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Development of generic core competences of health professionals in rheumatology: a systematic literature review informing the 2019 EULAR recommendations
  1. George E Fragoulis1,
  2. Lisa Edelaar2,3,
  3. Theodora P M Vliet Vlieland2,
  4. Annamaria Iagnocco4,
  5. Valentin Sebastian Schäfer5,
  6. Catherine Haines6,7,
  7. Jan Schoones8 and
  8. Elena Nikiphorou9,10
  9. on behalf of the EULAR Task Force
    1. 1Institute of Infection, Immunity and Inflammation, University of Glasgow School of Medicine, Glasgow, UK
    2. 2Department of Orthopaedics, Rehabilitation and Physical Therapy, J11, Leiden University Medical Center, Leiden, The Netherlands
    3. 3Amsterdam Rehabilitation Research Center, Reade, Amsterdam, The Netherlands
    4. 4Scienze Cliniche e Biologiche, Università degli Studi di Torino, Rome, Italy
    5. 5Medical Clinic III, Department of Oncology, Hematology and Rheumatology, University Hospital Bonn, Bonn, Germany
    6. 6EULAR, Zurich, Switzerland
    7. 7Department of Clinical Education, King's College London, London, UK
    8. 8Walaeus Library, Leiden University Medical Center, Leiden, The Netherlands
    9. 9Rheumatology Research, Academic Department of Rheumatology, King's College London, London, UK
    10. 10Applied Health Research, University College London, London, UK
    1. Correspondence to Dr Elena Nikiphorou; enikiphorou{at}


    Objective To identify generic competences on the desired knowledge, skills and of health professionals in rheumatology (HPRs) to inform the respective EULAR recommendations.

    Methods A systematic literature review was performed on the generic core competences (defined as knowledge, skills or attitudes) of HPRs (nurses, physical therapists (PTs) or occupational therapists (OTs)). Literature was obtained from electronic databases, published EULAR recommendations and via personal communication with representatives of national rheumatology societies and experts in the field. Qualitative, quantitative and mixed methods studies were included, and their methodological quality was scored using appropriate instruments.

    Results From 766 references reviewed, 79 fulfilled the inclusion criteria. Twenty studies addressed competences of multiple HPRs: 15 were of qualitative design, 1 quantitative, 1 mixed-methods, 2 systematic reviews and 1 opinion paper. The methodological quality of most studies was medium to high. Five studies concerned the development of a comprehensive set of competences. Key competences included: basic knowledge of rheumatic diseases, holistic approach to patient management, effective communication with colleagues and patients and provision of education to patients. The proposed competences were confirmed in studies focusing on one or more specific competences, on a rheumatic disease or on a specific profession (nurses, PTs or OTs).

    Conclusion Generic competences were identified for HPRs. Data were mostly derived from qualitative studies. All identified studies varied and were at national level, highlighting the need for the harmonisation of HPR competences across Europe. These findings underpin the development of EULAR recommendations for the core competences of HPRs.

    • physcial therapy
    • occupational therapy
    • nursing

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    Key messages

    What is already known about this subject?

    • Health professionals in rheumatology (HPRs) play an important role in the care for people with rheumatic and musculoskeletal diseases, and continuous education is necessary to assure the delivery of high-quality care.

    • A set of generic core competences for HPRs across Europe is currently lacking.

    What does this study add?

    • This review demonstrates that there is varying, yet adequate evidence, mainly from qualitative studies, regarding the generic knowledge, skills and attitudes of HPRs.

    • Key competences identified in multiple sets of competences included: having basic knowledge and understanding of rheumatic diseases and adopting a holistic approach to patient management based on a biopsychosocial model.

    • Evidence is mainly from northern European countries, so that generalisability to other European countries may be limited.

    How might this impact on clinical practice?

    • The results of this systematic literature review reinforce the message that achieving certain standards in terms of the core competences of HPRs is crucial for the optimal care of people with rheumatic diseases.

    • This systematic review has formed the basis of EULAR recommendations for the core competences of HPRs.

    • A set of core competences for HPRs may form the basis for a postgraduate curriculum at European as well as national level.


