Abstract
This current study examines measures of work-life balance among health administration faculty prior to and during the COVID-19 pandemic. A repeated cross-sectional design is used to analyze data collected from a national survey in 2018 and 2021. Changes in six different outcome measures of work-life balance were examined using multivariable logistic regression, controlling for health administration faculty characteristics. Compared to 2018 respondents, faculty respondents in 2021 were more likely to report that family and personal matters were interfering with their ability to do their job (OR = 1.93, p=0.001). Females more frequently reported that their career had suffered because of personal issues/obligations (OR = 1.82, p=0.003) but were less likely to report having enough time to get their teaching (OR = 0.68, p=0.026). Respondents with children 18 years or younger reported higher rates of regularly having to miss a meeting or event at home (OR = 1.88, p<0.001) and an event at work (OR = 3.74, p<0.001). These faculty also more frequently reported that family or personal matters were interfering with their ability to do their job (OR = 3.04, p<0.001) and that their career suffered because of personal issues/obligations (OR = 2.09, p=0.001). Given the implications of work-life conflicts to organizational outcomes, academic leaders and university decision-makers should consider adopting strategies to mitigate the effects of these disruptions to the work-life equilibrium of academics.
Keywords: work-life balance, COVID-19, health administration faculty
INTRODUCTION
The COVID-19 pandemic has impacted university faculty members who faced dynamic environments of rapidly-evolving institutional policies, campus restrictions, and disruptions to physical workspaces (Almost, 2020; Arora, Wray, O’Glasser, Shapiro, & Jain, 2021; Bernard & Lauer, 2021). Faculty members were required to transition to online and remote teaching modalities and halt other activities including research, recruitment, clinical care, and face-to-face student engagement (Almost, 2020; Arora et al., 2021; Oleschuk, 2020). Separately, home-life was upended given disruptions to essential goods supply chains, K-12 education, child-care, and economic activity in many industries (Aubry, Laverty, & Ma, 2021; Del Boca, Oggero, Profeta, & Rossi, 2020; Delaney et al., 2021; Jones et al., 2020; Staniscuaski et al., 2020). Without question, the pandemic has disrupted faculty member’s personal and professional routines, and the balance between the two.
Work-life balance, or the equilibrium between time spent on one’s career versus time spent on family or other personal matters, is a strong predictor of organizational turnover (Beckett, Nettiksimmons, Howell, & Villablanca, 2015; Shollen, Bland, Finstad, & Taylor, 2009; Smart, 1990), job dissatisfaction (Mache, Bernburg, Groneberg, Klapp, & Danzer, 2016; Shollen et al., 2009), and burnout (Aazami, Shamsuddin, & Akmal, 2015; Kazley, Dellifraine, Lemak, Mullen, & Menachemi, 2016; Lindfelt, Ip, Gomez, & Barnett, 2018; Nitzsche, Pfaff, Jung, & Driller, 2013). Recent surveys of academics in biology (Aubry et al., 2021) and employees of a health care delivery system (Delaney et al., 2021) each found that the pandemic has most disrupted the work-life balance of early careerists, females, and those who are parents. Similarly, the NIH reported that early-stage biomedical researchers and those with caregiving responsibilities have experienced poorer mental health outcomes as a result of the pandemic (Bernard & Lauer, 2021). Collectively, these studies provide useful insights but are limited to a handful of academic disciplines or a single practice organization. Moreover, these studies utilized cross-sectional designs, without a pre-period, which only capture snapshots of work-life balance or related outcomes during the pandemic. Given that disruptions to optimal work-life balance are associated with negative organizational outcomes, more research is needed to compare work-life balance before and during the pandemic in a broader set of academic settings.
The purpose of the current study is to examine work-life balance among respondents to a national survey of health administration faculty members conducted prior to the pandemic, in 2018, and during the COVID-19 pandemic in 2021. We investigate how measures of faculty member’s work-life balance have changed over time and are associated with individual characteristics such as gender, tenure status, and parental status. This study builds upon the growing literature of the impact of the pandemic on faculty members in higher-education and will thus be of interest to university leaders, especially those in the field of health administration.
