New models of care delivery that promote collaboration between oncology and mental health are urgently needed. The Bridge intervention, a person‐centered model of early, integrated psychiatric and cancer care for patients with serious mental illness, was developed to improve cancer outcomes in this underserved population.
Keywords: Vulnerable populations, Schizophrenia, Delivery of health care, Psycho‐oncology, Health care disparities
Abstract
Background.
Individuals with serious mental illness (SMI) experience increased cancer mortality due to inequities in cancer treatment. Psychiatric care at cancer diagnosis may improve care delivery, yet models for integrating psychiatry and cancer care are lacking. We assessed the feasibility and acceptability of a person‐centered collaborative care trial for SMI and cancer.
Subjects, Materials, and Methods.
We developed the Bridge intervention for patients with SMI (schizophrenia, bipolar disorder, and severe major depression) and cancer. Bridge includes proactive identification of SMI, person‐centered care from a psychiatrist and case manager, and collaboration with oncology. We conducted a 12‐week, single‐group trial in patients with SMI and a new breast, gastrointestinal, lung, or head/neck cancer. We assessed the feasibility of patient identification, enrollment and study completion; evaluated acceptability and perceived benefit with exit interviews with patients, caregivers, and oncology clinicians; and examined change in psychiatric symptoms with the Brief Psychiatric Rating Scale (BPRS).
Results.
From November 2015 to April 2016, 30/33 eligible patients (90.9%) enrolled, and 25/29 (86.2%) completed assessments at all timepoints, meeting feasibility criteria. Of 24 patients, 23 (95.8%) found meeting with the psychiatrist helpful; 16/19 caregivers (84.2%) shared that Bridge addressed key caregiving challenges. Oncology clinicians evaluated Bridge as “very” or “most” useful for 94.3% of patients. Exit interviews with all participant groups suggested that Bridge fostered patient‐clinician trust, increased access to psychiatric treatment, and enabled patients to initiate and complete cancer treatment. Psychiatric symptoms on the BPRS improved from baseline to 12 weeks.
Conclusion.
Bridge is a feasible and acceptable care delivery model for patients with SMI, their caregivers, and oncology clinicians. Randomized trials are warranted to assess the efficacy of improving cancer outcomes in this underserved population.
Implications for Practice.
Serious mental illness affects 13 million U.S. adults who experience increased cancer mortality. To improve outcomes, new models of integrated oncology and mental health care are urgently needed. This study found that it was feasible to identify, enroll, and retain patients with serious mental illness and a new cancer in a trial of integrated mental health and cancer care (Bridge). Patients, caregivers, and oncologists reported that Bridge facilitated the initiation and completion of cancer care. Randomized trials are warranted to investigate the impact on cancer outcomes. Trial procedures may inform consent, engagement, and trial retention for patients with mental illness.
Introduction
Serious mental illness (SMI), including schizophrenia, bipolar disorder, and severe major depression, affects 13 million U.S. adults [1]. Individuals with SMI die 15–30 years earlier than the general population [2], [3], [4], with cancer as the second leading cause of death [4]. Compared with people without mental illness, individuals with SMI have two‐ to four‐times greater mortality from breast, lung, colorectal, and oral cancers [3], [5], [6], [7]. Patients with SMI are more likely to be diagnosed with metastatic disease [8], [9] and less likely to receive timely, guideline‐concordant treatment [3], [6], [9], [10]. Among patients with schizophrenia treated for breast cancer at a National Cancer Institute‐designated cancer center, one half of patients experienced clinically significant disruptions in their cancer care including delays, modifications from recommended cancer treatment, and treatment interruptions; lack of psychiatric treatment at the time of cancer diagnosis was the strongest predictor of these disruptions [11]. Despite leading oncology organizations’ focus on health disparities [12], [13], [14], clinical trials have excluded patients with SMI. Without targeted interventions, individuals with SMI will continue to face barriers to cancer care and experience premature mortality.
Patient, clinician, and health care system factors contribute to cancer care inequities for patients with SMI. Psychiatric symptoms including cognitive disorganization and paranoia can affect a patient's ability to understand a cancer diagnosis and build a relationship with the oncologist, contributing to treatment delays [3], [9], [10], [15]. Patients with schizophrenia and bipolar disorder experience disproportionate poverty and social isolation, risk factors for decreased access to care [7], [16], [17], [18], [19]. Although psychosocial care is recognized to be essential for quality cancer care [20], [21], [22], access to psychiatry remains limited. These challenges increase the risk of inequities in cancer treatment that contribute to poor cancer survival. New models of integrated cancer and mental health care are urgently needed.
