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Sharma R, Mahajan N, Fadaleh SA, Patel H, Ivo J, Faisal S, Chang F, Lee L, Patel T. Medication Reviews and Clinical Outcomes in Persons with Dementia: A Scoping Review. PHARMACY 2023; 11:168. [PMID: 37888512 PMCID: PMC10609910 DOI: 10.3390/pharmacy11050168] [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: 08/06/2023] [Revised: 10/10/2023] [Accepted: 10/16/2023] [Indexed: 10/28/2023] Open
Abstract
Persons diagnosed with dementia are often faced with challenges related to polypharmacy and inappropriate medication use and could benefit from regular medication reviews. However, the benefit of such reviews has not been examined in this population. Therefore, the current scoping review was designed to identify the gaps in the current knowledge regarding the impact of medication reviews on the clinical outcomes in older adults with dementia. Relevant studies were identified by searching three databases (Ovid MEDLINE, Ovid EMBASE, and Scopus) from inception to January 2022 with a combination of keywords and medical subject headings. After the removal of duplicates and ineligible articles, 22 publications of the initial 8346 were included in this review. A total of 57 outcomes were identified, including those pertaining to the evaluation of medication use (n = 17), drug-related interventions (n = 11), drug-related problems (n = 10), dementia-related behavioral symptoms (n = 8), cost-effectiveness (n = 2), drug-related hospital admissions (n = 1), as well as outcomes classified as other (n = 7). Gaps identified through this scoping review included the paucity of studies measuring the impact of medication reviews on the medication management capacity and medication adherence, quality of life, and mortality.
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Affiliation(s)
- Rishabh Sharma
- School of Pharmacy, University of Waterloo, 10 Victoria St S A, Kitchener, ON N2G 1C5, Canada; (R.S.); (S.A.F.); (H.P.); (J.I.); (S.F.); (F.C.)
| | - Neil Mahajan
- Faculty of Health, Western University, 1151 Richmond St, London, ON N6A 5B9, Canada;
| | - Sarah Abu Fadaleh
- School of Pharmacy, University of Waterloo, 10 Victoria St S A, Kitchener, ON N2G 1C5, Canada; (R.S.); (S.A.F.); (H.P.); (J.I.); (S.F.); (F.C.)
| | - Hawa Patel
- School of Pharmacy, University of Waterloo, 10 Victoria St S A, Kitchener, ON N2G 1C5, Canada; (R.S.); (S.A.F.); (H.P.); (J.I.); (S.F.); (F.C.)
| | - Jessica Ivo
- School of Pharmacy, University of Waterloo, 10 Victoria St S A, Kitchener, ON N2G 1C5, Canada; (R.S.); (S.A.F.); (H.P.); (J.I.); (S.F.); (F.C.)
| | - Sadaf Faisal
- School of Pharmacy, University of Waterloo, 10 Victoria St S A, Kitchener, ON N2G 1C5, Canada; (R.S.); (S.A.F.); (H.P.); (J.I.); (S.F.); (F.C.)
| | - Feng Chang
- School of Pharmacy, University of Waterloo, 10 Victoria St S A, Kitchener, ON N2G 1C5, Canada; (R.S.); (S.A.F.); (H.P.); (J.I.); (S.F.); (F.C.)
| | - Linda Lee
- CFFM MINT Memory Clinic, 25 Joseph St, Kitchener, ON N2G 4X6, Canada;
- Schlegel-UW Research Institute for Aging, 250 Laurelwood Dr, Waterloo, ON N2J 0E2, Canada
- Department of Family Medicine, McMaster University, 100 Main St W 5th Floor, Hamilton, ON L8P 1H6, Canada
| | - Tejal Patel
- School of Pharmacy, University of Waterloo, 10 Victoria St S A, Kitchener, ON N2G 1C5, Canada; (R.S.); (S.A.F.); (H.P.); (J.I.); (S.F.); (F.C.)
