ABSTRACT
Introduction
Australians in regional areas face substantial barriers accessing alcohol and other drug specialist medical care. This study observed a newly implemented telehealth model of public addiction medicine specialist care, the TeleHUB model, in two regional New South Wales (NSW), Australia Local Health Districts: Murrumbidgee and Western NSW. A shared‐care approach was employed; a metropolitan hospital (St Vincent's Hospital, Sydney) acted as a central coordinating service for providing additional (Murrumbidgee, commencing August 2019) or fly‐in‐fly‐out replacement (Western NSW, commencing February 2021) telehealth consultations by an addiction medicine specialist, while local services provided in‐person support.
Methods
Interrupted time series analysis examining changes in monthly scheduled appointments with an addiction medicine specialist were conducted using retrospective administrative data pre‐ and post‐TeleHUB implementation. Data were collected for Murrumbidgee from October 2016 to March 2022 and for Western NSW from July 2016 to March 2022. Qualitative semi‐structured interviews examining staff and client acceptability of the model were conducted across participating sites.
Results
Monthly scheduled consultations post‐TeleHUB implementation increased compared to pre‐implementation in Murrumbidgee (16.6 per month, 95% confidence interval 4.0–37.9; p < 0.001) but there was no evidence of such an increase in Western NSW. Qualitatively, clients and staff reported telehealth reduced client anxiety and increased service accessibility.
Discussion and Conclusions
The TeleHUB model has the potential to improve and maintain service accessibility in addiction medicine specialist healthcare. This model could strengthen local services by providing additional specialist appointments and further support to local services through reduction of travel time and costs associated with fly‐in‐fly‐out models.
Keywords: addiction medicine, health services, rural population, telecommunications, telemedicine
Key Points
Addiction medicine specialists are disproportionately distributed across Australia, with regional and remote Australians facing greater barriers in accessing addiction medicine specialist care.
This study observed the implementation of the TeleHUB model in regional New South Wales, a telehealth service that provided addiction medicine specialist healthcare from the metropolitan Sydney area to regional healthcare centres.
Pre‐ and post‐implementation demonstrated sustained and increased monthly scheduled appointments. Staff and clients of the service shared experiences of increased agency and acceptance of the service delivery.
Telehealth models can provide an acceptable alternative to fly‐in‐fly‐out services within alcohol and other drug services.
1. Introduction
Australians living in regional and remote areas face greater barriers to accessing healthcare, particularly specialist health services, compared to people living in metropolitan areas [1]. Low population density and large distances between population centres in regional and remote Australia present challenges for the delivery of specialist healthcare services in these settings [2, 3, 4, 5].
Addiction medicine specialists are not universally available across all healthcare settings [6, 7, 8], and where services have reduced capacity for primary care, such as regional and remote Australia, they serve an important role in supporting local healthcare services. Addiction medicine specialists are disproportionately distributed across Australia with 87% of specialists placed in urban settings [9], yet the prevalence of Australians seeking alcohol and other drug treatment increases with remoteness [8]. There is greater demand, per head for alcohol and other drug treatment in regional and remote Australia that is not being addressed by the current distribution of services [10].
Access to existing alcohol and other drug services can be adversely affected by the need to travel long distances to attend appointments; approximately 28% of people in regional and remote areas accessing alcohol and other drug treatment report travelling 1 h or more, compared to only 10% in major cities [10]. Service delivery in regional and remote areas is further restricted by poor staff retention and costs associated with staff turnover [5, 8, 11]. Greater client demand and reduced service availability have resulted in long waiting periods of up to 3 months for people requiring access to addiction medicine specialists in many regional and remote areas of Australia [12]. Delayed access to specialist addiction healthcare may increase the presentation of other adverse outcomes associated with substance use. This may include housing concerns, heightened risk of infection and blood borne diseases, and increased mortality [13], which may place increased demand on availability for treatment and further support services. This raises further concerns for potential consequences of reduced or delayed access to addiction medicine specialist care, for both patients and services [14].
