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Jorgenson MR, Descourouez JL, Brady BL, Chandran MM, Do V, Kim M, Laub MR, Lichvar A, Park JM, Szczepanik A, Alloway RR. A call for transplant stewardship: The need for expanded evidence-based evaluation of induction and biologic-based cost-saving strategies in kidney transplantation and beyond. Clin Transplant 2021; 35:e14372. [PMID: 34033140 DOI: 10.1111/ctr.14372] [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: 03/17/2021] [Revised: 05/15/2021] [Accepted: 05/19/2021] [Indexed: 12/14/2022]
Abstract
Rising expenditures threaten healthcare sustainability. While transplant programs are typically considered profitable, transplant medications are expensive and frequently targeted for cost savings. This review aims to summarize available literature supporting cost-containment strategies used in solid organ transplant. Despite widespread use of these tactics, we found the available evidence to be fairly low quality. Strategies mainly focus on induction, particularly rabbit antithymocyte globulin (rATG), given its significant cost and the lack of consensus surrounding dosing. While there is higher-quality evidence for high single-dose rATG, and dose-rounding protocols to reduce waste are likely low risk, more aggressive strategies, such as dosing rATG by CD3+ target-attainment or on ideal-body-weight, have less robust support and did not always attain similar efficacy outcomes. Extrapolation of induction dosing strategies to rejection treatment is not supported by any currently available literature. Cost-saving strategies for supportive therapies, such as IVIG and rituximab also have minimal literature support. Deferral of high-cost agents to the outpatient arena is associated with minimal risk and increases reimbursement, although may increase complexity and cost-burden for patients and infusion centers. The available evidence highlights the need for evaluation of unique patient-specific clinical scenarios and optimization of therapies, rather than simple blanket application of cost-saving initiatives in the transplant population.
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Affiliation(s)
- Margaret R Jorgenson
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Jillian L Descourouez
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Bethany L Brady
- Department of Pharmacy, Indiana University Health University Hospital, Indianapolis, IN, USA
| | - Mary M Chandran
- Department of Pharmacy, Children's Hospital of Colorado, Aurora, CO, USA
| | - Vincent Do
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | - Miae Kim
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Melissa R Laub
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA
| | - Alicia Lichvar
- Department of Pharmacy Practice and Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Jeong M Park
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Amanda Szczepanik
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD, USA
| | - Rita R Alloway
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Miljković N, Godman B, van Overbeeke E, Kovačević M, Tsiakitzis K, Apatsidou A, Nikopoulou A, Yubero CG, Portillo Horcajada L, Stemer G, Kuruc-Poje D, De Rijdt T, Bochenek T, Huys I, Miljković B. Risks in Antibiotic Substitution Following Medicine Shortage: A Health-Care Failure Mode and Effect Analysis of Six European Hospitals. Front Med (Lausanne) 2020; 7:157. [PMID: 32478082 PMCID: PMC7235345 DOI: 10.3389/fmed.2020.00157] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 04/08/2020] [Indexed: 01/23/2023] Open
Abstract
Introduction: Medicine shortages result in great risk for the continuity of patient care especially for antimicrobial treatment, potentially enhancing resistance rates and having a higher economic impact. This study aims to identify, describe, assess, and assign risk priority levels to potential failures following substitution of antimicrobial treatment due to shortages among European hospitals. Furthermore, the study investigated the impact of corrective actions on risk reduction so as to provide guidance and improve future patient care. Methods: Health-care failure mode and effect analysis (HFMEA) was applied to hospitals in Austria (H-AT), Belgium (H-BE), Croatia (H-CR), Greece (H-GR), Spain (H-SP), and Serbia (H-SR). Multidisciplinary teams identified processes, failure modes, causes, and corrective actions related to antibiotic substitution following medicine shortages. Characteristics of study hospitals as well as severity, probability, and hazard scores (HSs) of failure modes/causes were analyzed using Microsoft Office Excel 2010 and IBM SPSS Statistics® via descriptive and inferential statistics. Results: Through HFMEA, 74 failure modes were identified, with 53 of these scoring 8 or above on the basis of assigned severity and probability for a failure. Severity of failure modes differed before and after corrective actions in H-CR, H-GR, and H-SR (p < 0.005). Their probability differed in all study hospitals (p < 0.005) when compared before and after corrective actions aimed to be implemented. The highest number of failure-mode causes was detected in H-CR (46) and the lowest in H-SP (16). Corrective actions can address failure modes and lower HSs; therein, all teams proposed the following: structuring communication among stakeholders, introducing electronic prescribing, strengthening pharmacists' involvement, and increasing effectiveness of the ward stock assessment. These proposed actions led to HS reductions up to 83%. Conclusion: There is a lack of structure in addressing risks associated with antibiotic substitution following shortages. Furthermore, lack of communication, data scarcity on availability of antibiotics, non-supportive information technology (IT) systems, and lack of internal substitution protocols hinder quick assessment of alternatives addressing patient needs. Nevertheless, the study shows that health-care professionals manage to secure optimal antimicrobial treatment for patients using available IT and human resources.
