The Joint Commission journal on quality improvement最新文献

{"title":"Reducing Failed Extubations in the Intensive Care Unit","authors":"Peter J. Pronovost MD, PhD (Associate Professor),&nbsp;Mollie Jenckes MSc (Research Associate),&nbsp;May To RN (Nurse),&nbsp;Todd Dorman MD (Associate Professor),&nbsp;Pamela A. Lipsett MD (Associate Professor),&nbsp;Sean Berenholtz MD (Assistant Professor),&nbsp;Eric B. Bass MD, MPH (Associate Professor)","doi":"10.1016/S1070-3241(02)28063-3","DOIUrl":"10.1016/S1070-3241(02)28063-3","url":null,"abstract":"<div><h3>Background</h3><p>Failed extubation is associated with substantially increased morbidity, mortality, and costs for patients receiving mechanical ventilation. A study was designed in 1998 to identify risk factors for failed extubation and use a quality improvement model to reduce failed extubation rates in a surgical intensive care unit (SICU) in an academic hospital.</p></div><div><h3>Methods</h3><p>Study design involved a prospective cohort SICU with a concurrent control SICU. The primary outcome was rate of failed extubations per 1,000 ventilator days. Information on risk factors for failed extubations was also collected. Performance improvement staff identified failed extubation patients, and respiratory therapy provided information on ventilator days. The quality improvement model implemented three phases between October 1998 and June 2000: (1) identifying factors associated with failed extubation, (2) developing a guideline to reduce failed extubation, and (3) implementing the guideline.</p></div><div><h3>Results</h3><p>Significant factors associated with failed extubation included suctioning more frequently than every 4<!--> <!-->hours versus the current model of “every 4<!--> <!-->hours or greater” (odds ratio [OR] 11.3; 95% confidence interval [CI] 1.5—88.3), being agitated or sedated versus being alert (OR 4.5, CI: 1.2—14.7), and oxygen saturation ≤ 95% versus ≥ 95% (OR 4.0; CI: 1.2–13). Failed extubation rate in the SICU decreased from 8/1,000 in October 1998 to 1.5/1,000 in June 2000, and control SICU rates remained unchanged (8/1,000).</p></div><div><h3>Discussion</h3><p>The intervention significantly reduced the rate of failed extubation in the SICU. By employing a quality improvement model and identifying risk factors for failed extubation, providers should be able to decrease risk of failed extubation for SICU patients.</p></div>","PeriodicalId":79382,"journal":{"name":"The Joint Commission journal on quality improvement","volume":"28 11","pages":"Pages 595-604"},"PeriodicalIF":0.0,"publicationDate":"2002-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1070-3241(02)28063-3","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"22106125","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Patient Visits Program: A Strategy to Highlight Patient Satisfaction and Refocus Organizational Culture","authors":"Mandeep Sidhu MD,&nbsp;Kent Berg MBA,&nbsp;Carola Endicott EdM (Vice President, Clinical Operations),&nbsp;William Santulli FACHE (Chief Executive),&nbsp;Deeb Salem MD (Chief Medical Officer and Physician-in-Chief)","doi":"10.1016/S1070-3241(02)28064-5","DOIUrl":"10.1016/S1070-3241(02)28064-5","url":null,"abstract":"<div><h3>Background</h3><p>Seeking patient input may improve patients’ perceptions of the quality of care and provide managers with helpful information for strategic decision making. In addition, the involvement of senior hospital leadership is critical to successful implementation of quality improvement initiatives and illustrates an organization’s commitment to enhancing quality from the top down.</p></div><div><h3>Implementing the PVP</h3><p>Senior management’s Patient Visits Program (PVP) at Tufts-New England Medical Center is a structured, ongoing initiative in which senior clinicians are paired with nonclinician administrators. During an initial evaluation period (Aug 1999-Feb 2001), PVP teams visited with patients and their families on a monthly basis to talk to them about their experiences. Patient suggestions were then evaluated and acted on.</p></div><div><h3>Discussion</h3><p>The PVP has been beneficial for patients and for the hospital team members—clinicians and nonclinicians alike—who participated in the patient interviews. The PVP may serve as a mechanism to enhance organizational awareness of the importance of patient satisfaction. The program provides opportunities for immediate service recovery, and faster, broader-reaching responses to quality complaints due to the multispecialty nature of the PVP teams. In addition, based on early available data, the PVP shows promise as an interventional strategy to improve patient satisfaction scores.