From the Society for Clinical Vascular Surgery
The associations of hemodialysis access type and access satisfaction with health-related quality of life Natalie Domenick Sridharan, MD, MSc,a Larry Fish, PhD,a Lan Yu, PhD,b Steven Weisbord, MD,c Manisha Jhamb, MD,c Michel S. Makaroun, MD,a and Theodore H. Yuo, MD, MSc,a Pittsburgh, Pa
ABSTRACT Objective: In addition to age and comorbidities, health-related quality of life (HRQOL) is known to predict mortality in hemodialysis (HD) patients. Understanding the association of vascular access type with HRQOL can help surgeons to provide patient-centered dialysis access recommendations. We sought to understand the impact of HD access type on HRQOL. Methods: We conducted a cross-sectional prospective study of community-dwelling prevalent HD patients in Pittsburgh, Pennsylvania. We assessed patient satisfaction with their access using the Vascular Access Questionnaire (VAQ) and HRQOL with the Short Form Health Survey. We compared access satisfaction and HRQOL across access types. We used logistic regression modeling to evaluate the association of access type with satisfaction and multivariate analysis of variance to evaluate the association of both of these variables on HRQOL. Results: We surveyed 77 patients. The mean age was 61.8 6 15.9 years. Arteriovenous ﬁstula (AVF) was used by 62.3%, tunneled dialysis catheter (TDC) by 23.4%, and arteriovenous graft (AVG) by 14.3%. There was a signiﬁcant difference in satisfaction by access type with lowest median VAQ score (indicating highest satisfaction) in patients with AVF followed by TDC and AVG (4.5 vs 6.5 vs 7.0; P ¼ .013). Deﬁning a VAQ score of <7 to denote satisfaction, AVF patients were more likely to be satisﬁed with their access, compared with TDC or AVG (77% vs 56% vs 55%; P ¼ NS). Multivariate regression analysis yielded a model that predicted 46% of the variance of VAQ score; important predictors of dissatisfaction included <1 year on dialysis (b ¼ 3.36; P < .001), increasing number of access-related hospital admissions in the last year (b ¼ 1.69; P < .001), and AVG (b ¼ 1.72; P ¼ .04) or TDC (b ¼ 1.67; P ¼ .02) access. Mean physical and mental QOL scores (the composite scores of Short Form Health Survey) were not different by access type (P ¼ .49; P ¼ .41). In an additive multivariate analysis of variance with the two composite QOL scores as dependent variables, 25.8% of the generalized variance in HRQOL (effect size) was accounted for by access satisfaction with only an additional 3% accounted for by access type. Conclusions: HD patients experience greatest satisfaction with ﬁstula, and access satisfaction is signiﬁcantly associated with better HRQOL. Controlling for access satisfaction, there is no signiﬁcant independent association of access type on HRQOL. Future research should investigate the relationship between access satisfaction, adherence to dialysis regimens, mortality, and the consequent implications for patient-centered care. (J Vasc Surg 2017;-:1-7.)
