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
- Institución
- Consejo Nacional de Investigaciones Científicas y Técnicas
- OAI Identificador
- oai:ri.conicet.gov.ar:11336/40653
Ver los metadatos del registro completo
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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 |
dc.relation.none.fl_str_mv |
info:eu-repo/semantics/altIdentifier/doi/10.1001/jama.2017.11358 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 application/pdf |
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American Medical Association |
publisher.none.fl_str_mv |
American Medical Association |
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reponame:CONICET Digital (CONICET) instname:Consejo Nacional de Investigaciones Científicas y Técnicas |
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CONICET Digital (CONICET) |
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CONICET Digital (CONICET) |
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Consejo Nacional de Investigaciones Científicas y Técnicas |
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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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13.070432 |