The Joint Commission journal on quality improvement最新文献

{"title":"Using a Unit Assessment Tool to Optimize Patient Flow and Staffing in a Community Hospital","authors":"John D. Rozich MD, PhD, MBA (Chief of Cardiology),&nbsp;Roger K. Resar MD (Change Agent)","doi":"10.1016/S1070-3241(02)28004-9","DOIUrl":"10.1016/S1070-3241(02)28004-9","url":null,"abstract":"<div><h3>Background</h3><p>Hospital environments are too often characterized by delays for patients receiving diagnostic testing and prolonged waiting times to complete needed therapy. Frequently there is confusion in scheduling, related at least in part to the complex interplay of clinical acuity and highly individualized care. Luther Midelfort recently began to change the process of patient flow to improve access to care, optimize outcomes by enabling timely intervention, and decrease the wasting of resources.</p></div><div><h3>Unit assessment tool</h3><p>The hospital developed a unit assessment tool based on the traffic light concept, which consisted of an assessment of current capacity and a graded, color-coded “workload tolerance” for each hospital unit. Each unit can instantly update its own status and query those of other work environments in the hospital.</p></div><div><h3>Experience with the unit assessment tool</h3><p>For most of the January–July 2001 period, there was generally a progressive decrease in the percentage of time that the units were coded as red (unit closed to new admissions), with concurrent increases in the percentage of time that the units were coded as green (unit open). Use of the tool appears to have contributed to a dramatic increase in staff satisfaction.</p></div><div><h3>Summary and conclusions</h3><p>The key to regulating patient flow has been to adopt a nursing-initiated capping trust policy whereby nurses are given the authority to limit new admissions. Initiatives are now under way to provide different units with novel models of resource sharing, ranging from flexible housekeeping to “flying nurse squads” to assist units that have become red.</p></div>","PeriodicalId":79382,"journal":{"name":"The Joint Commission journal on quality improvement","volume":"28 1","pages":"Pages 31-41"},"PeriodicalIF":0.0,"publicationDate":"2002-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1070-3241(02)28004-9","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"56461461","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 Quality Improvement Curriculum for Medical Students","authors":"Eric Henley MD, MPH (Assistant Professor)","doi":"10.1016/S1070-3241(02)28005-0","DOIUrl":"10.1016/S1070-3241(02)28005-0","url":null,"abstract":"<div><h3>Background</h3><p>Despite frequent recommendations that quality improvement (QI) be incorporated into medical education, reports of this activity are few. A pilot project to develop and implement a curriculum on QI into a family medicine clerkship was conducted in the 1999–2000 academic year.</p></div><div><h3>Intervention</h3><p>A five-part curriculum was developed and implemented on successive weeks of a family medicine clerkship. The curriculum involved students working alone and in small groups. After an orientation to QI principles, students performed a series of chart audits of diabetes care. They then met with QI coordinators from a local health system to review their results. Improvement recommendations were developed and presented to the clinic director. Evaluation included completion of the module, assessment of student knowledge and opinion, and interviews with the QI coordinators.</p></div><div><h3>Evaluation</h3><p>Two clinic sites and 30 third-year medical (M3) students participated. Each student conducted at least two chart audits, met with the QI coordinators, and developed at least one improvement recommendation. The QI coordinators felt that students were interested in the subject but needed more training in QI principles and more faculty development. Students assessed the curriculum as being moderately effective and useful.</p></div><div><h3>Discussion</h3><p>A curriculum in QI that involved active learning strategies was successfully implemented during a family medicine clerkship. Students viewed the curriculum as being appropriate to their learning. Future efforts should include more work on faculty development and role modeling of QI activity.