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Using Technology and Innovation to Address the Three Delays in Access to Cardiac Surgery

January 2018

Authors:

Dominique Vervoort

University of Toronto

Jacques Kpodonu

Harvard Medical School

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Afr. Ann Thorac. Cardiovasc.Surg.2018;13(1) 5-10

Afr. Ann. Thorac. CardiovascSurg.2018;13(1) 5-10

INTRODUCTION

CHIRURGIE CARDIAQUE / CARDIAC SURGERY

USING TECHNOLOGY AND INNOVATION TO ADDRESS

THE THREE DELAYS IN ACCESS TO CARDIAC SURGERY

D. VERVOORT, MD1.J. KPODONU, MD2

1. Program in Global Surgery and Social Change, Harvard Medical School

2. Beth Israel Deaconess, Harvard Medical School

Keywords:Technology; Innovation; Cardiac Surgery; Global Health

Correspondence:J. Kpodonu,MD

Beth Israel Deaconess Medical

Center Division of Cardiac Surgery

110 Francis Street, Suite 2A

Boston, MA 02215

Email: jkpodonu@bidmc.harvard.edu

Cardiovascular diseases (CVD) make up the leading cause of mortality in the world with 17.65 million

deaths every year, of which more than 80% occurs in low- and middle-income countries (LMICs)(1) .

With the ongoing shift of the global burden of CVD towards low-resource settings, a mortality rate of

25 million deaths is projected in these regions by 2030(2). Nevertheless, it is estimated that 93% of the

population in LMICs do not have access to safe cardiac surgical care, due to lack of nearby facilities,

limited specialist and allied health workforce, and high risk of catastrophic expenditure. As such, there

is a pressing need to address the barriers in receiving cardiac surgical care.

The Three Delays Framework can be used as a model to examine the barriers underlying access to

cardiac care. The First Delay, the delay in recognizing the disease and seeking care, comprises

health illiteracy, stigma of the condition, misperceptions of or lack of trust in modern medicine, and

economic barriers. The Second Delay, the delay in reaching care, includes the time and difficulty

reaching the nearest facility providing cardiac surgical care, dependent on road infrastructure, cli-

mate conditions, availability of private vehicles, public transport, or ambulatory services, and the

geographical distance to the facility. The Third Delay, the delay in receiving care, includes a four-fold

delay: a delay in receiving appropriate care at the initial facility, delay in timely referral to another

facility to receive definite care, delay in receiving appropriate definite care at a second facility, and a

delay in post-operative care and long-term follow-up in the setting of cardiac diseases.

The availability of workforce, in particular surgical specialist workforce, is a constant and widespread

issue in LMICs. Sub-Saharan Africa, for example, relies on only 1 cardiothoracic surgeon per 4 mil-

lion people. (3). In total, they possess only 1% of the world’s total cardiothoracic surgical workforce. In

addition, lack of surgical and medical infrastructure imposes an additional barrier for receiving care.

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Afr. Ann. Thorac. CardiovascSurg.2018;13(1) 5-10

For example, in LMICs, dedicated cardiac intensive care units (CICUs) with specialized personnel is

limited, but dramatically improves outcomes in patients following cardiac surgery.(4).

Telemedicine is a useful tool to overcome geographical barriers and lack of workforce in order to

provide quality care and medical education from a distance. Clinicians are able to use mobile

videoconference systems to remotely access a patient’s room and monitor vital signs. This, in turn,

can allow for better care and service for the patient, whilst saving time and reducing costs of clini-

cians, patients, and their families.(5). For heart failure, telecare decreased hospitalization and mor-

tality rates by 20% with corresponding reduction in medical expenses and increase in the quality of

life.(6) .Similarly, the use in follow-up after cardiac surgery has proven effective in reducing readmis-

sion rates and preventing unnecessary visits (and related costs and anxiety), with high levels of sa-

tisfaction by both surgeons and patients.(7). Moreover, the use of “electronic CICUs” (e-CICUs) ser-

viced through telemedicine and adapted to local needs has proven logistically feasible and effective

in reducing CICU and hospital length-of-stay for both adult and paediatric cardiac care compared to

pretelemedicine periods.(4,8).In a day and age of widespread cellular use and expanding internet

connectivity, the use and development of mobile health (mHealth) innovations to scale up access to

healthcare in low-resource settings becomes increasingly important.mHealth devices allow for

reductions in costs, higher ease of use, and portability to help bridge existing gaps in cardiac care

through decentralizing diagnostics and medical management to health professionals and CHWs in

remote locations.(9). In this study, we review existing and potential technological innovations to address

the three delays limiting access to cardiac surgical care in low- and middle-income countries.

