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Reece J, Yu M, Bevens W, Simpson-Yap S, Davenport R, Jelinek G, Neate S. Sociodemographic, Health, and Lifestyle-Related Characteristics Associated With the Commencement and Completion of a Web-Based Lifestyle Educational Program for People With Multiple Sclerosis: Randomized Controlled Trial. J Med Internet Res 2024; 26:e58253. [PMID: 39197163 DOI: 10.2196/58253] [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: 03/11/2024] [Revised: 04/10/2024] [Accepted: 07/02/2024] [Indexed: 08/30/2024] Open
Abstract
BACKGROUND Digital health interventions increase access to multiple sclerosis (MS)-related knowledge for people living with MS; however, our understanding of factors associated with engagement in web-based learning is limited. OBJECTIVE This study aims to examine associations between participant sociodemographic, health, and lifestyle-related characteristics and the commencement and completion of the Multiple Sclerosis Online Course (MSOC) in a randomized controlled trial (RCT). METHODS An intervention course was developed based on the Overcoming MS Program-an evidence-based lifestyle modification program for MS, and a standard care course was developed based on international MS website information. An RCT was conducted to compare the effectiveness of the intervention course versus the standard care course in improving health outcomes in people living with MS. Participant data were collected from a baseline survey. Associations between baseline participant characteristics and MSOC commencement and completion, respectively, were assessed using multivariate log-binomial regression. RESULTS Overall, 1893 participants enrolled in the RCT, and 45.27% (n=857) completed the baseline survey: 23.5% (n=444) in the intervention course and 21.8% (n=413) in the standard care course. Of these 857 participants, 631 (73.6%) commenced the standard care course or intervention course, and 49.1% (218/444) and 54.2% (224/413) completed the intervention course and standard care course, respectively. University education, partnered relationship status, and higher mental and physical quality of life were associated with 19%, 12%, 20%, and 22% higher rates of course commencement, respectively. Clinically significant fatigue was associated with a 10% reduction in the likelihood of commencement. Strongest associations with intervention course completion included middle and older adulthood, male sex, fatigue, and preexisting adherence to a diet program, with 96%, 27%, 24%, and 19% higher rates of completion observed, respectively, whereas higher self-efficacy was associated with up to 35% lower intervention course completion. Associations with standard care course completion included practicing meditation (20% higher completion), whereas employment was associated with 22% lower completion. CONCLUSIONS Sociodemographic and clinical factors, as well as lifestyle-related factors, were important factors in MSOC commencement and completion. These data may help guide the design and enhancement of digital health interventions tailored for people living with MS. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12621001605886; https://tinyurl.com/2vyve9p9. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.1186/s12883-023-03298-0.
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Affiliation(s)
- Jeanette Reece
- Neuroepidemiology Unit, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Maggie Yu
- Neuroepidemiology Unit, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - William Bevens
- Institute for Clinical and Translational Science, University of California, Irvine, CA, United States
| | - Steve Simpson-Yap
- Neuroepidemiology Unit, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
- The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, Australia
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Rebekah Davenport
- Melbourne School of Psychological Sciences, The University of Melbourne, Melbourne, Australia
| | - George Jelinek
- Neuroepidemiology Unit, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Sandra Neate
- Neuroepidemiology Unit, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
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Sharma V, O'Sullivan M, Cassetti O, Winning L, O'Sullivan A, Crowe M. Evaluating the harmonization potential of oral health-related questionnaires in national longitudinal birth and child cohort surveys. J Public Health Dent 2024. [PMID: 38953657 DOI: 10.1111/jphd.12632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 04/16/2024] [Accepted: 06/14/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND/OBJECTIVES Effective use of longitudinal study data is challenging because of divergences in the construct definitions and measurement approaches over time, between studies and across disciplines. One approach to overcome these challenges is data harmonization. Data harmonization is a practice used to improve variable comparability and reduce heterogeneity across studies. This study describes the process used to evaluate the harmonization potential of oral health-related variables across each survey wave. METHODS National child cohort surveys with similar themes/objectives conducted in the last two decades were selected. The Maelstrom Research Guidelines were followed for harmonization potential evaluation. RESULTS Seven nationally representative child cohort surveys were included and questionnaires examined from 50 survey waves. Questionnaires were classified into three domains and fifteen constructs and summarized by age groups. A DataSchema (a list of core variables representing the suitable version of the oral health outcomes and risk factors) was compiled comprising 42 variables. For each study wave, the potential (or not) to generate each DataSchema variable was evaluated. Of the 2100 harmonization status assessments, 543 (26%) were complete. Approximately 50% of the DataSchema variables can be generated across at least four cohort surveys while only 10% (n = 4) variables can be generated across all surveys. For each survey, the DataSchema variables that can be generated ranged between 26% and 76%. CONCLUSION Data harmonization can improve the comparability of variables both within and across surveys. For future cohort surveys, the authors advocate more consistency and standardization in survey questionnaires within and between surveys.
