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Huang Y, Chan SJ, Wright JD, Kuo JH, McManus CM, Lee JA, Kuo EJ. Does the Adoption of Molecular Testing Cause Decreased Thyroidectomy Rates in a National Cohort? A Quasiexperimental Study of High- Versus Low-Adoption States. Thyroid 2024; 34:388-398. [PMID: 38251649 DOI: 10.1089/thy.2023.0651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
Background: Over the last decade, the utilization of molecular testing (MT) for the evaluation of thyroid nodules has increased. Rates and patterns of adoption of MT and its effect on thyroidectomy rates nationally are unknown. Varying rates of MT adoption at the state level provide an opportunity to study the effects of MT on thyroidectomy rates using a quasiexperimental study design. Methods: We performed a retrospective analysis of American adult patients in the Merative™ MarketScan® Research Databases who underwent thyroid fine-needle aspiration (FNA) from 2011 to 2021. MT included commercially available DNA and RNA platforms and traditional targeted mutational analysis. Interrupted time series analysis was used to evaluate the inflection of MT adoption and thyroidectomy rates after 2015. Difference-in-differences (DID) analysis was used to causally analyze the effect of MT adoption on thyroidectomy rates in high-adoption (at least a 10% increase in MT utilization) versus low-adoption states (no more than 5% increase in MT utilization) from 2015 to 2021. Results: We identified 471,364 patients who underwent thyroid FNA. The utilization of MT increased over the study period from 0.01% [confidence interval, CI: 0.00% to 0.02%] to 10.1% [CI: 9.7% to 10.5%], in 2021, with an immediate (β2 = 1.61, p = 0.002) and deeper (β3 = 0.6, p < 0.001) increase in MT adoption after 2015. Utilization of MT was lower in black patients, the elderly, rural areas, and patients with Medicaid (p < 0.05). Thyroidectomy rates were inversely correlated with MT utilization (r = -0.98, p < 0.0001). From 2015 to 2021, the average MT utilization rate increased from 2.4% to 15.3% in high-adoption states and 1.6% to 5.6% in low-adoption states. In low-adoption states, thyroidectomy rates decreased more but to similar levels (18.5-13.2%) compared with high-adoption states (15.9-13.4%) with an adjusted DID rate of -3.3% [CI -5.6% to -0.8%]. Conclusions: The acceleration in adoption of MT after 2015 likely coincides with the publication of American Thyroid Association guidelines. Black, elderly, and rural patients are less likely to receive MT. Although thyroidectomy rates were inversely correlated with MT utilization, our study suggests that this correlation is not causal. The effect of MT on thyroidectomy rates may be overshadowed by decreasing aggressiveness of thyroid nodule evaluation.
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Affiliation(s)
- Yongmei Huang
- Department of Obstetrics and Gynecology, Columbia University, New York, New York, USA
| | - Stephanie J Chan
- Department of Surgery, Division of GI/Endocrine Surgery, Columbia University, New York, New York, USA
| | - Jason D Wright
- Department of Obstetrics and Gynecology, Columbia University, New York, New York, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York, USA
| | - Jennifer H Kuo
- Department of Surgery, Division of GI/Endocrine Surgery, Columbia University, New York, New York, USA
| | - Catherine M McManus
- Department of Surgery, Division of GI/Endocrine Surgery, Columbia University, New York, New York, USA
| | - James A Lee
- Department of Surgery, Division of GI/Endocrine Surgery, Columbia University, New York, New York, USA
| | - Eric J Kuo
- Department of Surgery, Division of GI/Endocrine Surgery, Columbia University, New York, New York, USA
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Richmond BK, Gallimore J. Genetic Considerations in the Tumorigenesis, Diagnosis, and Treatment of Differentiated Thyroid Cancer: Current State of the Science. Am Surg 2023; 89:4853-4859. [PMID: 37253623 DOI: 10.1177/00031348231180952] [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: 06/01/2023]
Abstract
Thyroid nodules remain a common diagnosis encountered in general and endocrine surgical practice, and thyroid cancer appears to be increasing in incidence in both the United States and worldwide. The understanding of the complex genetics surrounding thyroid neoplasia has increased substantially in recent years and, consequently, has become a consideration in risk stratification, diagnosis, prognosis, and treatment. Molecular genetic analysis of thyroid nodules is now a readily available technology for diagnostic purposes via analysis of fine-needle aspiration biopsy (FNAB) specimens. Although their routine use is controversial, they may aid in selecting which patients require surgery and those who may be safely observed. In the following review, the genetics of the tumorigenesis of thyroid cancer are reviewed, focusing on the most common and clinically relevant of the literally hundreds of known mutations. Following this, the current status of the use of genetic analysis and molecular diagnostics in the workup of thyroid nodules and the diagnosis of differentiated thyroid cancer is explored. Finally, evolving concepts relating to the use of thyroid cancer genetics in individualizing treatment planning, follow-up, and management of recurrent disease is discussed. The goal is to provide the general surgeon with a working knowledge of the most common genetic alterations present in differentiated thyroid cancer, their relevance in clinical practice, and how they impact prognosis and treatment.
