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Dukes K, Bunch JL, Chan PS, et al. Assessment of Rapid Response Teams at Top-Performing Hospitals for In-Hospital Cardiac Arrest. JAMA Intern Med. 2019;179(10):1398–1405. doi:10.1001/jamainternmed.2019.2420
How do rapid response teams differ between top-performing and non–top-performing hospitals for resuscitation care?
In this qualitative study of data collected from interviews with 158 key stakeholders at 9 Get With The Guidelines–Resuscitation hospitals, distinct differences were found in the organizational structure and function of rapid response teams. Top-performing hospitals feature rapid response teams with dedicated staff without competing responsibilities, serve as a resource for bedside nurses in surveillance of at-risk patients, collaborate with nurses during and after a rapid response, and can be activated by a member of the care team without fear of reprisal.
This study appears to provide important insights regarding strengthening rapid response teams across hospitals.
Rapid response teams (RRTs) are foundational to hospital response to deteriorating conditions of patients. However, little is known about differences in RRT organization and function across top-performing and non–top-performing hospitals for in-hospital cardiac arrest (IHCA) care.
To evaluate differences in design and implementation of RRTs at top-performing and non–top-performing sites for survival of IHCA, which is known to be associated with hospital performance on IHCA incidence.
Design, Setting, and Participants
A qualitative analysis was performed of data from semistructured interviews of 158 hospital staff members (nurses, physicians, administrators, and staff) during site visits to 9 hospitals participating in the Get With The Guidelines–Resuscitation program and consistently ranked in the top, middle, and bottom quartiles for IHCA survival during 2012-2014. Site visits were conducted from April 19, 2016, to July 27, 2017. Data analysis was completed in January 2019.
Main Outcomes and Measures
Semistructured in-depth interviews were performed and thematic analysis was conducted on strategies for IHCA prevention, including RRT roles and responsibilities.
Of the 158 participants, 72 were nurses (45.6%), 27 physicians (17.1%), 27 clinical staff (17.1%), and 32 administrators (20.3%). Between 12 and 30 people at each hospital participated in interviews. Differences in RRTs at top-performing and non–top-performing sites were found in the following 4 domains: team design and composition, RRT engagement in surveillance of at-risk patients, empowerment of bedside nurses to activate the RRT, and collaboration with bedside nurses during and after a rapid response. At top-performing hospitals, RRTs were typically staffed with dedicated team members without competing clinical responsibilities, who provided expertise to bedside nurses in managing patients who were at risk for deterioration, and collaborated with nurses during and after a rapid response. Bedside nurses were empowered to activate RRTs based on their judgment and experience without fear of reprisal from physicians or hospital staff. In contrast, RRT members at non–top-performing hospitals had competing clinical responsibilities and were generally less engaged with bedside nurses. Nurses at non–top-performing hospitals reported concerns about potential consequences from activating the RRT.
Conclusions and Relevance
This qualitative study’s findings suggest that top-performing hospitals feature RRTs with dedicated staff without competing clinical responsibilities, that work collaboratively with bedside nurses, and that can be activated without fear of reprisal. These findings provide unique insights into RRTs at hospitals with better IHCA outcomes.
In-hospital cardiac arrest (IHCA) affects more than 200 000 patients annually in the United States and is reported to be associated with poor survival.1,2 Efforts at improving IHCA outcomes have focused primarily on the timeliness and quality of resuscitation (eg, early defibrillation).3 However, given the high incidence of and low survival rates associated with IHCA, targeted efforts at preventing IHCA could be an even larger factor in in-hospital mortality.
Rapid response teams (RRTs) are a key strategy to prevent IHCA.4 Composed of health professionals with critical care expertise, an RRT evaluates patients with clinical deterioration on hospital wards, initiates life-saving treatments, and/or transfers patients to a higher level of care (eg, intensive care unit [ICU]).5 During the past decade, most acute care hospitals in the United States have deployed an RRT.6 The cost of staffing and maintaining an RRT is estimated to be more than $1 million over a 5-year period at a medium-size hospital.7
Although the concept of RRTs makes intuitive sense, the effectiveness of RRTs has not been consistently demonstrated.8-11 Given that an RRT is a complex, multidisciplinary intervention, differences in design and implementation across sites may account for why RRTs were associated with improved outcomes in some studies but not others.12,13 Therefore, identifying hospital practices that distinguish RRTs at top-performing sites could provide important insights about improving RRT performance.
