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. Author manuscript; available in PMC: 2015 Jun 2.
Published in final edited form as: JAMA Intern Med. 2015 Jun 1;175(6):1028–1035. doi: 10.1001/jamainternmed.2015.0406

Trends in in-hospital cardiopulmonary resuscitation in adults receiving maintenance dialysis

Susan P Y Wong 1, William Kreuter 2, J Randall Curtis 3, Yoshio N Hall 4, Ann M O’Hare 5
PMCID: PMC4451394  NIHMSID: NIHMS663620  PMID: 25915762

Abstract

Importance

Understanding cardiopulmonary resuscitation (CPR) practices and outcomes can help to support advance care planning in patients receiving maintenance dialysis.

Objective

To characterize patterns and outcomes of in-hospital CPR in US adults receiving maintenance dialysis.

Design

A national retrospective cohort study.

Setting

A comprehensive national registry for end-stage renal disease.

Participants

663,734 Medicare beneficiaries aged 18 years who initiated maintenance dialysis between January 1, 2000 and December 31, 2010.

Exposure

Receipt of in-hospital CPR from 91 days after dialysis initiation through the time of death, first kidney transplant or end of follow-up on December 31, 2011.

Main outcomes and measures

Incidence of CPR and survival after the first episode of CPR recorded in Medicare claims during follow-up.

Results

The annual incidence of CPR for the overall cohort was 1.4 events/1,000 in-hospital days (95% confidence interval [CI] 1.3–1.4). Approximately one in five (21.9%, 95% CI 21.4–22.3) CPR recipients survived to hospital discharge, with a median post-discharge survival of 5.0 months (interquartile range 0.7–16.8). Among patients who died in the hospital, 14.9% (95% CI 14.8–15.1) received CPR during their terminal admission. From 2000–2011, there was an increase in the incidence of CPR (1.0 events/1,000 in-hospital days [95% CI 0.9–1.1] to 1.6 events/1,000 in-hospital days [95% CI 1.6–1.7]; trend p<0.001), the proportion of CPR recipients who survived to discharge (15.2% [95% CI 11.1–20.5] to 28% [95% CI 26.7–29.4]; trend p<0.001) and the proportion of in-hospital deaths preceded by CPR (9.5% [95% CI 8.4–10.8] to 19.8% [95% CI 19.2–20.4]; trend p<0.001), with no substantial change in duration of post-discharge survival.

Conclusions and relevance

Among a national cohort of patients receiving maintenance dialysis, the incidence of CPR was higher and long-term survival worse than reported for other populations.

Introduction

In recent decades, use of in-hospital cardiopulmonary resuscitation (CPR) has been increasing and there has been a gradual shift toward increased use in sicker patients.1 A growing number of patients now survive an episode of CPR, but often subsequently face substantial disability.2 Advanced age and comorbidity are compounding factors associated with higher mortality and greater neurologic and non-neurologic impairment as well as functional dependence after CPR. 3–10

There is a paucity of published data on CPR outcomes among patients receiving maintenance dialysis. Most previous studies have been limited to cardiac arrests occurring in outpatient hemodialysis units.11–15 Rates of survival to hospital discharge across these studies have varied widely from 0 to 24.0%. Only one prior study has examined outcomes after inhospital CPR among dialysis patients.16 This single center study reported very low rates of survival to hospital discharge (8.0%) and significant disability following an episode of inhospital CPR in this population. To our knowledge, no prior studies have defined the incidence and outcomes of in-hospital CPR among a national cohort of dialysis patients.

Methods

Data Sources

We designed a study to define the incidence and outcomes of CPR among a national cohort of US dialysis patients using data from the United States Renal Data System (USRDS) registry, a comprehensive national data system that collects, analyzes, and distributes information about end-stage renal disease (ESRD) in the US. The USRDS is funded by the National Institute of Diabetes and Digestive and Kidney Diseases and collaborates with the Centers for Medicare and Medicaid Services (CMS) to prospectively gather demographic and clinical information on all US patients treated with maintenance dialysis. As mandated by CMS, patients are enrolled in the USRDS registry following onset of ESRD. Information on patients is collected using standardized forms completed by the nephrologist around the time of ESRD onset (CMS 2728 Form) and shortly after death (CMS 2746 Form). Patients who are not eligible for Medicare at the time of ESRD become eligible by reason of their ESRD. USRDS provides linked Medicare claims for patients in the registry.

