Teledentistry: Increasing utilisation of oral-health services for children in rural areas

Abstract

Introduction

The objective of this study was to evaluate factors influencing utilisation of follow-up oral-health services in general dentistry clinics among children subsequent to a teledentistry consultation and treatment with a paediatric dental specialist.

Methods

Conducted in 2017, the study included 144 children living in rural upstate New York who experienced a teledentistry consultation in 2015–2016 at one of several local general dentistry clinics. A remotely located paediatric dental specialist provided consultation services in the teledentistry visit and treatment services in the specialty dental clinic. Associations between follow-up services at the general dentistry clinics and patients’ characteristics, specialty treatment recommendations, case-management services, timeliness of treatments and travel distances were evaluated.

Results

The study results indicated that most children completed a treatment plan (97.2%) at the specialty clinic and subsequently accessed follow-up oral-health services at one of the local general dentistry clinics (77.1%) where teledentistry services were provided. Children’s utilisation of follow-up services in general dentistry clinics was associated with a shorter time to specialty treatment (p = 0.013) and fewer case-management contacts (p = 0.004). Children who had a longer time to treatment initiation (p < 0.001) or completion (p = 0.043) required significantly more case-management services than other children.

Discussion

The study found that case severity and compliance with treatment were predictors of utilisation of oral-health services in general dentistry clinics. An additional finding was that case-management interventions were important in facilitating specialty dental care.

Keywords

Case-management services children’s dental care utilisation community health centre specialty dental care teledentistry telehealth

Introduction

The importance of increasing access to oral-health services for underserved populations has dominated discussions about effective strategies to improve population oral health.¹ Innovations in dental service delivery to enable access to general and specialty dental care, especially for rural and underserved populations, include the use of teledentistry.² Teledentistry is used to provide oral-health screenings, assessments and examinations, urgent-care consultations, specialty-care consults and follow-up examinations, as well as being used for distance learning.³,⁴ The literature also suggests that teledentistry may be a useful tool in helping children establish a dental home.⁵

Telehealth services generally and teledentistry services more specifically assist with case finding, triaging patients to the most appropriate level of care, disease management and patient education.⁶,⁷ Some patients who participate in a teledentistry consultation may continue to receive preventive services in the local community, and others may be referred to a distant dentist for in-person treatment services.⁸ Teledentistry services appear to improve access, reduce costs and contribute to improved oral-health outcomes for the patients who benefit from these services.⁹ Teledentistry also has the potential to eliminate the disparities in oral health between rural and urban populations.¹⁰,¹¹

At Finger Lakes Community Health (FLCH), headquartered in Penn Yan, New York, teledentistry service provision is an initial intervention in a service delivery strategy that connects underserved patients to a comprehensive range of oral-health services.¹² FLCH began providing telehealth services in 2002, and currently provides telehealth, tele-behavioural health and teledentistry services for its predominantly rural patient population. FLCH’s nine primary-care medical clinics include six co-located dental clinics providing general dentistry services; two stand-alone dental centres are also sponsored by the organisation.

FLCH patients experience numerous impediments to specialty health and dental services, including language barriers, cultural beliefs, lack of insurance, poverty, low-paying jobs with limited or no time off and transportation barriers.¹² FLCH’s outreach programmes use a team-based approach that includes care coordination staff, patient advocates and community health workers (CHWs) to provide education, assistance and advocacy for patients, and to navigate patients in need to health services. CHWs assist with scheduling specialty appointments with the paediatric dentist at the Eastman Institute for Oral Health (EIOH), assessing and addressing barriers to care, arranging transportation to the EIOH, providing translation services and following up with parents when children miss appointments. They also work with patients after the specialty treatment is completed to ensure that they continue to see the local general dentist for follow-up and preventive oral-health services. Care coordination activities include an active interface with a registry of patients, monthly case conferences with the dental and teledental care team via videoconferencing and communication with parents and childcare centres.³

FLCH has a highly developed teledentistry programme for children in partnership with paediatric dental specialists at the EIOH in Rochester, New York.¹² The efficacy of this teledentistry programme has been documented in several studies describing the positive clinical outcomes for children who received a teledentistry service.¹³,¹⁴ Between the beginning of this collaboration in 2010 and 2015, FLCH facilitated 534 teledentistry consults for children with paediatric dental specialists at the EIOH.²

The objectives of this study were to evaluate whether children who received a teledentistry consultation and treatment with a paediatric dental specialist accessed follow-up oral-health services at one of the FLCH general dentistry clinics, and to assess the association between case-management services provided by the CHWs for these children and timeliness of treatment plan initiation/completion as well as follow-up visits at the FLCH.

