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• W2330924791 abstract "Free AccessSurgeryQuality Measures for the Care of Adult Patients with Obstructive Sleep Apnea R. Nisha Aurora, MD, Nancy A. Collop, MD, Ofer Jacobowitz, MD, PhD, Sherene M. Thomas, PhD, Stuart F. Quan, MD, Amy J. Aronsky, DO R. Nisha Aurora, MD Address correspondence to: R. Nisha Aurora, MD, Johns Hopkins School of Medicine, Johns Hopkins Sleep Disorders Center, 5501 Hopkins Bayview Circle, Fourth Floor, Baltimore, MD 21224 E-mail Address: [email protected] Johns Hopkins University, School of Medicine, Baltimore, MD Search for more papers by this author , Nancy A. Collop, MD Emory Sleep Center, Atlanta, GA Search for more papers by this author , Ofer Jacobowitz, MD, PhD ENT and Allergy Associates and Mount Sinai Hospital, New York, NY Search for more papers by this author , Sherene M. Thomas, PhD American Academy of Sleep Medicine, Darien, IL Search for more papers by this author , Stuart F. Quan, MD Division of Sleep Medicine, Harvard Medical School, Boston, MA Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA Arizona Respiratory Center, University of Arizona College of Medicine, Tucson, AZ Search for more papers by this author , Amy J. Aronsky, DO CareCentrix, Hartford, CT Search for more papers by this author Published Online:March 15, 2015https://doi.org/10.5664/jcsm.4556Cited by:65SectionsAbstractPDF ShareShare onFacebookTwitterLinkedInRedditEmail ToolsAdd to favoritesDownload CitationsTrack Citations AboutABSTRACTObstructive sleep apnea (OSA) is a prevalent disorder associated with a multitude of adverse outcomes when left untreated. There is significant heterogeneity in the evaluation and management of OSA resulting in variation in cost and outcomes. Thus, the goal for developing these measures was to have a way to evaluate the outcomes and reliability of the processes involved with the standard care approaches used in the diagnosis and management of OSA. The OSA quality care measures presented here focus on both outcomes and processes. The AASM commissioned the Adult OSA Quality Measures Workgroup to develop quality care measures aimed at optimizing care for adult patients with OSA. These quality care measures developed by the Adult OSA Quality Measures Workgroup are an extension of the original Centers for Medicare & Medicaid Services (CMS) approved Physician Quality Reporting System (PQRS) measures group for OSA. The measures are based on the available scientific evidence, focus on public safety, and strive to improve quality of life and cardiovascular outcomes for individual OSA patients.The three outcomes that were selected were as follows: (1) improve disease detection and categorization; (2) improve quality of life; and (3) reduce cardiovascular risk. After selecting these relevant outcomes, a total of ten process measures were chosen that could be applied and assessed for the purpose of accomplishing these outcomes.In the future, the measures described in this document may be reported through the PQRS in addition to, or as a replacement for, the current OSA measures group. The overall objective for the development of these measures is that implementation of these quality measures will result in improved patient outcomes, reduce the public health burden of OSA, and provide a measurable standard for evaluating and managing OSA.Citation:Aurora RN, Collop NA, Jacobowitz O, Thomas SM, Quan SF, Aronsky AJ. Quality measures for the care of adult patients with obstructive sleep apnea. J Clin Sleep Med 2015;11(3):357–383.INTRODUCTIONObstructive sleep apnea (OSA) is one of the most prevalent sleep disorders, affecting approximately to 3% to 7% of men and 2% to 5% of women in the general population.1–4 When polysomnographic criteria alone are considered, the prevalence rate increases dramatically to 24% in men and 9% in women.3 Despite the fact that OSA is a common disease, it remains considerably underdiagnosed, with 75% to 80% of cases remaining unidentified.5,6The implications of untreated OSA are significant from the individual patient, healthcare, and economic perspectives. For the affected individual, OSA is associated with a number of nocturnal symptoms, as well as with difficulty in daytime functioning secondary to daytime sleepiness, irritability, fatigue, and decreased cognitive functioning.1 In fact, untreated OSA has been shown to significantly reduce quality of life.7,8 Furthermore, untreated OSA (especially severe OSA) is associated with a multitude of adverse health outcomes including cardiovascular disease,9 disorders of glucose metabolism including insulin resistance and diabetes,10,11 stroke,12 and an increased risk of death.13 Another compelling motivation for early case identification and treatment of OSA is the higher prevalence of traffic accidents noted in persons with untreated OSA.14–16 From an economic perspective, the healthcare costs and resource utilization of undiagnosed OSA is staggering, running into billions of dollars per