Loss to follow up among men who have sex with men and heterosexual men living with HIV in Haiti

2020 ◽  
Vol 30 (Supplement_5) ◽  
Author(s):  
W Dunbar ◽  
N Sohler ◽  
Y Coppieters
Keyword(s):  
Proportional Hazards ◽  
Cox Proportional Hazards ◽  
Hiv Treatment ◽  
Hiv Care ◽  
Rank Test ◽  
Heterosexual Men ◽  
Loss To Follow Up ◽  
Sex With Men ◽  
Living With Hiv

Abstract Background Despite the benefits of adherence in HIV medication, health systems are struggling to keep all categories of patients in care due to loss to follow up (LTFU). Men who have sex with men (MSM) are at higher risk of HIV infection and also face several barriers to reach treatment, it is hypothesized that they may also have higher incidence of dropping-off. This study aims to determine whether MSM living with HIV have a greater risk of LTFU compared with heterosexual men and to identify the risk factors for the two groups. Methods A retrospective matched cohort study of electronic medical record data from 554 patients living with HIV and enrolled in care between 2015 and 2018 at a Port-au-Prince-based HIV clinic was performed. The 125 MSM and 429 heterosexual patients were matched on gender age and enrolment date. The primary outcome was LTFU defined as not refilling an ART prescription for a period of 90 days. MSM and heterosexual men was compared using t-tests and chi-square tests. The Kaplan-Meier technique was used to estimate time to LTFU after initiation of ART and the Cox Proportional Hazards regression model was used to determine predictors of LTFU. Results The sample had a mean age of 31.1 years (SD 8.0) for MSM and 32.4 years (SD 7.7) for heterosexual men. LTFU was significantly more common among the MSM group than the heterosexual group (MSM 48.8%, heterosexual men 34.7%; p = 0.012). Factors associated with LTFU were greater amongst younger patients, with lower educational and economic level. The median time to LTFU for MSM was 679 days and 1110 days for heterosexual men. The log rank test showed that this is statistically significant at p = 0.001. Conclusions This study showed that the risk of LTFU is significantly higher and the time to LTFU is significantly shorter for MSM relative to heterosexual men. Identifying predictors to LTFU in HIV clinical settings and providing appropriate services and supports are important steps in addressing this issue. Key messages Men who have sex with men continue to face barriers to effective HIV treatment in Haiti. Adapted interventions are needed to improve HIV care for Men who have sex with Men in Haiti.

scholarly journals Influence of Smoking Habits on the Prevalence of Dental Caries: A Register-Based Cohort Study

2021 ◽  
Author(s):  
Miguel A. de Araújo Nobre ◽  
Ana M. Sezinando ◽  
Inês C. Fernandes ◽  
Andreia C. Araújo
Keyword(s):  
Dental Caries ◽  
Proportional Hazards ◽  
Smoking Habit ◽  
Cox Proportional Hazards ◽  
Radiographic Examination ◽  
Rank Test ◽  
Significance Level ◽  
Cumulative Survival ◽  
Caries Lesions

Abstract Objective The study aimed to evaluate the influence of smoking habit on the prevalence of dental caries lesions in a follow-up study. Materials and Methods A total of 3,675 patients (2,186 females and 1,489 males) with an average age of 51.4 years were included. Outcome measures were the incidence of dental caries defined as incipient noncavitated, microcavitated, or cavitated lesions which had been diagnosed through clinical observation with mouth mirror and probe examination evaluating change of texture, translucency, and color; radiographic examination through bitewing radiographs; or secondary caries through placement of a new restoration during the follow-up of the study. Statistical Analysis Cumulative survival (time elapsed with absence of dental caries) was estimated through the Kaplan–Meier product limit estimator with comparison of survival curves (log-rank test). A multivariable Cox proportional hazards regression model was used to evaluate the effect of smoking on the incidence of dental caries lesions when controlled to age, gender, systemic status, frequency of dental hygiene appointments, and socioeconomic status. The significance level was set at 5%. Results Eight hundred sixty-three patients developed caries (23.5% incidence rate). The cumulative survival estimation was 81.8% and 48% survival rate for nonsmokers and smokers, respectively (p < 0.001), with an average of 13.5 months between the healthy and diseased state diagnosis. Smokers registered a hazard ratio for dental caries lesions of 1.32 (p = 0.001) when controlled for the other variables of interest. Conclusion Within the limitations of this study, it was concluded that smoking habit might be a predictor for dental caries.

