In the 1990s at the MacColl Institute, Edward Wagner, MD, MPH, the Father of the Chronic Care Model (CCM), recognized that there were "major barriers to the delivery of high-quality care for chronic illness" and that "chronically ill patients need time with their providers, regular assessments of clinical, behavioral, and psychosocial variables, and ready access to other resources such as pharmacists, nutritionists, and social workers."1 Since that time, different sectors of the medical field, beginning with the primary care physician, have begun to implement the CCM into practice, helping to manage patients with chronic diseases. This is initiated not only from the biologic stand point of the disease, but also from a biopsychosocial perspective. By reading this article, clinicians will gain an understanding that integration of healthcare teams will yield higher outcomes for the patient, whereas decreasing risk factors for comorbidities is imperative to managing chronic illnesses.
The structure of the CCM focuses on 6 factors: community resources, healthcare organization, self-management support, decision support, delivery system redesign, and clinical information systems.2,3 The design Figure 1 intends to educate patients while requiring them to become active in the care of their chronic illness, incorporating them into a practice team striving for improved outcomes. Effective bidirectional communication between a single patient's medical providers is paramount to execution of the model.
According to the Centers for Disease Control's 2011 Fact Sheet, diabetes is a chronic illness that affects 25.8 million people worldwide (8.3% of the US population) and is the leading cause of kidney failure, nontraumatic lower-limb amputations, and new cases of blindness among adults in the United States.4 Secondary to the comorbidities associated with the diagnosis of diabetes, the risk for death in a patient with diabetes compared with a nondiabetic of the same age is doubled4 and increased by 40% in patients with a previous history of lower-extremity diabetic ulceration.5 In management of diabetes as a chronic illness affecting a large portion of the population, how can clinicians utilize the CCM while understanding the biopsychosocial aspects of a diabetic patient for improving outcomes and lowering the risks of comorbidities related to macrovascular disease, retinopathy, nephropathy, and neuropathy as the primary cause of diabetic foot ulcers?
Biopsychosocial illnesses, including diabetes, must be approached by the clinician who understands that not only are biological factors, including the cause of the illness and the toll it takes on the body, important considerations, but that also the psychological components experienced by the patient dealing with diabetes and social components, such as economic and social status, are factors to be considered. The biopsychosocial components of a disease, when understood by the clinician and by a multidisciplinary team caring for the patient, make it easy to acknowledge how those components warrant the use of a CCM when approaching a chronic illness.
The link between diabetes and depression, particularly type 2 diabetes, has been well researched and documented,6-13 demonstrating that diabetes can serve as both a trigger and a consequence of depression, such that the two are chronic diseases that must be addressed simultaneously. By treating a patient's diabetes while treating his/her depression, both diabetes and depression will improve. Depression as a psychological component of the chronic illness of diabetes warrants incorporation of the 6 tenets of the CCM and when utilized appropriately can improve the clinical outcomes of the patient. The link between diabetes and depression in a treatment model that does not encompass the tenets of the CCM goes unrecognized. The challenge for the physician is to recognize the link between the 2 disease states through simple patient questioning, utilizing such tools as the Diabetes Empowerment Scale (DES).14 The next step is to then take action through the multidisciplinary approach to patient care.
