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Sinnott C, Ansari A, Price E, Fisher R, Beech J, Alderwick H, Dixon-Woods M. Understanding access to general practice through the lens of candidacy: a critical review of the literature. Br J Gen Pract 2024; 74:e683-e694. [PMID: 38936884 PMCID: PMC11441605 DOI: 10.3399/bjgp.2024.0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 05/13/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND Dominant conceptualisations of access to health care are limited, framed in terms of speed and supply. The Candidacy Framework offers a more comprehensive approach, identifying diverse influences on how access is accomplished. AIM To characterise how the Candidacy Framework can explain access to general practice - an increasingly fraught area of public debate and policy. DESIGN AND SETTING Qualitative review guided by the principles of critical interpretive synthesis. METHOD We conducted a literature review using an author-led approach, involving iterative analytically guided searches. Articles were eligible for inclusion if they related to the context of general practice, without geographical or time limitations. Key themes relating to access to general practice were extracted and synthesised using the Candidacy Framework. RESULTS A total of 229 articles were included in the final synthesis. The seven features identified in the original Candidacy Framework are highly salient to general practice. Using the lens of candidacy demonstrates that access to general practice is subject to multiple influences that are highly dynamic, contingent, and subject to constant negotiation. These influences are socioeconomically and institutionally patterned, creating risks to access for some groups. This analysis enables understanding of the barriers to access that may exist, even though general practice in the UK is free at the point of care, but also demonstrates that a Candidacy Framework specific to this setting is needed. CONCLUSION The Candidacy Framework has considerable value as a way of understanding access to general practice, offering new insights for policy and practice. The original framework would benefit from further customisation for the distinctive setting of general practice.
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Affiliation(s)
- Carol Sinnott
- Health Foundation professor of healthcare improvement studies, The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge
| | - Akbar Ansari
- Health Foundation professor of healthcare improvement studies, The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge
| | - Evleen Price
- Health Foundation professor of healthcare improvement studies, The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge
| | | | | | | | - Mary Dixon-Woods
- Health Foundation professor of healthcare improvement studies, The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge
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Zouch JH, Berg B, Pripp AH, Storheim K, Ashton-James CE, Ferreira ML, Grotle M, Ferreira PH. Reducing strain on primary healthcare systems through innovative models of care: the impact of direct access physiotherapy for musculoskeletal conditions-an interrupted time series analysis. Fam Med Community Health 2024; 12:e002998. [PMID: 39317459 PMCID: PMC11423733 DOI: 10.1136/fmch-2024-002998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2024] Open
Abstract
OBJECTIVES To evaluate the longitudinal impact of introducing a national, direct access physiotherapy model of care on the rates of primary and secondary care consultations for musculoskeletal (MSK) conditions. DESIGN Interrupted time series analysis using segmented linear regression. SETTING Norway primary care PARTICIPANTS: A cohort of 82 072 participants was derived from 3 population-based health surveys conducted across separate geographical regions in Norway. All participants surveyed were eligible for inclusion as a national representative sample of the Norwegian population. Registered MSK consultations were linked to the Norwegian Control and Payment of Health Reimbursement database and the Norwegian Patient Register using the International Classification of Primary Care diagnostic medical codes L-chapter for MSK conditions and spine related International Classification of Diseases, 10th Revision, codes. INTERVENTION Direct access to physiotherapy model of care introduced nationally in Norway in 2018. This model allowed Norwegians to consult directly with qualified physiotherapists for MSK conditions (eg, back pain, knee osteoarthritis) without the need for a medical referral in order to claim a social security reimbursement. MAIN OUTCOMES MEASURED Rates of primary care consultations per 10 000 population (general practitioner (GP) and physiotherapist consultations) and secondary care (specialist consultations and surgical procedures) measured from 2014 to 2021. RESULTS The introduction of the direct access physiotherapy model was associated with an immediate stepped reduction of 391 general practice consultations per 10 000 population, (95% CI: -564 to -216), without an associated change in physiotherapy consultations. Subgroup analyses suggested there was an associated reduction in physiotherapy consultations for those in the lowest education group of 150 consultations per quarter (95% CI:-203 to -97), 70 consultations per quarter in the intermediate education group (95% CI:-115 to -27) and a stepped reduction of 2 spinal surgical procedures per 10 000 population, for those aged between 40 and 60 years (95% CI: -3 to -1) following the introduction of the direct access physiotherapy model. CONCLUSION The national introduction of a direct access to physiotherapy model of care was associated with a reduction in the workload of GPs for the management of MSK conditions. The use of physiotherapists in direct contact roles is a potential strategic model to reduce the burden on the GP workforce in primary care worldwide.