Methods

Study subjects and data collection

The study sample consisted of 149 children experiencing serious dental decay (i.e. requiring extensive treatment procedures or extraction of teeth) who had a teledentistry consultation in one of the FLCH dental clinics between 1 January 2015 and 31 August 2016. FLCH health and dental records were reviewed to abstract de-identified data on study participants’ sociodemographic characteristics, behavioural or developmental disorders, current residence, teledentistry consultation, case-management services and clinical outcomes. In addition, information on follow-up visits at one of the FLCH dental clinics was recorded until 31 May 2017. Five subjects were excluded from the study sample due to missing information or not meeting the eligibility criteria (i.e. a teledentistry consultation at FLCH during the study period). The study was conducted according to a research protocol that was approved by the New York State Department of Health Institutional Review Board.

Statistical analyses

Subjects’ utilisation of follow-up oral-health services at one of the FLCH general dentistry clinics was defined as one or more follow-up visits per year on average after the specialty dental treatment in Rochester. The timeliness of initiation or completion of the dental treatment plan in Rochester was assessed by computing the number of weeks between (a) date of teledentistry visit and date of first in-person consultation with paediatric dentist and (b) date of first in-person consultation with paediatric dentist and date when treatment plan was completed, accounting for number of visits required to complete the treatment. Intensity of case-management services was constructed as the total number of CHWs’ contact attempts by telephone calls, letters and home visits, as well as transportation provided. Distance from the patients’ residence to the FLCH dental clinics where the teledentistry consultation occurred and EIOH in Rochester was computed as travel distance in miles between the two zip-code locations.

Key variables were analysed using descriptive statistics (i.e. frequency, percentage, mean and range). Associations between utilisation of follow-up oral-health services in general dentistry clinics and children’s sociodemographic characteristics (i.e. age, sex and race/ethnicity) as well as teledentistry service (i.e. travel distance to FLCH and treatment recommendation), case-management and clinical-outcome (i.e. treatment plan and timeliness of treatment) covariates were evaluated using Fisher’s exact test and the Mann–Whitney U-test.

Multivariable Poisson regression models with robust error variance were used to assess the adjusted associations (rate ratios (RR) and 95% conﬁdence intervals (95% CI)) of follow-up services at general dentistry clinics (i.e. number of follow-up visits) and intensity of case-management services (i.e. number of CHW–patient contacts) with treatment recommendation and timeliness of treatment initiation and completion (i.e. number of weeks), accounting for the number of weeks from the teledentistry consultation until the end of the study period.

Analyses were performed using SAS v9.4 (SAS Institute, Inc., Cary, NC). The two-tailed statistical significance level was defined as p < 0.05.

Results

Characteristics of study subjects

The current analysis included 144 children living in the Finger Lakes region of New York with a teledentistry consultation at one of the FLCH dental clinics located in Geneva, Newark, Ovid, Port Byron and Sodus (Figure 1).

Figure 1.

Finger Lakes Community Health general dentistry clinics where the study subjects had the live-video teledentistry consultation with a paediatric dental specialist located at the Eastman Institute for Oral Health in Rochester. Note: The counties bordered in black indicate the counties of residence of the children in the study.

The children in the study comprised 74 girls and 70 boys (Table 1). The age at the time of teledentistry consultation ranged from 2 to 10 years (M = 4.9 years), with 75% of children being younger than six years old at the time of the teledentistry consultation with a paediatric dental specialist. The majority were white (70.1%) and non-Hispanic (75.2%), and lived in a two-parent family (66.0%). Seventeen per cent of study children had a behavioural or developmental disorder. Overall, slightly more subjects who accessed follow-up oral-health services at the FLCH were girls, white, non-Hispanic and older, with no history of a behavioural or developmental disorder and were living in a two-parent family, although the differences were not statistically significant.

Table 1.

Characteristics of study subjects by utilisation of follow-up oral health services at one of the Finger Lakes Community Health (FLCH) general dentistry clinics.

