Publications by authors named "Peter A Najjar"

13 Publications

  • Page 1 of 1

Differential Index-Hospitalization Cost Center Impact of Enhanced Recovery After Surgery Program Implementation.

Dis Colon Rectum 2020 06;63(6):837-841

Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Background: Most hospitals in the United States are reimbursed for colectomy via a bundled payment based on the diagnosis-related group assigned. Enhanced recovery after surgery programs have been shown to improve the value of colorectal surgery, but little is known about the granular financial tradeoffs required at individual hospitals.

Objective: The purpose of this study is to analyze the index-hospitalization impact on specific cost centers associated with enhanced recovery after surgery implementation for diagnosis-related groups commonly assigned to patients undergoing colon resections.

Design: We performed a single-institution retrospective, nonrandomized, preintervention (2013-2014) and postintervention (2015-2017) analysis of hospital costs.

Setting: This study was conducted at an academic medical center.

Patients: A total of 1297 patients with diagnosis-related group 330 (colectomy with complications/comorbidities) and 331 (colectomy without complications/comorbidities) were selected.

Main Outcome Measures: The primary outcome was total index-hospitalization cost. Secondary outcomes included specific cost center expenses.

Results: Total median cost for diagnosis-related group 330 in the pre-enhanced recovery after surgery group was $24,111 ($19,285-$28,658) compared to $21,896 ($17,477-$29,179) in the enhanced recovery after surgery group, p = 0.01. Total median cost for diagnosis-related group 331 in the pre-enhanced recovery after surgery group was $19,268 ($17,286-$21,858) compared to $18,444 ($15,506-$22,847) in the enhanced recovery after surgery group, p = 0.22. When assessing cost changes after enhanced recovery after surgery implementation for diagnosis-related group 330, operating room costs increased (p = 0.90), nursing costs decreased (p = 0.02), anesthesia costs increased (p = 0.20), and pharmacy costs increased (p = 0.08). For diagnosis-related group 331, operating room costs increased (p = 0.001), nursing costs decreased (p < 0.001), anesthesia costs increased (p = 0.03), and pharmacy costs increased (p = 0.001).

Limitations: This is a single-center study with a pre- and postintervention design.

Conclusions: The returns on investment at the hospital level for enhanced recovery after surgery implementations in colorectal surgery result largely from cost savings associated with decreased nursing expenses. These savings likely offset increased spending on operating room supplies, anesthesia, and medications. See Video Abstract at http://links.lww.com/DCR/B204. IMPACTO DE LA IMPLEMENTACIÓN DEL PROTOCOLO DE RECUPERACIÓN MEJORADA DESPUÉS DE CIRUGÍA EN EL COSTO DE LA HOSPITALIZACIÓN ÍNDICE EN CENTROS ESPECÍFICOS: La mayoría de los hospitales en los Estados Unidos son reembolsados por la colectomía a través de un paquete de pago basado en el grupo de diagnóstico asignado. Se ha demostrado que los programas de recuperación después de la cirugía mejoran el valor de la cirugía colorrectal, pero se sabe poco sobre las compensaciones financieras granulares que se requieren en los hospitales individuales.El objetivo de este estudio es analizar el impacto del índice de hospitalización en centros de costos específicos asociados con la implementación de RMDC para grupos relacionados con el diagnóstico comúnmente asignados a pacientes que se someten a resecciones de colon.Realizamos un análisis retrospectivo, no aleatorio, previo (2013-2014) y posterior a la intervención (2015-2017) de los costos hospitalarios de una sola institución.Centro médico académico.Un total de 1. 297 pacientes con diagnóstico relacionado con el grupo 330 (colectomía con complicaciones/comorbilidades) y 331 (colectomía sin complicaciones/comorbilidades).El resultado primario fue el índice total de costos de hospitalización. Los resultados secundarios incluyeron gastos específicos del centro de costos.El costo medio total para el grupo relacionado con el diagnóstico de 330 en el grupo de recuperación pre-mejorada después de la cirugía fue de $24,111 ($19,285- $28,658) en comparación con $21,896 ($17,477- $29,179) en el grupo de recuperación mejorada después de la cirugía, p = 0.01. El costo medio total para DRG 331 en el grupo de recuperación pre-mejorada después de la cirugía fue de $19,268 ($17,286- $21,858) en comparación con $18,444 ($15,506-$22,847) en el grupo de recuperación mejorada después de la cirugía, p = 0.22. Al evaluar los cambios en los costos después de una recuperación mejorada después de la implementación de la cirugía para el grupo 330 relacionado con el diagnóstico, los costos de la sala de operaciones aumentaron (p = 0.90), los costos de enfermería disminuyeron (p = 0.02) los costos de anestesia aumentaron (p = 0.20) y los costos de farmacia aumentaron (p = 0.08). Para el grupo 331 relacionado con el diagnóstico, los costos de la sala de operaciones aumentaron (p = 0.001), los costos de enfermería disminuyeron (p < 0.001) los costos de anestesia aumentaron (p = 0.03) y los costos de farmacia aumentaron (p = 0.001).Este es un estudio de un solo centro con un diseño previo y posterior a la intervención.El retorno de la inversión a nivel hospitalario para una recuperación mejorada después de la implementación de la cirugía en la cirugía colorrectal se debe en gran parte al ahorro de costos asociado con la disminución de los gastos de enfermería. Es probable que estos ahorros compensen el aumento de los gastos en suministros de quirófano, anestesia y medicamentos. Consulte Video Resumen en http://links.lww.com/DCR/B204. (Traducción-Dr. Gonzalo Hagerman).
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http://dx.doi.org/10.1097/DCR.0000000000001662DOI Listing
June 2020