- CFFM MINT Memory Clinic, 25 Joseph St, Kitchener, ON N2G 4X6, Canada;
- Schlegel-UW Research Institute for Aging, 250 Laurelwood Dr, Waterloo, ON N2J 0E2, Canada
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Rijksen DOC, Zuidema SU, de Haas EC. Use of Benzodiazepines and Z-Drugs in Nursing Home Residents with Dementia: Prevalence and Appropriateness. J Alzheimers Dis Rep 2022; 5:871-879. [PMID: 35088036 PMCID: PMC8764627 DOI: 10.3233/adr-210041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Guidelines worldwide recommend restricted prescription of benzodiazepine receptor agonists (BZRAs), i.e., benzodiazepines and Z-drugs, for the treatment of dementia-associated behavioral and psychological symptoms and insomnia. Objective: To assess the prevalence and appropriateness of BZRA use among nursing home residents with dementia. Methods: This is a post-hoc analysis of BZRA prescriptions from two intervention studies on psychotropic drug use, conducted from 2016 to 2018. It includes 1,111 residents of dementia special care units from 24 Dutch long-term care organizations. We assessed the prevalence of use of continuous and as-needed BZRA prescriptions and their association with registered symptoms. Continuous BZRA prescriptions were evaluated for appropriateness, i.e., whether indication, dosage, duration, and evaluation accorded with guidelines for the treatment of challenging behavior in dementia and sleep disorders. Results: The prevalence of BZRA use is 39.2% (95% CI: 36.3%–42.0%): continuous 22.9%; only as-needed 16.3%. Combinations of preferred BZRAs and appropriate indications occur in 19.0% of continuous anxiolytic prescriptions and 44.8% of hypnotic prescriptions. Frequently registered inappropriate indications are aggression/agitation for anxiolytics (continuous: 75.7%; as-needed: 75.2%) and nighttime agitation for hypnotics (continuous: 40.3%; as-needed: 26.7%). None of the continuous prescriptions with appropriate indications were appropriate for all other items. For most of the prescriptions, duration and time to evaluation exceeded 4 weeks. Conclusion: BZRA use in nursing home residents with dementia is highly frequent. A large proportion of prescriptions do not follow the guidelines with regard to indication, exceed the recommended duration and are not evaluated in a timely manner. The discrepancy between evidence-based guidelines and daily practice calls for an exploration of factors maintaining inappropriate use.
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Affiliation(s)
- Dirk O C Rijksen
- Carintreggeland, Center for Specialized Geriatric Care, Hengelo, The Netherlands
| | - Sytse U Zuidema
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Esther C de Haas
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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Gangannagaripalli J, Porter I, Davey A, Ricci Cabello I, Greenhalgh J, Anderson R, Briscoe S, Hughes C, Payne R, Cockcroft E, Harris J, Bramwell C, Valderas JM. STOPP/START interventions to improve medicines management for people aged 65 years and over: a realist synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background
Drug-related problems and potentially inappropriate prescribing impose a huge burden on patients and the health-care system. The most widely used tools for appropriate prescription in older adults in England and in other European countries are the Screening Tool of Older People’s Prescriptions (STOPP)/Screening Tool to Alert to the Right Treatment (START) tools. STOPP/START tools support medicines optimisation for older adults.
Objectives
To identify, test and refine the programme theories underlying how interventions based on the STOPP/START tools are intended to work, for whom, in what circumstances and why, as well as the resource use and cost requirements or impacts.
Design
A realist synthesis.
Setting
Primary care, hospital care and nursing homes.
Patients
Patients aged ≥ 65 years.
Interventions
Any intervention based on the use of the STOPP/START tools.
Review methods
Database and web-searching was carried out to retrieve relevant evidence to identify and test programme theories about how interventions based on the use of the STOPP/START tools work. A project reference group made up of health-care professionals, NHS decision-makers, older people, carers and members of the public was set up. In phase 1 we identified programme theories about STOPP/START interventions on how, for whom, in what contexts and why they are intended to work. We searched the peer-reviewed and grey literature to identify documents relevant to the research questions. We interviewed experts in the field in our reference group to gain input on our list of candidate context–mechanism–outcome configurations, to identify additional context–mechanism–outcome configurations and to identify additional literature and/or relevant concepts. In phase 2 we reviewed and synthesised relevant published and unpublished empirical evidence and tested the programme theories using evidence from a larger set of empirical studies.