METHODS

A focused literature review was done searching the medical database PubMed using the keywords

“technology”, “innovation”, “low-income”, “low-resource”, “developing country”, “rheumatic heart di-

sease”, “congenital heart defect”, and “cardiac surgery” to identify literature on low-cost innovations

and technology to bridge the gap to accessing cardiac surgical care.

RESULTS

The First Delay - Delay in Seeking Care

Any delay in recognizing existing disease or being aware of the availability of necessary treatment

increases the likelihood of not receiving timely care and thus negatively influences outcomes and

long-term prognosis. Although cost is traditionally mentioned as an important factor in deciding to

seek care, other factors, such as recognizing the disease and the perception of the quality of the

available care, influence this decision more.(10,11).For the former, training community health wor-

kers (CHWs) to timely detect signs of cardiac surgical disease is an effective and low-cost way to

reduce the delay in seeking care. The use of handheld echocardiography, rather than sole auscul-

tation, is an effective and low-cost innovation to detect early cardiac disease, in particular RHD, by

trained non-physicians.(12,13) .This can be strengthened through web-based evaluation of echocar-

diograms using a cloud-based server through specialists from a distance.(14). More broadly, using

mHealth kits able to monitor vital signs (e.g., mobile blood pressure, oxymetry, pocket echocar-

diography, iPhone electrocardiogram, and point-of-care BNP) allows for timely referral for cardiac

interventions and lower probability of hospitalization or death.(15) .

The Second Delay - Delay in Reaching Care

Identifying and reaching the nearest facility able to provide affordable and quality cardiac care re-

lies upon the organization of the prehospital chain to access the clinical setting. Initiating effective

pre-hospital care through training lay first responders has proven to improve survival by reducing

the time to treatment in trauma care. (16).Mobile surgical units for cardiovascular disease further

reduce the time to treatment and can serve as a bridge between immediate life-saving care in the

pre-hospital setting and more complex permanent interventions upon reaching the surgical facility(17)

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The Third Delay - Delay in Receiving Care

In order to avoid delays in care and prevent needless suffering, decentralizing diagnosis and ma-

nagement of cardiac with appropriate medical therapy and timely referral to surgical facilities is

possible and necessary.(18) .Conferencing between remote hospitals and cardiac centers allows for

the optimization of and reduction in (unnecessary) patient transfers.(19). After receiving surgical care

for cardiac diseases, immediate and long-term medical care and follow-up screening is essential to

warrant optimal health outcomes. Cardiac rehabilitation, due to the costs and lack of widespread

specialized centers, is traditionally hardly accessible for patients in LMICs. Through telemedicine

using videoconferencing, patients are able to access rehabilitation at distant sites with similar re-

sults as conventional rehabilitation sites.(20).For example, the eRegister system by the World Heart

Federation ensures real-time patient data collection and secondary prophylaxis, whilst keeping pa-

tients reminded of appointments through the use of SMS reminders and CHWs compliant with dia-

gnostic guidelines through electronic forms.(21) .

DISCUSSION

Technological innovation has the ability to reduce all three delays in accessing cardiac surgical care,

in addition to strengthening post-operative and long-term primary health systems to ensure optimal

short- and long-term outcomes. The use of digital health kits including portable echocardiography

and mHealth devices able to monitor oxymetry, blood pressure, ECG, and point-of-care BNP allows

for efficient and cost-effective early diagnosis and follow-up of cardiac conditions ranging from RHD

to heart failure. In addition, the widespread use of smartphones, cellular use, and internet connecti-

vity allows for remote monitoring and conferencing of experienced specialists with less experienced

specialists in rural hospitals or community health workers in community facilities. Moreover, pa-

tients are able to be reminded of medication use, rehabilitation instructions, or screening reminders

through mobile texting. Altogether, mHealth can bridge the gap in accessing cardiac care.

