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Mazuru V, Mang S, Ajouri J, Muellenbach RM, Bals R, Feth M, Zeiner C, Wengenmayer T, Lepper PM, Rixecker TM, Seiler F. External Validation of the PREdiction of Survival on Extracorporeal Membrane Oxygenation Therapy (PRESET) Score: A Single Center Cohort Experience. ASAIO J 2024:00002480-990000000-00480. [PMID: 38728743 DOI: 10.1097/mat.0000000000002226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a life-threatening condition affecting >10% of intensive care unit (ICU) patients worldwide with a mortality of up to 59% depending on severity. Extracorporeal membrane oxygenation (ECMO) is a potentially life-saving procedure in severe ARDS but is technically and financially challenging. In recent years, various scoring systems have been proposed to select patients most likely to benefit from ECMO, with the PREdiction of Survival on ECMO Therapy (PRESET) score being one of the most used. We collected data from 283 patients with ARDS of various etiology who underwent veno-venous (V-V) ECMO therapy at a German tertiary care ICU from January 2012 to December 2022. Median age in the cohort was 56 years, and 64.31% were males. The in-hospital mortality rate was 50.88% (n = 144). The median (25%; 75% quartile) severity scores were 38 (31; 49) for Simplified Acute Physiology Score (SAPS) II, 12 (10; 13) for Sequential Organ Failure Assessment (SOFA) and 7 (5; 8) for PRESET. Simplified Acute Physiology Score-II displayed the best prognostic value (area under the receiver operating characteristic [AUROC]: 0.665 [confidence interval (CI): 0.574-0.756; p = 0.046]). Prediction performance was weak in all analyzed scores despite good calibration. Simplified Acute Physiology Score-II had the best discrimination after adjustment of our original cohort. The use of scores explored in this study for patient selection for eligibility for V-V ECMO is not recommendable.
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Affiliation(s)
- Vitalie Mazuru
- From the Department of Internal Medicine V - Pneumology, Allergology and Critical Care Medicine, Saarland University Medical Center and University of Saarland, Homburg, Germany
| | - Sebastian Mang
- From the Department of Internal Medicine V - Pneumology, Allergology and Critical Care Medicine, Saarland University Medical Center and University of Saarland, Homburg, Germany
| | - Jonas Ajouri
- Department of Anaesthesiology and Critical Care Medicine, Klinikum Kassel, Germany
| | - Ralf M Muellenbach
- Department of Anaesthesiology and Critical Care Medicine, Klinikum Kassel, Germany
| | - Robert Bals
- From the Department of Internal Medicine V - Pneumology, Allergology and Critical Care Medicine, Saarland University Medical Center and University of Saarland, Homburg, Germany
| | - Maximilian Feth
- Department of Anesthesiology, Critical Care, Emergency and Pain Medicine, Military Medical Center Ulm, Ulm, Germany
| | - Carsten Zeiner
- From the Department of Internal Medicine V - Pneumology, Allergology and Critical Care Medicine, Saarland University Medical Center and University of Saarland, Homburg, Germany
| | - Tobias Wengenmayer
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Philipp M Lepper
- Department of Emergency Medicine, Saarland University Medical Center and University of Saarland, Homburg, Germany
| | - Torben M Rixecker
- From the Department of Internal Medicine V - Pneumology, Allergology and Critical Care Medicine, Saarland University Medical Center and University of Saarland, Homburg, Germany
| | - Frederik Seiler
- From the Department of Internal Medicine V - Pneumology, Allergology and Critical Care Medicine, Saarland University Medical Center and University of Saarland, Homburg, Germany