The preferred access type for hemodialysis (HD) patients has been the arteriovenous ﬁstula (AVF) owing to its association with lower rates of morbidity and mortality compared with arteriovenous graft (AVG) or tunneled dialysis catheter (TDC).1 Evidence for this led to the creation of the National Vascular Access From the Division of Vascular Surgerya and Division of Nephrology,c University of Pittsburgh Medical Center; and the University of Pittsburgh, Institute for Clinical Research.b N.D.S. is funded by NIH grant T32 HS019486. T.H.Y. is funded by NIH grants KL2TR000146 and KL2-TR001856. Author conﬂict of interest: none. Presented at the Forty-ﬁfth Annual Symposium of the Society for Clinical Vascular Surgery, Orlando, Fla, March 18-22, 2017. Correspondence: Natalie Domenick Sridharan, MD, 200 Lothrop St, Ste A1017, Pittsburgh, PA 15213 (e-mail: [email protected]
). The editors and reviewers of this article have no relevant ﬁnancial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conﬂict of interest. 0741-5214 Copyright Ó 2017 by the Society for Vascular Surgery. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jvs.2017.05.131
Improvement Initiative, also known as the Fistula First initiative, by the Centers for Medicare and Medicaid Services in 2003.2 However, emerging evidence has suggested that some patients, speciﬁcally elderly patients and patients with signiﬁcant comorbidities, may derive less beneﬁt from the creation of an AVF, challenging the “ﬁstula-ﬁrst” dictum.3-5 While still recognizing that AVF provides the best outcomes in the HD population as a whole, providers have begun to move away from a ﬁstula-ﬁrst approach in every patient and toward providing more patientcentered recommendations.6 For instance, it is reasonable to consider that, in some situations, a poorly functioning AVF that requires multiple admissions and missed dialysis sessions may actually be less effective than a functional AVG or TDC. A key requirement for this more holistic approach is a focus on patient centered outcomes such as health-related quality of life (HRQOL).7 In addition to traditional risk factors, such as age and comorbidities, HRQOL is known to be associated with mortality in HD patients.8 However, evidence is lacking 1
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for understanding what factors impact HRQOL in HD patients.9 The component and possible predictor of HRQOL in which surgeons are most involved is creation and maintenance of the HD access. Understanding the association of vascular access type with HRQOL can help surgeons to provide more patient-centered dialysis access recommendations. To this end, we sought to understand the impact of HD access type on patient satisfaction with their access and their overall HRQOL. We hypothesized that patient satisfaction and QOL would vary signiﬁcantly by access type (AVF, AVG, or TDC).
METHODS The Institutional Review Board at the University of Pittsburgh approved this study protocol. Informed consent was obtained for each patient in this study. We conducted a cross-sectional prospective study of community-dwelling prevalent HD patients using validated questionnaires to assess patient satisfaction with their dialysis access as well as HRQOL. This project was undertaken at three HD centers in Western Pennsylvania. All patients who spoke English, had been on dialysis for $3 months, and were willing to participate in the study were enrolled. Four trained research assistants administered questionnaires between April 2016 and July 2016. Patients were interviewed while dialyzing during their regularly scheduled dialysis times. Study data were collected and managed using the REDCap mobile application hosted by the Clinical and Translational Science Institute at the University of Pittsburgh. REDCap (Research Electronic Data Capture) is a secure, web-based application designed to support data capture for research studies. All patients provided informed consent before enrollment. Assessment of patient satisfaction with access type. The Short Form-Vascular Access Questionnaire (VAQ) is a 13-item form that estimates the level of HD patients’ satisfaction with their vascular access. The VAQ was developed and validated in Toronto, Ontario, Canada, and found to have high testeretest reliability as well as internal consistency on psychometric evaluation.10,11 The form takes approximately 10 minutes to administer and assesses four domains of patient access satisfaction: overall satisfaction, physical symptoms, social functioning, and complications. Each item is rated by the patient on a Likert scale of 1 to 7, where 7 indicates the highest level of dissatisfaction. There is single summary score for 12 items. Higher scores indicated greater dissatisfaction. The VAQ score distributions were generally bimodal and not normally distributed, with patients either being highly satisﬁed or highly dissatisﬁed. To categorize the high and low satisfaction patients for the purposes of analysis, VAQ scores of <7 were considered
ARTICLE HIGHLIGHTS d
Type of Research: Single-center, prospective, crosssectional study Take Home Message: In 77 hemodialysis access patients, an arteriovenous ﬁstula was associated with higher degrees of satisfaction compared with tunneled catheters and grafts, and access satisfaction was associated with improved health-related quality of life. Recommendation: This study suggests that an arteriovenous ﬁstula, as opposed to other access types, leads to higher degrees of patient satisfaction and improvement in health-related quality of life.
