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Strehlow M, Alvarez A, Blomkalns AL, Caretta-Wyer H, Gharahbaghian L, Imler D, Khan A, Lee M, Lobo V, Newberry JA, Riberia R, Sebok-Syer S, Shen S, Gisondi MA. Precision emergency medicine. Acad Emerg Med 2024. [PMID: 38940478 DOI: 10.1111/acem.14962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 04/13/2024] [Accepted: 05/23/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Precision health is a burgeoning scientific discipline that aims to incorporate individual variability in biological, behavioral, and social factors to develop personalized health solutions. To date, emergency medicine has not deeply engaged in the precision health movement. However, rapid advances in health technology, data science, and medical informatics offer new opportunities for emergency medicine to realize the promises of precision health. METHODS In this article, we conceptualize precision emergency medicine as an emerging paradigm and identify key drivers of its implementation into current and future clinical practice. We acknowledge important obstacles to the specialty-wide adoption of precision emergency medicine and offer solutions that conceive a successful path forward. RESULTS Precision emergency medicine is defined as the use of information and technology to deliver acute care effectively, efficiently, and authentically to individual patients and their communities. Key drivers and opportunities include leveraging human data, capitalizing on technology and digital tools, providing deliberate access to care, advancing population health, and reimagining provider education and roles. Overcoming challenges in equity, privacy, and cost is essential for success. We close with a call to action to proactively incorporate precision health into the clinical practice of emergency medicine, the training of future emergency physicians, and the research agenda of the specialty. CONCLUSIONS Precision emergency medicine leverages new technology and data-driven artificial intelligence to advance diagnostic testing, individualize patient care plans and therapeutics, and strategically refine the convergence of the health system and the community.
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Affiliation(s)
- Matthew Strehlow
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Al'ai Alvarez
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Andra L Blomkalns
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Holly Caretta-Wyer
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Laleh Gharahbaghian
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Daniel Imler
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Ayesha Khan
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Moon Lee
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Viveta Lobo
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Jennifer A Newberry
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Ryan Riberia
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Stefanie Sebok-Syer
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Sam Shen
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Michael A Gisondi
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
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2
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Ortíz-Barrios MA, Coba-Blanco DM, Alfaro-Saíz JJ, Stand-González D. Process Improvement Approaches for Increasing the Response of Emergency Departments against the COVID-19 Pandemic: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:8814. [PMID: 34444561 PMCID: PMC8392152 DOI: 10.3390/ijerph18168814] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 08/15/2021] [Accepted: 08/17/2021] [Indexed: 12/23/2022]
Abstract
The COVID-19 pandemic has strongly affected the dynamics of Emergency Departments (EDs) worldwide and has accentuated the need for tackling different operational inefficiencies that decrease the quality of care provided to infected patients. The EDs continue to struggle against this outbreak by implementing strategies maximizing their performance within an uncertain healthcare environment. The efforts, however, have remained insufficient in view of the growing number of admissions and increased severity of the coronavirus disease. Therefore, the primary aim of this paper is to review the literature on process improvement interventions focused on increasing the ED response to the current COVID-19 outbreak to delineate future research lines based on the gaps detected in the practical scenario. Therefore, we applied the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to perform a review containing the research papers published between December 2019 and April 2021 using ISI Web of Science, Scopus, PubMed, IEEE, Google Scholar, and Science Direct databases. The articles were further classified taking into account the research domain, primary aim, journal, and publication year. A total of 65 papers disseminated in 51 journals were concluded to satisfy the inclusion criteria. Our review found that most applications have been directed towards predicting the health outcomes in COVID-19 patients through machine learning and data analytics techniques. In the overarching pandemic, healthcare decision makers are strongly recommended to integrate artificial intelligence techniques with approaches from the operations research (OR) and quality management domains to upgrade the ED performance under social-economic restrictions.
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Affiliation(s)
- Miguel Angel Ortíz-Barrios
- Department of Productivity and Innovation, Universidad de la Costa CUC, Barranquilla 081001, Colombia; (D.M.C.-B.); (D.S.-G.)
| | - Dayana Milena Coba-Blanco
- Department of Productivity and Innovation, Universidad de la Costa CUC, Barranquilla 081001, Colombia; (D.M.C.-B.); (D.S.-G.)
| | - Juan-José Alfaro-Saíz
- Research Centre on Production Management and Engineering, Universitat Politècnica de València, 46022 Valencia, Spain;
| | - Daniela Stand-González
- Department of Productivity and Innovation, Universidad de la Costa CUC, Barranquilla 081001, Colombia; (D.M.C.-B.); (D.S.-G.)
