Variations in access to specialty care for children with severe burns.

BACKGROUND: Pediatric burns account for 120,000 emergency department visits and 10,000 hospitalizations annually. The American Burn Association has guidelines regarding referrals to burn centers; however there is variation in burn center distribution. We hypothesized that disparity in access would be related to burn center access. METHODS: Using weighted discharge data from the Nationwide Inpatient Sample 2001-2011, we identified pediatric patients with International Classification of Diseases-9th Revision codes for burns that also met American Burn Association criteria. Key characteristics were compared between pediatric patients treated at burn centers and those that were not. RESULTS: Of 54,529 patients meeting criteria, 82.0% (n = 44,632) were treated at burn centers. Patients treated at burn centers were younger (5.6 versus 6.7 years old; p < 0.0001) and more likely to have burn injuries on multiple body regions (88% versus 12%; p < 0.0001). In urban areas, 84% of care was provided at burn centers versus 0% in rural areas (p < 0.0001), a difference attributable to the lack of burn centers in rural areas. Both length of stay and number of procedures were significantly higher for patients treated at burn centers (7.3 versus 4.4 days, p < 0.0001 and 2.3 versus 1.1 procedures, p < 0.0001; respectively). There were no significant differences in mortality (0.7% versus 0.8%, p = 0.692). CONCLUSION: The majority of children who met criteria were treated at burn centers. There was no significant difference between geographical regions. Of those who were treated at burn centers, more severe injury patterns were noted, but there was no significant mortality difference. Further study of optimal referral of pediatric burn patients is needed.

Timely access to care for patients with critical burns in India: a prehospital prospective observational study.

BACKGROUND: Low/middle-income countries carry a disproportionate burden of the morbidity and mortality from thermal burns. Nearly 70% of burn deaths worldwide are from thermal burns in India. Delays to medical care are commonplace and an important predictor of outcomes. We sought to understand the role of emergency medical services (EMS) as part of the healthcare infrastructure for thermal burns in India. METHODS: We conducted a prospective observational study of patients using EMS for thermal burns across five Indian states from May to August 2015. Our primary outcome was mortality at 2, 7 and 30 days. We compared observed mortality with expected mortality using the revised Baux score. We used Χ2 analysis for categorical variables and Wilcoxon two-sample test for continuous variables. ORs and 95% CIs are reported for all modelled predictor variables. RESULTS: We enrolled 439 patients. The 30-day follow-up rate was 85.9% (n=377). The median age was 30 years; 56.7% (n=249) lived in poverty; and 65.6% (n=288) were women. EMS transported 94.3% of patients (n=399) to the hospital within 2 hours of their call. Median total body surface area (TBSA) burned was 60% overall, and 80% in non-accidental burns. Sixty-eight per cent of patients had revised Baux scores greater than 80. Overall 30-day mortality was 64.5%, and highest (90.2%) in women with non-accidental burns. Predictors of mortality by multivariate regression were TBSA (OR 7.9), inhalation injury (OR 5.5), intentionality (OR 4.7) and gender (OR 2.2). DISCUSSION: Although EMS rapidly connects critically burned patients to care in India, mortality remains high, with women disproportionally suffering self-inflicted burns. To combat the burn epidemic in India, efforts must focus on rapid medical care and critical care services, and on a burn prevention strategy that includes mental health and gender-based violence support services.

Variations in Utilization of Inpatient Rehabilitation Services among Pediatric Trauma Patients.

OBJECTIVE: To assess clinical and nonclinical characteristics associated with the use of pediatric inpatient rehabilitation services among children with traumatic injuries. We hypothesized there would be no nonclinical variations in the use of pediatric inpatient rehabilitation services. STUDY DESIGN: Retrospective analysis of 1139 patients who were injured seriously (0-18 years of age) from our institutional trauma registry (2004-2014). Patients' nonclinical and clinical characteristics were analyzed. We used a full matching technique to compare characteristics between those admitted to rehabilitation (cases) to those discharged home (controls). We matched patients by age category, sex, maximum Abbreviated Injury Scale, and body region of maximum Abbreviated Injury Scale. We used survey-based multivariate logistic regression to identify characteristics associated with inpatient rehabilitation services, controlling for multiple injuries, distance from home to rehabilitation center, year of service, hospital length of stay, and clinically relevant interactions. RESULTS: Ninety-eight patients (8.6%) were admitted to inpatient rehabilitation and 968 (85.0%) were discharged home. Black and other minority patients had increased odds of receiving inpatient rehabilitation compared with white patients (OR, 7.6 [P< .001] and OR, 1.6 [P= .03], respectively). Patients with private compared with public insurance had increased odds of receiving inpatient rehabilitation (OR, 2.4; P< .001). CONCLUSIONS: Pediatric inpatient rehabilitation beds are a scarce resource that should be available to those with the greatest clinical need. The mechanism creating differences in the use of inpatient rehabilitation based on nonclinical characteristics such as race/ethnicity or insurance status must be understood to prevent disparities in access to inpatient rehabilitation services.