Implementation of a Perioperative Venous Thromboembolism Prophylaxis Program for Patients Undergoing Radical Cystectomy on an Enhanced Recovery After Surgery Protocol.

Eur Urol Focus 2020 01 15;6(1):74-80. Epub 2018 Sep 15.

Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Lank Center for Genitourinary Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, MA, USA. Electronic address:

Background: Novel venous thromboembolism (VTE) prophylaxis programs, including postdischarge pharmacologic prophylaxis, have been associated with decreased VTE rates. Such practices have not been widely adopted in managing radical cystectomy (RC) patients.

Objective: To evaluate the effect of a perioperative VTE prophylaxis program on VTE rates after RC.

Design, Setting, And Participants: Single-institution, nonrandomized, pre- and post-intervention analysis of 319 patients undergoing RC at Brigham and Women's Hospital between July 2011 and April 2017. Patient and outcome data were prospectively collected as part of the American College of Surgeons National Surgical Quality Improvement Program.

Intervention: Before June 2015, patients only received postoperative pharmacologic and mechanical VTE prophylaxis in the inpatient setting. Starting June 2015, a perioperative VTE prophylaxis program was implemented as part of an enhanced recovery after surgery (ERAS) protocol, including a 28-d course of postdischarge enoxaparin.

Outcome Measurements And Statistical Analysis: Primary outcome was 30-d postoperative VTE rate. Secondary outcomes were perioperative bleeding rates, 30-d complication, readmission, and mortality rates, and length of stay. Univariate analysis was performed comparing outcomes between pre- and post-intervention cohorts.

Results And Limitations: Of the 319 patients who underwent RC, 210 (66%) were in the pre- and 109 (34%) in the post-intervention cohort. VTE rate was significantly lower in the post-intervention cohort (n=1, 0.9% vs n=13, 6.2%; p=0.04). Rates of perioperative bleeding (35% vs 33%; p=0.80) and 30-d readmissions related to bleeding (1% vs 3.7%; p=0.19) did not differ significantly. Single-institution data limits generalizability, and patient compliance with postdischarge enoxaparin was unknown.

Conclusions: Implementation of a perioperative VTE prophylaxis program as part of an ERAS protocol that includes extended postdischarge pharmacologic prophylaxis was associated with decreased rate of VTE events after RC. Perioperative bleeding and readmissions related to bleeding did not increase with this intervention.

Patient Summary: This study evaluated whether clotting complication rates after radical cystectomy (RC) for bladder cancer can be reduced by implementing a new postoperative care pathway. This pathway reduced rates of clotting complications without increasing bleeding rates and should be considered for all patients undergoing RC.
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http://dx.doi.org/10.1016/j.euf.2018.08.025DOI Listing
January 2020

The Patient Safety Indicator Perioperative Pulmonary Embolism or Deep Vein Thrombosis: Is there associated surveillance bias in the Veterans Health Administration?

Am J Surg 2018 11 4;216(5):974-979. Epub 2018 Jul 4.

Boston University School of Medicine, Boston, MA, USA; Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA.

Background: Studies disagree whether surveillance bias is associated with perioperative venous thromboembolism (VTE) performance measures. A prior VA study used a chart-based outcome; no studies have used the fully specified administrative data-based AHRQ Patient Safety Indicator, PSI-12, as their primary outcome. If surveillance bias were present, we hypothesized that inpatient surveillance rates would be associated with higher PSI-12 rates, but with lower post-discharge VTE rates.

