{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T13:22:31Z","timestamp":1787664151441,"version":"build-2736575974"},"reference-count":43,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2026,6,19]],"date-time":"2026-06-19T00:00:00Z","timestamp":1781827200000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T00:00:00Z","timestamp":1787616000000},"content-version":"vor","delay-in-days":67,"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>Primary care forms the basis for valued outcomes in health systems, including population health, high quality care, and reduced health expenditures. However, the primary care system in the United States (US) faces many difficulties, including financial pressures and clinician burnout that accelerated following the Covid-19 pandemic. This study examines the ability of primary care practices to adapt to post-pandemic challenges using a lean management system for quality and process improvement.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We used data from the National Survey of Healthcare Organizations and Systems II, a nationally representative sample of 1,245 physician practices located across the US. We first described the status of lean implementation among these primary care practices. We then conducted bivariate analyses followed by multivariate logistic regressions to examine relationships between lean implementation and outcomes of interest, including pandemic response activities, financial performance after the pandemic, and impacts of workforce shortages on patient care.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Practices that adopted lean management were significantly larger in size (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.05), affiliated with a health system or federally qualified health center (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.0001), had a higher percentage of revenue from Medicaid (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.0001) but lower percentage from Medicare insurance (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.05), participated in more capitated payment arrangements and Accountable Care Organization contract types (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.01), and were more evenly distributed across geographic regions of the country (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001). Controlling for these contextual features, we found that lean practices were more likely to participate in an incident command system for pandemic response (OR\u2009=\u20092.45, 95% CI: 1.24\u20134.82), engage in efforts to address clinician burnout (OR\u2009=\u20091.29, 95% CI: 1.03\u20131.60), and report stronger financial performance after the pandemic (OR\u2009=\u20092.57, 95% CI: 1.40\u20134.73). Additionally, after adjusting for all other lean processes, practice use of rapid improvement events (OR\u2009=\u20090.20, 95% CI: 0.06\u20130.70) and real-time data analysis tools (OR\u2009=\u20090.31, 95% CI: 0.11\u20130.90) was associated with lower reported impacts of workforce shortages on patient care.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Health systems continue to face challenges, making them vulnerable to major disruptions as experienced with the recent pandemic. Lean management may enhance organizational resilience and theability of primary care practices to respond to rapidly evolving environments.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s12913-026-14968-3","type":"journal-article","created":{"date-parts":[[2026,6,19]],"date-time":"2026-06-19T09:55:03Z","timestamp":1781862903000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Lean management of crisis response and post-pandemic outcomes in US primary care practices"],"prefix":"10.1186","volume":"26","author":[{"given":"Dorothy Y.","family":"Hung","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stephen M.","family":"Shortell","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elicica","family":"Morris","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Catalina