Effect of a community health worker-led multicomponent intervention on blood pressure control in low-income patients in Argentina: A randomized clinical trial

Autores
He, Jiang; Irazola, Vilma; Mills, Katherine T.; Poggio, Rosana; Beratarrechea, Andrea Gabriela; Dolan, Jacquelyn; Chen, Chung-Shiuan; Gibbons, Luz; Krousel Wood, Marie; Bazzano, Lydia A.; Nejamis, Analia; Gulayin, Pablo; Santero, Marilina; Augustovski, Federico Ariel; Chen, Jing; Rubinstein, Adolfo Luis
Año de publicación
2017
Idioma
inglés
Tipo de recurso
artículo
Estado
versión publicada
Descripción
IMPORTANCE: Despite extensive knowledge of hypertension treatment, the prevalence of uncontrolled hypertension is high and increasing in low- and middle-income countries. OBJECTIVE: To test whether a community health worker–led multicomponent intervention would improve blood pressure (BP) control among low-income patients with hypertension. DESIGN, SETTING, AND PARTICIPANTS: A cluster randomized trial was conducted in 18 centers for primary health care within a national public system providing free medications and health care to uninsured patients in Argentina. A total of 1432 low-income adult patients with uncontrolled hypertension were recruited between June 2013 and April 2015 and followed up to October 2016. INTERVENTIONS: Nine centers (743 patients) were randomized to the multicomponent intervention, which included a community health worker–led home intervention (health coaching, home BP monitoring, and BP audit and feedback), a physician intervention, and a text-messaging intervention over 18 months. Nine centers (689 patients) were randomized to usual care. MAIN OUTCOMES AND MEASURES: The coprimary outcomes were the differences in systolic and diastolic BP changes from baseline to the end of follow-up of patients with hypertension. Secondary outcomes included the proportion of patients with controlled hypertension (BP <140/90 mm Hg). Three BP measurements were obtained at each of 2 baseline and 2 termination visits using a standard protocol, the means of which were used for analyses. RESULTS:      Of 1432 participants (mean age, 55.8 years [SD, 13.3]; 772 women [53.0%]), 1357 (94.8%) completed the trial. Baseline mean systolic BP was 151.7 mm Hg for the intervention group and 149.8 mm Hg for the usual care group; the mean diastolic BP was 92.2 mm Hg for the intervention group and 90.1 mm Hg for the usual care group. Systolic BP reduction from baseline to month 18 was 19.3 mm Hg (95% CI, 17.9-20.8 mm Hg) for the intervention group and 12.7 mm Hg (95% CI, 11.3-14.2 mm Hg) for the usual care group; the difference in the reduction was 6.6 mm Hg (95% CI, 4.6-8.6; P < .001). Diastolic BP decreased by 12.2 mm Hg (95% CI, 11.2-13.2 mm Hg) in the intervention group and 6.9 mm Hg (95% CI, 5.9-7.8 mm Hg) in the control group; the difference in the reduction was 5.4 mm Hg (95% CI, 4.0-6.8 mm Hg; P < .001). The proportion of patients with controlled hypertension increased from 17.0% at baseline to 72.9% at 18 months in the intervention group and from 17.6% to 52.2% in the usual care group; the difference in the increase was 20.6% (95% CI, 15.4%-25.9%; P < .001). No adverse events were reported. CONCLUSIONS AND RELEVANCE: Low-income patients in Argentina with uncontrolled hypertension who participated in a community health worker–led multicomponent intervention experienced a greater decrease in systolic and diastolic BP than did patients who received usual care over 18 months. Further research is needed to assess generalizability and cost-effectiveness of this intervention and to understand which components may have contributed most to the outcome. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01834131.
