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[PMID]: 29097273
[Au] Autor:Feder SL; Campbell Britton M; Chaudhry SI
[Ad] Address:Yale School of Nursing, PO Box 27399, West Haven, CT 06516-7399, USA. Electronic address: shelli.feder@yale.edu.
[Ti] Title:"They need to have an understanding of why they're coming here and what the outcomes might be." Clinician perspectives on goals of care for patients discharged from hospitals to skilled nursing facilities.
[So] Source:J Pain Symptom Manage;, 2017 Oct 30.
[Is] ISSN:1873-6513
[Cp] Country of publication:United States
[La] Language:eng
[Ab] Abstract:CONTEXT: The number of patients discharged from acute care hospitals to skilled nursing facilities (SNFs) is rising. These patients have increasingly complex needs and many experience poor outcomes while under SNF care, including hospital readmissions. Patients' goals of care (GoC) are viewed as a factor contributing to unplanned hospital readmissions from SNFs. However, clinicians' perspectives of GoC for hospitalized patients discharged to SNFs are not well-described. OBJECTIVES: To explore how clinicians view GoC for hospitalized patients discharged to SNFs. METHODS: Qualitative study employing semi-structured interviews and thematic analysis. RESULTS: Forty-one clinicians from one acute care hospital and two SNFs completed interviews ranging in length from 14-52 minutes (mean = 32). Of the sample, 22% were nurses, 20% physicians, 15% were from care management and 15% were from social services. Respondents viewed patients' GoC for continuing treatment at the SNF as important but acknowledged that they were infrequently discussed during hospitalization. Many respondents felt that patients and families had unrealistic GoC for SNF care. Factors that contributed to unrealistic GoC included patients' limited knowledge of: disease process, prognosis, and treatment options; and inconsistent or insufficient communication of GoC among hospital and SNF clinicians, the patient, and family members. Respondents associated a lack of GoC or unrealistic GoC with patients' dissatisfaction with SNF care, unplanned transitions to hospice, and hospital readmissions. CONCLUSIONS: Respondents reported that GoC conversations infrequently occurred during hospitalization, contributing to unrealistic patient and family expectations for SNF care and poor patient outcomes. Interventions are needed that facilitate timely, accurate, and consistent GoC discussions across care continuums.
[Pt] Publication type:JOURNAL ARTICLE
[Em] Entry month:1711
[Cu] Class update date: 171103
[Lr] Last revision date:171103
[St] Status:Publisher

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[PMID]: 29045355
[Au] Autor:Sullivan SS; Li J; Wu YB; Hewner S
[Ad] Address:Author Affiliations: PhD Student (Ms Sullivan), Associate Professor (Dr Wu), and Assistant Professor (Dr Hewner), School of Nursing, University at Buffalo, State University of New York; and Postoctoral Research Fellow (Dr Li), Perelman School of Medicine, University of Pennsylvania, Philadelphia.
[Ti] Title:Complexity of Chronic Conditions' Impact on End-of-Life Expense Trajectories of Medicare Decedents.
[So] Source:J Nurs Adm;47(11):545-550, 2017 Nov.
[Is] ISSN:1539-0721
[Cp] Country of publication:United States
[La] Language:eng
[Ab] Abstract:OBJECTIVE: The aim of this study is to determine if the pattern of monthly medical expense can be used to identify individuals at risk of dying, thus supporting providers in proactively engaging in advanced care planning discussions. BACKGROUND: Identifying the right time to discuss end of life can be difficult. Improved predictive capacity has made it possible for nurse leaders to use large data sets to guide clinical decision making. METHODS: We examined the patterns of monthly medical expense of Medicare beneficiaries with life-limiting illness during the last 24 months of life using analysis of variance, t tests, and stepwise hierarchical linear modeling. RESULTS: In the final year of life, monthly medical expense increases rapidly for all disease groupings and forms distinct patterns of change. CONCLUSION: Type of condition can be used to classify decedents into distinctly different cost trajectories. Conditions including chronic disease, system failure, or cancer may be used to identify patients who may benefit from supportive care.
