Cost Effectiveness of Cryptococcal Antigen Screening as a Strategy to Prevent HIV-Associated Cryptococcal Meningitis in South Africa
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{"title"=>"Cost Effectiveness of Cryptococcal Antigen Screening as a Strategy to Prevent HIV-Associated Cryptococcal Meningitis in South Africa", "type"=>"journal", "authors"=>[{"first_name"=>"Joseph N.", "last_name"=>"Jarvis", "scopus_author_id"=>"23094370100"}, {"first_name"=>"Thomas S.", "last_name"=>"Harrison", "scopus_author_id"=>"7201365875"}, {"first_name"=>"Stephen D.", "last_name"=>"Lawn", "scopus_author_id"=>"7006905471"}, {"first_name"=>"Graeme", "last_name"=>"Meintjes", "scopus_author_id"=>"13612258700"}, {"first_name"=>"Robin", "last_name"=>"Wood", "scopus_author_id"=>"7404053384"}, {"first_name"=>"Susan", "last_name"=>"Cleary", "scopus_author_id"=>"7006754284"}], "year"=>2013, "source"=>"PLoS ONE", "identifiers"=>{"issn"=>"19326203", "isbn"=>"1932-6203", "pui"=>"369379148", "sgr"=>"84880442531", "doi"=>"10.1371/journal.pone.0069288", "scopus"=>"2-s2.0-84880442531", "pmid"=>"23894442"}, "id"=>"2b8b3f85-bfa8-3df7-9047-be1fe02e3a5b", "abstract"=>"OBJECTIVES: Cryptococcal meningitis (CM)-related mortality may be prevented by screening patients for sub-clinical cryptococcal antigenaemia (CRAG) at antiretroviral-therapy (ART) initiation and pre-emptively treating those testing positive. Prior to programmatic implementation in South Africa we performed a cost-effectiveness analysis of alternative preventive strategies for CM.\\n\\nDESIGN: Cost-effectiveness analysis.\\n\\nMETHODS: Using South African data we modelled the cost-effectiveness of four strategies for patients with CD4 cell-counts <100 cells/µl starting ART 1) no screening or prophylaxis (standard of care), 2) universal primary fluconazole prophylaxis, 3) CRAG screening with fluconazole treatment if antigen-positive, 4) CRAG screening with lumbar puncture if antigen-positive and either amphotericin-B for those with CNS disease or fluconazole for those without. Analysis was limited to the first year of ART.\\n\\nRESULTS: The least costly strategy was CRAG screening followed by high-dose fluconazole treatment of all CRAG-positive individuals. This strategy dominated the standard of care at CRAG prevalence ≥0.6%. Although CRAG screening followed by lumbar puncture in all antigen-positive individuals was the most effective strategy clinically, the incremental benefit of LPs and amphotericin therapy for those with CNS disease was small and additional costs were large (US$158 versus US$51 per person year; incremental cost effectiveness ratio(ICER) US$889,267 per life year gained). Both CRAG screening strategies are less costly and more clinically effective than current practice. Primary prophylaxis is more effective than current practice, but relatively cost-ineffective (ICER US$20,495).\\n\\nCONCLUSIONS: CRAG screening would be a cost-effective strategy to prevent CM-related mortality among patients initiating ART in South Africa. These findings provide further justification for programmatic implementation of CRAG screening.", "link"=>"http://www.mendeley.com/research/cost-effectiveness-cryptococcal-antigen-screening-strategy-prevent-hivassociated-cryptococcal-mening-6", "reader_count"=>64, "reader_count_by_academic_status"=>{"Unspecified"=>4, "Professor > Associate Professor"=>3, "Researcher"=>7, "Student > Doctoral Student"=>2, "Student > Ph. D. Student"=>10, "Student > Postgraduate"=>11, "Student > Master"=>16, "Other"=>5, "Student > Bachelor"=>4, "Lecturer"=>1, "Professor"=>1}, "reader_count_by_user_role"=>{"Unspecified"=>4, "Professor > Associate Professor"=>3, "Researcher"=>7, "Student > Doctoral Student"=>2, "Student > Ph. D. Student"=>10, "Student > Postgraduate"=>11, "Student > Master"=>16, "Other"=>5, "Student > Bachelor"=>4, "Lecturer"=>1, "Professor"=>1}, "reader_count_by_subject_area"=>{"Unspecified"=>10, "Biochemistry, Genetics and Molecular Biology"=>1, "Nursing and Health Professions"=>1, "Medicine and Dentistry"=>29, "Agricultural and Biological Sciences"=>8, "Business, Management and Accounting"=>1, "Social Sciences"=>4, "Computer Science"=>1, "Decision Sciences"=>1, "Immunology and