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Ando T, Sasaki T, Abe Y, Nishimoto Y, Hirata T, Tajima T, Oguma Y, Haruta J, Arai Y. Association of polydoctoring and mortality among persons over 85 years with multimorbidity: a prospective cohort study in Japan. BJGP Open 2024:BJGPO.2024.0016. [PMID: 38658042 DOI: 10.3399/bjgpo.2024.0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 04/04/2024] [Accepted: 04/18/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND Polydoctoring can increase the risk of care fragmentation among patients with multimorbidity, but its impact on health outcomes remains unclear. AIM To determine the effects of polydoctoring, as measured by the regularly visited facilities (RVF) indicator, on patient outcomes among older individuals with multimorbidity. DESIGN & SETTING Data from the ongoing prospective cohort study, Kawasaki Aging and Wellbeing Project (KAWP), was utilised in this study. Among the 1026 KAWP participants aged 85-89 years, those with two or more chronic conditions were enrolled in this study. METHOD Care fragmentation and polydoctoring was evaluated using the RVF, which is a new indicator that measures the number of medical facilities consistently involved in a patient's care. Based on RVF, mortality was analysed using the Cox proportional hazards model, with adjustments for age, sex, frailty, and number of comorbidities. RESULTS A significant reduction in mortality rates was observed in participants with an RVF of ≥3 and 2-4 comorbidities (hazard ratio [HR] 0.43, 95% confidence interval [CI] = 0.18 to 0.99, P value = 0.048). However, no significant difference in mortality based on RVF was observed for those with ≥5 comorbidities. Notably, individuals with ≥5 comorbidities and an RVF of 0 had a significantly higher HR for death (HR 2.68, 95% CI = 1.05 to 6.84, P value = 0.039). CONCLUSION In older patients with multimorbidity, polydoctoring may reduce mortality in patients with ≤4 coexisting conditions, but it does not significantly impact mortality in those with ≥5 conditions. These findings provide insights for healthcare decision making in managing older patients with multimorbidity.
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Affiliation(s)
- Takayuki Ando
- Center for General Medicine Education, Keio University School of Medicine, Shinjuku-ku, Japan
| | - Takashi Sasaki
- Center for Supercentenarian Medical Research, Keio University School of Medicine, Shinjuku-ku, Japan
| | - Yukiko Abe
- Center for Supercentenarian Medical Research, Keio University School of Medicine, Shinjuku-ku, Japan
| | - Yoshinori Nishimoto
- Center for Supercentenarian Medical Research, Keio University School of Medicine, Shinjuku-ku, Japan
- Department of Neurology, Keio University School of Medicine, Shinjuku-ku, Japan
| | - Takumi Hirata
- Human Care Research Team, Tokyo Metropolitan Institute for Geriatrics and Gerontology, Itabashi-ku, Japan
| | - Takayuki Tajima
- Department of Physical Therapy, Graduate School of Human Health Sciences, Tokyo Metropolitan University, Arakawa-ku, Japan
- Sports Medicine Research Center, Keio University, Yokohama, Japan
| | - Yuko Oguma
- Sports Medicine Research Center, Keio University, Yokohama, Japan
| | - Junji Haruta
- Center for General Medicine Education, Keio University School of Medicine, Shinjuku-ku, Japan
- Medical Education Center, Keio University School of Medicine, Shinjuku-ku, Japan
| | - Yasumichi Arai
- Center for Supercentenarian Medical Research, Keio University School of Medicine, Shinjuku-ku, Japan
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Kern LM, Ringel JB, Rajan M, Casalino LP, Pesko MF, Pinheiro LC, Colantonio LD, Safford MM. Ambulatory Care Fragmentation and Total Health Care Costs. Med Care 2024; 62:277-284. [PMID: 38458986 PMCID: PMC10926993 DOI: 10.1097/mlr.0000000000001982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2024]
Abstract