Fly‐in‐fly‐out service delivery is a commonly implemented model of addiction medicine specialist healthcare delivery in regional and remote Australia to address gaps in addiction medicine specialist recruitment. Fly‐in‐fly‐out service provision relies on consistent availability of specialists to travel to multiple health service areas. Additional service costs such as travel and accommodation are barriers for local health services to support fly‐in‐fly‐out healthcare [12]. The provision of addiction medicine specialist consultations via real‐time internet‐based audio and video conferencing technology [12, 15, 16, 17], otherwise known as telehealth, is one potential method of overcoming some of the cost and distance barriers. While alcohol and other drug telehealth has been used for providing specialist addiction medicine services in Australia, mostly episodically and by individual providers, it has not been formally assessed as a systematic implementation. This study serves as a rigorous assessment of an alcohol and other drug telehealth model for specialist addiction medicine.
International studies show telehealth delivers comparable outcomes to face‐to‐face delivery, demonstrated by good retention rates, long‐term engagement with services and improved treatment outcomes, including treatment for substance use disorders [16, 17, 18, 19, 20, 21]. Clients have reported positive experiences with telehealth service delivery as well as a positive relationship with their clinician [22, 23, 24, 25]. Real‐time videoconferencing telehealth can be a cost‐effective method of providing addiction medicine specialist healthcare by reducing barriers to accessing appropriate healthcare through minimisation of transport and accommodation costs for both clinicians and patients [26].
Aforementioned studies however were largely conducted out of the Australian context, or if within the Australian context were not focused on addiction medicine specialist healthcare [11, 17, 18, 27]. This study presents an exploration of an addiction medicine specialist telehealth service within the context of Australia.
This study evaluated the TeleHUB model implemented within New South Wales (NSW), Australia. In this model, capital city‐based addiction medicine specialists collaborated via telehealth with district‐based alcohol and other drug treatment health professionals to deliver client care to regional and remote local communities. Pre‐implementation, regional sites employed addiction medicine specialists or utilised costly fly‐in‐fly‐out models. The TeleHUB model did not replace local healthcare services or professionals but acted in collaboration, providing extra resources for local sites, with an aim of increasing the capacity of the service and accessibility for patients. The TeleHUB model provided both additional and replacement appointments across the regional participating sites.
TeleHUB adopted a shared‐care approach, developed and delivered as a collaboration between city‐based coordinating services and regional local health services. Administrative staff at the central coordinating service facilitated addiction videoconferencing‐based consultations by city‐based addiction medicine specialists to local clients of alcohol and other drug services within their respective catchment areas. Local clinicians (nurses and health education officers) accompanied clients in person, or via telehealth at a third site, during consultations. The model had capacity for clients to have videoconferencing from their homes; however, this capacity was largely unutilised.
The specific aims of this study were to assess changes in the number of client consultations scheduled per month with addiction medicine specialists within participating regional sites before and after the implementation of the TeleHUB model and determine the acceptability of the model from the perspectives of both clients and service providers.
2. Methods
2.1. Study Design
This mixed‐methods study used a quasi‐experimental interrupted time series analysis of the number of addiction medicine specialist consultations pre‐ and post‐implementation of the TeleHUB intervention, and a thematic qualitative analysis of semi‐structured interviews with a sub‐sample of staff and clients.
2.2. Study Setting
The model was implemented across three health districts. Addiction medicine specialists were based at St Vincent's Hospital, Sydney (St Vincent's), an inner‐city hospital. Six participating Murrumbidgee Local Health District (Murrumbidgee) sites were involved commencing August 2019: Deniliquin, Griffith, Temora, Tumut, Wagga Wagga and Young. Murrumbidgee is a regional area of more than 125,000 km2 with a population of around 250,000 over 450 km to the south‐west of Sydney [28, 29]. One participating Western NSW Local Health District (Western NSW) site was involved, Dubbo, commencing February 2021. This regional city has an area of an approximate population of 54,000 and around 400 km to the northwest Sydney [28, 30].
2.3. Study Procedures
Retrospective routine clinical administrative NSW Health Drug and Alcohol Treatment Minimum Data Set data documenting agency involvement, services provided and demographics of treatment episodes were obtained from each of the districts involved [31].
Pre‐intervention data were collected from Murrumbidgee from October 2016 to July 2019 (34 months), and post‐intervention initiation data were collected from September 2019 to March 2022 (31 months). Pre‐intervention data from Western NSW were collected from July 2016 to January 2021 (56 months), and post‐intervention data were collected from March 2021 to March 2022 (13 months). Coronavirus disease (COVID‐19) pandemic public health orders (‘lockdown’) were active during the study period (31 March 2020 to 15 May 2020 and 24 June 2021 to 11 October 2021).