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3
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Kilaru AS, Xiong A, Lowenstein M, Meisel ZF, Perrone J, Khatri U, Mitra N, Delgado MK. Incidence of Treatment for Opioid Use Disorder Following Nonfatal Overdose in Commercially Insured Patients. JAMA Netw Open 2020; 3:e205852. [PMID: 32459355 PMCID: PMC7254182 DOI: 10.1001/jamanetworkopen.2020.5852] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
IMPORTANCE Timely initiation and referral to treatment for patients with opioid use disorder seen in the emergency department is associated with reduced mortality. It is not known how often commercially insured adults obtain follow-up treatment after nonfatal opioid overdose. OBJECTIVE To investigate the incidence of follow-up treatment following emergency department discharge after nonfatal opioid overdose and patient characteristics associated with receipt of follow-up treatment. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted using an administrative claims database for a large US commercial insurer, from October 1, 2011, to September 30, 2016. Data analysis was performed from May 1, 2019, to September 26, 2019. Adult patients discharged from the emergency department after an index opioid overdose (no overdose in the preceding 90 days) were included. Patients with cancer and without continuous insurance enrollment were excluded. MAIN OUTCOMES AND MEASURES The primary outcome was follow-up treatment in the 90 days following overdose, defined as a combined outcome of claims for treatment encounters or medications for opioid use disorder (buprenorphine and naltrexone). Analysis was stratified by whether patients received treatment for opioid use disorder in the 90 days before the overdose. Logistic regression models were used to identify patient characteristics associated with receipt of follow-up treatment. Marginal effects were used to report the average adjusted probability and absolute risk differences (ARDs) in follow-up for different patient characteristics. RESULTS A total of 6451 patients were identified with nonfatal opioid overdose; the mean (SD) age was 45.0 (19.3) years, 3267 were women (50.6%), and 4676 patients (72.5%) reported their race as non-Hispanic white. A total of 1069 patients (16.6%; 95% CI, 15.7%-17.5%) obtained follow-up treatment within 90 days after the overdose. In adjusted analysis of patients who did not receive treatment before the overdose, black patients were half as likely to obtain follow-up compared with non-Hispanic white patients (ARD, -5.9%; 95% CI, -8.6% to -3.6%). Women (ARD, -1.7%; 95% CI, -3.3% to -0.5%) and Hispanic patients (ARD, -3.5%; 95% CI, -6.1% to -0.9%) were also less likely to obtain follow-up. For each additional year of age, patients were 0.2% less likely to obtain follow-up (95% CI, -0.3% to -0.1%). CONCLUSIONS AND RELEVANCE Efforts to improve the low rate of timely follow-up treatment following opioid overdose may seek to address sex, race/ethnicity, and age disparities.
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Affiliation(s)
- Austin S. Kilaru
- National Clinician Scholars Program, Corporal Michael J. Crescenz Veterans Affairs Medical Center, University of Pennsylvania, Philadelphia
- Center for Emergency Care Policy and Research, Perelman School of Medicine, Department of Emergency Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Penn Injury Science Center, Philadelphia, Pennsylvania
| | - Aria Xiong
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Margaret Lowenstein
- National Clinician Scholars Program, Corporal Michael J. Crescenz Veterans Affairs Medical Center, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Penn Injury Science Center, Philadelphia, Pennsylvania
| | - Zachary F. Meisel
- Center for Emergency Care Policy and Research, Perelman School of Medicine, Department of Emergency Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Penn Injury Science Center, Philadelphia, Pennsylvania
| | - Jeanmarie Perrone
- Center for Emergency Care Policy and Research, Perelman School of Medicine, Department of Emergency Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Utsha Khatri
- National Clinician Scholars Program, Corporal Michael J. Crescenz Veterans Affairs Medical Center, University of Pennsylvania, Philadelphia
- Center for Emergency Care Policy and Research, Perelman School of Medicine, Department of Emergency Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Penn Injury Science Center, Philadelphia, Pennsylvania
| | - Nandita Mitra
- Perelman School of Medicine, Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia
| | - M. Kit Delgado
- Center for Emergency Care Policy and Research, Perelman School of Medicine, Department of Emergency Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Penn Injury Science Center, Philadelphia, Pennsylvania
- Perelman School of Medicine, Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia
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4
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Lin MP, Revette A, Carr BG, Richardson LD, Wiler JL, Schuur JD. Effect of Accountable Care Organizations on Emergency Medicine Payment and Care Redesign: A Qualitative Study. Ann Emerg Med 2020; 75:597-608. [PMID: 31973914 DOI: 10.1016/j.annemergmed.2019.09.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/10/2019] [Accepted: 09/13/2019] [Indexed: 02/04/2023]
Abstract