BACKGROUND The magnitude of the relationship between ambulatory care fragmentation and subsequent total health care costs is unclear. OBJECTIVE To determine the association between ambulatory care fragmentation and total health care costs. RESEARCH DESIGN Longitudinal analysis of 15 years of data (2004-2018) from the national Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, linked to Medicare fee-for-service claims. SUBJECTS A total of 13,680 Medicare beneficiaries who are 65 years and older. MEASURES We measured ambulatory care fragmentation in each calendar year, defining high fragmentation as a reversed Bice-Boxerman Index ≥0.85 and low as <0.85. We used generalized linear models to determine the association between ambulatory care fragmentation in 1 year and total Medicare expenditures (costs) in the following year, adjusting for baseline demographic and clinical characteristics, a time-varying comorbidity index, and accounting for geographic variation in reimbursement and inflation. RESULTS The average participant was 70.9 years old; approximately half (53%) were women. One-fourth (26%) of participants had high fragmentation in the first year of observation. Those participants had a median of 9 visits to 6 providers, with the most frequently seen provider accounting for 29% of visits. By contrast, participants with low fragmentation had a median of 8 visits to 3 providers, with the most frequently seen provider accounting for 50% of visits. High fragmentation was associated with $1085 more in total adjusted costs per person per year (95% CI $713 to $1457) than low fragmentation. CONCLUSIONS Highly fragmented ambulatory care in 1 year is independently associated with higher total costs the following year.
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Kern LM, Ringel JB, Rajan M, Casalino LP, Colantonio LD, Pinheiro LC, Colvin CL, Safford MM. Ambulatory Care Fragmentation, Emergency Department Visits, and Race: a Nationwide Cohort Study in the U.S. J Gen Intern Med 2023; 38:873-880. [PMID: 36417133 PMCID: PMC10039160 DOI: 10.1007/s11606-022-07888-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 10/26/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND It is unclear whether highly fragmented ambulatory care (i.e., care spread across multiple providers without a dominant provider) increases the risk of an emergency department (ED) visit. Whether any such association varies with race is unknown. OBJECTIVE We sought to determine whether highly fragmented ambulatory care increases the risk of an ED visit, overall and by race. DESIGN AND PARTICIPANTS We analyzed data for 14,361 participants ≥ 65 years old from the nationwide prospective REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study, linked to Medicare claims (2003-2016). MAIN MEASURES We defined high fragmentation as a reversed Bice-Boxerman Index ≥ 0.85 (≥ 75th percentile). We used Poisson models to determine the association between fragmentation (as a time-varying exposure) and ED visits, overall and stratified by race, adjusting for demographics, medical conditions, medications, health behaviors, psychosocial variables, and physiologic variables. KEY RESULTS The average participant was 70.5 years old; 53% were female, and 33% were Black individuals. Participants with high fragmentation had a median of 9 visits to 6 providers, with 29% of visits by the most frequently seen provider; participants with low fragmentation had a median of 7 visits to 3 providers, with 50% of visits by the most frequently seen provider. Overall, high fragmentation was associated with more ED visits than low fragmentation (adjusted risk ratio [aRR] 1.31, 95% confidence interval [CI] 1.29, 1.34). The magnitude of this association was larger among Black (aRR 1.48, 95% CI 1.44, 1.53) than White participants (aRR 1.23, 95% CI 1.20, 1.25). CONCLUSIONS Highly fragmented ambulatory care was an independent predictor of ED visits, especially among Black individuals.
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Affiliation(s)
- Lisa M Kern
- Weill Cornell Medicine, 420 East 70th Street, Box 331, New York, NY, 10021, USA.