To address this critical gap in care, we developed “Bridge,” a person‐centered model of early, integrated psychiatry and cancer care for patients with SMI, with the goal of improving cancer outcomes. To inform intervention development, we conducted qualitative interviews with oncology and mental health clinicians and applied the core principles of collaborative care to the needs of patients with SMI and cancer [23]. For this single‐group trial, we assessed the feasibility of patient identification, enrollment, and study completion as well as the acceptability and usefulness of the intervention according to patients, caregivers, and oncology clinicians. We examined change in psychiatric symptoms and quality of life and the frequency of disruptions in cancer care.
Subjects, Materials, and Methods
Participants
Patients.
Inclusion criteria included SMI (schizophrenia, schizoaffective disorder, bipolar disorder, or major depressive disorder with prior psychiatric hospitalization) confirmed by a board‐certified psychiatrist (K.I.) by electronic health record (EHR) review and patient interview. Also, patients had to have thoracic, gastrointestinal, breast, or head and neck cancer documented in an oncology consultation note or pathology; be within 8 weeks of their initial surgical, medical, or radiation oncology consultation at Massachusetts General Hospital (MGH); be ≥18 years of age; and be able to answer questions in English. Exclusion criteria included cognitive impairment severe enough to interfere with completing self‐report assessments with staff assistance, anticipated death before 12 weeks per the referring oncologist, and transfer of cancer care to another institution.
Caregivers.
Patients’ family or community‐based caregivers were eligible if they accompanied the patient to oncology appointments or communicated with the oncology or intervention team, were ≥18 years of age, and were able to answer questions in English.
Clinicians.
Oncology physicians and nurse practitioners who cared for patients during the Bridge trial were eligible.
Procedures
Recruitment and Informed Consent.
We developed tailored study recruitment and engagement procedures (Table 1). We identified patients by (a) screening oncology consultations in the EHR, (b) eliciting referrals from oncology clinicians, and (c) encouraging referrals from community mental health (CMH) clinicians. The MGH Cancer Center has an embedded Center for Psychiatric Oncology and Behavioral Sciences, which fosters collaboration between oncology and mental health in research and clinical care. To facilitate recruitment and referrals, the study psychiatrist and case manager strengthened collaborations with psychiatrists, medical directors, and nurse practitioners at MGH and community mental health agencies. To promote understanding, study clinicians used a verbal consent process to explain the risks and benefits of the study using concrete statements, provided the opportunity to ask questions, and documented capacity to consent with a validated tool [24], [25]. If patients had guardians, guardians provided consent and patients provided assent. We used verbal consent with caregivers and clinicians prior to exit interviews. The Dana‐Farber/Harvard Cancer Center Institutional Review Board approved all study procedures.
Table 1. Targeted trial procedures for patients with serious mental illness and cancer.
Abbreviation: SMI, serious mental illness.
The Bridge Intervention: Person‐Centered Collaborative Care for SMI and Cancer
Intervention Development.
To understand barriers to cancer care for patients with SMI, we conducted qualitative interviews with oncology and mental health clinicians. Oncologists identified the following challenges: uncontrolled psychiatric symptoms, social isolation, and difficulty establishing patient‐clinician trust, as well as lack of time, training in mental health, and limited access to psychiatry. To facilitate cancer care, clinicians underscored the need for timely psychiatry consultation, team‐based care, and a care delivery model that was person‐centered, flexible, and persistent.
Furthermore, Bridge was informed by the collaborative care model [26], [27], [28], [29]. Multiple randomized trials in primary care have demonstrated that collaborative care improves depression, functioning, patient satisfaction, and access to mental health care [30], [31]. More recently, collaborative care has been adapted to oncology, and emerged as an evidence‐based care delivery model to treat psychosocial symptoms. Across diverse cancer populations, including low‐income and minority patients, collaborative care interventions have been found to improve depression symptoms and to be cost effective [26], [32], [33], [34], [35]. Furthermore, among patients with SMI, collaborative care increases access to primary care and improves physical health outcomes [36], [37]. Consistent with the collaborative care framework, Bridge used a population‐based approach (e.g., screening the EHR for mental illness, systematically tracking psychiatric symptoms and cancer care, modifying treatment to improve outcomes), and an interdisciplinary team to improve clinician communication and address patient needs.
