Health Disparities in Otology: A PRISMA-Based Systematic Review

Abstract

Objective

Social determinants of health (SDOHs), including but not limited to sex, race, socioeconomic status, insurance status, and education level, play a significant role in health disparities and affect health outcomes. The purpose of this systematic review is to examine health disparities in otology within the United States and highlight areas warranting further research.

Data Sources

PubMed, Ovid MEDLINE.

Review Methods

Our search encompassed all years through January 10, 2021. All peer-reviewed primary literature of any design and publication date regarding health disparities and otology outcomes in the United States was eligible for inclusion. Eligibility assessment was performed via 3 independent investigators.

Results

Of the 6326 unique abstracts identified, 188 studies underwent full-text review, and 52 remained in the final review. The most frequently examined otologic condition was hearing loss (36.5%), followed by cochlear implantation (28.8%) and infection/effusion (15.4%). Vertigo/dizziness (1.9%), Ménière’s disease (1.9%), and tinnitus (1.9%) were the least represented otologic conditions. Comprehensive articles on multiple disparity topics were the most common (n = 18), followed by articles on race/ethnicity (n = 11) and socioeconomic status (n = 9). Language (n = 2), education (n = 2), and gender (n = 1) were the least discussed. Over 5-fold the number of articles were published between 2011 and 2020 compared to the preceding decade (42 vs 8).

Conclusion

This study captures the existing literature regarding health disparities and outcomes in otology. The lack of robust data suggests the need for future quality studies aimed at investigating disparities in otologic care, as well as a broader push for recording and reporting SDOHs.

Keywords

health disparities otology social determinants of health

Health disparities are defined as differences in access to clinical care, treatment, and disease that affect health outcomes at the individual and group levels.¹ The nonmedical factors, or social determinants of health (SDOHs), that contribute to health disparities encompass a broad range of social, demographic, and environmental factors. The framework adapted by the National Institute on Minority Health and Health Disparities (NIMHD) provides one way to conceptualize SDOHs by grouping them into domains (biological, behavioral, sociocultural, health care system, physical/built environment) and by showing how domains affect health outcomes in the individual, immediate community, and society as a whole.¹

Years of compelling evidence show that SDOHs profoundly affect health outcomes and are closely linked with social and economic advantage. For instance, those of low socioeconomic status (SES) are more likely to have disease risk factors such as smoke exposure and obesity, suffer from chronic disease, and have an overall shorter life expectancy compared to wealthier individuals.² Uninsured individuals are less likely to receive regular access to care and preventative medical services.² Racial and ethnic minorities are more likely to experience negative health outcomes than nonminorities even when insurance status and income are controlled.² The coronavirus disease 2019 (COVID-19) pandemic spotlighted and possibly exacerbated these longstanding health disparities through the disproportionate impact on underserved and minority communities in the United States.³

In the past decade, the relationship between SDOHs and health outcomes has been extensively studied in some medical fields but seems to be lacking in others. Research in disease burden and outcomes based on factors such as SES, race/ethnicity, and geographic location is limited in the field of otolaryngology, particularly in neurotology/otology.⁴ Despite being a relatively small surgical subspecialty, otologic complaints are commonplace in society. From 2009 to 2011, over 8.6 million emergency department (ED) visits were due to a primary otologic complaint, comprising a total of 2.21% of all ED visits during that time.⁶ Most visits were nonurgent (98%), with the most common diagnoses being unspecified otitis media, otitis externa, and otalgia.⁵ Among the ED visits, common demographic factors included individuals under age 18 (64%), median income of less than $39,000 (34.5%), Medicaid insurance (46.7%), and residence in a large metropolitan area (26.0%).⁵ These findings demonstrate the economic burden of nonurgent otology visits and suggest that these conditions may disproportionately affect patients with limited access to care.

To begin addressing health disparities in access to and quality of services for otologic conditions requires an assessment of the current literature. The purpose of this systematic review is to examine health care disparities in otology and impact on outcomes within the United States, assess gaps in the current literature, highlight areas in need of further research, and propose initial steps toward improving the care of disadvantaged communities.

