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Lynch T, Ryan C, Cadogan CA. 'I just thought that it was such an impossible thing': A qualitative study of barriers and facilitators to discontinuing long-term use of benzodiazepine receptor agonists using the Theoretical Domains Framework. Health Expect 2021; 25:355-365. [PMID: 34862703 PMCID: PMC8849267 DOI: 10.1111/hex.13392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 11/16/2021] [Accepted: 11/19/2021] [Indexed: 01/25/2023] Open
Abstract
Introduction Existing interventions to reduce long‐term benzodiazepine receptor agonist (BZRA) use lack theoretical underpinning and detailed descriptions. This creates difficulties in understanding how interventions work and how to replicate them in practice. The Theoretical Domains Framework (TDF) can be used to identify behaviour change determinants to target during intervention development. Objective To explore barriers and facilitators to discontinuing BZRA use from the perspective of both current and previous long‐term BZRA users. Design/Setting and Participants Semistructured TDF‐based interviews were conducted with community‐based individuals with current or previous experience of long‐term BZRA use. Data were recorded, transcribed and analysed using the framework method. Results Twenty‐eight individuals were interviewed. Despite commonalities in perceived barriers/facilitators to discontinuing BZRA use within individual TDF domains, individual participants had different experiences of identified determinants of BZRA discontinuation. For example, both similarities and differences existed within and between each participant group in terms of knowledge of the appropriate duration of BZRA use (‘Knowledge’ domain) and experience of withdrawal symptoms (‘Reinforcement’ domain). Compared to previous users, current users typically anticipated more barriers to discontinuing BZRA use and fewer positive consequences of discontinuation. Conclusion This study reports on barriers and facilitators to discontinuing BZRA use from the perspectives of current and previous long‐term users. The findings highlight the challenging nature of BZRA discontinuation and a multitude of barriers that impact participants’ behaviour regarding BZRA use. Future work will involve developing a theory‐based intervention to support BZRA discontinuation in primary care. Patient Contribution The study included patients as participants.
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Affiliation(s)
- Tom Lynch
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dubin, Ireland
| | - Cristín Ryan
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
| | - Cathal A Cadogan
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
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Emara AK, Grits D, Klika AK, Molloy RM, Krebs VE, Barsoum WK, Higuera-Rueda C, Piuzzi NS. NarxCare Scores Greater Than 300 Are Associated with Adverse Outcomes After Primary THA. Clin Orthop Relat Res 2021; 479:1957-1967. [PMID: 33835083 PMCID: PMC8373571 DOI: 10.1097/corr.0000000000001745] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 03/04/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND The association between preoperative prescription drug use (narcotics, sedatives, and stimulants) and complications and/or greater healthcare utilization (length of stay, discharge disposition, readmission, emergency department visits, and reoperation) after total joint arthroplasty has been established but not well quantified. The NarxCare score (NCS) is a weighted scalar measure of overall prescription opioid, sedative, and stimulant use. Higher scores reflect riskier drug-use patterns, which are calculated based on (1) the number of prescribing providers, (2) the number of dispensing pharmacies, (3) milligram equivalence doses, (4) coprescribed potentiating drugs, and (5) overlapping prescription days. The aforementioned factors have not been incorporated into association measures between preoperative prescription drug use and adverse events after THA. In addition, the utility of the NCS as a scalar measure in predicting post-THA complications has not been explored. QUESTIONS/PURPOSES (1) Is the NarxCare score (NCS) associated with 90-day readmission, reoperation, emergency department visits, length of stay, and discharge disposition after primary THA; and are there NCS thresholds associated with a higher risk for those adverse outcomes if such an association exists? (2) Is there an association between the type of preoperative active drug prescription and the aforementioned outcomes? METHODS Of 3040 primary unilateral THAs performed between November 2018 and December 2019, 92% (2787) had complete baseline information and were subsequently included. The cohort with missing baseline information (NCS or demographic/racial determinants; 8%) had similar BMI distribution but slightly younger age and a lower Charlson Comorbidity Index (CCI). Outcomes in this retrospective study of a longitudinally maintained institutional database included 90-day readmissions (all-cause, procedure, and nonprocedure-related), reoperations, 90-day emergency department (ED) visits, prolonged length of stay (> 2 days), and discharge disposition (home or nonhome). The association between the NCS category and THA outcomes was analyzed through multivariable regression analyses and a confirmatory propensity score-matched