Study Population

Using data from the USRDS registry, we identified all patients aged 18 years without a prior kidney transplant who initiated maintenance dialysis between January 1, 2000 and December 31, 2010 (Figure 1). We limited our study to those with Medicare Parts A and B as the primary payor for healthcare from 91 days after dialysis initiation through to the time of death, first kidney transplantation or end of follow-up on December 31, 2011. Patients who received a kidney transplant or died within 90 days of dialysis initiation were excluded from the analysis. The final analytic cohort comprised 663,734 patients. Mean follow up for the overall cohort was 2.9 years (standard deviation [SD] 2.5). This study was approved by the Institutional Review Board at the University of Washington.

Figure 1.

Figure 1

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Study Cohort

Primary Outcome Measures

From the linked Medicare claims, we ascertained all hospital admissions and all inhospital CPR events that occurred beyond 90 days after dialysis initiation using International Classification of Diseases (ICD) 9 diagnostic codes 99.60 and 99.63.17 Multiple CPR events that occurred during the same admission were counted as separate events if they occurred at least one calendar day apart. CPR events that occurred in the emergency department were excluded. We calculated the incidence of in-hospital CPR as the total number of in-hospital CPR events per 1,000 in-hospital days during follow-up. Multiple CPR events in the same patient contributed to incidence estimates. We also measured the proportion of patients surviving to hospital discharge after their first in-hospital CPR event. We measured median survival after discharge using the Kaplan-Meier method among members of this subgroup. Among cohort patients who died in the hospital at any time during follow-up, we measured the proportion who received CPR during their terminal hospitalization. CPR incidence, the proportion of CPR recipients who survived to hospital discharge, post-discharge survival and receipt of CPR prior to in-hospital death were reported for the overall cohort and over time.

Patient Characteristics

From the USRDS Patients and Medical Evidence Files (which are derived from the CMS 2728 and 2846 Forms, respectively), we obtained the following patient characteristics at the time of dialysis initiation: sex, race, age, listed cause of ESRD, calendar year of dialysis initiation, dialysis modality, and the following comorbidities: coronary artery disease, peripheral vascular disease, congestive heart failure, hypertension, diabetes mellitus, stroke, cancer and chronic obstructive pulmonary disease. For patients who received an episode of CPR, we used these sources in combination with Medicare claims for CPR events to calculate each patient’s age at the time of their initial CPR event. For cohort patients who died in the hospital during follow-up, we calculated their age at the time of death and obtained information on cause of death from the Patients File.

Statistical analysis

We described the characteristics of patients who received at least one episode of inhospital CPR and those of CPR recipients who survived to discharge following their first episode of in-hospital CPR using point estimates and 95% confidence intervals [CI] (Table 1). Incidence rate ratios of CPR were calculated using Poisson regression models to compare rates across different groups of patients. These models were adjusted for age, sex, race, cause of ESRD, comorbidities, dialysis modality and calendar year of dialysis initiation. Among those who received CPR, we used multivariable logistic regression analysis to examine patient characteristics associated with survival to discharge. These analyses were adjusted sex, race, cause of ESRD, comorbidities and dialysis modality documented at the time of dialysis initiation, and age and calendar year in which the index CPR event occurred. For CPR recipients who survived to discharge, risk of death following hospital discharge was measured using a Cox proportional hazards regression model adjusted for sex, race, cause of ESRD, comorbidities and dialysis modality documented at the time of dialysis initiation, and age and calendar year in which the index CPR event occurred. To examine patient characteristics associated with receipt of CPR prior to death among patients who died in the hospital, we used multivariate logistic regression models controlling for sex, race, cause of ESRD, comorbidities and dialysis modality documented at the time of dialysis initiation, and age and calendar year at the time of death.

Table 1.