Methods

A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (see Supplemental Material). Literature searches were conducted through PubMed and Ovid MEDLINE using the following keywords: adult otology, socioeconomic, ethnicity, gender, disparities, inequality, audit, adult otolaryngology, pediatric, healthcare access, sexual orientation, and demographics. Additional relevant articles were identified using the reference lists of included articles or were manually searched to better contextualize our findings. All reviews, commentaries, editorials, unpublished studies, and abstracts were excluded. Peer-reviewed primary literature of any design and publication date were eligible for inclusion. The last search was run on January 10, 2021.

After the initial search, studies were screened by 3 independent reviewers based on title to include only studies that focused on a disparity topic as it relates to otologic-related outcomes. Articles were excluded if they were based on populations outside of the United States or not directly related to the impact of health disparities on otologic outcomes. Articles discussing the impact of an otologic condition on social factors (eg, SES, geographic location, and language) were excluded. Investigators referred to the abstract and/or full text if the aim of the article was unclear. All disagreements regarding eligibility status were resolved by consensus among the 3 investigators. Two independent reviewers graded the quality of evidence for each study using a modified version of the Oxford Centre for Evidence Based Medicine levels of evidence⁶ (see Supplemental Table S1 in the online version of the article).

Disparity categories included individual topics (race/ethnicity, SES, gender, insurance status, geographic/urban-rural, language, and education) and comprehensive articles. Disparity topics were selected based on previous studies investigating SDOHs in laryngology and pediatric otolaryngology, in an attempt to make the study compatible with the current literature.^7,8 Gender, a social construct, was used instead of sex, a biological construct, to illuminate existing health differences that also encompass nonbinary populations. Socioeconomic status, or social class associated with resource access, was used instead of socioeconomic position to reflect the reported findings within the literature. Articles that addressed 2 individual disparity topics were assigned with both, while articles addressing more than 2 individual disparity topics, general health disparities, and/or barriers to care access were designated “comprehensive.” Each article was assigned 1 of 9 otology topics that included hearing loss (HL) (unspecified), cochlear implantation (CI), hearing aids (HAs), vertigo/dizziness (unspecified), Ménière’s disease, cholesteatoma, infection/effusion, neoplasm, and tinnitus. Descriptive statistics were generated to illustrate the frequency of health disparity categories across the various otology topics in the existing literature. Percentages and fractions were not used to describe frequency of disparity categories as some articles were assigned with 2 individual disparity topics.

Results

The literature search and manual reference search yielded a total of 6326 articles after duplicate removal. After title screening, 6138 articles were excluded for not clearly pertaining to the impact of health disparities on otologic disease burden or outcome. Full texts were retrieved for 136 articles, of which 52 met inclusion and were included in this review (see Supplemental Table S2 in the online version of the article). Figure 1 outlines the PRISMA flow diagram depicting the selection process.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram demonstrating search strategy.

The 3 most frequently examined otologic topics in relation to health disparities were HL (19/52, 36.5%), CI (15/52, 28.8%), and infection/effusion (8/52, 15.4%) ( Figure 2 ). Comprehensive (n = 18) and race/ethnicity (n = 11) were the most common disparity categories, followed by SES (n = 9), while education (n = 2), language (n = 2), and gender (n = 1) were the least discussed ( Figure 3 ). Six out of 52 articles (11.5%) were coded with 2 individual disparity topics. Nine out of 52 articles (17.3%) concerned surgical outcomes in the context of health disparities: surgery for otitis media (3/9), CI (3/9), cholesteatoma resection (1/9), and surgical management of vestibular schwannoma (2/9). As depicted in Figure 4 , there is an upward trend in the number of publications regarding health disparities in otology in the past 3 decades, with the first published in 1991. The largest growth was seen in 2011 to 2020, which was over 5-fold the number of publications in the preceding decade (42 vs 8).

Figure 2.

Number of articles discussing health disparity categories by otologic topic.

Figure 3.

Frequency of coded disparity categories within otology literature. *Note, total number will be greater than 52 as some articles coded with 2 individual disparity topics.

Figure 4.

Trends in number of health disparity-related studies per year over the past 4 decades.

While many articles included both adults and children, 22 out of 52 studies (42.3%) exclusively studied the pediatric population. The 3 otologic topics reported in pediatric-only articles consisted of CI (9/22), HL (8/22), infection/effusion (4/22), and cholesteatoma (1/22). Although comprehensive articles comprised the majority of articles (n = 9), there was a range of individual disparity topics addressed: SES (n = 4), geographic/urban-rural (n = 3), race/ethnicity (n = 2), and insurance status (n = 2). Two studies were coassigned with 2 individual disparity topics: race/ethnicity and SES (n = 1) and language and insurance status (n = 1).