    Health professionals play an important role in the care for people with rheumatic and musculoskeletal diseases (RMDs). This is through input and support on optimisation of disease outcomes1 and often through being the key players and coordinators of the multidisciplinary team that cares for this patient group.2–5 To assure the delivery of high-quality care, continuous education of health professionals in rheumatology (HPRs) is needed. The development of educational offerings serving this purpose should ideally be based on clearly described core competences for HPRs involved in the management of diseases of people with RMDs. This formed the rationale for the constitution of a task force to develop EULAR recommendations for the generic core competences of HPRs, informed by a systematic review of literature as well as expert opinion.

    Currently, a number of defined sets of competences for HPRs have been described in the literature, both for HPRs of multiple professions and for a HPRs with a specific background such as nurses,6 7 yet a comprehensive overview of competencies of HPRs reported in the literature is missing. The aim of this systematic review is to identify the desirable generic competences of HPRs with a particular focus on nurses, occupational therapists (OTs) and physical therapists (PTs). Ultimately, the goal is to inform the EULAR recommendations for the generic core competences of HPRs.8


    The results of this systematic literature review (SLR) underpinning the EULAR recommendations for the generic core competences of HPRs were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines by the Cochrane group.9 Thirteen main themes translated into research questions (online supplementary material 1) were formulated by consensus during the first EULAR Task Force meeting. These core questions formed the basis for the subsequent systematic search of literature and informed inclusion and exclusion criteria.

    Literature search

    Literature was obtained from a systematic search using three main sources: (1) electronic medical or health-related databases; (2) literature suggested after personal communication with representatives of national HPR societies, profession-specific organisations and experts in the field of HPRs and their education; and (3) EULAR recommendations or guidelines that specifically address or are relevant to HPRs. An additional search in Google Scholar and electronic educational databases was also performed.

    Electronic databases

    A search strategy was defined in collaboration with a trained librarian (JS). The research questions formed the basis for a broad search strategy encompassing various search terms for competences; major RMDs and HPRs; multiple professions of HPRs or nurses, PTs or OTs specifically (online supplementary material 2). Additional key words were used in accordance with the specific research questions.

    The following databases were searched with a specific time frame from 1 January 1990 to 20 February 2018: PubMed/Medline, Embase, Cochrane library, CENTRAL, Emcare, PsycINFO, Academic Search Premier and Web of Science.

    Key publications used to pilot-test the validity of the first output of the search strategy included Erwin et al,10 selected as an example of a study addressing comprehensive sets of competences for HPRs of multiple professions and Zangi et al11 as an example of EULAR recommendations addressing a specific competence (eg, patient education) for HPRs of multiple professions. After the completion of the above-mentioned search, a similar search strategy was also followed for Google Scholar and educational databases, namely ERIC and National Science Digital Library. This aimed to check the findings of the initial search.

    Representatives of EULAR member national HPR organisations, profession-specific organisations and experts

    The national presidents of the 25 EULAR HPR member associations, liaison persons of non-member national HPR organisations, EULAR HPR study group leaders and the HPR vice president, the standing committee chair and chair-elect were invited to complete a short questionnaire (online supplementary material 3) about their familiarity with sets of competences for HPRs, suggesting relevant literature, if any. Thirty-five national presidents and liaison persons and six members of the EULAR HPR study groups were invited to provide input. Results from questionnaires and personal contacts were gathered until 15 April 2018.

    EULAR recommendations or guidelines

    Published EULAR recommendations or points to consider for the management of osteoarthritis, rheumatoid arthritis, spondyloarthritis or interventions delivered by HPRs in general or nurses, PTs or OTs specifically were screened for relevant information on HPR competences.7 11–14