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Affiliation(s)
- Vinay Sharma
- Division of Restorative Dentistry and Periodontology, Dublin Dental University Hospital, Trinity College Dublin, Dublin, Ireland
| | - Michael O'Sullivan
- Division of Restorative Dentistry and Periodontology, Dublin Dental University Hospital, Trinity College Dublin, Dublin, Ireland
| | - Oscar Cassetti
- Division of Restorative Dentistry and Periodontology, Dublin Dental University Hospital, Trinity College Dublin, Dublin, Ireland
| | - Lewis Winning
- Division of Restorative Dentistry and Periodontology, Dublin Dental University Hospital, Trinity College Dublin, Dublin, Ireland
| | - Aifric O'Sullivan
- Institute of Food and Health, Science Centre, South, UCD, Dublin, Ireland
| | - Michael Crowe
- Division of Restorative Dentistry and Periodontology, Dublin Dental University Hospital, Trinity College Dublin, Dublin, Ireland
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Goverover Y, Sharan S, Krupp L, DeLuca J. Exploring the Efficacy of a Remote Strategy-Based Intervention for People With Multiple Sclerosis With Everyday Memory Impairments: A Pilot Study. Am J Occup Ther 2024; 78:7804205020. [PMID: 38801676 DOI: 10.5014/ajot.2024.050468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024] Open
Abstract
IMPORTANCE This pilot study evaluates a remote strategy-based intervention for individuals with multiple sclerosis who experience everyday memory impairments. The intervention can potentially inform cognitive rehabilitation for this population. OBJECTIVE To investigate the feasibility and efficacy of an intervention (TELE-Self-GEN) to determine whether it can alleviate everyday memory impairments of individuals with multiple sclerosis. DESIGN Pretest-posttest. SETTING Community. PARTICIPANTS Ten adults with multiple sclerosis. INTERVENTION Six synchronous treatment sessions were delivered online via Zoom. The treatment protocol embedded a memory strategy (self-generated learning) within a metacognitive framework, including self-awareness and self-management strategies. The treatment emphasizes when and how self-generation should be used. OUTCOME Measurements assessed feasibility and participants' satisfaction with the intervention and its delivery method, as well as memory, everyday memory, and functional performance. RESULTS Participants expressed high satisfaction with the virtual treatment, highlighting its convenience as a key factor. Treatment resulted in improvements in memory performance, perceived memory ability in daily life, and functional performance. CONCLUSIONS AND RELEVANCE Results provide initial proof of concept in the utilization of a remotely delivered, strategy-based treatment approach to improve memory performance and functional abilities. The pilot data support a larger randomized clinical trial of the TELE-self-GEN. Plain-Language Summary: The results of this pilot study highlight the promising potential of TELE-self-GEN for people with multiple sclerosis (MS), who face memory challenges every day. This remotely delivered, strategy-based occupational therapy treatment approach, TELE-self-GEN, has the potential to significantly improve functional memory. The study participants reported improvements in their memory performance, perceived memory ability in daily life, and functional performance. These encouraging results serve as a foundation for more extensive clinical trials using TELE-self-GEN for people with MS.