Microbiology"=>4, "Economics, Econometrics and Finance"=>4}, "reader_count_by_subdiscipline"=>{"Medicine and Dentistry"=>{"Medicine and Dentistry"=>29}, "Social Sciences"=>{"Social Sciences"=>4}, "Decision Sciences"=>{"Decision Sciences"=>1}, "Immunology and Microbiology"=>{"Immunology and Microbiology"=>4}, "Economics, Econometrics and Finance"=>{"Economics, Econometrics and Finance"=>4}, "Agricultural and Biological Sciences"=>{"Agricultural and Biological Sciences"=>8}, "Computer Science"=>{"Computer Science"=>1}, "Nursing and Health Professions"=>{"Nursing and Health Professions"=>1}, "Business, Management and Accounting"=>{"Business, Management and Accounting"=>1}, "Biochemistry, Genetics and Molecular Biology"=>{"Biochemistry, Genetics and Molecular Biology"=>1}, "Unspecified"=>{"Unspecified"=>10}}, "reader_count_by_country"=>{"South Africa"=>2, "Kenya"=>1, "France"=>1}, "group_count"=>5}

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Figshare

  • {"files"=>["https://ndownloader.figshare.com/files/1123880"], "description"=>"*<p>Medication costs were from government tender prices, test costs were from the National Health Laboratory Services, and lumbar puncture costs were based on the Uniform Patient Fee Schedule. The overhead and staff cost per inpatient day at the secondary level and the overhead and staff cost per outpatient department visit was taken from Cleary et al <a href=\"http://www.plosone.org/article/info:doi/10.1371/journal.pone.0069288#pone.0069288-Cleary1\" target=\"_blank\">[48]</a>. The overhead components of these costs were inflated using the Consumer Price Index, while clinical staff costs were recalculated using 2010 government salary scales. Costs were expressed in 2010 prices, and were converted to United States Dollars (US$) based on the average exchange rate between 1 January and 31 December 2010 (US$1 = ZAR7.34; <a href=\"http://www.oanda.com\" target=\"_blank\">www.oanda.com</a>).</p>", "links"=>[], "tags"=>["Global health", "Infectious diseases", "Fungal diseases", "cryptococcosis", "neurology", "Infectious diseases of the nervous system", "Cryptococcal meningitis", "Non-clinical medicine", "Health care policy", "Screening guidelines", "Public health", "Health screening", "Economics", "Health economics", "Cost-effectiveness analysis"], "article_id"=>749356, "categories"=>["Medicine", "Sociology"], "users"=>["Joseph N. Jarvis", "Thomas S. Harrison", "Stephen D. Lawn", "Graeme Meintjes", "Robin Wood", "Susan Cleary"], "doi"=>"https://dx.doi.org/10.1371/journal.pone.0069288.t002", "stats"=>{"downloads"=>1, "page_views"=>8, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Costs_/749356", "title"=>"Costs.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2013-07-19 02:35:28"}
  • {"files"=>["https://ndownloader.figshare.com/files/1123877"], "description"=>"<p>The results of one-way sensitivity analysis varying the background cryptococcal antigen prevalence in patients entering ART programmes with CD4 cell counts <100 cells/µL. The cost of current standard of care (no prevention, or status quo) is shown by the dotted line, and the cost of the CRAG screening with targeted treatment of CRAG positive individuals with high dose fluconazole (no LPs) is shown by the solid line. The screen and treat strategy dominated the standard of care at antigen prevalences of 0.6% and higher. The shaded area represents the range of baseline CRAG prevalence figures reported in patients with CD4 counts <100 cell/µL at ART programme entry. Costs are expressed as mean cost per patient/year in the ART programme.</p>", "links"=>[], "tags"=>["Global health", "Infectious diseases", "Fungal diseases", "cryptococcosis", "neurology", "Infectious diseases of the nervous system", "Cryptococcal meningitis", "Non-clinical medicine", "Health care policy", "Screening guidelines", "Public health", "Health screening", "Economics", "Health economics", "Cost-effectiveness analysis", "antigen"], "article_id"=>749353, "categories"=>["Medicine", "Sociology"], "users"=>["Joseph N. Jarvis", "Thomas S. Harrison", "Stephen D. Lawn", "Graeme Meintjes", "Robin Wood", "Susan Cleary"], "doi"=>"https://dx.doi.org/10.1371/journal.pone.0069288.g003", "stats"=>{"downloads"=>1, "page_views"=>5, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Sensitivity_analysis_by_background_antigen_prevalence_/749353", "title"=>"Sensitivity analysis by background antigen prevalence.", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2013-07-19 02:35:28"}