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Affiliation(s)
- James Henry Zouch
- Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Bjørnar Berg
- Centre for Intelligent Musculoskeletal Health, Oslo Metropolitan University Faculty of Health Sciences, Oslo, Norway
| | - Are Hugo Pripp
- Oslo Metropolitan University Faculty of Health Sciences, Oslo, Norway
- Oslo Centre of Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway
| | - Kjersti Storheim
- Department of Rehabilitation Science and Health Technology, Oslo Metropolitan University Faculty of Health Sciences, Oslo, Norway
- Department of Research and Innovation, Oslo University Hospital Division of Clinical Neuroscience, Oslo, Norway
| | - Claire E Ashton-James
- Sydney Medical School, Kolling Institute, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Manuela L Ferreira
- The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Margreth Grotle
- Department of Research and Innovation, Oslo University Hospital, Oslo, Norway
- Department of Rehabilitation and Technology, Oslo Metropolitan University Faculty of Health Sciences, Oslo, Norway
| | - Paulo H Ferreira
- Charles Perkins Centre, Sydney Musculoskeletal Health, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
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Zouch J, Bhimani N, Bussières A, Ferreira ML, Foster NE, Ferreira P. Prognostic Factors and Treatment Effect Modifiers for Physical Health, Opioid Prescription, and Health Care Utilization in Patients With Musculoskeletal Disorders in Primary Care: Exploratory Secondary Analysis of the STEMS Randomized Trial of Direct Access to Physical Therapist-Led Care. Phys Ther 2024; 104:pzae066. [PMID: 38696361 PMCID: PMC11365697 DOI: 10.1093/ptj/pzae066] [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: 04/06/2023] [Revised: 11/23/2023] [Accepted: 04/30/2024] [Indexed: 05/04/2024]
Abstract
OBJECTIVE The aims of the study were to identify prognostic factors associated with health care outcomes in patients with musculoskeletal (MSK) conditions in primary care and to determine whether characteristics associated with choice of care modify treatment effects of a direct-access physical therapist-led pathway in addition to general practitioner (GP)-led care compared to GP-led care alone. METHODS A secondary analysis of a 2-parallel-arm, cluster randomized controlled trial involving general practices in the United Kingdom was conducted. Practices were randomized to continue offering GP-led care or to also offer a direct-access physical therapist-led pathway. Data from adults with MSK conditions who completed the 6-month follow-up questionnaire were analyzed. Outcomes included physical health, opioid prescription, and self-reported health care utilization over 6 months. Treatment effect modifiers were selected a priori from associations in observational studies. Multivariable regression models identified potential prognostic factors, and interaction analysis tested for potential treatment effect modifiers. RESULTS Analysis of 767 participants indicated that baseline pain self-efficacy, pain severity, and having low back pain statistically predicted outcomes at 6 months. Higher pain self-efficacy scores at baseline were associated with improved physical health scores, reduced opioid prescription, and less health care utilization. Higher bodily pain at baseline and having low back pain were associated with worse physical health scores and increased opioid prescription. Main interaction analyses did not reveal that patients' age, level of education, duration of symptoms, or MSK presentation influenced response to treatment, but visual trends suggested those in the older age group proceeded to fewer opioid prescriptions and utilized less health care when offered direct access to physical therapy. CONCLUSIONS Patients with MSK conditions with lower levels of pain self-efficacy, higher pain severity, and presenting with low back pain have less favorable clinical and health care outcomes in primary care. Prespecified characteristics did not modify the treatment effect of the offer of a direct-access physical therapist-led pathway compared to GP-led care. IMPACT Patients with MSK conditions receiving primary care in the form of direct-access physical therapist-led or GP-led care who have lower levels of self-efficacy, higher pain severity, and low back pain are likely to have a less favorable prognosis. Age and duration of symptoms should be explored as potential patient characteristics that modify the treatment response to a direct-access physical therapist-led model of care.
