Enhanced patient journey associated with improved overall survival in colon cancer patients: A study by the Ligurian Oncology Network.

BACKGROUND: Colon cancer imposes a significant burden on global healthcare systems, necessitating efforts to improve oncology care quality and patient outcomes. We studied the correlation between care quality and survival outcomes among colon cancer patients within the Ligurian Oncology Network (Italy). METHODS: We developed an Overall Quality Score (OQS) to evaluate the impact of oncology care quality on survival outcomes within the Ligurian Oncology Network. OQS indicators were selected through expert consensus, covering screening, diagnosis, treatment, and follow-up. A sample of colon cancer patients diagnosed in 2012 was randomly selected from administrative healthcare data. Analyses were performed using two models: a binary model (High and Low OQS) and a stratified model (Low, Medium, and High OQS). Statistical analysis involved survival curves, log-rank tests, and Cox proportional hazards models using SAS 9.4. RESULTS: Of 175 eligible colon cancer patients, 150 were included. Following a median follow-up of 7.6 years, a correlation between High-OQS (⩾ 65%) and prolonged disease-free survival was observed (unadjusted HR 0.57, 95%CI 0.33-0.99, log-rank p=0.041). The five-year disease-free survival rate for High-OQS patients was 70% (95%CI 57-80%), compared to 53% (95%CI 41-64%) for Low-OQS patients. Similarly, the five-year overall survival rate was 78% (95%CI 65-86%) for High-OQS patients, compared to 58% (95%CI 45-68%) for Low-OQS patients (unadjusted HR 0.56, 95%CI 0.31-1.00, log-rank p=0.048). CONCLUSIONS: Our findings highlight the potential impact of the patient journey on colon cancer survival outcomes. Optimising care pathways might improve patient outcomes in colon cancer management.

Organisation and management of multi-professional care for cancer patients at end-of-life: state-of-the-art from a survey to community and hospital-based professionals.

Providing timely and satisficing End-of-Life care (EOLC) is a priority for healthcare systems since aging population and chronic diseases are boosting the global demand for care at end-of-life (EOL). In OECD countries the access to EOLC is insufficient. In Italy, the average rate of cancer patients assisted by the palliative care (PC) network at EOL was 28% in 2021, with high variability in the country. Among the Italian regions offering the best coverages, Tuscany has a rate of about 40%, but intraregional variation is marked as well. The study aims to explore the delivery of EOLC to adult cancer patients in public facilities in the Tuscany region through survey data collection among professionals. Two online surveys were delivered to Directors of community-based PC Functional-Units (FUs) and Directors of hospital-based medical-oncology units. All FU Directors responded to the survey (n = 14), and a response rate of 96% was achieved from hospital-unit Directors (n = 27). The results highlight the availability of numerous dedicated services, but reveal heterogeneity among and within organisations, including variations in the professionals involved, pathways, and tools adopted. Care continuity is supported by institutionalized collaboration between hospital and community settings, but hindered by fragmented care processes and heterogeneous transition pathways. Late referral to PC is perceived as a major constraint to EOLC. Developing structured pathways for patient transition to end-stage PC is crucial, and practices/processes should be uniformly implemented to ensure equity. Multi-professional care should be facilitated through tailored supporting tools. Both hospital-unit and FU Directors suggest developing shared pathways between organisations/professionals (82% and 80% respectively) and digital information sharing (61% and 80% respectively). Hospital and community-based professionals have similar perceptions about the concerns and challenges to EOLC provision in the region, but community-based professionals are more sensitive to the importance of improving communication on PC to the public and early discussing EOLC with caregivers. This finding suggests the need of enhancing hospital personnel's awareness about these issues. Professional training and the capacity to assess patients' needs and preferences should be improved. The identified needs can inform future research and interventions to improve the quality and outcomes of EOLC for cancer patients.

Addressing chronic diseases: a comparative study of policies towards type-2 diabetes and hypertension in selected European countries.

