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Table 1.  Characteristics of Study Participants
Characteristics of Study Participants
Table 2.  Health Professionals’ Perceptions of Clinical Effectiveness
Health Professionals’ Perceptions of Clinical Effectiveness
Table 3.  Health Professionals’ Perceptions of Patient Experience
Health Professionals’ Perceptions of Patient Experience
Table 4.  Health Professionals’ Perceptions of Access to Care
Health Professionals’ Perceptions of Access to Care
Table 5.  Health Professional Perception of Financial Impact or Cost
Health Professional Perception of Financial Impact or Cost
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Yunus  F, Gray  S, Fox  KC,  et al The impact of telemedicine in cancer care. J Clin Oncol. 2009;27(15_suppl):e20508-e20508. doi:10.1200/jco.2009.27.15_suppl.e20508
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Thaker  DA, Monypenny  R, Olver  I, Sabesan  S.  Cost savings from a telemedicine model of care in northern Queensland, Australia.   Med J Aust. 2013;199(6):414-417. doi:10.5694/mja12.11781PubMedGoogle Scholar
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Doolittle  GC, Spaulding  AO.  Providing access to oncology care for rural patients via telemedicine.   J Oncol Pract. 2006;2(5):228-230. doi:10.1200/jop.2006.2.5.228PubMedGoogle Scholar
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Kane  CK, Gillis  K.  The use of telemedicine by physicians: still the exception rather than the rule.   Health Aff (Millwood). 2018;37(12):1923-1930. doi:10.1377/hlthaff.2018.05077PubMedGoogle Scholar
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Gordon  J, Tsay  D, Coyne  S, Barchi  D, Fleischut  PM, Deland  EL.  Four challenges of launching a telehealth program.   NEJM Catal. July 2017. Accessed December 1, 2020. https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0459Google Scholar
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Janz  NK, Becker  MH.  The health belief model: a decade later.   Health Educ Q. 1984;11(1):1-47. doi:10.1177/109019818401100101PubMedGoogle Scholar
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Hsieh  H-F, Shannon  SE.  Three approaches to qualitative content analysis.   Qual Health Res. 2005;15(9):1277-1288. doi:10.1177/1049732305276687PubMedGoogle Scholar
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Viera  AJ, Garrett  JM.  Understanding interobserver agreement: the kappa statistic.   Fam Med. 2005;37(5):360-363.PubMedGoogle Scholar
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Whitten  PS, Mackert  MS.  Addressing telehealth’s foremost barrier: provider as initial gatekeeper.   Int J Technol Assess Health Care. 2005;21(4):517-521. doi:10.1017/S0266462305050725PubMedGoogle Scholar
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Rodler  S, Apfelbeck  M, Stief  C, Heinemann  V, Casuscelli  J.  Lessons from the coronavirus disease 2019 pandemic: will virtual patient management reshape uro-oncology in Germany?   Eur J Cancer. 2020;132:136-140. doi:10.1016/j.ejca.2020.04.003PubMedGoogle Scholar
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Krishnan  N, Fagerlin  A, Skolarus  TA.  Rethinking patient-physician communication of biopsy results—the waiting game.   JAMA Oncol. 2015;1(8):1025-1026. doi:10.1001/jamaoncol.2015.2334PubMedGoogle Scholar
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Parker  PA, Baile  WF, de Moor  C, Lenzi  R, Kudelka  AP, Cohen  L.  Breaking bad news about cancer: patients’ preferences for communication.   J Clin Oncol. 2001;19(7):2049-2056. doi:10.1200/JCO.2001.19.7.2049PubMedGoogle Scholar
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Weigel  G, Ramaswamy  A, Sobel  L, Salganicoff  A, Cubanski  J, Freed  M.  Opportunities and barriers for telemedicine in the U.S. during the COVID-19 emergency and beyond.  Kaiser Family Foundation. Published May 11, 2020. Accessed July 15, 2020. https://www.kff.org/womens-health-policy/issue-brief/opportunities-and-barriers-for-telemedicine-in-the-u-s-during-the-covid-19-emergency-and-beyond/
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    Original Investigation
    Oncology
    January 14, 2021

    Medical Oncology Professionals’ Perceptions of Telehealth Video Visits

    Author Affiliations
    • 1Sidney Kimmel Medical College, Philadelphia, Pennsylvania
    • 2Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
    • 3Sidney Kimmel Cancer Center, Department of Medical Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania
    JAMA Netw Open. 2021;4(1):e2033967. doi:10.1001/jamanetworkopen.2020.33967
    Key Points

    Question  How do medical oncologists perceive telehealth video visits for cancer care?