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Affiliation(s)
- Yael Goverover
- Yael Goverover, PhD, OTR/L, FAOTA, is Professor, Department of Occupational Therapy, New York University, New York, NY;
| | - Saumya Sharan
- Saumya Sharan, MS, OTR/L, is Student, Department of Occupational Therapy, New York University, New York, NY
| | - Lauren Krupp
- Lauren Krupp, MD, is Professor of Neurology and Director, Multiple Sclerosis Comprehensive Care Center, New York University Langone Health, New York, NY
| | - John DeLuca
- John DeLuca, PhD, is Senior Vice President for Research and Research Training and Professor of Physical Medicine and Rehabilitation and Neurosciences, Kessler Foundation, West Orange, NJ
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Zettl UK, Frahm N, Hecker M. Challenges in monitoring the quality of care in multiple sclerosis. THE LANCET REGIONAL HEALTH. EUROPE 2024; 42:100950. [PMID: 38840977 PMCID: PMC11152748 DOI: 10.1016/j.lanepe.2024.100950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 05/16/2024] [Indexed: 06/07/2024]
Affiliation(s)
- Uwe Klaus Zettl
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Centre, Rostock, Germany
| | - Niklas Frahm
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Centre, Rostock, Germany
| | - Michael Hecker
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Centre, Rostock, Germany
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Singer BA, Feng J, Chiong-Rivero H. Early use of high-efficacy therapies in multiple sclerosis in the United States: benefits, barriers, and strategies for encouraging adoption. J Neurol 2024; 271:3116-3130. [PMID: 38615277 PMCID: PMC11136864 DOI: 10.1007/s00415-024-12305-4] [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: 12/19/2023] [Revised: 03/04/2024] [Accepted: 03/04/2024] [Indexed: 04/15/2024]
Abstract
Multiple sclerosis (MS) is characterized by progressive neuroinflammation and neurodegeneration from disease onset that, if left untreated, can result in the accumulation of irreversible neurological disability. Early intervention with high-efficacy therapies (HETs) is increasingly recognized as the best strategy to delay or mitigate disease progression from the earliest stages of the disease and to prevent long-term neurodegeneration. Although there is growing clinical and real-world evidence supporting early HET intervention, foregoing this strategy in favor of a traditional escalation approach prioritizing lower-efficacy disease-modifying therapies remains a common approach in clinical practice. This review explores potential health care professional- and patient-related barriers to the early use of HETs in patients with MS in the United States. Barriers can include regulatory and reimbursement restrictions; knowledge gaps and long-term safety concerns among health care professionals; and various individual, cultural, and societal factors affecting patients. Potential strategies for overcoming these barriers and encouraging early HET use are proposed.
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Affiliation(s)
- Barry A Singer
- The MS Center for Innovations in Care, Missouri Baptist Medical Center, St Louis, MO, USA.
| | - Jenny Feng
- Ochsner Medical Center, New Orleans, LA, USA
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Stoll S, Costello K, Newsome SD, Schmidt H, Sullivan AB, Hendin B. Insights for Healthcare Providers on Shared Decision-Making in Multiple Sclerosis: A Narrative Review. Neurol Ther 2024; 13:21-37. [PMID: 38180727 PMCID: PMC10787702 DOI: 10.1007/s40120-023-00573-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 12/07/2023] [Indexed: 01/06/2024] Open
Abstract
Shared decision-making (SDM) between the patient and their healthcare provider (HCP) in developing treatment plans is increasingly recognized as central to improving treatment adherence and, ultimately, patient outcomes. In multiple sclerosis (MS), SDM is particularly crucial for optimizing treatment in a landscape that has grown more complex with the availability of newer, high-efficacy MS therapies. However, little direct evidence on the effectiveness of SDM is available to guide practice. Multiple factors, including patient age, ethnic background, perceptions, invisible MS symptoms, and psychological comorbidities can influence a patient's willingness and ability to participate in SDM. HCPs need to appreciate these factors and ask the right questions to break down obstacles to SDM. The HCP has a responsibility to help patients feel adequately informed and comfortable in having an active role in their care. This review identifies potential barriers to SDM and provides a strategy for HCPs to overcome these obstacles through patient (and caregiver) discussions to ensure optimal patient satisfaction with treatment and thus the best possible outcomes for their patients.