THE LINK BETWEEN DIABETES AND DEPRESSION
The question becomes: "Which came first, the chicken or the egg?" The research presents the question of whether it is the diagnosis of diabetes and the psychological burden placed upon a patient now managing a chronic illness that induces depression, or is it the diagnosis of depression and the associated hormonal imbalances and increase in proinflammatory cytokines that generates an increased risk of diabetes and thus diabetic complications?15 Although the debate is continuous as to the direction of the association, it has been shown that individuals with diabetes, compared with patients without diabetes of similar age, are at a 24% increased risk of developing depression,7 with an increase in that percentage as a patient's age increases.9
Those individuals with diabetes who were more likely to suffer from depression tended to be women, between the ages of 18 and 34 years, with less than a high school education, an annual income of less than $25,000, not married, and uninsured.10 This is of particular concern secondary to the strong association between socioeconomic status and comorbid depression.8 Major depression was associated with lower personal income ($2800 lower), and with each additional depressive symptom, there was an associated decrease in personal income ($1200 for each additional symptom), as determined by Dismuke and Egede16 in their study. They also recognized that patients with both diabetes and depression had lower work-related productivity, loss of productive work time, and increased functional disability when compared with their nondepressed counterparts.16
It is imperative for the clinician to understand how the 2 chronic illnesses, when presented together, increase the risk of associated complications for the patient. It is no surprise that poor diabetes management leads to chronic hyperglycemia, which may also result from depression and depressed mood.17 Having this information, DeGroot el al6 speculated that if "depression is associated with hyperglycemia, and hyperglycemia is associated with diabetes complications…, depression may also be associated with diabetes complications," and in their 27-study meta-analysis, the evidence overwhelmingly supports their hypothesis. They found a "consistent and statistically significant relationship between depression and a variety of diabetes complications," including macrovascular complications, retinopathy, nephropathy, neuropathy, and sexual dysfunction.6
Anderson et al12 suggest that the presence of diabetes "doubles the odds of comorbid depression… [with] 1 in every 3 individuals with diabetes having depression at a level that impairs functioning and quality of life, adherence to medical treatment and glycemic control, increasing the risk of diabetic complications." Therefore, depression in combination with a chronic illness, and in this case, diabetes, is associated with nonadherence to self-care regimens, failure to engage in treatment, and worse clinical outcomes including an increase in risk factors for additional comorbid diseases.
"People with both diabetes and depression had a 1.3-fold increased risk of death from all causes compared with people with only diabetes and a 2-fold increased risk of death from all causes compared with people with only depression, and a 2.5-fold increased risk of death compared with people without either diabetes or depression."18 Egede et al18 urge the need for greater attention to be paid toward recognizing and treating depression in the diabetic population for prevention of increased mortality from all causes beyond that due to having either diabetes or depression.
This research can be supported by a variety of additional studies, with these risks being largely associated with maintenance of a patient's diabetes through decreased motivation to partake in activities of self-care and self-management19 and "poorer quality of diabetes care among depressed patients."8 Lower adherence to recommended self-care activities has been linked to poorer glycemic control in patients with diabetes and depression when compared with diabetic patients without depression.20 This resulted in an increased level of functional impairment and an increase in healthcare costs.21 In addition, individuals with major depression were less likely to have had preventive care, such as mammograms, prostate examinations, Papanicolaou tests, heme blood stool evaluations, and thus an overall poorer quality-of-life indices.10
Individuals with depression were at increased risk of clinically significant microvascular and macrovascular complications, relative to individuals without diabetes at baseline. Patients with major depression and diabetes had a 36% higher risk of developing advanced microvascular complications and a 25% higher risk of developing advanced macrovascular complications.22 In addition, Vileikyte et al23 recognized that worse baseline neuropathy was associated with more severe baseline depressive symptoms and worsening depressive symptoms over time. These complications, vascular and neuropathic, are factors that together lend themselves to increased risk of limb loss for the patient faced with diabetes, depression, and an open wound on the lower extremity.22 Clinicians see a 3-fold increase in mortality in patients with both diabetes and depression who are suffering from their first lower-extremity ulceration versus those without depression24 and a 40% increased risk of mortality in patients with a history of lower-extremity ulceration when compared with their nondiabetic, nondepressed counterparts.5 Chronic wounds are a result of poor diabetic management; thus, they also may generate a depressed mood or depressive disorder in patients secondary to the lengthy battle in treating and closing wounds, often inducing anxiety and depression in the process. It has been shown, however, that an increase in foot self-care and screening leads to a statistically significant decrease in risk of foot ulceration.25 This underlines the importance of self-care education, regular follow-up appointments with members of a patient's medical team for prevention of ulceration, and early identification and intervention when ulcerations do arise.
"Diabetes is a complex disease that requires intensive self-care involving adherence to prescribed medications, monitoring of blood glucose, adherence to dietary and physical activity recommendations, preventive foot care, attendance at medical appointments, and regular screening for complications."15 Patients must cope with the diagnosis of diabetes on a daily basis, in addition to maintaining metabolic control, and must constantly be making decisions about their therapy. Pair the chronic illness of diabetes with the chronic illness of depression, and the chronicity exponentially increases, making intervention with the CCM much more imperative, so that all aspects of each disease can be managed by a team of providers dedicated to the patient's needs.
