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1.
JAMA ; 2020 Feb 16.
Artigo em Inglês | MEDLINE | ID: mdl-32062674

RESUMO

Importance: Patients with chronic illness frequently use Physician Orders for Life-Sustaining Treatment (POLST) to document treatment limitations. Objectives: To evaluate the association between POLST order for medical interventions and intensive care unit (ICU) admission for patients hospitalized near the end of life. Design, Setting, and Participants: Retrospective cohort study of patients with POLSTs and with chronic illness who died between January 1, 2010, and December 31, 2017, and were hospitalized 6 months or less before death in a 2-hospital academic health care system. Exposures: POLST order for medical interventions ("comfort measures only" vs "limited additional interventions" vs "full treatment"), age, race/ethnicity, education, days from POLST completion to admission, histories of cancer or dementia, and admission for traumatic injury. Main Outcomes and Measures: The primary outcome was the association between POLST order and ICU admission during the last hospitalization of life; the secondary outcome was receipt of a composite of 4 life-sustaining treatments: mechanical ventilation, vasopressors, dialysis, and cardiopulmonary resuscitation. For evaluating factors associated with POLST-discordant care, the outcome was ICU admission contrary to POLST order for medical interventions during the last hospitalization of life. Results: Among 1818 decedents (mean age, 70.8 [SD, 14.7] years; 41% women), 401 (22%) had POLST orders for comfort measures only, 761 (42%) had orders for limited additional interventions, and 656 (36%) had orders for full treatment. ICU admissions occurred in 31% (95% CI, 26%-35%) of patients with comfort-only orders, 46% (95% CI, 42%-49%) with limited-interventions orders, and 62% (95% CI, 58%-66%) with full-treatment orders. One or more life-sustaining treatments were delivered to 14% (95% CI, 11%-17%) of patients with comfort-only orders and to 20% (95% CI, 17%-23%) of patients with limited-interventions orders. Compared with patients with full-treatment POLSTs, those with comfort-only and limited-interventions orders were significantly less likely to receive ICU admission (comfort only: 123/401 [31%] vs 406/656 [62%], aRR, 0.53 [95% CI, 0.45-0.62]; limited interventions: 349/761 [46%] vs 406/656 [62%], aRR, 0.79 [95% CI, 0.71-0.87]). Across patients with comfort-only and limited-interventions POLSTs, 38% (95% CI, 35%-40%) received POLST-discordant care. Patients with cancer were significantly less likely to receive POLST-discordant care than those without cancer (comfort only: 41/181 [23%] vs 80/220 [36%], aRR, 0.60 [95% CI, 0.43-0.85]; limited interventions: 100/321 [31%] vs 215/440 [49%], aRR, 0.63 [95% CI, 0.51-0.78]). Patients with dementia and comfort-only orders were significantly less likely to receive POLST-discordant care than those without dementia (23/111 [21%] vs 98/290 [34%], aRR, 0.44 [95% CI, 0.29-0.67]). Patients admitted for traumatic injury were significantly more likely to receive POLST-discordant care (comfort only: 29/64 [45%] vs 92/337 [27%], aRR, 1.52 [95% CI, 1.08-2.14]; limited interventions: 51/91 [56%] vs 264/670 [39%], aRR, 1.36 [95% CI, 1.09-1.68]). In patients with limited-interventions orders, older age was significantly associated with less POLST-discordant care (aRR, 0.93 per 10 years [95% CI, 0.88-1.00]). Conclusions and Relevance: Among patients with POLSTs and with chronic life-limiting illness who were hospitalized within 6 months of death, treatment-limiting POLSTs were significantly associated with lower rates of ICU admission compared with full-treatment POLSTs. However, 38% of patients with treatment-limiting POLSTs received intensive care that was potentially discordant with their POLST.