BACKGROUND: Type-2 diabetes (T2D) and hypertension (HTN) are two of the most prevalent non-communicable diseases (NCDs): they both cause a relevant number of premature deaths worldwide and heavily impact the national health systems. This study illustrates the impact of HTN and T2D in four European countries (Albania, Bulgaria, Greece and Spain) and compares their policies towards the monitoring and management of HTN and T2D and the prevention of NCDs as a whole. This analysis is conducted throughout the DigiCare4You Project (H2020)-which implements an innovative solution involving digital tools for the prevention and management of T2D and HTN. METHODS: The analysis is implemented through desk research, and it is enriched with additional information directly provided by the local coordinators in the four countries, by filling specific semi-structured forms. RESULTS: The countries exhibit significant differences in the prevalence of HTN and T2D and available policies and programs targeted to these two chronic conditions. Each country has implemented strategies for HTN and T2D, including prevention initiatives, therapeutic guidelines, educational programs and children's growth monitoring programs. However, patient education on proper disease management needs improvement in all countries, registries about patients affected by HTN and T2D are not always available, and not all countries promoted acts to contain the increasing rates of risk factors related to NCDs. CONCLUSIONS: While political awareness of the risks associated with HTN, T2D and NCDs in general is growing, there is a collective need for countries to strengthen their policies for preventing and managing these chronic diseases.

Including environmental and social sustainability in the planning process of healthcare services: A case study of cancer screening programs in an inner area in Italy.

Healthcare systems plan their activities to achieve efficiency and effectiveness, without addressing environmental and social sustainability. This paper describes a new approach adopted in Italy to plan and deliver health prevention services in an inner area of the Tuscany region (in Italy) to guarantee proximity of care and environmental and social sustainability. The project examines the design and delivery of cancer screening programmes using a mobile screening unit to maximise social benefits while minimising environmental waste. A cost analysis was developed to estimate the difference in CO2 equivalent emissions, travel costs, and productivity losses, comparing the current screening programmes against the introduction of a comprehensive full-service mobile screening unit. The results indicate that the new service model reduces direct non-medical costs incurred by the population and improves environmental sustainability. This alternative can reduce, annually, over 95,000 euros in terms of travel costs and productivity losses, as well as 35 tons of CO2-equivalent travel emissions for a population of 59,000 inhabitants in a mountainous area with around 6000 people involved in the screening programme. The study supports the need to adopt a new planning methodology that considers environmental, social, and financial sustainability jointly in the provision of public health services in rural areas.

Unmet needs in end-of-life care for heart failure patients.

OBJECTIVE: To investigate end-of-life (EoL) care for heart failure (HF) in Tuscany (Italy) from healthcare professionals' perspective and identify areas for intervention. METHODS: All the directors of Cardiology units (n = 29) and palliative care (PC) units (n = 14) in Tuscany were surveyed on the practices of EoL care. RESULTS: Forty-five percent of cardiologists reported that their hospital had some EoL care services for HF patients. However, 75% did not have a multidisciplinary team providing EoL care for HF patients. Sixty-four percent stated that <25% of patients who might benefit from PC did receive it, and 18% stated that no patient received PC. For most of PC specialists, HF patients accounted for <25% of their patients. PC specialists believed that patients with cancer diseases were much more likely to receive PC than HF patients at EoL, and 36% judged that almost no HF patients were timely referred to hospice care. The majority of PC specialists reported that almost no HF patient prepared advance healthcare directives, as opposite to 57% for cancer patients, suggesting poor understanding or acceptance of their terminal condition. CONCLUSIONS: The management of HF patients in the EoL stage in Tuscany is often suboptimal. EoL care should be implemented to ensure an adequate quality of life to these patients.

Presence and Role of Associations of Cancer Patients and Volunteers in Specialist Breast Centres: An Italian National Survey of Breast Centres Associated with Senonetwork.

This article aims to present the results of a national, cross-sectional, voluntary, online survey on the presence and roles of associations of breast cancer patients and volunteers in Italian specialist breast centres. The survey was developed according to standard methods. The questionnaire was pre-tested by a random sample of three breast centres, loaded onto the SurveyMonkey platform, and piloted by one volunteer breast centre. The breast centre clinical leads were invited to participate via email. A link to the online instrument was provided. No financial incentives were offered. The results were reported using standard descriptive statistics. The response rate was 82/128 (65%). Members of associations were routinely present in 70% Italian breast centres. Breast centres most often reporting their presence were those certified by the European Society of Breast Cancer Specialists. Patient support (reception and information, listening, identification of needs, and psychological support) was the primary area where associations were reported to offer services. The magnitude of this phenomenon warrants a study to investigate the impact of the activities of associations on the quality of life of patients and on the cost-benefit ratio of the service, and the modes of their interactions with the nursing staff and the medical staff.