Methods: Using VA data, we examined Pearson correlations between hospital-level VTE imaging rates and risk-adjusted PSI-12 rates and post-discharge VTE rates. To determine the robustness of findings, we conducted several sensitivity analyses.

Results: Hospital imaging rates were positively correlated with both PSI-12 (r = 0.24, p = 0.01) and post-discharge VTE rates (r = 0.16, p = 0.09). Sensitivity analyses yielded similar findings.

Conclusions: Like the prior VA study, we found no evidence of PSI-12-related surveillance bias. Given the use of PSI-12 in nationwide measurement, these findings warrant replication using similar methods in the non-VA setting.
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http://dx.doi.org/10.1016/j.amjsurg.2018.06.023DOI Listing
November 2018

How Should Surgeons Interpret Operating Room Costs?: Valuing Our Time.

JAMA Surg 2018 04 18;153(4):e176234. Epub 2018 Apr 18.

Department of Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamasurg.2017.6234DOI Listing
April 2018

Financial Impact of Acute Kidney Injury After Cardiac Operations in the United States.

Ann Thorac Surg 2018 Feb 21;105(2):469-475. Epub 2017 Dec 21.

The Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, Maryland; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Surgery, University of Virginia, School of Medicine, Charlottesville, Virginia. Electronic address:

Background: Acute kidney injury (AKI) after major cardiac operations is a potentially avoidable complication associated with increased morbidity, death, and costly long-term treatment. The financial impact of AKI at the population level has not been well defined. We sought to determine the incremental index hospital cost associated with the development of AKI.

Methods: All patients undergoing coronary artery bypass grafting (CABG) or valve replacement operations, or both (clinical classification software codes 43 and 44), between 2008 and 2011 were identified from the Nationwide Inpatient Sample. AKI was identified using International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes (584.xx); patients with chronic renal failure were excluded. Mean total index hospitalization costs were compared between patients with and without AKI.

Results: At the population level, 1,078,036 individuals underwent major cardiac procedures from 2008 to 2011, with AKI developing in 105,648 (9.8%). Specifically, AKI developed in 8.0% of CABG, 11.4% of valve replacement, and 17.0% of CABG plus valve replacement patients (p < 0.001). Death was more common among patients with AKI vs those without (13.9% vs 1.3%, p < 0.001). Mean total index hospitalization cost was $77,178 for patients with AKI vs $38,820 for those without (p < 0.001). At the national level, the overall incremental annual index hospitalization cost associated with AKI was $1.01 billion.

Conclusions: AKI developed in 1 in every 10 patients nationwide after a cardiac operation. Achieving a 10% reduction in AKI in this population would likely result in an annual savings of approximately $100,000,000 in index-hospital costs alone. Support for research on mechanisms to detect impending damage and prevent AKI may lead to reduced patient morbidity and death and to substantial health care cost savings.
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http://dx.doi.org/10.1016/j.athoracsur.2017.10.053DOI Listing
February 2018

Institution-wide Implementation Strategies, Finance, and Administration for Enhanced Recovery After Surgery Programs.

Int Anesthesiol Clin 2017 ;55(4):90-100

*Department of Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts †Department of Quality and Safety, Brigham and Women's Hospital, Boston, Massachusetts ‡Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts.

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http://dx.doi.org/10.1097/AIA.0000000000000158DOI Listing
February 2019

Can We Reap the Benefits of Regionalization Without Paying the Price?

JAMA Surg 2017 09 20;152(9):e172152. Epub 2017 Sep 20.

Department of Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamasurg.2017.2152DOI Listing
September 2017

Potential impact of Affordable Care Act-related insurance expansion on trauma care reimbursement.

J Trauma Acute Care Surg 2017 05;82(5):887-895

From the Department of Surgery, Center for Surgery and Public Health (J.W.S., P.N., T.C.T., A.S., A.H.H.), Brigham & Women's Hospital; Program in Global Surgery and Social Change (J.W.S., M.G.S.), Harvard Medical School, Boston; John F. Kennedy School of Government (P.U.), Harvard University, Cambridge, Massachusetts; David Geffen School of Medicine at the University of California (P.U.), Los Angeles, Los Angeles, California; Harvard Business School (P.N.); Department of Health Policy and Management (T.C.T.), Harvard T.H. Chan School of Public Health; Harvard Medical School (K.W.S.); Department Of Otolaryngology & Office of Global Surgery (M.G.S.), Massachusetts Eye & Ear Infirmary, Boston; Department of Economics (D.M.C.), Harvard University; National Bureau of Economics Research (D.M.C.); and Division of Trauma, Department of Surgery (A.S., A.H.H.), Brigham & Women's Hospital, Boston, Massachusetts.

