Isn’t there enough evidence on the benefits of patient navigation?

IF 503.1 1区 医学 Q1 ONCOLOGY CA: A Cancer Journal for Clinicians Pub Date : 2023-06-26 DOI:10.3322/caac.21805
Electra D. Paskett PhD, Tracy Battaglia MD, MPH, Elizabeth A. Calhoun PhD, MEd, Michelle C. Chappell MS, Andrea Dwyer BS, Linda G. Fleisher PhD, MPH, Jennifer Greenwald MPH, Kristen J. Wells PhD, MPH
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Their primary research question focused on evaluating the effectiveness and cost-effectiveness of different cancer navigation models and programs. Multiple databases were searched to find quantitative PN intervention studies with any comparator as well as qualitative, mixed-methods, and systematic reviews. The Joanna Briggs Institute’s JBI Critical Appraisal Checklist for Systematic Review and Research Syntheses was used to examine the risk of bias for each of the systematic reviews. Findings of this umbrella review indicated that the risk of bias of the included systematic reviews seemed low; however, fewer than one half of the included reviews reported the likelihood of publication bias. The review concluded that PN is effective in increasing uptake or adherence to cancer screening, reducing the time from screening abnormality to diagnosis, increasing rates of diagnostic resolution, reducing the time from diagnostic resolution to treatment initiation, increasing treatment completion, increasing treatment adherence, increasing survivorship surveillance appointments for breast or cervical cancer, increasing quality of life, and increasing satisfaction with care. Furthermore, the review pointed to a lack of evidence regarding PN in palliative care and end-of-life phases. The review also concluded that most effectiveness and cost-effectiveness data for PN interventions were collected in the United States; therefore, Chan and colleagues call for additional research to evaluate the effectiveness and cost-effectiveness of PN outside of the United States, in survivorship and palliative care phases of the cancer continuum, for indigenous populations, and for individuals affected by rare cancers, hematologic malignancies, as well as advanced or metastatic cancer.<span><sup>1</sup></span></p><p>Although this review has many important contributions to the literature, there are points that need to be addressed. First, although Chan and colleagues updated the more recent literature, their conclusions do not differ from those of the myriad of other reviews. Now is the time for the implementation of PN in health care because the amount and consistency of evidence is sufficient demonstrating the impact of PN across the cancer continuum. This report solidifies the evidence—when can we all agree that enough evidence is enough and that PN needs to be an integral part of usual clinical care with reimbursement? The next phase of studies should collect and report on the implementation of PN in usual care.</p><p>Second, Chan and colleagues correctly point out the need for a consistent definition of PN. In our view, researchers and practitioners do PN a disservice when they do not use the definition of PN established and vetted by leading organizations like the American Cancer Society (ACS) National Navigation Roundtable (NNRT).<span><sup>4</sup></span> The use of inconsistent PN definitions and lumping together patient navigators with other categories of health care providers are important barriers to acceptance of PN as a billable service.</p><p>Third, on the same theme, including others who provide PN-like services in care and research studies of PN does not strengthen the evidence for PN but, instead, weakens it. Patient navigators have defined competencies, with formal training, certification, and the potential for accreditation: The Academy of Oncology Nurse and Patient Navigators (AONN) certification examinations are led by the AONN+ Foundation for Learning (https://aonnffl.org/); and certifications for Oncology Nurse Navigator–Certified Generalists and Oncology Patient Navigator–Certified Generalists are accredited through the ANSI National Accreditation Board (https://anabpd.ansi.org/). If other individuals who are not trained, certified, or accredited are performing this role, then (1) it weakens evidence of the effectiveness of the patient navigator‘s role in those individuals without adequate training who are performing this role, and (2) it weakens the case for reimbursement for a specific PN job code.</p><p>With the wide-ranging and successful research and evaluation efforts that have been conducted over the last few decades, the evidence supporting the impact of oncology navigation on a range of patient-related outcomes across the cancer continuum is extensive. Now, these efforts must shift to strategies and research focused on implementation, adaptation, scaling up, and sustainability. Implementation is complex and requires attention to the context for adaptation to local and institutional needs, assessing readiness for implementation, and understanding the enablers of implementation, planning for sustainability, and scaling of interventions.<span><sup>5</sup></span> These are dynamic processes that require ongoing evaluation and dissemination of lessons learned. We need to build on emerging efforts, such as the recent Centers for Disease Control and Prevention’s Community Guide recommendations for breast, cervical, and colorectal cancer screening based on a systematic review of the evidence,<span><sup>6</sup></span> the Centers for Medicare &amp; Medicaid Services Enhanced Oncology Model,<span><sup>7</sup></span> and the ACS capacity-building navigation grants and learning community.<span><sup>8</sup></span> Now, the need is to build evidence about successful implementation strategies at multiple levels and within different contexts to reach the goal of ensuring that this evidence-based intervention is integrated into all oncology care.</p><p>Key components to measuring the effectiveness and replicability of evidence-based interventions in PN are standard measures and approaches, such as those outlined in the AONN Standardized Metrics and Certifications.<span><sup>9</sup></span> These metrics provide a common framework for assessing program quality across the domains of patient satisfaction, clinical outcomes, and return on investment. Ongoing investment in assessing the scalability of navigation through the reporting of standard measures must be prioritized by institutions, health systems, and national organizations.</p><p>With the consistent evidence in favor of PN in oncology care further solidified by this comprehensive review of systematic reviews, it is our opinion that now is the time to turn our resources and attention to ensuring the adoption of evidence-based PN practices across our complex, multilayered health care system. Figure 3 in the review by Chan and colleagues clearly summarizes the barriers and facilitators across these multiple levels that must be addressed to support best-practice implementation and crystalizes the complexity of realizing the promise of oncology navigation. In other words, the health system needs to be ready to accept, adopt, and scale evidence-based PN.</p><p>The ACS NNRT was established in 2017 and is a national coalition of 80 member organizations to advance navigation efforts that eliminate barriers to quality care, reduce disparities, and foster ongoing health equity across the cancer continuum. In 2021, the NNRT established a 5-year aim to pursue the development of a sustainable model for oncology PN that would achieve health equity across the continuum of cancer care.<span><sup>10</sup></span> The NNRT has long recognized the importance of patient navigator role definitions, a competent PN workforce, and reimbursement of patient navigators as vital to the sustainability of PN. This new 5-year sustainability aim also recognizes that our complex health care systems and the oncology provider community must embrace a collective approach to successfully integrate navigation evidence into our everyday practice. Reimbursement of navigation services alone, without parallel efforts to eliminate barriers to the adoption of evidence-based practices, will not advance cancer equity. Indeed, it may well perpetuate existing inequities. The sustainability of PN will require collaboration across leaders from every level of the health care system, from policy makers to payors and, most importantly, health system administrators and oncology providers. Together, these stakeholders must hold each other accountable to adopt the unmistakable evidence before us. The time is now, the patient cancer care experience depends upon it.</p><p>Electra D. Paskett reports grants/contracts from Guardant Health, Genentech, the Merck Company Foundation, and Pfizer Canada, Inc., and personal fees from GlaxoSmithKline outside the submitted work. 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引用次数: 0