Diabetes may be both a trigger and a consequence of the chronic illness of depression. By treating both the patient's depression and the patient's diabetes through understanding the biopsychosocial aspects of both chronic diseases and using the CCM as a lattice, both illnesses will improve. As DeGroot et al6 believe, "it would be reasonable to speculate that underlying mechanisms linking depression and diabetes complications are a function of biological, social, and psychological variables that may interact with depression in differing ways to produce similar interactions with complications." Lustman et al17 confirm "the association of depression with hyperglycemia but… the mechanism nor the direction of the association" can be estimated with certainty.
Recognizing the link between both chronic illnesses of diabetes and depression calls for "an urgent need to proactively screen patients with diabetes for depression and refer them for treatment that is based on a multidisciplinary team approach and attends to the medical and psychological needs of the patients."13 Utilizing tools such as DES18 allows clinicians to ask simple questions of their patients and enables them to gauge the involvement of psychological component of their ability to manage the disease.
The DES was developed in 2000 by the Michigan Diabetes Research and Training Center to be utilized in practice as a self-assessment tool for patients Figure 2.14 The form has both a long and a short version that evaluates 3 subsets to determine the patient's psychosocial self-efficacy for managing the chronic illness of diabetes. Three subscales allow the clinician to evaluate the patient's ability to (1) manage the psychosocial aspects of diabetes, (2) assess his/her dissatisfaction and readiness to change, and (3) set and achieve goals.14
The DES can be completed by the patient and quickly reviewed by the clinician who can appropriately aim treatment interventions available within the CCM to each patient with the high likelihood of improving diabetes self-management and decreasing risk factors. Thus, referral and treatment, when positive indicators are appreciated on such evaluative measures, can be implemented with the primary goal of decreasing the risk of complications associated with the disease, on all levels. Although the DES may be an easy way to screen patients for symptoms of depression or distress, ongoing clinical conversation between the clinician and the patient is the most valuable tool26; thus, regular follow-up visits by patients are a necessary component of the CCM and its implementation.
The definition of depression in relation to diabetes needs to be further researched, as some studies suggest that major depressive disorder, depressive mood, and heightened distress over diagnosis can be easily confused by the physician, as well as being underclassified or overclassified.26 Secondary to this misdiagnosis, the implementation of a team of physicians to manage the diabetic patient and any patient with a chronic illness becomes critical to effectively treat all aspects of a chronic illness. Clinicians must remember that although a patient may not meet the criteria for major depressive disorder, he/she may have symptoms of depression, such as depressed mood, diminished interest, and loss of energy, all of which are quite common among diabetic patients and are associated with poor self-care.
Clinicians need to recognize that psychological pieces of a biopsychosocial illness exist in addition to biological and social components, so they can be addressed to help the patient remain a functional and productive member of society.
UTILIZATION OF THE CCM
We know that in patients with diabetes, glycemic control with a hemoglobin A1c (HbA1c) value of 7 mg/dL or less, a low-density lipoprotein cholesterol of 100 mg/dL or less, and a systolic blood pressure of 130 mm Hg or less all contribute to a decreased risk of complications associated with diabetes, including neuropathy, nephropathy, retinopathy, and macrovascular and microvascular disease. We also know that a large portion of a patient's diabetes management is self-care through adherence to medications, modifications of diet and exercise, and adherence to scheduling and attending follow-up appointments with his/her primary care physician and his/her specialist.
"Depression may impair glycemic control through negative effects on self-care behaviors,"22 that is, poor compliance to treatment "with poor outcomes… explained by lower compliance to the recommended self-care activities."20
The inability of the current care model to effectively meet the multifaceted needs of a patient battling a chronic illness, such as diabetes, is inadequate and needs refinement. The CCM is a multifaceted framework for enhancing healthcare delivery. The model is based on the paradigm shift from the current model of dealing with acute care issues to a system that is prevention based.27 The 6 tenets of the CCM must, when incorporated and addressed simultaneously with each patient, result in a decrease in risk factors, increased management of diabetes with depression, and improved overall quality of life for the patient.
