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Published in: BMC Health Services Research 1/2008

Open Access 01-12-2008 | Research article

The relationship between depressive symptoms, health service consumption, and prognosis after acute myocardial infarction: a prospective cohort study

Authors: Paul A Kurdyak, William H Gnam, Paula Goering, Alice Chong, David A Alter

Published in: BMC Health Services Research | Issue 1/2008

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Abstract

Background

The use of cardiovascular health services is greater among patients with depressive symptoms than among patients without. However, the extent to which such associations between depressive symptoms and health service utilization are attributable to variations in comorbidity and prognostic disease severity is unknown. This paper explores the relationship between depressive symptoms, health service cardiovascular consumption, and prognosis following acute myocardial infarction (AMI).

Methods

The study design was a prospective cohort study with follow-up telephone interviews of 1,941 patients 30 days following AMI discharged from 53 hospitals across Ontario, Canada between December 1999 and February, 2003. Outcome measures were post discharge use of cardiac and non-cardiac health care services. The service utilization outcomes were adjusted for age, sex, income, comorbidity, two validated measures of prognosis (cardiac functional capacity and risk adjustment severity index), cardiac procedures (CABG or PTCA) and drugs prescribed at discharge.

Results

Depressive symptoms were associated with a 24% (Adjusted RR:1.24; 95% CI:1.19–1.30, P < 0.001), 9% (Adjusted RR:1.09; 95% CI:1.02–1.16, P = 0.007) and 43% (Adjusted RR: 1.43; 95% CI:1.34–1.52, P < 0.001) increase in total, cardiac, and non-cardiac hospitalization days post-AMI respectively, after adjusting for baseline patient and hospital characteristics. Depressive-associated increases in cardiac health service consumption were significantly more pronounced among patients of lower than higher cardiac risk severity. Depressive symptoms were not associated with increased mortality after adjusting for baseline patient characteristics.