Abstract

In this issue of CA: A Cancer Journal for Clinicians, Chan and colleagues1 describe an umbrella review of 61 systematic reviews published between 2012 and 2022, along with a review of 53 primary studies published globally since 2021. Patient navigation (PN) has many definitions, and, in this, review PN was defined according to the definition of Wells et al.2 combined with that of Dalton et al.,3 which expanded the definition of PN to also include care coordination. Their primary research question focused on evaluating the effectiveness and cost-effectiveness of different cancer navigation models and programs. Multiple databases were searched to find quantitative PN intervention studies with any comparator as well as qualitative, mixed-methods, and systematic reviews. The Joanna Briggs Institute’s JBI Critical Appraisal Checklist for Systematic Review and Research Syntheses was used to examine the risk of bias for each of the systematic reviews. Findings of this umbrella review indicated that the risk of bias of the included systematic reviews seemed low; however, fewer than one half of the included reviews reported the likelihood of publication bias. The review concluded that PN is effective in increasing uptake or adherence to cancer screening, reducing the time from screening abnormality to diagnosis, increasing rates of diagnostic resolution, reducing the time from diagnostic resolution to treatment initiation, increasing treatment completion, increasing treatment adherence, increasing survivorship surveillance appointments for breast or cervical cancer, increasing quality of life, and increasing satisfaction with care. Furthermore, the review pointed to a lack of evidence regarding PN in palliative care and end-of-life phases. The review also concluded that most effectiveness and cost-effectiveness data for PN interventions were collected in the United States; therefore, Chan and colleagues call for additional research to evaluate the effectiveness and cost-effectiveness of PN outside of the United States, in survivorship and palliative care phases of the cancer continuum, for indigenous populations, and for individuals affected by rare cancers, hematologic malignancies, as well as advanced or metastatic cancer.1

