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  2. Abstract


To evaluate the implementation of an intensive group exercise program in patients with rheumatoid arthritis (RA).


In 4 regions in The Netherlands, the Rheumatoid Arthritis Patients In Training exercise program was implemented on a limited scale. Evaluation using the RE-AIM model included: Reach, the proportion of the target population participating; Efficacy, effects on muscle strength, aerobic capacity, functional ability, and psychological functioning; Adoption, program adoption by stakeholders; Implementation, intervention quality (quality audits); and Maintenance, stakeholders' willingness to continue the program in the future.


Twenty-five physical therapists from 14 practices were trained to provide the program. In total, 150 RA patients were recruited (by estimation, 2% of the target population). Of the 81 patients who had finished the 12-month intervention and were available for followup directly after the intervention, 62 patients provided clinical data. Muscle strength improved significantly, whereas aerobic capacity, functional ability, psychological functioning, and disease activity did not change. All 9 informed local patient organizations facilitated patient recruitment, and 35 of 51 rheumatologists involved referred one or more patients. All 10 approached health insurance companies funded the program for 12 months. The quality audits showed sufficient quality in 9 of 12 practices. All of the providers of the program were willing to provide the program in the future, whereas future reimbursement by health insurance companies remained unclear.


The implementation of an intensive exercise program for RA patients on a limited scale can be considered successful regarding its reach, adoption, and implementation. The limited effectiveness and the limited data regarding maintenance warrant additional research.


  1. Top of page
  2. Abstract

Dynamic forms of exercise therapy were found to be effective and safe (1, 2) and are recommended in the management of rheumatoid arthritis (RA) (3, 4). By 2004, exercise programs with sufficient intensity and frequency to improve aerobic fitness and/or muscle strength were not available on a large scale in The Netherlands. Therefore, the planned dissemination and implementation of dynamic exercise programs specifically for patients with RA were advocated.

Until now, only a limited number of articles (5–9) described the public health impact of exercise programs for people with arthritis by providing data on outcome and/or process measures of dissemination and implementation projects. Three studies (5–7) focused on the outcomes of the intervention in real life in terms of reduction of symptoms and disability. In general, the effectiveness of the programs was comparable with results obtained in trial settings. Two studies (8, 9) included a process evaluation. One study showed that a community-based physical activity program for patients with arthritis was successfully adopted by providers; however, the number of participants and the number of providers continuing to offer the intervention were found to be limited (8). The other study, on the implementation of an Internet-based physical activity program, performed in The Netherlands, found that health insurance companies were not willing to reimburse a stationary bicycle for home use or to reimburse regular physical therapy and the Internet-based physical activity program simultaneously. In addition, patients' lack of willingness to give up regular physical therapy in favor of the Internet-based program limited their future participation (9).

In the evaluation of dissemination and implementation processes, it is important to comprehensively evaluate the public health impact at both the individual and organizational levels (10). The RE-AIM model assesses the public health impact on both of these levels in the following 5 domains: Reach, the proportion of the target population participating in an intervention, information that is vital to determine whether the program is reaching the population in need; Efficacy, the effectiveness of the intervention in real life, which determines the external validity of interventions in more heterogeneous populations and probably less motivated individuals than those studied under the specific circumstances of a controlled trial; Adoption, the proportion of settings and practices adopting the intervention, information that deals with the willingness to adopt an innovative change; Implementation, the extent to which the intervention is implemented as intended in the real world, which describes the intervention-delivering performance of individuals in real-life settings; and Maintenance, the extent to which an intervention is sustained over time, describing whether the intervention is part of routine policies and established in everyday culture (10).

Because comprehensive evaluations of the dissemination and implementation of evidence-based exercise interventions for patients with rheumatic diseases are scarce, a dissemination and implementation study was conducted on a limited scale, exploring the public health impact of an intensive exercise program for patients with RA using all 5 domains of the RE-AIM model.


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  2. Abstract

This study was conducted between January 2005 and December 2007 in 4 selected regions in The Netherlands (region 1 = Nijmegen, region 2 = Rotterdam, region 3 = Delft/The Hague, and region 4 = Leiden). The total duration of the study was 3 years, with an enrollment period of 24 months (January 2005 until December 2006), during which patients could start with the exercise program at any time. The Medical Ethics Review Committee of the Leiden University Medical Center gave permission to use data from the records of physical therapists for the study.