comparison based on age, gender, race, BMI, smoking status, CCI, insurance status, preoperative diagnosis, and surgical approach, which removed significant differences at baseline. A similar regression model was constructed to evaluate the association between the type of preoperative active drug prescription (opioids, sedatives, and stimulants) and adverse outcomes after THA. RESULTS After controlling for potentially confounding variables like age, gender, race, BMI, smoking status, CCI, insurance status, preoperative diagnosis, and surgical approach, an NCS of 300 to 399 was associated with a higher odds of 90-day all-cause readmission (odds ratio 2.0 [95% confidence interval 1.1 to 3.3]; p = 0.02), procedure-related readmission (OR 3.3 [95% CI 1.4 to 7.9]; p = 0.006), length of stay > 2 days (OR 2.2 [95% CI 1.5 to 3.2]; p < 0.001), and nonhome discharge (OR 2.0 [95% CI 1.3 to 3.1]; p = 0.002). A score of 400 to 499 demonstrated a similar pattern, in addition to a higher odds of 90-day emergency department visits (OR 2.2 [95% CI 1.2 to 3.9]; p = 0.01). After controlling for potentially confounding variables like age, gender, race, BMI, smoking status, CCI, insurance status, preoperative diagnosis, and surgical approach, we found no clinically important association between an active opioid prescription and 90-day all-cause readmission (OR 1.002 [95% CI 1.001 to 1.004]; p = 0.05), procedure-related readmission (OR 1.003 [95% CI 1.001 to 1.006]; p = 0.02), length of stay > 2 days (OR 1.003 [95% CI 1.002 to 1.005]; p < 0.001), or nonhome discharge (OR 1.002 [95% CI 1.001 to 1.003]; p = 0.019); the large size of the database allowed us to find statistical associations, but the effect sizes are so small that the finding is unlikely to be clinically meaningful. A similarly small association that is unlikely to be clinically important was found between active sedative use and 90-day ED visits (OR 1.002 [95% CI 1.001 to 1.004]; p = 0.02). CONCLUSION Preoperative prescription drug use, as reflected by higher NCSs, has a dose-response association with adverse outcomes after THA. Surgeons may use the preoperative NCS to initiate and guide a patient-centered discussion regarding possible postoperative risks associated with prescription drug-use patterns (sedatives, opioids, or stimulants). An interdisciplinary approach can then be initiated to mitigate unfavorable patterns of prescription drug use and subsequently lower patient NCSs. However, given its nature and its reflection of drug-use patterns rather than patients' current health status, the NCS does not qualify as a basis for surgical denial or ineligibility. LEVEL OF EVIDENCE Level III, diagnostic study.
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Affiliation(s)
- Ahmed K. Emara
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Daniel Grits
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Alison K. Klika
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Robert M. Molloy
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Viktor E. Krebs
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Wael K. Barsoum
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Carlos Higuera-Rueda
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Nicolas S. Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
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Role of the prescriber in supporting patients to discontinue benzodiazepines: a qualitative study. Br J Gen Pract 2021; 71:e517-e527. [PMID: 33950855 PMCID: PMC8216269 DOI: 10.3399/bjgp.2020.1062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 02/22/2021] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Given the prevalence of long-term benzodiazepine (BZD) prescribing, increased monitoring through the implementation of prescription monitoring programmes (PMPs) may be the necessary impetus to promote BZD deprescribing. Despite evidence promoting the importance of patient-centred care, GPs have not been sufficiently supported to implement these principles through current deprescribing practice. AIM To investigate patients' perception of their prescriber's influence on ceasing BZD use, including their willingness to take their advice, and to understand how a patient's stage of change influences the barriers and facilitators they perceive to discontinuing BZDs. DESIGN AND SETTING An online survey and qualitative interviews with 22 long-term users of BZD (≥6 months), aged 18-69 years, recruited from the general population in Victoria, Australia. METHOD Two groups of users of BZD participated, one in the process of reducing their BZD and one not reducing, and were categorised according to their stage of change. Data underwent thematic analysis to identify barriers and facilitators to reducing BZDs both at the patient level and the prescriber level. RESULTS BZD patients' perceptions of the prescriber influence were characterised by prescribing behaviours, treatment approach, and attitude. Barriers and facilitators to reducing their BZD were mapped against their stage of change. Irrespective of their stage of change, participants reported they would be willing to try reducing their BZD if they trusted their prescriber. CONCLUSION This study illustrates that, with a few key strategies at each step of the deprescribing conversation, GPs are well positioned to tackle the issue of long-term BZD use in a manner that is patient centred.
