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Kwan BM, Ytell K, Coors M, DeCamp M, Morse B, Ressalam J, Reno JE, Himber M, Maertens J, Wearner R, Gordon K, Wynia MK. A stakeholder engagement method navigator webtool for clinical and translational science. J Clin Transl Sci 2021; 5:e180. [PMID: 34849255 PMCID: PMC8596067 DOI: 10.1017/cts.2021.850] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 08/09/2021] [Accepted: 09/02/2021] [Indexed: 11/29/2022] Open
Abstract
Stakeholder engagement is increasingly expected by funders and valued by researchers in clinical and translational science, yet many researchers lack access to expert consultation or training in selecting appropriate stakeholder engagement methods. We describe the development of a novel Stakeholder Engagement Navigator webtool. We conducted an environmental scan and literature review, along with investigator interviews, surveys, and engagement expert facilitated group discussion. We formally reviewed and cataloged 29 distinct engagement methods. To develop the webtool, we used an iterative design process that followed Design Thinking phases: empathize, define, ideate, prototype, and test. As prioritized during user testing, the Stakeholder Engagement Navigator webtool both educates and guides investigators in selecting an engagement method based on key criteria. The V1.0 Navigator webtool filters methods first by purpose of engagement (noted by 62% of users as the highest priority criteria), then by budget, time per stakeholder interaction, and total interactions. The tool is available at DICEMethods.org. The Stakeholder Engagement Navigator webtool is a user-centered, interactive webtool suitable for use by researchers seeking guidance on appropriate stakeholder engagement methods for clinical and translational research projects.
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Affiliation(s)
- Bethany M. Kwan
- The Data Science to Patient Value Initiative, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- The Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Department of Family Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Colorado Clinical and Translational Sciences Institute, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kate Ytell
- The Data Science to Patient Value Initiative, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- The Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Marilyn Coors
- Center for Bioethics and Humanities, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Matthew DeCamp
- The Data Science to Patient Value Initiative, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Center for Bioethics and Humanities, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Division of General Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Brad Morse
- The Data Science to Patient Value Initiative, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Division of General Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Julie Ressalam
- Center for Bioethics and Humanities, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jenna E. Reno
- The Data Science to Patient Value Initiative, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- The Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Department of Family Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Meleah Himber
- Center for Bioethics and Humanities, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Julie Maertens
- The Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Robyn Wearner
- Department of Family Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kaylee Gordon
- Colorado Clinical and Translational Sciences Institute, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Matthew K. Wynia
- The Data Science to Patient Value Initiative, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Center for Bioethics and Humanities, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Division of General Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Colorado School of Public Health, Department of Health Systems Management and Policy, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Barger S, Sullivan SD, Bell-Brown A, Bott B, Ciccarella AM, Golenski J, Gorman M, Johnson J, Kreizenbeck K, Kurttila F, Mason G, Myers J, Seigel C, Wade JL, Walia G, Watabayashi K, Lyman GH, Ramsey SD. Effective stakeholder engagement: design and implementation of a clinical trial (SWOG S1415CD) to improve cancer care. BMC Med Res Methodol 2019; 19:119. [PMID: 31185918 PMCID: PMC6560751 DOI: 10.1186/s12874-019-0764-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 06/04/2019] [Indexed: 01/21/2023] Open
Abstract
Background The Fred Hutchinson Cancer Research Center has engaged an External Stakeholder Advisory Group (ESAG) in the planning and implementation of the TrACER Study (S1415CD), a five-year pragmatic clinical trial assessing the effectiveness of a guideline-based colony stimulating factor standing order intervention. The trial is being conducted by SWOG through the National Cancer Institute Community Oncology Research Program in 45 clinics. The ESAG includes ten patient partners, two payers, two pharmacists, two guideline experts, four providers and one medical ethicist. This manuscript describes the ESAG’s role and impact on the trial. Methods During early trial development, the research team assembled the ESAG to inform plans for each phase of the trial. ESAG members provide feedback and engage in problem solving to improve trial implementation. Each year, members participate in one in-person meeting, web conferences and targeted email discussion. Additionally, they complete a survey that assesses their satisfaction with communication and collaboration. The research team collected and reviewed stakeholder input from 2014 to 2018 for impact on the trial. Results The ESAG has informed trial design, implementation and dissemination planning. The group advised the trial’s endpoints, regimen list and development of cohort and usual care arms. Based on ESAG input, the research team enhanced patient surveys and added pharmacy-related questions to the component application to assess order entry systems. ESAG patient partners collaborated with the research team to develop a patient brochure and study summary for clinic staff. In addition to identifying recruitment strategies and patient-oriented platforms for publicly sharing results, ESAG members participated as co-authors on this manuscript and a conference poster presentation highlighting stakeholder influence on the trial. The annual satisfaction survey results suggest that ESAG members were satisfied with the methods, frequency and target areas of their engagement in the trial during project years 1–3. Conclusions Diverse stakeholder engagement has been essential in optimizing the design, implementation and planned dissemination of the TrACER Study. The lessons described in the manuscript may assist others to effectively partner with stakeholders on clinical research.
