Primary Care

Primary Care

  • Patricia Welch Saleeby added an answer:
    Can anyone help with a review of epidemiological studies on interventions for control of diabetes in primary care setup in rural areas?

    Need interested researchers willing to collaborate on a Review of Epidemiological Studies on interventions for control of Diabetes in primary care setup in rural areas

    Patricia Welch Saleeby · Southern Illinois University Carbondale

    I am interested. This article might help you:

    http://care.diabetesjournals.org/content/30/7/1912.full

  • John Lennox Campbell added an answer:
    Does anyone know of good papers regarding implementation of clinical decision support systems in primary care?
    Looking at good (and bad!) examples of successful CDSS implementation in primary care/general practice
    John Lennox Campbell · University of Exeter

    ESTEEM full report:

    http://www.nets.nihr.ac.uk/projects/hta/085315

    Published paper in Lancet

    http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2961058-8/abstract

  • Closed account added an answer:
    How to manage a patient with diabetic neuropathy in primary care?
    Neuropathy is one of the major complication in diabetes mellitus type 2. What can be done for a patient with this condition in a primary care setting besides management for blood glucose control? How effective can it be in affecting the prognosis of complication process?
    Deleted · University of Science Malaysia

    All Type II DM patients will get periphery neuropathy one day, despite optimum blood glucose control, just a matter of duration. Blood sugar control by HbA1c is so far the best way to tightly control the blood sugar profile from most literatures and studies. 

  • Susan Wortman-Jutt added an answer:
    Should we routinely screen for depression?

    Depression is a mood disorder that affects the way a person feels, thinks or behaves, which may impair social or occupational functioning, also depression is common in primary care and hospital settings, but it is often not recognised by healthcare professionals. Because depression is potentially treatable, there has been interest in screening patients who present to primary care settings. This has led to calls for screening programmes to aid detection and management.
    Multiple recommendations for clinicians for screening for depression in adults have been published. But the existing evidence on depression screening recommendations are far from unanimously accepted.

    Susan Wortman-Jutt · Burke Rehabilitation Hospital

    In my clinical experience, patients with neurological disorders of almost any kind will benefit from counseling for coping strategies, whether they are formally diagnosed with depression or not, and regardless of whether they're taking anti-depressants (which are also a valuable tool).  I think screening is an excellent idea.  I would add that many people with neurological illnesses are suffering from grief, whether or not it is formally classified as depression.  Patients may be grieving the loss of independence, status, employment, relationships -- the life they knew before their diagnosis.  My subjective observation is that patients who do not find strategies for coping with their loss, will not do as well therapeutically.  So I would say "yes" to screening, but I wouldn't stop there.  Counseling would be a beneficial part of treatment for anyone suffering from a neurological illness, even if criteria for a diagnosis of depression is not met and medications are not necessary..

  • Alan T Kaell added an answer:
    How much do demographic shifts contribute, compared to non-demographic factors, to health care spending in high income countries?

    I would appreciate key reviews/summaries and published/unpublished manuscripts - looking at for example, ageing, expectations, population growth, time-to-death versus inappropriate use of expensive technology, health care practices, etc.

    For example, see

    Atella, et al. The effect of age and time to death on primary care costs: the Italian experience. Soc Sci Med. 2014;114:10-7. 

    Blakely et al. Health system costs by sex, age and proximity to death, and implications for estimation of future expenditure. NZ Med J. 2014;127(1393):12-25.

    Alan T Kaell · Stony Brook University

    Great question !

    As yet, I don't think we know the correlations or % contributions of demographics shifts and non demographic factors as they relate to health care spending.  Both of these broad factors likely have correlation. However, the categories are likely not to be truly independent of one another and therefore how each component in each catergory influences the other may be important. In addition, the shifts in both demographic factors and non-demographic factors may ultimately lead to changes in health care spending that evolve in different directions (even opposite) depending upon the changes in culture and societal and ultimately individual expectations, beliefs and attitudes toward health care spending /utilization.  The latter usually correlate positively, but policy may be likely important factors in ultimately determining changes in spending and/or utlization over time.  Media and governmental roles also contribute and what may be measured a a change over time could be mistakenly attributed to both demographic and non-demographic changes.