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Affiliation(s)
| | | | - Scott D Newsome
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hollie Schmidt
- Accelerated Cure Project for Multiple Sclerosis, Waltham, MA, USA
| | - Amy B Sullivan
- Mellen Center for Multiple Sclerosis, Cleveland Clinic, Cleveland, OH, USA
| | - Barry Hendin
- Integrated Multiple Sclerosis Center, Phoenix, AZ, USA
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Newsome SD, Binns C, Kaunzner UW, Morgan S, Halper J. No Evidence of Disease Activity (NEDA) as a Clinical Assessment Tool for Multiple Sclerosis: Clinician and Patient Perspectives [Narrative Review]. Neurol Ther 2023; 12:1909-1935. [PMID: 37819598 PMCID: PMC10630288 DOI: 10.1007/s40120-023-00549-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 09/19/2023] [Indexed: 10/13/2023] Open
Abstract
The emergence of high-efficacy therapies for multiple sclerosis (MS), which target inflammation more effectively than traditional disease-modifying therapies, has led to a shift in MS management towards achieving the outcome assessment known as no evidence of disease activity (NEDA). The most common NEDA definition, termed NEDA-3, is a composite of three related measures of disease activity: no clinical relapses, no disability progression, and no radiological activity. NEDA has been frequently used as a composite endpoint in clinical trials, but there is growing interest in its use as an assessment tool to help patients and healthcare professionals navigate treatment decisions in the clinic. Raising awareness about NEDA may therefore help patients and clinicians make more informed decisions around MS management and improve overall MS care. This review aims to explore the potential utility of NEDA as a clinical decision-making tool and treatment target by summarizing the literature on its current use in the context of the expanding treatment landscape. We identify current challenges to the use of NEDA in clinical practice and detail the proposed amendments, such as the inclusion of alternative outcomes and biomarkers, to broaden the clinical information captured by NEDA. These themes are further illustrated with the real-life perspectives and experiences of our two patient authors with MS. This review is intended to be an educational resource to support discussions between clinicians and patients on this evolving approach to MS-specialized care.
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Affiliation(s)
- Scott D Newsome
- Johns Hopkins University School of Medicine, 600 North Wolfe Street, Pathology 627, Baltimore, MD, 21287, USA.
| | - Cherie Binns
- Multiple Sclerosis Foundation, 6520 N Andrews Avenue, Fort Lauderdale, FL, 33309, USA
| | | | - Seth Morgan
- National Multiple Sclerosis Society, 1 M Street SE, Suite 510, Washington, DC, 20003, USA
| | - June Halper
- Consortium of Multiple Sclerosis Centers, 3 University Plaza Drive Suite A, Hackensack, NJ, 07601, USA
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Zuckerman AD, Banks AM, Wawrzyniak J, Rightmier E, Simonson D, Zagel AL, Turco E, Blevins A, DeClercq J, Choi L. Patient-reported outcomes and pharmacist actions in patients with multiple sclerosis managed by health-system specialty pharmacies. Am J Health Syst Pharm 2023; 80:1650-1661. [PMID: 37556317 DOI: 10.1093/ajhp/zxad180] [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: 08/08/2023] [Indexed: 08/11/2023] Open
Abstract
PURPOSE This study evaluated patient-reported outcomes (PROs) and pharmacist actions for patients on disease-modifying therapies (DMTs) for multiple sclerosis (MS) through health-system specialty pharmacies (HSSPs). METHODS A multisite, prospective cohort study of patients utilizing an HSSP for DMT fulfillment was performed. Primary outcomes were affirmative answers to PRO questions regarding impacted productivity, hospitalization, and relapse and pharmacist actions. Rates of pharmacist actions were reported as the number of person-years of treatment per action. Univariate and multivariate logistic regression were used to evaluate the association between each PRO and covariates, including the number of pharmacist actions performed, age, sex, insurance, site, and route of administration. RESULTS The 968 patients included had 10,562 fills and 6,946 PRO assessments. The most common affirmative PRO was impacted productivity (14.6%). Pharmacists performed 3,683 actions, most commonly general medication education (42.6%) and safety (33.3%). Rates of general medication education and nonfinancial coordination of care actions were similar across medication classes; other pharmacist actions varied by medication class. Insurance type was significantly associated with reporting impacted productivity; patients with Medicare and Medicaid were 2.2 and 3.1 times more likely to have reported impacted productivity, respectively (P < 0.001) than commercially insured patients. Patients who reported impacted productivity had more pharmacist actions (P < 0.001). CONCLUSION Patients on DMTs through an HSSP reported low rates of impacted productivity, relapse, and hospitalization due to MS, although patients with noncommercial insurance were more likely to have impacted productivity. Patients reporting impacted productivity and those taking certain DMTs may require more frequent pharmacist actions.