| | - Joanna B Ringel
- Weill Cornell Medicine, 420 East 70th Street, Box 331, New York, NY, 10021, USA
| | - Mangala Rajan
- Weill Cornell Medicine, 420 East 70th Street, Box 331, New York, NY, 10021, USA
| | - Lawrence P Casalino
- Weill Cornell Medicine, 420 East 70th Street, Box 331, New York, NY, 10021, USA
| | | | - Laura C Pinheiro
- Weill Cornell Medicine, 420 East 70th Street, Box 331, New York, NY, 10021, USA
| | | | - Monika M Safford
- Weill Cornell Medicine, 420 East 70th Street, Box 331, New York, NY, 10021, USA
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Abstract
BACKGROUND Understanding what drives fragmented ambulatory care (care spread across multiple providers without a dominant provider) can inform the design of future interventions to reduce unnecessary fragmentation. OBJECTIVES To identify the characteristics of beneficiaries, primary care physicians, primary care practice sites, and geographic markets that predict highly fragmented ambulatory care in the United States. RESEARCH DESIGN Cross-sectional analysis of Medicare claims data for beneficiaries attributed to primary care physicians and practices in 2018. We used hierarchical linear models with random intercepts and an extensive list of explanatory variables to predict the likelihood of high fragmentation. SUBJECTS A total of 3,540,310 Medicare fee-for-service beneficiaries met the inclusion criteria, attributed to 26,344 primary care physicians in 9300 practice sites, and 788 geographic markets. MEASURES We defined high care fragmentation as a reversed Bice-Boxerman Index score above 0.85. RESULTS Explanatory variables explained only 6% of the variation in highly fragmented care. Unobserved differences between primary care physicians, between practice sites, and between markets together accounted for 4%. Instead, 90% of the variation in high fragmentation was unobserved residual variance. We identified the characteristics of beneficiaries (age, reason for original Medicare entitlement, and dually eligible for Medicaid insurance), physicians (comprehensiveness of care), and practices (size, being part of a system/hospital) that had small associations with high fragmentation. CONCLUSIONS Variation in fragmentation was not explained by observed beneficiary, primary care provider, practice site, or market characteristics. Instead, the aggregate behavior of diverse health care providers beyond primary care, along with unmeasured patient preferences and behaviors, seem to be important predictors.
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Kaneko M, Shinoda S, Shimizu S, Kuroki M, Nakagami S, Chiba T, Goto A. Fragmentation of ambulatory care among older adults: an exhaustive database study in an ageing city in Japan. BMJ Open 2022; 12:e061921. [PMID: 35953252 PMCID: PMC9379480 DOI: 10.1136/bmjopen-2022-061921] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVES Continuity of care is a core dimension of primary care, and better continuity is associated with better patient outcomes. Therefore, care fragmentation can be an indicator to assess the quality of primary care, especially in countries without formal gatekeeping system, such as Japan. Thus, this study aimed to describe care fragmentation among older adults in an ageing city in Japan. DESIGN Cross-sectional study. SETTING The most populated basic municipality in Japan. PARTICIPANTS Older adults aged 75 years and older. INTERVENTIONS This study used a health claims database, including older adults who visited medical facilities at least four times a year in an urban city in Japan. The Fragmentation of Care Index (FCI) was used as an indicator of fragmentation. The FCI was developed from the Continuity of Care Index and is based on the total number of visits, different institutions visited and proportion of visits to each institution. We employed Tobit regression analysis to examine the association between the FCI and age, sex, type of insurance and most frequently visited facility. RESULTS The total number of participants was 413 600. The median age of the study population was 81 years, and 41.6% were men. The study population visited an average of 3.42 clinics/hospitals, and the maximum number of visited institutions was 20. The proportion of patients with FCI >0 was 85.0%, with a mean of 0.583. Multivariable analysis showed that patients receiving public assistance had a lower FCI compared with patients not receiving public assistance, with a coefficient of 0.137. CONCLUSIONS To our knowledge, this is the first study to demonstrate care fragmentation in Japan. Over 80% of the participants visited two or more medical facilities, and their mean FCI was 0.583. The FCI could be a basic indicator for assessing the quality of primary care.
