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Wan KS, Moy FM, Mohd Yusoff MF, Mustapha F, Ismail M, Mat Rifin H, Yoga Ratnam KK, Ismail H, Chong KK, Ahmad NA, Hairi NN. Treatment intensification and therapeutic inertia of antihypertensive therapy among patients with type 2 diabetes and hypertension with uncontrolled blood pressure. Sci Rep 2024; 14:12625. [PMID: 38824234 PMCID: PMC11144228 DOI: 10.1038/s41598-024-63617-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 05/30/2024] [Indexed: 06/03/2024] Open
Abstract
Treatment intensification is essential to ensure guideline targets are attained in diabetes patients. The failure to intensify treatment when the targets are not achieved is therapeutic inertia. This study aimed to determine the proportions and factors associated with treatment intensification and therapeutic inertia of antihypertensive therapy in type 2 diabetes patients with uncontrolled hypertension in Malaysia. A retrospective cohort analysis was conducted utilising registry data. Diabetes hypertensive patients with uncontrolled baseline systolic or diastolic blood pressure were included. Treatment intensification was the increase in the number of antihypertensive agents from the index treatment. Therapeutic inertia was the absence of treatment intensification when the second blood pressure reading was still uncontrolled. About 6956 patients were followed up over 2.5 ± 1.1 person-years. Treatment intensification was observed in 29.8% of patients, while 38.6% had therapeutic inertia. Chinese, Indian, and 'others' ethnic groups, retinopathy, more antihypertensive agents, and higher systolic blood pressure were associated with therapeutic inertia. Underweight, overweight patients and those with dyslipidaemia had lower risks for therapeutic inertia. The results indicate suboptimal quality of care in public health clinics in Malaysia. Further studies are needed to determine the underlying causes to formulate precise interventions to tackle the problem in Malaysia.
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Affiliation(s)
- Kim Sui Wan
- Institute for Public Health, National Institutes of Health, Ministry of Health Malaysia, Setia Alam, 40170, Shah Alam, Selangor, Malaysia.
- Centre for Epidemiology and Evidence-Based Practice, Department of Social and Preventive Medicine, Faculty of Medicine, Universiti Malaya, 50603, Federal Territory of Kuala Lumpur, Malaysia.
| | - Foong Ming Moy
- Centre for Epidemiology and Evidence-Based Practice, Department of Social and Preventive Medicine, Faculty of Medicine, Universiti Malaya, 50603, Federal Territory of Kuala Lumpur, Malaysia
| | - Muhammad Fadhli Mohd Yusoff
- Institute for Public Health, National Institutes of Health, Ministry of Health Malaysia, Setia Alam, 40170, Shah Alam, Selangor, Malaysia
| | - Feisul Mustapha
- Disease Control Division, Federal Government Administration Centre, Ministry of Health, 62590, Putrajaya, Malaysia
- Perak State Health Department, Ministry of Health Malaysia, 30000, Ipoh, Perak, Malaysia
| | - Mastura Ismail
- Family Health Development Division, Federal Government Administration Centre, Ministry of Health Malaysia, 62590, Putrajaya, Malaysia
| | - Halizah Mat Rifin
- Institute for Public Health, National Institutes of Health, Ministry of Health Malaysia, Setia Alam, 40170, Shah Alam, Selangor, Malaysia
| | - Kishwen Kanna Yoga Ratnam
- Institute for Public Health, National Institutes of Health, Ministry of Health Malaysia, Setia Alam, 40170, Shah Alam, Selangor, Malaysia
| | - Hasimah Ismail
- Institute for Public Health, National Institutes of Health, Ministry of Health Malaysia, Setia Alam, 40170, Shah Alam, Selangor, Malaysia
| | - Kah Kian Chong
- Medical Department, Hospital Port Dickson, Negeri Sembilan, 71050, Port Dickson, Malaysia
| | - Noor Ani Ahmad
- Institute for Public Health, National Institutes of Health, Ministry of Health Malaysia, Setia Alam, 40170, Shah Alam, Selangor, Malaysia
| | - Noran Naqiah Hairi
- Centre for Epidemiology and Evidence-Based Practice, Department of Social and Preventive Medicine, Faculty of Medicine, Universiti Malaya, 50603, Federal Territory of Kuala Lumpur, Malaysia
- Faculty of Public Health, Universitas Airlangga, Surabaya City, 60115, East Java, Indonesia
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Rahman ARA, Magno JDA, Cai J, Han M, Lee HY, Nair T, Narayan O, Panyapat J, Van Minh H, Khurana R. Management of Hypertension in the Asia-Pacific Region: A Structured Review. Am J Cardiovasc Drugs 2024; 24:141-170. [PMID: 38332411 PMCID: PMC10973088 DOI: 10.1007/s40256-023-00625-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2023] [Indexed: 02/10/2024]
Abstract
