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Allison BA, Angelino A, Joshua KH, Strayhorn L, Rogers P, Mann ES. "It Means Being Safe, Having Power over One's Body": Black Female Adolescent Experiences with Reproductive Health Counseling in Primary Care. J Pediatr Adolesc Gynecol 2024:S1083-3188(24)00178-5. [PMID: 38301797 DOI: 10.1016/j.jpag.2024.01.165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 12/05/2023] [Accepted: 01/19/2024] [Indexed: 02/03/2024]
Abstract
STUDY OBJECTIVE There is limited research examining the sexual and reproductive health (SRH) care needs and experiences of Black adolescents who are assigned female at birth (AFAB). This study aimed to understand the perspectives of Black AFAB adolescents in their receipt of SRH counseling in primary care and elicit preferences for SRH-related communication with clinicians. METHODS We interviewed English-speaking Black AFAB adolescents, ages 13-17, living in North Carolina between February and June 2022 about their SRH care experiences. The interviews were conducted via video conferencing, audio-recorded, professionally transcribed, and analyzed using a thematic approach. RESULTS We interviewed 23 adolescents (mean age 15.8 years) across 10 geographically diverse counties in North Carolina. Most conveyed positive perceptions of clinicians regarding trust and comfort. However, many expressed concerns about clinicians not doing enough to ensure patient confidentiality, provide them with enough information to make informed and autonomous decisions, and destigmatize discussing SRH issues during the clinical encounter. Suggested improvements include sociodemographic congruence between patients and clinicians (eg, younger Black women), ensuring time alone with clinicians across adolescence, and proactively sharing information to promote respect and autonomy. CONCLUSION Although Black AFAB adolescents had positive perceptions of their health care providers regarding relational components of care, many participants shared significant gaps and areas for improvement in the quality of care received to better align services with their preferences for SRH care. These findings can inform the development of SRH counseling best practices and clinician education to support respect and autonomy, which are routinely denied to Black AFAB adolescents.
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Affiliation(s)
- Bianca A Allison
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
| | - Alessandra Angelino
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina; Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kaitlin H Joshua
- Department of Sociology, University of North Carolina College of Arts and Sciences, Chapel Hill, North Carolina
| | - Lydia Strayhorn
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Peyton Rogers
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Emily S Mann
- Department of Health Promotion, Education, and Behavior, University of South Carolina Arnold School of Public Health, Columbia, South Carolina
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Ilias MR, Zhang X, Stinson N, Carrington K, Huff E, Freeman N, Wilson-Frederick S, Ampey B, Rajapakse N, Johnson LE, Mensah GA. Establishing a Community Engagement Consultative Resource: A CEAL Initiative. Am J Public Health 2024; 114:S22-S24. [PMID: 37733995 PMCID: PMC10785170 DOI: 10.2105/ajph.2023.307385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2023] [Indexed: 09/23/2023]
Affiliation(s)
- Maliha R Ilias
- Maliha R. Ilias and Xinzhi Zhang are with the Health Inequities and Global Health Branch, Center for Translation Research and Implementation Sciences (CTRIS), National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD. Nathaniel Stinson and Kelli Carrington are with the Division of Community Health and Population Science, National Institute on Minority Health and Health Disparities, NIH. Erynn Huff is with the Other Transaction Authority Office, Office of Management, NHLBI. Naomi Freeman is with the National Center for Advancing Translational Sciences, NIH. Bryan Ampey is with the Immediate Office of the Director, NHLBI. Nishadi Rajapakse is with the Division of Diabetes, Endocrinology, and Metabolic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, NIH. Shondelle Wilson-Frederick and Lenora E. Johnson are with the Office of Science Policy, Engagement, Education, and Communication, NHLBI. George A. Mensah is with CTRIS
| | - Xinzhi Zhang
- Maliha R. Ilias and Xinzhi Zhang are with the Health Inequities and Global Health Branch, Center for Translation Research and Implementation Sciences (CTRIS), National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD. Nathaniel Stinson and Kelli Carrington are with the Division of Community Health and Population Science, National Institute on Minority Health and Health Disparities, NIH. Erynn Huff is with the Other Transaction Authority Office, Office of Management, NHLBI. Naomi Freeman is with the National Center for Advancing Translational Sciences, NIH. Bryan Ampey is with the Immediate Office of the Director, NHLBI. Nishadi Rajapakse is with the Division of Diabetes, Endocrinology, and Metabolic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, NIH. Shondelle Wilson-Frederick and Lenora E. Johnson are with the Office of Science Policy, Engagement, Education, and Communication, NHLBI. George A. Mensah is with CTRIS
| | - Nathaniel Stinson
