Evaluation of an Infection surveillance program in residential aged care facilities in Victoria, Australia.

BACKGROUND: Infection surveillance is a key element of infection prevention and control activities in the aged care sector. In 2017, a standardised infection surveillance program was established for public residential aged care services in Victoria, Australia. This program will soon be expanded to a national level for all Australian residential aged care facilities. It has not been evaluated since its inception. METHODS: The current study aimed to evaluate the Victorian Healthcare Associated Infection Surveillance System (VICNISS) Coordinating Centre Aged Care Infection Indicator Program (ACIIP), to understand its performance and functionality. A mixed methods evaluation was performed using the Updated Guidelines for Evaluating Public Health Surveillance Systems developed by the United States Centers for Disease Control and Prevention as a framework. VICNISS staff who coordinate and manage the ACIIP were invited to participate in interviews. Residential aged care staff who use the program were invited to participate in a survey. Document analysis was also performed. RESULTS: Four VICNISS staff participated in the interviews and 38 aged care staff participated in the survey. The ACIIP is stable and able to be adapted quickly to changing definitions for infections. Users found the system relatively easy to use but have difficulties after the long intervals between data entry year on year. VICNISS staff provide expert guidance which benefits users. Users appreciated the benefit of participating and many use the data for improving local practice. CONCLUSIONS: The ACIIP is a usessful state-wide infection surveillance program for aged care. Further development of data validation, IT system capacity and models for education and user support will be required to support future scalability.

The same but different: a comparison of Staphylococcus aureus bloodstream infections in metropolitan and non-metropolitan hospitals (2010-2020).

BACKGROUND: Variation of infection rates between hospitals must be identified; differences may highlight opportunities for quality improvement in healthcare delivery to specific hospitals groups. AIMS: To analyse burden, time trends and risks of healthcare-associated (HA) Staphylococcus aureus bloodstream infections (SABSI) in patients admitted to Victorian metropolitan and non-metropolitan public acute care hospitals. METHODS: SABSI surveillance data submitted between 1 July 2010 and 30 June 2020 by all 118 Victorian public acute care hospitals were analysed. Aligned with the Australian Statistical Geography Standard Remoteness Structure, these hospitals were classified as metropolitan (major cities) or non-metropolitan (inner regional, outer regional, remote or very remote). RESULTS: Most SABSI were community associated: 66.9% and 75.0% of metropolitan (n = 9441) and non-metropolitan (n = 2756) hospital SABSI respectively. The overall HA-SABSI rate was statistically higher in metropolitan hospitals (1.13 per 10 000 occupied bed days (OBD)) compared with non-metropolitan hospitals (0.82 per 10 000 OBD; P < 0.001). In metropolitan and non-metropolitan hospitals, there was a statistically significant decline in the overall HA-SABSI rate (incidence rate ratio = 0.96; 95% confidence interval: 0.95-0.97; P < 0.001; and incidence rate ratio = 0.98; 95% confidence interval: 0.97-1.00; P = 0.044, respectively). In metropolitan and non-metropolitan hospitals, HA-SABSI were frequently associated with central venous (52.8%) and peripheral intravenous (62.2%) catheter use respectively. CONCLUSION: To reduce risks for SABSI and improve patient outcomes, hospital infection prevention and control programmes should be tailored according to local epidemiology. In common geographic locations, networking of hospitals should be considered as a means of strengthening delivery of these programmes.

IMpleMenting Effective infection prevention and control in ReSidential aged carE (IMMERSE): protocol for a multi-level mixed methods implementation study.

BACKGROUND: Older people living in residential aged care facilities are at high risk of acquiring infections such as influenza, gastroenteritis, and more recently COVID-19. These infections are a major cause of morbidity and mortality among this cohort. Quality infection prevention and control practice in residential aged care is therefore imperative. Although appointment of a dedicated infection prevention and control (IPC) lead in every Australian residential aged care facility is now mandated, all people working in this setting have a role to play in IPC. The COVID-19 pandemic revealed inadequacies in IPC in this sector and highlighted the need for interventions to improve implementation of best practice. METHODS: Using mixed methods, this four-phase implementation study will use theory-informed approaches to: (1) assess residential aged care facilities' readiness for IPC practice change, (2) explore current practice using scenario-based assessments, (3) investigate barriers to best practice IPC, and (4) determine and evaluate feasible and locally tailored solutions to overcome the identified barriers. IPC leads will be upskilled and supported to operationalise the selected solutions. Staff working in residential aged care facilities, residents and their families will be recruited for participation in surveys and semi-structured interviews. Data will be analysed and triangulated at each phase, with findings informing the subsequent phases. Stakeholder groups at each facility and the IMMERSE project's Reference Group will contribute to the interpretation of findings at each phase of the project. DISCUSSION: This multi-site study will comprehensively explore infection prevention and control practices in residential aged care. It will inform and support locally appropriate evidence-based strategies for enhancing infection prevention and control practice.