Although this review has many important contributions to the literature, there are points that need to be addressed. First, although Chan and colleagues updated the more recent literature, their conclusions do not differ from those of the myriad of other reviews. Now is the time for the implementation of PN in health care because the amount and consistency of evidence is sufficient demonstrating the impact of PN across the cancer continuum. This report solidifies the evidence—when can we all agree that enough evidence is enough and that PN needs to be an integral part of usual clinical care with reimbursement? The next phase of studies should collect and report on the implementation of PN in usual care.

Second, Chan and colleagues correctly point out the need for a consistent definition of PN. In our view, researchers and practitioners do PN a disservice when they do not use the definition of PN established and vetted by leading organizations like the American Cancer Society (ACS) National Navigation Roundtable (NNRT).4 The use of inconsistent PN definitions and lumping together patient navigators with other categories of health care providers are important barriers to acceptance of PN as a billable service.

Third, on the same theme, including others who provide PN-like services in care and research studies of PN does not strengthen the evidence for PN but, instead, weakens it. Patient navigators have defined competencies, with formal training, certification, and the potential for accreditation: The Academy of Oncology Nurse and Patient Navigators (AONN) certification examinations are led by the AONN+ Foundation for Learning (https://aonnffl.org/); and certifications for Oncology Nurse Navigator–Certified Generalists and Oncology Patient Navigator–Certified Generalists are accredited through the ANSI National Accreditation Board (https://anabpd.ansi.org/). If other individuals who are not trained, certified, or accredited are performing this role, then (1) it weakens evidence of the effectiveness of the patient navigator‘s role in those individuals without adequate training who are performing this role, and (2) it weakens the case for reimbursement for a specific PN job code.

With the wide-ranging and successful research and evaluation efforts that have been conducted over the last few decades, the evidence supporting the impact of oncology navigation on a range of patient-related outcomes across the cancer continuum is extensive. Now, these efforts must shift to strategies and research focused on implementation, adaptation, scaling up, and sustainability. Implementation is complex and requires attention to the context for adaptation to local and institutional needs, assessing readiness for implementation, and understanding the enablers of implementation, planning for sustainability, and scaling of interventions.5 These are dynamic processes that require ongoing evaluation and dissemination of lessons learned. We need to build on emerging efforts, such as the recent Centers for Disease Control and Prevention’s Community Guide recommendations for breast, cervical, and colorectal cancer screening based on a systematic review of the evidence,6 the Centers for Medicare & Medicaid Services Enhanced Oncology Model,7 and the ACS capacity-building navigation grants and learning community.8 Now, the need is to build evidence about successful implementation strategies at multiple levels and within different contexts to reach the goal of ensuring that this evidence-based intervention is integrated into all oncology care.

Key components to measuring the effectiveness and replicability of evidence-based interventions in PN are standard measures and approaches, such as those outlined in the AONN Standardized Metrics and Certifications.9 These metrics provide a common framework for assessing program quality across the domains of patient satisfaction, clinical outcomes, and return on investment. Ongoing investment in assessing the scalability of navigation through the reporting of standard measures must be prioritized by institutions, health systems, and national organizations.

With the consistent evidence in favor of PN in oncology care further solidified by this comprehensive review of systematic reviews, it is our opinion that now is the time to turn our resources and attention to ensuring the adoption of evidence-based PN practices across our complex, multilayered health care system. Figure 3 in the review by Chan and colleagues clearly summarizes the barriers and facilitators across these multiple levels that must be addressed to support best-practice implementation and crystalizes the complexity of realizing the promise of oncology navigation. In other words, the health system needs to be ready to accept, adopt, and scale evidence-based PN.

