Effect of an Incentive Spirometer Patient Reminder After Coronary Artery Bypass Grafting: A Randomized Clinical Trial
IMPORTANCE: Incentive spirometers (ISs) were developed to reduce atelectasis and are in widespread clinical use. However, without IS use adherence data, the effectiveness of IS cannot be determined. OBJECTIVE: To evaluate the effect of a use-tracking IS reminder on patient adherence and clinical out...
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| creator | Eltorai, Adam E. M Baird, Grayson L Eltorai, Ashley Szabo Healey, Terrance T Agarwal, Saurabh Ventetuolo, Corey E Martin, Thomas J Chen, Jane Kazemi, Layla Keable, Catherine A Diaz, Emily Pangborn, Joshua Fox, Jordan Connors, Kevin Sellke, Frank W Elias, Jack A Daniels, Alan H |
| description | IMPORTANCE: Incentive spirometers (ISs) were developed to reduce atelectasis and are in widespread clinical use. However, without IS use adherence data, the effectiveness of IS cannot be determined. OBJECTIVE: To evaluate the effect of a use-tracking IS reminder on patient adherence and clinical outcomes following coronary artery bypass grafting (CABG) surgery. DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial was conducted from June 5, 2017, to December 29, 2017, at a tertiary referral teaching hospital and included 212 patients who underwent CABG, of whom 160 participants were randomized (intent to treat), with 145 completing the study per protocol. Participants were stratified by surgical urgency (elective vs nonelective) and sex (men vs women). INTERVENTIONS: A use-tracking, IS add-on device (SpiroTimer) with an integrated use reminder bell recorded and timestamped participants’ inspiratory breaths. Patients were randomized by hourly reminder “bell on” (experimental group) or “bell off” (control group). MAIN OUTCOMES AND MEASURES: Incentive spirometer use was recorded for the entire postoperative stay and compared between groups. Radiographic atelectasis severity (score, 0-10) was the primary clinical outcome. Secondary respiratory and nonrespiratory outcomes were also evaluated. RESULTS: A total of 145 per-protocol participants (112 men [77%]; mean age, 69 years [95% CI, 67-70]; 90 [62%] undergoing a nonelective procedure) were evaluated, with 74 (51.0%) in the bell off group and 71 (49.0%) in the bell on group. The baseline medical and motivation-to-recover characteristics of the 2 groups were similar. The mean number of daily inspiratory breaths was greater in bell on (35; 95% CI, 29-43 vs 17; 95% CI, 13-23; P |
| doi_str_mv | 10.1001/jamasurg.2019.0520 |
| format | Article |
| fullrecord | <record><control><sourceid>proquest_pubme</sourceid><recordid>TN_cdi_pubmedcentral_primary_oai_pubmedcentral_nih_gov_6583822</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><ama_id>2730077</ama_id><sourcerecordid>2266331521</sourcerecordid><originalsourceid>FETCH-LOGICAL-a356t-46188c166d969d4a381836163bbfdaf1dee668cb9b544d7ac81a3ab81d1e89063</originalsourceid><addsrcrecordid>eNpdkU9r3DAQxU1paUKaL5BDEfTSy241ki3LPRQ2S_5BoCVNz2JsSVsttrSV7MD201dmk6WtLpJmfm94wyuKC6BLoBQ-bXHANMXNklFolrRi9FVxykDIhWCCvT6-q_KkOE9pS_ORlJa8eVuccNqIhnN2WkxX1ppuJMES9OTOd8aP7smQ7zsXw2BGE8k3HF2ukgczOK9zYWXn8jrE4DHuySrm755c7neYErmJaEfnN5_Jijyg12Fwv40m695512FPHqPD_l3xxmKfzPnzfVb8uL56XN8u7r_e3K1X9wvklRgXpQApOxBCZ7u6RC5BcgGCt63VaEEbI4Ts2qatylLX2ElAjq0EDUY2VPCz4sth7m5qB6Pn5SL2ahfdkJ2rgE792_Hup9qEJyUqySVjecDH5wEx_JpMGtXgUmf6Hr0JU1KM0RoEharM6If_0G2Yos_rZUoIzqFikCl2oLoYUorGHs0AVXOw6iVYNQer5mCz6P3faxwlLzFm4OIAZO2xy2pOaV3zPxmfqhA</addsrcrecordid><sourcetype>Open Access Repository</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype><pqid>2266331521</pqid></control><display><type>article</type><title>Effect of an Incentive