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The Barriers and Facilitators of Different Stakeholders When Deprescribing Benzodiazepine Receptor Agonists in Older Patients-A Systematic Review. Metabolites 2021; 11:metabo11040254. [PMID: 33923956 PMCID: PMC8073998 DOI: 10.3390/metabo11040254] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/15/2021] [Accepted: 04/16/2021] [Indexed: 11/16/2022] Open
Abstract
Treatment of older patients with benzodiazepines and Z-drugs (BZRA) is associated with an increased risk of side effects. However, this treatment is still used among these patients. Deprescribing can be a tool to reduce inappropriate medication. This review aims to identify and compare barriers and facilitators of stakeholders involved in BZRA deprescribing in older patients and uncover potential gaps in the research field. The search was conducted in PubMed, EMBASE, PsycINFO, and Cochrane Library. Ten articles based on qualitative data on BZRA deprescribing in older patients (≥65 years) published between 2005-2020 were included. Six articles referred to patients as stakeholders, two referred to physicians, and one to nurses and caregivers, respectively, indicating a need for more studies in the field. More barriers than facilitators were identified. Important findings were the patient willingness to deprescribe BZRA compared to physicians, who did not mention deprescribing to patients due to barriers such as expected patient resistance. Nurses mentioned barriers like lack of knowledge and the feeling that their options were not valued by physicians; education was found to be a shared deprescribing facilitator among the stakeholders. Being aware of deprescribing barriers and facilitators can be helpful in future successful deprescribing interventions.
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Chen YT, Liu CY, Chang CM, Lai YM, Wang BH, Yang TY, Hsu SC. Perceptions, clinical characteristics, and other factors associated with prolonged and high daily dose of benzodiazepine use among patients with anxiety or depressive disorders. J Affect Disord 2020; 271:215-223. [PMID: 32479319 DOI: 10.1016/j.jad.2020.03.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 01/20/2020] [Accepted: 03/24/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Benzodiazepines (BZDs) have been widely used to treat anxiety; however, the risk of adverse health effects caused by their long-term use is high. This study examined the factors associated with the duration and higher daily dose of BZDs use among a population with anxiety or depressive disorders. METHODS A cross-sectional study design was used. Patients from a psychiatric outpatient department who had been prescribed BZDs were recruited. Data were collected from 250 patients. RESULTS Nearly 94% of patients were long-term BZDs users. The mean duration of BZDs use was 5.5 years; and mean defined daily dose (DDD) of BZDs use, converted to diazepam milligram equivalent (DDD), was 1.53 DME-DDD. Patients who knew more about alternative treatments were less prone to use BZD longer. Patients aged 65 years or older and those with difficulty falling asleep were more prone to use BZDs longer. Patients who were currently taking BZDs at higher daily dose were those who felt more depressed, prescribed second generation antipsychotics, suffered from disrupted sleep, less aware of alternative treatments, had comorbid chronic physical illness, and were current smokers. LIMITATIONS The cross-sectional study design limited its ability to confirm causal relationships. CONCLUSIONS Long-term and excessive daily dose of BZDs use in patients with depressive or anxiety disorders needs to be noted. Providing information or program of non-pharmacological treatment in reducing anxiety and improving specific sleep disturbance is suggested. Elderly, suffering from depressive mood, had comorbid chronic physical illness need to be targeted for further intervention.