2.
Artigo em Inglês | MEDLINE | ID: mdl-31968182

RESUMO

RATIONALE: Gender gaps exist in academic leadership positions in critical care. Peer-reviewed publications are crucial to career advancement, yet little is known regarding gender differences in authorship of critical care research. OBJECTIVES: To evaluate gender differences in authorship of critical care literature. METHODS: We used a validated database of author gender to analyze authorship of critical care articles indexed in PubMed between 2008-2018 in 40 frequently-cited journals. High-impact journals were defined as those in the top 5% of all journals. We used mixed-effects logistic regression to evaluate the association of senior author gender with first and middle author gender, and first author gender with journal impact factor. RESULTS: Among 18,483 studies, 30.8% had female first authors and 19.5% had female senior authors. Female authorship rose slightly over the last decade (average annual increase of 0.44% (p<0.01) and 0.51% (p<0.01) for female first and senior authors, respectively). When the senior author was female, the odds of female co-authorship rose substantially (first author aOR1.93, 95%CI:1.71-2.17; middle author aOR1.48, 95%CI:1.29-1.69). Female first authors had higher odds of publishing in lower-impact journals than men (aOR1.30, 95%CI:1.16-1.45). CONCLUSIONS: Women comprise less than one-third of first authors and one-quarter of senior authors of critical care research, with minimal increase over the past decade. When the senior author was female, the odds of female co-authorship rose substantially. However, female first authors tend to publish in lower-impact journals. These findings may help explain the underrepresentation of women in critical care academic leadership positions and identify targets for improvement.

3.
Ann Emerg Med ; 75(2): 171-180, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31248675

RESUMO

STUDY OBJECTIVE: Physician Orders for Life-Sustaining Treatment (POLST) forms are intended to help prevent the provision of unwanted medical interventions among patients with advanced illness or frailty who are approaching the end of life. We seek to evaluate how POLST form completion, treatment limitations, or both influence intensity of treatment among patients who present to the emergency department (ED). METHODS: This was a retrospective cohort study of adults who presented to the ED at an academic medical center in Oregon between April 2015 and October 2016. POLST form completion and treatment limitations were the main exposures. Primary outcome was hospital admission; secondary outcomes included ICU admission and a composite measure of aggressive treatment. RESULTS: A total of 26,128 patients were included; 1,769 (6.8%) had completed POLST forms. Among patients with POLST, 52.1% had full treatment orders, and 6.4% had their forms accessed before admission. POLST form completion was not associated with hospital admission (adjusted odds ratio [aOR]=0.97; 95% confidence interval [CI] 0.84 to 1.12), ICU admission (aOR=0.82; 95% CI 0.55 to 1.22), or aggressive treatment (aOR=1.06; 95% CI 0.75 to 1.51). Compared with POLST forms with full treatment orders, those with treatment limitations were not associated with hospital admission (aOR=1.12; 95% CI 0.92 to 1.37) or aggressive treatment (aOR=0.87; 95% CI 0.5 to 1.52), but were associated with lower odds of ICU admission (aOR=0.31; 95% CI 0.16 to 0.61). CONCLUSION: Among patients presenting to the ED with POLST, the majority of POLST forms had orders for full treatment and were not accessed by emergency providers. These findings may partially explain why we found no association of POLST with treatment intensity. However, treatment limitations on POLST forms were associated with reduced odds of ICU admission. Implementation and accessibility of POLST forms are crucial when considering their effect on the provision of treatment consistent with patients' preferences.

