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Hackl CM, Lee WC, Sallam HS, Jneid H, Campbell KM, Serag H. Racial Disparities in Selected Complications and Comorbidities among People with Type 2 Diabetes. Healthcare (Basel) 2024; 12:846. [PMID: 38667608 PMCID: PMC11050140 DOI: 10.3390/healthcare12080846] [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: 03/26/2024] [Revised: 04/10/2024] [Accepted: 04/13/2024] [Indexed: 04/28/2024] Open
Abstract
Type 2 diabetes (T2D) is a growing public health concern, disproportionately impacting racial and ethnic minorities. Assessing disparities is the first step towards achieving the translation goal to reduce disparities in diabetes outcomes, according to the Centers for Disease Control and Prevention (CDC)'s Division of Diabetes. We analyzed the data of patients (18+ years) diagnosed with T2D between 1 January 2012 and 31 March 2017, using the electronic health records of the University of Texas Medical Branch at Galveston. We compared the crude rate and age-standardized rate (using direct method) of selected micro- and macrovascular complication rates, associated obesity, and insulin dependence among racial and ethnic groups. Our sample included 20,680 patients who made 394,106 visits (9922 non-Hispanic White patients, 4698 non-Hispanic Black patients, and 6060 Hispanic patients). Our results suggest a higher risk of acquiring macrovascular (hypertension, ischemic disease, and stroke) and microvascular (renal, ophthalmic, and neurological) complications in Black patients compared to non-Hispanic White and Hispanic patients. The rates of stage I or II obesity were higher in Black patients compared with White and Hispanic patients. The rates of insulin use rather than oral hypoglycemics were also higher in Black patients than White and Hispanic patients. The disparities in terms of the higher susceptibility to complications among Black patients are possibly linked to the socioeconomic disadvantages of this population, leading to poorer management. Prevention strategies are warranted to reduce the incidence of T2D complications in racial minorities.
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Affiliation(s)
- Caitlin M. Hackl
- John Sealy School of Medicine (JSSM), University of Texas Medical Branch (UTMB), Galveston, TX 77555, USA;
| | - Wei-Chen Lee
- Department of Family Medicine, John Sealy School of Medicine (JSSM), University of Texas Medical Branch (UTMB), Galveston, TX 77555, USA; (W.-C.L.); (K.M.C.)
| | - Hanaa S. Sallam
- Department of Internal Medicine, Division of Endocrinology, John Sealy School of Medicine (JSSM), University of Texas Medical Branch (UTMB), Galveston, TX 77555, USA;
- Department of Medical Physiology, Faculty of Medicine, Suez Canal University, Ismailia 41522, Egypt
| | - Hani Jneid
- Department of Internal Medicine, Division of Cardiology, John Sealy School of Medicine (JSSM), University of Texas Medical Branch (UTMB), Galveston, TX 77555, USA;
| | - Kendall M. Campbell
- Department of Family Medicine, John Sealy School of Medicine (JSSM), University of Texas Medical Branch (UTMB), Galveston, TX 77555, USA; (W.-C.L.); (K.M.C.)