</p></div><div><h3>Conclusions</h3><p>A structured, ongoing program such as the PVP is an effective strategy to highlight the value of patient satisfaction, refocus organizational culture, and generate specific suggestions for improving the quality of patient care.</p></div>","PeriodicalId":79382,"journal":{"name":"The Joint Commission journal on quality improvement","volume":"28 11","pages":"Pages 605-613"},"PeriodicalIF":0.0,"publicationDate":"2002-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1070-3241(02)28064-5","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"22106126","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Combined Effect of Public Profiling and Quality Improvement Efforts on Heart Failure Management","authors":"Chih-Wen Pai PhD (Senior Research Associate),&nbsp;Geriann K. Finnegan RN, MSA (Director of Quality Management),&nbsp;Martha J. Satwicz RN, MSN, MSBA (System Accreditation Specialist)","doi":"10.1016/S1070-3241(02)28065-7","DOIUrl":"10.1016/S1070-3241(02)28065-7","url":null,"abstract":"<div><h3>Background</h3><p>A before-and-after study was conducted to examine the combined effect of public profiling and quality improvement activities on management of heart failure (HF) in the hospital setting.</p></div><div><h3>Methods</h3><p>Thirty-one hospitals in southeastern Michigan participated in this profiling and quality improvement study. One hospital closed after the baseline measurement. Two quality indicators were developed to evaluate the key processes of HF care, and one profiling indicator was designed for public profiling. The baseline results of the profiling indicator were publicly released. The individual hospitals were identified in the profiling report by name as “having statistically higher (or lower) rates than average.” Remeasurement results were compared to the baseline results by using <em>t</em>-tests for the individual hospitals and all 30 hospitals as an aggregate.</p></div><div><h3>Results</h3><p>Two-thirds of the hospitals improved ejection fraction documentation; the aggregate result improved 5.4 percentage points (<em>p</em> &lt; 0.05). No change was observed in the aggregate measure of prescribing angiotensin-converting enzyme inhibitors (ACEIs) to eligible HF patients at discharge. Hospitals with low baseline rates made improvement in ACEI use at discharge, but those with good baseline performance tended to decline in performance. There was a 2.2 percentage point increase (<em>p</em> &lt; 0.05) in the profiling indicator.</p></div><div><h3>Summary and conclusions</h3><p>There seemed to be differential impacts of interventions across indicators and hospitals. Public profiling may have the most positive impact on hospitals with low performance at baseline. Maintaining the baseline good practice was a struggle for hospitals with relatively high baseline rates.</p></div>","PeriodicalId":79382,"journal":{"name":"The Joint Commission journal on quality improvement","volume":"28 11","pages":"Pages 614-624"},"PeriodicalIF":0.0,"publicationDate":"2002-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1070-3241(02)28065-7","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"22106128","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Veterans Affairs Root Cause Analysis System in Action","authors":"James P. Bagian MD, PE (Director),&nbsp;John Gosbee MD (Director),&nbsp;Caryl Z. Lee RN, MSN (Program Manager),&nbsp;Linda Williams RN, MSI (Information Technology Specialist),&nbsp;Scott D. McKnight PhD (Statistician),&nbsp;Dea M. Mannos MPH (Program Analyst)","doi":"10.1016/S1070-3241(02)28057-8","DOIUrl":"10.1016/S1070-3241(02)28057-8","url":null,"abstract":"<div><h3>Background</h3><p>The patient safety program in the Department of Veterans Affairs (VA) began in 1998, when the National Center for Patient Safety (NCPS) was established to lead the effort on a day-to-day basis. NCPS provides the structure, training, and tools, and VA facilities provide front-line expertise, feedback about the process, and root cause analysis (RCA) of adverse events and close calls.