Accordingly, we used data from HEROIC (Hospital Enhancement of Resuscitation Outcomes for In-hospital Cardiac Arrest), an ongoing mixed methods study of resuscitation practices at US hospitals.14,15 We compare and contrast the organizational structure and function of RRTs across hospitals with varying levels of performance on IHCA survival, which is known to be associated with hospital performance on IHCA incidence.16
The qualitative component of the HEROIC study included 9 hospitals selected from Get With The Guidelines–Resuscitation (GWTG-Resuscitation), a national IHCA quality improvement program. As detailed in Study Design and Sampling, top-performing and non–top-performing hospitals were defined based on their performance on risk-standardized survival rate for IHCA.17 On the surface, defining RRT practices across top-performing and non–top-performing hospitals based on IHCA survival may seem counterintuitive because the primary focus of RRT is to prevent IHCA and unexpected death, not to improve IHCA survival. However, data on IHCA incidence and overall hospital mortality are not available within GWTG-Resuscitation. The use of IHCA survival as a measure to define top-performing and non–top-performing hospitals was based on the premise that hospitals that excel in IHCA management also excel at other aspects of care on the IHCA spectrum (ie, IHCA prevention). A prior study found an inverse association between facility rates of IHCA survival and IHCA incidence.16 Therefore, hospitals that excel in IHCA survival are likely to provide meaningful insights regarding IHCA prevention, including the organization and function of RRTs. The University of Michigan Institutional Review Board approved this study. A small token incentive ($20 gift card) was offered to study participants for their time and participation in the study. All interviews were audio-recorded, transcribed, and deidentified (hence there was no need to have informed written consent from the participants).
The design of the HEROIC study has been described previously in detail.15 Briefly, 192 GWTG-Resuscitation hospitals reporting at least 20 patients with IHCA during 2012-2014 were categorized based on their performance on risk-standardized survival rate for IHCA.17 Hospitals were designated as top-performing if they were consistently in the highest quartile of risk-standardized survival rates during each year (2012-2014), intermediate if they were consistently in the middle 2 quartiles, and bottom-performing if they were consistently in the lowest quartile. The intermediate and bottom-performing groups are collectively referred to as non–top-performing hospitals. In addition to performance on the risk-standardized survival rate, hospital selection was also based on additional hospital variables obtained from American Hospital Association data to ensure a diverse group. Once study hospitals were selected, key informants were identified at each site in collaboration with each site’s GWTG-Resuscitation liaison and approached for participation in an interview during in-person site visits. Additional details regarding the Study Design are included in the eAppendix in the Supplement.
Our team visited each of the 9 study hospitals from April 19, 2016, to July 27, 2017, and conducted in-depth semistructured interviews with study participants. Interviewers were blinded to whether the site was a top-performing or a non–top-performing site. Interviews were conducted by a team of 2 researchers: a clinician and a qualitative researcher (P.S.C., T.C.G., J.L.L., M.H., S.L. Krein, J.E.K., S.L. Kronick, and B.K.N.). All interviews were conducted with the aid of interview guides designed a priori based on a clinical framework developed by our multidisciplinary team (P.S.C., T.C.G., J.L.L., M.H., S.L. Krein, J.E.K., S.L. Kronick, and B.K.N.) that included physicians (cardiologist, critical care, and hospitalist), nurses, and qualitative researchers. We used open-ended questions during the interview with probing questions to elicit additional details based on interviewee responses. All interviews were audio-recorded, transcribed, and deidentified (hence there was no need to have informed written consent from the participants). During interviews, we elicited participants’ perspectives about care of patients before, during, and after an IHCA. The interview also covered hospital-wide efforts for prevention of IHCA including RRTs, and holistic processes such as data collection, best practices, and areas for improvement. Additional details regarding study interviews are included in the eAppendix in the Supplement.
We performed thematic analysis on textual data from interview transcripts.18-20 Multiple members of the research team read the initial transcripts, conducted line-by-line open coding to identify codes (labels for units of meaning), and developed a preliminary codebook.21 Consensus was reached through team discussion. After several meetings, we developed a robust codebook to apply to remaining transcripts, yet remained open to identifying new codes that emerged from the data.
