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Canadian Journal of Cardiology

Heart Failure in Young Adults Is Associated With High Mortality: A Contemporary Population-Level Analysis

Published:September 20, 2017DOI:https://doi.org/10.1016/j.cjca.2017.05.009

      Abstract

      Background

      Data on young patients with heart failure (HF) are sparse. We examined the characteristics, health care use, and survival of younger vs older patients with HF.

      Methods

      We performed an analysis of linked administrative databases in Alberta, Canada. We identified 34,548 patients who had a first hospitalization for HF as the principal diagnosis from 2002-2014. Patients were stratified into 4 age groups: 20-44, 45-54, 55-64, and ≥ 65 years.

      Results

      Of the 34,548 patients, 496 (1.4%), 1319 (3.8%), 3359 (9.7%), and 29,374 (85%) were aged 20-44, 45-54, 55-64, and ≥ 65 years, respectively. The incidence of HF hospitalization decreased over time among patients ≥ 65 years and increased among men aged 20-64 years. In the year after the index HF hospitalization, compared with older patients, younger patients were less likely to present to the emergency department (ED) (eg, 67.2% of those aged 20-44 years vs 74.8% of those aged ≥ 65 years) or to be hospitalized for any reason (48.5% vs 61.2%), cardiovascular causes (28.6% vs 34.4%), or HF (14.8% vs 23.6%). Mortality rates were lower in younger patients aged 20-44 years but were still substantial: 3.9%, 12.4%, and 27.7% at 30 days, 1 year, and 5 years, respectively.

      Conclusions

      Although young patients, especially those < 45 years of age, accounted for a small proportion of the total population, adverse events were frequent, with half of the younger patients being readmitted, two-thirds presenting to an ED, and > 10% dying within a year.

      Résumé

      Introduction

      Les données sur les jeunes patients atteints d’insuffisance cardiaque (IC) sont rares. Nous avons examiné les caractéristiques, l’utilisation des soins de santé et la survie des patients atteints d’IC plus jeunes vs les patients atteints d’IC plus âgés.

      Méthodes

      Nous avons réalisé une analyse des banques de données administratives liées de l’Alberta, au Canada. Nous avons trouvé 34 548 patients qui ont eu de 2001 à 2014 une première hospitalisation dont le diagnostic principal était l’IC. Nous avons réparti les patients en 4 groupes d’âge : de 20 à 44 ans, de 45 à 54 ans, de 55 à 64 ans et ≥ 65 ans.

      Résultats

      Parmi les 34 548 patients, 496 (1,4 %), 1319 (3,8 %), 3359 (9,7 %) et 29 374 (85 %) étaient respectivement âgés de 20 à 44 ans, de 45 à 54 ans, de 55 à 64 ans et ≥ 65 ans. La fréquence des hospitalisations en raison d’IC diminuait au fil du temps chez les patients ≥ 65 ans et augmentait chez les hommes de 20 à 64 ans. Durant l’année qui suivait la première hospitalisation en raison d’IC, les patients plus jeunes étaient moins susceptibles que les patients plus âgés de se présenter au service des urgences (SU) (par ex. 67,2 % des patients de 20 à 44 ans vs 74,8 % des patients ≥ 65 ans) ou d’être hospitalisés toutes causes confondues (48,5 % vs 61,2 %), en raison de causes d’origine cardiovasculaire (28,6 % vs 34,4 %) ou d’IC (14,8 % vs 23,6 %). Les taux de mortalité étaient plus faibles chez les jeunes patients de 20 à 44 ans, mais demeuraient tout de même substantiels : 3,9 %, 12,4 % et 27,7 % après, respectivement, 30 jours, 1 an et 5 ans.