Women's choices of hospital for breast cancer surgery in Italy: Quality and equity implications.

This paper employs mixed logit regression to investigate the effects of providers characteristics on women's choice of hospital for breast surgery. Patient level data are used to model choices in Tuscany region, Italy. In particular, we focus on the effects of travel time and hospital quality indicators including quality standard (volumes of breast surgery), measurement of process (waiting times) and quality of surgical procedures. Variation in preferences related to individual characteristics such as age, education and travel distance from the hospital are also considered. Findings show that, on average, women prefer closer hospital with longer waiting times and higher quality (high volumes of interventions). We found preference heterogeneity associated to education: travel distance affects choice especially among less educated women (regardless of age), while among younger women (<65 years), less educated ones prefer shorter waiting times. These results could be used to optimize the allocation of resources toward breast cancer units that meet quality and efficacy standards to increase the efficiency and responsiveness of breast cancer care.

Healthcare costs of diabetic foot disease in Italy: estimates for event and state costs.

OBJECTIVE: This study aimed to estimate healthcare costs of diabetic foot disease (DFD) in a large population-based cohort of people with type-2 diabetes (T2D) in the Tuscany region (Italy). DATA SOURCES/STUDY SETTING: Administrative healthcare data of Tuscany region, with 2018 as the base year. STUDY DESIGN: Retrospective study assessing a longitudinal cohort of patients with T2D. DATA COLLECTION/EXTRACTION METHODS: Using administrative healthcare data, DFD were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. METHODS: We examined the annual healthcare costs of these clinical problems in patients with T2D between 2015 and 2018; moreover, we used a generalized linear model to estimate the total healthcare costs. PRINCIPAL FINDINGS: Between 2015 and 2018, patients with T2D experiencing DFD showed significantly higher average direct costs than patients with T2D without DFD (p < 0.0001). Among patients with T2D experiencing DFD, those who experienced complications either in 2015-2017 and in 2018 incurred the highest incremental costs (incremental cost of € 16,702) followed by those with complications in 2018 only (incremental cost of € 9,536) and from 2015 to 2017 (incremental cost of € 800). CONCLUSIONS: DFD significantly increase healthcare utilization and costs among patients with TD2. Healthcare costs of DFD among patients with T2D are associated with the timing and frequency of DFD. These findings should increase awareness among policymakers regarding resource reallocation toward preventive strategies among patients with T2D.

Including patient-reported measures in performance evaluation systems: Patient contribution in assessing and improving the healthcare systems.

In healthcare, the introduction of quality standards and indicators to assess performance triggered the development of multidimensional Performance Management Systems (PMSs). The concept of performance in healthcare has recently evolved and broadened its scope. One of the current challenges of PMSs is measuring and integrating the patient perspective into traditional measures. In the regional healthcare system of Tuscany (Italy), a PMS has been implemented and used since 2005. The PMS counts on the systematic involvement of clinicians and managers. Furthermore, the PMS also includes patients' perspective. Moreover, Tuscany has recently implemented the first regional permanent Patient-Reported Outcome and Experience Measures (PROMs and PREMs) Observatory in Italy. This paper presents the results of an action research aimed at analysing the integration of patient-reported outcome and experience indicators into a consolidated PMS. The study describes the process of identifying and discussing of patient-reported indicators with practitioners and categorising findings into three domains: design of patient-reported indicators, integration process into the PMS, and goal of adoption of the patient-related indicators. The paper also describes facilitators, challenges, and lessons learnt with respect to organisational, methodological, cultural, and responsibility-linked factors. The study discusses the ability to agree on how to transform patient data, especially PROMs, into effective performance indicators. The integration of patient-reported indicators into the PMS poses two main challenges: one in terms of sustainability of the performance system itself, and another regarding the attribution of the responsibility for patient outcomes between care settings and providers. This paper provides initial insights on how the integration of patient-reported indicators can make PMSs more inclusive and focussed on the patient-centred perspective.

Exploring Cost-Effectiveness of the Comprehensive Geriatric Assessment in Geriatric Oncology: A Narrative Review.

