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Multistakeholder Community Collaborative Spurs Development of Initiatives That Collectively Have Improved Blood Pressure Control Among Hypertensive Individuals


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Summary

A collaboration of the Rochester Business Alliance, the regional Chamber of Commerce and its health care team, the Finger Lakes Health Systems Agency, the primary care practice community, and more than 60 community organizations with more than 120 volunteers, the Rochester Blood Pressure Collaborative encourages and supports the development of programs to improve blood pressure control in metropolitan Rochester, NY. After the partners defined primary and secondary goals for the program, a series of workgroups design and support implementation of initiatives within provider organizations, employers, and community-based organizations. Early evidence suggests that this collaborative program has spurred implementation of a variety of promising initiatives at provider, employer, and community sites; has attracted growing interest from primary care physicians and their patients; and has increased the proportion of hypertensive patients who have achieved blood pressure control.

Evidence Rating (What is this?)

Moderate: The evidence consists of examples of various initiatives that have been spurred by the collaborative, along with trends and pre- and post-implementation comparisons of various metrics, including the number of participating practices and patients seen by these practices, and blood pressure control among hypertensive adults.
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Developing Organizations

Finger Lakes Health Systems Agency; Rochester Business Alliance
Collaborative participants include more than 120 health care, employer, and community volunteers representing more than 60 diverse community organizations, including the following:
  • Providers: Rochester General Health System, Unity Health System, University of Rochester Medical Center Primary Care Network, Highland Family Medicine, Rochester General Hospital Twig Practice, Lifetime Healthcare, Anthony L. Jordan Health Center, Westside Health Service, Greater Rochester Independent Practice Association, Jefferson Family Medicine, and Evergreen Family Medicine.
  • Employers: Bausch and Lomb, Eastman Kodak, Jasco Tools, Kodak, Paychex, Rochester Institute of Technology, Wegmans Food Markets, LiDestri Foods, and Xerox Corporation.
  • Other organizations: The Finger Lakes Health Systems Agency, the Chamber of Commerce for the greater Rochester area, United Way of Greater Rochester, University of Rochester Center for Community Health, Excellus Health Plan, Rochester Institute of Technology, MVP Healthcare, the Greater Rochester Health Foundation, and many churches and other community-based organizations.
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Date First Implemented

2009

Problem Addressed

Hypertension, defined as a sustained blood pressure of at least 140/90 millimeters of mercury (mm Hg),1 is a prevalent and deadly health problem in the United States. Many hypertensive patients fail to keep their blood pressure under control. Population-based interventions have the potential to address this problem, but implementation has proven difficult.
  • High prevalence, deadly consequences: A Centers for Disease Control and Prevention (CDC) analysis found that almost 29 percent of the U.S. population has hypertension, with prevalence being higher among women and increasing with age.2 In the United States, hypertension contributes to one of every seven deaths overall and to almost one-half of all cardiovascular-related deaths.3
  • Largely uncontrolled: Only approximately one-half of patients with hypertension have it under control as a result of diet, exercise, or pharmacologic treatment.4 Only 69 percent of hypertensive individuals receiving treatment from a primary care physician have the condition under control.5
  • Unrealized potential of population-based strategies: Approaches to chronic disease management such as Wagner’s chronic disease model emphasize the need to engage all community stakeholders to improve outcomes in conditions such as hypertension.6 Few communities have successfully established such engagement, however, and been able to develop and implement coordinated, multistakeholder initiatives to improve blood pressure control.6

What They Did

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Description of the Innovative Activity