The Bridge Intervention.
The core components of Bridge (Fig. 1) included the following: (a) early identification and tracking of patients with SMI; (b) person‐centered assessment and care (e.g., understanding patients’ priorities for their lives and framing cancer care accordingly, identifying and mitigating barriers to care, building patient‐clinician trust); (c) interdisciplinary team‐based care including comanagement between the intervention team and oncology to guide cancer treatment, and communication with community‐based clinicians; and (d) increased access to psychiatric expertise. The essential components of the person‐centered assessment were specified in the protocol [16].
Figure 1.
Bridge intervention schema.
Abbreviations: CMH, community mental health; ED, emergency department; EHR, electronic health record.
The intervention team included a psychiatrist with expertise in oncology and CMH, and a case manager (i.e., licensed clinical social worker) embedded in the cancer center. The psychiatrist performed the initial psychiatric assessment, communicated with community prescribers, and collaborated with the oncology team to shape the treatment plan. The case manager performed patient and caregiver outreach, communicated with the community mental health team, and monitored psychiatric symptoms and cancer care systematically. The psychiatrist led structured weekly case reviews with the case manager focused on patients experiencing increased psychiatric symptoms or challenges receiving cancer care to facilitate rapid adjustment of the treatment plan. The intervention team proactively communicated with the patient, caregiver, and oncologist and remained available for ongoing consultation by phone, text, and page. The case manager was the primary contact for patients and caregivers and the psychiatrist provided 24/7 pager coverage.
At the end of the 12‐week intervention, the team wrote a transition note (e‐mailed to the oncologist and documented in the EHR) that clarified the next steps for the patient's psychiatric care and transition to the community if clinically indicated. The intervention team continued to track cancer care and hospitalizations for an additional 12 weeks. To promote engagement in care, we scheduled additional psychiatry visits if clinically indicated in the hospital, clinic, or community (e.g., group home or shelter); held joint visits with oncology; and contacted caregivers and patients via phone or text.
Data Collection.
When possible, intervention staff administered assessments at the time of oncology visits. Patients completed assessments with assistance from intervention staff or caregivers, in person, by phone, or via REDCap, a Health Insurance Portability and Accountability Act‐compliant electronic survey tool. At baseline (within 2 weeks of consent), patients completed a demographics and resource use questionnaire, including primary and mental health care, and assessments of psychiatric symptoms and quality of life. During the initial comprehensive clinical assessment, the intervention psychiatrist confirmed the psychiatric diagnosis using structured questions informed by relevant modules of the Mini Neuropsychiatric Interview [38]. We evaluated psychiatric symptoms, quality of life, and severity of psychiatric illness with clinician‐administered assessments and patient‐reported questionnaires at 4–6 weeks and 12–14 weeks after baseline. Additionally, the research assistant conducted exit interviews with patients, caregivers, and oncology clinicians 12–20 weeks after baseline regarding the acceptability and usefulness of the intervention.
Outcome Measures
Intervention Feasibility.
We examined the feasibility of participant identification, enrollment, and Bridge trial completion. Feasibility criteria were met if at least (a) 30 patients with SMI and a new cancer diagnosis were enrolled over 12 months, (b) 50% of identified patients enrolled, (c) 75% of participants completed the diagnostic assessment, and (d) 75% of participants completed patient‐reported outcomes at all timepoints [39]. We recorded rates and reasons for withdrawal and rates of not completing study measures.
Intervention Delivery.
We tracked the number and location of psychiatry visits, patients for whom the psychiatrist prescribed medications, mode of communication (e.g., phone, email, text), caregiver involvement (e.g., caregiver identification, communication with intervention team, in‐person visits), and comanagement between psychiatry and oncology (e.g., in‐person joint visits).
Intervention Acceptability.
Intervention staff conducted semistructured exit interviews with patients, caregivers, and oncologists to evaluate acceptability and usefulness of the intervention. Intervention staff asked patients and caregivers about the helpfulness of the psychiatrist and case manager, and preferred visit frequency. Intervention staff asked caregivers about caregiving challenges and if and how the intervention addressed those challenges. Oncology clinicians rated intervention usefulness on a five‐point scale (from 1 “least useful” to 5 “most useful”). Oncology clinicians reported if their patient received the same treatment intensity as other patients with similar cancers, whether the patient had a cancer care disruption, and if the intervention impacted care quality.
