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Cooksley T, Klotz A, Marshall E, Weaver J, Font C, Lasserson D. The need for ambulatory emergency oncology: exemplified by the management of immune checkpoint inhibitor toxicity. Support Care Cancer 2023; 31:653. [PMID: 37878140 DOI: 10.1007/s00520-023-08132-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 10/19/2023] [Indexed: 10/26/2023]
Abstract
Cancer patients seeking emergency care can be vulnerable in increasingly overcrowded Emergency Departments and timely delivery of care is often aspirational rather than reality in many acute care systems. Ambulatory emergency care and its various international models are recognized as contributing to the safety and sustainability of emergency care services. This schema can logically be extended to the emergency oncology setting. The recent proliferation of immune checkpoint inhibitors (ICIs) has led to another opportunity for the management of oncologic complications in the ambulatory emergency care setting. More nuanced risk stratification of currently perceived high-risk toxicities may also afford the opportunity to personalize acute management. Virtual wards, which predominantly provide virtual monitoring only, and hospital at home services, which provide more comprehensive in-person assessment and interventions, may be well suited to supporting care for ICI toxicity alongside hospital-based assessment. Emergency management guidelines for immune-mediated toxicities will increasingly need to be both pragmatic and deliverable, especially as larger numbers of patients will present outside cancer centers. Identifying and modelling those suitable for emergency ambulatory care is integral to achieving this.
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Affiliation(s)
- Tim Cooksley
- Department of Acute Medicine, The Christie NHS Foundation Trust, Wilmslow Road, Manchester, UK.
- University of Manchester, Manchester, UK.
| | | | | | - Jamie Weaver
- Department of Acute Medicine, The Christie NHS Foundation Trust, Wilmslow Road, Manchester, UK
- University of Manchester, Manchester, UK
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Jivraj N, Lee YC, Tinker L, Bowering V, Ferguson SE, Croke J, Karakasis K, Chawla T, Lau J, Ng P, Dhar P, Shlomovitz E, Buchanan S, Dhani N, Oza AM, Stuart-McEwan T, Lheureux S. Management of Malignant Bowel Obstruction: An Innovative Proactive Outpatient Nurse-Led Model of Care for Patients With Advanced Gynecologic Cancer. J Nurs Care Qual 2023; 38:69-75. [PMID: 36214674 DOI: 10.1097/ncq.0000000000000661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Malignant bowel obstruction (MBO) in patients with advanced gynecologic cancer (GyCa) can negatively impact clinical outcomes and quality of life. Oncology nurses can support these patients with adequate tools/processes. PROBLEM Patients with GyCa with/at risk of MBO endure frequent emergency or hospital admissions, impacting patient care. APPROACH Optimizing oncology nurses' role to improve care for patients with GyCa with/at risk of MBO, the gynecology oncology interprofessional team collaborated to develop a proactive outpatient nurse-led MBO model of care (MOC). OUTCOMES The MBO MOC involves a risk-based algorithm engaging interdisciplinary care, utilizing standardized tools, risk-based assessment, management, and education for patients and nurses. The MOC has improved patient-reported confidence level of bowel self-management and decreased hospitalization. Following education, nurses demonstrated increased knowledge in MBO management. CONCLUSIONS An outpatient nurse-led MBO MOC can improve patient care and may be extended to other cancer centers, fostering collaboration and best practice.