</p></div>","PeriodicalId":79382,"journal":{"name":"The Joint Commission journal on quality improvement","volume":"28 1","pages":"Pages 42-48"},"PeriodicalIF":0.0,"publicationDate":"2002-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1070-3241(02)28005-0","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"56461472","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":"To Our Readers","authors":"Steven Berman","doi":"10.1016/S1070-3241(02)28001-3","DOIUrl":"https://doi.org/10.1016/S1070-3241(02)28001-3","url":null,"abstract":"","PeriodicalId":79382,"journal":{"name":"The Joint Commission journal on quality improvement","volume":"28 1","pages":"Page 2"},"PeriodicalIF":0.0,"publicationDate":"2002-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1070-3241(02)28001-3","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"91637088","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":"Implementing an Evidence-Based Acute Gastroenteritis Guideline at a Children’s Hospital","authors":"Paul H. Perlstein MD,&nbsp;Philip Lichtenstein MD (Community Pediatrician),&nbsp;Mitchell B. Cohen MD (Professor),&nbsp;Richard Ruddy MD (Director),&nbsp;Pamela J. Schoettker MS (Medical Writer),&nbsp;Harry D. Atherton BSEE, MS (Senior Research Associate),&nbsp;Uma Kotagal MBBS, MSc","doi":"10.1016/S1070-3241(02)28003-7","DOIUrl":"10.1016/S1070-3241(02)28003-7","url":null,"abstract":"<div><h3>Background</h3><p>Guidelines for preventing and treating acute gastroenteritis (AGE) have generally not been incorporated into medical practice. An evidence-based clinical practice guideline was adapted from national guidelines to meet the practice styles characterizing care in southwestern Ohio and implemented at the Children’s Hospital Medical Center (Cincinnati). Its efficacy was assessed in terms of emergency department (ED) encounters and admissions, mean and total hospital costs, and mean length of hospitalization.</p></div><div><h3>Methods</h3><p>Comparisons were made between patients seen during peak gastroenteritis months (December–May) before (fiscal years [FYs] 1994–1997) and after (FYs 1998 and 1999) guideline implementation. Data were extracted from hospital charts, clinical databases, and billing records.</p></div><div><h3>Results</h3><p>Following implementation, mean yearly ED encounters for AGE decreased 22% and mean yearly admissions decreased 33%. The percentage of admitted children with minor illness decreased (<em>p</em> = 0.002). Mean length of stay decreased 21% for children with minor illness (<em>p</em> = 0.0001) and 5% for others. Hydration status was noted in only 15% of ED charts examined but increased to 63% in FY 1998 and 86% in FY 1999 (<em>p</em> &lt; 0.001). The proportion of admitted patients who advanced to a regular diet by discharge increased from 4.9% (FY 1997) to 23% (FY 1998) and 76% (FY 1999; <em>p</em> &lt; 0.0001). Total inpatient days/year decreased by 43%. Mean hospital costs did not change significantly.</p></div><div><h3>Discussion</h3><p>Following implementation, fewer patients with AGE were seen in the ED and fewer were admitted to the hospital for care. Hospital stays were shorter, and children were more likely to resume their diets before discharge.</p></div>","PeriodicalId":79382,"journal":{"name":"The Joint Commission journal on quality improvement","volume":"28 1","pages":"Pages 20-30"},"PeriodicalIF":0.0,"publicationDate":"2002-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1070-3241(02)28003-7","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"56461447","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 Failure of a Controlled Trial to Improve Depression Care: A Qualitative Study","authors":"Lucy Rose Fischer PhD (Senior Research Investigator),&nbsp;Leif I. Solberg MD (Associate Medical Director for Care Improvement Research),&nbsp;Kay M. Zander MA (Senior Coordinator)","doi":"10.1016/S1070-3241(01)27054-0","DOIUrl":"10.1016/S1070-3241(01)27054-0","url":null,"abstract":"<div><h3>Background</h3><p>The DIAMOND Project (Depression Is A MANageable Disorder), a nonrandomized controlled effectiveness trial, was intended to improve the long-term management of depression in primary care medical clinics. The project tested whether a quality improvement (QI) intervention could implement a systems approach–so that there would be more reliable and effective monitoring of patients with depression, leading to better outcomes.</p></div><div><h3>The qualitative study</h3><p>A study was conducted in 1998–2000 to determine why a quality improvement intervention to improve depression care did not have a significant impact. Data consisted of detailed notes from observations of 12 project-related events (for example, team meetings and presentations) and open-ended interviews with a purposive sampling of 17 key informants. Thematic analytic methods were used to identify themes in the contextual data.