STUDY OBJECTIVE Accountable care organizations are provider networks aiming to improve quality while reducing costs for populations. It is unknown how value-based care within accountable care organizations affects emergency medicine care delivery and payment. Our objective was to describe how accountable care has impacted emergency care redesign and payment. METHODS We performed a qualitative study of accountable care organizations, consisting of semistructured interviews with emergency department (ED) and accountable care organization leaders responsible for strategy, care redesign, and payment. We analyzed transcripts for key themes, using thematic analysis techniques. RESULTS We performed 22 interviews across 7 accountable care organizations. All sites were enrolled in the Medicare Shared Savings Program; however, sites varied in region and maturity with respect to population health initiatives. Nearly all sites were focused on reducing low-value ED visits, expanding alternate venues for acute unscheduled care, and redesigning care to reduce ED admission rates through expanded care coordination, including programs targeting high-risk populations such as older adults and frequent ED users, telehealth, and expanded use of direct transfer to skilled nursing facilities from the ED. However, there has been no significant reform of payment for emergency medical care within these accountable care organizations. Nearly all informants expressed concern in regard to reduced ED reimbursement, given accountable care organization efforts to reduce ED utilization and increase clinician participation in alternative payment contracts. No participants expressed a clear vision for reforming payment for ED services. CONCLUSION Care redesign within accountable care organizations has focused on outpatient access and alternatives to hospitalization. However, there has been little influence on emergency medicine payment, which remains fee for service. Evidence-based policy solutions are urgently needed to inform the adoption of value-based payment for acute unscheduled care.
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Affiliation(s)
| | | | - Brendan G Carr
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | | | | | - Jeremiah D Schuur
- Warren Alpert School of Medicine at Brown University, Providence, RI
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5
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Smith SW, Lee DC, Goldfrank LR. Reflections on Mortality and Uncertainty in Emergency Medicine. JAMA Intern Med 2020; 180:88-90. [PMID: 31682680 DOI: 10.1001/jamainternmed.2019.4858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Silas W Smith
- Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, New York, NY.,Institute for Innovations in Medical Education, NYU Langone Health, New York, NY
| | - David C Lee
- Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, New York, NY.,Department of Population Health, New York University School of Medicine, New York, NY
| | - Lewis R Goldfrank
- Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, New York, NY
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6
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Borensztajn D, Yeung S, Hagedoorn NN, Balode A, von Both U, Carrol ED, Dewez JE, Eleftheriou I, Emonts M, van der Flier M, de Groot R, Herberg JA, Kohlmaier B, Lim E, Maconochie I, Martinón-Torres F, Nijman R, Pokorn M, Strle F, Tsolia M, Wendelin G, Zavadska D, Zenz W, Levin M, Moll HA. Diversity in the emergency care for febrile children in Europe: a questionnaire study. BMJ Paediatr Open 2019; 3:e000456. [PMID: 31338429 PMCID: PMC6613846 DOI: 10.1136/bmjpo-2019-000456] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 04/16/2019] [Accepted: 04/23/2019] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE To provide an overview of care in emergency departments (EDs) across Europe in order to interpret observational data and implement interventions regarding the management of febrile children. DESIGN AND SETTING An electronic questionnaire was sent to the principal investigators of an ongoing study (PERFORM (Personalised Risk assessment in Febrile illness to Optimise Real-life Management), www.perform2020.eu) in 11 European hospitals in eight countries: Austria, Germany, Greece, Latvia, the Netherlands, Slovenia, Spain and the UK. OUTCOME MEASURES The questionnaire covered indicators in three domains: local ED quality (supervision, guideline availability, paper vs electronic health records), organisation of healthcare (primary care, immunisation), and local factors influencing or reflecting resource use (availability of point-of-care tests, admission rates). RESULTS Reported admission rates ranged from 4% to 51%. In six settings (Athens, Graz, Ljubljana, Riga, Rotterdam, Santiago de Compostela), the supervising ED physicians were general paediatricians, in two (Liverpool, London) these were paediatric emergency physicians, in two (Nijmegen, Newcastle) supervision could take place by either a general paediatrician or a general emergency physician, and in one (München) this could be either a general paediatrician or a paediatric emergency physician. The supervising physician was present on site in all settings during office hours and in five out of eleven settings during out-of-office hours. Guidelines for fever and sepsis were available in all settings; however, the type of guideline that was used differed. Primary care was available in all settings during office hours and in eight during out-of-office hours. There were differences in routine immunisations as well as in additional immunisations that were offered; immunisation rates varied between and within countries. CONCLUSION Differences in local, regional and national aspects of care exist in the management of febrile children across Europe. This variability has to be considered when trying to interpret differences in the use of diagnostic tools, antibiotics and admission rates. Any future implementation of interventions or diagnostic tests will need to be aware of this European diversity.