as satisﬁed and scores of $7 were considered as dissatisﬁed. Assessment of HRQOL. HRQOL was assessed using the Short Form 36 (SF-36) questionnaire. This well-validated QOL questionnaire consists of 36 items and 8 subscales: physical functioning, physical role, pain, general health, vitality, social functioning, emotional role, and mental health. These eight subscales can then be summarized into two primary dimensions of functioning. These are the physical component summary score (PCS) and mental component summary score (MCS). For both summary scores, higher scores indicated increased QOL. The SF-36 has been validated in patients with end-stage renal disease.12 Demographic and historical questionnaires. A demographic questionnaire was developed by the study team and included an assessment of basic demographic information as well as patient access history including years on dialysis, prior accesses, number of hospital admissions in the previous year, number of access-related hospital admissions in the last year, number of access revisions, and any history of TDC. Statistical analysis. Descriptive characteristics are reported as means 6 standard deviations or as number of cases and percentages. Baseline characteristics were compared by chi-squared tests for categorical data and Student t tests for continuous data. Owing to a nonnormal data distribution, median VAQ scores were compared between the three groups (AVF, AVG, and TDC) using the Kruskall-Wallis test. Mean SF-36 scores were compared using analysis of variance. We used logistic regression modeling to evaluate the association of access type and various other predictors with satisfaction. Multivariate analysis of variance was used to evaluate the association of access type and VAQ score on both component scores of HRQOL (PCS and MCS). We used path analysis to test, directly, our hypothesis that access-related admissions and VAQ score mediated the
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Table I. Baseline characteristics overall and by access type (N ¼ 77) P
61.8 6 15.9
64.8 6 15.4
55.6 6 20.4
57.5 6 12.7
Years on dialysis <1 1-2
Black or African American
Other Kidney transplant history
First access type
Peritoneal dialysis TDC Unknown
Average no. of hospital admissions previous year
2.6 6 3.0
2.5 6 2.9
1.6 6 1.5
3.4 6 3.7
No. of access-related hospital admissions in the last year
0.5 6 0.9
0.4 6 0.9
0.8 6 1.2
0.5 6 0.9
No. of access revisions in last year
0.6 6 0.9
0.5 6 0.8
1.2 6 1.4
0.2 6 0.4
AVF, Arteriovenous ﬁstula; AVG, arteriovenous graft; TDC, tunneled dialysis catheter. Values are number (%) or mean 6 standard deviation. a Indicates statistical signiﬁcance (P < .05).
effect of access type on HRQOL score. Results were considered statistically signiﬁcant at a ¼ .05. Data analysis was performed using Stata Statistical Software: Release 14 (StataCorp LP, College Station, Tex) and IBM SPSS Statistics for Windows, Version 23 (IBM Corp, Chicago, Ill).
RESULTS The response rate, that is, the fraction of eligible patients who completed all surveys, was 79.5%. Of 97 eligible patients, 77 completed the surveys. The mean age was 61.8 6 15.9 years. AVF was used by 62.3%, TDC by 23.4%, and AVG by 14.3%. Baseline characteristics are summarized in Table I. As might be expected, for patients who had been on HD <1 year, TDC was more common than for patients who had been on HD longer. Patients with AVG required more operative revisions within the last year. Results of VAQ. There was a signiﬁcant difference in satisfaction by access type with lowest median VAQ score (indicating highest satisfaction) in patients with AVF followed by TDC and AVG (4.5 vs 6.5 vs 7.0; P ¼ .013). The mean and median scores for each item by access type are summarized in Table II.
By domain, patients with catheters were least bothered by physical symptoms, which included pain, bleeding, swelling, and bruising. However, patients with catheters also reported the greatest dissatisfaction with dialysisrelated complications, such as their vascular access not working, their access being difﬁcult to care for, or being worried about requiring hospitalization or replacement of the access. AVG access type was associated with the lowest satisfaction in the social functioning domain, which included access interference with sleep, bathing, activities of daily living, or appearance. Of the assessed domains, patients with AVG and TDC recorded highest levels of dissatisfaction within the social functioning domain. For AVG patients, this seemed to be related to access interference with daily activities, whereas for TDC patients, this was related to bathing and showering issues (Table II), Bleeding complications (within the physical symptoms domain) was another important item of particular dissatisfaction for AVG patients, whereas TDC patients were signiﬁcantly affected by worry about their access lasting (an item within the dialysis-related complications domain). Fig 1 presents median domain scores and overall scores by access type. Patients with AVF were more likely to be satisﬁed with their access, compared with patients with TDC or those with AVG, although this difference did not reach
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Table II. Vascular Access Questionnaire (VAQ) Scores by domain and access type Item Overall score
5.3 6 2.4
7.8 6 3.9
7.4 6 3.3
Physical symptoms During the past 4 weeks I was bothered by pain associated with my vascular access.
