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Outpatient Commitment: Current Evidence and Options Joseph P. Morrissey Continuity of Care Panel Baltimore, MD ~ October 4, 2013.

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Presentation on theme: "Outpatient Commitment: Current Evidence and Options Joseph P. Morrissey Continuity of Care Panel Baltimore, MD ~ October 4, 2013."— Presentation transcript:

1 Outpatient Commitment: Current Evidence and Options Joseph P. Morrissey Continuity of Care Panel Baltimore, MD ~ October 4, 2013

2 Review Team Joe Morrissey, PhD Joe Morrissey, PhD Mental health services, policy, criminal justice Mental health services, policy, criminal justice Marisa Domino, PhD Marisa Domino, PhD Mental health economics, vulnerable populations Mental health economics, vulnerable populations Sarah Desmarais, PhD Sarah Desmarais, PhD Forensic psychology, violence risk assessment Forensic psychology, violence risk assessment Christiane Voisin, MLS Christiane Voisin, MLS Literature specialist Literature specialist 2

3 Five Key Questions 1. What is outpatient commitment (OPC)? 2. Why is OPC so controversial? 3. How strong is the evidence for OPC? 4. Is OPC cost-saving? 5. Are there any options or alternatives to OPC? 3

4 4 1. What is outpatient commitment?

5 Outpatient Commitment  Community treatment version of traditional inpatient commitment  Both are civil law mandates ordering an individual to obtain treatment against one’s will or risk sanctions  Main difference: inpatient = confinement vs. outpatient = freedom to live in community  Ultimate OPC sanction: forced hospitalization 5

6 Types of Outpatient Commitment  Conditional release from hospital ( 40 states 1 )  Early 20 th century, started as trial release  Alternative to hospitalization ( 33 states 1 )  Least restrictive alternative  Preventive outpatient commitment ( 10 states 1 )  For those not yet meeting inpatient commitment criteria with the purpose of preventing further deterioration 6 1 Melton et al., 2007

7 Varying Terminology United States Outpatient Commitment (OPC) Assisted outpatient treatment (AOT) Involuntary outpatient commitment (IOC) Involuntary outpatient treatment (IOT) Conditional Release ( early release as inpatient ) Extended placement Conditional discharge Canada, UK, Australia Supervised Community Treatment Order (CTO) Compulsory community treatment Compulsory supervision Leave of absence (UK) Section 17 leave Supervised discharge (UK) Section 25A leave Conditional release (Aus) 7

8 Involuntary Commitment Criteria Inpatient * Danger to self or others Gravely disabled In need of protection or treatment for health and safety because of a mental disorder * Exact criteria vary by jurisdiction Outpatient * Mentally ill Capable of surviving safely in community with supports Based on psychiatric history, respondent in need of treatment to prevent further deterioration Current mental status negates/limits ability to voluntarily comply 8

9 States with OPC Statutes Currently, 45 States have OPC Currently, 45 States have OPC 5 States do not: ME, MA, CT, MD, NM 5 States do not: ME, MA, CT, MD, NM Use varies a lot for states with OPC statutes but no good, current, national data available Use varies a lot for states with OPC statutes but no good, current, national data available Lack of services, liability concerns, attitudes of key players, lack of ability to enforce, etc. Lack of services, liability concerns, attitudes of key players, lack of ability to enforce, etc. Clearest example: AOT in New York ( Robbins et al., 2010 ) Clearest example: AOT in New York ( Robbins et al., 2010 ) Recent NASMHPD, Inc. survey has low response rates; does document information gaps Recent NASMHPD, Inc. survey has low response rates; does document information gaps 9

10 10 2. Why is OPC so controversial?

11 OPC controversies Arguments for 1 OPC less damaging than being left untreated Increases treatment exposure and medication adherence Leads to better quality of life Reduces violence Better than inpatient or criminal justice confinement Leads to less inpatient or criminal justice confinement Arguments against 1 Unconstitutional Overly coercive Relies on deception Anti-therapeutic Disempowering Stigmatizing Discriminatory Inadequate services 11 1 Slate et al., 2013

12 12 3. How strong is the evidence for OPC?