[Mh] MeSH terms primary: Advance Care Planning/standards
Centers for Medicare and Medicaid Services (U.S.)/economics
Chronic Disease/economics
Hospice Care/economics
Terminally Ill/statistics & numerical data
[Mh] MeSH terms secundary: Advance Care Planning/organization & administration
Aged
Centers for Medicare and Medicaid Services (U.S.)/statistics & numerical data
Chronic Disease/classification
Chronic Disease/mortality
Communication
Costs and Cost Analysis
Electronic Health Records/standards
Electronic Health Records/statistics & numerical data
Hospice Care/utilization
Humans
Meaningful Use/standards
Meaningful Use/statistics & numerical data
Physician-Patient Relations
Prognosis
Retrospective Studies
Risk Assessment/methods
United States/epidemiology
Unnecessary Procedures/economics
Unnecessary Procedures/statistics & numerical data
[Pt] Publication type:JOURNAL ARTICLE
[Em] Entry month:1711
[Cu] Class update date: 171102
[Lr] Last revision date:171102
[Js] Journal subset:AIM; IM; N
[Da] Date of entry for processing:171018
[St] Status:MEDLINE
[do] DOI:10.1097/NNA.0000000000000541

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[PMID]: 28784245
[Au] Autor:Mullen MM; Divine LM; Porcelli BP; Wilkinson-Ryan I; Dans MC; Powell MA; Mutch DG; Hagemann AR; Thaker PH
[Ad] Address:Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States.
[Ti] Title:The effect of a multidisciplinary palliative care initiative on end of life care in gynecologic oncology patients.
[So] Source:Gynecol Oncol;147(2):460-464, 2017 Nov.
[Is] ISSN:1095-6859
[Cp] Country of publication:United States
[La] Language:eng
[Ab] Abstract:OBJECTIVES: To evaluate the effect of palliative care (PC) consultation on hospice enrollment and end-of-life care in gynecologic oncology patients. METHODS: A retrospective chart review of gynecologic oncology patients who died 1year before and after 2014 implementation of a PC initiative for patients at a single NCI-designated comprehensive cancer center. Patient demographics, admission and procedural history, anti-cancer therapy, and end-of- life care were collected retrospectively. Data was analyzed using Student's t-test, Mann-Whitney U test, Chi-Square test, or Fisher's exact test. RESULTS: We identified 308 patients. Median age at death was 63years (range 17 to 91). Most patients were white (78.2%), married (47.4%), and had ovarian (35.7%) or uterine cancers (35.4%). Introduction of the PC initiative was associated with increased PC consultations (40%, 53%, p=0.02), increased hospice enrollment (57%, 61%, p=0.29), and fewer procedures in the last 30days of life (44%, 31%, p=0.01). The rate of enrollment to inpatient hospice doubled from 12.5% to 25.7% (p=0.02) while time from inpatient hospice enrollment to death increased from 1.9 to 6.0days (p=0.02). Time from outpatient hospice enrollment to death increased from 26.2 to 35.4days (p=0.18). PC consultation was associated with a doubling of outpatient (40%) and inpatient (80%) hospice enrollment. CONCLUSIONS: The PC quality improvement initiative was associated with more palliative care consults, increased rates of inpatient and outpatient hospice utilization, increased time on hospice, and fewer procedures in the last 30days of life, although most women were not enrolled until the last days of life.
[Pt] Publication type:JOURNAL ARTICLE
[Em] Entry month:1708
[Cu] Class update date: 171103
[Lr] Last revision date:171103
[St] Status:In-Process

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[PMID]: 28783450
[Au] Autor:Wang R; Zeidan AM; Halene S; Xu X; Davidoff AJ; Huntington SF; Podoltsev NA; Gross CP; Gore SD; Ma X
[Ad] Address:Rong Wang, Amy J. Davidoff, and Xiaomei Ma, Yale School of Public Health; Rong Wang, Amer M. Zeidan, Xiao Xu, Amy J. Davidoff, Scott F. Huntington, Cary P. Gross, and Xiaomei Ma, Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center; Amer M. Zeidan, Stephanie Halene, Xiao Xu, Scott
[Ti] Title:Health Care Use by Older Adults With Acute Myeloid Leukemia at the End of Life.