1 (1-2) 2.1 6 2.1
During the past 4 weeks I was bothered by bleeding associated with my vascular access.
1 (1-5) 2.8 6 2.3
During the past 4 weeks I was bothered by swelling associated with my vascular access.
1 (1-1) 1.8 6 1.8
During the past 4 weeks I was bothered by bruising associated with my vascular access.
1 (1-5) 2.4 6 2.4
2.2 6 2.1
3 6 2.6
1 (1-1) 1.4 6 1.2 1 (1-1) 1.2 6 0.9 1 (1-1) 1.6 6 1.6
6 (1-7) 4.5 6 2.8 1 (1-1) 1.9 6 2.1 1 (1-5) 2.4 6 2.4
Social functioning During the past 4 weeks my access interfered with my daily activities (eg work, social, leisure activities or other regular daily activities).
During the past 4 weeks I was bothered by the appearance of my vascular access. During the past 4 weeks my access interfered with my sleep.
1.7 6 1.6
2.9 6 2.7
4.2 6 2.9
2.1 6 2.0
2.9 6 2.4
3.4 6 2.8
1 (1-1) 1.6 6 1.5
During the past 4 weeks my access caused me problems with bathing or showering.
1 (1-1) 1.0 6 0.2
2.8 6 2.2
2.5 6 2.5
6 (1-7) 4.7 6 2.8
1 (1-1) 1.5 6 1.5
Dialysis-related complications During the past 4 weeks my vascular access had problems (ie, did not work properly).
1 (1-1) 1.2 6 1.0
During the past 4 weeks my vascular access was difﬁcult to care for (ie, dressings, trying to keep access clean and protected).
1 (1-1) 1.7 6 0.9
During the past 4 weeks I was worried about being hospitalized because of problems with my access.
During the past 4 weeks I was worried about how long my vascular access would last.
2.1 6 2.1
3.4 6 2.5
1.4 6 1.4
2.3 6 2.5
1.9 6 1.9
2.0 6 2.0
3.7 6 2.6
2.6 6 2.8
AVF, Arteriovenous ﬁstula; AVG, arteriovenous graft; TDC, tunneled dialysis catheter.
statistical signiﬁcance (77% vs 56% vs 55%; Fig 2). Thus, there was a 48.9% risk reduction of dissatisfaction for ﬁstula patients. Potential factors associated with access satisfaction were evaluated in a multivariate regression model. The regression model predicted 46% of the variance of VAQ score. The factors identiﬁed as important predictors of dissatisfaction included less than one year on dialysis (b ¼ 3.36; P < .001), increasing number
of access-related hospital admissions in the last year (b ¼ 1.69; P < .001), and AVG (b ¼ 1.72; P ¼ .04) or TDC (b ¼ 1.67; P ¼ .02) access. Other possible predictors of satisfaction including age, sex, race, transplant history, and TDC history were not found to predict satisfaction. Age was not a predictor of VAQ score (P ¼ .36), nor was there any interaction seen between age and access type on overall satisfaction (P ¼ .25; P ¼ .83, respectively).
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Fig 1. There was a signiﬁcant difference in satisfaction by access type with lowest median Vascular Access Questionnaire (VAQ) score (indicating highest satisfaction) in patients with arteriovenous ﬁstula (AVF). Signiﬁcant differences are indicated by asterisks. By domain, patients with catheters were least bothered by physical symptoms, including pain, bleeding, swelling, and bruising. Patients with catheters were most dissatisﬁed with dialysis-related complications, such as their vascular access not working, their access being difﬁcult to care for, or being worried about requiring hospitalization or replacement of the access. Arteriovenous graft (AVG) access type was associated with most dissatisfaction with access interference with social functioning.
Fig 2. When dividing patients into binary groups, arteriovenous ﬁstula (AVF) patients were overall much more likely to be satisﬁed with their access, compared with tunneled dialysis catheter (TDC) or arteriovenous graft (AVG).