13 OPC Evidence Leading evidence reviews since 2000 Leading evidence reviews since 2000 RAND study (Ridgely et al. 2000) RAND study (Ridgely et al. 2000) UK report (Churchill et al., 2007) UK report (Churchill et al., 2007) Cochrane Collaborative report (Kisely et al., 2011) Cochrane Collaborative report (Kisely et al., 2011) Today, we’ll focus on the 3 major US studies Today, we’ll focus on the 3 major US studies Bellevue Study (Steadman et al., 2001) Bellevue Study (Steadman et al., 2001) Duke Mental Health Study (Swartz et al., 1999) Duke Mental Health Study (Swartz et al., 1999) New York AOT studies (Swartz et al., 2010; Swanson et al., 2013) New York AOT studies (Swartz et al., 2010; Swanson et al., 2013) 13

14 Bellevue Study Setting: NYC public general hospital Setting: NYC public general hospital Data Collection: Data Collection: Design: randomized controlled trial (RCT) Design: randomized controlled trial (RCT) Comparison: Patients being discharged from inpatient treatment to either OPC + intensive services (N= 78) or intensive services only (N= 64) Comparison: Patients being discharged from inpatient treatment to either OPC + intensive services (N= 78) or intensive services only (N= 64) Outcomes: hospital use, arrests, homelessness, medication 11 mos. Outcomes: hospital use, arrests, homelessness, medication 11 mos. Findings: Suggestive of reduced median hospital days, but no significant differences between-groups on hospital mos. Findings: Suggestive of reduced median hospital days, but no significant differences between-groups on hospital mos. Authors’ Conclusions: Contextual factors constrain the conclusions that can be drawn from this study. Authors’ Conclusions: Contextual factors constrain the conclusions that can be drawn from this study. 14

15 Bellevue Study Strengths Randomized controlled trial - breaks correlation between confounders & treatment assignment Limitations Small sample size More substance abuse in OPC group No consequences for nonadherence to order Many control participants and case managers thought they were on OPC orders 15

16 Duke Mental Health Study Main reports: Swartz et al., 2001; 2013 Main reports: Swartz et al., 2001; 2013 Setting: NC state psychiatric hospital Setting: NC state psychiatric hospital Data collection period: Data collection period: Design: randomized controlled trial (RCT) Design: randomized controlled trial (RCT) Comparison: Patients OPC eligible randomly assigned to be released under OPC (N=129) or remained hospitalized and released under usual procedures (N= 135) Comparison: Patients OPC eligible randomly assigned to be released under OPC (N=129) or remained hospitalized and released under usual procedures (N= 135) Duration: 12 month follow-up Duration: 12 month follow-up Participants: Persons with SMI involuntarily hospitalized Participants: Persons with SMI involuntarily hospitalized Outcomes: re-hospitalization, medication compliance, arrests, threatening behavior, homelessness, victimization Outcomes: re-hospitalization, medication compliance, arrests, threatening behavior, homelessness, victimization 16

17 Duke Mental Health Study Primary Finding ( with randomization ) Primary Finding ( with randomization ) No difference between groups in hospital outcomes over 12 month follow-up No difference between groups in hospital outcomes over 12 month follow-up Longitudinal analysis at person-month level finds OPC group had lower odds of any readmission (OR=.64, p<.01) especially for patients with psychotic disorders (OR=.44, p<.05) Longitudinal analysis at person-month level finds OPC group had lower odds of any readmission (OR=.64, p<.01) especially for patients with psychotic disorders (OR=.44, p<.05) Secondary Findings ( without randomization ) Secondary Findings ( without randomization ) Participants with 180+ days of OPC had 57% fewer readmits & 20 fewer days than control participants; even greater for individuals with non-affective psychotic disorders Participants with 180+ days of OPC had 57% fewer readmits & 20 fewer days than control participants; even greater for individuals with non-affective psychotic disorders  Authors Conclusions OPC can work to reduce hospital use if court orders are sustained and intensive services are provided OPC can work to reduce hospital use if court orders are sustained and intensive services are provided While OPC is cost neutral overall, a 40% savings is observed when orders are renewed While OPC is cost neutral overall, a 40% savings is observed when orders are renewed 17

