Neighborhood Socioeconomic Disadvantage and Acute Care Utilization in Washington State Medicaid: A Retrospective Cohort Study.

BACKGROUND: Neighborhood disadvantage has been associated with potentially preventable acute care utilization among Medicare beneficiaries, but this association has not been studied in a Medicaid population, which is important for informing more equitable care and policies for this population. OBJECTIVE: To describe the association between Area Deprivation Index (ADI) and acute care utilization (including potentially preventable utilization) among Medicaid beneficiaries in Washington State. DESIGN: Retrospective cohort study of 100% Medicaid claims. Mixed effects logistic regression was applied to estimate the association between state-level ADI decile and acute care utilization, adjusting for age, sex, self-identified race and ethnicity, Charlson Comorbidity Index, primary spoken language, individual Federal Poverty Level, homelessness, and rurality. Standard errors were clustered at the Census block group level. PARTICIPANTS: 1.5 million unique adult Medicaid beneficiaries enrolled for at least 11 months of a calendar year during the period 2017-2021. MAIN MEASURES: Binary measures denoting receipt of ED visits, low-acuity ED visits, hospitalizations in a calendar year. KEY RESULTS: Increasing levels of neighborhood socioeconomic disadvantage (by ADI decile) were associated with greater odds of any ED visits (adjusted odds ratio (aOR) 1.07, 95% confidence interval (CI) 1.06-1.07), low-acuity ED visits (aOR 1.08, CI 1.08-1.08), and any hospitalizations (aOR 1.02, CI 1.02-1.02). CONCLUSIONS: Among Medicaid beneficiaries, greater neighborhood socioeconomic disadvantage was associated with increased acute care utilization, including potentially preventable utilization. These findings signal potential barriers to outpatient care access that could be amenable to future intervention by health systems and payers.

Nutritional status and body composition of patients with head and neck cancer treated with perioperative evidence-based nutritional management.

We aimed to describe nutritional status and body composition profiles perioperative head and neck cancer (HNC) patients managed with whole-course nutritional support. Scored Nutritional Risk Screening (NRS 2002), Patient-Generated Subjective Global Assessment (PG-SGA), and body composition were conducted. The factors related to weight loss and skeletal muscle mass (SMM) were identified. Lower weight and body composition levels in low skeletal muscle index (SMI≤9.90 kg/m2) group were observed. Levels of albumin, prealbumin, prognostic nutritional index (PNI), and lymphocyte-to-monocyte ratio (LMR) were lower than pre-operative, but the values after 2 weeks were higher than 1 week post-operatively (all p<0.01). The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were increased at 1 and 2 weeks post-operative compared to pre-operative (both p<0.01). Post-operatively, NLR at 2 weeks was lowed than 1 week (p = 0.02). A negative correlation was observed between SMM loss and serum prealbumin (r = -0.255, p = 0.029). Pre-operative BMI (p<0.01), tumor differentiation (p = 0.003), and nutritional risk (p = 0.049) were risk factors for weight loss. In conclusions, for perioperative HNC patients, loss of adipose tissue occurred earlier than muscle. Prealbumin should be considered as an indicator for monitoring of recovery in clinical practice.

Evaluation of malnutrition by objective nutritional indexes and predictors in hospitalized patients with COVID-19.

Nutritional information on hospitalized patients with COVID-19 is limited. We aimed to (1) investigate the prevalence of nutrition risk defined by the Scored Nutritional Risk Screening (NRS 2002) and malnutrition assessed by prognostic nutritional index (PNI) and controlling nutritional status score (CONUT), (2) observe the nutritional intervention, and (3) explore the predictors of critical condition and mortality. Nutritional risk was 53.00% and the prevalence of malnutrition was 79.09% and 88.79% among 464 patients based on PNI and CONUT, respectively. The area under the receiver operating characteristic curve for hypersensitivity C-reactive protein (hs-CRP), platelet-to-lymphocyte ratio (PLR), PNI, neutrophil/lymphocyte ratio (NLR), systemic immune-inflammation index (SII), and CONUT were 0.714, 0.677, 0.243, 0.778, 0.742, and 0.743, respectively, in discerning critical patients. The mortality-related area under the curve of hs-CRP, PLR, PNI, NLR, SII, and CONUT were 0.740, 0.647, 0.247, 0.814, 0.758, and 0.767, respectively. The results showed that CONUT and NLR were significantly correlated with the critical conditions. Our study revealed a high prevalence of nutritional risk and malnutrition among hospitalized patients with COVID-19. NLR, PLR, hs-CRP, SII, and CONUT are independent predictors of critical conditions and mortality. CONUT and NLR could assist clinicians in discerning critical cases.