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Grotberg JC, Kraft BD, Sullivan M, Pawale AA, Kotkar KD, Masood MF. Advanced Respiratory Support Days as a Novel Marker of Mortality in COVID-19 Acute Respiratory Distress Syndrome Requiring Extracorporeal Membrane Oxygenation. ASAIO J 2024; 70:427-435. [PMID: 38295398 PMCID: PMC11062834 DOI: 10.1097/mat.0000000000002119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024] Open
Abstract
Emerging evidence suggests prolonged use of noninvasive respiratory support may increase mortality of patients with coronavirus disease 2019 (COVID-19)-associated acute respiratory distress syndrome who require extracorporeal membrane oxygenation (ECMO). Using a database of adults receiving ECMO for COVID-19, we calculated survival curves and multivariable Cox regression to determine the risk of death associated with pre-ECMO use of high-flow nasal oxygen (HFNO), noninvasive ventilation (NIV), and invasive mechanical ventilation (IMV) days. We investigated the performance of a novel variable, advanced respiratory support days (composite of HFNO, NIV, and IMV days), on Respiratory ECMO Survival Prediction (RESP) score. Subjects (N = 146) with increasing advanced respiratory support days (<5, 5-9, and ≥10) had a stepwise increase in 90 day mortality (32.2%, 57.7%, and 75.4%, respectively; p = 0.002). Ninety-day mortality was significantly higher in subjects (N = 121) receiving NIV >4 days (81.8% vs. 52.4%, p < 0.001). Each additional pre-ECMO advanced respiratory support day increased the odds of right ventricular failure (odds ratio [OR]: 1.066, 95% confidence interval [CI]: 1.002-1.135) and in-hospital mortality (1.17, 95% CI: 1.08-1.27). Substituting advanced respiratory support days for IMV days improved RESP score mortality prediction (area under the curve (AUC) or: 0.64 vs. 0.71). Pre-ECMO advanced respiratory support days were associated with increased 90 day mortality compared with IMV days alone. Adjusting the RESP score for advanced respiratory support days improved mortality prediction.
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Affiliation(s)
- John C. Grotberg
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Bryan D. Kraft
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Mary Sullivan
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Amit A. Pawale
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Kunal D. Kotkar
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Muhammad F. Masood
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
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3
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Pratt EH, Morrison S, Green CL, Rackley CR. Ability of the respiratory ECMO survival prediction (RESP) score to predict survival for patients with COVID-19 ARDS and non-COVID-19 ARDS: a single-center retrospective study. J Intensive Care 2023; 11:37. [PMID: 37658447 PMCID: PMC10472724 DOI: 10.1186/s40560-023-00686-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 08/25/2023] [Indexed: 09/03/2023] Open
Abstract
The respiratory ECMO survival prediction (RESP) score is used to predict survival for patients managed with extracorporeal membrane oxygenation (ECMO), but its performance in patients with Coronavirus Disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS) is unclear. We evaluated the ability of the RESP score to predict survival for patients with both non-COVID 19 ARDS and COVID-19 ARDS managed with ECMO at our institution. Receiver operating characteristic area under the curve (AUC) analysis found the RESP score reasonably predicted survival in patients with non-COVID-19 ARDS (AUC 0.76, 95% CI 0.68-0.83), but not patients with COVID-19 ARDS (AUC 0.54, 95% CI 0.41-0.66).
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Affiliation(s)
- Elias H Pratt
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, NC, USA.