Qualitative data were collected by conducting one‐to‐one, semi‐structured interviews with clients and clinic staff members at participating sites (see Supporting Information) from October 2022 to March 2023. Clients were considered eligible if they had completed at least one prior telehealth consultation. Eligible clients were provided with study information and invited to participate by their local clinician. Those who expressed interest were contacted by the research team to discuss participation and schedule an interview. Staff were considered eligible if they were health professionals involved with telehealth consultations, including management of telehealth consultations. Staff participants were contacted by email by the research team and invited to participate. Researchers independent from TeleHUB service delivery contacted potential participants, sought informed consent, and conducted interviews in English by telephone (B.S., C.C., J.R.) or face‐to‐face (L.Mc.W.). Client participants were reimbursed with a $25 gift voucher and staff were not reimbursed.
2.4. Primary Outcome
The primary outcome of this study was service capacity. This was defined as the change in monthly number of client consultations scheduled with an addiction medicine specialist within participating sites, before and after the implementation of the TeleHUB intervention.
2.5. Ethics
Ethical approval for this study was granted by the St Vincent's Hospital Sydney Human Research Ethics Committee (2020/ETH01952). A waiver of consent was granted for the retrospective collection of deidentified quantitative data relating to routinely collected client medical records. Participation in the qualitative component of the study was voluntary, with verbal consent captured in the audio recording of the interview.
2.6. Data Sources and Analysis
Data were drawn from routinely collected administrative data at each of the services from each site's respective clinical data systems. Scheduled appointments with an addiction medicine specialist were sourced from occasions of service data provided by the regions and aggregated by month. Autoregressive integrated moving average (ARIMA) models for an interrupted time series were fitted to monthly numbers of appointments for Murrumbidgee and Western NSW [32]. Square roots of monthly numbers of appointments were fitted for the Murrumbidgee dataset to obtain a series with more constant variance. Constant variance is an assumption of ARIMA models used to fit the series. The fable() R package used to forecast counterfactual series automatically back‐transforms square root transformed series.
The effect of the TeleHUB intervention was estimated by allowing a step at the time of the intervention and a linear trend after the intervention in fitted ARIMA models. An observation that the estimate of the step or linear trend is significantly different from zero is interpreted as evidence of a step change in level or a change in trend in monthly consultations, respectively, occurring at the time of the intervention [32]. ARIMA models were fitted using the forecast package in R [33]. Best fitting models among candidates with and without seasonal terms were selected using the auto.arima function with default corrected Akaike information criterion model selection criterion. In addition to the interrupted time series models, ‘counter‐factual’ series were forecast to facilitate intuitive informal comparison between observed consultation numbers after the interventions and what might have been expected if telehealth had not been introduced. The counter‐factual series were generated for each site by fitting separate time series models to observed monthly consultation numbers up to the time of the interventions only. These models were then used to forecast the numbers of observations expected in each site into the future (i.e., the period since telehealth was introduced) with accompanying 80% and 95% prediction intervals. Models including factors for COVID‐19 lockdowns were fitted for both sites. Two COVID‐19 lockdowns were modelled, the first between 31 March 2020 and 15 May 2020 and the second between 24 June 2021 and 11 October 2021. A COVID‐19 lockdown parameter was defined as a dummy or indicator variable where the entire month was locked down. Where lockdowns spanned a portion of the month, a value between zero and one was assigned depending on the proportion of days locked down.
De‐identified interviews were transcribed verbatim by a professional transcription service, bound by a confidentiality agreement. Interview data were analysed thematically according to Braun and Clark's reflexive framework [34] throughout the data collection period by the qualitative research team not involved in service delivery (B.S., C.C., J.R.). NVivo was used to store and code the interview data throughout analysis. Transcripts were initially read independently by the research team before revising themes and codes collaboratively after.
Themes were prioritised on the basis of their prevalence within the data, the richness of the particular passages that highlighted the themes, and how the theme assisted in clarifying and explaining the experience of the participants. A comparative process was conducted within consumer/staff group themes and across service sites to identify themes.
For the qualitative data collection, we estimated that approximately 40 clients and 20 clinic staff members would be interviewed to assess a range of personal experiences.