The Efficacy of Etoposide-Based Therapy in Adult Secondary Hemophagocytic Lymphohistiocytosis

2021 ◽  
pp. 1-9
Author(s):  
Leonard Naymagon ◽  
Douglas Tremblay ◽  
John Mascarenhas
Keyword(s):  
Hemophagocytic Lymphohistiocytosis ◽  
Proportional Hazards ◽  
Multivariable Analysis ◽  
Cox Proportional Hazards ◽  
Rank Test ◽  
Kaplan Meier ◽  
Hazard Ratios ◽  
Significant Difference ◽  
The Impact

Data supporting the use of etoposide-based therapy in hemophagocytic lymphohistiocytosis (HLH) arise largely from pediatric studies. There is a lack of comparable data among adult patients with secondary HLH. We conducted a retrospective study to assess the impact of etoposide-based therapy on outcomes in adult secondary HLH. The primary outcome was overall survival. The log-rank test was used to compare Kaplan-Meier distributions of time-to-event outcomes. Multivariable Cox proportional hazards modeling was used to estimate adjusted hazard ratios (HRs) with 95% confidence intervals (CIs). Ninety adults with secondary HLH seen between January 1, 2009, and January 6, 2020, were included. Forty-two patients (47%) received etoposide-based therapy, while 48 (53%) received treatment only for their inciting proinflammatory condition. Thirty-three patients in the etoposide group (72%) and 32 in the no-etoposide group (67%) died during follow-up. Median survival in the etoposide and no-etoposide groups was 1.04 and 1.39 months, respectively. There was no significant difference in survival between the etoposide and no-etoposide groups (log-rank <i>p</i> = 0.4146). On multivariable analysis, there was no association between treatment with etoposide and survival (HR for death with etoposide = 1.067, 95% CI: 0.633–1.799, <i>p</i> = 0.8084). Use of etoposide-based therapy was not associated with improvement in outcomes in this large cohort of adult secondary HLH patients.

scholarly journals 1036. Persistence of Guideline-Recommended Antiretroviral Therapy Regimens among Persons Living with HIV Newly Initiating Treatment in the US

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S548-S549
Author(s):  
Joshua P Cohen ◽  
Xingzhi Wang ◽  
Rolin L Wade ◽  
Helena Diaz Cuervo ◽  
Dionne M Dionne
Keyword(s):  
Antiretroviral Therapy ◽  
Proportional Hazards ◽  
Cox Proportional Hazards ◽  
Treatment Discontinuation ◽  
Forest Plot ◽  
Current Guideline ◽  
First Line ◽  
Persons Living With Hiv ◽  
Living With Hiv

Abstract Background Discontinuation of first-line antiretroviral therapy (ART) may lead to poor outcomes for persons living with HIV (PLWH). While single-tablet regimens (STRs) have been associated with greater persistence compared to multi-tablet regimens (MTRs), few real-world studies have assessed persistence with current guideline-recommended ART regimens. The study aims to assess persistence among treatment-naïve PLWH initiating guideline-recommended ART regimens Methods Longitudinal pharmacy claims were extracted from IQVIA’s US LRx database for PLWH initiating ART between Jan 1, 2016 - Jul 31, 2019 (index period), with the observational period up to Jan 31, 2020. Index date was defined as the date of the first ART claim for STRs, or the date of the last filled drug of 1st set of claims for MTRs. Persistence was measured as the number of days until treatment discontinuation (≥ 90-day gap in therapy) and presented via Kaplan-Meier curves. Risk of discontinuation was assessed via Cox proportional hazards models, with BIC/FTC/TAF used as the reference ART regimen. Results Overall, 90,949 PLWH initiated STRs and 20,737 initiated MTRs. Average (SD) age was 43 (14) years, 75% were male, and 75% had commercial insurance. At 6 months of follow-up, 71% of PLWH initiating STRs and 56% initiating MTRs remained on their ART regimen. The proportion remaining on their index regimen at 6 months of follow-up was 79% for BIC/FTC/TAF, 73% for EVG/COBI/FTC/TAF, 71% for DTG/ABC/3TC, 69% for DTG + FTC/TAF, 67% for EFV/FTC/TDF, 62% for EVG/COBI/FTC/TDF, and 38% for DTG + FTC/TDF. Risk of discontinuation was higher for MTRs compared to STRs (hazard ratio [HR]: 1.63, 95% CI: 1.61 - 1.66). Compared to the referent BIC/FTC/TAF, risk of discontinuation was higher for EVG/COBI/FTC/TAF (HR: 1.54, 95% CI: 1.48 - 1.60), DTG/ABC/3TC (HR: 1.58, 95% CI: 1.52, 1.65), DTG + FTC/TAF (HR: 1.83, 95% CI: 1.74 - 1.93), EFV/FTC/TDF (HR: 2.31, 95% CI: 2.21 - 2.41), EVG/COBI/FTC/TDF (HR: 2.58, 95% CI: 2.47 - 2.70), and DTG + FTC/TDF (HR: 6.20, 95% CI: 5.83 - 6.59). Table 1. Persistence with ART by regimen for STR and MTR Figure 1. Forest Plot of Hazard Ratios for Treatment Discontinuation Conclusion Among US adult PLWH, STRs were associated with longer persistence on first-line therapy compared to MTRs. Among STRs, persistence was highest for BIC/FTC/TAF. Disclosures All Authors: No reported disclosures

