You are here

Article Text

Article menu

Download PDFPDF

Emergency medicine
Protocol
Medical complexity in emergency and urgent care settings: a scoping review protocol
  1. Sumedh Bele1,
  2. Cassandra Chisholm2,
  3. Conne Lategan2,
  4. Kate Yakubets3,
  5. Diane Lorenzetti4,
  6. Marie-Claire Uwamahoro4,
  7. Naomi Popeski5,
  8. Tanvir C Turin6,
  9. Eddy Lang7,
  10. Doreen Rabi5
  1. 1Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
  2. 2University of Alberta College of Health Sciences, Edmonton, Alberta, Canada
  3. 3University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
  4. 4Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
  5. 5Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
  6. 6Family Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
  7. 7Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
  1. Correspondence to Mr Sumedh Bele; sumedh.bele{at}ndorms.ox.ac.uk

Abstract

Introduction Considering the impact of non-medical factors (personal and social) on patients with multiple chronic conditions, the term ‘medical complexity’ is gaining traction as it encompasses both medical and non-medical aspects of patients’ medical needs. When primary care is not able to provide timely care for chronic challenges or acute concerns, complex patients require care in emergency or urgent care settings. The concept of medical complexity is continually evolving, although without a universally accepted or standardised definition that determines if an adult patient is considered complex. Therefore, this scoping review aims to understand how medical complexity is defined, identify its defining attributes and examine its use in clinical care research. We also aim to consolidate and evaluate the evidence to suggest a more comprehensive and standardised definition of medical complexity and/or highlight key components required to define medical complexity in urgent care and emergency department settings.

Methods and analysis This protocol is developed according to the approach described by Arksey and O’Malley (2005) and expanded by Levac and colleagues. We will use Walker and Avant’s method of concept analysis (2005) to gain a comprehensive understanding of the concept of medical complexity. We will systematically search MEDLINE, CINAHL Plus, EMBASE, APA PsycINFO and Cochrane Library. A grey literature search will be conducted in Google and Google Scholar to identify additional information. Two reviewers will independently screen titles and abstracts for inclusion, followed by a screening of the full text of potentially relevant articles. Relevant data will be extracted from these studies. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist will be used to report the selection of studies at different stages.

Ethics and dissemination Scoping review methodology uses and reviews publicly available studies and data, so ethics approval is not required. We will disseminate the results of this scoping review through peer-reviewed publications and presentations at academic conferences and scientific meetings. We will also share these results with key stakeholders, including healthcare providers, community organisations and healthcare system leaders.

  • Chronic Disease
  • Emergency Service, Hospital
  • Health Services
  • Organisation of health services
  • Patient-Centred Care
http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi-org.ezproxy.u-pec.fr/10.1136/bmjopen-2024-086984

Statistics from Altmetric.com

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    STRENGTHS AND LIMITATIONS OF THIS STUDY

    • The key strength of this scoping review lies in our strategy of combining Arksey and O’Malley’s (2005) and Levac and colleagues’ (2010) approaches to conducting scoping reviews and using Walker and Avant’s method of concept analysis. These methodological approaches ensure a comprehensive overview of the literature and a structured and systematic understanding of medical complexity in urgent care and emergency department settings.

    • Another strength of this study is our approach of performing a comprehensive search across all key biomedical databases, including MEDLINE, EMBASE, CINAHL Plus, APA PsycINFO, Cochrane Library, Scopus and the Web of Science. Searching grey literature through Google Search further adds to the comprehensiveness of our search.

    • One of the limitations of this scoping review includes searching only the first 10 pages of Google Search and Google Scholar, which means we will only be able to capture limited information from grey literature and as a result, the concept analysis will be largely influenced by peer-reviewed literature.

    • We will only be able to include studies published in English and French, so we might miss studies in other languages, which is another weakness of this review.