- Maliha R. Ilias and Xinzhi Zhang are with the Health Inequities and Global Health Branch, Center for Translation Research and Implementation Sciences (CTRIS), National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD. Nathaniel Stinson and Kelli Carrington are with the Division of Community Health and Population Science, National Institute on Minority Health and Health Disparities, NIH. Erynn Huff is with the Other Transaction Authority Office, Office of Management, NHLBI. Naomi Freeman is with the National Center for Advancing Translational Sciences, NIH. Bryan Ampey is with the Immediate Office of the Director, NHLBI. Nishadi Rajapakse is with the Division of Diabetes, Endocrinology, and Metabolic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, NIH. Shondelle Wilson-Frederick and Lenora E. Johnson are with the Office of Science Policy, Engagement, Education, and Communication, NHLBI. George A. Mensah is with CTRIS
| | - Kelli Carrington
- Maliha R. Ilias and Xinzhi Zhang are with the Health Inequities and Global Health Branch, Center for Translation Research and Implementation Sciences (CTRIS), National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD. Nathaniel Stinson and Kelli Carrington are with the Division of Community Health and Population Science, National Institute on Minority Health and Health Disparities, NIH. Erynn Huff is with the Other Transaction Authority Office, Office of Management, NHLBI. Naomi Freeman is with the National Center for Advancing Translational Sciences, NIH. Bryan Ampey is with the Immediate Office of the Director, NHLBI. Nishadi Rajapakse is with the Division of Diabetes, Endocrinology, and Metabolic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, NIH. Shondelle Wilson-Frederick and Lenora E. Johnson are with the Office of Science Policy, Engagement, Education, and Communication, NHLBI. George A. Mensah is with CTRIS
| | - Erynn Huff
- Maliha R. Ilias and Xinzhi Zhang are with the Health Inequities and Global Health Branch, Center for Translation Research and Implementation Sciences (CTRIS), National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD. Nathaniel Stinson and Kelli Carrington are with the Division of Community Health and Population Science, National Institute on Minority Health and Health Disparities, NIH. Erynn Huff is with the Other Transaction Authority Office, Office of Management, NHLBI. Naomi Freeman is with the National Center for Advancing Translational Sciences, NIH. Bryan Ampey is with the Immediate Office of the Director, NHLBI. Nishadi Rajapakse is with the Division of Diabetes, Endocrinology, and Metabolic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, NIH. Shondelle Wilson-Frederick and Lenora E. Johnson are with the Office of Science Policy, Engagement, Education, and Communication, NHLBI. George A. Mensah is with CTRIS
| | - Naomi Freeman
- Maliha R. Ilias and Xinzhi Zhang are with the Health Inequities and Global Health Branch, Center for Translation Research and Implementation Sciences (CTRIS), National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD. Nathaniel Stinson and Kelli Carrington are with the Division of Community Health and Population Science, National Institute on Minority Health and Health Disparities, NIH. Erynn Huff is with the Other Transaction Authority Office, Office of Management, NHLBI. Naomi Freeman is with the National Center for Advancing Translational Sciences, NIH. Bryan Ampey is with the Immediate Office of the Director, NHLBI. Nishadi Rajapakse is with the Division of Diabetes, Endocrinology, and Metabolic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, NIH. Shondelle Wilson-Frederick and Lenora E. Johnson are with the Office of Science Policy, Engagement, Education, and Communication, NHLBI. George A. Mensah is with CTRIS
| | - Shondelle Wilson-Frederick
- Maliha R. Ilias and Xinzhi Zhang are with the Health Inequities and Global Health Branch, Center for Translation Research and Implementation Sciences (CTRIS), National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD. Nathaniel Stinson and Kelli Carrington are with the Division of Community Health and Population Science, National Institute on Minority Health and Health Disparities, NIH. Erynn Huff is with the Other Transaction Authority Office, Office of Management, NHLBI. Naomi Freeman is with the National Center for Advancing Translational Sciences, NIH. Bryan Ampey is with the Immediate Office of the Director, NHLBI. Nishadi Rajapakse is with the Division of Diabetes, Endocrinology, and Metabolic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, NIH. Shondelle Wilson-Frederick and Lenora E. Johnson are with the Office of Science Policy, Engagement, Education, and Communication, NHLBI. George A. Mensah is with CTRIS
| | - Bryan Ampey
- Maliha R. Ilias and Xinzhi Zhang are with the Health Inequities and Global Health Branch, Center for Translation Research and Implementation Sciences (CTRIS), National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD. Nathaniel Stinson and Kelli Carrington are with the Division of Community Health and Population Science, National Institute on Minority Health and Health Disparities, NIH. Erynn Huff is with the Other Transaction Authority Office, Office of Management, NHLBI. Naomi Freeman is with the National Center for Advancing Translational Sciences, NIH. Bryan Ampey is with the Immediate Office of the Director, NHLBI. Nishadi Rajapakse is with the Division of Diabetes, Endocrinology, and Metabolic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, NIH. Shondelle Wilson-Frederick and Lenora E. Johnson are with the Office of Science Policy, Engagement, Education, and Communication, NHLBI. George A. Mensah is with CTRIS