Fil: He, Jiang. University of Tulane; Estados Unidos
Fil: Irazola, Vilma. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina
Fil: Mills, Katherine T.. University of Tulane; Estados Unidos
Fil: Poggio, Rosana. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina
Fil: Beratarrechea, Andrea Gabriela. Instituto de Efectividad Clínica y Sanitaria; Argentina
Fil: Dolan, Jacquelyn. University of Tulane; Estados Unidos
Fil: Chen, Chung-Shiuan. University of Tulane; Estados Unidos
Fil: Gibbons, Luz. Instituto de Efectividad Clínica y Sanitaria; Argentina
Fil: Krousel Wood, Marie. University of Tulane; Estados Unidos
Fil: Bazzano, Lydia A.. University of Tulane; Estados Unidos
Fil: Nejamis, Analia. Instituto de Efectividad Clínica y Sanitaria; Argentina
Fil: Gulayin, Pablo. Instituto de Efectividad Clínica y Sanitaria; Argentina
Fil: Santero, Marilina. Instituto de Efectividad Clínica y Sanitaria; Argentina
Fil: Augustovski, Federico Ariel. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina
Fil: Chen, Jing. University of Tulane; Estados Unidos
Fil: Rubinstein, Adolfo Luis. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina
Materia
Hypertension
Community Health Worker
Lmic
Blood Pressure Control
Nivel de accesibilidad
acceso abierto
Condiciones de uso
https://creativecommons.org/licenses/by-nc-sa/2.5/ar/
Repositorio
CONICET Digital (CONICET)
Institución
Consejo Nacional de Investigaciones Científicas y Técnicas
OAI Identificador
oai:ri.conicet.gov.ar:11336/40653

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oai_identifier_str oai:ri.conicet.gov.ar:11336/40653
network_acronym_str CONICETDig
repository_id_str 3498
network_name_str CONICET Digital (CONICET)
spelling Effect of a community health worker-led multicomponent intervention on blood pressure control in low-income patients in Argentina: A randomized clinical trialHe, JiangIrazola, VilmaMills, Katherine T.Poggio, RosanaBeratarrechea, Andrea GabrielaDolan, JacquelynChen, Chung-ShiuanGibbons, LuzKrousel Wood, MarieBazzano, Lydia A.Nejamis, AnaliaGulayin, PabloSantero, MarilinaAugustovski, Federico ArielChen, JingRubinstein, Adolfo LuisHypertensionCommunity Health WorkerLmicBlood Pressure Controlhttps://purl.org/becyt/ford/3.3https://purl.org/becyt/ford/3IMPORTANCE: Despite extensive knowledge of hypertension treatment, the prevalence of uncontrolled hypertension is high and increasing in low- and middle-income countries. OBJECTIVE: To test whether a community health worker–led multicomponent intervention would improve blood pressure (BP) control among low-income patients with hypertension. DESIGN, SETTING, AND PARTICIPANTS: A cluster randomized trial was conducted in 18 centers for primary health care within a national public system providing free medications and health care to uninsured patients in Argentina. A total of 1432 low-income adult patients with uncontrolled hypertension were recruited between June 2013 and April 2015 and followed up to October 2016. INTERVENTIONS: Nine centers (743 patients) were randomized to the multicomponent intervention, which included a community health worker–led home intervention (health coaching, home BP monitoring, and BP audit and feedback), a physician intervention, and a text-messaging intervention over 18 months. Nine centers (689 patients) were randomized to usual care. MAIN OUTCOMES AND MEASURES: The coprimary outcomes were the differences in systolic and diastolic BP changes from baseline to the end of follow-up of patients with hypertension. Secondary outcomes included the proportion of patients with controlled hypertension (BP <140/90 mm Hg). Three BP measurements were obtained at each of 2 baseline and 2 termination visits using a standard protocol, the means of which were used for analyses. RESULTS:      Of 1432 participants (mean age, 55.8 years [SD, 13.3]; 772 women [53.0%]), 1357 (94.8%) completed the trial. Baseline mean systolic BP was 151.7 mm Hg for the intervention group and 149.8 mm Hg for the usual care group; the mean diastolic BP was 92.2 mm Hg for the intervention group and 90.1 mm Hg for the usual care group. Systolic BP reduction from baseline to month 18 was 19.3 mm Hg (95% CI, 17.9-20.8 mm Hg) for the intervention group and 12.7 mm Hg (95% CI, 11.3-14.2 mm Hg) for the usual care group; the difference in the reduction was 6.6 mm Hg (95% CI, 4.6-8.6; P < .001). Diastolic BP decreased by 12.2 mm Hg (95% CI, 11.2-13.2 mm Hg) in the intervention group and 6.9 mm Hg (95% CI, 5.9-7.8 mm Hg) in the control group; the difference in the reduction was 5.4 mm Hg (95% CI, 4.0-6.8 mm Hg; P < .001). The proportion of patients with controlled hypertension increased from 17.0% at baseline to 72.9% at 18 months in the intervention group and from 17.6% to 52.2% in the usual care group; the difference in the increase was 20.6% (95% CI, 15.4%-25.9%; P < .001). No adverse events were reported. CONCLUSIONS AND RELEVANCE: Low-income patients in Argentina with uncontrolled hypertension who participated in a community health worker–led multicomponent intervention experienced a greater decrease in systolic and diastolic BP than did patients who received usual care over 18 months. Further research is needed to assess generalizability and cost-effectiveness of this intervention and to understand which components may have contributed most to the outcome. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01834131.Fil: He, Jiang. University of Tulane; Estados UnidosFil: Irazola, Vilma. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Mills, Katherine T.. University of Tulane; Estados UnidosFil: Poggio, Rosana. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Beratarrechea, Andrea Gabriela. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Dolan, Jacquelyn. University of Tulane; Estados UnidosFil: Chen, Chung-Shiuan. University of Tulane; Estados UnidosFil: Gibbons, Luz. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Krousel Wood, Marie. University of Tulane; Estados UnidosFil: Bazzano, Lydia A.. University of Tulane; Estados UnidosFil: Nejamis, Analia. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Gulayin, Pablo. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Santero, Marilina. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Augustovski, Federico Ariel. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Chen, Jing. University of Tulane; Estados UnidosFil: Rubinstein, Adolfo Luis. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaAmerican Medical Association2017-09info:eu-repo/semantics/articleinfo:eu-repo/semantics/publishedVersionhttp://purl.org/coar/resource_type/c_6501info:ar-repo/semantics/articuloapplication/pdfapplication/pdfapplication/pdfhttp://hdl.handle.net/11336/40653He, Jiang; Irazola, Vilma; Mills, Katherine T.; Poggio, Rosana; Beratarrechea, Andrea Gabriela; et al.; Effect of a community health worker-led multicomponent intervention on blood pressure control in low-income patients in Argentina: A randomized clinical trial; American Medical Association; Journal American Medical Association; 318; 11; 9-2017; 1016-10250098-7484CONICET DigitalCONICETenginfo:eu-repo/semantics/altIdentifier/doi/10.1001/jama.2017.11358info:eu-repo/semantics/altIdentifier/url/https://jamanetwork.com/journals/jama/fullarticle/2654383info:eu-repo/semantics/openAccesshttps://creativecommons.org/licenses/by-nc-sa/2.5/ar/reponame:CONICET Digital (CONICET)instname:Consejo Nacional de Investigaciones Científicas y Técnicas2025-09-29T10:41:17Zoai:ri.conicet.gov.ar:11336/40653instacron:CONICETInstitucionalhttp://ri.conicet.gov.ar/Organismo científico-tecnológicoNo correspondehttp://ri.conicet.gov.ar/oai/requestdasensio@conicet.gov.ar; lcarlino@conicet.gov.arArgentinaNo correspondeNo correspondeNo correspondeopendoar:34982025-09-29 10:41:17.321CONICET Digital (CONICET) - Consejo Nacional de Investigaciones Científicas y Técnicasfalse
dc.title.none.fl_str_mv Effect of a community health worker-led multicomponent intervention on blood pressure control in low-income patients in Argentina: A randomized clinical trial
title Effect of a community health worker-led multicomponent intervention on blood pressure control in low-income patients in Argentina: A randomized clinical trial
spellingShingle Effect of a community health worker-led multicomponent intervention on blood pressure control in low-income patients in Argentina: A randomized clinical trial
He, Jiang
Hypertension
Community Health Worker
Lmic
Blood Pressure Control
title_short Effect of a community health worker-led multicomponent intervention on blood pressure control in low-income patients in Argentina: A randomized clinical trial
title_full Effect of a community health worker-led multicomponent intervention on blood pressure control in low-income patients in Argentina: A randomized clinical trial
title_fullStr Effect of a community health worker-led multicomponent intervention on blood pressure control in low-income patients in Argentina: A randomized clinical trial
title_full_unstemmed Effect of a community health worker-led multicomponent intervention on blood pressure control in low-income patients in Argentina: A randomized clinical trial
title_sort Effect of a community health worker-led multicomponent intervention on blood pressure control in low-income patients in Argentina: A randomized clinical trial
dc.creator.none.fl_str_mv He, Jiang
Irazola, Vilma
Mills, Katherine T.