    Study selection

    For this SLR, competences were defined as a ‘A set of knowledge, skills and attitudes that concern the consistent and appropriate use of communication, knowledge, skills, clinical reasoning, emotions, values and reflection on practice, for the benefit of people with RMDs and the community’. In line with this definition, studies were included if they concerned: competences or roles, knowledge, attitudes, skills or educational needs relevant for the management of people with RMDs, of HPRs in general, or specifically of nurses, PTs or OTs, at a postgraduate level. Studies were excluded if they concerned: HPRs’ competences regarding patients with RMDs ≤18 years old; conditions other than RMDs including comorbidities concurring in people with RMDs (eg, hip fracture in patients with arthritis); extended roles of HPRs; a very specific clinical intervention either or not in connection with a clinical trial or an intervention clearly attributable to only one profession (eg, provision of supervised exercise therapy) or related to an extended role; the competences of professionals other than HPRs, including those of physicians; the competences concerned HPRs at undergraduate level; and if the study was in a language other than English or Dutch or published before 1990. In addition, papers describing RMDs and their treatment or concerned merely personal beliefs and views of patients or HPRs were excluded. The reviewers (LE, TPMVV, GEF and VSS) screened independently all titles and abstracts to identify potentially eligible studies that were then reviewed in full text. Any disagreements were discussed between the authors and consensus reached. Full-text papers fulfilling the inclusion criteria were then proceeded to data extraction. For all excluded records and full-text papers, the reason(s) for exclusion were recorded. The reasons for exclusion were not recorded for the records obtained through the educational database search, as more than 99% of the records did not meet the inclusion criteria.

    Data extraction

    Data extraction was performed systematically and independently by two of the reviewers (LE and TPMVV). The following data were extracted from the studies: first author, year of publication, country where the study was performed and professions of HPRs addressed (nurses, PTs, OTs or combinations). Every piece of information related to HPR competences was noted, extracted and then assigned to one or more of the predefined research questions, according to the target group(s).

    Comprehensive sets of competences or single competences that HPRs of multiple professions (including nurses and/or PTs and/or OTs) have in common were considered as the most appropriate evidence to answer the research questions. Documents comprising the same elements but addressing only one profession (nurse, PT or OT) were used to validate the results from the documents addressing multiple professions. Competences of a specific profession were only extracted if they were potentially generalisable to other professions, for example, basic knowledge about RMDS or the provision of patient education and self-management support were considered to be generic competences, whereas the administration of intramuscular injections (nurses) or the provision of supervised exercise therapy (physical therapists) was not. After the extraction was completed, a third person (GEF) independently extracted 10% of the data. The latter was achieved as follows: a number was assigned in the selected full documents placed in alphabetical order (based on first author’s name). Subsequently, an online random digit generator ( was used to select a number equalling 10% (n=8) of the total number of selected documents from the list. Results of data extraction, in terms of the research questions that were addressed by each study, were compared between the first two reviewers and the third reviewer. Any discrepancies were openly discussed with coauthors, and consensus was reached.

    Methodological quality appraisal of the included studies

    Studies retrieved from the SLR were categorised as qualitative, quantitative or mixed-methods in terms of their design. The methodological quality of studies addressing multiple professions of HPRs was rated using appropriate tools, depending on the type of study. In detail, the methodological quality of qualitative studies was assessed using a modified version of the 12 criteria reported by Harden et al15,15 performed by a task force member (GEF) or the fellow (LE) and the methodologist (EN). Each item was scored as not present (0) or present (1). The sum of the 12 item scores constituted the final methodological quality score, presented as low, medium or high quality (online supplementary material 4). For reviews, A MeaSurement Tool to Assess systematic Reviews (AMSTAR criteria) was used with the score being defined as critically low, low, moderate and high quality.16 For quantitative studies or for studies using mixed methods, methodological quality was evaluated using the Mixed Methods Appraisal Tool (MMAT) score, with the final score expressed as a percentage [(number of ‘presence’ responses divided by the number of ‘relevant criteria’) × 100].17 Opinion papers were not scored. Any differences in rating between the assessors were openly discussed with coauthors, and consensus was reached.


    The initial literature in the medical or health-related electronic databases search yielded 1115 references (428 unique). In addition, 22 records were suggested by representatives of national HPR organisations or experts or concerned relevant EULAR recommendations. No records were obtained from profession-specific organisations. The additional search in the educational databases and Google Scholar yielded 191 and 150 references, respectively (319 unique). Figure 1 describes the selection processes. Main reasons for exclusion were that the competences did not concern adult patients, RMDs or HPRs or were about competences related to a very specific HPR intervention, either or not related to a clinical trial.

    Figure 1

    Diagram depicting the screening process performed that led to the identification of the studies included in the systematic literature review. Other sources are records that were suggested by representatives of national HPR organisations or experts or concerned relevant EULAR recommendations. *Reasons for exclusion exceed number of excluded records, because multiple reasons could exist per record. HPRs, health professionals in rheumatology.