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Affiliation(s)
- Autumn D Zuckerman
- Specialty Pharmacy Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Aimee M Banks
- Specialty Pharmacy Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Julie Wawrzyniak
- University of Rochester Specialty Pharmacy, UR Medicine, Rochester, NY, USA
| | | | - Dana Simonson
- Fairview Specialty Pharmacy, Fairview Pharmacy Services, Minneapolis, MN, USA
| | | | - Evan Turco
- WVU Medicine Specialty Pharmacy Services, Allied Health Solutions, Morgantown, WV, USA
| | - Abbi Blevins
- WVU Medicine Specialty Pharmacy Services, Allied Health Solutions, Morgantown, WV, USA
| | - Josh DeClercq
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Leena Choi
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
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Claflin S, Campbell JA, Taylor BV. Healthcare utilization and satisfaction among enrolees in an online course about multiple sclerosis: A cross-sectional study. Mult Scler Relat Disord 2023; 75:104728. [PMID: 37120966 DOI: 10.1016/j.msard.2023.104728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 04/18/2023] [Accepted: 04/22/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND Healthcare utilization and satisfaction are important for health outcomes among people living with multiple sclerosis (PwMS). However, there is little current evidence around healthcare utilization among PwMS, and less comparing PwMS to those not living with MS. OBJECTIVE To evaluate healthcare utilization and satisfaction among Understanding MS online course enrolees and to identify factors associated with healthcare satisfaction. METHOD In this international cross-sectional study, we evaluated participant characteristics (including health literacy and quality of life), healthcare utilization (number of visits, number of provider types), and satisfaction with healthcare (perceived healthcare sufficiency, quality, accessibility) among enrolees in the Understanding MS online course (N = 1068). We evaluated study outcomes using summary statistics. We compared participant characteristics and study outcomes between PwMS and those not living with MS using chi square and t-tests. RESULTS In this study cohort, PwMS were older, less likely to have a university degree, had lower health literacy, and lower quality of life. PwMS had significantly more healthcare visits in the previous year and visited a more diverse range of provider types than those not living with MS. PwMS were also more likely to report being satisfied with the healthcare they received. Among both PwMS and those not living with MS, higher health literacy and higher healthcare utilization were significantly associated with satisfaction with healthcare sufficiency, quality, and accessibility. CONCLUSION PwMS were more likely to be satisfied with the healthcare they received compared to those not living with MS. This may be due in part to the differences in health literacy and healthcare utilization between the two groups. We recommend that these relationships be rigorously assessed in future research.
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Affiliation(s)
- Suzi Claflin
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia.
| | - Julie A Campbell
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Bruce V Taylor
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
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Ott J, Biller-Andorno N, Glässel A. First Insights into Barriers and Facilitators from the Perspective of Persons with Multiple Sclerosis: A Multiple Case Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10733. [PMID: 36078447 PMCID: PMC9518524 DOI: 10.3390/ijerph191710733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/08/2022] [Accepted: 08/22/2022] [Indexed: 06/15/2023]
Abstract
Multiple Sclerosis (MS) is a complex, lifelong disease. Its effects span across different areas of life and vary strongly. In Switzerland, there is an intense discussion on how to optimize quality of care and patient safety. Patients should be more involved in the management of health care to improve the quality of care from the patient's perspective and form a more comprehensive perspective. This multiple-case study explores the question of how persons with MS experience and describe functioning related barriers, facilitating factors, and ethically relevant conflicts. To address this from a comprehensive perspective, the MS core set of the International Classification for Functioning, Disability, and Health (ICF) is used as theoretical framework. To explore barriers, facilitators, and relevant ethical issues, different narrative sources were used for thematic analysis and ICF coding: (a) MS transcripts from DIPEx interviews and (b) an autobiographical book of persons living with MS. Insights that were meaningful for daily practice and education were identified: (a) understanding the importance of environmental circumstances based on narrative sources; (b) understanding the importance of a person's individual life situation, and the ability to switch perspectives in the medical field; (c) respect for PwMS' individuality in health care settings; (d) creating meaningful relationships for disease management and treatment, as well as building trust.
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Affiliation(s)
- Joelle Ott
- Institute of Biomedical Ethics and Medical History, University Zurich, Winterthurerstrasse 30, CH-8006 Zurich, Switzerland
| | - Nikola Biller-Andorno
- Institute of Biomedical Ethics and Medical History, University Zurich, Winterthurerstrasse 30, CH-8006 Zurich, Switzerland
| | - Andrea Glässel
- Institute of Biomedical Ethics and Medical History, University Zurich, Winterthurerstrasse 30, CH-8006 Zurich, Switzerland
- Institute of Public Health (IPH), Department of Health Sciences Katharina-Sulzer-Platz 9, Zurich University of Applied Studies (ZHAW), CH-8401 Winterthur, Switzerland
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