The intervention to be implemented was the Rheumatoid Arthritis Patients In Training (RAPIT) program. The original RAPIT program was a group exercise program consisting of supervised aerobic and muscle strengthening exercises, with a frequency of 2 times per week and a duration of 24 months. It proved to be more effective than usual care with regard to physical capacity and physical and psychological functioning (1) in a randomized controlled trial (RCT). For the present study, health insurance companies were willing to reimburse only 12 months of the program, and under the condition that patients were actively stimulated to engage in regular physical activity during the program. To meet these health insurance companies' requirements, this implementation study concerned an intervention similar to the original RAPIT program, yet with a duration of 12 months and with physical therapists explicitly advocating engagement in physical activity in the community setting.

Implementation activities.

A general implementation plan was developed describing the implementation process, including 5 activities.

Provider identification and selection.

Providers were recruited based on 2 criteria: the availability of a facility to give group training for up to 10 patients and the willingness to attend and pay for a 3-day training course. In the 4 regions, a total of 92 physical therapists who were most likely to meet these criteria received written and verbal information about the project and were invited to participate.

Provider training and instruction.

Provider training consisted of a 3-day educational course provided by a national training institute for health professionals in The Netherlands (Dutch Institute of Allied Health Care, Amersfoort, The Netherlands) at the cost of $313.00, to be paid by the providers. All of the providers received an intervention guideline and patient record forms.

Patient information and recruitment.

All 9 local patient organizations that were active in the 4 regions were informed about the availability of the program. They received patient information leaflets to distribute to their members. In all 4 regions, written information was published on patient organizations' Web sites and in magazines.

Information for rheumatologists.

Fifty-one rheumatologists working in 11 rheumatologic centers in the 4 regions were informed about the program by mail, including a description of the intervention, referral forms, and patient information leaflets.

Negotiations with health insurance companies.

For negotiations with 10 health insurance companies who were active in the 4 regions, the economic analysis of the original RAPIT study (11) was updated. The annual costs were estimated at $1,428.90 per participating patient, based on 68 group sessions a year at the existing funding rate of $19.80 per patient for group sessions and 3 individual sessions for assessment and followup at the existing funding rate of $27.50.

Evaluation framework.

To evaluate the process and effect parameters of the implementation, the RE-AIM model was used (10).

Reach was defined as the absolute number of patients with RA participating in the program as compared with the total number of eligible RA patients in the catchment areas of the 11 rheumatologic centers in the 4 regions. For this information, the head of the department of rheumatology in each of the centers estimated the total number of patients with RA, preferably based on hospital registries. From the RAPIT study, it is known that 600 (25%) of 2,426 patients with RA were not eligible because of weight-bearing prostheses or comorbidity (12). To estimate the magnitude of the target population, we therefore considered 75% of all RA patients eligible for participation in the RAPIT program.

Efficacy was defined as the effectiveness as well as the safety of the intervention. For every individual patient enrolled in the study, data collection took place at baseline (start of the exercise program) and after 6 and 12 months. Providers were asked to return patients' demographics and outcomes of performance measures (aerobic capacity and functional muscle strength). Functional ability, psychological functioning, and disease activity were collected by means of a survey. Aerobic capacity was measured with the Åstrand Bicycle Test (13) and functional muscle strength was measured by the Timed-Stands Test (TST) (14, 15). Functional ability was measured by means of the Health Assessment Questionnaire (HAQ) (16), with a total score ranging from 0 (no functional limitations) to 3 (serious functional limitations). Psychological functioning was measured with a Dutch version of the Hospital Anxiety and Depression Scale (HADS), which contains 2 scales, one for anxiety and one for depression, both with a score range of 0–21 (17). Disease activity was assessed by a validated Dutch version of the Rheumatoid Arthritis Disease Activity Index (RADAI) (18–21). RADAI scores ranged from 0 to 10, where higher values mean higher disease activity.

Adoption was measured on multiple levels: the provider's level, the rheumatologist's level, the patient organization's level, the level of the individual patient, and the level of the health insurance companies. For this purpose, the proportion of physical therapists to become a provider was recorded. In addition, the proportions of rheumatologists referring one or more patients to the program and of local patient organizations supporting the program by bringing it to their members' attention were recorded. For adoption on the patient's individual level, the number of patients showing interest in the program by contacting a provider and the number of patients who eventually did not start and the reasons for not starting were recorded. Finally, the proportion of health insurance companies that were approached and funded the program was recorded.

