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Birken SA, Matulewicz R, Pathak R, Wagi CR, Peluso AG, Bundy R, Witek L, Krol B, Parchman ML, Nielsen M, Dharod A. Toward the Deimplementation of Computed Tomography Urogram for Patients With Low- to Intermediate-risk Microscopic Hematuria: A Mixed-method Study of Factors Influencing Continued Use. Urol Pract 2023; 10:511-519. [PMID: 37499130 PMCID: PMC10609652 DOI: 10.1097/upj.0000000000000429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 06/16/2023] [Indexed: 07/29/2023]
Abstract
INTRODUCTION Citing high costs, limited diagnostic benefit, and ionizing radiation-associated risk from CT urogram, in 2020 the AUA revised its guidelines from recommending CT urogram for all patients with microscopic hematuria to a deintensified risk-stratified approach, including the deimplementation of low-value CT urogram (ie, not recommending CT urogram for patients with low- to intermediate-risk microscopic hematuria). Adherence to revised guidelines and reasons for continued low-value CT urogram are unknown. METHODS With the overarching objective of improving guideline implementation, we used a mixed-method convergent explanatory design with electronic health record data for a retrospective cohort at a single academic tertiary medical center in the southeastern United States and semistructured interviews with urology and nonurology providers to describe determinants of low-value CT urogram following guideline revision. RESULTS Of 391 patients with microscopic hematuria, 198 (51%) had a low-value CT urogram (136 [69%] pre-guideline revision, 62 [31%] postrevision). The odds of ordering a low-value CT urogram were lower after guideline revisions, but the change was not statistically significant (OR: 0.44, P = .08); odds were 1.89 higher (P = .06) among nonurology providers than urology providers, but the difference was not statistically significant. Provider interviews suggested low-value CT urogram related to nonurology providers' limited awareness of revised guidelines, the role of clinical judgment in microscopic hematuria evaluation, and professional and patient influences. CONCLUSIONS Our findings suggest low-value CT urogram deimplementation may be improved with guidelines and implementation support directed at both urology and nonurology providers and algorithms to support guideline-concordant microscopic hematuria evaluation approaches. Future studies should test these strategies.
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Affiliation(s)
- Sarah A. Birken
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Richard Matulewicz
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ram Pathak
- Department of Urology, Mayo Clinic, Rochester, Minnesota
| | - Cheyenne R. Wagi
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Alexandra G. Peluso
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Richa Bundy
- Department of Internal Medicine, Informatics and Analytics, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Lauren Witek
- Department of Internal Medicine, Informatics and Analytics, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Bridget Krol
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | | | - Matthew Nielsen
- Department of Urology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ajay Dharod
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina
- Department of Internal Medicine, Informatics and Analytics, Wake Forest University School of Medicine, Winston-Salem, North Carolina
- Wake Forest University School of Medicine, Department of Internal Medicine (IM), Section on General Internal Medicine (GIM), Winston-Salem, North Carolina
- Wake Forest Center for Healthcare Innovation (CHI), Winston-Salem, North Carolina
- Wake Forest Center for Biomedical Informatics (WFBMI), Winston-Salem, North Carolina
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Birken SA, Wagi CR, Peluso AG, Kegler MC, Baloh J, Adsul P, Fernandez ME, Masud M, Huang TTK, Lee M, Wangen M, Nilsen P, Bender M, Choy-Brown M, Ryan G, Randazzo A, Ko LK. Toward a more comprehensive understanding of organizational influences on implementation: the organization theory for implementation science framework. Front Health Serv 2023; 3:1142598. [PMID: 37720844 PMCID: PMC10501605 DOI: 10.3389/frhs.2023.1142598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 08/17/2023] [Indexed: 09/19/2023]
Abstract
Introduction Implementation is influenced by factors beyond individual clinical settings. Nevertheless, implementation research often focuses on factors related to individual providers and practices, potentially due to limitations of available frameworks. Extant frameworks do not adequately capture the myriad organizational influences on implementation. Organization theories capture diverse organizational influences but remain underused in implementation science. To advance their use among implementation scientists, we distilled 70 constructs from nine organization theories identified in our previous work into theoretical domains in the Organization Theory for Implementation Science (OTIS) framework. Methods The process of distilling organization theory constructs into domains involved concept mapping and iterative consensus-building. First, we recruited organization and implementation scientists to participate in an online concept mapping exercise in which they sorted organization theory constructs into domains representing similar theoretical concepts. Multidimensional scaling and hierarchical cluster analyses were used to produce visual representations (clusters) of the relationships among constructs in concept maps. Second, to interpret concept maps, we engaged members of the Cancer Prevention and Control Research Network (CPCRN) OTIS workgroup in consensus-building discussions. Results Twenty-four experts participated in concept mapping. Based on resulting construct groupings' coherence, OTIS workgroup members selected the 10-cluster solution (from options of 7-13 clusters) and then reorganized clusters in consensus-building discussions to increase coherence. This process yielded six final OTIS domains: organizational characteristics (e.g., size; age); governance and operations (e.g., organizational and social subsystems); tasks and processes (e.g., technology cycles; excess capacity); knowledge and learning (e.g., tacit knowledge; sense making); characteristics of a population of organizations (e.g., isomorphism; selection pressure); and interorganizational relationships (e.g., dominance; interdependence). Discussion Organizational influences on implementation are poorly understood, in part due to the limitations of extant frameworks. To improve understanding of organizational influences on implementation, we distilled 70 constructs from nine organization theories into six domains. Applications of the OTIS framework will enhance understanding of organizational influences on implementation, promote theory-driven strategies for organizational change, improve understanding of mechanisms underlying relationships between OTIS constructs and implementation, and allow for framework refinement. Next steps include testing the OTIS framework in implementation research and adapting it for use among policymakers and practitioners.