[So] Source:J Clin Oncol;35(30):3417-3424, 2017 Oct 20.
[Is] ISSN:1527-7755
[Cp] Country of publication:United States
[La] Language:eng
[Ab] Abstract:Purpose Little is known about the patterns and predictors of the use of end-of-life health care among patients with acute myeloid leukemia (AML). End-of-life care is particularly relevant for older adults with AML because of their poor prognosis. Methods We performed a population-based, retrospective cohort study of patients with AML who were ≥ 66 years of age at diagnosis and diagnosed during the period from 1999 to 2011 and died before December 31, 2012. Medicare claims were used to assess patterns of hospice care and use of aggressive treatment. Predictors of these end points were evaluated using multivariable logistic regression analyses. Results In the overall cohort (N = 13,156), hospice care after AML diagnosis increased from 31.3% in 1999 to 56.4% in 2012, but the increase was primarily driven by late hospice enrollment that occurred in the last 7 days of life. Among the 5,847 patients who enrolled in hospice, 47.4% and 28.8% started their first hospice enrollment in the last 7 and 3 days of life, respectively. Among patients who transferred in and out of hospice care, 62% received transfusions outside hospice. Additionally, the use of chemotherapy within the last 14 days of life increased from 7.7% in 1999 to 18.8% in 2012. Patients who were male and nonwhite were less likely to enroll in hospice and more likely to receive chemotherapy or be admitted to intensive care units at the end of life. Conversely, older patients were less likely to receive chemotherapy or have intensive care unit admission at the end of life, and were more likely to enroll in hospice. Conclusion End-of-life care for older patients with AML is suboptimal. Additional research is warranted to identify reasons for their low use of hospice services and strategies to enhance end-of-life care for these patients.
[Mh] MeSH terms primary: Hospices/utilization
Leukemia, Myeloid/therapy
Medicare/statistics & numerical data
Terminal Care/utilization
[Mh] MeSH terms secundary: Acute Disease
Aged
Aged, 80 and over
Female
Hospitalization/statistics & numerical data
Humans
Intensive Care Units/utilization
Logistic Models
Male
Multivariate Analysis
Retrospective Studies
Tertiary Care Centers/statistics & numerical data
United States
[Pt] Publication type:JOURNAL ARTICLE
[Em] Entry month:1710
[Cu] Class update date: 171103
[Lr] Last revision date:171103
[Js] Journal subset:IM
[Da] Date of entry for processing:170807
[St] Status:MEDLINE
[do] DOI:10.1200/JCO.2017.72.7149

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[PMID]: 28752188
[Au] Autor:Accordino MK; Wright JD; Vasan S; Neugut AI; Gross T; Hillyer GC; Hershman DL
[Ad] Address:Department of Medicine, Columbia University College of Physicians and Surgeons, 161 Ft Washington Ave, Room 9-962, New York, NY, 10032, USA. Mkg2134@cumc.columbia.edu.
[Ti] Title:Association between survival time with metastatic breast cancer and aggressive end-of-life care.
[So] Source:Breast Cancer Res Treat;166(2):549-558, 2017 Nov.
[Is] ISSN:1573-7217
[Cp] Country of publication:Netherlands
[La] Language:eng
[Ab] Abstract:PURPOSE: For women with stage IV breast cancer (BC), the association between survival time (ST) and use of aggressive end-of-life (EOL) care is unknown. METHODS: We used the SEER-Medicare database to identify women with stage IV BC diagnosed 2002-2011 who died by 12/31/2012. Aggressive EOL care was defined as receipt in the last month of life: >1 ED visit, >1 hospitalization, ICU admission, life-extending procedures, hospice admission within 3 days of death, IV chemotherapy within 14 days of death, and/or ≥10 unique physician encounters in the last 6 months of life. Receipt of aggressive EOL care and hospice in the last month of life were determined using claims, and multivariable analysis was used to identify factors associated with receipt. Costs of care were also evaluated. RESULTS: We identified 4521 eligible patients. Of these, 2748 (60.8%) received aggressive EOL care. Factors associated with aggressive EOL care were race (OR 1.45, 95% CI 1.19-1.81 for blacks compared to whites) and more frequent oncology office visits (OR 1.56, 95% CI 1.28-1.90). Patients who lived >12 months after diagnosis were less likely to receive aggressive EOL care (OR 0.44, 95% CI 0.38-0.52), and more likely to utilize hospice (OR 1.43, 95% CI 1.21-1.69) compared to patients who lived ≤6 months. Patients with a shorter ST had significantly higher costs of care per-month-alive compared to patients with longer ST. CONCLUSION: Patients with a shorter ST were more likely to receive aggressive EOL care and had higher costs of care compared to patients who lived longer.