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Affiliation(s)
- Makoto Kaneko
- Department of Health Data Science, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Satoru Shinoda
- Department of Health Data Science, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Sayuri Shimizu
- Department of Health Data Science, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Makoto Kuroki
- Department of Health Data Science, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Sachiko Nakagami
- Medical Policy Division, Medical Care Bureau, City of Yokohama, Yokohama, Kanagawa, Japan
| | - Taiga Chiba
- Medical Policy Division, Medical Care Bureau, City of Yokohama, Yokohama, Kanagawa, Japan
| | - Atsushi Goto
- Department of Health Data Science, Yokohama City University, Yokohama, Kanagawa, Japan
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Hoo JX, Yang YF, Tan JY, Yang J, Yang A, Lim LL. Impact of multicomponent integrated care on mortality and hospitalization after acute coronary syndrome: a systematic review and meta-analysis. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2022; 9:258-267. [PMID: 35687013 PMCID: PMC10131244 DOI: 10.1093/ehjqcco/qcac032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/30/2022] [Accepted: 06/07/2022] [Indexed: 04/28/2023]
Abstract
AIMS Multicomponent integrated care is associated with sustained control of multiple cardiometabolic risk factors among patients with type 2 diabetes. There is a lack of data in patients with acute coronary syndrome (ACS). We aimed to examine its efficacy on mortality and hospitalization outcomes among patients with ACS in outpatient settings. METHODS AND RESULTS A literature search was conducted on PubMed, EMBASE, Ovid and Cochrane library databases for randomized controlled trials, published in English language between January 1980 and November 2020. Multicomponent integrated care defined as two or more quality improvement strategies targeting different domains (the healthcare system, healthcare providers and patients) for one month or more. The study outcomes were all-cause and cardiovascular-related mortality, hospitalization and emergency department visits. We pooled the risk ratio (RR) with 95% confidence interval (CI) for the association between multicomponent integrated care and study outcomes using the Mantel-Haenszel test. 74 trials (n = 93,278 patients with ACS) were eligible. The most common quality improvement strategies were team change (83.8%), patient education (62.2%) and facilitated patient-provider relay (54.1%). Compared with usual care, multicomponent integrated care was associated with reduced risks for all-cause mortality (RR 0.83, 95% CI 0.77-0.90; p<0.001; I2 = 0%), cardiovascular mortality (RR 0.81, 95% CI 0.73-0.89; p<0.001; I2 = 24%) and all-cause hospitalization (RR 0.88, 95% CI, 0.78-0.99; p = 0.040; I2 = 58%). The associations of multicomponent integrated care with cardiovascular-related hospitalization, emergency department visits and unplanned outpatient visits were not statistically significant. CONCLUSIONS In outpatient settings, multicomponent integrated care can reduce risks for mortality and hospitalization in patients with ACS.
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Affiliation(s)
- Jia-Xin Hoo
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Ya-Feng Yang
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Jia-Yin Tan
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Jingli Yang
- College of Earth and Environmental Sciences, Lanzhou University, Lanzhou, China
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia
| | - Aimin Yang
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Lee-Ling Lim
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
- Asia Diabetes Foundation, Hong Kong SAR, China
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Colvin CL, Safford MM, Muntner P, Colantonio LD, Kern LM. Health care fragmentation and blood pressure control among adults taking antihypertensive medication. THE AMERICAN JOURNAL OF MANAGED CARE 2022; 28:108-115. [PMID: 35404546 PMCID: PMC9358913 DOI: 10.37765/ajmc.2022.88837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVES To determine the association of fragmented ambulatory health care with uncontrolled blood pressure (BP) and apparent treatment-resistant hypertension (aTRH) among older adults taking antihypertensive medication, overall and by race and gender. STUDY DESIGN Cross-sectional study using data from 2868 REasons for Geographic And Racial Differences in Stroke (REGARDS) study participants 66 years and older who completed a study examination in 2013-2016, had Medicare fee-for-service coverage, and were taking antihypertensive medication. METHODS We used logistic regression to analyze the association of fragmented health care with uncontrolled BP and aTRH. Fragmented health care was operationalized as a reversed Bice-Boxerman Index score in the 75th percentile or higher, calculated using the number of ambulatory providers and health care visits in the year preceding the study examination. Uncontrolled BP was defined by systolic BP of at least 140 mm Hg or diastolic BP of at least 90 mm Hg. aTRH was defined by taking 3 or more classes of antihypertensive medication with uncontrolled BP or 4 or more classes with controlled BP. RESULTS The overall adjusted odds ratios (95% CIs) for uncontrolled BP, aTRH with controlled BP, and aTRH with uncontrolled BP associated with fragmented health care were 1.10 (0.89-1.37), 1.08 (0.80-1.47), and 1.32 (0.96-1.81), respectively. Fragmented health care was not associated with uncontrolled BP or aTRH among White participants, women, or men. Among Black participants, the odds ratio (95% CI) associated with fragmented health care was 1.21 (0.81-1.82) for uncontrolled BP, 1.22 (0.72-2.07) for aTRH with controlled BP, and 1.82 (1.07-3.11) for aTRH with uncontrolled BP. CONCLUSIONS Fragmented health care may increase the likelihood of aTRH with uncontrolled BP among older Black adults taking antihypertensive medication.