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Affiliation(s)
- Sarah A. Birken
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - Cheyenne R. Wagi
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - Alexandra G. Peluso
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - Michelle C. Kegler
- Emory Prevention Research Center, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Jure Baloh
- College of Public Health, Department of Health Policy and Management, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Prajakta Adsul
- Department of Internal Medicine, University of New Mexico, Albuquerque, NM, United States
- Comprehensive Cancer Center, University of New Mexico, Albuquerque, NM, United States
| | - Maria E. Fernandez
- Center for Health Promotion and Prevention Research, University of Texas Health Science Center at Houston School of Public Health, Houston, TX, United States
| | - Manal Masud
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, United States
| | - Terry T-K Huang
- Center for Systems and Community Design and NYU-CUNY Prevention Research Center, Graduate School of Public Health and Health Policy, City University of New York, New York, NY, United States
| | - Matthew Lee
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States
| | - Mary Wangen
- UNC Center for Health Promotion and Disease Prevention, University of North Carolina Chapel Hill, Chapel Hill, NC, United States
| | - Per Nilsen
- Department of Health, Medicine and Caring Sciences, Division of Society and Health, Linköping University, Linköping, Sweden
| | - Miriam Bender
- Sue & Bill Gross School of Nursing, University of California Irvine, Irvine, CA, United States
| | - Mimi Choy-Brown
- College of Education and Human Development, School of Social Work, University of Minnesota, St. Paul, MN, United States
| | - Grace Ryan
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Aliza Randazzo
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - Linda K. Ko
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, United States
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Danhauer SC, Dressler EV, Brown WM, Nightingale CL, Brenes GA, Petty WJ, Curtis A, Murkutla S, Huang J, Wagi CR, Lesser GJ, Weaver KE. Reducing Anxiety and Dyspnea via Device-Guided Breathing (RELAX): A Multi-Site Feasibility Study in Post-Treatment Lung Cancer Survivors at Community Cancer Clinics (WF-01213). Integr Cancer Ther 2023; 22:15347354231164406. [PMID: 37029555 PMCID: PMC10087642 DOI: 10.1177/15347354231164406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2023] Open
Abstract
INTRODUCTION Anxiety and dyspnea are 2 common symptoms for lung cancer survivors. Although research suggests decreasing respiration rate can reduce anxiety in several populations, potential benefits of device-guided breathing have not been studied in lung cancer survivors. This feasibility study (WF-01213) provides estimates of accrual, adherence, retention, and preliminary efficacy of 2 doses of a device-guided breathing intervention versus a usual breathing control group for improving self-reported anxiety and dyspnea in post-treatment lung cancer survivors. METHODS Stage I-IV lung cancer survivors were recruited through the NCI Community Oncology Research Program (NCORP) and randomized to 12 weeks of a device-guided breathing intervention (high dose vs. low dose) or control device. Self-reported outcomes (anxiety, depression, dyspnea, cancer-related worry, fatigue) were assessed at baseline, mid-intervention (Week-6), and post-intervention (Week-12). RESULTS Forty-six participants (ages 41-77, median = 65; 78% White) were randomized to the high-dose intervention (n = 14), low-dose intervention (n = 14), or control (n = 18) groups between July 2015 and September 2019. Study accrual rate was 0.92 per month for 50 months (projected accrual was 6.3/month). Fourteen participants (30%) withdrew early from the study, with almost half of those discontinuing at or immediately following baseline assessment. No participants were adherent with the intervention per protocol specifications. The proportion minimally adherent (using device at least 1x/week) was 43% (6/14), 64% (9/14), and 61% (11/18) for high-dose, low-dose, and control groups, respectively. Anxiety significantly decreased from baseline for all groups at Week 12. Adherence to the intervention was low across all treatment groups. CONCLUSIONS This study did not establish feasibility of a community-based randomized trial of 2 doses of device-guided breathing and a control group using an identical-looking device for lung cancer survivors. In both the high-dose and control groups, there were significant improvements from baseline for anxiety and dyspnea. In the low-dose group, there were significant improvements from baseline for anxiety and depression. Ratings and feedback on the intervention were mixed (although leaned in a positive direction). Participants reported liking the feeling of relaxation/calm, helping others, breathing awareness, and music. Participants reporting liking least finding/making time to use the device, frustration with the device, and completing study forms. TRIAL REGISTRATION: CLINICAL TRIALS ID NCT02063828, clinicaltrials.gov.
