{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,12]],"date-time":"2026-06-12T01:14:35Z","timestamp":1781226875556,"version":"3.54.1"},"reference-count":55,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2024,4,24]],"date-time":"2024-04-24T00:00:00Z","timestamp":1713916800000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2024,4,24]],"date-time":"2024-04-24T00:00:00Z","timestamp":1713916800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["BMC Health Serv Res"],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>This study evaluates the feasibility of a nine-month advanced quality-improvement program aimed at enhancing the quality of care provided by primary care physical therapists in the Netherlands. The evaluation is based on routinely collected health outcomes of patients with nonspecific low back pain, assessing three feasibility domains: (1) appropriateness, feasibility, and acceptability for quality-improvement purposes; (2) impact on clinical performance; and (3) impact on learning and behavioral change.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A mixed-methods quality-improvement study using a concurrent triangulation design was conducted in primary care physical therapist practice. Feedback reports on the processes and outcomes of care, peer assessment, and self-assessment were used in a Plan-Do-Study-Act cycle based on self-selected goals. The program\u2019s appropriateness, feasibility, and acceptability, as well as the impact on clinical performance, were evaluated using the Intervention Appropriate Measure, Feasibility Intervention Measure, Acceptability Intervention Measure (for these three measure, possible scores range from 4 to 20), and with a self-assessment of clinical performance (scored 0\u201310), respectively. The impact on learning and behavioral change was evaluated qualitatively with a directed content analysis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Ten physical therapists from two practices participated in this study. They rated the program with a mean of 16.5 (SD 1.9) for appropriateness, 17.1 (SD 2.2) for feasibility, and 16.4 (SD 1.5) for acceptability. Participants gave their development in clinical performance a mean score of 6.7 (SD 1.8). Participants became aware of the potential value of using outcome data and gained insight into their own routines and motivations. They changed their data collection routines, implemented data in their routine practice, and explored the impact on their clinical behavior.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>This explorative study demonstrated that a quality-improvement program, using health outcomes from a national registry, is judged to be feasible.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Impact statement<\/jats:title>\n                    <jats:p>This study provides preliminary evidence on how physical therapists may use health outcomes to improve their quality, which can be further used in initiatives to improve outcome-based care in primary physical therapy.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s12913-024-10958-5","type":"journal-article","created":{"date-parts":[[2024,4,24]],"date-time":"2024-04-24T07:02:14Z","timestamp":1713942134000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["Feasibility of a quality-improvement program based on routinely collected health outcomes in Dutch primary care physical therapist practice: a mixed-methods study"],"prefix":"10.1186","volume":"24","author":[{"given":"LSF","family":"Smeekens","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"AC","family":"Verburg","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"MJM","family":"Maas","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"R","family":"van Heerde","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"A","family":"van Kerkhof","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"PJ","family":"van der Wees","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2024,4,24]]},"reference":[{"key":"10958_CR1","unstructured":"Spath P, Kelly DL. Applying quality management in healthcare: a systems approach. Health Administration Press Chicago; 2017."