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Gonzalez-Aquines A, Rosales J, De Souza AC, Corredor-Quintero A, Barboza MA, Navia-Gonzalez V, Brunet-Perez F, Lagos-Servellon J, Novarro-Escudero N, Ortega-Moreno DA, Villarroel-Saavedra V, Abanto C, Barrientos-Guerra JD, Saltos-Mata F, Papavasileiou V, Todd O, Gongora-Rivera F. Availability and barriers to access post-stroke rehabilitation in Latin America. J Stroke Cerebrovasc Dis 2024; 33:107917. [PMID: 39111374 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 07/29/2024] [Accepted: 08/02/2024] [Indexed: 08/19/2024] Open
Abstract
OBJECTIVES To describe the availability and barriers to access post-stroke rehabilitation services in Latin America. MATERIALS AND METHODS We conducted a multi-national survey in Latin American countries. The survey consisted of three sections: (1) the national state of post-stroke rehabilitation; (2) the local state of post-stroke rehabilitation; and (3) the coverage and financing of post-stroke services. Stroke leaders from the surveyed countries were involved in developing and disseminating the survey. RESULTS 261 responses were collected from 17 countries. The mean age of respondents was 42.4 ± 10.1 years, and 139 (54.5 %) of the respondents were male. National clinical guidelines for post-stroke rehabilitation were reported by 67 (25.7 %) of the respondents. However, there were discrepancies between respondents within the same country. Stroke units, physiotherapy, occupational therapy, speech therapy, and neuropsychological therapy services were less common in public than private settings. The main barriers for inpatient and outpatient services included limited rehabilitation facilities, coverage, and rehabilitation personnel. The main source of financing for the inpatient and outpatient services was the national health insurance, followed by out-of-pocket payments. Private and out-of-pocket costs were more frequently reported in outpatient services. CONCLUSIONS Post-stroke rehabilitation services in Latin American countries are restricted due to a lack of coverage by the public health system and private insurers, human resources, and financial aid. Public settings offer fewer post-stroke rehabilitation services compared to private settings. Developing consensus guidelines, increasing coverage, and using innovative approaches to deliver post-stroke rehabilitation is paramount to increase access without posing a financial burden.
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Affiliation(s)
| | - Julieta Rosales
- Vascular Neurology Division, Department of Neurology, Fleni, Argentina. Montañeses, 2325, Buenos Aires, Argentina
| | - Ana Claudia De Souza
- Neurology and Neurosurgery Department, Hospital Moinhos de Vento, Brazil. Rua Ramiro Barcelos, 910, Bairro Moinhos de Ven, Porto Alegre, RS, 90.035-001
| | - Angel Corredor-Quintero
- Centro de ACV, Departamento de Neurología, Clínica Central del Quindío, Armenia, Colombia. Carrera 13 # 1N - 35, Armenia, Quindío, Colombia
| | - Miguel A Barboza
- Departamento de Neurociencias, Hospital Dr. Rafael A. Calderón Guardia, CCSS. San José, Costa Rica. Avenidas 7 y 9, calles 15 y 17, C. 17, San José, Aranjuez, Costa Rica
| | - Victor Navia-Gonzalez
- Facultad de Medicina, Clínica Alemana, Departamento de Neurologia, Universidad del Desarrollo, Chile. Avenida Manquehue Norte, 1410, Chile
| | | | - Javier Lagos-Servellon
- Hospital Nacional Mario Catarino Rivas, GXG5+665, 1 Calle, 21102, San Pedro Sula, Cortés, Honduras; Hospital CEMESA, 21 Calle A, 21104, San Pedro Sula, Honduras
| | - Nelson Novarro-Escudero
- Primary Stroke Center, Pacifica Salud, Panama. Pacific Boulevard and, Blvd, Pacífica, Panamá, Panama; Centro de Neurociencias, Ciudad de la Salud, Caja de Seguro Social, Panamá
| | - Diego A Ortega-Moreno
- Department of Neurology, University Hospital, Universidad Autonoma de Nuevo Leon, Gonzalitos y Madero S/N, Monterrey, Nuevo Leon, Mexico
| | - Victor Villarroel-Saavedra
- Hospital Obrero N 2-seguro de la Caja Nacional de Salud, Cochabamba, Bolivia. Av. Avenida Blanco Galindo km 5 ½, Bolivia
| | - Carlos Abanto
- Departamento de Enfermedades Neurovasculares, Instituto Nacional de Ciencias Neurológicas, Jr. Ancash 1271, Barrios Altos, Lima, Perú