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Affiliation(s)
- Sarah Barger
- Hutchinson Institute for Cancer Outcomes Research, Seattle, WA, USA
| | - Sean D Sullivan
- CHOICE Institute, School of Pharmacy, University of Washington, Seattle, WA, 98195, USA.
| | - Ari Bell-Brown
- Hutchinson Institute for Cancer Outcomes Research, Seattle, WA, USA
| | - Brad Bott
- Intermountain Healthcare, Salt Lake City, UT, USA
| | - Anne Marie Ciccarella
- Independent Patient Research Partner and SWOG Digital Engagement Committee Member, New York, NY, USA
| | - John Golenski
- Kairoi Healthcare Strategies, San Francisco, CA, USA
| | - Mark Gorman
- Cancer Survivor Advisor, Silver Spring, MD, USA
| | - Judy Johnson
- SWOG Lung Committee Patient Advocate, St. Louis, MO, USA
| | | | | | - Ginny Mason
- SWOG Breast Committee Patient Advocate, West Lafayette, IN, USA
| | - Jamie Myers
- University of Kansas, School of Nursing, Kansas City, KS, USA
| | - Carole Seigel
- SWOG GI (Pancreatic Cancer) Committee, Patient Advocate, Boston, MA, USA
| | | | | | - Kate Watabayashi
- Hutchinson Institute for Cancer Outcomes Research, Seattle, WA, USA
| | - Gary H Lyman
- Hutchinson Institute for Cancer Outcomes Research, Seattle, WA, USA
| | - Scott D Ramsey
- Hutchinson Institute for Cancer Outcomes Research, Seattle, WA, USA
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Abstract
Despite the growing recognition of the value of stakeholder engagement in research, there is limited guidance on effectively eliciting stakeholder views during the comparative effectiveness research (CER) process. This article outlines the potential role of each stakeholder (patient, provider, policymaker and payer) throughout the CER process and provides examples of practical questions that researchers can ask the four primary stakeholder groups at each step of the CER process. This guide aims to assist in the development of meaningful stakeholder-researcher shared decision-making to incorporate stakeholder views in the design, conduct and dissemination of patient-centered CER.
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Affiliation(s)
- Yoon Duk Hong
- Pharmaceutical Health Services Research Department, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Daisuke Goto
- Pharmaceutical Health Services Research Department, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - C. Daniel Mullins
- Pharmaceutical Health Services Research Department, University of Maryland School of Pharmacy, Baltimore, MD, USA
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O'Bryant SE, Edwards M, Johnson L, Hall J, Villarreal AE, Britton GB, Quiceno M, Cullum CM, Graff-Radford NR. A blood screening test for Alzheimer's disease. Alzheimers Dement (Amst) 2016; 3:83-90. [PMID: 27453929 PMCID: PMC4941038 DOI: 10.1016/j.dadm.2016.06.004] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction This study combined data across four independent cohorts to examine the positive and negative predictive values of an Alzheimer's disease (AD) blood test if implemented in primary care. Methods Blood samples from 1329 subjects from multiple independent, multiethnic, community-based, and clinic-based cohorts were analyzed. A “locked-down” referent group of 1128 samples was generated with 201 samples randomly selected for validation purposes. Random forest analyses were used to create the AD blood screen. Positive (PPV) and negative (NPV) predictive values were calculated. Results In detecting AD, PPV was 0.81, and NPV was 0.95 while using the full AD blood test. When detecting mild cognitive impairment, PPV and NPV were 0.74 and 0.93, respectively. Preliminary analyses were conducted to detect any “neurodegenerative disease”. The full 21-protein AD blood test yielded a PPV of 0.85 and NPV of 0.94. Discussion The present study creates the first-ever multiethnic referent sample that spans community-based and clinic-based populations for implementation of an AD blood screen.