Identifying barriers and enablers to participation in infection surveillance in Australian residential aged care facilities.

BACKGROUND: Infection surveillance is a vital part of infection prevention and control activities for the aged care sector. In Australia there are two currently available infection and antimicrobial use surveillance programs for residential aged care facilities. These programs are not mandated nor available to all facilities. Development of a new surveillance program will provide standardised surveillance for all facilities in Australia. METHODS: This study aimed to assess barriers and enablers to participation in the two existing infection and antimicrobial use surveillance programs, to improve development and implementation of a new program. A mixed-methods study was performed. Aged Care staff involved in infection surveillance were invited to participate in focus groups and complete an online survey comprising 17 items. Interviews were transcribed and analysed using the COM-B framework. RESULTS: Twenty-nine staff took part in the focus groups and two hundred took part in the survey. Barriers to participating in aged care infection surveillance programs were the time needed to collect and enter data, competing priority tasks, limited understanding of surveillance from some staff, difficulty engaging clinicians, and staff fatigue after the COVID-19 pandemic. Factors that enabled participation were previous experience with surveillance, and sharing responsibilities, educational materials and using data for benchmarking and to improve practice. CONCLUSION: Streamlined and simple data entry methods will reduce the burden of surveillance on staff. Education materials will be vital for the implementation of a new surveillance program. These materials must be tailored to different aged care workers, specific to the aged care context and provide guidance on how to use surveillance results to improve practice.

The 2018 Aged Care National Antimicrobial Prescribing Survey: results show room for improvement.

The annual Aged Care National Antimicrobial Prescribing Survey aims to identify local and national prescribing issues and guide antimicrobial stewardship goals In the 2018 point prevalence survey, medication charts of over 20,000 residents were reviewed from 407 participating facilities across Australia On the day of the survey, almost 10% of residents were prescribed an antimicrobial Nearly two-thirds of recently prescribed antimicrobials were for residents who had no documented signs or symptoms of infection Over a quarter of antimicrobials had been prescribed for longer than six months Incomplete documentation was a prominent barrier to proper review of antimicrobial therapy, with the indication, review date or stop date not documented for many prescriptions Recommendations include using appropriate microbiological testing to guide prescribing, following national antimicrobial prescribing guidelines, documenting the indication for the antimicrobial, and its start, stop and review dates, and monitoring and re-evaluating long-term antimicrobial use

Antimicrobial stewardship in residential aged care facilities: need and readiness assessment.

BACKGROUND: Information about the feasibility, barriers and facilitators of antimicrobial stewardship (AMS) in residential aged care facilities (RACFs) has been scant. Exploring the prevailing perceptions and attitudes of key healthcare providers towards antibiotic prescribing behaviour, antibiotic resistance and AMS in the RACF setting is imperative to guide AMS interventions. METHODS: Semi-structured interviews and focus groups were conducted with key RACF healthcare providers until saturation of themes occurred. Participants were recruited using purposive and snowball sampling. The framework approach was applied for data analysis. RESULTS: A total of 40 nurses, 15 general practitioners (GPs) and 6 pharmacists from 12 RACFs were recruited. Five major themes emerged; perceptions of current antibiotic prescribing behaviour, perceptions of antibiotic resistance, attitude towards and understanding of AMS, perceived barriers to and facilitators of AMS implementation, and feasible AMS interventions. A higher proportion of GPs and pharmacists compared with nurses felt there was over-prescribing of antibiotics in the RACF setting. Antibiotic resistance was generally perceived as an issue for infection control rather than impacting clinical decisions. All key stakeholders were supportive of AMS implementation in RACFs; however, they recognized barriers related to workload and logistical issues. A range of practical AMS interventions were identified, with nursing-based education, aged-care specific antibiotic guidelines and regular antibiotic surveillance deemed most useful and feasible. CONCLUSIONS: Areas of antibiotic over-prescribing have been identified from different healthcare providers' perspectives. However, concern about the clinical impact of antibiotic resistance was generally lacking. Importantly, information gathered about feasibility, barriers and facilitators of various AMS interventions will provide important insights to guide development of AMS programs in the RACF setting.