year,17,18 similar to other chronic disorders. The financial burden of OSA-related motor vehicle crashes alone is enormous. Furthermore, therapy for OSA seems to reduce comorbidities associated with OSA as well as healthcare costs and utilization.19,20Despite the individual health and economic imperatives to diagnose and treat OSA, there is substantial heterogeneity in how OSA patients are managed. In large part, this may be a function of the different pathways used to diagnose a patient with OSA. For example, the initial evaluation for OSA may begin in the primary care provider's office. The primary care provider may be confronted with patient symptoms such as snoring, excessive daytime somnolence, and pauses in breathing. In this paradigm of care, the primary care provider may then request a diagnostic sleep test and manage the patient without specialist input. Alternatively, the patient may be referred directly to a sleep specialist before or after the diagnostic sleep test for further evaluation. The evaluation by the sleep specialist is typically more detailed and includes a measure of sleepiness, a thorough physical exam with attention to the upper airway and a comprehensive differential diagnosis for the patient's sleep-related complaints. After evaluating the patient, the sleep specialist may co-manage the patient with the referring healthcare provider or return the patient back to the healthcare provider for all further care. Another factor explaining practice variation is the multiple medical disciplines included in the specialty of sleep medicine. In addition to the primary care provider and the sleep specialist, care for the patient with OSA may involve pulmonologists, otorhinolaryngologists, neurologists, psychiatrists, cardiologists, bariatric surgeons, anesthesiologists, obstetricians/gynecologists, and others. Given the aforementioned factors involved in the coordination and management of care of the OSA patient, considerable variability in practice patterns can occur, resulting in suboptimal or non-cost-effective care.Where there is substantial variation in medical practice, and consequently differences in cost and outcomes, measurement of adherence to evidence-based management guidelines can help highlight the most significant opportunities for improvement and reduce unintended variations in medical practice. This is particularly applicable to the diagnosis and treatment of OSA, because it is known that treatment can reduce costs,19,20 and in many cases, improve quality of life21 and reduce morbidity from symptoms and comorbid conditions.22–25 To this end, the AASM commissioned five Workgroups to develop quality care measures aimed at optimizing care for patients suffering from sleep-related disorders, including adult and pediatric OSA, restless legs syndrome, narcolepsy, and insomnia.26 These quality care measures focus on both outcomes, that is, what happens to a patient as a result of the care received, and processes, or the steps taken by a healthcare provider in the care of an individual patient. Both outcomes and processes are important in the care of the patient. Outcomes are often more directly relevant to the patient, whereas processes tend to be less influenced by factors outside an individual provider's control, such as patient preference. All of the adult OSA outcomes and processes detailed in this report were developed by the Adult OSA Quality Measures Workgroup and received final approval from the AASM Quality Measures Task Force and the AASM Board of Directors. The quality measures developed by the Adult OSA Quality Measures Workgroup are an extension of the original Centers for Medicare & Medicaid Services (CMS) approved Physician Quality Reporting System (PQRS) measures group for OSA.27 These were used for the basis of developing additional measures with the goals of standardizing and enhancing the management of OSA patients, evaluating how well this care is being delivered, and using the data collected to prospectively improve the quality of that care. These new measures are harmonized with the prior PQRS measures, are meaningful and based on scientific evidence, include outcome measures, and focus on public safety and prevention/treatment of cardiovascular disease, the latter two being National Quality Strategy (NQS) priorities.28 Nonetheless, it is acknowledged that with evolution in the practice of sleep medicine, these quality measures should be regularly reevaluated to assure the measurement of the most up-to-date standards of care.METHODSLiterature ReviewAs described in the parent paper26, a comprehensive search was conducted to identify any publications that addressed sleep apnea in terms of quality care or measures. All searches were limited to articles published between 2002–2013, pertaining to humans, and in the English language. Publication types such as news, letters, editorials, and case reports were excluded. A total of 795 articles were retrieved for review using this search.An additional search