    Introduction

    An ageing population and factors such as changes in lifestyles and psychosocial issues, including health inequities, are leading to a growing number of patients living with multiple conditions and facing challenges during their encounters with healthcare systems.1 2 They are usually identified as patients with ‘multimorbidity’, which is defined as the co-occurrence of two or more chronic conditions.3 However, considering the impact of non-medical factors (personal and social) on patients’ health, the term ‘medical complexity’ is increasingly being used to encompass both medical and non-medical factors.4

    The elements contributing to a patient’s complexity include long-term functional limitations, significant psychosocial challenges, such as mental health concerns and cognitive impairments, and increased healthcare utilisation.1 5 The social determinants of health further contribute to patient complexity, which include, but are not limited to, socioeconomic, behavioural, environmental, racial and cultural factors.6 The concept of medical complexity is continually evolving,7 although without a universally accepted or standardised definition that determines if an adult patient is considered complex. Patient complexity requires the consideration of multiple components contributing to the overall health of an individual. Safford and colleagues6 illustrate that various complexities have a significant impact on effective healthcare delivery. Traditional methods used to describe patient complexity fail to consider the interplay between different health determinant domains and neglect to consider the role that healthcare providers play in modifying their interactions. For example, the CONECT-6 case-finding tool to identify patients with complex health needs in the emergency department includes only one question about household income.8 It does not consider racial, cultural, environmental, behavioural and other socioeconomic factors. Notably, a well-recognised Vector Model of Complexity (VMC)6 considers interactions between biological, socioeconomic, cultural, environmental and behavioural forces as determinants of medical complexity. The VMC considers the idea that health determinants impact patients by both force and direction. Furthermore, the VMC acknowledges that various determinants can be additive in nature and explicitly interact to impact a patient’s complexity and the outcomes of care. The VMC does not negate medical care as the sixth important determinant of health for these patients, where consideration of a patient’s complexity is of paramount importance. The VMC allows for patient complexity to vary over time along with a patient’s own dynamic changes, and thus should be considered during each healthcare encounter.

    Patients living with a high burden of disease commonly require emergency or urgent care since primary care is already struggling with patient volume9 and time constraints.10 This results in patients who are medically complex seeking care in urgent care or emergency department settings.11 12 Urgent care centres are healthcare facilities that provide prompt medical attention for acute non-critical medical conditions, whereas emergency departments provide care for critical and life-threatening conditions. These settings are frequented by complex patients with chronic conditions who are unable to access timely or appropriate primary care.13 Evidence shows that increased social vulnerability is associated with increased hospitalisations and emergency department visits.14

    However, urgent care and emergency department settings face many challenges in providing optimal care for patients with complex healthcare needs due to time and resource pressures.15 Emergency department physicians continually seek to maximise their efficiency, reduce patient load and discharge patients with complex needs, which is encouraged within the emergency department.16 Moreover, complex patients may be discharged without their needs being fully addressed or a lack of appropriate follow-up resources arranged, thus failing to provide adequate care. A study analysing the causes of missed or delayed diagnoses in emergency departments determined that 34% of errors occurred due to patient-related complexity factors (eg, atypical presentation, complicated medical history, substance abuse, psychiatric issue and language barriers).17 Additional challenges in urgent care and emergency department settings include long wait times,18 brief interactions, minimal patient education and delays in patient boarding.19 Consequently, the urgent care and emergency department utilisation results in increased healthcare resource burden and fragmented care, with multiple repeat visits for such patients. This correlates with negative patient outcomes and higher mortality rates.20 21

    There is substantial heterogeneity in the literature when it comes to defining medical complexity, specifically in urgent care and emergency department settings.2 In order to have a healthcare system that optimally responds to patients with multiple medical needs and diverse, intersecting social, economic and environmental challenges, healthcare systems need to be able to quickly characterise, assess and communicate around patient complexity. It is imperative that the definitions of patients with complex needs be evaluated, as this can facilitate the development of a standardised definition for future research in this specific patient population and medical setting. However, evolving concepts like medical complexity warrant understanding its definition, defining attributes and uses in clinical care and research. Therefore, evidence from this scoping review will contribute to a better understanding of how urgent care and emergency department settings recognise and define patients with medical complexity, and ultimately, identify key patient components that need to be considered in the development of a standardised definition of medical complexity in these settings. With the significant healthcare resource utilisation and care delivery challenges set by patients with complex needs, identifying complex patients in these settings will inform the development of more appropriate clinical practice guidelines that can improve care and result in better patient outcomes.2