Hearing Loss

Of the 19 articles on hearing loss, SES (n = 5) and comprehensive (n = 5) were the most common disparity categories. Specific SES factors reported in the context of HL included employment (n = 2) and housing status (n = 1).^9-11 For race/ethnicity (n = 3), subtopics included race and sex differences in HL incidence (n = 1) and the association between skin pigmentation and HL risk (n = 2).^12-14 Geographic/urban-rural category was assigned to 4 studies: a retrospective analysis on time from HL symptoms to formal diagnosis in a rural population (n = 1), perceived barriers to hearing health care (n = 2), and experiences with newborn hearing screening and interventions in rural families (n = 1).^15-18 Hearing loss was the only otologic topic to include articles pertaining to education: in 1 article discussing health literacy in hearing health care utilization (n = 1) and in another analyzing education attainment and occupation with time to seek medical care after sudden unilateral HL (n = 1).^9,19 Similarly, the gender topic was only discussed in the setting of this otologic topic, specifically in a cross-sectional analysis of the relationship between HL and race- and sex-specific risk factors such as occupational noise exposure, smoking, and bone density (n = 1).¹² Quality of evidence ranged from 2 to 4.

Cochlear Implants and Hearing Aids

Most of the 15 CI articles were classified as comprehensive (n = 7), which included analyses of general barriers to CI (n = 5) and patient demographics associated with CI-related quality of life (n = 1) and with higher CI qualification rates (n = 1).^20-26 Socioeconomic status was the second most frequently cited disparity category (n = 2), with both articles pertaining to the pediatric population.^27,28 Two articles on race/ethnicity were found: 1 discussing barriers to CI access in African Americans and the development of an outreach program (n = 1) and the other colabeled with SES analyzing CI rates among different races/ethnic backgrounds and household incomes (n = 1).^29,30 Within the geographic/urban-rural category were 2 articles comparing the timing of HL diagnosis to CI in urban and rural populations, with 1 exclusively in the pediatric population (n = 1) and the other in the adult population (n = 1).^17,31 Language was discussed in 1 study (n = 1), which assessed the efficacy of the Hearing Implant Sound Quality Index scoring in Spanish-speaking CI users.³² In addition, insurance status was discussed in 1 article regarding delayed speech and auditory development in underinsured children (n = 1).³³

Hearing aids, including bone anchored, were less commonly reported otologic topics (3/52, 5.8%). Disparity categories included race/ethnicity (n = 1), geographic/urban-rural (n = 1), and insurance status (n = 1). Similar to the CI topic, the article pertaining to the geographic/urban-rural disparity category analyzed time of HL diagnosis to HA acquisition in rural and urban adults.³⁴ The second article analyzed trends in HA access and utilization in Medicare recipients across various education attainment levels and household incomes.³⁵ The third article analyzed surgical outcomes after bone-anchored HA placement among various racial and ethnic groups.³⁶ Quality of evidence for both CI and HA ranged from 3 to 4.

Infection/Effusion

Of the 8 articles, race/ethnicity (n = 3) and comprehensive (n = 3) were the most common disparity categories. One article was assigned both race/ethnicity and SES (n = 1). All infection/effusion studies pertained to otitis media (acute and chronic), and half were specific to the pediatric population. Articles within the race/ethnicity category pertained to disparities in diagnosis and access to care in infants (n = 2) and in surgical outcomes for otitis media (n = 1).^37-39 Three comprehensive articles reported on the following: various demographic factors associated with loss to follow-up after chronic otitis media management (n = 1), disparities in diagnosis and surgery of otitis media (n = 1), and SES and geographic risk factors associated with otitis media requiring tympanostomy tubes (n = 1).^40-42 Insurance status (n = 1) and geographic/urban-rural (n = 1) were discussed in separate articles, specifically in the utilization of services in children with Medicaid and outcomes of mobile ear surgery for chronic otitis media in rural areas, respectively.^43,44 Quality of evidence ranged from 2 to 4.