4.
JAMA Oncol ; 2019 Sep 19.
Artigo em Inglês | MEDLINE | ID: mdl-31536133

RESUMO

Importance: Palliative care is a patient-centered approach associated with improvements in quality of life; however, results regarding its association with a survival benefit have been mixed, which may be a factor in its underuse. Objective: To assess whether early palliative care is associated with a survival benefit among patients with advanced lung cancer. Design, Setting, and Participants: This retrospective population-based cohort study was conducted among patients with lung cancer who were diagnosed with cancer between January 1, 2007, and December 31, 2013, with follow-up until January 23, 2017. Participants comprised 23 154 patients with advanced lung cancer (stage IIIB and stage IV) who received care in the Veterans Affairs health care system. Data were analyzed from February 15, 2019, to April 28, 2019. Exposure: Palliative care defined as a specialist-delivered palliative care encounter received after lung cancer diagnosis. Main Outcomes and Measures: The primary outcome was survival. The association between palliative care and place of death was also examined. Propensity score and time-varying covariate methods were used to calculate Cox proportional hazards and to perform regression modeling. Results: Of the 23 154 patients enrolled in the study, 57% received palliative care. The mean (SD) age of participants was 68 (9.5) years, and 98% of participants were men. An examination of the timing of palliative care receipt relative to cancer diagnosis found that palliative care received 0 to 30 days after diagnosis was associated with decreases in survival (adjusted hazard ratio [aHR], 2.13; 95% CI, 1.97-2.30), palliative care received 31 to 365 days after diagnosis was associated with increases in survival (aHR, 0.47; 95% CI, 0.45-0.49), and palliative care received more than 365 days after diagnosis was associated with no difference in survival (aHR, 1.00; 95% CI, 0.94-1.07) compared with nonreceipt of palliative care. Receipt of palliative care was also associated with a reduced risk of death in an acute care setting (adjusted odds ratio, 0.57; 95% CI, 0.52-0.64) compared with nonreceipt of palliative care. Conclusions and Relevance: The results suggest that palliative care was associated with a survival benefit among patients with advanced lung cancer. Palliative care should be considered a complementary approach to disease-modifying therapy in patients with advanced lung cancer.

5.
Lung Cancer ; 131: 47-57, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-31027697

RESUMO

INTRODUCTION: With advances in treatments among patients with lung cancer, it is increasingly important to understand patients' values and preferences to facilitate shared decision making. METHODS: Prospective, multicenter study of patients with treated stage I lung cancer. At the time of study participation, participants were 4-6 months posttreatment. Value clarification and discrete choice methods were used to elicit participants' values and treatment preferences regarding stereotactic body radiation therapy (SBRT) and surgical resection using only treatment attributes. RESULTS: Among 114 participants, mean age was 70 years (Standard Deviation = 7.9), 65% were male, 68 (60%) received SBRT and 46 (40%) received surgery. More participants valued independence and quality of life (QOL) as "most important" compared to survival or cancer recurrence. Most participants (83%) were willing to accept lung cancer treatment with a 2% chance of periprocedural death for only one additional year of life. Participants also valued independence more than additional years of life as most (86%) were unwilling to accept either permanent placement in a nursing home or being limited to a bed/chair for four additional years of life. Surprisingly, treatment discordance was common as 49% of participants preferred the alternative lung cancer treatment than what they received. CONCLUSIONS: Among participants with early stage lung cancer, maintaining independence and QOL were more highly valued than survival or cancer recurrence. Participants were willing to accept high periprocedural mortality, but not severe deficits affecting QOL when considering treatment. Treatment discordance was common among participants who received SBRT or surgery. Understanding patients' values and preferences regarding treatment decisions is essential to foster shared decision making and ensure treatment plans are consistent with patients' goals. Clinicians need more resources to engage in high quality communication during lung cancer treatment discussions.


Assuntos
Carcinoma Pulmonar de Células não Pequenas/epidemiologia , Tomada de Decisão Clínica/métodos , Neoplasias Pulmonares/epidemiologia , Preferência do Paciente/estatística & dados numéricos , Pneumonectomia , Radiocirurgia , Idoso , Carcinoma Pulmonar de Células não Pequenas/terapia , Feminino , Humanos , Neoplasias Pulmonares/terapia , Masculino , Recidiva Local de Neoplasia , Estadiamento de Neoplasias , Participação do Paciente , Estudos Prospectivos , Qualidade de Vida
6.
Am J Hosp Palliat Care ; 36(7): 564-570, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30700127

