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Healthc Policy. May 2006; 1(4): 85–104.
PMCID: PMC2585357

Language: English | French

Performance Measurement in Healthcare: Part I – Concepts and Trends from a State of the Science Review

La mesure du rendement dans les soins de santé : Partie I – Concepts et tendances issus d’un examen de l’état de la science

Carol E. Adair, MSC, PhD, Elizabeth Simpson, MSC, Ann L. Casebeer, MPA, PHD, Judith M. Birdsell, MSC, PHD, Katharine A. Hayden, MLIS, MSC, PHD, and Steven Lewis, MA

Abstract

Objective:

Performance measurement is touted as an important mechanism for organizational accountability in industrialized countries. This paper describes a systematic review of business and health performance measurement literature to inform a research agenda on healthcare performance measurement.

Methods:

A search of the peer-reviewed business and healthcare literature for articles about organizational performance measurement yielded 1,307 abstracts. Multi-rater relevancy ratings, citation checks, expert nominations and quality ratings resulted in 664 articles for review. Key themes were extracted from the papers, followed by multi-reader validation. Information was supplemented with grey literature.

Results:

The performance literature was diverse and fragmented, and relevant evidence was difficult to locate. Most literature is non-empirical and originates from the United States and the United Kingdom. No agreement on definitions or concepts is evident within or across disciplines. Study quality is not high in either field. Performance measurement arose in public services and business at about the same time. The evolution of thought on performance measurement ranges from unfettered enthusiasm to sober reassessment.

Conclusions:

The research base on performance measurement is in its infancy, and evidence to guide practice is sparse. A coherent multidisciplinary research agenda on the topic is needed.

Résumé

Objectif :

La mesure du rendement est considérée comme étant un important méca-nisme de responsabilisation organisationnelle dans les pays industrialisés. Ce document décrit un examen systématique de la littérature sur la mesure du rendement dans les domaines des affaires et des soins de santé afin d’éclairer l’élaboration de programmes de recherche sur la mesure du rendement dans les soins de santé.

Méthodes :

Une recherche d’articles sur le rendement organisationnel dans des publications sur les affaires et les soins de santé évaluées par les pairs a permis de repérer 1 307 résumés. Des évaluateurs multiples ont déterminé la pertinence de chaque article; on a vérifié les citations, désigné des experts et établi des cotes de qualité. Ces critères ont permis de réduire à 664 le nombre d’articles à examiner. On a dégagé des thèmes clés des documents, puis on les a fait valider par des lecteurs multiples. On a aussi eu recours à la littérature grise pour compléter les données.

Résultats :

La littérature sur le rendement était diversifiée et fragmentée, et les preuves pertinentes difficiles à repérer. La majeure partie de la littérature est de nature non empirique et provient des États-Unis et du Royaume-Uni. On ne décèle aucun consensus quant aux définitions ou aux concepts, ni entre les disciplines ni à l’intérieur de celles-ci. La qualité des études laisse à désirer, et ce, dans les deux domaines. La mesure du rendement a fait son apparition dans la fonction publique et dans le monde des affaires à peu près en même temps. L’évolution de la pensée sur la mesure du rendement varie d’un enthousiasme sans réserve à une réévaluation sobre.

Conclusions :

La recherche sur la mesure du rendement en est encore à ses balbutiements, et les preuves pouvant guider la pratique sont rares. Un programme de recherche multidisciplinaire et cohérent sur le sujet s’avère nécessaire.

“… no one knows the extent to which some of the expenditures have brought good or ill to the recipients, and certainly no one knows whether better service might not have been achieved for smaller outlay more intelligently applied.”

Pennsylvania Children’s Commission, 1920s (cited in Beck et al. 1998: 164)

“Collectively (and perhaps belatedly) we have recognized the most important issue facing the health service is not how it should be organized or financed, but whether the care it offers actually works.”

Walshe and Ham, 1997 (Perkins 2001: 9)

In the context of rising healthcare expenditures, performance measurement (PM) is increasingly integral to accountability. Healthcare accountability mechanisms have traditionally included business planning, annual reporting and contracting (Alberta Government 1998). In recent years a richer sense of accountability has emphasized the achievement of goals effectively and efficiently and has stimulated PM. PM has been described most simply as “the use of statistical evidence to determine progress toward specific defined organizational objectives” (State of California 2003), although more comprehensive definitions exist. The PM process typically involves four stages – conceptualization and strategy; measures selection and development; data collection and analysis; reporting and use – and can occur at multiple levels of organizations and systems.