3. Results
3.1. Trends in Monthly Consultations
The reported number of scheduled addiction medicine specialist consultations within Murrumbidgee was highly variable (see Figure 1), particularly before the introduction of the TeleHUB model, with no recorded consultations in some months. There was some suggestion of nonconstant variance, which appears to be greater during 2018 and 2019 than in other years. As the Murrumbidgee series included months with zero consultations, the time series model was fitted to the square root of monthly consultations with an ARIMA (1,0,0) model. However, the coefficient for the trend post‐intervention was not statistically significant (see Table 1). Figure 1 presents the time series of observed scheduled consultation numbers at Murrumbidgee and counter‐factual post‐telehealth series forecast from consultations made pre‐telehealth, demonstrating an increase in the number of consultations following the introduction of telehealth. Since the Murrumbidgee model is fitted on the square root scale, the estimated increase in monthly consultations after the introduction of telehealth is 16.6 (95% confidence interval 4.0–37.9, p < 0.001). The estimated increase is 46% greater than the average of 36 consultations per month in the 34 months before telehealth was introduced. Plots of the autocorrelation and partial autocorrelation functions for the base Murrumbidgee model are provided in Figure S1.
FIGURE 1.
Monthly consultations—Murrumbidgee. Time series of observed consultations at Murrumbidgee (solid line) and counter‐factual post‐telehealth series forecast from consultations made pre‐telehealth (dashed line) with shaded 80% (dark) and 95% (light) confidence interval regions. New South Wales COVID‐19 lockdown periods shown by vertical grey bars.
TABLE 1.
Coefficients of autoregressive integrated moving average models fitted to monthly appointments with addiction medicine specialists in Murrumbidgee and Western NSW.
| Model details | Intercept | AR1 | AR2 | MA1 | MA2 | Step | Trend | COVID‐19 | AICc a |
|---|---|---|---|---|---|---|---|---|---|
| Murrumbidgee models | |||||||||
| Base model | 5.35 (0.46) | 0.27 (0.12) | — | — | — | 4.08 (1.06) | −0.02 (0.05) | — | 290 |
| COVID‐19 factor sensitivity | 5.35 (0.45) | 0.25 (0.12) | — | — | — | 4.05 (1.04) | −0.03 (0.05) | 0.93 (1.23) | 292 |
| Western NSW models | |||||||||
| Base model | 74.43 (4.91) | 0.81 (0.14) | — | −0.58 (0.17) | — | 7.13 (13.61) | −0.02 (1.53) | — | 600 |
| COVID‐19 factor sensitivity | 74.52 (4.94) | 0.81 (0.14) | — | −0.58 (0.17) | — | 7.59 (13.74) | −0.02 (1.53) | −2.83 (9.76) | 603 |
Note: Murrumbidgee models fitted to square roots of monthly consultation numbers. Values in parentheses are standard errors.
Abbreviations: AICc, corrected Akaike Information Criterion; AR1, first‐order autoregressive coefficient; AR2, second‐order autoregressive coefficient; MA1, first‐order moving‐average coefficient; MA2, second‐order moving‐average coefficient; NSW, New South Wales.
AICc of sensitivity with interpolated values not comparable with other Murrumbidgee models.
The time series of addiction medicine specialist consultation numbers in Western NSW (see Figure 2) exhibited less variability than the Murrumbidgee time series, thus the Western NSW series was fitted without a transformation. An ARIMA (1,0,1) model was chosen as the best fitting model, with Order 1 autoregressive and moving average coefficients (see Table 1). Reported consultation numbers after the introduction of telehealth were in good agreement with forecasts from the model fitted to the pre‐telehealth series, demonstrating no change in consultation numbers following the introduction of telehealth. Plots of the autocorrelation and partial autocorrelation functions for the base Western NSW model are provided in Figure S2.
FIGURE 2.
Monthly consultations—Western New South Wales. Time series of observed consultations at Western New South Wales (solid line) and counter‐factual post‐telehealth series forecast from consultations made pre‐telehealth (dashed line) with shaded 80% (dark) and 95% (light) confidence interval regions. New South Wales COVID‐19 lockdown periods shown by vertical grey bars.