Antibiotic prescribing practice in residential aged care facilities--health care providers' perspectives.

OBJECTIVE: To explore organisational workflow and workplace culture influencing antibiotic prescribing behaviour from the perspective of key health care providers working in residential aged care facilities (RACFs). DESIGN, SETTING AND PARTICIPANTS: Qualitative approach using semistructured interviews, focus groups and onsite observation between 8 January 2013 and 2 July 2013. Nursing staff, general practitioners and pharmacists servicing residents at 12 high-level care RACFs in Victoria were recruited. MAIN OUTCOME MEASURES: Emergent themes on antibiotic prescribing practices in RACFs. RESULTS: Sixty-one participants (40 nurses, 15 GPs and six pharmacists) participated. Factors influencing antibiotic prescribing practice have been divided into workflow-related and culture-related factors. Five major themes emerged among workflow-related factors: logistical challenges with provision of medical care, pharmacy support, nurse-driven infection management, institutional policies and guidelines, and external expertise and diagnostic facilities. Lack of onsite medical and pharmacy staff led to nursing staff adopting significant roles in infection management. However, numerous barriers hindered optimal antibiotic prescribing, especially inexperienced staff, lack of training of nurses in antibiotic use and lack of institutional infection management guidelines. With regard to culture-related factors, pressure from family to prescribe and institutional use of advance care directives were identified as important influences on antibiotic prescribing practices. CONCLUSIONS: Workflow- and culture-related barriers to optimal antibiotic prescribing were identified. This study has provided important insights to guide antimicrobial stewardship interventions in the RACF setting, particularly highlighting the role of nurses.

Assessing infection prevention and control programs in residential aged care in Australia: A multi-methods cross-sectional study.

AIM: To assess infection prevention and control programs in residential aged care facilities. METHODS: A cross-sectional survey and structured interviews from 10 residential aged care facilities in Victoria, Australia, were used. Infection prevention and control nurse leads from each facility completed a purpose-built survey based on best practice infection prevention control program core components, including staff training, policies and procedures, governance, and surveillance. Follow-up interviews with residential aged care staff, residents and family visitors were carried out to elaborate and verify survey data. RESULTS: Surveys from all 10 facilities were received and 75 interviews carried out. All facilities had an infection prevention and control lead nurse who had undergone additional training, and 60% of facilities had an infection prevention and control lead position description. All facilities had a committee to oversee their infection prevention and control program, and all had policies and procedures for standard and transmission-based precautions. One facility did not have a policy on healthcare-associated infection surveillance, and two facilities did not have an antimicrobial stewardship policy. All facilities provided staff training in hand hygiene and personal protective equipment use, but not all routinely assessed competency in these. CONCLUSIONS: The residential aged care facilities' infection prevention and control programs were generally in a strong position, although there were some areas that require improvement. Further assessment of the quality of infection prevention and control program components, such as content of education and training, and policies and procedures, and ongoing evaluation of programs is recommended. Geriatr Gerontol Int 2024; 24: 358-363.

Infections and antimicrobial use in Australian residential aged care facilities: a comparison between local and international prevalence and practices.

INTRODUCTION: In July 2011, 29 residential aged care facilities (RACF) located in the Grampians rural region, Victoria, participated in the Grampians healthcare-associated infection (HAI) and antimicrobial use point prevalence study. METHODS: On a single day, trained infection control consultants collected data using two surveys. The RACF survey enabled collection of information (e.g. occupancy levels) about each RACF and its residents. The resident survey was completed for eligible high-level care residents who presented with signs and symptoms of a HAI and/or were prescribed an antimicrobial. A literature review was undertaken so comparisons could be made against similar studies. RESULTS: The Grampians prevalence of residents presenting with ≥1 HAI (3.8%) was higher than the pooled prevalence (2.3%) for four international studies (P=0.01). The Grampians prevalence of residents prescribed ≥1 antimicrobial (8.3%) was higher than the pooled prevalence (5.8%) for eight international studies (P=0.009). CONCLUSION: The prevalence of the Grampians residents presenting with ≥1 HAI and residents prescribed ≥1 antimicrobial were both observed to be significantly higher than pooled data from similar international studies.