Variation in the Intensity of Care for Patients with Uncomplicated Renal Colic Presenting to U.S. Emergency Departments.

BACKGROUND: Renal colic results in > 1 million ED visits per year, yet there exists a gap in understanding how the majority of these visits, namely uncomplicated cases, are managed. OBJECTIVE: We assessed patient- and hospital-level variation for emergency department (ED) management of uncomplicated kidney stones. METHODS: We identified ED visits from non-elderly adults (aged 19-79 years) with a primary diagnosis indicating renal stone or colic from the 2011 Nationwide Emergency Department Sample. Patients with additional diagnostic codes indicating infection, sepsis, and abdominal aortic aneurysm were excluded. We used sample-weighted logistic regression to determine the association between hospital admission and having a urologic procedure with patient and hospital characteristics. RESULTS: Of the 1,061,462 ED visits for uncomplicated kidney stones in 2011, 8.0% of visits resulted in admission and 6.3% resulted in an inpatient urologic procedure. Uninsured patients compared to Medicaid insured patients were less likely to be admitted or have an inpatient urologic procedure (odds ratio [OR] = 0.72; 95% confidence interval [CI] 0.65-0.81 and OR = 0.80; 95% CI 0.72-0.87, respectively). Private- and Medicare-insured patients compared to Medicaid-insured patients were more likely to have an inpatient urologic procedure (OR = 1.20; 95% CI 1.11-1.30 and OR = 1.14; 95% CI 1.04-1.25, respectively). CONCLUSIONS: For patients with uncomplicated renal colic, there is variation in the management associated with nonclinical factors, namely insurance. No consensus guidelines exist yet to address when to admit or utilize inpatient urologic procedures.

The 6-Minute Walk Test as a Predictor of Summit Success on Denali.

OBJECTIVE: To test whether the 6-minute walk test (6MWT), including postexercise vital sign measurements and distance walked, predicts summit success on Denali, AK. METHODS: This was a prospective observational study of healthy volunteers between the ages of 18 and 65 years who had been at 4267 m for less than 24 hours on Denali. Physiologic measurements were made after the 6MWT. Subjects then attempted to summit at their own pace and, at the time of descent, completed a Lake Louise Acute Mountain Sickness Questionnaire and reported maximum elevation reached. RESULTS: One hundred twenty-one participants enrolled in the study. Data were collected on 111 subjects (92% response rate), of whom 60% summited. On univariate analysis, there was no association between any postexercise vital sign and summit success. Specifically, there was no significant difference in the mean postexercise peripheral oxygen saturation (Spo2) between summiters (75%) and nonsummiters (74%; 95% CI, -3 to 1; P = .37). The distance a subject walked in 6 minutes (6MWTD) was longer in summiters (617 m) compared with nonsummiters (560 m; 95% CI, 7.6 to 106; P = .02). However, this significance was not maintained on a multivariate analysis performed to control for age, sex, and guide status (P = .08), leading to the conclusion that 6MWTD was not a robust predictor of summit success. CONCLUSIONS: This study did not show a correlation between postexercise oxygen saturation or 6MWTD and summit success on Denali.

An observational study of adults seeking emergency care in Cambodia.

