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Cabrera Fernandez DL, Lopez KN, Bravo-Jaimes K, Mackie AS. The Impact of Social Determinants of Health on Transition From Pediatric to Adult Cardiology Care. Can J Cardiol 2024; 40:1043-1055. [PMID: 38583706 DOI: 10.1016/j.cjca.2024.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 03/28/2024] [Accepted: 03/28/2024] [Indexed: 04/09/2024] Open
Abstract
Social determinants of health (SDoH) are the economic, social, environmental, and psychosocial factors that influence health. Adolescents and young adults with congenital heart disease (CHD) require lifelong cardiology follow-up and therefore coordinated transition from pediatric to adult healthcare systems. However, gaps in care are common during transition, and they are driven in part by pervasive disparities in SDoH, including race, ethnicity, socioeconomic status, access to insurance, and remote location of residence. These disparities often coexist and compound the challenges faced by patients and families. For example, Black and Indigenous individuals are more likely to be subject to systemic racism and implicit bias within healthcare and other settings, to be unemployed and poor, to have limited access to insurance, and to have a lower likelihood of transfer of care to adult CHD specialists. SDoH also are associated with acquired cardiovascular disease, a comorbidity that adults with CHD face. This review summarizes existing evidence regarding the impact of SDoH on the transition to adult care and proposes strategies at the individual, institutional, and population and/or system levels. to reduce inequities faced by transition-age youth. These strategies include routinely screening for SDoH in clinical settings with referral to appropriate services, providing formal transition education for all transition-age youth, including training on navigating complex medical systems, creating satellite cardiology clinics to facilitate access to care for those who live remote from tertiary centres, advocating for lifelong insurance coverage where applicable, mandating cultural-sensitivity training for providers, and increasing the diversity of healthcare providers in pediatric and adult CHD care.
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Affiliation(s)
- Diana L Cabrera Fernandez
- Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Keila N Lopez
- Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Katia Bravo-Jaimes
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Andrew S Mackie
- Division of Cardiology, Stollery Children's Hospital and Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.
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Mackie AS. Welcome Back! Returning to the Fold in Congenital Cardiology Care After Loss to Follow-up. Can J Cardiol 2024; 40:419-421. [PMID: 38056627 DOI: 10.1016/j.cjca.2023.11.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 12/08/2023] Open
Affiliation(s)
- Andrew S Mackie
- Division of Cardiology, Stollery Children's Hospital and Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.
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Hardy RY, Chavez LJ, Grant VR, Chisolm DJ, Daniels CJ, Jackson JL. Healthcare Use Among Black and White Congenital Heart Disease Medicaid Enrollees. Pediatr Cardiol 2023; 44:1754-1762. [PMID: 37535077 DOI: 10.1007/s00246-023-03249-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 07/24/2023] [Indexed: 08/04/2023]
Abstract
Congenital heart disease (CHD) is the most common birth anomaly in the US. Research shows lost-to-follow-up trends and racial disparities in healthcare use. This study examines racial differences in healthcare use among Medicaid-covered children with CHD. Using 2010-2019 claims data from a pediatric Medicaid Accountable Care Organization, 960 Black and White children with complex CHD and ≥ 3 years of continuous Medicaid coverage were identified. Three cohorts were constructed (starting age: < 1-year-olds, 1-5-year-olds, 6-15-year-olds) and followed for 3 years. Multivariate analysis assessed annual healthcare use (cardiology, primary care, emergency department) by race, adjusting for patient and provider covariates. Overall, 51% of patients had an annual cardiology visit, and 54% had an annual primary care visit. Among the 1-5-year-old cohort, Black children were predicted to be 13% less likely to have an annual cardiology visit compared to their White counterparts (p = 0.001). Older Black children were predicted to be more likely to have a primary care visit compared to their White counterparts. Nearly half of Medicaid-enrolled children with complex CHD did not receive recommended cardiology care. Young Black children were less likely to receive an annual cardiac visit, while older Black children were more likely to receive primary care. While the percentage with an annual cardiac visit was low, the majority had seen a cardiologist within the 3-year window, suggesting these children are still receiving cardiology care, if less frequently than recommended. Opportunities exist for cardiology and primary care to collaborate to ensure patients receive timely recommended care.