A collaboration of the Rochester Business Alliance, the regional Chamber of Commerce and its health care team, the Finger Lakes Health Systems Agency, the primary care practice community, and more than 60 community organizations with more than 120 volunteers, the Rochester Blood Pressure Collaborative encourages and supports the development of programs to improve blood pressure control in metropolitan Rochester, NY. After the partners defined primary and secondary goals for the program, a series of workgroups design and support implementation of initiatives within provider organizations, employers, and community-based organizations. Key program elements are detailed below:
  • Primary and secondary goals: The partners set two primary and six secondary goals for the program, with progress in meeting them to be measured on a regular basis.
    • Primary goals: 
      • Fewer admissions: The partners set a goal of reducing the rate and number of hospital admissions for heart attack, heart failure, stroke, and dialysis initiation by 5 percent a year between 2011 and 2017 for adults residing in metropolitan Rochester (Monroe County, NY).
      • Greater blood pressure control: The partners set the goal of increasing the proportion of hypertensive adult patients (defined as patients seen in participating practices who have been diagnosed with high blood pressure in the past 3 years) achieving blood pressure control (defined as a reading of less than 140/90 mm Hg at the last office visit) from 62.7 percent in 2010 to 85 percent by 2020.
    • Secondary goals: 
      • Reduce annual health care costs for patients with hypertension (with a specific target to be determined after an analysis of health plan data).
      • Increase the number and proportion of adults who know their blood pressure and whether it is low, normal, or high.
      • Increase the proportion of adults who get their blood pressure checked regularly.
      • Increase the proportion of hypertensive adults who receive care from a participating practice.
      • Increase the number of people who seek care or implement strategies to manage their blood pressure.
      • Increase the number and percentage of practicing primary care physicians who actively engage in the program.
  • Multistakeholder workgroups to support program development, implementation: Multistakeholder workgroups take charge of developing action plans to address various barriers and opportunities related to blood pressure control. Workgroups focus on identifying and disseminating best practices, practitioner education, consumer/patient behavior change, community engagement, encouraging healthy worksites, monitoring and improving metrics and measures, and communication. Each workgroup creates a proposal and action plan within its area of focus, and then works with providers, employers, and community organizations to support implementation of the plan. Examples of workgroup activities are outlined below:
    • Best practices: This workgroup created a communitywide hypertension registry containing de-identified clinical data on more than 90,000 residents of greater Rochester (more than one-half of the estimated 172,000 residents with high blood pressure). The registry provides peer comparison data to participating practices and tracks the number of patients diagnosed with hypertension, the number and percentage of hypertensive patients not seen in the past 13 months, and the number and percentage who have reached their target blood pressure. Committee members reviewing the data identified “clinical inertia” as contributing to differences in physician and practice behaviors. In response to the data, the committee developed and operationalized training and outreach of practice improvement consultants (physicians, physician assistants, and pharmacists) who share data with practices and offer encouragement and suggestions to address this problem. They collect and share best practices, encourage team-based solutions to delivering high-quality chronic disease care, and report back to health system leaders on what support the practices need to improve outcomes. The consultants completed training in September 2012 and as of March 2013 had conducted more than 30 visits to practices.
    • Community engagement: This workgroup conducted a survey of 1,980 individuals (oversampling the African-American and Latino communities); it found that residents knew about the dangers of hypertension and the value of treatment but did not know how to make the necessary lifestyle changes to control blood pressure. With data suggesting the outcomes of high blood pressure are worse in the African-American and low-socioeconomic communities, the workgroup targeted community institutions in African-American and low-income communities (e.g., churches, barbershops and hair salons, pharmacies, community centers) for outreach and programs related to lifestyle changes. The Finger Lakes Health System Agency African-American Coalition has overseen the effort. In March 2013, a "blood pressure challenge" was issued that encourages residents to know their blood pressure and seek care if it is elevated.
    • Behavior change: This workgroup met with local behavior change experts and motivational psychologists who suggested that initiatives incorporate the concepts of building competence, encouraging autonomy, creating a sense of community, and building on a set of explicit common values. This workgroup vets each initiative in the project to ensure that these concepts have been integrated into the design and implementation.
    • Physician education: This workgroup worked with an American Society of Hypertension–designated specialist to provide physicians in participating practices with education about hypertension guidelines and their implementation through expert presentations, grand rounds, and conferences. The workgroup is currently identifying primary care physicians who wish to obtain education and pass the American Society of Hypertension examination so that they can serve as community resources.
    • Workplace wellness: This workgroup initiated a project in which employees learn more about high blood pressure and its treatment at their worksite. In executing this initiative, workgroup members learned that employees tend to be comfortable with support intended to help them receive care, but less comfortable having that support provided at the workplace. As a result, this workgroup has shifted its focus to placing blood pressure kiosks on site to make it easy to measure blood pressure, having information about hypertension available at the worksite, and incorporating blood pressure measurement into the Eat Well Live Well program developed and disseminated by Wegmans Food Markets; this program encourages healthy behaviors such as counting steps and eating more fruits and vegetables, with various work places competing on the results.
    • Metrics and measures: This workgroup collaborated with the Finger Lakes Health Systems Agency to define indicators to be used in the hypertension registry.
    • Communication: This workgroup conducted the initial population survey and has been crafting an integrated communications plan that will distribute information about high blood pressure to all participating groups. As part of this effort, the group is developing a public relations campaign that will celebrate project successes throughout the community.
  • Community performance report: The project plans to distribute a report twice each year to participating practices and committee participants that outlines progress toward the primary goal of better blood pressure control and select secondary goals, including increasing the number of new patients being seen in participating practices and reducing the number diagnosed with hypertension who have not been seen in the past 13 months.