    Findings  In this qualitative study, in which 29 medical oncology health professionals were interviewed prior to the coronavirus disease 2019 (COVID-19) pandemic, the barriers to and benefits of telehealth video visits were elucidated. Although oncologists disagreed on the scope of a virtual physical examination and the financial impact of video visits, most recognized the benefit of eliminating travel and the challenge of delivering serious or bad news.

    Meaning  Differing opinions of medical oncology health professionals regarding the barriers to and benefits of telehealth video visits provide insight into the challenges that limit telehealth quality as well as its expansion potential.

    Abstract

    Importance  Telehealth has emerged as a means of improving access and reducing cost for medical oncology care; however, use by specialists prior to the coronavirus disease 2019 (COVID-19) pandemic still remained low. Medical oncology professionals’ perceptions of telehealth for cancer care are largely unknown, but are critical to telehealth utilization and expansion efforts.

    Objective  To identify medical oncology health professionals’ perceptions of the barriers to and benefits of telehealth video visits.

    Design, Setting, and Participants  This qualitative study used interviews conducted from October 30, 2019, to March 5, 2020, of medical oncology health professionals at the Thomas Jefferson University Hospital, an urban academic health system in the US with a cancer center. All medical oncology physicians, physicians assistants, and nurse practitioners at the hospital were eligible to participate. A combination of volunteer and convenience sampling was used, resulting in the participation of 29 medical oncology health professionals, including 20 physicians and 9 advanced practice professionals, in semistructured interviews.

    Main Outcomes and Measures  Medical oncology health professionals’ perceptions of barriers to and benefits of telehealth video visits as experienced by patients receiving cancer treatment.

    Results  Of the 29 participants, 15 (52%) were women and 22 (76%) were White, with a mean (SD) age of 48.5 (12.0) years. Respondents’ perceptions were organized using the 4 domains of the National Quality Forum framework: clinical effectiveness, patient experience, access to care, and financial impact. Respondents disagreed on the clinical effectiveness and potential limitations of the virtual physical examination, as well as on the financial impact on patients. Respondents also largely recognized the convenience and improved access to care enabled by telehealth for patients. However, many reported concern regarding the health professional–patient relationship and their limited ability to comfort patients in a virtual setting.

    Conclusions and Relevance  Medical oncology health professionals shared conflicting opinions regarding the barriers to and benefits of telehealth in regard to clinical effectiveness, patient experience, access to care, and financial impact. Understanding oncologists’ perceptions of telehealth elucidates potential barriers that need to be further investigated or improved for telehealth expansion and continued utilization; further research is ongoing to assess current perceptions of health professionals and patients given the rapid expansion of telehealth during the COVID-19 pandemic.

    Introduction

    Telehealth is an emerging mode of care delivery that can improve access to care, reduce cost, and enhance patient and health professional experience while providing effective care.1 One central component of telehealth is the video visit, in which audiovisual technology is used to connect patients and health professionals in lieu of an in-person encounter.2 The video visit allows physicians to evaluate patients and provide treatment recommendations regardless of geographical distance. While physicians’ ability to perform a physical examination during the video visit is somewhat limited, many examination techniques are still feasible, and telehealth encounters and traditional in-person visits have similar performance characteristics.3-5

    Telehealth has promise for patients with cancer, where concerns regarding access, cost, and experience are common.6-9 A randomized controlled trial of video vs in-person visits for follow-up after radical prostatectomy demonstrated equivalent efficiency, similar satisfaction, and significantly lower cost for the video visits.10 In addition, multiple studies have demonstrated that telehealth can improve access to cancer care for patients in rural settings while achieving equal or better patient satisfaction and generating cost savings when compared with in-person visits.11-13

    Despite its many advantages, the use of telehealth in oncology is highly variable, and its uptake (until a recent surge due to the coronavirus disease 2019 [COVID-19] pandemic) has been limited nationally.14 Various factors likely contribute to slow adoption, including liability concerns, licensure challenges, reimbursement inconsistencies, and workflow ambiguity.15 We hypothesize that the perceptions health professionals have of this care delivery model are also a critical component of adoption, as the presence of perceived barriers to a service is associated with low utilization.16 However, to date, the perceptions of health professionals about the utility of telehealth for cancer care are not well understood.