| | | | - Filadelfo Saltos-Mata
- Hospital Teodoro Maldonado Carbo, Guayaquil, Ecuador. Q482+VGH, Av. 25 de Julio, Guayaquil, 090203, Ecuador
| | - Vasileios Papavasileiou
- Department of Neurosciences, Leeds Teaching Hospitals NHS Trust, England, St. James's University Hospital, Beckett Street, Leeds, West Yorkshire, LS9 7TF; School of Medicine, Faculty of Medicine and Health, University of Leeds, England, University of Leeds Woodhouse Lane Leeds, LS2 9JT
| | - Oliver Todd
- Academic Unit for Ageing and Stroke Research, University of Leeds, Leeds, England, LS2 9LH, UK; Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Trust, Bradford, England, BD9 6RJ, UK
| | - Fernando Gongora-Rivera
- Department of Neurology, University Hospital, Universidad Autonoma de Nuevo Leon, Gonzalitos y Madero S/N, Monterrey, Nuevo Leon, Mexico
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Panda BK, Suryawanshi VR, Attarde G, Borkar N, Iyer S, Shah J. Correlation of Quality Metrics of Acute Stroke Care with Clinical Outcomes in an Indian Tertiary-care University Hospital: A Prospective Evidence-based Study. Indian J Crit Care Med 2023; 27:806-815. [PMID: 37936803 PMCID: PMC10626231 DOI: 10.5005/jp-journals-10071-24566] [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] [Received: 08/09/2023] [Accepted: 09/25/2023] [Indexed: 11/09/2023] Open
Abstract
Aim To characterize the impact of adherence to quality metrics of stroke care on the clinical outcomes of ischemic stroke (IS) and intracerebral hemorrhage (ICH) admissions. Methods Consecutive patients with acute stroke were prospectively followed up for their demographic and clinical characteristics, acute stroke management, and associated clinical outcomes at discharge. Stroke quality metrics [adopted from the American Heart Association (AHA)/American Stroke Association's Get with The Guidelines (GWTG)] with a specific interest in an association between acute reperfusion therapies and functional recovery in stroke patients are analyzed and presented. A composite measure of care was considered "0 (non-adherence) to 1 (adherence)." An all-or-none measure of care was calculated to check whether eligible patients received all the quality-of-care interventions. Multivariate Cox regression models were used to study an association between optimal adherence and clinical outcomes. Results During the study period, of the total 256 stroke admissions, 200 (78.1%) patients had IS, and the remaining 56 (21.9%) patients had ICH. The median [interquartile range (IQR)] age of total stroke admissions was 57 (36-78) years. Male preponderance was observed (IS: 80% and ICH: 67.9%). The conformity of performance metrics in IS patients was from 69.1% [95% confidence interval (CI), 68.5-69.6] for the use of deep vein thrombosis prophylaxis (DVTp) to 97.8% (95% CI, 96.2-98.6) for the use of statins. In ICH patients, it ranged from 61.7% (95% CI, 60.4-62.5) for the use of DVTp to 89.9% (95% CI, 88.6-89.7) for stroke rehabilitation. The unadjusted odds ratio (OR) of mortality (in-hospital plus the 28th-day postdischarge) was higher in ICH patients vs IS patients (4.42, p = 0.005). Optimal adherence with intravenous recombinant tissue plasminogen activator (IV-rtPA) therapy [hazards ratio (HR) = 0.23], in-hospital acute measures [IS (HR = 0.41) and ICH (HR = 0.63)], and discharge measures [IS (HR = 0.35) and ICH (HR = 0.45)] were associated with reduced hazards of the 28th-day mortality in both cohorts. Compared to ICH, IS patients had significantly improved neurofunctional recovery [modified Rankin score (mRS) ≤ 2, p < 0.01]. Conclusion Adherence to quality metrics and performance measures was associated with low mortality and favorable clinical outcomes. Also, DVTp as an in-hospital (acute) measure of stroke care needs attention in both cerebrovascular events. How to cite this article Panda BK, Suryawanshi VR, Attarde G, Borkar N, Iyer S, Shah J. Correlation of Quality Metrics of Acute Stroke Care with Clinical Outcomes in an Indian Tertiary-care University Hospital: A Prospective Evidence-based Study. Indian J Crit Care Med 2023;27(11):806-815.