Context of the Innovation

Monroe County, NY, which includes the city of Rochester, has a population of 575,000. The Rochester Business Alliance includes representatives from Bausch and Lomb, Jasco Tools, Kodak, Paychex, Rochester Institute of Technology, Wegmans Food Markets, LiDestri Foods, and Xerox Corporation. The Finger Lakes Health Systems Agency is an independent community health planning organization that seeks to reduce health disparities in nine counties in upstate New York.

In 2008, Thomas DiNapoli, the Comptroller of New York state, asked the Rochester Business Alliance to investigate strategies to promote community health in a way that was scalable across the state. The alliance had previously created a team to address increasing health care costs, and this team took charge of the effort. After extensive research, the team determined that a population-based approach would be required to improve health and reduce costs. The team chose hypertension as a first target based on community feedback, the existence of evidence-based guidelines for care, the availability of cost-effective treatment, and the clear link between treatment and lower morbidity and mortality. The Rochester Business Alliance asked the Finger Lakes Health System Agency (which had strong ties with multiple community stakeholders) to jointly lead the effort.

Did It Work?

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Results

Early evidence suggests that this collaborative program has spurred implementation of a variety of promising initiatives at provider, employer, and community sites; has attracted growing interest from primary care physicians and their patients; and has increased the proportion of hypertensive patients who have achieved blood pressure control.
  • Many promising initiatives: The program has encouraged providers, employers, and community-based organizations to put in place a variety of promising programs that have the potential to improve blood pressure control among hypertensive residents of metropolitan Rochester. Examples are outlined below:
    • Provider initiatives: Providers in 80 practices and other care settings (most of which are part of 3 major health systems—University of Rochester Health System, Rochester General Health System, and Unity Health System) have agreed to participate in the program and implement the strategies and action plans developed by the workgroups. These providers collectively include roughly 40 percent of metropolitan Rochester's primary care providers, who care for approximately one-half of the county’s adults. Examples of implemented strategies include the following:
      • Blood pressure registry: Every 6 months, providers submit a spreadsheet with de-identified patient data to Finger Lakes Health Services Agency, which then enters the information into a registry of hypertensive patients. The blood pressure registry has become quite popular among participating physicians, as it contains 94,000 patients as of December 2012, up from 74,000 in 2010. By the end of 2013, program leaders expect the registry to contain information on 130,000 individuals. Practices routinely use the registry to identify hypertensive patients who have not recently been seen or have not reached their blood pressure goal and then proactively encourage them to come in for care.
      • Trained community health workers in inner-city clinics: As part of a pilot program operated in partnership with the University of Rochester Medical Center’s Center for Community Health, four inner-city primary care clinics have agreed to have trained health workers known as blood pressure advocates work as part of the care team. Blood pressure advocates talk with patients about monitoring and managing their hypertension and link them with community resources. Blood pressure advocates live in the communities they serve and have been trained by the Center for Community Health.
    • Employer initiatives: After a successful 2-year demonstration project held at six work sites, a number of area employers agreed to let employees volunteer to participate in a nine-module training program led by the Finger Lakes Health Services Agency. After completing the program, these employees oversee an onsite education program using a set curriculum at their employer site. These volunteers help hypertensive colleagues set goals related to lifestyle changes and share information about healthy choices. Employees also self-monitor their blood pressure at onsite kiosks in the workplace. Individual employers have also developed and implemented a variety of hypertension-related activities through existing employee wellness programs.
    • Community-based initiatives: Several community-based strategies have been implemented to help county residents, particularly low-income individuals and families, understand and alter their hypertension-related lifestyle behaviors. Examples include the following:
      • Community health ambassadors: Individuals in community organizations with an interest in health and wellness also go through the Finger Lakes Health Services Agency training program, and then serve as “ambassadors” in local workplaces and community groups, such as churches, barbershops and hair salons, pharmacies, and community centers. Ambassadors reach out formally and informally to community members, educating them about the dangers of hypertension, lifestyle modification and prevention strategies, and goal setting.
      • Health screenings: Clinicians offer health screenings and participate in a variety of health fairs and community and school events.
  • Growing interest from providers and patients: Between 2010 and 2012, the number of participating providers actively engaged in the program increased by 39 percent, from 210 to 292. Over the same time period, the number of hypertensive adults receiving care at participating practices grew by 56 percent, from 56,810 to 88,884. A growing number of these patients have initiated care for hypertension for the first time. In fact, the number of new patients diagnosed with hypertension by a participating practice in the past 6 months more than doubled between 2010 and 2011, from 460 to 924. (2012 data are not yet available.)
  • Better blood pressure control: The proportion of hypertensive adult patients achieving blood pressure control increased by 6.4 percent, from 62.7 percent in 2010 to 66.7 percent in 2012.