Characteristics of patients who received in-hospital cardiopulmonary resuscitation (CPR)

All (N=663,734)
n (%)		 Received CPR (N=33,731)
n (%)		 Survived to discharge (N=7,336)
% (95% CIa)
Sex
 Male 362,392 (54.6) 18,174 (53.9) 51.3 (50.1–52.4)
 Female 301,340 (45.4) 15,557 (46.1) 48.8 (47.6–50.0)
Race
 White 433,653 (65.3) 19,531 (57.9) 57.7 (56.6–58.9)
 Black 191,520 (28.9) 12,381 (36.7) 36.3 (35.2–37.4)
 Other 34,071 (5.1) 1,598 (4.7) 5.3 (4.8–5.9)
Age at CPR event
 <65 years 282,667 (42.6) 15,359 (45.5) 55.4 (54.2–56.5)
 ≥65 years 381,067 (57.4) 18,375 (54.5) 44.6 (43.5–45.8)
Cause of end-stage renal disease
 Hypertension 183,168 (27.6) 8,838 (26.2) 24.0 (23.1–25.0)
 Acute tubular necrosis 15,395 (2.3) 517 (1.5) 1.4 (1.2–1.7)
 Diabetes mellitus 307,921 (46.4) 18,330 (54.3) 57.3 (56.2–58.5)
 Glomerulonephritis 52,986 (8.0) 1,994 (5.9) 6.1 (5.5–6.6)
 Other 75,195 (11.3) 2,946 (8.7) 8.0 (7.4–8.6)
 Unknown 29,069 (4.4) 1,106 (3.3) 3.2 (2.8–3.6)
Modality
 Hemodialysis 621,189 (93.6) 31,870 (94.5) 95.0 (94.5–95.5)
 Peritoneal dialysis 42,545 (6.4) 1,861 (5.5) 5.0 (4.5–5.5)
Comorbidities
 Coronary artery disease 80,204 (12.1) 5,647 (16.7) 13.3 (12.5–14.1)
 Peripheral arterial disease 47,964 (7.2) 3,289 (9.8) 8.4 (7.8–9.1)
 Congestive heart failure 102,689 (15.5) 7,579 (22.5) 18.6 (17.7–19.5)
 Hypertension 228,602 (34.4) 16,318 (48.4) 41.9 (40.7–43.0)
 Diabetes mellitus 150,405 (22.7) 11,920 (35.3) 31.8 (30.7–32.8)
 Stroke 29,673 (4.5) 1,924 (5.7) 4.5 (4.0–5.0)
 Chronic obstructive pulmonary disease 25,650 (3.9) 1,704 (5.1) 4.0 (3.6–4.5)
 Cancer 18,645 (2.8) 937 (2.8) 2.2 (1.9–2.6)
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a

confidence interval

To facilitate comparisons with previously published studies in other populations that have measured CPR incidence as a function of the number of hospital admissions rather number of inpatient days and that have included only older adults, we conducted additional analyses to estimate the total number of in-hospital CPR events per 1,000 hospital admissions and repeated the primary analyses after stratification by age group (<65 and ≥65 years).

Statistical packages used included SAS v. 9 (Cary, NC) and SPSS v.19 (Somers, NY).

Results

CPR events

Overall, 80.9% (95% CI 80.8–81.0) of patients in the study cohort were admitted to the hospital at least once during follow-up. Of these, 6.3% (95% CI 6.2–6.4) underwent at least one episode of CPR while hospitalized. Among patients who underwent CPR, 4.4% (95% CI 4.2–4.6) received CPR more than once during follow-up. The annual incidence of in-hospital CPR for the entire cohort was 1.4 (95% CI 1.3–1.4) per 1,000 in-hospital days. The incidence of CPR was higher among men vs. women, black vs. white patients, patients aged <65 years vs. ≥65 years, those whose cause of ESRD was listed as either hypertension or diabetes mellitus vs. other causes, and those with vs. without coronary artery disease, congestive heart failure, hypertension, and diabetes mellitus (Supplemental eTable 1).

Survival to hospital discharge

The proportion of CPR recipients surviving to hospital discharge was 21.9% (95% CI 21.4–22.3). The proportion surviving to discharge was greater among women vs. men, white vs. black patients, those aged <65 years vs. ≥65 years, those whose listed cause of ESRD was due to diabetes mellitus and those who were treated with hemodialysis vs. peritoneal dialysis (Supplemental eTable 2). The median length of hospital stay after the index CPR event for patients who survived to discharge was 8.0 days (interquartile range [IQR] 3.0–14.0).