Characteristics of study subjects	All children (N = 144)		Utilisation of follow-up oral-health services at the FLCH
	All children (N = 144)		Yes (N = 111)		No (N = 33)		p
	n	%	n	%	n	%	p
Sex							0.164
Girls	74	51.4%	61	55.0%	13	39.4%
Boys	70	48.6%	50	45.1%	20	60.6%
Age at the time of teledentistry consultation with a paediatric dental specialist (years)							0.214
Mean (range)	144	4.9 (2.0–10.0)	111	5.0 (2.0–10.0)	33	4.7 (2.0–9.0)
Race							0.830
White	101	70.1%	77	69.4%	24	72.7%
Other race^a	43	29.9%	34	30.6%	9	27.3%
Ethnicity							0.441
Hispanic	26	18.1%	22	19.8%	4	12.1%
Other ethnicity^b	118	81.9%	89	80.2%	29	87.9%
Living situation							0.296
Lives in two-parent family	95	66.0%	76	68.5%	19	57.6%
Lives with single parent, other^c	49	34.0%	35	31.5%	14	42.4%
Behavioural or developmental disorder^d							0.793
No	120	83.3%	93	83.8%	27	81.8%
Yes	24	16.7%	18	16.2%	6	18.2%

Fisher’s exact test and the Mann–Whitney U-test were used to compare categorical and continuous variables, respectively.

^aBlack, Asian, Native American, mixed race, other, refused.

^bOther, refused.

^cLives with grandparent or other guardian, foster parents, unknown.

^dAttention deficit/hyperactivity disorder, autism, speech delay, developmental delay, physical disability.

Teledentistry consultation and dental treatment with a paediatric dental specialist

Most of the study children were diagnosed with extensive early childhood caries at one of the FLCH primary-health or general dental clinics (84.0%), while a smaller proportion (16.0%) were found in school oral-health programmes visited by FLCH’s dental hygienists (Table 2). Travel distance from the children’s home to a FLCH dental clinic varied from 3 to 74 miles (M = 15.4 miles; median = 13.5 miles), with a quarter of children residing more than 20 miles from a FLCH dental clinic. Proportionally more children who utilised follow-up oral-health services were identified at a FLCH dental clinic and resided closer to that clinic than children who did not use follow-up services. However, the differences were not statistically significant.

Table 2.

Teledentistry consultation and dental treatment with a paediatric dental specialist by utilisation of follow-up oral-health services at one of the FLCH general dentistry clinics.

Teledentistry consultation and dental treatment covariates	All children (N = 144)		Utilisation of follow-up oral health services at the FLCH
	All children (N = 144)		Yes (N = 111)		No (N = 33)		p
	n	%	n	%	n	%	p
Place where child was first identified as needing intervention							0.175
Finger Lakes health or dental clinic	121	84.0%	96	86.5%	25	75.8%
School oral-health programme	23	16.0%	15	13.5%	8	24.2%
Travel distance to one of the FLCH general dentistry clinics (miles)							0.171
Mean (range)	144	15.4 (3.0–74.0)	111	14.6 (3.0–71.0)	33	17.9 (3.0–74.0)
Treatment recommendation							0.028
General anaesthesia in the operating room	103	71.5%	78	70.3%	25	75.8%
Administration of nitrous oxide	31	21.5%	28	25.2%	3	9.1%
Oral sedation, local anaesthesia, papoose	10	7.0%	5	4.5%	5	15.2%
Number of CHW–patient contacts^a							0.003
Mean (range)	144	17.9 (0.0–94.0)	111	15.5 (0.0–57.0)	33	25.7 (3.0–94.0)
Number of weeks for initiating the treatment							0.012
Mean (range)	137	10.8 (0.0–51.9)	107	9.1 (0.0–38.7)	30	17.0 (1.6–51.9)
Number of weeks for completing the treatment accounting for number of visits							0.020
Mean (range)	135	1.7 (0.0–34.4)	106	2.0 (0.0–34.4)	29	0.2 (0.0–3.9)
Travel distance to the paediatric dentist (miles)							0.165
Mean (range)	144	49.1 (19.0–90.0)	111	48.5 (19.0–90.0)	33	51.3 (23.0–81.0)
Number of follow-up visits
Mean (range)			111	2.2 (1.0–5.0)
Number of weeks between completing the treatment plan and the first follow-up visit
Mean (range)			107	19.0 (0.0–69.6)

Fisher’s exact test and the Mann–Whitney U-test were used to compare categorical and continuous variables, respectively. Bold font indicates statistically significant differences at the p < 0.05 level.