Evidence Rating (What is this?)

Moderate: The evidence consists of examples of various initiatives that have been spurred by the collaborative, along with trends and pre- and post-implementation comparisons of various metrics, including the number of participating practices and patients seen by these practices, and blood pressure control among hypertensive adults.

How They Did It

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Planning and Development Process

Selected steps included the following:
  • Approaching community stakeholders: Representatives from the Rochester Business Alliance and the Finger Lakes Health System Agency approached representatives of community organizations (including health systems, physician groups, pharmacist groups, the American Heart Association, the American Diabetes Association, and others) to gauge their interest in participating.
  • Forging formal agreement among partners: The Rochester Business Alliance signed a partnership agreement with the Finger Lakes Health Services Agency that defined the initiative’s overall goals and specified the roles and responsibilities of each entity.
  • Creating and expanding leadership team: The project created a leadership team that included representatives from the Rochester Business Alliance, the regional Chamber of Commerce for the Rochester area and its health care team, which initially included representatives from Wegmans Food Markets, Xerox, Eastman Kodak, Bausch & Lomb, Rochester Institute of Technology, Paychex, LiDestri Foods, and the Finger Lakes Health Systems Agency, and then later expanded to include representatives from Excellus Health Plan, MVP Healthcare, the University of Rochester Medical Center, Unity Health System, Rochester General Health System, the United Way of Rochester, University of Rochester Center for Community Health, and the Greater Rochester Health Foundation. The team also includes representatives from the various workgroups described earlier. The team met and continues to meet on a weekly basis for 2 hours, and engages in additional discussions between meetings to develop approaches to improving the value of health care in the region.
  • Adopting established theory to guide initiatives: The leadership team turned to Self-Determination Motivation Theory as a guiding principle for the various initiatives. This theory proposes that human internal motivation is encouraged by participants experiencing the project as supporting their competence, autonomy, and relatedness with respect to behaving in healthier ways.7
  • Adopting multifaceted approach: The leadership team also embraced the notion that successfully addressing chronic illness requires multifaceted interventions. The intent is that those with high blood pressure will hear a common message encouraging lifestyle change and coordinated management of hypertension from multiple people and institutions that influence their lives, including their doctors, employer, pastor, neighbors, barber/hairdresser, teachers, community centers, and the local media (television and radio stations). The project is built on the notion that improving outcomes for patients with high blood pressure requires increasing patient involvement and empowerment in the care process; creating primary care practice environments that support and encourage a more collaborative, responsive model of care; and providing community support systems to reinforce the value of behavior change and proper medical followup.