was conducted to identify clinical practice guidelines, measures, systematic reviews, meta-analyses, and consensus recommendations published by the AASM or other organizations or groups in the National Guidelines Clearinghouse, the National Quality Measures Clearinghouse, PubMed, EMBASE, PsycInfo, and the Cochrane Library pertaining to obstructive sleep apnea (and all associated MeSH terms). All searches were limited to articles published between 2002–2013, pertaining to humans and adults, and in the English language. Publication types other than the ones listed above were excluded. A total of 136 articles resulted from this additional search. Workgroup members also performed “pearling,” where references from full articles found through the literature search were examined to identify any additional relevant evidence, resulting in another 5 articles.The titles and abstracts of all articles were each reviewed by two Workgroup members. Any disagreements were resolved by a third Workgroup member. Full articles of publications thought to be relevant were obtained and reviewed in full to identify and provide support for the drafted quality measures.Workgroup members graded the available evidence from the literature searches for the strength of association between the proposed process and the desired outcome. For this, they used the grading scheme shown in the Table 1.Table 1 Strength of association between process measure and desired outcome.Table 1 Strength of association between process measure and desired outcome.Measure SelectionIn considering the development of measures for adult OSA, the Workgroup sought to identify 1–3 outcomes that were patient-oriented, easily applicable, and well supported by the current literature and expert opinion. Process measures were then to be developed to correspond with each desired outcome yet not create significant burden for the patient, healthcare provider, or administrative staff. It was decided that a total of 2–10 process measures would be needed to achieve all of the outcomes.Initially, consideration was given to the following outcomes: improvement in quality of life, improvement in functional status, and cardiovascular risk reduction. After much thought and discussion, the Workgroup opted to include and refine the previous OSA measures, developed in conjunction with the American Medical Association's Physician Consortium for Performance Improvement (AMA-PCPI), which aimed to improve disease detection and categorization and focus on the following new outcomes: improvement in quality of life and cardiovascular risk reduction. Initially, the following process measures were chosen as there was consensus by the Work-group members on their importance: (1) quality of life assessment by the healthcare provider, (2) snoring assessment, (3) nocturnal oxygen saturation assessment after therapy is implemented, (4) measurement of weight, (5) blood pressure monitoring at every visit, (6) a history of near-miss motor vehicle crashes, sustained motor vehicle crashes and workplace accidents, (7) assessment of sleepiness via a questionnaire or scale, and (8) objective treatment adherence data. Subjective adherence data could be used if objective adherence data is not available.During the face-to-face meeting of all the Workgroups, it was decided that nocturnal oxygen saturation assessment after therapeutic intervention would be excluded. This process measure could potentially be burdensome to both the health-care provider and patient, and there was not enough standardization with regards to acceptable oxygen saturation levels to make it a meaningful measure. Other process measures were further honed over time. For example, the Workgroup agreed that because weight is a significant risk factor for OSA, a discussion about weight management would be important in overweight and obese patients. Additionally, given the strong association between OSA and hypertension, it would be important to address an elevated blood pressure reading with the patient. There was also concern that requiring that a quality of life (QoL) questionnaire be completed within one year of implementing treatment might be burdensome. The Workgroup and all of the BOD liaisons were surveyed, and the majority opinion was that it would be important to have a standardized, measurable approach to assessing quality of life, given that the tools to do this are widely available. However, the choice of questionnaire used was not specified to give flexibility to the provider, hopefully reducing any burden. The final process and outcome measures are depicted in Figure 1. The technical specifications associated with each of these quality measures can be found in the Appendix. These specifications outline how to calculate an individual provider's performance in meeting these measures using a combination of diagnostic and CPT codes and chart review.Figure 1: Adult OSA quality measures driver diagram.Download FigureQUALITY MEASURESOutcome 1 – Improve Disease Detection and