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Underwood M, Noufaily A, Blanchard H, Dale J, Harlock J, Gill P, Griffiths F, Spencer R, Slowther AM. GPs' views on emergency care treatment plans: an online survey. BJGP Open 2024:BJGPO.2023.0192. [PMID: 38191186 DOI: 10.3399/bjgpo.2023.0192] [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: 09/26/2023] [Accepted: 10/26/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND A holistic approach to emergency care treatment planning is needed to ensure that patients' preferences are considered should their clinical condition deteriorate. To address this, emergency care and treatment plans (ECTPs) have been introduced. Little is known about their use in general practice. AIM To find out GPs' experiences of, and views on, using ECTPs. DESIGN & SETTING Online survey of GPs practising in England. METHOD A total of 841 GPs were surveyed using the monthly online survey provided by medeConnect, a market research company. RESULTS Forty-one per cent of responders' practices used Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) plans for ECTP, 8% used other ECTPs, and 51% used Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) forms. GPs were the predominant professional group completing ECTPs in the community. There was broad support for a wider range of community-based health and social care professionals being able to complete ECTPs. There was no system for reviewing ECTPs in 20% of responders' practices. When compared with using a DNACPR form, GPs using a ReSPECT form for ECTP were more comfortable having conversations about emergency care treatment with patients (odds ratio [OR] = 1.72, 95% confidence interval [CI] = 1.1 to 2.69) and family members (OR =1.85, 95% CI = 1.19 to 2.87). CONCLUSION The potential benefits and challenges of widening the pool of health and social care professionals initiating and/or completing the ECTP process needs consideration. ReSPECT plans appear to make GPs more comfortable with ECTP discussions, supporting their implementation. Practice-based systems for reviewing ECTP decisions should be strengthened.
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Affiliation(s)
- Martin Underwood
- Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals of Coventry and Warwickshire, Coventry, UK
| | | | | | - Jeremy Dale
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Jenny Harlock
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Paramjit Gill
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Rachel Spencer
- Warwick Medical School, University of Warwick, Coventry, UK
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Eli K, Harlock J, Huxley CJ, Bernstein C, Mann C, Spencer R, Griffiths F, Slowther AM. Patient and relative experiences of the ReSPECT process in the community: an interview-based study. BMC PRIMARY CARE 2024; 25:115. [PMID: 38632508 PMCID: PMC11022317 DOI: 10.1186/s12875-024-02283-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 01/19/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) was launched in the UK in 2016. ReSPECT is designed to facilitate meaningful discussions between healthcare professionals, patients, and their relatives about preferences for treatment in future emergencies; however, no study has investigated patients' and relatives' experiences of ReSPECT in the community. OBJECTIVES To explore how patients and relatives in community settings experience the ReSPECT process and engage with the completed form. METHODS Patients who had a ReSPECT form were identified through general practice surgeries in three areas in England; either patients or their relatives (where patients lacked capacity) were recruited. Semi-structured interviews were conducted, focusing on the participants' understandings and experiences of the ReSPECT process and form. Data were analysed using inductive thematic analysis. RESULTS Thirteen interviews took place (six with patients, four with relatives, three with patient and relative pairs). Four themes were developed: (1) ReSPECT records a patient's wishes, but is entangled in wider relationships; (2) healthcare professionals' framings of ReSPECT influence patients' and relatives' experiences; (3) patients and relatives perceive ReSPECT as a do-not-resuscitate or end-of-life form; (4) patients' and relatives' relationships with the ReSPECT form as a material object vary widely. Patients valued the opportunity to express their wishes and conceptualised ReSPECT as a process of caring for themselves and for their family members' emotional wellbeing. Participants who described their ReSPECT experiences positively said healthcare professionals clearly explained the ReSPECT process and form, allocated sufficient time for an open discussion of patients' preferences, and provided empathetic explanations of treatment recommendations. In cases where participants said healthcare professionals did not provide clear explanations or did not engage them in a conversation, experiences ranged from confusion about the form and how it would be used to lingering feelings of worry, upset, or being burdened with responsibility. CONCLUSIONS When ReSPECT conversations involved an open discussion of patients' preferences, clear information about the ReSPECT process, and empathetic explanations of treatment recommendations, working with a healthcare professional to co-develop a record of treatment preferences and recommendations could be an empowering experience, providing patients and relatives with peace of mind.