Whole-course nutritional support therapy and indicators in head and neck cancer surgery.

BACKGROUND AND OBJECTIVES: This study investigated the effect of continuous perioperative nutritional support provided by a multidisciplinary team (MDT) to patients who underwent surgery for head and neck cancer (HNC). METHODS AND STUDY DESIGN: This study enrolled 99 patients with HNC and divided them into two groups: a management group (n=48), comprising patients who underwent surgery between August and December 2020 and received continuous perioperative nutritional support from the MDT; and a control group (n=51), comprising patients who underwent surgery between June and December 2017 and received routine nutritional guidance. Data on weight, nutritional indicators, and the prognostic nutritional index (PNI) were collected. We compared the changes in weight, nutritional indicators, PNI, Patient-Generated Subjective Global Assessment (PG-SGA) scores, and body composition. Factors influencing the PNI were analysed. RESULTS: The minimum weight, nutritional indicator, and PNI values observed postoperatively and at discharge were lower than those observed at admission. The serum nutritional index values observed at discharge and minimum PNI values observed postoperatively and at discharge were higher in the management group than in the control group. The PG-SGA score at 2 weeks postoperatively was higher than that on the day of surgery in the management group. The discharge PNI was influenced by management and age in these HNC surgical patients. In the management group, body composition data did not differ significantly between the preoperative and 1-, 2-, and 3-week postoperative time points. CONCLUSIONS: Continuous perioperative nutritional support by an MDT can improve the weight and serum nutritional index of patients receiving surgery for HNC and improve the PNI at discharge.

Safety and Efficacy of Transcatheter Occlusion of Perimembranous Ventricular Septal Defect with Aortic Valve Prolapse: A Six-Year Follow-Up Study.

BACKGROUND: With the rapid development of transcatheter techniques and instruments, transcatheter occlusion for patients with perimembranous ventricular septal defect (pVSD) and aortic valve prolapse (AVP) was constantly being tried, while the efficacy and safety of pVSD with AVP remain controversial. OBJECTIVE: The aim of this study was to evaluate long-term efficacy and safety of transcatheter occlusion of pVSD with AVP. METHODS: We retrospectively analyzed 164 children with pVSD and AVP who underwent transcatheter occlusion between January 2013 and November 2014. AVP was divided into 3 degrees according to right coronary leaflet morphology at end-diastole during aortic root angiography. Patient demographic and clinical data were collected. RESULTS: There were 97 males and 67 females (median age, 40.0 (30.0-62.7) months; average weight, 16.94 ± 9.02 kg). Mild (n = 63), moderate (n = 89), and severe (n = 12) AVP success rates were 93.7%, 89.9%, and 58.3%, respectively. Immediately after procedure, there was no new-onset aortic regurgitation (AR) above trivial degree, residual shunt above mild degree, or complications requiring medication or operation, except for 1 patient who developed transient complete atrioventricular block. During follow-up, 1 mild AVP patient aggravated from mild to moderate AR and 1 moderate AVP patient aggravated from trivial to moderate AR. The new-onset AR in mild, moderate, and severe AVP was 2%, 1.8%, and 20%, respectively. AR disappeared in 17 patients. Residual shunt occurred in 9 patients after procedure, 4 of which disappeared during the follow-up period. No serious complications occurred in any patient during follow-up. Five-year cardiovascular event-free survival rates for mild, moderate, and severe AVP were 89.6%, 94.5%, and 80.0%, respectively. CONCLUSION: Transcatheter occlusion of pVSD with mild and moderate AVP has a high success rate and few complications, which is safe and effective in long-term follow-up. Transcatheter occlusion of pVSD with severe AVP has low success rates and high AR incidence. Therefore, transcatheter occlusion of pVSD with AVP is recommended for mild to moderate, but not severe, AVP.

Use of Chronic Care Management Among Primary Care Clinicians.