Post-discharge survival

Among those alive at discharge, median survival from the time of discharge was 5.0 months (IQR 0.7–16.8). The proportion of patients who survived to 1 year after discharge was 31.3% (95% CI 30.3–32.4). The majority of patients (66.3%; 95% CI 65.2–67.4) were re-hospitalized at least once during follow-up. For CPR recipients who survived to discharge and died during follow-up, cardiovascular causes were reported as the primary or secondary cause of death for 43.0% (95% CI 41.9–44.1) of patients. Survival after discharge was more limited among men vs. women, white vs. black patients, those aged ≥65 years vs. <65 years, and patients with vs. without coronary artery disease, hypertension, diabetes mellitus and cancer (Supplemental eTable 3).

In-hospital deaths occurring after CPR

Among cohort members who died in the hospital during follow-up, 14.9% (95% CI 14.8–15.1) had received at least one episode of CPR during the terminal hospitalization. The subset that received CPR during the terminal admission were more likely to be men vs. women, those of black vs. white race, and those aged ≥65 years vs. <65 years (Supplemental eTable 4).

Trends in CPR Practice and Outcomes

Between 2000–2011 the incidence of CPR increased from 1.0 (95% CI 0.9–1.1) to 1.6 (95% CI 1.6–1.7) events/1,000 in-hospital days (adjusted trend, p<0.001) (Figure 2). The percentage of CPR recipients surviving to discharge increased from 15.2% (95% CI 11.1–20.5) to 28.0% (95% CI 26.7–29.4) (adjusted trend, p<0.001) (Figure 3). Slight variations in duration of post-discharge survival resulted in a small but statistically significant uptrend in post-discharge survival over time (adjusted trend, p<0.001), although the median survival after hospital discharge was 6.5 months (IQR 2.7–26.7) in 2000 and 5.9 months (IQR 1.7–17.9) in 2011 (Figure 3). Among CPR recipients who survived to discharge, median length of hospital stay after the initial CPR event did not change (8.5 days, IQR 4.0–20.3, to 8.0 days, IQR 4.0–14.0; trend p=0.70) over time. The proportion of in-hospital deaths preceded by CPR increased from 9.5% (95% CI 8.4–10.8) to 19.8% (95% CI 19.2–20.4) (adjusted trend, p<0.001) (Supplemental eFigure 1).

Figure 2.

Figure 2

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Incidence of cardiopulmonary resuscitation (CPR) (trend, p<0.001)

Figure 3.

Figure 3

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Survival to discharge and median post-discharge survival after inhospital cardiopulmonary resuscitation (all trends, p<0.001)

Discussion

To our knowledge, this is the first study to report national rates of in-hospital CPR utilization and outcomes among Medicare beneficiaries receiving maintenance dialysis. Rates of in-hospital CPR among members of this cohort were very high and survival beyond hospital discharge substantially worse than reported previously for other populations (Table 2).1,2,3,18,19

Table 2.

Comparison of in-hospital cardiopulmonary resuscitation (CPR) practices and outcomes between patient groups

General population Dialysis patients (our study)
Overall <65 years ≥65 years Overall <65 years ≥65 years
Inpatients who underwent CPR (%) 0.32 NA NA 6.3 7.2 5.7
Incidence of CPR
 Event per 1,000 admissions NA NA 2.717 10.7 9.7 1.4
 Event per 1,000 in-hospital days 0.91 NA NA 1.4 1.3 1.4
Survived to hospital discharge (%) 17.0–23.02,20 NA 18.317 21.9 27.4 18.1
Median post-discharge survival (months) 33.018 72.03 24.019 5.0 9.6 3.4
In-hospital deaths preceded by CPR (%) NA NA 4.217 14.9 19.2 12.8
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NA not available

In-hospital CPR use was 20 times more common among members of this cohort as compared with a nationally representative sample of the general population (6.3% vs. 0.3%).2 While the proportion of CPR recipients in this cohort surviving to hospital discharge (21.9%) was comparable to that reported for other hospitalized patients (17.0% to 23.0%),2,20 median survival after discharge was considerably worse. Members of this cohort survived a median of five months after hospital discharge as compared with almost three years for other hospitalized patients.18 Differences with prior reports in other populations were even more striking after accounting for differences in age. Compared with older Medicare beneficiaries,17 in-hospital CPR was more common and post-discharge survival after an episode of CPR more limited for both younger (age <65 years) and older (age ≥65 years) members of this cohort (Table 2). These results likely reflect a number of different factors for patients receiving maintenance dialysis, including more limited life expectancy, higher rates of cardiac arrest and cardiovascular-related comorbid conditions,14,21–24 and more frequent receipt of interventions intended to prolong life as compared with the general population.25