Results of SF-36. There were no differences in SF-36 scores based on access type for both mean PCS or MCS SF-36 composite scores (P ¼ .49 and P ¼ .41 for mean PCS and MCS scores, respectively; Fig 3). Association of access type satisfaction and HRQOL. Multivariate analysis of variance was used to examine the association of access type and access satisfaction on HRQOL. In an additive multivariate analysis of variance with the two composite SF-36 QOL scores (PCS and
Fig 3. There was no difference in either quality of life (QOL) summary score by access type (P ¼ nonsigniﬁcant). SF-36, Short Form-36.
MCS) as dependent variables, 25.8% of the generalized variance in HRQOL was accounted for by access satisfaction with only an additional 3% accounted for by access type. Thus, the effect size of satisfaction with access type far outweighs the effects size of access type on HRQOL, and more than one-quarter of the variance in these patients’ HRQOL could be predicted by their access satisfaction scores. We used path analysis to further test our hypothesis that access-related admissions and VAQ score mediated the effect of access type on HRQOL score. This analysis allowed us to provide estimates of the magnitude and signiﬁcance of hypothesized causal connections between variables. The paths in Fig 4 represent the hypothesized direction of the effects. Arrows illustrate proposed causal pathways. Coefﬁcients of signiﬁcant relationships are displayed. Negative coefﬁcients represent an inverse relationship. As shown in our multivariate analysis, the total effect of access type on VAQ was signiﬁcant (b ¼ 2.5; P ¼ .004). However, access type had no direct causal pathway with the PCS score of HRQOL, although AVG was signiﬁcantly associated with the MCS score of HRQOL (b ¼ 7.3; P ¼ .037). VAQ score was negatively correlated with both PCS and MCS (b ¼ 1.6 and 1.4, respectively; P ¼ .002).
DISCUSSION In this prospective survey of community-dwelling chronic HD patients, we found that different HD access types were associated with signiﬁcant differences in satisfaction with their access. Overall, patients were satisﬁed with their access. However, AVF patients are signiﬁcantly more likely to be satisﬁed with their access than either AVG or TDC patients. Patients with TDC scored highest levels of dissatisfaction within the dialysisrelated complications domain of the VAQ underscoring that access-related issues, such as the catheter not working or worry about the catheter not working propelled
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Fig 4. Directional arrows represent hypothesized causal pathways. Coefﬁcients of signiﬁcant relationships are displayed. Other pathways were found to be nonsigniﬁcant. Access type was found to have a nonsigniﬁcant direct relationship with health-related quality of life (HRQOL). Access satisfaction mediated the effect of access type on HRQOL. HD, hemodialysis.
their overall dissatisfaction score higher than the other access types. In addition to type of access, being on HD for <1 year and access-related hospitalizations were predictors of low satisfaction. Together, these three variables (access type, time on dialysis, and dialysis-related hospital admissions) predicted nearly one-half of the variance in satisfaction. Access-related hospitalizations are understandably related to increased dissatisfaction. It is not entirely clear why <1 year on dialysis would be a predictor of dissatisfaction. It is possible that patients starting dialysis are frustrated as they adjust to a new way of life while more seasoned patients have become desensitized. In the case of patients with TDC access, they may be anxious to obtain a more permanent access. It is also possible that, for those on dialysis longer, previous access type experiences may impact their current level of satisfaction though this could not be adequately assessed in a cross-sectional survey. Unlike satisfaction, HRQOL did not vary by access type. This may be due to the complex and multifactorial nature of the determinants of QOL; many of these factors cannot be adequately assessed in a cross-sectional survey study. However, we have identiﬁed an important (and potentially modiﬁable) predictor: access satisfaction. Access type satisfaction predicted more than onequarter of the variance in a patient’s overall QOL. This indicates that, for patients with end-stage renal disease on HD, the degree of access type satisfaction can drastically modify that patient’s QOL. Access type satisfaction is determined by the access’ effect on a patient’s physical functioning, social functioning, and the number of access-related complications (or even the worry of access-related complications). For the surgeon, this implies that creating a functioning access that does