Poggio, Rosana
Beratarrechea, Andrea Gabriela
Dolan, Jacquelyn
Chen, Chung-Shiuan
Gibbons, Luz
Krousel Wood, Marie
Bazzano, Lydia A.
Nejamis, Analia
Gulayin, Pablo
Santero, Marilina
Augustovski, Federico Ariel
Chen, Jing
Rubinstein, Adolfo Luis
author He, Jiang
author_facet He, Jiang
Irazola, Vilma
Mills, Katherine T.
Poggio, Rosana
Beratarrechea, Andrea Gabriela
Dolan, Jacquelyn
Chen, Chung-Shiuan
Gibbons, Luz
Krousel Wood, Marie
Bazzano, Lydia A.
Nejamis, Analia
Gulayin, Pablo
Santero, Marilina
Augustovski, Federico Ariel
Chen, Jing
Rubinstein, Adolfo Luis
author_role author
author2 Irazola, Vilma
Mills, Katherine T.
Poggio, Rosana
Beratarrechea, Andrea Gabriela
Dolan, Jacquelyn
Chen, Chung-Shiuan
Gibbons, Luz
Krousel Wood, Marie
Bazzano, Lydia A.
Nejamis, Analia
Gulayin, Pablo
Santero, Marilina
Augustovski, Federico Ariel
Chen, Jing
Rubinstein, Adolfo Luis
author2_role author
author
author
author
author
author
author
author
author
author
author
author
author
author
author
dc.subject.none.fl_str_mv Hypertension
Community Health Worker
Lmic
Blood Pressure Control
topic Hypertension
Community Health Worker
Lmic
Blood Pressure Control
purl_subject.fl_str_mv https://purl.org/becyt/ford/3.3
https://purl.org/becyt/ford/3
dc.description.none.fl_txt_mv IMPORTANCE: Despite extensive knowledge of hypertension treatment, the prevalence of uncontrolled hypertension is high and increasing in low- and middle-income countries. OBJECTIVE: To test whether a community health worker–led multicomponent intervention would improve blood pressure (BP) control among low-income patients with hypertension. DESIGN, SETTING, AND PARTICIPANTS: A cluster randomized trial was conducted in 18 centers for primary health care within a national public system providing free medications and health care to uninsured patients in Argentina. A total of 1432 low-income adult patients with uncontrolled hypertension were recruited between June 2013 and April 2015 and followed up to October 2016. INTERVENTIONS: Nine centers (743 patients) were randomized to the multicomponent intervention, which included a community health worker–led home intervention (health coaching, home BP monitoring, and BP audit and feedback), a physician intervention, and a text-messaging intervention over 18 months. Nine centers (689 patients) were randomized to usual care. MAIN OUTCOMES AND MEASURES: The coprimary outcomes were the differences in systolic and diastolic BP changes from baseline to the end of follow-up of patients with hypertension. Secondary outcomes included the proportion of patients with controlled hypertension (BP <140/90 mm Hg). Three BP measurements were obtained at each of 2 baseline and 2 termination visits using a standard protocol, the means of which were used for analyses. RESULTS:      Of 1432 participants (mean age, 55.8 years [SD, 13.3]; 772 women [53.0%]), 1357 (94.8%) completed the trial. Baseline mean systolic BP was 151.7 mm Hg for the intervention group and 149.8 mm Hg for the usual care group; the mean diastolic BP was 92.2 mm Hg for the intervention group and 90.1 mm Hg for the usual care group. Systolic BP reduction from baseline to month 18 was 19.3 mm Hg (95% CI, 17.9-20.8 mm Hg) for the intervention group and 12.7 mm Hg (95% CI, 11.3-14.2 mm Hg) for the usual care group; the difference in the reduction was 6.6 mm Hg (95% CI, 4.6-8.6; P < .001). Diastolic BP decreased by 12.2 mm Hg (95% CI, 11.2-13.2 mm Hg) in the intervention group and 6.9 mm Hg (95% CI, 5.9-7.8 mm Hg) in the control group; the difference in the reduction was 5.4 mm Hg (95% CI, 4.0-6.8 mm Hg; P < .001). The proportion of patients with controlled hypertension increased from 