Next, we reviewed the code reports, which included aggregated text coded using the same code, to identify major themes within the data and assess when data saturation had been reached (ie, no new themes emerge). Once major themes were identified, we reanalyzed coded segments associated with IHCA prevention to identify new patterns and themes that were directly relevant to RRT activities. The research team remained blinded to whether a site was a top-performing or non–top-performing site until analyses were complete. We used MAXQDA (VERBI Software) to manage the qualitative data analysis and reporting.
Table 122 lists characteristics of the 9 study hospitals (1-5, top; 6, intermediate; and 7-9, bottom). Included hospitals represented a diverse mix based on bed size, teaching status, and geographic census region (by design, as these variables were considered in selecting hospitals). All the included hospitals had an ICU, were located in an urban area, and most (7 [78%]) were nonprofit. All hospitals also provided interventional cardiac catheterization, electrophysiology, cardiac surgery, and intensivist services (data on availability of intensivist services was unknown for 1 hospital). The selected sites varied regarding the number of ICU beds (13-25 to >50), the proportion of ICUs to total beds (3.5% to 8.4%), and the proportion of nurses to total beds (1.0% to 3.4%).
Interviews were conducted with 158 hospital staff members (Table 2), which included 72 nurses (45.6%), 27 physicians (17.1%), 27 clinical staff (17.1%), and 32 administrators (20.3%). Between 12 and 30 people at each hospital participated in interviews.
Differences in RRT structure and function at top-performing and non–top-performing sites were identified in 4 principal domains: team design and composition, surveillance of at-risk patients, empowerment of bedside nurses to initiate rapid responses, and RRT collaboration with bedside nurses during and after a rapid response. These differences are summarized in Table 3.
At top-performing hospitals, RRTs were often staffed by members without other clinical responsibilities, allowing them to respond quickly, although 1 hospital recently had moved away from a separate, designated team. Rapid response team members often served on other emergency teams (eg, stroke team) or helped with other acute situations, and were familiar to bedside nursing staff throughout the hospital. “We are there as the primary emergency team for these in-house inpatients. We are a dedicated team, meaning the nurses do not have any other responsibilities, no other patient loads….” (RRT nurse; hospital 2 [top].)
Top-performing hospitals ensured that RRT members had the requisite level of skill and experience to effectively respond to an emergency. “[We decided] that the newer nurses coming in would take the [code pager] first, and then as they gain experience and comfort levels with their critical thinking…, progress to the rapid response,… to have an experienced nurse that would help them with the critical thinking. You don’t want a new nurse helping a new nurse.” (ICU nurse supervisor; hospital 5: [top].) “…Obviously they [RRT members] have to be knowledgeable. Second of all, they have to be very proactive…. Third… they have to not be intimidated and… fourth…, they need to be experienced. They can’t be a new person on the block.” (Senior medical director; hospital 1 [top].)
In contrast, RRTs at non–top-performing hospitals were often formed ad hoc when a response was activated. Members had competing responsibilities that had to be dropped or delegated to colleagues. “The people on the RRT, the nurse, the intern, and the second-year [resident], they have other patient responsibilities during the day, but if the team is activated, then they put them aside…” (Resident physician; hospital 8 [bottom].)
Top-performing hospitals had developed unique processes associated with patient surveillance. The RRT nurse at 1 hospital proactively engaged with bedside staff to identify patients at risk of clinical deterioration, before the patient progressed to a point at which a rapid response would be activated. At another hospital, bedside nurses often sought the expertise of RRT members in managing patients with complex medical conditions outside of a formal rapid response. Such interactions were enabled by having a dedicated RRT with limited patient care responsibilities. “We [RRT members] round once a night, so we’ll go to each and every [one] of the 25 different departments, and we will check in with the head nurse and see if there are problem patients that might be of concern to them…. We kindly call it ‘the naughty list’.” (RRT nurse; hospital 2 [top].) “…Because there aren’t rapid responses called 24 hours a day, [the RRT] will go and kind of look at hot patients. So, they’ll round on the floors… talk to the nurses, see if they have any concerns with any patients on their unit.” (Respiratory therapist; hospital 1 [top].)