scholarly journals A Proposal of a Personalized Surveillance Strategy for Gastric Cancer: A Retrospective Analysis of 9191 Patients

2019 ◽  
Vol 2019 ◽  
pp. 1-9 ◽  
Author(s):  
Si-wei Pan ◽  
Peng-liang Wang ◽  
Han-wei Huang ◽  
Lei Luo ◽  
Xin Wang ◽  
...  
Keyword(s):  
Gastric Cancer ◽  
Proportional Hazards ◽  
Cox Proportional Hazards ◽  
Rank Test ◽  
Surveillance Strategy ◽  
Risk Of Death ◽  
Kaplan Meier ◽  
Advanced Stages ◽  
Personalized Cancer

Background. In gastric cancer, various surveillance strategies are suggested in international guidelines. The current study is intended to evaluate the current strategies and provide more personalized proposals for personalized cancer medicine. Materials and Methods. In the aggregate, 9191 patients with gastric cancer after gastrectomy from 1998 to 2009 were selected from the Surveillance, Epidemiology, and End Results database. Disease-specific survival was analyzed by Kaplan-Meier method and the log-rank test. Cox proportional hazards regression analyses were used to confirm the independent prognostic factors. As well, hazard ratio (HR) curves were used to compare the risk of death over time. Conditional survival (CS) was applied to dynamically assess the prognosis after each follow-up. Results. Comparisons from HR curves on different stages showed that earlier stages had distinctly lower HR than advanced stages. The curve of stage IIA was flat and more likely the same as that of stage I while that of stage IIB is like that of stage III with an obvious peak. After estimating CS at intervals of three months, six months, and 12 months in different periods, stages I and IIA had high levels of CS all along, while there were visible differences among CS levels of stages IIB and III. Conclusions. The frequency of follow-up for early stages, like stages I and IIA, could be every six months or longer in the first three years and annually thereafter. And those with unfavorable conditions, such as stages IIB and III, could be followed up much more frequently and sufficiently than usual.

Validation of CA-125 concentration nadir within the normal range following primary treatment as a predictor of survival for epithelial ovarian cancer (EOC)

2007 ◽  
Vol 25 (18_suppl) ◽  
pp. 16007-16007
Author(s):  
A. Prat ◽  
J. Del Campo ◽  
S. Peralta ◽  
S. Cedres ◽  
A. Perez ◽  
...  
Keyword(s):  
Proportional Hazards ◽  
Cox Model ◽  
Primary Treatment ◽  
Cox Proportional Hazards ◽  
University Hospital ◽  
Stage Iii ◽  
Ca 125 ◽  
Rank Test ◽  
Normal Range