This article reviews available evidence regarding hypertension management in the Asia-Pacific region, focussing on five research questions that deal with specific aspects: blood pressure (BP) control, guideline recommendations, role of renin-angiotensin-aldosterone system (RAAS) inhibitors in clinical practice, pharmacological management and real-world adherence to guideline recommendations. A PubMed search identified 2537 articles, of which 94 were considered relevant. Compared with Europeans, Asians have higher systolic/diastolic/mean arterial BP, with a stronger association between BP and stroke. Calcium channel blockers are the most-commonly prescribed monotherapy in Asia, with significant variability between countries in the rates of angiotensin-converting enzyme inhibitors (ACEis)/angiotensin-receptor blockers (ARBs) and single-pill combination (SPC) use. In clinical practice, ARBs are used more commonly than ACEis, despite the absence of recommendation from guidelines and clinical evidence supporting the use of one class of drug over the other. Ideally, antihypertensive treatment should be tailored to the individual patient, but currently there are limited data on the characteristics of hypertension in Asia-Pacific individuals. Large outcome studies assessing RAAS inhibitor efficacy and safety in multi-national Asian populations are lacking. Among treated patients, BP control rates were ~ 35 to 40%; BP control in Asia-Pacific is suboptimal, and disproportionately so compared with Western nations. Strategies to improve the management of hypertension include wider access/availability of affordable treatments, particularly SPCs (which improve adherence), effective public health screening programs targeting patients to drive health-seeking behaviours, an increase in physician/patient awareness and early implementation of lifestyle changes. A unified Asia-Pacific guideline on hypertension management with pragmatic recommendations, particularly in resource-limited settings, is essential.
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Affiliation(s)
- Abdul R A Rahman
- An Nur Specialist Hospital, Jalan Gerbang Wawasan 1, Seksyen 15, 43650, Bandar Baru Bangi, Selangor, Malaysia.
| | - Jose Donato A Magno
- Division of Cardiovascular Medicine, Philippine General Hospital, Cardiovascular Institute, University of the Philippines College of Medicine, Angeles University Foundation Medical Center, Angeles, Philippines
| | - Jun Cai
- Hypertension Center, Fuwai Hospital, Beijing, People's Republic of China
| | - Myint Han
- Grand Hantha International Hospital, Yangon, Myanmar
| | - Hae-Young Lee
- Department of Internal Medicine, Seoul National University Hospital, 101, Daehak-ro Chongno-gu, Seoul, 03080, South Korea
| | - Tiny Nair
- PRS Hospital, Trivandrum, Kerala, India
| | - Om Narayan
- The Northern Hospital, 185 Cooper St., Epping, VIC, 3122, Australia
| | - Jiampo Panyapat
- Bhumibol Adulyadej Hospital, 171 Paholyothin Road, Saimai, Bangkok, 10220, Thailand
| | - Huynh Van Minh
- Department of Internal Medicine, Hue University of Medicine and Pharmacy, Hue, 530000, Vietnam
| | - Rohit Khurana
- The Harley Street Heart and Vascular Center, Gleneagles Hospital, Singapore, 258500, Singapore
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Chew BH, Mohd-Yusof BN, Lai PSM, Khunti K. Overcoming Therapeutic Inertia as the Achilles' Heel for Improving Suboptimal Diabetes Care: An Integrative Review. Endocrinol Metab (Seoul) 2023; 38:34-42. [PMID: 36792353 PMCID: PMC10008655 DOI: 10.3803/enm.2022.1649] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 02/06/2023] [Indexed: 02/17/2023] Open
Abstract
The ultimate purpose of diabetes care is achieving the outcomes that patients regard as important throughout the life course. Despite advances in pharmaceuticals, nutraceuticals, psychoeducational programs, information technologies, and digital health, the levels of treatment target achievement in people with diabetes mellitus (DM) have remained suboptimal. This clinical care of people with DM is highly challenging, complex, costly, and confounded for patients, physicians, and healthcare systems. One key underlying problem is clinical inertia in general and therapeutic inertia (TI) in particular. TI refers to healthcare providers' failure to modify therapy appropriately when treatment goals are not met. TI therefore relates to the prescribing decisions made by healthcare professionals, such as doctors, nurses, and pharmacists. The known causes of TI include factors at the level of the physician (50%), patient (30%), and health system (20%). Although TI is often multifactorial, the literature suggests that 28% of strategies are targeted at multiple levels of causes, 38% at the patient level, 26% at the healthcare professional level, and only 8% at the healthcare system level. The most effective interventions against TI are shorter intervals until revisit appointments and empowering nurses, diabetes educators, and pharmacists to review treatments and modify prescriptions.