Spirometer Patient Reminder After Coronary Artery Bypass Grafting: A Randomized Clinical Trial</title><source>MEDLINE</source><source>American Medical Association Journals</source><source>Alma/SFX Local Collection</source><creator>Eltorai, Adam E. M ; Baird, Grayson L ; Eltorai, Ashley Szabo ; Healey, Terrance T ; Agarwal, Saurabh ; Ventetuolo, Corey E ; Martin, Thomas J ; Chen, Jane ; Kazemi, Layla ; Keable, Catherine A ; Diaz, Emily ; Pangborn, Joshua ; Fox, Jordan ; Connors, Kevin ; Sellke, Frank W ; Elias, Jack A ; Daniels, Alan H</creator><creatorcontrib>Eltorai, Adam E. M ; Baird, Grayson L ; Eltorai, Ashley Szabo ; Healey, Terrance T ; Agarwal, Saurabh ; Ventetuolo, Corey E ; Martin, Thomas J ; Chen, Jane ; Kazemi, Layla ; Keable, Catherine A ; Diaz, Emily ; Pangborn, Joshua ; Fox, Jordan ; Connors, Kevin ; Sellke, Frank W ; Elias, Jack A ; Daniels, Alan H</creatorcontrib><description>IMPORTANCE: Incentive spirometers (ISs) were developed to reduce atelectasis and are in widespread clinical use. However, without IS use adherence data, the effectiveness of IS cannot be determined. OBJECTIVE: To evaluate the effect of a use-tracking IS reminder on patient adherence and clinical outcomes following coronary artery bypass grafting (CABG) surgery. DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial was conducted from June 5, 2017, to December 29, 2017, at a tertiary referral teaching hospital and included 212 patients who underwent CABG, of whom 160 participants were randomized (intent to treat), with 145 completing the study per protocol. Participants were stratified by surgical urgency (elective vs nonelective) and sex (men vs women). INTERVENTIONS: A use-tracking, IS add-on device (SpiroTimer) with an integrated use reminder bell recorded and timestamped participants’ inspiratory breaths. Patients were randomized by hourly reminder “bell on” (experimental group) or “bell off” (control group). MAIN OUTCOMES AND MEASURES: Incentive spirometer use was recorded for the entire postoperative stay and compared between groups. Radiographic atelectasis severity (score, 0-10) was the primary clinical outcome. Secondary respiratory and nonrespiratory outcomes were also evaluated. RESULTS: A total of 145 per-protocol participants (112 men [77%]; mean age, 69 years [95% CI, 67-70]; 90 [62%] undergoing a nonelective procedure) were evaluated, with 74 (51.0%) in the bell off group and 71 (49.0%) in the bell on group. The baseline medical and motivation-to-recover characteristics of the 2 groups were similar. The mean number of daily inspiratory breaths was greater in bell on (35; 95% CI, 29-43 vs 17; 95% CI, 13-23; P < .001). The percentage of recorded hours with an inspiratory breath event was greater in bell on (58%; 95% CI, 51-65 vs 28%; 95% CI, 23-32; P < .001). Despite no differences in the first postoperative chest radiograph mean atelectasis severity scores (2.3; 95% CI, 2.0-2.6 vs 2.4; 95% CI, 2.2-2.7; P = .48), the mean atelectasis severity scores for the final chest radiographs conducted before discharge were significantly lower for bell on than bell off group (1.5; 95% CI, 1.3-1.8 vs 1.8; 95% CI, 1.6-2.1; P = .04). Of those with early postoperative fevers, fever duration was shorter for bell on (3.2 hours; 95% CI, 2.3-4.6 vs 5.2 hours; 95% CI, 3.9-7.0; P = .04). Having the bell turned on reduced noninvasive positive pressure ventilation use rates (37.2%; 95% CI, 24.1%-52.5% vs 19.2%; 95% CI, 10.2%-33.0%; P = .03) for participants undergoing nonelective procedures. Bell on reduced the median postoperative length of stay (7 days; 95% CI, 6-9 vs 6 days; 95% CI, 6-7; P = .048) and the intensive care unit length of stay for patients undergoing nonelective procedures (4 days; 95% CI, 3-5 vs 3 days; 95% CI, 3-4; P = .02). At 6 months, the bell off mortality rate was higher than bell on (9% vs 0%, P = .048) for participants undergoing nonelective procedures. CONCLUSIONS AND RELEVANCE: The incentive spirometer reminder improved patient adherence, atelectasis severity, early postoperative fever duration, noninvasive positive pressure ventilation use, ICU and length of stay, and 6-month mortality in certain patients. With the reminder, IS appears to be clinically effective when used appropriately. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02952027</description><identifier>ISSN: 2168-6254</identifier><identifier>EISSN: 2168-6262</identifier><identifier>DOI: 10.1001/jamasurg.2019.0520</identifier><identifier>PMID: 30969332</identifier><language>eng</language><publisher>United States: American Medical Association</publisher><subject>Aged ; Clinical trials ; Coronary Artery Bypass - adverse effects ; Coronary Artery Disease - surgery ; Female ; Follow-Up Studies ; Heart surgery ; Humans ; Incidence ; Intensive Care Units ; Male ; Online First ; Original Investigation ; Patient Compliance ; Postoperative Complications - diagnosis ; Postoperative Complications - epidemiology ; Postoperative Complications - prevention & control ; Pulmonary Atelectasis - diagnosis ; Pulmonary Atelectasis - epidemiology ; Pulmonary Atelectasis - prevention & control ; Radiography ; Retrospective Studies ; Spirometry - methods ; Survival Rate - trends ; United States - epidemiology</subject><ispartof>Archives of surgery (Chicago. 1960), 2019-07, Vol.154 (7), p.579-588</ispartof><rights>Copyright American Medical Association Jul 2019</rights><rights>Copyright 2019 American Medical Association. All Rights Reserved.</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><cites>FETCH-LOGICAL-a356t-46188c166d969d4a381836163bbfdaf1dee668cb9b544d7ac81a3ab81d1e89063</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://jamanetwork.com/journals/jamasurgery/articlepdf/10.1001/jamasurg.2019.0520$$EPDF$$P50$$Gama$$H</linktopdf><linktohtml>$$Uhttps://jamanetwork.com/journals/jamasurgery/fullarticle/10.1001/jamasurg.2019.0520$$EHTML$$P50$$Gama$$H</linktohtml><link.rule.ids>64,230,314,776,780,881,3326,27903,27904,76236,76239</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/30969332$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Eltorai, Adam E. M</creatorcontrib><creatorcontrib>Baird, Grayson L</creatorcontrib><creatorcontrib>Eltorai, Ashley Szabo</creatorcontrib><creatorcontrib>Healey, Terrance T</creatorcontrib><creatorcontrib>Agarwal, Saurabh</creatorcontrib><creatorcontrib>Ventetuolo, Corey E</creatorcontrib><creatorcontrib>Martin, Thomas J</creatorcontrib><creatorcontrib>Chen, Jane</creatorcontrib><creatorcontrib>Kazemi, Layla</creatorcontrib><creatorcontrib>Keable, Catherine A</creatorcontrib><creatorcontrib>Diaz, Emily</creatorcontrib><creatorcontrib>Pangborn, Joshua</creatorcontrib><creatorcontrib>Fox, Jordan</creatorcontrib><creatorcontrib>Connors, Kevin</creatorcontrib><creatorcontrib>Sellke, Frank W</creatorcontrib><creatorcontrib>Elias, Jack A</creatorcontrib><creatorcontrib>Daniels, Alan H</creatorcontrib><title>Effect of an Incentive Spirometer Patient Reminder After Coronary Artery Bypass Grafting: A Randomized Clinical Trial</title><title>Archives of surgery (Chicago. 