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Affiliation(s)
- James Zouch
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Nazim Bhimani
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - André Bussières
- Département de Chiropratique, Université du Québec à Trois-Rivières, Trois-Rivières, Quebec, Canada
- School of Physical & Occupational Therapy, McGill University, Montreal, Quebec, Canada
| | - Manuela L Ferreira
- Sydney Musculoskeletal Health, The Kolling Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Nadine E Foster
- Surgical Treatment and Rehabilitation Service (STARS) Education and Research Alliance, The University of Queensland and Metro North Hospital and Health Service, Herston, Queensland, Australia
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Newcastle-under-Lyme, Staffordshire, United Kingdom
| | - Paulo Ferreira
- Faculty of Medicine and Health, Musculoskeletal Pain Hub, Charles Perkins Centre, Sydney Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
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Rebbeck T, Evans K, Ferreira P, Beales D, Sterling M, Bennell KL, Cameron I, Nicholas M, Ritchie C, Jull G, Treleaven J, Trevena L, Refshauge K, Connelly L, Foster N, Black D, Hodges P, Ferreira M, Shaw TJ, Simic M. Implementation of a novel stratified PAthway of CarE for common musculoskeletal (MSK) conditions in primary care: protocol for a multicentre pragmatic randomised controlled trial (the PACE MSK trial). BMJ Open 2021; 11:e057705. [PMID: 37039086 PMCID: PMC8718479 DOI: 10.1136/bmjopen-2021-057705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction Musculoskeletal (MSK) conditions constitute the highest burden of disease globally, with healthcare services often utilised inappropriately and overburdened. The aim of this trial is to evaluate the effectiveness of a novel clinical PAthway of CarE programme (PACE programme), where care is provided based on people’s risk of poor outcome. Methods and analysis Multicentre randomised controlled trial. 716 people with MSK conditions (low back pain, neck pain or knee osteoarthritis) will be recruited in primary care. They will be stratified for risk of a poor outcome (low risk/high risk) using the Short Form Örebro Musculoskeletal Pain Screening Questionnaire (SF-ÖMSPQ) then randomised to usual care (n=358) or the PACE programme (n=358). Participants at low risk in the PACE programme will receive up to 3 sessions of guideline based care from their primary healthcare professional (HCP) supported by a custom designed website (mypainhub.com). Those at high risk will be referred to an allied health MSK specialist who will conduct a comprehensive patient-centred assessment then liaise with the primary HCP to determine further care. Primary outcome (SF 12-item PCS) and secondary outcomes (eg, pain self-efficacy, psychological health) will be collected at baseline, 3, 6 and 12 months. Cost-effectiveness will be measured as cost per quality-adjusted life-year gained. Health economic analysis will include direct and indirect costs. Analyses will be conducted on an intention-to-treat basis. Primary and secondary outcomes will be analysed independently, using generalised linear models. Qualitative and mixed-methods studies embedded within the trial will evaluate patient experience, health professional practice and interprofessional collaboration. Ethics and dissemination Ethics approval has been received from the following Human Research Ethics Committees: The University of Sydney (2018/926), The University of Queensland (2019000700/2018/926), University of Melbourne (1954239), Curtin University (HRE2019-0263) and Northern Sydney Local Health District (2019/ETH03632). Dissemination of findings will occur via peer-reviewed publications, conference presentations and social media. Trial registration number ACTRN12619000871145.
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Affiliation(s)
- Trudy Rebbeck
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
- John Walsh Centre for Rehabilitation Research, New South Wales, Australia, Kolling Institute, Northern Sydney Local Health District and Faculty of Medicine and Health, The University of Sydney, St Leonards, New South Wales, Australia
| | - Kerrie Evans
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
- Healthia Limited, Brisbane, Queensland, Australia
| | - Paulo Ferreira
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Darren Beales
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Michele Sterling
- RECOVER Injury Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- NHMRC Centre of Research Excellence in Road Traffic Injury Recovery, The University of Queensland, Brisbane, Queensland, The University of Queensland, Brisbane, Queensland, Australia
| | - Kim L Bennell
- Centre for Health, Exercise and Sports Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Ian Cameron
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Michael Nicholas
- Pain Management Research Institute, Kolling Institute, Northern Sydney Local Health District and Faculty of Medicine and Health, The University of Sydney, St Leonards, New South Wales, Australia
| | - Carrie Ritchie
- RECOVER Injury Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- NHMRC Centre of Research Excellence in Road Traffic Injury Recovery, The University of Queensland, Brisbane, Queensland, The University of Queensland, Brisbane, Queensland, Australia
| | - Gwen Jull
- Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Julia Treleaven
- Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Lyndal Trevena
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Kathryn Refshauge
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Luke Connelly
- Department of Sociology and Business Law, The University of Queensland, Centre for the Business and Economics of Health, The University of Bologna, Bologna, Emilia-Romagna, Italy
| | - Nadine Foster
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK
- Surgical, Treatment and Rehabilitation Service (STARS) Education and Research Alliance, The University of Queensland and Metro North Hospital and Health Service, Brisbane, Queensland, Australia
| | - Deborah Black
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Paul Hodges
- Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Manuela Ferreira
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
- Pain Management Research Institute, Kolling Institute, Northern Sydney Local Health District and Faculty of Medicine and Health, The University of Sydney, St Leonards, New South Wales, Australia