Important factors in the implementation of the CCM are reliant on the design of practice where there is "delegation of roles within the practice team, the involvement of other disciplines, the organization of visits and follow-up, and the integration of psychoeducational interventions."28
Wagner et al28 stated that primary care practices can be reorganized to provide better care for patients with chronic illnesses in a system with other enhancements. In evaluating barriers to management of patients with type 2 diabetes, Brown et al29 noted that the interactions of patient, physician, and systemic factors of the disease provide the greatest limitations, underlying the need for a CCM where a team of physicians each cooperatively interacts with the patient, working toward improved outcomes and lowering risk factors for comorbid diseases.
In addition, Wagner et al28 believe that the design of the practice refers to the delegation of roles within the practice team, the involvement of other disciplines, the organization of visits and follow-up, and the integration of psychoeducational interventions.28
Communication and reinforcement for patients to take an active and central role in managing their diabetes, regular self-assessments, and the use of effective behavior change interventions must be emphasized.30 Within the CCM, clinicians are working to invoke forward progress to lower diabetic complications and to improve HbA1c, low-density lipoprotein cholesterol, and systolic blood pressure values. Successful programs include collaborative care planning and patient-centered problem solving. The practice team develops an individualized care plan with each patient, who has access to support when problems are encountered.30
The CCM strives for an informed, activated patient interacting with a prepared, proactive practice team, resulting in productive encounters and improved outcomes. The addition of team members can improve outcomes in chronic conditions.3 The creation of these teams may be the fundamental primary care redesign that allows other components of the CCM to succeed.3
When implemented correctly into a healthcare system, the CCM shows encouraging results for decreasing HbA1c levels, decreasing non-high-density lipoprotein cholesterol, and increasing the frequency of self-monitoring glucose levels.27 It has also shown that CCM-based interventions were effective for improving clinical, behavioral, psychological/psychosocial, and diabetes knowledge outcomes in patients with diabetes.27 With the incorporation of a CCM in large hospital centers, Group Health Cooperative, Puget Sound, and Kaiser Permanente noted savings per patient with lower HbA1c levels and decreased hospital stays,31,32 thus reductions in healthcare utilization and costs.33 Improving glycemic control in patients with diabetes and depression, by also treating their depression, clinicians can help lower healthcare utilization and costs.
In a randomized controlled trial of 874 patients 40 years or older who were followed up for 6 years after implementation of a structured individualized personal care plan with educational and surveillance support, the study revealed a reduction in the levels of risk factors for enrolled patients significant enough to have beneficial effects on diabetic complications.34 Individuals responding to cognitive behavioral therapy for treatment of depression with diabetes education had better glycemic control versus nonresponders to cognitive behavioral therapy for treatment of depression with diabetes education.35 Psychological interventions have shown a statistically significant reduction in HbA1c, reducing risks for macrovascular and microvascular complications often associated with diabetes.36 It makes sense that when the tenets of the CCM are utilized simultaneously for patients with chronic illnesses, clinical outcomes show greater improvement.2,3
Integration of the CCM, in addition to improving outcomes, can also improve follow-up and patient monitoring, as was shown at Harvard Vanguard Medical Associates in 2003. With implementation of population management, systems-based practice, and planned chronic illness support under the CCM, screening rates improved from 51% to 58%, meaning that a greater percentage of enrolled patients were taking an active role in their care.37
There is a palpable void in the current care model with failure to effectively address patient needs when managing a chronic illness. Recognition of a patient's multifaceted needs and utilization of organization resources through implementation of a CCM can only improve outcomes. When implementing the CCM, although the research varies relative to percentages for which risk factors are lowered for associated comorbidities, no study known by the authors of this article suggests that with accurate implementation of the CCM, risk factors increased. Although the system is not perfect, it has been shown that improved chronic disease management through utilization of the CCM should benefit most of the population with a given chronic illness.2
There are practical assessment tools available to the patient and the clinician, practice, or healthcare center that can be utilized to evaluate the efficacy of implementation of the CCM. Without constant self-evaluation and system evaluation of the CCM's implementation, treatment can become stagnant. Therefore, the outcomes that can be achieved through its use become muted. Utilization of both the Patient Assessment of Chronic Illness Care (PACIC) completed by the patient and the Assessment of Chronic Illness Care (ACIC) completed by members of the healthcare team is recommended.