Psychiatric Symptoms and Quality of Life.
Clinician‐Administered Measures.
The Brief Psychiatric Rating Scale (BPRS) is an 18‐item measure of psychiatric illness severity used commonly in patients with SMI with strong psychometrics and sensitivity to change [40]. Higher scores indicate more severe illness. The Clinical Global Impression‐Severity (CGI‐S) measures psychiatric illness severity from 1 (not ill) to 7 (extremely ill) based on observed and reported symptoms, functioning, and behavior [41].
Patient‐Reported Outcomes.
The Patient Health Questionnaire‐9 (PHQ‐9) is a nine‐item depression screen used extensively in cancer and SMI [42], [43], [44], [45]. Higher scores indicate worse depressive symptoms. The Functional Assessment of Cancer Therapy‐General (FACT‐G) has been validated with diverse tumor types and assesses emotional, social, and functional wellbeing in the past week [46]. Higher scores indicate better overall quality of life.
Statistical Analysis
We conducted statistical analyses using SPSS version 22.0 (IBM SPSS Statistics, Armonk, NY). We used descriptive statistics to characterize participants. To explore changes in clinician‐reported severity of psychiatric illness according to the BPRS, we computed dependent sample t tests comparing baseline and 12 weeks. For the CGI‐S, we dichotomized scores into two groups (worsened vs. improved or stayed the same) and compared scores at baseline and week 12, using a paired McNemar's test. For continuous patient‐reported outcomes with three timepoints (PHQ‐9 and FACT‐G), we conducted a repeated measures analysis of variance followed by t tests.
We evaluated acceptability via semistructured exit interviews with patients, caregivers, and oncology clinicians regarding the content, timing, and perceived benefit of the intervention. An interdisciplinary team extracted key themes from the exit interviews and developed a coding scheme. Two investigators independently coded transcripts; an interdisciplinary advisory panel resolved any coding discrepancies. The intervention team reviewed themes with patient, caregiver, and clinician participants to ensure representation of stakeholder perspectives [47].
Results
Participants
From November 2015 to April 2016, we enrolled 30 patients (Fig. 2). The research team screened 1,800 charts for approximately 2 minutes each for a total of 60 hours. Baseline patient and caregiver characteristics are presented in Table 2. Psychiatric diagnoses included bipolar disorder (n = 15, 50.0%), schizophrenia or schizoaffective disorder (n = 8, 26.7%), and severe major depression (n = 7, 23.3%). Eighteen patients (62.1%) reported disability benefits as their primary income source, and only four (13.8%) lived with a spouse. Eighteen patients (60.0%) identified at least one caregiver. Caregiver participants included four spouses, nine other family members, and seven CMH staff.
Figure 2.
Consort diagram.
Table 2. Baseline characteristics of patients and caregivers.
Patients could select more than one race.
Abbreviations: AA, Associate of Arts; BPRS, Brief Psychiatric Rating Scale; CGI, Clinical Global Impression; FACT‐G, Functional Assessment of Cancer Therapy‐General; GED, General Educational Development; GI, gastrointestinal; MGH, Massachusetts General Hospital; PCP, primary care physician; PHQ‐9, Patient Health Questionnaire‐9.
Intervention Feasibility
Within 5 months, 30/33 eligible patients (90.9%) consented and enrolled in the trial (including three guardians). Patients were identified by screening the EHR of new oncology consultations (n = 12, 40.0%), oncology referral (n = 13, 43.3%), and CMH referral (n = 5, 16.7%). All enrolled patients (100%) completed the diagnostic assessment, and 25/29 (86.2%, one deceased) completed clinician‐administered and patient‐reported assessments at all timepoints (Fig. 2), with no adverse events.