| | - Samantha Morrison
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Cynthia L Green
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Craig R Rackley
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, NC, USA
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Shah N, Xue B, Xu Z, Yang H, Marwali E, Dalton H, Payne PPR, Lu C, Said AS. Validation of extracorporeal membrane oxygenation mortality prediction and severity of illness scores in an international COVID-19 cohort. Artif Organs 2023; 47:1490-1502. [PMID: 37032544 DOI: 10.1111/aor.14542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/23/2023] [Accepted: 04/06/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Veno-venous extracorporeal membrane oxygenation (V-V ECMO) is a lifesaving support modality for severe respiratory failure, but its resource-intensive nature led to significant controversy surrounding its use during the COVID-19 pandemic. We report the performance of several ECMO mortality prediction and severity of illness scores at discriminating survival in a large COVID-19 V-V ECMO cohort. METHODS We validated ECMOnet, PRESET (PREdiction of Survival on ECMO Therapy-Score), Roch, SOFA (Sequential Organ Failure Assessment), APACHE II (acute physiology and chronic health evaluation), 4C (Coronavirus Clinical Characterisation Consortium), and CURB-65 (Confusion, Urea nitrogen, Respiratory Rate, Blood Pressure, age >65 years) scores on the ISARIC (International Severe Acute Respiratory and emerging Infection Consortium) database. We report discrimination via Area Under the Receiver Operative Curve (AUROC) and Area under the Precision Recall Curve (AURPC) and calibration via Brier score. RESULTS We included 1147 patients and scores were calculated on patients with sufficient variables. ECMO mortality scores had AUROC (0.58-0.62), AUPRC (0.62-0.74), and Brier score (0.286-0.303). Roch score had the highest accuracy (AUROC 0.62), precision (AUPRC 0.74) yet worst calibration (Brier score of 0.3) despite being calculated on the fewest patients (144). Severity of illness scores had AUROC (0.52-0.57), AURPC (0.59-0.64), and Brier Score (0.265-0.471). APACHE II had the highest accuracy (AUROC 0.58), precision (AUPRC 0.64), and best calibration (Brier score 0.26). CONCLUSION Within a large international multicenter COVID-19 cohort, the evaluated ECMO mortality prediction and severity of illness scores demonstrated inconsistent discrimination and calibration highlighting the need for better clinically applicable decision support tools.
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Affiliation(s)
- Neel Shah
- Division of Pediatric Critical Care, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Bing Xue
- Department of Computer Science & Engineering, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Ziqi Xu
- Department of Computer Science & Engineering, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Hanqing Yang
- Department of Computer Science & Engineering, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Eva Marwali
- National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Heidi Dalton
- INOVA Fairfax Hospital, Falls Church, Virginia, USA
| | - Philip P R Payne
- Institute for Informatics, School of Medicine, Washington University in St. Louis, Missouri, St. Louis, USA
| | - Chenyang Lu
- Department of Computer Science & Engineering, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Ahmed S Said
- Division of Pediatric Critical Care, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri, USA
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Rabie AA, Elhazmi A, Azzam MH, Abdelbary A, Labib A, Combes A, Zakhary B, MacLaren G, Barbaro RP, Peek GJ, Antonini MV, Shekar K, Al-Fares A, Oza P, Mehta Y, Alfoudri H, Ramanathan K, Ogino M, Raman L, Paden M, Brodie D, Bartlett R. Expert consensus statement on venovenous extracorporeal membrane oxygenation ECMO for COVID-19 severe ARDS: an international Delphi study. Ann Intensive Care 2023; 13:36. [PMID: 37129771 PMCID: PMC10152433 DOI: 10.1186/s13613-023-01126-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 04/05/2023] [Indexed: 05/03/2023] Open
Abstract
BACKGROUND The high-quality evidence on managing COVID-19 patients requiring extracorporeal membrane oxygenation (ECMO) support is insufficient. Furthermore, there is little consensus on allocating ECMO resources when scarce. The paucity of evidence and the need for guidance on controversial topics required an international expert consensus statement to understand the role of ECMO in COVID-19 better. Twenty-two international ECMO experts worldwide work together to interpret the most recent findings of the evolving published research, statement formulation, and voting to achieve consensus. OBJECTIVES To guide the next generation of ECMO practitioners during future pandemics on tackling controversial topics pertaining to using ECMO for patients with COVID-19-related severe ARDS. METHODS The scientific committee was assembled of five chairpersons with more than 5 years of ECMO experience and a critical care background. Their roles were modifying and restructuring the panel's questions and, assisting with statement formulation in addition to expert composition and literature review. Experts are identified based on their clinical experience with ECMO (minimum of 5 years) and previous academic activity on a global scale, with a focus on diversity in gender, geography, area of expertise, and level of seniority. We used the modified Delphi technique rounds and the nominal group technique (NGT) through three face-to-face meetings and the voting on the statement was conducted anonymously. The entire process was planned to be carried out in five phases: identifying the gap of knowledge, validation, statement formulation, voting, and drafting, respectively. RESULTS In phase I, the scientific committee obtained 52 questions on controversial topics in ECMO for COVID-19, further reviewed for duplication and redundancy in phase II, resulting in nine domains with 32 questions with a validation rate exceeding 75% (Fig. 1). In phase III, 25 questions were used to formulate 14 statements, and six questions achieved no consensus on the statements. In phase IV, two voting rounds resulted in 14 statements that reached a consensus are included in four domains which are: patient selection, ECMO clinical management, operational and logistics management, and ethics. CONCLUSION Three years after the onset of COVID-19, our understanding of the role of ECMO has evolved. However, it is incomplete. Tota14 statements achieved consensus; included in four domains discussing patient selection, clinical ECMO management, operational and logistic ECMO management and ethics to guide next-generation ECMO providers during future pandemic situations.