METHODS
Data
Since 2009, a national cohort of U.S. health administration faculty have been surveyed every three years regarding their individual characteristics, job responsibilities, salary, career satisfaction, and academic productivity. In 2015, questions regarding work-life balance were added to the survey and have been included in each subsequent instance thereafter. The current study utilizes a repeated cross-sectional design to analyze the data collected in 2018 and 2021. In each survey year, all full-time faculty (instructor, assistant, associate, or full professor rank) within U.S. programs affiliated with the Association of University Programs of Health Administration (AUPHA) were invited to participate. In addition, a non-duplicative list of individual members of the Academy of Management’s Health Care Management Division were invited to participate. Email invitations to the anonymous survey were distributed to participants during the month of February in each survey year. A detailed description of the recurring methodology of this triennial survey can be found elsewhere (Menachemi, 2016). The study was deemed exempt by Indiana Unviersity’s Institutional Review Board.
Variables
Our dependent variables are based on responses to the following survey questions related to work-life balance:
During the past 12 months, how often have you had to miss a meeting or event at HOME due to work responsibilities?
During the past 12 months, how often have you had to miss a meeting or event at WORK due to home responsibilities?
Participants were given the following response options on a five-point Likert scale: never, a few times a year, monthly, weekly, daily. Consistent with the methodology of Kazley et al (2016), we conflated responses into dichotomous categories: regularly (weekly, daily, or monthly) and other (a few times a year or never).
Additional dependent variables were based on the following survey items which required participants to respond with their level of agreement (from strongly disagree to strongly agree) using a five-point Likert scale:
“Family or personal matters are interfering with my ability to do my job”
“My career has suffered because of personal issues/obligations”
“I have enough time to get my teaching done”
“I have enough time to get my research done”
Responses to these four items were conflated into dichotomous categories: yes (strongly agree and agree) and other (don’t know, disagree, strongly disagree) respectively.
The main independent variable was a binary indicator for survey year that allowed us to examine changes from 2018 to 2021 presumably due to the pandemic. Other independent variables included tenure status (tenured vs. not tenured), gender and parental status. Gender was defined as female vs. male (n=2 respondents identifying as ‘other’ were categorized as male for analyses). Parental status was a binary variable indicating whether the respondent has children aged 18 or younger. We specifically defined parental status to examine having dependent children as opposed to adult aged children. Lastly, we utilized race (white, Black/African American, Asian, or other) and marital status (currently married vs. other) as control variables.
Analysis
To analyze the data, we first present descriptive statistics on the characteristics of health administration faculty respondents from the 2018 and 2021 survey years. Next, bivariate relationships between measures of work-life balance and independent variables of interest (survey year, gender, tenure-status, and parental status) were analyzed using Chi-Square analyses. We then modeled each outcome measure of work-life balance examining changes from 2018 to 2021 using multivariable logistic regression, controlling for faculty demographic characteristics. Finally, in order to examine whether certain groups had differential changes potentially due to the pandemic, we included interaction terms for survey year and key demographic variables including gender, tenure status and parental status. Findings were considered statistically significant at the p≤0.05 level and all analyses were conducted using Stata version 16 (College Station, TX: StataCorp LLC, 2019).
RESULTS
Demographic characteristics of HA faculty survey participants are presented in Table 1. There were 598 respondents in 2018 (42.4% response rate) and 366 respondents in 2021 (29.7% response rate) for a total of 964 individuals in our sample. Overall, the majority were white (82%), married (82%), and not tenured (53%). Further, 38% reported having children 18 years or younger and 50% of the sample was female.
Table 1:
Health Administration faculty respondent characteristics
| Characteristics | N (%) |
|---|---|
| Survey wave year (n=964) | |
| 2018 | 598 (62%) |
| 2021 | 366 (38%) |
| Gender (n=788) | |
| Female | 396 (50%) |
| Male | 392 (50%) |
| Parental Status | |
| No children ≤18 years | 596 (62%) |
| Has children ≤18 years | 368 (38%) |
| Race (n=775) | |
| White | 634 (82%) |
| Black or African American | 77 (10%) |
| Asian | 59 (8%) |
| Other or unknown | 5 (1%) |
| Age (n=964) | |
| 20s and 30s | 98 (10%) |
| 40s | 178 (18%) |
| 50s | 178 (18%) |
| 60s and older | 264 (27%) |
| Unknown age | 246 (26%) |
| Marital Status (n=792) | |
| Currently married | 651 (82%) |
| Other | 141 (18%) |
| Tenure status (n=908) | |
| Tenured | 423 (47%) |
| Not tenured | 485 (53%) |
Note: Response rates slightly varied by survey question.