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Affiliation(s)
- Nazlin Jivraj
- Division of Medical Oncology and Hematology (Drs Dhani, Lheureux, and Oza), Princess Margaret Cancer Centre (Mss Jivraj, Tinker, Bowering, Ng, and Buchanan and Dr Lau), Toronto, Ontario, Canada; Royal Hospital for Women and University of South Wales, Randwick, New South Wales, Australia (Dr Lee); Divisions of Gynecologic Oncology (Dr Ferguson), General Surgery (Drs Dhar and Shlomovitz), and Radiology (Dr Shlomovitz), University Health Network (Dr Croke and Mss Karakasis and Stuart-McEwan), Toronto, Ontario, Canada; Departments of Obstetrics and Gynecology (Dr Ferguson), Radiation Oncology (Dr Croke), and Surgery (Drs Dhar and Shlomovitz), and Lawrence S. Bloomberg Faculty of Nursing (Ms Stuart-McEwan), University of Toronto (Dr Oza), Toronto, Ontario, Canada; Mount Sinai Hospital, Toronto, Ontario, Canada (Dr Chawla); and Joint Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada (Dr Chawla)
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Font C, Cooksley T, Ahn S, Rapoport B, Escalante C. Emergency management of incidental pulmonary embolism (IPE). EMERGENCY CANCER CARE 2022; 1:7. [PMID: 35844667 PMCID: PMC9207846 DOI: 10.1186/s44201-022-00004-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/14/2022] [Indexed: 11/14/2022]
Abstract
Venous thrombo-embolic (VTE) disease is a common cause of complications in patients with cancer and is the second most common cause of death in oncology patients other than the malignant disease. Whilst symptomatic VTE comprises the majority of such presentations to an emergency department (ED), incidental pulmonary embolism (IPE) is an increasingly frequent reason for attendance. Many studies report that the consequences of IPE do not differ significantly from those with symptomatic presentations and thus most guidelines recommend using the same approach. The complexity of treatment in cancer patients due to increased prevalence of co-morbidities, higher risk of bleeding, abnormal platelet and renal function, greater risk of VTE recurrence, and medications with the risk of anticoagulant interaction are consistent across patients with symptomatic and IPE. One of the initial challenges of the management of IPE is the design of a pathway that provides both patients and clinicians with a seamless journey from the radiological diagnosis of IPE to their initial clinical workup and management. Increased access to ambulatory care has successfully reduced ED utilisation and improved clinical outcomes in high-risk non-oncological populations, such as those with IPE. In this clinical review, we consider IPE management, its workup, the conundrums it may present for emergency physicians and the need to consider emergency ambulatory care for this growing cohort of patients.
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Gómez-Centurión I, Oarbeascoa G, García MC, López Fresneña MC, Martínez Carreño MJ, Escudero Vilaplana V, González-Haba E, Bailén R, Dorado N, Juárez LM, Rodríguez Macías G, Font López P, Encinas C, Bastos-Oreiro M, Anguita J, Sanjurjo M, Díez-Martin JL, Kwon M. Implementation of a hospital-at-home (HAH) unit for hematological patients during the COVID-19 pandemic: safety and feasibility. Int J Hematol 2021; 115:61-68. [PMID: 34553338 PMCID: PMC8457036 DOI: 10.1007/s12185-021-03219-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 09/07/2021] [Accepted: 09/07/2021] [Indexed: 12/23/2022]
Abstract
Background “Hospital-at-home” (HAH) programs have been shown to optimize resource utilization, shorten hospitalization and prevent nosocomial infection. Methods We retrospectively analysed data regarding implementation of an HAH unit for caring patients with hematological malignancies in our center, during the COVID-19 pandemic. Results Between January and November 2020, 105 patients were treated in the HAH unit for a total of 204 episodes. Nine patients with multiple myeloma (MM) received autologous HSCT (auto-HSCT). Three patients with acute myeloid leukemia (AML) received consolidation therapy, 32 patients underwent clinical and analytical monitoring, 20 were transplant recipients early discharged (5 auto-HSCT and 15 allo-HSCT) and 2 had received CART cells therapy. Azacitidine, bortezomib and carfilzomib were administered at home to 54 patients with AML, myelodysplastic syndrome (MDS) or MM. A median of 17 (IQR 13–19) days of admission per patient and a total of 239 visits to the Hematology day-care hospital were avoided. Overall, 28 patients (14% of all episodes) needed admission to the hospital, 4 of them due to COVID-19. Conclusions Implementation of a Hematology HAH unit was feasible and safe, and provided thorough advanced care to a high-risk population. Advanced care-at-home strategies can be crucial during times of COVID-19 to minimize treatment interruptions and reduce the risk of cross-infections.
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Affiliation(s)
- Ignacio Gómez-Centurión
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007, Madrid, Spain.