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Affiliation(s)
- Rose Y Hardy
- Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH, 43205, USA.
| | - Laura J Chavez
- Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH, 43205, USA
| | - Victoria R Grant
- Center for Biobehavioral Health, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH, 43205, USA
| | - Deena J Chisolm
- Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH, 43205, USA
| | - Curt J Daniels
- Division of Cardiovascular Medicine & Nationwide Children's Hospital, The Ohio State University Department of Internal Medicine, 473 W 12th Ave., Columbus, OH, 43210, USA
| | - Jamie L Jackson
- Center for Biobehavioral Health, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH, 43205, USA
- College of Medicine, Department of Pediatrics, The Ohio State University, 370 W 9th Ave., Columbus, OH, 43210, USA
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Mackie AS, Bravo-Jaimes K, Keir M, Sillman C, Kovacs AH. Access to Specialized Care Across the Lifespan in Tetralogy of Fallot. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:267-282. [PMID: 38161668 PMCID: PMC10755796 DOI: 10.1016/j.cjcpc.2023.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/05/2023] [Indexed: 01/03/2024]
Abstract
Individuals living with tetralogy of Fallot require lifelong specialized congenital heart disease care to monitor for and manage potential late complications. However, access to cardiology care remains a challenge for many patients, as does access to mental health services, dental care, obstetrical care, and other specialties required by this population. Inequities in health care access were highlighted by the COVID-19 pandemic and continue to exist. Paradoxically, many social factors influence an individual's need for care, yet inadvertently restrict access to it. These include sex and gender, being a member of a racial or ethnic historically excluded group, lower educational attainment, lower socioeconomic status, living remotely from tertiary care centres, transportation difficulties, inadequate health insurance, occupational instability, and prior experiences with discrimination in the health care setting. These factors may coexist and have compounding effects. In addition, many patients believe that they are cured and unaware of the need for specialized follow-up. For these reasons, lapses in care are common, particularly around the time of transfer from paediatric to adult care. The lack of trained health care professionals for adults with congenital heart disease presents an additional barrier, even in higher income countries. This review summarizes challenges regarding access to multiple domains of specialized care for individuals with tetralogy of Fallot, with a focus on the impact of social determinants of health. Specific recommendations to improve access to care within Canadian and American systems are offered.
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Affiliation(s)
- Andrew S. Mackie
- Division of Cardiology, Department of Pediatrics, Stollery Children’s Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Katia Bravo-Jaimes
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Michelle Keir
- Southern Alberta Adult Congenital Heart Clinic, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Christina Sillman
- Adult Congenital Heart Disease Program, Sutter Heart and Vascular Institute, Sacramento, California, USA
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Ortinau CM, Wypij D, Ilardi D, Rofeberg V, Miller TA, Donohue J, Reichle G, Seed M, Elhoff J, Alexander N, Allen K, Anton C, Bear L, Boucher G, Bragg J, Butcher J, Chen V, Glotzbach K, Hampton L, Lee CK, Ly LG, Marino BS, Martinez-Fernandez Y, Monteiro S, Ortega C, Peyvandi S, Raiees-Dana H, Rollins CK, Sadhwani A, Sananes R, Sanz JH, Schultz AH, Sood E, Tan A, Willen E, Wolfe KR, Goldberg CS. Factors Associated With Attendance for Cardiac Neurodevelopmental Evaluation. Pediatrics 2023; 152:e2022060995. [PMID: 37593818 PMCID: PMC10530086 DOI: 10.1542/peds.2022-060995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/14/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Neurodevelopmental evaluation of toddlers with complex congenital heart disease is recommended but reported frequency is low. Data on barriers to attending neurodevelopmental follow-up are limited. This study aims to estimate the attendance rate for a toddler neurodevelopmental evaluation in a contemporary multicenter cohort and to assess patient and center level factors associated with attending this evaluation. METHODS This is a retrospective cohort study of children born between September 2017 and September 2018 who underwent cardiopulmonary bypass in their first year of life at a center contributing data to the Cardiac Neurodevelopmental Outcome Collaborative and Pediatric Cardiac Critical Care Consortium clinical registries. The primary outcome was attendance for a neurodevelopmental evaluation between 11 and 30 months of age. Sociodemographic and medical characteristics and center factors specific to neurodevelopmental program design were considered as predictors for attendance. RESULTS Among 2385 patients eligible from 16 cardiac centers, the attendance rate was 29.0% (692 of 2385), with a range of 7.8% to 54.3% across individual centers. In multivariable logistic regression models, hospital-initiated (versus family-initiated) scheduling for neurodevelopmental evaluation had the largest odds ratio in predicting attendance (odds ratio = 4.24, 95% confidence interval, 2.74-6.55). Other predictors of attendance included antenatal diagnosis, absence of Trisomy 21, higher Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery mortality category, longer postoperative length of stay, private insurance, and residing a shorter distance from the hospital. CONCLUSIONS Attendance rates reflect some improvement but remain low. Changes to program infrastructure and design and minimizing barriers affecting access to care are essential components for improving neurodevelopmental care and outcomes for children with congenital heart disease.