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Affiliation(s)
- Boon-How Chew
- Department of Family Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Malaysia
- Clinical Research Unit, Hospital Pengajar Universiti Putra Malaysia (HPUPM Teaching Hospital), Persiaran MARDI-UPM, Malaysia
- Corresponding author: Boon-How Chew Department of Family Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia Tel: +60-039769-9763, E-mail:
| | - Barakatun-Nisak Mohd-Yusof
- Department of Dietetics, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Pauline Siew Mei Lai
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Kamlesh Khunti
- National Institute for Health Research Applied Research Collaboration East Midlands, Leicester Diabetes Centre, UK
- Diabetes Research Centre, Leicester General Hospital, University of Leicester, Leicester, UK
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Medication non-adherence and therapeutic inertia independently contribute to poor disease control for cardiometabolic diseases. Sci Rep 2022; 12:18936. [PMID: 36344613 PMCID: PMC9640683 DOI: 10.1038/s41598-022-21916-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 10/05/2022] [Indexed: 11/09/2022] Open
Abstract
Poorly controlled cardiometabolic biometric health gap measures [e.g.,uncontrolled blood pressure (BP), HbA1c, and low-density lipoprotein cholesterol (LDL-C)] are mediated by medication adherence and clinician-level therapeutic inertia (TI). The study of comparing relative contribution of these two factors to disease control is lacking. We conducted a retrospective cohort study using 7 years of longitudinal electronic health records (EHR) from primary care cardiometabolic patients who were 35 years or older. Cox-regression modeling was applied to estimate how baseline proportion of days covered (PDC) and TI were associated with cardiometabolic related health gap closure. 92,766 patients were included in the analysis, among which 89.9%, 85.8%, and 73.3% closed a BP, HbA1c, or LDL-C gap, respectively, with median days to gap closure ranging from 223 to 408 days. Patients who did not retrieve a medication were the least likely to achieve biometric control, particularly for LDL-C (HR = 0.58, 95% CI: 0.55-0.60). TI or uncertainty of TI was associated with a high risk of health gap persistence, particularly for LDL-C (HR ranges 0.46-0.48). Both poor medication adherence and TI are independently associated with persistent health gaps, and TI has a much higher impact on disease control compared to medication adherence, implying disease management strategies should prioritize reducing TI.