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Affiliation(s)
- Bijoy Kumar Panda
- Department of Pharmacy Practice, Krishna Institute of Pharmacy, Krishna Vishwa Vidyapeeth (Deemed to be University), Karad, Maharashtra, India
| | - Vaibhav R Suryawanshi
- Department of Pharmacy Practice, Poona College of Pharmacy, Bharati Vidyapeeth (Deemed to be University), Pune, Maharashtra, India
| | - Gargi Attarde
- Department of Pharmacy Practice, Poona College of Pharmacy, Bharati Vidyapeeth (Deemed to be University), Pune, Maharashtra, India
| | - Nilima Borkar
- Department of Pharmacy Practice, Poona College of Pharmacy, Bharati Vidyapeeth (Deemed to be University), Pune, Maharashtra, India
| | - Shivakumar Iyer
- Department of Critical Care Medicine, Bharati Vidyapeeth (Deemed to be University), Medical College, Pune, Maharashtra, India
| | - Jignesh Shah
- Department of Critical Care Medicine, Bharati Vidyapeeth (Deemed to be University), Medical College, Pune, Maharashtra, India
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Giroux M, Sirois MJ, Gagnon MA, Émond M, Bérubé M, Morin M, Moore L. Identifying Quality Indicators for the Care of Hospitalized Injured Older Adults: A Scoping Review of the Literature. J Am Med Dir Assoc 2023; 24:929-936. [PMID: 37094747 DOI: 10.1016/j.jamda.2023.03.019] [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: 11/29/2022] [Revised: 03/01/2023] [Accepted: 03/12/2023] [Indexed: 04/26/2023]
Abstract
OBJECTIVES Older adults represent more than 50% of trauma admissions in many high-income countries. Furthermore, they are at increased risk for complications, resulting in worse health outcomes than younger adults and a significant health care utilization burden. Quality indicators (QIs) are used to assess the quality of care in trauma systems, but few QIs reflect responses to older patients' specific needs. We aimed to (1) identify QIs used to assess acute hospital care for injured older patients, (2) assess support for identified QIs and, (3) identify gaps in existing QIs. DESIGN Scoping review of the scientific and gray literature. METHODS Selection and data extraction were performed by 2 independent reviewers. The level of support was assessed by the number of sources reporting QIs and whether they were developed according to scientific evidence, expert consensus, and patients' perspectives. RESULTS Of 10,855 identified studies, 167 were eligible. Among 257 different QIs identified, 52% were hip fracture specific. Gaps were identified for head injuries, rib, and pelvic ring fractures. Although 61% of QIs assessed care processes, 21% and 18% focused on structures and outcomes, respectively. Although most QIs were based on literature reviews and/or expert consensus, patients' perspective was rarely accounted for. The 15 QIs with the highest level of support included minimum time between emergency department arrival and ward admission, minimum time to surgery for fractures, assessment by a geriatrician, orthogeriatric review for hip fracture patients, delirium screening, prompt and appropriate analgesia, early mobilizations, and physiotherapy. CONCLUSION AND IMPLICATIONS Multiple QIs were identified, but their level of support was limited, and important gaps were identified. Future work should focus on achieving consensus for a set of QIs to assess the quality of trauma care to older adults. Such QIs could be used for quality improvement and ultimately improve outcomes for injured older adults.