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Affiliation(s)
- Nenad Miljković
- Institute for Orthopaedic Surgery "Banjica", University of Belgrade, Belgrade, Serbia
| | - Brian Godman
- Division of Clinical Pharmacology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Strathclyde Institute of Pharmacy and Biomedical Sciences, Strathclyde University, Glasgow, United Kingdom.,Department of Public Health and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | | | - Milena Kovačević
- Department of Pharmacokinetics and Clinical Pharmacy, University of Belgrade, Belgrade, Serbia
| | - Karyofyllis Tsiakitzis
- General Hospital of Thessaloniki "G. Papanikolaou", Hospital Pharmacy Department, Thessaloniki, Greece
| | - Athina Apatsidou
- General Hospital of Thessaloniki "G. Papanikolaou", Hospital Pharmacy Department, Thessaloniki, Greece
| | - Anna Nikopoulou
- General Hospital of Thessaloniki "G. Papanikolaou", Hospital Pharmacy Department, Thessaloniki, Greece
| | | | | | - Gunar Stemer
- Gunar Stemer, Medicines Information and Clinical Pharmacy Services, Vienna General Hospital, Vienna, Austria
| | - Darija Kuruc-Poje
- General Hospital "Dr. Tomislav Bardek", Hospital Pharmacy Department, Koprivnica, Croatia
| | - Thomas De Rijdt
- Pharmacy Department, University Hospitals Leuven, UZ Herestraat, Leuven, Belgium
| | - Tomasz Bochenek
- Department of Drug Management, Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | - Isabelle Huys
- Clinical Pharmacology and Pharmacotherapy, KU Leuven, Leuven, Belgium
| | - Branislava Miljković
- Department of Pharmacokinetics and Clinical Pharmacy, University of Belgrade, Belgrade, Serbia
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C4 article: Challenges and solutions to appropriate and timely medication access in transplantation in the United States. Am J Transplant 2020; 20:362-376. [PMID: 31814278 DOI: 10.1111/ajt.15732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 11/20/2019] [Accepted: 11/21/2019] [Indexed: 01/25/2023]
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Di Giorgio D, Scrofina G, Scognamiglio B, Di Carluccio N, Tulimiero R, Pietrosanto A, Petrone P, De Iure M, Chimenti MG, Pozzetti E, Giacomazzi M, Berno R, Lupo M, Giaccone M, Pani M, Cesta E, Cruciani O, Maione C, Gramazio M, Derossi G. Tackling distribution-related shortages of medicines: An Italian case study evaluated in the European Union framework. MEDICINE ACCESS @ POINT OF CARE 2019. [DOI: 10.1177/2399202619856859] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Availability of human medicines is affected by problems associated with both manufacturing and distribution-related issues. The lack of definition of “shortages” or “unavailability” of medicines in European regulation represents an obstacle to the set up of proper preventive and counteracting measures. In this review, we describe how, within this framework, Italy started a program of shared activities, involving central and local authorities, police forces, and private stakeholders’ associations through an “ ad hoc technical forum,” that reduced the extent of the problem, at least in the short term, as demonstrated through some indicators defined by considering the key medicines affected by unavailability due to distribution-related issues. These measures should be strengthened and complemented with others so as to ensure their effectiveness in the long term.