16007 Background: Recent studies suggest that the CA-125 nadir within the normal range after surgery and chemotherapy treatment is a predictor of survival (Crawford, ASCO 2004; Crawford, Ann Oncol 2005) and relapse (Markman, J Clin Oncol 2006). In order to validate these previous findings, we have conducted a retrospective analysis of patients (pts) treated in our institution for EOC. Methods: Between March 1, 1997, and October 30, 2005, all pts treated for EOC at Vall d'Hebron University Hospital were identified from the tumor registry database and screened retrospectively for their standard prognostic factors (age at diagnosis (=65 vs. >65), stage (III-IV vs. IC-II), and suboptimal vs. optimal cytorreduction). Inclusion criteria: an elevated CA-125 at time of diagnosis (>35 U/mL); primary treatment (PT) that consisted in surgery and intravenous carboplatin/paclitaxel for a maximum of 6–9 cycles; complete clinical and radiological response to initial treatment with normalization of CA-125 (=35 U/mL); and disease status at the time of last follow-up. Standard Kaplan-Meier methods were used to plot the progression-free survival (PFS) of members of each of the nadir groups. The relative contribution of the different potential correlates of prognosis was assessed by the Cox proportional hazards method. Results: 123 pts were identified: 64 Group A (=10 U/mL), 42 Group B (11–20 U/mL), 17 Group C (21–35 U/mL). Median age: 56. Stage IC 25%, II 13%, III 52%, IV 10%. Median follow-up 39.2 months (m). Median PFS was 69.7 m, 27.7 m, and 15.8 m for A, B and C, respectively (p< .0001, log-rank test). The Cox model showed a highly-significant impact on PFS in relation to CA-125 nadir levels, residual tumor after surgery and stage. Hazard ratios (HR) for PFS (95% CI) of B vs. A, C vs. B, and C vs. A were 1.98 (p= .034), 2.35 (p= .02), and 4.67 (p< .001), respectively. HR for PFS (95% CI) of suboptimal vs. optimal cytorreduction and stage III-IV vs. IC-II were 1.84 (p= .058) and 3.2 (p= .002), respectively. Conclusions: The CA-125 nadir in the normal range following PT for EOC is a reproducible predictor of PFS in stage IC-IV. Prospective studies of maintenance-consolidation therapies or different approaches in selected pts based on CA-125 nadir seem warranted. No significant financial relationships to disclose.

scholarly journals Faktor risiko loss to follow up terapi ARV pada pasien HIV

2017 ◽  
Vol 33 (4) ◽  
pp. 173
Author(s):  
Listy Handayani ◽  
Riris Andono Ahmad ◽  
Yanri Wijayanti Subronto
Keyword(s):  
Risk Factors ◽  
Health Insurance ◽  
Antiretroviral Therapy ◽  
Protective Factor ◽  
Proportional Hazards ◽  
Cox Proportional Hazards ◽  
Loss To Follow Up ◽  
Kaplan Meier ◽  
Adherence Counseling

Risk factors for loss to follow up of antiretroviral therapy in HIV patientsPurposeThis study aimed to determine risk factors for loss to follow-up of antiretroviral therapy among HIV-infected patients in Dr. Sardjito Yogyakarta, 2011-2014.MethodsA retrospective cohort study was conducted involving 499 HIV patients. Observations were conducted for four years using medical records. Data analysis was performed using Kaplan-Meier and Cox proportional hazards regression tests.ResultsThere were 190 loss to follow-up patients. Risk factors for loss to follow-up of ARV therapy were: a student (AHR = 2.42; 95% CI = 1.20-4.89), the distance ≥ 10 km (AHR = 1.58; 95% CI = 1:09 to 2:31), using health insurance (AHR = 1.67; 95% CI = 1:11 to 2:51) and homosexual as a protective factor of loss to follow-up of antiretroviral therapy (HR = 0:49; 95% CI = 0.30-0.80).ConclusionBeing a college student, the distance between home and ARV service ≥10 km and using health insurance were the risk factors for loss to follow-up of ARV treatment. Adherence counseling for students, cooperation with the drug taking supervisor and decentralization ARV service, as well as effective and efficient services for patients who use health insurance need to be strengthened.

scholarly journals Survival of AIDS Patients Treated with Traditional Chinese Medicine in Rural Central China: A Retrospective Cohort Study, 2004–2012

2015 ◽  
Vol 2015 ◽  
pp. 1-7 ◽  
Author(s):  
Yantao Jin ◽  
Xin Wang ◽  
Zhengwei Li ◽  
Ziqiang Jiang ◽  
Huijun Guo ◽  
...  
Keyword(s):  
Chinese Medicine ◽  
Traditional Chinese Medicine ◽  
Proportional Hazards ◽  
Proportional Hazards Model ◽  
Cox Proportional Hazards ◽  
Hiv Treatment ◽  
Cox Proportional Hazards Model ◽  
Central China ◽  
Rank Test ◽  
Aids Patients