  • Andrei Gonzales I. added an answer:
    Are you familiar with the notion of complementary and alternative medicine more than conventional primary care?
    Conventional medicine prides itself on being science-based, and shuns alternative medicine for being "unproven," however, many of the non-communicable diseases have been taken care of successfully by alternative medicine. Conventional medicine is still behind and it will send your health into a downward spiral.
    Andrei Gonzales I. · Universidad Mayor de San Andres

    Thanks Dr. Partha Pratim Dhar, yes I tried to mean that a lot of traditional knowledge are inside of alternative medicine, so they are a lot of applications like Dr Partha mentioned; they are very useful, the problem is that a lot of people dont like this type of medicine because they are not proved scientifically, how ever they are a lot of new publications that are proving this facts, we scientists must try to help in this topics.
    I am aware that in many cases the knowledge of alternative medicine have been misrepresented, used only for trade and deceit and also for illegal things. It is a difficult task trying to keep the original knowledge that many cultures that left, most of this knowledge is dying with their carriers ancestors who had 80-100 years old.
    At this point I dare say that it is possible to mention that many people when they hear about alternative medicine only comes to their minds facts unconvincing, because the most part of the information is already infected, to the point that people believe in such superstitions.

    Another reason why many of knowledge of alternative medicine is not demonstrated is by the difficulty you have when making experiments or controlling the confounding factors in the observations.

    Then the task is to separate objectively all knowledge that show significant solutions and their real applications, but often involves taking a multivariate analysis and even a lot of protocols sustain that the essence of the expression of the fact it is on non physical (touchable) variables (subjective) and non counting this facts could affect the experiment (or observation) (For example the problem with the Masaru Emoto experiments ). To the other hand we must to correct the distorted knowledge.

    There are already people working on this topic, even objectively trying to improve the reputation of alternative medicine.

    A strong example in the application of alternative medicine is the effect of the moon on living organisms through its gravitational field, as this example there are others.

  • Singh Shivakumar added an answer:
    Can a practical clinical review of topics in primary care serve to aid an already existing clinical practice guidelines?

    As a primary care physician, I found that there is a certain gap in practical knowledge that clinical practical guidelines (CPG) seem to offer my fellow colleagues. Hence I embarked on a mission to write a book which not only simplifies pre-existing guidelines but allow physicians to learn the management of a disease by just reading one page. When I happen to discuss this (coincidentally) with an author of the bronchial asthma CPG, he vehemently challenged my idea, saying that everything has been written in the CPG. My argument however, was, my was more practical and it has incorporated everything that the CPG has described. Should I continue this endeavour, as it is tedious, by rewarding for all my primary care colleagues if they read it in the future?

    Singh Shivakumar · Stanley Medical College

    It is indeed a great idea to allow the primary care physicians to learn management of a disease in a single page by utilizing pre- existing guidelines . Please do not prejudge the response of the users . There is so much of information available to primary care doctors that they are overwhelmed by the advances in management . Please have confidence in your approach & do not ask experts , who formulate guidelines & continue your endeavour ,even if it is tedious . Primary care plays an important role in management of diseases & every effort should be made to simplify management of diseases by guiding the physicians .

  • Arthur Leibovitz added an answer:
    Are you aware of exemplar models of community based primary health care and/or integrated models of care for older adults with multimorbidities?
    I'm particularly interested in models that span multiple health and/or social care sectors.
    Arthur Leibovitz · Shmuel Harofe Hospital , Geriatric Medical Centre 1984 - 2011

    The key is probably the " case manager"  which  , as mentioned above by Joanne ,

    is now evolving . Pilot projects as to the responsabilities of this position will probably

    give results and recomandations in about 5 years,

  • Saeideh Ghaffarifar added an answer:
    Is the CIPP evaluation approach used for multidisciplinary primary care programs?

    Hi. The CIPP (context, input, process, and product evaluation) evaluation approach has been proposed for healthcare programs (1).

    I am looking for examples/references of this approach in a multidisiplinary primary care program setting.

    Thanks, David

    1. Kennedy-Malone L. Evaluation strategies for CNSs: application of an evaluation model... context, input, process, and product (CIPP) evaluation model developed by Stufflebeam. Clin Nurse Spec. 1996;10:195–198.

    Saeideh Ghaffarifar · Tabriz University of Medical Sciences

    Yes. You can also apply PRECEDE PROCEED model as well as other planning models. 