The Centers for Medicare and Medicade Services (CMS) initiated chronic care management (CCM) codes to reimburse clinicians for coordination activities, but little is known about uptake over time. We find that primary care clinicians drove increasing use over 4 years-a trend that may reflect either new coordination activities or new reimbursements for existing activities. That 5% of chronic care management was denied by Medicare underscores the need for future work evaluating facilitators and barriers to use. Such insight is especially vital given the large number of eligible beneficiaries that have not received chronic care management to date, as well as the limited number of clinicians who currently deliver these services.

Effects and mechanistic aspects of absorbing organic compounds by coking coal.

Coal is a porous medium and natural absorbent. It can be used for its original purpose after adsorbing organic compounds, its value does not reduce and the pollutants are recycled, and then through systemic circulation of coking wastewater zero emissions can be achieved. Thus, a novel method of industrial organic wastewater treatment using adsorption on coal is introduced. Coking coal was used as an adsorbent in batch adsorption experiments. The quinoline, indole, pyridine and phenol removal efficiencies of coal adsorption were investigated. In addition, several operating parameters which impact removal efficiency such as coking coal consumption, oscillation contact time, initial concentration and pH value were also investigated. The coking coal exhibited properties well-suited for organics' adsorption. The experimental data were fitted to Langmuir and Freundlich isotherms as well as Temkin and Redlich-Peterson (R-P) models. The Freundlich isotherm model provided reasonable models of the adsorption process. Furthermore, the purification mechanism of organic compounds' adsorption on coking coal was analysed.

Efficient two-step chemo-enzymatic synthesis of all-trans-retinyl palmitate with high substrate concentration and product yield.

A new two-step chemo-enzymatic approach for highly efficient synthesis of all-trans-retinyl palmitate is constructed in this study. In the first step, retinyl acetate as starting material was fully hydrolyzed to retinol by potassium hydroxide. In the hydrolysis system, anhydrous ethanol was the best co-solvent to increase the solubility of retinyl acetate. The addition amounts of 5 M potassium hydroxide and anhydrous ethanol were 8 and 10 mL against 10 g retinyl acetate, respectively, and 100 % hydrolysis rate was obtained. In the second step, esterification was catalyzed by immobilized lipase on macroporous acrylic resin AB-8 using the extracted retinol and palmitic acid as substrates in non-aqueous system. After optimization, the parameters of esterification reaction were confirmed as follows: non-aqueous solvent was selected as n-hexane, washing times of extraction solution was four times, retinol concentration was 300 g/L, substrate molar ratio of retinol to palmitic acid was 1:1.1, the amount of immobilized enzyme was 10 g/L, and the esterification temperature was 30 °C. Under the optimal conditions, this protocol resulted in a 97.5 % yield of all-trans-retinyl palmitate in 700-L reactor. After purification, all-trans-retinyl palmitate was obtained with above 99 % of purity and 88 % of total recovery rate. This methodology provides a promising strategy for the large-scale production of all-trans-retinyl palmitate.

Effect of conjugated linoleic acid on blood pressure: a meta-analysis of randomized, double-blind placebo-controlled trials.

BACKGROUND: Numerous studies on animals evidenced that conjugated linoleic acid (CLA) could decrease blood pressure (BP) in several rat models. However, such beneficial effect is not completely supported by studies on humans. METHODS: We searched the Pubmed, Cochrane Library, and the ClinicalTrials.gov databases for relevant randomized, double-blind placebo-controlled trials up to August 2014 to perform a meta-analysis. A random-effects model was used to calculate the combined treatment effects. RESULTS: Eight studies with nine trials, which involved 638 participants with CLA supplementation ranging from 2.0 g/day to 6.8 g/day, were included in this meta-analysis. Compared with placebo, the pooled estimate of change was -0.03 mm Hg (95% CI: -2.29, 2.24, P=0.98) and 0.69 mm Hg (95% CI: -1.41, 2.80, P=0.52) in systolic and diastolic BPs, respectively. No significant heterogeneity across studies for systolic BP; however, substantial heterogeneity for diastolic BP was identified. Publication bias was not found for both systolic and diastolic BPs. CONCLUSION: The findings of this meta-analysis did not support the overall favorable effect of CLA supplementation on BP regulation.

Prediction of Coal Ash Flow Temperature Based on Gray Relational Analysis, Support Vector Regression and Genetic Algorithm.