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Affiliation(s)
- Bryan K Richmond
- West Virginia University/Charleston Division, CAMC Institute for Academic Medicine, Charleston, WV, USA
| | - Jade Gallimore
- West Virginia University/Charleston Division, CAMC Institute for Academic Medicine, Charleston, WV, USA
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Stewardson P, Eszlinger M, Paschke R. DIAGNOSIS OF ENDOCRINE DISEASE: Usefulness of genetic testing of fine-needle aspirations for diagnosis of thyroid cancer. Eur J Endocrinol 2022; 187:R41-R52. [PMID: 35900312 DOI: 10.1530/eje-21-1293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 07/04/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Genetic testing is increasingly used to diagnose or rule out thyroid cancer in indeterminate fine-needle aspirations. This review evaluates the usefulness of these methods with considerations of advantages and limitations. DESIGN Given the diagnostic problem associated with the increasing incidental detection of indeterminate thyroid nodules in the context of thyroid cancer overtreatment, we consider the conditions and respective necessary settings for the role of genetic testing to improve presurgical malignancy risk stratification. METHODS We review diagnostic pathway requirements and commercially available molecular tests with their respective advantages and disadvantages and discuss the prerequisites required for local application and implementation including quality assurance for local ultrasound and cytopathology practices. RESULTS Recent improvements in available molecular diagnostic tests have brought high sensitivity and specificity in initial validation studies, but whether these promising results translate to other clinical settings depends on the quality of the local thyroid nodule diagnostic pathway. CONCLUSIONS Genetic testing can meaningfully improve presurgical malignancy risk assessment, but more work is needed to implement and use genetic testing effectively in local settings.
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Affiliation(s)
- Paul Stewardson
- Arnie Charbonneau Cancer Institute, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Markus Eszlinger
- Departments of Oncology, Pathology and Laboratory Medicine, Biochemistry and Molecular Biology, University of Calgary Cumming School of Medicine, Universitätsklinikum Halle, Institute of Pathology
| | - Ralf Paschke
- Departments of Medicine, Oncology, Pathology and Laboratory Medicine, Biochemistry and Molecular Biology, and Arnie Charbonneau Cancer Institute, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
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Bakker L, Aarts J, Uyl-de Groot C, Redekop W. Economic evaluations of big data analytics for clinical decision-making: a scoping review. J Am Med Inform Assoc 2021; 27:1466-1475. [PMID: 32642750 PMCID: PMC7526472 DOI: 10.1093/jamia/ocaa102] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 04/06/2020] [Accepted: 05/11/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE Much has been invested in big data analytics to improve health and reduce costs. However, it is unknown whether these investments have achieved the desired goals. We performed a scoping review to determine the health and economic impact of big data analytics for clinical decision-making. MATERIALS AND METHODS We searched Medline, Embase, Web of Science and the National Health Services Economic Evaluations Database for relevant articles. We included peer-reviewed papers that report the health economic impact of analytics that assist clinical decision-making. We extracted the economic methods and estimated impact and also assessed the quality of the methods used. In addition, we estimated how many studies assessed "big data analytics" based on a broad definition of this term. RESULTS The search yielded 12 133 papers but only 71 studies fulfilled all eligibility criteria. Only a few papers were full economic evaluations; many were performed during development. Papers frequently reported savings for healthcare payers but only 20% also included costs of analytics. Twenty studies examined "big data analytics" and only 7 reported both cost-savings and better outcomes. DISCUSSION The promised potential of big data is not yet reflected in the literature, partly since only a few full and properly performed economic evaluations have been published. This and the lack of a clear definition of "big data" limit policy makers and healthcare professionals from determining which big data initiatives are worth implementing.