| | - Hani Serag
- Department of Internal Medicine, Division of Endocrinology, John Sealy School of Medicine (JSSM), University of Texas Medical Branch (UTMB), Galveston, TX 77555, USA;
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Towne SD, Ory MG, Zhong L, Smith ML, Han G, Andreyeva E, Carpenter K, Ahn S, Preston VA. Examining Health Inequities in A1C Control over Time across Individual, Geospatial, and Geopolitical Factors among Adults with Type 2 Diabetes: Analyses of a Sample from One Commercial Insurer in a Southern State. J Prim Care Community Health 2024; 15:21501319241253791. [PMID: 38773826 PMCID: PMC11113025 DOI: 10.1177/21501319241253791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 04/14/2024] [Accepted: 04/19/2024] [Indexed: 05/24/2024] Open
Abstract
INTRODUCTION Type 2 diabetes impacts millions and poor maintenance of diabetes can lead to preventable complications, which is why achieving and maintaining target A1C levels is critical. Thus, we aimed to examine inequities in A1C over time, place, and individual characteristics, given known inequities across these indicators and the need to provide continued surveillance. METHODS Secondary de-identified data from medical claims from a single payer in Texas was merged with population health data. Generalized Estimating Equations were utilized to assess multiple years of data examining the likelihood of having non-target (>7% and ≥7%, two slightly different cut points based on different sources) and separately uncontrolled (>9%) A1C. Adults in Texas, with a Type 2 Diabetes (T2D) flag and with A1C reported in first quarter of the year using data from 2016 and 2019 were included in analyses. RESULTS Approximately 50% had A1Cs within target ranges (<7% and ≤7%), with 50% considered having non-target (>7% and ≥7%) A1Cs; with 83% within the controlled ranges (≤9%) as compared to approximately 17% having uncontrolled (>9%) A1Cs. The likelihood of non-target A1C was higher among those individuals residing in rural (vs urban) areas (P < .0001); similar for the likelihood of reporting uncontrolled A1C, where those in rural areas were more likely to report uncontrolled A1C (P < .0001). In adjusted analysis, ACA enrollees in 2016 were approx. 5% more likely (OR = 1.049, 95% CI = 1.002-1.099) to have non-target A1C (≥7%) compared to 2019; in contrast non-ACA enrollees were approx. 4% more likely to have non-target A1C (≥7%) in 2019 compared to 2016 (OR = 1.039, 95% CI = 1.001-1.079). In adjusted analysis, ACA enrollees in 2016 were 9% more likely (OR = 1.093, 95% CI = 1.025-1.164) to have uncontrolled A1C compared to 2019; whereas there was no significant change among non-ACA enrollees. CONCLUSIONS This study can inform health care interactions in diabetes care settings and help health policy makers explore strategies to reduce health inequities among patients with diabetes. Key partners should consider interventions to aid those enrolled in ACA plans, those in rural and border areas, and who may have coexisting health inequities.
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Affiliation(s)
- Samuel D. Towne
- School of Global Health Management and Informatics, University of Central Florida, Orlando, FL, USA
- Disability, Aging, and Technology Cluster, University of Central Florida, Orlando, FL, USA
- Department of Environmental and Occupational Health, School of Public Health, Texas A&M University, College Station, TX, USA
- Southwest Rural Health Research Center, Texas A&M University, College Station, TX, USA
- Center for Community Health & Aging, Texas A&M University, College Station, TX, USA
| | - Marcia G. Ory
- Department of Environmental and Occupational Health, School of Public Health, Texas A&M University, College Station, TX, USA
- Center for Community Health & Aging, Texas A&M University, College Station, TX, USA
| | - Lixian Zhong
- College of Pharmacy, Texas A&M University, College Station, TX, USA
| | - Matthew Lee Smith
- Center for Community Health & Aging, Texas A&M University, College Station, TX, USA
- Department of Health Behavior, School of Public Health, Texas A&M University, College Station, TX, USA
- Center for Health Equity & Evaluation Research, Texas A&M University, College Station, TX, USA
| | - Gang Han
- Department of Epidemiology and Biostatistics, School of Public Health, Texas A&M University, College Station, TX, USA
| | - Elena Andreyeva
- Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, TX, USA
| | - Keri Carpenter
- Center for Community Health & Aging, Texas A&M University, College Station, TX, USA
| | - SangNam Ahn
- Center for Community Health & Aging, Texas A&M University, College Station, TX, USA