Non–top-performing hospitals used a traditional model in which the physician in charge would be informed of a change in patient condition. Rapid responses were often called when the bedside nurse was unable to reach the physician, or when the patient’s condition continued to deteriorate. Often, rapid responses were activated “too late” and quickly became codes [cardiac arrest]. “…[Usually] the nurse… is already working to contact the physician and a lot of our rapid responses fall into the scenario of the physician not being able to respond at that time.” (Respiratory therapy director; hospital 9 [bottom].) “It’s not terribly unusual to hear a rapid response shortly thereafter followed by a code [cardiac arrest] called.” (Catheterization laboratory director; hospital 9 [bottom].)
Also, RRT members with competing responsibilities had limited time to assist bedside nurses by assessing patients’ conditions and intervening before a response was called. “Usually we only see them if we’re called because there’s only really one of us that covers that kind of service so a lot of times we’re busy and we don’t get to go and round and check up on, like ‘Hey, how is this person doing?’” (Resource nurse; hospital 8 [bottom].)
Top-performing hospitals empowered nurses to call RRTs based on their judgment and expertise without having to first check in with the physicians. This empowerment meant that treatment happened earlier and patients could receive a higher level of care, perhaps even transfer to the ICU. “…Nurses know that they are 100% supported, all the way up to the top of the organization, that they are empowered to call rapids regardless if they’re being told not to call a rapid [response]…” (Nurse; hospital 3 [top].) “…One of the things we’ve been trying to push more is more rapid response.… We’re trying to lower the threshold for nurses to call for help… the culture’s changed, they’re more willing to call RRTs.” (Hospitalist; hospital 4 [top].)
In contrast, nursing staff at non–top-performing hospitals sometimes worried about potential consequences of activating the RRT. They feared being judged as less competent and inviting displeasure from other staff members. Some comments reflected staff’s perception that this fear was not conducive to an effective team structure. “…One thing that we’ve really worked on as a team is to break down the silo of people being afraid to call rapid response team because they’re afraid the ICU nurse is [going to] think they’re stupid or… like why didn’t they just handle the situation.” (Nurse educator; hospital 7 [bottom].) “…A lot of them are afraid to call the physician. So sometimes the physician would be angry that they called a rapid response, but we always tell the nurses that, if you’re concerned with the patient, you can call.” (Code team nurse; hospital 6 [intermediate].)
Collaboration between RRT members and bedside nurses appeared to be better at top-performing hospitals both during a rapid response activation, and afterward, for debriefing and education. Often, RRT members used a rapid response as a learning opportunity to demonstrate useful skills for bedside nurses and spend time in debriefing afterward to identify opportunities for shared learning. “We always tell the nurses…, ‘Please don’t run away. When the rapid response team gets there... don’t turn and run. We need you because you know more, a heck of a lot more about that patient’.” (Nurse; hospital 3 [top]) “…The [RRT] team is… very good at training and teaching and explaining and helping people understand why something happened and maybe how we could prevent it...” (Nurse education leader; hospital 1 [top].)
A participant at a top-performing hospital described the role of education more broadly in preventing IHCA, including the crucial role of RRTs in patient surveillance in collaboration with floor nurses. “…If I look back historically, a lot has been around education and really trying to change the culture from, ‘We’re just a cardiac floor so we have a lot of code [cardiac arrest] events,’ to, ‘We should really never have any code [cardiac arrest] events on our floor.’” (Nursing director; hospital 2 [top].)
Staff at non–top-performing hospitals suggested that the RRT members engaged less with bedside nurses and often took over patient care responsibilities, suggesting that opportunities for collaboration and shared learning were missed. “…When we get there, they’re there with us really until we say, like, ‘Okay, I think we’re okay here. You can go figure out what you’re doing.’ Because a lot of the times it’s like if they’re not like ACLS [advanced cardiac life support] certified or anything and they can’t give the meds… so if they’re not doing something actively, then they can go check on other patients….” (ICU nurse; hospital 8 [bottom].)
In this large qualitative study of 9 hospitals participating in GWTG-Resuscitation, we identified important differences in RRT structure and function between top-performing and non–top-performing sites in IHCA survival. Top-performing hospitals tended to have dedicated RRT staff, collaborate with bedside nurses in surveillance of at-risk patients before a rapid response, and serve as a resource to provide education and debriefing afterwards. Bedside nurses were empowered to activate RRTs based on their clinical judgment and experience. In contrast, non–top-performing hospitals tended to have RRTs staffed with members with competing clinical responsibilities, and they were generally less engaged with bedside nurses. Hospital staff also reported concerns about potential consequences of calling the RRT. Several of our findings merit further discussion.