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Affiliation(s)
- Karin Eli
- Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK.
| | - Jenny Harlock
- Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| | - Caroline J Huxley
- Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| | - Celia Bernstein
- Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| | - Claire Mann
- Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| | - Rachel Spencer
- Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| | - Frances Griffiths
- Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| | - Anne-Marie Slowther
- Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
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Lound A, Bruton J, Jones K, Shah N, Williams B, Gross J, Post B, Day S, Brett SJ, Ward H. "I'd rather wait and see what's around the corner": A multi-perspective qualitative study of treatment escalation planning in frailty. PLoS One 2023; 18:e0291984. [PMID: 37733669 PMCID: PMC10513333 DOI: 10.1371/journal.pone.0291984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 09/08/2023] [Indexed: 09/23/2023] Open
Abstract
INTRODUCTION People living with frailty risk adverse outcomes following even minor illnesses. Admission to hospital or the intensive care unit is associated with potentially burdensome interventions and poor outcomes. Decision-making during an emergency is fraught with complexity and potential for conflict between patients, carers and clinicians. Advance care planning is a process of shared decision-making which aims to ensure patients are treated in line with their wishes. However, planning for future care is challenging and those living with frailty are rarely given the opportunity to discuss their preferences. The aim of the ProsPECT (Prospective Planning for Escalation of Care and Treatment) study was to explore perspectives on planning for treatment escalation in the context of frailty. We spoke to people living with frailty, their carers and clinicians across primary and secondary care. METHODS In-depth online or telephone interviews and online focus groups. The topic guide explored frailty, acute decision-making and planning for the future. Data were thematically analysed using the Framework Method. Preliminary findings were presented to a sample of study participants for feedback in two online workshops. RESULTS We spoke to 44 participants (9 patients, 11 carers and 24 clinicians). Four main themes were identified: frailty is absent from treatment escalation discussions, planning for an uncertain future, escalation in an acute crisis is 'the path of least resistance', and approaches to facilitating treatment escalation planning in frailty. CONCLUSION Barriers to treatment escalation planning include a lack of shared understanding of frailty and uncertainty about the future. Emergency decision-making is focussed on survival or risk aversion and patient preferences are rarely considered. To improve planning discussions, we recommend frailty training for non-specialist clinicians, multi-disciplinary support, collaborative working between patients, carers and clinicians as well as broader public engagement.
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Affiliation(s)
- Adam Lound
- Patient Experience Research Centre, School of Public Health, Imperial College London, London, United Kingdom
| | - Jane Bruton
- Patient Experience Research Centre, School of Public Health, Imperial College London, London, United Kingdom
| | - Kathryn Jones
- Patient Experience Research Centre, School of Public Health, Imperial College London, London, United Kingdom
| | - Nira Shah
- ProsPECT Study Public Advisor, Patient Experience Research Centre, School of Public Health, Imperial College London, London, United Kingdom
| | - Barry Williams
- ProsPECT Study Public Advisor, Patient Experience Research Centre, School of Public Health, Imperial College London, London, United Kingdom
| | - Jamie Gross
- London North West University Healthcare NHS Trust, London, United Kingdom
| | - Benjamin Post
- Department of Bioengineering and Department of Computing, Imperial College London, London, United Kingdom
- UKRI Centre in AI for Healthcare, Imperial College London, London, United Kingdom
| | - Sophie Day
- Patient Experience Research Centre, School of Public Health, Imperial College London, London, United Kingdom
| | - Stephen J. Brett
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Helen Ward