  • Joan Vaccaro added an answer:
    What are the barriers and facilitators to reporting errors in primary care?

    Patient safety reporting systems despite their limitations are great source of deriving insights into the delivery of safer care. Over the last 10 years, the national reporting and learning system has accrued over 10 million reports of patient safety incidents in England and Wales; most are from hospitals. Why does primary care especially in general practice lag behind?

    Joan Vaccaro · Florida International University

    The US has the Agency for Healthcare Research and Quality (AHRQ). The following link shows how patient safety errors are complied: http://www.ahrq.gov/professionals/quality-patient-safety/pfp/index.html

  • Is there any research done on the assessment of self-medication practices among students in Nepal?

    Thanks in advance for your replies.?

    Béatrice Marianne Ewalds-Kvist · Stockholm University

    This was what I found.

  • Rejina Kamrul added an answer:
    What are the most reliable measures (indicators) of treatment adherence in metabolic syndrome?
    We are looking at predicting adherence to medical and behavioral health care recommendations among individuals with metabolic syndrome. I'm curious if anyone might be able to provide personal insight into specific indicators (behavioral or otherwise) that have been effective/reliable in quantifying the construct of treatment adherence?
    Rejina Kamrul · University of Saskatchewan

    Successful management requires identification and addressing both root cause, barrier. Patient vary considerably in their readiness and capacity. Success can be defied as better quality of life. greater self esteem. higher energy level etc. There is an approach for obesity management from Canadian obesity network: www.obesitynetwork.ca

  • Jennifer M. Giddens added an answer:
    According to the American Association of Suicidology, a person commits suicide every 13.7 minutes. How can we reduce these statistics?

    Hi everyone! My name is Mandy. At the moment, I'm currently involved with a research study at UCSF, where we're doing a survey on how we can reduce suicide rates in primary care settings. According to the CDC, suicide rates in America are steadily increasing, becoming even higher than the rates of homicide. In fact, suicide is now the 10th leading cause of death, surpassing chronic liver disease.

    If you are a physician, nurse practitioner, or a physician assistant in the United States, it'll be great if you can help us fill out this 5-10 min survey! We already have about 120 responses for this study, but we're hoping to get more participants for a more extensive study. Here is the link! http://www.surveygizmo.com/s3/1607736/PCP-Perceptions-in-Clinical-Care

    Jennifer M. Giddens · Tampa Center for Research on Suicidality, Tampa FL

    I believe the best way to reduce the statistics of completed suicide (and even suicide attempts) is to completely revolutionize the way we understand suicidality.  The current models being followed are largely based on the works of Durkheim and Shneidman.  I do not believe these these models are correct for all of the cases of suicidality.  We need to start looking at suicidality in the same way we look at other disorders - based on phenomenology.  Doing so may lead to creating a classification system for suicidality disorders which may allow specific anti-suicidality treatments (not just anti-depressants or other treatments like CBT or DBT) to be found to help the people experiencing suicidality.  Without a classification system for different types of suicidality the results of any research will be muddled (just as the results would be muddled if you tested a treatment on a group of people with 'mood disorders' without specifically targeting those with Major Depressive Disorder).  Until then, researchers are kind of stuck because the likelihood of one treatment being effective for all types of suicidality is not very high (just as one treatment isn't effective for all mood disorders).

  • How Do I Validate Yale Food Addiction Scale (YFAS) In Another Language?

    In validating the YFAS in another language (Malay), I am curious to know if I would need to run factor analysis to see if the questions match the 8 domains (withdrawal, tolerance etc.) seen in the English version of YFAS? Or should I just run a Cronbach's alpha and determine the internal consistency of each domain and assume that it fits the model? If this is done, I would like to determine the validity through the test-retest method. Does this sound correct?

    Yogarabindranath Swarna Nantha · Ministry of Health Malaysia

    Hi Evelyne,

     Thanks for your feedback and it is never too late for any form of suggestion. In fact your advice came in at the right time. We are about to perform another round of pilot testing. I will consider running a confirmatory factor analysis once this is done. Take care and a tout a l'heure.

    Rabin

  • Is there a way of specifically testing the intrinsic motivation of physicians in primary care/tertiary care using a psychological framework?