    The goal of this study is to report the results of a qualitative interview study focused on eliciting medical oncology health professional perceptions regarding the use of telehealth for patient care prior to the COVID-19 pandemic.

    Methods
    Study Setting

    This study was conducted at Thomas Jefferson University, an urban academic health system in Philadelphia, Pennsylvania, with a cancer center that serves over 8000 patients each year. The practice is composed of 55 medical oncologists and 39 advanced practice professionals (APPs). In 2015, Jefferson launched JeffConnect, an enterprise-wide telehealth program that facilitates video visits for patients across a variety of use cases, including both scheduled visits and on-demand visits. Health professionals received training in the use of JeffConnect with both personalized guidance and online training modules. All Jefferson health professionals, including those in medical oncology, were incentivized (with relative value unit equivalents and an end-of-year bonus for high usage) to utilize video visits. This study was designed and conducted by a team consisting of an emergency medicine physician researcher with expertise in qualitative methods (K.R.), 2 medical oncology physician researchers (A.B. and N.H.), a research coordinator with expertise in qualitative methods (A.G.), and 2 MD/MPH candidate research assistants (A.H. and R.G.).

    Study Participants

    All medical oncology health professionals (physicians and APPs) at Thomas Jefferson University were eligible to participate. The aim of our volunteer and convenience sample selection was to include health professionals with various levels of experience with telehealth video visits, as the objective of the study was to obtain medical oncologists’ perceptions regardless of their frequency of offering or engaging in video visits. Potential participants were recruited first in a faculty meeting led by N.H. and A.B., who then emailed all health professionals instructing those interested to respond directly to nonclinical team members (A.G., R.G., and A.H.) to maintain anonymity among medical oncology colleagues. Health professionals who did not respond to the initial email were recruited directly via email and phone by R.G. and A.H. The study was approved by the Thomas Jefferson University institutional review board, and verbal consent was obtained from each participant. Interview quotations were scrubbed to remove identifying information.

    Data Collection

    We developed a semistructured interview guide designed to elicit health professionals’ perceptions regarding the utility of and barriers to delivery of telehealth services in cancer care (eAppendix in the Supplement). The initial interview guide was drafted by 1 member of the research team (N.H.) and based on previous literature on perceptions of telehealth. All other team members then contributed to and revised the draft until it reached its final form. Interviews were structured to be 1-on-1 to limit bias and influence that could result from larger interview groups with multiple participants. We targeted completion of 30 overall interviews, with a goal of 20 physician interviews and 10 APP interviews, with interviews continued until thematic saturation was reached. The interviews were conducted from October 30, 2019, to March 5, 2020, by 2 trained interviewers (R.G. and A.H.) via telephone or in person and were approximately 20 minutes in length. Health professionals were also asked to complete a demographic survey following the interview with questions regarding age, gender, race, number of years in practice, previous experience with telehealth, and specialty within oncology.

    Data Analysis

    Interviews were audio recorded and transcribed. Transcripts were verified for accuracy, identifying information was removed, and results were imported into NVivo 12 version 12 (QSR International) for coding and analysis. Given the exploratory nature of this study, the codebook was developed using a conventional content analysis approach, a common method of analysis when coding categories are derived directly from data.17 All members of the research team read the first 3 transcripts and identified concepts that captured health professionals’ perceptions. Team members discussed the identified concepts to create an initial code structure. This was applied to subsequent interviews by 2 coders (R.G. and A.H.) and refined to include new themes as they emerged. This process was iterative and continued until coders and at least 1 other team member (A.G.) agreed upon a final coding structure, with discrepancies resolved through consensus. The 2 coders applied the final structure to all transcripts. Coders double coded 43% of the transcripts. We calculated intercoder reliability in NVivo 12 by using the κ coefficient.18

    We organized themes and quotes into the 4 National Quality Forum (NQF) domains of clinical effectiveness, patient experience, access to care, and financial cost or impact on patients.1 Each table corresponds to 1 domain, and reveals positive and negative themes with accompanying participant quotes. We used descriptive statistics to characterize the study population based on information collected from the demographic survey. This qualitative study is reported according to the Consolidated Criteria for Reporting Qualitative Research (COREQ) reporting guideline.