- Patient Experience Research Centre, School of Public Health, Imperial College London, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
- National Institute for Health Research Imperial Biomedical Research Centre, London, United Kingdom
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The experiences of adult patients, families, and healthcare professionals of CPR decision-making conversations in the United Kingdom: A qualitative systematic review. Resusc Plus 2023; 13:100351. [PMID: 36686325 PMCID: PMC9850060 DOI: 10.1016/j.resplu.2022.100351] [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: 12/07/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 01/08/2023] Open
Abstract
Aim To conduct a qualitative systematic review on the experiences of patients, families, and healthcare professionals (HCPs) of CPR decision-making conversations in the United Kingdom (UK). Methods The databases PubMed, Embase, Emcare, CINAHL, and PsycInfo were searched. Studies published from 1 January 2012 describing experiences of CPR decision-making conversations in the UK were included. Included studies were critically appraised using the CASP tool. Thematic synthesis was conducted. Results From 684 papers identified, ten studies were included. Four key themes were identified:(i) Initiation of conversations - Key prompts for the discussion included clinical deterioration and poor prognosis. There are different perspectives about who should initiate conversations.(ii) Involvement of patients and families - HCPs were reluctant to involve patients who they thought would become distressed by the conversation, while patients varied in their desire to be involved. Patients wanted family support while HCPs viewed families as potential sources of conflict.(iii) Influences on the content of conversations - Location, context, HCPs' attitudes and emotions, and uncertainty of prognosis influenced the content of conversations.(iv) Conversation outcomes - Range of outcomes included emotional distress, sense of relief and value, disagreements, and incomplete conversations. Conclusions There is inconsistency in how these conversations occur, patients' desire to be involved, and between patients' and HCPs' views on the role of families in these conversations. CPR discussions raise ethical challenges for HCPs. HCPs need training and pastoral support in conducting CPR discussions. Patients and families need education on CPR recommendations and support after discussions.
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Kesten JM, Redwood S, Pullyblank A, Tavare A, Pocock L, Brant H, Hill EM, Tutaev M, Shum RZ, Banks J. Using the recommended summary plan for emergency care and treatment (ReSPECT) in care homes: a qualitative interview study. Age Ageing 2022; 51:6770071. [PMID: 36273344 PMCID: PMC9588387 DOI: 10.1093/ageing/afac226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is an advance care planning process designed to facilitate discussion and documentation of preferences for care in a medical emergency. Advance care planning is important in residential and nursing homes. AIM To explore the views and experiences of GPs and care home staff of the role of ReSPECT in: (i) supporting, and documenting, conversations about care home residents' preferences for emergency care situations, and (ii) supporting decision-making in clinical emergencies. SETTING/PARTICIPANTS Sixteen GPs providing clinical care for care home residents and 11 care home staff in the West of England. METHODS A qualitative research design using semi-structured interviews. RESULTS Participants' accounts described the ReSPECT process as facilitating person-centred conversations about residents' preferences for care in emergency situations. The creation of personalised scenarios supported residents to consider their preferences. However, using ReSPECT was complex, requiring interactional work to identify and incorporate resident or relative preferences. Subsequent translation of preferences into action during emergency situations also proved difficult in some cases. Care staff played an important role in facilitating and supporting ReSPECT conversations and in translating it into action. CONCLUSIONS The ReSPECT process in care homes was positive for GPs and care home staff. We highlight challenges with the process, communication of preferences in emergency situations and the importance of balancing detail with clarity. This study highlights the potential for a multi-disciplinary approach engaging care staff more in the process.