- Department of Health Management and Policy, College for Public Health and Social Justice at the Saint Louis University; St. Louis, MO, USA
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Han G, Spencer MS, Ahn S, Smith ML, Zhong L, Andreyeva E, Carpenter K, Towne SD, Preston VA, Ory MG. Group-based trajectory analysis identifies varying diabetes-related cost trajectories among type 2 diabetes patients in Texas: an empirical study using commercial insurance. BMC Health Serv Res 2023; 23:1116. [PMID: 37853393 PMCID: PMC10585813 DOI: 10.1186/s12913-023-10118-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 10/05/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND The trend of Type 2 diabetes-related costs over 4 years could be classified into different groups. Patient demographics, clinical factors (e.g., A1C, short- and long-term complications), and rurality could be associated with different trends of cost. Study objectives are to: (1) understand the trajectories of cost in different groups; (2) investigate the relationship between cost and key factors in each cost trajectory group; and (3) assess significant factors associated with different cost trajectories. METHODS Commercial claims data in Texas from 2016 to 2019 were provided by a large commercial insurer and were analyzed using group-based trajectory analysis, longitudinal analysis of cost, and logistic regression analyses of different trends of cost. RESULTS Five groups of distinct trends of Type 2 diabetes-related cost were identified. Close to 20% of patients had an increasing cost trend over the 4 years. High A1C values, diabetes complications, and other comorbidities were significantly associated with higher Type 2 diabetes costs and higher chances of increasing trend over time. Rurality was significantly associated with higher chances of increasing trend over time. CONCLUSIONS Group-based trajectory analysis revealed distinct patient groups with increased cost and stable cost at low, medium, and high levels in the 4-year period. The significant associations found between the trend of cost and A1C, complications, and rurality have important policy and program implications for potentially improving health outcomes and constraining healthcare costs.
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Affiliation(s)
- Gang Han
- Center for Community Health and Aging, Texas A&M University, College Station, TX, United States of America
- Department of Epidemiology and Biostatistics, School of Public Health, Texas A&M University, College Station, TX, United States of America
| | - Matthew Scott Spencer
- Department of Epidemiology and Biostatistics, School of Public Health, Texas A&M University, College Station, TX, United States of America
| | - SangNam Ahn
- Center for Community Health and Aging, Texas A&M University, College Station, TX, United States of America
- Department of Health Management and Policy, College for Public Health and Social Justice, Saint Louis University, St. Louis, MO, United States of America
| | - Matthew Lee Smith
- Center for Community Health and Aging, Texas A&M University, College Station, TX, United States of America
- Department of Health Behavior, School of Public Health, Texas A&M University, College Station, TX, United States of America
| | - Lixian Zhong
- Center for Community Health and Aging, Texas A&M University, College Station, TX, United States of America
- College of Pharmacy, Texas A&M University, College Station, TX, United States of America
| | - Elena Andreyeva
- Center for Community Health and Aging, Texas A&M University, College Station, TX, United States of America
- Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, TX, United States of America
| | - Keri Carpenter
- Center for Community Health and Aging, Texas A&M University, College Station, TX, United States of America
| | - Samuel D Towne
- Center for Community Health and Aging, Texas A&M University, College Station, TX, United States of America
- School of Global Health Management and Informatics, University of Central Florida, Orlando, FL, United States of America
- Disability, Aging, and Technology Cluster, University of Central Florida, Orlando, FL, United States of America
- Southwest Rural Health Research Center, Texas A&M University, College Station, TX, United States of America
| | - Veronica Averhart Preston
- Blue Cross and Blue Shield of Texas a subsidiary of Health Care Service Corporation, Richardson, TX, USA
| | - Marcia G Ory
- Center for Community Health and Aging, Texas A&M University, College Station, TX, United States of America.
- Department of Environmental and Occupational Health, School of Public Health, Texas A&M University, College Station, TX, United States of America.