      Conclusions

      Bien que les jeunes patients, particulièrement ceux < 45 ans, ne représentaient qu’une faible proportion de la population totale, les événements indésirables étaient fréquents, soit la moitié des patients plus jeunes était réadmis, les deux tiers se présentaient au SU et > 10 % mouraient dans la première année.
      Heart failure (HF) is a major public health issue whose disease burden increases with advancing age.
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      • et al.
      ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC.
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      • Jessup M.
      • Bozkurt B.
      • et al.
      2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
      Most studies using Medicare or administrative claims data have examined patients 65 years or older and have often relied on hospitalization data alone.
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      • Hanon O.
      • Hochadel M.
      • et al.
      Contemporary management of octogenarians hospitalized for heart failure in Europe: Euro Heart Failure Survey II.
      • Forman D.E.
      • Cannon C.P.
      • Hernandez A.F.
      • et al.
      Influence of age on the management of heart failure: findings from Get With the Guidelines-Heart Failure (GWTG-HF).
      Younger patients (< 65 years) with HF are less well characterized, particularly with respect to the interplay between their attendance at outpatient clinics, emergency departments (EDs), and hospitals. Accordingly, we examined the characteristics, resource use, and outcomes in young vs older patients with HF in the province of Alberta, Canada.
      • Kaul P.
      • McAlister F.A.
      • Ezekowitz J.A.
      • Grover V.K.
      • Quan H.
      Ethnic differences in 1-year mortality among patients hospitalised with heart failure.

      Methods

      Databases

      We linked the following 5 databases maintained by the Alberta Ministry of Health
      • Ezekowitz J.A.
      • Bakal J.A.
      • Kaul P.
      • Westerhout C.M.
      • Armstrong P.W.
      Acute heart failure in the emergency department: short and long-term outcomes of elderly patients with heart failure.
      • Kaul P.
      • Chang W.C.
      • Westerhout C.M.
      • Graham M.M.
      • Armstrong P.W.
      Differences in admission rates and outcomes between men and women presenting to emergency departments with coronary syndromes.
      : (1) the Discharge Abstract Database, which records information for all acute care hospitalizations (dates, principal diagnosis and up to 24 other diagnoses, procedures, lengths of stay, and discharge status); (2) the Ambulatory Care Database, which records all visits to hospital-based physician offices or EDs and includes up to 10 diagnostic fields; (3) the Practitioners Claims Database, which tracks all physicians' claims from outpatient services and records up to 3 diagnostic codes per encounter; (4) the Population Registry, which records basic demographic and geographic information for all 4.1 million citizens; and (5) the Alberta Vital Statistics, which records all deaths in the province. Each patient has a unique personal identifier allowing linkage of patient information across the databases, but the data are released to researchers in deidentified form.

      Study population: incident and prevalent HF

      We identified all patients ≥ 20 years of age hospitalized with HF as a principal diagnosis (International Classification of Diseases, Tenth Revision [ICD-10] code I50) between April 1, 2002 and March 31, 2014 in Alberta, Canada. The specificity and sensitivity of HF coding in the Alberta Health databases is 98.7% and 77.3%, respectively.
      • Kaul P.
      • McAlister F.A.
      • Ezekowitz J.A.
      • Grover V.K.
      • Quan H.
      Ethnic differences in 1-year mortality among patients hospitalised with heart failure.
      • Quan H.
      • Parsons G.A.
      • Ghali W.A.
      Validity of information on comorbidity derived from ICD-9-CCM administrative data.
      The first hospitalization with a principal diagnosis of HF during the study period was considered the index hospitalization for each patient. Patients were classified as either incident or prevalent patients with HF at the time of their index hospitalization. Incident patients were those without a previous diagnosis of HF recorded in all available data sources, including hospitalizations (1994 onward), hospital-based outpatient clinic or ED visits (1997 onward), and physician office claims (1994 onward). Prevalent patients were those with a previous diagnosis of HF in any setting, and these patients were further categorized as those with or without previous HF hospitalization. The HF incidence date for prevalent patients was the date of first diagnosis, regardless of setting. Concurrent hospitalizations or ED visits within 24 hours were considered the same episode of care.
      • Ezekowitz J.A.
      • Kaul P.
      • Bakal J.A.
      • Quan H.
      • McAlister F.A.
      Trends in heart failure care: has the incident diagnosis of heart failure shifted from the hospital to the emergency department and outpatient clinics?.