The PACIC was designed to assess the implementation of the CCM from the patient's perspective that focuses on the receipt of patient-centered care and self-management behaviors.38 It has been shown to be independently associated with improved patient outcomes in addition to improved self-management behaviors in adult populations with chronic illness, underlining the validity of the assessment tool.38,39 The PACIC, when combined with the 5 A's (ask, advise, agree, assist, and arrange) of the model of behavior change, shows validity in patient evaluations of services received under the CCM, specifically for management of type 2 diabetes.39 Patients who are more satisfied with the care they are receiving under the CCM may benefit more from its implementation, and this ultimately may lead to decreased risk factors associated with diabetes Figure 3.
The ACIC is a tool designed to help organizations and quality-improvement teams assess how well they are providing care for chronic illness in each of the 6 components of the CCM.30 The ACIC, when completed by members of the healthcare team, can pinpoint areas of necessary improvement within their CCM infrastructure to improve outcomes. "Feedback from participating teams suggests that they find the ACIC extremely useful for identifying areas in which they need to focus improvement efforts and in tracking progress over time. The instrument appears sensitive to intervention changes across different chronic illnesses and helps teams focus their efforts on adopting evidence-based chronic care changes."41
Changes in large hospital centers are difficult to induce because "conditions must be favorable in all 3 overlapping galaxies that affect healthcare institutions-the general community, the healthcare system, and the institution itself,"31 but changes in the private practice setting to support the CCM can be implemented, yielding large outcomes in patient care and diabetes management.
Optimizing the health of individuals with chronic conditions requires a high-quality medical care system that can both educate and support patients and deliver evidence-based clinical care42Figure 4. Redesign of hospital centers and healthcare institutions is important for improving outcomes and disease self-management and forging productive relationships between patients, physicians, and medical teams.42
Implementation of the CCM enables the clinician to begin to understand that when symptoms of depression are present, they need to be evaluated, classified, and treated simultaneously with diabetes interventions. The CCM can concurrently address multiple issues affecting the patient and include interventions to integrate psychological treatments.26 With respect to ease of future integration of this model and acceptance, the authors have found that education during residency training programs has shown improved outcomes with improved outlook on the management of chronic illnesses43 and is supported by various authors44 as the focus from acute care shifts toward that of chronic care. This type of residency training instills a substantial commitment to the cause of chronic illness care in new practitioners that can be carried into practice.
"Primary care practices and practitioners are so oriented to acute illness, they may not differentiate their clinical approach to patients with acute and chronic illness, relying instead on patient-initiated visits."1 However, the CCM challenges this perspective and understands that chronically ill patients need time with their providers, regular assessments of clinical, behavioral, and psychosocial variables, and ready access to other resources such as pharmacists, nutritionists, and social workers,1 all of which the CCM aims to satisfy. The bottom line is to have healthier patients, more satisfied providers, and cost savings while treating patients with diabetes-a chronic illness affecting 8% of the US population.4
It must be understood that although the authors are focusing on the connection between diabetes as a chronic illness and depression as a secondary chronic illness, with a large percentage of crossover between the 2 populations, the impact of psychosocial components in chronically ill patients cannot be underestimated. Clinicians need to shift the paradigm of thought, in the need for consistent use of the CCM to address all issues affecting patients. This is especially true for biopsychosocial issues and depression, so that clinicians can better manage their patient's disease, encourage self-management, and improve long-term outcomes while decreasing risk factors for additional comorbidities.
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8. Waitzfelder B, Gerzoff RB, Karter AJ, et al. Correlates of depression among people with diabetes: the Translating Research Into Action for Diabetes (TRIAD) study. Prim Care Diabetes 2010;4:215-22.
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, fasting glucose and future risk of elevated depressive symptoms over 2 years of follow-up in the English Longitudinal Study of Ageing. Psychol Med 2011;41:1889-96.
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13. Verma SK, Luo N, Subramaniam M, et al. Impact of depression on health related quality of life in patients with diabetes. Ann Acad Med Singapore 2010;39:913-9.