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Affiliation(s)
| | | | | | - Nadia Di Carluccio
- Public Companies and Social-Pharmaceutical Service Providers Association (Assofarm), Rome, Italy
| | - Romina Tulimiero
- Italian Generic Medicines Manufacturers Association (Assogenerici), Rome, Italy
| | - Adriano Pietrosanto
- Italian Generic Medicines Manufacturers Association (Assogenerici), Rome, Italy
| | - Pierluigi Petrone
- Pharmaceutical Distribution Logistic/Commercial Service Providers Association (ASSORAM), Rome, Italy
| | - Mila De Iure
- Pharmaceutical Distribution Logistic/Commercial Service Providers Association (ASSORAM), Rome, Italy
| | | | - Elisabetta Pozzetti
- Farmindustria the Association of Pharmaceutical Companies in Italy, Rome, Italy
| | | | - Riccardo Berno
- Italian Pharmacy Owners Federation (Federfarma), Rome, Italy
| | - Monica Lupo
- Italian Association of Providers of Service for Pharmacies (Federfarma Servizi), Rome, Italy
| | - Mario Giaccone
- Federation of the Orders of Italian Pharmacists (FOFI), Rome, Italy
| | - Marcello Pani
- Italian Society of Hospital Pharmacy (SIFO), Milan, Italy
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Lindquist NR, Patro A, Gitomer SA, Cañadas KT. Pediatric acute unilateral suppurative lymphadenitis: The role of antibiotic susceptibilities at a large tertiary pediatric care center. Int J Pediatr Otorhinolaryngol 2019; 120:11-14. [PMID: 30743188 DOI: 10.1016/j.ijporl.2019.01.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 01/16/2019] [Accepted: 01/16/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Nathan R Lindquist
- Department of Otolaryngology - Head and Neck Surgery at Baylor College of Medicine, Houston, TX, USA
| | | | - Sarah A Gitomer
- Department of Otolaryngology - Head and Neck Surgery at Baylor College of Medicine, Houston, TX, USA
| | - Karina T Cañadas
- Texas Children's Hospital, Department of Otolaryngology - Head and Neck Surgery at Baylor College of Medicine, Houston, TX, USA.
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Trends in United States Drug Shortages for Medications Used in Gastroenterology. MEDICINE ACCESS @ POINT OF CARE 2017. [DOI: 10.5301/maapoc.0000012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Introduction Drug shortages have become more severe in recent years; however, data describing how such shortages impact gastroenterology (GI) drugs are limited. We characterize longitudinal trends of drug shortages in the USA within the scope of GI practice. Methods Drug shortage data from the University of Utah Drug Information Service were analyzed from January 2001 to December 2014. A board certified gastroenterologist, an internal medicine physician, and a clinical pharmacist identified drug shortages within the scope of GI practice, whether they are used for high-acuity conditions, availability, formulation, or therapeutic category. Trends in the length of shortages for GI drugs were described using standard descriptive statistics and regression analysis. Results A total of 1,774 drug shortages were reported over the 14-year period. Of those, 253 shortages (14.3%) were classified within the scope of GI practice. The number of newly-reported GI drug shortages increased from 15 in 2001 to 44 in 2014. The majority of GI drugs (55.7%) were parenteral and 102 shortages (40.3%) were single source drugs. By the end of the study period, 44 (17.4%) GI drugs remained on active shortage with a median duration of 24.3 months (interquartile range [IQR] 6.9–32.1). The median duration for resolved shortages of GI drugs was 7.7 months (IQR 2.9–17.6). Conclusions There was a significant increase in shortages of drugs used in GI practice from 2001 to 2014. Many of these drugs were used for high-acuity conditions and alternative agents were also impacted. Gastroenterologists must be cognizant of current shortages in order to mitigate impact on patient care.
