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Stevens J, Miranda R, Pype P, Eecloo K, Deliens L, De Vleminck A, Pardon K. Complex advance care planning intervention in general practice (ACP-GP): a cluster-randomised controlled trial. Br J Gen Pract 2024; 74:e78-e87. [PMID: 38253546 PMCID: PMC10824347 DOI: 10.3399/bjgp.2023.0022] [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: 01/12/2023] [Accepted: 08/10/2023] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Advance care planning (ACP) is an iterative communication process about patients' preferences for future care. In general practice, there are barriers to ACP at patient, GP, and healthcare-system levels. A complex intervention may be necessary to reduce barriers. AIM To evaluate the effects of a complex ACP intervention for patients with chronic, life-limiting illness in general practice (ACP-GP). DESIGN AND SETTING A cluster-randomised controlled trial was undertaken in Belgian general practice. METHOD ACP-GP included a patient workbook, GP training, ACP conversations, and a documentation template. The control group received usual care. Outcomes were the 15-item ACP Engagement Survey for patients and the ACP Self-Efficacy scale for GPs. Linear mixed models evaluated differences at 3 months (T1, effectiveness evaluation) and 6 months (T2) post-baseline. Analysis was intention-to-treat. RESULTS In total, 35 GPs and 95 patients were randomised. Patient ACP engagement did not differ between the intervention and control group at T1 (baseline-adjusted mean difference = 0.34; 95% confidence interval [CI] = -0.02 to 0.69; P = 0.062) or T2 (baseline-adjusted mean difference = 0.20; 95% CI = -0.17 to 0.57; P = 0.28). For GP ACP self-efficacy, there were no significant differences between groups at T1 (baseline-adjusted mean difference = 0.16; 95% CI = -0.04 to 0.35; P = 0.11) or at T2 (baseline-adjusted mean difference = 0.11; 95% CI = -0.09 to 0.31; P = 0.27). CONCLUSION ACP-GP did not improve patient engagement and GP self-efficacy more than usual care. Both groups showed patterns of increase from baseline. Trial procedures and the COVID-19 pandemic may have increased awareness about ACP.
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Affiliation(s)
- Julie Stevens
- End-of-Life Care Research Group, VUB & Universiteit Gent, Brussels; Department of Family Medicine and Chronic Care, VUB, Brussels; Department of Public Health and Primary Care, Universiteit Gent, Ghent
| | - Rose Miranda
- End-of-Life Care Research Group, VUB & Universiteit Gent, Brussels; Department of Family Medicine and Chronic Care, VUB, Brussels
| | - Peter Pype
- End-of-Life Care Research Group, VUB & Universiteit Gent, Brussels; Department of Public Health and Primary Care, Universiteit Gent, Ghent
| | - Kim Eecloo
- End-of-Life Care Research Group, VUB & Universiteit Gent, Brussels; Department of Public Health and Primary Care, Universiteit Gent, Ghent
| | - Luc Deliens
- End-of-Life Care Research Group, VUB & Universiteit Gent, Brussels; Department of Family Medicine and Chronic Care, VUB, Brussels; Department of Public Health and Primary Care, Universiteit Gent, Ghent
| | - Aline De Vleminck
- End-of-Life Care Research Group, VUB & Universiteit Gent, Brussels; Department of Family Medicine and Chronic Care, VUB, Brussels
| | - Koen Pardon
- End-of-Life Care Research Group, VUB & Universiteit Gent, Brussels; Department of Family Medicine and Chronic Care, VUB, Brussels
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Dupont C, De Vleminck A, Deliens L, Gilissen J. Advance Care Planning in Belgium. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2023; 180:121-126. [PMID: 37391298 DOI: 10.1016/j.zefq.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 04/25/2023] [Accepted: 05/02/2023] [Indexed: 07/02/2023]
Abstract
This paper aims to 1) describe current levels of Advance Care Planning (ACP) development since 2002 in Belgium, 2) report on challenges and opportunities to inspire other countries with similar contextual characteristics and 3) support further development of ACP practice and research in Belgium. To address these aims, we consulted local researchers, 12 domain experts and (grey) literature (regulatory documents, reports, policy documents and practice guidelines) on ACP, palliative care, and related healthcare topics. Since 2002, when the Patient's Right Law was passed in the federal Parliament, Belgium has had a specific medicolegal context for ACP. Initiatives to improve the uptake of ACP have been taken, e.g. standardised documentation, reimbursement codes for physicians provided by the government, and implementation of quality indicators in hospitals and nursing homes. Most of these initiatives are grassroots or predominantly oriented towards a single group of professions, e.g. general practitioners, disregarding the role that other professions can play. The patient groups most often targeted are those with cancer and older adults. Limited but growing attention is given to those with low health literacy or other minority groups. Main barriers to ACP in Belgium are: no unified platform to exchange outcomes of ACP discussions or advance directives between healthcare professionals and though efforts are made, ACP is still predominantly oriented towards documentation.