| | - Nishadi Rajapakse
- Maliha R. Ilias and Xinzhi Zhang are with the Health Inequities and Global Health Branch, Center for Translation Research and Implementation Sciences (CTRIS), National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD. Nathaniel Stinson and Kelli Carrington are with the Division of Community Health and Population Science, National Institute on Minority Health and Health Disparities, NIH. Erynn Huff is with the Other Transaction Authority Office, Office of Management, NHLBI. Naomi Freeman is with the National Center for Advancing Translational Sciences, NIH. Bryan Ampey is with the Immediate Office of the Director, NHLBI. Nishadi Rajapakse is with the Division of Diabetes, Endocrinology, and Metabolic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, NIH. Shondelle Wilson-Frederick and Lenora E. Johnson are with the Office of Science Policy, Engagement, Education, and Communication, NHLBI. George A. Mensah is with CTRIS
| | - Lenora E Johnson
- Maliha R. Ilias and Xinzhi Zhang are with the Health Inequities and Global Health Branch, Center for Translation Research and Implementation Sciences (CTRIS), National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD. Nathaniel Stinson and Kelli Carrington are with the Division of Community Health and Population Science, National Institute on Minority Health and Health Disparities, NIH. Erynn Huff is with the Other Transaction Authority Office, Office of Management, NHLBI. Naomi Freeman is with the National Center for Advancing Translational Sciences, NIH. Bryan Ampey is with the Immediate Office of the Director, NHLBI. Nishadi Rajapakse is with the Division of Diabetes, Endocrinology, and Metabolic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, NIH. Shondelle Wilson-Frederick and Lenora E. Johnson are with the Office of Science Policy, Engagement, Education, and Communication, NHLBI. George A. Mensah is with CTRIS
| | - George A Mensah
- Maliha R. Ilias and Xinzhi Zhang are with the Health Inequities and Global Health Branch, Center for Translation Research and Implementation Sciences (CTRIS), National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD. Nathaniel Stinson and Kelli Carrington are with the Division of Community Health and Population Science, National Institute on Minority Health and Health Disparities, NIH. Erynn Huff is with the Other Transaction Authority Office, Office of Management, NHLBI. Naomi Freeman is with the National Center for Advancing Translational Sciences, NIH. Bryan Ampey is with the Immediate Office of the Director, NHLBI. Nishadi Rajapakse is with the Division of Diabetes, Endocrinology, and Metabolic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, NIH. Shondelle Wilson-Frederick and Lenora E. Johnson are with the Office of Science Policy, Engagement, Education, and Communication, NHLBI. George A. Mensah is with CTRIS
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Tamlyn AL, Tjilos M, Bosch NA, Barnett KG, Perkins RB, Walkey A, Assoumou SA, Linas BP, Drainoni ML. At the intersection of trust and mistrust: A qualitative analysis of motivators and barriers to research participation at a safety-net hospital. Health Expect 2023; 26:1118-1126. [PMID: 36896842 PMCID: PMC10154811 DOI: 10.1111/hex.13726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/27/2023] [Accepted: 01/31/2023] [Indexed: 03/11/2023] Open
Abstract
INTRODUCTION The underrepresentation of Black, Indigenous, and People of Color (BIPOC) individuals in healthcare research limits generalizability and contributes to healthcare inequities. Existing barriers and attitudes toward research participation must be addressed to increase the representation of safety net and other underserved populations. METHODS We conducted semi-structured qualitative interviews with patients at an urban safety net hospital, focusing on facilitators, barriers, motivators, and preferences for research participation. We conducted direct content analysis guided by an implementation framework and used rapid analysis methods to generate final themes. RESULTS We completed 38 interviews and identified six major themes related to preferences for engagement in research participation: (1) wide variation in research recruitment preferences; (2) logistical complexity negatively impacts willingness to participate; (3) risk contributes to hesitation toward research participation; (4) personal/community benefit, interest in study topic, and compensation serve as motivators for research participation; (5) continued participation despite reported shortcomings of informed consent process; and (6) mistrust could be overcome by relationship or credibility of information sources. CONCLUSION Despite barriers to participation in research studies among safety-net populations, there are also facilitators that can be implemented to increase knowledge and comprehension, ease of participation, and willingness to join research studies. Study teams should vary recruitment and participation methods to ensure equal access to research opportunities. PATIENT/PUBLIC CONTRIBUTION Our analysis methods and study progress were presented to individuals within the Boston Medical Center healthcare system. Through this process community engagement specialists, clinical experts, research directors, and others with significant experience working with safety-net populations supported data interpretation and provided recommendations for action following the dissemination of data.