1960)</title><addtitle>JAMA Surg</addtitle><description>IMPORTANCE: Incentive spirometers (ISs) were developed to reduce atelectasis and are in widespread clinical use. However, without IS use adherence data, the effectiveness of IS cannot be determined. OBJECTIVE: To evaluate the effect of a use-tracking IS reminder on patient adherence and clinical outcomes following coronary artery bypass grafting (CABG) surgery. DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial was conducted from June 5, 2017, to December 29, 2017, at a tertiary referral teaching hospital and included 212 patients who underwent CABG, of whom 160 participants were randomized (intent to treat), with 145 completing the study per protocol. Participants were stratified by surgical urgency (elective vs nonelective) and sex (men vs women). INTERVENTIONS: A use-tracking, IS add-on device (SpiroTimer) with an integrated use reminder bell recorded and timestamped participants’ inspiratory breaths. Patients were randomized by hourly reminder “bell on” (experimental group) or “bell off” (control group). MAIN OUTCOMES AND MEASURES: Incentive spirometer use was recorded for the entire postoperative stay and compared between groups. Radiographic atelectasis severity (score, 0-10) was the primary clinical outcome. Secondary respiratory and nonrespiratory outcomes were also evaluated. RESULTS: A total of 145 per-protocol participants (112 men [77%]; mean age, 69 years [95% CI, 67-70]; 90 [62%] undergoing a nonelective procedure) were evaluated, with 74 (51.0%) in the bell off group and 71 (49.0%) in the bell on group. The baseline medical and motivation-to-recover characteristics of the 2 groups were similar. The mean number of daily inspiratory breaths was greater in bell on (35; 95% CI, 29-43 vs 17; 95% CI, 13-23; P < .001). The percentage of recorded hours with an inspiratory breath event was greater in bell on (58%; 95% CI, 51-65 vs 28%; 95% CI, 23-32; P < .001). Despite no differences in the first postoperative chest radiograph mean atelectasis severity scores (2.3; 95% CI, 2.0-2.6 vs 2.4; 95% CI, 2.2-2.7; P = .48), the mean atelectasis severity scores for the final chest radiographs conducted before discharge were significantly lower for bell on than bell off group (1.5; 95% CI, 1.3-1.8 vs 1.8; 95% CI, 1.6-2.1; P = .04). Of those with early postoperative fevers, fever duration was shorter for bell on (3.2 hours; 95% CI, 2.3-4.6 vs 5.2 hours; 95% CI, 3.9-7.0; P = .04). Having the bell turned on reduced noninvasive positive pressure ventilation use rates (37.2%; 95% CI, 24.1%-52.5% vs 19.2%; 95% CI, 10.2%-33.0%; P = .03) for participants undergoing nonelective procedures. Bell on reduced the median postoperative length of stay (7 days; 95% CI, 6-9 vs 6 days; 95% CI, 6-7; P = .048) and the intensive care unit length of stay for patients undergoing nonelective procedures (4 days; 95% CI, 3-5 vs 3 days; 95% CI, 3-4; P = .02). At 6 months, the bell off mortality rate was higher than bell on (9% vs 0%, P = .048) for participants undergoing nonelective procedures. CONCLUSIONS AND RELEVANCE: The incentive spirometer reminder improved patient adherence, atelectasis severity, early postoperative fever duration, noninvasive positive pressure ventilation use, ICU and length of stay, and 6-month mortality in certain patients. With the reminder, IS appears to be clinically effective when used appropriately. 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M ; Baird, Grayson L ; Eltorai, Ashley Szabo ; Healey, Terrance T ; Agarwal, Saurabh ; Ventetuolo, Corey E ; Martin, Thomas J ; Chen, Jane ; Kazemi, Layla ; Keable, Catherine A ; Diaz, Emily ; Pangborn, Joshua ; Fox, Jordan ; Connors, Kevin ; Sellke, Frank W ; Elias, Jack A ; Daniels, Alan H</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-a356t-46188c166d969d4a381836163bbfdaf1dee668cb9b544d7ac81a3ab81d1e89063</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2019</creationdate><topic>Aged</topic><topic>Clinical trials</topic><topic>Coronary Artery Bypass - adverse effects</topic><topic>Coronary Artery