The literature includes reports on performance measurement initiatives across the healthcare spectrum from primary (e.g., Proctor and Campbell 1999) through tertiary care (e.g., Rowan and Angus 2000), public health (e.g., Corso 2000) and the voluntary sector (e.g., Dunn and Matthews 2001) that have been mounted in response to demands from governments, other payers, consumers, proponents of evidence-based practice and accreditation organizations. Substantial resources have been invested in PM system development from the policy level through front-line care delivery (Goddard et al. 1999). Given the scale of investment, a commensurate level of research on PM would be expected. However, because scientific and experiential information about PM spans multiple sources and disciplines, there is no easy way to identify and summarize relevant evidence.

We conducted a systematic review of the business and health PM literature to inform a research agenda on healthcare PM. Our intent was to draw broad issues and themes from diverse sources. This paper outlines methods, summarizes general PM concepts and trends from business/management and healthcare sources and offers recommendations for a research agenda to produce evidence for practice. Part II (which will be published next issue) details findings from the review according to the four stages of PM and outlines implications for practice, including common problems and solutions suggested by PM authors. It also provides a brief update on new developments at the policy level in PM in Canada.

Methods

Methods for systematic reviews of clinical effectiveness studies (ScHARR 1997; Clarke and Oxman 2001) guided our review process, but were not entirely suitable for a broad policy subject. We based our approach on the principle of replicability; in the end, the review was a hybrid of systematic and narrative review methods. There were four steps in the process: (a) refining the review questions, (b) searching for and selecting articles, (c) classifying and rating the articles for quality and (d) writing and validation.

First, to refine the review questions, we received feedback on initial drafts from 22 (54%) of 41 healthcare decision-makers surveyed from across Canada, and in a focus group with four of them. Participants strongly endorsed the need for the review and provided suggestions for scope and content. Specifically, they called for inclusion of the business/management literature based on an interest in cross-sector comparisons and business innovations that might apply to healthcare.1 The final questions focused on predominant models and frameworks, evidence for impact and recommendations for research.

Second, a professional librarian (KH) designed and ran searches of the business and healthcare peer-reviewed literature and the grey literature. The peer-reviewed literature searches included the databases ABI Inform, Business Index ASAP, PsycInfo, ABI Inform, Medline, Embase, Cinahl and Web of Science. Key words varied by database, but were close approximations to performance measurement, performance measurement system and health system performance. Searches were limited to English-language materials for 1992–2002 for health and 1997–2002 for business (to focus on more recent developments). Grey literature provided an appropriate policy and practice context; sources included PM-related Internet sites, conference proceedings, newsletters, press clippings and periodical indexes. The article selection and review process is shown in Figure Figure11.

FIGURE 1.
The Article Selection and Review Process

The initial 6,342 abstracts from the peer-reviewed literature were screened manually by CA for obvious irrelevancy, since the search terms yielded abstracts about unrelated topics such as occupational and athletic performance. After removal of duplicates, teams of three investigators for each of the two fields independently rated the 1,307 remaining abstracts from the two fields for relevancy based on a criterion statement focusing on organizational-level PM concepts or evidence and research recommendations that had been pre-tested on 50 articles. Full-text papers that rated a “yes” by two of three raters were retained for the review, and the percentage of agreement for this criterion was high (85.3% J = .77; p = .000). This “first wave” of articles numbered 617.

In the third step, six readers in two teams read, classified and rated the papers for quality. Articles were classified by publication year, country, organizational level, patient population (health only) and type of research (non-empirical or empirical). Reading teams also flagged frameworks, definitions, innovations and recommendations for research. Quality rating scales were developed, pre-tested on 20 papers for each article type and revised. Non-empirical and empirical papers were rated on 10- and 15-point scales, respectively. Inter-rater agreement (unblinded) was high (intra-class correlation coefficients were .88 (95% CI .82–.92, p = .000) for empirical articles and .92 (95% CI .88–.94, p = .000) for non-empirical articles. Papers with ratings above the mean were advanced to the writing stage (n = 365), although the cut-off was not strict and some subjective judgments were made at that stage about inclusion based on the pertinence of material to the major themes that were identified to that point. Reference lists for the highest-rated papers were searched, and 21 authors of the highest-rated papers (of 42 contacted) nominated an additional 39 “best” papers on the topic. Forty-seven more papers were included as a result of these citation searches and author nominations (“second wave” activities). All papers were tracked using Access and EndNote databases.