17.0% at baseline to 72.9% at 18 months in the intervention group and from 17.6% to 52.2% in the usual care group; the difference in the increase was 20.6% (95% CI, 15.4%-25.9%; P < .001). No adverse events were reported. CONCLUSIONS AND RELEVANCE: Low-income patients in Argentina with uncontrolled hypertension who participated in a community health worker–led multicomponent intervention experienced a greater decrease in systolic and diastolic BP than did patients who received usual care over 18 months. Further research is needed to assess generalizability and cost-effectiveness of this intervention and to understand which components may have contributed most to the outcome. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01834131.
Fil: He, Jiang. University of Tulane; Estados Unidos
Fil: Irazola, Vilma. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina
Fil: Mills, Katherine T.. University of Tulane; Estados Unidos
Fil: Poggio, Rosana. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina
Fil: Beratarrechea, Andrea Gabriela. Instituto de Efectividad Clínica y Sanitaria; Argentina
Fil: Dolan, Jacquelyn. University of Tulane; Estados Unidos
Fil: Chen, Chung-Shiuan. University of Tulane; Estados Unidos
Fil: Gibbons, Luz. Instituto de Efectividad Clínica y Sanitaria; Argentina
Fil: Krousel Wood, Marie. University of Tulane; Estados Unidos
Fil: Bazzano, Lydia A.. University of Tulane; Estados Unidos
Fil: Nejamis, Analia. Instituto de Efectividad Clínica y Sanitaria; Argentina
Fil: Gulayin, Pablo. Instituto de Efectividad Clínica y Sanitaria; Argentina
Fil: Santero, Marilina. Instituto de Efectividad Clínica y Sanitaria; Argentina
Fil: Augustovski, Federico Ariel. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina
Fil: Chen, Jing. University of Tulane; Estados Unidos
Fil: Rubinstein, Adolfo Luis. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina
description IMPORTANCE: Despite extensive knowledge of hypertension treatment, the prevalence of uncontrolled hypertension is high and increasing in low- and middle-income countries. OBJECTIVE: To test whether a community health worker–led multicomponent intervention would improve blood pressure (BP) control among low-income patients with hypertension. DESIGN, SETTING, AND PARTICIPANTS: A cluster randomized trial was conducted in 18 centers for primary health care within a national public system providing free medications and health care to uninsured patients in Argentina. A total of 1432 low-income adult patients with uncontrolled hypertension were recruited between June 2013 and April 2015 and followed up to October 2016. INTERVENTIONS: Nine centers (743 patients) were randomized to the multicomponent intervention, which included a community health worker–led home intervention (health coaching, home BP monitoring, and BP audit and feedback), a physician intervention, and a text-messaging intervention over 18 months. Nine centers (689 patients) were randomized to usual care. MAIN OUTCOMES AND MEASURES: The coprimary outcomes were the differences in systolic and diastolic BP changes from baseline to the end of follow-up of patients with hypertension. Secondary outcomes included the proportion of patients with controlled hypertension (BP <140/90 mm Hg). Three BP measurements were obtained at each of 2 baseline and 2 termination visits using a standard protocol, the means of which were used for analyses. RESULTS:      Of 1432 participants (mean age, 55.8 years [SD, 13.3]; 772 women [53.0%]), 1357 (94.8%) completed the trial. Baseline mean systolic BP was 151.7 mm Hg for the intervention group and 149.8 mm Hg for the usual care group; the mean diastolic BP was 92.2 