CategorizationDescriptionOutcome 1, which is not a measured outcome but rather a broad goal of care, is to improve detection and categorization of OSA.It is estimated that 3% to 7% of men and 2% to 5% of women in the adult general population have OSA.1–4 Nevertheless, despite increasing awareness by both the public and clinicians, OSA remains considerably underdiagnosed and treated.5,6 Furthermore, the therapeutic approaches used to treat people with OSA can vary according to severity.29–31 Thus, it is important to document disease severity in people in whom the diagnosis is made. To address these issues, the Workgroup chose 2 process measures (#1–2) focused on ascertaining OSA symptoms and severity that should result in improvement in disease detection and categorization.Supporting Evidence and RationaleRecognition of OSA is critically dependent on ascertainment of clinical symptoms. Any improvement in the diagnosis of OSA will flow from clinicians determining whether symptoms of OSA are present in their patients. The 2 most common symptoms of OSA are snoring and excessive daytime sleepiness.32,33 Thus, assessment of these symptoms and others will result in increased diagnostic testing for OSA and should be a useful process measure to increase disease detection.Current classification of severity of OSA relies exclusively on the results from determination of event frequency.34 This can only be obtained using polysomnography or home sleep apnea testing. In either case, people with more severe disease have been shown to be at greater risk for cardiovascular disease, neurocognitive impairment, and other adverse health outcomes.9–16 A more aggressive therapeutic approach may be pursued in such individuals in contrast to those with milder disease. Thus, the Workgroup decided it was important to have documentation of disease severity as a process measure for this outcome.Issues Addressed During DevelopmentAlthough the Workgroup agreed that “Improving Disease Detection and Categorization” is an important outcome measure, it was recognized that directly measuring and tracking this outcome would be challenging because of socioeconomic, hereditary, cultural, and other influences beyond the control of a healthcare facility or clinician, and that any change in this outcome might take a considerable amount of time to be realized.26 However, it was felt that Process Measure #1 (Baseline Assessment of OSA Symptoms) and Process Measure #2 (Severity Assessment at Initial Diagnosis) would directly impact this outcome and would be reasonable surrogates.Process Measure 1 – Baseline Assessment of OSA SymptomsDescriptionProportion of patients aged 18 years and older with a diagnosis of obstructive sleep apnea (OSA) with documentation of assessment of OSA symptoms at initial evaluation, including the presence of snoring and daytime sleepiness.Exceptions and Exception JustificationsMedical Reasons: None.Patient Reasons: Patients who decline assessment.System Reasons: Patients who had initial evaluation for OSA previously completed by another healthcare provider.If the patient refuses to be evaluated, then their information will not be available for inclusion. Additionally, if the patient has had this information obtained on a previous visit with another healthcare provider, then it would pose unnecessary burden to repeat this process.Supporting Evidence and RationaleIt is well-recognized that OSA is an underdiagnosed disorder that can pose significant economical and public health burdens if left untreated. Assessing OSA-related symptoms is an important first step in reducing the burden of undiagnosed disease. Clinical history and physical exam remain the cornerstone of initial disease detection. Thus, to improve disease detection, it is critical that all patients with suspected OSA be asked about OSA-related nocturnal and daytime symptoms. Process Measure 1 specifies that adult patients aged 18 years and older with a suspected diagnosis of OSA should have documentation of their presenting symptoms including, but not limited to, snoring and daytime sleepiness, at the time of initial evaluation for OSA. Both snoring and daytime sleepiness are relatively prevalent symptoms in those with OSA. It is estimated that snoring occurs in up to 30% to 50% of adults over the age of 50, and subjective sleepiness occurs in more than 30% of adults.35 Patients diagnosed with obstructive sleep apnea should be regularly assessed for the development and progression of both these symptoms as well as the patient's specific presenting symptoms to help guide therapeutic decisions. For example, continuous positive airway pressure (CPAP) settings may be modified in order to better treat the OSA which may improve snoring or daytime sleepiness.Relationship to Desired OutcomeIn order to improve detection and categorization of OSA, it is critical that all patients be asked about nocturnal and daytime symptoms that are associated with obstructive sleep apnea. Clinical history and physical exam