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Affiliation(s)
| | | | | | | | - Lisa M Kern
- Department of Medicine, Weill Cornell Medicine, 420 E 70th St, Box 331, New York, NY 10021.
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Kingery JR, Bf Martin P, Baer BR, Pinheiro LC, Rajan M, Clermont A, Pan S, Nguyen K, Fahoum K, Wehmeyer GT, Alshak MN, Li HA, Choi JJ, Shapiro MF, McNairy ML, Safford MM, Goyal P. Thirty-Day Post-Discharge Outcomes Following COVID-19 Infection. J Gen Intern Med 2021; 36:2378-2385. [PMID: 34100231 PMCID: PMC8183585 DOI: 10.1007/s11606-021-06924-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 05/06/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND The clinical course of COVID-19 includes multiple disease phases. Data describing post-hospital discharge outcomes may provide insight into disease course. Studies describing post-hospitalization outcomes of adults following COVID-19 infection are limited to electronic medical record review, which may underestimate the incidence of outcomes. OBJECTIVE To determine 30-day post-hospitalization outcomes following COVID-19 infection. DESIGN Retrospective cohort study SETTING: Quaternary referral hospital and community hospital in New York City. PARTICIPANTS COVID-19 infected patients discharged alive from the emergency department (ED) or hospital between March 3 and May 15, 2020. MEASUREMENT Outcomes included return to an ED, re-hospitalization, and mortality within 30 days of hospital discharge. RESULTS Thirty-day follow-up data were successfully collected on 94.6% of eligible patients. Among 1344 patients, 16.5% returned to an ED, 9.8% were re-hospitalized, and 2.4% died. Among patients who returned to the ED, 50.0% (108/216) went to a different hospital from the hospital of the index presentation, and 61.1% (132/216) of those who returned were re-hospitalized. In Cox models adjusted for variables selected using the lasso method, age (HR 1.01 per year [95% CI 1.00-1.02]), diabetes (1.54 [1.06-2.23]), and the need for inpatient dialysis (3.78 [2.23-6.43]) during the index presentation were independently associated with a higher re-hospitalization rate. Older age (HR 1.08 [1.05-1.11]) and Asian race (2.89 [1.27-6.61]) were significantly associated with mortality. CONCLUSIONS Among patients discharged alive following their index presentation for COVID-19, risk for returning to a hospital within 30 days of discharge was substantial. These patients merit close post-discharge follow-up to optimize outcomes.
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Affiliation(s)
- Justin R Kingery
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY, 10065, USA.
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, NY, USA.
| | - Paul Bf Martin
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY, 10065, USA
| | - Ben R Baer
- Department of Statistics and Data Science, Cornell University, Ithaca, NY, USA
| | - Laura C Pinheiro
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY, 10065, USA
| | - Mangala Rajan
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY, 10065, USA
| | | | - Sabrina Pan
- School of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Khoi Nguyen
- School of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Khalid Fahoum
- School of Medicine, Weill Cornell Medicine, New York, NY, USA
| | | | - Mark N Alshak
- School of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Han A Li
- School of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Justin J Choi
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY, 10065, USA
| | - Martin F Shapiro
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY, 10065, USA
| | - Margaret L McNairy
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY, 10065, USA
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Monika M Safford
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY, 10065, USA
| | - Parag Goyal
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY, 10065, USA
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
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