Intervention Delivery
The Bridge psychiatrist met with all enrolled patients (29 in‐person, 1 by phone). Patients had a median of four in‐person visits with the psychiatrist (interquartile range 2–5). Eleven patients (37.9%) had visits while hospitalized, and four (13.8%) had visits in the community (e.g., shelter, home). The Bridge psychiatrist prescribed medication for 13 patients (44.8%) during the trial. Patients communicated with the case manager and psychiatrist by phone (n = 12), e‐mail (n = 2), and text (n = 1). Caregivers communicated with the case manager and psychiatrist via phone (n = 13, 65.0%), e‐mail (n = 10, 50.0%), and text (n = 7, 35.0%). Intervention clinicians met with 16 caregivers (80.0%) in person.
Intervention clinicians communicated with the oncology team to develop a joint approach to cancer and mental health treatment for all patients. Eight patients (27.6%) had in‐person joint visits with oncology and psychiatry or case management. The intervention team collaborated with oncology to plan proactive hospitalizations for four patients (13.8%) to initiate or complete cancer treatment.
Intervention Acceptability
Patients and Caregivers.
Of 24 patients who completed exit interviews, 23 (95.8%) found meeting with the psychiatrist helpful, and 18 patients (90.0%) valued meeting with the case manager. Twenty‐two patients (91.7%) and 13 caregivers (68.4%) reported they had the right number of study visits; 6 caregivers (31.6%) reported too few. Of 20 caregivers, 19 (95.0%) identified aspects of caregiving to be challenging, and 16 (84.2%) reported that the intervention addressed these challenges.
Oncology Clinicians.
We completed exit interviews with 20 oncologists and six nurse practitioners. Nine clinicians cared for more than one patient in the trial and provided feedback for each participant; eight patients were evaluated by more than one clinician. Oncology clinicians had a mean 11.96 (SD = 9.25) years of clinical experience; 13 (50.0%) reported caring for fewer than 20 patients with SMI. Oncology clinicians found the intervention “very” or “most” useful (4.63/5, SD = 0.81) for 33 patients (94.3%), and reported that the intervention positively impacted cancer care for 30 patients (83.3%). Oncology clinicians reported that 22 patients (78.6%) received the same cancer treatment intensity as other patients with the same cancer type and stage without SMI, and eight patients (28.6%) had clinically significant cancer care disruptions during the intervention. Five of six patients (83.3%) who initially declined or experienced a delay in care received all recommended cancer treatment during the intervention.
Finally, we triangulated qualitative data from patients, clinicians, and caregivers, to elucidate how the Bridge intervention facilitated cancer care delivery (Table 3). Themes mapped on to needs that clinicians identified in prior qualitative research: (a) increasing access to psychiatric expertise, (b) building patient‐clinician trust, and (c) promoting comanagement between oncology and psychiatry. Oncology clinicians and caregivers emphasized that the intervention made it possible for patients to initiate and complete cancer treatment.
Table 3. Barriers to cancer care, intervention components, and participant feedback.
Abbreviation: SMI, serious mental illness.
Psychiatric Symptoms and Quality of Life
Per clinician assessment on the BPRS, patients’ psychiatric illness improved during the intervention (mean diff: 4.62; 95% confidence interval 0.86–8.37, t(25) = 2.53, p = .018). Furthermore, although 22 patients (75.9%) had at least moderately severe mental illness at enrollment (CGI‐S), only 16 (57.1%) had at least moderately severe psychiatric illness at 12 weeks (McNemar: p = .063). Patient‐reported depression symptoms (PHQ‐9) and quality of life (FACT‐G) improved or remained stable during the intervention (Table 4).
Table 4. Psychiatric symptoms and quality of life.
Abbreviation: df, degrees of freedom.
Discussion
Despite increasing recognition that psychosocial care is essential for quality cancer care [20], [48], and growing awareness that patients with SMI experience inequities in cancer treatment, research on potential solutions remains limited. Oncology teams have little guidance and limited resources regarding how to effectively integrate psychosocial care into cancer care delivery. To our knowledge, we have conducted the first interventional trial targeting patients with SMI and cancer.
We demonstrated that it was feasible to identify and enroll patients with SMI and a new cancer diagnosis in a person‐centered collaborative care trial with high rates of consent and study completion. Strikingly, we completed recruitment three times faster than anticipated. Furthermore, patients, caregivers, and clinicians reported that the Bridge model was acceptable, useful, and positively impacted cancer care. Consistent with collaborative care trials in oncology, psychiatric symptoms improved or remained stable during the intervention, although prior trials excluded patients with preexisting SMI [26]. In contrast, our trial specifically targeted patients with SMI, including patients with symptomatic bipolar disorder and schizophrenia. Importantly, patients who previously experienced delays initiated and completed cancer treatment. Additionally, our intervention was designed to mitigate the impact of social determinants of health (e.g., limited social support) that create barriers to cancer care and trial participation for underrepresented populations. For patients with SMI, involving psychiatry at cancer diagnosis, and using a team‐based approach, may decrease cancer care disruptions and therefore improve outcomes.