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Affiliation(s)
- Lytske Bakker
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, Netherlands.,Institute for Medical Technology Assessment, Erasmus University, Rotterdam, Netherlands
| | - Jos Aarts
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, Netherlands
| | - Carin Uyl-de Groot
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, Netherlands.,Institute for Medical Technology Assessment, Erasmus University, Rotterdam, Netherlands
| | - William Redekop
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, Netherlands.,Institute for Medical Technology Assessment, Erasmus University, Rotterdam, Netherlands
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Fazeli SR, Zehr B, Amraei R, Toraldo G, Guan H, Kindelberger D, Lee S, Cerda S. ThyroSeq v2 Testing: Impact on Cytologic Diagnosis, Management, and Cost of Care in Patients with Thyroid Nodule. Thyroid 2020; 30:1528-1534. [PMID: 32349630 DOI: 10.1089/thy.2019.0191] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Background: Novel molecular tests (MTs), such as ThyroSeq, may improve the management of thyroid nodules with indeterminate cytologic diagnoses; however, the impact of these tests on cost and outcome of management is unknown. Here, we evaluated the impact of ThyroSeq testing on the cytopathologic diagnosis, management, and cost of care in patients with thyroid nodules. Methods: In a retrospective study, using actual patient cohorts, the outcome and cost of management of patients with thyroid nodules seen before the introduction of ThyroSeq v2 at our institution (standard of care [StC] cohort) were compared with those seen after the introduction of this test (MT cohort). Results: A total of 773 consecutive patients entered the study (393 StC, 380 MT). The incidence of cytologically benign nodules decreased from 71.0% (StC) to 53.2% (MT) and those of atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) and follicular neoplasm/suspicious for follicular neoplasm (FN/SFN) increased from 8.9% (StC) to 21.3% (MT) and from 3.1% (StC) to 6.3% (MT), respectively. The overall rate of surgery did not change significantly (23.4% in StC vs. 23.2% in MT). Among patients who underwent surgery, the rate of overtreatment (surgeries performed on histologic benign nodules without clinical indication: compressive symptoms, hyperthyroidism resistant to medication, and nodule size >4 cm) slightly decreased from 18.8% (StC) to 16.7% (MT). The rate of malignancy decreased from 45.5% (StC) to 37.9% (MT) in AUS/FLUS and increased from 40.0% to 53.8% in FN/SFN. However, the overall rate of malignancy remained equal (47.8% in StC vs. 47.7% in MT). The average cost of care per patient in the AUS/FLUS and FN/SFN categories increased from $6,566 (StC) to $8,444 (MT) and from $9,313 (StC) to $10,253 (MT), respectively. Similarly, the overall average cost of care of a patient who underwent thyroid fine-needle aspiration increased from $3,088 (StC) to $4,282 (MT). Finally, the average cost per thyroid cancer detected increased from $26,312 (StC) to $38,746 (MT). Conclusions: Introduction of ThyroSeq v2 resulted in a shift toward indeterminate cytology results. The institutional rate of surgery, overtreatment, and malignancy did not change significantly. Lack of decrease in the rate of surgery along with the additional cost of ThyroSeq v2 increased the overall cost of care of patients including those with indeterminate cytology results.