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Affiliation(s)
- Charlèss Dupont
- End-of-Life Care Research Group, Dept of Family Medicine & Chronic Care, Vrije Universiteit Brussel & Dept of Public Health and Primary Care, Universiteit Gent, Belgium.
| | - Aline De Vleminck
- End-of-Life Care Research Group, Dept of Family Medicine & Chronic Care, Vrije Universiteit Brussel & Dept of Public Health and Primary Care, Universiteit Gent, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Dept of Family Medicine & Chronic Care, Vrije Universiteit Brussel & Dept of Public Health and Primary Care, Universiteit Gent, Belgium
| | - Joni Gilissen
- End-of-Life Care Research Group, Dept of Family Medicine & Chronic Care, Vrije Universiteit Brussel & Dept of Public Health and Primary Care, Universiteit Gent, Belgium; Senior Atlantic Fellow for Equity in Brain Health, Global Brain Health Institute (GBHI), University of California San Francisco (UCSF), San Francisco, USA
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van Lummel EVTJ, Meijer Y, Tjan DHT, van Delden JJM. Barriers and facilitators for healthcare professionals to the implementation of Multidisciplinary Timely Undertaken Advance Care Planning conversations at the outpatient clinic (the MUTUAL intervention): a sequential exploratory mixed-methods study. BMC Palliat Care 2023; 22:24. [PMID: 36922796 PMCID: PMC10015131 DOI: 10.1186/s12904-023-01139-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 03/01/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND Advance Care Planning (ACP) enables patients to define and discuss their goals and preferences for future medical treatment and care. However, the structural implementation of ACP interventions remains challenging. The Multidisciplinary Timely Undertaken Advance Care Planning (MUTUAL) intervention has recently been developed which takes into account existing barriers and facilitators. We aimed to evaluate the MUTUAL intervention and identify the barriers and facilitators healthcare professionals experience in the implementation of the MUTUAL intervention and also to identify suggestions for improvement. METHODS We performed a sequential exploratory mixed-methods study at five outpatient clinics of one, 300-bed, non-academic hospital. Firstly, semi-structured interviews were performed with a purposive sample of healthcare professionals. The content of these interviews was used to specify the Measurement Instrument for Determinants of Innovations (MIDI). The MIDI was sent to all healthcare professionals. The interviews and questionnaires were used to clarify the results. RESULTS Eleven healthcare professionals participated in the interviews and 37 responded to the questionnaire. Eight barriers and 20 facilitators were identified. Healthcare professionals agreed that the elements of the MUTUAL intervention are clear, correct, complete, and simple - and the intervention is relevant for patients and their proxies. The main barriers are found within the user and the organisational domain. Barriers related to the organisation include: inadequate replacement of staff, insufficient staff, and insufficient time to introduce and invite patients. Several suggestions for improvement were made. CONCLUSION Our results show that healthcare professionals positively evaluate the MUTUAL intervention and are very receptive to implementing the MUTUAL intervention. Taking into account the suggestions for improvement may enhance further implementation.