^aCHW–patient contacts by phone, letters or home visits or providing transportation.

CHW: community health worker.

The predominant treatment recommendation for the children as a result of the teledentistry consultation was general anaesthesia (71.5%), followed by nitrous oxide (21.5%) and oral sedation, local anaesthesia or a papoose board (7.0%; Table 2). Complex dental treatment under general anaesthesia is the treatment used for paediatric dental patients who are very young, need extensive treatment, have complex medical, physical or mental conditions, and/or need to travel long distances to receive specialty care, among other factors. Children who utilised follow-up services at a FLCH general dentistry clinic were significantly less likely to have had a treatment recommendation for general anaesthesia (70.3% vs. 75.8%) and more likely to have had one for nitrous oxide (25.2% vs. 9.1%) compared to children who did not use follow-up oral-health services at a local general dentistry clinic (p = 0.028).

Each of the study subjects identified for the teledentistry programme at FLCH was assigned to a CHW who contacted children’s families by phone (M = 16.6; range 0–84 calls), by letter (M = 1.1; range 0–11 letters) or in-home visits (M = 0.2; range 0–4 visits) or who provided transportation (n = 2 children) to ensure that all children received the needed dental care. During the study period, CHWs contacted each family an average of 17.9 times (Table 2). Children who used follow-up oral-health services required significantly fewer contacts by CHWs to complete the teledentistry consultation and/or dental treatment with a paediatric dentist than children who did not use follow-up services (M = 15.5 vs. 25.7 contacts; p = 0.003).

All children except one of the 144 in the study (99.3%) initiated dental treatment at the EIOH in Rochester, and 140 (97.2%) children completed the treatment plan. The number of weeks between the teledentistry consultation and the first in-person consultation with the paediatric dentist in Rochester was 10.8 weeks on average (Table 2). Children who used follow-up oral-health services at FLCH had significantly fewer weeks to dental treatment initiation at the EIOH than those who did not use follow-up services (M = 9.1 vs. 17.0 weeks; p = 0.012).

The number of visits required for completing the dental treatment plan varied from one to five visits, with a mean of 1.4 visits. The range in the number of weeks to complete the treatment plan accounting for the number of visits (i.e. average number of weeks per required visit) was within the same week up to 34.4 weeks (M = 1.7 weeks; Table 2). Children who used follow-up oral-health services at FLCH used significantly more weeks to complete the dental treatment per visit than those who did not use follow-up services (M = 2.0 vs. 0.2; p = 0.020).

The travel distance from the children’s homes to the EIOH in Rochester varied from 19 to 90 miles (M = 49.1 miles; Table 2). A quarter of children resided more than 58 miles from the paediatric dentist. Children who used follow-up oral-health services resided closer to the EIOH in Rochester than children who did not use such services. However, the difference was not statistically significant.

Utilisation of follow-up oral-health services at general dentistry clinics

The period from the teledentistry consultation until the end of the study period varied from 10 to 29 months, with a mean of 19 months. The majority of study children (n = 111; 77.1%) accessed follow-up oral-health services at one of the FLCH dental clinics, with one or more follow-up visits per year on average subsequent to a teledentistry consultation and treatment with a paediatric dental specialist.

Among the children who used follow-up oral-health services at one of the FLCH general dentistry clinics, the number of follow-up visits varied from one to five visits, with an average of 2.2 visits (Table 2). A quarter of children who used follow-up oral-health services had one follow-up visit, 50% of children had between one and three follow-up visits and 25% of children had three to five follow-up visits. The time between completing the treatment plan at the EIOH in Rochester and the first follow-up visit at the FLCH was 19 weeks on average (Table 2). A quarter of the study children had a first follow-up visit at one of the FLCH general dentistry clinics within one week or in less than three months from completing the dental treatment in Rochester. Half of children had a first follow-up visit in three to five months, and a quarter of children had a first follow-up visit more than five months later.