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Affiliation(s)
- Ahmed A Rabie
- Critical Care Department-ECMO care Unit (ECU), Riyadh Region Cluster1, King Saud Medical City, Riyadh, Saudi Arabia.
| | - Alyaa Elhazmi
- Internal Medicine Department, King Faisal University, Riyadh, Saudi Arabia
| | - Mohamed H Azzam
- Adult Critical Care Department, Dr. Sulaiman Alhabib Medical Group, Jeddah, Saudi Arabia
| | | | - Ahmed Labib
- Hamad Medical Corporation, Weill Cornell Medical College, Doha, Qatar
| | - Alain Combes
- INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Sorbonne Université, 75013, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | | | - Graeme MacLaren
- Cardiothoracic ICU, National University Hospital, Singapore, Singapore
| | - Ryan P Barbaro
- Division of Pediatric Critical Care and Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI, USA
| | - Giles J Peek
- Congenital Heart Center, University of Florida, Gainesville, FL, USA
| | | | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Abdulrahman Al-Fares
- Department of Anesthesia, Critical Care Medicine and Pain Medicine, Ministry of Health, Kuwait City, Kuwait
- Al-Amiri Hospital Center for Respiratory and Cardiac Failure, Kuwait Extracorporeal Life Support Program, Ministry of Health, Kuwait City, Kuwait
| | - Pranay Oza
- Riddhi Vinayak Multispecialty Hospital, Mumbai, India
| | - Yatin Mehta
- Medanta Institute of Critical Care and Anesthesiology, Medanta The Medicity, Sector-38, Gurgaon, 122001, Haryana, India
| | - Huda Alfoudri
- Department of Anaesthesia, Critical Care, and Pain Management, Al-Adan Hospital Ministry of Health, Hadiya, Kuwait
| | | | - Mark Ogino
- Chief Partnership Officer, Nemours Children's Health, Delaware Valley, USA
| | - Lakshmi Raman
- Division of Paediatric Critical Care, University of Texas, Southwestern Medical Center, Dallas, TX, USA
| | - Matthew Paden
- Division of Paediatric Critical Care, Emory University, Atlanta, GA, USA
| | - Daniel Brodie
- Department of Medicine, Columbia University College of Physicians & Surgeons, and Center for Acute Respiratory Failure, New York-Presbyterian/Columbia University Medical Center, New York, USA
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Huespe IA, Lockhart C, Kashyap R, Palizas F, Colombo M, Romero MDP, Prado E, Casabella García CA, Las Heras M, Carboni Bisso I. Evaluation of the discrimination and calibration of predictive scores of mortality in ECMO for patients with COVID-19. Artif Organs 2023:10.1111/aor.14493. [PMID: 36582133 PMCID: PMC9880702 DOI: 10.1111/aor.14493] [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: 07/25/2022] [Revised: 11/28/2022] [Accepted: 12/22/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND The criteria for the selection of COVID-19 patients that could benefit most from ECMO organ support are yet to be defined. In this study, we evaluated the predictive performance of ECMO mortality predictive models in patients with COVID-19. We also performed a cost-benefit analysis depending on the mortality predicted probability. We conducted a retrospective cohort study in COVID-19 patients who received ECMO at two tertiary care hospitals between March 2020 to July 2021. MATERIALS AND METHODS We evaluated the discrimination (C-statistic), calibration (Cox calibration), and accuracy of the prediction of death due to severe ARDS in V-V ECMO score (PRESERVE), the Respiratory