      Variables and outcomes

      Comorbidities were identified using established ICD code case definitions previously validated in Alberta.
      • Quan H.
      • Parsons G.A.
      • Ghali W.A.
      Validity of information on comorbidity derived from ICD-9-CCM administrative data.
      They were considered to be present if recorded in any diagnostic field in the index HF hospitalization or in a prior hospitalization/outpatient clinic/ED record. If present only in physician office claims, a diagnosis had to be present in at least 5 claims to be considered a comorbidity. Annual median household income in 2006 at the residential neighborhood level was obtained from census data from Statistics Canada. For prevalent patients, the duration of disease was calculated as the number of days between the HF incidence date and the date of index HF hospitalization or first outpatient diagnosis.
      Outcomes of interest included 1-year resource use among patients discharged alive from the index hospitalization, including all ED attendances and rehospitalizations and specifically those related to cardiovascular disease or HF. We also examined unadjusted rates and comorbidity adjusted odds ratios of in-hospital, 30-day, 1-year, and 5-year mortality.

      Statistical analysis

      We stratified patients based on their age at first HF hospitalization into 4 age categories: 20-44, 45-54, 55-64 and ≥ 65 years. Supplemental Tables S1, S3-S6 by age and sex are provided in an online supplement. We described baseline characteristics by age categories among incident and prevalent patients with HF. Results are presented as medians and interquartile range for continuous variables and proportions for categorical variables. The incidence rate of HF was calculated as the number of incident cases divided by the number of individuals within each observation year by age category. Estimated counts of Alberta population for each observation year were extracted from databases maintained by the Conference Board of Canada (http://www.conferenceboard.ca/). Poisson regression models were used to assess the trend of HF incidence rate by age category. Logistic regression models were used to estimate the odds ratio of younger age compared with the referent age category ≥ 65 years. The model was adjusted for comorbidities, annual median household income in 2006, urban residence, type of hospital, and year of admission. All tests were 2 sided, with a level of significance set at P < 0.05. Analyses were performed using SAS, version 9.4 (SAS Institute, Cary, NC).