This study aimed to explore the survival of AIDS patients treated with traditional Chinese medicine (TCM) in addition to combined antiretroviral therapy (cART) and of AIDS patients treated with cART. Data of patients taking cART between 30 October 2003 and 30 October 2004 in the National TCM HIV Treatment Trial Program area were retrospectively analyzed, with follow-up from 30 October 2004 to 30 October 2012. The log-rank test was used to compare survival between the two groups. A Cox proportional hazards model was used to determine hazard ratios to identify prognostic factors. The study included 521 patients in the TCM + cART group followed up for 3548 person-years and 375 patients in the cART group followed up for 2523 person-years. Mortality rates were 3.2/100 person-years and 4.2/100 person-years in the TCM + cART and cART groups, respectively. The difference in survival was significant. After adjusting for explanatory variables, the mortality rate of AIDS patients in the cART group was 1.7 times higher than in the TCM + cART group. Male sex, older age, little education, and lower CD4 cell count were risk factors for mortality. TCM intervention in addition to cART could increase survival of AIDS patients.

scholarly journals Incidence of Hypertension among Persons Living with HIV in China A Multicenter Study

2020 ◽  
Author(s):  
Hongwei Fan ◽  
fuping guo ◽  
Evelyn Hsieh ◽  
Wei-Ti Chen ◽  
Wei Lv ◽  
...  
Keyword(s):  
Cox Regression ◽  
Cox Proportional Hazards ◽  
Hiv Care ◽  
Multicenter Studies ◽  
Cox Regression Analysis ◽  
Incident Hypertension ◽  
Persons Living With Hiv ◽  
Living With Hiv ◽  
Prospective Longitudinal

Abstract Objectives Life expectancy among persons living with HIV (PLWH) has improved with increasing access to antiretroviral therapy (ART), however incidence of chronic comorbidities has simultaneously increased. No data are available regarding the incidence of hypertension among Chinese PLWH.Methods We analyzed data collected from patients enrolled in two prospective longitudinal multicenter studies of PLWH initiating ART in China. Incidence rate of hypertension per 100 person-years (PYs) among PLWH was calculated, and Cox proportional hazards models was used to evaluate the association between incident hypertension and traditional and HIV-associated risk factors.Results Of 1078 patients included in this analysis, 984 ART-naïve patients were hypertension-free at baseline, and contributed 2337.7 PYs of follow up, with a median follow-up period of 1.8 years (range: 1.2-3.2) after initiation of ART. Incidence of hypertension was 7.6 [95% confidence interval (CI): 6.5-8.7] per 100 PYs. In the Cox regression analysis, incidence of hypertension was positively associated with BMI [adjusted hazard ratio (aHR) 1.07 (1.01,1.13), p=0.02] and recent viral load (aHR 1.28, 95% CI:1.08-1.51, p=0), and negatively associated with recent CD4+/CD8+ ratio (aHR 0.14, 95% CI:0.06-0.31, p<0.001), zidovudine exposure (aHR 0.15, 95% CI: 0.10-0.24, p<0.001) and tenofovir exposure (aHR 0.13, 95% CI: 0.08-0.21, p<0.001).Conclusions The incidence of hypertension was relatively high among Chinese PLWH initiating ART. Independent risk factors for incident hypertension included recent low CD4+/CD8+ ratio and detectable HIV viremia, whereas receipt of ART was associated with reduced risk. Hypertension may be mitigated, in part, by excellent HIV care, including viral suppression with ART.

scholarly journals Incidence of Hypertension among Persons Living with HIV in China: A Multicenter Cohort Study

2020 ◽  
Author(s):  
Hongwei Fan ◽  
fuping guo ◽  
Evelyn Hsieh ◽  
Wei-Ti Chen ◽  
Wei Lv ◽  
...  
Keyword(s):  
Cox Regression ◽  
Cox Proportional Hazards ◽  
Hiv Care ◽  
Multicenter Cohort Study ◽  
Cox Regression Analysis ◽  
Incident Hypertension ◽  
Persons Living With Hiv ◽  
Living With Hiv ◽  
Prospective Longitudinal