The Comprehensive Geriatric Assessment (CGA) and the corresponding geriatric interventions are beneficial for community-dwelling older persons in terms of reduced mortality, disability, institutionalisation and healthcare utilisation. However, the value of CGA in the management of older cancer patients both in terms of clinical outcomes and in cost-effectiveness remains to be fully established, and CGA is still far from being routinely implemented in geriatric oncology. This narrative review aims to analyse the available evidence on the cost-effectiveness of CGA adopted in geriatric oncology, identify the relevant parameters used in the literature and provide recommendations for future research. The review was conducted using the PubMed and Cochrane databases, covering published studies without selection by the publication year. The extracted data were categorised according to the study design, participants and measures of cost-effectiveness, and the results are summarised to state the levels of evidence. The review conforms to the SANRA guidelines for quality assessment. Twenty-nine studies out of the thirty-seven assessed for eligibility met the inclusion criteria. Although there is a large heterogeneity, the overall evidence is consistent with the measurable benefits of CGA in terms of reducing the in-hospital length of stay and treatment toxicity, leaning toward a positive cost-effectiveness of the interventions and supporting CGA implementation in geriatric oncology clinical practice. More research employing full economic evaluations is needed to confirm this evidence and should focus on CGA implications both from patient-centred and healthcare system perspectives.

Integrating mammography screening programmes into specialist breast centres in Italy: insights from a national survey of Senonetwork breast centres.

BACKGROUND: Despite recommendations, mammography screening is often insufficiently integrated into specialist breast centres. A national, cross-sectional, voluntary, online survey on this issue was carried out among the Italian breast centres associated with Senonetwork, the Italian network of breast cancer services. METHODS: A 73-item questionnaire was created, pre-tested and piloted. Centres integrating and not integrating a screening programme were compared using the unified theory of acceptance and use of technology (UTAUT) model. Centres' clustering was performed using the Gower's distance metric. Groups and clusters were compared with the equality-of-means test. RESULTS: The response rate was 82/128 (65%). Overall, 84% (69/82) breast centres reported a collaboration with a screening programme in performing and/or reading mammograms and in the diagnostic work-up of women with abnormal screening results. The same proportion was observed among those centres responding to all questions (62/74). Performance expectancies (or the perceived usefulness of integration in terms of clinical quality, patient convenience, ease of job, and professional growth), satisfaction and motivation were higher in those centres collaborating with the screening programme. Effort expectancy indicators (or the degree to which the respondents believe that the integration is easy to implement) and those concerning the existence of facilitating conditions were lower both in centres collaborating and not collaborating with the screening programme. Among the former, six clusters of centres, distributed from 'no integration' to 'high', were identified. In cluster analysis, the highest level of integration was associated with higher agreement that integration eases the job, offers better opportunities for professional growth, and makes the working environment more satisfactory. The least integrated cluster assigned the lowest score to the statement that local health authority made available the resources needed. CONCLUSIONS: While confirming the positive effects of integrating screening programmes into breast centres, this survey has brought to light specific difficulties that must be faced. The results provide insights into the importance of integration focusing on the perspectives of professional career and motivation. The deficiency of facilitating conditions to integration is modifiable. Screening professionals' societies may have a role as initiators of the integration. Other supporting actions may be included in health laws at the national and regional level.

Provision of follow-up care for women with a history of breast cancer following the 2016 position paper by the Italian Group for Mammographic Screening and the Italian College of Breast Radiologists by SIRM: a survey of Senonetwork Italian breast centres.

INTRODUCTION: In 2016, the Italian Group for Mammography Screening and the Italian College of Breast Radiologists by the Italian Society of Medical and Interventional Radiology recommended that screening programmes and specialist breast centres actively invite women with a history of breast cancer to follow-up imaging. OBJECTIVE: A survey of breast centres associated with Senonetwork, the Italian network of breast cancer services, has offered the opportunity to assess the implementation of this recommendation. METHODS: A national, cross-sectional, voluntary, online survey was developed, pre-tested, and administered during the months July-October 2020. Five of the 73 questionnaire items concerned breast cancer follow-up. RESULTS: The response rate was 82/128 (65%). Of the 82 respondent centres, 69 (84%) were involved in a screening programme. Fifty-six (68%) reported the presence of a programme of active invitation to breast cancer follow-up targeted at patients living in their catchment area, with a significant north-to-south gradient. Four centres (5%) reported that the screening programme was responsible for actively initiating follow-up during the 10-year period since diagnosis. Only after 10 years did the proportion increase moderately. CONCLUSION: Screening programmes have still a marginal role in active breast cancer follow-up.