    Finally, 79 papers were included 20 of which concerned competences of multiple HPRs,3 4 10 11 18–33 43 competences of nurses,2 5–7 34–72 12 of physical therapists73–84 and 4 of OTs.85–88 Agreement between the reviewers in the screening process and in the validation of data extraction was 90% and 93%, respectively.

    Methodological quality

    Of the 20 studies that concerned competences that HPRs of multiple professions have in common, 15 had a qualitative design, 2 were systematic reviews, 1 concerned a quantitative study, 1 was a mixed-design study and another study was an opinion paper. Table 1 shows the results of the evaluation of the methodological quality. Overall, the methodological quality of the majority of the 15 qualitative studies was high3 11 19 21 22 24 26 31 32 or medium.4 10 18 Regarding the two systematic reviews, the quality of one was scored as moderate20 and one as critically low,30 according to the AMSTAR criteria. Agreement between the assessors was 94.1% (score given as categorical value, eg, medium or high in 16/17 qualitative studies and reviews). The MMAT score of the quantitative paper was 83.3%23 and of the mixed-method paper 62.5%.28 There were no differences in the scores given by the reviewers. The opinion paper was not appropriate for scoring.

    Table 1

    Methodological quality assessment of the 20 studies addressing the competences of multiple HPRs (nurses, physical therapists and occupational therapists)

    Key findings from studies assessing competences of multiple HPrs

    Table 2 describes the competences as extracted from the five studies focusing on comprehensive sets of competences that HPRs of multiple professions have in common.3 4 10 22 25 Despite differences in the categorisation of the areas of competences, the wording and level of detail, there were many similarities concerning the domains: basic knowledge and understanding of rheumatic diseases, holistic approach to the patient in the context of the biopsychosocial model, performing a comprehensive assessment, communicating effectively with patients and other HPRs or other professions, making appropriate referrals and providing education to patients on how to self-manage their disease. Some differences were also identified, for example: the extent to which HPRs should actively participate in research and formulate research questions or whether HPRs should be able to develop treatment plans or they just need to have basic knowledge and ability to give advice on various therapeutic approaches.

    Table 2

    Key findings of the papers underpinning the development of comprehensive sets of competences that HPRs of multiple professions have in common

    Aside from the main areas that were included in the comprehensive sets of competences, there were 15 papers addressing specific topics or a limited number of competences, knowledge areas, skills, attitudes or educational needs11 18–21 23 24 26–33 (table 3). In general, the findings from these papers confirmed the results of the studies on comprehensive sets of competences of HPRs. There were a few topics that were specifically addressed, for example, physical activity, a topic that concerns many people with musculoskeletal diseases. Many studies highlight the role of HPRs in giving advice and promoting physical activity, especially in patients with inflammatory arthritis. It appears, however, that there is a need for more education on this matter.24 26 Another topic concerned addressing sexual issues23 32 and competences regarding RMDs and their treatment options other than the most common ones like rheumatoid arthritis.20 32

    Table 3

    Key findings of the papers addressing specific topics regarding the competences that HPRs of multiple professions have in common

    Additionally, other competences addressed in the literature, although covered to a lesser extent, included educational leadership and mentorship in the field of RMDs and competence in practice setting and service development.3 28

    Key findings from studies specifically addressing competences of nurses, physiotherapists or OTs


    Most of the studies addressing competences of HPRs of a single profession focus on nurses.

    Overall, the potentially generic competences addressed in the identified nurses’ studies2 5–7 34–72 confirm those resulting from the studies describing desired competences for HPRs from multiple professional backgrounds. However, there are some competences in the nurses’ literature that are potentially generic yet stressed to a lesser extent in the literature addressing multiple HPRs. These include acting as the liaison person of the multidisciplinary team2 38 44 64 70 coordinating also the services provided.48 59 69 A limited number of studies referred also to the need of nurses to understand the cost-effectiveness association of the medications used7 58 and a leadership role in education and in developing as well as managing services.62