  • {"files"=>["https://ndownloader.figshare.com/files/1123875"], "description"=>"<p>Transition probabilities are listed as C1, C2, S1 etc. Variable names, descriptions and values are derived from <a href=\"http://www.plosone.org/article/info:doi/10.1371/journal.pone.0069288#pone-0069288-t001\" target=\"_blank\">table 1</a>, as follows: <b><i>S1</i></b> - Proportion with subclinical CM at baseline, CD4<50 cells/µL = 0.13, CD4 50–100 cells/µL = 0.03. <b><i>S2</i></b> - Of those with subclinical CM, Proportion with CSF infection = 0.5. <b><i>P1</i></b> - Proportion starting ART with CD4<50 cells/µl = 0.5. <b><i>C1</i></b> - Probability of developing CM, by baseline CD4 category and time on ART: <i>CD4<50 cells/µl = </i>252 per 1000 patient years (pyo) up to 3 months on ART, 72 per 1000 pyo 4–6 months on ART, 36 per 1000 pyo 7–9 months on ART, 0 per 1000 pyo 10–12 months. <i>CD4 50–100 cells/µl</i> = 56 per 1000 pyo up to 3 months on ART, 16 per 1000 pyo 4–6 months on ART, 8 per 1000 pyo 7–9 months on ART, 0 per 1000 pyo 10–12 months. <b><i>R1</i></b> - Relative risk of CM with low dose fluconazole prophylaxis = 0.21. <b><i>R2</i></b> - Relative risk of CM for CRAG positive taking high dose fluconazole prophylaxis = 0.1. <b><i>R3</i></b> - Relative risk of CM for CRAG positive with amphotericin for CSF positive patients, fluconazole for CSF negative patients = 0. <b><i>D1</i></b> - Probability of dying of acute CM = 45% dead at 1 month with CM. <b><i>D2</i></b> - Probability of dying of CM within 1 year = 55% dead at 12 months on ART.</p>", "links"=>[], "tags"=>["Global health", "Infectious diseases", "Fungal diseases", "cryptococcosis", "neurology", "Infectious diseases of the nervous system", "Cryptococcal meningitis", "Non-clinical medicine", "Health care policy", "Screening guidelines", "Public health", "Health screening", "Economics", "Health economics", "Cost-effectiveness analysis", "markov"], "article_id"=>749351, "categories"=>["Medicine", "Sociology"], "users"=>["Joseph N. Jarvis", "Thomas S. Harrison", "Stephen D. Lawn", "Graeme Meintjes", "Robin Wood", "Susan Cleary"], "doi"=>"https://dx.doi.org/10.1371/journal.pone.0069288.g001", "stats"=>{"downloads"=>1, "page_views"=>11, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Simplified_markov_model_structure_/749351", "title"=>"Simplified markov model structure.", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2013-07-19 02:35:28"}
  • {"files"=>["https://ndownloader.figshare.com/files/1123876"], "description"=>"<p>The cost of each of the four strategies divided into screening costs, preventive treatment (or “prevention”) costs and treatment costs. Screening costs (black shading) include all costs associated with CRAG screening including the CRAG assay. Prevention costs (grey shading) include all costs associated with prevention including universal fluconazole in the primary prophylaxis strategy; and fluconazole pre-emptive treatment for CRAG positive patients, LPs, clinic visits and in-patient amphotericin for screened patients with CNS involvement in the screen and treat strategies. Treatment costs (cross-hatched shading) include all costs associated with treatment of CM in patients who develop clinical CM. Costs are as outlined in <a href=\"http://www.plosone.org/article/info:doi/10.1371/journal.pone.0069288#pone-0069288-t002\" target=\"_blank\">table 2</a>, and expressed as mean cost per patient/year in the ART programme.</p>", "links"=>[], "tags"=>["Global health", "Infectious diseases", "Fungal diseases", "cryptococcosis", "neurology", "Infectious diseases of the nervous system", "Cryptococcal meningitis", "Non-clinical medicine", "Health care policy", "Screening guidelines", "Public health", "Health screening", "Economics", "Health economics", "Cost-effectiveness analysis"], "article_id"=>749352, "categories"=>["Medicine", "Sociology"], "users"=>["Joseph N. Jarvis", "Thomas S. Harrison", "Stephen D. Lawn", "Graeme Meintjes", "Robin Wood", "Susan Cleary"], "doi"=>"https://dx.doi.org/10.1371/journal.pone.0069288.g002", "stats"=>{"downloads"=>1, "page_views"=>2, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Cost_Breakdown_/749352", "title"=>"Cost Breakdown.", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2013-07-19 02:35:28"}