- Gregorio Marañón Institute of Health Research, Madrid, Spain.
| | - Gillen Oarbeascoa
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007, Madrid, Spain
- Gregorio Marañón Institute of Health Research, Madrid, Spain
| | - María Carmen García
- Gregorio Marañón Institute of Health Research, Madrid, Spain
- Nursing Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - María Carmen López Fresneña
- Gregorio Marañón Institute of Health Research, Madrid, Spain
- Nursing Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - María Josefa Martínez Carreño
- Gregorio Marañón Institute of Health Research, Madrid, Spain
- Nursing Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Vicente Escudero Vilaplana
- Gregorio Marañón Institute of Health Research, Madrid, Spain
- Department of Pharmacy, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Eva González-Haba
- Gregorio Marañón Institute of Health Research, Madrid, Spain
- Department of Pharmacy, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Rebeca Bailén
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007, Madrid, Spain
- Gregorio Marañón Institute of Health Research, Madrid, Spain
| | - Nieves Dorado
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007, Madrid, Spain
- Gregorio Marañón Institute of Health Research, Madrid, Spain
| | - Luis Miguel Juárez
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007, Madrid, Spain
- Gregorio Marañón Institute of Health Research, Madrid, Spain
| | - Gabriela Rodríguez Macías
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007, Madrid, Spain
- Gregorio Marañón Institute of Health Research, Madrid, Spain
| | - Patricia Font López
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007, Madrid, Spain
- Gregorio Marañón Institute of Health Research, Madrid, Spain
| | - Cristina Encinas
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007, Madrid, Spain
- Gregorio Marañón Institute of Health Research, Madrid, Spain
| | - Mariana Bastos-Oreiro
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007, Madrid, Spain
- Gregorio Marañón Institute of Health Research, Madrid, Spain
| | - Javier Anguita
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007, Madrid, Spain
- Gregorio Marañón Institute of Health Research, Madrid, Spain
| | - María Sanjurjo
- Gregorio Marañón Institute of Health Research, Madrid, Spain
- Department of Pharmacy, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - José Luis Díez-Martin
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007, Madrid, Spain
- Gregorio Marañón Institute of Health Research, Madrid, Spain
- Universidad Complutense de Madrid, Madrid, Spain
| | - Mi Kwon
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007, Madrid, Spain
- Gregorio Marañón Institute of Health Research, Madrid, Spain
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Lizano-Díez I, Amaral-Rohter S, Pérez-Carbonell L, Aceituno S. Impact of Home Care Services on Patient and Economic Outcomes: A Targeted Review. HOME HEALTH CARE MANAGEMENT AND PRACTICE 2021. [DOI: 10.1177/10848223211038305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Patient Support Programs (PSPs) reinforce patients’ care provided by health care professionals with the aim to improve adherence and patient empowerment. PSPs may include interventions such as home-based care, individualized medication counseling, support, training, and home delivery of medicines and/or devices. This study described these services and its impact on patient-reported outcomes and health care savings. We conducted an integrative literature review which was limited to publications from the last 10 years (2009-2019) and focused on diseases that require special support and/or parenteral administration. From 7040 total citations, we identified 64 home-based care services performed worldwide. Among the home-based care services, most were provided by nurses (n = 47/64; 73.4%) and addressed to cancer patients (n = 22/64; 34.4%); 23 out of 64 services (35.9%) incorporated telepharmacy. In general, home-based services and PSPs showed a positive impact on patients’ adherence to medication, patient satisfaction, and health-related quality of life. In addition, 14 (21.9%) services reported economic results, most of which showed that home therapy led to substantial cost savings.
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Abstract
PURPOSE OF REVIEW The past decade has witnessed unprecedented delivery to the clinical arena of a range of novel, innovative, and effective targeted anticancer therapies. These include immunotherapies, most prominently immune checkpoint inhibitors, as well as agents that target growth factors and cancer-related mutations. Many of these new cancer therapies are, however, associated with an array of toxicities, necessitating insight and vigilance on the part of attending physicians to achieve high-quality supportive care alongside toxicity management. In this review, we consider some of the key supportive care issues in toxicity management. RECENT FINDINGS Although both supportive care and targeted therapies have brought significant benefits to cancer care, the management of novel cancer therapy toxicities is nevertheless often complex. This is due in large part to the fact that target organs differ widely, particularly in the case of checkpoint inhibitors, with minor dermatological disorders being most common, while others, such as pneumonitis, are more severe and potentially life threatening. Accordingly, efficient management of these immune-related adverse events requires collaboration between multiple medical specialists. SUMMARY Supportive care is a key component in the management of new cancer therapy toxicities and needs to be incorporated into treatment pathways.