    Intrinsic and extrinsic motivation are almost inseparable. At times they work dynamically. However, there are many examples of testing out the intrinsic motivation component in other fields, less so in healthcare. So is it possible to specifically isolate factors to measure intrinsic motivation amongst physicians?

    Yogarabindranath Swarna Nantha · Ministry of Health Malaysia

    Thanks for your feedback Eswaran. Unfortunately, there are not fixed or validated questionnaire for 'intrinsic' motivation. There are lots of those for general motivation assessments.

    I have already designed one and I am on the verge of testing it out but need to confirm if it is sound more a psychological point of view.

  • Dharma N Bhatta added an answer:
    Is there any evidence of link between banned cosmetics use and maternal mortality?
    The world is struggling with MDG 5. In developing countries like Tanzania, a comprehensive strategy has been put in place during the last 20 years involving many aspects such as family planning, education to prevent teenage pregnancies, focused antenatal care (where up to 95% of pregnant mothers attend antenatal care), increasing skilled labour attendance (over 51% of all deliveries now attended by trained midwife), addressing PPH (use of misoprostol) and even training on post abortion care. Despite the efforts, the reduction in maternal mortality does not seem to match achievements in the implementation of these interventions and overall improvement on the services. Furthermore, in urban settings, we still see a number of unexplainable maternal mortalities despite readily availability of the services provides through these national interventions. Thre is political will and even our President is now tasking Regional and District Administrative Officers to investigate the maternal deaths. Obviously, it is time to think beyond the box. Is there any evidence that exposure to dangerous chemicals such as mercury compunds, triclosan, lead acetate, phthalates, oxybenzene, etc via persistent use of banned prodiucts e.g. food, cosmetics etc contribute to maternal mortality? Would a survey to attempt to establish the relationship (if it exists) be useful?
    Dharma N Bhatta · PS University

    Concern is interesting but this can be the confounding factor for maternal mortality and other moralities also. ANC coverage can help to aware and educate the risk of mortality. ANC neither predict nor prevent the maternal mortality at all in rural and poor settings. You did not mention about BEOC and CEOC serivices, increment of these services can help to reduce MMR. If the exposure of those chemical is in higher level, it could be the possible risk factors.

  • Jenni Moore added an answer:
    What should integrated care look like in the General Practice?

    We're looking at mapping out processes of care in the primary care setting. What should integrated care look like in General Practice? And how can we measure the extent of integration?

    Jenni Moore · Northland District Health Board

    Interesting discussion and aligned with my work. In searching for measures of integration i have come across a paper form NZ by Sue Pullon et al: Developing Indicators of Service Integration for child health: Perception of service providers and families of young children in an area of high need in New Zealand, published in the Journal of Child Health care 12 august 2013. http://chc.sagepub.com/content/early/2013/08/02/1367493513496673

  • Michael F Weaver added an answer:
    What are the best indicators to use when assessing safe opioid prescribing in a primary care chart review?

    I would like to start some research on whether primary care opioid prescribing for chronic non-cancer pain meets current guidelines, especially for patient safety. There are too many recommendations in our guidelines to use all of them, some are more/less important, and some are difficult to operationalize for a chart review or ongoing quality improvement.  I have seen some initial work on quality/safety indicators for opioid prescribing by others in unpublished and grey literature.  Does anyone know which would be the best to use, and where/how this is being measured?

    Michael F Weaver · University of Texas Health Science Center at Houston

    In terms of identifying indicators to help determine more safe versus less safe opioid prescribing practices for quality improvement (and potential research), I recommend to look at frequency of certain physician behaviors that can be verified through more than one source during chart review.  Frequency of office visits, frequency of urine drug testing (that takes into account the frequency of office visits), frequency of prescription refill requests without an office visit, documentation of use of risk assessment tools (such as the ORT mentioned by Vahid Mohabbati), use of a pain medication agreement, documentation of at least one discrete and specific pain diagnosis, and co-prescription of riskier medications such as benzodiazepines (as mentioned by Yacov Fogelman).  These can be identified in the chart and verified by cross-referencing with lab results, pharmacy records, charges billed, etc. For some general examples of how this has been done, you may want to see the following articles:

    Yanni LM, Weaver MF, Johnson BA, et al: Management of chronic nonmalignant pain: A needs assessment in an Internal Medicine Resident Continuity Clinic. J Opioid Manage 2008;4:201-211.