},{"key":"10958_CR2","first-page":"503","volume":"248","author":"ME Porter","year":"2008","unstructured":"Porter ME. Value-based Health care Delivery. 2008;248:503\u20139.","journal-title":"Value-based Health care Delivery"},{"key":"10958_CR3","doi-asserted-by":"crossref","unstructured":"Meerhoff GA, Verburg AC, Schapendonk RM, Cruijsberg J, Nijhuis-van der Sanden MW, van Dulmen SA et al. Reliability, validity and discriminability of patient reported outcomes for non-specific low back pain in a nationwide physical therapy registry: a retrospective observational cohort study 2021;16:e0251892.","DOI":"10.1371\/journal.pone.0251892"},{"key":"10958_CR4","doi-asserted-by":"crossref","unstructured":"Verburg AC, van Dulmen SA, Kiers H, Nijhuis-van der Sanden MW, van der Wees PJ. Patient-reported outcome-based quality indicators in Dutch primary care physical therapy for patients with nonspecific low back Pain. A Cohort Study; 2021.","DOI":"10.1093\/ptj\/pzab118"},{"key":"10958_CR5","first-page":"357","volume":"67","author":"RA Swinkels","year":"2015","unstructured":"Swinkels RA, Meerhoff GM, Custers JW, van Peppen RP, Beurskens AJ, Wittink H. Using outcome measures in daily practice: development and evaluation of an implementation strategy for physiotherapists in. Neth. 2015;67:357\u201364.","journal-title":"Neth"},{"key":"10958_CR6","unstructured":"van Dulmen S, van der Wees P. Eindrapport toepassing van minimale dataset en kwaliteitsindicatoren voor lage rugklachten in de fysiotherapie n.d."},{"key":"10958_CR7","doi-asserted-by":"crossref","unstructured":"Greenhalgh J, Dalkin S, Gibbons E, Wright J, Valderas JM, Meads D et al. How do aggregated patient-reported outcome measures data stimulate health care improvement? A realist synthesis. 2018;23(1):57\u201365.","DOI":"10.1177\/1355819617740925"},{"key":"10958_CR8","doi-asserted-by":"crossref","unstructured":"Koes BW, Van Tulder M, Lin C-WC, Macedo LG, McAuley J, Maher C. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. 2010;19(12):2075\u201394.","DOI":"10.1007\/s00586-010-1502-y"},{"key":"10958_CR9","volume-title":"\/ vereniging van Oefentherapeuten Cesar en Mensendieck (VvOCM). KNGF-richtlijn Lage rugpijn en lumbosacraal radiculair syndroom","author":"Koninklijk Nederlands Genootschap voor Fysiotherapie (KNGF)","year":"2021","unstructured":"Koninklijk Nederlands Genootschap voor Fysiotherapie (KNGF). \/ vereniging van Oefentherapeuten Cesar en Mensendieck (VvOCM). KNGF-richtlijn Lage rugpijn en lumbosacraal radiculair syndroom. Amersfoort\/Utrecht: KNGF\/VvoCM; 2021. n.d."},{"issue":"12","key":"10958_CR10","first-page":"1492","volume":"88","author":"JM Copeland","year":"2008","unstructured":"Copeland JM, Taylor WJ, Dean SG. Factors influencing the use of outcome measures for patients with low back pain: a survey of New. Z Phys Therapists. 2008;88(12):1492\u2013505.","journal-title":"Z Phys Therapists"},{"issue":"2","key":"10958_CR11","first-page":"125","volume":"89","author":"DU Jette","year":"2009","unstructured":"Jette DU, Halbert J, Iverson C, Miceli E, Shah P. Use of standardized outcome measures. Phys Therapist Practice: Perceptions Appl. 2009;89(2):125\u201335.","journal-title":"Phys Therapist Practice: Perceptions Appl"},{"key":"10958_CR12","first-page":"66","volume":"103","author":"SA van Dulmen","year":"2017","unstructured":"van Dulmen SA, van der Wees PJ, Staal JB, Braspenning J, Nijhuis-van der Sanden MW. Patient reported outcome measures (PROMs) for goalsetting and outcome measurement in primary care physiotherapy. Explorative Field Study. 2017;103:66\u201372.","journal-title":"Explorative Field Study"},{"key":"10958_CR13","doi-asserted-by":"crossref","unstructured":"Meerhoff GA, van Dulmen SA, Cruijsberg JK, Nijhuis-van der Sanden MW, Van der Wees PJ. Which factors influence the use of patient-reported outcome measures in Dutch physiotherapy practice? A cross-sectional study. 2020;72(1):63\u201370.","DOI":"10.3138\/ptc-2018-0028"},{"key":"10958_CR14","doi-asserted-by":"crossref","unstructured":"Irizarry T, DeVito Dabbs A, Curran CR. Patient portals and patient engagement: a state of the science review. 