Bivariate relationships between independent variables and measures of work-life balance appear in Table 2. Compared to 2018, a larger proportion of respondents in 2021 reported family and personal matters were interfering with their ability to do their job (15.7% vs. 24.1%, p=0.003). In addition, females were more likely than males to report their career has suffered due to personal issues or obligations (23.2% vs. 16.3%, p=0.016) but less likely to report they regularly missed a meeting or event at work due to home responsibilities in the past year (8.2% vs. 12.6%, p=0.042). Females were also less likely to report having enough time to get their teaching done (67.5% vs. 76.3%, p=0.006) and having enough time to get their research done (32.5% vs. 42.2%, p=0.006).
Table 2:
Bivariate relationships between health administration faculty characteristics and measures of work-life balance.
| During the last 12 months, I regularlya had to miss a meeting or event at HOME due to work responsibilities | During the last 12 months, I regularlya had to miss a meeting or event at WORK due to home responsibilities | Family or personal matters are interfering with my ability to do my jobb | My career has suffered because of personal issues/obligationsb | I have enough time to get my teaching doneb | I have enough time to get my research doneb | |
|---|---|---|---|---|---|---|
| Overallc | 171 (20.9%) | 83 (10.2%) | 157 (19.0%) | 159 (19.2%) | 596 (72.0%) | 303 (37.3%) |
| 2018 | 109 (22.1%) | 50 (10.1%) | 79 (15.7%) | 89 (17.7%) | 367 (73.0%) | 181 (36.6%) |
| 2021 | 62 (19.1%) | 33 (10.2%) | 78 (24.1%) | 70 (21.5%) | 229 (70.5%) | 122 (38.5%) |
| P-value | 0.314 | 0.965 | 0.003 | 0.173 | 0.434 | 0.581 |
| Female | 81 (20.7%) | 32 (8.2%) | 82 (21.0%) | 91 (23.2%) | 264 (67.5%) | 125 (32.5%) |
| Male | 83 (21.3%) | 49 (12.6%) | 71 (18.2%) | 64 (16.3%) | 299 (76.3%) | 161 (42.2%) |
| P-value | 0.832 | 0.042 | 0.321 | 0.016 | 0.006 | 0.006 |
| Tenured | 78 (20.2%) | 43 (11.1%) | 72 (18.4%) | 75 (19.0%) | 278 (70.9%) | 164 (41.8%) |
| Not tenured | 93 (21.6%) | 40 (9.3%) | 85 (19.5%) | 83 (19.0%) | 317 (72.9%) | 139 (33.2%) |
| P-value | 0.605 | 0.386 | 0.668 | 0.987 | 0.532 | 0.011 |
| Has children ≤18 years | 106 (29.0%) | 67 (18.3%) | 107 (29.3%) | 96 (26.1%) | 259 (71.0%) | 124 (34.2%) |
| No children ≤18 years | 65 (14.4%) | 16 (3.6%) | 50 (10.8%) | 63 (13.6%) | 337 (72.8%) | 179 (39.9%) |
| P-value | <0.001 | <0.001 | <0.001 | <0.001 | 0.561 | 0.095 |
Note: Response rates varied by survey question.
– Includes the following responses: Monthly, weekly, daily
– Includes the following responses: Strongly agree, agree
– Indicates the number and percentage of respondents with affirmative selections.
Compared to those without children less than 18 years, parents of dependent children were more likely to report an imbalance in four of the six measures of work-life balance, including family and personal matters were interfering with their ability to do their job (29.3% vs. 10.8%, p<0.001), their career had suffered due to family or personal obligations (26.1% vs. 13.6%, p<0.001), they regularly missed a meeting at home due to work responsibilities (29.0% vs. 14.4%, p<0.001), and they regularly missed a meeting at work due to home responsibilities (18.3% vs. 3.6%, p<0.001). Finally, respondents who were tenured were more likely than those untenured to report they had enough time to get their research done (41.8% vs. 33.2%, p=0.011).