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Ory MG, Han G, Jani SN, Zhong L, Andreyeva E, Carpenter K, Towne SD, Preston VA, Smith ML. Factors associated with higher hemoglobin A1c and type 2 diabetes-related costs: Secondary data analysis of adults 18 to 64 in Texas with commercial insurance. PLoS One 2023; 18:e0289491. [PMID: 37682942 PMCID: PMC10490838 DOI: 10.1371/journal.pone.0289491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 07/20/2023] [Indexed: 09/10/2023] Open
Abstract
OBJECTIVE This study will identify factors associated with higher hemoglobin A1c (A1c) values and diabetes-related costs among commercially insured adults in Texas diagnosed with type 2 diabetes. RESEARCH DESIGN AND METHODS This secondary data analysis was based on claims data from commercially insured individuals 18-64 years of age residing in Texas with diagnosed type 2 diabetes during the 2018-2019 study period. The final analysis sample after all the exclusions consisted of 34,992 individuals. Measures included hemoglobin A1c, diabetes-related costs, Charlson Comorbidity Index, diabetes-related complications, rurality and other socioeconomic characteristics. Longitudinal A1c measurements were modeled using age, sex, rurality, comorbidity, and diabetes-related complications in generalized linear longitudinal regression models adjusting the observation time, which was one of the 8 quarters in 2018 and 2019. The diabetes-related costs were similarly modeled in both univariable and multivariable generalized linear longitudinal regression models adjusting the observation time by calendar quarters and covariates. RESULTS The median A1c value was 7, and the median quarterly diabetes-related cost was $120. A positive statistically significant relationship (p = < .0001) was found between A1c levels and diabetes-related costs, although this trend slowed down as A1c levels exceeded 8.0%. Higher A1c values were associated with being male, having diabetes-related complications, and living in rural areas. Higher costs were associated with higher A1c values, older age, and higher Charlson Comorbidity Index scores. CONCLUSION The study adds updated analyses of the interrelationships among demographic and geographic factors, clinical indicators, and health-related costs, reinforcing the role of higher A1c values and complications as diabetes-related cost drivers.
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Affiliation(s)
- Marcia G. Ory
- Center for Community Health and Aging, Texas A&M University, College Station, Texas, United States of America
- Department of Environmental and Occupational Health, School of Public Health, Texas A&M University, College Station, Texas, United States of America
| | - Gang Han
- Center for Community Health and Aging, Texas A&M University, College Station, Texas, United States of America
- Department of Epidemiology and Biostatistics, School of Public Health, Texas A&M University, College Station, Texas, United States of America
| | - Sagar N. Jani
- Center for Community Health and Aging, Texas A&M University, College Station, Texas, United States of America
| | - Lixian Zhong
- Center for Community Health and Aging, Texas A&M University, College Station, Texas, United States of America
- College of Pharmacy, Texas A&M University, College Station, Texas, United States of America
| | - Elena Andreyeva
- Center for Community Health and Aging, Texas A&M University, College Station, Texas, United States of America
- Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, Texas, United States of America
| | - Keri Carpenter
- Center for Community Health and Aging, Texas A&M University, College Station, Texas, United States of America
| | - Samuel D. Towne
- Center for Community Health and Aging, Texas A&M University, College Station, Texas, United States of America
- Department of Environmental and Occupational Health, School of Public Health, Texas A&M University, College Station, Texas, United States of America
- School of Global Health Management and Informatics, University of Central Florida, Orlando, Florida, United States of America
- Disability, Aging, and Technology Cluster, University of Central Florida, Orlando, Florida, United States of America
- Southwest Rural Health Research Center, Texas A&M University, College Station, Texas, United States of America
| | - Veronica Averhart Preston