    Physical therapists

    Most of the literature about the competences that PTs working with people with RMDs should have, derived from studies referring to management of RA patients.75 77 79 81 82 Overall, the literature is in line with the generic competences as described for multiple HPRs.3 4 10 11 18–33 A potentially generic competence described in the literature on PT competences concerns the knowledge and skills to use new technologies, like wearable tools, which could provide significant input for monitoring and making decisions about treatment.81 There are fewer data supporting the role of PTs in having a leading role in the practice evaluation and improvement,73 in participating in clinical research and in understanding and providing guidance in specific domains, for example, sexual dysfunction in people with RMDs.77

    Occupational therapists

    Although there are many studies highlighting the central role of OTs in the care of patients with RMDs, the literature on their desired core competences is scarce. Apart from the substantiation of generic competences for HPRs in general, a leading role in practice evaluation and subsequent quality improvement85 and in providing advice about sexual issues arising in the context of RMDs87 is stressed in particular in the OT literature.


    This work demonstrates that there are relatively many studies in the literature addressing the desired competences of HPRs that are involved in the care of people with RMDs. The identified studies, of which the majority had a qualitative design, underpinned a range of HPR desired core competences, including having basic knowledge and understanding of rheumatic diseases, adopting a holistic approach to patient management in the context of the biopsychosocial model, performing a comprehensive assessment, communicating effectively with patients and other HPRs or other professions, making appropriate referrals and providing education to the patients on how to self-manage their disease.

    Despite the similarities, the identified sets varied largely with respect to their process of development, the types of HPRs being addressed, the categorisation of the competences and the level of detail. The differences observed in HPRs’ competences and practice between countries19 is a matter that needs to be addressed, possibly through educational programmes by international organisations.31

    Overall, the desired generic core competences as recognised from the five studies examining comprehensive sets of competences for multiple professions were confirmed in the literature that addressed a specific topic or RMD yet concerned multiple professions or described profession-specific competences (nursing, OT or PT). Nevertheless, there were some (potentially) generic competences that were highlighted only in one or a limited number of studies, such as the promotion of physical activity, addressing sexual issues or the ability to monitor and improve the quality of one’s own practice. As for the literature on the competences of nurses, PTs or OTs specifically, the literature search revealed a higher number of papers on nurses’ competences compared with papers for PTs or OTs. Although nurses play a pivotal role in the care for people with RMDs, relatively large proportions of patients with RMDs also have contact with PTs or OTs during the course of their disease.89 90 The extent to which professional organisations of PTs or OTs support specialisation in the area of RMDs may play a role in this respect.

    Most of the studies identified in this SLR were based on a qualitative methodology. Qualitative studies can be very efficient in addressing questions of specific nature, like policy making for educational and research issues.91 Furthermore, with qualitative studies, there is a possibility to modify the framework as new data come in and revise the direction of the research questions accordingly.91 In terms of the specific topic under study, it was not surprising that qualitative research formed the bulk of the studies retrieved from the search.

    The methodological quality of the studies was carefully assessed as part of this SLR, in view of its potential impact on the determination of level of evidence and strength of recommendations for the EULAR Task Force to develop recommendations for the generic core competences of HPRs.8 Although there are many tools developed for the assessment of the methodological quality of qualitative studies,92 we opted to use an adapted version of the ‘tool’ provided by Harden et al.15 Apart from the latter being a validated tool, it was considered both appropriate and easily interpretable and subsequently also proved its feasibility and high agreement between study reviewers. As for the methodological quality assessments of quantitative and mixed methods studies, we used the open source MMAT,17 which represents one of the most consistent methods to evaluate different study types.93 The AMSTAR criteria16 were used for reviews,94 95 while one opinion paper that was included in this SLR was not scored for its methodological quality as, to the best of our knowledge, there are no validated tools for that purpose. Studies addressing competences that HPRs of multiple professions have in common were used as a basis to form the answer to the research questions and subsequently formulate the recommendations, while studies for specific HPRs (eg, nurses) were used to reinforce the findings of the former. Therefore, we opted to assess the methodological quality of the studies regarding competences of multiple professions, the majority being of medium to high quality.