Implementation was defined as the extent to which the intervention guideline was carefully followed. For this purpose, first, the attendance rates were recorded for every patient, defined as the number of attended sessions divided by the number of sessions offered by their provider. Second, quality audits were performed by the first author (FJvdG) according to a checklist based on the contents of the intervention guideline. This checklist addressed 5 domains, with 15 items in total: 1) materials: adequate exercise area, aerobic training equipment, and exercise equipment; 2) the presence of program components: warming up/cooling down, aerobic and circuit training, and sports; 3) content: adaptation of program components to suit the needs of individual RA patients with respect to aerobic intensity, intensity of strength training, and coordination; 4) intensity: adequate intensity of warming up/cooling down, aerobic and circuit training, and sports to gain results; and 5) registration: presence of attendance lists, presence of patient records regarding aerobic training, and patient records regarding circuit training. In every domain, 1 point was given for each item being present or performed, resulting in a domain score ranging from 0–3 and a total score from 0–15.

Maintenance was defined as the extent to which the program became institutionalized or part of the standard routine and policy. Like adoption, it was measured on different levels: the provider's level, the level of the provider of the training course, the individual patient's level, and the level of the health insurance companies. For this purpose, providers were asked 1 year after they started the intervention: “Are you willing to keep providing the program in the future and under what condition?” and the provider of the training course was asked, “…whether the educational course would remain available.” To serve as the patient's level of maintenance, dropouts as well as the reasons for withdrawal were recorded. Finally, health insurance companies were asked if they were willing to keep funding the program in the future.

Statistical analysis.

Continuous variables were expressed as the mean ± SD or medians with interquartile ranges according to their distribution. Categorical data were expressed as numbers and percentages.

In the Efficacy domain, mean age and sex of patients who ended their participation prematurely and patients who completed the program were compared by means of the unpaired t-test and chi-square test, respectively. For the comparisons of the outcome measures between baseline and the 2 followup time points, it was taken into account that patients who left the program prematurely and censured data had led to a considerable number of incomplete pairs. In order to use all of the available data from all of the time points, a linear mixed-effects model (repeated-measures linear model) was used with the patient number as the random effect and time as the fixed effect. These analyses were based on intent-to-treat.

The linear mixed-effects model described above was also used to analyze the effects of attendance rate (attendance) and intervention quality (total quality score) on change scores (baseline to 6-month and 12-month followup). Two subgroups were created based on median attendance (greater than or less than median attendance) and on quality score of the practices providing the program (15 = optimal, <15 = not optimal). Two analyses were performed: one with attendance, time, and attendance × time, and one with quality, time, and quality × time as the fixed effects, and patient number as the random effect. In addition, the association between quality of intervention (optimal/suboptimal) and adherence (above/below median) was assessed using the chi-square test. Possible differences between the quality groups in baseline disease activity (RADAI) were assessed using a t-test for independent samples.

For all of the analyses, a P value less than 0.05 was considered to be statistically significant. All of the data were analyzed using SPSS software, version 12.0 (SPSS).


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  2. Abstract

Reach domain.

The estimation of the number of RA patients treated in the rheumatologic centers was based on registries in 6 centers and a rough appraisal in 5 other centers. In total, the approximate number of RA patients treated in 2005 and/or 2006 in the 11 centers was 9,830. Assuming that 75% of the patients would be eligible for participation in this exercise program (12), with 150 of 7,372 participants, 2.0% of the target population was reached (Table 1).

Table 1. Patient recruitment (Reach domain) and the adoption (Adoption domain) of the program by stakeholders in the 4 regions
  • *

    Seventy-five percent of the estimated total rheumatoid arthritis patients treated.

  • Health insurance companies could not be specified per region because they are working on the national level.

Reach domain     
 Rheumatologic centers, no.235111
 Eligible patients (A), no.*2,0851,7252,7717917,372
 Enrolled patients (B), no.32144460150
  Estimated reach (B/A), %
Adoption domain, no.     
 Addressed physical therapists531114592
 Participating physical therapists529925
 Physical therapy practices324514
 Referring rheumatologists10581235
 Patient organizations addressed11259
 Patient organizations participating11259
 Addressed health insurance companies1010101010
 Funding health insurance companies1010101010

Efficacy domain.