The coefficients of dummy variables for periods of COVID‐19 lockdown were not statistically significant when these variables were included in models fitted separately to Murrumbidgee and Western NSW consultation numbers (Table 1). Models with the same sets of autoregressive and moving average terms were selected by the auto.arima function when the dummy variables were included and the coefficients of the time series coefficients were not greatly affected. The estimated effect of the step change in consultation numbers in Murrumbidgee at the time of the intervention was approximately the same as the base model (16.4, 95% confidence interval 3.9–37.5, p < 0.001). Also, corrected Akaike information criterion estimates of base models for both sites were slightly lower than the corresponding models with the COVID‐19 dummy variables, suggesting the base models better describe the data in each case. A plot showing the effect of the COVID‐19 lockdown on forecast consultations after the intervention (i.e., the counter‐factual) is shown for Western NSW (Figure S3). Forecasts for Murrumbidgee were not changed because the intervention occurred in 2019 before COVID.
3.2. Client Interviews
Semi‐structured interviews were conducted with 12 clients (Murrumbidgee = 9; Western NSW = 3). The dominant theme that emerged from the interviews was accessibility of telehealth. Clients reported that they found it easier to meet with addiction medicine specialists over videoconferencing telehealth rather than face‐to‐face as it reduced their overall anxiety about the appointment.
You don't have to get as anxious about it. You don't feel like you've got to go in there and put on a show. You just walk into a room, talk to someone on the TV.
Another client with a lived experience of incarceration described that the experience of talking via a computer was easier for them than having to have the conversation in person.
Yes, it's just easier to talk to the computer than a human I don't know why, it's just me, because I've been in jail, I find it heaps easier too.
One of the biggest advantages of the TeleHUB model reported by clients was that they did not have to travel long distances to attend appointments. One participant reported on their unique circumstance of having to fly themselves to their appointments prior to TeleHUB,
It's a massive improvement and it's really helpful. So much better than having to fly in and out, particularly for someone with what I've got yeah. It's really, such a big improvement.
3.3. Staff Interviews
Semi‐structured interviews were conducted with 16 clinicians (Murrumbidgee = 5; Sydney = 7; Western NSW = 4). Staff believed that the TeleHUB model was effective at increasing accessibility to addiction medicine specialist care and reducing wait times for appointments.
It definitely increases accessibility, reduces geographical barriers. It reduced wait times. It allowed expansion of what would be otherwise metropolitan services to areas that were lacking in adequate specialist support.
Staff also reported that collaboration between local clinicians and specialists in the TeleHUB model facilitated professional development and the provision of high‐quality care.
‘The clinicians are very much feeling supported; they're not on their own anymore, so they can review plans, or review cases with the specialist; just equals a far better service’. Although directly asked about technical difficulties, ease of use, quality of communication, support from clinicians, information about telehealth, opportunities to ask questions, and level of comfort in the telehealth appointments, no themes emerged regarding improvement to or barriers to accessing telehealth from the interviews.
4. Discussion
The TeleHUB model provided both an alternative and additional model of delivery for addiction medicine specialist services in regional and remote areas of Australia. The TeleHUB model was not intended to replace FIFO completely however due to COVID‐19 health orders restrictions on travel, telehealth delivery filled this gap. The TeleHUB model provided additional consultations to Murrumbidgee on top of regular FIFO consultations. Our analysis of the TeleHUB model pre‐ and post‐ implementation within Murrumbidgee demonstrated an increase in consultations. The TeleHUB intervention within Western NSW replaced FIFO addiction medicine specialist consultations, all consultations were transitioned to the telehealth model with no change in post‐implementation specialist consultations recorded.
The TeleHUB adopted a shared care approach, administrative and clinical responsibilities were dispersed across the coordinating and regional sites. This approach reduced the work load for local services which are often under‐resourced, while also providing additional support for local health clinicians and administrative staff [5, 8, 11]. The TeleHUB model negated the need for high digital literacy for clients of the service as they were still engaged with their local health service and local health providers and are not required to organise telehealth consultations themselves. This has been documented as a previous barrier for clients accessing telehealth as a delivery model [17, 25, 35]. Clients of the TeleHUB services have the added benefit of continuing their therapeutic relationship with their local clinicians as well as increased access to addiction medicine specialist healthcare.
The clinical impact of this telehealth model is further supported by the analysis of client and staff experiences of engaging with the TeleHUB service. Despite largely supportive existing research demonstrating comparable treatment outcomes between telehealth and face‐to‐face delivery, there is also documented concern that telehealth consultation would affect therapeutic rapport or the quality of clinical assessment [22]. This was not evident in findings of the qualitative interviews with both clinicians and staff. Clinicians from both regional areas reported that clients were just as, if not more, comfortable interacting with their treating clinician online rather than in person, consistent with previous literature [16, 26].