Abstract Background Life expectancy among persons living with HIV (PLWH) has improved with increasing access to antiretroviral therapy (ART), however incidence of chronic comorbidities has simultaneously increased. No data are available regarding the incidence of hypertension among Chinese PLWH. Methods We analyzed data collected from patients enrolled in two prospective longitudinal multicenter studies of PLWH initiating ART in China. Incidence rate of hypertension per 100 person-years (PYs) among PLWH was calculated, and Cox proportional hazards models was used to evaluate the association between incident hypertension and traditional and HIV-associated risk factors. Results Of 1078 patients included in this analysis, 984 ART-naïve patients were hypertension-free at baseline, and contributed 2337.7 PYs of follow up, with a median follow-up period of 1.8 years (range: 1.2-3.2) after initiation of ART. Incidence of hypertension was 7.6 [95% confidence interval (CI): 6.5-8.7] per 100 PYs. In the Cox regression analysis, incidence of hypertension was positively associated with body mass index [adjusted hazard ratio (aHR) 1.07 (1.01,1.13), p=0.02] and recent viral load (aHR 1.28, 95% CI:1.08-1.51, p=0), and negatively associated with recent CD4+/CD8+ ratio (aHR 0.14, 95% CI:0.06-0.31, p<0.001), zidovudine exposure (aHR 0.15, 95% CI: 0.10-0.24, p<0.001) and tenofovir disoproxil fumarate exposure (aHR 0.13, 95% CI: 0.08-0.21, p<0.001). Conclusions The incidence of hypertension was relatively high among Chinese PLWH initiating ART. Recent low CD4+/CD8+ ratio and detectable HIV viremia were associated with incident hypertension, whereas receipt of ART was associated with reduced risk . Hypertension may be mitigated, in part, by excellent HIV care, including viral suppression with ART.

scholarly journals 1307. Virologic Failure in HIV-Infected Men Who Have Sex with Men and Transgender Women Treated in a Community-Based Model vs. a Hospital-based Model

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S471-S471
Author(s):  
Maximo O Brito ◽  
Shaveta Khosla ◽  
Supriya D Mehta ◽  
Richard M Novak
Keyword(s):  
Proportional Hazards ◽  
Proportional Hazards Model ◽  
Virologic Failure ◽  
Transgender Women ◽  
Cox Proportional Hazards ◽  
Cox Proportional Hazards Model ◽  
Hiv Care ◽  
Cumulative Probability ◽  
Community Based ◽  
Sex With Men

Abstract Background Men who have sex with men (MSM) and transgender women are disproportionately affected by HIV, especially those that belong to minority groups and lower socioeconomic status. The purpose of this study was to compare virologic failure in MSM and transgender women receiving HIV care at a community-based model (CBM) to a hospital-based model (HBM) of care. Methods This was a retrospective cohort study. We extracted data from electronic medical records of HIV-infected MSM and transgender women treated at one of the six community clinics or at a hospital-based clinic in Chicago between 2010 to 2014. The outcome was cumulative probability of virologic failure (i.e., viral load ≥200 copies/mL), measured in each semester of observation. We used multivariable Cox Proportional Hazards model to determine the association between CBM and HBM with virologic failure, adjusted for confounding variables. Results The sample consisted of 290 patients; of whom, 20 (7%) were transgender. Approximately half (49%) of the sample received care via CBM. Compared with patients receiving care at the HBM, CBM patients were more likely to be African American (72% vs. 61%), uninsured (50% vs. 39%) and with a history of substance abuse (38% vs. 24%). There was no difference in virologic failure between the two care models (57% in CBM vs. 52% in HBM; HRadj = 1.1; 95% CI: 0.8–1.6). Younger individuals (HRadj = 4.0; 95% CI: 2.3–7.1), alcohol users (HRadj = 1.6; 95% CI: 1.1–2.2) and patients without insurance (HRadj = 1.7; 95% CI: 1.1–2.6) were more likely to have virologic failure. Conclusion The CBM was as effective as a traditional HBM in providing care to MSM and transgender women despite their more marginalized status. Intensive outreach and targeted case management likely contributed to the effectiveness of this model and need further study. Disclosures All authors: No reported disclosures.

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