Hepatitis B immune status of staff in smaller acute healthcare facilities.

Objective To determine the proportion of staff employed in smaller Victorian public acute healthcare facilities with evidence of immunity to hepatitis B. Methods For optimal long-term immunity, a completed hepatitis B vaccination course and post vaccination hepatitis B surface antibody (anti-HBs) level ≥10 mIU/mL is desirable for all high-risk staff employed in healthcare facilities. For the financial years 2016/17-2019/20, a standardised surveillance module developed by the Victorian Healthcare Associated Infection Surveillance System (VICNISS) Coordinating Centre was completed by the smaller Victorian public acute healthcare facilities (individual hospitals with Results A total of 88 healthcare facilities reported hepatitis B immunity status of high-risk (Category A) staff (n = 29 920) at least once over 5 years; 55 healthcare facilities reported more than once. The aggregate proportion with evidence of optimal immunity was 66.3%. Healthcare facilities with 100-199 Category A staff employed reported the lowest evidence of optimal immunity (59.6%). Of all Category A staff with no evidence of optimal immunity, the majority had 'unknown' status (19.8%), with only 0.6% overall who declined vaccination. Conclusions Our study found evidence of optimal staff hepatitis B immunity in only two-thirds of Category A staff working in surveyed healthcare facilities.

Communities of practice in residential aged care: A rapid review.

BACKGROUND: Communities of practice (CoPs) have the potential to help address the residential aged care system's need for continuing education and quality improvement. CoPs have been used in healthcare to improve clinical practice; however, little is known about their application to the unique residential aged care context. OBJECTIVES: This rapid review of CoPs for residential aged care was conducted to summarise the features of CoPs, how they are developed and maintained, and assess their effectiveness. METHODS: MEDLINE and CINAHL databases were searched for studies published from January 1991 to November 2022 about CoPs in residential aged care. Data were extracted regarding the CoPs' three key features of 'domain', 'community' and 'practice' as described by Wenger and colleagues. Kirkpatrick's four levels of evaluation (members' reactions, learning, behaviour and results) was used to examine studies on the effectiveness of CoPs. The Mixed Methods Appraisal Tool was used for quality appraisal. RESULTS: Nineteen articles reported on 13 residential aged care CoPs. Most CoPs aimed to improve care quality (n = 9, 69%) while others aimed to educate members (n = 3, 23%). Membership was often multidisciplinary (n = 8, 62%), and interactions were in-person (n = 6, 46%), online (n = 3, 23%) or both (n = 4, 31%). Some CoPs were developed with the aid of a planning group (n = 4, 31%) or as part of a larger collaborative (n = 4, 31%), and were maintained using a facilitator (n = 7, 54%) or adapted to member feedback (n = 2, 15%). Thirteen (81%) studies evaluated members' reactions, and three (24%) studies assessed members' behaviour. The heterogeneity of studies and levels of reporting made it difficult to synthesise findings. CONCLUSIONS: This review revealed the variation in why, and how, CoPs have been used in residential aged care, which is consistent with previous reviews of CoPs in healthcare. While these findings can inform the development of CoPs in this context, further research is needed to understand how CoPs, including the membership makeup, delivery mode, facilitator type and frequency of meetings, impact quality of care.

An evaluation of influenza, pneumococcal and herpes zoster vaccination coverage in Australian aged care residents, 2018 to 2022.