    We acknowledge that our SLR has certain limitations. First, it was mainly focused on desired competences for HPRs in general or specifically for nurses, PTs or OTs. The search was not extended to other HPRs (eg, podiatrists and psychologists). However, this decision was based on a clearly defined focus, on the key HPR groups, right at the start of the SLR and with consensus from the group of experts involved in the specific EULAR Task Force (for more details please, see ref 8). Second, we found that for some research questions evidence was more robust and supported by more studies (eg, research questions 1–4). However, this could not lead directly to the conclusion that some of the competences are more relevant than the others. Of note, the task force formulated the research questions, without hierarchy regarding their importance. In addition, for some of the research questions, there was not enough evidence in the existing literature. For example, one of the research questions pertained to HPRs’ competences regarding the cost-effectiveness of pharmacological and non-pharmacological care (online supplementary material 1, research question 13). Since too little evidence was found, we could not expand on this, although we identified the need for further studies to draw firm conclusions relating to cost-effectiveness. Finally, with the data extraction of the literature on a specific profession, the decision as to what extent a described competence was potentially generic may be arbitrary. However, agreement between the reviewers during the screening process and validation of data extraction exceeded 90%. The same applies for the exclusion of studies addressing extended roles of HPRs. This, could have led to lack of description of some advanced competences required for specific professions (eg, nurses). The development of discipline specific competences in relevance to the unique role of HPR in the multidisciplinary team was discussed during the task force meeting and was captured in the research agenda of the recommendations.8 The observation that the majority of the studies were of qualitative design is noteworthy. This finding was inevitable due to the nature of the topic, where the conduct of quantitative studies underpinning the effectiveness of specific competences is unlikely. Studies with qualitative methodology are however increasingly employed and as outlined above can have certain advantages when used appropriately. It should also be noted that the methodological quality of most of the studies included in this SLR was medium or high.


    It is recognised that HPRs play a fundamental role in the holistic management of patients with RMDs. Although there is literature describing the desired competences of HPRs with some countries already producing relevant guidelines at national level, there is a lack of pan-European guidance on a set of core competences for HRPs. The latter would allow for a more harmonised training of HPRs and approach to the care of people with RMDs. This SLR highlights this unmet need and has been used to inform ‘2019 EULAR recommendations for the generic core competences of Health Professionals in Rheumatology’.8


    We would like to thank all the task force members for their contribution in formulating the research questions and the gathering and appreciation of the literature.



    • GEF and LE are joint first authors.

    • Twitter @ElenaNikiUK

    • Collaborators EULAR Task Force for the Development of generic core competences of Health Professionals in Rheumatology. Apart from the authors of this manuscript, the Task Force members were: Margôt Bakkers, (People with Arthritis and Rheumatism) PARE representative, The Netherlands; Lurdes Barbosa, Nurse, Serviço de Reumatologia (Hospital Dia Reumatologia - 6º Piso), Hospital Garcia de Orta, EPE, Almada, Portugal; Professor Nada Cikes, Rheumatologist, UEMS European Board of Rheumatology, University of Zagreb School of Medicine, Croatia; Dr Mwidimi Ndosi, Nurse, Epidemiologist, University of the West of England, Bristol, UK; Jette Primdahl, Nurse, Associate Professor at the University of Southern Denmark, King Christian X's Reuma Hospital and Hospital of South Jutland (ESNO), Denmark; Dr Yeliz Prior, Occupational Therapist, Epidemiologist, University of Salford, Salford Mid Cheshire NHS Trust, UK; Polina Pchelnikova, PARE representative, Russia; Valentin Ritschl, Occupational Therapist, data analyst, Medical University of Vienna, Austria; Hana Smucrova, Occupational Therapist, Institute of Rheumatology, Prague, Czech Republic; Inger Storrønning, Physical Therapist, University of Oslo, Diakonhjemmet Sykehus, Norway; Professor Marco Testa, Physical therapist, University of Genova Department of Neuroscience, Rehabilitation and Ophthalmology, Genetics, Maternal and Child Health Campus of Savona, Italy; Dieter Wiek, PARE representative, Germany.

    • Contributors Study design: TPMVV, EN, GEF and LE. Performed the systematic literature review: JS, LE, GEF and VSS (supervised by TPMVV and EN). Quality assessment and methodology: EN, TPMVV, GEF, LE and VSS. Manuscript drafting: GEF, LE and JS. revising manuscript and supervision: EN, CH and TPMVV.

    • Funding The task force would like to thank EULAR for financial support of this work.

    • Competing interests None declared.

    • Patient consent for publication Not required.

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

    • Data availability statement No data are available.