In multivariable logistic regression almost all of the significant bivariate relationships were again observed. HA faculty respondents in 2021 were more likely to report that family and personal matters were interfering with their ability to do their job than respondents in 2018 (OR = 1.93, p=0.001). Irrespective of year, females more frequently reported that their career had suffered because of personal issues/obligations (OR = 1.82, p=0.003) but were less likely to report having enough time to get their teaching done (OR = 0.68, p=0.026).
Respondents with dependent children reported higher rates of regularly having to miss a meeting or event at home due to work responsibilities (OR = 1.88, p=0.004) and regularly having to miss a meeting or event at work due to home responsibilities (OR = 3.74, p<0.001). Further, respondents with children 18 years or younger more frequently reported that family or personal matters were interfering with their ability to do their job (OR = 3.04, p<0.001) and that their career suffered because of personal issues/obligations (OR = 2.09, p=0.001).
Additionally, faculty who were Black or African American were less likely than whites to report regularly missing a home or work event (OR = 0.41, p=0.018; OR = 0.19, p=0.024, respectively) or that their career has suffered because of personal issues or obligations (OR = 0.44, p=0.030). Those who were married (OR = 0.50, p=0.034) and those over 50 (OR = 0.42, p=0.008) were less likely to report family or personal matters were interfering with their ability to do their job.
Finally, while we examined interaction terms in the model, we observed no statistically significant relationships (data not shown), suggesting that while overall work-life balance deteriorated from 2018 to 2021, no group had a steeper decline.
DISCUSSION
Compared to the pre-pandemic period, we found that overall, faculty members reported an increase in family and personal issues interfering with their ability to do their job in 2021 while the pandemic was still in effect. We further found that, compared to their counterparts, females and parents of dependent children had overall worse work-life balance in 2018 which persisted into the time period during the pandemic. Work-life balance has implications to important organizational outcomes, such as turnover and job dissatisfaction (Beckett et al., 2015; Mache et al., 2016; Shollen et al., 2009). Thus, given that faculty experienced work-life balance disruptions during the pandemic, one could expect worsening individual well-being and future adverse organizational outcomes. A cross-sectional survey of medical, graduate and health professions faculty at the University of Texas Southwestern reported that due to the pandemic, more faculty were considering leaving their job or reducing their employment, in part due to conflicts in work-life balance and increased occupational stressors (Matulevicius, Kho, Reisch, & Yin, 2021). In the same survey, faculty reported decreased productivity and delayed manuscript submissions attributable to the pandemic. As a result, some faculty have expressed concern about their failure to meet benchmarks for promotion and tenure (Arora et al., 2021). Determining how disruptions during the pandemic affected productivity, job satisfaction, and perceptions of burnout, was outside the scope of this current study. Nevertheless, these outcomes have important implications for individual well-being and organizations and should be considered in future research.
Similar to our findings, several studies evaluating the pandemic’s impact on academics found females and parents are facing greater work-life challenges (Aubry et al., 2021; Del Boca et al., 2020; Matulevicius et al., 2021; Bernard & Lauer, 2021). In our study, having children under the age of 18 was the strongest predictor, based on magnitude, of work-life imbalances in 4 of the 6 outcomes examined. School closings and shifts to online learning during the pandemic undoubtedly had an effect on faculty who are parents, and in particular mothers. Compared to fathers, mothers working outside of the home tend to take on a greater number of childcare and household responsibilities (Jones et al., 2020; Kazley et al., 2016; Staniscuaski et al., 2020) and our findings among health administration faculty have been seen in other disciplines as well (Arora et al., 2021; Feyman, Fener, & Griffith, 2021; Jones et al., 2020). The compounding effects of work-life imbalance prior to and during the pandemic among females and parents could lead to greater adverse outcomes downstream, such as greater gender inequities and negative impacts on career advancement (Oleschuk, 2020). Further, these stressors on work-life balance may lead to challenges for leadership pipelines, as women and parents are less likely to seek and hold leadership positions (Matulevicius et al., 2021). Interestingly we found Black and African-American faculty were less likely than whites to report missing events at home or work and less likely to report that their career has suffered. These observations were unexpected but raise questions that should be investigated. It may be that these observed relationships are random, or it may be that these faculty are sufficiently supported in their existing faculty positions. More research using mixed-methods or qualitative approaches are needed to understand these findings further to test these conjectures.