OBJECTIVE: To describe the characteristics and chief complaints of adults seeking emergency care at two Cambodian provincial referral hospitals. METHODS: Adults aged 18 years or older who presented without an appointment at two public referral hospitals were enrolled in an observational study. Clinical and demographic data were collected and factors associated with hospital admission were identified. Patients were followed up 48 hours and 14 days after presentation. FINDINGS: In total, 1295 hospital presentations were documented. We were able to follow up 85% (1098) of patients at 48 hours and 77% (993) at 14 days. The patients' mean age was 42 years and 64% (823) were females. Most arrived by motorbike (722) or taxi or tuk-tuk (312). Most common chief complaints were abdominal pain (36%; 468), respiratory problems (15%; 196) and headache (13%; 174). Of the 1050 patients with recorded vital signs, 280 had abnormal values, excluding temperature, on arrival. Performed diagnostic tests were recorded for 539 patients: 1.2% (15) of patients had electrocardiography and 14% (175) had diagnostic imaging. Subsequently, 783 (60%) patients were admitted and 166 of these underwent surgery. Significant predictors of admission included symptom onset within 3 days before presentation, abnormal vital signs and fever. By 14-day follow-up, 3.9% (39/993) of patients had died and 19% (192/993) remained functionally impaired. CONCLUSION: In emergency admissions in two public hospitals in Cambodia, there is high admission-to-death ratio and limited application of diagnostic techniques. We identified ways to improve procedures, including better documentation of vital signs and increased use of diagnostic techniques.

Emergency department-based health insurance enrollment for children: does linkage lead to insurance retention and utilization?

OBJECTIVES: Although 40% of emergency departments (EDs) report having an insurance linkage program, no studies have evaluated the long-term success of these programs. This study aimed to examine insurance retention and utilization by children initially referred to insurance by our ED insurance linkage program. METHODS: We retrospectively examined insurance records of all uninsured children successfully enrolled in public insurance by the insurance linkage program established in our suburban academic ED between 2004 and 2009. Emergency department-enrolled children were matched by age, sex, program, and year of enrollment to a control group of children from the same county who were enrolled in non-ED settings. Wilcoxon signed rank and χ tests were used to compare enrollment and claims variables. RESULTS: Emergency department-enrolled children retained insurance for longer, had a higher reenrollment rate, and were higher users of insurance. The average length of enrollment for ED children was 734 days versus 597 days in the control group. Eighty percent of the ED cohort reenrolled in insurance after initial eligibility expiration versus 64% of the control group. Children enrolled via the ED averaged 26 claims (vs 12 claims) and $20,087 (vs $5216) in hospital charges per year of enrollment. This higher utilization was reflected in increased primary care, specialty care, ED visits, inpatient, and mental health claims in the ED group. CONCLUSIONS: Emergency department-based insurance enrollment programs have the potential to improve access to health care for children. Policies aimed at expanding insurance enrollment among the uninsured population, including the Affordable Care Act, may consider the ED's potential as an effective enrollment site.

Waiting for Care: Length of Stay for ED Mental Health Patients by Disposition, Diagnosis, and Region (2009-2015).

Objective Emergency departments (EDs) face increasing mental health visits on a backdrop of insufficient mental health resources. We study ED length of stay (LOS) and disposition by 1) mental health vs. medical visits; 2) psychiatric vs. substance use visits; and 3) the four regions of the United States.  Methods We used weighted data from the National Hospital Ambulatory Medical Care Survey (2009-2015). Visits by patients ages 18-64 were categorized into mental health and medical groups. The mental health group was then subdivided into psychiatric, substance use, and co-occurring disorders. The LOS was compared by disposition. Mental health vs. medical LOS and disposition were examined across four regions of the US. Results An estimated 28 million mental health and 526 million medical visits were included in the study. Mental health visits had a median (interquartile range [IQR]) of 3.7 (4.7) hours while medical visits had a median (IQR) of 2.6 (2.7) hours. Mental health compared to medical visits were more likely to result in admission or transfer and to last >6 and >12 hours. Mental health visits resulting in transfer had the longest LOS with a median (IQR) of 6.23 (7.7) hours. Of mental health visit types, co-occurring disorders visits were more likely to be >6 and >12 hours regardless of disposition. Across US regions, there was significant variation in disposition patterns for mental health vs. medical visits. The odds of mental health visits lasting >6 and >12 hours were greatest in the Northeast and the least in the South with a median (IQR) of 4.6 (5.8) hours and 3.3 (4.0) hours, respectively. Conclusions Metal health compared to medical visits had longer LOS, especially when the patient had co-occurring disorders or required transfer. Regionally, there is a large variation in disposition for mental health vs. medical visits. This study makes it clear that there are no standards for managing psychiatric emergencies.