    The objectives of our study are to: (1) identify and examine how medical complexity has previously been defined and operationally used in urgent care and emergency departments, identify attributes contributing to those definitions, and how it is used in clinical care research; and (2) consolidate and evaluate the evidence to suggest a more comprehensive and standardised definition of medical complexity and/or highlight key components required to define medical complexity in urgent care and emergency department settings.

    Methods

    Design

    We chose to use the scoping review method because it provides a framework for conducting a comprehensive review of the current evidence and knowledge gaps on dynamic and emerging concepts such as medical complexity.22 We aim to examine the concept of medical complexity in both practice and research. Since the scoping review supports the inclusion of different types of literature (ie, peer-reviewed and grey literature), this methodology will result in a broader understanding of this concept in both practice and research. This protocol was developed according to the approach described by Arksey and O’Malley 22 and expanded by Levac and colleagues,23 which consists of five stages: (1) identify a research question; (2) identify relevant literature; (3) study selection; (4) data charting/extraction; and (5) collating, summarising and reporting the results. We will use Walker and Avant’s method of concept analysis (2005)24 to gain a comprehensive understanding of the concept of medical complexity. This method is helpful to understand concepts that are constantly evolving, confused, conflicting or undefined. This scoping review's results will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist.25 We will begin our review on 1 December 2024 and aim to complete this scoping review by 30 November 2025.

    Patient and public involvement

    This study is part of a larger project under the Canadian Collaboration for Complex Care (C4). This project has established a patient advisory council, which consists of patients and their family caregivers. Members of this council are engaged as advisors for various C4 projects, including this scoping review, where they are involved in defining the research question and search terms.

    Stage 1: identify a research question

    The study question formulation was iterative in nature. The research question was created through consultations with the research team, which included healthcare providers and patient partners. The focus of our review is on the definition of medical complexity and its utilisation within urgent care and emergency department settings. The primary research question for this review is: how is medical complexity defined and operationally used in urgent care and emergency department settings?

    Stage 2: identify relevant literature

    Search strategy

    The search strategy will be developed in accordance with the research question and study objective(s). The search strategy will combine keywords (title/abstract words) and relevant database-specific subject headings from two concepts: (1) patient complexity (eg, complex patient/patient complexity, complicated) and (2) emergency and acute care (eg, Emergency Medical Services/Emergency care/emergency services, urgent care/urgent healthcare/urgent visit, emergency department/emergency room/ED). The search strategies will be developed and revised in collaboration with a health sciences librarian (see online supplemental appendix I for draft search). No study design limits will be implemented in the search. No publication date limit will be applied to the search, and only studies published in English and French will be included in the results.

    Information sources

    The final search will be applied to the following databases: MEDLINE (Ovid interface, 1950 onwards), EMBASE (Ovid interface, 1974 onwards), CINAHL Plus with Full Text (EBSCOhost interface, 1982 onwards), APA PsycINFO (Ovid interface, 1803 onwards) and Cochrane Library (Wiley interface, 1991 onwards). Scopus and the Web of Science will be searched to identify additional articles that may have been missed by databases focused on biomedicine disciplines. A grey literature search will be conducted in Google and Google Scholar to identify additional information from professional association websites, health system websites, conference websites, and reports.

    Stage 3: study selection

    Data management

    Results of the search will be exported to the Covidence systematic review platform to remove duplicates, screen and manage all references (Covidence).23 Titles and abstracts will be screened by two independent reviewers for assessment against predetermined inclusion criteria in relation to our population, intervention, comparators and outcomes. If two independent reviewers’ decisions conflict over a study, the two reviewers will discuss and resolve any inconsistencies or refer the matter to a third reviewer.

