Care Plan Improvement in Nursing Homes: An Integrative Review

Abstract

Background: Care planning nowadays is a key activity in the provision of services to nursing home residents. A care plan describes the residents’ needs and the actions to address them, providing both individualized and standardized interventions and should be updated as changes in the residents’ conditions occur.

Objective: The aim of this review was to identify the core elements of the implementation of changes in nursing homes’ care plans, by providing an overview of the type of stakeholders involved, describing the implementation strategies used, and exploring how care plans changed.

Methods: An integrative literature review was used to evaluate intervention studies taking place in nursing homes. Data were collected from PubMed, CINHAL-EBSCO, and PsycINFO. English language articles published between 1995 and April 2015 were included. Data analysis followed the strategy of Knafl and Whittemore.

Results: Twenty-six articles were included. The stakeholders involved were professionals, family caregivers, and patients. Only a few studies directly involved residents and family caregivers in the quality improvement process. The implementation strategies used were technology implementation, audit, training, feedback, and supervision. The majority of interventions changed the residents’ care plans in terms of developing a more standardized care documentation that primarily focuses on its quality. Only some interventions developed more tailored care plans that focus on individualized needs.

Conclusion: Care plans generally failed in providing both standardized and personalized interventions. Efforts should be made to directly involve residents in care planning and provide professionals with efficient tools to report care goals and actions in care plans.

Keywords

Care plan elderly residents implementation nursing documentation nursing homes quality improvement stakeholders

INTRODUCTION

Care planning is considered to be a key activity in the provision of services to nursing home residents [1]. Elderly residents are often frail and have multiple disabilities and comorbidities that require specific treatment [2, 3]. Nowadays, long-term care (LTC) settings attempt to provide interdisciplinary and tailored care, acknowledging residents with and without cognitive impairment as unique, autonomous persons and try to involve them in care planning and delivery [4, 5]. The satisfaction of the older residents’ complex needs and the provision of both standardized and individualized support demands integrated care and a multidisciplinary approach. Thus, care planning becomes crucial to ensure a high level of quality in the care provided.

The goals of both the interdisciplinary care planning process and the written care plan include individualized care, continuity of care, and team communication [6]. However, it is important to distinguish between care planning and the actual care plan [7]. The former reflects the assessment process, in which residents’ needs and abilities are identified and care goals are set, whereas the latter describes how these needs will be met, indicating the actions required to reach the goals set and to evaluate their fulfillment. Ideally, a patient record delineates the patient’s journey from admission to discharge or death [8], describing his or her medical, nursing, mental, and psychosocial needs [9] and facilitating the information flow between healthcare professionals, ensuring the continuity, quality, and safety of care [10]. Furthermore, care plans need to be flexible and should be updated as changes in the residents’ condition occur [6]. However, nursing homes are not always effective at accomplishing such requirements. In fact, care plans often do not guide the delivery of daily care [11] and research suggests that there are discrepancies between the actions recorded in care plans and actual care delivery [12, 13]. Besides, residents’ nursing documentation frequently lacks completeness: an accurate assessment of the patients’ cognition is not always performed or documented despite it is essential in planning care, in order to make a reliable and individualized plan [14]. Moreover, albeit the person-centered approach is a recognized framework used to meet residents’ needs and to provide high quality dementia care in nursing homes, little emphasis is usually put on psychosocial aspects, indicating a lack of person-centeredness in nursing documentation [15]. This might not only affect the quality of care provided to residents, but also the costs the facilities have to bear [16]: it has been shown that high quality care programs may even cost less than poor quality improvement programs, as the latter are ineffective in planning, communicating, and coordinating care [17].

Quality improvement is stimulated in European and non-European countries by specific regulations and criteria to be met on care planning [6]. At policy level, many countries are promoting initiatives to improve care coordination and plans for common assessment schemes and evaluation by multidisciplinary teams to define care plans to be used in LCT settings [18]. Along with this, both clinical guidelines and regulations regarding comprehensive care plans [9, 19], as well as quality indicators that are used to measure nursing home residential care processes, have been developed [20].