Conclusion

Depressive symptoms are associated with significantly higher cardiac and non-cardiac health service consumption following AMI despite adjustments for comorbidity and prognostic severity. The disproportionately higher cardiac health service consumption among lower-risk AMI depressive patients may suggest that health seeking behaviors are mediated by psychosocial factors more so than by objective measures of cardiovascular risk or necessity.
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Literature
1.
go back to reference Simon G, Ormel J, VonKorff M, Barlow W: Health care costs associated with depressive and anxiety disorders in primary care. American Journal of Psychiatry. 1995, 152: 352-357.CrossRefPubMed Simon G, Ormel J, VonKorff M, Barlow W: Health care costs associated with depressive and anxiety disorders in primary care. American Journal of Psychiatry. 1995, 152: 352-357.CrossRefPubMed
2.
go back to reference Unutzer J, Patrick DL, Simon G, Grembowski D, Walker E, Rutter C, Katon W: Depressive symptoms and the cost of health services in HMO patients aged 65 years and older. A 4-year prospective study. JAMA. 1997, 277: 1618-1623. 10.1001/jama.277.20.1618.CrossRefPubMed Unutzer J, Patrick DL, Simon G, Grembowski D, Walker E, Rutter C, Katon W: Depressive symptoms and the cost of health services in HMO patients aged 65 years and older. A 4-year prospective study. JAMA. 1997, 277: 1618-1623. 10.1001/jama.277.20.1618.CrossRefPubMed
3.
go back to reference Frasure-Smith N, Lesperance F, Gravel G, Masson A, Juneau M, Talajic M, Bourassa MG: Depression and health-care costs during the first year following myocardial infarction. J Psychosom Res. 2000, 48: 471-478. 10.1016/S0022-3999(99)00088-4.CrossRefPubMed Frasure-Smith N, Lesperance F, Gravel G, Masson A, Juneau M, Talajic M, Bourassa MG: Depression and health-care costs during the first year following myocardial infarction. J Psychosom Res. 2000, 48: 471-478. 10.1016/S0022-3999(99)00088-4.CrossRefPubMed
4.
go back to reference Jiang W, Alexander J, Christopher E, Kuchibhatla M, Gaulden LH, Cuffe MS, Blazing MA, Davenport C, Califf RM, Krishnan RR, O'Connor CM: Relationship of depression to increased risk of mortality and rehospitalization in patients with congestive heart failure. Arch Intern Med. 2001, 161: 1849-1856. 10.1001/archinte.161.15.1849.CrossRefPubMed Jiang W, Alexander J, Christopher E, Kuchibhatla M, Gaulden LH, Cuffe MS, Blazing MA, Davenport C, Califf RM, Krishnan RR, O'Connor CM: Relationship of depression to increased risk of mortality and rehospitalization in patients with congestive heart failure. Arch Intern Med. 2001, 161: 1849-1856. 10.1001/archinte.161.15.1849.CrossRefPubMed
5.
go back to reference Lett HS, Blumenthal JA, Babyak MA, Sherwood A, Strauman T, Robins C, Newman MF: Depression as a risk factor for coronary artery disease: evidence, mechanisms, and treatment. Psychosomatic Medicine. 2004, 66: 305-315. 10.1097/01.psy.0000126207.43307.c0.PubMed Lett HS, Blumenthal JA, Babyak MA, Sherwood A, Strauman T, Robins C, Newman MF: Depression as a risk factor for coronary artery disease: evidence, mechanisms, and treatment. Psychosomatic Medicine. 2004, 66: 305-315. 10.1097/01.psy.0000126207.43307.c0.PubMed
6.
go back to reference Katon W: The impact of major depression on chronic medical illness. Gen Hosp Psychiatry. 1996, 18: 215-219. 10.1016/0163-8343(96)00065-5.CrossRefPubMed Katon W: The impact of major depression on chronic medical illness. Gen Hosp Psychiatry. 1996, 18: 215-219. 10.1016/0163-8343(96)00065-5.CrossRefPubMed
7.
go back to reference Fox KA, Dabbous OH, Goldberg RJ, Pieper KS, Eagle KA, Werf Van de F, Avezum A, Goodman SG, Flather MD, Anderson FAJ, Granger CB: Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE). BMJ. 2006, 333: 1091-10.1136/bmj.38985.646481.55.CrossRefPubMedPubMedCentral Fox KA, Dabbous OH, Goldberg RJ, Pieper KS, Eagle KA, Werf Van de F, Avezum A, Goodman SG, Flather MD, Anderson FAJ, Granger CB: Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE). BMJ. 2006, 333: 1091-10.1136/bmj.38985.646481.55.CrossRefPubMedPubMedCentral
