While several studies have identified medication-related discordance as a
problem,4, 6, 7, 28, 31 ours is the first to assess rates of clinician-patient concordance
in warfarin regimen, to examine the extent to which communication barriers
influence regimen concordance, and to explore the difference in concordance
when patients report their regimen verbally or with a visual aid. We found that
clinician-patient discordance in the weekly warfarin regimen is common, but
occurs less frequently when patients report their regimen using a visual aid. We
found that Cantonese language and inadequate health literacy are independently
associated with verbal, but not visual, discordance. Shifting assessment from the
verbal to the visual mode was more likely to be associated with concordance for
patients from all groups, but was particularly helpful for patients with
communication barriers. These findings are consistent with other work that
reveals that many patients have difficulty deciphering instructions on a
medication bottle17 and/or processing technical information, such as medication
instructions conveyed verbally.27
Our study has implications for reducing medication-related errors.32 In the
context of chronic disease, effective medication-related communication
requires—at a minimum—an accurate assessment of what the patient is taking, as
well as an explanation to the patient regarding modifications in the regimen. In
anticoagulant care, the components most critical to decisionmaking are (1) the
results of the patient’s blood work, and (2) the assessment of what the patient has
been taking. Clinicians frequently make management decisions by first assessing
adherence to the prescribed warfarin regimen through patients’ verbal reports.
Cantonese Spanish English Inadequate Marginal Adequate
45%
19% 17%
21%
13% 13%
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Inaccuracy in patients’ reports, or failure on the part of the clinician to verify
these reports, could place patients at risk for poor outcomes.
Our study lends support to the notion that patients most likely to experience
errors in medication-related communication are patients with limited English
proficiency11 and/or limited health literacy.33 Reducing medication-related
communication errors among patients with communication barriers likely requires
a rigorous review of medication regimens during the assessment phase of a visit.
Specifically, using a visual aid may improve the accuracy of patient reports and,
by extension, lead to greater regimen concordance between clinician and patient
over time. Since medication-related adverse events are common1
and warfarin is
involved in preventable adverse drug events at rates disproportionate to its use,2
routinely identifying discordance and developing interventions to reduce its
occurrence may reduce medication-related errors in anticoagulant care and other
settings.34 Results of studies in other contexts14, 15, 35, 36 suggest that visual aids can
augment verbal communication, particularly for patients with communication
barriers. Our own work in the anticoagulation setting suggests that visual aids
may ameliorate the negative consequences of regimen discordance on
anticoagulant outcomes.37
Our findings also have implications for medication adherence assessment in
the clinical and research contexts. While there is no gold standard to measure
adherence,16, 38 most experts agree that self-report is the most efficient means to
collect adherence data, both for routine clinical work38 and research.7, 29, 39 Despite
patients’ tendencies to overreport adherence because of social desirability,40 selfreport has been linked to clinical outcomes.39 Our work, however, suggests that
the accuracy of patients’ reports of adherence may be compromised by
unrecognized discordance, insofar as patients may report perfect adherence to an
erroneous medication regimen. This provides empiric support to the view
developed among some researchers that adherence assessment requires measuring
both regimen concordance (regimen knowledge) and medication-taking
behavior.7, 16, 28
Our study has a number of limitations. First, subjects were recruited from one
anticoagulation clinic, which may limit generalizability. Selecting one clinic that
uses standard algorithms for medication management and whose sole purpose is
to manage one medication permitted us to eliminate much of the influence that
system- and provider-related factors may have on variation in regimen
concordance. The relatively even distribution of languages and health literacy
levels allowed us to explore the impact of communication barriers on medication
regimen concordance. While the clinic serves a diverse, low-income population,
its performance with regard to anticoagulant outcomes is similar to that of other
anticoagulation clinics described in the literature,41, 42 the self-reported medication
adherence rates are similar to those in other chronic disease studies,5, 34, 39 and
concordance rates are similar to those reported in the few studies of regimen
discordance that group verbal and visual methods into a composite knowledge
score.6–8
Language, Literacy, and Medication Compliance
209
Second, our method of determining regimen concordance, while similar to
those in the few published studies,6–8, 28 does not allow us to determine (a)
whether visual concordance rates were higher than verbal concordance rates
because of the order in which we inquired about the regimen; (b) whether
discordance occurred because of miscommunication, poor recall, undocumented
changes in regimen, or because the clinician was misinformed as to what the
prescribed regimen truly should be; or (c) what dosages the patient was actually
taking at home. Our inability to include pharmacy dispensing data is unlikely to
significantly impact our results, as prior work has revealed that combining such
data sources does not change results of models predicting appropriate medication
use.43
Third, the fact that bilingual research assistants obtained the patient reports
raises the possibility that we overestimated concordance rates for patients with
limited English proficiency, insofar as the providers’ limited non-English
language proficiency may lead to lower “real-life” concordance. Similarly,
because we designed our study with statistical power to detect differences
between verbal and visual concordance, our sample size was likely too small to
enable us to detect modest differences in concordance between subgroups of
patients; this may explain our findings with regard to Spanish language and
concordance. Furthermore, because the study was observational, we cannot rule
out the possibility that the associations between limited English proficiency,
limited health literacy, and regimen concordance were a consequence of
unmeasured confounding. While we attempted to include relevant covariates in
models, our questionnaire did not include such factors as the number of
medications that patients were taking or the extent to which language
interpretation was available during clinical encounters. Finally, while the current
study does not address the clinical implications of discordance, we have recently
demonstrated that regimen discordance is associated with poor anticoagulant
outcomes.37, 44
There is growing recognition that communication barriers, such as limited
English proficiency and limited health literacy, are associated with lower quality
of care and place patients at risk for poor clinical outcomes.13, 45, 46 Given the
prevalence of chronic diseases,47 the challenge of managing multiple medications,
and the incidence of adverse drug events (particularly among the elderly2
), there
is a need to communicate more safely and effectively with patients about
medications. We found that, in a sample of diverse, older patients undergoing
chronic anticoagulation therapy, clinician-patient discordance in warfarin regimen
was common, but occurred less frequently when patients identified their regimen
using a visual aid. Assessing adherence without assessing regimen concordance
may lead to systematic inaccuracies in adherence assessment and could place
patients at risk for preventable adverse drug events. Medication assessment and
education may be improved through the use of visual aids, and this mode of
communication may be especially beneficial for patients with communication
barriers.
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210
Acknowledgments
This research was supported through grants from the American Heart
Association, Agency for Healthcare Research and Quality (PO1 HS10856),
National Center for Research Resources (K-23 RR16539-01 and M01RR00083-
41), and the UCSF Hellman Family Research Award.
Author affiliations
All of the authors are at the University of California–San Francisco Primary Care Research Center,
San Francisco General Hospital.
Address correspondence to: Dean Schillinger, MD; Associate Professor of Clinical Medicine, UCSF
Primary Care Research Center, San Francisco General Hospital, 1001 Potrero Avenue, Building 10, 3rd
floor, San Francisco California, 94110. Phone: 415-206-8940; e-mail: [email protected]
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