</p></div><div><h3>Monitoring the process</h3><p>Facility patient safety managers determine the disposition of adverse events and close calls occurring at their facilities. They use a safety assessment code (SAC) to prioritize the actual and potential severity and frequency of an event.</p></div><div><h3>Before-and-after study</h3><p>Before the new RCA system was implemented in 2000, the VA used another adverse event reporting system, focused review (FR). A comparison of the two processes indicates that the RCA process has shifted analyses of adverse events toward a human factors engineering approach—entailing a search for system vulnerabilities rather than human errors and other less actionable root causes.</p></div><div><h3>Case examples</h3><p>Two case examples—on hazards in the magnetic resonance imaging (MRI) room and on a cardiac pacemaker malfunction—illustrate how the RCA system works in actual operation. The cases illustrate that broadly applicable, high-impact actions can result from a thorough RCA process.</p></div><div><h3>Discussion</h3><p>NCPS monitors the quality and completeness of RCAs through the immediate review and feedback process. Still to be investigated is the effectiveness of RCA actions addressing the hypothesized root causes and contributing factors of the close calls and adverse events.</p></div>","PeriodicalId":79382,"journal":{"name":"The Joint Commission journal on quality improvement","volume":"28 10","pages":"Pages 531-545"},"PeriodicalIF":0.0,"publicationDate":"2002-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1070-3241(02)28057-8","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"22056818","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Comparing Clinical Automated, Medical Record, and Hybrid Data Sources for Diabetes Quality Measures","authors":"Eve A. Kerr MD, MPH,&nbsp;Dylan M. Smith PhD,&nbsp;Mary M. Hogan PhD, RN (Research Investigator),&nbsp;Sarah L. Krein PhD, RN,&nbsp;Leonard Pogach MD, MBA,&nbsp;Timothy P. Hofer MD, MS,&nbsp;Rodney A. Hayward MD","doi":"10.1016/S1070-3241(02)28059-1","DOIUrl":"10.1016/S1070-3241(02)28059-1","url":null,"abstract":"<div><h3>Background</h3><p>Little is known about the relative reliability of medical record and clinical automated data, sources commonly used to assess diabetes quality of care. The agreement between diabetes quality measures constructed from clinical automated versus medical record data sources was compared, and the performance of hybrid measures derived from a combination of the two data sources was examined.</p></div><div><h3>Methods</h3><p>Medical records were abstracted for 1,032 patients with diabetes who received care from 21 facilities in 4 Veterans Integrated Service Networks. Automated data were obtained from a central Veterans Health Administration diabetes registry containing information on laboratory tests and medication use.</p></div><div><h3>Results</h3><p>Success rates were higher for process measures derived from medical record data than from automated data, but no substantial differences among data sources were found for the intermediate outcome measures. Agreement for measures derived from the medical record compared with automated data was moderate for process measures but high for intermediate outcome measures. Hybrid measures yielded success rates similar to those of medical record–based measures but would have required about 50% fewer chart reviews.</p></div><div><h3>Conclusions</h3><p>Agreement between medical record and automated data was generally high. Yet even in an integrated health care system with sophisticated information technology, automated data tended to underestimate the success rate in technical process measures for diabetes care and yielded different quartile performance rankings for facilities. Applying hybrid methodology yielded results consistent with the medical record but required less data to come from medical record reviews.