    After that, the two independent reviewers will conduct a full-text review of studies relevant to the research question to determine eligibility. Reviewers will discuss any inconsistencies, and a third reviewer will resolve discrepancies as required. Reasons for any exclusion at full-text review will be documented. The final list of articles will be reported and presented in a PRISMA-ScR flow diagram.

    Inclusion criteria

    1. Studies that include only adult populations (aged >18 years).

    2. Studies that include a definition of medical/patient complexity or define attributes or articles that discuss development of measures for patient complexity models. Studies that focus primarily on the terminology of a complex patient.

    3. Studies from the urgent care and/or emergency department context.

    Exclusion criteria

    1. Studies not exploring a complex patient in urgent care and emergency department settings.

    2. Studies published in any language other than English or French.

    3. Studies focusing only on the paediatric population.

    Stage 4: data extraction

    We will develop a standardised data extraction form using Microsoft Excel sheets, and two reviewers will independently extract data from the included studies to minimise error.

    The extracted data will include summary details related to:

    1. The objective of the study, participants, concepts, context, study design, country and region, period of time and key findings relevant to the research question.

    2. Key components used to define or characterise complex patients.

    3. Definitions of complexity.

    If additional items are added to the data extraction form during this process that were not initially prespecified by the research team, this will be reported along with a rationale for their inclusion. Extracted data from the included studies for the review will be presented to the whole research team for consistency. To ensure a patient-centric approach in this review, we will share extracted data with key stakeholders and patient partners and seek their opinions on its relevance to this review.

    Stage 5: collating, summarising and reporting the results

    At this stage, Walker and Avant’s method24 will be employed to analyse the extracted data, which will involve identifying and collating current definitions of medical complexity, their context and defining attributes, uses and implications for research and clinical practice in urgent care and emergency department settings. A completed PRISMA-ScR diagram will highlight the review process and identify stages where the studies were disregarded.

    The final results of this scoping review will provide a synthesis of the evidence in the literature describing complex patients and current gaps in the current literature. We hypothesise being able to raise important considerations for a standardised definition and aim to use the most common attributes to propose a conceptual definition of medical complexity in urgent care and emergency department settings.

    Patient partners will get information on the synthesis of evidence and data extraction as a lay summary. The patient partners will provide input to determine if the scoping review addresses its objectives and if the findings are congruent from a patient’s perspective. These findings will be included in the publication of the results of this review in a peer-reviewed journal.

    Discussion

    This scoping review aims to map the existing literature to understand how medical complexity is currently defined, the attributes used in defining it and how it is operationalised. Moreover, our findings will provide a comprehensive overview of existing literature to identify knowledge gaps where further research is needed. The findings of this review will provide a comprehensive summary of existing evidence on medical complexity to inform decision-making in policy and practice. Thus, insights from this scoping review will inform healthcare providers, health systems leaders and policymakers and guide future research on medical complexity. The key strength of this scoping review lies in our strategy of combining Arksey and O’Malley 22 and Levac and colleagues’ 23 approaches to conducting a scoping review and using Walker and Avant’s method of concept analysis.24 These methodological approaches will ensure a comprehensive overview of the literature and a structured and systematic understanding of medical complexity in urgent care and emergency department settings. Patient partner engagement is another strength of this scoping review. We will only review the first 10 pages of Google Search and Google Scholar, which means we will only be able to capture limited information from grey literature, and as a result, the concept analysis will be largely influenced by peer-reviewed literature.

    This methodological decision was necessary to ensure feasibility and will not likely impact how clinicians or health services researchers conceptualise ‘complexity’; however, it may limit the capture of the diverse ways patients or the public use complexity in relation to their acute health needs. For this scoping review, we will only be able to include studies published in English and French. This is a necessary constraint to ensure the review is feasible but may limit the comprehensiveness of our concept analysis.