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Affiliation(s)
- Sid E. O'Bryant
- Institute for Healthy Aging, University of North Texas Health Science Center, Fort Worth, TX, USA
- Corresponding author. Tel.: +1-(817)-735-2963; Fax: +1-(817)-735-0611. Sid.O'
| | - Melissa Edwards
- Department of Psychology, University of North Texas, Denton, TX, USA
| | - Leigh Johnson
- Institute for Healthy Aging, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - James Hall
- Institute for Healthy Aging, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Alcibiades E. Villarreal
- Centro de Neurociencias y Unidad de Investigación Clínica, Instituto de Investigaciones Científicas y Servicios de Alta Tecnología (INDICASAT AIP), Ciudad del Saber, Panamá, Panamá
- Department of Biotechnology, Acharya Nagarjuna University, Guntur, India
| | - Gabrielle B. Britton
- Centro de Neurociencias y Unidad de Investigación Clínica, Instituto de Investigaciones Científicas y Servicios de Alta Tecnología (INDICASAT AIP), Ciudad del Saber, Panamá, Panamá
| | - Mary Quiceno
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - C. Munro Cullum
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Loggers ET, Gao H, Gold LS, Kessler L, Etzioni R, Buist DSM. Predictors of preoperative MRI for breast cancer: differences by data source. J Comp Eff Res 2015; 4:215-226. [PMID: 25960128 PMCID: PMC4641841 DOI: 10.2217/cer.15.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
AIM Investigate how the results of predictive models of preoperative MRI for breast cancer change based on available data. MATERIALS & METHODS A total of 1919 insured women aged ≥18 with stage 0-III breast cancer diagnosed 2002-2009. Four models were compared using nested multivariable logistic, backwards stepwise regression; model fit was assessed via area under the curve (AUC), R2. RESULTS MRI recipients (n = 245) were more recently diagnosed, younger, less comorbid, with higher stage disease. Significant variables included: Model 1/Claims (AUC = 0.76, R2 = 0.10): year, age, location, income; Model 2/Cancer Registry (AUC = 0.78, R2 = 0.12): stage, breast density, imaging indication; Model 3/Medical Record (AUC = 0.80, R2 = 0.13): radiologic recommendations; Model 4/Risk Factor Survey (AUC = 0.81, R2 = 0.14): procedure count. CONCLUSION Clinical variables accounted for little of the observed variability compared with claims data.