      Results

      Between April 1, 2002 and March 31, 2014, 34,548 patients experienced an index HF admission. Of these patients, 496 (1.4%), 1319 (3.8%), and 3359 (9.7%) were aged 20-44, 45-54, and 55-64, respectively. Those ≥ 65 years accounted for 85.0% of the population. Overall, 23,427 (67.8%) had a previous diagnosis of HF and 11,121 (32.2%) were incident presentations. The incidence of first HF hospitalization increased with increasing age (Supplemental Table S1). Although low, incidence rates among younger men (aged 20-64 years) increased over time (from 1 per 10,000 in 2002/2003 to 1.4 per 10,000 in 2012/2013) but were stable among younger women. In contrast, in patients ≥ 65 years, the incidence rates decreased over time among men and remained stable among women.
      Baseline characteristics of incident and prevalent patients by age category are presented in Table 1. In both patient groups, except for rates of congenital heart disease and asthma, which were higher in patients aged 20-44 and 45-54 years, rates of most comorbidities were higher in older patients. Younger patients had a shorter mean length of hospital stay compared with older patients, although median values were similar across age categories, suggesting fewer very prolonged hospital admissions in younger patients. In the subset of patients with prevalent HF who had been managed entirely in the outpatient setting before the index HF hospitalization, we examined the median days from diagnosis to hospitalization. The median (interquartile range) increased with increasing age: 139 (12-1030) in patients aged 20-44 years, 226 (24-1405) in patients 45-54 years, 405 (37-1528) in patients 55-64 years, and 908 (140-2328) in those aged ≥ 65 years (P < 0.0001).
      Table 1Baseline characteristics of hospitalized patients with HF by age categories
      Incident HF patients
      Defined as patients without any previous diagnosis of HF in a physician's office, outpatient clinic, ED, or hospital.
      Prevalent HF patients
      Defined as patients with a previous diagnosis of HF in a physician's office, outpatient clinic, ED, or hospital.
      Age, year20-4445-5455-64≥ 6520-4445-5455-64≥ 65
      No.29367714678684203642189220,690
      Male sex, (%)59.350.243.228.540.749.856.871.5
      Comorbidities, n (%)
       Previous MI7 (2.4)54 (8.0)207 (14.1)1470 (16.9)29 (14.3)204 (31.8)732 (38.7)8088 (39.1)
       Previous revascularization6 (2.0)47 (6.9)178 (12.1)935 (10.8)12 (5.9)143 (22.3)533 (28.2)4246 (20.5)
       AF49 (16.7)157 (23.2)398 (27.1)3623 (41.7)59 (29.1)219 (34.1)822 (43.4)12,494 (60.4)
       Hypercholesterolemia8 (2.7)52 (7.7)184 (12.5)1099 (12.7)13 (6.4)123 (19.2)417 (22.0)3948 (19.1)
       Hypertension125 (42.7)396 (58.5)1033 (70.4)7061 (81.3)98 (48.3)473 (73.7)1602 (84.7)18,550 (89.7)
       CVD12 (4.1)58 (8.6)159 (10.8)1936 (22.3)19 (9.4)72 (11.2)381 (20.1)6127 (29.6)
       Diabetes mellitus64 (21.8)238 (35.2)659 (44.9)3145 (36.2)55 (27.1)317 (49.4)1108 (58.6)8765 (42.4)
       Malignant disease9 (3.1)52 (7.7)158 (10.8)1586 (18.3)9 (4.4)31 (4.8)185 (9.8)4005 (19.4)
       PAD7 (2.4)44 (6.5)154 (10.5)1432 (16.5)21 (10.3)92 (14.3)434 (22.9)5374 (26.0)
       Renal failure34 (11.6)84 (12.4)195 (13.3)1652 (19.0)45 (22.2)156 (24.3)521 (27.5)6920 (33.4)
       COPD101 (34.5)249 (36.8)634 (43.2)3640 (41.9)91 (44.8)350 (54.5)1133 (59.9)12,383 (59.9)
       Asthma58 (19.8)110 (16.2)199 (13.6)931 (10.7)48 (23.6)154 (24.0)413 (21.8)3490 (16.9)
       CHD33 (11.3)30 (4.4)22 (1.5)111 (1.3)50 (24.6)57 (8.9)106 (5.6)537 (2.6)
      Type of hospital, n (%)
       Small community48 (16.4)146 (21.6)345 (23.5)2252 (25.9)34 (16.7)137 (21.3)486 (25.7)6011 (29.1)