Clients expressed an increase in agency over their healthcare that was afforded by the flexibility of the service. The TeleHUB model reduced identified personal costs and stressors such as time and travel commitments for clients, and clients described a reduction in anxiety towards attending specialist alcohol and other drug services. Previous experience or anticipated experience of stigma when seeking help for alcohol and other drug healthcare is well documented as having adverse impacts on treatment outcomes and client experience with healthcare [36]. This study's finding of client acceptance has the potential to improve treatment admission and retention, overall improving the clinical outcomes for regional alcohol and other drug treatment clients.
The TeleHUB implementation and data collection for this study occurred throughout the COVID‐19 pandemic public health orders, prohibiting travel (impacting FIFO), and in turn created greater awareness of the potential of remotely delivered care such as telehealth. Our analyses predate the COVID‐19 pandemic, arguably demonstrating that even during a period of transitioning healthcare and extra pressure placed on the healthcare system, TeleHUB was still able to both increase and sustain access to addiction medicine specialist healthcare to regional Australia. However, the COVID‐19 pandemic did delay the implementation of TeleHUB in Western NSW. This impacted data collection periods for this study as the Western NSW post‐implementation period of 13 months was shorter than the expected 18 months, but this was offset by an increase from 36 months to 54 months for the pre‐intervention period. Data available from Western NSW were limited to the large regional centre of Dubbo. Trends in consultation pre‐ and post‐implementation of TeleHUB within Western NSW may not reflect the wider Western NSW Local Health District. The additional analyses estimating the effects of COVID‐19 lockdowns on monthly consultations were included to give an indication of the sensitivity of our results to disruptions caused by the pandemic. These models suggest that COVID‐19 lockdowns had limited effect on consultation numbers. Admittedly, the lockdown variables used in these models cannot be expected to have comprehensively accounted for local effects of COVID‐19 in the sites studied. Staff members in the sites have advised that addiction consultations were maintained during the pandemic, but overall effects on client behaviour are unknown.
There were a number of other limitations to this study. The number of interviews conducted via telephone was lower than anticipated. This was attributed to limited capacity for local health services to follow‐up with patients about interview opportunity. This was addressed by face‐to‐face visits conducted by L.Mc.W., improving the interview uptake. Data used for this study were retrospectively retrieved from routinely collected administrative data. Administrative data are not collected for the same purpose as research data, it is recognised that this in turn creates limitations in data reporting [37]. The sites for this study already had telehealth infrastructure embedded within the service. Costs associated with establishing telehealth services in locations without existing infrastructure or appropriate staffing could act as a barrier in the application of this model more broadly.
Telehealth models specific to alcohol and other drug services warrant further research and consideration of their potential for wider application, particularly in locations across regional and remote Australia with few addiction medicine specialist services. The introduction of a telehealth modality of any model or area of healthcare needs to be carefully considered and appropriately resourced to account for education, staffing, and other local support needs. The clinical efficacy of this mode of service delivery deserves further investigation. The potential for telehealth to be expanded to other disciplines that are involved in collaborative alcohol and other drug care is another worthwhile consideration.
This study shows that telemedicine service delivery, as a supplement to existing public drug treatment services, is an acceptable delivery model for the alcohol and other drug sector that can support access to consultations with addiction medicine specialists in areas where there is a paucity of availability of specialists.
Author Contributions
Each author certifies that their contribution to this work meets the standards of the International Committee of Medical Journal Editors.
Funding
This work was supported by the NSW Health (H19/53776).
Conflicts of Interest
This study was funded by an NSW Ministry of Health Translational Research Grant Scheme (H19/53776). No investigators have any conflicts of interest to declare.
Supporting information
Data S1: Supporting Information.
Acknowledgements
The authors acknowledge Zhixin Liu for her statistical assistance in the preparation of this manuscript's analysis. Open access publishing facilitated by University of New South Wales, as part of the Wiley ‐ University of New South Wales agreement via the Council of Australian University Librarians.
Data Availability Statement
Data are available from the corresponding author on reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data S1: Supporting Information.
Data Availability Statement
Data are available from the corresponding author on reasonable request.