From 2000–2011, there was a small increase in overall rates of in-hospital CPR among members of this cohort. This trend is similar to that reported among the wider population of older Medicare beneficiaries17 and for the general inpatient population among whom there was an increase in rates of in-hospital CPR from 0.87 to 0.99 CPR events per 1,000 hospital days over a similar time period.1 Reasons for an increase in rates of in-hospital CPR are not clear, but it coincides with increases in the rates of hospital and intensive care unit admissions and the use of mechanical ventilation near the end-of-life among the wider population of Medicare beneficiaries suggesting broad trends towards more intensive patterns of care over this same time period.26

We also found an increase in the percentage of patients surviving to discharge after the initial CPR event. This upward trend in rates of hospital survival coincides with similar increases reported in the general population over this time frame, which has been attributed in part to advancements in resuscitation care.8,20 This increase might also be a reflection of concurrent changes in hospital discharge practices reported in the general and wider Medicare populations and increasing use of hospice and long-term care facilities following an episode of in-hospital CPR where patients might subsequently die.2,17 It seems less likely that improvements in survival to discharge may reflect more selective use of CPR in this population given the upward trend in the incidence of CPR and the proportion of in-hospital deaths preceded by CPR during the same time frame. Despite improvements in survival to discharge among members of this cohort, gains in post-discharge survival during the same time frame were minimal, likely reflecting the underlying frailty and limited life expectancy of patients receiving maintenance dialysis. The life expectancy of a patient following initiation of maintenance dialysis is approximately a quarter of that reported for a person of similar age in the general population.24

Although survival after an episode of CPR was generally poor, there were some differences in outcomes across patient subgroups. Not surprisingly, survival to hospital discharge was lower and median post-discharge survival more limited among members of our cohort with other significant comorbid illness, such as coronary artery disease (17.3%; 4.0 months), congestive heart failure (18.0%; 4.7 months), chronic obstructive pulmonary disease (17.2%; 4.0 months) and cancer (17.2%; 2.6 months). In contrast with reports in the general population where survival after an episode of CPR is better among white than black patients,19 duration of post-discharge survival after an episode of CPR was slightly longer among black patients receiving maintenance dialysis as compared with their white counterparts (6.1 vs. 5.4 months), a finding consistent with a robust body of literature reporting longer survival after dialysis initiation among black patients which has been variously attributed to racial differences in burden of comorbidity,27 access to kidney transplant and competing risk of death during the advanced stages of kidney disease,28 and biologic responses to dialysis.29 We found patients receiving peritoneal dialysis experienced fewer CPR events as compared with those receiving hemodialysis (1.2 vs. 1.4 events per 1,000 in-hospital days), which is consistent with prior reports indicating lower rates of cardiovascular-related events among patients receiving peritoneal dialysis vs. hemodialysis,24 however outcomes after CPR were quite comparable for both groups.

Collectively, our findings signal both a need and an opportunity to enhance advance care planning in this population.30 Information on population-level outcomes after CPR may be useful background for supporting discussions between patients, their families and providers about desired treatment intensity and preferences for resuscitation. Prior studies indicate that many dialysis patients have unrealistic expectations about CPR outcomes.31 Importantly, caution should be exercised in interpreting the modest improvement in survival to discharge after an episode of CPR over time to encourage increased CPR use in light of the persistently poor post-discharge survival among CPR recipients in this cohort. Available data in the general population suggest that when providers share more accurate information about CPR, many patients elect not to receive CPR.32 Most dialysis patients have not completed an advance directive or shared their end-of-life care preferences with their doctors,33,34 and patients are more likely to receive aggressive care when they do not have treatment-limiting directives in place.35,36 Facilitated disease-specific approaches to advance care planning, including among patients receiving maintenance dialysis, can lead to greater concordance between patient’s treatment preferences and care received at the end of life and more positive assessment from family members of patient-provider interactions around the time of death.37–40