    Results

    Analysis of intercoder reliability in this study showed a near perfect agreement (mean κ = 0.86). Supporting this result is the percentage of agreement analysis, which revealed a mean of 98.7% (spread, 86%-100%) agreement of all codes.

    We enrolled a total of 29 health professionals, including 20 physicians and 9 APPs (Table 1). The mean (SD) participant age was 48.5 (12.0) years, over half (15 [52%]) were women, and most (22 [76%]) were White. An equal proportion (11 [38%]) reported 5 or less years in practice and 21 or more years in practice. Most participants specialized in either liquid malignant neoplasms (14 [48%]) or solid malignant neoplasms (11 [38%]). Over half of respondents (15 [52%]) reported having used telehealth for at least 10 visits, while 3 (10%) reported no prior use of telehealth.

    Perceptions of Clinical Effectiveness

    Respondents had divergent thoughts on the clinical effectiveness of telehealth for oncologic care (Table 2). Specifically, health professionals had opposing opinions on the capabilities of a virtual physical examination. Some reported they could not examine a sore throat, graft vs host disease, or shortness of breath via telehealth; others stated that they could assess the mouth and skin, as well as respiratory distress. Health professionals who noted the limitations of physical examinations on telehealth cited the dependency on patient knowledge, and raised concerns that the discordance between the physical examination and patient history could cause potentially important missed findings. Respondents noted that the lack of effective physical examinations made telehealth inappropriate for a number of visit types, including first appointments, patients who are seen only every 6 months to 1 year, multiple successive encounters, and patients who are symptomatic or sick. Another practical limitation recognized by 1 respondent was the inability to provide written information explaining complex treatments, referrals, and labs slips.

    Other respondents found merits in the clinical effectiveness of telehealth. Some believed telehealth would allow for increased frequency of patient interactions, noting that for particularly high-risk patients, telehealth could be utilized to anticipate potential emergency department visits or hospital admissions. One respondent noted the potential use of telehealth for patients with communicable diseases, such as shingles, which may pose a risk to other patients in the office setting. Another respondent noted the utility of telehealth because laboratory tests were typically performed the day prior to the video visit, which allowed for results to be discussed at the time of the visit. This is in contrast to in-person encounters, where tests were often obtained by a phlebotomist immediately prior to examination.

    Perceptions of Patient Experience

    Many respondents were concerned with the patient experience of telehealth, often noting the relationship between health professionals and patients as uniquely important in oncology (Table 3). Respondents frequently shared concern that a decreased ability to bond with and support a patient through telehealth is a disservice. Another concern was that patients may experience difficulty comprehending complex treatment discussions that may be better facilitated through an in-person interaction. Several respondents noted that it was not feasible to have discussions regarding serious or bad news through telehealth. A few respondents attributed this to potential technology glitches that made these conversations inappropriate. Respondents also reported that patients had expectations of a physical examination that may not be met when conducted via telehealth, potentially leaving the patient feeling unsatisfied.

    Conversely, some respondents found telehealth to augment the patient experience as it provided more frequent follow-up and enhanced convenience, particularly regarding transportation difficulties or when follow-up questions arose after an in-person encounter. Several respondents also viewed telehealth as having the potential to improve the family’s experience of care by providing additional educational sessions to supplement in-person encounters and involving family members in video visit conversations who otherwise would be unable to attend.

    Perceptions of Access to Care

    Respondents reported several ways in which they felt telehealth improved access to care (Table 4). One noted that for patients living far from large, comprehensive cancer centers, telehealth allowed them to receive treatment locally while remaining under the care of experts who specialize in their type of cancer. Furthermore, for patients with responsibilities at home, such as caring for children or elderly parents, telehealth increased their ability to see their oncologist. One respondent felt that telehealth allowed for concerns to be addressed in real time and increased availability of in-person appointments for critically ill patients. However, another respondent felt that addressing acute issues via telehealth, rather than an office visit, could lead to delays in important interventions, such as hospital admission.