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Affiliation(s)
- Marianne Giroux
- Faculté de médecine, Université Laval, Québec City, Quebec, Canada; Centre de recherche du CHU de Québec-Université Laval - Axe Santé des Populations et pratiques optimales en santé, Quebec City, Quebec, Canada.
| | - Marie-Josée Sirois
- Faculté de médecine, Université Laval, Québec City, Quebec, Canada; Centre de recherche du CHU de Québec-Université Laval - Axe Santé des Populations et pratiques optimales en santé, Quebec City, Quebec, Canada; Centre de recherche en santé durable VITAM - Centre intégré de santé et service sociaux de la capitale nationale, Quebec City, Quebec, Canada
| | - Marc-Aurèle Gagnon
- Centre de recherche du CHU de Québec-Université Laval - Axe Santé des Populations et pratiques optimales en santé, Quebec City, Quebec, Canada
| | - Marcel Émond
- Faculté de médecine, Université Laval, Québec City, Quebec, Canada; Centre de recherche du CHU de Québec-Université Laval - Axe Santé des Populations et pratiques optimales en santé, Quebec City, Quebec, Canada; Centre de recherche en santé durable VITAM - Centre intégré de santé et service sociaux de la capitale nationale, Quebec City, Quebec, Canada
| | - Méanie Bérubé
- Centre de recherche du CHU de Québec-Université Laval - Axe Santé des Populations et pratiques optimales en santé, Quebec City, Quebec, Canada; Faculty of Nursing, Université Laval, Québec City, Quebec, Canada
| | - Michèle Morin
- Faculté de médecine, Université Laval, Québec City, Quebec, Canada; Centre de recherche du CISSS de Chaudière-Appalaches, Lévis, Québec, Canada
| | - Lynne Moore
- Faculté de médecine, Université Laval, Québec City, Quebec, Canada; Centre de recherche du CHU de Québec-Université Laval - Axe Santé des Populations et pratiques optimales en santé, Quebec City, Quebec, Canada
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Lens C, Coeckelberghs E, Seys D, Demeestere J, Weltens C, Vanhaecht K, Lemmens R. Variation in stroke care at the hospital level: A cross-sectional multicenter study. Front Neurol 2022; 13:1004901. [PMID: 36313511 PMCID: PMC9606690 DOI: 10.3389/fneur.2022.1004901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 09/20/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionStroke is one of the leading causes of mortality and disability. Improving patient outcomes can be achieved by improving stroke care and adherence to guidelines. Since wide variation in adherence rates for stroke guidelines still exists, we aimed to describe and compare stroke care variability within Belgian hospitals.Materials and methodsAn observational, multicenter study was performed in 29 Belgian hospitals. We retrospectively collected patient characteristics, quality indicators, and time metrics from the last 30 consecutive patients per hospital, diagnosed with ischemic stroke in 2019 with structured questionnaires. Mean adherence ratios (%) ± SD (minimum – maximum) were calculated.ResultsWe analyzed 870 patient records from 29 hospitals. Results showed large inter- and intrahospitals variations in adherence for various indicators. Almost all the patients received brain imaging (99.7%) followed by admission at a stroke unit in 82.9% of patients. Of patients not receiving thrombolysis, 92.5% of patients were started on antithrombotic drugs. Indicators with moderate median adherence but large interhospital variability were glycemia monitoring [82.3 ± 16.7% (26.7–100.0%)], performing clinical neurological examination and documentation of stroke severity [63.1 ± 36.8% (0–100%)], and screening for activities of daily living [51.1 ± 40.3% (0.0–100.0%)]. Other indicators lacked adequate adherence: swallowing function screening [37.0 ± 30.4% (0.0–93.3%)], depression screening [20.2 ± 35.8% (0.0–100%)], and timely body temperature measurement [15.1 ± 17.0% (0.0–60%)].ConclusionWe identified high adherence to guidelines for some indicators, but lower rates with large interhospital variability for other recommendations also based on robust evidence. Improvement strategies should be implemented to improve the latter.