One barrier in receiving care for cardiac surgical disease is the availability of equipment, in particular

to replace valves in patients with severe aortic stenosis or mitral stenosis, the latter commonly due

to rheumatic heart disease (RHD). Every year, over 290,000 valve replacements are done around

the world, the majority taking place in Europe and the United States, accounting for a US$2 billion

market. Due to the high costs, use in LMICs remains scarce in the light of the higher need due to

RHD. The creation of low-cost biomolecularly enhanced polymeric heart valve with hyaluronan, as

opposed to traditional use of tissue valves, allows for high biocompatibility and lifelong durability,

able to be placed using trans-catheter aortic valve replacement (TAVR). In addition, the polymeric

heart valve material does not require anticoagulation therapy, minimizing costs and need for close

monitoring and follow-up of patients.

In addition to potential widespread use of technology to improve patient care, the ability to improve

the skills and opportunities for surgeons arises in a similar manner. Mobile applications have al-

lowed students and health professionals around the world to practice their medical and surgical

knowledge and skills outside the clinical setting. For example, Touch Surgery, a free mobile applica-

tion with over 2 million users worldwide, lets users learn, prepare, and test for surgical procedures

at any given location at any given time through a library of over 150 interactive, cognitive surgical

simulations.(22) .Virtual reality is slowly becoming used to give students, residents, and surgeons

remote access to surgical procedures elsewhere in the world to learn from experts in a virtual real-

time manner. Moreover, a digital health platform can connect cardiac specialists all over the world

through a collaborative platform for training, education, research, and patient care, with the ability to

expedite information sharing and service coordination to create a practical pathway for the delivery

of cardiac care in LMICs. Lastly, such a platform would promote the establishment of a coalition of

stakeholders, including, but not limited to cardiothoracic surgeons, cardiologists, industry, govern-

ments, and funders, to discuss and advance cardiac care around the world.

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CONCLUSION

Access to cardiac surgery in developing countries remains scarce and delays in accessing treat-

ment and follow-up care occur at all levels of the care pathway. Innovative mHealth and technologi-

cal strategies to promote early diagnosis of surgical cardiac conditions, reduce readmission rates,

and ensure proper post discharge management of patients are feasible and affordable in bridging

the current gaps in LMICs. In addition, mobile connectivity allows for remote interaction between

patients and medical specialists, as well as the creation of a web-based community of health pro-

fessionals and stakeholders to improve cardiac care around the world.

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Paediatric and congenital heart disease (PCHD) is common but remains forgotten on the global health agenda. Congenital heart disease is the most frequent major congenital anomaly, affecting approximately 1 in every 100 live births. In high-income countries, most children now live into adulthood, whereas in low- and middle-income countries, over 90% of patients do not get the care they need. Rheumatic heart disease is the most common acquired cardiovascular disease in children and adolescents. While almost completely eradicated in high-income countries, over 30-40 million people live with rheumatic heart disease in low- and middle-income countries. Challenges exist in the care for PCHD and, increasingly, adult congenital heart disease (ACHD) worldwide. In this review, we summarize the current status of PCHD and ACHD care through the health systems lens of workforce, infrastructure, financing, service delivery, information management and technology, and governance. We further highlight gaps in knowledge and opportunities moving forward to improve access to care for all those living with PCHD or ACHD worldwide.

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Cardiovascular diseases are the leading cause of morbidity and mortality worldwide, and rapidly growing with the epidemiological transition of low- and middle-income countries (LMICs) from communicable to non-communicable diseases. Timely detection is paramount to avoid progressive disease with a poorer prognosis, yet screening mechanisms for cardiovascular diseases are limited beyond dedicated clinics and centers in LMICs. Moreover, diagnostic modalities are sparse, limiting conclusive diagnosis for many living with cardiovascular diseases in LMICs. However, opportunities arise to train community health workers and non-clinicians to screen people in their communities, whilst generating knowledge on the true burden in countries and regions to hold policy-makers and decision-makers accountable for the gaps in cardiac care.