Disease - surgery</topic><topic>Female</topic><topic>Follow-Up Studies</topic><topic>Heart surgery</topic><topic>Humans</topic><topic>Incidence</topic><topic>Intensive Care Units</topic><topic>Male</topic><topic>Online First</topic><topic>Original Investigation</topic><topic>Patient Compliance</topic><topic>Postoperative Complications - diagnosis</topic><topic>Postoperative Complications - epidemiology</topic><topic>Postoperative Complications - prevention & control</topic><topic>Pulmonary Atelectasis - diagnosis</topic><topic>Pulmonary Atelectasis - epidemiology</topic><topic>Pulmonary Atelectasis - prevention & control</topic><topic>Radiography</topic><topic>Retrospective Studies</topic><topic>Spirometry - methods</topic><topic>Survival Rate - trends</topic><topic>United States - epidemiology</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Eltorai, Adam E. 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M</au><au>Baird, Grayson L</au><au>Eltorai, Ashley Szabo</au><au>Healey, Terrance T</au><au>Agarwal, Saurabh</au><au>Ventetuolo, Corey E</au><au>Martin, Thomas J</au><au>Chen, Jane</au><au>Kazemi, Layla</au><au>Keable, Catherine A</au><au>Diaz, Emily</au><au>Pangborn, Joshua</au><au>Fox, Jordan</au><au>Connors, Kevin</au><au>Sellke, Frank W</au><au>Elias, Jack A</au><au>Daniels, Alan H</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Effect of an Incentive Spirometer Patient Reminder After Coronary Artery Bypass Grafting: A Randomized Clinical Trial</atitle><jtitle>Archives of surgery (Chicago. 1960)</jtitle><addtitle>JAMA Surg</addtitle><date>2019-07-01</date><risdate>2019</risdate><volume>154</volume><issue>7</issue><spage>579</spage><epage>588</epage><pages>579-588</pages><issn>2168-6254</issn><eissn>2168-6262</eissn><abstract>IMPORTANCE: Incentive spirometers (ISs) were developed to reduce atelectasis and are in widespread clinical use. However, without IS use adherence data, the effectiveness of IS cannot be determined. OBJECTIVE: To evaluate the effect of a use-tracking IS reminder on patient adherence and clinical outcomes following coronary artery bypass grafting (CABG) surgery. DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial was conducted from June 5, 2017, to December 29, 2017, at a tertiary referral teaching hospital and included 212 patients who underwent CABG, of whom 160 participants were randomized (intent to treat), with 145 completing the study per protocol. Participants were stratified by surgical urgency (elective vs nonelective) and sex (men vs women). INTERVENTIONS: A use-tracking, IS add-on device (SpiroTimer) with an integrated use reminder bell recorded and timestamped participants’ inspiratory breaths. Patients were randomized by hourly reminder “bell on” (experimental group) or “bell off” (control group). MAIN OUTCOMES AND MEASURES: Incentive spirometer use was recorded for the entire postoperative stay and compared between groups. Radiographic atelectasis severity (score, 0-10) was the primary clinical outcome. Secondary respiratory and nonrespiratory outcomes were also evaluated. RESULTS: A total of 145 per-protocol participants (112 men [77%]; mean age, 69 years [95% CI, 67-70]; 90 [62%] undergoing a nonelective procedure) were evaluated, with 74 (51.0%) in the bell off group and 71 (49.0%) in the bell on group. The baseline medical and motivation-to-recover characteristics of the 2 groups were similar. The mean number of daily inspiratory breaths was greater in bell on (35; 95% CI, 29-43 vs 17; 95% CI, 13-23; P < .001). The percentage of recorded hours with an inspiratory breath event was greater in bell on (58%; 95% CI, 51-65 vs 28%; 95% CI, 23-32; P < .001). Despite no differences in the first postoperative