The Role of Recipient Characteristics in Health Video Communication Outcomes: Scoping Review.

BACKGROUND: The importance of effective communication during public health emergencies has been highlighted by the World Health Organization, and it has published guidelines for effective communication in such situations. With video being a popular medium, video communication has been a growing area of study over the past decades and is increasingly used across different sectors and disciplines, including health. Health-related video communication gained momentum during the SARS-CoV-2 pandemic, and video was among the most frequently used modes of communication worldwide. However, although much research has been done regarding different characteristics of video content (the message) and its delivery (the messenger), there is a lack of knowledge about the role played by the characteristics of the recipients for the creation of effective communication. OBJECTIVE: The aim of this review is to identify how health video communication outcomes are shaped by recipient characteristics, as such characteristics might affect the effectiveness of communication. The main research question of the study is as follows: do the characteristics of the recipients of health videos affect the outcomes of the communication? METHODS: A scoping review describing the existing knowledge within the field was conducted. We searched for literature in 3 databases (PubMed, Scopus, and Embase) and defined eligibility criteria based on the relevance to the research question. Recipient characteristics and health video communication outcomes were identified and classified. RESULTS: Of the 1040 documents initially identified, 128 (12.31%) met the criteria for full-text assessment, and 39 (3.75%) met the inclusion criteria. The included studies reported 56 recipient characteristics and 42 communication outcomes. The reported associations between characteristics and outcomes were identified, and the potential research opportunities were discussed. Contributions were made to theory development by amending the existing framework of the Integrated-Change model, which is an integrated model of motivational and behavioral change. CONCLUSIONS: Although several recipient characteristics and health video communication outcomes were identified, there is a lack of robust empirical evidence on the association between them. Further research is needed to understand how the preceding characteristics of the recipients might affect the various outcomes of health video communication.

Systematic and continuous collection of patient-reported outcomes and experience in women with cancer undergoing mastectomy and immediate breast reconstruction: a study protocol for the Tuscany Region (Italy).

INTRODUCTION: Monitoring how patients feel and what they experience during the care process gives health professionals data to improve the quality of care, and gives health systems information to better design and implement care pathways. To gain new insights about specific gaps and/or strengths in breast cancer care, we measure patient-reported outcomes (PROs) and patient-reported experiences (PREs) for women receiving immediate breast reconstruction (iBR). METHODS AND ANALYSIS: Prospective, multicentre, cohort study with continuous and systematic web-based data collection from women diagnosed with breast cancer, who have an indication for iBR after mastectomy treated at any Breast Unit (BU) in Tuscany Region (Italy). Patients are classified into one of two groups under conditions of routine clinical practice, based on the type of iBR planned (implant and autologous reconstruction). Patient-reported information are obtained prior to and after surgery (at 3-month and 12-month follow-up). We estimate that there are around 700 annual eligible patients.Descriptive analyses are used to assess trends in PROs over time and differences between types of iBR in PROs and PREs. Additionally, econometric models are used to analyse patient and BU characteristics associated with outcomes and experiences. PREs are evaluated to assess aspects of integrated care along the care pathway. ETHICS AND DISSEMINATION: The study has been reviewed and obtained a nihil obstat from the Tuscan Ethics Committees of the three Area Vasta in 2017. Dissemination of results will be via periodic report, journal articles and conference presentations.

Research protocol for the validation of a new portable technology for real-time continuous monitoring of Early Warning Score (EWS) in hospital practice and for an early-stage multistakeholder assessment.