18 Duke Mental Health Study Strengths RCT-breaks correlation between confounders & treatment assignment Control group has face validity; similar inpatient history plus voluntary treatment Both groups received enhanced case management; strengthened control treatment & rendered effects more conservative Limitations No difference finding between groups raises issues about whether study was underpowered or had small differences between groups This issue cannot be resolved from published reports Duration of orders analysis lacks control group and is susceptible to interpretation biases Enhanced case management for control group decreases generalizability since enhancements are not true of usual treatment in most places 18

19 Duke Mental Health Study Strength of evidence for OPC Strength of evidence for OPC 1. Main experimental comparisons on hospital readmission and costs found no difference between groups. Evidence: strong, findings are null. 2. Stratification by length of orders (180+ days) is misleading; only credible interpretation is that those on OPC who were doing well were selected by their clinicians for an extension. So evidence of a length of order effect is weak. 3. However, additional multivariable analyses at person-month level (excluding length of orders) found that OPC group (esp. those with psychotic disorders) had a lower probability of hospitalization. So evidence of an OPC effect in these analyses is strong. 4. Overall, then, while the authors’ main conclusions about duration of OPC and cost savings are not supportable, this study does provide moderate evidence that OPC did reduce hospital use. 19

20 New York State AOT Study Statewide assessment of “Kendra’s Law” using administrative data and case manager reports (Swartz et al., 2010) Statewide assessment of “Kendra’s Law” using administrative data and case manager reports (Swartz et al., 2010) Study duration: Study duration: Design: Observational study with multi- variable statistical analyses of time series Design: Observational study with multi- variable statistical analyses of time series Comparison: Both pre-post and propensity matched comparison group Comparison: Both pre-post and propensity matched comparison group Participants: 3,576 AOT placements who had Medicaid Participants: 3,576 AOT placements who had Medicaid Outcomes: Hospital use, medications, receiving ACT/intensive case management/any case management Outcomes: Hospital use, medications, receiving ACT/intensive case management/any case management 20

21 New York State AOT Study Administrative Data Findings ( pre-post only ) Administrative Data Findings ( pre-post only ) Odds of admission reduced by 23% ( first 180 days )and by 41% during subsequent renewal ( 181+ days ); days hospitalized (20%/16%) were also reduced while medication possession (47%/88%) and receipt of ACT/intensive case management (242%/282%) increased. Odds of admission reduced by 23% ( first 180 days )and by 41% during subsequent renewal ( 181+ days ); days hospitalized (20%/16%) were also reduced while medication possession (47%/88%) and receipt of ACT/intensive case management (242%/282%) increased. Case Manager Data Findings ( control group ) Case Manager Data Findings ( control group ) Consumers on AOT+ACT/ICM had 43-57% lower odds of hospitalization than those on ACT/ICM alone and 2X higher odds of service engagement Consumers on AOT+ACT/ICM had 43-57% lower odds of hospitalization than those on ACT/ICM alone and 2X higher odds of service engagement Authors Conclusions Authors Conclusions Consumers who received court orders for AOT had improved policy-relevant outcomes Consumers who received court orders for AOT had improved policy-relevant outcomes 21

22 New York State AOT Study Strengths Large, observational study allows significantly more power than RCTs First observational study to use advances in observational design, including propensity score (PS) weighting. (Though not used often enough in the core papers). First study to look at medication possession/adherence as a core outcome Compares in some analyses, the use of ICM/ACT with AOT to ACT alone, estimating marginal contribution of AOT over voluntary receipt of IC M/ACT services. Limitations Propensity analysis on AOT-only subjects raises significant methodological concerns Within-subject PS Few covariates used for adjustment Non AOT controls not used for some analyses Only 46% of AOT subjects included in case manager analysis, raising generalizability concerns 22

23 New York State AOT Study Overall strength of evidence for AOT: Overall strength of evidence for AOT: 1. Main finding on length of orders is weak. 2. Comparison of AOT with ICM/ACT with ACT alone is moderately strong. Overall, we can conclude that ACT/ICM with AOT leads to lower hospitalization and greater engagement in services than ACT without AOT, in their sample. 3. Concerns about study selection criteria, availability of enhanced (ICM/ACT) services in NY, and duration of AOT analyses mean these findings may not generalize outside of NY. 23

24 24 4. Is OPC cost-saving?