- Blue Cross Blue Shield of Texas, a subsidiary of Health Care Service Corporation, Richardson, Texas, United States of America
| | - Matthew Lee Smith
- Center for Community Health and Aging, Texas A&M University, College Station, Texas, United States of America
- Department of Environmental and Occupational Health, School of Public Health, Texas A&M University, College Station, Texas, United States of America
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Dugani SB, Wood-Wentz CM, Mielke MM, Bailey KR, Vella A. Assessment of Disparities in Diabetes Mortality in Adults in US Rural vs Nonrural Counties, 1999-2018. JAMA Netw Open 2022; 5:e2232318. [PMID: 36125809 PMCID: PMC9490502 DOI: 10.1001/jamanetworkopen.2022.32318] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
IMPORTANCE US rural vs nonrural populations have striking disparities in diabetes care. Whether rurality contributes to disparities in diabetes mortality is unknown. OBJECTIVE To examine rates and trends in diabetes mortality based on county urbanization. DESIGN, SETTING, AND PARTICIPANTS In this observational, cross-sectional study, the US Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database was searched from January 1, 1999, to December 31, 2018, for diabetes as a multiple cause and the underlying cause of death among residents aged 25 years or older in US counties. County urbanization was categorized as metro, medium-small, and rural. Weighted multiple linear regression models and jackknife resampling, with a 3-segment time component, were used. The models included exposures with up to 3-way interactions and were age standardized to the 2009-2010 population. The analyses were conducted from July 1, 2020, to February 1, 2022. EXPOSURES County urbanization (metro, medium-small, or rural), gender (men or women), age group (25-54, 55-74, or ≥75 years), and region (Midwest, Northeast, South, or West). MAIN OUTCOMES AND MEASURES Annual diabetes mortality rate per 100 000 people. RESULTS From 1999-2018, based on 4 022 238 309 person-years, diabetes was a multiple cause of death for 4 735 849 adults aged 25 years or older. As a multiple cause, diabetes mortality rates in 2017-2018 vs 1999-2000 were highest and unchanged in rural counties (157.2 [95% CI, 150.7-163.7] vs 154.1 [95% CI, 148.2-160.1]; P = .49) but lower in medium-small counties (123.6 [95% CI, 119.6-127.6] vs 133.6 [95% CI, 128.4-138.8]; P = .003) and urban counties (92.9 [95% CI, 90.5-95.3] vs 109.7 [95% CI, 105.2-114.1]; P < .001). In 2017-2018 vs 1999-2000, mortality rates were higher in rural men (+18.2; 95% CI, 14.3-22.1) but lower in rural women (-14.0; 95% CI, -17.7 to -10.3) (P < .001 for both). In the 25- to 54-year age group, mortality rates in 2017-2018 vs 1999-2000 showed a greater increase in rural counties (+9.4; 95% CI, 8.6-10.2) compared with medium-small counties (+4.5; 95% CI, 4.0-5.0) and metro counties (+0.9; 95% CI, 0.4-1.4) (P < .001 for all). Of all regions and urbanization levels, the mortality rate in 2017-2018 vs 1999-2000 was higher only in the rural South (+13.8; 95% CI, 7.6-20.0; P < .001). CONCLUSIONS AND RELEVANCE In this cross-sectional study, US rural counties had the highest overall diabetes mortality rate. The determinants of persistent rural disparities, in particular for rural men and for adults in the rural South, require investigation.
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Affiliation(s)
- Sagar B. Dugani
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, Minnesota
- Division of Health Care Delivery Research, Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
| | | | - Michelle M. Mielke
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
- Now with Department of Epidemiology and Prevention, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Kent R. Bailey
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Adrian Vella
- Division of Endocrinology, Mayo Clinic, Rochester, Minnesota