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Affiliation(s)
- Eline V T J van Lummel
- Department of Intensive Care, Gelderse Vallei hospital, Ede, Netherlands. .,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands.
| | - Yoeki Meijer
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Dave H T Tjan
- Department of Intensive Care, Gelderse Vallei hospital, Ede, Netherlands
| | - Johannes J M van Delden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
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De Vleminck A, Craenen L, Stevens J, Lemaigre V, Pype P, Deliens L, Pardon K. Emotional cues and concerns of patients with a life limiting, chronic illness during advance care planning conversations in general practice. PATIENT EDUCATION AND COUNSELING 2023; 107:107563. [PMID: 36428170 DOI: 10.1016/j.pec.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 10/31/2022] [Accepted: 11/07/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To explore a) to what extent patients with serious illness express emotional cues and concerns during advance care planning (ACP) conversations with their general practitioner (GP), b) the content of cues/concerns and c) GPs' responses to cues/concerns. METHODS Cues/concerns and GPs' responses in 20 conversations were coded using the Verona Codes (VR-CoDES and Verona Codes-P). A qualitative thematic analysis was used to identify overarching themes within the content of the cues/concerns. RESULTS A total of 216 cues/concerns were identified (range: 1-28; mean: 13) in 85% of conversations; with 85% of these being cues/implicit expressions of emotions. In 72% of responses, the GP provided space for the patient to elaborate on cues/concerns. The most common theme cues/concerns were expressed about was "the consequences of illness on quality of life and burdening others". CONCLUSION Emotions were mainly communicated implicitly as cues and the content varied greatly. The amount of cues/concerns expressed show that ACP can evoke many emotions. PRACTICE IMPLICATIONS GPs should be attentive to implicit expressions of emotions as these provide opportunities to engage patients in tailored ACP conversations. As patients expressed many cues/concerns, GPs are recommended to have recurrent conversations with patients and actively ask about diverse ACP topics.
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Affiliation(s)
- Aline De Vleminck
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Belgium; Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Belgium.
| | - Lara Craenen
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Belgium; Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Belgium
| | - Julie Stevens
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Belgium; Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Belgium; Department of Public Health and Primary Care, Ghent University, Belgium
| | - Valentine Lemaigre
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Belgium
| | - Peter Pype
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Belgium; Department of Public Health and Primary Care, Ghent University, Belgium
| | - Luc Deliens
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Belgium; Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Belgium; Department of Public Health and Primary Care, Ghent University, Belgium
| | - Koen Pardon
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Belgium; Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Belgium
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van Lummel EVTJ, Savelkoul C, Stemerdink ELE, Tjan DHT, van Delden JJM. The development and feasibility study of Multidisciplinary Timely Undertaken Advance Care Planning conversations at the outpatient clinic: the MUTUAL intervention. BMC Palliat Care 2022; 21:119. [PMID: 35794617 PMCID: PMC9258045 DOI: 10.1186/s12904-022-01005-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 06/09/2022] [Indexed: 12/02/2022] Open
Abstract
Background Patients still receive non-beneficial treatments when nearing the end of life. Advance care planning (ACP) interventions have shown to positively influence compliance with end of life wishes. Hospital physicians seem to miss opportunities to engage in ACP, whereas patients visiting the outpatient clinic usually have one or more chronic conditions and are at risk for medical emergencies. So far, implemented ACP interventions have had limited impact. Structural implementation of ACP may be beneficial. We hypothesize that having ACP conversations more towards the end of life and involving the treating physician in the ACP conversation may help patient wishes and goals to become more concrete and more often documented, thus facilitating goal-concordant care. Aim To facilitate timely shared decision making and increase patient autonomy we aim to develop an ACP intervention at the outpatient clinic for frail patients and determine the feasibility of the intervention. Methods The United Kingdom’s Medical Research Council framework was used to structure the development of the ACP intervention. Key elements of the ACP intervention were determined by reviewing existing literature and an iterative process with stakeholders. The feasibility of the developed intervention was evaluated by a feasibility study of 20 ACP conversations at the geriatrics and pulmonology department of a non-academic hospital. Feasibility was assessed by analysing evaluation forms by patients, nurses and physicians and by evaluating with stakeholders. A general inductive approach was used for analysing comments. The developed intervention was described using the template for intervention description and replication (TIDieR). Results We developed a multidisciplinary timely undertaken ACP intervention at the outpatient clinic. Key components of the developed intervention consist of 1) timely patient selection 2) preparation of patient and healthcare professional 3) a scripted ACP conversation in a multidisciplinary setting and 4) documentation. 94.7% of the patients, 60.0% of the nurses and 68.8% of the physicians agreed that the benefits of the ACP conversation outweighed the potential burdens. Conclusion This study showed that the developed ACP intervention is feasible and considered valuable by patients and healthcare professionals. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-022-01005-3.