Neoplasm

Two of 52 articles (2/52, 3.8%) pertained to neoplastic disease, specifically vestibular schwannoma. This category included 1 article in race/ethnicity (n = 1), specifically on the association between race/ethnicity and disease presentation and management using the national Surveillance, Epidemiology, and End Results (SEER) database in vestibular schwannoma.⁴⁵ The second comprehensive article (n = 1) used the National Inpatient Sample (NIS) database to analyze factors associated with worse surgical outcomes after vestibular schwannoma resection.⁴⁶ Both neoplasm articles were level of evidence grade 3.

Ménière’s Disease, Cholesteatoma, Vertigo/Dizziness, and Tinnitus

Ménière’s disease (1/52, 1.9%), tinnitus (1/52, 1.9%), vertigo/dizziness (1/52, 1.9%), and cholesteatoma (2/52, 3.8%) were the least reported otologic conditions. Ménière’s disease was addressed in 1 comprehensive article (n = 1) that reported on various demographic factors associated with disease prevalence such as SES, geographic location, gender, and household income.⁴⁷ Tinnitus was studied in 1 article with race/ethnicity as the disparity category (n = 1) and its risk factors in African Americans in particular.⁴⁸ Vertigo/dizziness and cholesteatoma were each associated with an article under the geographic/urban-rural category.^49,50 Cholesteatoma was also associated with a comprehensive disparity article that discussed the relationship between factors such as race/ethnicity and income, as well as the choice of surgical procedures and postoperative complications.⁵¹ Levels of evidence for the articles on Ménière’s disease, cholesteatoma, tinnitus, and vertigo/dizziness were 3, 4, 2, and 4, respectively.

Discussion

This systematic review aims to report on all past and current literature exploring health disparities in the context of otologic conditions within the United States. Results demonstrate that the number of articles regarding health disparities in otology has dramatically increased over time, with the majority being published in the past decade. This move toward understanding SDOHs in otologic disease likely follows a broader push toward advancing health equity through initiatives brought forth by the United States Healthy People 2030 and the World Health Organization’s Commission on Social Determinants of Health in 2005.⁵² Despite some progress within the past 30 years, this review identifies clear gaps in the literature that warrant further investigation regarding otology and health disparities.

Of the 56 articles identified, health disparity studies regarding HL, including CI and HA placement, were the most common. There are many possible explanations for this. Hearing loss is relatively common, with an exceedingly high prevalence in adults over age 70.⁵³ In addition, HL has devastating effects in infants if not recognized early, including speech, language, and cognitive delay; long-term educational consequences; and poorer quality of life.⁵⁴ Statewide Early Hearing Detection and Intervention programs use federally funded tracking systems to collect data on screening and intervention outcomes.⁵⁵ The accessibility of hearing loss data may make studying disparities in disease burden and outcomes more feasible and robust compared to other otologic conditions that lack large nationwide databases.

Among the HL articles, it is clear that disparities exist in terms of access to hearing health care services. Individuals in rural communities have longer times to HL diagnosis, CI, and HA placement as compared to those in urban communities. There are likely many explanations for this, the most obvious being the disproportionate number of otologists in urban academic centers compared to rural communities. As of 2013, there were 9642 practicing otolaryngologists in the United States, with 5961 (61.8%) practicing in large metropolitan areas, and 2064 in counties with a mean population of approximately 21,000 were without an otolaryngologist altogether.⁵⁶ Socioeconomic status, insurance status, and education, while extrinsically linked, also seem to play a role in outcomes and access to hearing interventions. A retrospective analysis of 180 children showed higher family income and parental education to be associated with receiving CI at younger ages and higher speech intelligibility ratings, respectively.²⁸ In a retrospective analysis of adults receiving cochlear implants between 2009 and 2018, cochlear implant–qualified patients with military insurance were 13 times more likely to pursue CI compared to the Medicaid insured.²⁶ In another study, there was no difference in age of implantation between Medicaid-insured and privately insured children, but there was a notable discrepancy in surgical complications.²⁷ Medicaid-insured children had a 5-fold greater odds of postoperative complications, which may have been in part explained by a greater number of missed follow-up appointments compared to those with private insurance.²⁷

Unlike HL and CI, other otologic topics seem to receive less attention. Neoplasm was discussed in only 2 articles, and these studies demonstrated overall worse survival outcomes following surgery among Hispanic and black patients after vestibular schwannoma resection.⁴⁵ Furthermore, despite the high prevalence of dizziness and vertigo (estimated 15%-20%), only 1 study was identified that discussed the impact of geographic factors on vestibular testing, specifically among Medicare beneficiaries.^49,57 Additional studies should aim to examine health disparities among other otologic conditions, including but not limited to Ménière’s disease, cholesteatoma, vertigo, and dizziness.