Careful thought should be given to strategies and policies that could alleviate work-life balance concerns for faculty during and following the pandemic, with particular consideration towards females and parents with caregiving responsibilities. Other factors may modify the effect of the pandemic on work-life balance, such as those at the organizational-level, including student-faculty ratio, whether the university is public or private, or whether the educational program is undergraduate only, graduate only or both. While the survey tool used for this study cannot provide input on desired solutions to the pandemic’s impact on work-life balance, many leaders and institutions are recommending formal policy responses. For instance, some have suggested modernizing tenure and promotion and reevaluating how faculty meet benchmarks given the ongoing strenuous environment brought on by COVID-19 (Arora et al., 2021; Oleschuk, 2020). Recommendations include extension of faculty tenure-clocks, greater research and teaching support to affected faculty, pausing nonessential scholarship and service, and building diverse task forces to inform university decision-making processes which represent those disproportionally affected by the pandemic (Arora et al., 2021; Aubry et al., 2021; Oleschuk, 2020). Similarly, funding agencies have also considered greater support for academics with caregiving responsibilities and deadline extensions for grant proposals and reports (Oleschuk, 2020; Staniscuaski et al., 2020). Other organizational strategies, such as flexible remote working policies or extra parental leave, may prove beneficial to maintaining a healthy work-life balance environment (Del Boca et al., 2020). Importantly, while some institutions have already implemented some of these approaches (“COVID-19 and Tenure Review”, 2020; “Promotion/Tenure Clock Extensions Due to COVID-19”, 2020), we know very little their impact and whether they are helpful. Thus, future work should examine which strategies have been most effective and for whom. For instance, while extending the tenure clock may address work-life disruptions among pre-tenured faculty, this policy may not be as useful for tenured faculty. Notably, our findings suggest tenured faculty have been able to find time to work on their research, even during the pandemic. Thus, these faculty may need other policy approaches, such as seed-funding to re-start research, to address other disruptions to their work-life balance beyond time. For some faculty, working from home reduces commuting time to allow for more flexibility and opportunity to work on teaching, research, or addressing personal obligations. Still other faculty may feel that better child care or after-school resources at work or in their communities is needed to address imbalances in their work-life. We recommend additional research on these policy approaches, particularly among female faculty and faculty with children, to better inform the decision-making of administrators and intuitional leaders.
While this study was the first to consider how work-life balance has changed prior and during the pandemic among a national group of health administration faculty working in diverse university settings, there are important limitations to note. Given our study design, the relationships described can only be interpreted as associations. The anonymous nature of our survey data does not allow for analytical techniques with stronger causal inference, nor can we account for repeated observations among respondents across survey waves. In addition, we note the lower response rate during the 2021 survey potentially due to the pandemic’s impact on faculty workload and limited free time for volunteer questionnaires. If this lower response rate in 2021 is due to increased workloads, our results may underestimate the effect of the pandemic on work-life balance. Responses are also self-reported and may be subject to recall or social desirability bias. Our survey tool did not collect data on spousal or familial support during the pandemic, and notably children past the age of 18 still have unique parental challenges that were not captured in our analyses. Finally, outcomes measured in the current study are proxies for work-life balance and are not exhaustive. Nevertheless, a key strength of the study is that we examined changes in work-life balance from 2018 to 2021 in six different measures, all of which are relevant to university faculty members and organizations.
In conclusion, health administration faculty were more likely to report work-life imbalance during the pandemic compared to a previous national survey of this group. Females and parents of children under the age of 18 were more likely to report work-life conflicts prior to and during the pandemic. Institutional leaders and policymakers have an opportunity to consider immediate and long-term solutions to mitigate the effects of pandemic related disruptions on the work-life balance of academics.