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Celik S, Olgun N, Yilmaz FT, Anataca G, Ozsoy I, Ciftci N, Aykiz EF, Yasa S, Karakiraz E, Ulker Y, Demirhan YE, Celik SY, Arpaci I, Gunduz F, Temel D, Dincturk C, Sefer BE, Bagdemir E, Erdem E, Sarimehmetoglu E, Sahin F, Gulsen G, Kocakgol N, Gokmen S, Damar S, Celikoz Z, Korkusuz Y, Kirlak S, Dede T, Kahraman B, Sert A, Cetin N. Assessment the effect of diabetes education on self-care behaviors and glycemic control in the Turkey Nursing Diabetes Education Evaluating Project (TURNUDEP): a multi-center study. BMC Nurs 2022; 21:215. [PMID: 35932036 PMCID: PMC9354379 DOI: 10.1186/s12912-022-01001-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 07/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Diabetes education in Turkey is provided by diabetes nurse educators in almost all healthcare organizations. However, the education is not standardized in terms of learning content, duration, and methods. This multi-center study was performed to assess the self-care behaviors and glycemic control following education provided to the patients with type 2 diabetes mellitus by diabetes nurse educators. METHODS This was a descriptive and cross-sectional study and included 1535 patients admitted to 28 public hospitals for the treatment of type 2 diabetes mellitus. The education was assessed by using a Patient Identification Form and Self-care Scale. RESULTS The proportion of individuals who received diabetes education within the last year was 78.5%, with 46.7% of them having received it once. Of the patients, 84.8% reported that they received diabetes education individually. It was found that the proportion of individuals who received education about oral antidiabetics (78.5%) and glucose testing at home (78.5%) was higher than the proportion of individuals who received education about exercise (58.8%) and foot care (61.6%). The status of diabetes education, education intervals, and the correlation of the education method with self-care and glycemic control was evaluated. Self-care and glycemic control levels were better among the patients who received diabetes education thrice or more and in patients who received education both individually and in a group (p < 0.05). CONCLUSIONS Approximately three-quarters of individuals with type 2 diabetes mellitus received education by diabetes nurse educators in Turkey. Diabetes education is positively correlated with self-care and glycemic control levels among patients with type 2 diabetes mellitus. Efforts for generalization and standardized education for all diabetes patients are necessary.
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Affiliation(s)
- Selda Celik
- Hamidiye Faculty of Nursing, University of Health Sciences Turkey, Istanbul, Turkey. .,Mekteb-I Tıbbiye-I Şahane (Hamidiye), Külliyesi Selimiye Mahallesi Tıbbiye Caddesi No:38 34668 Üsküdar, Istanbul, Türkiye.
| | - Nermin Olgun
- Faculty of Health Sciences, Hasan Kalyoncu University, Gaziantep, Turkey
| | - Feride Taskin Yilmaz
- Faculty of Health Sciences, Sakarya University of Applied Sciences, Sakarya, Turkey
| | - Gulden Anataca
- University of Health Sciences Turkey, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
| | - Ilksen Ozsoy
- Istanbul Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
| | | | | | - Serap Yasa
- Canakkale Mehmet Akif Ersoy State Hospital, Canakkale, Turkey
| | | | | | | | - Sultan Yurtsever Celik
- University of Health Sciences Turkey, Bagcılar Training and Research Hospital, Istanbul, Turkey
| | - Inci Arpaci
- Şehit Kamil State Hospital, Gaziantep, Turkey
| | | | - Derya Temel
- Eskisehir Yunus Emre State Hospital, Eskisehir, Turkey
| | | | - Betul Essiz Sefer
- Kartal Kosuyolu Yuksek Ihtisas Training and Research Hospital, Istanbul, Turkey
| | - Elif Bagdemir
- Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Esin Erdem
- Usak Training and Research Hospital, Usak, Turkey
| | | | - Fatime Sahin
- Karabuk Training and Research Hospital, Karabuk, Turkey
| | - Gulay Gulsen
- Ondokuz Mayıs University Hospital, Samsun, Turkey
| | - Nese Kocakgol
- Gaziantep Dr. Ersin Arslan Training and ResearchHospital, Gaziantep, Turkey
| | | | - Suna Damar
- Usak Training and Research Hospital, Usak, Turkey
| | - Zekiye Celikoz
- Umraniye Training and Research Hospital, Istanbul, Turkey
| | - Yesim Korkusuz
- Kutahya Evliya Celebi Training and Research Hospital, Kutahya, Turkey
| | - Senay Kirlak
- Hamidiye Faculty of Medicine, University of Health Sciences Turkey, Istanbul Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Tugce Dede
- Acibadem Maslak Hospital, Istanbul, Turkey
| | | | - Arzu Sert
- Isparta City Hospital, Isparta, Turkey
| | - Nesrin Cetin
- Hamidiye Faculty of Medicine, University of Health Sciences Turkey, Istanbul Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
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