    Chelminski PR, Ives TJ, Felix KM, et al: A primary care, multi-disciplinary disease management program for opioid treated patients with chronic non-cancer pain and a high burden of psychiatric comorbidity. BMC Health Serv Res. 2005;5:3.

    Adams NJ, Plane MB, Fleming MF, et al: Opioids and the treatment of chronic pain in a primary care sample. J Pain Symptom Manage. 2001;22:791-796.

  • Chai Eng Tan added an answer:
    How does nursing home care to elderly patients living in their own homes work?
    I´m a spanish primary care nurse and I'm interested in how nursing home care to elderly patients living in their own homes works in different countries.
    I appreciate your information.
    Chai Eng Tan · Hospital Universiti Kebangsaan Malaysia (HUKM)

    For the first question:

    The plan for domiciliary care under the Ministry of Health Malaysia is to be executed by the primary care team (currently being piloted in several states before nationwide implementation).  Postnatal home visits have been long established by the maternal and child health section of the public primary care clinics.  I am also a family medicine specialist who happens to have an interest in home care, and thus, am working together with the nurses to develop the service further.  In Singapore, it is also run by the Family Medicine / primary care unit. 

     

    For the second question:

    For the home care service offered by the teaching hospital I'm working in, patients referred to us are patients who have reasonable logistic difficulty to come to the hospital / clinic for nursing procedures, staying within the catchment area, and agreeable to the terms of service.  These include stroke patients, patients with spinal cord injuries, cerebral palsy, diabetic foot ulcers, post-amputation etc. 

     

    For the third question:

    Services offered are nursing procedures such as changing Ryle's tube, changing urinary catheters and suprapubic catheters, wound dressing, caregiver education and monitoring of blood pressure and capillary blood glucose.  We are working to extend our services and now we include doctors doing house calls for complex cases, and in future may coordinate with rehabilitation or dietetic services.  However, due to logistics, it is still very challenging to coordinate services from various other departments.  Our services are partially subsidized as our teaching hospital is under the purvey of the Ministry of Education, whereas clinics under teh Ministry of Health offer their services at an even more highly subsidized rates.  We don't have the facility for telemonitoring at the moment.  So I do envy the Australians as described by Ms Franks above. 

  • William R Hazzard added an answer:
    Who should treat elderly patients in a community? Their primary care physician or a specialist in geriatrics?
    Geriatric medicine is a distinct medical specialty with vast specific knowledge accumulated over the last 30 years. On the other side most present primary care community physicians have not been exposed to systematic geriatric education. How could this gap be bridged?
    William R Hazzard · Wake Forest School of Medicine

    To Jenice in particular (but all who may read this): Thanks for your efforts within the hard-working, futuristic (but currently much maligned) VA, where I worked as director of Geriatrics & Extended Care ar VA Puget Sound from 2000-2010): I could not agree more. I would only suggest substitution of  "gerontologize" for "geriatricize". Gerontologize rolls off the tongue more easliy, plus it encompasses all we do and know as a scientific discipline that studies and values life from conception through death as well as caring for those nearing the end of their lives. Good luck! Bill

  • Terry Richmond added an answer:
    Do you have any information on successful implementations of fall-prevention strategies in your country?
    We will be looking at the implementation of the fall-prevention strategies in the acute sector, primary care and nursing homes.
    Terry Richmond · Kingston General Hospital

    Daily mobility assessments and falls risk assessments by nursing staff .Identification of falls risk patients with use of falling star logos.Daily walking program by 2 personal care assistants on all patients over 65yrs admitted to medicine program that come from home,retirement home or rehab.Frequent audits.Daily discussuins of mobility status and falls risk at board rounds. 

  • Are there any review articles on integration of sleep medicine in a primary care setting?
    There are several studies on integrating mental health services in primary care. I am interested in integrating sleep medicine services in a primary care setting.
    Pandi-Perumal Seithikurippu Ratnas · Somnogen Canada Inc
    Here is the first edition of Primary Care Sleep Medicine:

    http://link.springer.com/book/10.1007%2F978-1-59745-421-6

    Second edition will be released in few months!
  • Aoife Lawton added an answer:
    What are the visual, clinical and verbal barriers and facilitators to disclosure of domestic violence in a primary care setting?
    I'm looking for research around patient engagement in primary care - GP setting. Specifically around domestic violence discovery and disclosure.
    Aoife Lawton · Health Service Executive
    Dear Daniel and Jeanettte, the author has now published her Thesis.
    I thought you might be interested in it. It is openly accessible in our repository, available at http://www.lenus.ie/hse/handle/10147/316150
  • Closed account added an answer:
    How are EHRs influencing the safety of ambulatory care?
    Positively? Negatively? What is the evidence? What works? What doesn't? What is inspirational? What is a hazard? How do we know and what evidence do we have? If we don't have the evidence, how should we get it?
    I found your question intriguing. I was an EPIC software trainer and Go Live support consultant for an implementation in Connecticut in 2012. I found the experience exhausting, but I learned so much about the impact of data on patient management. One role I had was enforcer for the medication & problem list (meaningful use criteria) for admission, transfer to a new unit, and discharge. This required cooperation between the patient/family, ER, resident, nursing, and the physician of record's office. Our physician offices were the first to adopt EPIC. Once the whole suite of modules went live, it required rethinking the CPOE screens and workflow of patient care. Much of this occurred in real-time. You could not discharge a patient from the system without medication review and sign-off. Since that was a new practice, it led to many instances where my diplomatic skills were put to the test. But to the credit of the organization, we had an abundance of experienced support personnel 24/7 for the first 2 months to decrease any impact on patient safety. If you want to do a study, the EPIC trainers would be a good group for a qualitative interview. Many of them have been part of the training and implementation for several healthcare systems. You can find them on LinkedIn...a great source for a purposeful sample. For the large hospital systems with affiliate physician practices, the data you seek for a patient safety study can be de-identified and made available. Our medical center at UCONN has already started putting some data into RedCap (web based research database) and R2D2 (research registry and d-identified database).
  • Rodney P Jones added an answer:
    Does a long time series of deaths in Scotland shed light on what is happening in urgent care?
    Analysis of a time series of monthly deaths in Scotland from 1990 to 2012 shows evidence for a series of infectious like events which also appear to be linked to increases in ED attendance, medical admissions and a wobble in the gender ratio.

    http://www.bmijournal.org/index.php/bmi/article/viewFile/167/117

    Is this the missing piece of information explaining what is happening in urgent health care?

    Your comments and thoughts would be welcome.
    Rodney P Jones · Healthcare Analysis & Forecasting, Camberley, UK
    Have submitted some more work which suggests that the transmission of the agent reaches a minimum in the summer suggesting Vitamin D is of vital importance. This is somewhat timely given the explosion of studies demonstrating the beneficial effects of vitamin D against mortality and morbidity. So until we can all come up with a better solution (immunization or low cost anti-viral) vitamin D for the elderly seems a sensible first step.
  • Fernando A. Alonso López added an answer:
    Can someone tell me how or if they are incorporating Spirometry in their primary care offices?
    HEDIS guidelines require us to do Spirometry to gauge the severity of COPD, preferably when the patient is not suffering an acute exacerbation. Would someone share with me how they are addressing that guideline?
    Fernando A. Alonso López · Servicio Cántabro de Salud
    We have 2 nurses with skills about spirometry to make all our health center need. Using an spirometer and calibration bubble all the weeks
  • Aziz Sheikh added an answer:
    How can we improve patient's safety in the Middle East Region?
    The incidence of preventable adverse events, errors and near misses is relatively high in developing countries. Can you share some successful programs to improve patient's safety by improving systems?
    Aziz Sheikh · The University of Edinburgh
    You may find it useful to take a look at this recent paper on global safety priorities for primary care: http://www.ncbi.nlm.nih.gov/pubmed/24260028
  • James Harris added an answer:
    Can someone send me the the beck anxiety inventory for primary care 7 item self report instrument?
    Typically a 7 item self-report instrument
    James Harris · University of Phoenix
    David,

    Many Thanks! Have a good weekend; best, James

About Primary Care

The primary research focus is on the prevention, early diagnosis and management of common illness in general practice - particularly childhood infection, cancer, cardiovascular disease and stroke. Primary care has recently developed a new stream of clinical research which seeks to improve the conceptual understanding and effectiveness of early and more reliable diagnosis and monitoring in a number of chronic diseases. The primary aim is that Primary care has an international reputation for developing innovative methods of research synthesis and research use to ensure that research findings change clinical practice.

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