mm Hg for the intervention group and 90.1 mm Hg for the usual care group. Systolic BP reduction from baseline to month 18 was 19.3 mm Hg (95% CI, 17.9-20.8 mm Hg) for the intervention group and 12.7 mm Hg (95% CI, 11.3-14.2 mm Hg) for the usual care group; the difference in the reduction was 6.6 mm Hg (95% CI, 4.6-8.6; P < .001). Diastolic BP decreased by 12.2 mm Hg (95% CI, 11.2-13.2 mm Hg) in the intervention group and 6.9 mm Hg (95% CI, 5.9-7.8 mm Hg) in the control group; the difference in the reduction was 5.4 mm Hg (95% CI, 4.0-6.8 mm Hg; P < .001). The proportion of patients with controlled hypertension increased from 17.0% at baseline to 72.9% at 18 months in the intervention group and from 17.6% to 52.2% in the usual care group; the difference in the increase was 20.6% (95% CI, 15.4%-25.9%; P < .001). No adverse events were reported. CONCLUSIONS AND RELEVANCE: Low-income patients in Argentina with uncontrolled hypertension who participated in a community health worker–led multicomponent intervention experienced a greater decrease in systolic and diastolic BP than did patients who received usual care over 18 months. Further research is needed to assess generalizability and cost-effectiveness of this intervention and to understand which components may have contributed most to the outcome. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01834131.
publishDate 2017
dc.date.none.fl_str_mv 2017-09
dc.type.none.fl_str_mv info:eu-repo/semantics/article
info:eu-repo/semantics/publishedVersion
http://purl.org/coar/resource_type/c_6501
info:ar-repo/semantics/articulo
format article
status_str publishedVersion
dc.identifier.none.fl_str_mv http://hdl.handle.net/11336/40653
He, Jiang; Irazola, Vilma; Mills, Katherine T.; Poggio, Rosana; Beratarrechea, Andrea Gabriela; et al.; Effect of a community health worker-led multicomponent intervention on blood pressure control in low-income patients in Argentina: A randomized clinical trial; American Medical Association; Journal American Medical Association; 318; 11; 9-2017; 1016-1025
0098-7484
CONICET Digital
CONICET
url http://hdl.handle.net/11336/40653
identifier_str_mv He, Jiang; Irazola, Vilma; Mills, Katherine T.; Poggio, Rosana; Beratarrechea, Andrea Gabriela; et al.; Effect of a community health worker-led multicomponent intervention on blood pressure control in low-income patients in Argentina: A randomized clinical trial; American Medical Association; Journal American Medical Association; 318; 11; 9-2017; 1016-1025
0098-7484
CONICET Digital
CONICET
dc.language.none.fl_str_mv eng
language eng
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info:eu-repo/semantics/altIdentifier/url/https://jamanetwork.com/journals/jama/fullarticle/2654383
dc.rights.none.fl_str_mv info:eu-repo/semantics/openAccess
https://creativecommons.org/licenses/by-nc-sa/2.5/ar/
eu_rights_str_mv openAccess
rights_invalid_str_mv https://creativecommons.org/licenses/by-nc-sa/2.5/ar/
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application/pdf
application/pdf
dc.publisher.none.fl_str_mv American Medical Association
publisher.none.fl_str_mv American Medical Association
dc.source.none.fl_str_mv reponame:CONICET Digital (CONICET)
instname:Consejo Nacional de Investigaciones Científicas y Técnicas
reponame_str CONICET Digital (CONICET)
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instname_str Consejo Nacional de Investigaciones Científicas y Técnicas
repository.name.fl_str_mv CONICET Digital (CONICET) - Consejo Nacional de Investigaciones Científicas y Técnicas
repository.mail.fl_str_mv dasensio@conicet.gov.ar; lcarlino@conicet.gov.ar
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