Y.","family":"Quach","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elina","family":"Reponen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thomas","family":"Rotter","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Agustin","family":"Perez-Araos","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Karen E.","family":"Schifferdecker","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,6,19]]},"reference":[{"key":"14968_CR1","doi-asserted-by":"publisher","first-page":"795","DOI":"10.1111\/1468-0009.12638","volume":"101","author":"KC Stange","year":"2023","unstructured":"Stange KC, Miller WL, Etz RS. The role of primary care in improving population health. Milbank Q. 2023;101:795\u2013840.","journal-title":"Milbank Q"},{"key":"14968_CR2","unstructured":"National Academies of Sciences. Engineering and Medicine. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. National Academies; 2021."},{"key":"14968_CR3","unstructured":"Willis J, Antono B, Bazemore A, Jetty A, Petterson S, George J, et al. The state of primary care in the United States. A chartbook of facts and statistics. 2020."},{"issue":"6","key":"14968_CR4","first-page":"446","volume":"67","author":"DY Hung","year":"2022","unstructured":"Hung DY, Rundall TR, Lee J, Khandel N, Shortell SM. Managing through a pandemic: a daily management system for COVID-19 response and recovery. J Healthc Manag. 2022;67(6):446\u201357.","journal-title":"J Healthc Manag"},{"issue":"1","key":"14968_CR5","doi-asserted-by":"publisher","first-page":"195","DOI":"10.1186\/s12913-023-09190-4","volume":"23","author":"S Hughes Spence","year":"2023","unstructured":"Hughes Spence S, Khurshid Z, Flynn M, Fitzsimons J, De Br\u00fan A. A narrative inquiry into healthcare staff resilience and the sustainability of quality improvement implementation efforts during COVID-19. BMC Health Serv Res. 2023;23(1):195.","journal-title":"BMC Health Serv Res"},{"issue":"1","key":"14968_CR6","doi-asserted-by":"publisher","first-page":"307","DOI":"10.1186\/s12913-024-10771-0","volume":"24","author":"X Li","year":"2024","unstructured":"Li X, Martins AL. Leagility in the healthcare research: a systematic review. BMC Health Serv Res. 2024;24(1):307.","journal-title":"BMC Health Serv Res"},{"issue":"1","key":"14968_CR7","doi-asserted-by":"publisher","first-page":"841","DOI":"10.1186\/s12913-024-11278-4","volume":"24","author":"AM Mosadeghrad","year":"2024","unstructured":"Mosadeghrad AM, Afshari M, Isfahani P, Ezzati F, Abbasi M, Farahani SA, et al. Strategies to strengthen the resilience of primary health care in the COVID-19 pandemic: a scoping review. BMC Health Serv Res. 2024;24(1):841.","journal-title":"BMC Health Serv Res"},{"key":"14968_CR8","volume-title":"Management on the Mend: The Healthcare Executive Guide to System Transformation","author":"J Toussaint","year":"2015","unstructured":"Toussaint J, Adams E. Management on the Mend: The Healthcare Executive Guide to System Transformation. Appleton, WI: ThedaCare Center for Healthcare Value; 2015."},{"key":"14968_CR9","volume-title":"Banish Waste and Create Wealth in Your Corporation","author":"JP Womack","year":"2003","unstructured":"Womack JP, Jones DT. Banish Waste and Create Wealth in Your Corporation. New York, NY: Free; 2003."},{"issue":"1","key":"14968_CR10","doi-asserted-by":"publisher","first-page":"27","DOI":"10.1186\/s12913-018-3062-5","volume":"18","author":"DY Hung","year":"2018","unstructured":"Hung DY, Harrison MI, Truong Q, Du X. Experiences of primary care physicians and staff following lean workflow redesign. BMC Health Serv Res. 2018;18(1):27.","journal-title":"BMC Health Serv Res"},{"key":"14968_CR11","doi-asserted-by":"publisher","first-page":"652","DOI":"10.1186\/s12913-019-4502-6","volume":"19","author":"M Kaltenbrunner","year":"2019","unstructured":"Kaltenbrunner M, Bengtsson L, Mathiassen S, Hogberg H, Engstrom M. Staff perception of Lean, care-giving, thriving and exhaustion: a longitudinal study in primary care. BMC Health Serv Res. 2019;19:652\u201371.","journal-title":"BMC Health Serv Res"},{"issue":"2","key":"14968_CR12","doi-asserted-by":"publisher","first-page":"274","DOI":"10.1007\/s11606-020-06317-9","volume":"36","author":"DY Hung","year":"2021","unstructured":"Hung DY, Truong Q, Liang SY. Implementing lean quality improvement in primary care: impact on efficiency