Predictors of utilisation of follow-up oral-health services at general dentistry clinics and intensity of case-management services

The number of follow-up oral-health visits at one of the FLCH general dentistry clinics was significantly lower in children requiring more intense case management (RR = 0.985; p = 0.013) and a longer time to initiate treatment at the EIOH in Rochester (RR = 0.972; p = 0.004) than children who required fewer contacts by CHWs and fewer weeks to initiate the dental treatment (Table 3). The results were adjusted for treatment recommendations, case-management services, timeliness of treatment and time from the teledentistry consultation until the end of the study period.

Table 3.

Predictors of utilisation of follow-up oral-health services at general dentistry clinics and intensity of case-management services at FLCH.

Predictors of follow-up oral-health services and intensity of case-management services	RR	95% CI		p
Number of follow-up oral-health visits at general dentistry clinics (Model 1)
Treatment recommendation				0.110
General anaesthesia in the operating room	0.825	0.622	1.094
Oral sedation, local anaesthesia, papoose	0.558	0.311	1.003
Administration of nitrous oxide	1.000	Reference
Number of CHW–patient contacts^a	0.985	0.973	0.997	0.013
Number of weeks for initiating the treatment	0.972	0.953	0.990	0.004
Number of weeks for completing the treatment accounting for number of visits	1.017	0.997	1.037	0.103
Number of CHW–patient contacts^a (Model 2)
Treatment recommendation				0.199
General anaesthesia in the operating room	0.819	0.605	1.109
Oral sedation, local anaesthesia, papoose	1.184	0.700	2.004
Administration of nitrous oxide	1.000	Reference
Number of weeks for initiating the treatment	1.025	1.014	1.035	<0.001
Number of weeks for completing the treatment accounting for number of visits	1.020	1.001	1.039	0.043

Adjusted association estimates using Poisson regression (RR, 95% CI) with robust variance error, adjusted to the other covariates in the model and accounting for the number of weeks from the teledentistry consultation until the end of the study period. Bold font indicates statistically significant associations at the p < 0.05 level.

^aCHW–patient contacts by phone, letters or home visits, or providing transportation.

RR: rate ratio; CI: confidence interval.

The intensity of case-management services increased significantly with the time to treatment initiation (RR = 1.025; p < 0.001) and completion (RR = 1.020; p < 0.043), after adjusting for treatment recommendations, case-management services and number of weeks from the teledentistry consultation until the end of the study period (Table 3). A one-week increase in the time to treatment initiation was associated with a 2.5% increase in the number of CHW–patient contacts. Similarly, a one-week increase in the time to treatment completion was associated with a 2.0% increase in the number of CHW–patient contacts.

Discussion

This research describes the demographic characteristics of children who received a specialty dental consultation via teledentistry and dental treatment services at a distant specialty dental clinic and subsequently used follow-up oral-health services at a general dentistry clinic. Each child in this study was identified as needing a consultation with a paediatric dentist because of extensive early childhood caries or because of a behavioural issue or special need that prevented a general dentist from effecting treatment.

Telehealth offers tremendous prospective benefits to transform the health-care delivery system by overcoming travel distance, enhancing access to care and building efficiencies.¹⁵,¹⁶ The National Quality Forum identified six areas for measurement in telehealth: travel, timeliness of care, actionable information, added value to provide evidence-based best practices, patient empowerment and care coordination.¹⁶ This study was able to measure several of these indicators.

Each child under study experienced a teledentistry consultation as the gateway to specialty dental care, and almost all (97.2%) ultimately completed a recommended treatment plan through in-person services at the EIOH in Rochester. Teledentistry consultations were synchronous, involving examination by a paediatric dentist via videoconferencing in real time. Results from this study correspond to earlier findings that teledentistry is an effective modality for accurately determining dental treatment plans.¹⁷ Tracking of teledentistry services by FLCH found that 94% of children who experienced a teledentistry consultation in one of their dental clinics between 2010 and 2015 eventually completed specialty treatment in Rochester.¹² McLaren et al. found similar compliance rates among children in the FLCH teledentistry programme who were referred to the EIOH’s specialty services.¹³ Prior to the use of teledentistry, FLCH recorded a lower completion rate for dental treatment among targeted children.¹²