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Affiliation(s)
- Yu-Ting Chen
- School of Nursing, College of Medicine, Chang Gung University, Taoyuan, Address:No.259, Wenhua 1st Rd., Guishan Dist., Taoyuan City 33302, Taiwan; Department of Psychiatry, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan.
| | - Chia-Yih Liu
- Department of Psychiatry, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Address: No.5, Fuxing St., Guishan Dist., Taoyuan City 333, Taiwan; School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
| | - Chia-Ming Chang
- Department of Psychiatry, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Address: No.5, Fuxing St., Guishan Dist., Taoyuan City 333, Taiwan.
| | - Yu-Ming Lai
- School of Nursing, College of Medicine, Chang Gung University, Taoyuan, Address:No.259, Wenhua 1st Rd., Guishan Dist., Taoyuan City 33302, Taiwan.
| | - Bi-Hwa Wang
- School of Nursing, College of Medicine, Chang Gung University, Taoyuan, Address:No.259, Wenhua 1st Rd., Guishan Dist., Taoyuan City 33302, Taiwan.
| | - Tsui-Yun Yang
- School of Nursing, College of Medicine, Chang Gung University, Taoyuan, Address:No.259, Wenhua 1st Rd., Guishan Dist., Taoyuan City 33302, Taiwan; Department of Hematology and Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan.
| | - Shih-Chieh Hsu
- Department of Psychiatry, Chang Gung Memorial Hospital at Linkou, Taoyuan, Address: No.5, Fuxing St., Guishan Dist., Taoyuan City 333, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan (l)Department of Psychiatry, New Taipei Municipal TuCheng Hospital, New Taipei, Taiwan; Department of Psychiatry, New Taipei Municipal TuCheng Hospital, New Taipei, Taiwan.
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Substance Use Disorders in Later Life: A Review and Synthesis of the Literature of an Emerging Public Health Concern. Am J Geriatr Psychiatry 2020; 28:226-236. [PMID: 31340887 DOI: 10.1016/j.jagp.2019.06.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 06/10/2019] [Accepted: 06/15/2019] [Indexed: 11/22/2022]
Abstract
Substance use disorders (SUDs) among older persons are among the fastest growing health problems in the United States. The number of older persons is projected to exceed 72.1 million persons by 2030, following a trend of general population growth in the mid-1940s to 1960s. The generation, known as "baby boomers," who refashioned drug use during their 20-30s, are increasingly continuing drug habits into later life. This review aims to assess the epidemiology, impact, and treatment of geriatric SUDs. Academic databases including PubMed, PsychInfo, Ovid, and Medline, were queried up to December 2018 for terms of "geriatric," "older," "elderly," "substance abuse," "drug," "drug use," "drug abuse," "drug dependency," "illicit drugs," and "geriatric psychiatry." Articles identified included 17 government documents, 29 studies based upon government documents, 43 studies not related to US government surveys, 19 review articles, 9 commentary pieces, 4 newspaper articles, 2 textbooks, and 1 published abstract. Evaluated studies and documents together suggest that older individuals are using illicit drugs and meeting criteria for SUDs at higher rates than previous geriatric cohorts resulting in substantial negative impacts on medical and psychiatric conditions. These findings represent a novel trend since previous cohorts of older individuals were thought to rarely use illicit substances. Current treatment models are inadequate to address the new wave of older individuals with SUDs. The fields of geriatrics, addiction, and geriatric psychiatry must work together to establish comprehensive care models and treatment modalities for addressing this emerging public health concern.
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Fegadolli C, Carlini ELDA, Delgado DL, Gómez KZ, Varela NMD. Percepciones y experiencias de usuarios de benzodiazepinas en la atención primaria de salud en Cuba. SAUDE E SOCIEDADE 2019. [DOI: 10.1590/s0104-12902019181033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Resumen A pesar de que son ampliamente conocidos los perfiles de utilización de las benzodiazepinas (BZD) y los riesgos asociados, este conocimiento no ha conducido a visibles transformaciones que mejoren la seguridad de los tratamientos y la salud de los pacientes. Por tanto, es necesaria una mejor compresión del contexto de su utilización, con el fin de implementar acciones educativas eficaces, tomar decisiones clínicas pertinentes y perfeccionar su regulación en los servicios de salud. Este artículo se propone caracterizar el perfil de utilización de benzodiazepinas en un área de salud de Santiago de Cuba y analizar el contexto de consumo a partir de los sentidos construidos por usuarios crónicos. Se realiza un estudio de caso, que describe el perfil de consumo a partir de las recetas dispensadas en la Farmacia Principal Municipal, y se realizan entrevistas a profundidad a los usuarios crónicos. El contenido de las entrevistas fue realizado temáticamente. Los resultados revelan los siguientes temas: poca concientización sobre el beneficio-riesgo del tratamiento, sufrimiento con la dependencia y tolerancia, autonomía en el tratamiento y limitada credibilidad en las terapias alternativas. La proporción de adultos mayores que reciben las BZD es mayor que la identificada en otros estudios. Se concluye que los usuarios perciben aspectos negativos del uso, pero están presos en la dependencia. Se evidencia la importancia de estudiar estrategias para el tratamiento del insomnio y la ansiedad en la atención primaria de salud, así como valorizar las políticas de implementación de terapias naturales y otros abordajes para contribuir al uso racional de las BZD.