RESUMO

INTRODUCTION: The Oregon Physicians Orders for Life-Sustaining Treatment (POLST) Program allows patients with advanced illness to document end-of-life (EOL) care preferences. We examined the characteristics and associated EOL care among Veterans with and without a registered POLST. METHODS: Retrospective, cohort study of advanced-stage (IIIB and IV) patients with lung cancer who were diagnosed between 2008 and 2013 as recorded in the VA Central Cancer Registry. We examined a subgroup of 346 Oregon residents. We obtained clinical and sociodemographic variables from the VA Corporate Data Warehouse and EOL preferences from the Oregon POLST Registry. We compared hospice enrollment and place of death between those with and without a registered POLST. RESULTS: Twenty-two (n = 77) percent of our cohort had registered POLST forms. Compared to those without a registered POLST, Veterans with a POLST had a higher income ($51 456 vs $48 882) and longer time between diagnosis and death (223 days vs 119 days). Those with a registered POLST were more likely to be enrolled in hospice (adjusted odds ratio [aOR] = 2.37, 95% confidence interval [CI]: 1.01-5.54) and less likely to die in a VA facility (aOR = 0.27, 95% CI: 0.12-0.59). CONCLUSION: There was low submission to the POLST Registry among Veterans who received care in Veterans' Health Administration. Veterans who had a registered POLST were more likely to be enrolled in hospice and less likely to die in a VA care setting. The POLST may improve metrics of high-quality EOL care; however, opportunities for improvement in submission and implementation within the VA exist.


Assuntos
Planejamento Antecipado de Cuidados/organização & administração , Neoplasias Pulmonares/psicologia , Neoplasias Pulmonares/terapia , Assistência Terminal/psicologia , Veteranos/psicologia , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Oregon , Estudos Retrospectivos , Fatores Socioeconômicos
7.
J Thorac Oncol ; 14(2): 176-183, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30336324

RESUMO

INTRODUCTION: Patients with advanced lung cancer have a poor prognosis, but both chemotherapy and early palliative care (EPC) have been shown to improve survival and quality of life (QOL). The relationship between palliative care and receipt of chemotherapy receipt is understudied. We sought to determine if EPC is associated with chemotherapy receipt and intensity among patients with advanced stage lung cancer. METHODS: Retrospective cohort study of patients in the national Veterans Health Administration (VA) with stage IIIB or IV lung cancer diagnosed between January 2007- December 2013. EPC was defined as a specialist-delivered palliative care received within 90 days of cancer diagnosis. Outcomes included any chemotherapy receipt and high-intensity chemotherapy receipt defined as: i) more than 4 cycles of a platinum-based doublet, ii) ≥3 lines of chemotherapy, iii) Bevacizumab/Cetuximab triplet therapy, iv) Erlotinib use prior to 2011, and v) chemotherapy in the last days of life. Logistic regression was used to determine the association between EPC and chemotherapy receipt after adjustment for patient and tumor characteristics. RESULTS: Among the entire cohort (N=23,566), 37% received EPC and 45% received any chemotherapy. Among those with EPC, 34% received chemotherapy compared to 51% among those without EPC (Adjusted Odds Ratio (AOR=0.55, 95% CI: 0.51-0.58). Patients who received EPC had reduced receipt of high-intensity chemotherapy including >4 cycles of platinum-based doublet (AOR=0.68, 95% CI: 0.60-0.77), ≥ 3 lines of chemotherapy (AOR=0.61, 95% CI: 0.53-0.71), triplet therapy (AOR=0.68, 95% CI: 0.56-0.82) and use of erlotinib prior to 2011 (AOR=0.66, 95% CI: 0.55-0.79). Patients with EPC were more likely to receive chemotherapy in the last 14 (AOR=1.65, 95% CI: 1.44-1.87) and 30 days (AOR=1.67, 95% CI: 1.51-1.85) of life compared to those without EPC. CONCLUSIONS: EPC was associated with reduced receipt of both any chemotherapy and high-intensity chemotherapy. However, receipt of chemotherapy at the very end-of-life was increased among patients with EPC compared to those without EPC. Among patients with advanced lung cancer, EPC may optimize patient selection for chemotherapy receipt leading to reduced use of high-intensity therapy by focusing on quality of life in accordance with patients' performance, preferences and goals of care.

8.
Ann Am Thorac Soc ; 15(11): 1256-1264, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30382786

RESUMO

Telemedicine coverage of intensive care units is an organizational innovation that has been touted as a means to improve access to and quality of critical care. The purpose of this narrative review is to discuss the different organizational models of intensive care unit telemedicine and factors that have influenced its adoption and to review the existing literature to consider whether it has lived up to its promise. We conclude by suggesting future directions to fill in some of the existing gaps in the literature.