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Cross AJ, Thomas D, Liang J, Abramson MJ, George J, Zairina E. Educational interventions for health professionals managing chronic obstructive pulmonary disease in primary care. Cochrane Database Syst Rev 2022; 5:CD012652. [PMID: 35514131 PMCID: PMC9073270 DOI: 10.1002/14651858.cd012652.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a common, preventable and treatable health condition. COPD is associated with substantial burden on morbidity, mortality and healthcare resources. OBJECTIVES To review existing evidence for educational interventions delivered to health professionals managing COPD in the primary care setting. SEARCH METHODS We searched the Cochrane Airways Trials Register from inception to May 2021. The Register includes records from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine Database (AMED) and PsycINFO. We also searched online trial registries and reference lists of included studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) and cluster-RCTs. Eligible studies tested educational interventions aimed at any health professionals involved in the management of COPD in primary care. Educational interventions were defined as interventions aimed at upskilling, improving or refreshing existing knowledge of health professionals in the diagnosis and management of COPD. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed abstracts and full texts of eligible studies, extracted data and assessed the risk of bias of included studies. We conducted meta-analyses where possible and used random-effects models to yield summary estimates of effect (mean differences (MDs) with 95% confidence intervals (CIs)). We performed narrative synthesis when meta-analysis was not possible. We assessed the overall certainty of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Primary outcomes were: 1) proportion of COPD diagnoses confirmed with spirometry; 2) proportion of patients with COPD referred to, participating in or completing pulmonary rehabilitation; and 3) proportion of patients with COPD prescribed respiratory medication consistent with guideline recommendations. MAIN RESULTS We identified 38 studies(22 cluster-RCTs and 16 RCTs) involving 4936 health professionals (reported in 19/38 studies) and 71,085 patient participants (reported in 25/38 studies). Thirty-six included studies evaluated interventions versus usual care; seven studies also reported a comparison between two or more interventions as part of a three- to five-arm RCT design. A range of simple to complex interventions were used across the studies, with common intervention features including education provided to health professionals via training sessions, workshops or online modules (31 studies), provision of practice support tools, tool kits and/or algorithms (10 studies), provision of guidelines (nine studies) and training on spirometry (five studies). Health professionals targeted by the interventions were most commonly general practitioners alone (20 studies) or in combination with nurses or allied health professionals (eight studies), and the majority of studies were conducted in general practice clinics. We identified performance bias as high risk for 33 studies. We also noted risk of selection, detection, attrition and reporting biases, although to a varying extent across studies. The evidence of efficacy was equivocal for all the three primary endpoints evaluated: 1) proportion of COPD diagnoses confirmed with spirometry (of the four studies that reported this outcome, two supported the intervention); 2) proportion of patients with COPD who are referred to, participate in or complete pulmonary rehabilitation (of the four studies that reported this outcome, two supported the intervention); and 3) proportion of patients with COPD prescribed respiratory medications consistent with guideline recommendations (12 studies reported this outcome, the majority evaluated multiple drug classes and reported a mixed effect). Additionally, the low quality of evidence and potential risk of bias make the interpretation more difficult. Moderate-quality evidence (downgraded due to risk of bias concerns) suggests that educational interventions for health professionals probably improve the proportion of patients with COPD vaccinated against influenza (three studies) and probably have little impact on the proportion of patients vaccinated against pneumococcal infection (two studies). Low-quality evidence suggests that educational interventions for health professionals may have little or no impact on the frequency of COPD exacerbations (10 studies). There was a high degree of heterogeneity in the reporting of health-related quality of life (HRQoL). Low-quality evidence suggests that educational interventions for health professionals may have little or no impact on HRQoL