Resources Used and Skills Needed

  • Staffing: The Finger Lakes Health Services Agency employs 4.75 full-time-equivalent (FTE) staff who work on the Rochester Blood Pressure Initiative; these include 3 full-time individuals—a senior program manager, communications manager, and community engagement coordinator—along with a part-time worksite coordinator, medical director, data analyst, and administrative assistant. In addition, 3.5 FTE blood pressure advocates work in 4 medical practices. Finally, many employees at the partner organizations work on the blood pressure initiative as part of their regular job responsibilities, while hundreds of individuals volunteer their time to the program.
  • Costs: Data on program costs are unavailable.
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Funding Sources

Centers for Disease Control and Prevention; New York State Department of Health; Wegman Family Charitable Foundation; New York State Economic Development Council
The majority of funding comes from the Wegman Family Charitable Foundation, which provided initial funding of $200,000 for development and additional funding in the amount of $1,200,000 to implement the project. The foundation has also developed a plan to attract additional funding to maintain the project through 2014. Other supporters include the New York State Department of Health (which funds a portion of the worksite coordinator position); CDC (which pays for the full-time community engagement coordinator through a grant), and the New York State Economic Development Council (which funds the blood pressure advocate positions).end fs

Tools and Other Resources

National Heart, Lung, and Blood Institute. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure—Complete Report. 2003 Dec. Available at: http://www.nhlbi.nih.gov/guidelines/hypertension.

Torre JJ, Bloomgarden ZT, Dickey RA, et al. American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the diagnosis and treatment of hypertension. Endocr Pract. 2006;12(2):193-222. [PubMed]

Kaiser Permanente Care Management Institute. Hypertension guidelines. Oakland (CA): Kaiser Permanente Care Management Institute. 2005 Jun.

Adoption Considerations

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Getting Started with This Innovation

  • Enlist support of business community: Providers may underestimate the value of business community participation in this type of effort. Employers can play an important role in addressing hypertension, given their vested interest in promoting the health of their employees and their desire to manage health care costs. Many employers will devote financial or in-kind resources to a blood pressure initiative, and will incorporate blood pressure control programs into existing worksite programs.
  • Develop multifaceted intervention: Multifaceted interventions tend to be more effective than standalone programs in promoting blood pressure control, as use of multiple sites and programs make it more likely that educational messages and support programs will reach and resonate with hypertensive individuals. For this initiative, collaboration with the business community, providers, and community resources has also resulted in a deepening of relationships and a building of trust that has enabled the formation of successful partnerships.
  • Support physician efforts to improve hypertension: Physicians want to help patients improve blood pressure control but may not know how to do so. Providing onsite consultations with other clinicians can help physicians learn to implement effective programs. In addition, physicians appreciate that patients are hearing consistent messages outside the walls of the doctor’s office, making them more likely to undertake recommended lifestyle changes.
  • Assign data registry responsibility to neutral party: Having a neutral party (in this case, the Finger Lakes Health Services Agency) administer the data registry ensures that providers feel comfortable sharing data and view the initiative as a quality improvement program, not a competition.
  • Share data through (at least) annual reports: Distributing reports on an annual or biannual basis to participating practices and committee participants helps to maintain momentum for the program by highlighting progress toward established goals and allowing key stakeholders to identify the biggest opportunities for improvement.