Background: Nearly one quarter of trauma patients are uninsured and hospitals recoup less than 20% of inpatient costs for their care. This study examines changes to hospital reimbursement for inpatient trauma care if the full coverage expansion provisions of the Affordable Care Act (ACA) were in effect.

Methods: We abstracted nonelderly adults (ages 18-64 years) admitted for trauma from the Nationwide Inpatient Sample during 2010-the last year before most major ACA coverage expansion policies. We calculated national and facility-level reimbursements and trauma-related contribution margins using Nationwide Inpatient Sample-supplied cost-to-charge ratios and published reimbursement rates for each payer type. Using US census data, we developed a probabilistic microsimulation model to determine the proportion of pre-ACA uninsured trauma patients that would be expected to gain private insurance, Medicaid, or remain uninsured after full implementation of the ACA. We then estimated the impact of these coverage changes on national and facility-level trauma reimbursement for this population.

Results: There were 145,849 patients (representing 737,852 patients nationwide) included. National inpatient trauma costs for patients aged 18 years to 64 years totaled US $14.8 billion (95% confidence interval [CI], 12.5,17.1). Preexpansion reimbursements totaled US $13.7 billion (95% CI, 10.8-14.7), yielding a national margin of -7.9% (95% CI, -10.6 to -5.1). Postexpansion projected reimbursements totaled US $15.0 billion (95% CI, 12.7-17.3), increasing the margin by 9.3 absolute percentage points to +1.4% (95% CI, -0.3 to +3.2). Of the 263 eligible facilities, 90 (34.2%) had a positive trauma-related contribution margin in 2010, which increased to 171 (65.0%) using postexpansion projections. Those facilities with the highest proportion of uninsured and racial/ethnic minorities experienced the greatest gains.

Conclusion: Health insurance coverage expansion for uninsured trauma patients has the potential to increase national reimbursement for inpatient trauma care by over one billion dollars and nearly double the proportion of hospitals with a positive margin for trauma care. These data suggest that insurance coverage expansion has the potential to improve trauma centers' financial viability and their ability to provide care for their communities.

Level Of Evidence: Economic analysis, level II.
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http://dx.doi.org/10.1097/TA.0000000000001400DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5468098PMC
May 2017

Time-Driven Activity-Based Costing for Surgical Episodes.

JAMA Surg 2017 01;152(1):96-97

Harvard Business School, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamasurg.2016.3356DOI Listing
January 2017

Implementation of a Comprehensive Post-Discharge Venous Thromboembolism Prophylaxis Program for Abdominal and Pelvic Surgery Patients.

J Am Coll Surg 2016 12 28;223(6):804-813. Epub 2016 Sep 28.

Department of Quality and Safety, Brigham and Women's Hospital, Boston, MA; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, and Harvard TH Chan School of Public Health, Boston, MA.

Background: Prophylactic anticoagulation is routinely used in the inpatient setting; however, the risk of venous thromboembolism (VTE) remains elevated after discharge. Extensive evidence and clinical guidelines suggest post-discharge VTE prophylaxis is critical in at-risk populations, but it remains severely underused in practice.

Study Design: We performed a single-institution retrospective, nonrandomized, pre- and post-intervention analysis of a systematic post-discharge pharmacologic prophylaxis program against the primary end point, which is post-discharge symptomatic VTE. An institutional American College of Surgeons NSQIP dataset was used to identify patients and outcomes. Patients undergoing major abdominal surgery for malignancy or inflammatory bowel disease were eligible for the post-discharge VTE prevention program.

Results: Among 1,043 patients who underwent abdominal surgery for malignancy or inflammatory bowel disease, 800 (77%) were in the pre-intervention cohort and 243 (23%) patients were in the post-intervention cohort. Rates of inpatient VTE did not significantly differ between cohorts (0.7%, n = 6 pre-intervention vs 1.7%, n = 4 post-intervention; p = 0.25). However, compared with the pre-intervention cohort, patients in the post-intervention cohort demonstrated a significantly lower post-discharge VTE rate (2.5%, n = 20 pre-intervention vs 0.0%, n = 0 post-intervention; p < 0.01).