8.
go back to reference Granger CB, Goldberg RJ, Dabbous O, Pieper KS, Eagle KA, Cannon CP, Werf Van De F, Avezum A, Goodman SG, Flather MD, Fox KA: Predictors of hospital mortality in the global registry of acute coronary events. Arch Intern Med. 2003, 163: 2345-2353. 10.1001/archinte.163.19.2345.CrossRefPubMed Granger CB, Goldberg RJ, Dabbous O, Pieper KS, Eagle KA, Cannon CP, Werf Van De F, Avezum A, Goodman SG, Flather MD, Fox KA: Predictors of hospital mortality in the global registry of acute coronary events. Arch Intern Med. 2003, 163: 2345-2353. 10.1001/archinte.163.19.2345.CrossRefPubMed
9.
go back to reference Chen J, Rathore SS, Radford MJ, Wang Y, Krumholz HM: Racial differences in the use of cardiac catheterization after acute myocardial infarction. New England Journal of Medicine. 2001, 344: 1443-1449. 10.1056/NEJM200105103441906.CrossRefPubMed Chen J, Rathore SS, Radford MJ, Wang Y, Krumholz HM: Racial differences in the use of cardiac catheterization after acute myocardial infarction. New England Journal of Medicine. 2001, 344: 1443-1449. 10.1056/NEJM200105103441906.CrossRefPubMed
10.
go back to reference Alter DA, Iron K, Austin PC, Naylor CD: Socioeconomic status, service patterns, and perceptions of care among survivors of acute myocardial infarction in Canada. JAMA. 2004, 291: 1100-1107. 10.1001/jama.291.9.1100.CrossRefPubMed Alter DA, Iron K, Austin PC, Naylor CD: Socioeconomic status, service patterns, and perceptions of care among survivors of acute myocardial infarction in Canada. JAMA. 2004, 291: 1100-1107. 10.1001/jama.291.9.1100.CrossRefPubMed
12.
go back to reference Koenig HG, Meador KG, Cohen HJ, Blazer DG: Self-rated depression scales and screening for major depression in the older hospitalized patient with medical illness. Journal of the American Geriatrics Society. 1988, 36: 699-706.CrossRefPubMed Koenig HG, Meador KG, Cohen HJ, Blazer DG: Self-rated depression scales and screening for major depression in the older hospitalized patient with medical illness. Journal of the American Geriatrics Society. 1988, 36: 699-706.CrossRefPubMed
13.
go back to reference Association AP: 2000, Washington, DC: American Psychiatric Association Association AP: 2000, Washington, DC: American Psychiatric Association
14.
go back to reference Mark DB, Naylor CD, Hlatky MA, Califf RM, Topol EJ, Granger CB, Knight JD, Nelson CL, Lee KL, Clapp-Channing NE, et al: Use of medical resources and quality of life after acute myocardial infarction in Canada and the United States. New England Journal of Medicine. 1994, 331: 1130-1135. 10.1056/NEJM199410273311706.CrossRefPubMed Mark DB, Naylor CD, Hlatky MA, Califf RM, Topol EJ, Granger CB, Knight JD, Nelson CL, Lee KL, Clapp-Channing NE, et al: Use of medical resources and quality of life after acute myocardial infarction in Canada and the United States. New England Journal of Medicine. 1994, 331: 1130-1135. 10.1056/NEJM199410273311706.CrossRefPubMed
15.
go back to reference Alter DA, Brandes S, Irvine J, Iron K: Impact of socioeconomic status on cardiovascular outcomes in Canada. Expert Review of Pharmacoeconomics Outcomes Research. 2003, 3: 691-702. 10.1586/14737167.3.6.691.CrossRefPubMed Alter DA, Brandes S, Irvine J, Iron K: Impact of socioeconomic status on cardiovascular outcomes in Canada. Expert Review of Pharmacoeconomics Outcomes Research. 2003, 3: 691-702. 10.1586/14737167.3.6.691.CrossRefPubMed
16.
go back to reference Alter DA, Venkatesh V, Chong A: Evaluating the performance of the Global Registry of Acute Coronary Events risk-adjustment index across socioeconomic strata among patients discharged from the hospital after acute myocardial infarction. American Heart Journal. 2006, 151: 323-331. 10.1016/j.ahj.2005.07.013.CrossRefPubMed Alter DA, Venkatesh V, Chong A: Evaluating the performance of the Global Registry of Acute Coronary Events risk-adjustment index across socioeconomic strata among patients discharged from the hospital after acute myocardial infarction. American Heart Journal. 2006, 151: 323-331. 10.1016/j.ahj.2005.07.013.CrossRefPubMed