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Affiliation(s)
| | - Emily V Dressler
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - W Mark Brown
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | | | | | - William J Petty
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | | | | | - Jocelin Huang
- University of Minnesota Physicians, Minneapolis, MN, USA
| | - Cheyenne R Wagi
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Glenn J Lesser
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Kathryn E Weaver
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Wagi CR, Ali NA, Santiago-Datil WL, Rickloff MA, Corvin JA. Suffering in silence: Graduate student infertility. J Am Coll Health 2022; 70:2295-2302. [PMID: 33320787 DOI: 10.1080/07448481.2020.1851233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 10/13/2020] [Accepted: 11/06/2020] [Indexed: 06/12/2023]
Abstract
While fertility is a widely studied public health issue, infertility among college students is rarely examined. Research on fertility among college students focuses primarily on pregnancy prevention. Often constructed as hyper-fertile, cohorts of women in graduate studies are struggling with fertility issues and left to suffer in silence. Objective: This study aimed to identify barriers to access and gaps in available reproductive services to college attending women. Methods: This multi-method, exploratory study employed online surveys (n = 37), semi-structured interviews (n = 5), and an assessment of fertility-related school health services available at universities nationally to understand issues related to infertility, including experience with and access to services. Results: A near absence of fertility-related care on college campuses emerged nationally, while a clear need among female graduate students emerged locally. Perceptions of poor treatment and dismissal of concerns were prominent issues. Conclusions: Findings suggest the need for self-advocacy, while highlighting the potential role of university and community supports for women suffering from the dual burden of being a student while struggling with fertility related issues.
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Affiliation(s)
- Cheyenne R Wagi
- Department of Global Health, University of South Florida, Tampa, Florida, USA
| | - Noor A Ali
- Department of Global Health, University of South Florida, Tampa, Florida, USA
| | | | - Marissa A Rickloff
- Department of Global Health, University of South Florida, Tampa, Florida, USA
| | - Jaime A Corvin
- Department of Global Health, University of South Florida, Tampa, Florida, USA
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Birken SA, Ko LK, Wangen M, Wagi CR, Bender M, Nilsen P, Choy-Brown M, Peluso A, Leeman J. Increasing Access to Organization Theories for Implementation Science. Front Health Serv 2022; 2:891507. [PMID: 36925845 PMCID: PMC10012830 DOI: 10.3389/frhs.2022.891507] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 06/08/2022] [Indexed: 11/13/2022]
Abstract
Background Organization theories offer numerous existing, highly relevant, yet largely untapped explanations of the organizational dynamics underlying evidence-based intervention (EBI) implementation. Rooted in ideas regarding power, autonomy, and control, organization theories can explain how and why organizations adopt, implement, and sustain EBI use. Although they have gained visibility, organization theories remain underused in implementation research, perhaps due to their inaccessibility to implementation scientists. To improve access to organization theory among implementation scientists, we summarized organization theories with relevance to implementation science. Methods Led by the Cancer Prevention and Control Research Network (CPCRN) Organization Theory for Implementation Science workgroup, we employed a modified Delphi process to reach a consensus among 18 experts at the intersection of organization and implementation science regarding organization theories with relevance to implementation science. From texts that described the organization theories, using standardized abstraction forms, two investigators independently abstracted information regarding constructs, propositions regarding how or why constructs might influence implementation, the potential relevance of organization theories' propositions for implementation, and overviews of each theory. The investigators then reconciled discrepancies until reaching consensus. A third investigator reviewed reconciled abstraction forms for accuracy, coherence, and completeness. Findings We identified nine organization theories with relevance to implementation science: contingency, complexity, institutional, network, organizational learning, resource dependence, sociotechnical, and transaction cost economics. From the theories, we abstracted 70 constructs and 65 propositions. An example proposition from institutional theory is: "Coercive, mimetic, and normative pressures contribute to organizations…within an organizational field [becoming increasingly similar]." These propositions can be operationalized as levers to facilitate EBI implementation. Conclusions To increase use in the field, organization theories must be made more accessible to implementation scientists. The abstraction forms developed in this study are now publicly available on the CPCRN website with the goal of increasing access to organization theories among an interdisciplinary audience of implementation scientists through the CPCRN Scholars program and other venues. Next steps include consolidating organization theory constructs into domains and translating the resulting framework for use among researchers, policymakers and practitioners, aiding them in accounting for a comprehensive set of organization theory constructs thought to influence EBI implementation.