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Affiliation(s)
| | | | | | - Larry Kessler
- University of Washington, Department of Health Services, School of Public Health
- Fred Hutchinson Cancer Research Center, Public Health Sciences Division
| | - Ruth Etzioni
- University of Washington, Department of Health Services, School of Public Health
- Fred Hutchinson Cancer Research Center, Public Health Sciences Division
| | - Diana S. M. Buist
- Group Health Research Institute
- University of Washington, Department of Health Services, School of Public Health
- Fred Hutchinson Cancer Research Center, Public Health Sciences Division
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Trosman JR, Weldon CB, Schink JC, Gradishar WJ, Benson AB. What do providers, payers and patients need from comparative effectiveness research on diagnostics? The case of HER2/Neu testing in breast cancer. J Comp Eff Res 2014; 2:461-77. [PMID: 24236686 DOI: 10.2217/cer.13.42] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
AIMS Comparing effectiveness of diagnostic tests is one of the highest priorities for comparative effectiveness research (CER) set by the Institute of Medicine. Our study aims to identify what information providers, payers and patients need from CER on diagnostics, and what challenges they encounter implementing comparative information on diagnostic alternatives in practice and policy. MATERIALS & METHODS Using qualitative research methods and the example of two alternative protocols for HER2 testing in breast cancer, we conducted interviews with 45 stakeholders: providers (n = 25) from four academic and eight nonacademic institutions, executives (n = 13) from five major US private payers and representatives (n = 7) from two breast cancer patient advocacies. RESULTS The need for additional scientific evidence to determine the preferred HER2 protocol was more common for advocates than payers (100 vs 54%; p = 0.0515) and significantly more common for advocates than providers (100 vs 40%; p = 0.0077). The availability of information allowing assessment of the implementation impact from alternative diagnostic protocols on provider institutions may mitigate the need for additional scientific evidence for some providers and payers (24 and 46%, respectively). The cost-effectiveness of alternative protocols from the societal perspective is important to payers and advocates (69 and 71%, respectively) but not to providers (0%; p = 0.0001 and p = 0.0001). The lack of reporting laboratory practices is a more common implementation challenge for payers and advocates (77 and 86%, respectively) than for providers (32%). The absence of any mechanism for patient involvement was recognized as a challenge by payers and advocates (69 and 100%, respectively) but not by providers (0%; p = 0.0001 and p = 0.0001). CONCLUSION Comparative implementation research is needed to inform the stakeholders considering diagnostic alternatives. Transparency of laboratory practices is an important factor in enabling implementation of CER on diagnostics in practice and policy. The incongruent views of providers versus patient advocates and payers on involving patients in diagnostic decisions is a concerning challenge to utilizing the results of CER.
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Rao M, Concannon TW, Iovin R, Yu WW, Chan JA, Lypas G, Terasawa T, Gaylor JM, Kong L, Rausch AC, Lau J, Kitsios GD. Identification of topics for comparative effectiveness systematic reviews in the field of cancer imaging. J Comp Eff Res 2013; 2:483-95. [DOI: 10.2217/cer.13.61] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: With rapid innovations in diagnostic and therapeutic interventions in cancer care, comparative effectiveness reviews (CERs) are essential to inform clinical practice and guide future research. However, the optimal means to identify priority CER topics are uninvestigated. We aimed to devise a transparent and reproducible process to identify ten to 12 CER topics in the area of cancer imaging relevant to a wide range of stakeholders. Materials & methods: Environmental scans and explicit prioritization criteria supported interactions (email communications, web-based discussions and live teleconferences) with experts and stakeholders culminating in a three-phase deductive exercise for prioritization of CER topics. Results: We prioritized 12 CER topics in breast, lung and gastrointestinal cancers that addressed screening, diagnosis, staging, monitoring and evaluating response to treatment. Conclusion: Our project developed and implemented a transparent and reproducible process for research prioritization and topic nomination that can be further refined to improve the relevance of future CERs.