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Background Six billion people in low- and middle-income countries (LMICs) lack timely or ready access to safe and affordable cardiac surgical care when needed, which remains a low priority on the global public health and global surgery agenda. Here, we perform the first state-of-the-art review of cardiac surgical care in LMICs to highlight the important milestones and current progress, as well as challenges associated with the expansion of sustainable global cardiac surgery for those in need. Methods A literature review was performed searching the PubMed/MEDLINE and Google Scholar databases using a combination of cardiac surgery, global health, and LMIC keywords. The Institute for Health Metrics and Evaluation Global Burden of Disease Results Tool was used to assess the global burden of disease related to cardiovascular surgical diseases. Results High-income countries are estimated to have over hundred times as many cardiac surgeons per million population compared to low-income countries. There are over 4,000 cardiac centers worldwide, but less than one center per ten million population in LMICs. Approximately 1.5 million cardiac operations are performed globally, of which a disproportionally low number in LMICs. Despite the high costs associated with cardiac operations, recent data suggests the favorable cost-effectiveness thereof in LMICs. Opportunities arise to sustainably integrate cardiac surgery in holistic health systems strengthening interventions. Conclusions Skepticism underlying the need, feasibility, and cost-effectiveness of cardiac surgery in LMICs prevail, but recent advances, successful case studies, and existing data illustrate the potential of expanding cardiac care globally.

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An open-access, mobile compatible, electronic patient register for rheumatic heart disease ('eRegister') based on the World Heart Federation's framework for patient registers

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Evidence on feasibility and effective use of mHealth strategies by frontline health workers in developing countries: Systematic review

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Patient Outcomes of an International Telepediatric Cardiac Critical Care Program

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Mar 2015
TELEMED J E-HEALTH

An optimal model for telemedicine use in the international care setting has not been established. Our objective was to describe variables associated with patient outcome during the implementation of an international pediatric cardiac critical care (PCCC) telemedicine program. A retrospective review was performed of clinical records and a telemedicine database of patients admitted to the cardiac intensive care unit (CICU) at the Fundacion Cardiovascular de Colombia, Bucaramanga, Colombia, during the initial 10 months of our program, compared with patients admitted during a previous period. Information collected included demographic data, cardiac diagnosis and associated factors, Risk Adjustment for Congenital Heart Surgery (RACHS)-1 classification, and perioperative events. Primary outcome was composed of CICU and hospital mortality. Secondary outcomes were CICU and hospital length of stay (LOS). Of the 553 patients who were included, teleconsultation was done for 71 (12.4%), with a total of 156 encounters, including 19 for patients on extracorporeal membrane oxygenation. Three hundred twenty-one recommendations were given, and 42 real-time interventions were documented. RACHS-1 distribution was similar between study periods (p=0.427). Teleconsulted patients were significantly younger (44 versus 24 months; p=0.03) and had higher surgical complexity than nonteleconsulted patients (p=0.01). RACHS-1 adjusted hospital survival was similar between study periods. CICU and hospital LOS intervals were significantly shorter in the telemedicine period (10 versus 17 days [p=0.02] and 22 versus 28 days [p<0.001]). In surgical cases, preoperative CICU LOS was significantly shorter (3 versus 6 days; p<0.001). Variables associated with hospital mortality were higher RACHS-1 categories, lower weight, bypass time longer than 150 min, and use of circulatory arrest, as well as the presence of sepsis or necrotizing enterocolitis. Those associated with increased LOS were lower weight, extracorporeal membrane oxygenation, and cross-clamp time longer than 60 min. An international telemedicine service in PCCC was associated with lower CICU and hospital LOS. Prospective telemedicine interventions aimed to decrease mortality and LOS should focus on patients with higher RACHS-1 categories, lower-weight infants, and those with prolonged operative time and selective perioperative complications.