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Affiliation(s)
- Charlotte Lens
- Department of Public Health, Leuven Institute for Healthcare Policy, KU Leuven—University of Leuven, Leuven, Belgium
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Ellen Coeckelberghs
- Department of Public Health, Leuven Institute for Healthcare Policy, KU Leuven—University of Leuven, Leuven, Belgium
| | - Deborah Seys
- Department of Public Health, Leuven Institute for Healthcare Policy, KU Leuven—University of Leuven, Leuven, Belgium
| | - Jelle Demeestere
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
- Department of Neurosciences, Experimental Neurology, KU Leuven—University of Leuven, Leuven, Belgium
- VIB, Laboratory of Neurobiology, Center for Brain & Disease Research, Leuven, Belgium
| | - Caroline Weltens
- Department of Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Kris Vanhaecht
- Department of Public Health, Leuven Institute for Healthcare Policy, KU Leuven—University of Leuven, Leuven, Belgium
- Department of Quality, University Hospitals Leuven, Leuven, Belgium
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
- Department of Neurosciences, Experimental Neurology, KU Leuven—University of Leuven, Leuven, Belgium
- VIB, Laboratory of Neurobiology, Center for Brain & Disease Research, Leuven, Belgium
- *Correspondence: Robin Lemmens
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Geraedts M, de Cruppé W. [Effects of statutory quality assurance in acute inpatient care]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2022; 65:285-292. [PMID: 35122107 PMCID: PMC8888375 DOI: 10.1007/s00103-022-03489-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 01/10/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Statutory quality assurance (QA) serves to ensure and further develop the quality of service provision. Particularly prominent in Germany's acute inpatient care are mandatory quality reports (QRs) and participation in external quality assessments (eQAs). Their effects have not yet been comprehensively evaluated. OBJECTIVES What are the effects of eQAs and QRs on the quality of care? MATERIALS AND METHODS Based on a selective literature review, international evidence on the effects of QA was compiled. This was supplemented by analyses of the quality reports of the Federal Office for Quality Assurance (BQS), the Institute for Applied Quality Improvement and Research in Health Care (AQUA), and the Institute for Quality Assurance and Transparency in Healthcare (IQTIG), which have been responsible for eQAs since 2001. RESULTS According to international literature, at most weak effects of these measures can be expected, especially on process quality. Studies from Germany mostly observe only uncontrolled temporal trends and partly show improved quality indicators. Only one controlled study each was able to show weak positive effects on outcome and process quality for eQAs and QRs, respectively. CONCLUSIONS There are no convincing evaluation results for either the QRs or the eQAs. Deficiencies in the addressee-oriented design of the QRs and the reported indicator results in terms of their validity, risk adjustment, and temporal availability can be cited as potential causes. Statutory QA should be revised by paying more attention to the prerequisites for successful performance feedback and by again creating room for an intrinsically motivated assessment of one's own quality of care.