The results of the enrollment of patients and data collection are shown in Figure 1. Over the enrollment period of 24 months, 150 patients started with the program. One hundred twenty-one (81%) of them were women and their mean ± SD age was 51 ± 12 years. Thirty-three patients stopped with the exercise program prematurely before 6 months and did not take part in any further assessments, and 3 patients stopped before 12 months and did not take part in the further assessments. Of the 117 patients available for followup at 6 months, 103 provided clinical data for at least 1 outcome measure at that time point. At 12 months, another 3 patients had stopped with the exercise program between 6 and 12 months. In addition, 33 patients were included in the last year of the 24-month enrollment period, and had not completed the 12-month exercise program at the end of the data collection period. Of the 81 patients who had completed the 12-month program, 62 provided clinical data for at least one outcome measure. The 36 patients who ended the program prematurely did not differ from the 81 patients who completed the 12-month program with respect to age and sex (data not shown).

thumbnail image

Figure 1. Results of 24 months of patient enrollment and data collection in an intensive exercise program for patients with rheumatoid arthritis (RA) in 4 regions in The Netherlands.

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Concerning the efficacy, no significant differences between baseline and 6 months or 12 months were observed for aerobic capacity, HAQ score, and HADS score (Table 2). However, the TST improved significantly between baseline and the followup measurements. The RADAI scores did not significantly change over time, indicating that the intervention did not worsen disease activity.

Table 2. Differences in clinical outcomes between baseline and 6 and 12 months of followup in participants of a 12-month intensive exercise program for patients with rheumatoid arthritis*
 BaselineDifference, 6 monthsDifference, 12 months§
  • *

    Negative differences are an improvement, except for the Åstrand test, where a positive difference is an improvement. 95% CI = 95% confidence interval; HAQ = Health Assessment Questionnaire; HADS = Hospital Anxiety and Depression Scale; RADAI = Rheumatoid Arthritis Disease Activity Index.

  • One hundred fifty patients started the program and 140 patients provided clinical data.

  • One hundred seventeen patients completed 6 months of followup and 97 patients provided clinical data.

  • §

    Eighty-one patients completed 12 months of followup and 62 patients provided clinical data.

  • P < 0.05 (linear mixed model).

Åstrand test, liters of O2/minute   
 Mean (95% CI)2.5 (2.3, 2.6)−0.05 (−0.2, 0.1)0.08 (−0.1, 0.2)
Timed-Stands Test, seconds   
 Mean (95% CI)28.4 (26.3, 30.5)−7.6 (−9.7, −5.5)−10.2 (−12.3, −8.1)
HAQ (range 0–3)   
 Mean (95% CI)0.91 (0.81, 1.00)−0.06 (−0.15, 0.04)−0.06 (−0.18, 0.06)
HADS anxiety scale (range 0–21)   
 Mean (95% CI)6.0 (5.2, 6.7)0.2 (−0.4, 0.9)0.3 (−0.4, 1.0)
HADS depression scale (range 0–21)   
 Mean (95% CI)5.3 (4.6, 6.0)−0.3 (−0.9, 0.3)−0.4 (−1.0, 0.2)
RADAI (range 0–10)   
 Mean (95% CI)3.7 (3.4, 4.1)0.2 (−0.2, 0.6)−0.4 (−0.9, 0.2)

Adoption domain.

Twenty-five (27%) of the 92 physical therapists who were informed about the project fulfilled the inclusion criteria and agreed to become a provider (Table 1). They worked in 14 settings, including 9 private practices, 2 hospitals, 1 rehabilitation center, 1 nursing home, and 1 Physio Sport facility. In 12 of these settings, 14 groups started over the 2-year inclusion period. Two providers could not start a group because of a lack of patients. Of the 51 rheumatologists who were informed about the program, 35 (68%) referred 1 or more patients. All 9 local patient organizations that were informed about the program supported the initiative by actively bringing it to their members' attention. Of 223 patients who made inquiries on the program, 73 (33%) did not start, mostly because of the traveling distance to the practice.