</p></div><div><h3>Principal findings</h3><p>Overall, the project implementation was very limited. Five themes emerged: (1) The project received only lukewarm support from clinic and medical group leadership. (2) Clinicians did not perceive an urgent need for the new care system, and therefore there was a lack of impetus to change. (3) The improvement initiative was perceived as too complex by the physicians. (4) There was an inherent disconnect between the commitment of the improvement team and the unresponsiveness of most other clinic staff. (5) The doctor focus in clinic culture created a catch-22 dilemma–the involvement and noninvolvement of physicians were both problematic.</p></div><div><h3>Conclusion</h3><p>Problems in both predisposing and enabling factors accounted for the ultimate failure of the DIAMOND quality improvement effort.</p></div>","PeriodicalId":79382,"journal":{"name":"The Joint Commission journal on quality improvement","volume":"27 12","pages":"Pages 639-650"},"PeriodicalIF":0.0,"publicationDate":"2001-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1070-3241(01)27054-0","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"56461370","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":"Collaboration to Implement Smoking Cessation Guidelines During the Childbirth Continuum","authors":"Nancy P. Saks DNSc, RN (Clinical Researcher),&nbsp;Phyllis Hartigan MPH (Project Manager),&nbsp;Nicole Howard MPH (Program Specialist),&nbsp;Jack M. Schneider MD (Medical Director),&nbsp;Gene Nathan MD,&nbsp;Cheri Fidler MEd (Director),&nbsp;C.H. Beck Jr MD","doi":"10.1016/S1070-3241(01)27056-4","DOIUrl":"10.1016/S1070-3241(01)27056-4","url":null,"abstract":"<div><h3>Background</h3><p>Smoking during pregnancy has been linked with such negative outcomes as increased risk for spontaneous abortions, low birth weight, and perinatal and neonatal mortality. In spring 1998 three leading health care systems in San Diego initiated the Trilateral Partnership (“the Partnership”), whose mission is to improve the health and well-being of children. The Partnership chose tobacco control in pregnant women and their families as its first initiative.</p></div><div><h3>Program components—year one (1999)</h3><p>Three interventions were developed: intervention by the prenatal care provider, initiation of a referral process to telephone counseling for pregnant women, and intervention for women reporting spontaneously quitting smoking. To date, 83% of the more-than 20,000 women who have been seen in prenatal screening in 28 months counted themselves as nonsmokers. Eleven percent of the women reported they independently stopped smoking once they learned they were pregnant. Six percent reported that they were still smoking. Twenty-three percent of the women reported living in a household with other smokers.</p></div><div><h3>Program components—year two (2000)</h3><p>Activity focused on continuing the previous components, hospital intervention for all new mothers at the time of delivery, pediatric intervention at the newborn’s visits at 2 and 6 months of age, and development and refinement of a telephone protocol for new parents.</p></div><div><h3>Elements of success</h3><p>The noncontroversial topic of encouraging smoking cessation during pregnancy was one that enhanced immediate buy-in by most individuals contacted to support and engage in the program. Strong commitment and financial support from three health care systems opened doors for the Smoke-Free Families staff and increased the program’s visibility in the community.</p></div>","PeriodicalId":79382,"journal":{"name":"The Joint Commission journal on quality improvement","volume":"27 12","pages":"Pages 664-672"},"PeriodicalIF":0.0,"publicationDate":"2001-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1070-3241(01)27056-4","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"56461396","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":"Implementing Guidelines for Interdisciplinary Care of Low Back Pain: A Critical Role for Pre-Appointment Management of Specialty Referrals","authors":"J. Timothy Harrington MD (Associate Clinical Professor),&nbsp;Craig A. Dopf MD (Assistant Clinical Professor),&nbsp;Colleen S. Chalgren RN (Instructor)","doi":"10.1016/S1070-3241(01)27055-2","DOIUrl":"10.1016/S1070-3241(01)27055-2","url":null,"abstract":"<div><h3>Background</h3><p>Improving health care will require more effective guideline implementation and redesign of delivery processes and systems. Patient referral for specialty care is a key component of health system function that needs to be improved. Low back pain care is a widely documented example of the need for improvement. An interdisciplinary systemwide back pain program was developed using process improvement methods. Proactively managing referrals for specialty care—a departure from traditional referral processes—played a critical role in implementing the program.