25 New York State AOT Cost Savings Study Swanson et al., 2013 Swanson et al., 2013 Design: Observational study using administrative data in a multivariable time series analysis of state costs Design: Observational study using administrative data in a multivariable time series analysis of state costs Comparison: Both pre-post and propensity matched comparison group Comparison: Both pre-post and propensity matched comparison group Participants: 3,576 AOT placements who had Medicaid Participants: 3,576 AOT placements who had Medicaid Outcomes: State costs and cost components Outcomes: State costs and cost components 25

26 New York State AOT Cost Savings Study Strengths Appropriate set of cost measures from Medicaid claims and per diems at hospitals, jails, prisons Person-month panel of data, enables sophisticated analyses Reasonable control group matched on claims for ACT/ICM and inpatient stays (but may differ on other characteristics) Limitations Main analysis uses only pre-post comparisons /threat of regression to mean, other validity risks No head-to-head comparisons or pooled analyses using ACT with ICM as controls Incomplete cost data for 13% of AOT and lack of Medicare claims underestimates actual cost 26

27 New York State AOT Cost Savings Study Findings and Strength of Evidence Findings and Strength of Evidence 1. AOT requires a substantial investment of state resources but can reduce overall service costs for people with SMI. Strength of evidence: weak. 2. For those who don’t qualify for AOT, voluntary participation in intensive community-based services may also reduce overall service costs over time, depending on characteristics of target population and local service system. Strength of evidence: weak. 3. Conclusion: There is little evidence from this study that AOT can save states money. 27

28 Summary: Strength of Evidence for OPC 28 Legend: number of signs= strength of evidence; 0/+ /-=direction of effect (e.g., +=weak, ++=moderate, +++=strong) OutcomeBellevue Study Duke Mental Health StudyNYS-AOT Study RCT Long vs. Short ordersPre-Post OPC+ICM/ ACT vs. ICM/ACT alone Any hospitalization +000 (person)/ +++ (month) 0+++ Days in hospital Medication possession + Service engagement ++ Cost savings000+++

29 29 5. Are there any options to OPC?

30 OPC Alternatives We have looked into We have looked into Conditional Release Conditional Release Incompetency Incompetency Guardianship Guardianship Advanced Directives Advanced Directives Other options have been suggested in the literature(e.g., Rowe, 2013) Other options have been suggested in the literature(e.g., Rowe, 2013) 30

31 Conditional Release Trial release from hospital inpatient status Trial release from hospital inpatient status 5 main studies conducted in Australia & UK (Hatfield et al., 2004; Segal & Burgess, 2006; Segal et al., 2009; 5 main studies conducted in Australia & UK (Hatfield et al., 2004; Segal & Burgess, 2006; Segal et al., 2009; Burns et al., 2013) Burns et al., 2013) Settings: psychiatric hospitals Settings: psychiatric hospitals Sample sizes: 274 to +100,000 Sample sizes: 274 to +100,000 Designs: 4 pre-post and matched samples; 1 RCT Designs: 4 pre-post and matched samples; 1 RCT Data source: Administrative records, national registries, patient assessments Data source: Administrative records, national registries, patient assessments Outcomes: inpatient & outpatient service use, psychosocial functioning, mortality risk Outcomes: inpatient & outpatient service use, psychosocial functioning, mortality risk Patients most closely resemble those that could be placed on preventive OPC but has not been studies in US Patients most closely resemble those that could be placed on preventive OPC but has not been studies in US Usually requires split-commitment (inpatient +outpatient) Usually requires split-commitment (inpatient +outpatient) 31

32 Conditional Release Findings & Strength of Evidence Findings & Strength of Evidence 1. Promising evidence, moderate in strength: Reduces mortality risk compared to control Reduces mortality risk compared to control Reduces inpatient service utilization compared to control Reduces inpatient service utilization compared to control 2. Strong evidence: No differences in outcomes compared to preventive OPC No differences in outcomes compared to preventive OPC 3. Weak evidence: Despite decrease in overall inpatient service use, may actually increase risk of rehospitalization Despite decrease in overall inpatient service use, may actually increase risk of rehospitalization 32

33 Incompetency Judicial finding of incompetency or grave disability Judicial finding of incompetency or grave disability Inability to make personal decisions, including decisions regarding treatment Inability to make personal decisions, including decisions regarding treatment Various proposals in the literature about using incompetency vs. dangerousness as standard for civil commitment (Bloom & Faulkner, 1987; Geller et al., 1997) Various proposals in the literature about using incompetency vs. dangerousness as standard for civil commitment (Bloom & Faulkner, 1987; Geller et al., 1997) 33