All 10 of the health insurance companies that were approached agreed to fund the RAPIT program; however, only for a limited duration of 12 months. Health insurance companies' main motivation for the limited period of reimbursement was their reluctance to pay for “infinite” interventions, with no definitive proven therapeutic purposes in the longer term. To meet their condition, the intervention was shortened to 12 months and a module on the promotion of regular physical activity was added to the intervention guideline.

Implementation domain.

One indicator of implementation quality is patient attendance; the mean ± SD attendance rate per patient was 55% ± 23%. The results of the quality audits are shown in Table 3. Five of 12 providers who started one or more groups obtained the maximum possible total score of 15 points, 4 providers had a score between 11 and 14 points, and 3 providers had a score of 10 points or less. Overall, the lowest frequency of providers obtaining the maximum score was seen in the intensity domain, with 6 providers reaching the maximum score of 3. Attendance rate and quality of the program were significantly associated, with a higher mean ± SD attendance rate in patients treated in the high-quality practices (61% ± 18%) than in the practices with submaximal quality (51% ± 24%; P = 0.015).

Table 3. Results of quality audits regarding the execution of a 12-month intensive exercise program for patients with rheumatoid arthritis (5 domains, 0–3-point scale) performed in 12 providers' practices*
Practice no.MaterialComponentsContentIntensityRegistrationTotal score
  • *

    Quality score: a higher score means a higher quality.


Maintenance domain.

All of the providers were willing to continue with the program, provided that the health insurance companies maintained the funding and that there would be a sufficient number of participating patients. The provider of the training course confirmed the availability of the training course in the future. On the patient's level, it was observed that the majority of the patients who stopped prematurely did so during the first 6 months (Figure 1). None of the 10 health insurance companies could answer the question “Will you continue to fund the program in the future?” due to the rapid changes in health care funding policy on government and insurance company levels in The Netherlands.

Effects of attendance rate and program quality on program efficacy.

In a subgroup analysis, the impact of implementation (attendance rate and quality of the program) on efficacy was established. It was found that the attendance rate and the quality of the program had a significant impact on the change score of the HAQ, with a significantly greater improvement of the HAQ score seen in patients with a higher attendance rate (0.22 versus −0.09 after 6 months and 0.12 versus −0.08 after 12 months; P = 0.006 over 6 and 12 months) and exercising in a practice where the maximum quality score was reached (0.14 versus −0.02 after 6 months and 0.23 versus −0.10 after 12 months; P = 0.027 over 6 and 12 months). Attendance rate and the quality of the program had no significant impact on any of the other outcome measures, although overall a trend toward a greater improvement in the high-quality group was seen for the TST, the HADS anxiety and depression scales, and the Åstrand Bicycle Test. In the high attendance group, a trend toward more improvement was seen for the TST, the RADAI, and the HADS anxiety scale (data not shown). There were no significant differences in dropout rates or the patients' baseline disease activity scores between practices with high or low quality scores (data not shown).


  1. Top of page
  2. Abstract

This study, although performed on a limited scale, comprehensively describes the public health impact of a dynamic exercise program for patients with RA, considering all of the dimensions of the RE-AIM model.

In the Reach domain, the proportion of all of the RA patients who were eligible for the program and eventually took part was estimated to be 2%. This relatively low rate is comparable with the proportion of approximately 1% that can be extrapolated from the implementation studies of the Arthritis Foundation Aquatic Program (AFAP) and the Patients with Arthritis Can Exercise (PACE) program, developed by the Arthritis Foundation in the US (5). There are a number of possible explanations for the low number of participants that were already identified in previous studies (22, 23). An attendance frequency of 2 times per week is time consuming. Because the program was provided during working hours, patients with a paid job may not have been able to participate. The distance from the patient's home to the physical therapist's practice may also have played a role. Moreover, health insurance companies only funded the program for patients with a supplemental insurance package. In The Netherlands, there is a single statutory basic health care insurance policy for everyone. Statutory basic health care insurance covers the costs of basic medical care. Health care insurers offer supplementary packages to cover the cost of additional health care that may or may not include reimbursement of individual or group exercise therapy. The relatively higher reach in region 1 may be due to the fact that in this region the original RAPIT study was performed, with rheumatologists and patients being more familiar with the program. In our study, 33% of the patients receiving information contacted a provider but eventually did not start. These findings highlight the need for studies on more effective patient recruitment strategies.