17.
go back to reference Hlatky MA, Boineau RE, Higginbotham MB, Lee KL, Mark DB, Califf RM, Cobb FR, Pryor DB: A brief self-administered questionnaire to determine functional capacity (the Duke Activity Status Index). American Journal of Cardiology. 1989, 64: 651-654. 10.1016/0002-9149(89)90496-7.CrossRefPubMed Hlatky MA, Boineau RE, Higginbotham MB, Lee KL, Mark DB, Califf RM, Cobb FR, Pryor DB: A brief self-administered questionnaire to determine functional capacity (the Duke Activity Status Index). American Journal of Cardiology. 1989, 64: 651-654. 10.1016/0002-9149(89)90496-7.CrossRefPubMed
18.
go back to reference Vanhees L, Fagard R, Thijs L, Staessen J, Amery A: Prognostic significance of peak exercise capacity in patients with coronary artery disease. Journal of the American College of Cardiology. 1994, 23: 358-363.CrossRefPubMed Vanhees L, Fagard R, Thijs L, Staessen J, Amery A: Prognostic significance of peak exercise capacity in patients with coronary artery disease. Journal of the American College of Cardiology. 1994, 23: 358-363.CrossRefPubMed
19.
go back to reference Gravely-Witte S, Stewart DE, Suskin N, Higginson L, Alter DA, Grace SL: Cardiologists' charting varied by risk factor, and was often discordant with patient report. J Clin Epidemiol. 2008, 61 (10): 1073-1079. 10.1016/j.jclinepi.2007.11.017.CrossRefPubMedPubMedCentral Gravely-Witte S, Stewart DE, Suskin N, Higginson L, Alter DA, Grace SL: Cardiologists' charting varied by risk factor, and was often discordant with patient report. J Clin Epidemiol. 2008, 61 (10): 1073-1079. 10.1016/j.jclinepi.2007.11.017.CrossRefPubMedPubMedCentral
20.
go back to reference Alter DA, Chong A, Austin PC, Mustard C, Iron K, Williams JI, Morgan CD, Tu JV, Irvine J, Naylor CD: Socioeconomic status and mortality after acute myocardial infarction. Annals of Internal Medicine. 2006, 144: 82-93.CrossRefPubMed Alter DA, Chong A, Austin PC, Mustard C, Iron K, Williams JI, Morgan CD, Tu JV, Irvine J, Naylor CD: Socioeconomic status and mortality after acute myocardial infarction. Annals of Internal Medicine. 2006, 144: 82-93.CrossRefPubMed
21.
go back to reference Zhang JX, Iwashyna TJ, Christakis NA: The performance of different lookback periods and sources of information for Charlson comorbidity adjustment in Medicare claims. Medical Care. 1999, 37: 1128-1139. 10.1097/00005650-199911000-00005.CrossRefPubMed Zhang JX, Iwashyna TJ, Christakis NA: The performance of different lookback periods and sources of information for Charlson comorbidity adjustment in Medicare claims. Medical Care. 1999, 37: 1128-1139. 10.1097/00005650-199911000-00005.CrossRefPubMed
22.
go back to reference Sytkowski PA, Kannel WB, D'Agostino RB: Changes in risk factors and the decline in mortality from cardiovascular disease. The Framingham Heart Study. New England Journal of Medicine. 1990, 322: 1635-1641.CrossRefPubMed Sytkowski PA, Kannel WB, D'Agostino RB: Changes in risk factors and the decline in mortality from cardiovascular disease. The Framingham Heart Study. New England Journal of Medicine. 1990, 322: 1635-1641.CrossRefPubMed
23.
go back to reference Kerr EA, Heisler M, Krein SL, Kabeto M, Langa KM, Weir D, Piette JD: Beyond comorbidity counts: how do comorbidity type and severity influence diabetes patients' treatment priorities and self-management?. Journal of General Internal Medicine. 2007, 22: 1635-1640. 10.1007/s11606-007-0313-2.CrossRefPubMedPubMedCentral Kerr EA, Heisler M, Krein SL, Kabeto M, Langa KM, Weir D, Piette JD: Beyond comorbidity counts: how do comorbidity type and severity influence diabetes patients' treatment priorities and self-management?. Journal of General Internal Medicine. 2007, 22: 1635-1640. 10.1007/s11606-007-0313-2.CrossRefPubMedPubMedCentral
24.
go back to reference Austin PC, Daly PA, Tu JV: A multicenter study of the coding accuracy of hospital discharge administrative data for patients admitted to cardiac care units in Ontario. American Heart Journal. 2002, 144: 290-296. 10.1067/mhj.2002.123839.CrossRefPubMed Austin PC, Daly PA, Tu JV: A multicenter study of the coding accuracy of hospital discharge administrative data for patients admitted to cardiac care units in Ontario. American Heart Journal. 2002, 144: 290-296. 10.1067/mhj.2002.123839.CrossRefPubMed