[Pt] Publication type:JOURNAL ARTICLE
[Em] Entry month:1707
[Cu] Class update date: 171103
[Lr] Last revision date:171103
[St] Status:In-Process
[do] DOI:10.1007/s10549-017-4420-4

  6 / 14034 MEDLINE  
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[PMID]: 28444607
[Au] Autor:Walker A; Breitsameter C
[Ad] Address:Katholisch-Theologische Fakultät, Lehrstuhl für Moraltheologie, Ludwig-Maximilians-University Munich, Geschwister-Scholl-Platz 1, 80539, Munich, Germany. andreas.walker@kaththeol.uni-muenchen.de.
[Ti] Title:The Provision of Spiritual Care in Hospices: A Study in Four Hospices in North Rhine-Westphalia.
[So] Source:J Relig Health;56(6):2237-2250, 2017 Dec.
[Is] ISSN:1573-6571
[Cp] Country of publication:United States
[La] Language:eng
[Ab] Abstract:This article considers the role and the practices of spiritual care in hospices. While spiritual care was firmly established as one of the four pillars of practical hospice care alongside medical, psychological and social care by Cicely Saunders, the importance and functions of spiritual care in daily practice remain arguable. When speaking about spirituality, what are we actually speaking about? What form do the spiritual relations take between full-time staff and volunteers on the one hand, and the patients and their family members on the other? These were central questions of a qualitative study that we carried out in four hospices in North Rhine-Westphalia, Germany, to explore how spiritual care is provided in hospices and what significance spirituality has in hospices. The study shows that the advantages of a broader definition of spirituality lie in "spiritual care" no longer being bound to one single profession, namely that of the chaplain. It also opens the way for nurses and volunteers-irrespective of their own religious beliefs-to provide spiritual end-of-life care to patients in hospices. If the hospice nurses and volunteers were able to mitigate the patients' fear not only by using medications but also in a psychosocial or spiritual respect, then they saw this as a successful psychological and spiritual guidance. The spiritual guidance is to some degree independent of religious belief because it refers to a "spirit" or "inner core" of human beings. But this guidance needs assistance from professional knowledge considering religious rituals if the patients are deeply rooted in a (non-Christian) religion. Here, the lack of knowledge could be eliminated by further education as an essential but not sufficient condition.
[Pt] Publication type:JOURNAL ARTICLE
[Em] Entry month:1704
[Cu] Class update date: 171102
[Lr] Last revision date:171102
[St] Status:In-Process
[do] DOI:10.1007/s10943-017-0396-y

  7 / 14034 MEDLINE  
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[PMID]: 28438589
[Au] Autor:Miller SC; Lima JC; Intrator O; Martin E; Bull J; Hanson LC
[Ad] Address:Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA; Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island, USA. Electronic address: susan_miller@brown.edu.
[Ti] Title:Specialty Palliative Care Consultations for Nursing Home Residents With Dementia.
[So] Source:J Pain Symptom Manage;54(1):9-16.e5, 2017 Jul.