       Medium community17 (5.8)40 (5.9)92 (6.3)471 (5.4)17 (8.4)56 (8.7)117 (6.2)1102 (5.3)
       Large community58 (19.8)111 (16.4)250 (17.0)1499 (17.3)33 (16.3)101 (15.7)295 (15.6)3611 (17.5)
       Teaching170 (58.0)380 (56.1)780 (53.2)4462 (51.4)119 (58.6)348 (54.2)994 (52.5)9966 (48.2)
       Concurrent ED273 (93.2)617 (91.1)1338 (91.2)7929 (91.3)163 (80.3)497 (77.4)1586 (83.8)18,164 (87.8)
      LOS, day, (median, IQR)8 (4, 13)7 (5, 13)8 (5, 13)8 (5, 15)7 (3, 11)7 (4, 12)7 (4, 13)8 (5, 16)
      MHI, CAD$, (median, IQR)59,217 (52,216-72,202)58,559 (52,162-67,440)58,559 (52,162-67,440)58,559 (52,046-67,074)58,727 (52,162-69,101)58,559 (52,162-68,487)58,307 (52,162-67,054)57,435 (52,046-65,726)
      Urban residence, n (%)236 (80.6)527 (77.8)1087 (74.1)6813 (78.5)158 (77.8)472 (73.5)1380 (72.9)15,769 (76.2)
      AF, atrial fibrillation; CHD, congenital heart disease; COPD, chronic obstructive pulmonary disease; CVD, cerebrovascular disease; ED, emergency department; HF, heart failure; IQR, interquartile range; LOS, length of stay; MHI, median household income; MI, myocardial infarction; PAD, peripheral artery disease.
      Defined as patients without any previous diagnosis of HF in a physician's office, outpatient clinic, ED, or hospital.
      Defined as patients with a previous diagnosis of HF in a physician's office, outpatient clinic, ED, or hospital.
      Although the rates of subsequent ED presentations and rehospitalizations within 1 year were lowest in younger patients, they were still substantial (Table 2). Approximately 70% of patients aged 20-44 years had a repeated ED visit compared with 75% of patients aged ≥ 65 years, and rates of 1-year rehospitalization were approximately 50% and 60% in the 2 age groups, respectively. The in-hospital, 30-day, 1-year, and 5-year mortality rates were 3.9%, 12.4%, and 27.7% in the youngest patients and 11.5%, 35.3%, and 72.8% in the oldest age group, respectively (Fig. 1). Differences in mortality between younger and older patients with HF remained even after adjustment for covariates (Supplemental Table S2). All analyses stratified by sex and age category are presented in Supplemental Tables S3 to S6.
      Table 2One-year nonfatal outcomes by age categories in patients discharged alive after HF hospitalization
      Age, years20-4445-5455-64≥ 65
      No. discharged alive4331164291323,281
      Any ED visit291 (67.2)763 (65.5)2018 (69.3)17,415 (74.8)
       No. (%) followed by hospitalization105 (24.2)287 (24.7)816 (28.0)8355 (35.9)
       Median days to event (IQR)46 (13, 131)49 (10, 135)47 (13, 135)47 (14, 130)
      ED visit for HF77 (17.8)197 (16.9)630 (21.6)6126 (26.3)
       No. (%) followed by hospitalization48 (11.1)117 (10.1)411 (14.1)4107 (17.6)
      ED visit for CV133 (30.7)366 (31.4)1018 (34.9)8797 (37.8)
       No. (%) followed by hospitalization69 (15.9)191 (16.4)577 (19.8)5514 (23.7)
      Any rehospitalization210 (48.5)572 (49.1)1571 (53.9)14,252 (61.2)
       Median days to event (IQR)59 (18, 137)70 (19, 167)72 (22, 169)67 (22, 166)
      Rehospitalization for CV124 (28.6)327 (28.1)932 (32.0)8019 (34.4)
       Median days to event (IQR)61 (18, 145)72 (19, 176)87 (26, 194)74 (24, 178)
      Rehospitalization for HF64 (14.8)171 (14.7)526 (18.1)5496 (23.6)
       Median days to event (IQR)65 (18, 113)61 (17, 171)84 (24, 179)71 (22, 175)
      Data are presented as n (%) or median (IQR).
      CV, cardiovascular; ED, emergency department; HF, heart failure; IQR, interquartile range.
      Figure thumbnail gr1
      Figure 1Unadjusted 30-day, 1-year, and 5-year case fatality by age category among patients hospitalized with heart failure.