In 2004, the Institute for Healthcare Improvement promoted the deployment of RRTs at US hospitals by including RRTs as 1 of the 6 strategies to improve patient safety.4 However, published studies have shown heterogeneity in the effectiveness of RRTs. Although some studies have shown a significant reduction in mortality and IHCA with RRTs,8,9 others, including a large randomized clinical trial,11 have not shown a benefit.10 The MERIT (Medical Early Response Intervention and Therapy) trial is the only multicenter clinical trial of RRTs that randomized 23 sites in Australia to a medical emergency team (MET; similar to RRT) or usual care and found no overall reduction in unexpected IHCA or overall mortality with the MET.11 However, greater use of resuscitation teams as the MET at control hospitals may have diluted the effect of the intervention. Moreover, a post hoc analysis showed that hospitals with greater use of the intervention (ie, high MET calling rate) had a lower incidence of IHCA and unexpected death compared with other hospitals.23 Thus, site-level variation in how RRTs are designed and implemented, which has been demonstrated in recent studies,24,25 likely contributes to the heterogeneity of RRTs’ effectiveness in clinical practice.13
To our knowledge, this is the first qualitative multicenter evaluation of hospital strategies for IHCA prevention including the roles of RRTs across the performance spectrum of IHCA survival. Our findings provide important insights regarding RRT practices at top-performing hospitals for IHCA survival and may explain why RRTs have been more successful at some sites compared with others. Using a dedicated team structure, top-performing hospitals ensured that a small group of skilled and experienced clinicians became highly specialized in hospital emergency response over time. Such a dynamic may have allowed team members to hone their cognitive and psychomotor skills and foster communication and relationships with each other and bedside nurses. A distinct pattern of collaboration between RRT staff and bedside nurses was also present, which included the engagement of RRTs in the surveillance and management of at-risk patients prior to activation of the RRT, and debriefing and education afterward. Thus, individual rapid responses were incorporated into a broad pattern of collaboration between hospital staff to ensure high-quality patient care. Hospital leadership supported bedside nurses to activate the RRT without fear of reprisal. Empowering hospital staff to act in the best interest of the patients likely fostered trust and mutual respect, which is critical for achieving organizational excellence.26 The importance of teamwork, collaboration, empowerment, and timely activation and response noted above have broad similarities with best practices for other team-based hospital processes such as rapid treatment for ST-elevation myocardial infarction, and high-performing resuscitation teams.15,27
In contrast, non–top-performing hospitals adopted an ad hoc approach to RRTs. Routinely bringing new members to the RRT, with varying levels of skill and communication, may have hindered the success of RRTs at these hospitals. Activations of RRTs were treated as individual events to be addressed in the moment and appeared less likely to offer collaborative opportunities for shared learning and improvement over time. Fear of reprisal and concerns about being judged as less competent may have reduced nurses’ willingness to activate the RRT, eroded nurses’ trust, and likely reflect broader issues of communication, education, hierarchy, workplace culture, and environment at such hospitals.28,29 Because an RRT will not be effective unless activated, identifying and addressing such barriers is likely to have a meaningful influence on the effectiveness of RRTs.
Our findings should be interpreted considering the following limitations. First, top-performing hospitals in HEROIC were based on achieving high IHCA survival. However, the goal of the RRT is to prevent IHCA (ie, reduce IHCA incidence) and not necessarily improve IHCA survival. Although a prior study of GWTG-Resuscitation sites reported a modest association between hospital rates of IHCA incidence and survival,16 a dedicated study of RRTs at hospitals with exceptionally low IHCA incidence may be able to yield additional insights. Second, our exclusion of hospitals with fewer than 20 IHCA events was based on statistical considerations. It is possible that hospitals with exceptionally low IHCA incidence were inadvertently excluded. Third, while the HEROIC study interviewed participants regarding IHCA prevention and RRTs, the primary focus was on resuscitation teams. Additional themes may emerge in a dedicated study focused on RRT roles and responsibilities. Fourth, although there were no obvious differences between top-performing and non–top-performing hospitals regarding resources such as availability of ICU beds, nurses, and specialist cardiac and intensive care services, it is possible that unmeasured differences in availability and allocation of resources toward IHCA prevention and management account for the observed differences in RRT practices. Nevertheless, our findings highlight what is achievable for RRTs in well-resourced settings (top-performing hospitals). Future implementation of best practices will need to be guided by local context and available resources at each site. Fifth, RRT processes at individual hospitals may have evolved over time. The extent to which changes were associated with patient outcomes will need to be determined in future studies.