14. Michigan Diabetes Research and Training Center: Diabetes Empower Scale (DES and DES-SF). 2011. http://www.med.umich.edu/mdrtc/profs/survey.html#des
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17. Lustman PJ, Anderson RJ, Freedland K, de Groot M, Carney RM, Clouse RE. Depression and poor glycemic control: a meta-analytic review of the literature. Diabetes Care 2000;23:934-42.
18. Egede LE, Nietert PJ, Zheng D. Depression and all-cause and coronary heart disease mortality among adults with and without diabetes. Diabetes Care 2005;28:1339-45.
19. Black SA, Markides KS, Ray LA. Depression predicts increased incidence of adverse health outcomes in older Mexican Americans with type 2 diabetes. Diabetes Care 2003;26:2822-8.
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21. Ciechanowski PS, Katon WJ, Russo JE. Depression and diabetes: impact of depressive symptoms on adherence, function, and costs. Arch Intern Med 2000;160:3278-85.
22. Lin EHB, Rutter CM, Katon W, et al. Depression and advanced complications of diabetes: a prospective cohort study. Diabetes Care 2010;33(2):264-9.
23. Vileikyte L, Peyrot M, Gonzalez JS, et al. Predictors of depressive symptoms in persons with diabetic peripheral neuropathy: a longitudinal study. Diabetologia 2009;52:1265-73.
24. Ismail K, Winkley K, Stahl D, Chalder T, Edmonds M. A cohort study of people with diabetes and their first foot ulcer: the role of depression on mortality. Diabetes Care 2007;30:1473-9.
25. Gonzalez JS, Vileikyte L, Ulbrecht JS, et al. Depression predicts first but not recurrent diabetic foot ulcers. Diabetologia 2010;53:2241-8.
26. Gonzalez JS, Fisher L, Polonsky WH. Depression in diabetes: have we been missing something important? Diabetes Care 2011;34:236-9.
27. Piatt GA, Orchard TJ, Emerson S, et al. Translating the Chronic Care Model into the community: results from a randomized controlled trial of a multifaceted diabetes care intervention. Diabetes Care 2006;29:811-7.
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30. Glasgow RE, Funnell MM, Bonomi AE, Davis C, Beckham V, Wagner EH. Self-management aspects of the improving chronic illness care breakthrough series: implementation with diabetes and heart failure teams. Ann Behav Med 2002;24(2):80-7.
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34. Olivarius N, Beck-Neilsen H, Andreasen A, HøØrder M, Pedersen PA. Randomised controlled trial of structured personal care of type 2 diabetes mellitus. BMJ 2001;323:1-9.
35. Lustman PJ, Griffith LS, Freedland KE, Kissel SS, Clouse RE. Cognitive behavior therapy for depression in type 2 diabetes mellitus: a randomized, controlled trial. Ann Intern Med 1998;129:613-21.
36. Alam R, Sturt J, Lall R, Winkley K. An updated meta-analysis to assess the effectiveness of psychological interventions delivered by psychological specialists and generalist clinicians on glycaemic control and on psychological status. Patient Educ Couns 2009;75:25-36.
37. Kumura J, DaSilva K, Marshall R. Population management, systems-based practice, and planned chronic illness care: integrating disease management competencies into primary care to improve composite diabetes quality measures. Dis Manag 2008;11(1):13-22.
38. Schmittdiell J, Mosen DM, Glasgow RE, Hibbard J, Remmers C, Bellows J. Patient Assessment of Chronic Illness Care (PACIC) and improved patient-centered outcomes for chronic conditions. J Gen Intern Med 2008;23(1):77-80.
39. Glasgow RE, Whitesides H, Nelson CC, et al. Use of the Patient Assessment of Chronic Illness Care (PACIC) with diabetic patients. Diabetes Care 2005;28(11):2655-61.
40. Improving Chronic Illness Care [online]. 2011. http://www.improvingchroniccare.org/
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41. Bonomi AE, Wagner EH, Glasgow RE, VonKorff M. Assessment of Chronic Illness Care (ACIC): a practical tool to measure quality improvement. Health Serv Res 2002;37:791-820.
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