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Affiliation(s)
- Joanna May Kesten
- Address correspondence to: Joanna May Kesten, NIHR ARC West at University Hospitals Bristol and Weston NHS Foundation Trust, 9th Floor, Whitefriars, Lewins Mead, Bristol BS1 2NT, UK.
| | - Sabi Redwood
- The National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK,Population Health Sciences, Bristol Medical School, University of Bristol
| | - Anne Pullyblank
- West of England Academic Health Science Network (West of England AHSN), Bristol, UK,North Bristol NHS Trust, Bristol, UK
| | - Alison Tavare
- West of England Academic Health Science Network (West of England AHSN), Bristol, UK
| | - Lucy Pocock
- Population Health Sciences, Bristol Medical School, University of Bristol
| | - Heather Brant
- The National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK,Population Health Sciences, Bristol Medical School, University of Bristol
| | - Elizabeth M Hill
- The National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK,Population Health Sciences, Bristol Medical School, University of Bristol
| | | | - Rui Zhi Shum
- Population Health Sciences, Bristol Medical School, University of Bristol
| | - Jon Banks
- The National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK,Population Health Sciences, Bristol Medical School, University of Bristol
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McDermott A, Woodall CA, Chamberlain C, Selman L, Pocock LV. Which patients received a ReSPECT form, what was documented and what were the patient outcomes? A protocol for a retrospective observational study investigating the impact of the COVID-19 pandemic on the implementation of the ReSPECT process. BMJ Open 2022; 12:e060253. [PMID: 35820746 PMCID: PMC9277023 DOI: 10.1136/bmjopen-2021-060253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is a UK advance care planning (ACP) initiative aiming to standardise the process of creating personalised recommendations for a person's clinical care in a future emergency and therefore improve person-focused care. Implementation of the ReSPECT process across a large geographical area, involving both community and secondary care, has not previously been studied. In particular, it not known whether such implementation is associated with any change in outcomes for those patients with a ReSPECT form.Implementation of ReSPECT in the Bristol, North Somerset and South Gloucestershire (BNSSG) Clinical Commissioning Group (CCG) area overlapped with the first UK COVID-19 wave. It is unclear what impact the pandemic had on the implementation of ReSPECT and if this affected the type of patients who underwent the ReSPECT process, such as those with specific diagnoses or living in care homes. Patterns of clinical recommendations documented on ReSPECT forms during the first year of its implementation may also have changed, particularly with reference to the pandemic.To determine the equity and potential benefits of implementation of the ReSPECT form process in BNSSG and contribute to the ACP evidence base, this study will describe the characteristics of patients in the BNSSG area who had a completed ReSPECT form recorded in their primary care medical records before, during and after the first wave of the COVID-19 pandemic; describe the content of ReSPECT forms; and analyse outcomes for those patients who died with a ReSPECT form. METHODS AND ANALYSIS We will perform an observational retrospective study on data, collected from October 2019 for 12 months. Data will be exported from the CCG Public Health Management data resource, a pseudonymised database linking data from organisations providing health and social care to people across BNSSG. Descriptive statistics of sociodemographic and health-related variables for those who completed the ReSPECT process with a clinician and had a documented ReSPECT form in their notes, in addition to their ReSPECT form responses, will be compared between before, during and after first COVID-19 wave groups. Additionally, routinely collected outcomes for patients who died in our study period will be compared between those who completed the ReSPECT process with a community clinician, hospital clinician or not at all. These include emergency department attendances, emergency hospital admissions, community nurse home visits, hospice referrals, anticipatory medication prescribing, place of death and if the patient died in preferred place of death. ETHICS AND DISSEMINATION Approval has been obtained from a National Health Service Research Ethics Committee (20/YH/0185). Findings will be disseminated to policy decision-makers, care providers and the public through scientific meetings and peer-reviewed publication.