chest radiograph mean atelectasis severity scores (2.3; 95% CI, 2.0-2.6 vs 2.4; 95% CI, 2.2-2.7; P = .48), the mean atelectasis severity scores for the final chest radiographs conducted before discharge were significantly lower for bell on than bell off group (1.5; 95% CI, 1.3-1.8 vs 1.8; 95% CI, 1.6-2.1; P = .04). Of those with early postoperative fevers, fever duration was shorter for bell on (3.2 hours; 95% CI, 2.3-4.6 vs 5.2 hours; 95% CI, 3.9-7.0; P = .04). Having the bell turned on reduced noninvasive positive pressure ventilation use rates (37.2%; 95% CI, 24.1%-52.5% vs 19.2%; 95% CI, 10.2%-33.0%; P = .03) for participants undergoing nonelective procedures. Bell on reduced the median postoperative length of stay (7 days; 95% CI, 6-9 vs 6 days; 95% CI, 6-7; P = .048) and the intensive care unit length of stay for patients undergoing nonelective procedures (4 days; 95% CI, 3-5 vs 3 days; 95% CI, 3-4; P = .02). At 6 months, the bell off mortality rate was higher than bell on (9% vs 0%, P = .048) for participants undergoing nonelective procedures. CONCLUSIONS AND RELEVANCE: The incentive spirometer reminder improved patient adherence, atelectasis severity, early postoperative fever duration, noninvasive positive pressure ventilation use, ICU and length of stay, and 6-month mortality in certain patients. With the reminder, IS appears to be clinically effective when used appropriately. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02952027</abstract><cop>United States</cop><pub>American Medical Association</pub><pmid>30969332</pmid><doi>10.1001/jamasurg.2019.0520</doi><tpages>10</tpages><oa>free_for_read</oa></addata></record> |
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| identifier | ISSN: 2168-6254 |
| ispartof | Archives of surgery (Chicago. 1960), 2019-07, Vol.154 (7), p.579-588 |
| issn | 2168-6254 2168-6262 |
| language | eng |
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| source | MEDLINE; American Medical Association Journals; Alma/SFX Local Collection |
| subjects | Aged Clinical trials Coronary Artery Bypass - adverse effects Coronary Artery Disease - surgery Female Follow-Up Studies Heart surgery Humans Incidence Intensive Care Units Male Online First Original Investigation Patient Compliance Postoperative Complications - diagnosis Postoperative Complications - epidemiology Postoperative Complications - prevention & control Pulmonary Atelectasis - diagnosis Pulmonary Atelectasis - epidemiology Pulmonary Atelectasis - prevention & control Radiography Retrospective Studies Spirometry - methods Survival Rate - trends United States - epidemiology |
| title | Effect of an Incentive Spirometer Patient Reminder After Coronary Artery Bypass Grafting: A Randomized Clinical Trial |
| url | https://sfx.bib-bvb.de/sfx_tum?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2025-01-22T06%3A01%3A14IST&url_ver=Z39.88-2004&url_ctx_fmt=infofi/fmt:kev:mtx:ctx&rfr_id=info:sid/primo.exlibrisgroup.com:primo3-Article-proquest_pubme&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rft.genre=article&rft.atitle=Effect%20of%20an%20Incentive%20Spirometer%20Patient%20Reminder%20After%20Coronary%20Artery%20Bypass%20Grafting:%20A%20Randomized%20Clinical%20Trial&rft.jtitle=Archives%20of%20surgery%20(Chicago.%201960)&rft.au=Eltorai,%20Adam%20E.%20M&rft.date=2019-07-01&rft.volume=154&rft.issue=7&rft.spage=579&rft.epage=588&rft.pages=579-588&rft.issn=2168-6254&rft.eissn=2168-6262&rft_id=info:doi/10.1001/jamasurg.2019.0520&rft_dat=%3Cproquest_pubme%3E2266331521%3C/proquest_pubme%3E%3Curl%3E%3C/url%3E&disable_directlink=true&sfx.directlink=off&sfx.report_link=0&rft_id=info:oai/&rft_pqid=2266331521&rft_id=info:pmid/30969332&rft_ama_id=2730077&rfr_iscdi=true |