Cardiovascular Risk and Events in 17 Low-, Middle-, and High-Income Countries

Article

Full-text available

Aug 2014

Background: More than 80% of deaths from cardiovascular disease are estimated to occur in low-income and middle-income countries, but the reasons are unknown. Methods: We enrolled 156,424 persons from 628 urban and rural communities in 17 countries (3 high-income, 10 middle-income, and 4 low-income countries) and assessed their cardiovascular risk using the INTERHEART Risk Score, a validated score for quantifying risk-factor burden without the use of laboratory testing (with higher scores indicating greater risk-factor burden). Participants were followed for incident cardiovascular disease and death for a mean of 4.1 years. Results: The mean INTERHEART Risk Score was highest in high-income countries, intermediate in middle-income countries, and lowest in low-income countries (P<0.001). However, the rates of major cardiovascular events (death from cardiovascular causes, myocardial infarction, stroke, or heart failure) were lower in high-income countries than in middle- and low-income countries (3.99 events per 1000 person-years vs. 5.38 and 6.43 events per 1000 person-years, respectively; P<0.001). Case fatality rates were also lowest in high-income countries (6.5%, 15.9%, and 17.3% in high-, middle-, and low-income countries, respectively; P=0.01). Urban communities had a higher risk-factor burden than rural communities but lower rates of cardiovascular events (4.83 vs. 6.25 events per 1000 person-years, P<0.001) and case fatality rates (13.52% vs. 17.25%, P<0.001). The use of preventive medications and revascularization procedures was significantly more common in high-income countries than in middle- or low-income countries (P<0.001). Conclusions: Although the risk-factor burden was lowest in low-income countries, the rates of major cardiovascular disease and death were substantially higher in low-income countries than in high-income countries. The high burden of risk factors in high-income countries may have been mitigated by better control of risk factors and more frequent use of proven pharmacologic therapies and revascularization. (Funded by the Population Health Research Institute and others.).

Cardiac Surgery Capacity in Sub-Saharan Africa: Quo Vadis?

Article

Full-text available

Jun 2014

Background: Current data on cardiac surgery capacity on which to base effective concepts for developing sustainable cardiac surgical programs in Africa are lacking or of low quality. Methods: A questionnaire concerning cardiac surgery in Africa was sent to 29 colleagues-26 cardiac surgeons and 3 cardiologists in 16 countries. Further, data on numbers of surgeons practicing in Africa were retrieved from the Cardiothoracic Surgery Network (CTSNet). Results: There were 25 respondents, yielding a response rate of 86.2%. Three models emerged: the Ghanaian/German model with a senior local consultant surgeon (Model 1); surgeons visiting for a short period to perform humanitarian surgery (Model 2); and expatriate surgeons on contract to develop cardiac programs (Model 3). The 933 cardiothoracic surgeons listed by CTSNet translated into one surgeon per 1.3 million people. In North Africa, the figure was three surgeons per 1 million and in sub-Saharan Africa (SSA), one surgeon per 3.3 million people. The identified 156 cardiac surgeons represented a surgeon to population ratio of 1:5.9 million people. In SSA, the ratio was one surgeon per 14.3 million. In North Africa, it was one surgeon per 1.1 million people. Open heart operations were approximately 12 per million in Africa, 2 per million in SSA, and 92 per million people in North Africa. Conclusion: Cardiothoracic health care delivery would worsen in SSA without the support of humanitarian surgery. Although all three models have potential for success, the Ghanaian/German model has proved to be successful in the long term and could inspire health care policy makers and senior colleagues planning to establish cardiac programs in Africa.

Creation and Global Deployment of a Mobile, Application-Based Cognitive Simulator for Cardiac Surgical Procedures

Article

Feb 2016

Several modern learning frameworks (eg, cognitive apprenticeship, anchored instruction, and situated cognition) posit the utility of nontraditional methods for effective experiential learning. Thus, development of novel educational tools emphasizing the cognitive framework of operative sequences may be of benefit to surgical trainees. We propose the development and global deployment of an effective, mobile cognitive cardiac surgical simulator. In methods, 16 preclinical medical students were assessed. Overall, 4 separate surgical modules (sternotomy, cannulation, decannulation, and sternal closure) were created utilizing the Touch Surgery (London, UK) platform. Modules were made available to download free of charge for use on mobile devices. Usage data were collected over a 6-month period. Educational efficacy of the modules was evaluated by randomizing a cohort of medical students to either module usage or traditional, reading-based self-study, followed by a multiple-choice learning assessment tool. In results, downloads of the simulator achieved global penetrance, with highest usage in the USA, Brazil, Italy, UK, and India. Overall, 5368 unique users conducted a total of 1971 hours of simulation. Evaluation of the medical student cohort revealed significantly higher assessment scores in those randomized to module use versus traditional reading (75% ± 9% vs 61% ± 7%, respectively; . P < 0.05). In conclusion, this study represents the first effort to create a mobile, interactive cognitive simulator for cardiac surgery. Simulators of this type may be effective for the training and assessment of surgical students. We investigated whether an interactive, mobile-computing-based cognitive task simulator for cardiac surgery could be developed, deployed, and validated. Our findings suggest that such simulators may be a useful learning tool.