in performing common clinical tasks. J Gen Intern Med. 2021;36(2):274\u20139.","journal-title":"J Gen Intern Med"},{"issue":"3","key":"14968_CR13","doi-asserted-by":"publisher","first-page":"363","DOI":"10.1111\/1475-6773.13605","volume":"56","author":"DY Hung","year":"2021","unstructured":"Hung DY, Mujal G, Jin A, Liang SY. Patient experiences after implementing lean primary care redesigns. Health Serv Res. 2021;56(3):363\u201370.","journal-title":"Health Serv Res"},{"issue":"10","key":"14968_CR14","doi-asserted-by":"publisher","first-page":"2358","DOI":"10.1007\/s11606-021-07178-6","volume":"37","author":"DY Hung","year":"2022","unstructured":"Hung DY, Mujal G, Jin A, Liang SY. Road to better work-life balance? Lean redesigns and daily work time among primary care physicians. J Gen Intern Med. 2022;37(10):2358\u201364.","journal-title":"J Gen Intern Med"},{"issue":"5","key":"14968_CR15","first-page":"296","volume":"47","author":"SM Shortell","year":"2021","unstructured":"Shortell SM, Blodgett JC, Rundall TG, Henke RM, Reponen E. Lean management and hospital performance: adoption vs. implementation. Joint Comm Qual Patient Saf. 2021;47(5):296\u2013305.","journal-title":"Joint Comm Qual Patient Saf"},{"issue":"5","key":"14968_CR16","first-page":"325","volume":"68","author":"T Roey","year":"2023","unstructured":"Roey T, Hung DY, Rundall TR, Fournier PL, Zhong A, Shortell SM. Lean performance improvement and facilitators of outcomes in U.S. public hospitals. J Healthc Manag. 2023;68(5):325\u201341.","journal-title":"J Healthc Manag"},{"issue":"2","key":"14968_CR17","doi-asserted-by":"publisher","first-page":"67","DOI":"10.1097\/QMH.0000000000000440","volume":"33","author":"J Lee","year":"2024","unstructured":"Lee J, Hung DY, Rundall TR, Fournier PL, Reponen E, Tierney A, Shortell SM. Associations between lean IT management and financial performance in U.S. hospitals. Qual Saf Health Care. 2024;33(2):67\u201376.","journal-title":"Qual Saf Health Care"},{"key":"14968_CR18","unstructured":"OneKey Healthcare Industry Database - Overview. https:\/\/www.onekeydata.com\/onekey\/overview. Accessed July 24, 2025."},{"issue":"2","key":"14968_CR19","doi-asserted-by":"publisher","first-page":"e245237","DOI":"10.1001\/jamahealthforum.2024.5237","volume":"6","author":"M Mackwood","year":"2025","unstructured":"Mackwood M, Fisher E, Schmidt RO, Yang CW, O\u2019Malley AJ, Rodriguez HP, Shortell S, Akr\u00e9 EL, Schifferdecker KE. Changes in US primary care access and capabilities during the COVID-19 pandemic. JAMA Health Forum. 2025;6(2):e245237.","journal-title":"JAMA Health Forum"},{"issue":"2\u20133","key":"14968_CR20","doi-asserted-by":"publisher","first-page":"85","DOI":"10.1007\/s10742-020-00210-y","volume":"20","author":"AJ O\u2019Malley","year":"2020","unstructured":"O\u2019Malley AJ, Park S. A novel cluster sampling design that couples multiple surveys to support multiple inferential objectives. Health Serv Outcomes Res Methodol. 2020;20(2\u20133):85\u2013110.","journal-title":"Health Serv Outcomes Res Methodol"},{"key":"14968_CR21","volume-title":"Embracing the Incident Command System: above and beyond theory","author":"WM Phibbs","year":"2014","unstructured":"Phibbs WM, Snawder MA. Embracing the Incident Command System: above and beyond theory. Washington DC: Federal Bureau of Investigation Law Enforcement Bulletin, U.S. Department of Justice; 2014."},{"key":"14968_CR22","unstructured":"Shingo Institute. The Shingo Model. https:\/\/shingo.org\/shingo-model\/. Accessed July 13, 2025."},{"issue":"1","key":"14968_CR23","doi-asserted-by":"publisher","first-page":"145","DOI":"10.1007\/s11606-021-07134-4","volume":"37","author":"EC Dillon","year":"2022","unstructured":"Dillon EC, Stults CD, Deng S, Martinez M, Szwerinski N, Koenig PT, et al. Women, younger clinicians\u2019, and caregivers\u2019 experiences of burnout and well-being during COVID-19 in a US healthcare system. J Gen Intern Med. 2022;37(1):145\u201353.","journal-title":"J Gen Intern Med"},{"issue":"1","key":"14968_CR24","doi-asserted-by":"publisher","first-page":"888","DOI":"10.1186\/s12913-024-11366-5","volume":"24","author":"J Melnikow","year":"2024","unstructured":"Melnikow J, Xing G, Miller ME, Loureiro S, Padovani AJ, Whitney R, et al. Workplace support for physicians during the COVID-19 Pandemic: Did it affect burnout? BMC Health Serv Res. 2024;24(1):888.","journal-title":"BMC Health Serv Res"},{"issue":"10","key":"14968_CR25","doi-asserted-by":"publisher","first-page":"1910","DOI":"10.3390\/pr10101910","volume":"10","author":"O McDermott","year":"2022","unstructured":"McDermott O, Antony J, Bhat S, Jayaraman R, Rosa A, Marolla G, et al. Lean six sigma in healthcare: a systematic literature review on motivations and benefits. Processes. 