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Affiliation(s)
- Adam McDermott
- Palliative and End of Life Care Research Group/Centre for Academic Primary Care, Bristol Medical School, Bristol, UK
| | - Claire A Woodall
- Centre for Academic Primary Care, Bristol Medical School, Bristol, UK
| | - Charlotte Chamberlain
- Palliative and End of Life Care Research Group, Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Lucy Selman
- Palliative and End of Life Care Research Group, Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Lucy Victoria Pocock
- Palliative and End of Life Care Research Group/Centre for Academic Primary Care, Bristol Medical School, Bristol, UK
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Implementation of ReSPECT in acute hospitals: A retrospective observational study. Resuscitation 2022; 178:26-35. [PMID: 35779800 DOI: 10.1016/j.resuscitation.2022.06.020] [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: 04/26/2022] [Revised: 06/09/2022] [Accepted: 06/24/2022] [Indexed: 11/21/2022]
Abstract
AIMS To evaluate, in UK acute hospitals, the early implementation of the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT), which embeds cardiopulmonary resuscitation (CPR) recommendations within wider emergency treatment plans. To understand for whom and how the process was being used and the quality of form completion. METHODS A retrospective observational study evaluating emergency care and treatment planning approaches used in acute UK hospitals (2015-2019), and in six English hospital trusts the extent of ReSPECT use, patient characteristics and completion quality in a sample 3000 patient case notes. RESULTS The use of stand-alone Do Not Attempt Cardiopulmonary Resuscitation forms fell from 133/186 hospitals in 2015 to 64/186 in 2019 (a 38% absolute reduction). ReSPECT accounted for 52% (36/69) of changes. In the six sites, ReSPECT was used for approximately 20% of patients (range 6%-41%). They tended to be older, to have had an emergency medical admission, to have cognitive impairment and a lower predicted 10 year survival. Most (653/706 (92%)) included a 'not for attempted resuscitation' recommendation 551/706 (78%) had at least one other treatment recommendation. Capacity was not recorded on 13% (95/706) of forms; 11% (79/706) did not record patient/family involvement. CONCLUSIONS ReSPECT use accounts for 52% of the change, observed between 2015 and 2019, from using standalone DNACPR forms to approaches embedding DNACPR decisions within in wider emergency care plans in NHS hospitals in the UK. Whilst recommendations include other emergencies most still tend to focus on recommendations relating to CPR. Completion of ReSPECT forms requires improvement. STUDY REGISTRATION https://www.isrctn.com/ISRCTN11112933.
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Eli K, Huxley CJ, Hawkes CA, Perkins GD, Slowther AM, Griffiths F. Why are some ReSPECT conversations left incomplete? A qualitative case study analysis. Resusc Plus 2022; 10:100255. [PMID: 35734306 PMCID: PMC9207560 DOI: 10.1016/j.resplu.2022.100255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/10/2022] [Accepted: 05/20/2022] [Indexed: 11/17/2022] Open
Abstract
Background As an emergency care and treatment planning process (ECTP), a key feature of the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is the engagement of patients and/or their representatives in conversations about treatment options including, but not limited to, cardiopulmonary resuscitation (CPR). However, qualitative research suggests that some ReSPECT conversations lead to partial or no decision-making about treatment recommendations. This paper explores why some ReSPECT conversations are left incomplete. Methods Drawing on observation and interview data collected in four National Health Service (NHS) hospital sites in England, this paper offers an in-depth exploration of six case studies in which ReSPECT conversations were incomplete. Using thematic analysis, we triangulate fieldnote data documenting these conversations with interview data in which the doctors who conducted these conversations shared their perceptions and reflected on their decision-making processes. Results We identified two themes, both focused on ‘mismatch’: (1) Mismatch between the doctor’s clinical priorities and the patient’s/family’s immediate needs; and (2) mismatch between the doctor’s conversation scripts, which included patient autonomy, the feasibility of CPR, and what medicine can and should do to prolong a patient’s life, and the patient’s/family’s understandings of these concepts. Conclusions This case study analysis of six ReSPECT conversations found that mismatch between doctors’ priorities and understandings and those of patients and/or their relatives led to incomplete ReSPECT conversations. Future research should explore methods to overcome these mismatches.
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Affiliation(s)
- Karin Eli
- Warwick Medical School, University of Warwick, UK
- Corresponding authors at: Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry CV4 7AL, UK.
| | | | | | - Gavin D. Perkins
- Warwick Medical School, University of Warwick, UK
- University Hospitals Birmingham NHS Foundation Trust, UK
| | | | - Frances Griffiths
- Warwick Medical School, University of Warwick, UK
- Corresponding authors at: Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry CV4 7AL, UK.
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