Despite the above limitations, our study provides unique insights regarding the organization and function of RRTs using the example of top-performing hospitals for IHCA survival. Although the design of our study does not permit a causal interpretation and validation remains a key next step, the domains that we identified reflect strategies that can potentially overcome barriers for optimal RRT function (eg, empowerment of nurses) and facilitate timely response and collaboration. A careful understanding of the cost implications of adopting these strategies is also needed. If successful, these strategies could advance the goal of improving safety and reduce unexpected death and IHCA in hospitalized patients.
Substantial differences exist in the organizational structure and function of RRTs between top-performing and non–top-performing hospitals for IHCA survival, which may have implications for improving RRT care across US hospitals.
Accepted for Publication: May 13, 2019.
Corresponding Author: Saket Girotra, MD, SM, Division of Cardiovascular Diseases, Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA 52242 (email@example.com).
Published Online: July 29, 2019. doi:10.1001/jamainternmed.2019.2420
Author Contributions: Drs Dukes and Bunch are co–first authors. Dr Girotra had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Bunch, Guetterman, Krein, Reisinger, Girotra.
Acquisition, analysis, or interpretation of data: Dukes, Bunch, Chan, Guetterman, Lehrich, Trumpower, Harrod, Krein, Kellenberg, Kronick, Iwashyna, Nallamothu, Girotra.
Drafting of the manuscript: Dukes, Bunch, Krein, Girotra.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Guetterman, Trumpower, Girotra.
Obtained funding: Nallamothu.
Administrative, technical, or material support: Dukes, Bunch, Guetterman, Lehrich, Trumpower, Kellenberg, Kronick, Nallamothu, Girotra.
Supervision: Guetterman, Kronick, Nallamothu, Girotra.
Conflict of Interest Disclosures: Dr Bunch reported being an elected member of the Advisory Committee of the International Society for Rapid Response Systems. Dr Chan reported receiving grants from the National Heart, Lung, and Blood Institute; receiving consultant funding from the American Heart Association; and receiving personal fees from Optum Rx during the conduct of the study. Dr Guetterman reported being supported by career development award K01LM012739 from the National Institutes of Health/National Library of Medicine during the conduct of the study. Mr Trumpower reported receiving grants from the Department of Health and Human Services and National Institutes of Health during the conduct of the study. Dr Harrod reported receiving grants from the National Institutes of Health during the conduct of the study. Dr Krein reported receiving grants from the National Institutes of Health and being supported by a Department of Veterans Affairs Health Services Research and Development Service research career scientist award RCS 11-222 during the conduct of the study. Dr Kellenberg reported receiving grants R01HL123980 from the National Institutes of Health during the conduct of the study. Dr Kronick reported receiving grants from the National Institutes of Health during the conduct of the study. Dr Iwashyna reported receiving grants from the Department of Veterans Affairs Health Services Research and Development Service and from the National Heart, Lung, and Blood Institute during the conduct of the study. Dr Nallamothu reported receiving grants from the National Heart, Lung, and Blood Institute, from the Department of Veterans Affairs Health Services Research and Development Service (IIR 13-079), and from Apple Inc during the conduct of the study; receiving personal fees from the American Heart Association outside the submitted work; and being a coinventor on US Utility Patent Number US15/356,012 (US20170148158A1) entitled “Automated Analysis of Vasculature in Coronary Angiograms” that uses software technology with signal processing and machine learning to automate the reading of coronary angiograms, held by the University of Michigan (the patent is licensed to AngioInsight Inc, in which Dr Nallamothu holds ownership shares). Dr.Girotra is supported by a career development award from the National Heart, Lung, and Blood Institute (K08HL122527) and a Department of Veterans Affairs Health Services Research and Development Service pilot grant (I21HX002365). No other disclosures were reported.
Funding/Support: This study was funded by grant R01HL123980 from the National Institutes of Health.
Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
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