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Affiliation(s)
- Autumn L Tamlyn
- Boston Medical Center, Section of Infectious Disease, Boston, MA, USA
| | - Maria Tjilos
- Boston Medical Center, Section of Infectious Disease, Boston, MA, USA
| | - Nicholas A Bosch
- Boston Medical Center, The Pulmonary Center, Department of Medicine, Boston, MA, USA.,Boston University Chobanian & Avedisian School of Medicine, Section of Pulmonary, Allergy, Sleep, & Critical Care, Department of Medicine, Boston, MA, USA
| | - Katherine Gergen Barnett
- Boston Medical Center, Department of Family Medicine, Boston, MA, USA.,Boston University Chobanian & Avedisian School of Medicine, Department of Family Medicine, Boston, MA, USA.,Harvard Center for Primary Care, Center for Primary Care, Boston, MA, USA.,Aspen Health Innovation, Washington, DC, USA
| | - Rebecca B Perkins
- Boston Medical Center, Department of Obstetrics and Gynecology, Boston, MA, USA.,Boston University Chobanian & Avedisian School of Medicine, Department of Obstetrics and Gynecology, Boston, MA, USA
| | - Allan Walkey
- Boston Medical Center, The Pulmonary Center, Department of Medicine, Boston, MA, USA.,Boston University Chobanian & Avedisian School of Medicine, Section of Pulmonary, Allergy, Sleep, & Critical Care, Department of Medicine, Boston, MA, USA.,Boston University School of Public Health, Department of Health Law Policy & Management, Boston, MA, USA
| | - Sabrina A Assoumou
- Boston Medical Center, Section of Infectious Disease, Boston, MA, USA.,Boston University Chobanian & Avedisian School of Medicine, Section of Infectious Disease Department of Medicine, Boston, MA, USA
| | - Benjamin P Linas
- Boston Medical Center, Section of Infectious Disease, Boston, MA, USA.,Boston University Chobanian & Avedisian School of Medicine, Section of Infectious Disease Department of Medicine, Boston, MA, USA.,Boston University School of Public Health, Department of Epidemiology, Boston, MA, USA
| | - Mari-Lynn Drainoni
- Boston University School of Public Health, Department of Health Law Policy & Management, Boston, MA, USA.,Boston University Chobanian & Avedisian School of Medicine, Section of Infectious Disease Department of Medicine, Boston, MA, USA
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Tan YY, Papez V, Chang WH, Mueller SH, Denaxas S, Lai AG. Comparing clinical trial population representativeness to real-world populations: an external validity analysis encompassing 43 895 trials and 5 685 738 individuals across 989 unique drugs and 286 conditions in England. THE LANCET. HEALTHY LONGEVITY 2022; 3:e674-e689. [PMID: 36150402 DOI: 10.1016/s2666-7568(22)00186-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 08/05/2022] [Accepted: 08/05/2022] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Randomised controlled trials (RCTs) inform prescription guidelines, but stringent eligibility criteria exclude individuals with vulnerable characteristics, which we define as comorbidities, concomitant medication use, and vulnerabilities due to age. Poor external validity can result in inadequate treatment decision information. Our first aim was to quantify the extent of exclusion of individuals with vulnerable characteristics from RCTs for all prescription drugs. Our second aim was to quantify the prevalence of individuals with vulnerable characteristics from population electronic health records who are actively prescribed such drugs. In tandem, these two aims will allow us to assess the representativeness between RCT and real-world populations and identify vulnerable populations potentially at risk of inadequate treatment decision information. When a vulnerable population is highly excluded from RCTs but has a high prevalence of individuals actively being prescribed the same medication, there is likely to be a gap in treatment decision information. Our third aim was to investigate the use of real-world evidence in contributing towards quantifying missing treatment risk or benefit through an observational study. METHODS We extracted RCTs from ClinicalTrials.gov from its inception to April 28, 2021, and primary care records from the Clinical Practice Research Datalink Gold database from Jan 1, 1998, to Dec 31, 2020. We referred to the British National Formulary to classify prescription drugs into drug categories. We conducted descriptive analyses and quantified RCT exclusion and prevalence of individuals with vulnerable characteristics