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Liu J, Bloomgarden Z. The Chinese Metabolic Management Centers. J Diabetes 2022; 14:362-364. [PMID: 35712984 PMCID: PMC9366566 DOI: 10.1111/1753-0407.13290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Jianmin Liu
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic DiseasesRuijin Hospital, Shanghai Jiao Tong University School of MedicineShanghaiChina
- Shanghai National Clinical Research Center for Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission of the PR China, Shanghai Key Laboratory for Endocrine Tumor, State Key Laboratory of Medical GenomicsRuijin Hospital, Shanghai Jiao Tong University School of MedicineShanghaiChina
| | - Zachary Bloomgarden
- Department of Medicine, Division of Endocrinology, Diabetes, and Bone DiseaseIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
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Sreelal TP, Thulaseedharan JV, Nair S, Ravindran RM, Vijayakumar K, Varma RP. Hypertension control in Kerala, India: a prescription-based study at primary and secondary level health care institutions. Indian Heart J 2022; 74:296-301. [PMID: 35644270 PMCID: PMC9453055 DOI: 10.1016/j.ihj.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 05/18/2022] [Accepted: 05/25/2022] [Indexed: 11/24/2022] Open
Abstract
Objective We undertook a prescription-based study to identify the provider and institution-level factors related to achieving guideline-recommended control of hypertension and diabetes mellitus in Kerala, India. Methods This cross-sectional study in primary and secondary care hospitals in Kerala included both public and private institutions. One practitioner was selected from each institution. Data on institutional and provider factors were collected using a structured questionnaire. Prescriptions were photographically captured and data on disease status and drugs prescribed were recorded. Factors associated with disease control were identified using binary logistic regression. Results Totally 4679 prescriptions were included for analysis. For hypertension-only patients, control levels were 31.5% and was significantly higher in public hospitals (Adjusted odds ratio (AOR) 1.96, 95% confidence intervals (CI) 1.50–2.57). Among patients with diabetes only, diabetes control was seen in 36.6%. When both conditions were present, control was achieved in only 17.0% patients. Being prescribed two or more drugs indicated lower control, whatever the respective condition. Among antihypertensive prescriptions rationality of 26.7% were questioned, such as lack of Renin Angiotensin System (RAS) inhibitor in diabetic hypertensives, dual RAS blockage, and indication for beta-blocker monotherapy. Conclusions In this prescription-based study in Kerala, India, a majority of hypertensive patients did not have controlled blood pressure levels, particularly if diabetes coexisted. This has serious implications as Kerala is the state with the highest burden of hypertension in India. Several prescription patterns were of questionable rationality. Further research and actions on rationality of anti-hypertensive prescriptions and barriers to treatment intensification is warranted.
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Affiliation(s)
- Thekkumkara Prabhakaran Sreelal
- DM Wayanad Institute of Medical Sciences (WIMS) Medical College, Wayanad, Kerala, 673577, India; Health Action by People, Thiruvananthapuram, Kerala, 695011, India
| | - Jissa Vinoda Thulaseedharan
- Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, 695011, India
| | - Sanjeev Nair
- Department of Pulmonary Medicine, Government Medical College, Thrissur, Kerala, 680596, India; Health Action by People, Thiruvananthapuram, Kerala, 695011, India
| | - Rekha Melathuparambil Ravindran
- State Health Systems Resource Centre - Kerala, Thiruvananthapuram, Kerala, 695014, India; Health Action by People, Thiruvananthapuram, Kerala, 695011, India
| | | | - Ravi Prasad Varma
- Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, 695011, India; Health Action by People, Thiruvananthapuram, Kerala, 695011, India.
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Baharudin N, Mohamed-Yassin MS, Daher AM, Ramli AS, Khan NAMN, Abdul-Razak S. Prevalence and factors associated with lipid-lowering medications use for primary and secondary prevention of cardiovascular diseases among Malaysians: the REDISCOVER study. BMC Public Health 2022; 22:228. [PMID: 35120488 PMCID: PMC8815195 DOI: 10.1186/s12889-022-12595-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 01/12/2022] [Indexed: 01/05/2023] Open
Abstract
Background Lipid-lowering medications (LLM) are commonly used for secondary prevention, as well as for primary prevention among patients with high global cardiovascular risk and with diabetes. This study aimed to determine the prevalence of LLM use among high-risk individuals [participants with diabetes, high Framingham general cardiovascular (FRS-CVD) score, existing cardiovascular disease (CVD)] and the factors associated with it. Methods This is a cross-sectional analysis from the baseline recruitment (years 2007 to 2011) of an ongoing prospective study involving 11,288 participants from 40 rural and urban communities in Malaysia. Multiple logistic regression was used to identify characteristics associated with LLM use. Results Majority (74.2%) of participants with CVD were not on LLM. Only 10.5% of participants with high FRS-CVD score, and 17.1% with diabetes were on LLM. Participants who were obese (OR = 1.80, 95% CI: 1.15–2.83), have diabetes (OR = 2.38, 95% CI: 1.78–3.19), have hypertension (OR = 2.87, 95% CI: 2.09–3.95), and attained tertiary education (OR = 2.25, 95% CI: 1.06–4.78) were more likely to be on LLM. Rural residents had lower odds of being on LLM (OR = 0.58, 95% CI: 0.41–0.82). In the primary prevention group, participants with high FRS-CVD score (OR = 3.81, 95% CI: 2.78–5.23) and high-income earners (OR = 1.54, 95% CI: 1.06–2.24) had higher odds of being on LLM. Conclusions LLM use among high CVD-risk individuals in the primary prevention group, and also among individuals with existing CVD was low. While CVD risk factors and global cardiovascular risk score were positively associated with LLM use, sociodemographic disparities were observed among the less-educated, rural residents and low-income earners. Measures are needed to ensure optimal and equitable use of LLM.