      Discussion

      In this retrospective population-level cohort study, younger patients with HF had many important differences from their older counterparts. The incidence of HF hospitalization decreased over time among patients ≥ 65 years. Although low, incidence rates among men younger (aged 20-64 years) than the oldest group increased over time but were stable among younger women. More than half of the younger patients had no previous history of HF in any setting, compared with just one-quarter of those aged ≥ 65 years. For those with a previous diagnosis of HF in the outpatient setting, the time from diagnosis to first HF hospitalization was markedly shorter in younger compared with older patients. HF in the young was associated with a significant mortality and morbidity burden, with approximately 50% of young patients being readmitted to the hospital, ∼ 70% presenting to the ED, and 12% dying within 1 year of the index HF hospitalization.
      As with previous studies, the incidence of first HF hospitalization in our study was lower in younger compared with older patients.
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      We observed a rise in incident HF among younger men (but not women) in Alberta. This is consistent with the findings from Sweden, where the incidence of first HF hospitalization increased significantly from 1987-1991 to 2002-2006 in those < 54 years, relatively more so in men than in women.
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      The extent to which sex differences observed in our study and the Swedish registry are attributable to male predominance of drug abuse and excessive alcohol consumption require further study.
      Previous studies of young patients with HF have largely been limited to hospitalizations,
      • Barasa A.
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      Heart failure in young adults: 20-year trends in hospitalization, aetiology, and case fatality in Sweden.
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      with a few linked to ambulatory clinic visits.
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      To our knowledge, this is the only study to examine what appears to be a complex use pattern of ED services. After receiving an outpatient diagnosis of HF, we found young patients were admitted to the hospital much sooner than older patients. A plausible explanation for this finding is the different causes of HF in younger patients, including congenital heart disease and inherited cardiomyopathy. The population of adults with congenital heart disease is growing exponentially. This poses significant risk of adverse events, including arrhythmia and HF, and requires lifelong cardiology care. Transitions from pediatric to adult services are a recognized care gap, with up to half of patients not receiving appropriate follow-up.
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      Unlike older patients, who may more readily attribute HF symptoms and functional limitations to age, younger patients with higher societal and family demands may be more likely to seek medical attention sooner.
      After discharge from a first HF hospitalization, younger patients had lower readmission rates to the hospital than did older patients. This may reflect atypical presentations in younger patients, who are less likely to have peripheral edema, pulmonary rales, and radiological evidence of pulmonary edema.
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      Clinical characteristics and outcomes of young and very young adults with heart failure: The CHARM programme (Candesartan in Heart Failure Assessment of Reduction in Mortality and Morbidity).
      Physicians may be reassured by the absence of classic symptoms and signs and therefore discharge patients from the ED. Younger patients also have fewer comorbidities and less frailty, perhaps encouraging discharge and outpatient management. Nevertheless, young patients still had rehospitalization rates by 1 year of approximately 50% for any cause and 15% for HF.
      Mortality data in young patients with HF are scarce.
      • Barasa A.
      • Schaufelberger M.
      • Lappas G.
      • et al.
      Heart failure in young adults: 20-year trends in hospitalization, aetiology, and case fatality in Sweden.
      • Robertson J.
      • McElduff P.
      • Pearson S.A.
      • et al.
      The health services burden of heart failure: an analysis using linked population health data-sets.
      • Jhund P.S.
      • Macintyre K.
      • Simpson C.R.
      • et al.
      Long-term trends in first hospitalization for heart failure and subsequent survival between 1986 and 2003: a population study of 5.1 million people.
      One-year case fatality after a first hospitalization in the Swedish national registry was 11%-12% in the 18- to 54-year-old age group and 13% in the New South Wales study for those aged 45-49 years.
      • Barasa A.
      • Schaufelberger M.
      • Lappas G.
      • et al.
      Heart failure in young adults: 20-year trends in hospitalization, aetiology, and case fatality in Sweden.
      • Robertson J.
      • McElduff P.
      • Pearson S.A.
      • et al.
      The health services burden of heart failure: an analysis using linked population health data-sets.
      We found 5-year mortality rates of 28%, 32%, and 42% among patients aged 20-44, 45-54, and 55-64 years, respectively. Our results provide a guide for counselling patients with respect to longer-term prognosis.

      Limitations

      The linked administrative data sets in Alberta allow capture and follow-up of all interactions within the health care system. However, some limitations warrant consideration. The diagnosis of HF in hospital administrative registries relies on the accuracy of patient records and the responsible physicians. However, the accuracy of Alberta administrative data has been validated in patients with HF and for comorbidities. Data on ejection fraction, laboratory results, biomarkers, and causes of HF are lacking. The number of younger patients is relatively small, increasing imprecision in results.

      Conclusions

      Compared with the elderly, younger patients with HF are more likely to initially present to secondary care and to be hospitalized sooner if diagnosed in primary care. Short- and long-term mortality among young patients with HF remains high. After discharge, more than half of the young patients with HF are readmitted, and more than two-thirds present to an ED within a year. The high mortality and adverse outcome rates are a major cause for concern and warrant better understanding.

      Disclosures

      The authors have no conflicts of interest to disclose.

      Supplementary Material

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