for comparison to identify populations without treatment decision information. Exclusion and prevalence were assessed separately for different age groups, individual clinical specialities, and for quantities of concomitant conditions by clinical specialities, where multimorbidity was defined as having two or more clinical specialties, and medications prescribed, where polypharmacy was defined as having five or more medications prescribed. Population trends of individuals with multimorbidity or polypharmacy were assessed separately by age group. We conducted an observational cohort study to validate the use of real-world evidence in contributing towards quantifying treatment risk or benefit for patients with dementia on anti-dementia drugs with and without a contraindicated clinical speciality. To do so, we identified the clinical specialities that anti-dementia drug RCTs highly excluded yet had corresponding high prevalence in the real-world population, forming the groups with highest risk of having scarce treatment decision information. Cox regression was used to assess if the risk of mortality outcomes differs between both groups. FINDINGS 43 895 RCTs from ClinicalTrials.gov and 5 685 738 million individuals from primary care records were used. We considered 989 unique drugs and 286 conditions across 13 drug-category cohorts. For the descriptive analyses, the median RCT exclusion proportion across 13 drug categories was 81·5% (IQR 76·7-85·5) for adolescents (aged <18 years), 26·3% (IQR 21·0-29·5) for individuals older than 60 years, 40·5% (IQR 33·7-43·0) for individuals older than 70 years, and 52·9% (IQR 47·1-56·0) for individuals older than 80 years. Multimorbidity had a median exclusion proportion of 91·1% (IQR 88·9-91·8) and median prevalence of 41·0% (IQR 34·9-46·0). Concomitant medication use had a median exclusion proportion of 52·5% (IQR 50·0-53·7) and a median prevalence of 94·3% (IQR 84·3-97·2), and polypharmacy had a median prevalence of 47·7% (IQR 38·0-56·1). Population trends show increasing multimorbidity with age and consistently high polypharmacy across age groups. Populations with cardiovascular or otorhinolaryngological comorbidities had the highest risk of having scarce treatment decision information. For the observational study, populations with cardiovascular or psychiatric comorbidities had highest risk of having scarce treatment decision information. Patients with dementia with an anti-dementia prescription and contraindicated cardiovascular condition had a higher risk of mortality (hazard ratio [HR] 1·20 [95% CI 1·13-1·28 ; p<0·0001]) compared with patients with dementia without a contraindicated cardiovascular condition. Patients with dementia with comorbid delirium (HR 1·25 [95% CI 1·06-1·48]; p<0·0088), intellectual disability (HR 2·72 [95% CI 1·53-4·81]; p=0·0006), and schizophrenia and schizotypal delusional disorders (HR 1·36 [95% CI 1·02-1·82]; p=0·036) had a higher risk of mortality compared with patients with dementia without these conditions. INTERPRETATION Overly stringent RCT exclusion criteria do not appropriately account for the heterogeneity of vulnerable characteristics observed in real-world populations. Treatment decision information is scarce for such individuals, which might affect health outcomes. We discuss the challenges facing the inclusivity of such individuals and highlight the strength of real-world evidence as an integrative solution in complementing RCTs and increasing the completeness of evidence-based medicine assessments in evaluating the effectiveness of treatment decisions. FUNDING Wellcome Trust, National Institute for Health Research (NIHR) University College London Hospitals Biomedical Research Centre, NIHR Great Ormond Street Hospital Biomedical Research Centre, Academy of Medical Sciences, and the University College London Overseas Research Scholarship.
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Affiliation(s)
- Yen Yi Tan
- Institute of Health Informatics, University College London, London, UK.
| | - Vaclav Papez
- Institute of Health Informatics, University College London, London, UK
| | - Wai Hoong Chang
- Institute of Health Informatics, University College London, London, UK
| | | | - Spiros Denaxas
- Institute of Health Informatics, University College London, London, UK
| | - Alvina G Lai
- Institute of Health Informatics, University College London, London, UK
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