Coal ash flow temperature significantly influences the operating conditions of entrained flow bed gasification. The relationship between the flow temperature of coal ash and its chemical composition remains uncertain despite being determined by it. To construct a reliable and accurate predictive method, machine learning models were used, and different support vector regression models were built to predict the flow temperature. The prediction results of the proposed gray relational analysis-genetic algorithm-support vector regression model can achieve high accuracy, with a root-mean-square error of 28.37, mean absolute error of 19.48K, and average deviation of 1.58%. Moreover, the prediction results of the proposed model are more accurate and efficient than those calculated by FactSage software, with a mean absolute error of 93.73K. This demonstrates the viability of applying the proposed machine learning model to predict the flow temperature of coal ash and its promising potential application in the area of coal chemical engineering.

Oral diet management for carcinoma at the base of tongue with radiotherapy and chemotherapy associated dysphagia: a case report.

Introduction: Tongue cancer is one of the common malignancy of the head and neck, and directly impacts chewing, swallowing, and other eating activities. Based on the evidence-based guidelines and clinical management, this paper presents nutrition management experience of a patient with tongue cancer who had a dysphagia and feeding reflux while undergoing radiotherapy and chemotherapy. Methods: Nutritional risk screening and comprehensive nutritional assessment were performed based on the patient's medical history, and personalized nutritional programs were developed under the guidance of the clinical pharmaceutical consensus of parenteral nutrition and nutritional treatment guidelines for patients with tumors during radiotherapy. For the management of oral feeding, the patient's swallowing function was evaluated to manage oral feeding. Thickening powders were used to improve the consistency of the patient's food, which successfully achieved oral feeding of the patient. Results: The patient finally ate five meals a day by mouth, and energy requirements were met using industrialized nutritional supplements, and homogenized food was added in between the meals. The energy provided by enteral nutrition can reached approximately 60-75%. The patient's weight and albumin levels had increased significantly at the time of discharge. Discussion: The nutritional management of patients with dysphagia should be jointly managed by clinicians, nurses, nutritionists, and family members to effectively improve the quality of life (QOL) and nutritional status of patients. To ensure adequate nutritional supply, appropriate swallowing training may delay the deterioration of the chewing function and improve the eating experience of such patients.

Association Between Capitated Payments and Preventive Care Among U.S. Adults.

Introduction: There is increasing interest in using capitation rather than fee for service to promote primary care and population health. The goal of this study was to examine the association between practice reimbursement mix (majority fee for service versus majority capitation versus other) and receipt of common preventive screening examinations and health counseling from 2012 to 2018. Methods: Using the National Ambulatory Medical Care Survey, a retrospective cross-sectional study of 24,864 visits with primary care clinicians among patients aged 18-75 years without a cancer diagnosis was conducted. The main dependent measures were age- and sex-appropriate receipt of breast cancer screening, osteoporosis screening, cervical cancer screening, chlamydia testing, colon cancer screening, diabetes screening, and hyperlipidemia screening as well as 3 health counseling items. Multivariable logistic regression was performed to assess the association between reimbursement mix and receipt of preventive care, adjusted for patient, visit, and practice characteristics. Results: Majority capitation reimbursement was associated with a greater likelihood of receiving breast cancer screening (AOR=2.11, 95% CI=1.16, 3.84, p=0.014) and osteoporosis screening (AOR=4.34, 95% CI=1.74, 10.8, p=0.0017) than majority fee-for-service or other reimbursement mixes. Reimbursement mix was not associated with the likelihood of receiving 9 other preventive care or health counseling services. Conclusions: Larger amounts of capitation reimbursement may improve some but not all aspects of preventive care compared with fee for service.

Progression of aortic regurgitation following transcatheter closure of intracristal ventricular septal defects in children: a mid- to long-term follow-up study.