Given the relevance of cost-effectiveness issues related to care coordination and planning in nursing homes, and considering the role that care plans play in such processes, it becomes crucial to understand how care plans can be improved and efficiently implemented in daily routine. In fact, implementation of programs or innovations is never easy [21], especially when they involve complex processes such as care planning. Changes in healthcare are the result of different factors that interact at different levels such as patients, professionals, and organizational and economic context [22]. The ideal model for change in healthcare includes both impact and process theories, which focus on the core elements that found the implementation of change. Impact theories describe how specific interventions facilitate the change as well as the factors and causes that contribute to it. Process theories include the organization, planning, schedule and use of the preferred implementation activities, and how the target groups are influenced by them [22]. Therefore, in order to describe the implementation of changes in nursing homes’ care plans, we focused on core elements such as the target groups involved, the implementation activities used, and the resulting changes.

Thus, the aim of this integrative review was to provide an overview of the type of stakeholders included in intervention studies concerning elderly residents’ care plans, to describe the implementation strategies used and to explore how care plans changed in terms of being more comprehensive, accurate, or individualized.

METHODS

Search strategy

The electronic databases PubMed, CINHAL-EBSCO, and PsycINFO were searched for English literature published between 1995 and April 2015. Key words used in the search were terms that described elderly residents’ care documentation (care plan elderly, nursing care plan, goals of care, health record, documentation) and the target settings (residential facility, nursing home). The search string is available in the Supplementary Material. Reference lists of the relevant journal articles were also reviewed.

Selection of studies

The review included studies of any design involving care plans of older people living in nursing homes. Few papers used the term medical record instead of care plan: only when it was clear that the record was comprehensive and contained all aspects of residents’ care and needs, were they included as well. Articles were included when they described the implementation of healthcare interventions that changed residents’ nursing care plans (1) by modifying the care plans’ framework, (2) by adding new tools to care plans (electronic and/or paper version), (3) by reporting the interventions’ outcomes into residents’ care plans. Articles were excluded when they described studies that (1) referred to a specific type of nursing documentation or care planning phase (e.g., fall care plans, medication monitoring care plans, discharge plans, advance care planning, etc.) with no indications that it was integrated into the residents’ comprehensive care plans, (2) were not intervention studies but focused only on the analysis of the care plans’ content, checking for accuracy or adherence, (3) did not take place in nursing homes for olderpeople.

We focused on care plans, regardless of type of residents’ disease. However, given our interest in dementia research, when the selected interventions also involved residents with dementia, this was specified in the studies’ description.

Data management and analysis

Based on the inclusion criteria just described, two authors (EM and RC) selected the relevant articles, independently screening titles and abstracts. When clear or sufficient information was not provided, the full text was reviewed. In particular, a data extraction form within Microsoft Excel was developed and filled with each paper’s relevant information: country, research methods, type and steps of the intervention, outcomes, implementation strategies used, and description of the resulting changes on care plans. The methodological framework specific to the integrative review method proposed by Whittemore and Knafl was used to summarize past empirical literature and to provide a better comprehensive understanding of the implementation of changes in nursing homes’ care plans [23]. Strategies for data analysis, as described by Whittemore and Knafl [23], were followed. Firstly, primary sources were divided into subgroups according to a logical system that facilitates analysis (data reduction). In fact, based on the type of intervention, two subgroups were identified. Secondly, data tables were elaborated and, starting from the specific implementation strategy used in each intervention study, codes were generated (data display). Thirdly, links were determined (data comparison) and codes were combined in categories. Table 1 provides an overview of the codes and categories identified. Eventually findings were summarized into a new conceptualization of the topic (conclusion drawing and verification) describing the overall impact of the implementation strategies identified on the residents’ care plans.

Methodological assessment quality

The quality of included publications was assessed using Mixed Method Appraisal Tool (MMAT) version 2011, designed for the appraisal stage of complex systematic literature reviews that include qualitative, quantitative, and mixed methods studies [24]. The overall qualitative score of each retained study is presented using the MMAT descriptors, i.e., the number of stars obtained by applying the tool (Table 2). Scores can vary from 25% (*), when one methodological quality criterion is met, to 100% (****) when all criteria are met.

RESULTS

Using the mentioned exclusion and inclusion criteria, 26 studies were identified and included in the present review (Fig. 1). Two of these were qualitative, three mixed-methods, and 21 quantitative. Table 2 provides an overview of the characteristics of included studies and the related MMAT scores. Studies were conducted in both non-European (USA, Australia, Taiwan, Japan, Brazil) as well as European countries (The Netherlands, Sweden, UK, Norway).