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Affiliation(s)
- Noorhida Baharudin
- Department of Primary Care Medicine, Faculty of Medicine, Universiti Teknologi MARA, Selayang Campus, Jalan Prima Selayang 7, 68100, Batu Caves, Selangor, Malaysia.
| | - Mohamed-Syarif Mohamed-Yassin
- Department of Primary Care Medicine, Faculty of Medicine, Universiti Teknologi MARA, Selayang Campus, Jalan Prima Selayang 7, 68100, Batu Caves, Selangor, Malaysia
| | - Aqil Mohammad Daher
- Department of Community Medicine, School of Medicine, International Medical University, Bukit Jalil, 57000, Kuala Lumpur, Malaysia
| | - Anis Safura Ramli
- Department of Primary Care Medicine, Faculty of Medicine, Universiti Teknologi MARA, Selayang Campus, Jalan Prima Selayang 7, 68100, Batu Caves, Selangor, Malaysia.,Institute of Pathology, Laboratory and Forensic Medicine (I-PPerForM), Universiti Teknologi MARA, Sungai Buloh Campus, Jalan Hospital, 47000, Sungai Buloh, Selangor, Malaysia
| | - Nor-Ashikin Mohamed Noor Khan
- Department of Physiology, Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh Campus, Jalan Hospital, 47000, Sungai Buloh, Selangor, Malaysia
| | - Suraya Abdul-Razak
- Department of Primary Care Medicine, Faculty of Medicine, Universiti Teknologi MARA, Selayang Campus, Jalan Prima Selayang 7, 68100, Batu Caves, Selangor, Malaysia.,Institute of Pathology, Laboratory and Forensic Medicine (I-PPerForM), Universiti Teknologi MARA, Sungai Buloh Campus, Jalan Hospital, 47000, Sungai Buloh, Selangor, Malaysia.,Hospital Universiti Teknologi MARA (HUiTM), 42300, Bandar Puncak Alam, Selangor, Malaysia.,Cardio Vascular and Lungs Research Institute (CaVaLRI), Universiti Teknologi MARA, Sungai Buloh Campus, Jalan Hospital, 47000, Sungai Buloh, Selangor, Malaysia
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Examination of Electrolyte Replacements in the ICU Utilizing MIMIC-III Dataset Demonstrates Redundant Replacement Patterns. Healthcare (Basel) 2021; 9:healthcare9101373. [PMID: 34683053 PMCID: PMC8536187 DOI: 10.3390/healthcare9101373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 09/27/2021] [Accepted: 10/05/2021] [Indexed: 11/17/2022] Open
Abstract
Electrolyte repletion in the ICU is one of the most ubiquitous tasks in critical care, involving significant resources while having an unclear risk/benefit ratio. Prior data indicate most replacements are administered while electrolytes are within or above reference ranges with little effect on serum post-replacement levels and potential harm. ICU electrolyte replacement patterns were analyzed using the MIMIC-III database to determine the threshold governing replacement decisions and their efficiency. The data of serum values for potassium, magnesium, and phosphate before and after repletion events were evaluated. Thresholds for when repletion was administered and temporal patterns in the repletion behaviors of ICU healthcare providers were identified. Most electrolyte replacements happened when levels were below or within reference ranges. Of the lab orders placed, a minuscule number of them were followed by repletion. Electrolyte repletion resulted in negligible (phosphate), small (potassium), and modest (magnesium) post-replacement changes in electrolyte serum levels. The repletion pattern followed hospital routine work and was anchored around shift changes. A subset of providers conducting over-repletion in the absence of clinical indication was also identified. This pattern of behavior found in this study supports previous studies and may allude to a universal pattern of over-repletion in the ICU setting.
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