A retrospective observational cohort study: Epidemiology and outcomes of pediatric unintentional falls in US emergency departments.

INTRODUCTION: The objective is to determine how outcomes from unintentional falls differ for children with and without developmental disabilities, with a sensitivity analysis specifically examining those with ADHD. MATERIALS AND METHODS: This is a retrospective observational cohort study of 2010-2015 data from the Nationwide Emergency Department Sample (NEDS). The NEDS is a sampling of ED visits across 953 hospitals in 36 states. Unintentional falls for children with and without developmental disabilities were compared, adjusting for age, sex, payment source, income, mechanism, injury severity score (ISS). A sensitivity analysis was then performed for children with ADHD (n=139,642) and those without any developmental disabilities. A priori chosen outcomes included hospital admission, length of stay, intubation, and surgery. Logistic regression analysis estimated adjusted odds ratios for outcomes. RESULTS: Among children who presented to the ED with unintentional falls (n=13,217,237), there were 223,445 (1.7%) with developmental disabilities. The majority of those with developmental disabilities were male, ages 10-14 years. Compared to children without developmental disabilities, those with developmental disabilities were more likely to have an inpatient admission (aOR=2.27, 95% CI=2.10-2.44), length of stay more than 2 days (aOR=1.73, 95% CI=1.51-1.98), intubation (aOR=4.77, 95% CI=3.62-6.27) and surgery (aOR=2.11, 95% CI=1.93-2.32). A sensitivity analysis showed that 139,642 (1%) of children ages 5-17 years had ADHD. Of those with ADHD, the majority was also male, ages 10-14 years. Compared to children without ADHD, those with ADHD had a higher odds of inpatient admission (aOR=1.74, 95% CI=1.58-1.91), length of stay greater than 2 days (aOR=1.59, 95% CI=1.37-1.85), intubation (aOR=3.96, 95% CI=2.73-5.73), and surgery (aOR=1.82, 95% CI=1.60-2.06). CONCLUSIONS: Children with developmental disabilities, in particular those with ADHD, who experience falls are often older and male. They had greater odds of poor outcomes. These children need additional anticipatory guidance and attention to adequate treatment to prevent injuries from unintentional falls.

Shifting the Paradigm of Emergency Care in Developing Countries.

Background The global agenda does not address a significant amount of preventable death in low- and middle-income countries (LMICs). While illnesses requiring acute care are increasing at an alarming rate in these countries, there are inadequate numbers of physicians or nurses to deal with the growing burden. Many people feel that emergency systems are too expensive and restricted in scope to have public health implications in resource-limited areas. Little empirical data exists to suggest otherwise. The goal of this study was to delineate the type and frequency of emergency conditions and define a novel method to estimate the burden of emergency diseases in Fort Liberte, Haiti. Methods A retrospective, cross-sectional medical record review was performed on all emergency room visits to Fort Liberte Hospital in 2009 and 2010. The type, frequency, and annual incidence of emergency conditions were identified and used to determine the burden of emergency disease. A disability-adjusted life year (DALY) calculation was estimated using a variation on a model of indirect national data extrapolation to cities. Results Nineteen months of data available yielded 2000 charts with 2284 diagnoses in total. Trauma was the most common illness at 13% of all charts, followed by abdominal pain at 11%, gastroenteritis at 8%, skin and soft tissue infections at 7%, and hypertension at 6%. The DALY calculation showed disability from emergency conditions to be five times that of HIV, malaria, and TB combined. Conclusions Sufficient emergency burden of disease affects population health in Fort Liberte, Haiti to warrant addressing it as a public health concern. The kinds of conditions described in this review may be amenable to task shifting as a feasible, sustainable, and scalable way to address the burden in a cost-effective manner.

Nationwide Assessment of Factors Associated with Nonoperative Management of Pediatric Splenic Injury.