</p></div>","PeriodicalId":79382,"journal":{"name":"The Joint Commission journal on quality improvement","volume":"28 10","pages":"Pages 555-565"},"PeriodicalIF":0.0,"publicationDate":"2002-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1070-3241(02)28059-1","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"22056820","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Hub-and-Spoke Model of Care: Providing Specialty Care in Patients’ Own Communities","authors":"Karen E. McKinley RN (Vice President, Operations, Patient Access and Care Management),&nbsp;Lissa Bryan-Smith RN, MHA (Vice President, Operations, Division of Medicine),&nbsp;Tracy L. Dosch LPN (Clinic Operations Manager, Community Practice Division),&nbsp;Bruce H. Hamory MD (Executive Vice President, Chief Medical Officer),&nbsp;Brian H. Fillipo MD (Associate Chief Medical Officer)","doi":"10.1016/S1070-3241(02)28061-X","DOIUrl":"10.1016/S1070-3241(02)28061-X","url":null,"abstract":"","PeriodicalId":79382,"journal":{"name":"The Joint Commission journal on quality improvement","volume":"28 10","pages":"Pages 574-575"},"PeriodicalIF":0.0,"publicationDate":"2002-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1070-3241(02)28061-X","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"22056822","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Nurse Practitioner Intervention Model to Maximize Efficient Use of Telemetry Resources","authors":"Peter A. Gross MD,&nbsp;Denise Patriaco RN, MSN, FNPC (Cardiology Nurse Practitioner),&nbsp;Kellie McGuire RN, MSN, FNPC (Cardiology Nurse Practitioner),&nbsp;Joan Skurnick PhD (Project Statistician),&nbsp;Louis Evan Teichholz MD","doi":"10.1016/S1070-3241(02)28060-8","DOIUrl":"10.1016/S1070-3241(02)28060-8","url":null,"abstract":"<div><h3>Background</h3><p>Telemetry monitoring is widely used in hospitals; the importance of being able to monitor and examine dysrhythmias has been universally accepted. Yet it is often used for patients who do not actually require this technology.</p><p>A model to improve the efficiency of telemetry use entailed the use of an advanced practice nurse (APN; identical to a nurse practitioner) to provide concurrent review and intervention of floating telemetry, which is available for patients independently of the floor location and who do not need an intensive care unit bed.</p></div><div><h3>Addressing overuse</h3><p>The demand for floating telemetry at Hackensack University Medical Center had equaled or exceeded the telemetry availability virtually 100% of the time, even after local guidelines had been disseminated in 1998. The APN carried out concurrent monitoring and intervened with the attending physician when patients were on telemetry for longer than 48<!--> <!-->hours and did not meet the local telemetry guidelines.</p></div><div><h3>Results</h3><p>The mean number (standard error [SE]) of hours per patient declined from 65.2 ± 0.7<!--> <!-->hours (95% confidence interval, 63.8 to 66.6<!--> <!-->hours) for the 11 months before the intervention to a mean of 49.6 ± 0.4<!--> <!-->hours (95% confidence interval, 48.7 to 50.2<!--> <!-->hours) for the 29 months after intervention—representing a decrease of 34% (<em>p</em> &lt; 0.0001). This decrease led to an increase in the number of patients per month put on telemetry.</p></div><div><h3>Discussion</h3><p>The APN model, an aggressive approach that induced change almost immediately, was then applied to other quality improvement projects.</p></div>","PeriodicalId":79382,"journal":{"name":"The Joint Commission journal on quality improvement","volume":"28 10","pages":"Pages 566-573"},"PeriodicalIF":0.0,"publicationDate":"2002-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1070-3241(02)28060-8","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"22056821","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Problem of Bias When Nursing Facility Staff Administer Customer Satisfaction Surveys","authors":"R. Tamara Hodlewsky MA, MS (PhD Candidate),&nbsp;Frederic H. Decker PhD (Senior Director)","doi":"10.1016/S1070-3241(02)28058-X","DOIUrl":"10.1016/S1070-3241(02)28058-X","url":null,"abstract":"<div><h3>Background</h3><p>Customer satisfaction instruments are being used with increasing frequency to assess and monitor residents’ assessments of quality of care in nursing facilities. There is no standard protocol, however, for how or by whom the instruments should be administered when anonymous, written responses are not feasible. Researchers often use outside interviewers to assess satisfaction, but cost considerations may limit the extent to which facilities are able to hire outside interviewers on a regular basis. This study was designed to investigate the existence and extent of any bias caused by staff administering customer satisfaction surveys.</p></div><div><h3>Methods</h3><p>Customer satisfaction data were collected in 1998 from 265 residents in 21 nursing facilities in North Dakota. Half the residents in each facility were interviewed by staff members and the other half by outside consultants; scores were compared by interviewer type. In addition to a tabulation of raw scores, ordinary least-squares analysis with facility fixed effects was used to control for resident characteristics and unmeasured facility-level factors that could influence scores.