Assuntos
Cuidados Críticos/organização & administração , Telemedicina/organização & administração , Humanos
9.
Ann Am Thorac Soc ; 2018 Aug 09.
Artigo em Inglês | MEDLINE | ID: mdl-30092141

RESUMO

Telemedicine coverage of intensive care units (ICUs) is an organizational innovation that has been touted as a means to improve access to and quality of critical care. The purpose of this narrative review is to discuss the different organizational models of ICU telemedicine and factors that have influenced its adoption, and to review the existing literature to consider whether it has lived up to its promise. We conclude by suggesting future directions to fill in some of the existing gaps in the evidence.

10.
Crit Care Med ; 46(3): 347-353, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29474319

RESUMO

OBJECTIVE: Many ICU patients do not require critical care interventions. Whether aggressive care environments increase risks to low-acuity patients is unknown. We evaluated whether ICU acuity was associated with outcomes of low mortality-risk patients. We hypothesized that admission to high-acuity ICUs would be associated with worse outcomes. This hypothesis was based on two possibilities: 1) high-acuity ICUs may have a culture of aggressive therapy that could lead to potentially avoidable complications and 2) high-acuity ICUs may focus attention toward the many sicker patients and away from the fewer low-risk patients. DESIGN: Retrospective cohort study. SETTING: Three hundred twenty-two ICUs in 199 hospitals in the Philips eICU database between 2010 and 2015. PATIENTS: Adult ICU patients at low risk of dying, defined as an Acute Physiology and Chronic Health Evaluation-IVa-predicted mortality of 3% or less. EXPOSURE: ICU acuity, defined as the mean Acute Physiology and Chronic Health Evaluation IVa score of all admitted patients in a calendar year, stratified into quartiles. MEASUREMENTS AND MAIN RESULTS: We used generalized estimating equations to test whether ICU acuity is independently associated with a primary outcome of ICU length of stay and secondary outcomes of hospital length of stay, hospital mortality, and discharge destination. The study included 381,997 low-risk patients. Mean ICU and hospital length of stay were 1.8 ± 2.1 and 5.2 ± 5.0 days, respectively. Mean Acute Physiology and Chronic Health Evaluation IVa-predicted hospital mortality was 1.6% ± 0.8%; actual hospital mortality was 0.7%. In adjusted analyses, admission to low-acuity ICUs was associated with worse outcomes compared with higher-acuity ICUs. Specifically, compared with the highest-acuity quartile, ICU length of stay in low-acuity ICUs was increased by 0.24 days; in medium-acuity ICUs by 0.16 days; and in high-acuity ICUs by 0.09 days (all p < 0.001). Similar patterns existed for hospital length of stay. Patients in lower-acuity ICUs had significantly higher hospital mortality (odds ratio, 1.28 [95% CI, 1.10-1.49] for low-; 1.24 [95% CI, 1.07-1.42] for medium-, and 1.14 [95% CI, 0.99-1.31] for high-acuity ICUs) and lower likelihood of discharge home (odds ratio, 0.86 [95% CI, 0.82-0.90] for low-, 0.88 [95% CI, 0.85-0.92] for medium-, and 0.95 [95% CI, 0.92-0.99] for high-acuity ICUs). CONCLUSIONS: Admission to high-acuity ICUs is associated with better outcomes among low mortality-risk patients. Future research should aim to understand factors that confer benefit to patients with different risk profiles.