Background: Early surgical closure is warranted to prevent aortic valve lesion and aortic regurgitation (AR) in intracristal ventricular septal defects (icVSDs). Experiences for transcatheter device closure of icVSDs are still limited. Our objectives are to investigate AR progression following transcatheter closure of icVSDs in children and to explore the risk factors for AR progression. Methods and results: From January 2007 to December 2017, 50 children with icVSD who had successfully undergone transcatheter closure were enrolled. With 4.0 (interquartile range: 3.0-6.2) years of follow-up, AR progression was observed in 20% (10/50) of patients after icVSD occlusion, among which 16% (8/50) remained in mild level and 4% (2/50) evolved to moderate. None progressed to severe AR. Freedom from AR progression was 84.0%, 79.5%, and 79.5% at 1, 5, and 10 years of follow-up. A multivariate Cox proportional-hazards model revealed that x-ray exposure time [hazard ratio (HR): 1.11, 95% confidence interval (CI): 1.04-1.18, P = 0.001] and the ratio of pulmonary to systemic blood flows (HR: 3.38, 95% CI: 1.11-10.29, P = 0.032) were independent predictors for AR progression. Conclusions: Our study suggested that transcatheter closure of icVSD in children is safe and feasible in mid- to long-term follow-up. No serious AR progression occurred after icVSD device closure. Greater left-to-right shunting and longer x-ray exposure time were both risk factors for AR progression.

Comparison of GLIM, SGA, PG-SGA, and PNI in diagnosing malnutrition among hepatobiliary-pancreatic surgery patients.

Objective: To compare the diagnostic value of four tools-the Global Leadership Initiative on Malnutrition (GLIM) criteria, the subjective global assessment (SGA), patient-generated subjective global assessment (PG-SGA), and prognostic nutritional index (PNI) in malnutrition among hospitalized patients undergoing hepatobiliary-pancreatic surgery. Meanwhile, to observe the nutritional intervention of these patients. Methods: Present study was a cross-sectional study, including 506 hospitalized patients who underwent hepatobiliary-pancreatic surgery between December 2020 and February 2022 at Ningbo Medical Center Lihuili Hospital, China. The incidence rate of malnutrition was diagnosed using the four tools. The consistency of the four tools was analyzed by Cohen's kappa statistic. Data, including nutritional characteristics and nutritional interventions, were collected. The nutritional intervention was observed according to the principles of Five Steps Nutritional Treatment. Results: The prevalence was 36.75, 44.58, and 60.24%, as diagnosed by the GLIM, PG-SGA, and PNI, respectively, among 332 tumor patients. Among the 174 non-tumor patients, the prevalence was 9.77, 10.92, and 32.18% as diagnosed by the GLIM, SGA, and PNI. The diagnostic concordance of PG-SGA and GLIM was higher (Kappa = 0.814, <0.001) than SGA vs. GLIM (Kappa = 0.752, P < 0.001) and PNI vs. GLIM (Kappa = 0.265, P < 0.001). The univariate analysis revealed that older age, lower BMI and tumorous were significantly associated with nutritional risks and malnutrition. Among 170 patients with nutritional risk, most of patients (118/170, 69.41%) did not meet the nutritional support standard. Conclusion: The incidence of nutritional risk and malnutrition is high among patients with hepatobiliary and pancreatic diseases, specifically those with tumors. The GLIM showed the lowest prevalence of malnutrition among the four tools. The PG-SGA and GLIM had a relative high level of agreement. There was a low proportion of nutritional support in patients. More prospective and well-designed cohort studies are needed to confirm the relevance of these criteria in clinical practice in the future.

Organizational capacity among hospitals in Medicare and commercial bundled payments.

OBJECTIVES: Hospitals must strategically build organizational capacities to succeed in bundled payment arrangements. Given differences between Medicare and commercial arrangements, capacities may vary between hospitals in Medicare vs both Medicare and commercial bundled payment programs. This study compared organizational capacities between these 2 hospital groups. STUDY DESIGN: National survey of American Hospital Association (AHA) member hospitals with experience in bundled payment programs. METHODS: We analyzed data from October 31, 2017, to April 30, 2018, collected from AHA member hospitals with bundled payment experience in only Medicare (Medicare-only hospitals) or in both Medicare and commercial insurers (multipayer hospitals). Survey questions examined capacity in 4 areas: (1) physician performance feedback, (2) care management, (3) postacute care provider utilization, and (4) health information technology. RESULTS: Our sample included 114 hospitals reporting experience in Medicare or commercial bundled payment programs. Both Medicare-only and multipayer hospitals reported high organizational capacities in performance measurement of physician-level quality and cost feedback and in incorporation of health information technology. More multipayer hospitals reported high capacity for coordinating hospital to postacute care settings (88% vs 52%). Although nearly all hospitals in both groups reported formalized relationships with skilled nursing facilities (98%), fewer hospitals reported such relationships with long-term acute care hospitals (83%) and inpatient rehabilitation facilities (80%). CONCLUSIONS: Although they have similar capacity in a number of areas, Medicare-only and multipayer hospitals differed with respect to other aspects of organizational capacity.