2015;17(6):e148.","DOI":"10.2196\/jmir.4255"},{"key":"10958_CR15","doi-asserted-by":"crossref","unstructured":"Sorondo B, Allen A, Bayleran J, Doore S, Fathima S, Sabbagh I et al. Using a patient portal to transmit patient reported health information into the electronic record: workflow implications and user experience. 2016;4(3).","DOI":"10.13063\/2327-9214.1237"},{"key":"10958_CR16","doi-asserted-by":"crossref","unstructured":"Ivers N, Jamtvedt G, Flottorp S, Young JM, Odgaard-Jensen J, French SD et al. Audit and feedback: effects on professional practice and healthcare outcomes. 2012.","DOI":"10.1002\/14651858.CD000259.pub3"},{"key":"10958_CR17","unstructured":"van der Wees P, van der Vleuten C. Marjo Maas Ria Nijhuis\u2013van der Sanden Geert Rutten Yvonne Heerkens n.d.:187."},{"key":"10958_CR18","doi-asserted-by":"crossref","unstructured":"Gibbons C, Porter I, Gon\u00e7alves-Bradley DC, Stoilov S, Ricci-Cabello I, Tsangaris E et al. Routine provision of feedback from patient-reported outcome measurements to healthcare providers and patients in clinical practice 2021.","DOI":"10.1002\/14651858.CD011589.pub2"},{"key":"10958_CR19","doi-asserted-by":"crossref","unstructured":"Greenhalgh J, Dalkin S, Gooding K, Gibbons E, Wright J, Meads D et al. Functionality and feedback: a realist synthesis of the collation, interpretation and utilisation of patient-reported outcome measures data to improve patient care. 2017;5:1\u2013280.","DOI":"10.3310\/hsdr05020"},{"key":"10958_CR20","doi-asserted-by":"crossref","unstructured":"Maas MJ, Nijhuis-van der Sanden MW, Driehuis F, Heerkens YF, van der Vleuten CP, van der Wees PJ. Feasibility of peer assessment and clinical audit to self-regulate the quality of physiotherapy services: a mixed methods study 2017;7:e013726.","DOI":"10.1136\/bmjopen-2016-013726"},{"key":"10958_CR21","doi-asserted-by":"crossref","unstructured":"Maas MJ, van der Wees PJ, Braam C, Koetsenruijter J, Heerkens YF, van der Vleuten CP et al. An innovative peer assessment approach to enhance guideline adherence in physical therapy: single-masked, cluster-randomized controlled trial. 2015;95(4):600\u201312.","DOI":"10.2522\/ptj.20130469"},{"key":"10958_CR22","unstructured":"Phillips Fox D. Peer review of health care professionals: a systematic review of the literature. Melbourne. 2009. https:\/\/www.safetyandquality.gov.au\/wp-content\/uploads\/2012\/01\/25738-LitReview.pdf (accessed June 2022)."},{"key":"10958_CR23","doi-asserted-by":"crossref","unstructured":"Maas MJ, Driehuis F, Meerhoff GA, Heerkens YF, van der Vleuten CP, Nijhuis-van der Sanden MW et al. Impact of self-and peer assessment on the clinical performance of physiotherapists in primary care: a cohort study 2018;70:393\u2013401.","DOI":"10.3138\/ptc.2017-40.pc"},{"key":"10958_CR24","first-page":"1","volume":"18","author":"NA Kampstra","year":"2018","unstructured":"Kampstra NA, Zipfel N, van der Nat PB, Westert GP, van der Wees PJ, Groenewoud AS. Health outcomes measurement and organizational readiness support quality improvement: a. Syst Rev. 2018;18:1\u201314.","journal-title":"Syst Rev"},{"key":"10958_CR25","doi-asserted-by":"crossref","unstructured":"McDonald PL, Foley TJ, Verheij R, Braithwaite J, Rubin J, Harwood K et al. Data to knowledge to improvement: creating the learning health system. 2024;384.","DOI":"10.1136\/bmj-2023-076175"},{"key":"10958_CR26","unstructured":"Creswell JW, Plano Clark VL, Gutmann ML, Hanson WE. An expanded typology for classifying mixed methods research into designs 2003:209\u201340."},{"key":"10958_CR27","first-page":"452","volume":"36","author":"DJ Bowen","year":"2009","unstructured":"Bowen DJ, Kreuter M, Spring B, Cofta-Woerpel L, Linnan L, Weiner D, et al. How we Des Feasibility Stud. 2009;36:452\u20137.","journal-title":"How we Des Feasibility Stud"},{"key":"10958_CR28","doi-asserted-by":"crossref","unstructured":"Ogrinc G, Armstrong GE, Dolansky MA, Singh MK, Davies L. SQUIRE-EDU (standards for QUality Improvement Reporting Excellence in Education): publication guidelines for educational improvement. 