34 Guardianship  Court-appointed ‘guardian’ after finding of incompetency or grave disability  Provides treatment consent  Requires patient to live at specified place  Requires patient to attend treatment 3 main studies conducted in UK (Hatfield et al., 2001) and US (Mass and California; Geller et al., 1998; Lamb & Weinberger, 1992) 3 main studies conducted in UK (Hatfield et al., 2001) and US (Mass and California; Geller et al., 1998; Lamb & Weinberger, 1992) Settings: psychiatric hospitals Settings: psychiatric hospitals Sample sizes: 57 to 274 Sample sizes: 57 to 274 Designs: Pre-post comparisons and matched samples Designs: Pre-post comparisons and matched samples Data source: Administrative records, patient assessments Data source: Administrative records, patient assessments Outcomes: Inpatient service utilization, family support, adverse events Outcomes: Inpatient service utilization, family support, adverse events 34

35 Guardianship Findings & Strength of Evidence Findings & Strength of Evidence Mixed evidence, weak evidence on inpatient service utilization with contradictory findings Mixed evidence, weak evidence on inpatient service utilization with contradictory findings Weak evidence on victimization reduction and improved functioning Weak evidence on victimization reduction and improved functioning Legal criteria distinct from OPC criteria Legal criteria distinct from OPC criteria Additional implementation issues Additional implementation issues Slow judicial process, difficult for urgent care situations? Slow judicial process, difficult for urgent care situations? Identification and appointment of appropriate guardian? Identification and appointment of appropriate guardian? Potential for abuse of guardian role? Potential for abuse of guardian role? 35

36 Psychiatric Advanced Directives (PADS) Legal documents that permit competent adults to make choices in the present about their future psychiatric treatment if they lose their decision- making capacity Legal documents that permit competent adults to make choices in the present about their future psychiatric treatment if they lose their decision- making capacity In UK & Europe, known as “joint crisis plans” In UK & Europe, known as “joint crisis plans” Mixed evidence regarding effectiveness (Swanson et al., 2008; Thornicroft et al., 2011); actively being studied in US & abroad Mixed evidence regarding effectiveness (Swanson et al., 2008; Thornicroft et al., 2011); actively being studied in US & abroad 36

37 Research Evidence: OPC Alternatives Strengths Studies conducted in multiple jurisdictions, including US Most had 12-month or more follow-up periods Some comparisons between OPC & alternatives Limitations No RCTs comparing alternatives to no OPC Comparison/control groups typically differ in clinically meaningful ways Many studies underpowered Different legal mechanism from OPC Different criteria from OPC No studies of costs 37

38 Overall Summary 1. Moderate evidence exists in support of OPC regarding reduced hospital use and increased engagement in services. 2. Whether court orders without intensive treatment have any effect is an unanswered question. 3. Whether OPC save states money cannot be determined from current research. 4. Evidence-based options to OPC require further assessment regarding for whom they are appropriate and under what circumstances. 38

39 References Bloom, J.D., Faulkner, L.R. Competency determinations in civil commitment. (1987). Am J Psychiatry 144(2), Burns, T., Rugkasa, j., Dawson, J., Yeeles, K., Vazquez-Montes, M., Voysey, M., Sinclair, J., Priebe, S. (2013). Community treatment orders for patients with psychosis (OCTET): a randomized controlled trial. Lancet 381(9878), Churchill, R. (2007). International experiences of using community treatment orders. (Diss.), Institute of Psychiatry, Kings College London Geller, J, I., McDermeit, M., Grudzinskas, A. J., Jr., Lawlor, T., & Fisher, W. H. (1997). A competency-based approach to court-ordered outpatient treatment. New Directions for Mental health Services, 75, Geller, J., Grudzinskas, A. J., Jr., McDermeit, M., Fisher, W. H., & Lawlor, T. (1998). The efficacy of involuntary outpatient treatment in Massachusetts. Administration and Policy in Mental Health, 25, Hatfield, B., Shaw, J., Pinfold, V., Bindman, J., Evans, S., Huxley, P., & Thornicroft, G. (2001). Managing severe mental illness in the community using the Mental Health Act 1983: A comparison of Supervised Discharge and Guardianship in England. Social Psychiatry And Psychiatric Epidemiology, 36,