    Ethics and dissemination

    As the scoping review methodology uses and reviews publicly available studies and data, no ethics approval is required. The results of this review will be disseminated to the International Academic Community through the publication of the final study in an academic journal. In addition, results will be presented at local and international academic conferences and scientific meetings. We will also share these results with key stakeholders in Canada, including healthcare providers, community organisations and health system leaders, specifically the leadership of the Emergency Medicine Strategic Clinical Network—a learning health system within Alberta that supports the integration of innovations and new evidence in emergency medical care. We believe that the results of this review will inform clinical care, policy formulation and future research on medical complexity in urgent care and emergency department settings around the world.

    Ethics statements

    Patient consent for publication

    References

    1. ↵
      1. Wolff JL,
      2. Starfield B,
      3. Anderson G
      . Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Arch Intern Med 2002;162:2269–76. doi:10.1001/archinte.162.20.2269
      OpenUrlCrossRefPubMedWeb of Science
    2. ↵
      1. Nicolaus S,
      2. Crelier B,
      3. Donzé JD, et al
      . Definition of patient complexity in adults: A narrative review. J Multimorb Comorb 2022;12. doi:10.1177/26335565221081288
    3. ↵
      1. Skou ST,
      2. Mair FS,
      3. Fortin M, et al
      . Multimorbidity. Nat Rev Dis Primers 2022;8:48. doi:10.1038/s41572-022-00376-4
      OpenUrlCrossRefPubMed
    4. ↵
      1. Manning E,
      2. Gagnon M
      . The complex patient: A concept clarification. Nurs Health Sci 2017;19:13–21. doi:10.1111/nhs.12320
      OpenUrlPubMed
    5. ↵
      1. Schaink AK,
      2. Kuluski K,
      3. Lyons RF, et al
      . A scoping review and thematic classification of patient complexity: offering a unifying framework. J Comorb 2012;2:1–9. doi:10.15256/joc.2012.2.15
      OpenUrlPubMed
    6. ↵
      1. Safford MM,
      2. Allison JJ,
      3. Kiefe CI
      . Patient complexity: more than comorbidity. the vector model of complexity. J Gen Intern Med 2007;22 Suppl 3:382–90. doi:10.1007/s11606-007-0307-0
      OpenUrlPubMed
    7. ↵
      1. Valderas JM,
      2. Starfield B,
      3. Sibbald B, et al
      . Defining comorbidity: implications for understanding health and health services. Ann Fam Med 2009;7:357–63. doi:10.1370/afm.983
      OpenUrlAbstract/FREE Full Text
    8. ↵
      1. Hudon C,
      2. Bisson M,
      3. Dubois M-F, et al
      . CONECT-6: a case-finding tool to identify patients with complex health needs. BMC Health Serv Res 2021;21:157. doi:10.1186/s12913-021-06154-4
      OpenUrlPubMed
    9. ↵
      1. Tonelli M,
      2. Wiebe N,
      3. Manns BJ, et al
      . Comparison of the Complexity of Patients Seen by Different Medical Subspecialists in a Universal Health Care System. JAMA Netw Open 2018;1:e184852. doi:10.1001/jamanetworkopen.2018.4852
    10. ↵
      1. Grant RW,
      2. Ashburner JM,
      3. Hong CS, et al
      . Defining patient complexity from the primary care physician’s perspective: a cohort study. Ann Intern Med 2011;155:797–804. doi:10.7326/0003-4819-155-12-201112200-00001
      OpenUrlCrossRefPubMedWeb of Science
    11. ↵
      1. Hanlon AL,
      2. Pauly MV,
      3. Huang L, et al
      . Medical Complexity Mediates Healthcare Resource Use in the Socially Vulnerable. J Healthc Manag 2022;67:173–91. doi:10.1097/JHM-D-21-00072
      OpenUrlPubMed
    12. ↵
      1. Ahn S,
      2. Hussein M,
      3. Mahmood A, et al
      . Emergency department and inpatient utilization among U.S. older adults with multiple chronic conditions: a post-reform update. BMC Health Serv Res 2020;20:77. doi:10.1186/s12913-020-4902-7
      OpenUrlPubMed