25.
go back to reference Little RJA, Rubin D: Statistical analysis with missing data. 2002, New York: Wiley, 2 Little RJA, Rubin D: Statistical analysis with missing data. 2002, New York: Wiley, 2
26.
go back to reference Frasure-Smith N, Lesperance F, Talajic M: Depression and 18-month prognosis after myocardial infarction. Circulation. 1995, 91: 999-1005.CrossRefPubMed Frasure-Smith N, Lesperance F, Talajic M: Depression and 18-month prognosis after myocardial infarction. Circulation. 1995, 91: 999-1005.CrossRefPubMed
27.
go back to reference van Melle JP, de Jonge P, Spijkerman TA, Tijssen JG, Ormel J, van Veldhuisen DJ, Brink van den RH, Berg van den MP: Prognostic association of depression following myocardial infarction with mortality and cardiovascular events: a meta-analysis. Psychosomatic Medicine. 2004, 66: 814-822. 10.1097/01.psy.0000146294.82810.9c.CrossRefPubMed van Melle JP, de Jonge P, Spijkerman TA, Tijssen JG, Ormel J, van Veldhuisen DJ, Brink van den RH, Berg van den MP: Prognostic association of depression following myocardial infarction with mortality and cardiovascular events: a meta-analysis. Psychosomatic Medicine. 2004, 66: 814-822. 10.1097/01.psy.0000146294.82810.9c.CrossRefPubMed
28.
go back to reference Lane D, Carroll D, Ring C, Beevers DG, Lip GY: Mortality and quality of life 12 months after myocardial infarction: effects of depression and anxiety. Psychosomatic Medicine. 2001, 63: 221-230.CrossRefPubMed Lane D, Carroll D, Ring C, Beevers DG, Lip GY: Mortality and quality of life 12 months after myocardial infarction: effects of depression and anxiety. Psychosomatic Medicine. 2001, 63: 221-230.CrossRefPubMed
29.
go back to reference Sorensenf C, Friis-Hasche E, Haghfelt T, Bech P: Postmyocardial infarction mortality in relation to depression: a systematic critical review. Psychother Psychosom. 2005, 74: 69-80. 10.1159/000083165.CrossRefPubMed Sorensenf C, Friis-Hasche E, Haghfelt T, Bech P: Postmyocardial infarction mortality in relation to depression: a systematic critical review. Psychother Psychosom. 2005, 74: 69-80. 10.1159/000083165.CrossRefPubMed
30.
go back to reference Dickens C, McGowan L, Percival C, Tomenson B, Cotter L, Heagerty A, Creed F: Depression is a risk factor for mortality after myocardial infarction: fact or artifact?. Journal of the American College of Cardiology. 2007, 49: 1834-1840. 10.1016/j.jacc.2007.01.075.CrossRefPubMed Dickens C, McGowan L, Percival C, Tomenson B, Cotter L, Heagerty A, Creed F: Depression is a risk factor for mortality after myocardial infarction: fact or artifact?. Journal of the American College of Cardiology. 2007, 49: 1834-1840. 10.1016/j.jacc.2007.01.075.CrossRefPubMed
31.
go back to reference Ko DT, Mamdani M, Alter DA: Lipid-lowering therapy with statins in high-risk elderly patients: the treatment-risk paradox. JAMA. 2004, 291: 1864-1870. 10.1001/jama.291.15.1864.CrossRefPubMed Ko DT, Mamdani M, Alter DA: Lipid-lowering therapy with statins in high-risk elderly patients: the treatment-risk paradox. JAMA. 2004, 291: 1864-1870. 10.1001/jama.291.15.1864.CrossRefPubMed
32.
go back to reference Lee DS, Tu JV, Juurlink DN, Alter DA, Ko DT, Austin PC, Chong A, Stukel TA, Levy D, Laupacis A: Risk-treatment mismatch in the pharmacotherapy of heart failure. JAMA. 2005, 294: 1240-1247. 10.1001/jama.294.10.1240.CrossRefPubMed Lee DS, Tu JV, Juurlink DN, Alter DA, Ko DT, Austin PC, Chong A, Stukel TA, Levy D, Laupacis A: Risk-treatment mismatch in the pharmacotherapy of heart failure. JAMA. 2005, 294: 1240-1247. 10.1001/jama.294.10.1240.CrossRefPubMed
33.
go back to reference Barsky AJ, Orav EJ, Bates DW: Somatization increases medical utilization and costs independent of psychiatric and medical comorbidity. Arch Gen Psychiatry. 2005, 62: 903-910. 10.1001/archpsyc.62.8.903.CrossRefPubMed Barsky AJ, Orav EJ, Bates DW: Somatization increases medical utilization and costs independent of psychiatric and medical comorbidity. Arch Gen Psychiatry. 2005, 62: 903-910. 10.1001/archpsyc.62.8.903.CrossRefPubMed