  • {"files"=>["https://ndownloader.figshare.com/files/1123882"], "description"=>"<div><p>Objectives</p><p>Cryptococcal meningitis (CM)-related mortality may be prevented by screening patients for sub-clinical cryptococcal antigenaemia (CRAG) at antiretroviral-therapy (ART) initiation and pre-emptively treating those testing positive. Prior to programmatic implementation in South Africa we performed a cost-effectiveness analysis of alternative preventive strategies for CM.</p><p>Design</p><p>Cost-effectiveness analysis.</p><p>Methods</p><p>Using South African data we modelled the cost-effectiveness of four strategies for patients with CD4 cell-counts <100 cells/µl starting ART 1) no screening or prophylaxis (standard of care), 2) universal primary fluconazole prophylaxis, 3) CRAG screening with fluconazole treatment if antigen-positive, 4) CRAG screening with lumbar puncture if antigen-positive and either amphotericin-B for those with CNS disease or fluconazole for those without. Analysis was limited to the first year of ART.</p><p>Results</p><p>The least costly strategy was CRAG screening followed by high-dose fluconazole treatment of all CRAG-positive individuals. This strategy dominated the standard of care at CRAG prevalence ≥0.6%. Although CRAG screening followed by lumbar puncture in all antigen-positive individuals was the most effective strategy clinically, the incremental benefit of LPs and amphotericin therapy for those with CNS disease was small and additional costs were large (US$158 versus US$51per person year; incremental cost effectiveness ratio(ICER) US$889,267 per life year gained). Both CRAG screening strategies are less costly and more clinically effective than current practice. Primary prophylaxis is more effective than current practice, but relatively cost-ineffective (ICER US$20,495).</p><p>Conclusions</p><p>CRAG screening would be a cost-effective strategy to prevent CM-related mortality among patients initiating ART in South Africa. These findings provide further justification for programmatic implementation of CRAG screening.</p></div>", "links"=>[], "tags"=>["Global health", "Infectious diseases", "Fungal diseases", "cryptococcosis", "neurology", "Infectious diseases of the nervous system", "Cryptococcal meningitis", "Non-clinical medicine", "Health care policy", "Screening guidelines", "Public health", "Health screening", "Economics", "Health economics", "Cost-effectiveness analysis", "cryptococcal", "antigen", "hiv-associated", "meningitis"], "article_id"=>749358, "categories"=>["Medicine", "Sociology"], "users"=>["Joseph N. Jarvis", "Thomas S. Harrison", "Stephen D. Lawn", "Graeme Meintjes", "Robin Wood", "Susan Cleary"], "doi"=>"https://dx.doi.org/10.1371/journal.pone.0069288", "stats"=>{"downloads"=>1, "page_views"=>12, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Cost_Effectiveness_of_Cryptococcal_Antigen_Screening_as_a_Strategy_to_Prevent_HIV_Associated_Cryptococcal_Meningitis_in_South_Africa_/749358", "title"=>"Cost Effectiveness of Cryptococcal Antigen Screening as a Strategy to Prevent HIV-Associated Cryptococcal Meningitis in South Africa", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2013-07-19 02:35:28"}
  • {"files"=>["https://ndownloader.figshare.com/files/1123879"], "description"=>"<p>Mean cost = Mean per-patient cost for prevention and/or treatment of CM, US$, during first year of ART.</p><p>Life years = Mean life expectancy one year after ART programme entry.</p><p>ICER = ratio of difference in cost to difference in outcome.</p>*<p>Uncertainty interval.</p>†<p>Higher cost than more effective option(s).</p>", "links"=>[], "tags"=>["Global health", "Infectious diseases", "Fungal diseases", "cryptococcosis", "neurology", "Infectious diseases of the nervous system", "Cryptococcal meningitis", "Non-clinical medicine", "Health care policy", "Screening guidelines", "Public health", "Health screening", "Economics", "Health economics", "Cost-effectiveness analysis"], "article_id"=>749355, "categories"=>["Medicine", "Sociology"], "users"=>["Joseph N. Jarvis", "Thomas S. Harrison", "Stephen D. Lawn", "Graeme Meintjes", "Robin Wood", "Susan Cleary"], "doi"=>"https://dx.doi.org/10.1371/journal.pone.0069288.t003", "stats"=>{"downloads"=>1, "page_views"=>6, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Cost_effectiveness_/749355", "title"=>"Cost-effectiveness.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2013-07-19 02:35:28"}