Conclusions: A systematic post-discharge VTE prophylaxis program including provider education, local guideline adaptation, bedside medication delivery, and education for at-risk patients, was associated with significantly fewer post-discharge VTE events.
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http://dx.doi.org/10.1016/j.jamcollsurg.2016.09.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6309555PMC
December 2016

A cadaveric procedural anatomy course enhances operative competence.

J Surg Res 2016 Mar 3;201(1):22-8. Epub 2015 Oct 3.

Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts. Electronic address:

Background: Inadequate anatomy training has been cited as a major contributor to declines in surgical resident operative competence and confidence. We report the impact of a procedurally oriented general surgery cadaveric dissection course on trainee-operative confidence and competence.

Materials And Methods: After obtaining institutional review board approval, postgraduate year 2 and 3 general surgery residents were prospectively enrolled into two cohorts: (1) an intervention group (n = 7) participating in an 8-wk procedurally oriented cadaver course and (2) controls (n = 7) given access to course materials without participation in cadaver dissection. At both the beginning and end of the study, we used two evaluation instruments: (1) an oral examination using standardized templates and (2) a questionnaire assessing operative confidence.

Results: There were no intergroup differences in baseline characteristics, including number of operative procedures performed to date. Residents who took the anatomy course had significantly higher improvements in examination scores on common bile duct exploration (mean ± standard error, 33 ± 8% versus 10 ± 7%, P = 0.04), femoral endarterectomy (43 ± 5% versus 11 ± 7%, P = 0.003), fasciotomies (55 ± 10% versus 22 ± 9%, P = 0.04), inguinal hernia repair (20 ± 9% versus -14 ± 5%, P = 0.005), superior mesenteric artery embolectomy (38 ± 10% versus 2 ± 11%, P = 0.04), and in overall examination scores (31 ± 4% versus 8% ± 3%, P = 0.0006). In addition, they reported higher operative confidence on common bile duct exploration (P = 0.008) and superior mesenteric artery embolectomy (P = 0.02), and a trend toward higher overall operative confidence (P = 0.06).

Conclusions: In this study, we demonstrate that a procedurally oriented cadaver course covering a wide range of essential general surgery procedures resulted in significant improvements in self-reported operative confidence and competence as assessed by oral examination.
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http://dx.doi.org/10.1016/j.jss.2015.09.037DOI Listing
March 2016

The truth about trauma readmissions.

Am J Surg 2016 Apr 31;211(4):649-55. Epub 2015 Dec 31.

Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, 1620 Tremont Street, Boston, MA 02121, USA.

Background: There is a paucity of data on the causes and associated patient factors for unplanned readmissions among trauma patients.

Methods: We examined patients admitted for traumatic injuries between 2007 and 2011 in the California State Inpatient Database. Using chi-square tests and multivariate logistic regression models, we determined rates, reasons, locations, and patient factors associated with 30-day readmissions.

Results: Among 252,752 trauma discharges, the overall readmission rate was 7.56%, with 36% of readmissions occurring at a hospital different from the hospital of initial admission. Predictors of readmissions included being discharged against medical advice (odds ratio [OR]: 2.56 [2.35 to 2.76]); Charlson scores ≥2 (OR: 2.00 [1.91 to 2.10]); and age ≥45 years (OR: 1.29 [1.25 to 1.33]). Major reasons for readmissions were musculoskeletal complaints (22.29%), psychiatric conditions (9.40%), and surgical infections (6.69%).

Conclusions: Health and social vulnerabilities influence readmission among trauma patients, with many readmitted at other hospitals. Targeted interventions among high-risk patients may reduce readmissions after traumatic injuries.
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http://dx.doi.org/10.1016/j.amjsurg.2015.09.018DOI Listing
April 2016

Prophylactic antibiotics and prevention of surgical site infections.

Surg Clin North Am 2015 Apr 10;95(2):269-83. Epub 2015 Jan 10.

Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA. Electronic address:

Healthcare-associated infections present a significant source of preventable morbidity and mortality. More than 30% of all healthcare-associated infections are represented by surgical site infections, making them the most common subtype. Studies suggest that 40% to 60% of these infections are preventable, yet many hospitals have yet to implement evidence-based best practices. This article reviews the impact of surgical site infections, describes their measurement and reporting, and most importantly provides perioperative strategies for their prevention with a focus on the appropriate use of prophylactic antibiotics.
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http://dx.doi.org/10.1016/j.suc.2014.11.006DOI Listing
April 2015