In step four, one reader for each field prepared a written summary, which was validated by a second reader. The principal investigator then wrote a comprehensive draft report after reading all first- and second-wave papers and readers’ summaries. Grey literature was incorporated at this stage if it provided important context or additional insight on emerging themes. The draft review was then read and revised by team members. Feedback from two external reviewers was also incorporated.

Results

The “first wave” group of selected peer-reviewed articles included 81 (22%) from the business literature and 284 (78%) from health. First-author country of residence was the United States (69%), United Kingdom (15.3%), Australia (3.6%), Canada (3.6%) and all others (8.5%). The ratio of non-empirical to empirical papers was about two to one (69.3% vs. 30.7%). The business literature had more empirical papers (40.7%) than the health literature (28.0%), which might be attributable to the difference in search timeframes. Mean quality ratings were moderate and variable overall: 9.1 out of 15 (SD 2.93) for empirical papers and 6.6 out of 10 (SD 1.81) for non-empirical papers, even after selection for relevancy and quality. Mean quality ratings were not significantly different for business vs. health papers for non-empirical papers (6.1 vs. 6.0; p = .66) or empirical papers (8.8 vs. 9.2; p = .58).

Concepts

The concept performance measurement has no agreed-upon definition in or across the literature reviewed. It sits within a dizzying array of related theoretical ideas, research- and practice-based tools, initiatives and rhetoric. Nevertheless, the generally implied purpose of PM across all materials was the pursuit of excellence in organized human enterprise. Performance measurement systems are also conceptualized in multiple ways with many synonyms, including “organizational performance assessment system” (Leggat et al. 1998), “outcomes management system” (Jones and Brown 2001) and even the more general “continuous measurement process” (Nadzam and Nelson 1997; Rosenblatt et al. 1998). Definitions for all concepts were extracted to an omnibus glossary in the main report (Adair et al. 2003). For each concept, the principal investigator (with concurrence from the review team) selected the definition that seemed to fit best with the most frequently implied meaning across the body of literature (Table (Table11).

TABLE 1.
Selected definitions for healthcare performance measurement terms

With respect to its function in organizations, some authors characterize PM as only one part of a larger health information framework (Schneider et al. 1999). Others view it as an overarching activity that encompasses a variety of other related initiatives (Neely et al. 1995). PM is described by some as an internal organizational activity only, while others consider its primary purpose to be external, e.g., “PM has become a preferred means of ensuring external accountability” (McCorry et al. 2000: 636). Still others recognize that performance measures have utility for both internal and external reporting (e.g., Trabin et al. 1997).

The relationship between PM and related activities, such as total quality management (TQM), is an area of great conceptual confusion. For example, contemporary quality improvement processes are seen to rely on PM, but PM exercises are also described as having quality improvement activities as a key component. These endeavours seem to be increasingly blurred with time. Accreditation processes now emphasize the use of performance measures, benchmarking activities now often link directly to quality award schemes and TQM is touted as a mechanism to take action on PM results. The lack of conceptual clarity is not surprising, given the breadth of organizational types (e.g., for profit/not for profit) and levels (individual to system) at which PM is applied, and the diversity of disciplines producing PM-related research (at least 17 sub-disciplines were identified). Studies across disciplines were rare.

Performance measures for health have been developed for the three classical components of care defined by Donabedian (1988) (structure, process and outcomes) and at all care levels, from patient to population (Tansella and Thornicroft 1998; McIntyre et al. 2001). At the patient level, PM manifests primarily as measurement of the process or outcomes of treatment; at the service or program level, as program evaluation (measurement of program attributes for planning); at the system level, as a mechanism for organizational control and ensuring efficient use of resources; and at the population level, as the collection and reporting of high-level information for broad planning, policy making and accountability (Thompson and Harris 2001; Coyne 2002; Studnicki et al. 2002). While there are some commonalities in PM across levels, and data for one level are often rolled up for higher-level use, stakeholder priorities for and uses of PM data can be very different by level (Goddard et al. 1998; Legnini et al. 2000).