Organizational Capacity of Hospitals Co-Participating in Accountable Care Organizations and Bundled Payments.

Building organizational capacity is critical for hospitals participating in payment models such as bundled payments and accountable care organizations, particularly "co-participant" hospitals with experience in both models. This study used a national survey of American Hospital Association member hospitals with bundled payment experience, with (co-participant hospitals) or without (bundled payment hospitals) accountable care organization experience. Questions examined capacity in 4 domains: performance feedback, postacute care provider utilization, care management, and health information technology. Of 424 hospitals, 38% responded. Both co-participant and bundled payment hospitals reported high capacity for performance feedback and risk stratification and predictive risk assessment using health information technology systems. The hospital groups did not differ in care management capacity, but bundled payment hospitals reported higher postacute care provider utilization capacity. Experience with multiple payment models may prompt hospitals to make different investments or adopt different strategies than hospitals with experience in a single model.

Nationwide Hospital Performance on Publicly Reported Episode Spending Measures.

BACKGROUND: Medicare has implemented strategies to improve value by containing hospital spending for episodes of care. Compared with payment models, publicly reported episode-based spending measures are underrecognized strategies. OBJECTIVE: To provide the first nationwide description of hospitals' episode-based spending based on publicly reported Clinical Episode-Based Payment (CEBP) measures. DESIGN, SETTING, AND PARTICIPANTS: We used 2017 Hospital Compare data to assess spending on six CEBPs among 1,778 hospitals. We examined spending variation and its drivers, correlation between CEBPs, and spending by cost performance categories (for individual CEBPs, below vs above average spending; for across-CEBP comparisons, high vs low vs mixed cost). We also compared hospital spending performance on CEBPs with a global Medicare Spending Per Beneficiary measure. MAIN OUTCOMES AND MEASURES: Episode spending. RESULTS: Episode spending varied by CEBP type, with skilled nursing facility (SNF) care accounting for the majority of spending variation for procedural episodes but not for condition episodes. Across CEBPs, greater proportions of episode spending were attributed to SNF care at high-(18.1%) vs mixed-(10.7%) vs low-cost (9.2%) hospitals (P > .001). There was low within-hospital CEBP correlation and low correlation and concordance between hospitals' CEBP and Medicare Spending Per Beneficiary performance. CONCLUSIONS: Variation reduction and savings opportunities in SNF care for procedural episodes suggest that they may be better suited for existing payment models than condition episodes are. Spending performance was not hospital specific, which highlights the potential utility of episode spending measures beyond global measures.

The one-year impact of accountable care networks among Washington State employees.

OBJECTIVE: To estimate the impact of a new, two-sided risk model accountable care network (ACN) on Washington State employees and their families. DATA SOURCES/STUDY SETTING: Administrative data (January 2013-December 2016) on Washington State employees. STUDY DESIGN: We compared monthly health care utilization, health care intensity as measured through proxy pricing, and annual HEDIS quality metrics between the five intervention counties to 13 comparison counties, analyzed separately by age categories (ages 0-5, 6-18, 19-26, 18-64). DATA COLLECTION/EXTRACTION METHODS: We used difference-in-difference methods and generalized estimating equations to estimate the effects after 1 year of implementation for adults and children. PRINCIPAL FINDINGS: We estimate a 1-2 percentage point decrease in outpatient hospital visits due to the introduction of ACNs (adults: -1.8, P < .01; age 0-5: -1.2, P = .07; age 6-18: -1.2, P = .06; age 19-26; -1.2, P < .01). We find changes in primary and specialty care office visits; the direction of impact varies by age. Dependents age 19-26 were also responsive with inpatient admissions declines (-0.08 percentage points, P = .02). Despite changes in utilization, there was no evidence of changes in intensity of care and mixed results in the quality measures. CONCLUSIONS: Washington's state employee ACN introduction changed health care utilization patterns in the first year but was not as successful in improving quality.