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Affiliation(s)
- Madhu Rao
- Institute for Clinical Research & Health Policy Studies (ICRHPS), Tufts Medical Center & Tufts University School of Medicine, MA, USA
- Division of Nephrology, Tufts Medical Center, MA, USA
| | | | - Ramon Iovin
- Institute for Clinical Research & Health Policy Studies (ICRHPS), Tufts Medical Center & Tufts University School of Medicine, MA, USA
| | - Winifred W Yu
- Institute for Clinical Research & Health Policy Studies (ICRHPS), Tufts Medical Center & Tufts University School of Medicine, MA, USA
| | - Jeffrey A Chan
- Institute for Clinical Research & Health Policy Studies (ICRHPS), Tufts Medical Center & Tufts University School of Medicine, MA, USA
| | - Georgios Lypas
- Department of Medical Oncology, Dana Farber Cancer Institute, MA, USA
- Genetic Oncology Unit, Hygeia Hospital, Athens, Greece
| | - Teruhiko Terasawa
- Institute for Clinical Research & Health Policy Studies (ICRHPS), Tufts Medical Center & Tufts University School of Medicine, MA, USA
- Department of Internal Medicine, Fujita Health University School of Medicine, Tsu, Mie, Japan
| | - James M Gaylor
- Institute for Clinical Research & Health Policy Studies (ICRHPS), Tufts Medical Center & Tufts University School of Medicine, MA, USA
| | - Lina Kong
- Institute for Clinical Research & Health Policy Studies (ICRHPS), Tufts Medical Center & Tufts University School of Medicine, MA, USA
| | - Andrew C Rausch
- Institute for Clinical Research & Health Policy Studies (ICRHPS), Tufts Medical Center & Tufts University School of Medicine, MA, USA
| | - Joseph Lau
- Brown Center for Evidence Based Medicine, Brown University, Providence, RI, USA
| | - Georgios D Kitsios
- Department of Internal Medicine, Lahey Hospital & Medical Center, 41 Mall Road, Burlington, MA 01805, USA
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Gold LS, Buist DS, Loggers ET, Etzioni R, Kessler L, Ramsey SD, Sullivan SD. Advanced diagnostic breast cancer imaging: variation and patterns of care in Washington state. J Oncol Pract 2013; 9:e194-202. [PMID: 23943885 PMCID: PMC3770510 DOI: 10.1200/jop.2012.000796] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Because receipt of breast imaging likely occurs in nonrandom patterns, selection bias is an important issue in studies that attempt to elucidate associations between imaging and breast cancer outcomes. The purpose of this study was to analyze use of advanced diagnostic imaging in a cohort of patients with breast cancer insured by commercial, managed care, and public health plans by demographic, health insurance, and clinical variables from 2002 to 2009. METHODS We identified women with breast cancer diagnoses from a Surveillance Epidemiology and End Results (SEER) registry whose data could be linked to claims from participating health plans. We examined imaging that occurred between cancer diagnosis and initiation of treatment and classified patients according to receipt of (1) mammography or ultrasound only; (2) breast magnetic resonance imaging (MRI); and (3) other advanced imaging (computed tomography [CT] of the chest, abdoment, and pelvis; positron emission tomography [PET]; or PET-CT). We used logistic regression to identify factors associated with receipt of breast MRI as well as other advanced imaging. RESULTS Commercial health plan, younger age, and later year of diagnosis were strongly associated with receipt of breast MRI and other advanced imaging. Women with prescription drug plans and those who had less comorbidities were more likely to have received breast MRI. CONCLUSION Use of breast MRI and other advanced imaging is increasing among patients newly diagnosed with breast cancer; individual patient and insurance-related factors are associated with receipt of these imaging tests. Whether use of diagnostic advanced imaging affects outcomes such as re-excision, cancer recurrence, mortality rates, and costs of breast cancer treatment remains to be determined.
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Affiliation(s)
- Laura S. Gold
- School of Pharmacy, University of Washington; School of Public Health, University of Washington; Group Health Research Institute, Group Health Cooperative; and Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Diana S.M. Buist
- School of Pharmacy, University of Washington; School of Public Health, University of Washington; Group Health Research Institute, Group Health Cooperative; and Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Elizabeth T. Loggers
- School of Pharmacy, University of Washington; School of Public Health, University of Washington; Group Health Research Institute, Group Health Cooperative; and Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Ruth Etzioni
- School of Pharmacy, University of Washington; School of Public Health, University of Washington; Group Health Research Institute, Group Health Cooperative; and Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Larry Kessler
- School of Pharmacy, University of Washington; School of Public Health, University of Washington; Group Health Research Institute, Group Health Cooperative; and Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Scott D. Ramsey
- School of Pharmacy, University of Washington; School of Public Health, University of Washington; Group Health Research Institute, Group Health Cooperative; and Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Sean D. Sullivan
- School of Pharmacy, University of Washington; School of Public Health, University of Washington; Group Health Research Institute, Group Health Cooperative; and Fred Hutchinson Cancer Research Center, Seattle, WA
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