To evaluate variation in care nationwide for children with splenic injuries at pediatric trauma, adult trauma, and nontrauma centers. We used the National Inpatient Sample from 2001 to 2010 to identify pediatric patients with splenic injury. We analyzed demographic, clinical, and hospital status characteristics. The primary objective was comparison of splenectomy rates at pediatric, adult, and nontrauma centers. We identified 34,599 patients with splenic injury. Throughout the study, 3,979 (11.5%) patients underwent splenectomy: 8.2 per cent of patients at pediatric trauma, 17.6 per cent at adult trauma, and 14.5 per cent at nontrauma centers. Multivariate regression analysis demonstrated patients had decreased odds of splenectomy at pediatric trauma centers compared with adult and nontrauma centers (OR = 0.42, P < 0.001). In addition, children aged 14 to 17 years (OR = 2.5) with injury severity score > 14 (OR = 5.8) had increased odds of undergoing splenectomy. In this nationwide sample, children with splenic injury treated at adult trauma and nontrauma centers had significantly higher rates of splenectomy compared with children treated at pediatric trauma centers. We highlight the need for interventions that ensure all injured children receive appropriate and high quality trauma care.

Characteristics and outcomes of pediatric patients presenting at Cambodian referral hospitals without appointments: an observational study.

BACKGROUND: Emergency medicine is a young specialty in many low- and middle-income countries (LMICs). Although many patients seeking emergency or acute care are children, little information is available about the needs and current treatment of this group in LMICs. In this observational study, we sought to describe characteristics, chief complaints, management, and outcomes of children presenting for unscheduled visits to two Cambodian public hospitals. METHODS: Children enrolled in the study presented without appointment for treatment at one of two Cambodian public referral hospitals during a 4-week period in 2012. Researchers used standardized questionnaires and hospital records to collect demographic and clinical data. Patients were followed up at 48 h and 14 days after initial presentation. Multivariate logistic regression identified factors associated with hospital admission. RESULTS: This study included 867 unscheduled visits. Mean patient age was 5.7 years (standard deviation 4.8 years). Of the 35 different presenting complaints, fever (63%), respiratory problems (25%), and skin complaints (24%) were most common. The majority of patients were admitted (51%), while 1% were transferred to another facility. Seven patients (1%) died within 14 days. Follow-up rates were 83% at 48 h and 75% at 14 days. Predictors of admission included transfer or referral from another health provider, seeking prior care for the presenting problem, low socioeconomic status, onset of symptoms within 24 h of seeking care, abnormal vital signs or temperature, and chief complaint of abdominal pain or fever. CONCLUSIONS: While the admission rate in this study was high, mortality was low. More effective identification and management of children who can be treated and released may free up scarce inpatient resources for children who warrant admission.

Reducing early infant mortality in India: results of a prospective cohort of pregnant women using emergency medical services.

OBJECTIVES: To describe the demographic characteristics and clinical outcomes of neonates born within 7 days of public ambulance transport to hospitals across five states in India. DESIGN: Prospective observational study. SETTING: Five Indian states using a centralised emergency medical services (EMS) agency that transported 3.1 million pregnant women in 2014. PARTICIPANTS: Over 6 weeks in 2014, this study followed a convenience sample of 1431 neonates born to women using a public-private ambulance service for a 'pregnancy-related' problem. Initial calls were deemed 'pregnancy related' if categorised by EMS dispatchers as 'pregnancy', 'childbirth', 'miscarriage' or 'labour pains'. Interfacility transfers, patients absent on ambulance arrival, refusal of care and neonates born to women beyond 7 days of using the service were excluded. MAIN OUTCOME MEASURES: death at 2, 7 and 42 days after delivery. RESULTS: Among 1684 women, 1411 gave birth to 1431 newborns within 7 days of initial ambulance transport. Median maternal age at delivery was 23 years (IQR 21-25). Most mothers were from rural/tribal areas (92.5%) and lower social (79.9%) and economic status (69.9%). Follow-up rates at 2, 7 and 42 days were 99.8%, 99.3% and 94.1%, respectively. Cumulative mortality rates at 2, 7 and 42 days follow-up were 43, 53 and 62 per 1000 births, respectively. The perinatal mortality rate (PMR) was 53 per 1000. Preterm birth (OR 2.89, 95% CI 1.67 to 5.00), twin deliveries (OR 2.80, 95% CI 1.10 to 7.15) and caesarean section (OR 2.21, 95% CI 1.15 to 4.23) were the strongest predictors of mortality. CONCLUSIONS: The perinatal mortality rate associated with this cohort of patients with high-acuity conditions of pregnancy was nearly two times the most recent rate for India as a whole (28 per 1000 births). EMS data have the potential to provide more robust estimates of PMR, reduce inequities in timely access to healthcare and increase facility-based care through service of marginalised populations.