remain the cornerstone of initial disease detection.Opportunities for Improvement/GapsIt is well-recognized that OSA is an underdiagnosed disorder and this lack of disease recognition poses significant economical and public health burdens. Assessing OSA-related symptoms is an important first step in reducing the burden of undiagnosed disease.Issues Addressed During DevelopmentNone.Process Measure 2 – Severity Assessment at Initial DiagnosisDescriptionProportion of patients aged 18 years and older with a diagnosis of obstructive sleep apnea that had an apnea hypopnea index* (AHI), a respiratory disturbance index** (RDI), or respiratory event index*** (REI) documented or measured within 2 months of initial evaluation for suspected obstructive sleep apnea.*Apnea-hypopnea index (AHI) for polysomnography performed in a sleep lab is defined as (Total apneas + hypopneas per hour of sleep)36**Respiratory disturbance index (RDI) is defined as (total apneas + hypopneas + respiratory-effort-related arousals per hour of sleep)36***Respiratory event index (REI) is a measure of respiratory events per unit of time for home sleep apnea testing.37 It should be noted that, in light of the limited number of channels utilized for home sleep apnea testing, the REI may underestimate the severity of OSA or fail to capture the diagnosis because of underestimation of the true event index.Exceptions and Exception JustificationsMedical Reasons: Patients with a medical, neurological, or psychiatric disease that prohibits successful completion of a sleep study; patients in whom a sleep study would present a bigger risk than benefit or pose an undue burden should not be included in the eligible population.Patient Reasons: Patients who declined AHI/RDI/REI measurement; patients who have financial reasons for not completing testing.System Reasons: Test was ordered but not completed; Patients who decline because their insurance (payer) does not cover the expense.In patients that have physical or mental limitations, such as motor paralysis or intellectual disability, completing a sleep study may pose a significant burden on the patient and/or their family. If a patient refuses to have a sleep study, then this measure cannot be assessed. Also, paying for a sleep study may pose significant financial burden. These patients should be excluded from the assessment.Supporting Evidence and RationaleExpeditious diagnosis and treatment of OSA are important in reducing the burden associated with OSA-related comorbidities. However, history and physical exam alone are not sufficient to diagnose OSA. Objective testing with either in-laboratory polysomnography or home sleep apnea testing is necessary and required for the diagnosis of OSA and classification of disease severity.35,38,39 Determining OSA severity is important given that patients with moderate or severe OSA are at higher risk for cardiovascular diseases, neurocognitive dysfunction, lower quality of life, and other comorbid conditions.9,40,41 Thus, physicians evaluating patients with suspected sleep apnea should try to establish the patient's level of OSA severity in an expeditious manner as early case identification is important in prompt initiation of treatment and reduction of OSA-associated comorbidities.Relationship to Desired OutcomeThis process measure directly feeds into the outcome as OSA detection and categorization cannot occur without an objective evaluation of breathing during sleep.42 A sleep study is needed, as clinical evaluation alone has limited sensitivity and specificity.Opportunities for Improvement/GapsGiven the enormous burden of undiagnosed OSA, this measure provides an opportunity to address this burden by requiring study based disease diagnosis and categorization. It provides the opportunity to expedite appropriate treatment for OSA.Issues Addressed During DevelopmentThere were some concerns raised that the requirement to obtain a sleep study within 2 months of initial evaluation was an insufficient amount of time and may not be possible in certain settings. However, after assessing the burden and benefits, the Workgroup was confident that 2 months was in fact an appropriate amount of time, given that the required sleep study could be an in-laboratory or home sleep apnea test (types I - IV).Outcome Measure 2 – Improve Quality of LifeDescriptionProportion of patients aged 18 years and older diagnosed with obstructive sleep apnea (OSA) that showed any improvement in their quality of life (QoL) from baseline within one year of starting treatment.Exceptions and Exception JustificationsMedical Reasons: Patients who have been diagnosed with a terminal or advanced disease with an expected lifespan of less than 6 months; patients with an unstable or poorly controlled medical disease; patients who have been diagnosed with severe psychiatric disorders (e.g., severe depression, schizophrenia).Terminal illness will likely result in a deterioration in QoL and thus mask any improvement related to the treatment of OSA. Unstable