BACKGROUND: For older persons, vaccination mitigates the harmful impact of vaccine preventable infections. Our study objectives were to evaluate in the Victorian public sector residential aged care services (PSRACS) (1) the existence of local vaccination policies and admission assessment practices, (2) the current documented status of resident influenza, pneumococcal and herpes zoster vaccination uptake and (3) changes in documented resident vaccination uptake over time. METHODS: Standardised data were annually reported by all PSRACS between 2018 and 2022. The influenza, pneumococcal and herpes zoster vaccination status of each resident was classified as vaccinated, declined, contraindicated or unknown. Annual trends in vaccination status were assessed using Spearman's correlation. RESULTS: In 2022, most PSRACS reported an influenza immunisation policy existed (87.1%) and new residents were assessed for their influenza vaccination status (97.2%); fewer PSRACS reported the same for pneumococcal disease (73.1% and 78.9%) and herpes zoster (69.3% and 75.6%). The median resident influenza, pneumococcal and herpes zoster (70-79 years old) vaccination uptake was 86.8%, 32.8% and 19.3% respectively. The median unknown status was 6.9%, 63.0% and 76.0% respectively. Statistical evidence of an increase in annual uptake was observed for the herpes zoster (all resident) surveillance module (rs = 0.900, p = 0.037). CONCLUSIONS: Our study showed local influenza vaccination policies and practices exist and influenza vaccination uptake was consistently high. Pneumococcal and herpes zoster vaccination uptake were lower. Quality improvement strategies that at least determine the status of those residents classified as unknown are required.

Improving management of urinary tract infections in residential aged care facilities.

BACKGROUND: Antimicrobial resistance rates are higher in Australian residential aged care facilities (RACFs) than other community or hospital settings. This is driven by antibiotic overuse and misuse. Urinary tract infection (UTI) is consistently the most common infection treated with antibiotics in Australian RACFs. OBJECTIVE: The aim of this article is to provide an overview of how general practitioners (GPs) can support appropriate UTI management in RACFs following antimicrobial stewardship (AMS) principles. DISCUSSION: GPs are well placed to improve UTI management in RACFs. In this article, criteria for suspected, proven, recurrent and relapsed UTI are outlined, in addition to key AMS practices for the assessment, prevention, treatment and review of UTIs. Included are recommendations for the judicious use of urine dipstick testing, a widespread and longstanding practice in RACFs, and first-line empirical antibiotic prescribing for suspected UTIs.

Ophthalmic Antimicrobial Prescribing in Australian Healthcare Facilities.

The National Antimicrobial Prescribing Survey (NAPS) is a web-based, standardized tool, widely adopted in Australian healthcare facilities to assess the reasons for, the quantity of, and the quality of antimicrobial prescribing. It consists of multiple modules tailored towards the needs of a variety of healthcare facilities. Data regarding ophthalmological antimicrobial use from Hospital NAPS, Surgical NAPS, and Aged Care NAPS were analysed. In Hospital NAPS, the most common reasons for inappropriate prescribing were incorrect dose or frequency and incorrect duration. Prolonged duration was also common in Aged Care prescribing: about one quarter of all antimicrobials had been prescribed for greater than 6 months. All three modules found chloramphenicol to be the most prescribed antimicrobial with a high rate of inappropriate prescribing, usually for conjunctivitis.

Evaluating peripheral intravascular catheter insertion, maintenance and removal practices in small hospitals using a standardized audit tool.

AIM: The aim of this study was to evaluate clinical practice about peripheral intravenous catheter (PIVC) insertion, maintenance and removal in a cohort of Victorian hospitals. DESIGN: A standardized PIVC audit tool was developed, and results from point prevalent surveys were conducted. METHODS: Hospitalized patients requiring a PIVC insertion were eligible for audit. Audit data submitted between 2015 and 2019 were extracted for the current study. RESULTS: 3566 PIVC insertions in 15 Victorian public hospitals were evaluated. 57.6% of PIVCs were inserted in wards, 18.7% in operating theatres and 11.6% in Emergency Departments (ED). 45.2% were inserted by nurses and 38.2% by medical staff. The preferred site for insertion was the dorsum of the hand and forearm (58.8%). 22.6% did not report a visual infusion phlebitis score at least daily, and 48% did not document a daily dressing assessment. Reasons for PIVC removal included no longer required (63%) and phlebitis (4.8%). No bloodstream infections were reported.

Prophylactic Antimicrobial Prescribing in Australian Residential Aged-Care Facilities: Improvement is Required.