Our study was strengthened by the inclusion of a nationally representative population of patients receiving maintenance dialysis and by comprehensive and uniform ascertainment of inhospital CPR events. Nonetheless, several limitations of our study merit consideration. First, although we used a previously published approach to case finding,17 the sensitivity and specificity of administrative codes for CPR from Medicare claims have not been validated. Studies of CPR in other populations have employed a variety of strategies to identify CPR events through administrative claims,2,9,19 use of registry data1,19,20 and chart review,18 which might account for some of the differences we observed in CPR practices and outcomes between patients receiving maintenance dialysis and studies conducted in other populations. Several recent reports have used data from the American Heart Association Get with the Guidelines (GWTG) Resuscitation Registry,1,19,20 a national quality improvement registry constructed from information collected prospectively by trained personnel using standardized definitions of cardiac arrest and CPR.41,42 While this approach allows for careful characterization and ascertainment of cases from participating hospitals engaged in quality improvement, an advantage of using administrative claims is that we were able to capture CPR events occurring across a range of inpatient settings among members of this cohort. Second, we do not have information on several factors that might impact survival after CPR including details of the cardiac arrest event such as initial cardiac arrest rhythm, treatments used during and after resuscitation, and in-hospital location of the arrest, as well as hospital-level characteristics such as the number of CPR events handled at each facility per year and whether the arrest was attended by a designated resuscitation (“code”) team.21 Third, we do not have details on more patient-centered outcomes such as level of disability, hospice referral and nursing home utilization following CPR. Lastly, our results may be limited by the accuracy of the information on comorbidities ascertained at the time of dialysis initiation reported on the CMS 2728 Form,43 which might not entirely capture comorbidities and level of illness severity around the time of cardiac arrest.

In conclusion, the incidence of in-hospital CPR among dialysis patients is high despite poor long-term survival after an episode of CPR, findings that support the relevance of advance care planning in this population.

Supplementary Material

efigure 1
etable 1
etable2
etable3
etable4

Acknowledgments

This study was supported by a Beeson Career Development Award from the National Institute on Aging to Dr. O’Hare and U01-DK102105. Dr. Wong was supported by T32DK746730 and the Clinical Scientist in Nephrology Award from the American Kidney Fund. These funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Drs. O’Hare and Wong had access to all the data in the study and take full responsibility for the integrity of the data and accuracy of the data analysis. This work was conducted at the University of Washington and does not represent the opinion of the USRDS.

Footnotes

The authors disclose no financial conflict of interest.

Contributor Information

Susan P. Y. Wong, Email: spywong@uw.edu, Department of Medicine, Kidney Research Institute and Palliative Care Center of Excellence, University of Washington, 1959 NE Pacific Street, Box 356521, Seattle, WA 98195, Phone: 206-384-5804, Fax: 206-685-8661

William Kreuter, Email: billyk@uw.edu, Senior Computer Specialist, Center for Cost and Outcomes Research, University of Washington, 325 9th Avenue, Box 359736, Seattle, WA 98104, Phone: 206-744-1806, Fax: 206-744-9889

J. Randall Curtis, Email: jrc@u.washington.edu, Professor of Medicine, Director, Palliative Care Center of Excellence, Section Head, Pulmonary and Critical Care Medicine, Harborview Medical Center, A. Bruce Montgomery American Lung Association Endowed Chair in Pulmonary and Critical Care Medicine, University of Washington, 325 9th Avenue, Box 359762, Seattle, WA 98104, Phone: (206) 744-3356, Fax: (206) 744-8584

Yoshio N. Hall, Email: yhall@uw.edu, Associate Professor of Medicine, Department of Medicine and Kidney Research Institute, University of Washington, RDU 1160 S. Columbian Way, Seattle, WA 98108, Phone: 206-685-7315, Fax: 206-685-9399

Ann M. O’Hare, Email: Ann.OHare@va.gov, Associate Professor of Medicine, Department of Medicine, Palliative Care Center of Excellence, and Kidney Research Institute, University of Washington, VA Puget Sound Healthcare System and Group Health Research Institute, RDU 1160 S. Columbian Way, Seattle, WA 98108, Phone: 206-277-3192, Fax: 206-764-2022

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Supplementary Materials

efigure 1
NIHMS663620-supplement-efigure_1.docx (39.7KB, docx)
etable 1
NIHMS663620-supplement-etable_1.docx (58.1KB, docx)
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NIHMS663620-supplement-etable2.docx (96.9KB, docx)
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NIHMS663620-supplement-etable3.docx (95.1KB, docx)
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NIHMS663620-supplement-etable4.docx (92.3KB, docx)

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