not inﬂict excessive social or physical disability on a patient can have a meaningful impact on a patient’s QOL. Patient-centered outcomes research, with a focus on outcomes such as QOL, has emerged as an important component of comparative effectiveness research and improved health care delivery. AVF has long been recognized as the optimal type of HD vascular access because of its superior patency, lower rates of infectious complications, and its association with lower all-cause mortality compared with AVG or TDC. However, it is unclear if the health beneﬁts of AVF translate to QOL beneﬁts. Focusing on QOL outcomes in no way ignores the health consequences of TDC or health beneﬁts of AVF, but rather recognizes that patient QOL has real implications for their health outcomes. For HD patients, HRQOL has been associated with nonadherance to a dialysis regimen and also independently associated with mortality.8,13 The results of our analysis contribute to the evolving view that some patients, particularly elderly patients and those with multiple comorbidities who are likely to have poor ﬁstula maturation rates or may never use a ﬁstula owing to the competing risk of mortality, may be appropriate for AVG or even consideration of “destination” TDC.4,14,15 These patients may beneﬁt from an access that provides maximal functionality and decreased hospitalizations, improving their access satisfaction and thus positively impacting their HRQOL.7 In select cases, creating a poorly functioning AVF, or an AVF that fails to mature despite multiple reinterventions, is likely a less patient-centered approach to HD access as compared with a well-functioning AVG or TDC. Our study provides additional evidence for the use of AVF in appropriate patients. This access type is not only associated with lower morbidity and mortality than catheters and grafts, but also increased patient satisfaction. Although AVF itself was not independently associated with improved HRQOL in our patient population, HRQOL was highly dependent on access satisfaction. A number of factors have previously been associated with variations in HRQOL in end-stage renal disease patients on HD including anemia, dialysis center personnel, and fatigue.1,16 However, many of these factors are not surgically modiﬁable. We have shown for the ﬁrst time that access type satisfaction is signiﬁcantly associated with QOL. As the “Fistula First” initiative has evolved over time, surgeons and nephrologists have been reevaluating the existing evidence to make their recommendations more patient centered.17 Using knowledge of a patient’s vascular anatomy, age, and comorbidities, in addition to considering patient concerns regarding social functioning and physical disabilities, surgeons may be able to offer patients the most “satisfying” HD access, which can have considerable implications for patient QOL.17,18 Surgeons are uniquely positioned to provide an access type that offers
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improved levels of patient satisfaction based on patient preferences. Further research is certainly needed in this emerging ﬁeld on how to incorporate patient preference without sacriﬁcing mortality or morbidity outcomes. This study has several limitations. Given the observational nature of our study, several questions, including time on dialysis, number of hospitalizations, and catheter experience, were subject to patient recall. Despite visiting multiple dialysis centers in the region, the preponderance of patients used AVF. Although the number of patients using catheters was similar to national ﬁgures, AVG was used by a disproportionately small number of patients compared with the national average.19 Thus, the satisfaction levels and HRQOL of AVG patients may be underrepresented in this analysis. Additionally, we performed a cross-sectional study of community-dwelling HD patients, which provides data from a single time point, by necessity not sampling patients who are acutely hospitalized. Follow-up data and the incorporation of sequential VAQ scores, including dialysis-related complications, can provide important data on temporal associations. Response bias is also possible in that patients with lower satisfaction or QOL may have not participated in our study; however, we had a very high response rate (79.5%) from eligible patients at all centers. Finally, elderly patients have been identiﬁed as a distinct group of HD patients that may derive less beneﬁt from AVF. Although we did not ﬁnd a measurable effect of age on access type satisfaction, we did not have enough patients to perform a subgroup analysis and thus cannot draw conclusions for this subgroup speciﬁcally.
CONCLUSIONS Community-dwelling HD patients experience greatest satisfaction with ﬁstula, and access satisfaction is signiﬁcantly associated with better HRQOL. Controlling for access satisfaction, there is no independent association of access type on HRQOL. As surgeons move away from the ﬁstula-ﬁrst-only approach to dialysis access, future research should investigate ways to incorporate patient satisfaction and preference into surgical decision making.
AUTHOR CONTRIBUTIONS Conception and design: NS, SW, MJ, TY Analysis and interpretation: NS, LF, LY, TY Data collection: NS Writing the article: NS Critical revision of the article: LF, LY, SW, MJ, MM, TY Final approval of the article: NS, LF, LY, SW, MJ, MM, TY Statistical analysis: NS, LF, LY Obtained funding: TY Overall responsibility: NS
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