While the existing data regarding health disparities in otology are limited, our findings suggest that the body of literature will continue to grow over time. A plausible explanation for the relative lack of literature is the difficulty in defining SDOHs. Healthy People 2020 defines SDOHs as “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health.”² Similar to the framework adapted by the NIHMD, Healthy People 2020 groups SDOHs into 5 key domains, including “economic instability, education, health and healthcare, neighborhood and built environment, and social and community context.”⁵⁸ While similar, these frameworks and many others demonstrate the lack of a universal definition of SDOHs and which factors should be included. In addition, while grouping into domains aids in easier conceptualization, each SDOH in itself lies on a continuum, is multifaceted, and is often intertwined with other SDOHs. For example, economic instability refers to financial hardship, which in itself is relative but also related to educational opportunities, accessible health care, and the ability to live in a safe environment. Race/ethnicity, while not an official domain in either framework, is a source of discrimination at the individual and institutional levels, which can affect financial stability, health care access, and living environment. Furthermore, it is important to recognize the inherent challenge in using race/ethnicity as a SDOH given that racism, legacies of segregation, and racial discrimination all likely contribute to existing disparities more than the construct of race/ethnicity itself. The very nature of SDOHs makes it difficult to create a universal framework of tools for which health care systems can identify, quantify, and report on these factors. This may explain the apparent lack of articles within otology research that expand beyond health outcomes on the individual level according to the NIMHD research framework.

Attempts have been made to capture and record SDOHs into the electronic health record (EHR) as International Classification of Diseases, 10th Revision (ICD-10) Z codes, which can be assigned by nonphysician providers such as case managers and social workers.^59,60 Z codes ( Table 1 ) are often underused, however, likely due to a multitude of factors, including provider time constraints, lack of insurance reimbursement, and the unfamiliarity with the obstacles a patient is facing.⁵⁹ Automated questionnaires that directly link answers with Z codes in the patient chart to ICD-10 Z codes may be useful. One particular program developed a systematic strategy to screen for SDOHs that involved a questionnaire with positive answers linked to an ICD-10 code in the EHR. Each ICD-10 code was associated with a resource and referral guide relevant to the social and economic challenge indicated on the questionnaire.⁶⁰ The authors note the success of this program in streamlining workflows, identifying and addressing patients’ unmet needs, and minimizing time of clinical staff.⁶⁰ In another study, authors report on a streamlined workflow developed at Kaiser Permanente Northwest that enabled patient navigators to identify and document just over 45,000 SDOHs into an EMR from a pool of approximately 11,000 patients in 2 years.⁶¹ Among these, over 18,000 referrals to community resources were made, and the progress of such referrals was tracked using a SmartSet in the EMR.⁶¹ Further research is needed in this realm to develop a concrete consensus-driven framework for reporting SDOHs. Formulation of consensus-driven SDOH reporting standards will facilitate improved understanding of their relationship to otologic outcomes and allow for generalization across studies. Ultimately, greater uniformity in data reporting will facilitate the development of evidence-based strategies and policies to combat health disparities.

Table 1.

International Classification of Diseases, 10th Revision Z Codes and Applicable Scenarios, Adapted From Friedman and Banegas.⁶¹

Z code	Application scenarios
Problems related to education and literacy (Z55)	Low-level literacy, lack of access to education
Problems related to employment and unemployment (Z56)	Unemployment, stressful work schedule, sexual harassment at work, military deployment, threat of job loss
Occupational exposure to risk factors (Z57)	Occupational exposure to radiation, dust, toxic agricultural agents, environmental tobacco smoke
Problems related to housing and economic circumstances (Z59)	Homelessness, low income, inadequate food and/or safe drinking water
Problems related to social environment (Z60)	Social rejection, victim of adverse discrimination, difficulty with acculturation, anxiety concerning migration
Problems related to upbringing (Z62)	Institutional upbringing; history of childhood physical, sexual, verbal; or psychological abuse; history of neglect
Other problems related to primary support group, including family circumstances (Z63)	Alcoholism/drug addiction in family, death of family member, caretaker stress
Problems related to certain psychosocial circumstances (Z64)	Problems relating to unwanted pregnancies, problems with probation officer, counselor, or social worker
Problems related to other psychosocial circumstances (Z65)	Imprisonment, incarceration, victim of crime or terrorism, legal problems, exposure to disaster/war