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Affiliation(s)
- Cynthia M. Ortinau
- Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, Missouri, United States
| | - David Wypij
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts, United States; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, United States; Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States
| | - Dawn Ilardi
- Department of Neuropsychology, Children’s Healthcare of Atlanta, Atlanta, Georgia, United States; Department of Rehabilitation Medicine, Emory University, Atlanta, Georgia, United States
| | - Valerie Rofeberg
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts, United States
| | - Thomas A. Miller
- Division of Cardiology, Maine Medical Center, Portland, Maine, United States
| | - Janet Donohue
- Department of Pediatrics, C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, Michigan, United States
| | - Garrett Reichle
- Department of Pediatrics, C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, Michigan, United States
| | - Mike Seed
- Department of Paediatrics, Division of Paediatric Cardiology, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Justin Elhoff
- Department of Pediatrics, Division of Critical Care Medicine, Baylor School of Medicine, Houston, Texas, United States
| | - Nneka Alexander
- Department of Neuropsychology, Children’s Healthcare of Atlanta, Atlanta, Georgia, United States
| | - Kiona Allen
- Department of Pediatrics, Division of Cardiology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern Feinberg School of Medicine, Chicago, Illinois, United States
| | - Corinne Anton
- Department of Cardiology, Children’s Health, Dallas, Texas, United States; Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, United States
| | - Laurel Bear
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Gina Boucher
- Phoenix Children’s Hospital Heart Center, Phoenix, Arizona, United States
| | - Jennifer Bragg
- Department of Pediatrics, Mount Sinai Hospital, New York, New York, United States
| | - Jennifer Butcher
- Department of Pediatrics, C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, Michigan, United States
| | - Victoria Chen
- Department of Pediatrics, Division of Developmental-Behavioral Pediatrics, Cohen Children’s Medical Center, New Hyde Park, New York, United States; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - Kristi Glotzbach
- Department of Pediatrics, Division of Critical Care Medicine, University of Utah, Salt Lake City, Utah, United States
| | - Lyla Hampton
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Caroline K. Lee
- Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, Missouri, United States
| | - Linh G. Ly
- Department of Paediatrics, Division of Neonatology, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Bradley S. Marino
- Department of Pediatric Cardiology, Cleveland Clinic Children’s, Cleveland, Ohio, United States
| | | | - Sonia Monteiro
- Department of Pediatrics, Baylor School of Medicine, Houston, Texas, United States
| | - Christina Ortega
- Department of Psychology, Joe DiMaggio Children’s Hospital, Hollywood, Florida, United States
| | - Shabnam Peyvandi
- University of California San Francisco Benioff Children’s Hospital, San Francisco, California, United States
| | | | - Caitlin K. Rollins
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts, United States; Department of Neurology, Harvard Medical School, Boston, Massachusetts, United States
| | - Anjali Sadhwani
- Department of Psychiatry and Behavioral Sciences, Boston Children’s Hospital, Boston, Massachusetts, United States; Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, United States
| | - Renee Sananes
- Department of Psychology, Division of Cardiology, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Jacqueline H. Sanz
- Division of Neuropsychology, Children’s National Hospital; Departments of Psychiatry and Behavioral Sciences & Pediatrics, The George Washington University School of Medicine, Washington D.C., United States
| | - Amy H. Schultz
- Division of Cardiology, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, Washington, United States
| | - Erica Sood
- Nemours Cardiac Center, Nemours Children’s Health, Wilmington, Delaware, United States; Department of Pediatrics, Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - Alexander Tan
- Department of Neuropsychology, Children’s Health Orange County, Orange, California, United States
| | - Elizabeth Willen
- Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, Missouri, United States
| | - Kelly R. Wolfe
- Section of Neurology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Caren S. Goldberg
- Department of Pediatrics, C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, Michigan, United States
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McGrath L, Patel K, Colina Garcia I, Shalen E, Burton Y, Khan A. Factors Associated With Nonattendance at the Adult Congenital Heart Disease Clinic. Am J Cardiol 2023; 201:247-251. [PMID: 37393726 DOI: 10.1016/j.amjcard.2023.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/30/2023] [Accepted: 06/05/2023] [Indexed: 07/04/2023]