BACKGROUND AND OBJECTIVE: Inappropriate antimicrobial use can lead to adverse consequences, including antimicrobial resistance. The objective of our study was to describe patterns of prophylactic antimicrobial prescribing in Australian residential aged-care facilities and thereby provide insight into antimicrobial stewardship strategies that might be required. METHODS: Annual point prevalence data submitted by participating residential aged-care facilities as part of the Aged Care National Antimicrobial Prescribing Survey between 2016 and 2020 were extracted. All antimicrobials except anti-virals were counted; methenamine hippurate was classified as an antibacterial agent. RESULTS: The overall prevalence of residents prescribed one or more prophylactic antimicrobial on the survey day was 3.7% (n = 4643, 95% confidence interval 3.6-3.8). Of all prescribed antimicrobials (n = 15,831), 27.1% (n = 4871) were for prophylactic use. Of these prophylactic antimicrobials, 87.8% were anti-bacterials and 11.4% antifungals; most frequently, cefalexin (28.7%), methenamine hippurate (20.1%) and clotrimazole (8.8%). When compared with prescribing of all antimicrobial agents, prophylactic antimicrobials were less commonly prescribed for pro re nata administration (7.0% vs 20.3%) and more commonly prescribed greater than 6 months (52.9% vs 34.1%). The indication and review or stop date was less frequently documented (67.5% vs 73.8% and 20.9% vs 40.7%, respectively). The most common body system for which a prophylactic antimicrobial was prescribed was the urinary tract (54.3%). Of all urinary tract indications (n = 2575), about two thirds (n = 1681, 65.3%) were for cystitis and 10.6% were for asymptomatic bacteriuria. CONCLUSIONS: Our results clearly identified immediate antimicrobial stewardship strategies that aim to improve prophylactic antimicrobial prescribing in Australian residential-aged care facilities are required.

Topical antimicrobial prescribing patterns in residents of Australian aged-care facilities: use of a national point prevalence survey to identify opportunities for quality improvement.

BACKGROUND: Australian residential aged care facilities (RACFs) are encouraged to participate in an annual Aged Care National Antimicrobial Prescribing Survey. This data source was analysed to describe patterns of topical antimicrobial prescribing and thereby provide insight into antimicrobial stewardship (AMS) changes that might be required. METHODS: 2018 and 2019 survey data was analysed. RESULTS: The overall prevalence of the 52,431 audited residents (629 facilities) who were prescribed 1 or more topical antimicrobials was 2.9%. Of all prescribed antimicrobials (n=4899), 33.0% were for topical application. Most frequently prescribed topical antifungals were clotrimazole (85.3%) and miconazole (9.1%), and antibacterials chloramphenicol (64.1%) and mupirocin (21.8%). Tinea (38.3%) and conjunctivitis (23.8%) were the 2 most common indications. Topical antimicrobials were sometimes prescribed for pro re nata administration (38.8%) and greater than 6 months (11.3%). The review or stop date was not always documented (38.7%). CONCLUSIONS: To reduce the possibility of adverse consequences associated with antimicrobial use, antimicrobial stewardship programs in Australian residential aged care facilities should at least ensure mupirocin is appropriately used, first line antimicrobial therapy is prescribed for tinea, chloramphenicol is prescribed for conjunctivitis only if necessary, pro re nata orders for prescriptions are discouraged and to avoid prolonged duration of prescriptions, review or stop dates are always documented.

Antimicrobial stewardship in Australia: the role of qualitative research in programme development.

Antimicrobial stewardship (AMS) in Australia is supported by a number of factors, including enabling national policies, sectoral clinical governance frameworks and surveillance programmes, clinician-led educational initiatives and health services research. A One Health research programme undertaken by the National Centre for Antimicrobial Stewardship (NCAS) in Australia has combined antimicrobial prescribing surveillance with qualitative research focused on developing antimicrobial use-related situational analyses and scoping AMS implementation options across healthcare settings, including metropolitan hospitals, regional and rural hospitals, aged care homes, general practice clinics and companion animal and agricultural veterinary practices. Qualitative research involving clinicians across these diverse settings in Australia has contributed to improved understanding of contextual factors that influence antimicrobial prescribing, and barriers and facilitators of AMS implementation. This body of research has been underpinned by a commitment to supplementing 'big data' on antimicrobial prescribing practices, where available, with knowledge of the sociocultural, technical, environmental and other factors that shape prescribing behaviours. NCAS provided a unique opportunity for exchange and cross-pollination across the human and animal health programme domains. It has facilitated synergistic approaches to AMS research and education, and implementation of resources and stewardship activities. The NCAS programme aimed to synergistically combine quantitative and qualitative approaches to AMS research. In this article, we describe the qualitative findings of the first 5 years.