overall, and when using the COPD-specific HRQoL instrument, the St George's Respiratory Questionnaire (at six months MD 0.87, 95% CI -2.51 to 4.26; 2 studies, 406 participants, and at 12 months MD -0.43, 95% CI -1.52 to 0.67, 4 studies, 1646 participants; reduction in score indicates better health). Moderate-quality evidence suggests that educational interventions for health professionals may improve patient satisfaction with care (one study). We identified no studies that reported adverse outcomes. AUTHORS' CONCLUSIONS The evidence of efficacy was equivocal for educational interventions for health professionals in primary care on the proportion of COPD diagnoses confirmed with spirometry, the proportion of patients with COPD who participate in pulmonary rehabilitation, and the proportion of patients prescribed guideline-recommended COPD respiratory medications. Educational interventions for health professionals may improve influenza vaccination rates among patients with COPD and patient satisfaction with care. The quality of evidence for most outcomes was low or very low due to heterogeneity and methodological limitations of the studies included in the review, which means that there is uncertainty about the benefits of any currently published educational interventions for healthcare professionals to improve COPD management in primary care. Further well-designed RCTs are needed to investigate the effects of educational interventions delivered to health professionals managing COPD in the primary care setting.
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Affiliation(s)
- Amanda J Cross
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - Dennis Thomas
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
| | - Jenifer Liang
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - Michael J Abramson
- School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
| | - Johnson George
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - Elida Zairina
- Department of Pharmacy Practice, Faculty of Pharmacy, Universitas Airlangga, Surabaya, Indonesia
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van der Smissen D, van der Heide A, Sudore RL, Rietjens JAC, Korfage IJ. Measuring advance care planning behavior in Dutch adults: translation, cultural adaptation and validation of the Advance Care Planning Engagement Survey. BMC Med Res Methodol 2021; 21:194. [PMID: 34563115 PMCID: PMC8467154 DOI: 10.1186/s12874-021-01389-5] [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: 01/27/2021] [Accepted: 08/21/2021] [Indexed: 11/28/2022] Open
Abstract
Background Advance care planning (ACP) enables people to define, discuss, and record preferences for treatment and care. Measures of ACP behavior are lacking in the Netherlands. We aimed to translate, culturally adapt and validate the 34-item ACP Engagement Survey into Dutch. Methods Following validation guidelines, we tested content validity, internal consistency, reproducibility, construct validity, interpretability and criterion validity among persons with and without chronic disease. Results Forward-backward translation indicated the need of only minor adaptations. Two hundred thirty-two persons completed baseline and retest surveys; 121 were aged ≥60 years. Persons with chronic disease (n = 151) considered the survey more valuable than those without (66 vs. 59, p < 0.001, scale of 20–100), indicating good content validity. Internal consistency (Cronbach’s alpha: 0.97) and reproducibility (intraclass correlation: 0.88) were good. Total ACP Engagement was higher among persons with chronic disease than those without (2.9 vs. 2.4, p < 0.01, scale of 1 to 5), indicating good psychometric support for construct validity and interpretability. Positive correlations of the ACP Engagement Survey and the General Self-Efficacy survey indicated good criterion validity (p < 0.05). Conclusions This study provided good psychometric support for the validity and reliability of the Dutch 34-item ACP Engagement Survey. This instrument can be used to assess involvement in ACP in adults with and without chronic disease. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-021-01389-5.
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Affiliation(s)
- Doris van der Smissen
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000, Rotterdam, CA, The Netherlands.
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000, Rotterdam, CA, The Netherlands
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, CA, USA.,Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical, San Francisco, CA, USA
| | - Judith A C Rietjens
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000, Rotterdam, CA, The Netherlands
| | - Ida J Korfage
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000, Rotterdam, CA, The Netherlands
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