Applying the methodological framework by Whittemore and Knafl [23], we identified two subgroups based on the type of intervention: the stakeholders involvement interventions subgroup, which includes interventions that imply the direct involvement of stakeholders (i.e., healthcare professionals, residents, and family carers) in the quality improvement process, and the professional-oriented interventions subgroup, which includes interventions targeted at professionals, to provide them with tools or support during the process (e.g., education, feedback, audit). Within these subgroups, seven categories were identified: three (professional care providers, care providers and family caregivers, and patients involvement) pertaining to the first subgroup and four (ICT implementation, audit, training, feedback and supervision) to the second one. Then, following the three aims that guided the present review, each intervention was described by specifying the core elements of the implementation of changes in nursing home residents’ care plans, that is the type of stakeholders involved, the implementation strategies used and how care plans changed, checking whether they resulted in being more comprehensive, accurate or individualized.

Stakeholders involvement interventions

Professional care providers’ involvement

As described in Table 1, this category includes those studies in which care providers participated in the quality improvement process. Three papers [25 –27] belong to this category. Studies by Teresi et al. [25] and Hampton et al. [26] aimed to improve documentation and care provision of the targeted problem. The first study aimed to train staff on how to prevent episodes of resident-to-resident mistreatment describing risk factors, such as dementia. The second one aimed to decrease antipsychotic medication occurrences by preventing and predicting disruptive behaviors that may occur in residents with dementia (Table 2). They both delineated the process through which staff, by means of team meetings or coordinated work, developed and implemented a different care approach that resulted in better care documentation. The study by Teresi et al. showed a significant increase in the reporting of the targeted problem by staff (p < 0.001), whereas Hampton et al. did not collect data on reporting but described the supplement form developed to enhance the residents’ care plan. However, the methodological quality of these interventions, as measured by the MMAT, was moderate (**) and low (*), respectively. The staff involved in the third study [27] supported the development and implementation of a completely new care plan, which was aimed to reflect all care aspects and needs of residents. Yet, no information was provided on whether and how the new model was implemented in the investigated nursing home and no criteria of the MMAT were met (Table 2).

Professional care providers and family caregivers’ involvement

The studies included in this category described the collaboration between care providers and family carers to improve specific care aspects. Specifically, two studies [28, 29] actively involved both professionals and family caregivers in the improvement process. The first one [28], in order to promote family participation in care planning, involved family carers in care plan meetings that were usually organized and attended only by the staff responsible for the treatment and care of residents. However, it was not reported exactly how care plans changed after the intervention. Only the nurses’ perception about the strengthening of their roles in the development of residents’ care plans and the doubts of family carers on the implementation into the plans of the issues discussed during the meetings were reported. The second one [29] studied the effect of the implementation of a standardized registration method to be used with patients for whom the dying phase had started. The method required an assessment by both nurses and relatives on documentation, symptom burden, and communication between patients, professional caregivers, and family. Documentation of care during the dying phase increased in all involved settings, showing that some aspects of care were significantly more often documented in the intervention period (p < 0.05). Both papers had good methodological quality parameters (***).

Patients’ involvement

This category includes studies that actively involved not only staff and family caregivers, but also the elderly persons themselves. In fact, five papers [30, 34] described interventions in which the improvement process was also based on the residents’ inputs by observing or interviewing them, or by directly involving them in the care planning process. The latter case occurred in the study by Boorsma et al. [30] that depicted the implementation of a multidisciplinary integrated care model to guide the design of individualized care plans. The plans developed were then adapted to personal whishes by discussing it with the resident, the family carers as well as the general practitioner. The majority of the involved residents were affected by cognitive impairment (58.2%). Content analysis of care plans was performed: it emerged a significant improvement in the reporting of the number of actions on care plans and in the quality of care provided as perceived by the residents themselves (p = 0.07). The other three papers [31 –33] described the implementation of tools or care models that required direct observations of or interviews with residents. Such approaches were used to obtain information to address specific problems or care areas (medication monitoring for people with dementia, managing behavioral and psychological symptoms of dementia, and improving the quality of life of nursing home residents, respectively) and consequently to develop individualized care plans. All interventions reported the number of the new individualized care plans developed and put in place. However, one paper did not provide specific information on the care plan assessment [32]. Another intervention [34] used the function of storytelling to be incorporated in the care plan to make it more meaningful for the resident. It introduced a qualitative case study and the adaptation of the care plan based on the residents’ personal information. However, it is important to underline the apparent lack of quality of these intervention studies. In fact, only two of them [30, 31] obtained a very high methodological quality score (****), one study [33] a low score (*), and the remaining two [32, 34] did not meet any MMAT methodological quality criteria.