</p></div><div><h3>Methods</h3><p>Program components included guidelines for care, defined provider roles, uniform service coding, provider and patient education, pre-appointment specialty referral management, and monitoring of management processes. To evaluate program performance, system back pain visits were compared before, during, and after implementation of referral management. A case series study was performed on 581 consecutive patients with low back pain or lumbar radiculopathy referred for consultative spine care between April 1998 and March 1999.</p></div><div><h3>Results</h3><p>A shift of care was accomplished for acute back pain from spine orthopedists to primary physicians and for chronic back pain from spine orthopedists to medical specialists. More than 95% of initial assignments were accurate. Seventy-six percent of surveyed chronic back pain patients improved, and 90% were highly satisfied with the referral management process. This program has saved an estimated $400,000 per year in manpower cost and has reduced specialty service billings by 20%.</p></div><div><h3>Discussion</h3><p>Pre-appointment referral management offers an approach for improving guideline implementation, access to specialty services, and the effectiveness of care for complex health problems. It deserves broader study and adoption.</p></div>","PeriodicalId":79382,"journal":{"name":"The Joint Commission journal on quality improvement","volume":"27 12","pages":"Pages 651-663"},"PeriodicalIF":0.0,"publicationDate":"2001-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1070-3241(01)27055-2","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"56461381","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":"Methods for Evaluating the Provision of Well Child Care","authors":"Kathleen M. Schneider PhD,&nbsp;R. Todd Wiblin MD, MS,&nbsp;Kimberley S. Downs RN, CPHQ (Formerly Director of Medicaid Quality Improvement, is Director of Special Projects),&nbsp;Brian E. O’Donnell PhD (Statistician Consultant)","doi":"10.1016/S1070-3241(01)27057-6","DOIUrl":"10.1016/S1070-3241(01)27057-6","url":null,"abstract":"<div><h3>Background</h3><p>Well child visits are important for reducing the incidence of avoidable illness and disease. The Omnibus Reconciliation Act of 1989 (OBRA ‘89) set goals for well child or Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) visits. Many health plans are evaluated in terms of the number of well child visits provided, yet the method used for collecting the data influences the indicator results and conclusions drawn from them.</p></div><div><h3>Methods</h3><p>In a retrospective cohort design, medical record review and administrative data were compared as methods for ascertaining the number of well child visits received by Iowa Medicaid-eligible children for the period from July 1, 1997 through December 31, 1998. Compliance with the American Academy of Pediatrics’ “Recommendations for Preventive Pediatric Health Care” periodicity guidelines was assessed.</p></div><div><h3>Results</h3><p>Using administrative data, 29.6% (<em>n</em> = 1,489) of children received a well child visit. If medical record review was used, 39.6% (<em>n</em> = 1,003) of children had a visit. The concordance between the rates was quite low (kappa = 0.30). Medical record review supported that an EPSDT visit was provided for only 68% of the children who had a claim or encounter billed as providing well child care (<em>n</em> = 441).</p></div><div><h3>Discussion</h3><p>Administrative data may underestimate the performance of EPSDT visits in comparison to medical record review. In addition, having a claim for an EPSDT visit did not necessarily mean the child received the basic components of a well child exam. The methodology for performance indicators used to evaluate health plans should be carefully validated.</p></div>","PeriodicalId":79382,"journal":{"name":"The Joint Commission journal on quality improvement","volume":"27 12","pages":"Pages 673-682"},"PeriodicalIF":0.0,"publicationDate":"2001-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1070-3241(01)27057-6","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"56461407","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":"Using Performance Measures to Identify Plans of Action to Improve Care","authors":"Norman Weinberg MD (Chair)","doi":"10.1016/S1070-3241(01)27058-8","DOIUrl":"10.1016/S1070-3241(01)27058-8","url":null,"abstract":"<div><h3>Background</h3><p>Health care organizations dedicate enormous time and resources collecting data to measure the performance of physicians, hospitals, and other medical facilities. These measures may reflect outcomes, processes of care, patient perceptions of the quality of care, and resource utilization and cost. However, less thought is given to how the performance data should be used to improve care. The data must be translated into clinically relevant terms that assess the decisions of the clinical staff and the functioning of the systems that support the delivery of care. The processes of care are identified through record review, analysis of the system of care delivery, and patient interview, and are then further assessed to determine the underlying causes.