Assuntos
Unidades de Terapia Intensiva/estatística & dados numéricos , APACHE , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
11.
Crit Care Med ; 45(10): 1607-1615, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28640021

RESUMO

OBJECTIVES: Identifying subgroups of ICU patients with similar clinical needs and trajectories may provide a framework for more efficient ICU care through the design of care platforms tailored around patients' shared needs. However, objective methods for identifying these ICU patient subgroups are lacking. We used a machine learning approach to empirically identify ICU patient subgroups through clustering analysis and evaluate whether these groups might represent appropriate targets for care redesign efforts. DESIGN: We performed clustering analysis using data from patients' hospital stays to retrospectively identify patient subgroups from a large, heterogeneous ICU population. SETTING: Kaiser Permanente Northern California, a healthcare delivery system serving 3.9 million members. PATIENTS: ICU patients 18 years old or older with an ICU admission between January 1, 2012, and December 31, 2012, at one of 21 Kaiser Permanente Northern California hospitals. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We used clustering analysis to identify putative clusters among 5,000 patients randomly selected from 24,884 ICU patients. To assess cluster validity, we evaluated the distribution and frequency of patient characteristics and the need for invasive therapies. We then applied a classifier built from the sample cohort to the remaining 19,884 patients to compare the derivation and validation clusters. Clustering analysis successfully identified six clinically recognizable subgroups that differed significantly in all baseline characteristics and clinical trajectories, despite sharing common diagnoses. In the validation cohort, the proportion of patients assigned to each cluster was similar and demonstrated significant differences across clusters for all variables. CONCLUSIONS: A machine learning approach revealed important differences between empirically derived subgroups of ICU patients that are not typically revealed by admitting diagnosis or severity of illness alone. Similar data-driven approaches may provide a framework for future organizational innovations in ICU care tailored around patients' shared needs.


Assuntos
Análise por Conglomerados , Cuidados Críticos , Unidades de Terapia Intensiva , Aprendizado de Máquina , Idoso , California , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Determinação de Necessidades de Cuidados de Saúde
13.
Ann Am Thorac Soc ; 11(2): 167-72, 2014 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-24575984

RESUMO

RATIONALE: Time-varying demand for critical care may strain the capacities of intensive care units (ICUs) to provide optimal care. Intensivists and ICU nurses may be the best judges of the strain on their ICU. Yet, it is not clear what ICU and hospital factors contribute to this perceived sense of strain among ICU providers. OBJECTIVES: To identify measureable ICU and hospital factors associated with perceived strain by intensivists and ICU nurses. METHODS: During a 6-month prospective cohort study, we surveyed nurses and physicians responsible for bed management regarding the ability of a 24-bed medical ICU (MICU) to provide optimal critical care. We simultaneously assessed time-varying ICU-level factors, including patient census, number of admissions, average patient acuity, number of interhospital transfer requests, and censuses of other hospital units. To identify factors associated with strain, we used an algorithm for covariate selection in regression models that selects variables that contribute sufficiently to model prediction to justify their inclusion. MEASUREMENTS AND MAIN RESULTS: Of 254 surveys, 226 (89%) were completed by 18 charge nurses and 17 physicians. On a scale of 1 to 10 (where a higher score indicated more strain), the median perceived strain score among nurses was 6 (interquartile range, 3-7) and among physicians was 5 (interquartile range, 3-7), with moderate correlation within days (interclass correlation coefficient, 0.45; 95% confidence interval: 0.30, 0.60). Average patient acuity, MICU census, number of MICU admissions, and general ward census were included in the most efficient model of strain perceived by nurses. Only MICU census was strongly associated with strain perceived by physicians. CONCLUSIONS: A model containing commonly available metrics of ICU census, average patient acuity, and the proportion of new admissions has validity as a model of ICU nurses' perceived ICU capacity strain. However, only ICU census was associated with increased perceived capacity strain by physicians, highlighting the need for involvement of multiple stakeholder groups to improve our understanding of ICU capacity strain.


Assuntos
Atitude do Pessoal de Saúde , Ocupação de Leitos/estatística & dados numéricos , Enfermagem de Cuidados Críticos/normas , Cuidados Críticos/normas , Número de Leitos em Hospital/estatística & dados numéricos , Unidades de Terapia Intensiva/estatística & dados numéricos , Corpo Clínico Hospitalar , Supervisão de Enfermagem , APACHE , Estudos de Coortes , Feminino , Necessidades e Demandas de Serviços de Saúde , Humanos , Modelos Lineares , Masculino , Análise Multivariada , Transferência de Pacientes/estatística & dados numéricos , Estudos Prospectivos , Inquéritos e Questionários
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