    Finally, respondents felt as though telehealth visits, and specifically the technology required to perform them, were restrictive for older patients, patients who did not speak English, and for those with limited socioeconomic resources.

    Perceptions of Financial Impact or Cost

    Respondents had starkly different opinions regarding the financial impact of care (Table 5). Some reported that the copayment for a telehealth visit was unacceptable to patients who did not view video visits as “real” or equal to in-person appointments. Others felt as though the costs eliminated by telehealth visits, such as parking, gas, tolls, and lost work time made them cost-beneficial for patients. Overall, the ambiguity of insurance coverage status for telehealth and the inability to accurately estimate the copayment cost were negative aspects of video visits identified by several respondents.

    Discussion

    In this single-center, qualitative study we examined medical oncologists’ perception of the benefits of and barriers to telehealth video visits for patients. We found that respondents often had conflicting opinions regarding the clinical efficacy, quality of patient experience, accessibility, and financial impact of telehealth. Health professionals’ perceptions of telehealth and of the patient experience are critical, as previous research has demonstrated that health professional acceptance of telehealth is fundamental to telehealth adoption.19 Concerns regarding the clinical efficacy of a telehealth physical examination are the most commonly reported challenges for the virtual management of cancer during the COVID-19 pandemic.20 Our institution offers training in performing a virtual physical examination; however, to our knowledge no research or practice advisories have been published regarding the technique of a virtual physical examination for cancer care. Future research regarding the efficacy of the virtual physical examination, as well as practice recommendations, are necessary given the rapid rise of telehealth for oncologic care.

    While recognizing the convenience of telehealth, many respondents emphasized the importance of the health professional-patient relationship in oncology and voiced concerns that patients would feel unsupported, particularly regarding serious or bad news delivery. While our study demonstrated that many respondents felt there was a reduced health professional-patient bond that resulted in a worse patient experience compared with in-person visits, this perception is not universal. Previously, telehealth has been suggested as a means to facilitate a patient-centered care approach that decreases the anxiety associated with an in-person consultation regarding bad news in oncologic care.21 This perspective is supported by a study of 351 patients with cancer that found the most important elements for patients receiving information about their cancer were factors related to content, including the physician’s knowledge or competence. Elements related to support—including factors such as being comforted or showing concern; and facilitation, which included being told in a private setting or in person—were rated lower, but still regarded as important by patients.22 Notably, this study, among others, recognized the individual preferences of patients and found that these preferences have been associated with certain demographic factors such as gender, age, education, and patient faith in their physician.21,23 Patient acceptability of telehealth regarding the delivery of bad news is still largely unknown. However, our study indicated that many health professionals find this mode of delivery to be inappropriate. Future research is necessary to examine how patients view the acceptability of telehealth in regards to receiving bad news or complex information about their oncologic care.

    It is important to note that all but 1 interview was conducted between October 30 and November 22, 2019. Therefore, this study is limited in its ability to assess current perceptions of medical oncology health professionals, whose views of telehealth may have changed after a surge in use during the COVID-19 pandemic. Our cancer center’s internal report showed an increase in telehealth appointments, from 1.0% of all visits in February 2020 to 52.4% in April 2020. To assist in the rapid expansion of video visit use necessitated by COVID-19, our institution developed an oncology telehealth task force. The task force facilitated patient enrollment in the video application system, triaged and scheduled appointments, and coordinated technology test visits prior to video visit appointments. Although the formal impact of the task force has not been reported, it is possible that its efforts mitigated previously identified challenges in video visit use. In order to investigate the changing perceptions of telehealth during the COVID-19 pandemic, we have an ongoing study reevaluating oncology health professionals’ insights at our institution.