40 References 7. Hatfield, B., Bindman, J., & Pinfold, V. (2004). Evaluating the use of supervised discharge and guardianship in cases of severe mental illness: A follow-up study. Journal of Mental Health, 13, Kisely, S. R., Campbell, L. A., & Preston, N. J. (2011). Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Cochrane Database Syst Rev(2), CD doi: / CD pub3 9. Lamb, H. R., & Weinberger, L. E. (1992). Conservatorship for gravely disabled psychiatric patients: A four-year follow-up study. American Journal of Psychiatry, 149, Melton, G., Petrila P, Poythress, NG, & Slobogin, C. (2007). Psychological evaluations for the courts: A handbook for mental health professionals and lawyers (3rd ed.). New York: Guilford. 11. Ridgely MS, Petrilla, J., Borum R. (2001). The Effectiveness of Involuntary Outpatient Treatment: Empirical Evidence and the Experience of Eight States. Santa Monica, Calif: Rand. 12. Rowe, M. Alternatives t o outpatient commitment. (2013). J Am Acad Psych & Law, 41(3),

41 References 13. Robbins, P. C., Keator, K. J., Steadman, H. J., Swanson, J. W., Wilder, C. M., & Swartz, M. S. (2010). Assisted outpatient treatment in New York: regional differences in New York's assisted outpatient treatment program. Psychiatr Serv, 61(10), doi: /appi.ps , Segal, S. P., & Burgess, P. M. (2006). Conditional release: A less restrictive alternative to hospitalization?. Psychiatric Services, 57, Segal, S. P., Preston, N., Kisely, S., & Xiao, J. (2009). Conditional release in Western Australia: Effect on hospital length of stay. Psychiatric Services, 60, Slate, R.N., Buffington-Vollum, J.K., Johnson, W.W. Outpatient Commitment. Ch. 5 in The Criminalization of Mental Illness: Crisis and Opportunity for the Justice System, 2 nd Ed. Durham, N.C.: Carolina Academic Press, Steadman, H. J., Gounis, K., Dennis, D., Hopper, K., Roche, B., Swartz, M., & Robbins, P. C. (2001). Assessing the New York City involuntary outpatient commitment pilot program. Psychiatr Serv, 52(3), Swanson, J.W., Swartz, M.S., Elbogen, E.B., Van Dorn, R.A., Wagner, H.R., Moser, L.A., Wilder, C., Gilbert, A.R. Psychiatric advance directives and reduction of coercive crisis interventions. J Ment Health 17(3)

42 References 19. Swanson, J. W., Van Dorn, R. A., Swartz, M. S., Robbins, P. C., Steadman, H. J., McGuire, T. G., & Monahan, J. (2013). The Cost of Assisted Outpatient Treatment: Can It Save States Money? Am J Psychiatry. doi: /appi.ajp Swartz, M. S., Swanson, J. W., Wagner, H. R., Burns, B. J., Hiday, V. A., & Borum, R. (1999). Can involuntary outpatient commitment reduce hospital recidivism?: Findings from a randomized trial with severely mentally ill individuals. Am J Psychiatry, 156(12), Swartz, M. S., Wilder, C. M., Swanson, J. W., Van Dorn, R. A., Robbins, P. C., Steadman, H. J., Monahan, J. (2010). Assessing outcomes for consumers in New York's assisted outpatient treatment program. Psychiatr Serv, 61(10), doi: /appi.ps Swartz, M. S., & Swanson, J. W. (2013). Economic grand rounds: Can states implement involuntary outpatient commitment within existing state budgets? Psychiatr Serv, 64(1), 7-9. doi: /appi.ps Thornicroft, G., Farrelly, S., Szmukler, G., Birchwood, M., Warheed, W., Flach, C., Barrett, B., Byford, S., Henderson, C., Sutherby, K., Lester, H., Rose, D., Dunn, G., Leese, M., Marshall, M. (2013) Clinical outcomes of Joint Crisis Plans to reduce compulsory treatment for peopl e with psychosis: a randomized controlled trial. Lancet 381(9878),


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