Professional-oriented interventions

Implementation of information and communication technology tools

Seven studies implemented Information and Communication Technology (ICT) tools [35 –41]. All studies but one [39] specified that the main implementation strategy used was the provision of education targeted at staff to instruct them on how to use ICT tools.

Three studies [35 –37] described the implementation of a new computerized documentation system and compared it with the previously hand-written procedures. Munysia et al. [35] revealed a lack of time-saving for staff in using the new systems that hindered realization of documentation efficiency: twelve months after implementation, the proportion of time spent by caregivers on documentation was significantly higher than when the paper-based system was used (p < 0.01). Equally, Daly et al. [36] showed that the new computerized care plan took longer to be completed. However, the implementation of the system resulted in the improvement of care documentation’s comprehensiveness, as a significant effect was found in the experimental computerized care plan group in relation to nursing interventions and activities listed (p = 0.001 and p = 0.007). On the other hand, Shu-Hui et al. [37] showed that nurses saved time in preparing the computerized documentation, as they were able to complete a more comprehensive care plan within 48 hours after admission, and that they were significantly satisfied in relation to completeness (p = 0.006), organization (p = 0.004), and consistency (p = 0.01) of the nursing records. The remaining studies [38 –41] embedded an ICT tool into the existing care plan format or reporting system. In three studies, the tool implementation positively resulted in a more complete documentation [38 –40]. Specifically Fossum et al. [38] analyzing the effects of a computerized decision-support system on residents’ pressure ulcers and malnutrition, showed a significant increase in the number of related care indicators reported in the records (p = 0.02 and p = 0.002, respectively). Similarly, Wagner et al. [39], which also involved residents with dementia (64.7%), showed that the implementation of the falls incident reporting system resulted in more complete documentation (p < 0.001). Yet, contrary to the other studies included in this category that identified staff education as the main strategy to embed the systems in the care homes, this one just described that the form was routed to the care planning nurse to update the residents’ care plans. Hansebo et al. [40] implemented the Resident Assessment Instrument/Minimum Data Set in nursing home wards that housed patients with dementia. The tool gave a comprehensive assessment of the resident and increased the percentage of daily notes and nursing care plans, but aspects such as psychosocial well-being, activities, mood, and behavior were still infrequently reported [40]. However, in these studies no specific information on how extensively the staff used the ICT device could be retrieved. Another study [41], in which a computerized algorithms for geriatric problems was developed and tested, revealed that the ICT tool was used infrequently by nursing home providers during daily practice except for falls, even if they all agreed that it improved patients’ care and saved time. Many involved residents were affected by cognitive impairment (55.4%). The overall methodological quality of these papers, as measured by MMAT, varied from moderate to very high (scoring from ** to ***).

Audit as a guide for the improvement process

In four studies [42 –45], auditing was used not only as a tool to assess the effects of the intervention, but also as a model to guide the improvement process. All papers contained the scheme or the reference to the audit tool used within the nursing homes and the description of the following implementation process that introduced changes via care plans. In particular, three studies [42 –44] used audit tools to guide the implementation of best practices in the provision of care. In the study by Fallon et al. [42], staff were trained in the use of audit tools designed to be administered directly to residents with dementia in the pre intervention phase with the aim to implement oral health recommendations: care plans were rated after the intervention and appeared to be of better quality and more comprehensive in one facility (p < 0.001) but not in the other one. Yet, this result should be considered with caution as, unlike the other studies of this category, the methodological score of this intervention is low (*). On the other hand, in the other two studies [43, 44], audit tools were used pre and post intervention to determine the level of compliance with the audit criteria in care plans in relation to physical restraint use and continence management, respectively. Both studies involved residents with dementia. Findings were controversial, as the level of compliance varied across criteria or involved settings due to management and organizational issues. One purpose of the quality improvement project described by Watson-Wolfe et al. [45] was to test the utility of an educational in-service to facilitate the use of antipsychotic in dementia that was guided by an audit tool commonly used in LTC practice: an increase in the percentage of nursing documentation of non-pharmacological interventions was shown.