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Affiliation(s)
- Shoreh R Fazeli
- Department of Pathology & Laboratory Medicine at Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, USA
| | - Bradley Zehr
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Razie Amraei
- Department of Pathology & Laboratory Medicine at Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, USA
| | - Gianluca Toraldo
- Lahey Hospital and Medical Center Endocrinology, Burlington, Massachusetts, USA
| | - Haixia Guan
- Section of Endocrinology, Diabetes and Nutrition, Department of Medicine, Boston University Medical Center, Boston, Massachusetts, USA
| | - David Kindelberger
- Department of Pathology, Harvard Vanguard Medical Associates Atrius Health, Boston, Massachusetts, USA
| | - Stephanie Lee
- Section of Endocrinology, Diabetes and Nutrition, Department of Medicine, Boston University Medical Center, Boston, Massachusetts, USA
| | - Sandra Cerda
- Department of Pathology & Laboratory Medicine at Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, USA
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Khan TM, Zeiger MA. Thyroid Nodule Molecular Testing: Is It Ready for Prime Time? Front Endocrinol (Lausanne) 2020; 11:590128. [PMID: 33162941 PMCID: PMC7581778 DOI: 10.3389/fendo.2020.590128] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 09/22/2020] [Indexed: 12/19/2022] Open
Abstract
Cytologically indeterminate thyroid nodules remain a diagnostic and clinical challenge, and molecular testing has been advocated and advanced as a diagnostic modality to help guide treatment. While studies have expounded on the improved diagnostic certainty with these tests, data demonstrating meaningful clinical impact and supporting their routine use is still limited at best. In this review, we discuss the limitations regarding diagnostic accuracy, impact on surgical decision-making and outcomes, and cost-effectiveness of molecular testing. By highlighting the limitations of these tests, we aim to promote more thoughtful utilization of these tools in the management of thyroid nodules going forward.
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Nicholson KJ, Roberts MS, McCoy KL, Carty SE, Yip L. Molecular Testing Versus Diagnostic Lobectomy in Bethesda III/IV Thyroid Nodules: A Cost-Effectiveness Analysis. Thyroid 2019; 29:1237-1243. [PMID: 31407625 PMCID: PMC7366255 DOI: 10.1089/thy.2018.0779] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Background: Molecular tests (MT) using gene expression and/or mutational analysis have been developed to reduce the need for diagnostic surgery for indeterminate (Bethesda III/IV) thyroid nodules. Prior cost-effectiveness studies have shown mixed results but none has included the recent and more comprehensive versions of the two commonly utilized MT. The aim of this study is to compare the cost-effectiveness of diagnostic lobectomy (DL), the Afirma Gene Sequencing Classifier (GSC), and ThyroSeq version 3 (TSv3). Methods: A decision tree from the payer perspective was created using a base case of a 40-year-old euthyroid woman with a solitary 2 cm Bethesda III or IV thyroid nodule. In this model, all patients in the DL arm had lobectomy, which was also performed for patients with positive MT, while those with negative MT underwent 20 years of surveillance. The outcome was a correct diagnosis, defined as malignant histology after DL or 20 years of nodule stability after negative MT. Costs were obtained from the Centers for Medicare & Medicaid Services (CMS) data and existing literature, and probabilities were obtained from the literature. Sensitivity analysis was performed for costs, pretest probability of malignancy, and performance parameters. Results: The cost per correct diagnosis was $14,277 for TSv3, $17,873 for GSC, and $38,408 for DL. TSv3 was preferred over both GSC and DL. One-way sensitivity analysis between TSv3 and GSC demonstrated that the results were robust to variations in cost, cancer prevalence, and length of surveillance. In the two-way sensitivity analysis, TSv3 was preferred over GSC at all considered test costs, and in probabilistic sensitivity analysis, TSv3 was the preferred management strategy in 68.5% of cases. Conclusions: In hypothetical modeling to determine whether surgery versus MT is optimal for indeterminate (Bethesda III/IV) nodules, either of the major MT was considerably more cost-effective than DL, although TSv3 was more likely to be cost-effective than GSC. Use of either MT adjunct should be strongly considered in the absence of other indications for thyroidectomy.