| | - Tim J Shaw
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Milena Simic
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
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5
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Alnaqbi A, Shousha T, AlKetbi H, Hegazy FA. Physiotherapists' perspectives on barriers to implementation of direct access of physiotherapy services in the United Arab Emirates: A cross-sectional study. PLoS One 2021; 16:e0253155. [PMID: 34115810 PMCID: PMC8195403 DOI: 10.1371/journal.pone.0253155] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 05/29/2021] [Indexed: 11/18/2022] Open
Abstract
Background There are two primary ways of accessing physiotherapy for service users around the world. The direct access, as opposed to the indirect access which requires a referral from a general physician, has several merits including better quality, timeliness, cost effectiveness of treatment and better probability of preventing acute conditions from turning into chronic ailments. Despite these benefits, several countries including the UAE, do not allow direct access to physiotherapists. This study aims to understand the level of awareness among practicing physiotherapists in the United Arab Emirates (UAE) about direct access and to determine whether any of their demographic variables influence the way they perceive the concept. Further, the study sought to explore the perceived barriers and benefits of direct access according to the participating physiotherapists. Subjects and methods An observational cross-sectional study was employed. The questionnaire survey developed by Bury and Stokes in 2013 was adapted and employed in this study. The instrument had six sections with close-ended items using a Likert five-point scale to rate them. Two hundred and sixty-four physiotherapists answered the questionnaire shared with them through a web link. Finally, MANOVA was employed to explore any influence of demographic variables on the opinions of the respondents. Results The findings showed that 70% of participants were aware about direct access while nearly 30% were completely unaware. Younger physiotherapists were more willing to endorse the practice whereas older ones were more apprehensive of the barriers. The main barriers reported were the limited support from the physicians and policy makers, professional autonomy, and the limited scope of practice for the physiotherapists, as well as evidence-based practice. The impact of demographic variables on direct access indicated that physiotherapists under the age of 23 endorsed direct access more strongly than other age groups. Conclusion More efforts are needed to implement direct access in the UAE, considering the benefits of improved professional status, cost savings, patient satisfaction, and higher efficiency. This study recommends leadership support, professional autonomy, and mentorship as possible ways to achieve this goal.
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Affiliation(s)
- Arwa Alnaqbi
- Physiotherapy Deparment, Kuwait Hospital, MOHAP, Dubai, UAE
| | - Tamer Shousha
- Department of Physiotherapy, College of Health sciences, University of Sharjah, Sharjah, UAE
- Faculty of Physical Therapy, Department of Physical Therapy for Musculoskeletal Disordered and its Surgery, Cairo University, Giza, Egypt
| | - Hamda AlKetbi
- Physical Medicine & Rehabilitation Department, Rashid Hospital, DHA, Dubai, UAE
| | - Fatma A. Hegazy
- Department of Physiotherapy, College of Health sciences, University of Sharjah, Sharjah, UAE
- Faculty of Physical Therapy, Department of Physical Therapy for Growth and Development Disorders in Children and Its Surgery, Cairo University, Giza, Egypt
- * E-mail:
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Yang M, Bishop A, Sussex J, Roland M, Jowett S, Wilson ECF. Economic evaluation of patient direct access to NHS physiotherapy services. Physiotherapy 2021; 111:40-47. [PMID: 33785196 DOI: 10.1016/j.physio.2020.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Our aim was to undertake an economic evaluation of patient direct access to physiotherapy in the UK NHS by comparing the number of patients treated, waiting time, cost and health gain from a direct access pathway versus traditional GP-referral to NHS physiotherapy. DESIGN The authors used a discrete event simulation (DES) model to represent a hypothetical GP practice of 10,000 patients. Costs were measured from the perspective of the NHS and society. Outcomes were predicted waiting times, the total number of patients with musculoskeletal conditions who received physiotherapy and quality adjusted life years (QALYs) gained, each estimated over a one year period. Model inputs were based on a pilot cluster randomised controlled trial (RCT) conducted in four general practices in Cheshire, UK, and other sources from the literature. RESULTS Direct access could increase the number of patients receiving at least one physiotherapy appointment by 63%, but without investment in extra physiotherapist capacity would increase waiting time dramatically. The increase in activity is associated with a cost of £4999 per QALY gained. CONCLUSIONS Direct access to physiotherapy services would be cost-effective and benefit patients given current cost per QALY thresholds used in England. This is because physiotherapy itself is cost-effective, rather than through savings in GP time. Direct access without an increase in supply of physiotherapists would increase waiting times and would be unlikely to be cost saving for the NHS owing to the likely increase in the use of physiotherapy services.
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Affiliation(s)
- Miaoqing Yang
- RAND Europe, Westbrook Centre, Milton Road, Cambridge CB4 1YG, UK.
| | - Annette Bishop
- Research Institute for Primary Care and Health Sciences, Keele University, Keele ST5 5BG, UK.
| | - Jon Sussex
- RAND Europe, Westbrook Centre, Milton Road, Cambridge CB4 1YG, UK.
| | - Martin Roland
- Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge CB2 0SR, UK.
| | - Sue Jowett
- Research Institute for Primary Care and Health Sciences, Keele University, Keele ST5 5BG, UK; Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham B15 2TT, UK.
| | - Edward C F Wilson
- Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge CB2 0SR, UK; Health Economics Group, University of East Anglia, Norwich, NR4 7TJ, UK.
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