Training on documenting and reporting

The papers included in this category [46, 47] presented the implementation of nursing models that included specific training on how to document and report residents’ information into care plans. Both studies concerned written procedures, not computerized ones, and respectively had moderate (**) and very high methodological quality (****). In one study [46] that aimed to describe the effects of an educational training on care documentation’s content and comprehensiveness, significant improvements were shown, with increased numbers of: notes, nursing diagnosis, status, goals, outcomes, interventions planned and implemented, and discharge notes (p varies from <0.0001 to = 0.05). However, the content of the records usually reflected the nurses’ judgment rather than the residents’ description of symptoms. This was attributed to the language impairment that affected some of the involved residents, in particular those suffering from dementia. In contrast to these findings, the second paper [47], where the educational training on the use of an emotion-oriented approach in the care for residents with dementia also addressed the system of reporting and style of writing, did not observe any differences between intervention and control homes, as reports were still brief and incomplete.

External feedback and supervision

Three intervention studies [48 –50] addressed feedback and supervision by appointing external professionals to give support to staff members involved in the quality improvement project. In the project by Rask et al. [48] on the implementation of a fall management program, staff attended an intensive training and a geriatric nurse practitioner and a nurse educator gave support to the facilities through monthly teleconferences during program implementation. The implementation strategy used seemed to be effective, as care process documentation significantly improved in many aspects (p varies according to the aspect of care documentation considered). Nurse educators were also involved in the study by Goldman et al. [49], which aimed to implement three best practice protocols (prevention of decline in the activities of daily living of eating and dressing; recognition of pain symptoms especially in cognitive impaired residents or with communication difficulties; depression). Educators acted as consultants, observing pattern of communication and providing feedback, suggestions, or concerns related to care plans. It emerged that the program led to a more sensitive care planning, but no detailed information on care plans was provided. In another study [50], the implementation of a new care planning system included consultation, advice, and support from external colleagues and experts. After the intervention, all nursing homes involved in the project turned out to produce more informative nursing records, but no specific data could be retrieved in the paper. Only one study [48] fulfilled all quality criteria as defined by the MMAT (***), whereas the other two did not meet them.

DISCUSSION

This integrative review in which 26 articles were included showed that professional care providers, family caregivers, and patients were involved in studies concerning elderly residents’ care plans. However, in only five of the included studies [30 –34] were residents directly involved in the quality improvement process and the family caregivers in only two[28, 29].

The majority of studies [25–27 , 36–50] used more than one strategy, such as staff education to the introduction of ICT tools, staff, families, and patients involvement in the care planning process, external feedback, supervision, and audit tools to implement the interventions in nursing homes. All these studies focused on the quality of care documentation, indicating that after the intervention was implemented, care plans were more informative, complete, and updated. Specifically, the improvement in the care process documentation consisted of an increase in the number of items listed, such as care goals, medication charts, activities, progress and daily notes or, possibly, the revision of the information reported. Thus, these interventions complied with specific care planning requirements and guidelines, as documentation must be accurate, complete, provide evidence of the care given and document changes in the resident’s condition [51]. To assess such quality of care documentation, interventions were guided by measurable objectives or quality indicators that could be easily identified and retrieved in the care plans. Similarly, interventions in which the improvement process were guided by specific audit tools and that assessed whether the newly developed care plans met specific criteria, demonstrated increased levels of compliance with documentation and with organizational criteria and the improvement in the implementation of nursing best practices [42 –45].

Four studies used implementation strategies that required the direct involvement of residents [32 –34] and of all stakeholders at the same time, i.e., residents, family caregivers, and professionals [30]. These studies referred to the post-intervention care plans as being more individualized, that is, based on the resident’s personal characteristics, experiences, and needs. Consistent with the vision of person-centered care that focuses on individuality and care being organized to meet the person’s needs [52], these interventions aimed to develop care plans that reflected the residents’ personal history, habits in the residential setting, and wishes. It is important to highlight that these studies shared the same implementation strategy: in fact, they all involved the residents in the care planning process by observing or interviewing them. Yet, only one of these interventions [30] showed a higher number of actions listed in the new individualized care plan developed. The others [32 –34] were less specific, delineating the general care areas addressed in the personalized plan. This issue also accounts for their lower methodological quality score.