2019;94(10):1461.","DOI":"10.1097\/ACM.0000000000002750"},{"key":"10958_CR29","unstructured":"https:\/\/www.npi.nl\/cursussen-en-opleidingen\/e-learning-en-toetsen\/13025-e-learning-hoe-gebruik-ik-data-in-de-praktijk. n.d."},{"key":"10958_CR30","doi-asserted-by":"crossref","unstructured":"Kr\u00e4geloh CU, Czuba KJ, Billington DR, Kersten P, Siegert RJ. Using feedback from patient-reported outcome measures in mental health services: a scoping study and typology. 2015;66:224\u201341.","DOI":"10.1176\/appi.ps.201400141"},{"key":"10958_CR31","first-page":"1","volume":"12","author":"Z Hildon","year":"2012","unstructured":"Hildon Z, Neuburger J, Allwood D, van der Meulen J, Black N. Clinicians\u2019 and patients\u2019 views of metrics of change derived from patient reported outcome measures (PROMs) for comparing providers\u2019. Perform Surg. 2012;12:1\u201313.","journal-title":"Perform Surg"},{"key":"10958_CR32","first-page":"298","volume":"88","author":"Z Hildon","year":"2012","unstructured":"Hildon Z, Allwood D, Black N. Making data more meaningful: patients\u2019 views of the format and content of quality indicators comparing health. care Providers. 2012;88:298\u2013304.","journal-title":"care Providers"},{"key":"10958_CR33","doi-asserted-by":"crossref","unstructured":"Pronovost PJ, Hudson DW. Improving healthcare quality through organisational peer-to-peer assessment: lessons from the nuclear power industry. 2012;21:872\u20135.","DOI":"10.1136\/bmjqs-2011-000470"},{"key":"10958_CR34","first-page":"81","volume":"23","author":"J Wakefield","year":"2003","unstructured":"Wakefield J, Herbert CP, Maclure M, Dormuth C, Wright JM, Legare J, et al. Commit Change Statements can Predict Actual Change Pract. 2003;23:81\u201392.","journal-title":"Commit Change Statements can Predict Actual Change Pract"},{"key":"10958_CR35","first-page":"145","volume":"41","author":"SMA Rehring","year":"2021","unstructured":"Rehring SMA, Steiner JF, Reifler LM, Glenn KA, Daley MF. Commitment to change statements and actual practice change after a Continuing Medical. Educ Intervention. 2021;41:145\u201352.","journal-title":"Educ Intervention"},{"key":"10958_CR36","doi-asserted-by":"crossref","unstructured":"Steenbruggen RA, van Heusden-Scholtalbers LA, Hoogeboom TJ, Maas M, Brand P, van der Wees P. Impact and feasibility of a tailor-made patient communication quality improvement programme for hospital-based physiotherapists: a mixed-methods study. 2021;10:e001286.","DOI":"10.1136\/bmjoq-2020-001286"},{"key":"10958_CR37","first-page":"1","volume":"12","author":"BJ Weiner","year":"2017","unstructured":"Weiner BJ, Lewis CC, Stanick C, Powell BJ, Dorsey CN, Clary AS, et al. Psychometric Assess Three New Developed Implement Outcome Measures. 2017;12:1\u201312.","journal-title":"Psychometric Assess Three New Developed Implement Outcome Measures"},{"key":"10958_CR38","doi-asserted-by":"crossref","unstructured":"Cousins JB, Whitmore E. Framing participatory evaluation 1998;1998:5\u201323.","DOI":"10.1002\/ev.1114"},{"key":"10958_CR39","doi-asserted-by":"crossref","unstructured":"van Staa A, de Vries K. Directed content analysis: een meer deductieve dan inductieve aanpak bij kwalitatieve analyse 2014;19.","DOI":"10.5117\/2014.019.003.046"},{"key":"10958_CR40","first-page":"846","volume":"42","author":"ME Kiger","year":"2020","unstructured":"Kiger ME, Varpio L. Thematic analysis of qualitative data. AMEE Guide 131. 2020;42:846\u201354.","journal-title":"AMEE Guide 131"},{"key":"10958_CR41","unstructured":"Friese S. Qualitative data analysis with ATLAS. Ti. Sage; 2019."},{"key":"10958_CR42","doi-asserted-by":"crossref","unstructured":"O\u2019Connor C, Joffe H. Intercoder reliability in qualitative research: debates and practical guidelines 2020;19:1609406919899220.","DOI":"10.1177\/1609406919899220"},{"key":"10958_CR43","first-page":"54","volume":"50","author":"D Kirkpatrick","year":"1996","unstructured":"Kirkpatrick D. Great Ideas Revisit. 1996;50:54\u201360.","journal-title":"Great Ideas Revisit"},{"key":"10958_CR44","first-page":"1396","volume":"94","author":"SA van Dulmen","year":"2014","unstructured":"van Dulmen SA, Maas M, Staal JB, Rutten G, Kiers H, Nijhuis-van der Sanden M, et al. Effectiveness of peer assessment for implementing a Dutch physical therapy low back pain guideline. Cluster Randomized Controlled Trial. 