Current practice in healthcare

Table Table22 provides a summary of the relationships among PM-related initiatives and tools as they are described in the healthcare literature according to the predominant level of activity and how the various initiatives seem to have evolved over time.

TABLE 2.
Healthcare improvement activities and trends

The business PM literature

In business, PM was traditionally a top-down activity for organizational control (Lebas 1995; Smith and Goddard 2002). In a paper considered profoundly influential, Eccles (1991) predicted widescale redesign of business PM. The idea has now evolved into a more holistic, organizationwide, strategic management approach (Smith and Goddard 2002). Neely (1999) describes an exponential increase in the number of PM publications in the 1990s and the diffusion of PM language in corporate annual reports. This explosion of interest is attributed to a need for organizational change spurred by globalization and increasingly competitive markets, as well as an increase in active marketing by PM system and service vendors (Smith et al. 1997; Neely 1999; Malmi 2001).

The non-empirical business literature is characterized by the promotion of largely proprietary systems and the reporting of practical problems (Holloway 2001). Holloway (2001: 170) charges that much of the literature “merely proselytizes for particular models or approaches,” contains “a litany of failed or abandoned PM systems” and provides little in the way of analysis of the problematic side of PM. Busby and Williamson (2000: 336) describe the attitude towards PM in business as “simply an unquestioned belief that it leads to positive improvement.” Very few organizations have actually quantified change in performance associated with the implementation of PM (Mooraj et al. 1999), and cost–benefit studies are non-existent (Neely et al. 1995).

Few examples of empirical studies of PM system effectiveness were found in the business literature, and most were case series or surveys. In a New Zealand study, Upton (1998) investigated the association between performance measures and organizational performance. Overall, organizations using non-financial measures of the type found in newer PM schemes performed better. Unfortunately, the finding was based on the self-report of one respondent from each of 85 firms, rather than more rigorous evidence. In a longitudinal survey, Fawcett and Cooper (1998) found that between 1989 and 1994, higher-performing companies reported increasing use of measures. Key methodological challenges noted in the business literature included the tendency to attribute any and all organizational improvement to the PM system when other, uncontrolled factors may be present, and the problem of endogeneity (the same measures that make up the PM system are used to evaluate it) (Holloway 2001; McAdam and Bannister 2001). High-quality articles (both non-empirical and empirical) about PM in business that emerged from the review include Neely et al. 1995; Neely 1999, 2000; Bourne et al. 2000; and Holloway 2001.

The health PM literature

PM arose in the public service and private sectors at virtually the same time, unlike other management innovations that typically originate in the private sector and then subsequently move into the public realm (Smith and Goddard 2002). This situation may result, at least in part, from an urgent need for PM in organizational structures where no natural market exists. Business models and tools for PM (e.g., the Balanced Scorecard) have been applied in public services including health, but the public sector has also developed its own systems, instruments and analysis techniques (e.g., Khim and Hian 2001; Smith and Goddard 2002). Although there is no doubt that PM has been implemented more extensively in business (Malmi 2001), the chorus of calls in policy and research documents for its application in public and health services has been pronounced since the late 1980s (e.g., Relman 1988).

Several stages of the evolution of thought about PM emerged from the healthcare literature. During the 1980s and early 1990s, the calls for PM were abundant, along with unfettered enthusiasm for its promise for improving healthcare. This stage could be characterized as the performance measurement imperative (Relman 1988; Williams et al. 1992; Hall 1996). The mid-1990s brought rapid, uncoordinated proliferation of measures and systems and, in the United States, a burgeoning support industry. This proliferation and fragmentation stage has been colourfully described by Hermann et al. (2000: 149) as a time of  “letting many flowers bloom.”  The later 1990s heralded a distinct sober reassessment/reflection period. This stage was likely stimulated by practice experiences that revealed the great cost and complexity of system implementation, multiple failures and lack of standardization that impaired comparability. At this stage, some authors questioned whether PM, or some aspects of it, were even useful or feasible (Epstein 1995; Baumgarten 1998; Jencks 2000). More recently, the literature reflects a trend towards consensus and initial solutions, including acknowledgment of the complexities of PM, a redirection of energies towards more thoughtful, problem-solving approaches in practice (Viccars 1998; Jarvi et al. 2002; Mannion and Davies 2002; Smee 2002) and calls for broader consensus about PM at all levels (e.g., Bishop and Pelletier 2001; McLoughlin et al. 2001).