INTRODUCTION: The real-time continuous monitoring of vital parameters in patients affected by multiple chronic conditions and/or COVID-19 can lead to several benefits to the Italian National Healthcare System (IT-NHS). The UBiquitous Integrated CARE (UBICARE) technology is a novel health digital platform at the validation stage in hospital setting. UBICARE might support the urgent need for digitalisation and early intervention, as well as minimise the face-to-face delivery of care in both hospital and community-based care settings. This research protocol aims to design an early-stage assessment of the multidimensional impact induced by UBICARE within the IT-NHS alongside technology validation in a hospital ward. METHODS AND ANALYSIS: The targeted patients will be medium/high-risk hypertensive individuals as an illustrative first example of how UBICARE might bring benefits to susceptible patients. A mixed-method study will be applied to incorporate to the validation study a multistakeholder perspective, including perceived patient experiences and preferences, and facilitate technology adoption. First, semistructured interviews will be undertaken with a variety of stakeholders including clinicians, health managers and policy-makers to capture views on the likely technology utility, economic sustainability, impact of adoption in hospital practice and alternative adoption scenarios. Second, a monocentric, non-randomised and non-comparative clinical study, supplemented by the administration of standardised usability questionnaires to patients and health professionals, will validate the use of UBICARE in hospital practice. Finally, the results of the previous stages will be discussed in a multidisciplinary-facilitated workshop with IT-NHS relevant stakeholders to reconcile stakeholders' perspectives. Limitations include a non-random recruitment strategy in the clinical study, small sample size of the key stakeholders and potential stakeholder recruitment bias introduced by the research technique. ETHICS AND DISSEMINATION: The Ethics Committee for Clinical Experimentation of Tuscany Region approved the protocol. Participation in this study is voluntary. Study results will be disseminated through peer-reviewed publications and academic conferences.

A Performance Management System in Healthcare for All Seasons?

Health systems face challenges which are inherent to care demand and supply evolution (i.e., demographic change, new technologies) or are the results of unexpected occurrence originating outside the health system, such as economic shocks or epidemic outbreaks. Both challenges often require a paradigm shift in governance and organization, financing and resource allocation, accountability frameworks, as well as public health system responses. Based on key reviews and seminal papers of performance management, public health, sustainability and resilience, the article presents three emerging challenges for performance management systems in healthcare: i) the inclusion of the population approach; ii) the measurement and consideration of the multi-facets concepts of value; iii) the importance of resilience and sustainability. Performance management systems need to evolve to cope with this changing scenario. The article sheds light on uncovered areas by performance management, and it proposes a research agenda for scholars of both performance management and health service research.

Waiting time information in the Italian NHS: A citizen perspective.

Public involvement in the management and communication of waiting times is known to support initiatives to reduce waiting times, as well as increase fairness and promote transparency and accountability. In order to improve transparency and communication to citizens, Italy recently updated the National Regulatory Plan for Waiting Lists (2019-2021), which calls for the disclosure of waiting time information on healthcare provider webpages. This study analyses waiting time information for outpatient visits and digital services available on the institutional website pages of 144 public healthcare organisations in nine regions and two autonomous provinces of Italy. Web pages were analysed both in terms of the available information/services, using a grid, and in terms of the quality of the text using an advanced readability assessment tool (READ-IT). This information was complemented and validated by regional healthcare key informants during research-specific workshops. Waiting time information disclosure, digital services and text readability varied both within and between the regional healthcare systems and organisations. The types and characteristics of waiting time information and statistics vary considerably with a negative impact on their use for benchmarking and their readability and usability for booking purposes. Overall, communication weaknesses due to low harmonization and clarity of information can undermine efforts in effectively informing and involving the public through online waiting time data disclosure.

Managing the performance of general practitioners and specialists referral networks: A system for evaluating the heart failure pathway.

High quality chronic disease management requires coordinated care across different healthcare settings, involving multidisciplinary teams of professionals, and performance evaluation systems able to measure this care. Inter-organizational performance should be measured considering the professional relationships between general practitioners (GPs) and specialists, who are usually linked through informal referral networks. The aim of this paper is to identify and evaluate the performance of naturally occurring networks of GPs and hospital-based specialists providing care for congestive heart failure (CHF) patients in Tuscany, Italy. The analysis focuses on the identification and classification of networks, following CHF patients (n = 15,841) through primary care and inpatient care using administrative data, and on the assessment of process and outcome indicators for CHF patients in these referral networks. We demonstrate the existence of informal links between GPs and hospitals based on patterns of patient flow. These networks which are not geographically based vary in the intensity of relationships and quality of care. Such referral networks may represent the most effective accountability level for chronic disease management, since they encompass the multiple care settings experienced by patients. Overall, an integrated approach to evaluation and performance management that considers the naturally occurring links between professionals working in different settings may enable more efficient, integrated care and quality improvements.