Abstract
Adults with congenital heart disease (CHD) are a complex population for whom adult CHD-specific care results in better outcomes. Our objective was to identify factors associated with no-shows and cancelations in an adult CHD (ACHD) clinic and evaluate the efficacy of a social worker intervention to promote ambulatory follow-up. The medical record identified adults with a scheduled appointment in the adult CHD clinic from January 2017 to March 2021. Social worker intervention was performed between March 2020 and May 2021 and consisted of phone calls to those who did not show up. Logistic regression and descriptive statistics were performed. Of 8,431 scheduled visits, 56.7% were completed, 4.6% were no-shows, and 17.5% were canceled by patients. The factors associated with no-shows were Medicaid (odds ratio [OR] 1.63, 95% confidence interval [CI] 1.26 to 2.12, p <0.001), previous no-show (OR per 1% increase in previous no-show rate 1.13, 95% CI 1.12 to 1.15, p <0.001), satellite clinic location (OR 3.15, 95% CI 2.06 to 4.74, p <0.001), virtual visit (OR 1.97, 95% CI 1.28 to 2.92, p = 0.001), and Hispanic ethnicity (OR 1.48, 95% CI 1.03 to 2.10, p = 0.031). The factors associated with cancelations were female gender (OR 1.45, 95% CI 1.25 to 1.68, p <0.001) and virtual visits (OR 2.24, 95% CI 1.50 to 3.40, p <0.001). Social worker outreach calls did not impact frequency of rescheduling. No patients accepted additional support. In conclusion, Medicaid insurance, previous number of no-shows, and Hispanic ethnicity were found to be associated with a higher risk of no-show, identifying a high-risk population that may benefit from targeted interventions. Social worker outreach did not have an appreciable impact on the rescheduling rates.
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Affiliation(s)
- Lidija McGrath
- Adult Congenital Heart Disease Program, Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon.
| | - Karishma Patel
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Ibett Colina Garcia
- Adult Congenital Heart Disease Program, Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon
| | - Evan Shalen
- Division of Cardiology, Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon
| | - Yunwoo Burton
- Division of Cardiology, Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon
| | - Abigail Khan
- Adult Congenital Heart Disease Program, Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon
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Keir M, Borman M, Clegg R, Colbert J, Guron N, Harper L, Helmerson D, Patzer J, Reynolds S, Alvarez N. Caring for the Aging Patient With Adult Congenital Heart Disease: A Review of Cardiac and Noncardiac Comorbidities. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2022; 1:274-281. [PMID: 37969485 PMCID: PMC10642149 DOI: 10.1016/j.cjcpc.2022.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 10/12/2022] [Indexed: 11/17/2023]
Abstract
As the demographics of congenital heart disease (CHD) have shifted, there are now more adults living with CHD than children in North America. This presents unprecedented challenges as patients with CHD acquire noncardiac comorbidities and seek care for a variety of reasons, including noncardiac surgery and emergency department (ED) visits. CHD shifts from a one organ problem to a multisystem disease and requires a team of specialists to maintain high-quality longitudinal care. In this review, we summarize the challenges patients with CHD and their providers face as they age. We review the demographics of CHD and health care utilization. We examine the rates of noncardiac comorbidities and the current quality of care received by adult patients with CHD.
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Affiliation(s)
- Michelle Keir
- Southern Alberta Adult Congenital Heart Clinic, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Meredith Borman
- Section of Gastroenterology, Division of Internal Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robin Clegg
- Southern Alberta Adult Congenital Heart Clinic, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Jillian Colbert
- Southern Alberta Adult Congenital Heart Clinic, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Nita Guron
- Southern Alberta Adult Congenital Heart Clinic, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Lea Harper
- Section of Respirology, Division of Internal Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Doug Helmerson
- Section of Respirology, Division of Internal Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jessica Patzer
- Southern Alberta Adult Congenital Heart Clinic, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Stephen Reynolds
- Southern Alberta Adult Congenital Heart Clinic, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Nanette Alvarez
- Southern Alberta Adult Congenital Heart Clinic, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
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