With respect to efficacy, it is difficult to draw an overall conclusion from our study. Except for the positive effects on muscle strength, effects on aerobic capacity, functional ability, and psychological functioning as found in the original RCT could not be substantiated. A possible explanation may be insufficient intensity, because in 6 providers the intervention was not appropriately carried out with respect to its intensity. This may have had an impact on improvement in functional capacity. Indeed, it was found that patients exercising in groups with higher quality showed more improvement in HAQ scores. A direct comparison of the outcomes of the present study with the results of the original RCT (1) is, however, difficult. First of all, comparisons are hampered by the difference in duration of the intervention, with the intervention in the present study lasting 12 months, whereas the original RAPIT intervention was 24 months (1). Moreover, different outcome measures were used. For this implementation study, only assessments that could be completed by the patients or the providing physical therapists could be employed. Comparisons with the original RAPIT study are also hampered by the relatively small number of patients from whom data were available at 12 months. Due to the slow inclusion of patients and the tight project schedule, data collection was ended after 24 months, when 33 patients had not yet completed the program. Moreover, 36 patients (24%) had ended the program prematurely, which is slightly higher than the 19% of patients who did not complete the program in the original RAPIT study (24) and the 17% noncompleters reported by Domaille et al (7) in a study on a 6-week exercise and education program in patients with knee osteoarthritis. In addition, 19 patients who finished the program did not provide clinical data.

The adoption of the program can in part be considered a success; a considerable proportion of all of the stakeholders supported the implementation. Sixty-eight percent of the participating rheumatologists did actually refer one or more patients to the program, a sufficient number of providers were recruited to offer the program in the 4 regions, and all of the local patient organizations brought the program to their members' attention. However, with respect to adoption by health insurance companies it should be noted that, although they were all willing to fund the program, reimbursement was limited to 12 months. In the literature, results regarding adoption are scarce. Boutaugh (5) reported a lack of reimbursement in the implementation of the PACE program and the AFAP, indicating low adoption by health insurance companies. In addition, van den Berg et al (9) reported limitations regarding reimbursement of a physical activity program for RA patients.

In the Implementation domain, the intervention quality did not fully meet criteria expectations in 7 of the 12 providers, despite the training course and provided training materials. However, it has to be taken into account that for the assessment of the quality of the provided intervention there were no validated measurement instruments available. Therefore, we used a self-developed instrument that had not been tested on psychometric properties. Moreover, all of the domains had the same weight, although some, in particular the intensity domain, may have been more important than others. Boutaugh (5) also reported on low implementation because of alterations in dose and content, so that the intervention was not provided to the target population as it was intended, compromising its effectiveness. On the other hand, de Jong et al (6) found a comparable outcome of osteoarthritis programs in real life as in the RCTs, and therefore assumed the program was delivered as intended. These observations highlight the need for measurement instruments to evaluate the quality of exercise programs and the development of methods to maintain program quality, for example, by means of periodically scheduled audits and/or refresher courses, when the program is implemented on a wider scale.

Regarding the Maintenance domain, it should be noted that the results regarding continuation of the intervention from the provider's point of view are actually hypothetical because they only reflect the providers' willingness. To investigate the success of the implementation over a long term, periodically scheduled evaluations reflecting all of the domains are needed.

In general, the limited scale implementation of an intensive exercise program for patients with RA as described in this study can be considered moderately successful. The reach of the program was fair; however, this study concerned a first implementation attempt with a limited project duration. On the other hand, adoption and implementation quality of the intervention were relatively good. Both the limited effectiveness and the lack of data to draw conclusions regarding actual maintenance in the future, however, warrant additional research.


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  2. Abstract

All authors were involved in drafting the article or revising it critically for important intellectual content, and all authors approved the final version to be submitted for publication. Mr. van der Giesen had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study conception and design. Van der Giesen, Hopman-Rock, de Jong, Munneke, Hazes, van Riel, Vliet Vlieland.

Acquisition of data. Van der Giesen, van Lankveld, de Jong, van Riel, Peeters, Ronday, Vliet Vlieland.

Analysis and interpretation of data. Van der Giesen, van Lankveld, Hopman-Rock, Munneke, Hazes, Peeters, Ronday, Vliet Vlieland.


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