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Affiliation(s)
- Dorine Borensztajn
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Shunmay Yeung
- Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, UK
| | - Nienke N Hagedoorn
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Anda Balode
- Department of Pediatrics, Rīgas Stradiņa Universitāte, Children's Clinical University Hospital, Riga, Latvia
| | - Ulrich von Both
- Division of Paediatric Infectious Diseases, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University (LMU), Munich, Germany.,German Centre for Infection Research DZIF, Munich, Germany
| | - Enitan D Carrol
- Department of Infectious Diseases, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.,Department of Clinical Infection, Microbiology, and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Juan Emmanuel Dewez
- Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, UK
| | - Irini Eleftheriou
- Second Department of Paediatrics, P & A Kyriakou Children's Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Marieke Emonts
- Paediatric Immunology, Infectious Diseases and Allergy, Newcastle upon Tyne Hospitals NHS Foundation Trust, Great North Children's Hospital, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Michiel van der Flier
- Pediatric Infectious Diseases and Immunology, Amalia Children's Hospital, Radboudumc, Nijmegen, The Netherlands.,Pediatric Infectious Diseases and Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ronald de Groot
- Pediatric Infectious Diseases and Immunology, Amalia Children's Hospital, Radboudumc, Nijmegen, The Netherlands
| | - Jethro Adam Herberg
- Section of Paediatrics, Imperial College, London, UK.,Paediatric Emergency Department, Imperial College Healthcare NHS Trust, London, UK
| | - Benno Kohlmaier
- Department of General Paediatrics, Medical University of Graz, Graz, Austria
| | - Emma Lim
- Paediatric Immunology, Infectious Diseases and Allergy, Newcastle upon Tyne Hospitals NHS Foundation Trust, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - Ian Maconochie
- Section of Paediatrics, Imperial College, London, UK.,Paediatric Emergency Department, Imperial College Healthcare NHS Trust, London, UK
| | - Federico Martinón-Torres
- Genetics, Vaccines, Infections and Pediatrics Research group (GENVIP), Hospital Clinico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Ruud Nijman
- Section of Paediatrics, Imperial College, London, UK.,Paediatric Emergency Department, Imperial College Healthcare NHS Trust, London, UK
| | - Marko Pokorn
- Department of Infectious Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Franc Strle
- Department of Infectious Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Maria Tsolia
- Second Department of Paediatrics, P & A Kyriakou Children's Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Gerald Wendelin
- Department of General Paediatrics, Medical University of Graz, Graz, Austria
| | - Dace Zavadska
- Department of Pediatrics, Rīgas Stradiņa Universitāte, Children's Clinical University Hospital, Riga, Latvia
| | - Werner Zenz
- Department of General Paediatrics, Medical University of Graz, Graz, Austria
| | - Michael Levin
- Section of Paediatrics, Imperial College, London, UK.,Paediatric Emergency Department, Imperial College Healthcare NHS Trust, London, UK
| | - Henriette A Moll
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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Farmer SA, Brown NA. Value-Based Approaches for Emergency Care in a New Era. Ann Emerg Med 2017; 69:684-686. [PMID: 28185663 DOI: 10.1016/j.annemergmed.2016.11.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Indexed: 11/18/2022]
Affiliation(s)
- Steven A Farmer
- Center for Healthcare Innovation and Policy Research, George Washington University, School of Medicine and Health Sciences, Washington, DC; Department of Health Policy, George Washington University, Milken Institute School of Public Health, Washington, DC; Margolis Center for Health Policy, Duke University, Durham, NC.
| | - N Adam Brown
- Center for Healthcare Innovation and Policy Research, George Washington University, School of Medicine and Health Sciences, Washington, DC
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