The literature on the effectiveness of healthcare PM is also sparse, but the general view is that there is little evidence that PM schemes have had either indirect impact on behaviour or direct impact on the quality of patient care or health gain at the system level. While many isolated examples of successful quality improvement initiatives can be found, few evaluations of organizationwide PM exist. Among the notable reported successes on a large scale include the transformation of the Veterans Health Administration system in the United States in the 1990s (Kizer et al. 2000) and improvements in access to primary healthcare in the United Kingdom (Pickin et al. 2004), published since our review. The extent to which these system improvements are attributable to the PM initiatives that made it possible to chart progress is not reported.

Many initial claims about PM effectiveness are purely anecdotal. For example, in the context of accreditation in Australia, Collopy (1998: 175) reports that the Australian Council on Healthcare Standards “has evidence of numerous alterations in practice and improvement in patient care induced by indicator monitoring,” and in the context of an application of the Balanced Scorecard (BSC) at Duke Children’s Hospital, Voelker et al. (2001) provide an example of reduced cost per case, profitability, patient satisfaction, reduced length of stay and reduced readmissions. Grol et al. (2002) contend that there is more evidence about the effectiveness of traditional clinical-level interventions, such as audit/feedback and continuing medical education, than about newer strategies for health services improvement, such as portfolio learning and organizational development. In a review of PM models, Leggat et al. (1998: 8) conclude that most were “in the early stages of development with no hard evidence as to their long-term impact.”

Some weak evidence of positive impact comes from PM-system user reports. These range from general satisfaction with the PM system to user opinions about specific changes, such as in administrative or care processes (Lemieux-Charles et al. 2000), to reports of improvement resulting from PM-based action (Turpin et al. 1996). Smith (1993) also provides some examples of reported potential for adverse effects of PM derived from case study interviews. However, uncontrolled case studies and opinions about systems have significant limitations in supporting causal inferences about the impact of PM on health services improvement itself (Hulley et al. 2001). These study designs, as their authors frequently acknowledge, cannot rule out other explanations for their findings, including historical trends and reporting or selection biases (Turpin et al. 1996; Smith 1993).

Our review uncovered only a handful of empirical studies that examined PM effectiveness more directly by including actual measures of health services outcomes. Studies supporting and refuting attribution of reductions in coronary bypass surgery mortality to publication of performance data are reviewed by Jencks (2000). Longo et al. (1997) report positive changes in response to indicator information in the context of obstetric care, and Kazandjian and Lied (1998) found positive impact of participation in a multi-hospital PM project on caesarean-section rates. Finally, in a time-series study, Petitti et al. (2000) demonstrated that even in the absence of incentives, physician-specific profiling of process and outcomes positively influenced diabetes care organizationwide.

Overall, the clarity of ideas in the non-empirical literature and the quality of empirical work is stronger in more recent health literature. However, empirical studies remain varied with respect to questions and methods, and no coherent research direction is evident. Multidisciplinary papers were rare. Of particular note are the variety of perspectives and approaches in the US literature, the depth and general theoretical quality of the UK literature and the relative paucity of Canadian literature. At least two dozen high-quality papers on healthcare PM were identified and listed in an appendix to the full report (Adair et al. 2003). These are recommended as key readings in the field for researchers and decision-makers (Adair et al. 2003).

Discussion

Our review was challenged by the diverse sources and locations of the knowledge and practice base on PM. It required a breadth of search and synthesis far greater than the scope of a systematic review on a clinical question. This situation limited the depth of the review on any single aspect of PM, but allowed us to identify broader themes and issues that were generalizable across sources. More in-depth reviews of specific topics and the many strands of relevant empirical literature are warranted. The diversity of terms and discipline-specific perspectives also necessitated that we cast a large search net (favouring sensitivity over specificity), resulting in a labour-intensive review process. Of particular note, there was almost no convergence on author-nominated papers and only 33% overlap between nominated and selected papers, further evidence that a bounded and identifiable PM literature does not yet exist. Despite these limitations, the review identified a rich set of PM research and practice-related issues, which themselves raised two fundamental questions for our team.