Sustaining This Innovation

  • Commit to frequent partner meetings: As noted, partner representatives meet every week for 2 hours to monitor program activities and results and discuss potential program enhancements. These meetings help keep the initiative on the “radar screens” of busy executives. Program developers believe that much of this program's success and growth is due to the willingness of these partners (at the individual and organizational level) to commit time and resources to the effort.
  • Build on successes: Small successes help build trust among participating employers and provider groups, enabling the development of more complex initiatives over time.
  • Reinforce value of blood pressure control to physicians: To maintain provider enthusiasm for the program, the leaders of participating medical groups should regularly emphasize the value of hypertension control with frontline physicians. For example, Rochester medical group leaders share data about medical group performance at practice meetings and recognize individual physicians who do a good job in helping their patients achieve better control.
  • Refine and improve data sharing and reporting over time: Program developers are currently undertaking efforts to produce a community dashboard that will report outcomes from the various initiatives. Developers also continue to refine data-sharing systems to address ongoing challenges related to the control of incoming data. These challenges include expanding the number of practices submitting data, creating and calculating a rolling average (which makes comparisons difficult), working with practices that change electronic medical record systems (which often results in lost data), and dealing with practices that treat data submission as a low priority (which often results in delays or submission of data that require significant "cleansing").

More Information

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Contact the Innovator

Lawrence M. Becker
Director, Strategic Partnerships and Alliances
Chairman, Plan Administration Committee
Corporate Human Resources
Xerox Corporation
100 Clinton Avenue South
XRX2 – 027
Rochester, NY 14644
(585) 423-5653
E-mail: lawrence.becker@xerox.com

Howard Beckman, MD, FACP, FAACH
Director, Innovative Strategies
Finger Lakes Health Systems Agency
Clinical Professor of Medicine and Family Medicine
University of Rochester School of Medicine and Dentistry
1150 University
Rochester, NY 14607
(585) 224-3123
E-mail: howardbeckman@flhsa.org

John D. Bisognano, MD, PhD
Professor of Medicine
University of Rochester
601 Elmwood Avenue
Box 679-7
Rochester, NY
(585) 273-2422
E-mail: john_bisognano@urmc.rochester.edu

Al Bradley
Project Manager, High Blood Pressure Collaborative
Finger Lakes Health Systems Agency
1150 University
Rochester, NY 14607
(585) 244-3109
E-mail: albradley@flhsa.org

Innovator Disclosures

Mr. Becker, Dr. Beckman, Dr. Bisognano, and Mr. Bradley reported having no financial interests or business/professional affiliations relevant to the work described in the profile, other than the funders listed in the Funding Sources section.

References/Related Articles

Bisognano JD, Speranza PS, Becker LM, et al. Creating community collaboration to improve the care of patients with high blood pressure: lessons from Rochester, New York. J Clin Hypertens. 2012;14(3):178-83. [PubMed]

Beckman H. The FLHSA/RBA Community High Blood Pressure Collaborative Update. 2012 Dec. PowerPoint presentation.

Egan BM, Zhao Y, Axon RN. US trends in prevalence, awareness, treatment, and control of hypertension, 1988-2008. JAMA. 2010;303:2043-50. [PubMed]

Ryan RM, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. Am Psychol. 2000;55:68-78. [PubMed]

Footnotes

2 Centers for Disease Control and Prevention. Racial/ethnic disparities in prevalence, treatment, and control of hypertension—United States, 1999-2002. MMWR Morb Mortal Wkly Rep. 2005;54(1):7-9. [PubMed]
3 Gillespie C, Kukline EV, Briss PA, et al. Vital signs: prevalence, treatment and control of hypertension, United States, 1999-2002 and 2005-2008. MMWR Morb Mortal Wkly Rep. 2011:60:103-8. [PubMed]
4 Centers for Disease Control and Prevention, National Institutes of Health. Heart disease and stroke. In: Healthy people 2010: objectives for improving health. Available at: http://www.cdc.gov/dhdsp/docs/hp2010.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).
5 Egan BM, Zhao Y, Axon RN. US trends in prevalence, awareness, treatment, and control of hypertension, 1988-2008. JAMA. 2010;303:2043-50. [PubMed]
6 Bisognano JD, Speranza PS, Becker LM, et al. Creating community collaboration to improve the care of patients with high blood pressure: lessons from Rochester, New York. J Clin Hypertens. 2012;14(3):178-83. [PubMed]
7 Ryan RM, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. Am Psychol. 2000;55:68-78. [PubMed]
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Original publication: July 31, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 31, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.