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Affiliation(s)
- Kristina J. Nicholson
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mark S. Roberts
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, Department of Health Policy and Management, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kelly L. McCoy
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sally E. Carty
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Linwah Yip
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Address correspondence to: Linwah Yip, MD, Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, 3471 Fifth Avenue Ste 101, Pittsburgh, PA 15213
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Caulley L, Rodin D, Kilty S, Randolph G, Hunink MG, Shin JJ. Evidence-Based Medicine in Otolaryngology Part 10: Cost-Effectiveness Analyses in Otolaryngology. Otolaryngol Head Neck Surg 2019; 161:375-387. [DOI: 10.1177/0194599819852104] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Clinicians seek to pursue the most clinically effective treatment strategies, but costs have also become a key determinant in contemporary health care. Economic analyses have thus emerged as a valuable resource to both quantify and qualify the value of existing and emerging interventions and programs. Cost-effectiveness analyses estimate the benefits gained per monetary unit, providing insights to guide resource allocation. Herein, we delineate the related concepts and considerations to facilitate understanding and appraisal of these analyses, so as to better inform the stakeholders in our otolaryngology community.
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Affiliation(s)
- Lisa Caulley
- Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Danielle Rodin
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Shaun Kilty
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Otolaryngology–Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Gregory Randolph
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Myriam G. Hunink
- Department of Epidemiology and Department of Radiology, Erasmus MC, Rotterdam, the Netherlands
- Center for Health Decision Sciences, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Jennifer J. Shin
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
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Mitchell J, Yip L. Decision Making in Indeterminate Thyroid Nodules and the Role of Molecular Testing. Surg Clin North Am 2019; 99:587-598. [PMID: 31255193 DOI: 10.1016/j.suc.2019.04.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Cytologically indeterminate thyroid nodules are associated with a broad range (5%-75%) of malignant risk and accurately informing definitive management poses a challenge. Advancements in molecular testing of fine-needle aspiration biopsies have improved preoperative diagnostic accuracy and prognostication. For indeterminate nodules, such testing ideally will reduce the need for surgery for benign nodules and potentially guide appropriate extent of initial surgery for malignancy.
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Affiliation(s)
- Janeil Mitchell
- Fox Valley Surgical Associates, Endocrine Surgery, 1818 North Meade Street, Appleton, WI 54911, USA
| | - Linwah Yip
- Department of Surgery, Division of Endocrine Surgery, University of Pittsburgh School of Medicine, Kaufman Medical Building, 3471 Fifth Avenue, Suite 101, Pittsburgh, PA 15213, USA.
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10
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Cost effectiveness of immediate biopsy versus surveillance of intermediate-suspicion thyroid nodules. Surgery 2018; 164:1330-1335. [DOI: 10.1016/j.surg.2018.06.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 05/03/2018] [Accepted: 06/05/2018] [Indexed: 01/07/2023]
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Banizs AB, Silverman JF. The utility of combined mutation analysis and microRNA classification in reclassifying cancer risk of cytologically indeterminate thyroid nodules. Diagn Cytopathol 2018; 47:268-274. [DOI: 10.1002/dc.24087] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 08/15/2018] [Accepted: 09/10/2018] [Indexed: 01/11/2023]
Affiliation(s)
- Anna B. Banizs
- Department of Pathology; Allegheny General Hospital; Pittsburgh Pennsylvania
| | - Jan F. Silverman
- Department of Pathology; Allegheny General Hospital; Pittsburgh Pennsylvania
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Angell TE, Vyas CM, Barletta JA, Cibas ES, Cho NL, Doherty GM, Gawande AA, Howitt BE, Krane JF, Marqusee E, Strickland KC, Alexander EK, Moore FD, Nehs MA. Reasons Associated with Total Thyroidectomy as Initial Surgical Management of an Indeterminate Thyroid Nodule. Ann Surg Oncol 2018. [DOI: 10.1245/s10434-018-6421-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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