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Affiliation(s)
- Bernardo L Rapoport
- Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria
- The Medical Oncology Centre of Rosebank, Johannesburg, South Africa
- The Multinational Association for Supportive Care in Cancer (MASCC), Infection and Myelosuppression Study Group, Aurora, Ontario, Canada
| | - Tim Cooksley
- The Multinational Association for Supportive Care in Cancer (MASCC), Infection and Myelosuppression Study Group, Aurora, Ontario, Canada
- Manchester University Foundation Trust
- The Christie, University of Manchester, Manchester, UK
| | - Douglas B Johnson
- Department of Medicine, Vanderbilt University Medical Center and Vanderbilt Ingram Cancer Center, Nashville, Tennessee, USA
| | - Ronald Anderson
- Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria
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Cooksley T, Font C, Scotte F, Escalante C, Johnson L, Anderson R, Rapoport B. Emerging challenges in the evaluation of fever in cancer patients at risk of febrile neutropenia in the era of COVID-19: a MASCC position paper. Support Care Cancer 2020; 29:1129-1138. [PMID: 33230644 PMCID: PMC7682766 DOI: 10.1007/s00520-020-05906-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 11/18/2020] [Indexed: 12/13/2022]
Abstract
Patients with cancer are at higher risk of more severe COVID-19 infection and have more associated complications. The position paper describes the management of cancer patients, especially those receiving anticancer treatment, during the COVID-19 pandemic. Dyspnea is a common emergency presentation in patients with cancer with a wide range of differential diagnoses, including pulmonary embolism, pleural disease, lymphangitis, and infection, of which SARS-CoV-2 is now a pathogen to be considered. Screening interviews to determine whether patients may be infected with COVID-19 are imperative to prevent the spread of infection, especially within healthcare facilities. Cancer patients testing positive with no or minimal symptoms may be monitored from home. Telemedicine is an option to aid in following patients without potential exposure. Management of complications of systemic anticancer treatment, such as febrile neutropenia (FN), is of particular importance during the COVID-19 pandemic where clinicians aim to minimize patients' risk of infection and need for hospital visits. Outpatient management of patients with low-risk FN is a safe and effective strategy. Although the MASCC score has not been validated in patients with suspected or confirmed SARS-CoV-2, it has nevertheless performed well in patients with a range of infective illnesses and, accordingly, it is reasonable to expect efficacy in the clinical setting of COVID-19. Risk stratification of patients presenting with FN is a vital tenet of the evolving sepsis and pandemic strategy, necessitating access to locally formulated services based on MASCC and other national and international guidelines. Innovative oncology services will need to utilize telemedicine, hospital at home, and ambulatory care services approaches not only to limit the number of hospital visits but also to anticipate the complications of the anticancer treatments.
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Affiliation(s)
- Tim Cooksley
- Department of Acute Medicine and Critical Care, The Christie, Wilmslow Road, Manchester, UK.