Systematic reviews of the literature showed that teledentistry plays an important role in early diagnosis and treatment planning of dental caries in children, with an accuracy comparable to traditional in-person consultations.⁹,¹⁸,¹⁹ A majority of studies also evaluated the effectiveness of the teledentistry modality, reporting increased access to general and specialty dental care, particularly for rural and underserved populations, improved continuity and timeliness of care, cost savings and acceptability among providers and patients.⁹,¹⁹ The increasing availability of high-quality, cost-effective and innovative technology (i.e. smart phones and mobile devices, communication systems and applications and videoconferencing) is expected to enhance the use of teledentistry services that can lead to improvements in access to care and oral-health outcomes for patients.⁹

Severe early childhood caries (i.e. progressive pattern of dental caries) is associated with the demographic, socio-economic and travel characteristics of children’s families, nutritional preferences and practices, rural homes and other determinants of health.¹,²⁰ The study analyses found no significant differences by sex, race, ethnicity, age, living situation or the presence or absence of a behavioural disorder between the children who eventually used follow-up oral-health services and those who did not.

One outcome of interest was whether the study children who had significant caries experience at outset ultimately used follow-up oral-health services in one of the FLCH general dentistry clinics after specialty treatment at the EIOH. This study found that the majority of children (77.1%) used follow-up oral-health services at one of the FLCH general dentistry clinics. Other studies have also suggested that teledentistry screenings for oral disease are effective in promoting increased compliance with follow-up examinations and improved access to dental care.¹³

The apparent failure by families to seek follow-up dental services for some children who required treatment in the operating room (an indicator of case severity) and a greater number of contacts by CHWs was concerning. Children who did not return to an FLCH dental clinic may have used follow-up oral-health services at the EIOH. However, the authors were unable to verify this supposition. These data may indicate that parents who allowed dental conditions to progress to a significant level despite numerous contacts from CHWs are in need of improved oral-health literacy. The data also suggest that without the persistence of CHWs, these children were at risk for not receiving necessary services.

The results indicated that children who needed more time to accomplish dental treatment and had fewer follow-up visits required significantly more intense case-management services. The team-based approach to patient management at FLCH involving CHWs is intended to address the social determinants of health and health inequities, provide education, promote care-seeking behaviours and ultimately increase access to care.^21–23 The efficacy of these teams was validated by this research that found important positive effects of case-management interventions on treatment compliance.

This study has several limitations, and therefore the results are preliminary in nature. The limited number of study participants may have diminished the statistical power to detect modest effects. Data lags are also posing challenges for research studies that use electronic health-care data sources. The current study period was selected to ensure availability and validity of the relevant dental patient information which was compiled from multiple record-keeping systems. Completeness and adequacy of patient records and information extraction may have affected the study findings. However, any misclassification is expected to be similar across groups being compared, and thus any bias is likely towards the null hypothesis.

Conclusions

This study suggests that teledentistry consultations promoted access and utilisation of specialty oral-health care. The results indicate that case severity and compliance with treatment are predictors of utilisation of oral-health services in general dentistry clinics. The study findings also suggest that patient navigation and case-management interventions are important in facilitating specialty dental care, as well as follow-up care at community dental clinics, particularly in underserved rural communities with high rates of early childhood caries. One of the most valuable aspects of teledentistry is the potential for reducing health-care inequities that result from lack of access to specialists and to timely oral-health care.

Future research should evaluate the impact of teledentistry on reducing oral disease and increasing utilisation of preventive and routine oral-health services among population groups who may be more vulnerable to experiencing difficulties accessing oral-health care. A study of the long-term dental utilisation patterns of those children who experience a teledentistry consultation and a surgical intervention in early childhood would be instructive.

Footnotes

Acknowledgements

Special appreciation is extended to the leadership and staff of Finger Lakes Community Health who gave generously of their time and provided significant insight into the planning and data collection for this study, especially Ms Terry Yonker, Telemedicine Clinical Care Coordinator, Dr Tony Mendicino, Dental Director, Ms Sirene Garcia, Director of Special Programs, Ms Kathleen Dorety, Executive Assistant to CEO, Ms Carly Sisson, Patient Navigator/Teledental Care Coordinator, Ms Casey Castner, Ms Kimberly Johnson and Dr Sean McLaren of the Eastman Institute for Oral Health.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article: The research reported in this manuscript has been funded through the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under grant number U81HP27843.

ORCID iD

Simona Surdu

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