Extracorporeal Membrane Oxygenation Survival Score (RESP) score, and the PREdiction of Survival on ECMO Therapy-Score (PRESET) score. In addition, we compared the RESP score with Plateau pressure instead of Peak pressure. RESULTS We included a total of 36 patients, 29 (80%) of them male and with a median (IQR) APACHE of 10 (8-15). The PRESET score had the highest discrimination (AUROCs 0.81 [95%CI 0.67-0.94]) and calibration (calibration-in-the-large 0.5 [95%CI -1.4 to 0.3]; calibration slope 2.2 [95%CI 0.7/3.7]). The RESP score with Plateau pressure had higher discrimination than the conventional RESP score. The cost per QALY in the USA, adjusted to life expectancy, was higher than USD 100 000 in patients older than 45 years with a PRESET > 10. CONCLUSION The PRESET score had the highest predictive performance and could help in the selection of patients that benefit most from this resource-demanding and highly invasive organ support.
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Affiliation(s)
- Ivan Alfredo Huespe
- Unidad de Terapia Intensiva Adultos, Hospital Italiano de Buenos AiresBuenos AiresArgentina,Área de investigación en medicina InternaHospital Italiano de Buenos AiresBuenos AiresArgentina,Universidad de Buenos AiresBuenos AiresArgentina,Global Clinical Scholars Research TraineeHarvard Medical SchoolBostonMassachusettsUSA
| | - Carolina Lockhart
- Unidad de Terapia Intensiva Adultos, Hospital Italiano de Buenos AiresBuenos AiresArgentina
| | - Rahul Kashyap
- Global Clinical Scholars Research TraineeHarvard Medical SchoolBostonMassachusettsUSA,Department of Anesthesiology and Perioperative MedicineMayo ClinicRochesterMinnesotaUSA,Department of ResearchWellSpan HealthYorkPennsylvaniaUSA
| | - Fernando Palizas
- Unidad de Terapia Intensiva Adultos, Clínica BazterricaBuenos AiresArgentina
| | - Malena Colombo
- Instituto Universitario del Hospital ItalianoBuenos AiresArgentina
| | | | - Eduardo Prado
- Unidad de Terapia Intensiva Adultos, Hospital Italiano de Buenos AiresBuenos AiresArgentina
| | | | - Marcos Las Heras
- Unidad de Terapia Intensiva Adultos, Hospital Italiano de Buenos AiresBuenos AiresArgentina
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Munshi L, Brodie D, Fan E. Extracorporeal Support for Acute Respiratory Distress Syndrome in Adults. NEJM EVIDENCE 2022; 1:EVIDra2200128. [PMID: 38319864 DOI: 10.1056/evidra2200128] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Extracorporeal Support for ARDS in AdultsThere is a subset of patients who develop severe ARDS for whom supportive care with mechanical ventilation is insufficient or possibly injurious. The use of ECMO as an adjunct to treat these patients is reviewed.
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Affiliation(s)
- Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Sinai Health System/University Health Network, University of Toronto
- Institute of Health Policy, Management and Evaluation, University of Toronto
| | - Daniel Brodie
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York
- Center for Acute Respiratory Failure, NewYork-Presbyterian Hospital, New York
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Sinai Health System/University Health Network, University of Toronto
- Institute of Health Policy, Management and Evaluation, University of Toronto
- Toronto General Hospital Research Institute
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