The ACS NNRT was established in 2017 and is a national coalition of 80 member organizations to advance navigation efforts that eliminate barriers to quality care, reduce disparities, and foster ongoing health equity across the cancer continuum. In 2021, the NNRT established a 5-year aim to pursue the development of a sustainable model for oncology PN that would achieve health equity across the continuum of cancer care.10 The NNRT has long recognized the importance of patient navigator role definitions, a competent PN workforce, and reimbursement of patient navigators as vital to the sustainability of PN. This new 5-year sustainability aim also recognizes that our complex health care systems and the oncology provider community must embrace a collective approach to successfully integrate navigation evidence into our everyday practice. Reimbursement of navigation services alone, without parallel efforts to eliminate barriers to the adoption of evidence-based practices, will not advance cancer equity. Indeed, it may well perpetuate existing inequities. The sustainability of PN will require collaboration across leaders from every level of the health care system, from policy makers to payors and, most importantly, health system administrators and oncology providers. Together, these stakeholders must hold each other accountable to adopt the unmistakable evidence before us. The time is now, the patient cancer care experience depends upon it.

Electra D. Paskett reports grants/contracts from Guardant Health, Genentech, the Merck Company Foundation, and Pfizer Canada, Inc., and personal fees from GlaxoSmithKline outside the submitted work. Tracy Battaglia reports grants/contracts from the American Cancer Society, the Merck Company Foundation, and the National Institutes of Health Clinical Center outside the submitted work. The remaining authors disclosed no conflicts of interest. The authors are the Steering Committee for the National Navigation Roundtable of the American Cancer Society. The views here are those of the authors and not of the National Navigation Roundtable or the American Cancer Society.