comorbid illnesses will produce fluctuations in QoL that will confound any impact of OSA treatment. Severe psychiatric disorders are associated with reductions in QoL, which may mask changes related to OSA treatment. Furthermore, depressive symptoms may be caused by OSA. Simultaneous treatment of depression and OSA may make changes in QoL difficult to interpret.Patient Reasons: Patients who change treatment modalities within one year of starting their initial treatment; patients who do not return for a follow-up appointment within one year of initiating treatment; patients who decline or are unable to complete the QoL assessment instrument; patients who do not have an impaired QoL at baseline.If patients change treatment during the follow-up interval, there may be an inadequate length of time to determine whether an improvement in QoL has occurred. Furthermore, change in therapy is usually prompted by treatment failure or intolerance, and the therapy may actually lead to a temporary reduction in QoL. In addition, it will be difficult to assess which therapeutic intervention would be responsible for an improvement in QoL until the patient was stable on their “final” treatment. Some patients with OSA do not have an impairment in their QoL and treatment is initiated to mitigate the impact of OSA on cardiovascular risk. For these patients, there is no reason to expect any improvement in QoL. Exclusion of patients who refuse to participate or do not return for follow-up is self-explanatory.System Reasons: None.Supporting Evidence and RationaleQuality of life is now considered one of the most fundamental patient-reported outcomes in healthcare. The duration and improvement in QoL is used to determine whether innovative and expensive therapies should be incorporated as standard therapies.43 For the vast majority of patients with OSA, a reduction in their QoL as reflected by symptoms such as intractable daytime sleepiness or fatigue, poor sleep quality, and inability to sleep in the same bedroom with their bed partner is the primary reason for seeking care. Thus, treatment for OSA should result in an improvement in the QoL of patients.There is substantial evidence that OSA is associated with a reduction in QoL. The domains of physical functioning, general health, and vitality appear to be the most severely impacted.7 The prevalence of impaired quality of life ranges from 41% to 88% depending on QoL domain assessed and the assessment tool.44,45 Quality of life can be assessed using validated generic QoL instruments such as the Medical Outcomes Study SF-36 or SF-12. However, validated OSA specific instruments may be more sensitive and germane to people with OSA.46 Instruments such as the Calgary Sleep Apnea Quality of Life Inventory (SAQLI) or Functional Outcomes of Sleep Questionnaire (FOSQ) have been shown to be useful in identifying impaired QoL in persons with obstructive sleep apnea.There have been a number of studies investigating the impact of treatment of OSA on QoL.46 In randomized controlled trials, QoL improves after adequate treatment of OSA with positive airway pressure,21,47 oral appliances,48 and upper airway surgery.49 All of these treatment modalities are commonly utilized for the treatment of OSA.Acceptable validated QoL instruments include, but are not limited to, the following: Medical Outcomes Study SF-36,50 Medical Outcomes Study SF-12,51 Nottingham Health Profile,52 EuroQoL,53 EQ-5D,54 FOSQ,55 SAQLI.56 Although use of a validated QoL instrument will be expected to result in some amount of patient burden, as well as healthcare provider/staff effort to extract the data, use of a non-validated measure or a chart note indicating improved QoL will not provide any reliable or consistent measure of this outcome.Opportunities for Improvement/GapsAlthough QoL is impaired in OSA and has been shown to improve with treatment, there are no studies documenting its assessment before and/or after initiating treatment in clinical populations.Issues Addressed During DevelopmentThere were several issues that were considered in the development of this outcome measure. Foremost, was the feasibility of collecting the required information because ascertainment of quality of life is not normally done as part of typical clinical evaluations. This issue was discussed in the context of the practice burden required to collect the data as well. In addition, the question of whether there should be a standardized data collection instrument was debated. Feedback from stakeholders emphasized the potential burden of administering a questionnaire to fulfill this measure as well as greater specification of the exceptions. It was acknowledged that an additional limitation was the inherent subjectivity of quality of life assessments, alth" @default.
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• W2330924791 title "Quality Measures for the Care of Adult Patients with Obstructive Sleep Apnea" @default.
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