2014;94:1396\u2013409.","journal-title":"Cluster Randomized Controlled Trial"},{"key":"10958_CR45","doi-asserted-by":"crossref","unstructured":"Epstein RM, Siegel DJ, Silberman J. Self-monitoring in clinical practice: a challenge for medical educators 2008;28:5\u201313.","DOI":"10.1002\/chp.149"},{"key":"10958_CR46","doi-asserted-by":"crossref","unstructured":"Daves DA, Mazmanian PE, Fordis M, Van Harrision R, Thorpe KE, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence 2006;296:1094\u2013102.","DOI":"10.1001\/jama.296.9.1094"},{"key":"10958_CR47","first-page":"38","volume":"12","author":"JO Prochaska","year":"1997","unstructured":"Prochaska JO, Velicer WF. Transtheoretical Model Health Behav Change. 1997;12:38\u201348.","journal-title":"Transtheoretical Model Health Behav Change"},{"key":"10958_CR48","doi-asserted-by":"crossref","unstructured":"Ajzen I. The theory of planned behavior 1991;50:179\u2013211.","DOI":"10.1016\/0749-5978(91)90020-T"},{"key":"10958_CR49","doi-asserted-by":"crossref","unstructured":"Scholte M, Neeleman-van der Steen CW, van der Wees PJ, Nijhuis-van der Sanden MW, Braspenning J. The reasons behind the (non) use of feedback reports for quality improvement in physical therapy: a mixed-method study. 2016;11(8):e0161056.","DOI":"10.1371\/journal.pone.0161056"},{"issue":"11","key":"10958_CR50","first-page":"e28854","volume":"23","author":"N Alvarado","year":"2021","unstructured":"Alvarado N, McVey L, Elshehaly M, Greenhalgh J, Dowding D, Ruddle R, et al. Analysis of a web-based dashboard to support the Use of National Audit Data in Quality Improvement. Realist Evaluation. 2021;23(11):e28854.","journal-title":"Realist Evaluation"},{"key":"10958_CR51","unstructured":"Ryan RM, Deci EL. Self-determination theory 2017."},{"key":"10958_CR52","unstructured":"Dewey J, Authentic IEL. Experiential learning 1938."},{"key":"10958_CR53","doi-asserted-by":"crossref","unstructured":"Kluger AN, DeNisi A. The effects of feedback interventions on performance: a historical review, a meta-analysis, and a preliminary feedback intervention theory. 1996;119:254.","DOI":"10.1037\/0033-2909.119.2.254"},{"key":"10958_CR54","doi-asserted-by":"crossref","unstructured":"Anderson R. New MRC guidance on evaluating complex interventions. 2008;337.","DOI":"10.1136\/bmj.a1937"},{"key":"10958_CR55","unstructured":"Maas MJ, van Poelgeest E, Weymans C, PJvd W. Module 3 feedback op proces en uitkomsten. KNGF; 201."}],"container-title":["BMC Health Services Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12913-024-10958-5.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s12913-024-10958-5\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12913-024-10958-5.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,4,24]],"date-time":"2024-04-24T07:13:28Z","timestamp":1713942808000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmchealthservres.biomedcentral.com\/articles\/10.1186\/s12913-024-10958-5"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,4,24]]},"references-count":55,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2024,12]]}},"alternative-id":["10958"],"URL":"https:\/\/doi.org\/10.1186\/s12913-024-10958-5","relation":{"has-preprint":[{"id-type":"doi","id":"10.21203\/rs.3.rs-3210049\/v1","asserted-by":"object"}]},"ISSN":["1472-6963"],"issn-type":[{"value":"1472-6963","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,4,24]]},"assertion":[{"value":"27 July 2023","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"5 April 2024","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"24 April 2024","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"The study protocol was approved by the Medical Ethical Committee of Radboud university medical center (registration #2021\u201313329). This study complies with the Declaration of Helsinki. All participants provided written informed consent.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare that they have no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"509"}}