This study is not without limitations. The lack of standardized terms to characterize health disparities may have affected the number of studies included in our analysis simply based on the selected search terms applied. Furthermore, our study was limited to published articles, potentially leading to publication bias. It is plausible that additional studies have aimed to identify health disparities within otology but are ultimately not published if disparities are not identified. Exclusion of non-US studies is an additional limitation to our study. Originally, we sought to examine disparities in care on the international level but ultimately decided to confine our results to disparities within the United States to avoid extrapolating trends from populations with different health care systems and social frameworks. Despite these limitations, our study provides a comprehensive review of the existing literature and points to the need for further evaluation and characterization of health disparities in otology through high-quality studies.

Conclusion

The aim of this systematic review is to capture the existing literature regarding health disparities in otology and to identify gaps in the data in order to provide a framework for developing quality interventions to address and mitigate these disparities in the future. Our results suggest that health disparities are unequally studied across otologic diseases, most commonly in hearing loss, cochlear implant, and infection/effusion. Health disparity topics such as race/ethnicity, comprehensive, and SES were the most commonly represented in the literature, followed by geographic/urban-rural, insurance status, gender, education, and language. These findings point to the relative paucity of data describing health disparities in otology and posit the need for future quality studies aimed at investigating the existing social and economic barriers to otologic care. Further investigation of the mechanisms that lead to disparities is required in order to guide the development of targeted interventions aimed at addressing these differences in care. Identification and characterization of the existing health care disparities can provide important insights into potential areas of health care reform and may serve as a call to action to improve and equalize opportunities for patients seeking otologic care. We recommend inclusion of these data in subsequent otologic studies and to make efforts to incorporate SDOHs when designing future studies.

Supplemental Material

sj-docx-1-oto-10.1177_01945998211039490 – Supplemental material for Health Disparities in Otology: A PRISMA-Based Systematic Review

Supplemental material, sj-docx-1-oto-10.1177_01945998211039490 for Health Disparities in Otology: A PRISMA-Based Systematic Review by Braeden Lovett, Alexandra Welschmeyer, James Dixon Johns, Sarah Mowry and Michael Hoa in Otolaryngology–Head and Neck Surgery

Supplemental Material

sj-docx-2-oto-10.1177_01945998211039490 – Supplemental material for Health Disparities in Otology: A PRISMA-Based Systematic Review

Supplemental material, sj-docx-2-oto-10.1177_01945998211039490 for Health Disparities in Otology: A PRISMA-Based Systematic Review by Braeden Lovett, Alexandra Welschmeyer, James Dixon Johns, Sarah Mowry and Michael Hoa in Otolaryngology–Head and Neck Surgery

Supplemental Material

sj-docx-3-oto-10.1177_01945998211039490 – Supplemental material for Health Disparities in Otology: A PRISMA-Based Systematic Review

Supplemental material, sj-docx-3-oto-10.1177_01945998211039490 for Health Disparities in Otology: A PRISMA-Based Systematic Review by Braeden Lovett, Alexandra Welschmeyer, James Dixon Johns, Sarah Mowry and Michael Hoa in Otolaryngology–Head and Neck Surgery

Footnotes

Author Contributions

Braeden Lovett, conducted literature search and screening, results analysis, manuscript drafting, figure/table creation; Alexandra Welschmeyer, conducted literature search and screening, results analysis, manuscript drafting, figure/table creation; James Dixon Johns, conducted literature search and screening, oversaw project and edited manuscript; Sarah Mowry, oversaw project and edited manuscript; Michael Hoa, senior author, conceptualized and designed project, interpreted data, oversaw project and edited manuscript.

Disclosures

Competing interests: None.

Sponsorships: None.

Funding source: None.

Supplemental Material

Additional supporting information is available in the online version of the article.

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