| | - Carme Font
- Hospital Clinic de Barcelona, Barcelona, Spain
| | - Florian Scotte
- Interdisciplinary Cancer Course Department (DIOPP), Gustave Roussy Cancer Institute, Villejuif, France
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Elliott MJ, Love S, Donald M, Manns B, Donald T, Premji Z, Hemmelgarn BR, Grinman M, Lang E, Ronksley PE. Outpatient Interventions for Managing Acute Complications of Chronic Diseases: A Scoping Review and Implications for Patients With CKD. Am J Kidney Dis 2020; 76:794-805. [PMID: 32479925 DOI: 10.1053/j.ajkd.2020.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 04/02/2020] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Patients with chronic kidney disease (CKD) have high rates of emergency department (ED) use and hospitalization. Outpatient care may provide an alternative to ED and inpatient care in this population. We aimed to explore the scope of outpatient interventions used to manage acute complications of chronic diseases and highlight opportunities to adapt and test interventions in the CKD population. STUDY DESIGN Scoping review of quantitative and qualitative studies. SETTING & POPULATION Outpatient interventions for adults experiencing acute complications related to 1 of 5 eligible chronic diseases (ie, CKD, chronic respiratory disease, cardiovascular disease, cancer, and diabetes). SELECTION CRITERIA FOR STUDIES MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, grey literature, and conference abstracts were searched to December 2019. DATA EXTRACTION Intervention and study characteristics were extracted using standardized tools. ANALYTICAL APPROACH Quantitative data were summarized descriptively; qualitative data were summarized thematically. Our approach observed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) extension for scoping reviews. RESULTS 77 studies (25 randomized controlled trials, 29 observational, 12 uncontrolled before-after, 5 quasi-experimental, 4 qualitative, and 2 mixed method) describing 57 unique interventions were included. Of identified intervention types (hospital at home [n = 16], observation unit [n = 9], ED-based specialist service [n = 4], ambulatory program [n = 18], and telemonitoring [n = 10]), most were studied in chronic respiratory and cardiovascular disease populations. None targeted the CKD population. Interventions were delivered in the home, ED, hospital, and ambulatory setting by a variety of health care providers. Cost savings were demonstrated for most interventions, although improvements in other outcome domains were not consistently observed. LIMITATIONS Heterogeneity of included studies; lack of data for outpatient interventions for acute complications related to CKD. CONCLUSIONS Several interventions for outpatient management of acute complications of chronic disease were identified. Although none was specific to the CKD population, features could be adapted and tested to address the complex acute-care needs of patients with CKD.
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Affiliation(s)
- Meghan J Elliott
- Department of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
| | - Shannan Love
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Maoliosa Donald
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Bryn Manns
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Teagan Donald
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Zahra Premji
- Department of Libraries and Cultural Resources, University of Calgary, Calgary, AB, Canada
| | - Brenda R Hemmelgarn
- Department of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Michelle Grinman
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Eddy Lang
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
| | - Paul E Ronksley
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
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Lanzola G, Bossi P, Quaglini S, Zini EM. An Environment for Guidelinebased Decision Support Systems for Outpatients Monitoring. Methods Inf Med 2018; 56:283-293. [DOI: 10.3414/me16-01-0142] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 05/19/2017] [Indexed: 01/31/2023]
Abstract
SummaryObjectives: We propose an architecture for monitoring outpatients that relies on mobile technologies for acquiring data. The goal is to better control the onset of possible side effects between the scheduled visits at the clinic.Methods: We analyze the architectural components required to ensure a high level of abstraction from data. Clinical practice guidelines were formalized with Alium, an authoring tool based on the PROforma language, using SNOMED-CT as a terminology standard. The Alium engine is accessible through a set of APIs that may be leveraged for implementing an application based on standard web technologies to be used by doctors at the clinic. Data sent by patients using mobile devices need to be complemented with those already available in the Electronic Health Record to generate personalized recommendations. Thus a middleware pursuing data abstraction is required. To comply with current standards, we adopted the HL7 Virtual Medical Record for Clinical Decision Support Logical Model, Release 2.Results: The developed architecture for monitoring outpatients includes: (1) a guideline-based Decision Support System accessible through a web application that helps the doctors with prevention, diagnosis and treatment of therapy side effects; (2) an application for mobile devices, which allows patients to regularly send data to the clinic. In order to tailor the monitoring procedures to the specific patient, the Decision Support System also helps physicians with the configuration of the mobile application, suggesting the data to be collected and the associated collection frequency that may change over time, according to the individual patient’s conditions. A proof of concept has been developed with a system for monitoring the side effects of chemo-radiotherapy in head and neck cancer patients.Conclusions: Our environment introduces two main innovation elements with respect to similar works available in the literature. First, in order to meet the specific patients’ needs, in our work the Decision Support System also helps the physicians in properly configuring the mobile application. Then the Decision Support System is also continuously fed by patient-reported outcomes.
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