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Vulto AG, Jaquez OA. The process defines the product: what really matters in biosimilar design and production? Rheumatology (Oxford) 2017; 56:iv14-iv29. [PMID: 28903544 PMCID: PMC5850795 DOI: 10.1093/rheumatology/kex278] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 06/12/2017] [Indexed: 12/15/2022] Open
Abstract
Biologic drugs are highly complex molecules produced by living cells through a multistep manufacturing process. The key characteristics of these molecules, known as critical quality attributes (CQAs), can vary based on post-translational modifications that occur in the cellular environment or during the manufacturing process. The extent of the variation in each of the CQAs must be characterized for the originator molecule and systematically matched as closely as possible by the biosimilar developer to ensure bio-similarity. The close matching of the originator fingerprint is the foundation of the biosimilarity exercise, as the analytical tools designed to measure differences at the molecular level are far more sensitive and specific than tools available to physicians during clinical trials. Biosimilar development, therefore, has a greater focus on preclinical attributes compared with the development of an original biological agent. As changes in CQAs can occur at different stages of the manufacturing process, even small modifications to the process can alter biosimilar attributes beyond the point of similarity and impact clinical effectiveness and safety. The manufacturer's ability to provide consistent production and quality control will greatly influence the acceptance of biosimilars. To this end, preventing drift from the required specifications over time and avoiding the various implications brought by product shortage will enhance biosimilar integration into daily practice. As most prescribers are not familiar with this new drug development paradigm, educational programmes will be needed so that prescribers see biosimilars as fully equivalent, efficacious and safe medicines when compared with originator products.
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Affiliation(s)
- Arnold G. Vulto
- Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Orlando A. Jaquez
- Department of Medical Affairs, Biogen International GmbH, Zug, Switzerland
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Tan YX, Moles RJ, Chaar BB. Medicine shortages in Australia: causes, impact and management strategies in the community setting. Int J Clin Pharm 2016; 38:1133-41. [PMID: 27383246 DOI: 10.1007/s11096-016-0342-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 06/24/2016] [Indexed: 10/21/2022]
Abstract
Background Medicine shortages are an ongoing global problem. The Therapeutic Goods Administration (TGA) dedicated a website for monitoring of medicine shortages in Australia in May 2014, as part of the Medicine Shortage Information Initiative. This study aimed to explore the views of pharmacists regarding medicine shortages in the community setting and the impact of the TGA website in Australia. Setting Community pharmacies in New South Wales, Australia. Method Twenty semi-structured interviews were conducted with community pharmacists. Data collected were analysed thematically utilising the framework analysis method. Main outcome measure Qualitative analysis conducted using the framework approach. Results Findings clearly indicated that medicine shortages were experienced on a regular basis, but most participants were unaware of the TGA website. Medicine shortages reportedly impacted both pharmacists and consumers; and various workarounds were undertaken to manage the issue. The "price disclosure policy" was found to be a prominent contributing factor in emerging shortages. Suggestions were made for ways to improve the growing occurrence of shortages. Conclusion Overall, the study found that there was a lack of familiarity with the TGA website, despite experiencing regular shortages of medicines in practice. Also highlighted, was the importance of pharmacists prioritising patient care over business decisions. To reduce prescribing of out-of-stock medicines notifying doctors about shortages was also considered important, to allow for early action to be taken at higher levels of the supply chain. Findings of this study may help direct future policy-making around the world, as medicine shortages is a problem shared by healthcare providers in most countries around the world.
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Affiliation(s)
- Yee Xi Tan
- Faculty of Pharmacy, The University of Sydney, A15 Pharmacy and Bank Building, Sydney, NSW, 2006, Australia
| | - Rebekah J Moles
- Faculty of Pharmacy, The University of Sydney, A15 Pharmacy and Bank Building, Sydney, NSW, 2006, Australia
| | - Betty B Chaar
- Faculty of Pharmacy, The University of Sydney, A15 Pharmacy and Bank Building, Sydney, NSW, 2006, Australia.