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难道没有足够的证据证明患者导航的好处吗?
在这一期的CA:临床医生癌症杂志中,Chan及其同事1描述了2012年至2022年间发表的61项系统综述,以及自2021年以来全球发表的53项主要研究的综述。患者导航(Patient navigation, PN)有很多定义,在本文中,review PN是根据Wells等人2和Dalton等人3的定义来定义的,后者将PN的定义扩展到也包括护理协调。他们的主要研究问题集中在评估不同癌症导航模型和项目的有效性和成本效益上。我们检索了多个数据库,以找到任何比较物的定量PN干预研究,以及定性、混合方法和系统评价。乔安娜布里格斯研究所的JBI系统评价和研究综合关键评估清单用于检查每个系统评价的偏倚风险。该综述的结果表明,纳入的系统评价的偏倚风险似乎很低;然而,不到一半的纳入综述报告了发表偏倚的可能性。该综述的结论是,PN在增加接受或坚持癌症筛查、减少从筛查异常到诊断的时间、增加诊断决定论率、减少从诊断决定论到开始治疗的时间、增加治疗完成率、增加治疗依从性、增加乳腺癌或宫颈癌的生存监测预约、提高生活质量和提高护理满意度方面是有效的。此外,回顾指出缺乏关于姑息治疗和临终阶段PN的证据。该综述还得出结论,大多数PN干预措施的有效性和成本效益数据是在美国收集的;因此,Chan和他的同事呼吁进行更多的研究,以评估在美国以外的地区,在癌症连续体的生存和姑息治疗阶段,对土著人群,受罕见癌症、血液恶性肿瘤以及晚期或转移性癌症影响的个体,PN的有效性和成本效益。虽然这篇综述对文献有许多重要的贡献,但仍有一些需要解决的问题。首先,尽管Chan和他的同事们更新了最近的文献,但他们的结论与无数其他综述的结论并没有什么不同。现在是在卫生保健中实施PN的时候了,因为证据的数量和一致性足以证明PN在整个癌症连续体中的影响。这份报告巩固了证据——我们什么时候才能一致认为足够的证据就足够了,PN需要成为常规临床护理的一个组成部分并得到报销?下一阶段的研究应收集和报告日常护理中PN的实施情况。其次,Chan和他的同事正确地指出了对PN的一致定义的必要性。在我们看来,当研究人员和从业者不使用由美国癌症协会(ACS)国家导航圆桌会议(NNRT)等主要组织建立和审查的PN定义时,他们对PN造成了伤害使用不一致的PN定义和将患者导航员与其他类别的医疗保健提供者混为一谈是接受PN作为收费服务的重要障碍。第三,在同一主题上,包括其他提供PN类服务的护理和研究PN的人并没有加强PN的证据,相反,削弱了它。患者导航员具有明确的能力,经过正式培训,获得认证,并有可能获得认证:肿瘤护士和患者导航员学会(AONN +学习基金会)认证考试由AONN+学习基金会(https://aonnffl.org/)领导;肿瘤护士导航员认证通才和肿瘤患者导航员认证通才通过ANSI国家认证委员会(https://anabpd.ansi.org/)认证。如果其他没有经过培训、认证或认可的个人正在履行这一角色,那么(1)它削弱了那些没有经过充分培训的人在履行这一角色时患者导航员角色有效性的证据,(2)它削弱了特定PN工作代码的报销情况。在过去的几十年里进行了广泛而成功的研究和评估工作,支持肿瘤导航对癌症连续体中一系列患者相关结果的影响的证据是广泛的。现在,这些努力必须转向侧重于实施、适应、扩大规模和可持续性的战略和研究。 实施是复杂的,需要注意适应地方和机构需要的背景,评估实施的准备情况,了解实施的促成因素,规划可持续性,以及干预措施的规模这些是动态的进程,需要不断评价和传播所吸取的经验教训。我们需要在新出现的努力的基础上继续努力,例如最近疾病控制和预防中心在对证据进行系统审查的基础上提出的关于乳腺癌、宫颈癌和结直肠癌筛查的社区指南建议。医疗补助服务增强肿瘤学模式,7和ACS能力建设导航拨款和学习社区现在,需要的是在多个层面和不同背景下建立关于成功实施策略的证据,以达到确保将这种循证干预纳入所有肿瘤治疗的目标。衡量PN中循证干预的有效性和可复制性的关键组成部分是标准措施和方法,如AONN标准化指标和认证中概述的标准措施和方法。9这些指标为评估患者满意度、临床结果和投资回报等领域的项目质量提供了一个通用框架。机构、卫生系统和国家组织必须优先考虑通过报告标准措施来评估导航可扩展性的持续投资。通过对系统综述的全面回顾,支持PN在肿瘤治疗中的一致证据进一步巩固,我们认为现在是时候将我们的资源和注意力转移到确保在我们复杂的、多层次的卫生保健系统中采用基于证据的PN实践。图3清楚地总结了这些多层次的障碍和促进因素,这些障碍和促进因素必须得到解决,以支持最佳实践的实施,并明确了实现肿瘤导航承诺的复杂性。换句话说,卫生系统需要准备好接受、采用和扩大循证PN。ACS NNRT成立于2017年,是一个由80个成员组织组成的全国联盟,旨在推进导航工作,消除优质护理的障碍,减少差异,并促进整个癌症连续体的持续健康公平。2021年,NNRT制定了一项为期5年的目标,旨在追求肿瘤PN可持续模式的发展,从而在整个癌症治疗过程中实现健康公平NNRT长期以来一直认识到患者导航员角色定义的重要性,合格的PN劳动力,以及患者导航员的报销对PN的可持续性至关重要。这个新的5年可持续发展目标也认识到,我们复杂的医疗保健系统和肿瘤提供者社区必须采用集体方法,成功地将导航证据整合到我们的日常实践中。仅仅对导航服务进行报销,而不同时努力消除采用循证实践的障碍,不会促进癌症公平。事实上,它很可能使现有的不平等永久化。PN的可持续性将需要卫生保健系统各个层面的领导者之间的合作,从政策制定者到付款人,最重要的是,卫生系统管理员和肿瘤提供者。这些利益攸关方必须共同承担责任,采纳摆在我们面前的确凿证据。现在是时候了,病人的癌症治疗经验取决于它。Electra D. Paskett报告了Guardant Health、Genentech、默克公司基金会和辉瑞加拿大公司的资助/合同,以及葛兰素史克公司在提交的工作之外的个人费用。Tracy Battaglia报道了美国癌症协会、默克公司基金会和美国国立卫生研究院临床中心在提交工作之外的资助/合同。其余作者没有披露任何利益冲突。作者是美国癌症协会全国导航圆桌会议指导委员会。这里的观点是作者的观点,而不是国家导航圆桌会议或美国癌症协会的观点。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
CiteScore
873.20
自引率
0.10%
发文量
51
审稿时长
1 months
期刊介绍: CA: A Cancer Journal for Clinicians" has been published by the American Cancer Society since 1950, making it one of the oldest peer-reviewed journals in oncology. It maintains the highest impact factor among all ISI-ranked journals. The journal effectively reaches a broad and diverse audience of health professionals, offering a unique platform to disseminate information on cancer prevention, early detection, various treatment modalities, palliative care, advocacy matters, quality-of-life topics, and more. As the premier journal of the American Cancer Society, it publishes mission-driven content that significantly influences patient care.
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