Table 3:
Adjusted relationship between measures of work-life balance and individual health administration faculty characteristics
| MODEL 1 | MODEL 2 | MODEL 3 | MODEL 4 | MODEL 5 | MODEL 6 | |
|---|---|---|---|---|---|---|
| Regularly had to miss a meeting or event at HOME due to work responsibilitiesa (N=758) |
Regularly had to miss a meeting or event at WORK due to home responsibilitiesa (N=752) |
Family/personal matters are interfering with the ability to do my jobb (N=755) |
My career has suffered because of personal issues/obligationsb (N=757) |
I have enough time to get my teaching doneb (N=761) |
I have enough time to get my research doneb (N=744) |
|
| Characteristic | OR (C.I.) | OR (C.I.) | OR (C.I.) | OR (C.I.) | OR (C.I.) | OR (C.I.) |
| 2021 (vs. 2018) | 0.87 (0.60–1.26) | 0.98 (0.59–1.63) | 1.93 (1.31–2.83)*** | 1.33 (0.91–1.94) | 0.93 (0.65–1.24) | 1.17 (0.85–1.59) |
| Female | 0.96 (0.66–1.39) | 0.67 (0.40–1.12) | 1.32 (0.89–1.97) | 1.82 (1.22–2.69)** | 0.68 (0.45–0.88)* | 0.73 (0.53–1.01) |
| Has children ≤18 years | 1.88 (1.23–2.87)** | 3.74 (1.94–7.21)*** | 3.04 (1.91–4.82)*** | 2.09 (1.34–3.24)*** | 1.14 (0.66–1.28) | 0.87 (0.61–1.24) |
| Race | ||||||
| White | Reference | Reference | Reference | Reference | Reference | Reference |
| Black/African American | 0.41 (0.20–0.86)* | 0.19 (0.04–0.81)* | 0.85 (0.44–1.63) | 0.44 (0.21–0.92)* | 1.43 (0.81–2.53) | 1.12 (0.67–1.88) |
| Asian | 0.44 (0.20–0.97) | 0.40 (0.14–1.18) | 0.90 (0.44–1.83) | 0.70 (0.33–1.47) | 1.17 (0.63–2.17) | 1.29 (0.73–2.29) |
| Other or unknown | 1.07 (0.11–10.50) | - | - | - | 1.51 (0.16–14.00) | 1.06 (0.17–6.58) |
| Age | ||||||
| 20s-30s | Reference | Reference | Reference | Reference | Reference | Reference |
| 40s | 1.23 (0.67–2.25) | 0.94 (0.44–1.99) | 0.70 (0.39–1.26) | 1.62 (0.86–3.05) | 1.16 (0.67–2.10) | 0.61 (0.35–1.04) |
| 50s | 1.13 (0.61 –2.10) | 0.60 (0.26–1.38) | 0.42 (0.22–0.80)** | 1.09 (0.56–2.13) | 0.99 (0.57–1.71) | 0.51 (0.30–0.89) |
| 60s and over | 0.55 (0.28–1.08) | 0.41 (0.16–1.05) | 0.47 (0.24–0.91)* | 0.97 (0.49–1.95) | 1.95 (1.09–3.49) | 0.95 (0.55–1.63) |
| Unknown age | 1.19 (0.54–2.63) | 1.33 (0.49–3.60) | 1.28 (0.60–2.74) | 1.92 (0.86–4.29) | 1.52 (0.73–3.18) | 0.80 (0.40–1.60) |
| Currently married | 0.71 (0.40–1.33) | 0.30 (0.09–1.00) | 0.50 (0.26–0.95)* | 0.80 (0.46–1.40) | 1.11 (0.71–1.75) | 0.82 (0.53–1.27) |
| Tenured | 0.92 (0.63–1.33) | 1.31 (0.79–2.18) | 0.97 (0.65–1.44) | 0.98 (0.67–1.44) | 0.86 (0.62–1.20) | 1.54 (1.13–2.11)** |
p<0.05
p<0.01
p<0.001
Includes the following responses: Monthly, weekly, daily
Includes the following responses: Strongly agree, agree
ACKNOWLEDGEMENT:
Research reported in this publication was in part supported by the National Library of Medicine of the National Institutes of Health under award number T15LM012502. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the National Library of Medicine.
Footnotes
All authors have no potential conflicts of interests to report.
Contributor Information
Heather Taylor, Department of Health Policy and Management, Indiana University, Fairbanks School of Public Health, 1050 Wishard Blvd, Indianapolis IN 46202.
Casey P. Balio, East Tennessee State University College of Public Health, Center for Rural Health Research, Department of Health Services Management and Policy.
Ashley S. Robertson, Fairbanks School of Public Health, 1050 Wishard Blvd, Indianapolis IN 46202.
Nir Menachemi, Fairbanks Endowed Chair and Professor of Health Policy and Management, Indiana University, Fairbanks School of Public Health, Scientist, Regenstrief Institute, Inc..
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