  • {"files"=>["https://ndownloader.figshare.com/files/1123878"], "description"=>"*<p>The incidence of CM varied according to CD4 count strata, and time on ART to account for CD4 cell count increases and the acompanying reduction in risk of developing CM. The time stratification was into 3 month blocks according to time from ART initiation, and the data used to derive these probabilities was from a large South African cohort <a href=\"http://www.plosone.org/article/info:doi/10.1371/journal.pone.0069288#pone.0069288-Jarvis5\" target=\"_blank\">[45]</a>.</p>", "links"=>[], "tags"=>["Global health", "Infectious diseases", "Fungal diseases", "cryptococcosis", "neurology", "Infectious diseases of the nervous system", "Cryptococcal meningitis", "Non-clinical medicine", "Health care policy", "Screening guidelines", "Public health", "Health screening", "Economics", "Health economics", "Cost-effectiveness analysis", "assumptions"], "article_id"=>749354, "categories"=>["Medicine", "Sociology"], "users"=>["Joseph N. Jarvis", "Thomas S. Harrison", "Stephen D. Lawn", "Graeme Meintjes", "Robin Wood", "Susan Cleary"], "doi"=>"https://dx.doi.org/10.1371/journal.pone.0069288.t001", "stats"=>{"downloads"=>1, "page_views"=>2, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Baseline_input_assumptions_and_transition_probabilities_/749354", "title"=>"Baseline input assumptions and transition probabilities.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2013-07-19 02:35:28"}

PMC Usage Stats | Further Information

  • {"unique-ip"=>"1", "full-text"=>"0", "pdf"=>"0", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"1", "cited-by"=>"0", "year"=>"2013", "month"=>"7"}
  • {"unique-ip"=>"34", "full-text"=>"32", "pdf"=>"17", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"4", "supp-data"=>"1", "cited-by"=>"0", "year"=>"2013", "month"=>"8"}
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  • {"unique-ip"=>"14", "full-text"=>"17", "pdf"=>"9", "abstract"=>"1", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2013", "month"=>"10"}
  • {"unique-ip"=>"27", "full-text"=>"25", "pdf"=>"14", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"2", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2013", "month"=>"11"}
  • {"unique-ip"=>"12", "full-text"=>"11", "pdf"=>"3", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2013", "month"=>"12"}
  • {"unique-ip"=>"13", "full-text"=>"14", "pdf"=>"5", "abstract"=>"1", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2014", "month"=>"1"}
  • {"unique-ip"=>"12", "full-text"=>"15", "pdf"=>"4", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2014", "month"=>"2"}
  • {"unique-ip"=>"21", "full-text"=>"24", "pdf"=>"19", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"1", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2014", "month"=>"3"}
  • {"unique-ip"=>"11", "full-text"=>"9", "pdf"=>"4", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"2", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2014", "month"=>"5"}
  • {"unique-ip"=>"18", "full-text"=>"16", "pdf"=>"12", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"2", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2014", "month"=>"6"}
  • {"unique-ip"=>"20", "full-text"=>"23", "pdf"=>"16", "abstract"=>"1", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"1", "supp-data"=>"3", "cited-by"=>"0", "year"=>"2014", "month"=>"4"}
  • {"unique-ip"=>"10", "full-text"=>"8", "pdf"=>"6", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2015", "month"=>"4"}
  • {"unique-ip"=>"14", "full-text"=>"12", "pdf"=>"9", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"3", "supp-data"=>"1", "cited-by"=>"0", "year"=>"2015", "month"=>"5"}