Correction: Hydration Status as a Predictor of High-altitude Mountaineering Performance.

[This corrects the article DOI: 10.7759/cureus.918.].

Correction: Hydration Status as a Predictor of High-altitude Mountaineering Performance.

[This corrects the article DOI: 10.7759/cureus.918.].

Characteristics and outcomes of women using emergency medical services for third-trimester pregnancy-related problems in India: a prospective observational study.

OBJECTIVES: Characterise the demographics, management and outcomes of obstetric patients transported by emergency medical services (EMS). DESIGN: Prospective observational study. SETTING: Five Indian states using a centralised EMS agency that transported 3.1 million pregnant women in 2014. PARTICIPANTS: This study enrolled a convenience sample of 1684 women in third trimester of pregnancy calling with a 'pregnancy-related' problem for free-of-charge ambulance transport. Calls were deemed 'pregnancy related' if categorised by EMS dispatchers as 'pregnancy', 'childbirth', 'miscarriage' or 'labour pains'. Interfacility transfers, patients absent on ambulance arrival and patients refusing care were excluded. MAIN OUTCOME MEASURES: Emergency medical technician (EMT) interventions, method of delivery and death. RESULTS: The median age enrolled was 23 years (IQR 21-25). Women were primarily from rural or tribal areas (1550/1684 (92.0%)) and lower economic strata (1177/1684 (69.9%)). Time from initial call to hospital arrival was longer for rural/tribal compared with urban patients (66 min (IQR 51-84) vs 56 min (IQR 42-73), respectively, p<0.0001). EMTs assisted delivery in 44 women, delivering the placenta in 33/44 (75%), performing transabdominal uterine massage in 29/33 (87.9%) and administering oxytocin in none (0%). There were 1411 recorded deliveries. Most women delivered at a hospital (1212/1411 (85.9%)), however 126/1411 (8.9%) delivered at home following hospital discharge. Follow-up rates at 48 hours, 7 days and 42 days were 95.0%, 94.4% and 94.1%, respectively. Four women died, all within 48 hours. The caesarean section rate was 8.2% (116/1411). On multivariate regression analysis, women transported to private hospitals versus government primary health centres were less likely to deliver by caesarean section (OR 0.14 (0.05-0.43)) CONCLUSIONS: Pregnant women from vulnerable Indian populations use free-of-charge EMS for impending delivery, making it integral to the healthcare system. Future research and health system planning should focus on strengthening and expanding EMS as a component of emergency obstetric and newborn care (EmONC).

Hydration Status as a Predictor of High-altitude Mountaineering Performance.

BACKGROUND: Hydration status is a controversial determinant of athletic performance. This relationship has not been examined with mountaineering performance. METHODS: This was a prospective observational study of mountaineers who attempted to climb Denali in Alaska. Participants' urine specific gravity (SG), and ultrasound measurements of the inferior vena cava size and collapsibility index (IVC-CI) were measured at rest prior to ascent. Upon descent, climbers reported maximum elevation gained for determination of summit success. RESULTS: One hundred twenty-one participants enrolled in the study. Data were collected on 111 participants (92% response rate); of those, 105 (87%) had complete hydration data. Fifty-seven percent of study participants were found to be dehydrated by IVC-CI on ultrasound, and 55% by urine SG. No significant association was found with summit success and quantitative measurements of hydration: IVC-CI (50.4% +/- 15.6 vs. 52.9% +/- 15.4, p = 0.91), IVC size (0.96 cm +/- 0.3 vs. 0.99 cm +/- 0.3, p = 0.81), and average SG (1.02 +/- 0.008 vs. 1.02 +/- 0.008, p = 0.87). Categorical measurements of urine SG found 24% more successful summiters were hydrated at 14 Camp, but this was not found to be statistically significant (p = 0.56). Summit success was associated with greater water-carrying capacity on univariate analysis only: 2.3 L, 95% confidence interval (2.1 - 2.5) vs. 2.1 L, 95% confidence interval (2 - 2.2); p < 0.01. CONCLUSIONS: Intravascular dehydration was found in approximately half of technical high-altitude mountaineers. Hydration status was not significantly associated with summit success, but increased water-carrying capacity may be an easy and inexpensive educational intervention to improve performance.