First, there seems to be a simple unifying concept of performance, defined as how an entity does in relation to articulated goals and/or other similar entities. Performance in this context is entirely relative; its meaning is rooted in the gap between the “is” and the “ought.” There can be measures that do not connote performance; indeed, the healthcare system is full of measures that merely describe quantities. A very frequent sentiment in both the business and health literatures is that PM must become more about management than just measurement, more about action rather than just awareness.

Second, the issue of causality is a difficult one to disentangle, that is, the relative roles of PM systems and data, leadership and management factors in producing change. PM systems are essential to documenting improvement; it is not clear how and whether they are supposed to cause it, or whether a culture of improvement and focused achievement of performance, united by well-understood goals, can lead to good performance even in the absence of much performance measurement. The causal assumptions of authors whose articles were reviewed were rarely made explicit. A unifying theory for PM that encompasses this complexity for both fields – and perhaps across fields – does not exist and is greatly needed. Such questions require a greater level of research sophistication in both theory and methods.

Conclusion

An unequivocal finding of this review was that the science of PM is in its infancy, lagging far behind practice in both healthcare and business. The necessity of PM and its potential benefits are widely supported, but rhetoric and good intentions appear to outweigh demonstrations of successful implementation. Where PM is implemented, there is little substantive evidence of positive impact on decision-making, improvement in health services delivery or health outcomes. Many authors advocate generally for more PM research; others call for a specific research program or agenda (Neely et al. 1995; McLoughlin et al. 2001). For example, Kaplan and Norton (2001: 160) suggest that “researchers can now begin a systematic research program, using multiple research methods to explore the key factors in implementing more effective measurement and management systems.” Johnson (1998: 253) advocates an international research effort: “The shape of a research agenda, so badly needed in this field, should not depend on one vision of future healthcare delivery. The utility of research will be enhanced if it is independent of any particular form of healthcare delivery. Furthermore, there may be important, practical reasons to plan and orchestrate the research internationally.”

The good news is that more rigorous studies of system-level PM are starting to appear. A stellar example is the recent publication by Beck et al. (2005), published after our review was complete. While this study found no evidence that a PM-related intervention (report card feedback on acute myocardial infarction care) changed practice, more research of this calibre will no doubt identify specific PM approaches and mechanisms that can achieve health gains. In our view, effective research in this field needs to go beyond the emergence of quality research by individual research teams. Advancement of the field depends on a comprehensive and coordinated research agenda, including programmatic funding, standard nomenclature, theory development, international and transdisciplinary projects, innovative research–practice partnerships and mechanisms to optimize knowledge transfer and exchange.

Acknowledgments

The State of the Science Review was funded by the Alberta Heritage Foundation for Medical Research, and significant in-kind support was received from the Alberta Mental Health Board. Thanks are due to K. Omelchuk, H. Gardiner, S. Newman, S. Clelland, A. Beckie, K. Lewis-Ng, I. Frank, J. Osborne, D. Ma, X. Kostaras and O. Berze for their assistance on parts of the broader review. T. Sheldon and C. Baker provided methodologic consultation, and E. Goldner and S. Lewis reviewed the main report. Findings have been presented in part at Academy Health, Nashville, Tennessee, June 2003; World Psychiatric Association, Paris, France, July 2003; International Conference on the Scientific Basis of Health Services, Washington, DC, September 2003; and American Evaluation Association, Reno, Nevada, November 2003.

Notes

1The mental health literature was separated as a special case study of the health literature. Findings specific to that review are not presented in this paper.

Contributor Information

Carol E. Adair, Associate Professor, Departments of Community Health Sciences and Psychiatry, University of Calgary, Calgary, AB.

Elizabeth Simpson, Health Research Consultant, Red Deer, AB.

Ann L. Casebeer, Associate Professor, Department of Community Health Sciences, Associate Director, Centre for Health and Policy Studies, University of Calgary, Calgary, AB.

Judith M. Birdsell, Principal Consultant, ON Management Ltd., Adjunct Associate Professor, Haskayne School of Business, University of Calgary, Calgary, AB.

Katharine A. Hayden, Associate Librarian, Information Resources, University of Calgary, Calgary, AB.

Steven Lewis, President, Access Consulting Ltd., Adjunct Professor, Department of Community Health Sciences, University of Calgary, Calgary, AB.

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