The strategies we used can serve as a model for engaging patients with SMI in cancer care and research. Specifically, we screened the EHR for SMI and sought referrals from oncology and mental health clinicians because mental illness is not systematically identified in oncology. We used a verbal consent process given limited health literacy and difficulty comprehending abstract risk. To foster engagement in care and increase continuity, the intervention was person‐centered and provided longitudinal follow‐up across settings. We partnered with CMH clinicians, frequently the primary connection to the health care system for patients with SMI, to guide clinicians in how to support patients’ decision‐making and ability to access cancer care. We gained understanding of the importance of collaborating with diverse caregivers to facilitate care delivery for patients with SMI, particularly patients with few social supports and limited insight into the need for cancer treatment. We broadened the definition of the caregiver to include other family (i.e., adult children) and CMH clinicians and staff who may be the patients’ primary advocates. In future studies, we will coenroll caregivers to understand caregiver needs and integrate caregivers into care delivery.
Several limitations of this feasibility trial warrant attention. Without a comparison group, we cannot conclude that the intervention caused improvements in psychiatric symptoms, quality of life, or cancer care delivery. Although patients were monitored up to 24 weeks, psychiatric symptoms were not assessed at this timepoint and the maintenance of the intervention effects on psychiatric symptoms cannot be reported. Additionally, the clinician‐administered measures were conducted by a study interventionist. As a pilot, the intervention was conducted at a single comprehensive cancer center by one case manager and one psychiatrist (the principal investigator), which may not generalize to other care settings as this underserved population may be more likely to be seen in the community. Nonetheless, the intervention team developed partnerships with CMH clinics to facilitate referrals, accounting for 16.7% of trial participants. Furthermore, cancer centers may have inadequate access to integrated mental health treatment and specialty care resources. To increase the potential to disseminate this intervention, we employed a collaborative care approach to use that psychiatric expertise as efficiently as possible.
Conclusion
Individuals with SMI and cancer can participate in a collaborative care‐informed intervention integrated into cancer care. In this pilot trial, patients, caregivers, and oncology clinicians provided converging evidence of the potential for person‐centered approaches and early, integrated psychiatry in cancer care to enable patients with SMI to receive needed cancer treatment. Randomized trials are necessary to investigate whether the Bridge model can promote equity in cancer care, decrease suffering, and increase cancer survival for patients with SMI.
See http://www.TheOncologist.com for supplemental material available online.
Acknowledgments
The authors thank Helen P. Knight for assistance with qualitative interviews that informed intervention development. This study was supported by an American Cancer Society Institutional Research Grant; Program in Cancer Outcomes Research Training (PCORT) Fellowship through the National Cancer Institute (principal investigator G. Scott Gazelle).
Author Contributions
Conception/design: Kelly E. Irwin, Elyse R. Park, Amy E. Corveleyn, Joseph A. Greer, Andrew A. Nierenberg, Jennifer S. Temel, David P. Ryan, William F. Pirl
Provision of study material or patients: Kelly E. Irwin, Amy E. Corveleyn
Collection and/or assembly of data: Kelly E. Irwin, Lauren E. Fields, Amy E. Corveleyn
Data analysis and interpretation: Kelly E. Irwin, Lauren E. Fields, Giselle K. Perez, Jamie M. Jacobs
Manuscript writing: Kelly E. Irwin, Elyse R. Park, Lauren E. Fields, Joseph A. Greer, Giselle K. Perez, Catherine A. Callaway, Jamie M. Jacobs, William F. Pirl
Final approval of manuscript: Kelly E. Irwin, Elyse R. Park, Lauren E. Fields, Amy E. Corveleyn, Joseph A. Greer, Giselle K. Perez, Catherine A. Callaway, Jamie M. Jacobs, Andrew A. Nierenberg, Jennifer S. Temel, David P. Ryan, William F. Pirl
Disclosures
The authors indicated no financial relationships.
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