2022;10(10):1910.","journal-title":"Processes"},{"issue":"3","key":"14968_CR26","doi-asserted-by":"publisher","first-page":"557","DOI":"10.1111\/deci.12510","volume":"53","author":"S Narayanan","year":"2022","unstructured":"Narayanan S, Vickery SK, Nicolae ML, Castel MJ, McLeod MK. The effects of lean implementation on hospital financial performance. Decis Sci. 2022;53(3):557\u201377.","journal-title":"Decis Sci"},{"issue":"1","key":"14968_CR27","doi-asserted-by":"publisher","first-page":"237","DOI":"10.1186\/s12913-023-09258-1","volume":"23","author":"J Evans","year":"2023","unstructured":"Evans J, Leggat SG, Samson D. A systematic review of the evidence of how hospitals capture financial benefits of process improvement and the impact on hospital financial performance. BMC Health Serv Res. 2023;23(1):237\u201343.","journal-title":"BMC Health Serv Res"},{"issue":"4","key":"14968_CR28","doi-asserted-by":"publisher","first-page":"785","DOI":"10.1016\/j.jom.2007.01.019","volume":"25","author":"R Shah","year":"2007","unstructured":"Shah R, Ward PT. Defining and developing measures of lean production. J Oper Manag. 2007;25(4):785\u2013805.","journal-title":"J Oper Manag"},{"issue":"8","key":"14968_CR29","doi-asserted-by":"publisher","first-page":"e242547","DOI":"10.1001\/jamahealthforum.2024.2547","volume":"5","author":"K Schifferdecker","year":"2024","unstructured":"Schifferdecker K, Yang C, Mackwood M, et al. Safety Net Primary Care Capabilities After the COVID-19 Pandemic. JAMA Health Forum. 2024;5(8):e242547.","journal-title":"JAMA Health Forum"},{"key":"14968_CR30","doi-asserted-by":"crossref","unstructured":"Kirkland C, Oldfield-Tabbert K, Karnik H, Orr J, Martin S, Leider JP. Public health workforce gaps, impacts, and improvement strategies from COVID-19. Int J Environ Res Public Health. 2022;19(20).","DOI":"10.3390\/ijerph192013084"},{"issue":"6","key":"14968_CR31","doi-asserted-by":"publisher","first-page":"e2114386","DOI":"10.1001\/jamanetworkopen.2021.14386","volume":"4","author":"X Hu","year":"2021","unstructured":"Hu X, Dill MJ. Changes in physician work hours and patterns during the COVID-19 pandemic. JAMA Netw Open. 2021;4(6):e2114386.","journal-title":"JAMA Netw Open"},{"issue":"1","key":"14968_CR32","doi-asserted-by":"publisher","first-page":"e220001","DOI":"10.1001\/jamahealthforum.2022.0001","volume":"3","author":"GR Wilensky","year":"2022","unstructured":"Wilensky GR. The COVID-19 pandemic and the US health care workforce. JAMA Health Forum. 2022;3(1):e220001.","journal-title":"JAMA Health Forum"},{"issue":"1","key":"14968_CR33","first-page":"59","volume":"73","author":"BZ Pirdal","year":"2022","unstructured":"Pirdal BZ, Toplu FS, Esen BK, Aydin SN, Erginoz E, Can G. An assessment on loss of workforce due to COVID-19 among healthcare personnel: A university hospital experience. Work. 2022;73(1):59\u201367.","journal-title":"Work"},{"issue":"8","key":"14968_CR34","doi-asserted-by":"publisher","first-page":"730","DOI":"10.30773\/pi.2022.0361","volume":"20","author":"KM Han","year":"2023","unstructured":"Han KM, Lee SM, Hong M, Kim SJ, Sohn S, Choi YK, et al. COVID-19 pandemic-related job loss impacts on mental health in South Korea. Psychiatry Investig. 2023;20(8):730\u20139.","journal-title":"Psychiatry Investig"},{"issue":"1","key":"14968_CR35","doi-asserted-by":"publisher","first-page":"56","DOI":"10.1108\/17410380610639506","volume":"17","author":"S Bhasin","year":"2006","unstructured":"Bhasin S, Burcher P. Lean viewed as a philosophy. J Manuf Technol Manage. 