[Is] ISSN:1873-6513
[Cp] Country of publication:United States
[La] Language:eng
[Ab] Abstract:CONTEXT: U.S. nursing home (NH) residents with dementia have limited access to specialty palliative care beyond Medicare hospice. OBJECTIVES: The objective of this study was to examine the value of expanded palliative care access for NH residents with moderate-to-very severe dementia. METHODS: We merged palliative care consultation data in 31 NHs in two states to Medicare data to identify residents with consultations, moderate-to-very severe dementia, and deaths in 2006-2010. Initial palliative consultations were identified as occurring later and earlier (1-30 days and 31-180 days before death, respectively). Three controls for each consultation recipient were selected using propensity score matching. Weighted multivariate analyses evaluated the effect of consultations on hospital or acute care use seven and 30 days before death and on (potentially) burdensome transitions (i.e., hospital or hospice admission three days before death or two plus acute care transitions 30 days before death). RESULTS: With earlier consultation (vs. no consultation), hospitalization rates in the seven days before death were on average 13.2 percentage points lower (95% confidence interval [CI] -21.8%, -4.7%) and with later consultation 5.9 percentage points lower (95% CI -13.7%, +4.9%). For earlier consultations (vs. no consultations), rates were 18.4 percentage points lower (95% CI -28.5%, -8.4%) for hospitalizations and 11.9 lower (95% CI -20.7%, -3.1%) for emergency room visits 30 days before death; they were 20.2 percentage points lower (95% CI -28.5%, -12.0%) for burdensome transitions. CONCLUSION: Consultations appear to reduce acute care use and (potentially) burdensome transitions for dying residents with dementia. Reductions were greater when consultations were earlier.
[Pt] Publication type:JOURNAL ARTICLE
[Em] Entry month:1704
[Cu] Class update date: 171102
[Lr] Last revision date:171102
[St] Status:In-Process

  8 / 14034 MEDLINE  
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[PMID]: 28273749
[Au] Autor:Mah K; Rodin RA; Chan VWS; Stevens BJ; Zimmermann C; Gagliese L
[Ad] Address:1 Department of Anesthesia and Pain Management, Toronto General Hospital (K.M., R.A.R., and L.G.) and Toronto Western Hospital (V.W.S.C.), University Health Network, Toronto, Ontario, Canada.
[Ti] Title:Health-Care Workers' Judgments About Pain in Older Palliative Care Patients With and Without Delirium.
[So] Source:Am J Hosp Palliat Care;34(10):958-965, 2017 Dec.
[Is] ISSN:1938-2715
[Cp] Country of publication:United States
[La] Language:eng
[Ab] Abstract:Delirium complicates pain assessment and management in advanced cancer. This retrospective cohort study compared health-care workers' (HCWs) cancer pain judgments between older patients with advanced cancer with and without a diagnosis of delirium. We reviewed HCWs' daily chart notations about pain presence and good pain control in 149 inpatients with advanced cancer, ≥65 years of age, admitted to a palliative care inpatient unit. Any day with 1 or more notations of pain presence was counted as 1 day with pain; days with notation(s) indicating good pain control were similarly counted. Proportions of days that HCWs judged inpatients to have pain and good pain control were calculated. Patients with and without a delirium diagnosis were compared on both pain outcomes. The moderating effect of highest analgesic class administered was examined. Although most patients received opioid analgesics, mean proportions of days with judged pain were high (39%-60%) and mean proportions of days with judged good pain control were low (<25%) across groups. Among patients receiving either opioid or nonopioid medication, patients with delirium demonstrated lower proportions of days with judged good pain control than patients without delirium ( P ≤ .001), even though groups did not differ in proportions of days with judged pain ( P = .62). Cancer pain is difficult to manage in advanced cancer, especially when delirium is present; however, misinterpretation of delirium symptoms as pain cues may inflate pain judgments. Findings require replication but suggest the need for better pain assessment in older patients with advanced cancer and delirium.
[Pt] Publication type:JOURNAL ARTICLE
[Em] Entry month:1703
[Cu] Class update date: 171103
[Lr] Last revision date:171103
[St] Status:In-Process
[do] DOI:10.1177/1049909116672641

  9 / 14034 MEDLINE  
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[PMID]: 28196448
[Au] Autor:Dillon E; Chuang J; Gupta A; Tapper S; Lai S; Yu P; Ritchie C; Tai-Seale M
[Ad] Address:1 Palo Alto Medical Foundation Research Institute, Mountain View, CA, USA.