Results
We developed a single logic model structured around three key mechanisms: (1) personalisation, (2) systematisation and (3) evidence implementation. Personalisation: STOPP/START-based interventions are based on shared decision-making, taking into account patient preferences, experiences and expectations (mechanisms), leading to increased patient awareness, adherence, satisfaction, empowerment and quality of life (outcomes). Systematisation: STOPP/START tools provide a standardised/systematic approach for medication reviews (mechanisms), leading to changes in professional and organisational culture and burden/costs (outcomes). Evidence implementation: delivery of STOPP/START-based interventions is based on the implementation of best evidence (mechanisms), reducing adverse outcomes through appropriate prescribing/deprescribing (outcomes). For theory testing, we identified 40 studies of the impact of STOPP/START-based interventions in hospital settings, nursing homes, primary care and community pharmacies. Most of the interventions used multiple mechanisms. We found support for the impact of the personalisation and evidence implementation mechanisms on selected outcome variables, but similar impact was achieved by interventions not relying on these mechanisms. We also observed that the impact of interventions was linked to the proximity of the selected outcomes to the intervention in the logic model, resulting in a clearer benefit for appropriateness of prescribing, adverse drug events and prescription costs.
Limitations
None of the available studies had been explicitly designed for evaluating underlying causal mechanisms, and qualitative information was sparse.
Conclusions
No particular configuration of the interventions is associated with a greater likelihood of improved outcomes in given settings.
Study registration
This study is registered as PROSPERO CRD42018110795.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 23. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | - Ian Porter
- Health Services and Policy Research Group, University of Exeter Medical School, Exeter, UK
| | - Antoinette Davey
- Health Services and Policy Research Group, University of Exeter Medical School, Exeter, UK
| | - Ignacio Ricci Cabello
- Gerència d’Atenció Primària de Mallorca, Fundació Institut d’Investigació Sanitària Illes Balears – IdISBa, Mallorca, Spain
| | - Joanne Greenhalgh
- School of Sociology and Social Policy, University of Leeds, Leeds, UK
| | - Rob Anderson
- Health Services and Policy Research Group, University of Exeter Medical School, Exeter, UK
- Evidence Synthesis & Modelling for Health Improvement (ESMI) Research Group, University of Exeter Medical School, Exeter, UK
| | - Simon Briscoe
- Health Services and Policy Research Group, University of Exeter Medical School, Exeter, UK
| | - Carmel Hughes
- School of Pharmacy, Queen’s University Belfast, Belfast, UK
| | - Rupert Payne
- Population Health Sciences, University of Bristol, Bristol Medical School, Bristol, UK
| | - Emma Cockcroft
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for the South West Peninsula, University of Exeter Medical School, Exeter, UK
| | - Jim Harris
- Health Services and Policy Research Group, University of Exeter Medical School, Exeter, UK
| | - Charlotte Bramwell
- Health Services and Policy Research Group, University of Exeter Medical School, Exeter, UK
| | - Jose M Valderas
- Health Services and Policy Research Group, University of Exeter Medical School, Exeter, UK
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Manias E, Kabir MZ, Maier AB. Inappropriate medications and physical function: a systematic review. Ther Adv Drug Saf 2021; 12:20420986211030371. [PMID: 34349978 PMCID: PMC8287273 DOI: 10.1177/20420986211030371] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 06/17/2021] [Indexed: 01/10/2023] Open
Abstract
Background and aims: Inappropriate medication prescription is highly prevalent in older adults and is associated with adverse health outcomes. The aim of this study was to examine the associations between potentially inappropriate medications (PIMS) and potential prescribing omissions with physical function in older adults situated in diverse environments. Methods: A systematic search was completed using the following databases: MEDLINE, CINAHL, PsycINFO, EMBASE and COCHRANE. Results were extracted from the included studies. Results: In total, 55 studies reported on 2,767,594 participants with a mean age of 77.1 years (63.5% women). Study designs comprised 26 retrospective cohort studies, 21 prospective cohort studies and 8 cross-sectional studies. Inappropriate medications in community and hospital settings were significantly associated with higher risk of falls (21 out of 30 studies), higher risk of fractures (7 out of 9 studies), impaired activities of daily living (ADL; 8 out of 10 studies) and impaired instrumental ADL (IADL) score (4 out of 6 studies). Five out of seven studies also showed that PIMs were associated with poorer physical performance comprising the Timed Up and Go test, walking speed, grip strength, time to functional recovery, functional independence and scale of functioning. Many medication classes were implicated as PIMs in falls, fractures and impairment in physical performance including