Telemedicine in Prehospital Stroke Evaluation and Thrombolysis: Taking Stroke Treatment to the Doorstep

Article

Dec 2015

Importance Mobile stroke treatment units (MSTUs) with on-site treatment teams that include a vascular neurologist can provide thrombolysis in the prehospital setting faster than treatment in the hospital. These units can be made more resource efficient if the need for an on-site neurologist can be eliminated by relying solely on telemedicine for physician presence.Objective To test whether telemedicine is reliable and remote physician presence is adequate for acute stroke treatment using an MSTU.Design, Setting, and Participants Prospective observational study conducted between July 18 and November 1, 2014. The dates of the study analysis were November 1, 2014, to March 30, 2015. The setting was a community-based study assessing telemedicine success of the MSTU in Cleveland, Ohio. Participants were the first 100 residents of Cleveland who had an acute onset of stroke-like symptoms between 8 am and 8 pm and were evaluated by the MSTU after the implementation of the MSTU program at the Cleveland Clinic. A vascular neurologist evaluated the first 100 patients via telemedicine, and a neuroradiologist remotely assessed images obtained by mobile computed tomography (CT). Data were entered into the medical record and a prospective registry.Main Outcomes and Measures The study compared the evaluation and treatment of patients on the MSTU with a control group of patients brought to the emergency department via ambulance during the same year. Process times were measured from the time the patient entered the door of the MSTU or emergency department, and any problems encountered during his or her evaluation were recorded.Results Ninety-nine of 100 patients were evaluated successfully. The median duration of telemedicine evaluation was 20 minutes (interquartile range [IQR], 14-27 minutes). One connection failure was due to crew error, and the patient was transported to the nearest emergency department. There were 6 telemedicine disconnections, none of which lasted longer than 60 seconds or affected clinical care. Times from the door to CT completion (13 minutes [IQR, 9-21 minutes]) and from the door to intravenous thrombolysis (32 minutes [IQR, 24-47 minutes]) were significantly shorter in the MSTU group compared with the control group (18 minutes [IQR, 12-26 minutes] and 58 minutes [IQR, 53-68 minutes], respectively). Times to CT interpretation did not differ significantly between the groups.Conclusions and Relevance An MSTU using telemedicine is feasible, with a low rate of technical failure, and may provide an avenue for reducing the high cost of such systems.

eICU reduces mortality in STEMI patients in resource-limited areas

Article

Dec 2014

Timely healthcare access poses a formidable challenge in the semiurban and rural areas of the developing world. This is particularly noticeable in emergency situations such as ST-segment elevation myocardial infarction (STEMI).

International Telemedicine in Pediatric Cardiac Critical Care: A Multicenter Experience

Article

Jun 2014

Objective: To describe our multicenter experience in telemedicine-assisted pediatric cardiac critical care (PCCC) with four hospitals in Latin America from July 2011 to June 2013. Materials and methods: This was a descriptive study based on telemedicine encounters related to quality of communication, assessed information, activities, and recommendations. Comparison among centers was performed. A postimplementation survey was conducted through a 5-point Likert scale questionnaire investigating acceptance among professionals involved with the telemedicine service through the assessment of general satisfaction, perception about the work system, usefulness, and impact on medical practice. Results: One thousand forty consultations were conducted for 476 patients. Postoperatively, patients were distributed into Risk Adjustment Classification for Congenital Heart Surgery (RACHS-1) categories as follows: 2%, 26%, 36%, 26%, and 10% in categories 1, 2, 3, 4, and 6, respectively. A real-time intervention took place in 23% of encounters. Of the 2,173 recommendations given, 70 were related to extracorporeal membrane oxygenation management. There was a different RACHS-1 distribution and encounter characteristics among centers. From a total of 51 surveys sent, 27 responses were received, and among responders, overall satisfaction was very high (4.27 ± 0.18), as well as work system quality (4.4 ± 0.37). Telemedicine was considered useful in the cardiac intensive care unit (3.86 ± 0.60), for patient outcomes (3.8 ± 0.51), and for education (3.7 ± 0.71). There was a difference in overall satisfaction, perception about telemedicine usefulness in education, and impact on medical practice among centers. Conclusions: An international, multicenter telemedicine program in PCCC is technologically and logistically feasible. Prospective interventions in our international multicenter telemedicine program should consider differences in staff composition, perception of needs, and patient population among centers.

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