[Ti] Title:Provider Perspectives on Advance Care Planning Documentation in the Electronic Health Record: The Experience of Primary Care Providers and Specialists Using Advance Health-Care Directives and Physician Orders for Life-Sustaining Treatment.
[So] Source:Am J Hosp Palliat Care;34(10):918-924, 2017 Dec.
[Is] ISSN:1938-2715
[Cp] Country of publication:United States
[La] Language:eng
[Ab] Abstract:CONTEXT: Advance care planning (ACP) is valued by patients and clinicians, yet documenting ACP in an accessible manner is problematic. OBJECTIVES: In order to understand how providers incorporate electronic health record (EHR) ACP documentation into clinical practice, we interviewed providers in primary care and specialty departments about ACP practices (n = 13) and analyzed EHR data on 358 primary care providers (PCPs) and 79 specialists at a large multispecialty group practice. METHODS: Structured interviews were conducted with 13 providers with high and low rates of ACP documentation in primary care, oncology, pulmonology, and cardiology departments. The EHR problem list data on Advance Health Care Directives (AHCDs) and Physician Orders for Life-Sustaining Treatment (POLST) were used to calculate ACP documentation rates. RESULTS: Examining seriously ill patients ≥65 years with no preexisting ACP documentation seen by providers during 2013 to 2014, 88.6% (AHCD) and 91.1% (POLST) of 79 specialists had zero ACP documentations. Of 358 PCPs, 29.1% (AHCD) and 62.3% (POLST) had zero ACP documentations. Interviewed PCPs often believed ACP documentation was beneficial and accessible, while specialists more often did not. Specialists expressed more confusion about documenting ACP, whereas PCPs reported standard clinic workflows. Problems with interoperability between outpatient and inpatient EHR systems and lack of consensus about who should document ACP were sources of variations in practices. CONCLUSION: Results suggest that providers desire standardized workflows for ACP discussion and documentation. New Medicare reimbursement for ACP and an increasing number of quality metrics for ACP are incentives for health-care systems to address barriers to ACP documentation.
[Pt] Publication type:JOURNAL ARTICLE
[Em] Entry month:1702
[Cu] Class update date: 171103
[Lr] Last revision date:171103
[St] Status:In-Process
[do] DOI:10.1177/1049909117693578

  10 / 14034 MEDLINE  
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[PMID]: 28193106
[Au] Autor:Glover TL; Garvan C; Nealis RM; Citty SW; Derrico DJ
[Ad] Address:1 Biobehavioral Nursing Science, College of Nursing, University of Florida, Gainesville, FL, USA.
[Ti] Title:Improving End-of-Life Care Knowledge Among Senior Baccalaureate Nursing Students.
[So] Source:Am J Hosp Palliat Care;34(10):938-945, 2017 Dec.
[Is] ISSN:1938-2715
[Cp] Country of publication:United States
[La] Language:eng
[Ab] Abstract:OBJECTIVE: It is imperative that nurses are proficient and comfortable providing care to patients at the end of life. Recent studies show that nurses' knowledge of end-of-life care is less than optimal. Effective, evidence-based methods to infuse palliative and end-of-life care education into the undergraduate nursing curriculum are needed. METHODS: A descriptive pre- and postassessment evaluating senior nursing students' acquisition of knowledge on end-of-life care after attending the End-of-Life Nursing Education Consortium (ELNEC) core course was conducted. The course evaluation included qualitative statements. RESULTS: Before the ELNEC course, one-third of the students had cared for a dying patient during clinical rotations, yet 85% reported they had not received adequate training in end-of-life care. Posttest questions related to palliative care, symptom management, communication, and grief indicated that students acquired significant knowledge after participating in the ELNEC course ( P < .05). CONCLUSION: The ELNEC core course is an effective way to improve nursing students' knowledge of palliative and end-of-life care.
[Pt] Publication type:JOURNAL ARTICLE
[Em] Entry month:1702
[Cu] Class update date: 171103
[Lr] Last revision date:171103
[St] Status:In-Process
[do] DOI:10.1177/1049909117693214


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