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Affiliation(s)
- Max Geraedts
- Institut für Versorgungsforschung und Klinische Epidemiologie, Fachbereich Medizin, Philipps-Universität Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Deutschland.
| | - Werner de Cruppé
- Institut für Versorgungsforschung und Klinische Epidemiologie, Fachbereich Medizin, Philipps-Universität Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Deutschland
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Geraedts M, Ebbeler D, Timmesfeld N, Kaps M, Berger K, Misselwitz B, Günster C, Dröge P, Schneider M. Quality Assurance Measures and Mortality After Stroke. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:857-863. [PMID: 34730084 PMCID: PMC8948340 DOI: 10.3238/arztebl.m2021.0339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 07/09/2021] [Accepted: 07/20/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Quality assurance for acute in-hospital care in Germany is based on compulsory comparisons between institutions, so-called external quality assurance (EQA). The effectiveness of EQA has not yet been adequately studied. The purpose of the QUASCH project, which is supported by the Innovation Fund of the Federal Joint Committee, is to investigate the association between EQA and health care outcomes, specifically with respect to stroke. METHODS The analyses were based on data from 379 825 patients insured by the AOK health insurance fund who were acutely admitted to a hospital because of stroke over the period 2007-2017. Data on 47 659 patients were derived from EQA documentation in the state of Hesse, in which stroke EQA had already been introduced in 2003; data on the remaining 332 166 patients were from other federal states, where 117 734 of these patients had been treated under EQA conditions. The association of EQA with mortality over the period of observation was analyzed by multivariate Cox regression, with the following covariates: age, sex, comorbidities, time period of occurrence, nursing care level, type of stroke, socio-economic deprivation in the region of origin, and treatment in a stroke unit. RESULTS Compared to treatment without EQA, mortality risk under EQA in the state of Hesse was significantly lower (hazard ratio [HR]: 0.93; 95% confidence interval: [0.92; 0.95]). The reduction in mortality risk with EQA was somewhat lower in the other federal states (HR: 0.96 [0.95; 0.97]). Treatment in a stroke unit was associated with a mortality risk that was lower still (HR: 0.86 [0.85; 0.87]). Mortality risk rose with age, comorbidities, and need for nursing care; it was lower in women and in persons whose stroke occurred in a later period. CONCLUSION Quality assurance measures are associated with lower mortality risk after stroke. The concentration of care in specially qualified institutions is associated with stronger effects than EQA alone.
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Affiliation(s)
- Max Geraedts
- Institute for Health Services Research and Clinical Epidemiology, Department of Medicine, Philipps University of Marburg
| | - Dijana Ebbeler
- Institute for Health Services Research and Clinical Epidemiology, Department of Medicine, Philipps University of Marburg
| | - Nina Timmesfeld
- Department of Medical Informatics, Biometry and Epidemiology, Faculty of Medicine, Ruhr University Bochum
| | - Manfred Kaps
- Department of Neurology, University Hospital of Giessen/Marburg, Justus Liebig University of Giessen
| | - Klaus Berger
- Institute of Epidemiology and Social Medicine, Medical Faculty, Westphalian Wilhelms University of Münster
| | | | - Christian Günster
- Research Institute of the AOK [German public health insurance company], AOK Federal Association
| | - Patrik Dröge
- Research Institute of the AOK [German public health insurance company], AOK Federal Association
| | - Michael Schneider
- Institute for Health Services Research and Clinical Epidemiology, Department of Medicine, Philipps University of Marburg
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Affiliation(s)
- Monique F Kilkenny
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (M.F.K.).,The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (M.F.K.)
| | - Dawn M Bravata
- Precision Monitoring to Transform Care Quality Enhancement Research Initiative, Health Services Research and Development, Department of Veterans Affairs, Indianapolis, IN (D.M.B.).,Health Services Research and Development Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Department of Veterans Affairs, Indianapolis, IN (D.M.B.).,Medicine Service, Richard L. Roudebush VA Medical Center, Indianapolis, IN (D.M.B.).,Departments of Medicine and of Neurology, Indiana University School of Medicine, Indianapolis (D.M.B.).,William M. Tierney Center for Health Services Research, Regenstrief Institute, Indianapolis, IN (D.M.B.)
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