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Affiliation(s)
- Sarah A. Birken
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Linda K. Ko
- Washington School of Public Health, Health Systems and Population Health, Seattle, WA, United States
| | - Mary Wangen
- UNC Center for Health Promotion and Disease Prevention, University of North Carolina Chapel Hill, Chapel Hill, NC, United States
| | - Cheyenne R. Wagi
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Miriam Bender
- Sue & Bill Gross School of Nursing, University of California, Irvine, Irvine, CA, United States
| | - Per Nilsen
- Division of Society and Health, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Mimi Choy-Brown
- School of Social Work, College of Education and Human Development, University of Minnesota, St. Paul, MN, United States
| | - Alexandra Peluso
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Jennifer Leeman
- School of Nursing, University of North Carolina Chapel Hill, Chapel Hill, NC, United States
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Wheeler SB, Birken SA, Wagi CR, Manning ML, Gellin M, Padilla N, Rogers C, Rodriguez J, Biddell CB, Strom C, Bell RA, Rosenstein DL. Core functions of a financial navigation intervention: An in-depth assessment of the Lessening the Impact of Financial Toxicity (LIFT) intervention to inform adaptation and scale-up in diverse oncology care settings. Front Health Serv 2022; 2:958831. [PMID: 36925862 PMCID: PMC10012722 DOI: 10.3389/frhs.2022.958831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 09/21/2022] [Indexed: 11/11/2022]
Abstract
Background Lessening the Impact of Financial Toxicity (LIFT) is an intervention designed to address financial toxicity (FT) and improve cancer care access and outcomes through financial navigation (FN). FN identifies patients at risk for FT, assesses eligibility for financial support, and develops strategies to cope with those costs. LIFT successfully reduced FT and improved care access in a preliminary study among patients with high levels of FT in a single large academic cancer center. Adapting LIFT requires distinguishing between core functions (components that are key to its implementation and effectiveness) and forms (specific activities that carry out core functions). Our objective was to complete the first stage of adaptation, identifying LIFT core functions. Methods We reviewed LIFT's protocol and internal standard-operating procedures. We then conducted 45-90 min in-depth interviews, using Kirk's method of identifying core functions, with key LIFT staff (N = 8), including the principal investigators. Interviews focused on participant roles and intervention implementation. Recorded interviews were transcribed verbatim. Using ATLAS.ti and a codebook based on the Model for Adaptation Design and Impact, we coded interview transcripts. Through thematic analysis, we then identified themes related to LIFT's intervention and implementation core functions. Two report back sessions with interview participants were incorporated to further refine themes. Results Six intervention core functions (i.e., what makes LIFT effective) and five implementation core functions (i.e., what facilitated LIFT's implementation) were identified to be sufficient to reduce FT. Intervention core functions included systematically cataloging knowledge and tracking patient-specific information related to eligibility criteria for FT relief. Repeat contacts between the financial navigator and participant created an ongoing relationship, removing common barriers to accessing resources. Implementation core functions included having engaged sites with the resources and willingness necessary to implement FN. Developing navigators' capabilities to implement LIFT-through training, an established case management system, and connections to peer navigators-were also identified as implementation core functions. Conclusion This study adds to the growing evidence on FN by characterizing intervention and implementation core functions, a critical step toward promoting LIFT's implementation and effectiveness.
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Affiliation(s)
- Stephanie B Wheeler
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.,Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Sarah A Birken
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC, United States.,Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC, United States
| | - Cheyenne R Wagi
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - Michelle L Manning
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Mindy Gellin
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Neda Padilla
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Cindy Rogers
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Julia Rodriguez
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Caitlin B Biddell
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.,Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Carla Strom
- Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC, United States
| | - Ronny Antonio Bell
- Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC, United States
| | - Donald L Rosenstein
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.,Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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