    Many respondents found the copayment associated with telehealth and overall ambiguity regarding coverage of telehealth to be major limitations to their use. According to the Center for Connected Health Policy, as of April 30, 2020, in response to COVID-19, several private insurers, including Aetna, Cigna, and BlueCross BlueShield, announced that they would offer telehealth services at no charge to the patient during the pandemic.24 Pennsylvania Medicaid announced that health professionals should bill the same for video visits and in-person visits.25 Although Medicaid did not officially change its cost-sharing requirements for its beneficiaries, it did allow health professionals to reduce or waive cost-sharing for telehealth visits without the risk of facing administrative sanctions.26 Furthermore, Medicare waived some prior restrictions to accessing telehealth to allow any beneficiary, not only those in rural areas, to receive telehealth services, to do so from their homes, and to use a smart-phone in lieu of other equipment such as computers or tablets.27 While it remains unclear how long these changes will last, COVID-19 has ushered in a new era for telehealth services, and further research regarding the barriers to offering them due to perceived financial impact is necessary.

    Limitations

    This study had several limitations. All participants were health professionals at a single, urban, academic cancer center, and thus results may have limited transferability to different geographic settings. In addition, the majority of respondents (48.3%) practiced liquid oncology, treating tumors such as leukemia and lymphoma. This may have disproportionately represented perceptions unique to treating these cancer types, which in 2019 accounted for only approximately 10% of all new cancer cases in the US.28 However, our study did have a representative sample of health professionals based on gender and racial diversity in oncology, as 15 of 29 participants (52%) were women, and 2 of 29 (7%) were Black. According to the American Society of Clinical Oncology, 32% of oncologists are women and 2.3% are Black.29 Although initial recruitment was conducted by 2 authors working at the cancer center (N.H. and A.B.), all subsequent communication with participants and recruitment was conducted by nonclinical team members (A.G., R.G., and A.H.) to minimize participation bias.

    Though this study demonstrated health professionals’ perceptions of the barriers to and benefits of telehealth for oncologic care, further research is necessary. Perceptions of telehealth acceptability, including specific benefits and disadvantages, may have changed given the rapid expansion of telehealth secondary to the COVID-19 pandemic and the establishment of the medical oncology telehealth taskforce at our institution. Furthermore, it is critical to directly examine patient perceptions of telehealth and whether the patient experience of telehealth, as well as its potential limitations and benefits, align with those of health professionals.

    Conclusions

    This study demonstrated the conflicting opinions of medical oncology health professionals on telehealth and provides insight into potential barriers or limitations to its utilization, as well as the benefits of this health care delivery modality. More specifically, our results emphasize the need to address oncology patients’ access to telehealth technology, especially for older populations, and the acceptability of delivering serious or bad news as telehealth continues to change the landscape of patient-health professional interactions. This is especially relevant during the COVID-19 pandemic, as many institutions worldwide have needed to create or expand telehealth programs.

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    Article Information

    Accepted for Publication: November 28, 2020.

    Published: January 14, 2021. doi:10.1001/jamanetworkopen.2020.33967

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Heyer A et al. JAMA Network Open.

    Corresponding Author: Arianna Heyer, BA, Sidney Kimmel Medical College, 1025 Walnut St, Ste 700, Philadelphia, PA 19107 (Arianna.heyer@jefferson.edu).

    Author Contributions: Dr Handley, the principal investigator, had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Mss Heyer and Granberg were co–first authors.

    Concept and design: Heyer, Rising, Binder, Handley.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Heyer, Granberg, Rising, Binder, Handley.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Heyer, Granberg, Gentsch.

    Obtained funding: Binder, Handley.

    Administrative, technical, or material support: Heyer, Rising, Gentsch, Handley.

    Supervision: Rising, Binder, Handley.

    Conflict of Interest Disclosures: Dr Handley reported serving as the site principal investigator for a multi-center phase 3 clinical trial sponsored by Nektar Therapeutics, ending on June 30, 2020, outside the submitted work. No other disclosures were reported.

    Funding/Support: This research was funded through the Provost’s Pilot Clinical Research Award, an internal grant at Thomas Jefferson University. The principal investigator receiving the award was Dr Handley, and the coinvestigators were Drs Binder and Rising. Publication was made possible in part by support from the Thomas Jefferson University Open Access Fund, the Jefferson College of Population Health, and the Sidney Kimmel Medical College.

    Role of the Funder/Sponsor: The funders 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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