34.
go back to reference Guadagnoli E, Hauptman PJ, Ayanian JZ, Pashos CL, McNeil BJ, Cleary PD: Variation in the use of cardiac procedures after acute myocardial infarction. New England Journal of Medicine. 1995, 333: 573-578. 10.1056/NEJM199508313330908.CrossRefPubMed Guadagnoli E, Hauptman PJ, Ayanian JZ, Pashos CL, McNeil BJ, Cleary PD: Variation in the use of cardiac procedures after acute myocardial infarction. New England Journal of Medicine. 1995, 333: 573-578. 10.1056/NEJM199508313330908.CrossRefPubMed
35.
go back to reference Muller DW, Topol EJ, Califf RM, Sigmon KN, Gorman L, George BS, Kereiakes DJ, Lee KL, Ellis SG: Relationship between antecedent angina pectoris and short-term prognosis after thrombolytic therapy for acute myocardial infarction. Thrombolysis and Angioplasty in Myocardial Infarction (TAMI) Study Group. American Heart Journal. 1990, 119: 224-231. 10.1016/S0002-8703(05)80008-0.CrossRefPubMed Muller DW, Topol EJ, Califf RM, Sigmon KN, Gorman L, George BS, Kereiakes DJ, Lee KL, Ellis SG: Relationship between antecedent angina pectoris and short-term prognosis after thrombolytic therapy for acute myocardial infarction. Thrombolysis and Angioplasty in Myocardial Infarction (TAMI) Study Group. American Heart Journal. 1990, 119: 224-231. 10.1016/S0002-8703(05)80008-0.CrossRefPubMed
36.
go back to reference Clark AM, Hartling L, Vandermeer B, McAlister FA: Meta-analysis: secondary prevention programs for patients with coronary artery disease. Annals of Internal Medicine. 2005, 143: 659-672.CrossRefPubMed Clark AM, Hartling L, Vandermeer B, McAlister FA: Meta-analysis: secondary prevention programs for patients with coronary artery disease. Annals of Internal Medicine. 2005, 143: 659-672.CrossRefPubMed
37.
go back to reference Ciechanowski P, Wagner E, Schmaling K, Schwartz S, Williams B, Diehr P, Kulzer J, Gray S, Collier C, LoGerfo J: Community-integrated home-based depression treatment in older adults: a randomized controlled trial. JAMA. 2004, 291: 1569-1577. 10.1001/jama.291.13.1569.CrossRefPubMed Ciechanowski P, Wagner E, Schmaling K, Schwartz S, Williams B, Diehr P, Kulzer J, Gray S, Collier C, LoGerfo J: Community-integrated home-based depression treatment in older adults: a randomized controlled trial. JAMA. 2004, 291: 1569-1577. 10.1001/jama.291.13.1569.CrossRefPubMed
38.
go back to reference Thombs BD, Bass EB, Ford DE, Stewart KJ, Tsilidis KK, Patel U, Fauerbach JA, Bush DE, Ziegelstein RC: Prevalence of depression in survivors of acute myocardial infarction. Journal of General Internal Medicine. 2006, 21: 30-38. 10.1111/j.1525-1497.2005.00269.x.CrossRefPubMedPubMedCentral Thombs BD, Bass EB, Ford DE, Stewart KJ, Tsilidis KK, Patel U, Fauerbach JA, Bush DE, Ziegelstein RC: Prevalence of depression in survivors of acute myocardial infarction. Journal of General Internal Medicine. 2006, 21: 30-38. 10.1111/j.1525-1497.2005.00269.x.CrossRefPubMedPubMedCentral
39.
go back to reference Amin AA, Jones AMH, Nugent K, Rumsfeld JS, Spertus JA: The prevalence of unrecognized depression in patients with acute coronary syndrome. American Heart Journal. 2006, 152: 928-934. 10.1016/j.ahj.2006.05.006.CrossRefPubMed Amin AA, Jones AMH, Nugent K, Rumsfeld JS, Spertus JA: The prevalence of unrecognized depression in patients with acute coronary syndrome. American Heart Journal. 2006, 152: 928-934. 10.1016/j.ahj.2006.05.006.CrossRefPubMed
Metadata
Title
The relationship between depressive symptoms, health service consumption, and prognosis after acute myocardial infarction: a prospective cohort study
Authors
Paul A Kurdyak
William H Gnam
Paula Goering
Alice Chong
David A Alter
Publication date
01-12-2008
Publisher
BioMed Central
Published in
BMC Health Services Research / Issue 1/2008
Electronic ISSN: 1472-6963
DOI
https://doi.org/10.1186/1472-6963-8-200

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