antipsychotic, sedative, anti-anxiety, anticholinergic, antidiabetic, opioid and antihypertensive medications. For patients not receiving musculoskeletal medications, such as calcium, vitamin D and bisphosphonates, older adults were found to be at risk of a hospital admission for a fall or fracture. Conclusion: Inappropriate medication prescriptions are associated with impaired physical function across longitudinal and cross-sectional studies in older adults situated in diverse settings. It is important to support older people to reduce their use of inappropriate medications and prevent prescribing omissions. Plain language summary Inappropriate medications and physical function Background and aims: The use of inappropriate medications is very common in older adults and is associated with harmful health problems. The aim was to examine associations between potentially inappropriate medications and potential prescribing omissions with physical function in older adults situated in diverse environments. Methods: Library databases were examined for possible studies to include and a systematic search was completed. Relevant information was obtained from the included studies. Results: In total, 55 studies reported on 2,767,594 participants who were an average age of 77.1 years and about 6 out of 10 were women. A variety of different study designs were used. Inappropriate medication prescriptions in community and hospital settings were significantly associated with higher risk of falls (21 out of 30 studies), higher risk of fractures (7 out of 9 studies), problems with activities of daily living (ADL), such as eating, bathing, dressing, grooming, walking and toileting (8 out of 10 studies) and problems with instrumental ADL such as managing medications, house cleaning and shopping (4 out of 6 studies). Five out of seven studies also showed that inappropriate medications were associated with poorer physical performance involving the Timed Up and Go test, walking speed, grip strength, time to functional recovery, functional independence and scale of functioning. Many types of medication classes were shown to be associated with a risk of falls, fractures and problems with physical performance. Omitted medications were also associated with falls and fractures. Conclusion: Inappropriate medication prescriptions are associated with problems relating to physical function. It is important to support older people to reduce their use of inappropriate medications and prevent prescribing omissions.
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Affiliation(s)
- Elizabeth Manias
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, 221 Burwood Highway, Burwood, VIC 3125, Australia
| | - Md Zunayed Kabir
- Department of Medicine and Aged Care, The Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia
| | - Andrea B Maier
- Department of Medicine and Aged Care, @ Age Melbourne, The Royal Melbourne Hospital, The University of Melbourne, VIC, Australia
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Spinewine A, Evrard P, Hughes C. Interventions to optimize medication use in nursing homes: a narrative review. Eur Geriatr Med 2021; 12:551-567. [PMID: 33751478 PMCID: PMC8149362 DOI: 10.1007/s41999-021-00477-5] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 02/25/2021] [Indexed: 12/30/2022]
Abstract
PURPOSE Polypharmacy, medication errors and adverse drug events are frequent among nursing home residents. Errors can occur at any step of the medication use process. We aimed to review interventions aiming at optimization of any step of medication use in nursing homes. METHODS We narratively reviewed quantitative as well as qualitative studies, observational and experimental studies that described interventions, their effects as well as barriers and enablers to implementation. We prioritized recent studies with relevant findings for the European setting. RESULTS Many interventions led to improvements in medication use. However, because of outcome heterogeneity, comparison between interventions was difficult. Prescribing was the most studied aspect of medication use. At the micro-level, medication review, multidisciplinary work, and more recently, patient-centered care components dominated. At the macro-level, guidelines and legislation, mainly for specific medication classes (e.g., antipsychotics) were employed. Utilization of technology also helped improve medication administration. Several barriers and enablers were reported, at individual, organizational, and system levels. CONCLUSION Overall, existing interventions are effective in optimizing medication use. However there is a need for further European well-designed and large-scale evaluations of under-researched intervention components (e.g., health information technology, patient-centered approaches), specific medication classes (e.g., antithrombotic agents), and interventions targeting medication use aspects other than prescribing (e.g., monitoring). Further development and uptake of core outcome sets is required. Finally, qualitative studies on barriers and enablers for intervention implementation would enable theory-driven intervention design.
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Affiliation(s)
- Anne Spinewine
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Avenue Mounier 72/B1.72.02, Woluwe-Saint-Lambert, 1200, Brussels, Belgium.