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Mendelevich VD. Addictophobia in modern psychiatry (benzodiazepines and other psychopharmacological drugs). Zh Nevrol Psikhiatr Im S S Korsakova 2019; 119:75-81. [DOI: 10.17116/jnevro20191191275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Deprescribing Benzodiazepines in Older Patients: Impact of Interventions Targeting Physicians, Pharmacists, and Patients. Drugs Aging 2018; 35:493-521. [PMID: 29705831 DOI: 10.1007/s40266-018-0544-4] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Benzodiazepines (BZDs; including the related Z-drugs) are frequently targets for deprescribing; long-term use in older people is harmful and often not beneficial. BZDs can result in significant harms, including falls, fractures, cognitive impairment, car crashes and a significant financial and legal burden to society. Deprescribing BZDs is problematic due to a complex interaction of drug, patient, physician and systematic barriers, including concern about a potentially distressing but rarely fatal withdrawal syndrome. Multiple studies have trialled interventions to deprescribe BZDs in older people and are discussed in this narrative review. Reported success rates of deprescribing BZD interventions range between 27 and 80%, and this variability can be attributed to heterogeneity of methodological approaches and limited generalisability to cognitively impaired patients. Interventions targeting the patient and/or carer include raising awareness (direct-to-consumer education, minimal interventions, and 'one-off' geriatrician counselling) and resourcing the patient (gradual dose reduction [GDR] with or without cognitive behavioural therapy, teaching relaxation techniques, and sleep hygiene). These are effective if the patient is motivated to cease and is not significantly cognitively impaired. Interventions targeted to physicians include prescribing interventions by audit, algorithm or medication review, and providing supervised GDR in combination with medication substitution. Pharmacists have less frequently been the targets for studies, but have key roles in several multifaceted interventions. Interventions are evaluated according to the Behaviour Change Wheel. Research supports trialling a stepwise approach in the cognitively intact older person, but having a low threshold to use less-consultative methods in patients with dementia. Several resources are available to support deprescribing of BZDs in clinical practice, including online protocols.
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Sirdifield C, Chipchase SY, Owen S, Siriwardena AN. A Systematic Review and Meta-Synthesis of Patients’ Experiences and Perceptions of Seeking and Using Benzodiazepines and Z-Drugs: Towards Safer Prescribing. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2016; 10:1-15. [DOI: 10.1007/s40271-016-0182-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Abstract
Benzodiazepines have been in clinical use since the 1960s. Benzodiazepines act through allosteric modulation of the GABAA receptor to enhance the activity of GABA, an inhibitory neurotransmitter, resulting in a slowing of neurotransmission and sedative and anxiolytic effects. Initially benzodiazepines were thought to have low dependence liability, though over time there has been increasing evidence of benzodiazepine dependence. Benzodiazepines are commonly used to treat anxiety and insomnia, though increasingly they are considered second line treatments for most indications. Concerns about the effects of benzodiazepines on cognition, falls and their implication in opioid related mortality have emerged. Few pharmacological treatments for benzodiazepine dependence have been shown to be effective with gradual taper the most common treatment strategy for benzodiazepine dependence.
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Affiliation(s)
- Suzanne Nielsen
- National Drug and Alcohol Research Centre, UNSW, 22-32 King Street, Randwick, NSW, 2031, Australia. .,South East Sydney Local Health District (SESLHD) Drug and Alcohol Services, 591-623 S Dowling St, Surry Hills, NSW, 2010, Australia.
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Putnam M. Updating the journal's submission categories and format. JOURNAL OF GERONTOLOGICAL SOCIAL WORK 2014; 57:769-772. [PMID: 25272165 DOI: 10.1080/01634372.2014.966641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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