    13. ↵
      1. Coster JE,
      2. Turner JK,
      3. Bradbury D, et al
      . Why Do People Choose Emergency and Urgent Care Services? A Rapid Review Utilizing a Systematic Literature Search and Narrative Synthesis. Acad Emerg Med 2017;24:1137–49. doi:10.1111/acem.13220
      OpenUrlCrossRefPubMed
    14. ↵
      1. Hogg-Graham R,
      2. Benitez JA,
      3. Lacy ME, et al
      . Association Between Community Social Vulnerability and Preventable Hospitalizations. Med Care Res Rev 2024;81:31–8. doi:10.1177/10775587231197248
      OpenUrlPubMed
    15. ↵
      1. Sartini M,
      2. Carbone A,
      3. Demartini A, et al
      . Overcrowding in Emergency Department: Causes, Consequences, and Solutions-A Narrative Review. Healthcare (Basel) -> Healthc (Basel) 2022;10:1625. doi:10.3390/healthcare10091625
    16. ↵
      1. Grace SG
      . Emergency department: A sociological perspective. Emerg Med Australas 2020;32:875–6. doi:10.1111/1742-6723.13553
      OpenUrlPubMed
    17. ↵
      1. Kachalia A,
      2. Gandhi TK,
      3. Puopolo AL, et al
      . Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med 2007;49:196–205. doi:10.1016/j.annemergmed.2006.06.035
      OpenUrlCrossRefPubMedWeb of Science
    18. ↵
      1. Webster F,
      2. Rice K,
      3. Dainty KN, et al
      . Failure to cope: the hidden curriculum of emergency department wait times and the implications for clinical training. Acad Med 2015;90:56–62. doi:10.1097/ACM.0000000000000499
      OpenUrlCrossRefPubMed
    19. ↵
      1. Laam LA,
      2. Wary AA,
      3. Strony RS, et al
      . Quantifying the impact of patient boarding on emergency department length of stay: All admitted patients are negatively affected by boarding. J Am Coll Emerg Physicians Open 2021;2:e12401. doi:10.1002/emp2.12401
    20. ↵
      1. Liu CW,
      2. Einstadter D,
      3. Cebul RD
      . Care fragmentation and emergency department use among complex patients with diabetes. Am J Manag Care 2010;16:413–20.
      OpenUrlPubMed
    21. ↵
      1. Prior A,
      2. Vestergaard CH,
      3. Vedsted P, et al
      . Healthcare fragmentation, multimorbidity, potentially inappropriate medication, and mortality: a Danish nationwide cohort study. BMC Med 2023;21:305. doi:10.1186/s12916-023-03021-3
      OpenUrlCrossRefPubMed
    22. ↵
      1. Arksey H,
      2. O’Malley L
      . Scoping studies: towards a methodological framework. Int J Soc Res Methodol 2005;8:19–32. doi:10.1080/1364557032000119616
      OpenUrlCrossRef
    23. ↵
      1. Levac D,
      2. Colquhoun H,
      3. O’Brien KK
      . Scoping studies: advancing the methodology. Implement Sci 2010;5:69. doi:10.1186/1748-5908-5-69
      OpenUrlCrossRefPubMed
    24. ↵
      1. Walker LO,
      2. Avant KC
      . Strategies for Theory Construction in Nursing. 4. Pearson/Prentice Hall Upper Saddle River, NJ, 2005.
    25. ↵
      1. Tricco AC,
      2. Lillie E,
      3. Zarin W, et al
      . PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med 2018;169:467–73. doi:10.7326/M18-0850
      OpenUrlCrossRefPubMed

    Footnotes

    • Correction notice This article has been corrected since it was published. The name of the author (CC) was misspelled.

    • Contributors SB and DR contributed to the overall study rationale and design. NP, TCT, EL, M-CU and DL provided expert opinions on the methods and conduct of the study. SB, CC, CL and KY wrote the initial draft of the manuscript. All authors contributed to the revision of the manuscript and approved the final version. SB is responsible for the overall content as guarantor.

    • Funding This project is funded by the Canadian Institute of Health Research Team Grant

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were involved in the design, conduct, reporting or dissemination plans of this research. Refer to the Methods section for further details.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.