  • {"unique-ip"=>"4", "full-text"=>"4", "pdf"=>"4", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2015", "month"=>"6"}
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  • {"unique-ip"=>"21", "full-text"=>"24", "pdf"=>"14", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"5", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2015", "month"=>"3"}
  • {"unique-ip"=>"23", "full-text"=>"24", "pdf"=>"17", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2015", "month"=>"2"}
  • {"unique-ip"=>"16", "full-text"=>"15", "pdf"=>"9", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"2", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2015", "month"=>"8"}
  • {"unique-ip"=>"19", "full-text"=>"15", "pdf"=>"3", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"3", "supp-data"=>"0", "cited-by"=>"1", "year"=>"2015", "month"=>"9"}
  • {"unique-ip"=>"13", "full-text"=>"14", "pdf"=>"5", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2015", "month"=>"10"}
  • {"unique-ip"=>"22", "full-text"=>"20", "pdf"=>"12", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"1", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2014", "month"=>"7"}
  • {"unique-ip"=>"19", "full-text"=>"18", "pdf"=>"21", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"2", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2014", "month"=>"8"}
  • {"unique-ip"=>"19", "full-text"=>"19", "pdf"=>"12", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"1", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2014", "month"=>"9"}
  • {"unique-ip"=>"15", "full-text"=>"13", "pdf"=>"9", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"2", "supp-data"=>"2", "cited-by"=>"0", "year"=>"2014", "month"=>"10"}
  • {"unique-ip"=>"14", "full-text"=>"16", "pdf"=>"10", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2016", "month"=>"2"}
  • {"unique-ip"=>"23", "full-text"=>"24", "pdf"=>"9", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"1", "supp-data"=>"2", "cited-by"=>"1", "year"=>"2014", "month"=>"11"}
  • {"unique-ip"=>"6", "full-text"=>"5", "pdf"=>"3", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"1", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2014", "month"=>"12"}
  • {"unique-ip"=>"15", "full-text"=>"14", "pdf"=>"7", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"2", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2015", "month"=>"1"}
  • {"unique-ip"=>"23", "full-text"=>"19", "pdf"=>"10", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"2", "supp-data"=>"0", "cited-by"=>"2", "year"=>"2015", "month"=>"11"}
  • {"unique-ip"=>"11", "full-text"=>"11", "pdf"=>"2", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"1", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2015", "month"=>"12"}
  • {"unique-ip"=>"24", "full-text"=>"28", "pdf"=>"14", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"3", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2016", "month"=>"1"}
  • {"unique-ip"=>"11", "full-text"=>"12", "pdf"=>"8", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2016", "month"=>"3"}
  • {"unique-ip"=>"7", "full-text"=>"12", "pdf"=>"3", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2016", "month"=>"4"}
  • {"unique-ip"=>"12", "full-text"=>"8", "pdf"=>"7", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"4", "supp-data"=>"1", "cited-by"=>"0", "year"=>"2016", "month"=>"5"}
  • {"unique-ip"=>"8", "full-text"=>"6", "pdf"=>"5", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"1", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2016", "month"=>"6"}
  • {"unique-ip"=>"9", "full-text"=>"8", "pdf"=>"3", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"1", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2016", "month"=>"7"}
  • {"unique-ip"=>"6", "full-text"=>"4", "pdf"=>"4", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"3", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2016", "month"=>"8"}
  • {"unique-ip"=>"10", "full-text"=>"12", "pdf"=>"5", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"1", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2016", "month"=>"9"}
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Relative Metric

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