</p></div><div><h3>Examples</h3><p>Examples, drawn from case studies, are provided to illustrate how to identify and address components of care requiring improvement.</p></div><div><h3>Discussion</h3><p>Physician behavior is an important component of care in all performance measures. Modification of some patterns of behavior, including those of nursing and other support staff, may be needed to reduce some types of error. For this reason it is important to involve physicians in the process of discovering root causes. When the root cause involves the medical care system, an interdisciplinary approach will be needed. This may involve administrators, nurses, pharmacists, home care and discharge planners, and office personnel. One recommended approach to QI is to identify system errors and then design changes in the system to reduce that type of error.</p></div><div><h3>Conclusion</h3><p>Performance measures must be translated into the components(s) of care that are implicated in the measure. Once this component has been identified as the reason behind the suboptimal measure, its root cause should be used to structure the most effective intervention.</p></div>","PeriodicalId":79382,"journal":{"name":"The Joint Commission journal on quality improvement","volume":"27 12","pages":"Pages 683-688"},"PeriodicalIF":0.0,"publicationDate":"2001-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1070-3241(01)27058-8","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"56461420","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":"Making Health Care Quality Reports Easier to Use","authors":"Judith H. Hibbard DrPH (Professor of Health Policy),&nbsp;Ellen Peters PhD (Research Scientist),&nbsp;Paul Slovic PhD (Director),&nbsp;Melissa L. Finucane PhD (Research Scientist),&nbsp;Martin Tusler MS (Research Assistant)","doi":"10.1016/S1070-3241(01)27051-5","DOIUrl":"10.1016/S1070-3241(01)27051-5","url":null,"abstract":"<div><h3>Background</h3><p>Although there is evidence that consumers want comparative quality information, most studies indicate that consumers make limited use of the data in decision making. The reasons for the limited use appear to be the complexity of the information and the difficulty of processing and using the amount of information in reports. The purpose of this investigation was to determine whether there are approaches to reporting comparative information that make it easier for consumers to comprehend the information. Further, the degree to which consumers who have a low level of skill can accurately use that information when it is presented in a format that is easier to use was examined.</p></div><div><h3>Methods</h3><p>The study used an experimental design to examine how different presentation approaches affect the use of information. Participants were randomly assigned to different conditions and were asked to review information and complete a decision task related to using comparative information and making health plan selections. Two separate convenience samples were used in the study: an elderly Medicare sample (<em>N</em> = 253), and a nonelderly sample (<em>N</em> = 239).</p></div><div><h3>Results</h3><p>The findings indicate that there are data presentation approaches that help consumers who have lower skills use information more accurately. Some of these presentation strategies (for example, relative stars) improve comprehension among the lower skilled, and other strategies (for example, evaluative labels) appear to aid those in the midrange of comprehension skill.</p></div><div><h3>Conclusions</h3><p>Using these approaches in reporting would likely increase the use of the comparative information and increase the efficacy of reporting efforts.</p></div>","PeriodicalId":79382,"journal":{"name":"The Joint Commission journal on quality improvement","volume":"27 11","pages":"Pages 591-604"},"PeriodicalIF":0.0,"publicationDate":"2001-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/S1070-3241(01)27051-5","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"56461327","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}