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Quadri F, Mazer-Amirshahi M, Fox ER, Hawley KL, Pines JM, Zocchi MS, May L. Antibacterial Drug Shortages From 2001 to 2013: Implications for Clinical Practice. Clin Infect Dis 2015; 60:1737-42. [DOI: 10.1093/cid/civ201] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 03/05/2015] [Indexed: 01/02/2023] Open
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Value of solid organ transplant-trained pharmacists in transplant infectious diseases. Curr Infect Dis Rep 2015; 17:475. [PMID: 25870143 DOI: 10.1007/s11908-015-0475-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Advances in organ transplantation have led to improved graft and patient survival. Transplant pharmacist's education and training uniquely position them to contribute knowledge and skills to the management of these highly complex patients. In 2004, the United Network for Organ Sharing bylaws added requirements that all transplant programs identify one or more pharmacists with experience in transplant pharmacotherapy to be responsible for providing pharmaceutical care to solid organ transplant recipients. These bylaws also delineated the transplant pharmacist's roles and responsibilities. To further support these efforts, in 2007 the Centers for Medicare and Medicaid Services accreditation standards for transplant centers also mandated that a center have a designated, qualified expert in transplant pharmacology as a multidisciplinary team member. The transplant pharmacist is a consistent member of the transplant team that can add value to the multidisciplinary approach of prevention and treatment of transplant infectious diseases through all phases of transplant care.
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Fox ER, Sweet BV, Jensen V. Drug shortages: a complex health care crisis. Mayo Clin Proc 2014; 89:361-73. [PMID: 24582195 DOI: 10.1016/j.mayocp.2013.11.014] [Citation(s) in RCA: 143] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Revised: 11/20/2013] [Accepted: 11/25/2013] [Indexed: 12/15/2022]
Abstract
National tracking of drug shortages began in 2001. However, a significant increase in the number of shortages began in late 2009, with numbers reaching what many have termed crisis level. The typical drug in short supply is a generic product administered by injection. Common classes of drugs affected by shortages include anesthesia medications, antibiotics, pain medications, nutrition and electrolyte products, and chemotherapy agents. The economic and clinical effects of drug shortages are significant. The financial effect of drug shortages is estimated to be hundreds of millions of dollars annually for health systems across the United States. Clinically, patients have been harmed by the lack of drugs or inferior alternatives, resulting in more than 15 documented deaths. Drug shortages occur for a variety of reasons. Generic injectable drugs are particularly susceptible to drug shortages because there are few manufacturers of these products and all manufacturers are running at full capacity. In addition, some manufacturers have had production problems, resulting in poor quality product. Although many suppliers are working to upgrade facilities and add additional manufacturing lines, these activities take time. A number of stakeholder organizations have been involved in meetings to further determine the causes and effects of drug shortages. A new law was enacted in July 2012 that granted the Food and Drug Administration additional tools to address the drug shortage crisis. The future of drug shortages is unknown, but there are hopeful indications that quality improvements and additional capacity may decrease the number of drug shortages in the years to come.
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Affiliation(s)
- Erin R Fox
- University of Utah Hospitals and Clinics, Salt Lake City.
| | | | - Valerie Jensen
- Food and Drug Administration, Center for Drug Evaluation and Research, Silver Spring, MD
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Abstract
Drug shortages are a growing problem in developed countries. To some extent they are the result of technical and organisational failures, but to view drug shortages simply as technical and economic phenomena is to miss the fact that they are also ethical and political issues. This observation is important because it highlights both the moral and political imperative to respond to drug shortages as vigorously as possible, and the need for those addressing shortages to do so in ethically and politically sophisticated ways. This brief article outlines the ethical issues that need to be considered by anyone attempting to understand or address drug shortages.
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Affiliation(s)
- Wendy Lipworth
- Australian Institute of Health Innovation, University of New South Wales ; Centre for Values, Ethics and the Law in Medicine, University of Sydney
| | - Ian Kerridge
- Centre for Values, Ethics and the Law in Medicine, University of Sydney ; Royal North Shore Hospital, Sydney
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