- Pharmacy Department, CHU UCL Namur, Université Catholique de Louvain, Yvoir, Belgium.
| | - Perrine Evrard
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Avenue Mounier 72/B1.72.02, Woluwe-Saint-Lambert, 1200, Brussels, Belgium
| | - Carmel Hughes
- School of Pharmacy, Queen's University Belfast, Belfast, UK
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Evrard P, Henrard S, Foulon V, Spinewine A. Benzodiazepine Use and Deprescribing in Belgian Nursing Homes: Results from the COME-ON Study. J Am Geriatr Soc 2020; 68:2768-2777. [PMID: 32786002 DOI: 10.1111/jgs.16751] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 06/02/2020] [Accepted: 07/03/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND/OBJECTIVES To describe the use and deprescribing of benzodiazepine receptor agonists (BZRAs) among nursing home residents (NHRs), to evaluate appropriateness of use and to identify factors associated with BZRA use and deprescribing. DESIGN Posthoc analysis of the Collaborative Approach to Optimize Medication Use for Older People in Nursing Homes (COME-ON) study, a cluster controlled trial that evaluated the impact of a complex intervention on potentially inappropriate prescriptions (PIPs) in nursing homes (NHs). SETTING A total of 54 NHs in Belgium. PARTICIPANTS A total of 797 NHRs included in the study who had complete medical, clinical, and medication information at baseline and at the end of the study (month 15). MEASUREMENTS Data were recorded by participating healthcare professionals. Reasons why BZRA use was considered as PIPs were assessed using the 2019 American Geriatrics Society Beers Criteria® and the Screening Tool of Older Persons' Prescriptions (STOPP) criteria, version 2. Deprescribing included complete cessation or decreased daily dose. We identified factors at the NHR, prescriber, and NH levels associated with BZRA use and BZRA deprescribing using multivariable binary and multinomial logistic regression, respectively. RESULTS At baseline, 418 (52.4%) NHRs were taking a BZRA. The use of BZRA for longer than 4 weeks, with two or more other central nervous system active drugs, and in patients with delirium, cognitive impairment, falls, or fractures was found in more than 67% of BZRA users. Eight NHR-related variables and two prescriber-related variables were associated with regular BZRA use. Deprescribing occurred in 28.1% of BZRA users (32.9% in the intervention group and 22.1% in the control group). In addition to four other factors, dementia (odds ratio [OR] = 2.35; 95% confidence interval [CI] = [1.45-3.83]) and intervention group (OR = 1.74; 95% CI = 1.07-2.87) were associated with deprescribing. CONCLUSION Use of BZRAs was highly prevalent, and reasons to consider it as PIP were frequent. Deprescribing occurred in one-fourth of NHRs, which is encouraging. Future interventions should focus on specific aspects of PIPs (ie, indication, duration, drug-drug and drug-disease interactions) as well as on nondementia patients.
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Affiliation(s)
- Perrine Evrard
- Clinical Pharmacy Research Group, Université Catholique de Louvain, Louvain Drug Research Institute, Brussels, Belgium
| | - Séverine Henrard
- Clinical Pharmacy Research Group, Université Catholique de Louvain, Louvain Drug Research Institute, Brussels, Belgium.,Institute of Health and Society, Université Catholique de Louvain, Brussels, Belgium
| | - Veerle Foulon
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Anne Spinewine
- Clinical Pharmacy Research Group, Université Catholique de Louvain, Louvain Drug Research Institute, Brussels, Belgium.,Pharmacy Department, Université Catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
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Petersen CL, Curto D, Mishra MK, Cano P, Weeks WB. Reducing Psychotropic Use in Older Non-demented Spanish Care Home Residents: a Before-After Comparison of Three Methods. J Gen Intern Med 2020; 35:383-385. [PMID: 31713039 PMCID: PMC6957638 DOI: 10.1007/s11606-019-05517-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 10/22/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Curtis L Petersen
- The Dartmouth Institute for Health Policy and Clinical Practice, 5th Floor Williamson Translational Research Building, Dartmouth Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH, 03766, USA.
| | - David Curto
- Sanitas Mayores (a subsidiary of Bupa, London, England), Barcelona, Spain
| | - Manish K Mishra
- The Dartmouth Institute for Health Policy and Clinical Practice, 5th Floor Williamson Translational Research Building, Dartmouth Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH, 03766, USA
| | - Pedro Cano
- Sanitas Mayores (a subsidiary of Bupa, London, England), Barcelona, Spain
| | - William B Weeks
- The Dartmouth Institute for Health Policy and Clinical Practice, 5th Floor Williamson Translational Research Building, Dartmouth Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH, 03766, USA
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