2006;17(1):56\u201372.","journal-title":"J Manuf Technol Manage"},{"key":"14968_CR36","doi-asserted-by":"crossref","unstructured":"\u00c5hlstr\u00f6m P, Danese P, Hines P, Netland TH, Powell DJ, Shah R, et al. Is lean a theory? Viewpoints and outlook. Int J Oper Prod Manag. November 2021.","DOI":"10.1108\/IJOPM-06-2021-0408"},{"key":"14968_CR37","volume-title":"Responding to the Grand Challenges in Healthcare Via Organizational Innovation: Needed Advances in Management Research","author":"DY Hung","year":"2022","unstructured":"Hung DY, Lee J, Rundall TG. Transformational Performance Improvement: Why Is Progress Slow? Chap. 2 in Advances in Healthcare Management, Volume 21. In: Shortell SM, Burns LR, Hefner J, editors. Responding to the Grand Challenges in Healthcare Via Organizational Innovation: Needed Advances in Management Research. London, United Kingdom: Emerald Publishing Limited; 2022."},{"key":"14968_CR38","unstructured":"Lean Enterprise Institute. Understanding the Fundamentals of Value Stream Mapping. https:\/\/www.lean.org\/the-lean-post\/articles. Accessed July 30, 2025."},{"key":"14968_CR39","doi-asserted-by":"publisher","first-page":"1050","DOI":"10.1136\/bmjqs-2019-010575","volume":"29","author":"T Mihaljevic","year":"2020","unstructured":"Mihaljevic T. Tiered daily huddles: the power of teamwork in managing large healthcare organisations. BMJ Qual Saf. 2020;29:1050\u20132.","journal-title":"BMJ Qual Saf"},{"key":"14968_CR40","unstructured":"Fritze C. The Toyota Production System \u2013 The Key Elements and the Role of Kaizen in the System. https:\/\/www.researchgate.net\/publication\/289519018_The_Toyota_Production_System_-_The_Key_Elements_and_the_Role_of_Kaizen_within_the_System. Accessed August 1, 2025."},{"key":"14968_CR41","first-page":"198","volume":"48","author":"P Christoff","year":"2018","unstructured":"Christoff P. Running PDSA cycles. Curr Probl Pediatr Adolesc Health Care. 2018;48:198\u2013201.","journal-title":"Curr Probl Pediatr Adolesc Health Care"},{"issue":"2","key":"14968_CR42","doi-asserted-by":"publisher","first-page":"83","DOI":"10.36401\/JQSH-21-X1","volume":"4","author":"M Alkiayat","year":"2021","unstructured":"Alkiayat M. A practical guide to creating a pareto chart as a quality improvement tool. Glob J Qual Saf Healthc. 2021;4(2):83\u20134.","journal-title":"Glob J Qual Saf Healthc"},{"key":"14968_CR43","unstructured":"American Society for Quality. https:\/\/asq.org\/quality-resources\/statistical-process-control. Accessed August 7, 2025."}],"container-title":["BMC Health Services Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s12913-026-14968-3","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12913-026-14968-3.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12913-026-14968-3.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T12:57:00Z","timestamp":1787662620000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1186\/s12913-026-14968-3"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,6,19]]},"references-count":43,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,12]]}},"alternative-id":["14968"],"URL":"https:\/\/doi.org\/10.1186\/s12913-026-14968-3","relation":{},"ISSN":["1472-6963"],"issn-type":[{"value":"1472-6963","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6,19]]},"assertion":[{"value":"25 August 2025","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"10 June 2026","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"19 June 2026","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"Dartmouth College\u2019s Committee for the Protection of Human Subjects approved the study as exempt (00032337). Consent to participate was not applicable. This research was conducted in accordance with the Quality Assurance, Norms and Standards of the World Health Organization.","order":1,"name":"Ethics","label":"Ethics approval and consent to participate","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"There are no individual\u2019s personal data represented in this manuscript.","order":2,"name":"Ethics","label":"Consent for publication","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"The authors declare no competing interests.","order":3,"name":"Ethics","label":"Competing interests","group":{"name":"EthicsHeading","label":"Declarations"}}],"article-number":"1181"}}