Only four studies seemed to be not effective: two of them referred to the implementation of ICT tools [35, 41] showing a lack of documentation efficiency by using the computerized system and its infrequent use by staff, respectively. This is in line with recent literature on the adoption of electronic health records, which identifies the disruption of clinical practice and the staff acceptance as major limits to their implementation [53, 54]. Despite this evidence, it is interesting to note that only three studies [35 , 41] administered specific questionnaires or surveys to assess staff satisfaction about the implementation of the ICT tools. Another intervention [47] that aimed to implement a new care model and reporting system, showed no clear differences in the content of the residents’ reports, that appeared to be still brief and incomplete. Different staff expectations and organizational obstacles were cited as the main barriers to the implementation of the intervention. Eventually, due to the change of the setting’s organizational policy, one site involved in an intervention study showed no compliance with specific care plans’ criteria [43]. Thus, it emerged that obstacles related to the organizational context were the main reasons for interventions not being effective in changing care plans. Specifically, staff constraints and change at the policy or management level occurred during the interventions.

Indicators for the quality of care provided in LTC settings highlight the importance of involving the older persons with and without cognitive impairment in the assessment of their preferences and needs as well as reporting in their care plan tailored interventions together with usual and standardized care [20 , 56]. However, only few papers explicit the direct involvement of the residents in the care planning process as well as the sharing of the care plan between the resident, the professional, and the family caregiver. Furthermore, all interventions analyzed in the present review that also included persons with dementia, did not make any distinction between the care plans of cognitively intact and impaired residents. This is in line with the fact that the care plan’s format is traditionally the same for both groups of nursing home residents. Only one study [46] underlined that due to cognitive deficits, the care plans’ content of residents with dementia reflected the nurses’ observation and judgment rather than the residents’ description of symptoms. Considering that the demand for LTC services for people with dementia is increasing worldwide and that international recommendations promote the delivery of an adequate long-term care plan in order to ensure a good quality of life throughout the dementia journey, it becomes crucial to involve cognitive impaired residents, who are the majority of clients of these services, and to develop care plans that accurately describe their special needs [57].

Another finding is that when studies focus on the reporting of residents’ personal needs and wishes in their care plans, their methodological score is often not high, due to the lack of measurable items to be retrieved in the tailored documentation. This is in line with the finding that there is more evidence on professional-oriented interventions than on those interventions that involve patients or the organization [22]. Furthermore, it seems that no identification of barriers and facilitators had been performed prior to the implementation of the quality improvement interventions, even if it is a fundamental prerequisite for effective initiatives to changing clinical practice[58, 59].

Strengths and limitations

This review can be used by both clinicians and researchers to inform future interventions and research on the improvement of care plans, identifying effective implementation strategies and key elements that may influence the process. However, some limitations should be taken into account. First, our aim was to present an overview of the type of stakeholders involved and implementation strategies used, without assessing effects estimates or risk of bias in included studies. As a result, the effects of the interventions just described should be interpreted with caution. Secondly, as typical for an integrative review, the studies identified and discussed are heterogeneous, addressing different medical, psychosocial, and organizational conditions. However, we were only interested in the implementation strategies used and how they changed care plans.

CONCLUSION

The care plan document should provide both individualized and standardized interventions. However, our findings showed that quality improvement projects in nursing homes often did not meet such care plans requirements. Thus, efforts should be made to develop standardized documentation that it is also tailored to the resident’s cognitive functioning, needs, and personal wishes and that can be reported in the care plans as measurable items such as quality indicators. This can be done by both directly involving the residents in the care planning process and adopting implementation strategies and tools which guide professionals to efficiently reporting the care goals and actions in the residents’ care plan. This would allow care plans to be more informative and individualized at the same time and research interventions to be more methodologically robust. Furthermore, considering that the main barriers to the improvement projects were obstacles related to the organizational context and to a lack of satisfaction by professionals about the tools implemented, it seems necessary to involve both the staff and the management to effective change care plans and improve the care planning process.

Footnotes

ACKNOWLEDGMENTS

The study has received funding from the European Union’s Seventh Framework Programme FP7/2007-2013 under grant agreement n°258883. We thank all participating researchers and services involved in the IMPACT consortium for their support.

Authors’ disclosures available online ().

Appendix

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