</p></div><div><h3>Results</h3><p>Significant positive bias was found when staff members interviewed residents. The bias was not limited to questions directly affecting staff responsibilities but applied across all types of issues. The bias was robust under varying constructions of satisfaction and dissatisfaction.</p></div><div><h3>Discussion</h3><p>A uniform method of survey administration appears to be important if satisfaction data are to be used to compare facilities. Bias is an important factor that should be considered and weighed against the costs of obtaining outside interviewers when assessing customer satisfaction among long term care residents.</p></div>","PeriodicalId":79382,"journal":{"name":"The Joint Commission journal on quality improvement","volume":"28 10","pages":"Pages 546-554"},"PeriodicalIF":0.0,"publicationDate":"2002-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1070-3241(02)28058-X","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"22056819","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Microsystems as Practical Neopragmatism and “Strong Poetry”: Comments from the Microsystem Series Editor—and Microsystem Student","authors":"James Espinosa MD, FACEP, FAAFP","doi":"10.1016/S1070-3241(02)28052-9","DOIUrl":"10.1016/S1070-3241(02)28052-9","url":null,"abstract":"","PeriodicalId":79382,"journal":{"name":"The Joint Commission journal on quality improvement","volume":"28 9","pages":"Pages 494-495"},"PeriodicalIF":0.0,"publicationDate":"2002-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1070-3241(02)28052-9","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21978008","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Microsystems in Health Care: Part 1. Learning from High-Performing Front-Line Clinical Units","authors":"Eugene C. Nelson DSc, MPH (Director),&nbsp;Paul B. Batalden MD (Professor and Director),&nbsp;Thomas P. Huber MS (Project Manager),&nbsp;Julie J. Mohr MSPH, PhD,&nbsp;Marjorie M. Godfrey MS, RN (Director),&nbsp;Linda A. Headrick MD, MS,&nbsp;John H. Wasson MD (Director)","doi":"10.1016/S1070-3241(02)28051-7","DOIUrl":"10.1016/S1070-3241(02)28051-7","url":null,"abstract":"<div><h3>Background</h3><p>Clinical microsystems are the small, functional, front-line units that provide most health care to most people. They are the essential building blocks of larger organizations and of the health system. They are the place where patients and providers meet. The quality and value of care produced by a large health system can be no better than the services generated by the small systems of which it is composed.</p></div><div><h3>Methods</h3><p>A wide net was cast to identify and study a sampling of the best-quality, best-value small clinical units in North America. Twenty microsystems, representing different component parts of the health system, were examined from December 2000 through June 2001, using qualitative methods supplemented by medical record and finance reviews.</p></div><div><h3>Results</h3><p>The study of the 20 high-performing sites generated many best practice ideas (processes and methods) that microsystems use to accomplish their goals. Nine success characteristics were related to high performance: leadership, culture, macro-organizational support of microsystems, patient focus, staff focus, interdependence of care team, information and information technology, process improvement, and performance patterns. These success factors were interrelated and together contributed to the microsystem’s ability to provide superior, cost-effective care and at the same time create a positive and attractive working environment.</p></div><div><h3>Conclusions</h3><p>A seamless, patient-centered, high-quality, safe, and efficient health system cannot be realized without the transformation of the essential building blocks that combine to form the care continuum.</p></div>","PeriodicalId":79382,"journal":{"name":"The Joint Commission journal on quality improvement","volume":"28 9","pages":"Pages 472-493"},"PeriodicalIF":0.0,"publicationDate":"2002-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1070-3241(02)28051-7","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21978007","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}